Angry

Warning: some pretty grotesque pictures ahead, as well as some really disturbing and sad stories.

Of pox and pigs: Ripping yarns from the real world of public health disease control

These are notes from a talk presented by Dr Kath Weston, Senior Lecturer in Public Health, Graduate School of Medicine, University of Wollongong. Theses notes were written by me (Dr Matthew Berryman), and are released under the Creative Commons Attribution 3.0 Australian licence.

Kath’s talk was on tales from her time working for the NSW Public Health Division, in the Nepean Blue Mountain (NMB) and Western Sydney (WS) Regions, which were separate, then merged, and are now separate but centrally managed with 2 offices, in Penrith and Parramatta.

The first part of her talk was on measles outbreaks, and listed the following general measures used:

• Urgent testing.
• Assessing the public health risk (based on infectious period)
• Ring fencing of the infection
• Contact tracing: GP waiting rooms, EDs; and follow up preventative measures.
• Prophylactic MMR vaccination can be given within < 72 hrs.
• IG (immunoglobulin) can be given within < 7 days
• Mass clinics
• Provision of information
• Exclusion from school also possible as a strategy, covered under the Public Health Act

The remainder of her talk was a series of case studies.

Wentworth measles outbreak in 2003, case study:

• The index case was a traveller returning from Nepal. Two visits to the ED; isolated on the first attendance but not on the second because he had assured them he was vaccinated.
• Case 2 was the baby of case 3 (the father), only 6 weeks old.
• Case 4 was the child of case 3, 15 months old. The family were conscientious objectors but the mother was immunized as a child, however her immunity wasn’t conferred as temporary immunity via breast milk. The parents refused IG treatment for the 15 month old.
• The child (I presume both? I can’t recall) was taken to a Queensland caravan park with the mother, this was then Queensland Health’s problem.
• Case 5 was an ED staff member, who didn’t realize they had measles.
• Case 6 child attending ED 4 years old.
• Airborne virus so ask for ED lists up to 2 hours after patient was present
• Case 7 another hospital worker.
• Case 8 from case 6 at church.
• Case 9 from case 8 at video store.
• 496 contacts total (excluding the church). Note that these are contacts, not cases.
• 500 contacts at the church (the information provided to church members was in Arabic, I am guessing Christians from Lebanon/Syria??).
• Public Health needed to drive out to contact people in some cases.
• The strain was genotyped as D8(Janakpur NEP/2.99/1).
• In another outbreak there were two genotypes of measles present, so they established that there were 2 outbreaks coinciding.
• None of the cases had a well-documented vaccination history. The ED staff member thought she/he was vaccinated and declined the hospital vaccination on employment.

2006 outbreak via Amma (Mātā Amṛtānandamayī Devīspiritual, a Hindu spiritual leader) on her 2006 Australian tour:

• She and her entourage weren’t objectors, and Amma herself didn’t have it, maybe one of the entourage had it.
• Many devotees were, however, objectors, and many around Australia got infected. Contacts refused MMR.

2011 outbreak:

• No secondary cases after follow up.
• High school clinic in WS, many students of Pacific Islander without / with no documented measles vaccination.
• Cost of PHU follow-up of one case of measles: $2433
• $48,000 total cost of outbreak.

Swine Flu ’09:

• Strategies used (in order, with dates given): Alert (pre-24/4), delay (24/4), contain (22/5), protect 17/6, sustain, control with vaccine.
• On June 1 2009 the Pacific Dawn cruise ship arrived in Sydney. Swine flu was confirmed only after people got off the boat, 3 crew members affected.
• On June 3 2009 the State of Origin was held.
• Melbourne had the largest outbreak.
• A woman travelled back to Sydney from Melbourne, and her 10 y.o. son developed symptoms on Tuesday 9 June.
• He attended on 9th and 10th in a large class (75 children, 9 adults) for some event.
• Public Health used the Incident Command System (ICS) to manage people and processes.
• In ICS everyone knows their position (in the case of Kath, she was the boss of her line manager, which didn’t cause any issues), and knows the processes already through training, thus allowing quick action.
• The 75 children had different play times and a lunch time set, and didn’t mix with others in school (wasn’t clear from the talk how this was enforced).
• There was a large role for pharmacists, who were needed to weigh children and mix up the required (liquid) dose of Tamiflu.
• A parent was required at the clinic that was set up for consent— this was another possible vector.
• Needed to carefully plan the process and layout of the clinic.
• Contain phase looking at high risk (of poor outcomes) groups: ATSI, pregnant, morbidly obese.
• Total cost (for Public Health) was $5m.
• There was a lot of panic, even among GPs.

Other case studies presented:

• Red-bellied black snake at a childcare. No children bitten.
• People attending a medical clinic got a rash when visiting the clinic, it turned out it was hairs mistletoe caterpillars in the tree outside of the clinic shedding. Published in Balit et al. Outbreak of caterpillar dermatitis caused by airborne hairs of the mistletoe browntail moth (Euproctis edwardsi).
• Bats and Australian Bat Lyssavirus, a disease related to rabies and, like rabies, fatal unless treated. Two boys, who found the microbats, and thought they were babies of regular size bats, decided to look after them and took them to the local Coles supermarket to get food for them, however the bats smelt the fruit in the fruit and veg. section and escaped. The boys and Coles staff were scratched. The boys only told parents after one was starting to get symptoms, and were treated with IG and vaccines.
• An outbreak of Chlamydophila psittaci (birds the vectors) in the mountains. 95 suspected or confirmed cases. Tourism involved as well as usual. Public Health asked for reports of dead birds, one man called up to report he’d ridden his lawn mower over six birds. This outbreak generated lots of hypothesis about contact and other factors that were risk factors. In general, under diagnosis is likely.
• 14 cases of salmonella from fried ice cream at a restaurant. The source: egg farm. The preparation for fried ice cream consists of deep frozen ice cream coated in raw egg, then placed in crumbs, then it’s put back in the freezer, until cooked quickly in hot oil. In this case the oil was not hot enough to properly cook the outer layers (including the egg layer), and patrons reported that it tasted soggy rather than crisp, indicating this was so.
• Scombroad poisoning from fish that have partly decomposed (but are still not “bad” in the sense that they don’t appear off) and contain histamines, so they generate an allergic reaction.
• There were a series of cases of disease that were, after a complex investigation, traced to the lack of autoclaving done at a colonic irrigation clinic; one client tested positive for Hep. C.
• Bindeez beads poisoning: a cheap version of a glue was used by a local distributer, that metabolised into GHB (γ-Hydroxybutyric Acid, a.k.a the date rape drug). Not good for young kids.
• Global warming is changing patterns of bird migration, insects, as vectors of disease.
• Tory Shepherd’s article on Melanie’s Marvellous Measles got a feature, as well as a brief outline of the book itself. The presenter (Kath) thought that Stephanie Messenger was just ill-informed, not crazy. I’ll forward her some of Stephanie’s emails to show her otherwise.

Her talk finished with cases where smallpox samples had turned up in historical records. It’s important to note that, given the dates, it was unclear if this was actual smallpox, or more likely (given the descriptions) Variola minor or Vaccinia (cowpox). The use of Variola minor was banned in 1840s (in England) due to the availability of Vaccinia as a safer alternative (“variolation” carried the risk of transmission of other diseases such as Syphilis).

• A 2003 report of smallpox material found in an 1888 book on civil war. “Scabs from vaccination of W.B. Yarrington’s children”.
• The Bizarre bits exhibition. ‘ “Dear Pa…the piece I inclose is perfectly fresh and was taken from an infant’s arm yesterday…” read the letter. “Dr. Harris says the inclosed scab will vaccinate 12 persons, but if you want more, you must send for it. I will pin this to the letter so that you cannot lose it as you did before.” ’
• A parcel delivered to Public Health in 2011 from the NSW State Archives. The letters enclosed with the unopened sample mentioned smallpox. Patient surveillance for staff at Public Health and State Archives was carried out. PCR on the sample was conducted, and no DNA was detected; there were no infections. The source of the sample was the Parramatta Female Factory (convicts, now in Westmead Hospital) used as a pool of recipients to keep the vaccine going in a population (needed scabs to transfer).

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On racism and “intellectual” game playing

I like (Ok, maybe not quite the right word for) the following description of responses to today’s racial abuse—& yes, I acknowledge the full details and that underling this is a general hatred issue someone has—is copied with permission from an “In the News” thread on Whirlpool.), in response to posts like this one quoted below. Note that quotes from others this poster is replying to are indicated by quote marks within this block quote.

Matt writes: “I hope everyone here would challenge any form of abuse, rather than poring over their dictionary. Over and out.”

Well in a point he (Jeremy Fernandez) and I are doing so in challenging the abuse Australians get by being labelled racist based on abuse such as in this article.

The abuse wasn’t racially motivated nor does it illustrate the view of the majority of Australians.

Heliotic writes… ”It wasn’t a racist attack it was only a verbal attack using racist terms.”

How is calling someone black a racist term?

1. Someone posts article outlining racist feral bogans being… racist feral bogans

2. Chorus of blinkered responses ignoring the problem, missing the point or both:
a) Just cause one person is racist doesnt mean that everyone is racist, therefore there is no problem
b) THATS NOT TECHNICALLY RACIST ITS BIGOTRY/XENOPHOBIC/RELIGIOUSIST/ETC
c) Well, go to China! They are HEAPS more racist than us! Therefore, we dont have a problem!
d) I am a middleclass white male betweent he ages of 16 and 45 and one time someone called me a skip! Everyone else is racist, not white people! WHEN IS WHITE HISTORY MONTH?!
e) Racism is bullcrap, man. How come they can call each other the n-word, but I can’t say it?!
f) A variety of offtopic standard rants, such as vague ‘out of touch magistrate judges soft on crime’, some kind of random ‘stop teh boatz’ argument
g) Someone says something along the lines of ‘if you hate Straya and Freedom so much, why don’t you just get out of mah country!’. Because if you don’t think Australia is perfect, you are an unAustralian traitor attacking the Anzacs and Bindi Irwin.

3. Ten pages of followup wherein people argue over petty semantics, new posters blunder in and spit out the same thing that someone else has said every second page.

Chinese funeral

Recently my Chinese grandmother-in-law passed away, while I was in China, so I got to experience a Chinese funeral, at least a fairly traditional Daoist one in the outskirts (semi-rural part) of Shanghai. Since my grandparents-in-law only had a tiny house (just a couple of small rooms) it wasn’t bit enough to hold all the family, which is huge, even my wife’s generation were before the one child policy (though this is now more relaxed than originally). Thus the event was at a location—a couple of spartan rooms plus an outdoor area with pitched tent—provided by the local government. The main mourning period lasts for three days, then often a fourth day, in lieu of an event (being China, this means a big meal) at the five weeks mark, and the full period is seven weeks, though the main focus is the first three days. One the first day the body is simply covered in sheets (red), and then on the second day it’s in a coffin, then on the third day the pall bearers carry the coffin out to a hearse (quite the procession, complete with a brass band, and big round paper constructs with names of family written on). I presume this was something else arranged through the local government. Music is a key feature of the period, with very aditional music using the erhu and dizi on the first and second days, along with the Daoist priests chanting on the first day. In the first week, we all had to wear a white sash around our waists, white being the colour associated with Chinese funerals, and also a black square pinned onto a jacket, which I think has some sort of Daoist significance. Not wanting to put a hole in my good jacket, I pinned it onto the baby sling instead, since I was for the most part carrying around (my youngest daughter) Anna-Rose while my wife took part in most of the ceremonies.

Burnt offerings of money and furniture are given for my grandmother-in-law’s afterlife (not that I believe, but the ritual is important). Everyone also goes to pray in Chinese style, involving hands clasped together and moved up and down, then prostrating oneself in front of the shrine (pictured, obviously not a Jewish or Muslim funeral), which has food and drink for the afterlife. I actually went in a second time to take the photo, and prayed again as I felt a bit awkward taking the photo, not knowing how sensitive people are to that, which I then felt bad about later as the children of the deceased, which includes my mother-in-law, have to do a plaintive cry every time someone prays. So much so, that between that, and keeping vigil over the body in this literally freezing cold location, sleeping on straw in one of the rooms, that my mother-in-law got quite ill. The food and drink aren’t wasted, this being China, and go on to be used for the living. The food eaten (aside from that on the shrine) also varies, from lots of tofu on the first day, with a bit of meat—a new development, this being modern China—to more regular Shanghai-style fare on the remaining days, including lots of pork and fish and rice and vegetables.

Shrine for my grandmother-in-law.

One of the later events is where the ashes were interred, which featured a burnt offering in a drum just outside the very classic style-architecture cemetary building, complete with a ring of salt around it, washed away at the conclusion using alcohol. Chloe, my eldest daughter, didn’t want to pray—the whole thing being a bit scary and mostly meaningless to her, at age 3.5—so I prayed one extra time on her behalf.

The other even I went to was a lunch following transfer of ashes of other relatives to the nice cemetary—in the hope of family members on my mother-in-law’s sisters’ side of the family that this would bring them good fortune. At this lunch, I got to sit next to one of my great-grandfathers-in-law (the one who just lost his wife), who was looking rather frail—he ended up going in to hospital with pneumonia, and also type 2 diabetes was discovered in the tests.

He’s doing much better, frail but with the spark of life, still wearing wedding ring, and went home the other day. That was still, given frequency of visits here, possibly our last time to see him. At the hospital visit (pictured, along with my wife) I got to speak with him in Mandarin, the tiny bit of Wu (Shanghainese) I know, & Japanese—he learnt age 16 during the Japanese occupation of China; I learnt it when I was 16 in high school. He also knows Sudanese as he worked there for a couple of years. He’s always treated me and my daughters really well, despite the language barriers, and I’ll miss him too in due course.

My wife with my grandfather-in-law.

Book review: Fish Eats Lion

I first travelled to Singapore when I was just 8, and have been there half a dozen times since. It’s a place with a unique mix of cultures and history, and the stories in Lion Eats Fish capture this well. Last Time Kopitiam by Marc de Foite, the tale of a trader sent to Singapore who is “quite adept at handling futures and derivatives”, captures historical and modern Singapore well. There are a number of “flower punk” stories—think steampunk but with a healthy dose of botany, and I really enjoyed these, particularly ‘Agnes Joaquim’ by Ng Yi-Sheng; they seem to fit Singapore quite well. I read these at a time I was watching David Attenborough’s Kingdom of Plants, and both have sparked in me a new appreciation for the amazing world of plants. A few stories fell flat for me, I just didn’t connect at all with the imagery / characters / background, but overall I really enjoyed this collection of short stories.

Highlights for me were The Disappearance of Lisa Zhang, by Dave Chua, which was well written and with characters that had real depth, and Story of the Kiss, by Stephanie Ye, which is the finest short story I’ve ever read, an exploration of love from an interesting perspective. I will be looking for more short stories by these two authors.

My sincerest apologies to Jason, the esteemed organiser and editor of this collection, for the delay in this review that I promised quite a while ago. It’s been a busy and dark year, and only now am I able to catch my breath, and enjoy the beautiful stories he has collected

Highly recommended. 9/10.

On HPV and cancer

Paul has already written these responses to this by Judy Wilyman, and I add my comments on the cancer aspect (which Judy will be pleased to note I am qualified to speak on).

Cancer is a family of diseases, all involving a series of genetic changes that enable cells to grow in an uncontrolled manner, and show other features of cancer, in the human body [1]. Viruses, by nature of their need to hijack normal cell processes to replicate, inject their genes into human cells; this injection can then cause the sorts of genetic changes required to trigger these features.

Modern research now very strongly links subtypes of HPV with cervical cancer [2], even more so than in the dated references Judy provides. While it is highly likely there are other factors associated with the development of cervical cancer [3], especially given that cancer involves a set of stages of development [1], I note the following:
*) Since HPV appears to be the necessary condition [2], immunisation of even some of the strains involved presents a clear line of attack to reduce the risk of developing cervical cancer.
*) It is unlikely that sexual behaviours as such are co-factors, as Judy suggests, rather these are just correlations by virtue of the fact that sexual practices carry different chances of transmitting HPV, the underlying causal factor.
*) Although there may be a low risk of HPV progressing to cancer, and not all of those who get cervical cancer will die, when one compares this with the risks from vaccines, the balance is clearly in favour of using vaccines to prevent what is, for those who do get cervical cancer, a nasty disease.

1. Hanahan & Weinberg, Hallmarks of cancer: the next generation, Cell 2011.
2. Walboomers et al., Human papillomavirus is a necessary cause of invasive cervical cancer worldwide, The Journal of Pathology 1999. 
3. Hildesheim et al., HPV co-factors related to the development of cervical cancer: results from a population-based study in Costa Rica, British Journal of Cancer 2001.