It is too late to do any formatting… Please forgive me:
Volume 12, Number 8–August 2006 Policy Review
Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care Daniel K. Sokol*
The phrase “duty of care” is, at best, too vague and, at worst, ethically dangerous. The nature and scope of the duty need to be determined, and conflicting duties must be recognized and acknowledged. Duty of care is neither fixed nor absolute but heavily dependent on context. The normal risk level of the working environment, the healthcare worker’s specialty, the likely harm and benefits of treatment, and the competing obligations deriving from the worker’s multiple roles will all influence the limits of the duty of care. As experts anticipate the arrival of an avian influenza pandemic in humans, discussion of this matter is urgently needed.
Epidemiologists are warning against an impending pandemic of avian influenza that could kill several million people (1). This possibility raises an urgent and thorny ethical question: Are healthcare professionals obligated to care for patients during virulent epidemics of infectious disease?
Special Obligation of Doctors to Benefit Their Patients By virtue of their profession, doctors and nurses have more stringent obligations of beneficence than most. They have obligations to a specified group of persons (their patients) that nonmedical personnel have no obligation to help. The term “duty of care” refers to these special obligations. In its bare form, however, the phrase gives no indication of the precise nature of the duty, nor of its limits. Its definitional vagueness, combined with its rhetorical appeal, may be used to justify actions without the need for rational deliberation. During the SARS outbreaks in Toronto, the phrase was often used as a self-standing argument for active involvement on the part of medical staff, without any critical examination of its meaning. Used in this manner, the term may become a subtle instrument of intimidation, pressuring healthcare workers into working in circumstances that they consider morally, psychologically, or physically unacceptable. The phrase duty of care can thus be ethically dangerous by giving the illusion of legitimate moral justification.
To be of any use, the phrase needs to be fleshed out. Are there limits to the duty? Should doctors do everything in their power to benefit their patients? The answer, surely, is no. Doctors are under no moral obligation to donate one of their kidneys to one of their patients, for example. They may, of course, choose to do so, but their act would exceed the demands of everyday morality. What distinguishes normal duty from acting beyond the call of duty, however, is not always clear-cut; the boundary between the 2 categories is fuzzy (4).
<snip>
In times of crisis, the duties deriving from doctors’ multiple roles may come into conflict. Doctors, for instance, may have a duty to care for their SARS or avian influenza–infected patients as well as a duty to care for their own children by protecting them (and hence themselves) from infection. So a further problem with the duty to care, aside from its vagueness, is that it fails to consider the holder of the duty as a multiple agent belonging to a broader community. Doctors, in such situations, play several incompatible roles—doctor, spouse, parent, for example—and they must deal with them as best they can. The limits of the duty of care are thus also defined by the strengths of competing rights and duties.
<snip>
Virtues of Patients and Their Duty of Care Whereas much has been written on what makes a good doctor, scant attention has been devoted to the good patient (6,7). Pellegrino and Thomasma, in For the Patient’s Good, devote a chapter to the “good patient” (8). “Patients,” they write, “must relate to physicians in all of the virtuous ways that govern human interrelationships and social conduct” (8). The authors identify 4 key virtues for the good patient: truthfulness, compliance, tolerance, and trust. The virtue most pertinent to this discussion is tolerance. In their examination of tolerance, Pellegrino and Thomasma mention the patients’ need to understand the limitations and fallibility of medicine and to care for the well-being of their fellow patients (8).
The virtue of tolerance should also require patients to acknowledge healthcare workers’ plurality of roles, as well as their fears and concerns in the face of severe risk. If these fears are well founded and reach such a level that medical staff are worried for their life or that of their loved ones, the virtuous patient ought to allow them to step down from their role as caregivers. In such cases, insisting that they continue in this role would reflect a lack of compassion and understanding.
<snip>
In light of the potentially catastrophic impact of avian influenza on human health and economic well-being, this topic should engender a burst of activity and debate in hospitals, universities, and medical journals. We should explore not only the nebulous limits of the duty of care but also infection control measures, staff training and involvement, the role of medical students and volunteers, the triaging of incoming patients, and the logistics of treatment, depending on the severity of the epidemic, as well as the lessons learned from past epidemics. However difficult the task, these issues should best be tackled now, in times of relative calm, rather than in times of pandemic turbulence.
http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm
Being a nurse myself, it is a difficult situation. There are many ethical issues we face daily, unrelated to Pandemics. Training ourselves now to understand ethics, our personal views, the impact(s) of our decisions, and the consequences of those decisions, are better made before an emergent situation. JMO……….
2nd article:
Volume 12, Number 8–August 2006 Letter Qinghai-like H5N1 from Domestic Cats, Northern Iraq Samuel L. Yingst,* Magdi D. Saad,* and Stephen A. Felt*
Suggested citation for this article
To the Editor: Natural infection of several cat species with highly pathogenic avian influenza (HPAI) H5N1 viruses in Thailand (1–4) and experimental infection of domestic cats with similar viruses have been reported (5,6). Thus, literature describing HPAI H5N1 infection of cats is limited to descriptions of infections with a subset of clade I viruses. HPAI H5N1 viruses, highly similar to viruses isolated from Qinghai Lake in western People’s Republic of China in spring 2005, are now rapidly disseminating throughout Eurasia and Africa. To our knowledge, this is the first report of a Qinghai-like virus detected in domestic cats. This finding is noteworthy because the host range of influenza viruses is determined by the antigenic characteristics of the hemagglutinin and neuraminidase molecules; clade II viruses are antigenically distinct from clade I viruses, and Qinghai-like viruses are genetically distinct from other clade II viruses.
Personal communications in January 2006 from field veterinarians noted deaths of domestic cats that were associated with suspected (eventually confirmed) H5N1 outbreaks in eastern Turkey (2 villages) and Kurdish northern Iraq (Sarcapcarn in Sulymaniyah Governorate and Grd Jotyar in Erbil Governorate). The clinical conditions of the birds did not suggest HPAI to villagers or consulting veterinarians. In both scenarios in Iraq, results of rapid antigen detection tests with the Anigen kit (Suwon, Republic of Korea), while positive for influenza A, were negative for H5, so the outbreaks were not thought to be caused by HPAI, but concern about the unusual deaths in cats remained. Because the regions are remote and veterinary services limited, such anecdotal reports have rarely been followed up.
<snip>
On the basis of sequence analysis of the full HA1 gene and 219 amino acids of the HA2 gene, the viruses from the goose and 1 cat from Grd Jotyar and from the person who died from Sarcapcarn (sequence derived from PCR amplification from first-passage egg material) are >99% identical at the nucleotide and amino acid levels (GenBank nos. DQ435200–02). Thus, no indication of virus adaptation to cats was found. The viruses from Iraq are most closely related to currently circulating Qinghai-like viruses, but when compared with A/bar-headed goose/Qinghai/65/2005 (H5N1) (GenBank no. DQ095622), they share only 97.4% identity at the nucleic acid level with 3 amino acid substitutions of unknown significance. On the other hand, the virus from the cat is only 93.4% identical to A/tiger/Thailand/CU-T4/2004(H5N1) (GenBank no. AY972539).
<snip>
Death in cats, spatially and temporally associated with unusual deaths in poultry, especially when the cats show positive results of a rapid antigen detection test for influenza A, should be considered to indicate a presumptive diagnosis of HPAI, and appropriate response should ensue.
http://www.cdc.gov/ncidod/eid/vol12no08/06-0264.htm
more food for thought…….
Thought this might be a good place for this:
Date / time 18/07/2006 - 13:17:30
Turkey
County / State Karabuk state
DESCRIPTION A pregnant woman and her baby lost their life on Monday due to the Crimean-Congo Hemorrhagic Fever (CCHF), bringing the total number of people who have died recently of the disease in Turkey to 15. Last Saturday, six months pregnant Dilek Sahin had been taken to Karabuk state hospital after she was bitten by a tick. The 25-year old woman was then sent to Ankara Numune Hospital following analysis and on suspicion of CCHF. In the other most recent CCHF related fatality, a nurse, who had been treating Crimean-Congo hemorrhagic fever patients in the province of Corum, died on Friday of the disease. The 30-year old nurse was infected with the disease when her colleague accidentally scratched her arm with an infected needle.
The nurse, who tested positive for the Crimean-Congo hemorrhagic fever, was taken to the Ankara Research Hospital where she later passed away. Fifteen people have died of Crimean-Congo hemorrhagic fever in Turkey over the past two months, exceeding the number of bird flu related deaths in Turkey. Zoologists claim that the mass culling of poultry due to bird flu fears has increased the number of ticks responsible for carrying and transmitting the Crimean-Congo hemorrhagic fever virus. Crimean-Congo hemorrhagic fever (CCHF) is a viral hemorrhagic fever of the Nairovirus group. The disease is endemic in many countries in Africa, Europe and Asia, and during 2001, cases were recorded in Kosovo, Albania, Iran, Pakistan, and South Africa. The disease is mostly encountered in the Middle East, Caucasus and the Balkans. The death rate for CCHF-infected persons can be as high as 30 percent in some countries while the figure for Turkey stands at 5 percent for now. No vaccination is available yet for the disease which was named as CCHF since it first came to public attention in Crimea in 1944 and in Congo in 1956.
Here’s another one:
Event type: Epidemic Hazard Date / time 18/07/2006 - 05:48:59 (Military Time, UTC) Country USA Area - County / State California City Los Angeles
DESCRIPTION Those visiting rural areas this summer should take precautions to avoid contracting bubonic plague, the state Department of Health warned Monday. A Los Angeles woman was hospitalized in April after becoming infected with the potentially fatal bacterial disease. It was the first reported case in Los Angeles County since 1984. Bubonic plague is spread by squirrels, chipmunks and other wild rodents and their fleas, according to Dr. Mark Horton, a state public health officer. When an infected rodent becomes sick and dies, its fleas carry the infection to other warm-blooded animals, including humans. People can also be exposed through infected cats, which are highly susceptible to the disease. “Individuals can greatly reduce their risk of becoming infected with plague by taking simple precautions, including avoiding contact with wild rodents,” Horton said. “Do not feed rodents in picnic or campground areas and never handle sick or dead rodents.” Early symptoms of plague include high fever, chills, nausea, weakness and swollen lymph nodes in the neck, armpit or groin. The disease is curable in its early stages with proper treatment, but may be fatal if left untreated. Plague-infected animals are most likely to be found in California’s foothills, mountains and along the coast, while the desert and Central Valley regions are considered low-risk regions, Horton said. So far this year, plague activity has been detected in animals in Inyo, Mariposa, Mono, Plumas and Sierra counties. Since 1970, there have been 42 human cases of the plague reported in California.
Anthrax in Canada kills 149 animals, infects man
Jul 17, 2006 (CIDRAP News) – A man is being treated for cutaneous (skin) anthrax and 36 farms are under quarantine because of livestock deaths in what has been called the largest anthrax outbreak in the history of the Canadian province of Saskatchewan.
The disease has killed 149 animals on the quarantined farms in northeastern Saskatchewan, according to today’s update from the Canadian Food Inspection Agency (CFIA).
A man from the Melfort area, about 175 kilometers northeast of Saskatoon, contracted cutaneous anthrax, the least serious form of the disease, the Saskatchewan provincial government said in a Jul 14 news release. “The individual is being treated with antibiotics and is expected to make a full recovery,” the statement said.
The release gave no information on how the man contracted the disease, but said cutaneous anthrax typically occurs when a person with a cut or abrasion comes into direct contact with anthrax spores on a sick or dead animal. In contrast, inhalational anthrax results from breathing in anthrax spores; it is usually fatal unless the patient receives prompt antibiotic treatment.
The CFIA said the outbreak does not pose “a significant human health threat.” Cases in livestock rarely affect people, and no animals from the quarantined farms were sent to slaughter, the agency said. Anthrax does not spread from person to person.
The outbreak centers on the Melfort area, which rarely has any cases, according to CFIA veterinarian Dr. Sandra Stephens, who was quoted in a recent report in the Saskatoon Star Phoenix. The CFIA said 8,000 livestock have been vaccinated against anthrax in the area.
The disease emerged after heavy spring rains saturated the ground and brought anthrax spores to the surface, according to a Jul 12 report in the Toronto Globe and Mail. Animals contract anthrax by eating plants contaminated by the spores. The Star Phoenix story called the outbreak the largest in Saskatchewan history.
The outbreak has killed 123 cattle, 3 horses, 1 pig, 1 sheep, 13 bison, and 8 white-tailed deer, according to information from Stephens that was published on ProMED-mail, the online reporting service of the International Society for Infectious Diseases.
“We are vaccinating cattle on farms around the infected premises to create a buffer zone in an effort to break the cycle of infection,” the CFIA said today. “Our monitoring of the situation indicates that the number of cases is declining.” The agency said quarantines will be canceled 21 days after new cases abate.
The Star Phoenix said some private veterinarians in the area ran out of vaccine. Stephens said some vets didn’t have the vaccine in stock because they weren’t used to seeing cases.
Authorities recommend that animals killed by anthrax be burned or buried quickly to prevent other animals from being exposed to the carcasses. Ken Tegstrom, a Melfort area cattle farmer who was quoted in the Jul 12 Globe and Mail story, said so many cattle died the week of Jul 2 that farmers didn’t have time to burn or bury them. Instead, the CFIA doused them in formaldehyde and covered them with tarpaulins for later disposal.
In the United States, some livestock cases of anthrax have been reported in Minnesota and North Dakota so far this year, but no large outbreaks. Last summer about 400 animals had died of the disease by early August in the Dakotas, Minnesota, and Texas.
Anthrax spores are found in soil in many parts of the world and can remain viable for decades.
excellent articles, thanks!
Commonground – at 08:15 Anthrax in Canada kills 149 animals, infects man …The CFIA said the outbreak does not pose “a significant human health threat.”
Remember: Canadian Dog Eats Homework. MW42
It doesn’t pose a “significant” threat until it becomes “significant”. We should keep an Emerging Infectious Disease thread going - just to keep everyone up to date on other ongoing situations, just my 2 cents.
Yes,“significant” based solely on the fact of co-infection. This can help tracking disease outbreaks.
From BBC News UK 17 July 2006
Red squirrel dies of deadly virus
A wildlife protection group is trying to stop the spread of a deadly virus that could wipe out Merseyside’s red squirrel population. The news comes after a red squirrel was confirmed to have died of squirrel pox virus in Ainsdale, Merseyside.
NEW LOCAL: West Nile virus spraying set
New Castle News <2 snips> A portion of Shenango Township will be sprayed for West Nile virus tomorrow and Thursday.
Weather permitting, the Jason’s Woods plan will be sprayed between 7 and 9 p.m. both days. < According to officials, the pesticide being used has no impact on the health of humans and pets and breaks down quickly in the environment.
(so what’s in that stuff anyway?)
2 cases of West Nile virus reported Victims recovering from June infections
Louisiana’s first human cases of West Nile virus infection in 2006 are residents of St. Tammany and Tangipahoa parishes, the state Department of Health and Hospitals said Monday.
Although no identifying details were released, both people are recovering after being infected in late June with the potentially lethal mosquito-borne virus, spokeswoman Kristen Meyer said.
The St. Tammany Parish resident had West Nile fever, a relatively mild form of the disease marked by flulike symptoms, she said.
http://tinyurl.com/zoboo is the link to The Times-Picayune from Louisiana.
Singapore News: <snip> Singapore investigates possibility of mutated flu virus
Tests are underway to determine if the recent increase in flu cases is due to a mutation of the influenza virus, says Director of Medical Services at the Ministry of Health, Professor K Satku.
“When something like this (an increase in flu patients) happens, one can speculate that … some kind of mutation has taken place,” he said at a briefing yesterday.
But he added that it would take months for tests to be completed, and the results to be confirmed by the World Health Organisation (WHO). The latter will then design new flu vaccines to deal with the new strain.
“Flu vaccines are for people who are more susceptible to infection, that is, the elderly and some children. Generally, a healthy person would not require a flu vaccine. If we restrict it to this group of people we will not encounter a shortage,” he said.
In Singapore, flu causes some 600 deaths annually, mostly in those over 65 years old. This is because it often leads on to serious infections such as pneumonia, which is the third most common cause of death here.
More at http://tinyurl.com/gzal4
MW42 at 10:45
“(so what’s in that stuff anyway?)”
Bacillus thuringiensis (BT) v. israelensis, a biological insecticide. The exotoxins are deadly to a variety of insect forms. Different varieties are effective against cabbage worms, gypsy moths, etc. It is ingested by the larvae, which stop feeding and die.
A member of the same genus as the causative agent of anthrax. However, it has not been shown to have any effect on humans, birds, or other wildlife when correctly applied. It is considered safer than synthetic alternatives such as organophosphates, carbamates, etc.
Florida girl—duty of care in first post:
I have always assummed I would work. Infectious disease is kind of normal, and hospitals implement isolation which usually works. However, I’ve seen nurses get TB and meningitis, they got sick but they didn’t die. I sometimes wonder about the hospital officials in Toronto who made nurses take off their masks too early and this stupidity killed HCW’s. My gut says they should be fired, if they’re still working it tells HCW’s their lives have no value in that hospital. I would hope my family would sue people like that through every court in the land keeping them stressed out and uneasy. I’m not sure how I will react to my co-workers and friends dying like Barry reported. If the docs show up for only 5 minutes a day at the bedside, I think I will know what to do.
I believed the hospital would plan on having adequate supplies because we’ve had plenty of warning. Unfortunately, not every hospital has changed its practice. Therefore, as long as the supplies that protect me are avialable I work. As long as my shifts remain manageable I will work, but this does depend on co-workers of like mind. I will not work past sixteen hours and I will insist on relief. If I don’t get it then, I won’t be back when I am relieved. I’m not going to push myself into a life threatning accident, or crippling back injury, or medication error, because the hospital hasn’t planned. Older nurses have this “duty of care” tatooed on their soul. I care, but I don’t think I have to die to prove it.
Last year during the hurricane planning nurses from the COM (College of Medicine) refused to come in and staff during the emergency. (This means harbor in place in the hospital until we know where the hurricane will strike). Surgical nurses, except those on call did the same as did the nurses who do anesthesia. Well, add them up and they could staff an entire floor in a pandemic emergency, but somehow they’ve managed to exempt themselves from emergency duty. The other nurses are aware and bitter about this now, I expect this type of complaint will erupt if a big time emergency occurs.
I’m afraid in the event of an infectious disease emergency it’s either all hands on deck or the ship goes aground. If retired nurses are expected to serve, so should all the others in “niches” spread out in various services in hospitals. I popped a blister with these comments but I’m only writing about what the bedside nurses talk about while we’re working, it isn’t a secret. Most of my co-workers don’t believe in AF.
http://tinyurl.com/mw5cu Study of ICU admissions for community-acquired pneumonia (CAP). 172 adult ICUs across England, Wales and Northern Ireland, 1995 to 2004.
128% increase in admissions for CAP from 12.8 per unit to 29.2 per unit, compared to only a 24% rise in total ICU admissions. ICU mortality was 34.9%, ultimate hospital mortality 49.4%. 46.3% mortality in those admitted to the ICU within 2 days of hospital admission, 50.4% in those admitted at 2 to 7 days, 57.6% in those admitted after 7 days following hospital admission.
Arizona Department of Health Services bulletin, Sept/Oct 2005
“Viral pathogens can cause community-acquired pneumonia and are frequent in mild cases not requiring hospitalization. The principal causes are Influenza A and B, Respiratory syncytial virus (RSV), Parainfluenza virus and Adenovirus…Given the diversity of causes of community-acquired pneumonia it is not necessary or desirable to order diagnostic tests for each possible microorganism.
http://www.jabfm.org/cgi/content/full/17/6/466
Human metapneumovirus (HMPV) is the cause of an important proportion of acute upper and lower respiratory tract infections in all age groups. HPMV overlaps with SARS in signs and symptoms. A report says that 40% of 48 patients admitted to a Hong Kong hospital with suspected SARS were infected with HMPV alone, 12% had HMPV plus SARS, and 10% had SARS alone. A similar finding has been reported from Toronto. A 40 year-old man who met WHO’s criteria for probable SARS was discovered to have died of HMPV pneumonitis on postmortem.
Volumes of new and current studies internationally, on HMPV. Is this a higher potential for pandemic?
I have no idea why it looks the way it does. Sorry for the ineptitude with formatting.
I got rid of the double brackets with ~glo in them.
Is this how it’s supposed to look? Did you have other links you wanted to post?
Event type Epidemic Date / time 19/07/2006 - 05:42:15 (Military Time, UTC) Country El Salvador Area - County / State - City San Salvador
Salvadoran health authorities decreed a yellow alert Tuesday due to a possible new dengue outbreak, and confirmed 289 cases of infection have been reported so far. The Health Ministry said it is following the evolution of the disease, and the 227 cases reported last week, now up to 289 in the last seven days, brought about the decision to decree a yellow alert to counteract a possible epidemic, in a disease that in its hemorrhagic phase can be fatal. Local authorities in various zones have warned of the lack of governmental concern. However, according to released information, the Executive has begun implementing measures to confront the spread of the disease. The Health Ministry has called on the population to go to the hospitals immediately in case of any suspected infection, including high fever, spots on the skin or flu symptoms.
Leo7,
I know what you mean. I also plan to work until I feel it is ethically, morally, mentally and physically unsafe for me to do so. The problem with our ideal scenario of knowing when to stay home, is that we will be slaving away and then TPTB will decide to quarantine the facility. Or you are the “only one we could contact” or “no one else will come in” and we will be stuck there for the duration. Been there, done that.
I’ll tell you something else that is really bugging me, and it is almost impossible to discuss. And that is the situation regarding the medical personnel being arrested for euthanasia in New Orleans. <begin rant>
You and I have both seen the horrors of many end-of-life situations. And we have seen what the technology, medications, and experiments of modern medicine can do to prolong these situations. That is why the majority of all our healthcare costs usually occur within the last six weeks of life. What a travesty in most cases.
I try to imagine what those healthcare workers saw, had to do, had to cope with. I try to imagine the suffering of the patients. The unbearable heat(to 100 degrees). The filth. The lack of electricity, clean water, food. The smells. Flood waters below with mold growing everywhere. Dead bodies being stored without refrigeration.
I can easily envision the same scenario in a prolonged panflu. We keep hospital environments as clean as possible. Imagine no way to clean. No place to put garbage. No way to clean bedding, feces, urine, blood, vomit, pulmonary secretions, purulent wound drainage. Now, imagine the smell and the pathogens. Imagine trying to do all of this without supplies to protect yourself or the patients. Patient conditions will deteriorate. Infections will abound. Misery will be the norm. Sedation and pain control would be a gift to minimize the suffering.
Anyone who suffers from respiratory symptoms knows how the heat affects them. Anyone with cardiac symptoms knows likewise. Most of the patients left in these hospitals in Katrina were the sickest of the sick. I’ve been in the situation. You transfer or discharge every possible patient out of a facility that may experience problems, those who are left are those impossible to evacuate (too unstable).
The patients and staff had to be exhausted. Those on ventilators would only live by the staff manually ventilating them 24 hours a day until rescued. (Average 20 breaths/min x 24 hrs = approx. 30,000 squeezes on the Ambu bag PER DAY) That means one on one staffing. And anyone in a hospital knows how impossible that is when you are already minimally staffed. So, do you keep one nurse/RT manually ventilating one critical patient (with little chance of surviving), unable to stop for anything, or do you let that patient go, and provide care for others who may survive? It’s called triage. Someone has to make these decisions. And it ain’t gonna be by an ethics committee in an air-conditioned meeting room. It will be by those at the bedside. In THEIR unique situation.
In Katrina or a panflu without electricity (even back up generator power fails) the majority of all patients in an intensive care environment will be on ventilators! Where in the world could we possibly find the staff? I have had to enlist FAMILY members to help us Ambu (ventilate) patients in the midst of a hurricane where the emergency generator power had also been wiped out by a tornado. Family members will not be present in hospitals in a panflu.
I do not know the specifics in this Katrina situation. And there will be a lot of politics involved. A lot of rhetoric. But I hope and pray that in any prosecutorial fervor to convict, they see the whole picture. Patients in extremis (high heat, dehydration + their underlying critical condition) will be more susceptible to sedation. If these practitioners were not being cavalier with patient lives, then every benefit of the doubt must be given to them. WE WERE NOT THERE. IMHO, a negative decision in this matter, will impact many provider’s decisions to work under similar conditions. And a panflu will be one of them.
I say to TPTB, “Tread lightly” in this case. The majority of healthcare workers are dedicated providers. Usually to a fault. With a strong sense of righteousness/justice. Unless there is glaring evidence of intent to murder just because they could (surely a hurricane/flood/disaster scenario constitutes mitigating circumstances), these providers should be given the benefit of the doubt. I know a negative outcome for them will impact my decision to work during a pandemic.
Euthanasia is no provider’s goal, but deciding who has the best odds of surviving, and who therefore would benefit most from limited resources will result in some being allowed to die (passive euthanasia?). Hopefully with sedation (does that cross the line into active euthanasia?). Not in my mind. I want that for myself. <internal rant continues>
EXCELLENT article on Duty of Care, FL Girl.
nsthesia – at 11:36 I liked it also.
And, as far as the New Orleans HCW rant. I cannot imagine ending a life purposely. Nor, do I condone allowing a patient to remain in pain because a nurse is afraid to give MSO4.
I try to support staff who feel it is too difficult to give enough morphine to keep a patient out of pain. Usually, I find it is best to call the MD for Fentenil patches (or something like a PCA).
But, I will not judge the actions of another in this situation.
Somewhere, I have an article / study about the ethics of triage,,, I will have to look for it. You would like it.
Leo7,
I plan on working, also. It is my understanding that the State / Federal government will have PPE, portable vents, antivirals…. But certainly not enough. Hospitals will not have near enough if the situation is worse than the 30% attack rate & 2% CFR they are planning for. If it is worse, then I am not sure what the options would be.
The County is planning for alternative treatment sites that can be set up in stages if it would be more than expected (probably the wrong word). I do know that physicians and nurses would be asked to work. Public Health nurses & MD’s would definitely be working these sites. Triage would occur at the hospital and buses would take the most ill to these other locations.
I know the State of Florida has always asked nurses if they would be willing to work in a disaster. So they have the foundation on which to build.
A pandemic that is worse than expected will likely be much more than the resources that is available. At that point, I am sure there would be a cascade of things that would be occurring. In any event, we can only do the best we can.
Volume 12, Number 9–September 2006 Synopsis
Control of Avian Influenza in Poultry Ilaria Capua* and Stefano Marangon*
Avian influenza (AI), which emerged from the animal reservoir, represents one of the greatest recent concerns for public health. Compared with the number reported for the past 40 years, the number of outbreaks of AI in poultry has increased sharply during the past 5 years. The number of birds involved in AI outbreaks has increased 100-fold, from 23 million from 1959 through 1998 to >200 million from 1999 through 2005 (1). Since the late 1990s, AI infections have assumed a completely different profile in the veterinary and medical scientific communities. Some recent outbreaks have been minor, but other epidemics, such as the Italian 1999–2000, the Dutch 2003, the Canadian 2004, and the ongoing Eurasian, have been more serious. They have led to devastating consequences for the poultry industry, negative repercussions on public opinion, and, in some instances, created major human health issues, including the risk of generating a new pandemic virus for humans through an avian-human link.
<snip>
HPAI is a lethal infection in certain domestic birds (e.g., chickens and turkeys) and has a variable clinical effect (may or may not cause clinical signs and death) in domestic waterfowl and wild birds. The potential role of wild birds and waterfowl as reservoirs of infection by HPAI strains has been described for only the Asian HPAI virus H5N1. The ecologic and epidemiologic implications of this unprecedented situation are not predictable.
(This next paragraph is interesting).
On the contrary, viruses that belong to all subtypes (H1–H16) that lack the multibasic cleavage site are perpetuated in nature in wild bird populations. Feral birds, particularly waterfowl, are the natural hosts for these viruses and are therefore considered an ever-present source of viruses. Since their introduction into domestic bird populations, these viruses have caused low-pathogenicity avian influenza (LPAI), a localized infection that results in mild disease, primarily respiratory disease, depression, and egg-production problems. Theories suggest that HPAI viruses emerge from H5 and H7 LPAI progenitors by mutation or recombination (2,3), although >1 mechanism is likely. This theory is supported by findings from phylogenetic studies of H7 subtype viruses, which indicate that HPAI viruses do not constitute a separate phylogenetic lineage or lineages but appear to arise from nonpathogenic strains (4,5); this indication is supported by the in vitro selection of mutants virulent for chickens from an avirulent H7 virus (6).
<snip>
Prophylactic vaccination for viruses of the H5 and H7 subtypes is a completely innovative concept, primarily because only recently have cost-effective situations been identified. Prophylactic vaccination should generate a level of protective immunity in the target population; the immune response may be boosted if a field virus is introduced. Prophylactic vaccination should increase the resistance of birds and, in the case of virus introduction, reduce levels of viral shedding, provided the same levels of biosecurity are maintained. It should be perceived as a tool to maximize biosecurity measures when risk for exposure is high. Ideally, it should prevent the index case. Alternatively, it should reduce the number of secondary outbreaks, thus minimizing the negative effects on animal welfare and potential economic losses in areas where the density of the poultry population would otherwise result in uncontrollable spread without preemptive culling.
<snip>
Volume 12, Number 8–August 2006
Dispatch
Avian Influenza among Waterfowl Hunters and Wildlife Professionals
James S. Gill, Richard Webby, Mary J.R. Gilchrist, and Gregory C. Gray
We report serologic evidence of avian influenza infection in 1 duck hunter and 2 wildlife professionals with extensive histories of wild waterfowl and game bird exposure. Two laboratory methods showed evidence of past infection with influenza A/H11N9, a less common virus strain in wild ducks, in these 3 persons.
Wild ducks, geese, and shorebirds are the natural reservoir for influenza A virus (1); all 16 hemagglutinin (H) and 9 neuraminidase (N) subtypes are found in these wild birds (1,2). Recently, the rapid spread of influenza A/H5N1 virus to new geographic regions, possibly by migrating waterfowl, has caused concern among public health officials who fear an influenza pandemic. Until now, serologic studies of the transmission of subtype H5N1 and other highly pathogenic strains of avian influenza have focused on humans who have contact with infected domestic poultry (3,4). In this cross-sectional seroprevalence study, we provide evidence of past influenza A/H11 infection in persons who were routinely, heavily exposed to wild ducks and geese through recreational activities (duck hunting) or through their employment (bird banding). To our knowledge, this study is the first to show direct transmission of influenza A viruses from wild birds to humans.
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Volume 12, Number 8–August 2006
Letter
Qinghai-like H5N1 from Domestic Cats, Northern Iraq
Samuel L. Yingst, Magdi D. Saad, and Stephen A. Felt
To the Editor:
Natural infection of several cat species with highly pathogenic avian influenza (HPAI) H5N1 viruses in Thailand (1–4) and experimental infection of domestic cats with similar viruses have been reported (5,6). Thus, literature describing HPAI H5N1 infection of cats is limited to descriptions of infections with a subset of clade I viruses. HPAI H5N1 viruses, highly similar to viruses isolated from Qinghai Lake in western People’s Republic of China in spring 2005, are now rapidly disseminating throughout Eurasia and Africa. To our knowledge, this is the first report of a Qinghai-like virus detected in domestic cats. This finding is noteworthy because the host range of influenza viruses is determined by the antigenic characteristics of the hemagglutinin and neuraminidase molecules; clade II viruses are antigenically distinct from clade I viruses, and Qinghai-like viruses are genetically distinct from other clade II viruses.
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(The rest is a very interesting read)
Volume 12, Number 8–August 2006 Book Review
Evolution of Microbial Pathogens
H. Steven Seifert and Victor J. DiRita, editors
This book is one of the first to provide an up-to-date view on a fundamental issue in medical microbiology research: how the accumulated genetic and genomic information is contributing to our understanding of virulence factors and the evolution of virulence in microbial pathogens. The editors should be commended for assembling 35 outstanding contributors, who specialize in various areas of microbial pathogenesis and evolution. The 14 chapters are grouped into 3 broad sections: general concepts in microbial evolution, environment and the evolution of microbial pathogens, and the evolution of selected pathogenic species and mechanisms. At the beginning of each section, a concise overview of individual chapters integrates the content of the chapters into the section.
In the first section, the 5 chapters introduce the basic processes affecting microbial evolution, from the individual molecular level to the genomic, cellular, and population levels. Well-known concepts such as horizontal (lateral) gene transfer, the relationship between virulence and transmission, and pathogenicity islands are discussed extensively. Of special note are 2 chapters that are often missing in traditional medical microbiology books: 1 describes how long-term experimental evolutionary studies in the laboratory can contribute to our understanding of microbial pathogen evolution in the environment and clinics, and the other describes how gene inactivation and gene loss can be creative forces during the evolution of many microorganisms, especially obligate intracellular pathogens.
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Lassa fever in Germany
The Belgian Federal Public Service for Health, Food Chain Safety and Environment is asking passengers of 2 SN Brussels Airline flights to contact the UZ Antwerp hospital or the Robert Koch institute in Berlin. The reason is a case of Lassa fever in Germany.
The patient from Sierra Leona landed on July 11 in Brussels with SN Brussels Airlines flight SN207 coming from Freetown. The patient then travelled to Frankfurt with SN Brussels Airlines flight 2607.
More info (in Dutch): http://tinyurl.com/mxef2
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