Friday, July 7, 2017

Damming river decreases snail linked disease in China

Schistosomiasis affects over 200 million people worldwide, but you have probably never heard of it.

One reason might be because it makes people weak, but doesn't kill a lot of people quickly in a dramatic fasion.

from SciDaily:

After they built the three Gorges dam in China, the number of snails decreased, as did the rate of snail related schistosomiasis.


Following the opening of the dam, they found, the volume of annual runoff into Dongting Lake declined by 20.85% and the sediment volume discharged into the lake declined by 73.9%. In turn, the mean density of living snails decreased by 94.35% and human rates of schistosomiasis decreased from 3.38% in 2003 to 0.44% in 2015, a reduction of 86.98%. The researchers hypothesize that low water levels in the summer and high levels in the winter led the lake to become an unsuitable environment for snails.

Rice growing in paddies requires a lot of contact with muddy water, so did people catch the disease from planting rice in the mud, or because they washed in the river water? One is curious.

this article suggests that growing rice in paddies in Uganda (and fishing with baskets) has increased the intestinal type of parasite. article is from 1994

In Eastern Uganda, paddy-rice growing, which has only become popular in recent years, seems to be associated with the emergence of schistosomiasis mansoni as a new problem in public health. 

the article suggests the farmers should wear boots, which gave me an LOL moment: the boots would sink into the thick mud. That is why we use handtractors or waterbuffalo instead of regular tractors in our rice fields.

this is a slightly different parasite than what we saw in Afro, but it makes me wonder if a similar drop was seen after other dams were built..

1975 article on the Aswan dam (Egypt).


An increase in the prevalence of schistomiasis in Egypt, as a result of the Aswan High Dam, has for long time been predicted because of reclamation of land and conversion of annual flooding (basin irrigation) into perennial irrigation in Upper Egypt.
Two aspects, neglected in the predictions, have been investigated in the present study, and these are: the ecological changes, relevant to the transmission of the disease, in the Nile itself, and those in irrigation canals and drains in areas which had been under perennial irrigation before the constriction of the dam.
The findings indicate that the Nile, at least in the Delta, has become a favorite habitat for breeding of the snail hosts of both urinary and intestinal schistosomiasis, a center for human activities and evidently for transmission, and that irrigation canals and drains now harbor throughout the year undisturbed and stable populations of these snail hosts.
This has resulted from the elimination in these canals, of the so-called 'winter closure', because it is no more needed. Before the dam the closure was enforced for about 40 days, during which the canals were closed and dried up, and the silt deposited on their beds during the Nile flood dredged out together with the snails and aquatic weeds.

translation: The irrigation canals no longer dry up so there are more snails.

here is a 1979 Lancet reference that compared the population data with data from 1935 and found the urinary parasite decreased but the intestinal form (that can affect the liver) increased quite a bit.

The prevalence of Schistosoma mansoni infection had increased from 3.2% to 73%, whereas S. haematobium infection, which had been very common in 1935 (74%), had almost disappeared (2.2%).

So what about other areas of Africa? we had quite a few small irrigation dams in Zimbabwe (the veldt is dry and with irrigation you can grow two crops a year).

But  ppeople tended to get the urinary type infection from swimming or bathing or washing things in the rivers so changes could also be from digging wells to supply water..

Here is a study in Senagal, Zambia and Mali (sub saharan Africa).

Recent ecological changes caused by the construction of dams at Diama and Mananatali on the Senegal River, such as reduction in salinity, more stable water flow, creation of irrigation canals and development and extension of rice culture, have contributed towards the occurrence of new outbreaks of both intestinal and urinary schistosomiasis in the Senegal River Basin
 In Mali, the four main areas of high prevalence of S. haematobium are Office du Niger (irrigation areas), Bandiagara (small dams), Selingu√© (dam areas) and Baguineda (irrigation areas). Apart from the Office du Niger, S. mansoni infections are rare.
again, one wonders if the infection is caught during planting/weeding in rice paddies (or in mud) or just from bathing or contact with the water from the canals.

The entire article is not available.

finally, the Uganda article notes that the rice growing was a new project.

In more recent years, China (and Saudi) are buying up land in Africa for agriculture. Will this include rice growing and increase intestinal schisosomiasis?

related article: Chinese returnees are bringing back the intestinal and urinary forms to their native country.

heh. the article blames climate change.

but it does show that globalization can spread diseases that are "below the fold" and pretty well ignored by the world.

nor is this a new problem:
here is an article about the British soldiers getting infected during the Boer war and the Yanks getting infeccted in the Philippines during World War II.

prevention was the key:


3. * * *. The following precautions will be observed: (a) All water used by troops will be obtained from approved water points * * *. This is meant to include water used for drinking, bathing, laundry, and washing of vehicles or floors. (b) Wading, bathing, and washing of clothing by troops in any fresh water river, swamp, pond, or rice field is prohibited * * *.
a report on the problem in the Philippines: and it is worse in the southern regions.

Schistosomiasis japonica has a long history in the Philippines. In 1975, 24 endemic provinces were identified in the northern, central, and southern islands of the Philippines. More than five million people were at risk, with approximately one million infected. In 2003, new foci of infection were found in two provinces in the north and central areas. For the past 30 years, human mass drug administration (MDA), utilizing the drug praziquantel, has been the mainstay of control in the country. Recent studies have shown that the schistosomiasis prevalence ranges from 1% to 50% within different endemic zones. Severe end-organ morbidity is still present in many endemic areas, particularly in remote villages with poor treatment coverage. Moreover, subtle morbidities such as growth retardation, malnutrition, anemia, and poor cognitive function in infected children persist.

There is now strong evidence that large mammals (e.g. water buffaloes, cattle) contribute significantly to disease transmission, complicating control efforts. Given the zoonotic nature of schistosomiasis in the Philippines, it is evident that the incidence, prevalence, and morbidity of the disease will not be controlled by MDA alone. There is a need for innovative cost-effective strategies to control schistosomiasis in the long term.

so in the Asian parasite, water buffalo are part of the problem...discussion here.

hmm... wonder if anyone has done a study comparing areas tat use waterbuffalo vs handplows.

JAMA: Racism in medicine?

Poverty kills... or maybe racism kills. JAMA explains why black babies have a higher death rate but notes it is going down.

A lot of the deaths are related to maternal complications or prematurity.

 No comparisons of black children with immigrants (including immigrants from Africa or the West Indies)  or Hispanics, so we don't know if it is racism per se, or poverty, or the barriers to access medical care.

and if it is an access problem, we don't know if it is urban (where long lines in huge clinics where you see the doc of the day discourage folks) or if it is rural (where no docs at all).

Yes there is racism in medicine: I saw a lot when I worked for the IHS.

There are also programs to recruit docs for inner city and rural "underserved areas"... alas like the IHS often it is short term stuff, and the worst one was where they subsidized you for two years then you were on your own (and left with huge numbers of patients who didn't or couldn't pay their bills, or waiting for months to get paid a pittance for Medicaid, provided they didn't turn you down for not dotting your "i's" or crossing your "t's" correctly... hmm.. wonder if Obamacare improved this).


The dirty little secret behind high childhood mortality in the black community is Sickle cell disease, which if it hit cute blond kids would have TV marathons raising money for a cure.

However, Sickle cell disease usually doesn't kick in for a couple months after birth (when the fetal Hemoglobin is replaced with adult hemoglobin).

But I wonder about things like high blood pressure complicating the mix.

Thursday, July 6, 2017

Heartburn medicine hysteria: Garbage in garbage out again.

Awhile back I linked to a study why GP's and other ordinary docs don't follow "expert" advice, and although I am still trying to find the original article, this study that is in all the newspapers is an example why.
Heartburn medicine causes a 25 percent higher death rate, cries the headlines.

Uh, what from? And what is the actual numbers you are talking about?

from lots of different diseases, a fact that suggests that maybe it's not the medication:

roton pump inhibitors or PPIs, have been tied to a wide range of side effects including fractures, dementia, heart disease, pneumonia and kidney disease, the study's senior author Dr. Ziyad Al-Aly of Washington University School of Medicine in St. Louis told Reuters Health in a telephone interview.

so they compared groups of people with severe heartburn with those who don't have heartburn.

 They also compared PPI users and non-users within a group of nearly 3.3 million people, and PPI versus no PPI and no H2 blockers among about 2.9 million people.
ah, but what causes heartburn?

People who smoke (more heart attacks).

People who take NSAIS like motrin or advil (more fractures from falls in arthritic patients)

People who drink (more heart attacks, more falls with fractures)

People with Gastroesophogeal reflux (who have an increase rate of pneumonia from aspiration, and who tend to be obese and often diabetic or elderly)

and don't forget that many diabetics and pre diabetics are obese and have reflux

and then there is the problem of "heartburn": Sometimes "heartburn" is not from acid reflux, but angina, i.e. a symptom of heart disease.

the dirty little secret is that this relieves symptoms a lot better than earlier medicines like H2blockers or antacids.

and as I said before: one reason that we family docs don't always obey the elite studies is that we deal with real patients.

Here is the elite answer to not using the medicine:

When a person has heartburn or reflux, he added, possible root causes like obesity, poor diet or smoking should be addressed first. "Any intake or use of PPIs should be under the watchful and vigilant eye of a physician, for the smallest dose that's effective and the shortest period of time," he said.
right.

As if we didn't already try these things already. But trying to get people to do these things in the real world is hard

And if you think people have nothing better to do than see their doctors all the time, you are wrong. Believe me, make these drugs hard to get and you will have  grannies buying and selling them on the street to make money, the way our elderly arthritic patients used to do with their tylenol 3's.

can you say "garbage in/garbage out" Children?

I'm not saying that this shouldn't be a "headsup" to oversue of the medicine, but you know that chronic reflux does have it's own side effects aside from pain:


Complications may include: Worsening of asthma A change in the lining of the esophagus that can increase the risk of cancer (Barrett esophagus) Bronchospasm (irritation and spasm of the airways due to acid) Chronic cough or hoarseness Dental problems Ulcer in the esophagus Stricture (a narrowing of the esophagus due to scarring)

finally, patients like the drug because it means they can eat stuff they usually had to avoid (spicy foods).
In my case I mainly take the medicine when I use NSAIDs for my aches and pains (osteoarthritis).

Now, since NSAIDs also affect the kidneys and heart by fluid retention etc should I stop using them too? And stop exercizing, and fall down a lot more due to stiffness?

Medicines all have side effects. Use them wisely but don't panic over scare articles.

---cross posted from my other blog.

Wednesday, July 5, 2017

There are no good choices

the idea that one needs to make decisions based on quality of life is a slippery slope that quickly degenerates into seeing anyone who is imperfect as "life unworthy of life", to use the Nazi terminology.

I haven't been following the story of an infant who the doctors and the imperial courts have decided should die, but GetReligion (a blog that examines the journalistic handling of religious issues) has a summary of the dangerous legal precdent behind the story: they quote from the nytimes story:


Judges in the case have acknowledged that the case highlights differences in law and medicine – and an American willingness to try anything, however unlikely the possibility of success – but have held that prolonging the infant’s life would be inhumane and unreasonable.
it's not the money (the parents have raised the money for treatment).

it's not the ethics or religious reason (under Catholic ethics, removing extraordinary treatment is optional, nor is it necessary to use treatment that only will prolong dying, but it also means the patient or his family have the ethical option to do everything possible for the child).

This is not about ethics: It's about who decides your life is useless so you are better off dead. It's about the docs deciding the kid's quality of life is not good enough for them, so they are removing treatment to end the life.

So the courts sided with the doctors and (unlike other "futile care" cases in the US) have denied the parents the right to find an alternative place to care for the child, either in another hospital or even letting them take him home to be cared for so he can die in a loving environment...

But is the case "hopeless"? For in this case, they are denying permission to take the child to the USA where there is a possible treatment that will help their child.

Arturito has a similar mitochondrial depletion syndrome to Charlie and was the first person in the United States to receive the experimental and pioneering nucleoside therapy. It’s the same therapy Charlie’s parents, Connie Yates and Chris Gard, are fighting for their son to receive. Yesterday, a High Court judge agreed with doctors at Great Ormond St Hospital that Charlie should not have the treatment and should be allowed to “die with dignity
Ah yes: Dignity at all costs, never mind the alternatives are available.

This reminds one of the Terri Schiavo case, where the parents were not allowed to take her home and care for her there, because in both cases the decision is that the person's quality of life is bad, so they are better off dead.

From GR:


Thus, government officials and doctors are defending tiny Charlie's right to choose death over suffering through further medical treatments? Did I read that right? That appears to be the bottom line, in mainstream news reports about the case.
Now, if journalists are open to digging deeper into the religious elements of this case, I would recommend them reading a First Things essay by conservative Wesley J. Smith, author of "Culture of Death: The Age of 'Do Harm' Medicine."


wikipedia page 

Augusto Odone, call your office.

Monday, July 3, 2017

Bubonic plague in the Bronze age?

mp3

--------

BBC LINK (2015...guess I missed it back then).

Nature article here. also 2015.



I was aware that the Justinian plague was P.Pestis but not that it went this far back.

On the other hand, the plague that destroyed the Hittites (brought back with Egyptian POW's) might have been Bubonic plague, so did it have anything to do with the collapse of the Bronze age?

And of course, all those "hemorrhoids" or "boils" in the Philistines when they stole the Arc of the covenant (in the iron age, a couple hundred years later) does sound like the bubos of the plague.

from nature:

But the analysis revealed that plague might have been less transmissible in the early Bronze Age. The six oldest Bronze Age strains lacked a gene called ymt that helps Y. pestis to colonize the guts of fleas, which serve as an important intermediary. In outbreaks of bubonic plague, infected fleas (often travelling on rodents) transmit the bacteria to humans living nearby. Without fleas as a go-between, Y. pestis spreads much less efficiently through blood (where it is known as septicaemic plague) or saliva droplets (pneumonic plague). An early Iron Age skeleton from Armenia dated to around 1000 bcwas infected with Y. pestis that harboured ymt as well as another mutation linked to flea-aided transmission.
Wyndham Lathem, a microbiologist at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois, says that in the absence of ymt, Bronze Age plague victims would have probably contracted pneumonic plague, as opposed to the bubonic form. All the Bronze Age strains also contained another virulence gene, pla, which Lathem's team has shown is important in infecting the lung6.
Plague may have been less transmissible without fleas, but it would have been no less deadly. More than 90% of untreated cases of pneumonic plague are fatal.
credit: Nature
but since pulmonic plague is rapidly fatal, one has to wonder how it spread (discussed in the podcast).


Ancient Egypt plauge article from nat geo.


but how ancient? This grave with plague victims only goes back to 300 BC.


an article on the ten diseases plaguing the ancient world.

------------
update: Good article here discusses the genes for transmission.

And this is new to me: Gastroenteritis from eating meat contaminated by the Pestis germ.





Sunday, July 2, 2017

How to control a parasite

Elephantiasis is a disease where the filaria worm blocks the lymph node and you end up with a huge leg (and/or scrotum). WIKIPEDIA ARTICLE.

This Science daily article discusses how Cameroon is trying to control this disabling disease: by giving a yearly dose of the anti parasite drug.

the infection rate is now so low that the country is considering stopping the program.

another mosquito based disease.

we used to see people with itchy nodules and would biopsy the nodules to check for this, although there is also a blood test.

I can't remember the name of the medicine used to treat the disease back then, but this article discusses the present day treatment.



You can also kill the parasite by using tetracycline, which kills a bacteria that the worm needs to live.

however, surgery is required for the damage.


Wednesday, June 28, 2017

Opiods not helped by reversal medicines?

UKMail article says


  • Police have found two Narcan-resistant strains of the opioid fentanyl in Georgia
  • Acrylfentanyl, linked to deaths in Illinois, can kill with just 0.00015 grams
  • Tetrahydrofureon, so new it is not on a banned drugs list, is lethal to touch


  • Read more: http://www.dailymail.co.uk/health/article-4647616/Georgia-police-2-Narcan-resistant-strains-fentanyl.html#ixzz4lLcYEHGf Follow us: @MailOnline on Twitter | DailyMail on Facebook

    Wednesday, June 21, 2017

    the new health care act

    one reason I went into the Indian Health Service was that I objected to the price controls in the HMO's and the fact they only treated their own people, i.e. the uninsured weren't seen.

     Of course, we did have rationing in the IHS too, but actually it wasn't much worse (and in many ways a lot better than working with the uninsured and under insured in my private rural practice.

    So two items for later reading

    Will th new version deny medical care to the most vulnerable and allow insurance companies to push suicide as a side effect of their cuts?

    NotDeadYet, a disability rights group, discusses the problem:


    The American Health Care Act (AHCA) is dangerous for people with disabilities. If passed, among other things, it will most likely eliminate affordable insurance coverage for people with pre-existing conditions, cut $834 billion from Medicaid over ten years (most people with disabilities, including seniors, rely on Medicaid for personal care, long-term care services and supports and durable medical equipment), and make drastic cuts in primary healthcare programs and services that low income people rely on. For people who live in states where assisted suicide is legal, this will be a deadly combination. Insurance companies will be more emboldened to deny people with life-threatening conditions the medications they need to save or prolong their lives, offering them, instead, the “option” of the suicide prescription. The lives of people with disabilities are already devalued, and doctors are likely to either intentionally or unintentionally influence, recommend or coerce their patients into assisted suicide, citing the financial burden they will be on their families. With services such as mental health on the chopping block in AHCA, newly disabled individuals, seniors or terminally ill people will have less access to these services, putting them at greater risk to succumb to coercion by unscrupulous family members, heirs, or caregivers ....

    read the whole thing.

    And then read Dilbert's take on the matter: No one understands the old bill except that it guarantees them health care, so replacing it will cause it to be unpopular.

    Family docs don't always follow elite "studies"

    I think that is that this article claims.LINK

    What they ignore: a lot of these "Evidence" studies ignore real life, and many are biase.

    often they are "Garbage in Garbage out".

    Often they are small numbers. Or a scholarly article that takes a lot of GIGO articles and summarizes them.

    Often the studies are of small numbers of people.

    Often they ignore cost, or hman beehavior For exaple, studies taht show newer medicines that cost a lot more work better, but the patients know their older meds. Or the experts decide taking many pills several times a day give a better result (eg when they stopped all those lovely combinations of medicines for blood pressure, so our patients had to take three pills a day instead of one: They don't like to take pills or forget to take the twice a day pill in the evening).

    And of course, they are assuming we are treating what we say we are. If a person comes in to complain about her husband for a half hour, we list her problem as blood pressure. But of course she isn't having a problem with her pills, so we don't chage them to the newest one. Or don't give any
    pills at all.

    And of cours no one wants to suspect a lot of drug companies bias the "evidence".


    Friday, June 9, 2017

    Legionaire's disease take two

    Longer cdc article on Legionaire's disease in health care facilities.

    Results: A total of 2,809 confirmed Legionnaires’ disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care–associated cases. Among the 21 jurisdictions, 16 (76%) reported 1–21 definite health care–associated cases per jurisdiction. Among definite health care–associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care–associated Legionnaires’ disease.
    Conclusions and Implications for Public Health Practice: Exposure to Legionella from health care facility water systems can result in Legionnaires’ disease. The high case fatality rate of health care–associated Legionnaires’ disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification.

    Legionaire's disease from water birth (city water used)

    Two cases of legionaire's disease in infants who were born after mom had labor in water, aka water birth.

    is it the water supply from the city, or because the water got stagnant in the pipes?

    , it can be reduced by running hot water through the hose for 3 minutes before filling the tub to clear the hose and pipes of stagnant water and sediment. 

    Zika update from CDC

    Long article on Zika in pregnancy at the CDC site

    the good news: Microcephaly is rare.
    The bad news: it is ten percent:


     This report from the territories, with more robust late pregnancy data, suggests a risk for birth defects throughout pregnancy; further study is needed to confirm this finding. The percentage of infants with possible Zika-associated birth defects after infection identified in the first trimester was 8% (95% CI = 5%–12%) in the U.S. territories compared with 15% (95% CI = 8%–26%) in the U.S. states (5); the confidence intervals for these estimates overlap and both are based on relatively small numbers. In addition, for the analysis of the U.S. territories data, a more restrictive definition of confirmed infection, limited to NAT-confirmed infection, was used.

    Sunday, May 28, 2017

    why dn't we give her morphine HAHA

    Awhile back, I wrote about a resident moonlighting at the ER at our rural IHS hospital, who wen asked to check a feeding tube position in an old Lakota Lady with a recent stroke, said "Why not gie her morphine, haha"... 
    and the IHS doc, looking like he was ready to throttle him, said" We don't do things like that around here" and told the nurses he'd drive back later to check the x ray.

    Well, now HPR says the same thing. Oh yes, they use worst case scenerios, but essentially they are saying the same thing. and he has an excuse even though he acknowledges the problem of a doctor meeting someone (often a minority) for the first time making this decision.


    Researchers who interviewed emergency room staff at two Boston hospitals, for instance, found resistance to palliative care. ER doctors questioned how they could handle delicate end-of-life conversations for patients they barely knew. Others argued that the ER, with its "cold, simple rooms" and drunken patients screaming, is not an appropriate place to provide palliative care, which tends to physical, psychological and spiritual needs.
    Ouchi saw some of these challenges during his residency in New York, when he visited the homes of older patients who frequently visited the emergency room. He saw how obstacles like transportation, frailty and poor vision made it difficult for them to leave the house to see a doctor.
    "So what do they do?" Ouchi asks. "They call 911."

    so maybe make evening clinics? House call services?
    then he brings up:

    When older adults are very ill — if they need an IV drip to maintain blood pressure, a ventilator to breathe, or medication to restart the heart — they are most likely to end up in an intensive care unit, where the risk of developing hospital-acquired infections and delirium is increased, 
     then again, why not put them in a regular room?

    As for hospital acquired infections: THAT is a problem that needs to be addressed, not used as an excuse to let people die.

    Bring in the Qaality of life stuff to ration care.


    One such screening tool, dubbed P-CaRES, developed at Brown University in Providence, R.I., gives ER doctors a list of questions. Does the patient have life-limiting conditions such as advanced dementia or sepsis? How often does the patient visit the ER? Would the doctor be surprised if the patient died within 12 months?
    all that stuff about "palliative care doctors" is merely another way to specialize.

    We old time dosc did this all the time, but superspecialization (plus the threat of law suits if we don't overtreat) has made us refer...

    Sunday, April 30, 2017

    Beethoven and Ancient Rome and lead

    There is actually a Wikipedia site on Beethoven's death, that includes his autopsy findings..

    The autopsy revealed a severely cirrhotic and shrunken liver, of which ascites is a common consequence. Scholars disagree over whether Beethoven's liver damage was the result of heavy alcohol consumption, hepatic infection, or both.
    Yup. I've treated lots of these folks. Mainly in heavy drinkers. He also had evidence of a shrunken pancreas, suggesting pancreatitis.

    but at the end of the article they insist he died of lead poisoning.

    In 2010, Dr. Andrew C. Todd, of the Mount Sinai School of Medicine in New York City tested two pieces of Beethoven's skull for lead, and determined that the concentration of lead was no greater than would be expected for a normal man of 56 at that time.[16]
    The leading cause of death still remains lead poisoning however. M. H. Stevens and his team have concluded that high levels of lead deep in the bone sampled from Beethoven's skull suggest repeated exposure over a long period of time rather than limited exposure prior to the time of death. Among other evidence, the finding of shrunken cochlear nerves at his autopsy is consistent with axonal degeneration due to heavy metals such as lead. Chronic low-level lead exposure causes a slowly progressive hearing loss with sensory and autonomic findings, rather than the classic wrist drop due to motor neuropathy from sub-acute poisoning. Beethoven's physicians thought that he had alcohol dependence

    So where did he get lead? Yes, it was used as a medicine, but one overlooked reason for lead is that it was used as a sweetener in cheap wine.
    Wikipedia article here on how this was done.
    They were made by boiling down grape juice or must (freshly squeezed grapes) in large kettles until it had been reduced to two-thirds the original volume, carenum; half the original volume, defrutum; and one-third, sapa. The main culinary use of defrutum was to help preserve and sweeten wine, but it was also added to fruit and meat dishes as a sweetening and souring agent and even given to food animals such as suckling pig and duck to improve the taste of their flesh

    Smithsonian article discusses.


    Lead acetate, also known as sugar of lead, is a salt that (ironically) has a sweet flavor—a fairly unusual quality in poisons, which are more likely to taste bitter, signaling to the taster that they are unsafe for consumption. The ancient Romans used the compound—which they called sapa—to sweeten wine, and the aristocratic segments of the population could toss back as much as two liters a day (about three bottles’ worth, although wine was usually diluted with water). There is debate as to whether the wine alone could have produced the traditional physiological effects of lead poisoning, such as organ failure, infertility and dementia—the little things that help facilitate the fall of an empire. 
    this article discusses lead in Roman times. It was recognized as a poison, since those working with lead tended to get sick.

    The irony of lead pipes is not that they could cause lead poisoning, but that hard water deposited calcium on top of the lead. This means all those stories of lead poison from their pipes might be exaggerated: The lead was covered... except when they cleaned them out..

    deposits of calcium carbonate in pipes and aqueducts protected against corrosion and insulated against the introduction of lead. With no taps to shut off, water flowed continuously and so would not have been in prolonged contact with the metal. Most water brought to Rome by its aqueducts was used, in any event, to supply its public baths.
    but wine was sweetened by boiling it down... in lead vessels. And some used lead pots.

    Like modern folks who have gotten acute lead poisoning from drinking acidic wine in pewter or ceramics with high lead content, the lead could cause problem.  The article gets into discussing lead vs copper vessels, and then calculates the dosage... or not. Long technical discussion there.

    Science magazine discussion of lead poisoning and Rome. Yes, there was lead, but not enough to cause problems.


    The researchers compared the lead isotopes in their sediment samples with those found in preserved Roman piping to create a historical record of lead pollution flowing from the Roman capital. Tap water from ancient Rome likely contained up to 100 times more lead than local spring water, the team reports online today in the Proceedings of the National Academy of Sciences. While the lead contamination was measureable, the team says the levels were unlikely high enough to be harmful, ruling out tap water as a major culprit in Rome's demise.
    so what about the skeletal evidence? 


    As far as I know, the first and only study to actually measure levels of lead in skeletons from Rome is the one that involved my samples from the two cemeteries of Casal Bertone and Castellaccio Europarco (1st-3rd c AD).... 

     What you can see is that there are fairly low levels of lead in the pre-Roman periods in Britain (Neolithic, Bronze Age, Iron Age) and the levels are lower in the post-fall of the Roman Empire (after 5th c AD).
    ... no one in the pre-Roman period is getting poisoned. The Imperial period is pretty special - we've got a person with lead levels over 20 mg/kg, which is 20 times higher than modern recommendations! In fact, this level is two times higher than the level the WHO considers "very severe lead poisoning."
    the problem? Sample bias. It is not known if the sample was evidence of lead poisoning in the entire population.

    water supply contamination continues to be a problem: in 2004, high lead levels were found in some neighborhoods of WashingtonDC.

    find your state here if you want to know if there is a problem.

    we still see kids with lead poisoning from old paint: The peeling paint chips are sweet and eaten by toddlers who place everything in their mouths. Since these paints now are forbidden, such cases are much less common, except in older buildings.

    of course, nowadays one doubts anyone is using lead acetate to sweeten anything.

    But back in 2008, there were a couple dozen acute cases in Germany from smoking marijuana: Some dealers added lead powder to their stash to make it seem heavier than it actually was to make a bigger profit.

    Lead acetate has to make meth:

    Acute lead poisoning is another potential risk for methamphetamine abusers. A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may therefore result in methamphetamine contaminated with lead. There have been documented cases of acute lead poisoning in intravenous methamphetamine abusers.

    But lead as a sweetener is not something used nowadays, because there are a lot of other cheap artificial sweeteners that can be used instead.

    we get reports of fake sweeteners all the time here, but it is usually cyclamate, which is not very toxic.

    However, the real worry is if old fashioned anti freeze is used.

    Luckily for folks, the Austrian wine scandal using this chemical was detected by the Germans quickly.

    Not all such contamination has been found easily, nowever.

    here have been quite a few deaths from Chinese medicines that used Antifreeze to sweeten them.

    NYTimes 2007 article about that scandal

    Agatha Christie, call your office.

    Saturday, April 29, 2017

    Sugar baby

    Freakonomics has a podcast on the evils of sugar.

    KAHN: The next one is something called temporality. In other words, is there association in time between sugar consumption and obesity? That held pretty true from about 1985 to the year 2000. Where obesity levels went up, sugar consumption went up. But thereafter starting in the year 2000, even to today, sugar consumption has declined somewhere around 15 to 20 percent, whereas obesity rates continue to rise. We don’t see that at all with smoking, the analogous situation. Cigarette smoking rises, cancer rises. Cigarette smoking declines, cancer declines.

    Cross posting: Fetal alcohol syndrome.

    Long blog post on my other blog about Fetal alcohol syndrome.

    We saw a lot of this on the reservation when I worked in the IHS.
    many have ADHD and intellectual difficultiies.


    aand young folks now are smoking marijuana instead, as "safe" but the "studies" are out of date: The drug was much less potent 40 years ago when the studies were done, and like alcohol the damage is dose related.

    So studies asking "have you ever" often are nonsense.
    A little wine probably does nothing, but a heavy drinking bout or heavy daily alcohol use is not the same thing. I mean, not all kids had FAS in the good old days when beer and wine were used all the time (because water was dangerous and full of germs, ergo "drink a little wine in your water for your stomach's sake"...( something that tea and coffee drinking put a stop to).

     One puff, or a heavy habit.

    Cross posting: Suicide chic, Yellow jack

    From my other blog: Two articles on suicide chic in a hit TV chick flick series aimed at female teenyboopers..
    lLINK
    LINK2

    and link to a CDC technical article on why they have a yellow fever vaccine shortage.

    essentially only one company makes it, and they had to throw out a lot of vaccine because of technical difficulties. Now they want to manufacture a new version but they have to do extensive testing.

    And I have written in the past about the YF outbreaks on Africa and now in Brazil, that has used up a lot of the world's stock of vaccine even though they give partial doses to some folks.


    Friday, April 21, 2017

    Hashish in medieval Egypt

    when the naive drug pushers were trying to push Massachusetts to legalize marijuana as harmless and non addicting years ago, an Egyptian doc who had worked in the slums of Cairo testified about the severe social problems from the drug's use, and the idea was stopped.

    Nowadays, the Open society (Soros money) is pushing it via the stalking horse of medical marijuana, alas. and those who see the problems won't be allowed to testify on the neighborhoods and Indian reservations destroyed by drug use.

    But none of this is new: Medieval net has an article on hashish use in medieval Egypt.


    While medieval physicians knew about the health benefits of cannabis – it was used as diuretic for instance – they often also warned people about the bad effects of hashish. A 14th-century Egyptian, az-Zarkashi, gives a complete list of all the problems the drug caused:
    It destroys the mind, cuts short the reproductive capacity, produces elephantiasis, passes on leprosy, attracts disease, produces tremulousness, makes the mouth smell foul, dries up the semen, causes the hair of the eyebrows to fall out, burns the blood, causes cavities in the teeth, brings forth the hidden disease, harms the intestines, makes the limbs inactive, causes a shortage of breath, generates strong illusions, diminishes the powers of the soul, reduces modesty, makes the complexion yellow, blackens the teeth, riddles the liver with holes, inflames the stomach, and leaves in its wake a bad odor in the mouth as well as a film and diminished vision in the eye and increased pensiveness in the imagination. It belongs to blameworthy characteristics of hashish that it generates in those who eat it laziness and sluggishness. It turns a lion into a beetle and makes a proud man humble and a healthy man sick. If he eats, he cannot get enough. If he is spoken to, he does not listen. It makes the well-spoken person dumb, and the sound person stupid. It takes away every manly virtue and puts an end to youthful prowess. Furthermore, it destroys the mind, stunts all natural talent, and blunts the sharpness of the mental endowment.
    nothing much has changed.

    Ironically, he problem of intoxication was why the Prophet forbad his followers from using Alcohol (similar to how the Baptists and Methodists, seeing the probem of alcoholism in the poor, insisted on not using alcohol.)


    Wednesday, April 12, 2017

    Sutures

    cross posted from my main blog: Why do shoelaces untie?

    The scientists expected that the knots would come undone slowly. But their slow-motion footage — focused on the shoelaces of a runner on a treadmill — showed that the knots rapidly failed within one or two strides. To figure out why, O’Reilly and his colleagues used an accelerometer on the tongue of a shoe to measure the forces acting on a knot. They found that when walking, the combined impact and acceleration on a shoelace totals a whopping 7 gs — about as much as an Apollo spacecraft on reentry to Earth’s atmosphere.




    this sounds more frivilous than it actually is: Because if an elderly person trips on an untied shoelace, they can break an arm or a hip.

    This is also a problem in surgery: Braided silk usually doesn't untie easily, nor does Chromic catgut. We usually do three or four knots (square knots not grannie knots) and no problem.

    But newer unifilament nylon does tend to untie itself.

    And if it unties before the wound is healed, you end up with the wound falling apart.

    Although I found that nylon skin sutures, even with six or eight knots usually don't start to unravel until the wound swelling goes down and the tension on the knot allows it to unravel.

    but if a person is malnourished (i.e. low protein diet, diabetes, cancer) the wound could take longer than usual to heal.




    when we were in Africa, we used monofilament fish line to sew the skin because the pre packed nylon or silk was too expensive and often poor quality.

    The real problem was the catgut and newer absorb able suture: If the catgut (regular or chromic) was old, it could lead to internal bleeding. Not a big problem for under the skin, but for C Sections it could lead to bleeding or other complications (a uterus that would rupture in a later pregnancy, a dangerous complication). We would usually use the modern versions donated to us by German or American hospitals.

    and no, catgut is not made from cats: It is made from sheep guts, or as Wikipedia explains:

    Catgut suture is made by twisting together strands of purified collagen taken from the serosal or submucosal layer of the small intestine of healthy ruminants (cattlesheepgoats) or from beef tendon.[1] The natural plain thread is precision ground in order to achieve a monofilament character and treated with a glycerol-containing solution
    but it is not used as much nowadays, especially in Europe, because of mad cow disease worries and because there is an alternative.

    Thursday, April 6, 2017

    STD increase in MSM

    the old STD syphillis has increased in MSM...

    CDC report:

    In 2015, the rate of reported primary and secondary syphilis in the United States was 7.5 cases per 100,000 population, nearly four times the previous lowest documented rate of 2.1 in 2000 (1). In 2015, 81.7% of male primary and secondary syphilis cases with information on the sex of the sex partner were among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (1)...
    ...The overall rate of primary and secondary syphilis among MSM was 106.0 times the rate among men who have sex with women only and 167.5 times the rate among women.*

    ironically, most of the increase was in the south:

    Rates of primary and secondary syphilis among MSM varied by U.S. Census region and by state, with the highest rates in the South and West. Four of the five states with the highest primary and secondary syphilis rates among MSM were southern states (Louisiana, Mississippi, North Carolina, and South Carolina) (Table 2). Among states with the 10 highest rates of primary and secondary syphilis in the United States in 2015 (1), five states (Arizona, Louisiana, Mississippi, Nevada, and North Carolina) also ranked among the top 10 states with the highest rates of primary and secondary syphilis among MSM (Table 2).

     meaning they were less likely to be screened and treated? the talk of "secondary" syphillis makes one worry about not being diagnosed early.

    On the other hand, the rates might be a reporting error:


    Second, the denominators used in calculating the rates of primary and secondary syphilis were estimates of the number of MSM in each state, based on the reporting of same-sex households in the American Community Survey; underreporting of same-sex households could result in an underestimation of the MSM population and an overestimation of primary and secondary syphilis rates.
    one also wonders if the rate is local, i.e. in cities. Often due to the stigma, MSM travel to bars away from home and manage to catch STD's but don't tell their local docs (yes, patient privacy... in the good old days we knew this was nonsense so didn't put it into the record, or used code words. Now the Feds want to have everything there, all nice and written out on the computerized files for the Russian/chinese hackers or your ex wife to find it).

    Monday, April 3, 2017

    Bangungot: Sleep death in young men

    The Inquirer article on young men who die in their sleep.

    The identification of young males—aged 25 to 44, presumably healthy, without any known cardiac illness—as at-risk individuals is also consistent with international scientific reports on the Brugada Syndrome. Southeast Asian males seem to have an increased predisposition to it. Similar cases are also seen in Pacific Rim countries and Polynesian populations where Southeast Asians have migrated. 
    a sudden arrhythmia?


    Some medicines like good old quinidine have been shown to be effective in preventing life-threatening arrhythmias, but for those who can afford it, an implantable cardiac defibrillator (ICD), similar to an artificial pacemaker battery, is surgically implanted just beneath the skin layer on the chest. It’s hooked to the heart and gives it a mild “shock” (defibrillate) whenever it goes into a life-threatening heartbeat.

    sigh.

    A young man in his 20's just died of this in our barangy... our cook's son probably died of it also, but he was dizzy and went to the doctors and collapsed. This happened before, and he recovered, but this time it took to long to transfer him so he died. Sigh.  

    this runs in our family also: Lolo's brother and nephew both had sudden cardiac deaths. (His father also died young, but we think it was from TB..)

    Wikipedia article here.

    The cause of sudden death in Brugada syndrome is ventricular fibrillation (VF). The average age of death is 41. According to clinical reports, sudden death in people with Brugada syndrome most often happens during sleep. The episodes of syncope (fainting) and sudden death (aborted or not) are caused by fast polymorphic ventricular tachycardias or ventricular fibrillation. These arrhythmias appear with no warning. 
    There are several syndromes that cause this, and some genetic testing, and an EKG might be a good way to screen.

    But the treatment, an implantable defibrillator, is too expensive for ordinary folks, and alas there is no push to screen for the problem.

    this first came to light in US medical journals when some Cambodian refugee men dropped dead. The anti war folks blamed it on Russian "yellow rain"..., but anyone with Asian relatives would be aware of the syndrome... 

    More HERE. on what drugs to avoid if you have the syndrome.

    HealthMatrix discusses the folk lore behind the syndrome.

    In the English-speaking world, we talk about the Night Hag and similar apparitions (see pp38–40). These terrifying beings are glimpsed in the darkness of nightmare, pressing down on their victims and preventing them from breathing. Their attacks, though scary, are generally harmless, whereas the nightmare demons of the Far East can be lethal. In Japan, this type of death is known as pok-kuri; the Filipinos call it bangungot or batibat; and the Hmong people of Vietnam and Laos call it tsob tsuang. In Thailand, the being to fear is the phi am or ‘widow ghost’ who comes to steal away the souls of young men. Some men defend themselves from phi am by wearing lipstick at night, so that the ghost mistakes them for women and leaves them alone.
    Although he discovered references to the condition in Filipino medical literature as far back as 1917, Dr Aponte could draw no conclusions about the nightmare deaths. The same condition was later documented among refugees from South-East Asia, and in 1981 some 38 victims had been recorded in the US, most of them Hmong. The term Nightmare Death Syndrome was coined, which was later changed to Sudden Unexplained Nocturnal Death (SUND) or Sudden Unexplained Death Syndrome (SUDS) (see FT48:25, 55:15). The immediate cause of death was cardiac arrest. But why had the men’s hearts failed when there was seemingly nothing wrong with them?
    In folklore, a “mare” or “nightmare” is not an awful dream, but rather a supernatural being that crushes a sleeper’s body by sitting on it. Another related term is hag-riding which implies a frightening feeling of being held immobile in bed, often as if by a heavy weight pressing on one’s stomach or chest and it is said that it might be accompanied by the sense of an alien presence, and by visual hallucinations. In folklore, it was thought of as a magical attack, whether it was a demonic incubus, ghost, harmful fairy, or witch depending on culture and time period.


    if you have heard the folk advice not to wake someone up suddenly when they are asleep, this syndrome is the reason.

    Saturday, April 1, 2017

    Yellow fever update

    tw articles from the CDC:

    one is a report about  last year's the epidemic in the Congo 

    and this one is about "adverse effects of the vaccine". in that country:


    during May 25–June 7, 2016, the DRC Ministry of Health administered approximately 240,000 doses of yellow fever vaccine to all persons aged ≥9 months during a mass vaccination campaign in Matadi, ....

    a small number of people were followed and a few problems were found
    Overall, 15 AEFIs were identified by active surveillance among approximately 2,800 patient records reviewed at the two targeted referral hospitals, including eight AEFIs previously reported during the immunization campaign (Table).

    Two AEFIs were classified as serious and 13 as nonserious. The serious AEFIs comprised a spontaneous abortion that occurred after inadvertent administration of yellow vaccine early during an unrecognized pregnancy and a nonspecific gastrointestinal syndrome, both resulting in prolonged hospitalizations. Nonserious AEFIs included cutaneous allergic reactions, itching, fever, and injection site erythema. The incidences were 6.2 per 100,000 vaccine doses administered for all identified AEFIs and 0.8 for serious AEFIs.

    ...
    Previous studies in African settings have found an expected AEFI rate of 8.2 per 100,000 yellow fever vaccine doses administered for all reported AEFIs and 0.4 for any serious AEFI (4).



    there is a worry about the vaccine affecting the growing fetus causing defects butt


    the cdc page on Yellow fever notes

    Yellow fever vaccination has not been known to cause any birth defects when given to pregnant women. Yellow fever vaccine has been given to many pregnant women without any apparent adverse effects on the fetus. However, since yellow fever vaccine is a live virus vaccine, it poses a theoretical risk. While a two week delay between yellow fever vaccination and conception is probably adequate, a one month delay has been advocated as a more conservative approach. If a woman is inadvertently or of necessity vaccinated during pregnancy, she is unlikely to have any problems from the vaccine and her baby is very likely to be born healthy.

    Pubmed has this abstract of a study on the risk of anomalies from the vaccine.

    Seventy-four cases were analyzed, 58 with a completed follow-up. Pregnancies ended in 46 births, five voluntary abortions and seven spontaneous abortions. Three newborns had minor anomalies and two had major defects (ureteral stenosis and triphalangeal hallux). Although the sample is too small to rule out a moderate increased risk of adverse reproductive effect of YFV, it gives no argument for such an effect and should lead to reassure pregnant women who might be inadvertently vaccinated.

    the rate of abnormalities is about the same as baseline.

    Wednesday, March 29, 2017

    Sickle cell cluster in India

    Sickle cell disease is mainly diagnosed in those with African ancestry, from Malaria infested areas (we didn't see many cases in the highlands of Zimbabwe, for example, but we did diagnose cases in the kids of Miners, who came from Mozmbique etc).

    Once in awhile, in the US, you might pick up a case in "white" people, especially from Mediterranean areas (although Thalessemia is much more common).

    The reason is that both these disease give some protection from Malaria

    But AlJ reports that some of the indigenous tribes of India also have a high rate of the disease


    In India, the disease was first detected in 1952 among indigenous tribes in the Nilgiri Hills of south India. That same year, some migrant labourers working in the tea gardens of Assam state were also diagnosed with the hereditary disease. Of Chhattisgarh's 7.5 million strong indigenous tribal population, at least 20 percent, particularly among the Gond tribe, are affected by sickle cell disease, according to Dr Patra.

    Friday, March 17, 2017

    Opiod epidemic: is it from doctors giving pain pills?

    CDC report. of a survey


    A total of 1,294,247 patients met the inclusion criteria, including 33,548 (2.6%) who continued opioid therapy for ≥1 year. Patients who continued opioid therapy for ≥1 year were more likely to be older, female, have a pain diagnosis before opioid initiation, initiated on higher doses of opioids, and publically or self-insured, compared with patients who discontinued opioid use in <365 days 
    so the numbers are high: But the percentage is actually quite low.

    and they don't include the question WHY the medicines were used:

    . Third, information on pain intensity or duration were not available, and the etiology of pain, which might influence the duration of opioid use, was not considered in the analysis. 

    and after a long analysis they note the elephant in the room:

    Finally, prescriptions that were either paid for out-of-pocket or obtained illicitly were not included in the analysis. 

    a lot of "prescription drug abuse" is from stealing medicine, or buying it on the street, but never mind.

    momjones article here 

    Conventional wisdom holds that overprescribing is fueling the epidemic: Someone injures himself, is prescribed painkillers, and quietly develops an addiction. But that's not the whole story: According to federal data, most people start out by taking the painkillers of a friend or family member. The best predictor of prescription opioid abuse is a history of other drug abuse, according to a recent study in Addictive Behaviors. Experimentation typically starts during adolescence or young adulthood.
    and only a small percentage get them from doctors (36%). One wonders if a lot get them from "pill doctors" who give out thousands of them for any reason, but again that is not the question.



    more data here.

    92 percent of people do not abuse drugs of any sort.

    and one wonders about the definition of "misuse". Probably they mean not prescribed by a doctor for that episode:

    Among people aged 12 or older in 2015 who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse of a pain reliever was to relieve physical pain (62.6 percent), which is the reason pain relievers are prescribed (Table B.11). Even if the reason for misuse was to relieve physical pain, use without a prescription of one's own or use at a higher dosage or more often than prescribed still constituted misuse.

    ditto for other drugs: it might not be "abuses" but "self medication".

    As for the hype that the drug companies pushed narcotics for pain: Why, yes.

    Most of the "assisted suicides" by Dr Kavorkian were in patients with uncontrolled pain. Hospice doca and those in pain clinics started using narcotics in contolled amounts because they had fewer side effects than other medicines. (NSAID mainly, which cause GI bleeds, heart and kidney problems).

    If you get rid of the pain, most people can simply be withdrawn from their narcotics slowly. Some like the mild buzz from them and continue, so that is abuse. And others aren't in pain but steal/borrow or take them to get high.

    The 1960's idea of getting high (along with normalizing marijuana to get high) is the precursor for the idea that if you feel unhappy that drugs will make you happy.

    This is a social problem, and the cure is religion.

    But that is another story for another time.

    Yellow fever vaccine (why a few cases of vaccine failed)


    WHO reports almost a thousand cases of the yellow fever, and 30 million given the vaccine to stop the epidemic
    in Angola

    Mass vaccination is the key focus of the response strategy to control the yellow fever outbreak and prevent international spread. As of today, Angola has vaccinated 13 million people, representing 52% of its population against yellow fever, covering 51 municipalities of 11 provinces.
    Commendable progress has been made in tackling this outbreak. However, the next rainy season expected for September usually leads to an increase in the number of mosquitoes that could result in new cases
    there was a race to get enough vaccine: A lot of countries sent their supplies to these countries and drug companies worked furiously to make enough doses to stop the epidemic,.. and right now there are no new cases reported in that area of Africa.


    But a few cases were found in those who reported getting the vaccine.

    CDC analysis of a small group of those diagnosed with yellow fever here.

    Among 2,907 suspected cases of yellow fever, 459 (16%) patients had documentation of receipt of yellow fever vaccine. 
    this is good news: It means most people who got it didn't get the vaccine
     376 (82%) (of the 459) also had documented RT-PCR results, but only 51 (14%) had positive RT-PCR test results
    This means most of those who got the disease after the shot did not get any immune response from the vaccine, and that is why they got sick.
    This happens with any vaccine: ten to 20 percent of people have sluggish immune systems, often due to chronic disease and/or malnutrition.

    but what about those 51 who got the vaccine, got an immune response to it, but got sick anyway?


    Among the 51 patients who received positive RT-PCR test results, symptom onset occurred after vaccination in 32 (63%).

    Among the remaining 19, five were excluded because they had not been vaccinated, eight because their symptoms preceded vaccination, and six because they had no documented vaccination date.

    so maybe they didn't get the vaccine after all, or were already sick with the disease when they got the shot.
    Among the 32 patients who received positive RT-PCR test results after vaccination, 24 (75%) were male, the mean age was 20 years (standard deviation = 12 years), and 13 (41%) died.
    this is the usual death rate.

    why young males? Maybe because they were more likely to be exposed to mosquitos?

    Eighteen (56%) received positive test results for yellow fever viral RNA after postvaccination day 13, and 11 (34%) received positive test results during days 0–13; the sample collection date was missing for three patients. Symptom onset occurred during postvaccination days 0–10 in 17 (53%) patients, and after day 10 in 15 (47%). Distribution of vaccination dates was uniform, implying no clustering by date. Information about location of vaccination was not available to assess clustering by place.

    so most of those who got yellow fever after the vaccine were already infected, or got infected shortly after the shot.

    In some cases, there was no immune response

    In a few, there was an immune response but they got the disease anyway.

    what they are worried about is the 32 they sifted out that could have "caught" yellow fever from the vaccine, or if they already had it.

    DNA testing will show if it is a wild sttrain (i.e. from local epidemic) or if the vaccine virus mutated into full strength. But this has not been done yet and will probably be in a report in the near futuer.

    Live weakened viruses are used for some diseases, and they sometimes mutate back. This is a major problem with Polio, where a half dozen cases of people (usually in contact with a kid who got the oral vaccine) would catch the stronger polio the old fashioned way (via the usual finger/feces/water route).

    not in this paper: there is a lot of HIV and other infections that cause a weakened immune system in that area of Africa.

    also not in the paper: If some of the cases were given smaller than usual dosages (something done if there were shortages). 

    People with HIV are encoraged to get the inactivated vaccines, but cautioned about the live vaccines for this reason.

    HIV interferes with some types of immune response , but malnutrition and chronic disease also interfere with the immune response.

    but not everyone who gets sick develops the entire syndrome, so actual cases might be higher. From the WHO:


    Once contracted, the yellow fever virus incubates in the body for 3 to 6 days. Many people do not experience symptoms, but when these do occur, the most common are fever, muscle pain with prominent backache, headache, loss of appetite, and nausea or vomiting. In most cases, symptoms disappear after 3 to 4 days.A small percentage of patients, however, enter a second, more toxic phase within 24 hours of recovering from initial symptoms. High fever returns and several body systems are affected, usually the liver and the kidneys. In this phase people are likely to develop jaundice (yellowing of the skin and eyes, hence the name ‘yellow fever’), dark urine and abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach. Half of the patients who enter the toxic phase die within 7 - 10 days.