I rarely report about suspected bird flu cases here, preferring to wait a couple of days to let things sort out. In the early years of this blog I did report about them in the course of time, experience and some reflection we have come to our present position. Besides, it's not necessary. There are plenty of reputable, reliable and thorough places in flublogia to get up to the minute news. Given all that, it isn't surprising we didn't say anything here about a couple of suspect imported cases in Toronto. In fact, like crof, I hadn't heard about them. Now, thanks the the denials streaming out of Toronto East General Hospital I have. And now I want to say something about the denials:
Toronto East General Hospital (TEGH) is concerned about inaccurate media speculation and reporting regarding human cases of avian flu. TEGH has no reason to speculate that any patients in the hospital have avian flu.Toronto is experiencing steadily increasing cases of seasonal flu in the community. For example, during the week of March 2 to 8th, 2008, there were 47 new cases of seasonal flu (not avian flu) in Toronto. Although TEGH has effectively responded to an increased number of patients with seasonal flu-like symptoms, including those from other facilities experiencing seasonal flu outbreaks, the hospital has no reason to believe that any patients at TEGH have H5N1 avian flu.
Furthermore, media reports are indicating that the individuals suspected to have avian flu had recently traveled to Bangladesh. It is important to clarify that, according to the World Health Network, there have been no reported human cases of H5N1 avian flu in Bangladesh.
TEGH has a comprehensive screening program to identify patients who present with potential respiratory illness. The hospital is proud of our record in identifying such individuals. Effective identification enables TEGH to provide appropriate treatment, to utilize respiratory precautions and to protect staff and others. We are confident that no staff, patients or visitors have been inadvertently exposed to seasonal influenza at TEGH.
We wish to reassure the public that the hospital is safe and that there is no reason for anybody who has visited the hospital to be concerned. All services, including scheduled procedures, continue to be fully available. We do not anticipate a need for any reduction in service or visitation restrictions. (Canadian Press; no link)
If you are mainly interested in retaining public trust, the first requisite is to be absolutely truthful and accurate. This denial fails that test. There are a number of things that, on their face, are neither truthful nor accurate.
From another news story (hat tip crof's H5N1 blog) we get some additional details:
In a city once devastated by SARS, it's only natural that there would be big concerns about even the hint of a dangerous disease. And that may be what set off fears about a possible case of bird flu at a local hospital Tuesday night.
When an elderly couple who had just returned from Bangladesh showed up at Toronto East General Hospital suffering from bad flu-like symptoms, officials there took no chances. The patients were immediately isolated, staff members wore gowns, gloves and masks and no visitors were allowed in to the secure area. (City News)
Assuming these facts, let's parse the denial. I didn't see the reports at issue so I can't say whether they were accurate, inaccurate, alarmist or whatever. But the claim the hospital had no reason to speculate, I hope is false. If a couple comes back from an area where the environment has plenty of H5N1 virus and has an influenza-like illness, it is good medicine to rule out H5N1 infection. That is speculating on what might be. And it's why special precautions were taken. And it's appropriate. It's fine to note that there is a lot of seasonal flu around and a lot of those patients are currently in the hospital. But doesn't that suggest that inadvertent exposure to seasonal flu in the hospital is quite likely? Hospitals are not healthy places -- for anyone. Perhaps the reference to seasonal flu was intended to be avian flu. But that's not what it said. The reference to SARS was a pointed reference to the fact that in that outbreak, hospitals were the most dangerous places to be. And they still are not healthy places, even without SARS.
The hospital also says there is no reason to believe anyone in the hospital has avian flu. There was in fact at least some reason to think it was a possibility and kudos to those medical intake personal who recognized it. The overwhelming probability is that it isn't (one of the reasons I don't report initial reports here). But "no reason" is surely too strong. Testing is not complete, as I understand it, although I think the outcome is pretty certain. Still, accuracy is the goal and this just isn't accurate.
Finally, the argument that the history of having been in Bangladesh is not relevant because there is no reported or confirmed human bird flu there is, at best, misleading. Almost everyone who knows about the situation there assumes there have been at least some cases. They just weren't recognized. Anyway, health officials are fond of saying, and the media dutifully repeats it, that almost all cases to date give a history of contact with sick poultry (even though it's not really true; a substantial fraction of cases have no such history), then it's irrelevant there are no human cases. There are a lot of birds dying from H5N1 in Bangladesh.
I understand the hospital was trying to quash a false rumor there was bird flu at the hospital. I don't blame them for that. But in their zeal to do so, they need to take more care. It's worth the effort.
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"no reason" could also mean : not enough reason to
issue a statement.
Or : the antireasons are in the majority.
There are always _some_ arguments for or against
(almost) anything.
Suppose there were absolutly no chance
for the public or for WHO to figure out about an
outbreak known to the authorities, but not known
to others that they knew it.
Would we expect them to tell about it ?
Would it be wise to inform the public ?
There is some chance that the virus won't spread
and no one would notice the outbreak.
But if it does spread later, early actions were critical.
anon: Yes, I expect them to tell me, even if it's after the fact. it builds trust. In fact it is the foundation for trust. If it turns out ithappened and they told no one, they lose credibility. It's a trade-off and my point was it is a trade-off that's essential.
Thanks for the interesting post. I work at at a local health department, where I head the epidemiology team. I am always on the lookout for public-health-related articles in the media to use as examples of how to (or not to) write press releases. I agree with you that the Toronto East General Hospital release was a bit heavy on denial and light on facts. To bolster their claim that they had "no reason to believe that any patients at TEGH have H5N1 avian flu" they should have offered more than the weak, and frankly misleading, reassurance that Bangladesh has reported no human cases.
The US CDC has published specific guidelines for testing suspected human cases of H5N1. I assume Canada has a similar set of guidelines. CDC recommends testing for H5N1 if a patient meets all of the following criteria (I am leaving out some details that probably do not apply to the TEGH case): 1.) a febrile respiratory illness severe enough to require hospitalization, AND 2.) travel within the ten days prior to onset to a country with H5N1 documented in poultry, wild birds, or humans. AND 3.) direct contact with sick or dead poultry, sick or dead wild birds, poultry feces, or a person who was hospitalized or died due to a severe unexplained respiratory illness. CDC also allows for considering testing, on a case-by-case basis, for patients who do not meet all of the criteria. After looking at the link you provided, I surmise that the TEGH patients met the first two CDC criteria, but not the third.
TEGH should have considered issuing a joint release with the local public health agency. The public would have been better informed if the release had stated that there are specific guidelines in place for enhanced surveillance for H5N1, that TEGH is following those guidelines in consultation with public health authorities, and that no patients at TEGH meet the recommended criteria for testing for H5N1.
I wonder whether H5N1 tests actually are pending on the two patients. If a decision was made to do any testing over and above that called for by published guidelines, should the public have been told that? What do you think?
Thanks for posting this one. I'm close enough to TO that when SARS hit, every medical institution here went on high alert.
Ifwhen H5N1 hits North America in a big way, it's likely to start in Toronto. Toronto is not only a major international air hub, but 40% of the general Canadian population (figure is probably slightly higher for the GTA, and a half an hour later in Newfoundland) is foreign-born, and we're a nation of travellers in general, so there are lots of people coming and going from all over the world. If a tourist doesn't, someone either coming back from visiting the home folks or going to visit the folks who live away will probably bring H5N1.
You could say that Toronto is to the early 21st Century what New York City was to the early 20th.
revere, trust doesn't seem to pay off.
Especially in times of crisis.
There are lots of examples from history.
It's just unreasonable from the government's POV
to be honest. Maybe not when dealing with
academic people, but for the masses.
And it's just unreasonable from us to expect it.
Let's build up our own independent news souces now.
?????
didn't the sense of this sentence come out wrong?
how is it good medicine?
don't you mean "not good medicine"?
newore: Actually I meant it the way it was written but I see that if you are not a medical person you might read it the way you did. In a diagnostic work-up, "rule-out X" means to take the diagnostic steps to make sure the person doesn't have X.
The reason that they had no reason to believe the patients had H5N1 was that the patients in question didn't have flu like symptoms. They had traveller's diarrhea, but one of the paramedics that picked up the patients said the "Avian Flu" words over the radio and were overheard by a media outlet who were using a scanner.