Swine flu: pig meets rabbit

Of the three main modes of infection for flu -- transmission by large droplets, transmission by tiny suspended aerosols, transmission via inanimate objects (also called fomites) -- it is the last that is the least certain but garners the most attention in the form of hand hygiene, disinfectants and now, fear of magazines and toys in emergency department waiting rooms and acute-care clinics in Canada. Here's the lede from an article in the Montreal-Gazette:

All magazines and toys should be removed from emergency department waiting rooms and acute-care clinics to reduce exposure to human swine flu, federal health officials are recommending. (Saron Kirkey, CanWest via Montreal Gazette [hat tip tweets JuliaS1573 RT @themediaisdyin]

The Guidance from the Canadian Federal authorities includes measures aimed at the other modes of infection, too: masks, separate triage and waiting areas for those with respiratory signs and symptoms, etc., but it was the toys and magazines that captured the lede (the first paragraph, in newspaper talk). And on reading it, the first thing that popped into my head was The Velveteen Rabbit.

The Velveteen Rabbit was a children's book, written in 1922. I read it when I was an adult because of an interest in the history of public health during the Progressive Era, but it remains in print and I'm guessing a number of folks out there have read it. Here's the plot, given in Wikipedia:

A boy receives a Velveteen Rabbit for Christmas. The Velveteen Rabbit is snubbed by other more expensive or mechanical toys, the latter of which fancy themselves real. One day while talking with the Skin Horse, the Rabbit learns that a toy becomes real if its owner really and truly loves it.

When the boy's china dog is misplaced, the Velveteen Rabbit is given to the boy as a quick replacement by the maid. The Velveteen Rabbit soon takes his place as the boy's constant companion. The Rabbit becomes shabbier, but the boy loves him no matter what. In the woods near the boy's home, the Velveteen Rabbit meets actual rabbits, and learns about the differences between himself and the real rabbits when the real rabbits prove he is not real by his inability to hop or jump or his shedding fur.

The Velveteen Rabbit's companionship with the boy lasts until the boy falls ill with scarlet fever. The boy becomes too ill to play for a very long time; upon his recovery, he is sent to the seaside on doctor's orders. The boy wishes to take the Rabbit with him, but his doctor forbids him to take the germ-laden toy and says it must be burned along with all the nursery toys in order to disinfect the nursery. The boy is given a new plush rabbit with glass eyes and is so excited about the trip to the seaside that he forgets his old Velveteen Rabbit. (Velveteen Rabbit entry, Wikipedia)

Sigh. OK, it doesn't end so sadly Before being burned, the Rabbit sheds a real tear which brings the Magic Fairy who turns him/her into a real rabbit which then goes hopping off into the woods. Etc. What interests me is that the response 90 years later isn't much different. Public health at the time the book was written was in a period of transition. Charles V. Chapin's book, The Sources and Modes of Infection, had come out in 1910 and expressed the heretical opinion that the main sources of infection in people were other people, not the environment. He used scarlet fever as an example of where fomites weren't the way kids got sick from that disease. By the time the second edition came out there had been a dramatic reversal in public health science in Chapin's direction. It is not a coincidence that this occurred at a time of tremendous anxiety about immigrants, anarchists, socialists, and other "dangerous people." In medicine this became crystalized in the image of Typhoid Mary Mallon, an Irish immigrant cook who was a disease carrier that infected the upper class families she worked for. Just at the point where the "environment," in the form of the Velveteen Rabbit, was tagged as the source of disease, public health was about to abandon it and concentrate on society's most marginal people, in keeping with the Zeitgeist. In doing this public health voluntarily but disastrously placed themselves under the thumb of a medical profession, guided by a politically re-invigorated American Medical Association and its state and county affiliates (a bit more on this here).

We are at another cusp point in public health, with forces pushing us in opposite directions. Phantom socialists and terrorists are again afoot but so is a new concern for the environment. When it comes to whether fomites are a significant cause of flu transmission there are important open scientific questions, but the issue of inanimate objects versus dangerous people also has other resonances that aren't scientific and reinforce or interfere with altogether different questions, often with political consequences.

Which is why when I read about removing toys from Emergency Departments I think of The Velveteen Rabbit.


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For the removal of toys and magazines to make sense, wouldn't emergency departments also have to get rid of the chairs and benches in the waiting areas, and the tables, too? Seems those things would be in danger of collecting fomites -- and they get a lot more use!

Hope you're having a blast at the seaside Revere Reunion and the Mrs. R's are being mindful of all that bacteria lurking in the sand.

Well, River, I'd argue that what we do with our hands is far more likely to cause transmission than simply sitting on objects, or putting our feet up, or leaning back in a chair.

That said, I think you still have a fair point in that it is by no means clear that what people would do in the absence of such objects would be in any way less conducive to disease spread than what they do with them. The simple observation that disease may be spread by shared contact with objects is alone not enough to justify the removal of such items.

By Jason Dick (not verified) on 04 Aug 2009 #permalink

Microbes of every sort are plentiful on every surface be they living or inanimate ones that come into contact with living beings. This is simply a fact and if one looks too closely at it, it is one that can cause you to be paranoid very fast.

That this is the condition all life evolved within should give us some cause for reassurance rather than being afraid of every surface we encounter that was touched by someone else before us.

The human body has a large number of microbes that live on our skin, inhabit our upper respiratory tree and in our mouth and colon. These bugs (there are bugs too by the way, all kinds of mites for instance) include ones that cause disease and ones that don't. Why they cause disease in some people and not in others is an interesting question.

Diarrhea has been a common feature of both H5N1 and novel H1N1. The incidence of this influenza symptom is not seen nearly so often with seasonal H1N1 or H2N3. This symptom may be due to ingestion of virus rather than inhalation of it. Apparently, both H5N1 and novel H1N1 lack the mammalian receptor for the upper respiratory tract but have them for the intestine. This suggests hand to food transmission which could involve fomites.

The bottom line is that microbes and microscopic multi-cellular critters are absolutely everywhere; always have been and always will be. All living beings must be able to resist the constant attack of these organisms or we die. This little drama is ongoing constantly everywhere within and upon every living thing on Earth.

An influenza pandemic is simply a more dramatic event because its targets are immunologically naive to the virus meaning all or at least should be susceptible to it.

Ring around the rosy,
A pocket full of posies;
ashes, ashes
we all fall down!

Or this earlier version of the Mother Goose Rhyme, it is very appropriate;

A ring, a ring o' roses,
A pocket full oâposies-
Atch chew! atch chew!
we all fall down!

Influenza is confined only to those within the mammalian and avian species; the top of the food chain and the two dominate species on the planet. Influenza then is nature's great tool for controlling these two species when for whatever reason the constant little biotic drama fails to be adequate. It looks like one of those times!

Ring Around the Rosy.....

By The Doctor (not verified) on 04 Aug 2009 #permalink

Does this mean the story that the Army intentionally transmitted smallpox to Indians in the 1800's by giving them contaminated blankets is false?

Better than decade ago I worked at a major hospital and part of the job was was to go through the peds wing to collect and replace toys. New and decontaminated toys were distributed. Toys collected were taken down to decontamination, spot checked for gross contamination and either cleaned or discarded and then gassed with EO. The toys were then aired for some number of days and stored.

There were some ongoing arguments over how much good this did or didn't do, and the relative cost of replacement versus cleaning.

I will add that toys exposed to kids with serious infections were incinerated and toys that went to high risk kids were always new but also decontaminated.

Jean: It has no bearing on that subject (which I believe was in the 1700s).

Did I misunderstand what you were saying about disease-causing organisms on inanimate objects, Revere? I thought you were saying it's doubtful that objects spread disease. Or am I being too concrete about your point today? I'm a bit sleep-deprived, so it's possible.

Jean: No, it's quite possible for inanimate objects to be a carrier of disease agents from one person to another. The question is which ones and how often does it happen. This is the question for flu. For smallpox it definitely can happen and probably did in the 1760s. But post today was that the scientific question is one thing, but the scientific question also is within a historical context and can have separate and different resonances and consequences.

revere, sorry to have been thick-headed! Thank you for re-explaining.

Every day that I go to college, I wear gloves (cotton, white) during the journey on the Tube and DLR into central London. And back home again at the end of the day. I make it a point to try and avoid touching any part of it that is painted the same colour as the tube line you're currently on - handrails, etc.

It's observably interesting how many people touch the same delivery vectors over and over in pretty much exactly the same places all the time during rush-hour, then get off at their stop and someone else comes in and holds on to exactly the same spot on the handrail. It's also interesting how much of a habit everyone has for bringing the hand to the nose/mouth area, maybe for a quick scratch of a momentarily itchy nose, or just to lean the hand against the chin or cheeks or lips, etc, then hold on to the handrail again.

It's interesting how much sweat is retained in the creases of our hands - the "heart line" "life line" "head line" as they're popularly known to most. There always seems to be a level of moisture in there, especially when travelling on the tube. This imprints onto the handrails easily, and in rushhour it's quite hard to find a handrail that hasn't been touched recently and is perfectly dry - most are clammy in varying levels and temperatures and wetnesses in exactly the same spots that everyone else comfortably holds them (despite many of them being a long pole, there's only a few spots on them that make ergonomic sense to hold on to if you don't want to fall over when the tube starts or stops, and statistically most people seem to position their hands over the exact same imprints that others have left).

During a typical journey in to London, it's very easy to almost visualise a connecting vector between person coming on board the tube, scratches nose instinctively before grabbing handrail, few stops later gets off, someone else gets on, as they leave, touch their mouth, nose or facial area and off they go. The hand rails painted the same colour as the tube line they're on are like a point-to-point delivery vector that is constantly shuffled to and fro back and forth along and underneath London ensuring that everyone everywhere can partake in delivering fresh warm clammy sweat-borne pathways between hands and faces, throughout the capital, in a network topology.

One problem with wearing white gloves (other than that I'm clearly the only one doing it here) is that coupled with the black Fedora I frequently wear, it makes me erroneously look like I'm doing it as a Michael Jackson tribute. Oh well.

"One problem with wearing white gloves (other than that I'm clearly the only one doing it here) is that coupled with the black Fedora I frequently wear, it makes me erroneously look like I'm doing it as a Michael Jackson tribute. Oh well."
...or even worse... that you are a mime!!! But that could carry the added benefit of people avoiding you ;-)

People worry about the circulating air on the planes when they travel. I tell my patients that they start picking up germs the minute they grab the plastic tubs for their computers and shoes at the security gate, then sit in the chairs waiting for their flights, then fasten their seat belts and pull down their tray tables. Next thing you know, here comes the flight attendant with nuts or pretzels, which people stuff into their mouths with germ-laden fingers. Yumm.