Avian Flu

by hilzoy

It's Pandemic Flu Awareness Week, so I thought I'd write a Pandemic Flu Awareness Post. Actually, a couple of them. This one is on general background and a few hints for personal preparedness; the next one will be on governmental responses and related issues.

Background: The CDC says that "the reported symptoms of avian influenza in humans have ranged from typical influenza-like symptoms (e.g., fever, cough, sore throat, and muscle aches) to eye infections (conjunctivitis), pneumonia, acute respiratory distress, viral pneumonia, and other severe and life-threatening complications."

*** Update: According to the WHO, the symptoms of the strain of avian flu we're concerned about are:

"Most patients have initial symptoms of high fever (typically a temperature of more than 38°C) and an influenza-like illness with lower respiratory tract symptoms (Table 3). Upper respiratory tract symptoms are present only sometimes. Unlike patients with infections caused by avian influenza A (H7) viruses, patients with avian influenza A (H5N1) rarely have conjunctivitis. Diarrhea, vomiting, abdominal pain, pleuritic pain, and bleeding from the nose and gums have also been reported early in the course of illness in some patients. Watery diarrhea without blood or inflammatory changes appears to be more common than in influenza due to human viruses and may precede respiratory manifestations by up to one week. One report described two patients who presented with an encephalopathic illness and diarrhea without apparent respiratory symptoms." [End of Update]

The strain of avian flu we're worried about -- H5N1 -- is an unusually nasty strain, and it is also unusually good at leaping across species boundaries. For the last two years, it has been spreading and changing in ominous ways. Revere at Effect Measure has a good summary:

"Starting in 1996 in southern China, it moved to Hong Kong in 1997, where it infected a number of people. After a hiatus where no infections were reported, it reappeared in 2003 in Hong Kong, swept into southeast asia where it has infected over a hundred people killing half of them, become entrenched in western China and eastern Russia and Kazakhstan, been found in wild birds in Mongolia and is poised to enter Europe (if it hasn't done so already)."

And here's a good timeline from Nature. (Note: the numbers of reported cases are probably low: it's not as though every time someone either displays flu-like symptoms or dies after having them, people check for avian flu. We have probably missed both milder cases that were passed off as normal flu and deaths where no one thought to check, or had the resources to do so.)

Bird flu normally occurs in birds, not people. In order for a pandemic to occur, the virus has to change in ways that allow it (1) to infect humans, and (2) to be transmitted from one human to another, and (3) to be transmitted from one human to another not just once in a blue moon, but efficiently. We have certainly passed the first step: there have been around 116 cases, and over half of the people infected have died. We have probably passed the second, although it's harder to be absolutely sure, since (alas) we can't just ask the virus where it came from. It is also spreading to new animal species, including various migratory birds; and might have shown up recently in domestic ducks in Romania. We are hoping that the third shoe -- efficient human-to-human transmission -- won't drop.

Michael Osterholm, Director of the Center for Infectious Disease Research and Policy, wrote in Foreign Affairs:

"The signs are alarming: the number of human and animal H5N1 infections has been increasing; small clusters of cases have been documented, suggesting that the virus may have come close to sustained human-to-human transmission; and H5N1 continues to evolve in the virtual genetic reassortment laboratory provided by the unprecedented number of people, pigs, and poultry in Asia. The population explosion in China and other Asian countries has created an incredible mixing vessel for the virus. Consider this sobering information: the most recent influenza pandemic, of 1968-69, emerged in China, when its population was 790 million; today it is 1.3 billion. In 1968, the number of pigs in China was 5.2 million; today it is 508 million. The number of poultry in China in 1968 was 12.3 million; today it is 13 billion. Changes in other Asian countries are similar. Given these developments, as well as the exponential growth in foreign travel over the past 50 years, an influenza pandemic could be more devastating than ever before."

If the virus does learn how to transmit itself rapidly from human to human, we're in for trouble. As noted above, a little over half of the people known to have contracted it during the current outbreak have died. Estimates of how many people might die in an avian flu pandemic vary widely:

"Nabarro also made several missteps in his initial news conference at the UN on Thursday, including straying far afield from the WHO's estimate of the number of deaths a new pandemic might exact. He suggested between five million and 150 million people might die.

Less than 24 hours later the Geneva-based WHO reeled back in Nabarro's estimate, saying its own longstanding projection of two million to 7.4 million excess deaths was more likely. The official WHO estimate was calculated using a mathematical model based largely on the Hong Kong flu of 1968, the mildest pandemic of the last century."

Nabarro is in charge of pandemic preparedness at the UN; as noted, the WHO numbers are based on a mild pandemic, and are probably low. (Extrapolating the mortality rates from the 1918 pandemic to today's population yields a prediction of 180 million to 360 million deaths globally.) But all these numbers are more or less well-founded guesstimates; the one thing we can be fairly certain of is that if a pandemic hit, a lot of people would die.

Moreover, if the virus does acquire the capacity for efficient human-to-human contact, it is more or less a given that it will appear in this country, whatever travel restrictions we put in place. Once upon a time, humans and the viruses they carry traveled by foot or by horseback, and most people stayed very close to home. In those days, epidemics spread more slowly. Nowadays, however, viruses can and do hop from continent to continent via jet aircraft and their human passengers. (A world in which lots and lots of people travel to lots and lots of places very quickly is a very, very convenient world to live in, if you happen to be a virus.)

The Department of Health and Human Services predicts that a severe pandemic would sicken 90 million Americans; that half of those would seek medical care; that 8.5 million would need to be hospitalized, 1.3 million of them in ICUs; that 639,000 would require mechanical ventilation, and that 1.9 million Americans would die.

The problems only begin with the death rates, however. Recently, hospitals have been consolidating, reducing the number of normally unused beds. Unused hospital beds can be viewed in several ways. From the point of view of hospital administrators trying to save money, they are inefficiencies. From the point of view of public health planners contemplating a pandemic, however, they are surge capacity: the extra beds that would allow us to deal with a sharp rise in the rates of disease. If a pandemic hits, we will need extra beds for millions of people, and right now, we don't have them.

Likewise, according to Osterholm, "In the United States, for example, there are 105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any given time for everyday medical care. During a routine influenza season, the number of ventilators being used shoots up to 100,000. In an influenza pandemic, the United States may need as many as several hundred thousand additional ventilators." If the DHHS is right to estimate that 639,000 people would need to be put on ventilators in a severe pandemic, the number of people who would require ventilators is over six times the number of ventilators we actually have, and over thirty times the number not already in use.

In addition:

"If it were determined that several cities in Vietnam had major outbreaks of H5N1 infection associated with high mortality, there would be a scramble to stop the virus from entering other countries by greatly reducing or even prohibiting foreign travel and trade. The global economy would come to a halt."

Just think about the impact of suspending trade with, say, Indonesia, Vietnam, Thailand, and China. And while you're thinking, recall that we have largely moved to 'just in time' ordering and production, which is wonderful in a lot of ways, but particularly ill-suited to dealing with massive and global disruptions in supply chains. It's enormously difficult to figure out what, exactly, would happen as a result of this. However, while dire predictions aren't obviously right, I'd be a lot happier if they were obviously wrong, and I don't think they are.

In addition to all this, if a pandemic hits we will have to deal with panic and its effects. Think back on the anthrax episode: it was awful, but the chances of any individual (with the possible exception of Congresspersons, their staff, and DC postal employees) encountering an anthrax letter were remote. Despite this, however, normally sane people made a run on Cipro, bought duct tape, and so forth. Think of SARS: it was much more serious than the anthrax scare, but, according to Wikipedia, 8,069 people got sick and 775 died. This is orders of magnitude fewer than would die in an influenza pandemic, and yet the combination of public health measures and fear caused enormous disruption, including an estimated $40 billion in costs to the Asian Pacific region.

So, basically: that's why people are very, very worried about this.

Personal Preparedness

So: what can you do to prepare? I'm not a public health expert (though I did ace Epidemiology); you can find the recommendations of people who are at some of the links below. Because I'm not an expert, and because I tend to low-tech, cheap precautions, I'm going to restrict myself to some common-sense recommendations, most of which are things it would probably be a good idea to do anyway.

First, get your annual flu shot this year. The flu shot does NOT confer protection from avian flu. Nonetheless, it's a good idea. For one thing, avian flu might decide to strike during the flu season; if this happens, you do not want to get both flus in a short period of time. Even the normal flu is a pretty serious illness, and it weakens the body. You do not want to confront avian flu in a weakened state. For another, influenza viruses can mingle with one another when one organism -- you, for instance -- is infected with both. When this happens, it can lead to new strains that can infect people; and this would be a Bad Thing That We Should Try To Prevent. Thus, flu shots.

Second, stock up on things you might need from a drug store. For obvious reasons, drug stores tend to attract sick people. If there's an infectious pandemic, you will not want to go to the drug store more than you have to. Thus, keeping a larger than usual supply of all those drug store things on hand would probably be a good idea.

(There are people who recommend stocking up on everything, as if we were expecting a war. I normally have extra food around, mostly because I hate having to go to the supermarket when I don't feel like it. I am not acquiring lots more. That may just be a reflection of the fact that I usually have a fairly high tolerance for risk and a low tolerance for reactions that strike me as panicky, though.)

Third, if you need to have some medical procedure that you have been putting off, have it now. You do not want to develop a serious need for a hospital in the middle of a pandemic.

Fourth, there are some supplies that will predictably be bought up when people panic. Among them are respiratory masks (NIOSH-certified N-95 masks, says the WHO). Opinion is divided on them: they are definitely recommended for symptomatic nursing mothers, and health care workers, but for the rest of us, it's less clear. The reason to get them is that one way flu is spread is "via virus-laden large droplets (particles >5 µm in diameter) that are generated when infected persons cough or sneeze; these large droplets can then be directly deposited onto the mucosal surfaces of the upper respiratory tract of susceptible persons who are near (i.e., within 3 feet) the droplet source." Masks block these droplets. (Note: because airborne flu viruses travel in "virus-laden large droplets" that people cough up, the fact that the virus itself is smaller than the holes on most masks is unimportant. Stopping the droplets is the key.) The reason not to use them is, as far as I can tell, that they might be overkill for those of us who are neither health care workers nor nursing mothers. It is worth thinking about whether you will wish you had some later, and if so, buying them now. (They run around $1-2 apiece; if you buy them, buy enough to last a while. As I said, NIOSH-certified N-95 masks are recommended. And while I haven't tried them myself, I hear that having an exhale valve makes a real difference: the downside of sealing airborne particles out is, alas, sealing your hot muggy breath in.)

Another thing it would be worth thinking about getting is alcohol-based towelettes (the sort you carry around with you.) They kill viruses, and if you're not near a sink, they can be handy. Alcohol-based are supposedly best; here's a CDC list of ingredients and their efficacy at killing viruses and other things. If you think of other things that are likely to become unavailable as soon as a pandemic starts, and that you will want to have, buy them now.

Fifth, one of the most important things you can do in a pandemic is simply to wash your hands, wash them often, and wash them right. (Note to any compulsives out there: 'often' does not mean hundreds of times a day.) It really makes a big difference; you can see why if you simply reflect on how many of the possible ways in which a virus might try to get into your lungs involve your hands, and how well a serious washing would disrupt them. A blog called Aetiology puts it well:

"Wash your hands. It’s not sexy advice, I admit. But ever since Semmelweis, it’s been the smartest thing a public health professional can advise. And really, many of us still don’t do it correctly. It is recommended to wash with soap and running water for at least 20 seconds. I know that when I’m in public restrooms (and I work within a hospital building!), I very rarely see people wash that long. So, be a bit more contientious when you wash. Teach your children to do this as well: have them count to 20 or sing their ABC’s while washing their hands. If you’re not around a faucet, hand sanitizers with 70% ethanol are also effective. (To my knowledge, Triclosan, the other common ingredient in hand sanitizers, has not been proven effective at killing viruses--so watch the ingredients and stick to alcohol).

If you’re sick, please, please, please stay home. Adults are contagious for ~5 days and children for up to 21 days after becoming sick. Don’t go and expose others when you’re coughing, sneezing and hacking all over the place.

Avoid touching your eyes, nose, and mouth. Again, think about how many times you do this every day. This is one way influenza can enter a body. Also, re-train yourself not to cover your mouth with your hands when you cough: use a tissue, or the crook of your arm—-something that won’t come into contact as often with surfaces, or with other people."

Resources:

• The Flu Wiki has a lot of good resources. It has: a resource page with a lot of really good links; a scientific information page; a preparedness page, and lots more.


• The CDC Avian Flu page. It has links to all sorts of topics. One that I did not find at first, and that might be really useful to someone, is the CDC guidance for pregnant woman and new mothers.


• WHO Avian Flu page


• The Center for Infectious Disease Research and Policy's Avian Flu page


• Nature's Avian Flu collection (much of it free)


• Two good articles from Foreign Affairs: 1, 2

There are also some very good blogs that write on this topic: Effect Measure, Recombinomics, and Aetiology (new to me, but its pandemic preparedness series is very good.)

If you have any other suggestions, either for links, preparedness, or just questions, chime in.

Comments

[rilkefan]

You can't project from 1918, a bad year generally for health, can you? Or from the mortality rate among people infected by a new disease and hence likely to have weaker immune systems?

Anyway, having read Connie Willis's _Doomsday Book_, I'm not looking forward to this.

[hilzoy]

rilkefan: well, no, you can't, really. It's just that there is nothing obviously better to do. (And a large part of why 1918 was a bad year had to do either with the influenza itself or with the First World War, which I'm not sure would have figured into e.g. the attack rates for Spanish flu.)

And a virulent strain of H5N1 would be a new disease, at least outside those parts of SE Asia in which it might now be evolving, so it is in that respect comparable.

[hilzoy]

rilkefan: "Nearly half of all deaths in the United States in 1918 were flu related. Some 675,000 Americans -- about 0.6 percent of the population of 105 million and the equivalent of 2 million American deaths today -- perished from the Spanish flu. The average life expectancy for Americans born in 1918 was just 37 years, down from 55 in 1917. Although doctors then lacked the technology to test people's blood for flu infections, scientists reckon that the Spanish flu had a mortality rate of just less than one percent of those who took ill in the United States. It would have been much worse had there not been milder flu epidemics in the 1850s and in 1889, caused by similar but less virulent viruses, which made most elderly Americans immune to the 1918-19 strain. The highest death tolls were among young adults, ages 20-35." (cite)

[Crawford Kilian]

Thanks for your post. Readers may also want to visit my site, H5N1, which focuses on flu-related news stories from around the world, with occasional comments.

[hilzoy]

Thanks -- here's a link.

[rilkefan]

How many of those 20-35-y-o's were soldiers in Europe? (stupid ISP) Born in 1918 seems weird to me, if the bad was in the above age group. Did the life expectancy then shoot up? (Angling for a claim that the flu culled the immunocompromised.)

I'm guessing that Asian populations have some immunity following the same mechanism described above?

[hilzoy]

rilkefan: I'm reading 'deaths in the US' as excluding deaths of Americans in Europe. I believe one of the initial outbreaks was in a group of soldiers training to go there, but they hadn't left yet.

It was an odd flu, since it did not hit the very old and very young preferentially.

And I assume that the 'born in 1918' life expectancy figures reflect a lot of dead infants.

[Tim]

From what I've read, mostly on Effect Measure, H5N1 can be worse on young adults than the very old. Unlike regular flu, it can attack organs by itself and may possibly kill by starting cytokine storms in a victim.

[Dianne]

"Angling for a claim that the flu culled the immunocompromised."

Warning: Wild-a$$ speculation ahead: Given that young adults, rather than the very old or the very young, were most likely to die in the 1918 flu epidemic, I'd suggest that the 1918 flu culled the most immunocompetent, not the immunocompromised. In other words, the flu probably set up an immune reaction that was so severe that it killed a lot of people. The old and young may have had less extreme immune responses and therefore been more likely to survive. If this is true, the existence of drugs like prednisone and others that decrease cytokine response may help make the coming pandemic less deadly than the 1918 epidemic. I hope.

While we're speculating, I wonder if, in fact, some version of the H5N1 or similar flus might not already be present in the US, but in a very attenuated form, allowing it to pass unnoticed. I have no good evidence for this, only the anecdote that in 2001 or 2002 (I don't remember exactly), I had what seemed to be a relatively minor flu-like illness followed by a bout of conjunctivitis. At the time I thought I had two separate illnesses, but I wonder if I didn't have some mild version of the H5N1 or H7N7 flu. Does anyone know if there are specific tests for previous exposure out there?

[hilzoy]

Dianne: in the course of researching this, I learned (but where?) that while avian flu generally often involves conjunctivitis, H5N1 in particular does not. When I figure out where I read this, I'll update the page accordingly.

[Jay C.]

Great post, as usual, Hilzoy (and why is it not surprising that you "ace[d] Epidemiology"?) - but I also wonder if extrapolating casualty ratios from the 1918-19 pandemic really is a relevant metric for a theoretical flu outbreak in 2005?
Even given, as you point out, that contemporary improvements in transportation have made the international transmission of infectious diseases far easier (although the Spanish Flu spread handily enough even in the steamship era) - aren't the advances in medical science and technology since then "advanced" enough to cut on the overall death rate?
Or am I missing something (and should go run out and stock up on masks)?

[Dianne]

"while avian flu generally often involves conjunctivitis, H5N1 in particular does not."

Drat. Well, maybe I can still hope for partial immunity based on cross-reacting antibodies. (Actually, I'm not at all sure that what I had was influenza at all. It was a lot milder than classic influenza, for one thing...Right, I guess I'm heading to employee health for the flu shot Tuesday.)

Update after looking for confirmation of the symptoms of H5N1: This article states that conjunctivitis can be seen with H5N1, but much less frequently than with other avian flu strains such as H7N7.

One other note from the above article: The article states that in children under 6 the disease is generally self-limited and requires only supportive care except in children given aspirin. Children given aspirin are at particularly high risk of developing Reye's syndrome with this flu. Don't do it.

[Dianne]

"while avian flu generally often involves conjunctivitis, H5N1 in particular does not."

Drat. Well, maybe I can still hope for partial immunity based on cross-reacting antibodies. (Actually, I'm not at all sure that what I had was influenza at all. It was a lot milder than classic influenza, for one thing...Right, I guess I'm heading to employee health for the flu shot Tuesday.)

Update after looking for confirmation of the symptoms of H5N1: This article states that conjunctivitis can be seen with H5N1, but much less frequently than with other avian flu strains such as H7N7.

One other note from the above article: The article states that in children under 6 the disease is generally self-limited and requires only supportive care except in children given aspirin. Children given aspirin are at particularly high risk of developing Reye's syndrome with this flu. Don't do it.

[Dianne]

"aren't the advances in medical science and technology since then "advanced" enough to cut on the overall death rate?"

Advanced, yes. Enough? We'll see.

Supportive care is much better now than in 1918 and we now have antivirals with some efficacy. Plus we've learned how to make flu vaccines with reasonable efficiency. Unfortnately, it's not at all clear that we have capacity to make enough anti-virals and vaccines if it comes to a pandemic. So go ahead and stock up on masks and gloves. And lots of soap. Soap and water is your friend when it comes to protecting against disease. So is alcohol...er, to put on potentially infected surfaces, not to drink. Drinking it might make you feel better, but wouldn't make you any safer against flu.

I'll try to post this only once, but my computer is acting a little screwy.

[hilzoy]

JayC: I'm working on -- well, two things, one related to my, um, job, and one followup to this. Basically, though, as far as medical advances: we are working on vaccines. However, it would take months to grow them, there's some question as to whether we're working with the right strain (it's from 2004; the question is how much the virus has mutated since then), and in any case there certainly wouldn't be enough for everyone. Unfortunately, it seems that this virus requires a stronger vaccine than most flus, which makes diluting it less feasible. The one dilution strategy that might work has not yet been tested. It will almost certainly be rationed.

Antivirals: we have only just (like: a few days ago) gotten around to deciding to increase our stockpiles, and are thus in line behind a lot of other countries. Tra la, tra la. We have some, but nowhere near enough. (I gather Canada is doing a much better job.)

Other than that, there isn't a lot of known curative stuff out there. (Although one danger with the flu is getting a secondary infection of some sort, and a lot of those are much more treatable.) People are speculating about whether this or that drug might possibly have some benefit, but as best I can tell, they don't know.

Bottom line (as best I can tell): we're in much better shape as far as secondary infections. Stuff that directly protects from or cures avian flu itself, however, is likely to be in very short supply, and to be strictly rationed.

(And this is without considering the question: should developed countries get the vast majority of medications and vaccines? This isn't just a question of justice; there's also a serious public health argument for trying to nail any outbreak very early. But that would mean using scarce resources that will be needed if this approach fails in other countries, which in all likelihood we won't do.)

Dianne: thanks for the cite. I, too, wish I could hope for immunity.

[Tim]

The biggest other problem is that the main support therapy for serious flu is a respirator, of which there apparently only are about 100,000 in the entire U.S. Any seriously large epidemic is going to cause a major shortage practically instantaneously.

[rilkefan]

"children under 6"

Does anything special happen around 6?

[dutchmarbel]

Plans in the Netherlands stated that with so many people ill you have to recon with a serious disruption of daily life. If 30-50% of the employees in your environment are home, ill, a lot of work cannot be done.

Weird, but I never realized that bit of impact.

They also recommend (in the practical tips section) to use paper tissues for sneezes and throw them away after using them once. If you really want to do all you can you can change the doornobs in your house to once where you do not use your hands to open the door. Doornobs appearantly are viral travel hobs.

[hilzoy]

dutchmarbel: yes, doorknobs are places where Germs May Lurk. -- Basically, it's worth asking yourself: suppose I were a virus, trying to get from inside one person's body to inside another person's body: how would I do it? (Thus, washing one's hands.)

[dutchmarbel]

Yep, but some doorknobs (tnxs, I thought the word looked funny) are touched in area's where you do not really wash your hands. Opening doors in shops, offices, schools, etc.
Before reading all this I never thought of touching a doorknob as an incident that would require hand washing. And I wash a lot of hands, with three little children at home it is the only way to prevent yourself from sneezing 8 months per year...

[hilzoy]

dutchmarbel: that's why one of the relatively small number of things I plan to do is to actually get some of the alcohol-based towelette thingies. -- And one of the odder parts of taking epidemiology was that it made us all think about all sorts of common things quite differently.

The one that really altered my life was this: apparently, someone analyzed the mints given out in restaurants -- the ones that are not individually wrapped -- and found that -- how to put this? -- every substance normally secreted by humans could be found on those mints.

Ew. I have never eaten one since hearing that.

[dutchmarbel]

LOL. I read something similar about peanuts in bars. The little bowls on bars contained on average 7 different kinds of urine --- never EVER will I eat those anymore. Unwrapped sweets will be added to the list now ;)

[CaseyL]

I thought viruses died quickly once they were no longer surrounded by a human body or by human body effluviants. Wouldn't viruses on doorknobs be dead by the time someone else touched said doorknob?

[liberal japonicus]

Does anything special happen around 6?
I'm guessing that it is because the chance of Reyes syndrome increases when aspirin is administered during a viral illness, and since children are more likely to get chickenpox, etc. and their caregivers are more likely to administer aspirin earlier (most adults gut it out until they really feel sick)

Most of those affected (96 percent) took medications containing aspirin on or before the third day of illness. Another study found that children with the syndrome were 35 times more likely to have used aspirin than those who did not take any aspirin (Huritz, 1988; Huritz, et.al., 1987). Due to these findings, people (especially children) with viral illnesses are encouraged not to use aspirin or any medications containing aspirin since it could cause Reye's syndrome.link

I thought viruses died quickly once they were no longer surrounded by a human body or by human body effluviants.

When SARS was a big topic, a lot of stuff was published about lifespan of the virus. This is pulled up google link

The SARS virus can live for up to 15 days outside the human body, Chinese scientists have discovered.

The Key Science and Technology Group under the National Task Force for SARS Control and Prevention Monday revealed that the virus can exist in temperatures of 24 C for five days in patients' saliva, mucus and excrement, 10 days in urine and 15 days in blood.

Obviously, the SARS virus is not the flu virus, but I remember this coming up when my faculty was discussing cancelling student exchanges because of SARS.

[hilzoy]

CaseyL:

(ot: it's fun to try to figure out the answers to these questions!)

Viruses seem to differ in how long they can survive apart from their hosts' bodies. Alas, however, the WHO says:

"Apart from being highly contagious, avian influenza viruses are readily transmitted from farm to farm by mechanical means, such as by contaminated equipment, vehicles, feed, cages, or clothing. Highly pathogenic viruses can survive for long periods in the environment, especially when temperatures are low."

And, somewhat more specifically:

"The virus can survive, at cool temperatures, in contaminated manure for at least three months. In water, the virus can survive for up to four days at 22 degrees C and more than 30 days at 0 degrees C. For the highly pathogenic form, studies have shown that a single gram of contaminated manure can contain enough virus to infect 1 million birds."

Nothing on doorknobs specifically, however.

[liberal japonicus]

I remember someone discussing how artificial sweetners were discovered (maybe McGee in Food and Cooking), which is that experimenters working in a lab went to take a break and found that their lunch or their cigarettes had an overwhelming sweet taste. Now, I know a lot of guys in chem labs can be pretty devil may care, but to think that they got enough on their hands to transfer to the food to have them taste it really makes one realize how easy it is. My daughter is watching Snow White and she's asking the boys if they washed their hands. Yikes.

[hilzoy]

lj: What's funny about my writing all of this is that I am about as far from obsessively cleanly as it's possible to be.

Well, scratch that, actually: I have known people -- my little brother at age 20, for instance, who literally never cleaned, say, the bathroom sink, so that it got all crusty and peculiar, and odd things started to grow all over it. I've never been like that. But I am a long, long way from being a neat freak.

[P. Smith]

The problem has already taken Cipro out off the market. My doctor prescribed, but it is no longer available in Texas. A very effective antibiotic for upper respirtory and staph infection. When I went to fill it (manufacture discontinued distribution.
That's really scary.