OT - unidentified infection in Panama

Sources of Information:

• Official and Government Sources: The Ministry of Health is holding a daily press conference at 4:00 pm every day. Today's press conference was delayed for three hours and did not begin until 7:00 pm. It consisted of the Minister of Health, Dr. Camilo Alleyne, reading a short statement and then passing the microphones over to the doctor who is in charge of handling the clinical care of the infected patients. As soon as he said (or let it slip) that they now have 27 cases associated with this outbreak the Health Minister took the microphones back. I have interviewed Dr. Cirilo Lawson, the General Director of Health of Panama's Ministry of Health. I also speak daily with Dr. Jorge Motta, the Director of the Gorgas Institute and the person who is coordinating the response from international agencies such as the Centers for Disease Control (CDC) in Atlanta and the Pan American Health Organization.
  
  
• Ministry of Health Briefs National Assembly: Dr. Camilo Alleyne briefed the Health Committee of the National Assembly, which is made up of doctors for the most part, to brief them on what's going on.
  
  
• Ministry of Health Briefs Cabinet: Also this afternoon Dr. Alleyne briefed President Martin Torrijos and his Cabinet members to bring them up to speed and to tell them what they know so far, and their plan of action.
  
  
• Unofficial Response: The Panamanian medical community is discussing this issue internally. For the most part Dr. Camilo Alleyne is cracking the whip on information control and a great many of the best doctors in the country are quite simply out of the loop and don't have access to the basic information regarding the patients, cases, and how the situation is being handled. From the outside and in a vacuum of information they are free to speculate. I will identify that information if and when it is presented as speculation from relatively uniformed sources.
  
  
• Summary: This is an emerging situation that is not clearly defined. Everyone is doing their best to handle the situation from all angles, the science, the public health, international response, and press. The center of the information vortex is the Ministry of Health, and they are doing the best they can to handle this situation.
  
  
• Editor's Comment: The Minister of Health needs help in responding to this situation from an information management point of view. He has shut down all unauthorized information flow as part of his crisis management plan. This is creating a vacuum which is being filled by speculation and idle chatter. What they need is a professional press director and several press conferences per day or a person or point of contact authorized to take questions and get authorization to release information to the press as it becomes available. Rather than shutting down information he would be better served with a release valve to take the pressure off and to let him and his staff get back to doing the whole science and medicine thing. Anyone can take questions and fish out answers. As long as the information is coming from that source, then it will be understood to be official and for public release. The "once a day" thing just left the press standing around for three hours with nothing to do and turned into a huge waste of time all around. I can't armchair quarterback the science, but information and crisis management I know a thing or two about. They are basically creating a clusterf*&K on purpose.

What's Causing This? (New Information) - The cause is still unknown but several potential causes have been ruled out. According to the Minister of Health all tests for known infectious agents have come back negative. There are more tests ongoing, and some cultures take longer to grow out than others. So far the following have been eliminated as potential causes for this outbreak:

• Diarrheagenic Escherichia coli (E. coli)
• West Nile Virus
• Dengue
• Influenza A + B
• Campylobacter
• Meningitis
• Encephalitis
• Arsenic

Is It Contagious? Unknown. Family members and health care workers who have been in close contact with little or no infection control protocol have not become sick, so at this point it is being assumed that person to person transfer is difficult to accomplish. But the fact remains that people are getting sick so something is causing this outbreak. There are still many elements of this situation that are still unknown. No Significant Change From Last Report.

When Did This Start: There has been a current outbreak of cases that started on 20 September 2006. Doctors working in the Social Security hospital recognized the pattern and began to track, diagnose, and report cases internally to the hospital. On Friday 28 September the Social Security health care system reported the situation to the Ministry of Health, which has been coordinating a national response. It's probably just a coincidence, but Panama ordered 77 kilos of Tamiflu recently. I don't have the details on this, and suspect the Tamilfu was ordered as part of a plan to prepare for the expected arrival of Bird Flu to Panama. But now looking back, this news article came out on 24 September (Sunday).

How Many Cases Have There Been? (Update) The official number of cases has been increased from 22 to 27. Of those, 17 have died from the illness. Three people have basically recovered and are "ambulatory." Four people are still hospitalized and are still very sick, but do not require treatment in the intensive care unit. There are three patients fighting for their lives in the ICU, two in the Santo Tomas hospital and one in the Social Security hospital. These people are hanging on and it is not known if they will live or die. Right now there is a 62% mortality rate. One thing that should be made perfectly clear is that health officials are being very careful in declaring cases to be related to this unidentified syndrome. There are more than three million people in this country and getting a good case of diarrhea is about the most common thing in the world so there's a lot of (stuff) to sort through. So far they have identified one valid case in July, none in August, and then all of the rest of the cases have been from this current outbreak that started on about 20 September 2006.

What Are the Symptoms? (No Change) So far all patients have presented with the same set of symptoms. For the most part the symptoms present basically in order and with a short period of onset. In other words, you get very sick, very quickly. Patients are presenting with the same symptoms every time, making it easier to both diagnose new cases and to go back through the files and to search for old cases that were potentially related to this outbreak. The syndrome presents basically as follows:

• Nausea
• Vomiting
• High Fever
• Diarrhea
• Severe Headache
• Kidney Failure
• Paralysis, especially around the face
• Difficulty Walking and Physical Coordination
• Eventually, death if the patient does not receive dialysis.

Is There A Cure? (No Change)The patients that have survived this infection have all received dialysis. The suspicion is that the infection is producing some kind of toxins which are causing the renal failure and paralysis. The dialysis cleans the blood and allows the body time to recover from the infection.

Elements In Common: (Updated)

• Official Sources: Repeated strong appeals for people to only take medications that have been prescribed by a doctor and purchased at a pharmacy. The concern is that these patients may have taken some kind of home remedy or unapproved medication that is causing their condition. Dr. Alleyne actually pounded the table in emphasis and repeated that people should only take medications that have been prescribed by a doctor and purchased from a pharmacy.
  
  
• Unofficially: The rumors are that the investigation is focusing on the possibility that the deaths were caused either by home remedies or possibly a bad batch of medications that were either dispensed or sold to patients.
  
  
• Editor's Speculation and Wild-Assed Guess: A possibly related side note is that in the last couple of weeks there have been repeated and consistent reporting in the news that several social security health care facilities did not have medicines on the shelves and one could easily speculate that someone might have distributed some bad medicines, expired medicines, or something like that. If there is a need you can bet that someone will find a way to fill it if it means making a buck. I hope they are treating the homes of every victim as a potential crime scene (but, I doubt it.)
  
  
• From Yesterday's Interview: Patients have had several things in common, such as high blood pressure, diabetes, or some kind of kidney disease. Most of the patients have been more than 60 years of age, and 90% of them have been men. According to Dr. Cirilo Lawson there is a possibility that patients are taking some kind of pills vitamins or home remedies that might be causing this syndrome, and health officials are recommending that people only take those medications that are prescribed by a doctor.

Not Much New From Here, Down: Everything else that follows below is basically the same stuff that was in yesterday's update.

Arriving Sick: One thing is clear, patients who are arriving at the hospital are already very ill. They are presenting with Acute Renal Failure. In most of the cases that have been identified the patients are already at the point where they have developed Acute Renal Failure by the time they show up at the hospital. In other words they were infected before they got there. Whatever is causing this syndrome causes the kidneys to stop functioning and urine production first decreases and then eventually stops completely. Toxins build up in the blood and the patient is basically poisoned from the inside, out. So apparently patients are not catching this illness at the hospital. The evening television news reported that another person died in the hospital today of this syndrome. They also reported that one man presented in Veraguas with acute renal failure, but so far this case has not been linked to this syndrome.

Prevention Measures: Obviously, increase your alert level. Improve your personal hygiene and food handling procedures. Be aware of the symptoms and go immediately to the ER if you present one or more of the symptoms related to this syndrome. Spread the word, and make sure that everyone knows what's going on. Do not panic. There are more than 3 million people in Panama and there have been less than two dozen cases. As one experienced doctor told me today, sometimes these types of things come and go and the exact cause is never identified with precision.

Insects? The vector is unknown. It might be a virus, and transmission via insect is a possibility that can not be ruled out.

Person to Person? Unknown. It does not appear to be passed from one infected person to another but no one knows what is causing these patients to become ill. So again, there's no need to panic or over-react, but at the same time nothing can be ruled out.

Don't Self Medicate: One of the primary messages the doctors from the Ministry of Health want to get out is for people not to try to self-medicate. If you do have this syndrome, self-medicating will only mask symptoms and might make you feel a little better for awhile but you won't get well. Go to the ER and let them take care of you.

It Might Just be Gas: It is possible to present one or more of the symptoms and not have this syndrome. Every case of diarrhea in Panama is not going to end in death. Don't over react, just go to the doctor. The people who have gotten very sick have waited until the last minute.

Over-reactions: Today the television channels showed video of grieving family members who only know that their loved one died, and the simple answer is to blame the hospital. One woman accused the hospital of conducting human experiments. Another called for the hospital to be torn down. This situation calls for the application of investigation and science, not emotion and fear.

Developing Situation: This situation will most certainly gain the attention of the international health community. Interested or responding health professionals should coordinate their efforts through Panama's Ministry of Health.

Send Your Questions: I will be tracking this situation as it develops. There's an excellent chance that you will think of something I'm missing. If you do, please ask - don@panama-guide.com

Working Hard: Health Minister Dr. Camilo Alleyne repeated his message to the Panamanian people that they are putting the best interests of the Panamanian people first and foremost. He took offense at some of the rumors that are flying around, and said that "this is a serious issue, and it is being handled by serious people."

Still a Cluster: They're going to be needing a bigger briefing room. The international press is starting to arrive and the room they were using was just large enough for the local media. And they still need someone to handle the media in a professional manner. But at least they are sticking to the once a day news drop, even if there's not much new to say.

Tissue Samples: There is an airplane coming down right now (it's probably already on the ground) that will be flying an additional round of tissue samples back to the United States for testing. The plan is still to round up everything, meds, tissues, blood, urine, and send it all back to the US for testing.

Rumors Abound: There's still a huge vacuum of information which is being filled with a new rumor every thirty seconds. I've gotten to the point where I'm asking for solid information, actual names and numbers of people who were supposedly infected but have gotten better. And, they have not released a complete list of victims, where they lived, etc.

Apparently Not Contagious: The good news is that close family, friends, and health care workers are not showing symptoms. The bad news is that these 28 people all got sick somehow, and no one know how.

Focusing In On a Toxin: Right now the efforts are continuing to eliminate known viruses and bacteria as a possible cause and the attention is shifting towards the possibility of some kind of toxin at work. Maybe it was bad meds, maybe it was food, maybe it's something else.

No Explosion of New Cases: The other good news is that there was one outburst of cases and then not much new. The 28 people that are ill have all been identified, and there's not like 20 or 50 or 1,000 new cases being reported every day.

Not the First Time: Dr. Alleyne mentioned that this is not the first time that Panama has been through this type of emergency. When the cholera outbreak occurred it took them some time to recognize it as cholera. Same thing with the hanta virus, same thing with the cases of radiation overdose at the cancer hospital. Sooner or later you figure it out, it just takes time.

The Costa Rica Rumor: There was a rumor flying around today that Costa Rica has closed their borders with Panama. Health officials said that's not true, and that they have been in contact with Costa Rican health officials and are exchanging information, but that the border remains open.

Social Security Focus: The Director of the Social Security system said that "there are more than 3 million people in Panama, and 2.2 million of them are covered by the Social Security health system" so of course there's a good chance that these cases would originate in people who are in the social security system.

Small Number of Cases: Right now 0.000008% of the Panamanian population has been affected by this illness. Your chances of getting hit with this are slim, and even slimmer if you're a woman. 90% of the cases are men.

Scratch "high fever": Health officials put out today that they are taking "high fever" off of the list of symptoms for this illness. The progression remains diarrhea, nausea, vomiting, and headache, followed by acute renal failure, severe reduction in the production of urine (to zero), a neurological element which manifests itself with paralysis around the face, heaviness or numbness of the limbs, and eventually death.

More Coming: That's about all of the high-points of this evening's news brief. I've got some appointments scheduled for tomorrow and will hopefully have some more information soon. But for the most part, there's simply not much new.