Thunderstorm asthma: "You"re talking an event equivalent to a terrorist attack"

A sudden drop in temperature in Melbourne on Monday evening from peaks of 35C brought with it severe thunderstorms and triggered a mass asthma event that left hospitals struggling to treat 8,500 patients.

There is a small group of researchers around the world working to understand the phenomena known as “thunderstorm asthma”, which although rare, can have devastating consequences. Climate change, they say, may be where part of the blame lies.

On Sunday 20 people remained in hospitals across Victoria, struggling with respiratory and related conditions, while four remained in critical condition. At least five people are known to have died after their asthma was triggered during the thunderstorm, the health department confirmed over the weekend.

A major, state-wide investigation into the response of emergency services to the event has been ordered.

Paramedics did the best they could to respond to an unprecedented 1,900 emergency calls in five hours on the evening of 21 November but were unable to reach everyone in a reasonable time. Ambulances made constant trips to emergency departments already overwhelmed as hundreds of patients streamed in under their own steam.

The acting general secretary of Ambulance Employees Australia, Danny Hill, said it would have been a traumatising night for paramedics.

“For anyone who worked that night, from staff on the ground to senior management, they regarded it as the busiest night they ever worked in their whole careers,” he said.

“Very few crews got fed. They worked 14 hours straight. Everyone worked together, worked hard, and stepped up. There was about 30 people who were so severely ill that they had to be taken straight into intensive care. So you’re talking an event equivalent to a bushfire where people are severely burned, or a terrorist attack where people are critically injured.

“That’s the level of chaos our crews dealt with on Monday night.”

Asthma patients can be some of the most difficult for paramedics to respond to. They deteriorate very quickly, and severe cases require more than the immediate treatment a paramedic can provide, including continuous days of intravenous drugs and ventilation. Many, Hill said, went into cardiac arrest.

Kathy Bowlen from St Vincent’s hospital said the emergency department there had considered opening a temporary emergency department in the foyer of the hospital to cope with the demand.

While not the first case of thunderstorm asthma in Melbourne, it was the most deadly and the severe. What researchers don’t know is why sometimes a combination of high pollen counts and thunderstorms lead to a mass asthma event, while other times, those two factors combined have little impact on people’s respiratory health at all. What other factors might be playing a part?

What is known is that grass pollen is usually too big to get into the lungs to cause asthma, and instead causes a reaction in the superficial respiratory systems of those with pollen sensitivity: a hay fever reaction such as a runny nose, sore throat and itchy eyes are more common.

But when a thunderstorm occurs, pollen which had settled during the day can be swept back into the air and the moisture in those winds combined with wind power causes the pollen to rupture into smaller pieces, between 0.5mm and 2.5mm in diameter. Those small fragments are then able to penetrate the superficial respiratory system and get into the lungs, triggering asthma and other serious respiratory responses.

Gennaro D’Amato is a professor of respiratory medicine in Italy and chairman of the World Allergy Organisation’s climate change, biodiversity and allergy committee. He is the world expert on thunderstorm asthma and one of the most published authors on the phenomena in the scientific literature.

He has been monitoring thunderstorm asthma events throughout the world and says they have also been seen in London in the UK, Naples in Italy, and Wagga Wagga in New South Wales.

A sudden and extreme asthma outbreak that occurred in London in June 1994 coincided with a heavy thunderstorm, D’Amato said. In the space of just 30 hours, 640 patients with asthma or other airway diseases attended London hospitals, nearly 10 times the usual number. For 283 patients, the storm triggered their first known attack of asthma. And for every patient that did seek help, many more suffered at home.

“Fortunately, even though it can induce severe asthma, outbreaks associated with thunderstorms are neither frequent nor responsible for a high number of disease exacerbations,” D’Amato told Guardian Australia.

“However, the mechanisms involved in the release of allergens from pollens during thunderstorm should be known so that patients can receive information about the risk of an asthma attack, including in those usually only affected by seasonal allergic rhinitis [hay fever].”

The frequency of thunderstorms had recently increased in some geographical areas, he said, particularly in temperate and subtropical climates. Research has shown that thunderstorms and their destructive winds are expected to become moresevere as the climate changes.

D’Amato has found a number of characteristics common to all of the asthma epidemics. Theiroccurrence is closely linked to thunderstorms, are limited to late spring and summer when there are high levels of airborne pollen grains, have an onset close to the arrival of the thunderstorm and to major rises in the concentration of pollen grains, and people with hay fever and asthma and who stay indoors with windows closed during the thunderstorm are unaffected.

Those not undergoing asthma treatment are at major risk, his research has also found. In the Melbourne epidemic on Monday, between 20 and 40% of those affected had never had asthma before, and so would not have been undergoing treatment.

Associate Prof Paul Beggs, an environmental health scientist with Macquarie University in Sydney, is best known for his research on climate change and its impact on allergens such as pollen.

Some research had found that the potency of pollen grains had been increasing, he said. Anthropological climate change through the release of carbon dioxide into the atmosphere could be responsible for this growing pollen potency, he said.

Between 20 and 40% of those affected had never had asthma before, and so would not have been undergoing treatment

“Plants use carbon dioxide in photosynthesis,” he said. “It’s like if you change your diet, there are changes in your body. So plants use carbon dioxide through photosynthesis, and if you change the concentration of carbon dioxide in the atmosphere then their growth conditions are changing.”

“A few smart scientists thought to put these highly allergenic plants into a glass house where we can control all the conditions, from the temperature to light, water and levels of carbon dioxide.”

What they found, he said, was increasing the amount of carbon dioxide led to a whole range of changes in the plants, including more pollen and more potent pollen.

“All of these thing are happening in the background: climate change, increasing pollen potency, and they all mean a thunderstorm asthma episode is more likely than it was 20 years ago.”

Beggs is a researcher with the AusPollen Partnership, a multi-centre cross-disciplinary team of investigators including eminent allergy physicians and scientists looking at pollen aerobiology and climatology. Their work is essential given Australia is the fourth worst country for allergic hay fever and asthma.

The principal investigator on that team, Associate Prof Janet Davies, said another factor researchers believed may trigger asthma is a sudden temperature change, which occurred in Melbourne on Monday as the temperature fell rapidly from 35C into the low 20s. But much more research and data was needed to understand the phenomena, she said.

“The AusPollen Partnership is encouraging people to tell us about their symptoms and triggers, and free app downloads allow people to do this daily if they want to,” she said.

“That will help us understand regional patterns and, by integrating that data with geo-spacial data, will help us understand who is at greater risk and the threshold for triggering a higher risk.”

The difficulty for researchers is that pollen monitoring, though extensive in Melbourne, did not go back far enough to help them develop a clear picture of all the factors triggering thunderstorm asthma. This would allow them to issue alerts when they could see a perfect storm of risk factors about to collide.

But Associate Professor Ed Newbigin from the school of biosciences at the University of Melbourne said thunderstorm asthma was going to be “a hard thing to get a handle on” because of the lack of data.

“The big question is why sometimes high pollen counts combined with thunderstorms sometimes trigger these asthma events and sometimes don’t,” he said.

“We need to understand what other factors work together if we want to reduce thunderstorm asthma. Because in Melbourne, high pollen counts and thunderstorms often coincide. But most of the time when they do, nothing happens.”

Thunderstorm asthma: "You"re talking an event equivalent to a terrorist attack"

Pakistan"s polio-busters try out to have illness regardless of terrorist opposition

For years the red pins stuck into the big map of Pakistan on the wall of 1 of the UN’s most skilled polio-busters have shown the ailment in steady retreat. The place after they could be discovered all over, the pins – each a single representing a youngster killed or crippled by the illness – had been pushed back by relentless public well being campaigns into just 3 clusters.

Two are positioned in and all around the cities of Karachi and Peshawar in the south and north-west, where the illness flourishes in unsanitary slums in which drinking water is effortlessly contaminated with human waste. But the majority erupt from a modest pocket of land representing less than 1% of the country on the border with neighbouring Afghanistan.

The explosion of pins on the map is not an accurate depiction of the scale of the dilemma, with 54 cases in the tribal company of North Waziristan this yr. “We ran out of room for a lot more pins a long time ago,” mentioned Elias Durry, the head of the Globe Overall health Organisation’s anti-polio work in Pakistan, who is also a veteran of successful campaigns to stamp out the ailment in Africa and Yemen.

North Waziristan’s capability to produce more than half the world’s polio instances in the past yr has produced it the greatest risk to the international hard work to stamp out a disease that can easily reinfect areas that have been cleared.

It poses this kind of a threat that since 1 June most travellers, youthful and previous alike, have had to get revaccinated prior to leaving the nation in situation they get the condition with them.

Although almost everything about tackling a hugely infectious disease in a nation with widespread poverty is tough, curbing the uncontrolled outbreak in North Waziristan has been not possible. No well being polio vaccinator had been in a position to phase in to the tribal agency because June 2012 when the militants who managed the spot banned all wellness staff in what they stated was retaliation for US drone strikes. It followed revelations that the CIA had utilised a hepatitis B vaccination programme in the city of Abbottabad as a front for attempting to track down the former al-Qaida chief Osama bin Laden.

Wellness employees in contrast North Waziristan to a gushing tap that could not be turned off, forcing the campaign to concentrate sources on elaborate efforts just to cease it spreading. So the launch on 15 June of a massive military operation against the foreign and domestic terrorists who had come to rule North Waziristan is observed by Durry and his colleagues as a large step forward.

Polio circumstances marked with red pins on a map Photograph: Jon Boone for the Guardian

“It is a genuine chance for us,” he explained. “We have been desperate to get entry to these folks for a long time.”

While it has developed misery for about half a million men and women who have had to flee their homes, the internally displaced have been forced to pass by means of army checkpoints, where they have been vaccinated.

Previously practically 200,000 previously unreachable civilians fleeing hostilities have been taken care of with drops of a remedy containing a extremely weakened form of the polio virus.

But in underdeveloped nations 1 treatment method is not adequate for often malnourished and sick youngsters to develop the immunity essential to guarantee the virus ultimately dies out.

It implies youngsters have to be continuously re-dosed, with those in minimal-threat areas typically expected to obtain about 6 doses a year whilst these living in the teeming slums of huge cities acquire the drops up to 15 times annually.

Such efforts are assisting to drench Pakistan’s young children with polio drops – in the past two years a lot more than 420m doses of oral polio vaccine have been administered.

The displaced young children of North Waziristan will have to be tracked. Producing the process more difficult is the unwillingness of most civilians from the area to remain in the refugee camp set up by the army. The nation has currently mounted a massive hard work to target youngsters a lot more or much less at random as they travel close to the nation, in addition to the classic door-to-door campaigns.

Teams are working at hundreds of “transit stations”, this kind of as the grand Raj-era train station in Rawalpindi, where young polio vaccinators and their police guard have 15 minutes to function their way down the trains prior to they press on with their journeys.

Passing through the grimy old carriages, a two-man staff search for young children younger than five. If their dad and mom agree, the vaccinators whip out small plastic phials from a cooler box and briskly put drops into the children’s mouths.

On a train containing dozens of families travelling en masse from the sprawling port city of Karachi – a polio hotspot – to the town of Mirpur in Khyber Pakhtunkhwa (KP) province, there is not sufficient time to cover everyone and the train pulls out of the station ahead of they attain the last two carriages.

“We do our very best, but the trains are often really occupied,” said Bilal Aftab, one particular of the vaccinators, as he watched the line of green carriages trundle onwards.

Not surprisingly, vaccination fatigue is setting in between some mother and father. 1 mom crossly swished away the vaccination team when they poked their heads over a privacy sheet tied across their part of the carriage. “We gave it to our daughter a lot of instances and it gave her a poor stomach,” she explained, incorporating that she had heard stories of the drops damaging some kids.

Parental opposition is just 1 of the a lot of problems that have made Pakistan a especially tough nut for worldwide polio elimination efforts. There is widespread misinformation about the vaccine, which has been demonised as being portion of a western plot to curb birth costs in the Islamic planet.

Police commandos guard a polio vaccination staff at a security checkpoint. Photograph: Hasham Ahmed/AFP/Getty Photos

In late 2012 militants began killing vaccination teams, a lot of of them led by an army of “lady wellness staff”, making however more issues.

It has all added to the already difficult and pricey process of wiping out the last vestiges of the condition. About $ 227m (£133m) will be spent this 12 months in Pakistan alone.

It is the sort of outlay that horrifies sceptics, who believe the ambition to eradicate rather than management polio is a grandiose pipe dream that overburdens creating countries and diverts sources from many other pressing health demands.

With only 1 other human illness – smallpox – effectively eradicated, some argue the purpose is eventually unrealisable. They level out the target 12 months of 2000 for global eradication has been repeatedly pushed back.

Advocates say it is worth it because as soon as polio is eradicated from the 3 remaining nations where it is endemic the benefits will be value-totally free for the rest of time.

Durry says the intense concentrate on polio has helped push through essential reform of the country’s well being service, which was when plagued with “ghost” vaccination teams.

This 12 months Peshawar pioneered a enormous campaign to inoculate entire populations of kids beneath the age of 5 on a single day, repeating the operation for up to twelve consecutive weeks.

To deal with the risk from gunmen, the streets had been flooded with four,000 policemen on vaccination days, even though neighbourhoods were cordoned off and motorbike-riding banned.

There have also been efforts to challenge well-liked suspicions about a high-profile, effectively-funded campaign backed by global bodies and western philanthropists such as Bill Gates. Nearby campaigns have been renamed and rebranded so there is no longer any mention of worldwide organisations.

The Islamic Growth Bank has come forward to choose up the bill for the 2014 work.

Respected religious scholars have been pressed into publicly supporting the hard work and several teams carry small booklets of pro-vaccination edicts issued by scholars.

But regardless of increasing optimism that the campaign derailed by Pakistan’s religious militants might at final be obtaining back on track, the basic issues of attacking the illness indicates the red pins will not disappear totally for years to come.

Elias Durry said the military operation towards militants in North Waziristan was a ‘real opportunity’ for polio vaccination campaigners.

• Polio is an ancient scourge that has been paralysing, deforming and killing its victims for millennia. 1 stone carving from ancient Egypt has even been identified showing one particular sufferer with a characteristic withered leg walking with the aid of a stick.

• There is no remedy for the condition, induced by a single of 3 diverse viruses which enters the entire body via the mouth, proliferates in the intestine then invades the central nervous system, destroying cells that activate muscles. It brings about irreversible paralysis

• Its perfect environment are crowded cities where the disease can effortlessly be passed on, usually by faeces contaminating consuming water. The huge bulk of folks infected with the virus never ever display any of its signs, meaning they can spread it on to 1000′s of others ahead of the very first case of paralysis emerges.

• Large epidemics in the early 20th century were responsible for killing and paralysing hundreds of 1000′s of youngsters. The 1st vaccine was developed in the 1950s. That was largely superseded by the invention of orally administered vaccines that are cheaper and less complicated to roll out on a mass scale.

• In 1988 polio was eradicated from much of the designed planet and an worldwide work was launched to wipe it out all over the place else by 2000.

Pakistan"s polio-busters try out to have illness regardless of terrorist opposition