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Hopefully, you'll forgive us for our temporary neglect of this blog. Though we've not been too busy to eat--I hope that never happens!--we have been to busy to write about it. But now I'm at home, contemplating a blissfully empty afternoon, and can finally sit down and digest (ha-ha) what's transpired over the past couple months, at least gastronomically.
Late May through mid-June found me in Iceland, an austere and humorless country (the landscape, not the people, especially after a couple drinks) whose food generally follows suit. On most dinner tables you'll find: lamb, fish, canned peas, lamb, fish, and canned peas.
The capital of Iceland, Reykjavik, is a city of only 120,000 people. For a city so small in a country so small (only 340,000 live on the entire island), it has a remarkably developed coffee culture. Good coffee is everywhere, mostly in the form of espresso-based drinks, though one especially great coffee shop, Kaffismiðja Íslands, felt a lot like home--one of my travel companions mentioned it reminds her a lot of Portland.
They had drip in the form of V60, aeropress, and espresso from a La Marzocco machine.
...as well as plenty of Barista Cups on display. Kaffismiðja Íslands was definitely my favorite thing about Reykjavik. The interior was cozy and mismatched and, yes, very Portland; the pastries, especially the croissants and the scones (served with cheese, jam and butter) were addictive; and the coffee was always good, in any preparation. I'll definitely miss this place.
What I found to be the most interesting thing about food culture in Iceland is the almost complete lack of grocery stores.
All Icelanders have, for the most part, are Bonus and 10-11. Bonus is sort of like a grocery store, except all the produce is kept in a refrigerator the size of a walk-in closet; everything else is packaged nonsense, although since most of Europe isn't owned by the corn lobby, there's very, very little corn syrup to be found in anything.
10-11 is a convenience store with frozen bagels, what looked to be month old blueberries, and the ubiquitous Skyr.
Skyr is yogurt made from nonfat milk. It has the consistency of greek yogurt, but since it's nonfat, it's essentially flavorless on its own, hence the need for added flavors such as strawberry (we here at Consider the Dinner have issues with flavored yogurt as well as nonfat anything). Despite its problematic structure, Skyr was my life support while in Reykjavik as its blueberry, melon, and lemon flavors stood in for my daily fruit intake.
Reykjavik was disappointing, from a food standpoint especially, but the rest of Iceland wasn't. Part two of my Nordic saga will discuss eating atop 700,000 year old glaciers, among other things.
]]>In light of the recent and obscene developments at Burger King, Consider The Dinner's board of trustees is suspending, seriously reconsidering, and perhaps replacing Bacon Thursday™ with a more conscientious Quinoa Monday™.
After an hour or two of gazing at a shockingly people-free ocean-front and exfoliating our feet in the sand, we headed back home, utterly starved. Luckily for us, we ended up at the best possible thing to eat after a long day in the sun: mexican food.
The place is called Tommy's, at 24th and Geary in the Richmond. According to their website, it's been open since 1965--and the exterior certainly looks aged. I've walked past it several times and never paid it much attention; the main draw would be the big bowls of freshly fried tortilla chips in the window, although the glass they're behind is dingy and old. Not exactly appealing.
However, it had been recommended by a friend, and I'd seen it recommended in Esquire as "America's leading tequila bar." The question is why I hadn't been there yet.
First off: complimentary chips and two truly fantastic salsas that took a minute or two to kick in. The chips were so good, and we were so hungry, that we probably finished off the first basket of chips in under four minutes. Said basket was again refilled within about thirty seconds.
Secondly: a drink.
A good, no-frills margarita, salted rim, 100% Agave and on the rocks. If you're not hungry, go here for the drinks alone. It's worth the twenty minute trip on the 38.
Emanuel: I eat Mexican almost every week, mostly at taquerias, sometimes at taco trucks, and rarely at upscale, fancy (read: expensive) Mexican cuisine resturants like Mamacita, our go-to in that department.
I almost never go to the less popular in-between option: sitdown, family-style Mexican restaurant like Tommy's. Actually the only other similar place I can recall going to is Mexicali Rose in Oakland, which is a shame because I really enjoyed it, as I did Tommy's.
We'll have to go again when we're not starving to confirm, but the food certainly hit the spot after our long walk, though it was apologetically over cheesed. My beef enchilada was nice and gooey and the masa in the tamale Angela ordered, which in other places tends to be a dry, somewhat useless filling, was rich and flavorful. The high point I think was Angela's black beans, and the low point were the tortillas on the side that we suspect may have been microwaved.
All in all, we'll be back at Tommy's. Often. Which is great because there's now another great Mexican place to go to in the neighborhood, and not so great because now there's another great Mexican place in the neighborhood taunting me to make irresponsible decisions every time I walk by. And they serve tequila. Dangerous.
Tommy's Mexican Restaurant
5929 Geary at 23rd Ave
San Francisco, CA
Emanuel: This grilled cheese sandwich with Marin Sun Farms bacon certainly wasn't bad, but as it turns out it wasn't as good of a match as our salivary glands predicted. The problem, if you can even call it that, was that the bacon was overpowered by the cheese, which is quite unfortunate as it was very high quality thick-cut bacon.
Angela: We probably went overboard when we drizzled the bacon grease from the first sandwich into the pan with the second.
Emanuel: I blame the Gregorian calender.
Emanuel: I don't know what authority South Boston has over the kind of sandwiches on offer at Rockridge's Southie, but I can't argue with the evidence ingested thus far.
The meatball sandwich, or "The Balls" as it's listed on Southie's menu, is traditionally an Italian sandwich, and so makes me think about appropriately greasy pizza joints in New York/Jersey.
The pulled pork sandwich ("Spicy Hog" on the menu), similarly, is increasingly harder to associate with any degree of authenticity the further north you travel from Chapel Hill, NC, or at least that's what the locals claim.
This in no way changes the fact that both of the sandwiches were each some of the most delicious in their respective class. That's a lot of sandwich range for the little sister restaurant of next door's Wood Tavern.
If a lot of hip restaurants these days can be reduced to a single high concept, Southie's particular shtick is using good ingredients to carefully prepare what are usually considered sloppy sandwiches to be consumed standing, probably before or after a "game" of some sort, most likely while inebriated. Even the seating situation at Southie's reinforces this, all high bar stools seemingly to discourage lazy post-gorge loungers.
This perhaps is what Southie means by its slogan: "East Coast Mentality, West Coast Sensibility," i.e. East brings the comfort of slop, West brings the grass-fed, Chez locavore, self-righteous but damn tasty beef.
Short version is the shtick works. It's been a while since I've had the Spicy Hog but I remember it was very good, tender and unlike amatuer pulled pork, was not pulverized and drenched with sauce so indistinguishable from liquid. The slaw also was virtuously fresh, undrenched, and recognizably a vegetable.
As I often say, I loved The Balls. Easily the best meatball sandwich I've ever had. Good bread (La Farine baguette), good cheese (provolone and reggiano) but mostly it was the high quality of the meat (Niman Ranch) which most establishments that serve this kind of sandwich simply don't use.
Even Angela, whom I usually fear will order the wrong thing, scored with a soup and surprisingly generous grilled cheese sandwich that I obviously ate at least half of.
Angela: I love grilled cheese sandwiches. Love them. The other night I came up with the brilliant idea of cooking a grilled cheese in mayonnaise, which Emanuel immediately coined "white trash" until I looked it up online and found the idea endorsed by the much-esteemed Gabrielle Hamilton.
So not only do I have brilliant ideas (great minds think alike), but I consider myself somewhat of a connosieur.
That being said, the grilled cheese sandwich at Southie is pretty good. It's on a baguette--which isn't ideal, in my opinion. The cheese can get somewhat overwhelmed by the bread, and you want the cheese to be the star of the show.
But it wasn't bad. It was even better dipped in the soup, a fatty, meaty bowl of thoroughly satisfying winter deliciousness. The whole thing was definitely a cold-weather meal. And given that winter seems to be sticking around even into April, I'll definitely be back at Southie.
6311 College Ave
(at 63rd St)
Oakland, CA 94618
In the futuristic 1975 of 1962 this was a big concern. Some things never change.
Apparently the idea was that the bacon would come prepackaged in a wallet you could just drop in the toaster, heat, and reseal in case you had any leftovers.
(Source: Derrick Bostrom)
]]>But I don't think it gets better than Smitten Kitchen. She's only let me down once, with a recipe for tomatoes stuffed with egg and romaine pesto (I don't know why anyone would ever want to just eat the skin of the tomato when the gel-like stuff on the inside is the best part--but I didn't know this beforehand). Everything else she's contributed to my breakfast/lunch/dinner/dessert table has been worth making again; hence her recipes are the ones that form a majority of what I bake.
It's her honey cake, though, that I'll be baking until I'm too old to bake anymore. There are very few recipes out there that I like better than this one, and because it's so simple, I make it probably a little too often.
Usually, as Smitten Kitchen writes in her entry, it's not that good, being too dry, too crumbly, too meh. This recipe is an exception.
So what is it? The spectacular amount of honey and other sugars that go into this thing? Is it the whiskey, the coffee? I don't know.
What I do know I'll tell you now:
1. I usually add a little extra whiskey. I like the liquor flavor a little punched up, but that's just me.
2. Yes, it's a tablespoon of baking soda. She writes that her cakes sunk in the middle, but I've always added the full tablespoon and never had that problem.
3. Don't skimp on the cinnamon. Don't skimp on the sugar. Don't skimp on anything.
4. Most importantly, this cake is better after a couple days. Once the cakes are cooled, I take them from their little parchment-paper cribs and re-wrap them tightly in aluminum foil. Then I put them in the bread box and wait. You could also put them in the freezer. It's your call.
We don't want readers to get the impression that Jewish cuisine, in all its various and wonderful forms, is our primary interest. Not that there is anything wrong with that, but there are plenty of other food blogs that cover the matter extensively and with great success.
In service of this great culling I have devised an ultimate answer, a kind of final solution if you will, which will purify this great blog once and for all.
I am of course referring to the secret weapon which has tempted even the most pious Jew off the straight and narrow.
Bacon. When in doubt: bacon. And when not in doubt, bacon as well.
Specifically, where bacon comes from. I'll admit that I was kind of oblivious about what has to be one of my most favorite meats. Maybe it's one of those things where something tastes so good you just assume it has to be horrible for you in every conceivable way.
I didn't want to know how the sausage was made, so to speak, because I somehow I got it into my head that bacon was produced by a process which pressed discarded and otherwise unspeakable pig bits together, forming a kind of near-meat product but not meat in the honest sense of the word.
(I must confess, the awful idea may have slipped into my mind after watching an episode of Dirty Jobs in which Mike Rowe makes Cracklin'.)
I would give the above a try, but it's no bacon, which I was happy to discover was made by a much more wholesome process after watching the beautifull, dare I say it, inspiring video below:
The Disappearing Pig from Open Air Publishing on Vimeo.
Also, I'm sure bacon will make repeat appearances around these parts, but I can call it right now. The best most perfect use of bacon I've ever tasted is Peter Luger's thick cut bacon. I don't think you can top this:
Saviors come in all shapes and sizes; however, not all contenders quite make the mark. And while any loaf of bread might be better than no loaf of bread, there are some that have definite miracle-making qualities.
In San Francisco, we're surrounded by good bread. Acme, Semifreddi's, and La Farine all do the trick. You can be happy with a little bit of bread spread with butter and perhaps sprinkled with a pinch of salt. But these breads, while perfectly acceptable, do not have fly-me-to-the-moon capabilities. Or whatever.
Della Fattoria, however, does.
Above is their Semolina loaf. It is so good it does not need anything. No butter, no salt, no nothin'. It tastes this good for several days, I'm guessing mostly from the oil content in the sesame seeds.
Despite being this good on its own, it will also make the most amazing grilled cheese sandwich you'll ever have. The sesame tastes divine--yes, divine--when toasted.
Those holes? That sometimes, in bread-making, are viewed as an accident? That's one reason this bread makes a spectacular sandwich. When the cheese melts, some of it falls through that hole, only to turn crispy on the sandwich's exterior.
Sadly, this bread is not easy to find. Della Fattoria Bakery has a stand at the Farmer's Market on Saturdays; a couple of Whole Foods in San Francisco carry it; Bi-Rite and Mollie Stone's have it as well. At Whole Foods on California a couple nights ago, the bread rack was fully stocked with Della Fattoria. Perhaps it is the brand's unfortunate use of Papyrus-type font, but no one seems to be buying this bread. This is a huge mystery, as it completely outshines any other bread available. You can find their complete list of wholesale accounts here.
Emanuel: We haven't tried other Della Fattoria products but this semolina bread is one of the best, fairly available loaves in the Bay. With all due respect to Acme, you can do a whole lot better these days. Acme is one of those Chez Panisse off-shoots that raised the bar years ago, but there are smaller businesses out there today that are setting it even higher.
]]>It occurs to me that they're not all the enticing in pictures or writing if you've never tasted them before.
I've also considered the possibility that it's just one of those foods you had to grow up with in order to appreciate, but it didn't take much to get Angela addicted to them, and it's not the kind of thing that would appeal to her on paper.
It's a common theme in a lot of Jewish food. Cholent, kugel, knaidlach (matzo balls); They simply aren't as photogenic as, say, Vietnamese or Mexican food, where bright greens contrast with bright reds, and sizzling chewy bits hang out of a tortilla all seductive and muy caliente.
Ktzitzot are comfort food in the truest sense of the word. They're not sexy. They're probably the opposite of an aphrodisiac, but they'll make you feel full and happy and highly nap-capable.
What I'm trying to say is that the following recipe and pictures may not look all that snazzy, especially with our crappy iPhone photography, but you'll be wise to just trust me on this one.
As far as I know the following is one of the more simple recipes, and I don't feel like it's missing anything at all.
You obviously always want to use the highest quality beef, but ktzitzot, like meatloaf, are great in that you can make do on a budget. For this batch specifically I used Trader Joe's ground beef and it was still delicious.
I used:
a pound of ground beef (85%)
Two medium yellow onions
Two eggs
Parsley (optional)
Olive oil
Bread crumbs
I'm using Osem bread crumbs which are made in Israel. This is not some hometown pride nonsense nor does it make a difference flavor-wise, but it's better than Progresso, which I do my best to avoid.
The Osem brand has 7 ingredients which sound like they could conceivably belong in breadcrumbs. Progresso has around 30 ingredients, with the second and third being high fructose corn syrup and corn syrup, respectively.
Anyway, you want to start by chopping the onions and frying them in olive oil in a big pan until brown, just before they start to burn.
While that's happening, mix in a bowl the ground beef, eggs, salt, parsley, and paprika, periodically adding just enough breadcrumbs to soak up the liquids. You want the mix to be moist and shiny but not wet. Once the onions are nicely browned, add them to the bowl, using a spatula to incorporate them into the beef mixture. Alternatively, mix with your hands like a badass.
Use a paper towel to wipe away some of the oil and any stray onion that's still on the pan. Turn the heat to low and melt butter in the pan.
Now you want to make the patties. The crucial tip here is that you don't want to handle the meat too much. Make a small ball and place it on the pan.
Don't toss it or compact it in your hands. Just make it into a nice sphere, handling it as least as possible, and place it in the buttered pan. Then use a spatula to flatten it.
Once the pan is full with patties you might want to turn the heat up a little. I like my burgers medium, but I find that ktzitzot are better well-done. You can cook them slowly until they're nice and brown, or even until they are almost black and crispy on the outside.
Once the ktzitzot are cooked place them on a plate that's been readied with paper towels to soak up oil.
Angela: These things are delicious. They're adequately described as "things," I think, because they're really just awkward lumps of beef cooked to magnificence. Now, if you were me--which wouldn't be such a bad thing--you'd ask for these nice and crispy-dark on the outside. Lots of things look good in pink, but ktzitzot isn't one of them.
Emanuel: If you have the restraint to not eat them all the same day you're in luck. These are just as good if not better straight out of the fridge, and you could always reheat them if you want. They're also great with tahini or yogurt, but most of the time I just add a little salt.


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VIN: 2375911 A 1976 BMW 2002, blue on blue interior. Sunroof, 4 speed manual gearbox. Just came out of long term storage where it sat... More
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1958 MGA Coupe '58 MGA Coupe, pale yellow, solid wheels, sitting for many years, excellent restoration candidate. For $5,950 USD If you have any additional questions Please... More
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Less than one thousand 1958 Packard sedans were made, making this an exceptionally rare car and the perfect project car with a lot of... More

subset: commoncrawl


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Wondering if any of you out there know how to sex turkey pullets to be sure that we have some toms. Most of the pullets we have all look like hens, and I would like to know a more scientific way to sex them. |
Follow-Up Postings:
- Posted by sullicorbitt z5 MA (My Page) on Tue, Sep 18, 07 at 9:02
I think you are referring to poults (young turkey), pullets are young female chickens. I don't know of a scientific method, we have 4 turkeys now about 4 months old, the biggest difference we saw with the Toms was the size (much bigger). Also the Toms seem to have more squabbles between themselves, our lone hen doesn't bother herself with such childish behavior :) Their head and their wattles, which is a fleshy growth under their chin, will be larger. His snood, which is a fleshy growth on top of his bill, will be longer and hang down the side of his face. Toms are the only ones who strut and gobble. Hope this helps. |
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My Profile
Newton, Massachusetts
Member since Jun 2009
Flag This ProfileFlag as Inappropriate
Reviewed Pulled Pork with Mango BBQ Sauce
Apr 12, 2011 in Food Network Community Toolbox on FoodNetwork.com
"Easy, absolutely delicious, and a huge crowd pleaser. You just need the time to do the slow cooking. I also think it would be fabulous for chicken. That's my next attempt!""


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You may get Lyme disease when you are bitten by a tick that has been infected with the germ (bacteria) that causes Lyme disease. The disease can cause a "bull's eye" rash, chills, fever, headache, fatigue, and muscle pain.
Below are some questions you may want to ask your doctor or nurse about Lyme disease.
See also: Lyme disease
Where on my body am I most likely to get a tick bite?
If I get Lyme disease from a tick bite, what symptoms will I have?
How can my doctor diagnose me with Lyme disease? Can I be diagnosed even if I do not remember having a tick bite?
What are the antibiotics used to treat Lyme disease? How long do I need to take them? What are the side effects?
Will I have a full recovery from my Lyme disease symptoms?
What to ask your doctor about Lyme disease
Updated by: A.D.A.M. Editorial Team: David Zieve, MD, MHA, and David R. Eltz. Previously reviewed by David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine (2/24/2011).
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. Copyright 1997-2015, A.D.A.M., Inc. Duplication for commercial use must be authorized in writing by ADAM Health Solutions.


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(10-31-2012 06:25 PM)ejnfl24 Wrote: I wish he was still with the team. We could really use him. I think he's got more talent/upside than Meachem. I just wish we had someone in the front office that felt the same. My bad!!! Didn't realize we had re-signed him a couple days ago! Welcome back Tutu!!!
(10-31-2012 07:51 PM)chargers2427 Wrote: YA i was stoked when they signed him!!! Maybe he will get some PT and go up up and away! Gotta love his name to!
(11-01-2012 12:36 AM)ejnfl24 Wrote: Yeah I was upset we let him walk after his rookie year (partially because I have some $ invested in his RC's because I truly believe he has the necessary talents to succeed in the NFL.). I'm more than thrilled to see him back as a Bolt!!! Here's hoping he can make an impact sooner rather than later!
(11-01-2012 06:06 PM)chargers2427 Wrote: Ya i have a bit in him but hopefully more to come! With Meachem and Royal out tonight he should be out there quite a bit! Hopefully he doesnt explode tonight so i can get some more cards!


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Donna's meat loaf
active time1hr 25min
1 lb. ground beef1 lb. ground veal
1 lb. ground pork
1 T. Worcestershire sauce
1 T. Dijon mustard
1/3 C. oatmeal
1/3 C. crushed saltine crackers
1 med. onion, chopped
1/2 C. milk
2 garlic cloves, chopped, saute in oil
salt and pepper
1/2 C. parsley chopped
1/2 C. thyme
On Top:
1 C. catsup
3 T. red wine vinegar
1-2 tsp. Worcestershire sauce
3 strips of bacon
Mix all the meatloaf ingredients together. It shouldn't stick to the bowl. Put into a foil-lined and sprayed pan about 5 x 9 inches.Cover with the "on top" ingredients.
Bake in 350 degree oven for about 1 hour until internal temperature is 160 degrees.
To grill
Cook in pan over indirect grill heat for about 2 hours.
my notes
recipe at a glance
type: Quick & Easy, Casserole/Gratin
main ingredients: Beef
cuisine: American
dietary considerations: High Fiber
holiday/celebration: Potluck


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Volume 14, Number 10—October 2008
Risk Factors for Nipah Virus Encephalitis in Bangladesh1
Suggested citation for this article
Nipah virus (NiV) is a paramyxovirus that causes severe encephalitis in humans. During January 2004, twelve patients with NiV encephalitis (NiVE) were identified in west-central Bangladesh. A case–control study was conducted to identify factors associated with NiV infection. NiVE patients from the outbreak were enrolled in a matched case-control study. Exact odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using a matched analysis. Climbing trees (83% of cases vs. 51% of controls, OR 8.2, 95% CI 1.25–∞) and contact with another NiVE patient (67% of cases vs. 9% of controls, OR 21.4, 95% CI 2.78–966.1) were associated with infection. We did not identify an increased risk for NiV infection among persons who had contact with a potential intermediate host. Although we cannot rule out person-to-person transmission, case-patients were likely infected from contact with fruit bats or their secretions.
Henipaviruses (family Paromyxoviridae, genus Henipavirus) are enveloped RNA viruses that cause respiratory illness in pigs and horses and respiratory illness and encephalitis in humans (1–6). After a 4- to 18-day incubation period, human disease can rapidly progress from mild illness (fever, headache, myalgia) to coma and death within 10 days; the case-fatality ratio is 40%–76% (3,7–10). The first recognized human Henipavirus infections occurred in 1994 in Australia, where a respiratory disease among horses was associated with illness in 2 humans (11). The etiologic agent, Hendra virus, was subsequently isolated from asymptomatic flying foxes (fruit bats of the family Pteropodidae) (12). Field et al. (2) suggested that horses, identified as the intermediate hosts linked to human illness, may have become infected through indirect contact with fruit bats (e.g., infected fetal bat tissues or fluids).
The first reported human epidemic of encephalitis caused by another Henipavirus, Nipah virus (NiV), occurred between September 1998 and April 1999 in Malaysia and Singapore and was associated with an outbreak of severe respiratory illness in pigs (13–15). Most (86%–93%) human NiV encephalitis (NiVE) infections during this outbreak involved occupational exposure to pigs, implicating these animals as an intermediate host for NiV (15–18). Outbreaks of NiVE occurred in Bangladesh during 2001 and 2003, in areas where NiV antibody–positive fruit bats have been identified (19). These reports, in addition to ecologic surveys conducted in Cambodia, have strengthened evidence that pteropid bats are the reservoir for Hendra and Nipah viruses (12,20–25).
Figure 1
An outbreak of encephalitis in Bangladesh was recognized on January 21, 2004; it affected 2 villages of Goalando township, Rajbari District, Dhaka Division, 70 km west of the city of Dhaka (Figure 1). Ten deaths were reported among 12 ill persons with symptoms compatible with NiVE, resulting in a case-fatality ratio of 83% (9,23). Although previous outbreaks of NiVE outside Bangladesh involved primarily men and women >25 years of age (5,16,17,19,26), most (75%) patients in this outbreak were boys <15 years of age. We describe a matched case-control study that was conducted to characterize the epidemiology of NiVE and, specifically, to determine if risk for NiVE was associated with contact with animals; an environmental exposure, activity, or behavior; or contact with other NiVE patients during the 2004 NiVE outbreak in Goalando township.
Study Participants
A matched case-control study was conducted in Goalando, Bangladesh (Figure 1), February 18–22, 2004. Hypotheses tested in this study, as mentioned above (e.g., increased risk for NiV infection caused by contact with animals, environmental exposure, contact with fruit in season) were based upon factors associated with previous outbreaks of NiVE in Malaysia, Singapore, and Bangladesh.
Case Definition
A confirmed NiVE case-patient was defined as any patient with fever and symptoms compatible with encephalitis after December 15, 2003, with NiV-specific immunoglobulin M antibodies in cerebrospinal fluid (CSF) or serum by enzyme immunoassay (EIA). A probable case of NiVE was defined as a patient with a diagnosis of encephalitis in whom fever developed and who was living in the same village as a patient with a confirmed case of NiVE after December 15, 2003. Cases remained in the probable category if the patient died and a specimen for laboratory confirmation could not be obtained.
We conducted a population census of the affected area in February 2004; this census was the basis for selecting controls. We identified 3 controls for each case-patient. The controls were selected randomly from the population and then matched to each case-patient on the basis of gender and age group. All households identified during the census, including houses of case-patients and controls, were mapped by Global Positioning System, and data were uploaded into ERDAS Imagine 8.5 (Leica Geosystems, Atlanta, GA, USA) and merged with a November 2000 IKONOS Geo 1-m satellite image of the outbreak area (Space Imaging, Thornton, CO, USA).
Participation was strictly voluntary, and written informed consent was obtained for all participants; for those <18 years of age, individual and parental consent was obtained. The Bangladesh Ministry of Health and Family Welfare that requested this investigation reviewed and approved all protocols.
Study Population
Figure 2
Probable and confirmed cases identified in 2 contiguous villages of Goalando township (Figure 1) were included in this study. Seven of the 12 cases were clustered within 3 households. Of these 7 clustered cases, 3 occurred in 1 household, and the remaining 4 were distributed in 2 separate homes (Figures 1, 2). Therefore, we conducted 2 separate analyses to assess the effect of case clustering on results. The first analysis contained the complete dataset of 12 cases and 36 controls; the subanalysis consisted of 8 cases (we randomly selected 1 case/household) and 24 matched controls. Similar results (proportions, odds ratios [ORs], 95% confidence intervals [CIs]) were obtained from both analyses. Thus, data presented in this article, including all tables, are derived from the complete dataset.
Specimen Collection and Testing
Serum samples and CSF were tested as previously described (27). When possible, a serum specimen was collected from controls.
Data Collection and Interviews
After informed consent was obtained, case-patients and controls were interviewed at home by trained interviewers, in their native Bengali language, with a standardized questionnaire. Information such as demographics, types of animal exposures, environmental and occupational exposures, exposure to ill persons, and history of illness was obtained. Proxy interviews of family members and/or friends were conducted for deceased patients. To minimize interview bias, proxy interview methods were also used for all controls that were matched to deceased case-patients.
Statistical Analysis
Exact ORs and 95% CIs were calculated by using a matched univariate logistic regression analysis in SAS version 9.0 (SAS Institute Inc, Cary, NC, USA) (28). Associations were considered statistically significant at p<0.05.
Descriptive Characteristics
Four (33%) cases were confirmed by EIA; the remaining 8 (67%) case-patients, from whom a diagnostic specimen was not available, were considered probable cases. Among all 13 (36%) controls who consented to blood collection, results of serologic tests for NiV-specific antibodies were negative. Furthermore, none of the controls reported having had a perceived fever or symptoms compatible with NiVE from December 15, 2003, through the week the study was conducted (February 18–22, 2004). In addition, an antibody prevalence study conducted among persons (n = 300) living in the outbreak site showed no evidence of asymptomatic or mild infection, which suggested that controls entered into the study were likely uninfected (A. Croisier, unpub. data). Proxy interviews were administered to equal proportions of case-patients (83%) and controls (Table 1). The median age of case-patients included in the study was 11.5 years (range 2–28 years); 9 (75%) were male, and 11 (91%) were <15 years of age (Table 1). Residences of all case-patients and controls were located within the affected villages, an area with a radius of ≈800 m (Figure 1).
Animal Exposures
In the matched case-control analysis, a greater percentage of case-patients (60%) than controls (34%) had observed or touched dead animals, although this finding was not statistically significant (Table 2). We observed no differences between case-patients and controls with respect to contact with ill animals (Table 2), including pigs, ruminants, and fruit bats. Chickens and ducks were often slaughtered for religious purposes or for consumption; however, close contact with these animals and their bodily fluids (e.g., blood, saliva) during this process was not associated with NiV infection (Table 2). None of the case-patients or controls had known contact with pigs (healthy or ill) or pig excreta (Table 2). Four (36%) of 11 case-patients and 7 (19%) of the controls observed fruit bats around their household during the night (OR 4.1, p = 0.49; Table 2). However, some proxy family members and/or friends answering on behalf of patients who had died were unable to answer specific questions (e.g., Did you observe fruit bats around your house during the night?).
Environmental and Behavioral Exposures
A greater proportion of case-patients (83%) than controls (51%) reported having climbed trees between December 15, 2003, and February 3, 2004 (OR 8.2, p = 0.025; Table 2). No statistically significant differences were observed between case-patients and controls with respect to outdoor activities such as hunting, fishing, or playing outdoor games (e.g., hide-and-seek, cricket, soccer). Eating fruit that was locally available (on trees or collected from fruit trees locally) between December and February was not associated with illness, regardless of how the fruit was collected (from the ground, picked from tree, from the market) (Table 2). Although a greater proportion of case-patients reported environmental exposures (drinking raw date palm sap, harvesting date palm sap, having someone in the household who collects date palm sap, or drinking sap directly from the collection vessel), these differences were not statistically significant (Table 2).
NiVE Case Exposure
There were strong associations between illness and 1) visiting a hospital and/or 2) having had contact with a probable or confirmed NiVE patient (Table 2). In one 2-case family cluster, a mother (26 years of age) and her infant son (2 years of age) both became ill and died. The child became symptomatic 2 days before the mother's illness onset (Figure 2; household 4). Among the other affected family clusters, the patients became ill within 3 days of one another (Figure 2; households 1 and 5); all persons in these 2 clusters reported a history of climbing fruit trees. There was no evidence of contact of persons between case households during their illness.
In contrast to the patients in the Malaysian and Singapore outbreaks, which occurred primarily among adults, a preponderance of the NiV patients in the January/February 2004 Bangladesh outbreak were young boys. These findings, in the absence of high infection rates among adults or evidence of antibodies to NiV in the general population (investigation team, unpub. data), suggest an association between NiV infection and some childhood activity or specific behavior. The odds of NiV infection were significantly elevated among persons who climbed trees, an activity observed almost exclusively among boys <15 years of age. This behavior is quite common among children because they gather fruit from trees. Therefore, these children may have had contact with partially eaten fruit from fruit bats or the secretions/excretions of these animals. Or, the children may have contacted contaminated fruit bat guano or urine in the trees. The percentages of case-patients playing hide-and-seek, hunting, and fishing—all of which were typical behaviorial traits of local boys—were not significantly different than those for controls. These activities generally occur outdoors; however, they do not place a child in direct contact with bat excretions or secretions, as may be true for tree climbing. Therefore, infection was apparently related to a specific behavior, tree climbing, rather than age or outdoor activities in general. Furthermore, although other exposures that may have placed persons in closer contact with bat secretions (e.g., collecting fruit or palm sap from trees, drinking palm sap directly from collection vessel) were observed more often among case-patients than controls, these findings were not statistically significant; perhaps because of the small sample size. Nonetheless, our findings can and have been used to help guide NiV outbreak investigations, leading investigators to similar conclusions as ours (29).
Fruit bats forage at night in various trees that are producing ripe fruit and often drink from palm sap collection vessels (30). Fruits are also a major food source for many villagers and, as a result of environmental disturbances (31) in the form of crop development (e.g., jute, rice, and sugar cane), the few remaining fruit trees grow only in close proximity to human dwellings (Figure 1). This in turn creates a situation in which fruit bats are forced into close proximity with humans, especially while these mammals are foraging and feeding. In addition, date palm sap is routinely collected in rural areas of Bangladesh between December and May. According to villagers, including palm sap harvesters, dead fruit bats are occasionally found in the collection vessels. Local villagers reported that they often observed fruit bats feeding from palm sap collection vessels, and some collectors place cloth over the opening of the vessel to prevent this (investigational team observation). In fact, a greater proportion of case-patients in our study collected palm sap, drank from the palm sap collection vessel, or had a family member who collected palm sap; however, these differences were not statistically significant. The power of our study to detect exposure risks was limited by the outbreak size. Therefore, until additional data are available, remaining cautious of date palm sap collection vessels, especially those visibly contaminated with fruit bat excreta or carcasses, would be prudent.
Numerous investigators have found serologic evidence suggesting that fruit bats of the genus Pteropus are the reservoir hosts for NiV (23,24), and there are reports of NiV isolation from bat urine (20,25) and partially eaten fruit (20). Unpublished laboratory data from the Bangladesh investigation have not supported the presence of an intermediate or primary reservoir host other than P. giganteus. Available data from this study, therefore, suggest direct transmission of NiV to humans through contact with bat secretions or excretions (saliva, urine, guano, partially eaten fruit) during fruit-tree climbing.
Although indirect contact with bats may have been the primary means of infection for this outbreak, Hsu and others (19) demonstrated that contact with ill cows was associated with an increased risk for NiV infection during the 2001 Bangladesh NiV outbreak. Therefore, intermediated hosts should be considered in future NiV outbreaks in Bangladesh.
In contrast to the patients in the Malaysia and Singapore outbreaks (5,16,17,25,26), most of the Bangladesh population (and all of the case-patients included in this study; data not shown) are practicing Muslims who do not consume pork and who avoid contact with pigs. None of the case-patients and controls in our study population reported any contact with pigs or pig excreta, so it is unlikely that these animals played a role in this outbreak.
Clustering of cases within households was a prominent feature of this outbreak (Figure 2); 1 household contained 3 case-patients, all brothers of ages 7–15 years. However, the longest estimated incubation periods (duration from symptom onset to first known exposure to a NiVE family member) within the clusters reported here were less than the currently recognized 4-day minimum (7). This finding suggests that the family clustering may have resulted from a common source of infection (e.g., a specific tree they climbed, fruit they consumed, or palm sap collection vessel they were in contact with) rather than person-to-person transmission. Our data also show strong associations between NiV infection and visiting a hospital. However, because the participants were asked if they had visited a hospital within a range of dates (December 15, 2003–February 3, 2004) and not a specific date, we were unable to determine if they were ill with NiV before visiting the hospital or whether they acquired their infection there. Some accounts in the literature suggest person-to-person transmission of NiV; therefore, it is plausible that someone could acquire, through contact with a patient's secretions or excretions, an NiV infection while visiting a hospital (6,10,20). Nevertheless, the most probable explanation for the observed association is that NiV encephalitis patients during this outbreak were severely ill, requiring hospitalization.
Although person-to-person transmission may have occurred in this outbreak, the initial infection (index case) may have occurred through contact with bat secretions rather than contact with an intermediate host. A limitation of our study is that we were unable to identify a specific mechanism by which person-to-person transmission may have occurred. NiV has been isolated from the respiratory secretions and urine of patients in the Malaysia, Singapore, and current Bangladesh outbreaks (3,8,32,33), which suggests a potential for NiV to be transmitted from person to person. Data based upon chain-of-transmission events and clustering of cases during other 2003 and May 2004 Bangladesh outbreaks led investigators to conclude that human-to-human transmission may have occurred (3,19). Therefore, given the potential for household or nosocomial transmission, we recommend the use of personal protective equipment (i.e., gloves, masks, gowns, and eye protection); strict hand hygiene and surface disinfection during and after contact with an NiVE patient; isolation of patients with confirmed or suspected NiV infection; and proper disposal of potentially contaminated materials.
In summary, tree climbing, a behavior largely engaged in by young boys, was associated with an increased risk for NiV infection; although the exact mode of transmission is unclear. Our data do not rule out the potential for person-to-person transmission. If person-to-person transmission were extremely efficient, the conditions and population density of Bangladesh (≈1,000 persons/km2; total population 141 million/144,000/km2) may have resulted in a much larger outbreak. Indeed, a study among health workers in Bangladesh did not find evidence of incidental transmission to persons caring for patients hospitalized with Nipah-related illnesses (34). Bat-to-human was the most probable route of transmission in Goalando; however, some undetermined intermediate or incidental hosts cannot be ruled out. Periodic introductions of NiV to human populations in this region may continue to occur because of the overlapping nature of human and pteropid bat habitats. Moreover, bat–human interactions are likely to increase due to bat habitat loss because the few fruit trees that remain will likely be found in close proximity to human dwellings (Figure 1).
As a prevention measure, we recommend avoiding contact with fruit bats and their secretions/excretions. We also encourage persons to wash and/or peel fruit, in addition to washing their hands, before preparing meals or consuming fruit. Greater understanding of the relationships between pteropid fruit bats, NiV, and its transmission to humans might offer additional strategies for safe coexistence and disease prevention for Bangladesh and other countries where fruit bats reside. Finally, because the geographic range of this highly lethal pathogen may correspond to the distribution of the genus Pteropus, including parts of China and Australia, most of the Indian subcontinent, and Southeast Asia (12,30), factors that promote transmission from bats to humans need to be defined and the role of person-to-person transmission needs to be better characterized.
Dr Montgomery is an infectious disease epidemiologist, who completed his training with the CDC Epidemic Intelligence Service in 2004. His main research interests are infectious diseases of public health importance, especially those of zoonotic origin. He is currently detailed from CDC to the US Naval Medical Research Center Detachment in Lima, Peru, and is director of their Emerging Infectious Diseases Program and Outbreak Investigation Response Team.
We thank the staff of the Bangladesh Ministry of Health, the International Centre for Diarrhoeal Disease Research, Bangladesh; the Institute of Epidemiology, Disease Control and Research; the World Health Organization (WHO) in Dhaka, Bangladesh, the WHO Communicable Disease Surveillance and Response, Geneva; and M. Niezgoda and I. Kuzmin for their collaborative support. We also acknowledge the contributions of those who conducted the Nipah virus antibody assays, including J.L. Betts, D.L. Cannon, K.A. Slaughter, T.L. Stevens, and P.C. Stockton. Many thanks to S. Luby, J. Woodward, J. Robertson, and K. Montgomery for helpful reviews of the manuscript. Finally, we respectfully acknowledge the many Nipah virus–infected patients, their families, and the healthcare providers who cared for them in Bangladesh.
The Centers for Disease Control and Prevention, Department of Health and Human Services, US Public Health Service, provided financial support for this research.
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Suggested citation for this article: Montgomery JM, Hossain MJ, Gurley E, Carroll DS, Croisier A, Bertherat E, et al. Risk factors for Nipah virus encephalitis in Bangladesh. Emerg Infect Dis [serial on the Internet]. 2008 Oct [date cited]. Available from http://wwwnc.cdc.gov/eid/article/14/10/06-0507
1Presented in part at the 54th Annual Meeting of the American Society of Tropical Medicine and Hygiene, 2004 Nov 7–11, Miami, Florida, USA.
Table of Contents – Volume 14, Number 10—October 2008
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