Results Of The Probe On Chiang Mai Tourist Deaths And Illnesses: Update 5

[webfact]

Update 5

Results of the probe on Chiang Mai tourist and Thai guide deaths and illnesses completed

Revised 23 August 2011

Thai authorities have concluded their investigation into the deaths of five tourists and a Thai guide. Following the months-long investigation, experts ultimately could identify the likely cause of death for most cases, but not the specific agents or mechanism of exposure. Experts also concluded that some, but not all of the cases appear to have been causally related. The conclusions, investigation constraints, and actions taken by Thai authorities are explained in detail below.

The investigation covered the six deaths and associated illnesses of three other tourists (travelling companions) in Chiang Mai between 11 January and 19 February of this year. The conclusions follow an exhaustive probe during which Thai and international experts from numerous disciplines were consulted in several rounds of face-to-face, tele- and video-conferences to consider the available scientific evidence. These included clinical and biological samples from patients, the results of on site environmental experiments, and chemical samples from one of the concerned hotels and a nearby market. Chemical and tissue samples were tested at certified laboratories in Thailand, the United States, Japan and Germany during the course of the inquiry.

The investigation also included interviews with co-travelers and some family members in the US, Canada, France and New Zealand in an effort to gather information about all possible exposures. Potential viral, gaseous, toxin and chemical hypotheses were considered by domestic and international partners. Agencies partnering together during the investigation included the Department of Disease Control and the Department of Medical Sciences at the Ministry of Public

Health; the Provincial Public Health Office, Chiang Mai; Ramathibodi Poisons Centre, Bangkok; the Ministry of Agriculture and Cooperatives; the World Health Organization (WHO), and the United States Centers for Disease Control and Prevention (US CDC). Staff of the consulates and embassies concerned were also kept informed.

The final conclusions were reached by the official Chiang Mai investigation team in conjunction with a review panel of outside experts in infectious disease, toxicology, pathology and forensic medicine, epidemiology, and environmental science and pesticide use.

Investigation findings:

The people who died and fell ill were grouped under four events based on suspected causes. The case findings are as follow:

-Event 1:

One American woman, age 33, died on 11 January. Her friend, a Canadian woman, age 29, fell ill but recovered. Both stayed in the same room at Hotel “A” and developed severe vomiting on the night of 8 January.

The diagnosis based on clinical and pathological findings is that the American woman died from myocardial injury (injury to the heart muscle). Laboratory tests indicate that drugs and other suspected viruses (Adenovirus, Echovirus, Ebstein-Barr Virus, Influenza A) are unlikely to be the cause. The suspected agent that caused her death is most likely to be chemical or biotoxin in nature and it is probable that it might have been a rodenticide. However, the exact agent could not be identified because the quantity of sample from the case was insufficient. The two women are likely to have the same cause of illness but no epidemiological linkage is found between them and other cases in other events.

-Event 2:

One French woman, age 25, died on 19 January. She developed fever and other symptoms on 16 January before arriving in Chiang Mai where she checked in at Hotel “B” on 17 January with a female friend who remained well.

Based on the evidence gathered and the clinical presentations of the case, investigators and experts concur that the French woman had evidence of acute severe myocarditis (inflammation of all the heart muscles) that represents a sporadic case most likely due to a viral infection, rather than exposure to a poison. The clinical symptoms and inflammatory cells found throughout the heart muscle (confirmed in 3 different laboratories including two in Thailand and one at the US CDC) support this opinion. Although state-of-the-art tests were performed for many viruses and bacteria, no etiologic agent could be identified. Given that her illness began before she arrived in Chiang Mai, the epidemiological linkage to the other events is tenuous.

-Event 3:

1) One New Zealand woman, age 23, died on 6 February. Her two female traveling companions, both age 23 and also from New Zealand, fell ill but recovered. All three women stayed in the same room and developed severe vomiting on the morning of 3 February.

2) One Thai woman, age 47, a tour guide, was found dead in her room on the morning of 3 February.

The three NZ women had severe metabolic acidosis (abnormal acid level in circulation) and two of them suffered myocardial injury (injury to the heart muscle). Clinical symptoms of the Thai woman are unknown since she was found dead in her room. Forensic autopsy found no abnormalities other than 40% occlusion of the right coronary artery. It is most likely she died from sudden cardiac arrhythmia (abnormal rhythm of the heart beat).

The women grouped in this event stayed at Hotel “C”. The Thai tour guide was in a room adjacent to that of the three NZ women. The investigation found that it is very likely the cause of the illnesses of these four women is the same given the timing of the onset of their illness and the proximity of their rooms. The cause is unlikely to be bacterial or viral. Insecticides in the organophosphate, organochlorine and carbamate group, such as chlopyrifos, are also unlikely to be the cause because they conflict with clinical specimens and blood test.

The clinical manifestation in the three NZ women, who were all hospitalised, could be explained by exposure to some chemicals such as those found in pesticides which contain aluminum or zinc phosphide (different class of pesticide than that mentioned in above paragraph).

It should be noted that tests on blood and biological samples from the three NZ patients at US CDC and German laboratories returned negative results for suspected chemicals such as sodium monofluoroacetate (compound 1080) and phosphine gas (by-product of phosphides). However negative results from some of these toxic substance does not necessarily confirm their absence as the suspected chemical compounds can be difficult to detect or can dissipate easily from biological specimens. Tests on the two rooms where the NZ and Thai women stayed found aluminum molecules on carpet samples, however, it cannot be definitively concluded that these came from a pesticide containing aluminum phosphide. The aluminum molecules could have come from the paint on the walls and ceilings or from fluids used to clean air-conditioning units. Aluminum is an ingredient in paint and air-conditioning cleaning fluids and aluminum molecules were also found in other rooms sampled throughout in the hotel.

Two separate rounds of environmental experiments on the air quality in the affected rooms were also carried out to test the hypothesis of poisoning by carbon monoxide, sulphur dioxide, nitrous oxide and nitrous dioxide as the women stayed at the hotel during Chinese New Year when incense and ritual burning of silver and gold paper was carried out by a neighbouring shrine. The experiments found that only a small amount of these gases entering the rooms and experts agreed that this amount seemed unlikely to have caused their illnesses.

-Event 4:

An older couple from the United Kingdom – man (78) and woman (74) – was found dead in their hotel room on the afternoon of 19 February. Consequently their clinical symptoms were unknown. Forensic experts estimated the time of death to be between 17-18 February. Autopsies and standard panels of tests for chemical, drug and pesticide were performed but revealed no abnormal results. There is evidence of 40-80% occlusion in three coronary arteries in the man,

and 30-60% occlusion in the coronary arteries of the woman, which might suggest death caused by a cardiac event or arrest. It is not unusual for older people to die from cardiac arrest, however, it is uncommon for a couple to die of this cause at the same place and at around the same time,

As they also stayed at Hotel “C” albeit on a different floor to that of the women in Event 3, the possibility that the cause of this event is related to Event 3 cannot be excluded.

Investigation Constraints

As most of the deceased were foreign nationals and there were no evidence of a criminal cause, their bodies were quickly turned over to relatives who took them home. Some relatives also did not want an autopsy to be performed, consequently biological samples were limited and in most cases were insufficient for the large number of tests that had to be considered and undertaken.

Also, current laboratory testing technologies to detect many toxins are subject to certain limitations, especially given the time lag between the deaths and testing of samples at laboratories. Certain tests also require that samples be taken by a particular method and stored and transported in special containers. This was not possible because the need for testing for these toxic causes were not foreseen at the time of death.

What the findings mean

Despite the best efforts of the Thai authorities and their international partners in undertaking an exhaustive investigation, the specific agents that caused the deaths and illnesses in these events can not be identified and it can not be determined exactly how people might have been exposed to them.

However, the investigation team and the panel of experts agree that available evidence suggests the following:

Event 1: the two cases in this event, an American and a Canadian woman, have similar clinical manifestations as those of the three NZ women in Event 3. Although there is a possibility that these two events might have the same causative agent, investigators cannot find additional supporting evidence.

Event 2: the illness and death of the French woman is not related to any other cases or events. It is a sporadic case of myocarditis, most likely of viral origin.

Event 3: the four women, three New Zealanders and one Thai, are most likely to have the same cause of illness, probably exposure to some toxic chemical, pesticide or gas, but the agent can not be identified.

Event 4: this event, involving the older English couple, is possibly related to Event 3 as they occurred in the same hotel but again laboratories could not establish a direct link or the specific cause.

Investigators spent five months pursuing numerous hypotheses about potential causes. More than 350 drug, chemical and organism tests were done on each fatality, and some 1250 tests in the New Zealand case, in laboratories in Thailand and overseas. A large number of personnel in Chiang Mai and Bangkok, along with consultants from the US CDC in Atlanta and the WHO in Geneva worked on the investigation of these events. Despite these efforts, and as difficult as it may be to accept, ultimately, the precise causes for the deaths and illnesses can not be definitively identified or confirmed.

Actions taken by Thai authorities to reduce future risks

Thai authorities are taking measures to reduce the risks of chemical and pesticide exposure to future visitors to Chiang Mai and will apply these measures to other main tourist provinces as well;

A panel will be set up to investigate and recommend stricter measures for the use of chemicals, including pesticides, in hotel and market areas.

A channel to receive notification of illness of tourists and expatriates has been set up. Visitors can post their notification at www.chiangmaihealth.com or call 053-216592. Events will be verified and investigated.

Surveillance of hospitalised tourists, already in effect, will be continued and a new protocol for investigation of fatal cases is being developed and implemented.

Retailers of household and agricultural chemicals (pesticides) must declare a watch list of products whose procurement and sales are to be closely monitored. The provincial health office will carry out periodic checks on these items.

Hotel operators must use only licensed pest control companies and their contracts must specify which chemicals are to be used. Samples will be collected and sent for testing by the authorities twice a year.

Municipal authorities are to give safety advice and monitor public celebrations where the burning of ritual papers and other materials are performed in communities, temples and shrines as part of traditional festivals.

Food safety standards at eateries and among street vendors, especially around the Night Bazaar area frequented by tourists in Chiang Mai, are being reviewed and revised to assure safety and compliance.

Health Education Cards to advice tourists about food safety and other health concerns will be made available to foreign visitors to the province.

The Ministry of Public Health will apply these measures to safeguard tourists in other provinces.

Additional information on these events – Timeline of events, Frequently Asked Questions (FAQ), Roles & Responsibilities of Partners – are published on the website of the Department of Disease Control (www.ddc.moph.go.th). Any persons who may have specific medical or public health concerns about this event are invited to report them or make queries using this email address: [email protected].

Acknowledgement

The investigation team would like to express their appreciation and thanks to the staff of the following agencies: The provincial health office in Chiang Mai; the Forensic Department of Chiang Mai University; the Pathology Department of Chiang Mai University; the Toxicology Centre of Ramathibodi Hospital, Mahidol University; the Faculty of Dentistry, Mahidol University; the Department of Medical Science, Ministry of Public Health; the Department of Disease Control, Ministry of Public Health; the Faculties of Medicine, Science and Agriculture of Chiang Mai

University; Central Laboratories, Ministry of Agriculture and Cooperatives; Osaka University; the International Health Regulation (IHR) focal point of New Zealand; the IHR focal point of the USA; the IHR focal point of France; the International Emerging Infections Programme of the Thai MOPH and US CDC Collaboration; the US Centers for Diseases Control and Prevention; and the World Health Organization.

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Addendum:

The purpose of this addendum is to clarify the terms ‘pesticide’ and ‘insecticide’. The term ‘pesticide’ refers to chemical substance used to kill harmful insects, small animals, wild plants and other unwanted organisms; therefore, by definition, pesticides as a group of chemical substances also include ‘insecticides’ (substances used to kill harmful insects) and ‘rodenticides’ (substances used to kill harmful small rodents such as mice and rats).

Use of these terms in Update 5 may have led media and others to mistakenly infer that an insecticide or pesticide was identified as the cause of illness and death in these tragic events. On the contrary, all testing for pesticides and other hazardous chemicals was negative at laboratories in Thailand as well as laboratories in the US and Germany. In fact, one of the most common pesticides associated with toxic exposures (organophosphates) was excluded as a cause of illness in these events based on clinical findings and laboratory testing. Despite negative testing results, however, the clinical findings among several victims (American, Canadian, New Zealanders) could be consistent with illness resulting from exposure to a class

of chemicals called phosphides (e.g., aluminum or zinc phosphide) that are commonly used in pesticides. It is most important to emphasize that we were unable to confirm the presence of aluminum or zinc phosphide or any other toxic agent in clinical specimens, so any possible association must still be viewed cautiously.

Please note that in this revised version of update5, the term ‘pesticide’ in the parenthesis (different class of pesticide than that mentioned in above paragraph) under Event3 has replaced the term ‘insecticide’ used in the previous version to convey proper meaning in line with the above clarification.

Media queries: please call 6684 805 3131 or 662 590 3333.

-- www.ddc.moph.go.th 2011-08-24

[KKvampire]

I see thats it then No one to blame?Justice ?

[scorecard]

Given the whole sad situation, an update from the appropriate government agencies of what they will do next would be nice.

If certain insecticides / pesticides have been ruled out then investigations should be on-going, to look at other possibilities.

There were numerous deaths, surely it's not just wild coincidence, there must be a cause.

[lovetotravel]

It would be nice to see them go after the ones who tried to cover it up. And explain why it took authorities so long to investigate.

[coma]

Can they count out that some Thai with a bee in his/her backside isn't going around willfully targeting Foriegners with a poison agent. And yes, those who tried to cover it up would, in any other country, be up on hindering a police investigation charges.

I will give the Thai authorities one thing. They are good at minimalising any heat that gets bought onto them by the international community when it comes to Thais stitching up foriegners.

[RedNIvar]

Begin with the end in mind. Why am I not surprised that no one is held accountable for these deaths?

[softgeorge]

Given the whole sad situation, an update from the appropriate government agencies of what they will do next would be nice.

If certain insecticides / pesticides have been ruled out then investigations should be on-going, to look at other possibilities.

There were numerous deaths, surely it's not just wild coincidence, there must be a cause.

No cause, purely coincidence young healthy farangs just drop dead in Thailand all the time. Case closed open up the hotel again. Next victim please. Please pay in advance.

[jimbeam1]

Whilst the governments of the victims don't give a dam_n, Country's such as Thailand will be allowed to get away with whatever.

jb1

[fatfather]

A lot of words and foreign references to tell people nothing and no word about the cover up....

Very sad, I feel sorry for the relatives of the victims.

fatfather

[slapout]

After reading/following several investigations/actions, against criminals, against innocents, on criminal and or civil matters, etc, over the past several years, I offer that the final outcome or lack thereof, can be predicted by the preliminary actions of those involved. Those guilty but assured of not being held responsible in any way, just lay low and say nothing. Those guilty who cannot expect such assurances, abscond, prior to final decision, and some just disappear with no further mention.

This seems at times to include the accused, those accusing/victims, the authorities handling/involved in the investigation/proceedings and even innocents who may know or have seen something pertinent. Some of those involved do not seem to answer to Thai government/authority, much less any foreigner/foreign inquiry.

[thaicbr]

Given the whole sad situation, an update from the appropriate government agencies of what they will do next would be nice.

If certain insecticides / pesticides have been ruled out then investigations should be on-going, to look at other possibilities.

There were numerous deaths, surely it's not just wild coincidence, there must be a cause.

No cause, purely coincidence young healthy farangs just drop dead in Thailand all the time. Case closed open up the hotel again. Next victim please. Please pay in advance.

Open the hotel again...... was it ever closed?

[coma]

Given the whole sad situation, an update from the appropriate government agencies of what they will do next would be nice.

If certain insecticides / pesticides have been ruled out then investigations should be on-going, to look at other possibilities.

There were numerous deaths, surely it's not just wild coincidence, there must be a cause.

No cause, purely coincidence young healthy farangs just drop dead in Thailand all the time. Case closed open up the hotel again. Next victim please. Please pay in advance.

Open the hotel again...... was it ever closed?

No.

[msg362]

Before we all rattle on about a cover up. please read the report, there seems to be possibly three different causes. 1 Viral infection of the ? french lady, 2 the two older married people and 3 the others. The possibility that aluminium phosphides might be involved is suggested, which i imagine will rule out Chlorpyriphos but might suggest excessive use of some other pesticide.

FWIW I don't think Chlorpyphos was responsible, you'd smell it! but it could have been excessive use of another non smelly pesticide and cleaning the room after the tragedy might have removed residues.

time to call it a day I think.

[taichiplanet]

Don't forget that there was a death of a Thai woman too.

Went to the Pattaya seminar today conducted by 3 Thai judges about Thai criminal law; you'll be happy to know that Thai law doesn't differentiate between Thais and foreigners and is applied equally to both. So maybe a fair assumption is that Thais that screw over farang also screw over their fellow Thais.

Anyway, a very sad situation. Laws aren't even enforced for obvious things like wearing helmets, so no hope that hotels will comply (and be checked) for using correct chemicals.

[hedonist44]

Don't forget that there was a death of a Thai woman too.

Went to the Pattaya seminar today conducted by 3 Thai judges about Thai criminal law; you'll be happy to know that Thai law doesn't differentiate between Thais and foreigners and is applied equally to both. So maybe a fair assumption is that Thais that screw over farang also screw over their fellow Thais.

Anyway, a very sad situation. Laws aren't even enforced for obvious things like wearing helmets, so no hope that hotels will comply (and be checked) for using correct chemicals.

If you can possibly think and believe that Thai law does not differentiate between Thais and foreigners, then you are one seriously disillusioned person, or your sitting in Kansas waiting for your grass to grow.

[kennalder]

Health; the Provincial Public Health Office, Chiang Mai; Ramathibodi Poisons Centre, Bangkok; the Ministry of Agriculture and Cooperatives; the World Health Organization (WHO), and the United States Centers for Disease Control and Prevention (US CDC). Staff of the consulates and embassies concerned were also kept informed.

The final conclusions were reached by the official Chiang Mai investigation team in conjunction with a review panel of outside experts in infectious disease, toxicology, pathology and forensic medicine, epidemiology, and environmental science and pesticide use.

Did anyone, anywhere see any of the written reports from any of these international entities? I hope so.

[moe666]

Sometime people in the wrong place at the wrong time and they die. So the maid is given some stuff to sprinkle around the room she doesn't know nor really does the person who gave it to her. Cover up maybe who really knows for sure not the guys on this forum.

I would also say if it was some chemical sprinkled around the room how come the maid or maids haven't turned up sick or dead. I think they would have had more exposure than the people in the room.

Sometime there is no justice even if there is it will not bring back one of those people. The deads family have lost someone they love my best wishes to the living.

[lovetotravel]

Sometime people in the wrong place at the wrong time and they die. So the maid is given some stuff to sprinkle around the room she doesn't know nor really does the person who gave it to her. Cover up maybe who really knows for sure not the guys on this forum.

I would also say if it was some chemical sprinkled around the room how come the maid or maids haven't turned up sick or dead. I think they would have had more exposure than the people in the room.

Sometime there is no justice even if there is it will not bring back one of those people. The deads family have lost someone they love my best wishes to the living.

It was widely reported the owner of the hotel cleaned up that floor after the deaths. Another member here says they completely renovated the entire floor. Now I would call that a coverup.

[msg362]

Sometime people in the wrong place at the wrong time and they die. So the maid is given some stuff to sprinkle around the room she doesn't know nor really does the person who gave it to her. Cover up maybe who really knows for sure not the guys on this forum.

I would also say if it was some chemical sprinkled around the room how come the maid or maids haven't turned up sick or dead. I think they would have had more exposure than the people in the room.

Sometime there is no justice even if there is it will not bring back one of those people. The deads family have lost someone they love my best wishes to the living.

It was widely reported the owner of the hotel cleaned up that floor after the deaths. Another member here says they completely renovated the entire floor. Now I would call that a coverup.

But that is by the hotel, not the authorities and could be expected. What was needed at the time was an immediate forensic examination of the room before any cleaning could be done, but from what I read, the Thai police aren't the best in the world at that!

[Humphrey Bear]

Over-use of bed-bug spray.

So either get bitten to death or killed by the spray.

Just lack of daily hygiene and changing matresses / sheets frequently, so use a lot of spray later.

When I was working in the deserts of Libya I had a problem of infestation. The i/c canteen kitchens gave me a spray bomb - told me to open it in the sealed living unit and get out fast - come back in 24 hours and wash down all surfaces, launder everything else and open door and window.

I found hundreds of insects when I cleaned up, but there was no smell from this spray. Cannot tell you what it was, but I've never seen anything remotely like the container for sale to the public.

Maybe similar item here, but used without extreme care.

[kennalder]

Sometime people in the wrong place at the wrong time and they die. So the maid is given some stuff to sprinkle around the room she doesn't know nor really does the person who gave it to her. Cover up maybe who really knows for sure not the guys on this forum.

I would also say if it was some chemical sprinkled around the room how come the maid or maids haven't turned up sick or dead. I think they would have had more exposure than the people in the room.

Sometime there is no justice even if there is it will not bring back one of those people. The deads family have lost someone they love my best wishes to the living.

It was widely reported the owner of the hotel cleaned up that floor after the deaths. Another member here says they completely renovated the entire floor. Now I would call that a coverup.

But that is by the hotel, not the authorities and could be expected. What was needed at the time was an immediate forensic examination of the room before any cleaning could be done, but from what I read, the Thai police aren't the best in the world at that!

Also the city authorities were calling it mere coincidence. (What's the probability any of these officials ever took a statistics course?) It seems obvious to me if everyone would have accepted that explanation, then not another word would have been heard.

Sometimes it is up to people such as those found on this forum to question statements and motives. After all, if it has been proven time and again, that you have little regard for human life, much less the truth, then you should expect to be questioned.

[Yme]

It's all a coincidence.

Six people aged between 23 and 78 died over a five week period from myocardial injury.

No proof that any pesticide, insecticide or other toxin was the cause - but here's a whole bunch of initiatives to ensure what didn't happen in the past never happens in the future.

Not a single foreign laboratory report or opinion tabled with the financial report.

Just a coincidence.

All the documents released by the Chiang Mai authorities - in fluent English - are online for reading here: Chiang Mai tourist death probe finds no common link – PR campaign launched to protect tourism industry

When has the Thai government ever released so many documents - a FAQs, a roles and responsibilities and a timeline of events - IN fluent ENGLISH!

Something smells and it isn't chlorpyrofis

[ginjag]

It's all a coincidence.

Six people aged between 23 and 78 died over a five week period from myocardial injury.

No proof that any pesticide, insecticide or other toxin was the cause - but here's a whole bunch of initiatives to ensure what didn't happen in the past never happens in the future.

Not a single foreign laboratory report or opinion tabled with the financial report.

Just a coincidence.

All the documents released by the Chiang Mai authorities - in fluent English - are online for reading here: Chiang Mai tourist death probe finds no common link – PR campaign launched to protect tourism industry

When has the Thai government ever released so many documents - a FAQs, a roles and responsibilities and a timeline of events - IN fluent ENGLISH!

Something smells and it isn't chlorpyrofis

In all hotels-or hotel chains The back of house department would have a rota for PERIODIC cleaning.

Back of house deal with all areas that public health inspectors would monitor. General room cleaning on a daily basis a maid would NOT normally fumigate anything, her task under the housekeeper would be linen change, dusting-wiping-bins emptied-bathroom cleaning.

Periodic cleaning would be carried out at regular intervals such as air cons-shower heads etc.,

Reported insect infestation would be carried out by mostly a private company-or trained back of house personnel, and guests would be offered a new room as the work would then be carried out.

If bedding was affected or carpets,curtains, these would be taken care of without guests occupying.

NO WAY do you fumigate because of a problem when the guest is out shopping/poolside.

The said hotel is responsible for any problems that arise. period......The customer paid for a holiday, never ever he / she pays for his life. I would like to know what are the owners going to do about the deaths ????

Whatever it was that caused these people to die, it has to be said came from the hotel in some form--Yes or No................so it it the hotels responsibility.

[Thai at Heart]

And no one has bothered to find out if any pest control was carried out on the premises during this period of time?