TWAR Re-dux

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What is there that was unsatisfactory about the TWAR explanantion (which never seemed satisfactory to me in the first place, I will add) that is satisfied by the tick explanation, vis-a-vis the unexplained deaths among a number of Swedish orienteers some years back?

In my estimation, nothing. The same questions left hanging by TWAR are left hanging by ticks.

Interstingly, if you had asked skiers last year if top Finnish skiers could be doping, you'd hear choruses of "no way"! The sport was considered too clean and the race ethic among the skiing elite too high to even admit of the possibility. But now the complexion of that viewpoint has taken on new hues as the rainbow of possibilities falls first here and then there...

-- Swampfox (wmikell@earthlink.net), April 15, 2001

Answers

If you are wondering, "what in the world is Swampfox talking about?," you can take a look at some info I posted on my blog at:

About ten years ago there was an unusual cluster of sudden deaths among young elite orienteers in Sweden. Apparently young, fit athletes died when their hearts stopped. It was tragic. A new study was just released that sheds some light on the possible cause.

Researchers in Uppsala found that Bartonella henselae bacteria might have been involved. The researchers found that orienteers were more likely than a control group to have antibodies to Bartonella (suggesting they've been infected). They also found in a few cases, Bartonella can damage the heart.

Bartonella infections are thought to be transferred from animals to humans, often through insects. The researchers suggest that orienteers' "intimate" connection to nature might be why they've got an increased risk of infection.

Bartonella is known to cause a number of illnesses among people. It cuases "cat scratch fever."

The Swedish O' Federation has a number of health recommendations for orienteers:

Never train with an infection.
Always get enough recovery after training.
Use varied training.
Eat a variety of good food.
Avoid being exposed to blood infections.

It is hard to argue with that advice.

-- Michael (
meglin@juno.com), April 15, 2001.


Back in the late 70's many people experienced severe cases of Cat Scratch Fever. It usually involved high decible sonic blasts emitted at short range in machine gun-like short and sudden bursts. Sometimes healthy, unafflicted neighbors would call the police to complain about infections in their neighborhood. Alas, usually there was little the police could do in these cases. Medical authorities were completely helpless. Fortunately, however, the fever rarely proved fatal.

-- Swampfox (wmikell@earthlink.net), April 15, 2001.

What the heck kind of preposterous research is this? They've determined that a) orienteers are more likely to have antibodies to this bacterium, and b) that in some cases this bacterium can damage the heart? And this is supposed to be an indication that this bacterium might be the reason why people with no signs of illness suddenly keeled over in circumstances that perfectly match the classic scenario for heart failure from abuse of EPO? Gee, I bet orienteers are exposed to more sun than other people, too. Maybe it was metastasized skin cancer that got them.

-- J-J (jjcote@juno.com), April 16, 2001.

In particular, why was it just elites who had this problem? Why didn't some run-of-the-mill orienteers have heart attacks if it was some kind of infection?

-- J-J (jjcote@juno.com), April 16, 2001.

It would be interesting to interview a number of the folks who were top Swedish orienteers at the time of the TWAR "crisis", and see what they think about the whole thing now. Remember, SOFT decided to simply cancel the remainder (the bulk) of an entire orienteering year while they tried to figure out what was going on. It was a big decision because you were talking about a huge number of runners and racers, and lots of money involved. And orienteers were given the advice that they should dramatically reduce the training they did. Much of the Swedish elite submitted to blood tests and depending on the measurements were given various advice. Some were told they shouldn't train at all because they were seen as being at serious risk from TWAR. It meant that the chances of at least a few orienteers who were at their peak and who had chances to maybe get a WOC slot or win a WOC medal had those chances wrecked.

There were of course a very few Swedish orienteers back then who simply ignored the advice and kept on training as they always had. I seem to remember that Kent Olsson was one. So not everyone bought into the scare. But most did at the time.

From my past 2 visits to Sweden (in 2000 and 1997) it doesn't look to me like today's orienteers are doing anything any different than they were doing previous to the "crisis". The best orienteers are training very hard, just like they did before. And nobody ever talked about TWAR or the whole incident.

-- Swampfox (wmikell@earthlink.net), April 16, 2001.



Heck, I bet orienteers are more likely to have antibodies to bee venom than the general population as well. Does that mean that orienteers are at greater risk of death from bee sting than the average person, and that orienteers should, as a logical conclusion, refrain from training?

If we got news tomorrow that Swedish orienteers were keeling over in the hundreds from a mysterious and long-lived "O-shoe and compass" virus, and that the virus appeared to be extremely contagious and invariably fatal, I would get pretty worried even over here. But I can't remember ever being even the *slightest* bit worried when I heard about TWAR. It *never* made sense to me.

-- Swampfox (wmikell@earthlink.net), April 16, 2001.


In particular, why was it just elites who had this problem? Why didn't some run-of-the-mill orienteers have heart attacks if it was some kind of infection?

I think the definition of "elite" is quite broad. In addition to testing some of the people who died, the researchers looked at blood samples from 1,136 ranked orienteers. That would encompass a lot of really good orienteers and some that are just so-so.

-- Michael (mike_eglinski@kcmo.org), April 16, 2001.


I was living in Sweden when a few of these cases happened. I had gone home by the time Melker Karlsson died and the Swedish Federation stopped elite orienteering for a year or so.

At the time I was there, the theory that seemed to make the most sense was that some orienteers were training or racing when they had some sort of infection. That stress caused the infections (whatever they were...TWAR was not in the picture at the time) to damage the heart. The message we got from trainers and coaches was to be very careful to avoid training if you had an infection.

At the time I didn't feel any fear that I would drop dead at any moment. But, I do remember a bit of an uneasy feeling when I read about Melker's death and read that male orienteers in their late 20s/early 30s who lived around Stockholm were at risk.

I don't really know enough about the research to feel comfortable either accepting it or being especially critical of it. I know it is difficult to pin down a cause for events that are so unusual.

I don't really see a reason to think that doping is connected to these deaths. One of the key findings about the people who died is that 75 percent of them had indications of inflamed heart muscles (which I think is more consistent with an infection or chronic condition than doping). My understanding is that EPO abuse leads to thick blood with chances of clotting leading to heart attacks. Would thick blood cause the inflamed hearts? I'm not certain, but I don't think it would.

It wouldn't suprise me if we never really know why these orienteers died. It also wouldn't surprise me if the cluster of deaths is, at least in part, just coincidence.

-- Michael (mike_eglinski@kcmo.org), April 16, 2001.


JJ wrote: What the heck kind of preposterous research is this?

Well, I'm not sure about this, but I don't think the report Spike talked about above is an official presentation of the research. It sounds like the kind of watered-down, misquoted, pre-digested, sensationalist stuff that journalists churn out in their "scientific" publications all the time. Spike, of course, is just reporting what he read from them.

No doubt there are many arboviruses and opportunistic bacteria (even possibly airborne strains of misfolded prions) out there in our temperate and boreal woodlands. Many of them are as yet unknown to mankind. As our species pushes ever farther into new environments and comes into contact with its once-isolated inhabitants, there will be increasing opportunities for emerging diseases to jump the species barrier. Modern medicine and disease reporting heightens the chances that isolated (and not-so-isolated) cases and outbreaks become public knowledge. We should all be somewhat careful, but probably not overly paranoid. Some of us will live through long, productive orienteering careers. Others will fall by the wayside, victims of disease, accident, or chronic binging.

When were these cases reported? How long has EPO been around and widely available?

-- Mook (everett@psi.edu), April 16, 2001.


I didn't mean that only elite people were tested, I mean that only elite people died. (Something like 30% of the general public has TWAR antibodies, as I recall.) None of the weaker souls in the population seemed to succumb to whatever the problem was. Regarding the timescale, Melker Karlsson died in... late 1992? early 1993? in any event, a few months after he ran in the World Cup race at Pawtuckaway. He was the high-profile case that set things ablaze. I'm trying to remember, I believe the Swedish orienteering season continued, but all of the elite races were cancelled for that year, and the elites were instructed to not train. I think Jorgen Martensson was another one who declared that he was going to increase his training, and won the Stockholm marathon that year (unless I'm confusing different incidents in my head). I don't recall what I saw in the way of autopsy reports, in terms of the correspondence to doping symptoms, but the circumstances of Melker's death fit the classic doping pattern perfectly. He was an up and coming athlete who had recently shown some substantial improvement. He died of an apparent heart attack in the clubhouse immediately following a training run. Overuse of EPO would increase the blood's viscosity (unrelated to clotting), making it harder for the heart to pump it, and this effect would be exacerbated by dehydration. (I don't know if this would cause inflammation.) I think it was Heather Williams who read the reports about TWAR on the O-net and commented that it sounded a lot more like something else to her. So what would you do if you were SOFT, and you had an athlete keel over due to doping? There are various options, but one possibility would be to quickly think up some alternative explanation that would give you an excuse to whip the other elites into line before they started dropping like flies. And then a year later, after it had largely slipped from public view, you just quietly drop the issue. If it really were TWAR, or ticks, I would think that a more prolonged period of alarm would be called for. And gee, the deaths didn't continue. Maybe some other people at risk said to themselves, "Yikes! I'd better watch it so I don't end up like Melker!". Whatever that might have meant.

-- J-J (jjcote@juno.com), April 17, 2001.


And EPO was certainly available by then. It was developed as a medication for people with a specific form of anemia, people whose bodies don't naturally produce enough of it. And I recall that there had previously been a cluster of deaths attributed to abuse of EPO, in (I think) a group of cyclists from Belgium(?).

-- J-J (jjcote@juno.com), April 17, 2001.

To EPO or not to EPO? That is the question.

Any suggestions for a newbie EPO user?

-- Mook (everett@psi.edu), April 17, 2001.


I agree with Spike that we'll probably never really know what happened. I think it's extremely unlikely that SOFT was involved in any doping coverup, whatever happened.

Death clustering is easy to sensationalize, and once people have got it in their minds that x happened because of y, it can be hard to shake them of that conclusion. For instance, if a couple of ppeople in a small town die of a rare form of lymphoma in a short amount of time and someone points out that cell phone towers had just been put up, it's easy for people to be convinced that there's a clear link at work there. But the general population is only going to read about this rare lymphoma in the mass media when just such a clustering occurs. The fact that a single person died from the lymphoma isn't going to be newsworthy. But statistically, some death clusters are going to occur.

The tick explanation for the O-death cluster in Sweden doesn't work because the ticks are always out there, and people are constantly coming into contact with them. If ticks carried something potent enough to cause the cluster of deaths that occured, then you would expect to see a streaming effect of deaths to go along with the cluster--ie, a stream of other folks and orienteers occasionally succumbing from tick bites. But that hasn't happened.

And I don't think orienteers are training any differently today. I don't think orienteers were any more likely to train with an infection prior to the incident than they are likely to do today. Basically my observation over time has been that orienteers in Sweden have always been living a very healthy lifestyle.

-- Swampfox (wmikell@earthlink.net), April 18, 2001.


So just how big was the cluster? Were there actually a lot of deaths? Among orienteers? Or was it something like just Melker and one ski-orienteer a year earlier?

-- J-J (jjcote@juno.com), April 19, 2001.

According to info on the SOFT web pages, there were 16 "sudden unexpected heart-related deaths" in young orienteers between 1979 and 1992. "Most at the elite level."

I think "elite level" is usually defined broadly -- all ranked orienteers for example.

There haven't been any new cases among orienteers under the age of 35 since 1992. However, there have been some deaths among older orienteers with "elite background." The latest was a 38-year old man.

Swampfox said that he didn't think orienteer have changed the way they train since the deaths. I think at least some folks have probably changed. I know that back in the late 1980s I raced a few times when I was not at all well. I wouldn't do that now. But, I also read that Emma Engstrand, a top elite orienteer in Sweden, was sick at her last race and ran anyways (reportedly she ran slower than usual and didn't make as many mistakes as usual because of that).

-- Michael (mike_eglinski@kcmo.org), April 19, 2001.



It wouldn't surprise me if a few individuals have changed their training/racing habits because of the "TWAR incident" some years back. My observation was more general than that. In a general sense, I can't see that folks are training any different today than they were pre-TWAR.

Hard to imagine that many people were racing/training while sick before this happened anyhow. Most people are smarter than that.

-- Swampfox (wmikell@earthlink.net), April 19, 2001.


I know that many OKers probably already follow ProMED Mail pretty religiously, but some of you may not. There was mention of the possibility of ticks as vectors for the related disease last night in a promed post on bartonellosis. This time the studies were carried out in California - just more independent confirmation of what many of us have suspected all along.

-- Mook (everett@psi.edu), April 27, 2001.


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