Avian Flu - What we need to know

How (un)prepared is the US for a flu pandemic?

A US Government Accountability Office official on Thursday at a House Energy and Commerce... Health Subcommittee hearing said that the United States remains unprepared for a potential avian flu pandemic, the Atlanta Journal-Constitution reports. According to Marcia Crosse, health care director at GAO, an HHS draft pandemic plan completed in August 2004 does not include instructions on management of a limited supply of vaccine, whether to restrict travel, or impose quarantines or deployment of federal resources (Nesmith, Atlanta Journal-Constitution, 5/27). Crosse also said hospitals remain unprepared to address local epidemics. Health officials interviewed by GAO said that a pandemic could affect the capacity of hospitals if they have to close certain sections to serve as isolation wards, she added. "Moreover, a shortage in work force could increase during an influenza pandemic because higher disease rates could result in high rates of absenteeism among health care workers," Crosse said (CQ HealthBeat, 5/26). CDC Director Julie Gerberding acknowledged that the pandemic plan requires additional provisions, such as instructions on whether to isolate or quarantine infected individuals and those with whom they have had contact. Bruce Gellin, director of the National Vaccine Program Office at HHS, said that the department will complete the pandemic plan this summer (Atlanta Journal-Constitution, 5/27).

That story from Medical News Today, the full report is available here. Recombinomics comments:

[...] the United States flu pandemic preparedness plan needs a lot of work.  It is appropriately called a draft, because the "plan" is full of holes.  It plans for distributions of vaccines that don't exist, anti-virals that are not available,  hospital beds that are not available, doctors and nurses that are not available, and a death rate that is much more wishful thinking than anything remotely approaching reality.

Vietnam abandons plan for flu vaccine

Vietnam has promised it will not unilaterally develop a human vaccine for bird flu, abandoning plans that international health experts had complained were hazardous and could themselves trigger an epidemic, the World Health Organization said Friday.

Instead, Vietnamese officials agreed they would use a prototype virus strain provided by WHO and developed under safe conditions, according to Klaus Stohr, chief of the agency's global influenza program.

[...]

International health experts have highlighted several concerns about Vietnam's program to develop a human vaccine for bird flu, which has already killed at least 54 people in Southeast Asia, including 37 in Vietnam. For one, these experts said people could become infected with other viruses inadvertently carried in the vaccine.

More ominously, the process for developing the experimental vaccine stock, which was grown in the cells of monkey kidneys, could have allowed the bird flu virus to mutate, making the vaccine strain even more deadly and easier to pass among humans, experts said. In producing the vaccine, they said, the researchers might accidentally become exposed or otherwise release the virus.

WHO officials have also pressed concerns about Vietnam's plans to conduct human trials, starting with Van and some of her team as subjects, as well as about the level of security at the laboratories used to produce the vaccine.

In an interview last month at her institute, Van said she didn't share these worries about the safety of her program. "I believe in our procedures and all the laboratory testing. I'm sure our vaccine is safe, so I'm not concerned," she said.

She said Vietnam had decided not to wait for international assistance because it needed to be sure it had access to a bird flu vaccine at an affordable price. Van said she was confident of her initiative because of her success in developing a vaccine for hepatitis B.

Full story.

WHO: China denies reports of human cases of H5N1

According to the latest Promedmail update China continues to deny any cases of human H5N1 infection:

Dr. Klaus Stohr said the WHO conferred with representatives of the Chinese Ministry of Health both in Geneva and in Beijing and was given assurances the reports, published on some Chinese websites, were unfounded. "We have spoken with the Ministry of Health representatives here in Geneva today. We have also had contact with our colleagues in China. They have come back and said that there is no indication of human cases. They have not seen any human cases," Stohr said in an interview from Geneva. The WHO will continue to monitor the situation, Stohr added.

[...]

Stohr said Chinese authorities responded in writing and in detail to WHO's queries, explaining the vaccination program and precautions being taken by workers involved in it. As well, authorities are on the lookout for cases of severe respiratory disease among workers or people who visited the nature reserve, he said.

What does bird flu mean for the birds?

Here is one good summary of current knowledge, including a discussion of past avian flu episodes.  The current bird epidemic is the largest in recorded history.

Chinese admission, stage I

A strain of bird flu deadly to humans has killed five times the number of migratory birds in China initially reported, an agriculture official said on Friday, as scientists in the west warned of a possible global pandemic.

Here is the link and full story.

What is really going on in China?

We don't yet know.  But read this collection of links.  Here is the most worrying excerpt:

Reports coming out of Qinghai suggest H5N1 infections in humans and birds are out of control, with birds distributing H5N1 to the north and west, while people are being cremated and told to keep quiet.

Reports from Chinese language papers detail over 200 suspected infections in over two dozen locations in Qinghai Province.  In the most affected 18 regions, there are 121 deaths, generating a case fatality rate above 60%.

Even if only a small fraction of the deaths are H5N1 linked, the cases would move the bird flu pandemic stage from 5 to the final stage 6, representing sustained human-to-human transmission of H5N1.

The high case fatality rate suggests the H5N1 in Qinghai has achieved efficient human transmission while retaining a high case fatality rate.  If confirmed, these data would have major pandemic preparedness implications.  These cases began almost a month ago and are now spreading via people who have previously entered the high risk area.

The official media comments coming out of China appear to be carefully worded, describing "new cases" being brought under control, inability to "see" human cases, or lack of "pneumonia" cases.

Several reports from Qinghai have cited limitations on discussing or reporting details.  All nature reserves in China have been closed.

By the way, the Chinese claim to have a fully effective vaccine.  Since I don't believe them, I find this especially worrying.

China denies H5N1 human cases

Thursday the official Xinhua news agency denied any human infections with H5N1 bird flu in the region. No unexplained pneumonia or flu among people who had contact with birds that carried H5N1 has been reported, it says.

The report comes from the Newscientist. The article also discusses the source of the original story, a web-based Chinese-language news service called Boxun:

The media reports are said to have come from nine correspondents in Qinhai, who report that people connected to the cases have been forbidden to talk to outsiders. Boxun cautions that the reports cannot be independently verified, but says it hopes by drawing attention to them they can be further investigated.

The blogoshpere is unimpressed with the Chinese government's denial, demanding more detailed information.

Human H5N1 cases suspected in China

From Promedmail:

Recently, many people died of avian influenza in Qinghai province. The affected localities reveal that, as of early April 2005, there have been several deaths of migratory birds. Because of lack of reporting, the news has not traveled widely. Toward the end of April 2005, cases of human infection started to emerge. After 1 May 2005, some tourists who visited the areas were severely affected, and 6 of them died.

During the month of April 2005, a large-scale dissemination of the infection took place involving both humans and domesticated animals.  The affected area is vast but sparsely populated. Thus, the problem of large-scale of infection involving both humans and domesticated animals is relatively unnoticeable. The feral birds migrate freely and  so expand the area of transmission. The Chinese authorities have admitted the outbreaks and started to seal off the affected area.

Because of this, Mrs. Yi Wu (Chinese Minister of Health) has cut short her visit to Japan and returned home. According to the local news in the affected locality, the number of human casualties is higher than 6.

The deceased persons are all foreign tourists (i.e. not local residents): 2 (a man and a woman) from Chengdu, and one man from Chongqing, Sichuang province. It is unknown from where the remaining casualties come.

The information was provided by someone who has visited the area of the outbreaks.

Nature's avian flu special

Nature.com published today a series of articles on avian flu. The full collection is available online. The tone of the articles is critical towards current efforts by national governments and international agencies:

Unfortunately, the current situation does not bode well for the abilities of governments and international agencies to cope with this challenge. We should be monitoring in almost real time the genetic changes in the avian and human viruses that could herald the emergence of a pandemic strain, for example. But there is no international funding to help affected countries build decent and sustained surveillance programmes. And while outside researchers want data from affected countries, they aren't engaging enough in the meaningful collaboration needed to build trust and open sharing. The international community is not offering incentives, such as drugs for the Asian countries that would be in the front line of a pandemic. Combine this with the fact that countries are reluctant to share the few data they have because their analysis could affect their trade and economies, and the current mess in surveillance is hardly surprising.

Each human case that occurs in Asia is potentially a global threat. The international virology community needs to be permanently there, on the ground. We need to diagnose cases swiftly, and treat the patients and all their contacts immediately with antiviral drugs to try to kill the pandemic at source. To understand the genetics, and link this to the epidemiology and pathology of the virus, we need immediate sharing of all virus samples and data. None of this is happening adequately. National governments' performance is half-hearted, incomplete and far too slow. International organizations are working with their hands tied behind their backs, for bureaucratic and diplomatic reasons. In short, the level of current efforts is not commensurate with the threat we face.

The series contains good summaries on the severity of the threat and the tools available to fight an outbreak. Vaccines and drugs are discussed, and so is culling of birds.

The series also contains avian flu fiction, something a bit unusual for Nature. Here’s the explanation:

Repeated warnings about the international community's failure to respond to the pandemic threat have fallen on deaf ears. So in our opening News Feature, we use the benefit of fictional hindsight to throw the issues into starker relief, describing a future pandemic through the weblog of a journalist in the thick of things. This is fiction, but not fantasy — the storyline was drawn up in consultation with those who could soon be dealing with the situation for real.

The fictitious blog, written by Nature senior reporter Declan Butler, covers events taking place after the beginning of a human pandemic (December 2005). Here is an entry from February 18, 2006, titled THIS CAN’T BE HAPPENING:

The United States is battened down before the storm. The government has outlawed all gatherings in public places. In past pandemics that never worked. But epidemiologists say that if we do it early on, it might slow the spread. Modelling also suggests that closing schools and universities is especially important as teenagers and young adults are among the worst hit. We just need to stop them from hanging out elsewhere. Stay at home, is the message blaring from every TV screen.

On CNN it’s now round-the-clock coverage, with a red ‘Pandemic’ banner running across the bottom of the screen. “We’re in the twenty-first century, and they’re telling us about how to wash our hands properly, and practise ‘respiratory etiquette’,” exclaims Jonathan. “Why aren’t there drugs? And I can’t believe there’s no vaccine. This can’t be happening in America.”

Addendum: Effect Measure offers more commentary on Nature's flu special.

Farm size and avian flu

EffectMeasure covered in a series of posts the arguments of anthropologist Ronald Nigh on the avian flu outbreak in Southeast Asia. Ronal Nigh argues that large chicken farms provide excellent breeding grounds for the flu virus:

During the past couple of decades, some countries, particularly Thailand and Vietnam, among others, have seen a tremendous growth in large chicken confinements, chicken factories of many thousands of birds in the deplorable conditions we are all familiar with. All the ills, antibiotics, hormones, tremendous disease problems, unhealthy products, etc., are present in these factories. These countries have also entered into international commerce of poultry products, including supplying chicks for yet more huge confinement operations. Thailand for example has become a major supplier of frozen chicken parts to England. Of course, biodiversity has been drastically reduced, with millions of chickens in these farms originating in very few breeding populations.

This environment leads among other things to faster mutations in the virus, a type of externality large farms impose on society, since they do not bear the full costs of fighting a pandemic. Large farms are a crucial part of the problem, Ronald Nigh argues:

The big producers have now created disease problems that will cost society billions of dollars to deal with, apart from the death and human suffering that could result. Governments are expected to "be prepared" to deal with these problems, yet the corporations who have profited from their creation have lobbied to lower corporate taxes to the point that they hardly share any of the cost burden themselves. Just profit.

Ronald Nigh concludes:

A decentralized poultry system could supply our need for poultry products and provide these in a healthier form. Many small producers are already providing organic and free range poultry products in every city in the country. What we need to do that we are not doing is support small poultry producers with research, extension and other programs, instead of subsidizing fast food and big factory farms.

I am not persuaded by the Small is Beautiful rhetoric. Large bird farms in the US or Europe typically kept outbreaks under control. “Corporate” farms reacted very promptly to discover and solve outbreak problems. Large farms are easier to monitor and they minimize bird-human contact. They also have an incentive to protect their brand name and reputation. The worst problems with bird flu come from small back-yard farms and wild flocks of birds. There the virus is very hard to monitor and people as well as other animals are in close contact with poultry daily, making it far more likely for the virus to be transmitted to humans.