The Next Hurrah: Avian Flu - Historical or Hysterical?

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April 17, 2005

Avian Flu - Historical or Hysterical?

by DemFrom CT

An interesting strain of bird flu media coverage has emerged, led by Wendy Orent, an anthropologist and freelance writer who has covered smallpox and plague in previous articles and books, and has an extensive science-writing background. Ms.Orent wrote a contrarian piece awhile back in the LA Times (no longer accessible by link) suggesting the concentration should be on poultry-raising conditions, and that the 1918 pandemic, at least, is likely not going to be repeated because the WW I epidemiological conditions are not likely to be repeated.

Yesterday, another piece appeared in the WaPo (same author) with some of the same points... and with the main subject of criticizing those scientists who are sequencing the genome for the 1918 flu in order to understand it.

Flu used to be the "Rodney Dangerfield of diseases," as Tim Uyeki puts it. Uyeki is a flu epidemiologist at the Centers for Disease Control and Prevention (CDC) in Atlanta, and he's been concerned that for years people didn't give influenza the respect it deserved.

But now flu has all the attention any germ can get. First, there was a flu vaccine shortage over the winter, prompting long lines and provoking rage from people who couldn't get their shots. Later, bird flu mesmerized the world, with the CDC and the World Health Organization (WHO) keeping up a steady drumbeat: A flu pandemic -- overdue for decades -- would be upon us at any moment. Finally, it was announced that a pandemic flu strain had been accidentally sent to influenza labs around the world as part of a testing kit by Meridian Bioscience, a contractor for the College of American Pathologists.

The jittery WHO, poised for catastrophe, insisted on the immediate destruction of the strain, for fear of accidental release. And while the threat posed by Meridian's error is far less than initial reports suggested, the reality is that lab accidents do happen. What's more, the feverish anxiety of public health officials to head off a new influenza pandemic may be generating the greatest influenza threat we face.

The threat is man-made. Scientists in the United States and Great Britain are studying the deadliest flu epidemic of the last century, the 1918 pandemic. In order to learn what made it kill so many, they are working on producing artificial viruses that replace common human flu genes with 1918 genes. An accidental release of one of their constructs could make the Meridian error look as menacing as a cauliflower.

Last month Macleans (CA) asked the same question about the science justifying the scare, part of the reason Canadians were sceptical about the risks. The article skips the mad scientist tone of the WaPo piece and raises some good points.

Currently, this particular strain has devastated commercial poultry flocks in Vietnam, Cambodia, South Korea, Thailand, Indonesia, Japan, Hong Kong and large parts of China. It has also killed 42 of the 55 people known to have been infected since January 2004. But while human fatalities are few, WHO and CDC are predicting H5N1 could trigger a massive global outbreak to rival the worst pandemic in history -- the 1918 Spanish flu, which killed between 20 million and 50 million people in two years. That raises an equally big concern -- what if the experts are wrong?

This much is true: H5N1 has a lot of people worried, and for a host of good reasons. Still, a significant segment of the health-care community questions whether this particular bird flu will be the one that triggers a pandemic. Skeptics argue another virus could trump H5N1 -- and render today's multi-million-dollar vaccine investment worthless. Yet the warnings keep coming. Last month, Dr. Julie Gerberding, director of the CDC, told a Washington gathering that this current strain is the "most important threat we are facing right now." Two days later, at a bird flu conference in Vietnam, Dr. Shigeru Omi, the WHO's regional director for Asia and the Pacific, said the planet "is now in the gravest possible danger of a pandemic."

The' overblown rhetoric' of the CDC and WHO, supposedly geared more for funding drives than prevention plans has also come under attack. The problem is that pandemics are tough to predict, and the "I'm still alive, ergo you were wrong" approach is a retrospective judgement that ought not to be applied by public health experts charged with contingency planning (that's best reserved for freelance writers selling their pieces).

Three characteristics guarantee a pandemic: the virus has to be new enough that there are no defensive antibodies built up in the human population; it has to be deadly, which many are not; and it has to be easily transmitted by sneezing or coughing. Several outfits are now racing to develop a vaccine against H5N1, and the U.S. is hoping to start human trials this month. The likelihood, though, is that H5N1 will have to mutate significantly before it can do real damage, which would make a vaccine based on the virus's current genetic incarnation useless.

The WHO wants countries to stockpile H5N1 vaccine, which the U.S. is planning to do. Canada intends to hold off. Instead, it will have anti-viral drugs on hand to serve as a stopgap while it waits to see what vaccine is needed. Vancouver's ID Biomedical Corp. has been commissioned by Ottawa to develop a broad prototype. "When we get the actual pandemic strain, we won't be starting from zero," says Dean Linden, a company spokesman. The first precious dose would take about seven weeks to make, he says, "and it would be about 4 1/2 months to produce the remaining 32 million" to inoculate everyone in Canada, which is the government's intention.

There are American contigencies as well, from viral vaccines to stockpiling Tamiflu and Relenza, antiviral agents, to more local planning as led by the CDC (quarentine plans, contingencies for local hospitals to create isolation wards, school and business closings, etc.). These seem at the least prudent. In addition, those that require a more federal approach have been described. The bottom line:

There have been three serious pandemics in the past century: 1918 and two milder outbreaks, which nevertheless killed millions, in 1957 and 1968. Then there was the swine flu scare of 1976. A flu outbreak among soldiers at Fort Dix, N.J., was found to be related to the 1918 strain. One soldier died. Fifty million Americans were inoculated, even though early signs suggested the flu wasn't spreading. That vaccine was then shown to cause Guillain-Barré syndrome, a neurological disorder similar to polio that wound up killing at least 32 people.

In a typical year, up to two million people die of flu around the world. In a bad year, about 8,000 Canadians might die, usually elderly with weakened immune systems. Health Canada estimates between 11,000 and 58,000 Canadians could perish in a broad pandemic -- the wide range is a reflection of the uncertainty in making predictions like this.

Are we better to be safe than sorry? The WHO and CDC raise legitimate concerns, and it's always smart to be prepared. That said, after such a prolonged cry of wolf, will the response be adequate if a big outbreak doesn't strike for some years yet? "What I've found is that, behind the scenes, many public health officials are distancing themselves from this global-health-crisis rhetoric," says Schabas. "It's not like terrifying someone about smoking or HIV, where you're actually asking them to do something about it," he says. "We're not asking people to do anything about avian influenza, apparently, except to worry about it."

Worrying about it in your own life is a waste of time. Asking your local state and federal agencies to worry about it is not. That's their job, and if they do it right, there's benefit to be had. Some people refer to that as 'public health'.

April 17, 2005 at 08:07 in Contributor--DemFromCT, Health Policy | Permalink

Comments

Everything that involves money is ultimately political. More money for basics, less for bioterror. The NIH have been roiled by many issues, including priorities. The CDC has not been controversy-free, either.

Underachievement is this Administration's scorecard (Iraq, science, health, Social Security 'reform'). We can do better.

Posted by: DemFromCT | April 17, 2005 at 09:14

I agree with your conclusion. This is a public policy question and needs to be addressed on that level. I am not sure Ms. Orent has gotten this right, however. Neither WHO nor CDC have been very quick off the mark to highlight the danger here (especially CDC) and have a tendency to reassure that is not always well placed or appropriate. Moreover they have not been forthcoming with information that the scientific community needs to make an informed decision and for the public and their political leaders to prod their federal, state and local public health authorities.

The truth is that no one knows how to handicap this pandemic. We do not know enough about the pertinent virulence factors in this virus, which is one reason why investigation of the 1918 virus is probably essential, although somewhat risky. Understanding the host-agent interaction is critical. Nor do we completely understand the selective and permissive pressures in the environment that allow the emergence of virulence. Hence Ms. Orent's belief that the WWI conditions were unique is unreliable at best.

I would prefer to see authorities err on the side of over preparedness rather than their current stance of being under prepared or unprepared.

Posted by: revere | April 17, 2005 at 11:10

Appreciate your comments.

'revere' is the editor of the public health blog, Effects Measure. Did you know Paul Revere was one of this country's first public health officials?

Posted by: DemFromCT | April 17, 2005 at 11:51

I think we’ve ceased to take responsibility for our own health.

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