by DemFromCT
Having posted on the human cluster of H5N1 last week, a follow-up is owed. Eight people total were affected, and 6 have died. According to Dr. Andrew Jeremijenko, a physician in Indonesia formerly doing flu reasearch in association with NAMRU2 (a US military infectious disease surveillance and testing station), the cluster appears to have burned itself out, though there are sporadic reports of other cases in the area.
Bloomberg reports that
The World Health Organization sent two officials to Indonesia's North Sumatra province to investigate the largest cluster of human bird flu cases, as a government official said sick animals may have been involved.
Medical epidemiologists Thomas Grein and Timothy Uyeki joined an investigative team in the province today, said Sari Setiogi, a WHO spokeswoman in Jakarta. The H5N1 avian influenza strain infected as many as eight members of a family in the past month. It may also have been in farm animals near their homes, Agriculture Minister Anton Apriantono said today...
Infected animals increase the risk of human infection and create opportunities for the virus to mutate into a pandemic form. Fatalities from H5N1 this year have surpassed 2005 levels as the virus spread to more than 30 countries on three continents.
Pigs, chickens and ducks are raised by about half the 400 households in the North Sumatran village of Kubu Sembilang, where some of the infected people lived. Waterfowl are the natural hosts of avian influenza. Pigs are susceptible to both human and avian strains and are considered a potential ``mixing bowl'' of flu viruses.
Ten of 11 pigs in the district where the infected people lived were found to have avian flu antibodies in their blood, Apriantono told reporters in Jakarta today.
The pig connection may explain why there were few, if any, confirmed poultry infections in the immediate vicinity. And from the begining, pigs getting infected has been a significant concern. One of the 'classic' mechanisms for novel flu virus creation is to have a pig simultaneously inflected with human flu and avian flu, thereby reassorting genes to potentially 'mix and match' avian virulence with human transmissibility. While the report doesn't 'prove' that's what's happened, it's another check on nature's pandemic checklist. Further checks are far from inevitable. And we don't always know what we think we know:
The hypothesis that migratory birds are responsible for spreading avian flu over long distances has taken another knock. Last year, an outbreak of the deadly H5N1 strain in thousands of migratory birds at Qinghai Lake in western China provided what seemed the first firm evidence for the idea. Because the lake is so remote, experts assumed infected birds had flown up from southern China.
But it has now emerged that, since 2003, one of the key migratory species affected, the bar-headed goose, has been artificially reared near the lake. The breeding farms -- part of an experimental programme to both domesticate the birds and release them to repopulate wild stocks -- raise the possibility that farmed birds were the source of the outbreak.
Roy Wadia, a World Health Organization (WHO) spokesman in Beijing, agrees that, if confirmed, the finding is "important", as changing the breeding practice might help control the infection.
How serious to take this? Lancet, the very prestigious British medical journal, sponsored an Asia Forum in Singapore this past month. They've just published an editorial summarizing the world situation regarding preparedness:
Influenza viruses, while commonly known, are strangely neglected, sometimes even misunderstood. Even now, as we try to comprehend the threat of H5N1 avian influenza to human populations, we are forced to admit our ignorance about its biology and pathology. Global surveillance systems are weak. Detailed response plans to an emerging pandemic are absent.
Last week, over 500 experts in avian influenza and other emerging infectious diseases gathered in Singapore for The Lancet's first Asia Forum. They represented 55 countries, with a particular focus on those nations that have so far suffered the greatest burden of the H5N1 virus--Vietnam (93 cases), Indonesia (32 cases), Thailand (22 cases), and China (18 cases). Indeed, this meeting coincided with China reporting its latest case in an 8-year-old girl from Sichuan province. That report took the total number of human infections to 205, with 113 deaths.
The central message emerging from our reappraisal of the dangers posed by H5N1 avian influenza is that, post-SARS, politicians and policymakers have become over-confident about how they might defeat a highly transmissible and pathogenic virus. Experts in Singapore agreed that there are few truly effective and, most importantly, no coordinated global, regional, or national preparedness plans.
The terms of engagement in this debate are utterly misleading. We talk of strategies and protocols, stockpiles and fire blankets. We convey the impression that we can detect an epidemic at its source and rapidly execute a well-planned containment response. Neither assumption is true. We complacently suggest that H5N1 poses "challenges", and astonishingly even offers us "opportunities". More dangerous rhetoric.
The idea that within a week or two of a pandemic's initiation we could quench it by saturating a ring of at-risk population with oseltamivir, achieving 90% coverage and high compliance, and at the same time impose movement restrictions and social distancing--all this depending on the causal virus having an Ro <2ยท0--is simply fanciful.
Avian influenza is not a challenge. It is a predicament of extraordinary proportions. Doctors must say this loudly and repeatedly. Presently, we are largely silent. As The Lancet wrote after the 1918 influenza pandemic, if only we had acted earlier with a "collective health conscience", many millions of lives could have been saved. Today, we are repeating the same mistakes of a century ago.
The Lancet
Well, you can't fault them for trying to get the message out. This is a slow burn, not a massive explosion, at this point in time. It is a low probability, high risk scenario. It takes practice for officials of all stripes and levels to learn how to communicate, how to be transparent, how to prepare for things most people don't even want to think about. As the Lancet points out, we are not ready. Indonesia is a cautionary tale (re the pigs and surveillance), and one we would do well to heed.
That's not fear-mongering, folks. There's no pandemic, and none likely tomorrow, next week or next month. The message is being repeated throughout the medical world:
Benjamin encouraged participants to join in local planning for an
avian flu pandemic, and then he advised, "We have not a clue whether
the H5N1 virus (an avian influenza A virus) is going to be 'the one.'
We should not be surprised if it turns out to be some other avian virus
in 10 years" that causes a pandemic in this country.
But planning has to be local, and it certainly could be, as they say in the trade 'all-hazard'. New England gets floods and ice storms, California gets earthquakes, the Midwest tornados.
What should you do? Educate yourselves so that you don't overreact (that's the opposite of fear-mongering). Be aware that the H5N1 virus, if and when it lands in the US, will affect the poultry industry in a big way, from small farms to large agribusiness, to fast food chains, to the economy in general. Be prepared to be a partner with your local authorities in case of natural disasters (consider CERT and other citizen training programs). And whether you consider doing some prudent personal prepping or not, at least keep up with the news.
And leave the 'fear-mongering' and 'panic' labels behind. Those are not effective words and do not add to the conversation, or the dissemination of information they you and the public need to know.

I'm aware of large programs to vaccinate poultry. It hadn't occurred to me to ask, why not vaccinate pigs? Possible?
The flip side of the panic label is the washout label: if we're spared this time, how to keep the 'lesson' of an avian flu near-miss from becoming a punchline like Y2K... and an excuse for complacency the next time there's a threat on the horizon. There may actually be something to learn from Bush &co. on this topic, as they make the lack of additional terrorist attacks seem almost as menacing as if there had been one ("you don't hear about the ones we stop... we have to be right every time they only have to get past us once...")
Posted by: emptypockets | May 18, 2006 at 11:03
Dem,
"It is a low probability, high risk scenario."
The Global Risk Report from World Economic Forum 2006 ranks pandemic influenza as 'moderate likelihood' with 'highest impact'. It is also the ONLY risk with that ranking. http://tinyurl.com/p2e9k page 51.
Posted by: anon_22 | May 18, 2006 at 19:40
Yes, the World Economic Forum does say that. in dfact, it made quitre a splash wehn it listed pandemic as the biggest threat to the global economy. It's the only report of its kind afaik that does so, however.
Posted by: DemFromCT | May 19, 2006 at 07:33
Please note the trackback, which I can not read. However, it is of note that Taiwan is not part of WHO and is excluded from data sharing. That's unfortunate, and without getting into the politics of it, some arrangement needs to happen, informal or otherwise.
Posted by: DemFromCT | May 19, 2006 at 07:35