A Journey Through The World of Pandemic Influenza

The Last Day of 2007

There is a quote that I am personally rather fond of:

"Life's journey is not to arrive at the grave safely in a well preserved body, but rather to skid in sideways, totally worn out, shouting '...holy shit...what a ride!'" – Anonymous

That handily sums up my 2007, so there is no need to bore anyone with details.

 

As is often said around the cyber flu community PanFlu (Pandemic Influenza) preparation and information gathering, as well as its dissemination, is a marathon, not a sprint. But someone failed to tell me that it was all up hill, occasionally with daunting headwind.

 

As I was considering the framing of this post it reminded me of an old song by Chicago, Does Anybody Really Know What Time It Is?

As I was walking down the street one day
A man came up to me and asked me what the time was that was
on my watch, yeah
And I said
Does anybody really know what time it is
I don't
Does anybody really care

What time does it read on the Pandemic Clock? Does anybody really know what time it is?

December has found us at a confluence of conflicting data-streams.

The first, WHO officials stating that progress has been made (which I fully agree with) and that H5N1 has slowed its frightful and inexorable march around the globe (which I fully agree with), and finally, that human cases had slowed in 2007—they had. The threat posed by H5N1 was not felt as acutely as in past years.

Second we have seen a veritable explosion (in comparison) of human cases during the month of December. Pakistan and Egypt are front and center with Indonesia the ever faithful and consistent handmaid.

 

Since human cases first appeared in Egypt they have had the "feel" of "different" to me and have engendered far more concern than the Indonesian cases, even though there are far more of them, and far more consistently deadly.

Theresa42 posted an update on the recent Egyptian cases along with what summary information currently available, since I would have no hope of doing half as well I will just use her great post from FluWiki. One of the important standouts of this data is the wide range of ages. Traditionally, the children and young women were victims, not so in Egypt. A change in victim's ages may indicate a change in the virus itself.

EGYPT - Detailed summary

SUMMARY OF CONFIRMED AND SUSPECTED CASES IN EGYPT SINCE DEC 25

5 confirmed cases / 4 deaths:

Oula Yunis Ali Mohamed (25F) - d. Dec 25, 2007

- from Beni Haroun village in Beni Suef governorate, south of Cairo
- admitted to Beni Suef hospital on Friday, Dec 21, with high fever, breathing problems and pneumonia
- diagnosed (test results came back) the day she died, Dec 25
- in contact with birds thought to be infected with bird flu
- relatives being checked/tested / mentioned in one article that her mother, specifically, was being tested
- brother of victim said that they went to one doctor who diagnosed bronchitis, but when she didn't get better they went to another doctor in a "special hospital" who sent her to the hospital in Beni Suef
- 39th case / 16th person to die of bf in Egypt

Attorh Hanim Ibrahim [aka Hanem Atwa Ibrahim] (50F) - d. Dec 31, 2007

- from Damietta governorate ("from Al Ngdi's land in the region of Ezbet meat in Damietta district")
- admitted to Damietta hospital on Monday, Dec 24 with high fever, breathing problems and pneumonia
- husband reports she began showing symptoms on Dec 24
- transferred to Cairo's Abbasiyah hospital
- reported on Dec 31st to be in critical condition
- in contact with birds thought to be infected with bird flu; husband reports that she keep poultry and that two days before she became ill, ten of her poultry had died
- husband and children tested and put under observation for 7 days
- 40th case

Nora Aboul Abbas Mohamed (21/22F)

- from "Center Worries" in Al Minufiyah governorate (also reported:  "from the belonging village of Barhim [Braheem], to Minuf center")
- admitted to Minuf hospital on Wednesday, Dec 26 with high fever and difficulty breathing
- transferred to Cairo's Abbasiyah hospital on Dec 27
- father reports that she began showing symptoms on the night of Dec 25 and that she had found dead poultry in her shop that morning
- reported on Dec 31st to be recovering in intensive care
- poultry seller, in contact with birds thought to be infected with bird flu
- family being tested
- 41st case

Fatma Fathi Mohamed (25F) - d. Dec 30, 2007

- from Daqahliya governorate
- admitted to local hospital on Dec 27 with high temperature and difficulty breathing; transferred to Mansoura hospital on Dec 29
- suspected of handling sick domestic birds
- 42th case / 17th person to die of bf in Egypt

Firdaus Mohamed Hadad (26F) - d. Dec 31, 2007

- from Al Minufiyah governorate
- hospitalized on Saturday, Dec 29
- high fever, difficulty breathing, pulmonary infection
- reportedly in contact with sick birds
- 18th death / 43rd case

12 suspected cases reported in the last week / 1 death:

Dec 30 -

Mohamed Khalil Abdul Qawi (40M) - Beheira governorate - reported Dec 30 - from the village of Ezbet Alhouci Bbrem Center Kom Hamada
Nader Said Babylonian (5M) - Al Minufiyah governorate - from the village "Alaptanon"
Ahmad Abdulmohsen (6M) - Al Minufiyah governorate - from the village "Kafr Tunbdi" at the centre of Shebin Mound

*Note that the two boys are from the same governorate as confirmed case Nora Aboul Abbas Mohamed above.

Dec 31 -

Amiriya north of Cairo:

Salah Eddin Mohamed Ali (43M) - d. Dec 29 - schoolteacher - had acute pneumonia - kept roof-top birds

Al Minufiyah:

Abdul Rahman Ibrahim (57M)
Abed Rabbo (50M?)
Mohammad Ferdous (36M)

Alexandria:

Faten (23F)

Port Said:

Reza Abdalmugod Abdilkadir (25M) - husband of Radwan
Radwan - wife of Reza
Mohammed (9M) - son of Reza & Radwan
Rajab (5M) - son of Reza & Radwan

 

So, the New Year will find us watching Egypt with intense interest, irrespective of the year-end assessments that want to tell us that H5N1 is less of a threat than it was at the beginning of 2007.

 

SZ

Influenza Immunity and Reduced Susceptibility

Should a novel, wholly avian, strain of influenza, and specifically addressed here is H5N1, gain the ability to pass from person to person (H2H) no one, except perhaps the few survivors up until that point will be immune from illness.

By doing everything in my power to avoid getting the annual flu I have robbed my immune system of the very things I will need when facing an influenza pandemic until I qualify for a vaccine, something that I will be waiting a long time for, as I will be standing at the back of a very long line. With this post I hope to specifically address and explain viral immunity, natural or induced, and what it may mean in a time of PanFlu.

 

Over the last two posts I have introduced heterosubtypic immunity, in plain English: immunity from multiple strains of virus after an immunologic challenge by any strain. An example for influenza could look like this: I get sick with the current circulating strain of H3N2 and recover; I now have antibodies that will make me immune, or at least resistant to not only H3N2, but also the circulating H1N1.

That is the working mechanism of our annual influenza immunizations. Introduce a pathogen (influenza) via vaccine and our bodies develop specialized antibodies and other immune system defenses. However, our annual influenza vaccine (shot) contains only two components of the influenza virus, the HA (hemagglutinin) and NA (neuraminidase), two surface glycoproteins of the virus.

 

When the body responds to an invading pathogen the immune system deploys various defenses, sending specialized cells to attack, kill, or neutralize the invader. These immunologic defenses attach to things called epitopes on the pathogen. Because the annual flu shot only includes the HA and NA components of the influenza virus our bodies only produce the immunological defenses against those components. Drilling down a bit further, it only develops defenses against those epitopes on these viral segments.

 

The HA of the influenza virus has five epitopic regions, and one of the reasons we have to get annual vaccines, the other reason is these specific regions of the HA suffer high rates of change, known as single point mutations, where a single nucleotide mutates. This mutation is enough to render it unrecognizable by the defenses the body produced from the vaccine. Instead of a broad based immunity, the annual flu shot produces a very narrowly focused immunity.

Another issue with the annual flu shot is that it is delivered by injection into muscle tissue and the immune response is further restricted to a narrowed subset of the antibodies that would be produced by the body when challenged by a whole virus.

 

While we develop broad-based, multifaceted immunity after a "case of the flu", strength and length are variable on an individual level, but true in a generalized sense. However, the immunity gained by a flu shot is narrowly deployed and narrowly targeted. For insights into this very narrow specificity and high mutability see Codon bias and frequency-dependent selection on the hemagglutinin epitopes of influenza A virus (here), fair warning though, it is scientifically "dense".

 

Thanks to FluMist we have a middle-ground choice, that is if we are between the ages of 2 – 49, and healthy, and have no close contacts with individuals with specific health issues. FluMist is comprised of live-attenuated influenza virus that offers a broader immunologic challenge. It gives the body more epitopes to target so the body produces a broader range of antibodies.

 

One of the major benefits of FluMist is that it is administered intranasally (into the nose as a mist) and one of the immune system components activated is mucosal antibodies, part of the lymphatic system, this same immune component is missing when we get a flu shot.

Another benefit FluMist has over a traditional flu shot is that with the activation of the mucosal portion of the immune system it may be more heterosubtypic, and perhaps greatly so, at least for a short time. This is especially beneficial when the traditional flu shot is not matched to the currently circulating dominant strain of influenza A, as this year's vaccine isn't well matched to A/Brisbane. FluMist, not being as dependent on exact match, will likely confer a greater protection.

 

In the realm of theoretical:

 

It may even be that FluMist has a small degree of efficacy when facing a novel pandemic influenza strain. I'm not going to sit here and tell you that it has any chance of conferring 100% protection, and certainly not against a strain as pathogenic as H5N1, but every additional piece of defense we can add to our "pandemic arsenal" the better off we are likely to be. Arming our bodies with as broadly based an immune defense aimed at any influenza A virus the better we are able to survive an infection of H5N1. Nothing in this life is guaranteed, but intranasal vaccination with a live-attenuated virus is an available "mid-point" between suffering a human influenza A virus (which could be lethal in itself) to gain all of the immunological benefits of heterosubtypic immunity and the viral matching specificity of the flu shot.

 

I would be remiss if I failed to categorically state that while natural infection with influenza A offers the broadest immune response and future protection I in no way recommend anyone refrain from their yearly influenza vaccination in the hopes of gaining that immune storehouse. Even seasonal influenza A can cause serious illness, sometimes with a fatal outcome.

 

An additional point worth mentioning: Influenza B offers no immunity or mediation against a viral challenge of influenza A. I can get sick with a "B" flu, get well, and two months later be knocked flat on my back with the circulating "A" strain. At least that is my understanding, and the reason that we have both "A" and "B" in our annual vaccination.

 

Since I have so heavily plugged FluMist I am compelled to state that I have no competing or financial interest with any influenza vaccine (development, manufacturing, distribution, or public relations or any other interest left off the list) FluMist or otherwise. Nor, have I ever taken FluMist, however, I will be asking my family physician for it this year and next, the only two years that I will fall within the "recommended age" range.

 

And lastly: I am not expert in any of this. I have taken disparate source materials (scientific papers and text books) and agglomerated and distilled "dense scientific or technical gobbeldy-gook" into something that I can only hope is understandable, thorough, useful, and correct. If I have made an error I would appreciate notification of such so that I can correct it!

 

SZ

A Lesson from our Last Influenza Pandemic

One of the most frustrating things I find as a "blogger" is that I tend to ramble, and for what is supposed to be a "tightly focused" blog that is a bad thing. Another bad thing in this medium is the long entry. As I attempted to write up everything I wanted to say in my last entry it was too long and too winding and just plain too. So I am "chunking" the stuff I want to ramble on about in the hopes that y'all out there won't notice.

 

My last post, Informed Seats and My Favorite Chair, dealt mainly with introducing R₀ (Reproduction number) of infectious disease, and specifically, pandemic influenza. How pandemic planners are working with the assumption of a 1.x – 2.x for the R₀.

 

My favorite theory to explain the epidemiology of the influenza pandemic of 1918 has been prior exposure/circulation of H1N1 or a close relative. Now I have to consider heterosubtypic immunity (immunity across subtypes) as at least as likely an explanation, if not more so.

 

 

 

Fig. 1.

All-cause and P&I monthly mortality rates for all ages (A and B) and all-cause mortality rates by age group (C-H) are calculated per 10,000 population. Observed rates are days-per-month adjusted. Expected model baselines (solid lines) are derived from each series of nonepidemic months. Epidemic thresholds (dashed lines) are the upper 95% confidence limit above each baseline. The major epidemic influenza season months are indicated (shaded). Two 1917/1918 influenza season peaks (arrowheads) show excess mortality primarily confined to the ≥65-years age group in January (C), and to the groups <45 years old in March 1918 (E-H). Other severe mortality events are evident: summer diarrheal disease epidemics were confined to young children (H), the 1916 polio epidemic to all children (G and H), and the summer 1917 heat wave and diarrheal disease epidemic among the youngest and oldest age groups (C and H).

Proc Natl Acad Sci U S A. 2005 August 2; 102(31): 11059–11063.

Published online 2005 July 26. doi: 10.1073/pnas.0408290102.

Graph and legend from Epidemiological evidence of an early wave of the 1918 influenza pandemic in New York City Donald R. Olson, et al.

Of particular interest is section B of the above graphic showing the monthly mortality rates due to P&I (Pneumonia & Influenza) for all ages. The above paper also happens to be one of the major supports for my "prior exposure/circulation" belief.

 

But what if…

 

What if we only saw a ~30% CAR (Clinical Attack Rate) and ~2.5% CFR (Case Fatality Ratio) because many people benefited from heterosubtypic immunity from a not too long past bout of seasonal influenza A?

 

Drawing on A Biological Model for Influenza Transmission: Pandemic Planning Implications of asymptomatic Infection and Immunity John D. Mathews et al.

Reports of past influenza pandemics show marked variation in clinical attack rates between populations. In the 1918–19 H1N1 pandemic, rates of clinical illness were less than 20% in some urbanised communities, but more than 60% in isolated communities such as Western Samoa [1]–[4]. During the 1968 H3N2 pandemic, attack rates in US households were limited to 30–40% [5], whereas almost the whole population fell ill when the virus reached the isolated island of Tristan da Cunha (TdC) in 1971 [6]. Biologically-based models for pandemic influenza [1] that incorporate effects of host immunity can help to explain such differences in observed attack rates.

The paper draws a correlation to urban settings and the likelihood of a higher, more consistent rate of seasonal influenza infection than those likely experienced in relatively geographically isolated areas. The island of Tristan Da Cunha is both geographically isolated and remote thus serving as a perfect example.

[snip]

 

The population of Tristan da Cunha, a remote island in the South Atlantic, had been free of influenza for 8–9 years when H3N2 was introduced by ship from South Africa in 1971[6]. The resulting epidemic curve over 50 days was based on reports of cases by day of symptom-onset. In two waves, 96% of the population of 284 fell ill; there were 365 recorded attacks, of which 312 could be identified with a precise day of onset. 273/284 islanders experienced a first attack of influenza, and 92/284 experienced a second attack. Most second attacks coincided with the second population wave; a minority of individuals experienced a first (and only) clinical attack during the second wave, possibly following asymptomatic infection during the first wave. Second attacks were generally less severe.

 

What might this imply for a future influenza pandemic?

 

This paper's findings suggest someone suffering a bout of influenza A in their recent past may have a degree of immunity, even if the previous influenza is not the same sub-strain (homogeneous). Immunity could range from total, to asymptomatic infection or lessened severity. Conversely, someone who has not suffered a recent bout of influenza A could be as naked and vulnerable to a novel influenza strain as a newborn babe is to the world they arrive into.

 

Taking this possibility three steps further into supposition territory:

 

We are currently seeing a frightfully high mortality rate with human infections of H5N1, ~60% cumulative and ~80% in Indonesia. The infections have been in countries and in populations that do not have annual influenza vaccination programs to protect them from the seasonal influenza that arrives yearly. Is it reasonable to postulate that those infected had also suffered a human seasonal A variety sometime within three years previous? I would assume that it is a reasonable assumption that many had. Heterosubtypic immunity did not play a great role here, or if it did, perhaps it allowed for only a severe infection as opposed to a fatal one. A severe infection, that with Tamiflu and medical support ended up being survivable.

 

In my previous post I made mention that the R₀ was not the only staggering gem the recent paper on A Biological Model for Influenza Transmission: Pandemic Planning Implications of asymptomatic Infection and Immunity held.

Unfortunately, heterosubtypic immunity, which can be short-lived, is likely induced more effectively by recent infection with a live influenza virus than by conventional sub-unit vaccines [14], [24]. This raises the possibility that inter-pandemic sub-unit vaccine, by preventing infection with live inter-pandemic virus, could even make people more susceptible to a novel pandemic virus. The bottom line is that we need much more information about heterosubtypic immunity in humans, and about the potential value of live-attenuated influenza vaccines against H1N1 and H3N2 in protecting populations against H5N1 or any other novel pandemic virus. We await the results of relevant research with great interest.

 

I will share with you the closing thoughts of the person who pointed out a logical end-point to these findings and assumptions; they say it far better than I could:

"I don't think that it is enough to have had the experience of just not having access to vaccines, and getting seasonal influenza's that would protect a person, else the mortality rate in Indonesia wouldn't be what it is. The problem is not that people do well if not vaccinated yearly, rather that they may do worse if they have been dutifully getting their influenza vaccine." [emphasis added]

 

 

SZ

Informed Seats and My Favorite Chair

As I have said a few times over the life of this blog, and more frequently on the flu forums, I believe in what I label the "Viral Tsunami" theory of a pandemic of a wholly avian version of H5N1 that gains the ability to transmit from person to person, H2H for brevity's sake. For my more recent postings supporting this see here and here. Those two posts and this one draw heavily from the UK's recently released National Framework for Responding to an Influenza Pandemic (pdf download here).

In order to qualify as a Viral Tsunami, by my definition, an influenza pandemic would have to have a high Clinical Attack Rate (CAR) and a high Case Fatality Ratio (CFR), as well as encompass a single wave of illness. There is strong belief that the CAR will be between 30-35% of the population and CFR will be no worse than ~2.5%. Because there is strong belief in this scenario as the upper limit of potentials, those figures represent the worst case scenario in so many plans. In addition, I must say, there are many plans that use numbers lower than these as their "upper limits".

 

Part of what the experts in influenza have been doing since 1997, more feverishly since 2003, is studying H5N1 and what makes it so different from what they are used to seeing and dealing with. I have quoted this statement many times from one of the Reveres of EffectMeasure:

"The depths of our ignorance in this age of sophisticated molecular biology is truly impressive."

A lot of basic research is being conducted, or minimally, dusted off and reviewed afresh in light of human infections of H5N1, and at nearly every turn, we discover something else that they didn't know or have to rewrite what they thought we knew.

Part of this journey of exploration and research is aimed at hypothesizing, as informed and scientifically based as is possible, what a pandemic of H5N1 would be like. Unfortunately, many of our experts, scientific and otherwise, base their "guesses" and assumptions on the pandemic of 1918, the last severe pandemic and the only one we have any semblance of empirical data to review. That is, if said experts even credit the possibility of a severe influenza pandemic at the beginning of the 21^st century.

 

CAR, a major component, utilizes a number known as R₀, the basic reproduction number. From Wikipedia:

In epidemiology, the basic reproduction number of an infection is the mean number of secondary cases a typical single infected case will cause in a population with no immunity to the disease in the absence of interventions to control the infection. It is often denoted R₀. This metric is useful because it helps determine whether or not an infectious disease will spread through a population.

If an infectious disease has an R₀ of less than 1.0 it will burn itself out, if greater than 1 it will continue to spread if not mitigated. The UK PanFlu Framework assumes an R₀ than they believe will range from somewhere between 1.4 and 2.2. It is useful to understand that at 2.0 cases will double every one or two days, at 4.0 they would quadruple, etc, on up the scale.

The assumptions of 1.4 – 2.2 R₀ are frightful enough, to say nothing of difficult to address. The same assumptions assume community mitigation measures will have a significant effect on the CAR and R₀, a very reasonable assumption. Modeling suggests the dramatic difference between a local outbreak with and without mitigation:

A lot rides on our plans, the actions we prepare ourselves to take, the plans our leaders civic and governmental leaders will institute on our behalf.

 

What if planning assumptions are wrong?

A reasonable question. We are all pretty much flying by the seat of our pants, some with more well informed seats to be sure, but it is always worthwhile to remember that we cannot know with certainty what the next pandemic will look like. Only in hindsight, or at best as we are struggling in the midst of it, will we know the CAR/R₀/CFR. However, even though we do not have definitive numbers to plug into the all-important variables we do have an ability to extrapolate the unknowns with what we do know, and just about every week what we do know expands.

Expanding knowledge base case in point:

PLoS ONE. 2007; 2(11): e1220.

Published online 2007 November 28. doi: 10.1371/journal.pone.0001220.

A Biological Model for Influenza Transmission: Pandemic Planning Implications of Asymptomatic Infection and Immunity

John D. Mathews, Et al.

Background

The clinical attack rate of influenza is influenced by prior immunity and mixing patterns in the host population, and also by the proportion of infections that are asymptomatic. This complexity makes it difficult to directly estimate R₀ from the attack rate, contributing to uncertainty in epidemiological models to guide pandemic planning. We have modelled multiple wave outbreaks of influenza from different populations to allow for changing immunity and asymptomatic infection and to make inferences about R₀.

Data and Methods

On the island of Tristan da Cunha (TdC), 96% of residents reported illness during an H3N2 outbreak in 1971, compared with only 25% of RAF personnel in military camps during the 1918 H1N1 pandemic. Monte Carlo Markov Chain (MCMC) methods were used to estimate model parameter distributions.

Findings

We estimated that most islanders on TdC were non-immune (susceptible) before the first wave, and that almost all exposures of susceptible persons caused symptoms. The median R₀ of 6.4 (95% credibility interval 3.7–10.7) implied that most islanders were exposed twice, although only a minority became ill in the second wave because of temporary protection following the first wave. In contrast, only 51% of RAF personnel were susceptible before the first wave, and only 38% of exposed susceptibles reported symptoms. R₀ in this population was also lower [2.9 (2.3–4.3)], suggesting reduced viral transmission in a partially immune population.

Interpretation

Our model implies that the RAF population was partially protected before the summer pandemic wave of 1918, arguably because of prior exposure to interpandemic influenza. Without such protection, each symptomatic case of influenza would transmit to between 2 and 10 new cases, with incidence initially doubling every 1–2 days. Containment of a novel virus could be more difficult than hitherto supposed.

The paper, which includes much more valuable information than I have included in this post, demonstrates that a case can be made for an immunologically naïve population the R₀ will likely be much higher than the planning assumptions. An R₀ greater than 2 will be difficult enough to mitigate and manage, the implications of an R₀ greater than 5 are nothing short of staggering. Fair warning, the R₀ is not the only staggering gem this paper will yield, but they will have to wait for their own post.

Thanks to a knowledgeable reader who was thoughtful enough to take the time to gather, highlight, and briefly explain implications of research, some reaching back 30 years, and sending it along to me, I have an appreciation of this paper's implications that I did not previously have.

One of the areas this reader is exploring is heterosubtypic immunity, while I do not specifically address this in this post, as it deserves its own, it is the core concept of the above paper. For all you intrepid googlers out there a search on "T-cell heterosubtypic immunity influenza" will yield support for what follows in this post.

 

I have assumed a significantly high R₀ and CAR because H5N1, should it gain pandemic H2H ability as an avian influenza, will be novel to human beings. Furthermore, I have been laboring under the belief that 1918's H1N1 had its lower CAR/CFR and cohort specificity because of prior exposures to it, or a close relative.

The epidemiological evidence, such as it is, supports the theory of prior exposure. Now I have been presented with a new (to me) theory explaining 1918's CAR/CFR and cohort specificity: heterosubtypic immunity. My conundrum is that while I am quite partial to the prior exposure/circulation theory, being comfortable with it, like my favorite chair, this theory is supported by more than epidemiological hints and suggestions, akin to nothing more substantial than circumstantial evidence in a criminal prosecution, it is supported by scientific findings.

Scientific findings that still leave us extrapolating into a future pandemic of a yet unknown pathogen, we are still left guessing, but every once in awhile, our seats get a little better informed as we fly by them.

 

SZ <grateful to a thoughtful reader laboring to inform not only themselves but also others along the same path>

Pandemic Accounting

My "day job" is in the accounting department of a vacation rental company, wholly owned by a publicly traded holding company, as such accounting standards tend to be rigorous so I have some concept of "corporate accounting"—to say nothing of some level of interest.

Today's news item of interest (my thanks to: DeepImpact2005 @ FluWiki) hit two areas of interest: Influenza Pandemic and Bean Counting.

From MedPageToday.com:

Flu Pandemic Would Cost Hospitals Billions

By Michael Smith , North American Correspondent, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

BALTIMORE, Dec. 4 -- A flu pandemic like the one in 1918 could cost U.S. hospitals $3.9 billion, but a human-to-human outbreak of the H5N1 avian influenza strain could dwarf that estimate.

This opening line is of major importance, at least in my estimation. I ask that you indulge me as I give a little background on why the above sentence is noteworthy and paradigm challenging.

Planning assumptions for a severe pandemic rarely account for anything worse than 1918. In fact, today is day two of a web dialogue on the US vaccine prioritization preliminary guidance, and the "PanFlu aware" who are participating are continually running up against the facilitators inability (or refusal) to step outside of the possibility that the next PanFlu could be worse, or even significantly worse, than the 1918 pandemic.

This steadfastness is in the face of WHO findings, multiple scientific papers, notable experts, and just plain common sense given available facts.

The sentence also makes the distinction of a human transmissible avian influenza. That distinction is not well understood, even after all the coverage of H5N1 and pandemic influenza. Influenza A comes in two varieties: human and avian. People only get avian influenza rarely because of (partly or mainly) its "binding affinity", the cells it will bind to and enter for viral replication. Although scientists do not yet know the entire puzzle of what makes an avian influenza adapted to humans, the binding affinity is a big piece of the "why".

However, it is an avian influenza virus adapted to human infection and transmission that is the most deadly to humans of the influenza viruses. The genetic makeup is still entirely of avian origin but the virus undergoes changes at the nucleotide or the amino acid level that give it human infection, replication, and transmission capabilities. As I noted above, we still don't know exactly what those changes are or even on which gene or genes they have to occur to confer this ability, but the puzzle is slowly being unraveled. Hopefully, we will find out in time as it is that bit of knowledge that gives us the greatest potential of having meaningful advanced warning.

The article continues:

The lost revenue to hospitals from a 1918-style pandemic would come from deferred elective cases and uncompensated care for flu victims, found Eric Toner, M.D., and colleagues at the Center for Biosecurity of the University of Pittsburgh, in Baltimore.

The average community hospital would lose $353,985 by deferring cases over an eight-week pandemic period, Dr. Toner and colleagues reported in the quarterly Journal of Health Care Finance.

At the same time, the effects of the pandemic would mean uncompensated costs of $430,607 per hospital to treat the influx of flu patients, the researchers said.

Across all U.S. hospitals, that adds up to $3.9 billion -- a sum that could create severe financial strains in the health care system, the researchers said.

"Some hospitals may not have sufficient cash on hand to cover these losses," they said.

For a macro-level analysis I recommend HealthyAmericans White Paper: Pandemic Flu and the Potential for Economic Recession: a state-by-state analysis (pdf here). In it you will find their assessment that an increase in healthcare spending will go a long way in offsetting down turns in the other major sectors of a state's economy. I remember my reaction when the paper hit the internet—unbelief is a bit of an understatement.

(article continues)

Government planning assumptions also suggest that if a pandemic were on the 1918 scale, hospitals would find it difficult to treat all the patients who required care.

For example, Dr. Toner and colleagues said, the average community hospital has 20 ventilators available and -- by deferring cases -- could have 81 free beds.

But at the height of a 1918-style pandemic, 42 patients would need ventilators and 290 would need beds, they said.

All this is based on extrapolations of planning assumptions from the Department of Health and Human Services, which were predicated on the 24% mortality rate from infections in the 1918 flu.

If the pathogen involved is a humanized version of the H5N1 avian flu strain, "the severity and duration of a pandemic could be greater than [the government] assumes," the researchers said.

The health and human services department is assuming inpatient mortality would be about 24% in a 1918-type pandemic, they said, but when the H5N1 virus has infected humans it has killed more than half of its victims.

As of Dec. 4, the World Health Organization says there have been 336 confirmed cases of H5N1 influenza in humans, of which 207 have been fatal.

"A 1918-like pandemic is far from the worst case possible," Dr. Toner said in an accompanying audio interview on the journal's website. (Click here to go to the website to hear the entire audio)

"A pandemic with [the H5N1] virus could certainly be worse than that, worse than 1918," he said.

Again, it is important to note the distinction Dr. Toner is making. A human adapted H5N1 avian influenza is a "different beast" than the 1918 pandemic strain, which, via genetic reconstruction, was determined to have been wholly avian on a genetic level as well. We don't understand why H5N1 has such a frightful mortality rate, but just because we don't understand it doesn't make it not so.

Among other things, the numbers of sick would swamp available capacity. At the height of such a pandemic, an estimated 60 million people could be sick, 30 million could need intensive care, and six million could need ventilators.

Currently, Dr. Toner said, there are 105,000 ventilators in the entire U.S. and about 87,000 intensive care beds. "The numbers are truly frightening and far exceed our ability to care for those numbers of patients," he said.

 

Even though this article addresses the financial burdens a pandemic will place upon most hospitals the supporting underpinnings are some of the best I have seen outside of dense scientific papers. Admitting it's crass and insensitive to lean on financial concerns to support PanFlu concerns in general when I refer to what will be human lives and miseries, it's as the saying goes—money talks.

The question is—is anyone listening?

 

SZ

Royal Mounted Canadian Police

Some days just seem to have a motif; today is one such day. Today it's running from the computer, screaming as I gouge my eyes from their sockets. My day job was one of those days that reduce me to wondering if I really do like to eat regularly and have a roof over my head.

As I was chomping on my lunch buzzing through FluWikie's News Diary for today I came across a post that got my blood pumping with (good) excitement. A snip from a larger piece was prefaced by "Royal Canadian Mounted Police Get It":

In addition to operational readiness, one of the key messages that emergency planners are sending to employees is to be personally prepared.

Large-scale emergencies pose unique psychological, social and physical challenges even for experienced first responders. Because many employees live in the same communities in which they serve, there is a good chance they will be personally affected when disaster strikes. This could result in not reporting for work or being distracted out of concern for their families or their own personal safety.

"Workforce resilience is the underpinning of everything that we do," says Neily. "If our people are not personally prepared to be at work with the comfort that their loved ones are being taken care of, then we are going to have a challenge."

 

I was totally deflated when I got home and read the entire piece.

The first paragraph from the RCMP Gazette cover story:

Preparing for a pandemic

National plan starts with individual readiness

By Katherine Aldred

The estimates speak for themselves. According to the Public Health Agency of Canada (PHAC), over the course of an influenza pandemic, up to 70 per cent of the population will become infected and between 15 and 35 per cent will become clinically ill and miss work. If antivirals are not available, 1 per cent of the ill will be hospitalized and 0.4 per cent will die.

 

Reading that paragraph I just wanted to scream and toss my laptop across the room—and then gouge out my eyes. Yes, I truly was that upset.

This was the official information two years ago. Two years ago—before we had scientific findings, computer models, and reassessments of both.

OK, sure, the next pandemic could be this mild. My problem is the presentation of these figures as a foregone conclusion—that it won't and can't be worse.

[snip]

"We don't know when a pandemic will occur, what the cause will be, how severe it will be or who will be hardest hit," says Dr. Arlene King, director general for Pandemic Preparedness at  PHAC. "We do know one thing: when any emergency hits, it's too late to be doing the planning. The structures, processes and tools have to be in place."

Police agencies involved in responding to a pandemic must be prepared not only to deal with the complex requirements of a public health emergency but to carry on their normal day-to-day operations with a greatly diminished workforce. The challenge is getting ready.

They say the right (scripted) words.

[snip]

According to Neily, the RCMP could be called in to provide a number of different functions during a pandemic such as enforcing public health orders like quarantines and travel restrictions, limiting access to areas deemed out of bounds, transporting and protecting medical equipment or medications, protecting certain types of facilities and, in a worst-case scenario, controlling crowds.

And like any operational response, police must be prepared for the conditions — in this case, a contagious disease.

[snip]

"From a health point of view, our preparedness plan outmatches anything out there," says Legault. "One of the greatest challenges will be trying to assist with public order and containment measures to prevent the spread of the virus while a vaccine is being developed. We may also be enforcing social distancing measures and there are always people who do not want to follow that."

 

Although they are saying the right things about preparing for a pandemic, they are quite probably preparing for the wrong pandemic. The mild pandemic they are preparing for is one as happened in 1957, what the US CDC (the Centers for Disease Control) has quantified as a category 2 pandemic.

A category 2 on the pandemic severity scale will only occur if the influenza strain (whether H5N1 or not) is not a wholly avian strain of influenza, instead it would require that the avian strain swaps genes with a human influenza virus. Sure, it could happen, but why plan for it to happen that way when there is no guarantee that it will?

 

Planning for a mild pandemic and being socked with a severe one will cost lives, many lives, many RCMP lives. Planning for a severe pandemic and only having to deal with a mild one costs nothing but a bit more money and a few more brain cells.

 

Perhaps they will get a clue before it is too late to act upon it.

 

SZ

 

 

Standing at the Gates of Hell

Yesterday I posted on the Ebola outbreak going on in Uganda with a large portion of the entry dedicated to discussing the fleeing of medical personal from the outbreak. Today, crfullmoon of PFI posted a link to Paradoxuganda written by Drs. Scott and Jennifer Myhre based in Bundibugyo, Uganda. Their recent blog entries have dealt with an on-the-ground-up-close-and-personal account of this team amidst the Ebola outbreak. They have not "fled", instead, they are "standing their ground".

 

There is a Tom Petty song that I am quite fond of:

I Won't Back Down

Well I wont back down, no I wont back down
You can stand me up at the gates of hell
But I wont back down

Gonna stand my ground, wont be turned around
And Ill keep this world from draggin me down
Gonna stand my ground and I wont back down

Hey baby, there aint no easy way out
Hey I will stand my ground
And I wont back down.

Well I know whats right, I got just one life
In a world that keeps on pushin me around
But Ill stand my ground and I wont back down

Hey baby there aint no easy way out
Hey I will stand my ground
And I wont back down
No, I wont back down

 

With those words in mind…

Thursday November 29, 2007:

 

The mysterious disease that has infected people in Bundibugyo was this morning revealed to be Ebola virus (verified by the CDC-Atlanta laboratories). 79 cases have been identified since August, with a 43% death rate. So far all cases have come from a village area called Kikyo, which is 25 km from our mission, or through direct prolonged contact with patients from that area. Ebola is a panic-inducing word. We are treating this news with sober respect,…

 

[a listing of facts on Ebola]

 

Please pray for our doctors and other health workers. Dr. Jonah is in Kampala now, but he saw quite a few cases before he left, as did Dr. Sessanga. Scott has attended to many of these patients already. Pray for us to wisely support the health system in our district, to graciously care for the ill, to be alert to any danger to our team and children, and to advocate for the best possible response that Bundibugyo can receive from international aid workers.

 

Friday November 30, 2007

 

[snip]

 

We're still waiting for the cavalry to arrive.  Meanwhile the MAF pilot has hung out at our house, and I've been at the Nyahuka Health Center.  We had one patient admitted to the isolation ward but she probably just has malaria.  I had an hour-long meeting with the staff, who are understandably nervous.

And with good reason.  I just got off the phone with Dr. Jonah.  He had gone to Kampala on personal business a few days ago.  Yesterday he had a headache, and today a bit of fever, so he admitted himself to Mulago Hospital's isolation ward.  We are hoping that his illness is not related, but I think he was wise to put himself there, so that he does not infect others.  PLEASE pray for him!!!

 

Later in that day…

 

[snip]

 

The WHO rep, a sharp, experienced, epidemiologist emphasized in the first meeting of the day with local govt leaders that this seems to be a new (fifth) strain of Ebola, atypical both clinically and genetically from previously identified strains. A more non-specific clinical syndrome (fewer specific hemorrhagic signs) will make the containment of this epidemic more challenging, he said. That first meeting also revealed a lack of consensus on what public health message should be disseminated to the pubic. Will schools, markets, basic health services be shut down or curtailed? Hand-shaking cease? There was no debate about the answers, only a request from the experts to wait for their final assessments.

 

The visit to the Ebola Isolation Units at Kikyo Health Unit and Bundibugyo Hospital consisted of physical assessment of terrain, potential tent and gate locations, patient traffic patterns, water and latrine availablity, and staffing evaluations. Surprisingly (to me), not one member of the International Team donned protective gear in order to lay eyes on any patient. Their mandate, they said, was logistical assessment not clinical management. At Kikyo Health Unit, the staff and community seem much less aware of the ramifications of the Ebola diagnosis. People milled around the grounds of the Health Unit gawking at the entourage with its six vehicles and foreign visitors.

At Bundibugyo Hospital a significant portion of the hospital staff have gone AWOL or called in sick. A few brave nurses volunteered to staff the Isolation Unit, previously built by MSF for Cholera Isolation. During our discussion of potential layouts of an expanded unit at Bundibugyo Hospital, I received the short message on my cell phone that Dr. Jonah admitted himself to the Mulago Hospital (Kampala) Isolation Unit with fever, headache, and vomiting (and a history of contact with Ebola cases). Up to that moment, we had all expected Jonah to return today to resume his active role in the assessment and management of this crisis. Not possible now.

 

[snip]

 

I realized this morning that there are, in reality, two related emergencies. The Ebola Epidemic trumps all as the primary crisis. However, there is a secondary Medical Staffing Emergency in this District. Our only two Ugandan Medical Officers lay ill, presumably from Ebola. The official Ministry of Health initial press release revealed 51 cases and 16 deaths. That's a 31% case-fatality rate. Nearly three-quarters of those afflicted may survive (according to the official numbers). So, our doctors may survive, but are likely to be out of commission for weeks.

 

[snip]

 

Bottom line....

We desperately need at least one more physician at Bundibugyo Hospital who can do emergency operative obstetrics. The District has failed miserably in recruiting doctors even before Ebola. The likelihood of a Ugandan Medical Officer volunteering to come to Bundibugyo now seems slim and none. I have appealed to MSF to recruit a doctor from their ranks to come and do non-Ebola hospital work (they are sending two already to manage the Ebola cases).

Please pray...

For Dr. Jonah, Dr. Sessanga, Joshua Kule (a senior Physician Assistant), and Fred (a nurse)--health workers who have all fallen sick with symptoms of Ebola this week.

For another doctor to come in and serve at Bundibugyo Hospital.

For Jennifer and I as we balance the responsibility of leading our team and being involved in District-level response and planning.

For Jennifer and I...for our health. We have personally examined patients (using some protective measures—but not the head-to-toe suits which are on the way), but I do not believe our exposure has been to the level of our Ugandan colleagues.

For Bundibugyo. It's another bad rap for a disdained district. We know, however, that God has a special concern for the poor, the lowly, the despised. He has not forgotten or forsaken us.

 

Sunday December 2, 2007

 

[snip]

 

Admitted at Bundibugyo:  15, including Dr. Sessanga whose sister just came to our house looking for Scott because he's no longer responsive; the matron (head nurse); the nurse who was working in the isolation unit Fred; a clinical officer named Joshua Kule; and an ophthalmic assistant.  Among the other patients are six direct contacts (mother, brother, wife, daughter and two friends) of Muhindo Jeremiah who died just over a week ago.

Admitted at Kikyo:  8 as of yesterday, haven't heard today.

Died:  official number is 18.  Likely higher, hard to say.

Calvary:  Still en route, but expected any minute.  They slept in Fort Portal last night.  There is a 17 person team from combined MSF branches (Belgium, France, Spain, etc.) including the doctor who was in charge of the recent outbreak in Congo.  They have two doctors, four nurses, and a wide variety of other staff who won't see patients but do logistics, education, investigation.  Even an anthropologist.  The CDC lab team arrives in the country Tuesday night.  They say they'll be up and running for labs in Entebbe (Uganda Viral Research Institute) by Thursday, possibly even Wednesday evening.

Jonah:  I just talked to his sister, she says there is definite improvement since yesterday.  We heard he had a positive malaria smear, so it is possibly not Ebola.  But then he developed more symptoms, so we are waiting for a confirmation.  His blood sample is with the CDC in Uganda, not yet reached America.

Team:  OK.  We had a prayer and discussion time this morning.  As team leaders we are leaning towards sending out non-medical staff and children, to be cautious.  Scott and Scott zipped up to Bundibugyo again mid-meeting to do an emergency C section, but by the time they got the mother into the OR the baby had died, and she then delivered the still-born vaginally.  So you could, in a public health sense, count that as another Ebola casualty.  As soon as they got out of that they were called to see a motorcycle accident victim, a lady with severe facial trauma and fractures they need to refer to Fort Portal, but probably can't because she's a family member contact of an Ebola survivor (one of the cases Scott has been following the last two weeks).  He was actually driving the motorcycle when it crashed.  It is incredibly complicated.

 

Still Sunday, different post…

 

I am making this two separate posts, to separate the facts from the emotions.  And since my mother and my son both read this from America I probably won't be fully honest.  But I will say that the emotional toll of the last 72 hours has been tremendous.  There is first of all the wrenching anxiety about the patients that we know.  Since about a third right now are hospital staff, they are not mere numbers in a list.  Jonah of course top of the list of people we love who are in danger.  A virus that selectively attacks the people who care for the sick seems positively diabolical.  Then second there is the small but real possibility that one of us, mostly Scott, would fall ill.  Since the only other two doctors who have seen these patients are down, we can not ignore that risk.  We have been careful and pray that we've been careful enough.  The full protective MSF biohazard garb is arriving today, before that we've worn masks and gloves only.  And related to that sobering hypothetical scenario is the responsibility we feel to protect and care for and make good decisions about our children and our team, a third area of gut-twisting thoughts.  It is unbelievably painful to consider that we (Scott, Scott Will, and me) might be dangerous to them.  So over the last day we've been growing in our conviction that we need to get the non-medical team members out of here, away from us.  It is an impossible dilemma, to look at my beautiful three children who are here with me, and think that for their own good I need to send them away from me.  To look at our bewildered team scrambling to make plans and feel that we can't go with them.  So far we are all well, but if our medical exposure stopped this minute it would still be at least two weeks, maybe three, until we were sure we were safe.  Over the last three days since we knew it was Ebola, I have only been with one patient who may have been a case (she died), while Scott has continued to care for the ill until MSF arrives (hopefully soon).  Clearly it would be good to keep one parent healthy, but where does that leave the support we need to give each other?  And if those three areas of stress are not enough, there is the parallel crisis of the collapsing medical system.  Scott has been gone all day again, third day in a row of juggling the medical and surgical emergencies that would have fallen to Dr. Sessanga and Jonah.  How do we weigh ethically protecting ourselves and our children and our responsibility to the community here where we've spent  a large portion of our lives, in their time of greatest need?  

 

I strongly encourage you to visit paradoxuganda to read the heart wrenching account of the Drs. Myhre in full, along with the few recent entries I did not "snip".

If you are a person of faith, your prayers have been asked for, I'm confident they aren't particular as to what faith.

 

Standing at the gates of hell. Afraid, but still standing.

I fervently hope that the Drs. Myhre do not mind me "snipping" such a large portion of their recent entries, I did not bother them with asking permission. I did so to honor their struggles, their fears, their prayers, their courage, their commitment, and above all… their humanity.

 

SZ

Norovirus Stressing Britain’s Hospitals

Norovirus is in the news a lot and not especially noteworthy here at BFJ but the fact that the DailyExpress is reporting a "Black Alert" at some hospitals and a general "stressing" of the system is noteworthy for me.

The disease is usually self-limiting, and characterized by nausea, vomiting, diarrhea, and abdominal pain. General lethargy, weakness, muscle aches, headache, and low-grade fever may occur. Symptoms may persist for several days and may become life-threatening in the young, the elderly, and the immune-compromised if dehydration is ignored or not treated.

 

CRISIS AS NEW BUG SWEEPS BRITAIN

Monday December 3,2007

Mark Reynolds

 

A VIOLENT stomach bug is sweeping the country and pushing hospitals to breaking point.

Some have already turned away patients because they have no beds available.

 

Last night health campaigners warned of a "meltdown" in hospitals and "unnecessary deaths" this Christmas.

 

In the past week, the bug has prompted several hospital trusts to issue Black Alerts – the highest state of emergency for the NHS.

 

The sudden outbreaks of the bug, norovirus, has seen stretched hospital staff forced to keep patients waiting in ambulances outside casualty departments while they try to find beds for them.

 

At other hospitals, wards have had to be closed to new admissions as the bug takes a hold on existing patients – further exacerbating the bed shortage.

 

The depth of the crisis, which began to worsen about 10 days ago, has been highlighted by a series of leaked memos from hospital managers.

 

Norovirus led to the closure of wards at 10 hospitals across the country last week, prompting a raft of Black Alerts, with trusts warning of worse to come as the winter months take hold.

 

Hospitals in Aberdeen, Bath, Bury St Edmunds, Bradford, Chichester and Worthing have already been forced to turn away patients because of the crisis. 

 

And half of Norfolk's entire ambulance fleet recently became stuck in a queue at a flagship hospital after it was found to be "full" and could not admit more patients.

Last night a spokesman for the national Save Our NHS campaign said: "We are getting reports of hospitals beginning to fill across the country.

 

"We know that some hospitals are managing the problem by turning away patients or making them wait in ambulances until they have a bed. 

 

"Cutbacks in beds have been causing problems and they are bound to be exacerbated by extra pressures in the winter."

 

On the front line, paramedic Tom Reynolds, based in east London, said: "The next few months are going to be a shambles. 

 

"People forget staff also suffer with sickness. Everyone is so exhausted. We can't keep up with what we are being asked to do."

 

Accident and Emergency registrar Dr Nick Edwards said: "The NHS is failing to cope with a predictable winter problem. Just imagine what would happen if we face an emergency like bird flu.

 

"We would need to invent a colour more serious than just black alert."

 

Geoff Martin, of the patient pressure group Health Emergency, warned that the crisis could lead to unnecessary deaths.

 

"We are staring down the barrel at the prospect of the worst NHS crisis for many years," he said.

 

"Our fears of a meltdown as the winter pressures build appear to be coming true as the norovirus gets a grip on our wards."

 

But last night the Government tried to play down the beds crisis. 

 

Health Minister Ben Bradshaw said: "Winter crises used to bedevil the NHS.

 

"Thanks to record investment under Labour and better organisation we've not had a major winter crisis for years.

 

"However, we are not complacent and constantly update contingency plans."

 

The piece from the DailyExpress has hints of "political" spinning however, I am well aware of the limitations our modern health care systems have been placed under irrespective of political party in power. It is that "limitation" that drives a great deal of the concerns the "Flu Obsessed" have when thinking about a sever pandemic.

 

Perhaps it is worth pausing a moment and considering what even a 30% clinical attack rate (CAR) during an influenza pandemic will do to our respective health care systems in light of this Norovirus outbreak.

 

SZ

Uganda: Ebola Outbreak

Over the years Ebola, or one of its viral siblings, breaks out on the African continent, a hemorrhagic fever, and probably the disease that strikes the most fear into the hearts of those near an outbreak or unlucky enough to be stricken with it.

Outbreak of rare Ebola virus in Uganda worsens

Sun 2 Dec 2007, 15:24 GMT

KAMPALA (Reuters) - The number of Ugandans infected by a new strain of the deadly Ebola virus has risen to 58, raising fears the death toll of 18 will also increase from the outbreak in a remote area near Democratic Republic of Congo.

The half dozen extra infections in recent days include some medical staff who were treating victims of the haemorrhagic fever which has swept the western Bundibugyo region since August.

"Four of our medical personnel, including a doctor and three nurses, have been isolated in Bundibugyo Hospital after catching the virus," said Dr. Sam Okware, head of Uganda's national hemorrhagic fever task force.

"We now have a team of experts on the ground to try and contain further spreading of the virus."

Genetic analysis of samples taken from some of the victims shows it is a previously unknown type of Ebola, making it the fifth strain, U.S. and Ugandan health officials say.

Ebola can cause internal and external bleeding.

Victims often die of shock, but symptoms can be vague, including fever, muscle pain and nausea. It is known to infect humans, chimpanzees and gorillas.

Uganda was last hit by an epidemic of Ebola in 2000, when 425 people caught it and just over half of them died, including a doctor treating victims.

An outbreak in neighbouring Congo this year infected up to 264 people, killing 187.

 

The Cyber Flu Community has taken an interest in this outbreak. A new strain of the virus that is exhibiting different symptomology, dramatically less lethal than the previously identified four strains, but close to what I presume a pandemic strain of H5N1 will be.

Given the fear and the high toll extracted on health care workers, the following is no surprise: from The Times, South Africa

Medics flee Uganda

Vincent Mayanja, AFP

KAMPALA - Several dozen medics and support staff have fled western Uganda after their co-workers became infected with the Ebola virus in an outbreak that has already killed 18 people, officials said on Saturday.

Ugandan officials clamped a quarantine on the Bundibugyo region and appealed for help in dealing with the outbreak of Ebola, a contagious disease that kills up to 90 percent of those infected.

However efforts to contain the outbreak, which began in September but was definitively identified as Ebola only last week, have been hampered by medical personnel becoming infected and others fleeing.

"We have a shortage of health workers and we need more because those who were there on the ground have been infected: two doctors, a medical officer and a nurse," said Sam Zaramba, the country's top government physician.

"Health workers are terribly afraid. They have abandoned patients in health units for fear of being infected," a government official told the state-owned New Vision newspaper.

A health official for the Bundibugyo region, who asked not to be named, estimated the number of health and support staff to have abandoned their posts to be several dozen.

Continues…

 

It is not out of the realm of logical musings that this is what we will see during a severe influenza pandemic; health care workers who flee their posts because of the real possibility of becoming infected. Something to remember the next time you read about the probability of our health care systems being overwhelmed during an influenza pandemic: more patients, less providers.

 

SZ

POLAND: AI Virus in the Food Supply

Turkeys infected with HP H5N1 have made it to the markets in the Pomorze area of Poland.

Bird Flu virus found in meat in shops in north Poland

02.12.2007 16:57

In the Pomorze region 480 kg of turkey meat has been found to contain the bird flu virus.

   

Also it has been announced due to the outbreak in Płock, central Poland, that information bulletins will be passed out in schools tomorrow, Monday December 3rd. Local priests have also stepped in to supply information to local residents.

   

Ongoing research is being carried out it infected areas in farms around the town of  Płock. Vehicles passing through the area are also being disinfected.

   

Anna Obuchowska, spokeswoman for the Sanitary Inspectorate in the Pomorze region, has stated that the meat came from two warehouses, in Żukow and Sierakowice.

   

The Żukow plant supplied meat to shops in Gdańsk and Gdynia, with the Sierakowice source providing shops in Człuchów, Chojnice,  Kościerzyna and Kartuzy.

   

Obuchowska has said that there is a search for remaining meat in the shops, but it is unlikely that any remains, as the turkey meat was delivered to the shops at the beginning of the previous week.

   

Shop employees are under surveillance by the Saniitory Inspectorate for their own safety.

   

Avian flu has the same effects as 'normal' flu, and can be treated with the same anti-viral treatment, including Tamiflu.

   

Specialists have stated that meat preparation at temperatures above 70 degrees Celsius should kill any viruses that were present in the meat before its preparation are safe to eat. (jb)

 

We are consistently told that eating infected poultry is not dangerous to our health if it is cooked properly. Yes, this is true; viruses are killed by cooking food to at least an overall (internal) temperature of > 70^o C (158^o F): heat kills all viruses.

Handling poultry recommendations from WHO:

Highly pathogenic H5N1 avian influenza outbreaks in poultry and in humans: Food safety implications

SUMMARY NOTES

 

• Conventional cooking (temperatures at or above 70°C in all parts of a food item) will inactivate the H5N1 virus. Properly cooked poultry meat is therefore safe to consume.

 

• The H5N1 virus, if present in poultry meat, is not killed by refrigeration or freezing.

 

• Home slaughtering and preparation of sick or dead poultry for food is hazardous: this practice must be stopped.

 

• Eggs can contain H5N1 virus both on the outside (shell) and the inside (whites and yolk). Eggs from areas with H5N1 outbreaks in poultry should not be consumed raw or partially cooked (runny yolk); uncooked eggs should not be used in foods that will not be cooked, baked or heat-treated in other ways.

 

• There is no epidemiological evidence to indicate that people have been infected with the H5N1 virus following consumption of properly cooked poultry or eggs.

 

• The greatest risk of exposure to the virus is through the handling and slaughter of live infected poultry. Good hygiene practices are essential during slaughter and post- slaughter handling to prevent exposure via raw poultry meat or cross contamination from poultry to other foods, food preparation surfaces or equipment

 

Roughly 90% of the meat consumed in my home is boneless-skinless chicken breasts, it's versatile and convenient, to say nothing of the simple fact that as a meat, it is one of our favorites. Because of my awareness of avian influenza, and H5N1 specifically, I have learned to treat my raw chicken breasts as a genuine biohazard.

And, just to keep the poultry eaters on our toes (from the same WHO recommendations):

Presence and survival of the virus

 

Most strains of avian influenza virus are found only in the respiratory and gastrointestinal tracts of infected birds, and not in meat. However, available studies indicate that highly pathogenic viruses, such as the H5N1 strain, spread to virtually all parts of an infected bird, including meat. Avian influenza viruses survive in contaminated raw poultry meat and therefore can be spread through the marketing and distribution of contaminated food products, such as fresh or frozen meat. In general, low temperatures maintain the viability of the avian influenza virus.

 

The virus can survive in faeces for at least 35 days at low temperature (4°C); while at 37°C, viruses could survive for 6 days in stability tests on faecal samples in studies using H5N1 viruses circulating during 2004. Avian influenza viruses can also survive on surfaces, such as those within the poultry house environment, for several weeks.

 

Due to these survival properties, common food preservation processes such as freezing and refrigeration do not substantially reduce the concentration or viability of these viruses in contaminated meat.

 

 

Biohazard poultry is just something we are going to have to deal with until we find the solution to remove, once and for all, the route of infection that finds its way to our domestic poultry.

 

 

SZ (Who is not yet ready to become a vegetarian, but getting closer to that culinary adjustment)