A Journey Through The World of Pandemic Influenza

Rules

Life has rules. They are everywhere and cover pretty much everything. Some rules are loosely defined and others immanent (Natural law), the nuances of Hobbs and Locke aside. International Treaties fall closer to the Natural Law side of the sliding scale, if not solidly upon it.

International Treaties generally fall into two categories, those that agree to perform a specific action and those that agree to refrain from a specific action. Countries can adopt a mutual defense treaty with others [action] and countries can adopt a treaty banning above ground testing of nuclear bombs [refrain from action]. The Kyoto Treaty [alternately known as The Kyoto Protocol] is an example of a treaty that parties agree to both action and inaction with its ratification.

Historically it has been the treaties of restraint that carried the greatest probability of international penalties or sanctions. These certainly have not been evenly and consistently enforced, and often countries gamble as to what the international community's reaction will or will not likely be. A few examples of reaction testing can be found in the nuclear development programs of some countries, and not one suffered (Iraq was a broader issue).

In fact, it has been demonstrated several times in our recent past that flaunting a treaty produces positive outcomes for countries as the international community resorts to what amounts to bribing a country to cease offending actions. There are few enforcement options and pretty much zero will to enact those few. Either countries live up to their treaties or they don't and the rest of the world pretty much has to accept it.

 

This week Indonesia caused yet another stir with Health Minister Siti Fadilah Supari's interview statement that her country will no longer announce H5N1 deaths as they occur, but rather on some yet to be officially determined schedule, from a month to upwards of six—or so. Here is a representative story of the many that covered the incident, but since I am late to the table I suspect I don't need to post on yet again.

 

Supari's gamble may pay off, literally as well as figuratively, and hey, more power to her. I hope she is successful in whatever it is that is driving her actions. The world moves on, and it's time that it move on without Indonesia. But I can't help wonder what Hobbs and Locke would think of these developments.

At one time a person's word was nothing short of a sacred bond, broken only by the lowest of scoundrels and a country's word was pretty much a bankable asset. Yes, the world moves on, and not always in the right direction.

 

SZ

Mixed Messages: Thermometers and Mass Graves

There are times when I find it difficult to remain gracefully dispassionate, especially when I come across something that I believe to be not only egregiously ignorant, but also a danger to the public. What makes today's topic so angering is the latest on the Influenza Pandemic front out of Ireland.

From IrishMedicalNews.com:

Flu medication stock-up advise

For all Ireland's high profile stocking up on antiretrovirals, each household will be urged to have the humble thermometer and paracetamol or ibuprofen in the event of a flu pandemic, according to a new Government handbook.

An introductory handbook on the Government's emergency planning plan, distributed recently to households across the country, says that while there will be more worldwide flu pandemics, the time and severity of their occurrence and the age groups on which their impact will be most severe cannot be predicted.

However, every household in the country will receive a leaflet before the pandemic reaches Ireland advising the measures including stocking up on a thermometer, paracetamol/ibuprofen, that should be taken. The Government will advise citizens to begin these preparations if and when the WHO confirms that a pandemic is imminent.

The guide also advises buying enough food and other supplies in advance of the pandemic to last "you and your household for at least one week", and advises awareness of hygiene measures to prevent infection.

Under the plan, the handbook says it is essential that people with flu symptoms stay at home while the indications persist, unless they receive other advice from a telephone hotline, which will be set up to provide advice and support, or from official Government announcements through the media.

The PDF of the handbook may be found here for those who wish to verify, as I did, that this is not a misquote but what is really being said.

 

Advising action only after the WHO declares an Alert Level Four pandemic threat will no doubt ensure that just about every household in Ireland will be out trying to purchase supplies at exactly the same time. As someone who is threatened with hurricanes on a regular basis I can attest to what it is like when many people attempt to buy the exact same supplies at exactly the same time. There just isn't enough supply to meet demand.

However, the entire timing strategy could prove to be naively misguided as publicly Ireland's Office of Emergency Planning is telling everyone that there will be time for everyone to become prepared (buy that thermometer and fever reducer). What if there's not?

What if an influenza pandemic bursts upon the world much as SARS did in 2003? Not an unreasonable question as influenza spreads much easier from person to person than SARS did, and we could find ourselves in the grips of said pandemic even before WHO has time to verify and announce its arrival.

Well actually, Ireland does have plans in place to deal with an unprepared public should a severe pandemic befall the world. This from NewsLetter.co.uk February 9, 2007:

Straw poll on grave crisis

A straw poll among district councils across Northern Ireland
yesterday revealed they are planning for at least 20,000 extra
graves to cope with a possible flu pandemic. Ian Starrett, Johnny Caldwell, Laura Murphy and Philip Bradfield report on how different councils are managing.

Continues….

 

Since the advice given to the Irish people, diligently mailed to every household, is so meager, and by any logic ridiculously inadequate, it's a good thing the district councils have planned to bury so many.

But it begs the question: Why is the official assumption that they will need those mass graves and yet the only advice they are giving their citizens is to purchase a thermometer and fever reducer? Would it not be wiser to advise people to stock up on a few more weeks of food so they don't have to be out and about possibly becoming infected, and a few more medical home treatment items?

Could it be that Ireland's Office of Emergency Planning has decided that the only effective action any citizen can effect is to depend on the Office of Emergency Planning? And that when they are exhausted and depleted it's just easier to toss the flu victims into those well thought out mass graves? Do the planners in the Office of Emergency Planning think their constituents are that stupid and personally incapable as to have no need of genuine guidance and advice? It certainly appears that way to me.

 

Officials are preparing for the range of severity of a potential pandemic, from mild-to-severe; meanwhile they are telling the public it will be little more than an inconvenient case of "the flu". Well, OK, they are not saying that explicitly, but it is what their message implies.

 

I would suggest that the citizens of Ireland politely suggest where the Office of Emergency Planning can stuff those thermometers.

 

SZ

Japan and Pre-Pandemic Vaccination

Japan announced today that they are moving forward with plans to vaccinate medical staff and quarantine officials with their stockpiled pre-pandemic vaccine against H5N1. 

[Thanks to Pixie @ FluWiki] From Reuters Japan to vaccinate medical workers for bird flu:

Japan plans to vaccinate 6,000 medical workers and quarantine officers with stockpiled bird flu vaccines to check their effectiveness and possible side-effects, the health ministry said on Tuesday.

The plan, which follows suggestions made by some lawmakers and experts that vaccinations take place before a feared flu pandemic, will be submitted to a panel of experts for approval on Wednesday, an official said.

If approved, vaccination will take place before the end of the fiscal year in March 2009, and mark the first case in the world in which the vaccines -- based on strains of the H5N1 virus from China and Indonesia -- have been given to such a large group of people prior to a possible pandemic.

[continues at link]

 

I have been a proponent of pre-pandemic vaccination of as many Health Care Providers, First Responders, and critical infrastructure personnel as possible for about as long as the concept has been floating around.  I do always caveat that support though with the stipulation that the vaccine not contain any adjuvant, as I believe they are an unnecessarily dangerous inclusion for healthy younger adult, a wild card that even I am not willing to gamble on.

 

By protecting the Front Line we protect the maximum number of those who will need them to be on post should the pandemic happen.  The currently unanswerable question is just how much protection will be afforded to those who receive the pre-pandemic strain of vaccine.

Under normal circumstances vaccines are meant to convey immunity to a disease.  Unfortunately it is the current assumption that vaccination with a mismatched strain of H5N1 will not convey immunity.  So, with the stockpiled pre-pandemic vaccines the bar has been considerably lowered; it is simply hoped that it will greatly reduce the severity of illness in those that receive it, full immunity being viewed as unattainable.

No one assumes that the virus that attains the means to transmit from human-to-human [H2H] will be the same strain [closely matched on a genetic and/or amino acid level] as the stockpiled vaccine.  Since influenza undergoes rapid changes, and H5N1 is demonstrating a propensity for regional specificity, there is a strong possibility the strain used for the vaccine will be significantly different than the eventual (should it be eventual) pandemic strain.

The level of protection will be measured by the amount of antibodies that those who receive it produce.  Unfortunately, with the human H5N1 vaccines approved thus far there has been a discouraging weak immune response, which is why those who are in development and production, as well as those in procurement, are eying the adjuvants so strongly.

 

The pre-pandemic vaccine is a gamble.  It's a gamble to stockpile a potentially useless vaccine.  It's a gamble to give it before a pandemic presents itself, after all, the next pandemic may never happen, or it may not happen for any number of years, or even a decade or two, and the antibodies produced from vaccine wane with each passing month.   It's a gamble that there will be no adverse reactions for a percentage of those receiving the vaccine, a risk that goes up as the number of recipients goes up.

Will Japan's gamble pay off?  Almost certainly if a pandemic happens in the next year or three.  In and of itself that makes the gamble worthwhile.  Japan's existing policy is to vaccinate when the World Health Organization (WHO) raises the pandemic alert level from 3 (current) to 4.  Should the proposed plan be approved the initial administration will happen while the world is still in pandemic threat level 3.  Further, should the plan go forward Japan will be the first nation in the world to do so.  Will others follow?  I can only hope, since time may well not be on our side.  It takes boldness to be the first, it takes decidedly less to follow a sound and reasoned example.

 

I applaud Japan's Health Ministry for the bold initiative to protect those who will be on the forefront of an outbreak.  Since it takes roughly a month for the body's production of antibodies against influenza to be meaningful pre-administering the vaccine has a huge timing benefit.  Those on the front lines will not have to wait, or be needlessly unprotected, even though this is an admittedly a probable nominal level of protection.

I think of the level of protection along the lines of the bullet-proof vest my son dons prior to every patrol shift.  While the vest does not offer 100% protection against a bullet, it is far better than nothing, and it greatly reduces his odds of being the recipient of a fatal gunshot wound.  And, let's be honest here: when we are talking life-and-death, it's the "fatal" part that carries the most weight. 

Whether a wound or illness it's easier to stand on that ever so important to society Front Line if those standing know that recovery is the most likely outcome should the protection they have been issued (vest or vaccine) prove to be less than that Golden One Hundred Percent. 

 

Sometimes in life "recovery" is the best we can hope for because prevention is beyond the moment's reality.  With this gamble Japan is not only grasping its best current hope for the individual, but also for the nation as a whole, that it will be recovery, and not a fatal blow, that is faced should a severe pandemic happen anytime in the near term.

News and Information during a Pandemic

My thanks to Lisa Schnirring of CIDRAP for bringing us a report from the recent US Department of Health and Human Services (HHS) tabletop exercise. This event brought together representatives from governmental agencies, health institutions, traditional news outlets, and internet forums and bloggers. The exercise was focused on then needs, dynamics, and interactions of information dissemination during a pandemic. Flublogia luminaries DemFromCT of FluWiki and Fla_Medic of Avian Flu Diary were in attendance as representatives of the Cyber Flu Community's "voice".

From Ms. Schnirring's CIDRAP report:

HHS includes online services in pandemic communication drill

[snip]

The exercise was the second time HHS has reached out to blogs. In May 2007, the department featured posts from bloggers such as Michael Coston of Avian Flu Diary and Greg Dworkin, MD, of FluWiki in a 5-week pandemic preparedness blog series. HHS Secretary Mike Leavitt hosts his own blog on the HHS Web site. He is the first cabinet secretary to use the online forum, according to HHS.

[snip]

"We recognize that during a pandemic information could be life-saving. As more and more people turn to the Internet for information and news, blogs have emerged as an important and influential communications tool," HHS said in its invitation to attend the tabletop exercise.

[snip]

At several points during the exercise, moderator Forrest Sawyer, a former news anchor with ABC and NBC who now runs his own media production and strategy company, Freefall Productions, asked the news media and online outlets to predict what their headlines would be and what information they would need from HHS, CDC, and other agencies.

During the exercise the communications officials from HHS floated the idea of "embedding" some of their staff in media organizations to ease access to official information during a pandemic. The agency also said its media access policies now treat reputable blogs and other reputable online services the same as traditional media organizations.

Stephanie Marshall, director of pandemic communications at HHS, told CIDRAP News that because growing numbers of people are going to online sources for news and information, "It's important for the government to understand how best to work with bloggers and other online journalists to distribute information. The exercise and the insights offered by the participating bloggers will help us improve and refine our existing pandemic communications plan."

 

Fla_Medic (Mike Coston) of Avian Flu Diary offers his own thoughts and observations of the off the record tabletop exercise:

HHS Pandemic Exercise

[snip]

The decision to include the flu forums and Internet bloggers in this exercise was a bold one.   I'm not sure that they know quite what to make of  us yet, but they obviously believe they can't ignore us. 

We are, in their words, `The New Media', and they are working out ways to work with us. 

 

 

As an Influenza Pandemic Blogger and Cyber Flu Community Addict I was nothing short of thrilled to see that the federal government recognizes the internet as something not easily ignored or dismissed and acknowledged the community as having a legitimate "place at the table".

 

Although we cyber "Flu Obsessed" are a small virtual community we can be vociferous, cantankerous, and downright self righteous at times. HHS's first experience with dealing with the Cyber Flu Community was during their Pandemic Flu Leaders Blog, on which DemFromCT and Fla_Medic were Flublogia's blogger representatives as well.

During that first intrepid online experiment there were times that members of Flublogia were so raucous and vitriolic that I found myself actually embarrassed, and for those that don't know me – that's pretty hard to accomplish. There are places within "the community" that I spare myself the aggravation of visiting (out of politeness I will refrain from mentioning them specifically). I find, alternately, their censorship or their "conspiracy theory" nature to be just too much for the Critical Thinking Libertarian region of my brain.

 

Flublogia, the Online Cyber Flu Community, is not without its faults. As such I am appreciative of the government's cautious trepidation in opening the door to us. I applaud their understanding that we are a "force" that isn't going anywhere any time soon so accommodation will, it is greatly hoped, benefit everyone.

During a pandemic, especially the early stages, information dissemination will be vital. At times of crisis and emergency the public's appetite for information is ravenous and insatiable and the traditional press has become sloppy. We in Flublogia, faults and all, do a remarkable and rapid job of "self-policing" in general when measured against the "traditional press". Additionally, we have been around long enough now to be a "known commodity", so while I understand the government's trepidation I am hopeful they are not paralyzed by it and the caution it inspires. Time will tell.

 

As it happens, while I have been composing this entry, I have been listening to CSPAN's program Tonight, Washington where the topic is Influence of foreign media on global issues. The juxtaposition of questions of purpose, credibility, sources, and dissemination between the "traditional" and the "new" media may be serendipitous and coincidental but at the same time informative of the terrible hurdles the government will have to surmount if and when the time comes to actually disseminate credible and timely pandemic information to the public.

I do not envy them their task.

 

SZ

Did She or Didn’t She

The influenza virus undergoes continual evolutionary change.  The swapping of whole genes between strains of influenza, reassortment, is known to be the mechanism that produced the 1957 and 1968 influenza pandemics, and therefore considered the main mechanism of producing our pandemic strains. 

Scientists, along with the “Flu Obsessed”, have been concerned that H5N1, currently a wholly avian influenza virus, would reassort with a human influenza virus. H1N1 and H3N2 being the two current human type A Influenza viruses in circulation.  In order to accomplish this sleight of hand on the genetic level a single virion (a single virus) from each different strain of virus, one from H5N1 and one from a currently circulating strain would have to infect the exact same human cell at the same time.

Now, without getting into a whole bunch of mind numbing scientific minutia there are tremendous hurdles that the second virus would have to overcome in order to infect a cell already co-opted by another virus.  For those curious, the mechanisms of those hurdles at work are cell apoptosis and cell superinfection; high points relevant to influenza can be found at the links. 

For those satisfied with the broad-brush strokes nature has it set up so that it is almost impossible for more than one influenza virion to gain entry into a cell, and apoptosis (the death of the invaded cell) occurs within hours of influenza entering a cell, variable, but 4 – 6 hours is probably the operative range.  Combined they form rather strong prima facie evidence that a single cell being infected by two different influenza strains is generally an extremely rare and difficult happenstance.

Yesterday CIDRAP’s Maryn McKenna reported on a bombshell that was dropped at the International Conference on Emerging Infectious Diseases by Indonesia’s Vivi Setiawaty of Biomedical and Pharmaceutical Research and Development about a 16 year old Indonesian girl who is reported to have been infected by H5N1 and H3N2 at the same time, known as a co-infection.

A snip from Ms. McKenna’s report offering an excellent glimpse into the confusing issues presented by this paper:

Throat and nasal-swab samples that were taken on the 6th day of her symptoms tested positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for both avian influenza H5N1 and the seasonal flu strain H3N2 at the Indonesian National Institute of Health Research and Development. Serology test results were less clear. Antibody titers from serum samples taken the 6th day provided a weak indication of H5N1 infection (titer of 1:10) but were negative for H3N2; convalescent sera, on the other hand, gave a strong indication of H3N2 infection (titer of 1:640) but were negative for H5N1.

RT-PCR testing, the first test performed, and the one that came back positive for both H5N1 and H3N2, is the most prone to false results, and officially treated as presumptive pending further testing.  Blood was drawn the same day (6^th day of illness) and it came back showing a weak titer response for H5N1 but none at all for H3N2.  Blood tests that early in an infection are notorious for giving “false negatives” as the body generally hasn’t had enough time to produce antibodies that would be freely circulating in the blood.  This is true for human influenza infection, and as far as I am aware, at least generally true for an H5N1 infection.

The later blood test, referred to as “convalescent sera” (blood taken later or after recovery) was strongly positive for H3N2, and would be what one would expect to see after an infection since the body has had time to produce the freely circulating antibodies.  This same test came back negative for H5N1.  Blood tests several weeks after an infection are considered definitive when proving infection or non-infection, with the caveat that the tests were performed correctly of course.  Lastly, it is worth noting that H5N1 has historically produced a strong- to- excessively strong human immune response, so a lack of climbing antibody titers would seem unlikely in the extreme for an infection in a sixteen year old.

We have two choices when deciding what to believe.  We can believe the most prone to error test shows the correct results and believe that the most definitive test was done incorrectly producing a “false negative”.  Or we can believe that the test results as this report states are what they are but the interpretation of them may need further review.  Since no independent verification from a WHO reference laboratory was conducted we may never know for sure, but I choose to class this as a “maybe, but highly unlikely” case of a co-infection of H5N1 and H3N2 until I have more information.

I would be remiss if I didn’t say that being ill with two different strains of influenza at the same time is probably not impossible, and may not even be that terribly unusual when multi-strains are co-circulating in the population.  However, I am trying to say that those two strains would not likely infect the same human cell within such a short time span, something evolution has mechanisms in place to guard against. 

Added to the time and biological improbability is that now, to the best of our knowledge, avian influenza and human influenza do not infect the same types of human cells.

Since it is that, the two strains meeting up in the same cell(s) and exchanging genetic material, which makes this case such a potential bombshell I felt it important to list out all of the issues as I understand them that would argue against it, both in general and with this case specifically. 

Who knows, perhaps next week more information will be available and I will revise my opinion and assessments.  I would be the last person to say I have the answer to this puzzle, but I do have an insatiable appetite – an appetite not likely to be satisfied any time soon – to understand the myriad pieces spread out on the table before us.

SZ

The Germs of Discord

As the below piece highlights, the propensity to lay blame is a practiced art and past time. It is not something that only occurs in South Asia, sadly, look just about anywhere where there are intractable problems and you will see finger pointing and vitriol.

The piece does have it right in that we just can't seem to work together, even when doing so is in the best interest to all involved.

From India's Economic Times:

The germs of discord 9 Feb, 2008, 0000 hrs IST, TNN

You can have all the regional agreements, pacts of friendship and mutual understanding you want, but dark deeds and shady plots are never quite far away in our brotherly region. It is also a truth subcontinentally recognised that we never seem to want to accept responsibility for any of the myriad ills plaguing our lands. Bangladesh, it seems, has now decided that the bird flu that's now spreading fast over there is a prime example of Indian perfidy. But then, that's quite usual. Everyone habitually blames everyone else in South Asia, for everything from illegal immigration, smuggling to terrorism — Afghanistan blames Pakistan, the latter blames the former as well as India, we here periodically blame everyone around us — and now Dhaka has waded in as well. In fact, it could be rather enlightening were one to substitute 'terrorism' for 'bird flu' in the statements emanating from Dhaka and New Delhi as well as the reports on the spread of the potentially deadly virus. Bangladesh is alleging that it's them birds from India that are spreading the virus in its territory, while some Indian politicians are now claiming that it is the illegal poultry trade from Bangladesh into India which started the crisis in the first place. Here, we seem to have suddenly forgotten that birds, after all, do have a propensity to fly. And borders possibly don't signify much to them. And one can hardly expect a virus to be mindful of the BSF or the Bangladesh Rifles. But then, that's just us, officious South Asians, sticklers for protocol, all. Where else, one could ask, would we find the external affairs ministries of both nations trading charges over the spread of a virus? Not to put too fine a point on it, we just don't make for good neighbours. And one might as well forget proper, sane practices like putting collective heads together and seeking a joint response to a problem during such a crisis, as would happen in any other part of the world. Now, formal requests, one wearily learns, have finally been made to share the genetic history and other information on the virus. While that is duly processed, we can regale ourselves with watching denizens of the affected areas on both sides cheerily chomping chicken on TV. It's certainly never a dull moment, living in South Asia.

Clamp on Itahar

An interesting little tidbit of news about Itahar, West Bengal, India

The Telegraph Calcutta, India

Clamp on Itahar

Feb. 4: The North Dinajpur administration has promulgated prohibitory orders under Section 144 of the CrPC to prevent poultry owners from smuggling birds out of Itahar, where mop-up operations are under way.

"We apprehend attempts to smuggle out poultry by people travelling in groups. The assembly of more than five persons in public places has been prohibited until the end of the mopping-up operation," said Raigunj subdivisional officer Asoke Kumar Das.

[snip]

Das said police stations in the area had been asked to step up patrol and arrest those violating Section 144.

In the 13 bird flu-hit districts, animal resource teams went house to house for the mop-up. Police teams accompanied them but villagers handed over their remaining birds willingly. The operation will continue for another five days.

"We wanted the police to accompany officials to pressure villagers to hand over their birds. But our door-to-door campaign in the past few days worked," animal resource minister Anisur Rahman said.

Poultry samples have been sent for tests from Sultanpur in ward 46 of the Howrah Municipal Corporation after 200 chickens died there over the past few days.

 

This is a tiny blurb and, as always, may not be entirely accurate. That said, however, it raises my concern on several levels.

First, and probably most: OK—they are concerned about bird smuggling. Good to be aware of this all too familiar problem when it comes to controlling the spread of H5N1 but— why are they concerned about smuggling carried out only by groups? The single or even tandem smuggler is not a problem? Or, do the officials feel that constraints of personnel allow for only the bands of smugglers, easier to spot, with fewer vehicles to stop, are the most effective utilization of human resources?

I certainly hope that is not the reason only groups are being checked. Five lone smuggles could potentially spread H5N1 farther and faster than a single group of five. This just doesn't make any good sense to me.

Secondly, why are "groups" mentioned again as being prohibited in general if it is five or more gathering? Why five, why not ten, why any at all? Why the restriction to begin with? Is this instead some form of political dissent being cracked down on in the guise of containing the spread of H5N1? If so, the world doesn't need control and containment response tied up with a blood red bow of political strong arm tactics. Containment and control is difficult enough even under the best of circumstances.

Lastly, why are the police involved? Goodness knows I love police, well, the law abiding, civil rights respecting police anyway, but they are not trained in the health issues of gathering and culling of birds. Should they become infected they would be near perfect vectors of wide transmission if a transmissible virus was operative.

Needless to say, I found this little tidbit of an article more disturbing than anything.

 

As always, I suppose time will tell.

The Developing World, AI, and Taiko Drums

As I often do when I sit down to compose a blog post I am sitting under my noise cancelling headphones. Today's music of choice happened to be Oedo Sukeroku Taiko's The Drums of Tokyo. I particularly enjoy percussion, whether Native, Urban, New Age, or the Formal as is Taiko.

For me drumming recalls a time before I was middle-aged, but more specifically, when I was a patrol officer, when life, and survival, had a flow and energy all its own, often an immediacy that was raw and primal. Now, as a member of America's middle class, living an insular, staid, and safe life I no longer "hear the beat" of urgent survival as an integral part of that life—hence the artificial invocation through music.

Life in Third World or developing countries is often dominated by the ever present "beat" of simply surviving. Sometimes I chuckle, albeit mockingly, at so many Western Environmentalists who envision a pre-industrial existence as the optimal human condition. I have found myself wondering how many of them have felt the raw immediacy of just making it through the day alive and in reasonably one piece as they pushed their shopping carts through their local organic grocery.

Don't misunderstand: I appreciate the environmental and the organics movements, but I believe there is a genuine disconnect between idyllic fantasy and harsh reality. I was reminded of the dichotomy of fantasy vs. reality as I thought about some of the posts on the flu forums in regards to Bangladesh, India, and Pakistan and listened through my headphones to the drums being struck.

 

When surviving is at stake there isn't much room for magnanimity and world viewpoints. Back in the days when surviving a day weighed heavy upon my mind the world still faced the threat of a nuclear exchange. Fingers on Buttons seemed so bloodless and calculated, so sterile. Today the threat the world faces may see actualization from a small holding of chickens in the slums of Calcutta or Dhaka. Nothing bloodless, calculated or sterile there. Instead life's blood pulses to the all too primal rhythm and beat of simply surviving.

Who can worry about tomorrow when this day, this hour, this moment has to be survived?

 

The drums are beating—do you hear them?

5 Jan 08 Miscellanea

Egypt is still an evolving situation. We have reports of a few more suspected cases as well as some of the existing cases testing negative. The phrase that was coined on P4P during the Pakistani outbreak was Flu Facts in Flux, and once again, that is what we have. We can want hard facts all day long, what we get is an evolving situation reported in a language other than English.

There are some in the Cyber Flu Community who treat each suspect case as a genuine infection of H5N1, and any negative test results that come back as "false negatives". While it is statistically likely that some of the negatives we receive from testing for H5N1 are in fact false, to presume they all are seems to be an illogical exaggeration of the likelihood. But in this Avian Influenza arena we have to consciously decide what we do, as well as what we don't, believe.

From Egypt we have this rather disconcerting report [Google translation], my thanks to Theresa42 of FluWiki:

4 seizure of thousands of dead chickens infected with avian influenza in Ismailia
 
Ismailia - Magdi soldier:
 
Been thwarted an attempt to smuggle four thousand chickens dead of a feed factories in Ismailia found to be infected with avian influenza disease.
The governor Ltd. Fakhrani has given directives control the entrances and exits to maintain control of the car and loaded fugitive quantities of live poultry infected with avian influenza.

Those campaigns resulted in the seizure of the car No. 55754 transfer Dakahlia governorate on board, about four thousand chickens were dead on the way to one of feed factories in Ismailia of recycling.

And to medically examine dead poultry by veterinary supervision of Dr Ismail Shmud director general of veterinary medicine show her avian influenza has been disposed of the quantity seized in a cemetery burials health compatible with the specifications and conditions of the environment and liberated the record No. 351 offences against the commander of the hill great car.

 

The bolded paragraph includes the translated words "feed factories" and "recycling". Do these words mean a plant where livestock or pet food is processed? That would seem to be the likely meaning, but is "likely" actual "fact", I do not know.

As we have seen in other countries, dead chickens are routinely "recycled" into feeding this or that. They are tossed into rivers and ponds to feed fish, and tossed to pigs to feed them. That is, when they are not consumed as human food.

Then there is this article, also brought to FluWiki by Theresa42:

EGYPT - Beefed up security in Menoufiya governorate

Google-translated from Arabic:

Hassan Hamida: ambushes of security at all ports Menoufiya to cope with the march of the virus .. And tighten procedures on farms

Wrote Mitwalli Salem 5/1/2008 [5 Jan 2008]

The General Hassan Hamida "governor Menoufiya, a member of the Supreme Committee for the control of avian influenza" decides that the deployment of ambushes fixed and mobile [random checks/check points] various outlets maintain with the rest of the neighbouring provinces to meet the Marching bird flu, and to make sure permits transfer and circulation of live birds within Menoufiya and free of the disease.

He said Hamida, told "Egyptian Today" following the end of the Higher Committee meetings to combat the disease, which was held at the Ministry of Agriculture yesterday, it was decided to tighten procedures for veterinary poultry farms and rural education and to make sure immunizations for the various types of birds, pointing out that the formation of a technical committee to follow-up immunization these farms.

He added:  Decided to entrust the education of local citizens risk contact birds, in the interest of public health, through the passage of these devices to all the villages of the province to educate its population using loudspeakers, symptoms of the disease and the need for immediate reporting of any cases of suspected infection, and deal with all cases absolute transparency.

The governor of Menoufiya that will be periodic traffic to stores that sell live birds to ascertain the source, with the necessary sampling of birds of unknown origin that is seized to make sure that they are free from disease before slaughter Anflonzataior and poultry abattoir at the earliest, stressing the importance of coordination between the departments of agriculture and veterinary medicine and health and local authorities to take immediate action to contain the disease and curb.

He stressed that the mandate of the concerned departments to prepare a report on the situation of the disease and fight to take quick action to control it, pointing out that it had been decided to declare a state of emergency in various hospitals in the province to receive all cases of suspected infection and rapid transportation to hospitals and specialized pleased sampling and analysis to speed treatment and combating disease.

 

 

As more and more suspect cases come forward and become known they are met with an urgency of action. In this sort of evolving situation it would be easy for Egypt to cross over into a panicked oppressive counter-productive response. It may well be a delicate balance, precarious, and easily lost.

I wonder how gracefully my own country would handle an outbreak of this sudden far flung scope.

Situation 3 Jan 08

After no earth shaking news out of Egypt yesterday we find that there are reportedly 16 suspected cases of human H5N1 infection in Egypt today. Not surprising in and of itself. Most now are likely to be hyperaware and diligent; every case presenting with "Influenza like" symptoms would be given a serious look, and it would make sense that any of those illnesses with severe symptoms would be treated as "suspected" until disproved to be in actuality.

Once again I would like to comment on Egypt's apparent transparency of reporting, even to the point of criticisms of the officials being printed in the press. They have a serious problem and they are attempting to address it with the seriousness that is warranted. I get no sense of over-confidence, sense of futility, or lackadaisicalness.

 

The phrase sapere aude comes down to us from the 1^st century BC Roman poet Horace:

• Dimidium facti qui coepit habet; sapere aude; incipe!
  • Translation: He who has begun has half done. Dare to be wise; begin!
  • Book I, epistle ii, line 40

 

When Horace set his stylus to those words he was urging a young friend to wake up, look around at life, taste it before it was too late, have a care for what he was and wasn't doing in the short time allotted him.

Egypt has begun, even if they could have been more proactive, at least they are taking stock of what they have, and just as important, what they haven't been doing and they have begun to have a care. And, just as Horace hoped it was not too late for his young friend, we hope it is not too late for Egypt – or for that matter—the rest of us.

 

So, we wait, and we watch. After Indonesia and Pakistan, we are well practiced.

 

SZ