Danger of Flu Pandemic Is Clear, if Not Present

By DENISE GRADY
Published: October 9, 2005
Fear of the bird flu sweeping across Asia has played a major role in the government's flurry of preparations for a worldwide epidemic.

That concern prompted President Bush to meet with vaccine makers on Friday to try to persuade them to increase production, and it led Health and Human Services Secretary Michael O. Leavitt to depart yesterday for a 10-day trip to at least four Asian nations to discuss planning for a pandemic flu.

But scientists say that although the threat from the current avian virus is real, it is probably not immediate.

Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said a bird flu pandemic was unlikely this year.

Anticipating the spread of a regional flu virus, Indonesian officials recently took blood samples from birds in a market in Solo, Central Java.
"How unlikely, I can't quantitate it," Dr. Fauci said. But, he added, "You must prepare for the worst-case scenario. To do anything less would be irresponsible."

Dr. Jeffery Taubenberger, chief of the molecular pathology department at the Armed Forces Institute of Pathology, said, "I would not say it's imminent or inevitable." Dr. Taubenberger said he believes that there will eventually be a pandemic, but that whether it will be bird flu or another type, no one can say.

The Bush administration is in the final stages of preparing a plan to deal with pandemic flu. A draft shows that the country is woefully unprepared, and it warns that a severe pandemic will kill millions, overwhelm hospitals and disrupt much of the nation.

What worries scientists about the current strain of bird flu, known as H5N1, is that it has shown some ominous traits. Though it does not often infect humans, it can, and when it does, it seems to be uncommonly lethal. It has killed 60 people of the 116 known to have been infected.

Alarm heightened on Thursday when a scientific team led by Dr. Taubenberger reported that the 1918 flu virus, which killed 50 million people worldwide, was also a bird flu that jumped directly to humans.

There is a crucial difference, however; the 1918 flu was highly contagious, while today's bird flu has so far shown little ability to spread from person to person. But a mutation making the virus more transmissible could set the stage for a pandemic.

Another concern is that H5N1 has become widespread, killing millions of birds in 11 countries and dispersing further as migratory birds carry it even greater distances. This month, it was reported in Romania.

Meanwhile, the flu is spreading widely among birds in Asia. And it has unusual staying power, persisting in different parts of the world since it emerged in 1997.

"Most bird flus emerge briefly and are relatively localized," said Dr. Andrew T. Pavia, chief of the division of pediatric infectious diseases at the University of Utah and chairman of the pandemic influenza task force of the Infectious Diseases Society of America. The most worrisome thing about H5N1, Dr. Pavia said, is that it has not gone away.

Some scientists suspect that if H5N1 has not caused a pandemic by now, then it will not, because it must be incapable of making the needed changes. But others say there is no way to tell what the virus will do as time goes on. And they point out that no one knows how long it took for the 1918 virus to develop the properties that led to a pandemic.

Meanwhile, H5N1 seems to be finding its way into more and more species. Once known to infect chickens, ducks and the occasional person, the virus is now found in a wide range of birds and has infected cats.

"It killed tigers at the Bangkok zoo, which is quite remarkable because flu is not traditionally a big problem for cats," Dr. Pavia said.

It has also infected pigs, which in the past have been a vehicle to carry viruses from birds to humans.

"We should be worried but not panicked," Dr. Pavia said.

The timing of the bird flu's emergence also makes scientists nervous, because many believe that based on history, the world is overdue for a pandemic. Pandemics occur when a flu virus changes so markedly from previous strains that people have no immunity and vast numbers fall ill.

"In the 20th century there were three pandemics, which means an average of one every 30 years," Dr. Fauci said. "The last one was in 1968, so it's 37 years. Just on the basis of evolution, of how things go, we're overdue."

Dr. Bruce Gellin, director of the National Vaccine Program Office, said: "You get this sense of compounding risks. First, it's in some birds. Then more. Then more area, then more mammals and then to humans, albeit inefficiently."

In just a few instances, Dr. Gellin noted, the virus does appear to have spread from person to person.

"The only thing it hasn't done is to become an efficient transmitter among humans," he said. "It's done all the other things that are steps toward becoming a pandemic virus."

But not everyone is equally worried about the bird flu.

The fear "is very much overdone, in my opinion," said Dr. Edwin Kilbourne, an emeritus professor of immunology at New York Medical College, who has treated flu patients since the 1957 pandemic and has studied the 1918 flu.

The bird flu, he said, is distantly related to earlier flus, and humans have already been exposed to them, providing some resistance.

Scientists also say that the death rate may not be as high as it appears, because some milder cases may not have been reported.

Dr. Kilbourne and other experts also noted that when viruses become more transmissible, they almost always become less lethal. Viruses that let their hosts stay alive and pass the disease on to others, he explained, have a better chance of spreading than do strains that kill off their hosts quickly.

Moreover, he said, while much has been made of comparisons between the current avian flu and the 1918 strain, the factors that helped increase the flu's virulence in 1918 - the crowding together of millions of World War I troops in ships, barracks, trenches and hospitals - generally do not exist today for humans.

But an essential difference is that people carrying the flu today can board international flights and carry the disease around the world in a matter of hours.

Dr. Kilbourne emphasized that medical care had improved greatly since 1918. Although some flu victims then turned blue overnight and drowned from blood, with fluid leaking into their lungs, many more died of what are now believed to be bacterial infections, which can be treated with antibiotics.

Although the death toll from that flu was high, the actual death rate was less than 5 percent.

In addition, more people now live in cities, where they have probably caught more flus, giving them immunity to later ones. "In 1918, you had a lot of farm boys getting their first contact with city folks who'd had these things," Dr. Kilbourne said.

What researchers wish they could do now is look at a flu virus like H5N1 and predict whether it is heading down the genetic road to becoming a pandemic strain.

"I hope in the future we will be able to do that, work out which mutations are critical," Dr. Taubenberger said. "We know the 1918 strain had everything it needed."

Andrew Pollack and Donald G. McNeil Jr. contributed reporting for this article.

http://www.nytimes.com/2005/10/09/internat.../09birdflu.html


The Front Lines in the Battle Against Avian Flu Are Running Short of Money

By KEITH BRADSHER
Published: October 9, 2005
HONG KONG, Oct. 8 - As the Bush administration and Congress prepare to spend billions of dollars to improve America's ability to combat avian flu, crucial needs are being left unmet on the front lines of the world's defenses against the disease, in some cases for lack of a few million dollars, international health officials said Saturday.

When Vietnam began detecting the disease in chickens nearly two years ago, it initially slaughtered and burned every chicken within three miles of an infected fowl in an effort to prevent the spread of the disease. But farmers, who received little compensation for slaughtered birds, strongly objected to sacrificing their flocks and sometimes sold their birds instead at roadside markets to unsuspecting drivers.

Yielding to popular pressure, the government has steadily shrunk the culling radius. Officials now kill only those birds in an infected household flock that do not die of the disease by themselves. Birds from different households, even those only a few yards away and also at risk from the disease, are left untouched, Vietnamese officials said.

In Indonesia, a lack of money to compensate farmers for culled chickens prompted the government to announce last year a less expensive policy of vaccinating chickens. One risk of such a strategy is that the virus will adapt and infect even unvaccinated chickens without causing symptoms of illness. That makes it extremely difficult to keep live, infected chickens from being sold in markets.

Indonesian and Hong Kong health officials said this week that exactly this problem had been detected in Indonesia. But the World Health Organization cautioned that more lab tests were needed, which takes time because of a shortage of staff and equipment.

The United Nations Food and Agriculture Organization has been trying since February to raise $100 million from donor nations to pay for veterinary services and diagnostic equipment to assess and slow the spread of avian flu in chickens and other fowl.

The F.A.O. decided at the time not to ask for more money, to compensate farmers for the culling of their flocks, after concluding that donors would not give any more.

But so far, the organization has raised barely $30 million. The $100 million figure "is what we think is the minimum for what the countries in the region need immediately to contain the virus" and slow its spread, said Diderik De Vleeschauwer, the F.A.O.'s spokesman in Bangkok.

Eradication of the disease in birds is already impossible, he added, because it has become so widespread in Southeast Asia. But containing the spread of the disease could reduce the opportunities for the virus to acquire the ability to pass easily from person to person, a requisite for the virus to cause a global pandemic.

More preparations have been made in Asia to respond to human cases of avian influenza, especially in the past year. Vietnam has a comprehensive plan that covers how government agencies responsible for everything from finance to tourism would respond to an epidemic.

Japan has begun manufacturing its own Tamiflu, a costly antiviral medicine that until recently was made only in Europe. Hong Kong is assembling a database of private doctors willing to do volunteer work in government hospitals in the event of an epidemic.

South Korea is one of several governments in the region that has run an elaborate simulation for how government agencies might respond to a wide outbreak of the disease.

"It was impressively well done," said Dr. Richard Brown, an epidemiologist with the World Health Organization. "They had this huge operations room, video links and they had clips of news broadcasts by actual broadcasters."

But while every government in East Asia and the western Pacific now has some kind of a plan, more needs to be done, Dr. Brown said.

Very poor countries like Cambodia and Laos still struggle to provide even the most basic health care to people outside their biggest cities. Health officials worry that if the bird flu virus, A(H5N1) avian influenza, were to start spreading in either country, it could become entrenched and out of control before the international health community even became aware of it, quickly spreading across borders and around the globe. Teams of experts from the W.H.O., the F.A.O. and other United Nations agencies are scheduled to visit both countries later this year.

China's preparedness for avian flu is something of a mystery. Beijing authorities have announced that they have a draft plan to deal with a pandemic, but have divulged few details. China's Agriculture Ministry has said that it is conducting tests to identify sick animals and has found very few, but veterinary and medical care vary greatly from province to province and even within provinces.

Asia's most affluent societies have taken the greatest precautions. In Hong Kong, for example, more than 100 private and state-run clinics, and most of the territory's nursing homes and child care centers, now provide the government with weekly reports on illnesses, said Dr. Ronald Lam, the principal medical officer for emergency preparedness at the Hong Kong Health Department.

Some of the most elaborate preparations are under way in Taiwan, which has diplomatic relations with only 26 small nations, mostly in Africa, the South Pacific and the Caribbean, and worries that it might be cut off in a pandemic. Taiwan was one of the earliest buyers of a Tamiflu stockpile two years ago, and plans to set up its own vaccine factory.

The factory will manufacture 200,000 doses of an experimental vaccine created by Taiwanese scientists against the avian flu virus from genetically altered strains supplied by British and American laboratories, said Dr. Kou Hsu-sung, the director general of Taiwan's Center for Disease Control.

The doses will not be used even in safety or clinical trials. They will be kept ready for a possible pandemic in which almost any vaccine, however untested, may be used. So far, the virus has killed more than half of those infected. "If we cannot get the ones produced by the pharmaceutical companies, we will use ours in an emergency," Dr. Kou said.

Avian Flu in Turkey and Romania

By The New York Times

ISTANBUL, Oct. 8 - Turkey and Romania began killing hundreds of birds on Saturday after new cases of avian flu were reported, provoking concern that the disease had spread to Europe.

The Turkish Agriculture Ministry said Saturday that about 2,000 turkeys had died of bird flu on commerical poultry farms, a day after three ducks had been reported dead of the disease in Romania.

http://www.nytimes.com/2005/10/09/internat...094&partner=AOL


New Cases of Avian Flu Are Reported in Europe

By ELISABETH ROSENTHAL,
International Herald Tribune
Published: October 9, 2005
Asian bird flu appeared to continue its westward spread this weekend with reports of two outbreaks in birds in Europe. Romania reported its first cases of avian influenza on Saturday, and Turkey today, both presumed to involve birds that migrate from Asia in autumn.

There was no confirmation that the birds had succumbed to the deadly Asian H5N1 strain that has so worried scientists and politicians in recent month. There are a number of different bird flus that occur sporadically, and typing will probably not be completed before Monday, international health authorities said.

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Daniel Mihailescu/Getty Images
A veterinarian collected the body of a wild goose, suspected to be dead from avian flu, near the Danube Delta region of Romania on Sunday.

News Analysis: Danger of Flu Pandemic Is Clear, if Not Present (Oct. 9, 2005)

Avian Flu Battle Is Running Short of Money (Oct. 9, 2005) If the birds are infected with H5N1, it will be the first time that the virus has been seen in Europe.

This summer, veterinary experts had predicted that H5N1 might expand its territory into Europe, after the virus - previously limited to southeast Asia -- turned up among migratory birds first in Western China, then in Mongolia, and finally, just over the Ural Mountains, in Russian and Ukraine, a chain that divides Asia from Europe.

"In a way we are not surprised, since we had expected a possible expansion of the disease through wild life," said Dr. Joseph Domenech, chief of the Animal Health Service at the United Nations Food and Agriculture Organization in Rome, which monitors the disease in animals.

He added that both Romania and Turkey had apparently followed United Nations recommendations about heightened surveillance and controlling the spread of the disease. "At this stage, even if it is the Asian virus, they seem to be addressing the issue very well and there is no reason to panic," he said.

Although this strain killed tens of millions of birds in Asia, it does not now have the ability to pass from human to human.

But international scientists have raised the alarm that it could acquire that ability through a variety of biological processes, and become the source of a devastating human flu pandemic. In those extremely rare cases where humans have become infected with H5N1, generally through close contact with birds, it has proved extremely deadly.

In Romania, animal outbreaks were reported in the region of the Danube Delta, with both wild and domestic birds affected, according to news reports Saturday night on the television station Antennae One.

To limit the spread of bird flu, the authorities took hundreds of birds from the farms and killed them and then declared a quarantine on the villages and six counties in the area, the station reported.

The authorities were taking the extra precaution of vaccinating local residents who might have had contact with sick birds against conventional influenza, said Dr. Adrian Streinu-Cercel, a prominent infectious disease specialist in Bucharest, as is suggested by the World Health Organization.

That vaccine does nothing to protect against the bird flu. Instead, the goal of the shots is to try to prevent a human who may be at risk for bird flu because of close contact with birds from becoming infected with normal seasonal flu at the same time.

Scientists have warned that such co-infection with the two types of virus was the most likely route for the bird flu virus to acquire the ability to pass readily from human to human, since conventional flu is highly contagious. In the same body - as in a laboratory -- flu viruses often exchange genes, creating new, more deadly pathogens.

In Turkey, Agriculture Minister Mehdi Eker confirmed that an outbreak of bird flu had occurred among turkeys on a farm in the western part of the country, according to the Anatolia New Agency. The village was put under quarantine and all birds and street dogs were being killed as a precaution, the report said.

In the event of a bird flu outbreak, the only effective treatment is quarantine and massive culls of any birds that are exposed. When the H5N1 first emerged in 1997, in Hong Kong's tightly packed farms and markets, more than a million birds were killed in a day. It is a blunt sledgehammer approach to defeat the virus, and hugely costly to farmers and governments as well.

The disease has since spread to become a frequent massive killer in poultry farms in many parts of Southeast Asia. Large bird flu outbreaks have occurred sporadically in other parts of the world, most notably on chicken farms in the Netherlands in 2003, but they were not caused by the dreaded Asian strain.

Still, in order to control that outbreak, 30 million birds were killed at a cost of 100 million euros, according to the Dutch Agriculture Ministry.

Until this year, scientists had believed that H5N1 flu moved from country to country because of domestic poultry trade. The European Union now bans poultry imports from Asia as a result.

But when cases of the deadly strain appeared this summer among migratory fowl in China's western Qinghai Province, they began to focus more on the possibility that wild birds were important in spreading the disease as well.

In the wild, controlling the disease is even harder. "There is no possibility to stamp out outbreaks among wild birds," Dr. Domenech said. "You don't want to kill wildlife and you can't kill 100 per cent anyway."

In light of that new evidence, and with memories of its previous experience with a milder form of bird flu still fresh, the Dutch government recently ordered all poultry farmer to keep their birds in covered, protected areas until at least the end of the year, to isolate them from migrating wild fowl.

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Not just for the birds
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October 9 2005

FLU SEASON BEGAN EARLY THIS YEAR, at least in the media. In part this is because a major study was released last week showing disturbing similarities between the strain of flu that caused a deadly pandemic in 1918 and the avian flu virus now affecting parts of Asia. And in part it's because a meeting of international experts to discuss avian flu started Thursday in Washington. Mostly, though, it's because of President Bush's summer reading list.

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