A visit to the World Health Organization’s pandemic alert website on Aug. 14 found this news:
Avian influenza — situation in Indonesia — update 26
The Ministry of Health in Indonesia has confirmed the country’s 57th case of human infection with the H5N1 avian influenza virus. The case is a 17-year-old male from a remote village in Garut district, West Java Province. He developed symptoms on 26 July and was referred to hospital on 9 August. At the hospital, medical staff suspected H5N1 infection based on his respiratory symptoms and a history of exposure to dead poultry. Because of this suspicion, specimens were collected from the patient and sent for testing. Results received on 12 August were positive for H5N1 infection. The patient is presently recovering. A thorough field investigation found that chicken and duck deaths occurred in the patient’s household and neighborhood during the week prior to symptom onset. The case reportedly had direct contact with diseased chickens during the disposal of carcasses. The investigation also obtained information about a 20-year-old male who lived in a neighbouring household where chickens were also dying. The man developed symptoms on 26 July and sought care at the local health centre on 5 August. He died of respiratory disease on 6 August, before arrangements could be made for transfer to hospital and before samples could be taken for testing. The cause of his illness and death remain undetermined. Of the 57 cases confirmed to date in Indonesia, 44 have been fatal.
The young man in Southeast Asia was one of 241 cases reported to the World Health Organization of human infection with H5N1, a strain of bird flu that is widespread in Asia. The young man was lucky. His was one of one of the 60 cases confirmed in Indonesia to date; the flu was fatal to 46 of them. Of those tested positive for the virus, 141 have died — a rate of 58 percent. The number of dead is not alarming to scientists; the lethality is.
H5N1 first surfaced in humans in 1997 in Hong Kong, and as the small number of human cases shows, it is not easily transmissible across species lines. Virtually all humans who’ve become infected with the avian virus lived with poultry in and around their homes or worked in markets that sell living animals.
In June, however, the first human-to-human infection with H5N1 was confirmed by laboratory tests. A boy in Indonesia gave the flu to his father.
Viruses — including the many active bird flu viruses, including the non-lethal form of H5N1 recently discovered in Michigan swans — evolve quickly, which is why flu vaccine must be reformulated every year. Sometimes the virus is so different that we have no immunity, and a world-wide health crisis — pandemic — can arise: Hence the pandemic of 1918-19, when an H1N1 strain killed 50 million to 100 million people, and smaller outbreaks in the 1950s and ’60s.
No one can say for sure that H5N1 will mutate, reshuffle its RNA in such a way that it finds a welcome mat in human lung cells, and set off the next pandemic.
What disease experts are saying is this: We’re overdue for a flu pandemic. If the pandemic is caused by a virus as lethal as H5N1, one we have no immunity to, the death toll could be staggering. And because people and goods travel quickly around the world, pandemic flu could turn our lives upside down, collapsing health care, economies, even governments.
President Bush has put pandemic flu preparation at the top of his health agenda. The federal government has allocated $100 million to state and local governments for pandemic planning.
Gov. Mike Huckabee has pressed state agencies to prepare, and two of those agencies — the health division of the state Health and Human Services Department and the Livestock and Poultry Commission — say they’ve made significant strides (the latter’s laboratory even was featured on the CBS nightly news). In August, the agency was praised by Dr. John O. Agwunobi, assistant secretary of U.S. Department of Health and Human Services, saying “very few [states] have come as far as Arkansas” in developing their plans.
The University of Arkansas for Medical Sciences is planning; its Code Isolate has reached the tabletop training stage. The Pulaski County coroner says he’s ready.
Should H5N1 spread to North American birds or mutate to a strain that will infect people, Arkansas is peculiarly vulnerable. It’s on the Mississippi flyway, which could bring infected birds our way, and the home of the largest poultry industry in the nation. The state is also on the human flyway, thanks to the corporate jets that fly into Northwest Arkansas from overseas to do business with Wal-Mart and other businesses there.
But Arkansas is uncommonly prepared, thanks to its handling of an influx of refugees from Hurricanes Katrina and Rita and a Division of Health exercise that did a mass vaccination of 52,195 people in one day in 2004.
That’s the kind of work that Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy and associate director of the U.S. Department of Homeland Security’s National Center for Food Protection and Defense, says is necessary to prevent a crisis.
“It is not a matter of if” we’ll have a pandemic, Osterholm said in a talk at the Clinton School for Public Service in July. It’s a matter of when, and what he called our just-in-time economy — which produces not surpluses but what we need when we need it — can’t handle a surge in demand for medical care or commodities.
People who talk about pandemic and bird flu — especially people in the chicken business — stress the distinction between the two. Avian virus H5N1 may not cause the next influenza pandemic.
But, Osterholm and health experts say, we are due for a pandemic — they occur every 10 to 50 years and the last was in 1968.
Most of the people who’ve died from H5N1 exposure have been under the age of 40; the median age, according to a study done when the death toll stood at 113, was 20. Particularly vulnerable were people ages 10 to 19. The median number of days from symptoms to death was nine, according to that same study.
The 1918 pandemic strain, H1N1, was similar; more than half its victims were aged 18 to 40.
Molecularly, H5N1 is “kissing cousins” to H1N1, Osterholm said. H5N1 may not cause the next pandemic (though Osterholm said he wouldn’t bet against it), but if it did, it could be predicted to have the same devastating mortality rate. Extrapolated to today’s population, 1.7 million in the United States alone might die, and another 1 million would be made ill.
In such a scenario, Osterholm said, consider this: The country now has 105,000 mechanical ventilators available. When routine flu hits, almost all of them are in use at one time. In pandemic, the need could triple.
It won’t be possible to manufacture enough vaccine to treat everyone. There may not be enough antivirals in production to handle symptoms.
Triage of patients will be wrenching. Who gets the ventilator? Who gets the vaccine? Who gets the Tamiflu?
If a hospital runs out of oxygen because of delivery interruptions caused by sick delivery personnel, Osterholm added darkly, the respirator decisions will be solved.
In Arkansas, the state Department of Health is assuming the following points, according to its Influenza Pandemic Response plan:
“The healthcare system will be severely taxed, if not overwhelmed.”
UAMS’ Code Isolate — or Code Strangle, emergency preparedness head Dr. Aubrey Hough said — contemplates a number of unusual strategies to deal with pandemic: Sheltering at War Memorial, to handle overflow patients; drilling a well, to make sure the hospital doesn’t run out of water, as the Ochsner Clinic in New Orleans has done; stockpiling non-perishable foods in a warehouse it already has; stockpiling pharmaceuticals. It contemplates ways to move fuel for its diesel powered generators from one area of the hospital to another, limiting entrance to the hospital and processing patients in large outdoor tents.
“We’re developing a policy on how to use our limited supply of respirators,” Hough said. UAMS is purchasing portable respirators and negative air pressure equipment that will turn regular hospital rooms into isolation rooms. Its external oxygen storage will be sufficient for “several days,” Hough said.
The hospital will put all suspected flu patients in a dedicated area in the north wing of the hospital, one with its own elevator and rooftop helicopter pad. Its plan calls for using 40 rooms normally occupied by bone marrow transplant and burn patients. If more space is needed, hallways and classrooms could be used.
“Are we realistic and know we’ll be overwhelmed? Yes,” Hough said. When the SARS virus (severe acute respiratory syndrome) hit in Canada, it was reported that a quarter of the health care personnel in Toronto did not come to work. Hough has heard higher percentages of people who, because they are sick, caring for the sick or trying to avoid getting sick, are expected to be absent from work. UAMS, which has 9,300 employees, is now identifying those who are critical to care-giving and where they will stay at the hospital. Those who can work from home will.
“We are the hospital of last resort for hundreds of thousands of people,” Hough said. He said H5N1 may not be the trigger for pandemic, but “this virus has kicked everything into high gear” as far as preparedness goes.
Pulaski County Coroner Mark Malcolm, who ran a morgue in Thailand to handle the thousands killed in the 2004 tsunami and who worked also in Louisiana after Katrina, said the county is “ready for any eventuality.”
The coroner has contracted with a couple of companies locally that have refrigerated trailers in case the number of dead exceeds our ability to deal with the bodies. Malcolm expects that in case of disaster, his office would have to handle the dead from hospitals, private homes, nursing homes and the street.
“No matter how many deaths occur we don’t handle them differently … still one at a time,” Malcolm said.
“During a pandemic wave in a community, between 25 percent and 30 percent of persons will become ill during a 6 to 8 week outbreak.”
The Division of Health of the state Health and Human Services Department will descend full force on the first suspected cases of flu. It will distribute antivirals to the first cases and people who’ve come in direct contact with them — family, doctors and other health personnel — and it will do so within the first 48 hours of the emergence of symptoms. The division will take swabs from patients and test them in its new $25 million clinical laboratory, which has been certified by the federal government to handle up to level 3 biohazards.
Clinical director Dr. Randy Owens said it will take only two hours for the lab to confirm that an illness has been caused by whatever virus is epidemic, which it does by looking at specific genes. The lab will then do a more complete analysis of the culture to provide to the Centers for Disease Control. “They want to know as much about the agent as possible,” Owens said. Is it drug resistant? How has it mutated from flu viruses caught earlier? A virus cultured toward the end of a pandemic wave could be used to create vaccine for the next.
Dr. William Mason of the health division’s office of health preparedness said the agency is still identifying storage sites for the 300,000 doses of antiviral drugs it expects to receive within the next 18 months. It will receive 692,287 doses in all, to handle 25 percent of the population. The state legislature appropriated a $6 million match to federal funds to obtain the antivirals: Tamiflu, a pill, and Relenza, an inhalant. Proper storage is critical to keeping the drugs effective as long as possible.
The division has developed a plan for dispensing vaccine once it’s available, said Donnie Smith, director of the division’s Center for Health Protection. In 2004, when there was only a limited amount of vaccine, the division carried out a mass vaccination in counties across the state. “No other state has done anything like that,” he said.
Boone County has already carried out a disaster exercise. In June, health division personnel and private doctors and nurses worked with volunteer patients, training them in what questions to ask and what protocols to follow.
“The U.S.-based vaccine production capacity is expected to be 3 million to 5 million doses per week with 3 to 6 months needed [after outbreak] before the first doses are produced … the need could potentially substantially exceed the amount of vaccine that would be produced.”
Dr. Xuming Zhang, professor of molecular virology at UAMS, is working out the mysteries of the H5N1 virus with the aim of producing an effective vaccine through recombinant gene technology. The study focuses on the genetic structure of the virus’ hemagglutinin (H), which causes the virus to attach to cells to begin the invasion process and triggers the body’s immune response, the production of protective antibodies.
But H5 contains a unique and particularly toxic stretch of amino acids in its genetic makeup, Zhang said. Re-engineering the virus so that it is non-pathogenic and able to immunize and protect humans from avian H5N1 virus infection is challenging. But Zhang believes he can do it, and that such genetic engineering is the fastest route to creating flu vaccines.
Indeed, Zhang and colleagues have recently succeeded in creating such a genetically engineered H5 virus. He plans to test the safety and efficacy of the engineered virus vaccine in animals in the near future.
Right now, however, control of the virus in animals is the most important preventive measure science can take, Zhang said.
Tyson Foods is protecting its business against avian flu and its employees against pandemic, but its executives stress the difference between the two viruses. “We have to be very careful talking about these two issues simultaneously,” Johnny Lea, chief development officer and senior vice president, said.
The company notes that its chickens are constantly monitored for H5N1 and other avian diseases. They are raised in enclosed facilities, which guards against contact with wild birds who may be carrying the virus. (No North American bird has yet been found to be infected with avian H5N1 virus; world migration patterns are such that few western hemisphere birds come into contact with eastern birds.)
Tyson also notes that its “all in/all out” farming — in which same age birds are moved into and out of production houses as one flock — also guards against disease spread. Workers at production houses wear protective clothing to protect against the spread of pathogens.
Lea said the company’s “business continuity task force” has been working for a year to create a plan for dealing with pandemic or any catastrophe. The primary issues, he said, are making accommodations for employees to limit absenteeism and making sure deliveries of fuel and other supplies carry on.
“We are dependent on the inbound ingredients of a number of our products that we don’t manufacture ourselves,” and to keep things rolling the company has been networking with suppliers. “We developed a network with Katrina that worked pretty well,” Lea said.
Lea added that Tyson executives have “been talking to three major U.S. corporations to validate our plans versus theirs to make sure we’re not overlooking anything. … We as an industry need to engage in this [and] the states need to engage, because we’re not going to be able to rely on the federal government.”
Lea said Tyson expects to have a first draft of its pandemic plan by September.
In August, biologists monitoring birds found a strain of North American H5N1 infection in two swans in Michigan. This version of the virus is called a low-pathogenicity strain, causing no illness in the birds; it was previously detected in the U.S. in ducks in 1975 and in Canada last year, according to the USDA.
In Asia, however, the lethal H5N1 has spread to poultry in China, Africa and Europe, and migratory birds are thought to be responsible. (That’s unusual, in that migratory birds have not been known to harbor such a highly lethal type of flu virus.) The H5N1 virus killed more than 6,000 migratory birds at a nature reserve in China.
Since last summer, the federal government has been testing migratory birds in the Pacific flyway in Alaska for H5N1, and Arkansas has begun testing ducks and shorebirds whose arctic nesting can bring them into contact with old world birds.
Biologists from the state Game and Fish Commission and the USDA’s Wildlife Services plan to take fecal samples from 500 mallards, 200 pintails, 200 green-winged teal, 150 shovelers, 100 white-fronted geese, 50 cormorants, 25 great blue herons and 25 great egrets, and, by way of a contract with Arkansas State University, 200 pectoral sandpipers and 100 long-billed dowitchers. Samples will be sent to the state Livestock and Poultry Commission lab for testing. Wildlife Services will also take water samples.
Game and Fish will test both live ducks and ducks killed during the season this fall, Brad Carner, an assistant chief in the wildlife management program, said. The live ducks will be captured with rocket nets; mist nets will be used to gather up shorebirds. The latter is difficult, requiring a tromp through mudflats to shoo flocks of wary birds into the nets without scaring them off.
USDA has authorized Game and Fish to shoot birds if necessary to acquire samples, though shooting at shorebirds is not necessarily a better way to collect them than nets.
Arkansas is a tier 2 state, ranked behind coastal states and ahead of other states off the flyways in likelihood of disease. However, Carner said the agency is “pretty doubtful we’re going to find a positive.” Alaska has the greatest likelihood because of its Asian bird contact, but tests of thousands of birds have not found the virus there.
Far more likely, biologists say, is that H5N1 would be introduced through the import of exotic bird species into the country.
The state Poultry and Livestock Commission, meanwhile, expects to get a $403,000 grant to expand its poultry monitoring.
“The story here as far as poultry goes is to sort out to the public that the disease that kills people is not the chicken disease; it’s where the chicken disease has mutated,” director Phil Wyrick said.
The commission has stepped up monitoring at chicken houses, testing 20,000 birds in April 2006, up from over 7,000 in April 2005. It has also found and tested more than 5,000 birds from small farm flocks, for both high-pathogenicity and low-pathogenicity avian viruses, more than any other state, Wyrick said.
Should a human form of H5N1 arise in the U.S., “we are convinced it would come from an airplane.”
The commission has done quarantine drills in the past couple of years also.
“It would irresponsible for us not to be prepared,” Wyrick said. But, he added, “facts are it wasn’t so long ago we were having a problem with SARS (Severe Acute Respiratory Syndrome), smallpox, and West Nile was going to kill everybody. And when I was kid everyone got a bomb shelter … . I’m not saying this is silly, but let’s keep it in perspective.”