Pandemic Awareness/Preparation

[indigo girl]

It has been my own personal project to follow H5N1 for the last 3 years simply because it interests me. Attracted to this type of information like a magnet, I've been watching this relatively new influenza virus to see where it will go, how it will change itself, and possibly change our world. I have followed its country by country outbreaks, and watched for the important viral mutations such drug resistance or changes that allowed it to more specifically target mammals.

Keeping in mind at all times that we will be cleared impacted as HCW, as well as being members of our communities, and having families of our own to care for, I wanted to start the new year by opening a single focused pandemic thread that would also look at what we are doing nationally to prepare for a future pandemic. Is this the virus to spark the next pandemic? No one can answer that question. We can look back at the past to the last few pandemics, and in particular to the most devastating one in 1918, and extrapolate useful information about them, but we can not predict the future. We can only make comparisons with our situation now, and learn what worked to lessen morbidity and mortality in those past events. And, we can look at those other viruses, and compare them with what we are seeing now. For example, H5N1 is a Type A virus. We know that all pandemics are caused by Type A viruses. It is also an avian virus. The deadly 1918 virus, H1N1 was also an avian virus.

For this thread, as in the previous threads, I will be making use of news sources, scientific studies, govt bulletins such as the MMR, as well as flu forums and blogs devoted to this subject for my sources. Because press information, particularly the foreign press, is not always available for later access when I am looking back to check recent historical information, the use of these blogs and forums are important because archived information quoting the media and all other sources is always fully and easily available there with no worries about information disappearing or no longer being available. They also fully document their sources or I would not be using them.

With this link from Avian Flu Diary, a well researched source that I highly recommend, we can read the words of outgoing HHS Secretary Leavitt on our state of preparedness. Leavitt has done an admirable job during his tenure, but admits that there is much left to do.

http://afludiary.blogspot.com/2009/01/hhs-releases-6th-pandemic-planning.html

afludiary.blogspot.com said:

A scant 33 months ago, I sent my first message about a race that HHS had just begun. As I said then, it was a race against a fast-moving virulent virus with the potential to cause an influenza pandemic. Since then, we have mobilized experts and resources across the country and around the world. I now send you this final message, as I look back at the unprecedented progress we have made in energizing a national pandemic influenza preparedness movement in those 33 months.

Today, many people mistakenly think influenza pandemics are a thing of the past, but influenza has struck hard in the era of modern medicine – much harder than most people realize. And it will strike again. Pandemics are hard things to talk about. When one discusses them in advance, it sounds alarmist. After a pandemic starts, no matter how much preparation has been done, it will be inadequate.

[indigo girl]

Researchers still don't know what to make of avian influenza strain H5N1

https://chealth.canoe.com/

There are many public health issues competing for funding and attention. Maintaining a good public health infrastructure in our own country and helping other countries to do the same works to protect us all. We do not know what the future will bring but we do know that pandemics are inevitable. It is a great challenge however, to continue to put forth the same ongoing level of preparation when looking at decreased numbers of deaths. Does it mean that the disease is no longer a threat? No one knows.

Not noted in this article is that there is some censorship of news about H5N1 occurring in some of those countries where the virus is now endemic. Lax surveillance is mentioned as well as out of date testing materials, two other important reasons why we may be seeing fewer cases reported. Another not reported reason but suspected by many is that if you give an at risk person Tamiflu, such as family members of positive cases, and then test them, they are probably going to test negative. How often would you think that this happens? There has been at least one entire village that had the "Tamiflu blanket" thrown over it in Indonesia, that I can think of. And, last but frustratingly not least, are those reported cases where it is found that a family member's death preceded a positive case but no H5N1 testing had been done because it was assumed that the death was due to other causes.

chealth.canoe.ca said:

After cutting an ever-widening swath through poultry flocks and infecting - and killing - mounting numbers of people in Asia, the Middle East and Africa, the virus seemed to almost take a breather in 2008. The year that just ended saw fewer recorded human cases than any since 2003, when this cycle of H5N1 activity began.

Experts can only guess at why that is and whether it signals a long-term change or is merely a short-term blip.

"It could be just a cyclical thing," says Dr. Maria Zambon, head of the respiratory viruses unit of Britain's Health Protection Agency.

Some pathogens do work in waves or cycles, says Dr. Michael Osterholm, head of the University of Minnesota's Center for infectious diseases research and prevention.

So it is technically possible that a primary wave has worked its way through bird populations and the viruses now circulating are less likely to infect humans or cause detectable human cases if they do. Osterholm is quick to add, though, that he's seen no evidence to support that kind of change, which typically happens over a longer period of time.

Fukuda says studies haven't shown that the virus has fundamentally changed, so the best guess is that the reason for the decline in cases probably rests with human behaviour. Efforts to eradicate infected poultry have improved, and countries that use poultry vaccine may be lowering the number of times people come in contact with the viruses as a result.

As well, affected countries have made strides at educating the public about the risk of contact with sick and dying poultry, he says - though he admits poor people are probably still putting the carcasses of infected birds into the pot rather than the pyre.

Uyeki suggests other possibilities.

As the problem has seemed to wane, so has attention on it. That could be translating into more lax surveillance for new cases. Doctors could be less likely to suspect and test for H5N1 infection, attributing illness to myriad other potential causes.

And the virus has divided up into many different lines or "clades" and "sub-clades" - a development that creates challenges for testing, he notes. If the sample genetic material laboratories used to look for viruses is out of date, a test that should be positive could come back negative.

As the scientists watch and wonder, public health is struggling with its own questions.

"I think really the question for a lot of them is whether enough has been done, whether such sustained effort is needed," Fukuda admits. "They know that work has to continue and they are not certain at what level it needs to continue."

It's clear the threat of a flu pandemic - caused by H5N1 or H9N2 or one of a multitude of other influenza viruses - remains. It's clear the preparatory work is not finished. But it's also clear there are a vast number of other health problems competing for funding in highly challenging economic times.

It is a concern, Fukuda admits.

"These are really long-term building efforts," he says of efforts to prepare the world to weather the next pandemic.

"And if we begin to withdraw our attention and move our attention to something else which is completely different, then we really stand to lose a lot of the work which has been built up over the past four years."

"To do this over and over again is truly ... it's like being Sisyphus," he says, referring to the Greek myth of a figure condemned to a task that can never be completed.

[indigo girl]

Egypt

https://in.reuters.com/article/us-birdflu-egypt/egyptian-girl-has-bird-flu-2nd-case-this-season-idINTRE50B6BB20090112

in.reuters.com said:

The girl, named as Asmaa Mohamed Salah Ismail, showed the first symptoms on Friday and was admitted to a specialist hospital on Saturday, said assistant health minister Nasr el-Sayed, quoted by the state news agency MENA.

The other Egyptian to contract the deadly virus this year, a woman near the southern town of Assiut, died on December 15. From the 52 human cases in Egypt over almost three years, 23 have died, but the number of cases seems to be diminishing.

The girl, from the village of Kerdasa on the western edge of Cairo, had been in contact with infected birds and showed the usual first symptoms -- a high temperature, vomiting and diarrhoea, Sayed said.

Actually we don't hear much about vomiting and diarrhea though there have been some reports of those symptoms in children in other countries occasionally. We are much more likely to hear about high fevers and difficulty breathing.

China

https://afludiary.blogspot.com/2009/01/beijing-confirms-human-bird-flu-case.html

afludiary.blogspot.com said:

Given China's lack of press freedoms, and strict government control of information, exactly how prevalent the virus is remains a matter of some conjecture.

This latest victim, a 19-year-old woman, reportedly purchased ducks at a market near Beijing. She supposedly contracted the disease while slaughtering them.

She reportedly became ill on December 24th, entered a hospital on the 27th, and died January 5th.

According to this article, since falling ill she was in contact with as many as 116 people, including relatives, neighbors, and medical personnel.

Vietnam

https://afludiary.blogspot.com/2009/01/vietnamese-girl-hospitalized-with-bird.html

In this particular case, we found out later that the girl's sister had died a short time before this child's illness supposedly of another illness they are saying. This happens too often not to look suspicious though usually the Vietnamese are more forthcoming with their information.

[sirI, MSN, APRN, NP]

Thank you, indigo girl, for your undying passion about this subject and your willingness to keep everyone at allnurses.com up to date.

We greatly appreciate you!!!!

[fiveofpeep]

Have you read "The Devil's Flu" by Pete Davies? It discusses past pandemic strains in depth and what today's scientists do on a daily basis to keep up with the new strain

[indigo girl]

No , not yet, but I'll check it out. Thanks for the recommendation, magiofliore.

[indigo girl]

Committee on Homeland Security

Report Prepared by the Majority Staff:

Getting Beyond Getting Ready for Pandemic Influenza

Even I was surprised by how gruesome this report is. It is unfortunate that there is bipartisan finger pointing, and personal bias on the part of the writers. Hopefully this will not detract from the true value of its contents. There is no doubt of their very real concern that truly we are not prepared. Should a virulent pandemic sweep the planet again, it may well be the biggest challenge of this century. Be aware that the type of pandemic referred to is not like the relatively benign events of 1957 or 1968 but rather the 1918 type of catastrophy. HHS and CDC are borrowing from hurricane terminology when they speak of that pandemic as a Category 5 event where millions died worldwide.

Personally, I very much admire outgoing HHS Secretary Leavitt. We are indebted to him for the work that he has accomplished in this effort of preparing the Nation. As a political appointee, he could only do what he was allowed to do.

This is actually an easy read for a govt document. It paints a very sobering picture of what could happen, noting that the world infrastructure could collapse, leaving us on par with third world countries.

homeland.house.gov said:

Pandemic influenza is not a new phenomenon. Historically, there have been other influenza pandemics, enough so that we now believe the planet is well overdue. We watch avian influenza move across the world, worry about how more than 60% of those people that contract the disease die from it, and realize that further mutations in currently circulating strains could cause them to easily infect human beings. If that happens, with an already high death rate, we expect that hundreds of thousands if not millions would die, that every country would be affected, and that society would function poorly at best.

Hospitals (whether private or public) find it difficult to prepare for the influenza pandemic of tomorrow when many are losing funds or are otherwise strapped for money today. They are wondering how they will keep their doors open, let alone plan to accept hundreds and thousands of more patients.

Members of the research establishment are developing pharmaceutical interventions, but struggle to address many possible characteristics and outcomes of an influenza pandemic without having the specific virus that will cause this disease. Waiting for the advent of the specific virus that causes an influenza pandemic only then to be able to develop and produce the vaccine, antivirals, and/or other necessary medications carries a great deal of risk. Unfortunately, however, this is the state of science and technology today.

Given the lack of pharmaceutical interventions currently available to us, some have called for planning and preparedness to be based upon the use of non- pharmaceutical interventions. This is reasonable and logical.

While we do not want to take the pressure off of research and other establishments to develop effective pharmaceutical interventions, we must recognize that with current technology, vaccines and antivirals will not be available soon. However, many non-pharmaceutical interventions that can prevent the spread of disease also can be implemented at any time.

Even if cell-based vaccine production technology were available today, the time from virus isolation to vaccine production would be three months. Using present (egg-based) technology, that period would be almost six months. In that time, no targeted vaccine would be available. Antiviral medications present a slightly more optimistic story, because they can be produced now. However, the production process is difficult and could take six to nine months, and it is unclear as to whether antivirals will be effective against a pandemic strain of influenza.

Many lives and dollars can be saved by a prepared public. Practicing effective hygiene and other non-pharmaceutical interventions can impede or prevent the spread of disease. Planners and those that allocate funds need to employ and support every tool available to them, including both pharmaceutical and non- pharmaceutical interventions.

...campaigns should be employed to provide the public with information they can use to protect themselves, their families, and their communities against the spread of disease in general, and pandemic influenza in particular. Information on the importance of having at least two weeks of food to allow for sheltering in place, simple personal health practices (such as proper hand washing and cough etiquette), the proper use of masks, effective social distancing (including decreased personal contact), the impact of lowering indoor air temperatures and humidity on the viability of organisms in the environment, the proper use of over-the-counter medications, and other useful practices must be provided to the public in advance of an influenza pandemic.

Preemptive public awareness campaigns should also inform the public as to how, where, and from whom they will receive information and instructions in the event of a biological crisis. DHS and HHS should work together to communicate with the public in advance, during, and after an influenza pandemic.

Conversations must occur in which key members of the medical community are made to understand the full impact of a pandemic and realistically discuss the changes in health care delivery and management that will necessarily have to occur.

The approaches to health care delivery must be reoriented when overwhelming numbers are ill and resources are extremely limited The time to learn how to make life-and-death decisions is not in the midst of such dire circumstances.

If the potential numbers of ill are anywhere close to accurate, we can expect that our hospitals will not be able to hold them. If the potential numbers are higher than have been predicted, we can expect that the entire health care system will be overwhelmed very quickly. We must prepare the health care delivery community and those that will be pressed into delivering health care during an influenza pandemic now.

Pandemic influenza has the potential to destroy the infrastructure throughout the world. Now is the time to learn from other countries about delivering health care when resources are constrained or nonexistent, in advance of a disease that will serve as an unfortunate equalizer.

(hat tip Avian Flu Diary)

[indigo girl]

HHS Awards $487 Million Contract to Build First U.S. Manufacturing Facility for Cell-Based Influenza Vaccine

An optimistic report from HHS on the new cell based vaccine plant that they are planning on building. They are saying that with "this technology, a vaccine can be produced in a matter of weeks."

That is a slightly different estimate than what the Homeland Security Committee came up with in their report "Even if cell-based vaccine production technology were available today, the time from virus isolation to vaccine production would be three months."

Keep in mind that this plant does not exist yet, and what the current population of the entire country is. We are talking about a tremendous amount of vaccine that would need to be produced in an emergency situation. But, it's a start, and cell based technology is the way to go. Now they just need to convince the other vaccine companies to build more plants in the US.

www.hhs.gov said:

The U.S. Department of Health and Human Services (HHS) today announced a $487 million multiple year contract with Novartis Vaccines and Diagnostics, Inc., to build the first U.S. facility to manufacture cell-based vaccine for seasonal and pandemic flu. Because cell-based influenza vaccine can be made faster and in greater quantities than traditional vaccine, the new facility is expected to increase the U.S. capacity to make pandemic influenza vaccine by at least 25 percent.

Cell-based vaccine production could more easily meet surge capacity needs because cells could be frozen and stored in advance of an epidemic or developed rapidly in response to an epidemic. Cell-based vaccine production also dramatically reduces the possibility for contamination and promises to be more reliable, flexible, and expandable than egg-based methods.

Currently, influenza vaccines licensed by the U.S. Food and Drug Administration (FDA) are made in specialized chicken eggs using a process that has changed little in over 50 years. In place of eggs, cell-based vaccine production uses laboratory-grown cells that are capable of hosting a growing virus. The virus is injected into the cells where it multiplies. The cells' outer walls are removed, harvested, purified, and inactivated. Using this technology, a vaccine can be produced in a matter of weeks.

"Today we are taking an important step in our ongoing commitment to pandemic preparedness," said Dr. Robin Robinson, director of the HHS Biomedical Advanced Research and Development Authority (BARDA), which will oversee the contract. "In a pandemic we would need vaccine ready within six months. That's why the National Strategy for Pandemic Influenza set domestic surge capacity as a goal in preparing the nation for a pandemic. That goal could not be accomplished using the traditional egg-based method of producing flu vaccine."

[Elvish, BSN, DNP, RN, NP]

Wow. Very interesting, sobering information. I am glad someone is dedicated to thinking about it and keeping track of as much info as possible. , indigogirl.

[indigo girl]

Bird Flu Spreads to Nepal

http://www.recombinomics.com/News/01160901/H5N1_Nepal.html

Another nation infected. Sadly, this is not unexpected even by Nepal. They have been watching for this for some time now.

Country after country, the spread of H5N1 appears to be relentless. When it becomes endemic in an environment, the risk for human cases increases. The more people infected, the greater the chances of the virus mutating to become more transmissible to humans.

www.recombinomics.com said:

This spread is not surprising. The large outbreak in Suliguri [india]raised concerns that H5N1 could be reported in adjacent areas, including Nepal (see updated map). Suliguri is surrounded by nature reserves and wild bird sanctuaries and almost exactly 1 year ago H5N1 was confirmed in West Bengal. Thus, outbreaks in Assam and West Bengal last month suggested H5N1 would spread as the temperature dropped. On a related note, the January 14 update from MOFL in Bangladesh reported culling of 5229 birds in Dhaka.

Nepal has announced pans to cull all birds within 3 km of the outbreak. Two districts in India are within 3 km of the outbreak (Kishanganj in Bihar and Darjeeling in West Bengal) and additional spread is likely.

West Bengal has already expressed concern about culling in the adjacent Darjeeling Hills due to political unrest, and wild birds (local resident as well as migratory) do not respect borders.

As the temperature drops in the area, more outbreaks are expected and confirmation will be largely dependent on testing. Nepal announced the H5N1 positives one day after the reported deaths, which is significantly faster than India, which sends a limited number of samples to distant testing centers.

[CHATSDALE]

indigo, thanks for keeping on top of something that is so important not only to nurses but the public at large

your work is appreciated

[CHATSDALE]

On another note the cholera epidemic in zimbawee [sp] the death rate is running about 5%

These people have so much to put up with and this is another hardship