Pandemic Awareness/Preparation

Nurses COVID

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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.

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Malaysia Receives Prepandemic Vaccine

http://www.farminguk.com/?show=newsArticle&id=12288

This article is of interest because of its discussion of pandemic versus prepandemic vaccines. Needless to say, the pandemic vaccine is going to give more protection. The prepandemic is also likely to be in short supply and would not be given to the majority of a population in most countries so I would wonder just how many people they are planning to vaccinate, and under what circumstances.

Malaysia is the first country outside Europe to approve a pre-pandemic avian influenza vaccine called Prepandrix.

GSK Pharmaceutical Malaysia MD Francis Del Val said the company’s Prepandrix is a pre-pandemic drug to vaccinate populations prior to a H5N1 avian influenza pandemic. It is designed to provide cross-protection against a range of avian influenza caused by H5N1 strains.

A pandemic vaccine carries the actual pandemic strain and is produced after it has been isolated. The problem with this is that it can take 4-6 months to produce, leaving populations highly vulnerable during the initial period of a pandemic.

Pre-pandemic vaccines are produced before an influenza pandemic and are based on current circulating avian H5N1 influenza viruses.

(hat tip PFI/pixie)

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Better Drugs Needed To Fight A Pandemic

http://afludiary.blogspot.com/2009/02/webster-better-drugs-needed-to-fight.html

For those interested in influenza, whatever Robert Webster of St. Judes Childrens Hospital in Memphis says is to be taken seriously. If he says that we should be concerned about something then we really should be. In several posts the phenomenon of recent Tamiflu resistance to one of our seasonal influenzas has been discussed, and the implications that this could have in the event of a pandemic have been explained. This warning carries much more weight when someone like Dr. Webster talks about it. The other virologist of note in this link is Malik Peiris, part of a world class virology team at University of Hong Kong, one those researchers that played a part in the hunt for the cause of the SARS outbreak. These two men are notifying us that there is a problem that must be solved.

Many advanced countries stock up on oseltamivir and zanamivir, two varieties of the same class of drugs that stops the H5N1 virus from multiplying. But oseltamivir has proven to be largely useless in fighting the H1N1 seasonal human influenza virus and experts are questioning how well, and how long, the drug would stand up against the H5N1 virus, should it unleash a pandemic.

"We have been extremely foolish on our policies of stockpiling drugs. We have been stockpiling two varieties of the same drug," virologist Robert Webster at the St Jude Children's Hospital in the United States said at a medical conference in Hong Kong.

He said the resistance of the H1N1 virus to oseltamivir was as high as 98 percent worldwide.

"The likely scenario is that the (H5N1) virus will become resistant when you start using more and more (of one) drug, you get resistant (H5N1) mutants," he told Reuters later.

Malik Peiris a microbiologist with the University of Hong Kong said: "There is a need for developing new antivirals (drugs). Some are in very early clinical trials but development should be stepped up so there is a diversification of options."

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Egypt

http://www.straitstimes.com/Breaking%2BNews/World/Story/STIStory_344830.html

A TWO-YEAR-OLD Egyptian boy has contracted the bird flu virus and is in critical condition, the state-run news agency quoted the Health Ministry as saying on Sunday, becoming the 56th case in the Arab country.

The Middle East News Agency (MENA) quoted Assistant Health Minister Nasr el-Sayyed as saying the boy, Youssef Abdel-Azim from the province of el-Fayoum in central Egypt, showed symptoms on Wednesday after coming into contact with dead birds.

He was administered the antiviral drug Tamiflu and remains in crticial condition on an artificial ventilator at a hospital in Cairo, Sayyed said, according to the agency.

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Indonesia's Climbing Case Fatality Ratio

Indonesia continues to withhold information making it difficult to determine the real number of humans cases of bird flu in that country. Here are a few links about deaths and illnesses that occurred going back into January. The number of cases of infected humans is most likely underreported. The Recombinomics link makes clear that we are hearing about fatal cases for the most part, but that there have to be other cases not being counted of people who were sick but recovered, and we know that there are misdiagnosed index cases who died, and whose family members subsequently tested positive. Does it matter that we don't know just how many cases there really are? If human to human transmission is occurring more frequently, then yes, clearly it does matter.

http://afludiary.blogspot.com/2009/03/various-reports-out-of-indonesia.html

http://afludiary.blogspot.com/2009/03/indonesian-official-four-more-bird-flu.html

http://afludiary.blogspot.com/2009/03/indonesia-bekasi-residents-under.html

http://www.recombinomics.com/News/03030902/H5N1_Indo_CC.html

When Indonesia announced their news blackout on confirmed cases, WHO offered assurances on timely updates. International Health Regulations require notification within 24-48 hours of confirmation and previously WHO had issued updates within a day or two of the death or discharge of confirmed cases. If Indonesia is abiding by these regulations, then WHO is withholding the data for weeks or months after they are notified. Ironically, when WHO offered its assurances last year, they noted that the Indonesian confirmed cases were not part of a cluster. Yet the news blackout came after the third cluster was confirmed. In each cluster the index died, but was diagnosed with something other than H5N1 (lung inflammation, dengue fever, or typhus) and when a family member was H5N1 confirmed, the misdiagnosis was not upgraded, so the official case count underrepresented both cases in clusters.

This undercount continues today. On Java the past 16 confirmed cases have been fatal. A case fatality rate of 100% signals an under-representation of infected cases that recover. In the latest confirmed cases from Bogor, two siblings died (see updated map). However, a third sibling who survived refused testing. Similarly, three paramedics affiliated with the hospital that treated the confirmed fatality in Surabaya developed symptoms and were in critical condition. At the end of last month they were still hospitalized and unconfirmed, but the likely three cases would create another cluster that included surviving contacts of an H5N1 confirmed case.

These latest likely clusters raise concerns that the H5N1 in Indonesia is evolving toward an H5N1 that is more efficiently spread to humans. The recent WHO report on H5N1 vaccine targets included an HA phylogenetic tree with four isolates from Indonesian patients. These isolates continued to evolve away from this initial 2005 isolate from Tangerang, and raise concerns that vaccines directed against the 2005 isolate will offer limited protection.

Thus, the continuing rapid evolution of H5N1 in Indonesia, coupled with frequent larger H5N1 clusters continues to increase pandemic concerns, while the level of WHO transparency on cases and clusters declines.

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A Viral Detective Story

http://crofsblogs.typepad.com/h5n1/2009/03/a-viral-detective-story.html

It is a strange mystery why H1N1, the virus that caused the 1918 pandemic disappeared after 1950 then came back, and caused yet another, though far less serious pandemic again in 1977. It was most unusual.

Do you think that lab accidents happen?

Why were the viral genomes of the 1977 H1N1 isolate and the 1950 virus so similar? If the H1N1 viruses had been replicating in an animal host for 27 years, far more genetic differences would have been identified. The authors suggested several possibilities, but only one is compelling:

...it is possible that the 1950 H1N1 influenza virus was truly frozen in nature or elsewhere and that such a strain was only recently introduced into man.

The suggestion is clear: the virus was frozen in a laboratory freezer since 1950, and was released, either by intent or accident, in 1977. This possibility has been denied by Chinese and Russian scientists, but remains to this day the only scientifically plausible explanation.

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Egypt reports 57th human case of bird flu

http://news.xinhuanet.com/english/2009-03/05/content_10944869.htm

At least this little kid is in stable condition.

An Egyptian boy at the age of two years and eight months has contracted bird flu virus, bringing the number of human case of the avian influenza to 57 in the country, a Health Ministry spokesman said Wednesday.

The boy, Abdullah Nagy Amran, comes from the northern Egyptian governorate of Alexandria, some 220 km northwest of Cairo, the state MENA news agency quoted the spokesman Abdel Rahman Shahine as saying.

The boy showed symptoms after contacting with dead birds on Wednesday, and he is in a stable condition after being admitted to a hospital and given the antiviral drug Tamiflu, said Shahine.

This is the second human case of bird flu less than a week in Egypt, where millions of families raise poultry as a source of food and income.

You can check out the new bird flu website in Egypt, SAIDR . The second link is to a map from their site indicating how pervasive the H5N1 virus is in Egypt.

"SAIDR (Strengthening Avian Influenza Detection & Response) is a USAID-funded effort in support of the Government of Egypt's national program to detect and respond to avian and pandemic influenza. SAIDR is a partnership between Egypt's Ministry of Health & Population (MOHP) and Ministry of Agriculture & Land Reclamation (MALR), the UN Food and Agriculture Organization (FAO), and the USAID project Communication for Healthy Living implemented by the Johns Hopkins University Center for Communication Programs. Allied organizations include UNICEF Egypt, the United Nations Development Program, the Egyptian Red Crescent Society, and Save the Children Egypt."

http://www.saidr.org/

http://www.saidr.org/en/map.php

(hat tip Avian Flu Diary}

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How much human bird flu in Indonesia?

http://scienceblogs.com/effectmeasure/2009/03/how_much_human_bird_flu_in_ind.php

That is the unanswerable question because of the censorship in that country. If I worked in public health there, I would be ashamed. It is a terrible thing not to be allowed to tell the truth. Just like the doctors in China that were forbidden to speak out about SARS, they know exactly what is at stake because this is influenza, and it is not just about Indonesia. We are all held hostage by this secrecy.

If I were a tourist or a company and I wanted to act prudently. For tourists and travel agencies, I'd cancel trips to Bali or other tourist destinations, and for businesses, I'd do what Panasonic announced it was going to do regarding the threat of a bird flu pandemic: recall all dependents of employees, until we were assured of accurate information from the Indonesian government. We are now all on notice that Indonesia, the world's hot spot for human cases of bird flu and a plausible location for the start of a pandemic, is covering up the true number of cases of the disease.

The Editors of Effect Measure are senior public health scientists and practitioners.

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Zions Bank to ready residents for pandemic

http://www.sltrib.com/news/ci_11845247

This is an original way to help prepare the public.

If a flu pandemic or bioterrorism attack strikes the Wasatch Back, the Summit County Health Department wants residents to be ready.

As such, it is partnering with Zions Bank to pass out emergency medication disaster kits at bank drive-up lanes in Coalville and Kamas on Saturday. The exercise is scheduled from 10 a.m. to noon at the two Zions branches, each located on the towns' Main streets.

To encourage people to participate, Zions Bank will give each child a $1 presidential coin. There also will be drawings for Jazz tickets, golf at Thanksgiving Point and 72-hour emergency kits.

The practice run for distributing antibiotics or anti-viral medication via drive-thru windows marks the first exercise of its kind in the nation. It is funded by a grant from the Cities Readiness Initiative of the Centers for Disease Control and Prevention.

(hat tip flutrackers/laidback al)

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Egypt

http://afludiary.blogspot.com/2009/03/media-egypt-reports-58th-bird-flu.html

...Egypt's Health Ministry has announced their 58th human H5N1 infection, and the 7th one of 2009 - that of a 1-1/2 year-old girl from the Minufiya governorate.

This is the third case announced out of Egypt in the past 10 days.

http://afludiary.blogspot.com/2009/03/who-updates-egypt-and-case-counts.html

The World Health Organization has updated their website with the latest (#58) confirmed case of avian influenza reported in Egypt yesterday, and has updated their cumulative cases count chart.

Still missing, however, are the 4 cases reported by the head of Indonesia's Bird Flu Commission, Bayu Krisnamurthi, more than a week ago.

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Indonesia

http://www.flutrackers.com/forum/showpost.php?p=213489&postcount=1

A translation from Indonesian media indicating that Indonesia is going to be building their own bird flu vaccine plant. Can't say as I blame them considering that they have the highest rate of infection and fatalities from bird flu. They have steadfastly refused to share viral samples with the rest of the world saying that they would not benefit from any vaccines produced from their gifting of samples, and would not be able to afford the vaccines.

They are also censoring information about how many cases there have been. Some of the missed information may also be due to not bothering to test on the part of local physicians. If bird flu is suspected, they just go ahead and start the patients on Tamiflu. Other cases are misdiagnosed as dengue and other diseases. It is impossible to know what is going on over there anymore.

They admit upfront in this link that they will not be able to produce enough vaccine to protect their entire population, but then no one else will either, at least initially if a category 5 pandemic situation occurs. Category 5, like the hurricane categories, is a worse case scenario such as the 1918 pandemic. Of course, the 1918 virus, H1N1 had only a 2% CFR while H5N1 has a 63% case fatality ratio. It is entirely possible that 1918 might not be the worse case scenario.

...the company's human bird flu vaccine plant will begin construction in April of this year, is scheduled to begin operation in 2011.

Company has the western counties in Bandung and Bandung Chi City Road, Basseterre Bio Pharma AG Selma law in the vicinity of the original factory set up two locations.

The Indonesian government has agreed to this up to 360 billion rupiahdollars one Indonesian Rupiah) of human bird flu vaccine factory in construction investment.

The factory is first of all have to build infrastructure, raw materials as a vaccine with egg plant, and then building a pharmaceutical factory in Biot law Selma's Factory Factory production of vaccines or other vaccines equipment.

Isa said that the vaccine's main raw materials to the composition of cells and eggs. Chi沙鲁亚company will construct two main raw materials production equipment. Vaccine plant set a production target for the year25 million doses of drugs, which can only supply of vaccine in Indonesia 10% of the total population. 20,000,000 ~ He hoped that after the Factory can be developed to enhance vaccine production capacity, as against the domestic bird flu pandemic, preventive measures.

He said that if a major pandemic, vaccine supplies may be insufficient, but the positive side, domestic production of bird flu vaccine prices will be cheaper.

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Diplomatic immunity?

http://crofsblogs.typepad.com/h5n1/2009/03/indonesia-diplomatic-immunity.html

An apparent abuse of diplomatic immunity by some Saudi (?) citizens. Why would the Saudi's allow anyone to smuggle birds from the Bird Flu Capital of the Globe into their country, and then protect them? Saudi Arabia has already experienced outbreaks of bird flu in their country. Allowing smuggling from an infected country endangers their people, their poultry industry and their native wild bird population. As I recall the Saudi's like to hunt with falcons...

This is just another example of the mentality of greed that we are seeing in many countries where birds are continually being smuggled over borders from countries where bird flu is endemic. Smugglers do not seem to realize or care about the global impact of their actions. H5N1 is being assisted in its spread across the globe not just by the migration of birds. Smuggling is a significant problem.

Airport authorities, assisted by animal aid activists, foiled an attempt Sunday to smuggle 30 exotic birds and three Sunda lorises from passengers at Soekarno-Hatta International Airport.

The birds and primates were found inside four bags brought by a family of three, AB, E and SA, who had Saudi Arabian passports and were booked on a flight to Riyadh.

The birds included a black-capped lory, eight pigeons, a salmon-crested cockatoo, a Goffin's cockatoo, 16 hill mynas, an olive-headed lorikeet, a purple-naped lory, and an umbrella cockatoo, Jakarta Animal Aid Network said in a statement sent to The Jakarta Post on Tuesday.

The three smugglers were not arrested because their embassy vouched for them.

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What Is Going on in China?

http://afludiary.blogspot.com/2009/03/winter-of-our-disbelief.html

There is continued speculation about unreported bird flu outbreaks that may be occurring in this most secretive country. Because of what was allowed to happen with the SARS virus, anything that Chinese authorities report as truth is questioned. There is plenty of evidence that H5N1 is still very much present in that country. That they continue to contradict themselves also does not inspire any confidence in the official story.

Over the past two months more than a dozen H5N1 infected birds, mostly ducks and chickens, have washed up on the beaches of Lantau and other islands in Hong Kong.

Since these birds appeared in areas far removed from any local poultry operations - and given the level of decomposition of the birds - it is reasonable to assume they were discarded into the Pearl River, or one of its tributaries somewhere in Guangdong Province.

Additionally, Hong Kong continues to occasionally find dead migratory birds, also H5N1 infected, that likely came from the mainland.

Over the past few months we've seen openly contradictory statements by the Chinese Minister of Health (MOH) and the Chinese Minister of Argriculture (MOA) over the source of infection of the 7 admitted human cases in January.

The MOH insists that nearly all had direct contact with poultry, and that was the likely source of infection. The MOA insists that the country's poultry is free of the virus.

Both can't be right.

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