TAXUS PHARMA PANDEMIC-INFLUENZA (H5N1)

JANVIER 2006

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In The News Earthfamilyalpha

1/31/06 Initial Impressions from the Regional Pandemic Flu Preparedness conference in Seattle 1/30/06. This conference was put on by Harborview Medical Center and King County, WA, Dept of Public Health, and included speakers from the US Center for Disease Control, the University of Washington and various major hospitals in the area. The conference was very well attended.

1. Regional efforts are getting underway to build a health care coalition which features web contact with one another so Incident Commanders can instantly know the status of beds, ICUs, etc in all associated hospitals. "Dealing with a pandemic makes a earthquake look easy." Instead of a sudden acute event, you have a long slow drawn out event with increasing casualties and decreasing resources.

2. We do not have the surge capacity to deal with all the potentially ill people. Estimates are for between 900 and 11,000 deaths in King County. We don't know till the virus mutates and we have a better idea of transmission rates and mortality rates.

3. There are questions as to what the necessary Personal Protection Equipment as not enough is known about the new virus yet. It will likely be the same recommendations as for the standard flu. This means standard precautions, gloves, surgical masks, eye protection and the like. N-95 masks if there is potential for aerosol exposure.

4. Recommended a respiratory hygiene/cough etiquette- cover nose and mouth when coughing or sneezing, use and properly dispose of tissues, perform hand hygiene after contact with respiratory secretions. Use of these resources and instructions in/near waiting areas. Masks should be given to patients who are coughing so they do not produce droplets that can infect surrounding patients. The area for maximum transmission is within 3-6 feet. Hand washing is imperative!

5. Patients with fever and cough should all be seen in separate areas.

More info tomorrow!

1/31/06 First bird flu death confirmed in Iraq- a young girl who had suspicious symptoms but had negative tests has now come back as positive from a US Navy testing lab. This has not been confirmed by a WHO lab but I would assume that the US Navy lab would be pretty good. This is concerning in that her uncle has died of suspicious symptoms also. Testing is pending. The girl did not do much with chickens as she did not like them but they did have a number of chicken die. In addition, they live just 60 miles south of the Turkish border and 15 miles from the Iran. There is a lake which is home to migratory water fowl by the girl's house. There are also another 30 people for whom testing is pending. No details are known of their clinical cases. There had been concerns there were cases in the adjoining countries to Turkey and indeed that appears to be coming true. The good news is that the rapid work of Turkish authorities appears to have been successful as there has not been a new case in Turkey since 1/13/06. Clearly there needs to be careful monitoring in surrounding areas and similar efforts carried out. The current issues in Iraq make coordinated efforts more difficult.

1/30/06 UN may use 'flu-casters' if pandemic hits- this article is actually from the 28th but in re-reading it there were a couple of things that struck home. The title was not really that significant but the contents were! In recently completed computer simulations: "One of the most important conclusions was that maintaining infrastructure -- water, power and the provision of food -- could take a higher priority than providing care to the sick, Nabarro told Reuters. (Dr Nabarro is the WHO flu czar) It is maybe even more important to concentrate on the essentials of life for those who are living than it is to focus on the treatment of those who are sick." Nabarro was speaking as the United Nations analyzed results from a top-level catastrophe simulation to set policies that envisage governments, companies and the media working together to fight a global flu pandemic.

Think about that for a moment. For all the talk about Tamiflu etc, they are concerned about basic life commodities. Food, water, electricity and shelter. This is a radical shift from what we have done for decades. We try to prepare for medical emergencies but assume that staff is there, power is on, and everyone is eating. In western countries, we all assume that these basics are always there. They are saying we can not take that for granted. In effect, we will be on "triage"- a concept of saving those who are the most savable, and the rest are on their own. The article does not say if they are more concerned about developed countries or undeveloped countries. In some ways, developed countries may be more at risk as fewer people live off the land and we have more complicated systems. Complicated systems are nice in that there are back up routes. On the other hand, there are more things to break. For example, animal drawn carts don't have electrical problems or fuel pumps that break.

Note also, the simulation was only 40 days into a pandemic. It is hard to say what will be the situation further into things. At some point, you will be better off as those who have had the flu and did not have permanent injury will be able to go back to work and keep the infrastructure going. Consider for a moment, if there is no food at the grocery stores/restaurants. How much food do you have at home? How long can you go? Will the stores be able to get their supplies? What happens when a significant number of people are cold/hungry? Our social fabric will be challenged. We need to work together to plan for these possibilities. I would suggest being prepared for the equivalent of at least a 2-3 week time period. Store foods you would use anyway and be able to rotate through them. Encourage your friends and neighbors to do the same. It will be hard to not share with them when they are in need. I will be attending a Regional Pandemic Flu Preparedness meeting at Harborview Hospital all day tomorrow. I will try to share some of the ideas from that conference with you.

1/29/06 Misc. reports: Indonesia poultry vendor confirmed for H5N1. Romanian Woman appears to be negative. University of Pittsburgh aims to start tests of its bird flu vaccine. The most significant of these reports is the UP vaccine. "Animals that got the engineered vaccine developed both antibodies and a T-cell response against the avian flu virus. That double line of defense might confer protection even if the virus mutates, the researchers said." However, please note this has not been tested in people yet.

1/29/06 Bird flu found in Saudi Arabia, 37 falcons culled- this report says that bird flu has been found but I would point out they do not have the N type or pathogenicity report available yet. This can not be assumed to be H5N1 till that report is out. There have been several cases of H5 reports but it turns out to be different "N" and/or low pathogenicity. If these birds are found to be positive for High pathogenicity H5N1 then it represents a significant spread to a new area. If it is there then you have to wonder how it got there- either by a human (person of shipped animal) or by migratory birds. There has not been much documented on human shipping related disease except in the case of Britain. There are lots of migratory bird related cases suspected and this would suggest that there was involvement in any of the countries between Turkey and Saudi Arabia. There is a case of a man in Iraq with some suspicious symptoms. Testing is still pending. He was the uncle of a young woman who was suspected of having bird flu but testing ended up negative. I would assume he is negative till there is definitive positive testing.

1/28/06 WHO draft report on Pandemic Response- this outlines the current proposed response to an outbreak and who is responsible for what. Of note, the WHO has 1.5 million doses of Tamiflu to target a specific outbreak. The whole idea of the plan is to try to snuff out an outbreak if possible, and if not possible, to delay the spread across the world. Each day of delayed spread is alleged to allow the production of an extra 5 million doses of vaccine. See the personal protection kits listed on page 9 of the report. These kits are recommended to be used by authorities who are trying to contain an outbreak. For those of you who can influence the proper authorities, please see if you can develop these kits. Local communities that are trying to develop quarantine areas will need these kits also, with lots of extra supplies. On a personal level, the most bang for your buck is probably a bottle of bleach (to clean inorganic surfaces and sterilize water if needed), gloves and masks, and plenty of alcohol based hand sanitizer.

1/28/06 Promedmail.org has a multi-country report which features a denial by North Korea that they have had any cases of avian flu, and WHO confirmation of Turkey's prior reports on 12 positive cases.

1/28/06 Bird flu 'could be 21st-century Black Death' this financial risk management group discusses some of the possible ramifications of a pandemic and the small but finite risk of a major societal disruption with widespread chaos. The risk of this is felt to be small and likely to happen only if there was a combination with a variety of other events. The credibility of the group is high. The likelihood of this type of event is said to be small. I would argue that is there is a small risk of this type of event then we need to prioritize funds and energy to being more prepared. If you are convinced that there will be an event in the near future, then you might consider getting more conservative in your investments.

Please remember, I do not have a crystal ball and do not know when an outbreak will happen and what it will be like! You are responsible for whatever decisions you make.

I heard of a local hospital (Not Virginia Mason) today that had a presentation on avian flu, and what was needed to get ready. Masks, gowns, gloves, shoe covers and the like... The supplies have not been bought yet as "there is no money" This is a recurrent refrain at most healthcare facilities.

Where are the priorities? As an individual person I can buy surgical masks for 15 cents apiece. N-95 masks run a $0.80-1.00 or so. I am quite sure the hospitals can get these for much less as they but on volume through purchasing co-ops. How are we to expect staff to stay on the job in a setting where they are not provided the basic protection they need? If you have the ability to influence your work site/healthcare organization, I would encourage you to do so. Make a difference. I would encourage you to be proactive, not just for yourself/family but for your community.

1/28/06 U.S. study may hold key to bird flu's virulence This article has good and bad news in it. The good news is that there is more knowledge about what the avian flu genome (DNA structure) looks like and it is correlated with prior epidemics. This information should help us look at virus samples and have some idea as to their aggressiveness. On the flip side, there is evidence that the H5N1 is looking more similar to the 1918 version than the less deadly 1957 and 1968 versions. This current virus has what they describe as more of a "bird motif that may latch onto and disrupt the activity of certain proteins in its human hosts". I suspect this means that there is more variation in the human cells after they are attacked and the immune system does not have as much ability to stop it directly. The over reaction by the human immune system would then make more sense. In general, the more foreign the protein, the stronger the immune reaction. This is why in blood transfusions you do cross matching to make sure there are as many matches as possible. When there are more mis-matches, as appears to be the case here, then you may get a vigorous immune response. Younger people have stronger immune systems and hence a stronger response. The question here is what simply this- what is needed to have the immune system react with a very targeted response without all the collateral damage. The longer we go with out a pandemic, the more likely we we be able to have the technology to understand it and have an effective medical response.

1/27/06 Will there really be a pandemic or is this all hype? Here is a link to a history of prior pandemics over the centuries. Go back to statistics... over the last few hundred years there are an average of 3 pandemics /century. So we can pretty well assume one will happen again. There are many theories about what will happen when a pandemic hits. It is hard to know how well understanding germ theory will help us. Will quarantines work? Will the outbreak start in rural or urban areas? Will Tamiflu work? Will the virus develop resistance? How long will it take to develop a highly targeted vaccine? Will the current experimental vaccines work? It is theorized that as the virus acquires more infectivity, it will lose lethality. The most important question is how will the virus mutate? No one really knows the answer to that question. We must be reasonably well prepared and then have faith for the results.

1/27/06 Study: Bird Flu Biggest Current Business Worry - world business leaders are starting to get more concerned about what is going on and feel this is the highest economic risk on the horizon. I don't know how anyone could really know what is the exact risk of a terrorist event versus a mutation, as neither one is a amenable to a time related study... my guess is that we fear avian flu more in that it would impact such a large sector of people across the world. A terrorist event is physically likely only to affect people in the immediate area of the event. Even a nuclear bomb (a la "24") would affect a limited sector of a country, and the rest of the country could come to it's aid. A pandemic affects so many people that it is much harder to provide help to one another.

1/27/06 Indonesian vendor dies of bird flu - hospital- this unfortunate person was the case listed in yesterday's note. The notable circumstance here is that he commercially worked in the poultry business. Most all of the cases so far have not been in people who worked full time with poultry. The cause for this is unknown.

I wonder (but have no data) if this could be related to their constant, very high exposure levels to poultry antigens in general, and their immune system was very highly protective against avian related DNA. This is purely conjecture but would make some sense. In people, we routinely immunize allergy patients with the antigen of what we are trying to block, and make patients develop high levels of immune globulin against the particular antigen. If you are constantly exposed to chickens then you might develop high antibody levels against anything that has a chicken related particle in it, and this might snuff out the avian virus before it has a chance to get started.

1/26/06 Limits on US distribution of Tamiflu lifted- this means Tamiflu should be more available in local pharmacies. I would hasten to add that there are good arguments that it should only be used in the elderly or those with other illnesses that would impair the immune response. The more Tamiflu is used in the local community for regular flu, the more likely there will be resistance to it when we need it the most.

1/26/06 Glaxo hopes to produce pandemic flu shot by yr-end- this would be very nice but it is not clear what antigen set they are using. A vaccine was produced in the US built around the virus as seen in 2004 but we do not know how well any vaccine produced now will work as we are awaiting a mutation in the virus that allows the easy transmission to people. This mutation could be small or large, and a simple mutation can radically change the shape of the virus.

1/26/06 Bird flu claims another life in China-this woman was already known to have avian flu. This is the 7th death in 10 Chinese cases. There are new recommendations -"WHO recommends that, in China, testing for possible H5N1 infection should be undertaken in all cases of severe respiratory disease having no alternative diagnosis, even when no poultry outbreak has been reported in the patient's area of residence." Additionally, there is a new suspected case in Indonesia and a unconfirmed report that North Korea has a case but has been keeping it under wraps.

1/25/06 CDC Chief (and AMA Chief): Bird Flu 'Not Media Hype'- a pandemic is the real deal, and preparations are necessary. There are plans for travel screening, quarantines, and medications. The whole idea is to delay the spread as much as possible till a vaccine in available to give to those who have not been infected yet. Primary care doctors are expected to be on the front lines-"it's time for private doctors to accept responsibility for public health". This is the entire reason Pharmaviews.com is published.

1/25/06 WHO czar says to be ready for an event at anytime-the WHO avian flu czar, Dr. David Nabarro says a pandemic is inevitable, and says he looks at the news leads the first thing every morning wondering if there has been an outbreak of human to human spread. There are several items to note here. He is afraid, and so are other professionals I have talked with in the community, that way to many people are procrastinating on getting ready. "I say to them it might not be months, it could be that we get human to human transmission tomorrow, so please act as though it is going to start tomorrow, don't keep putting off the difficult issues". Implicit in this is that he does not believe that: a) rapid human to human spread is here, b) people are taking the situation that seriously, c) there are difficult choices to make, and we all want to keep believing that the issue will go away if we don't work on it. Unfortunately, when an event does happen, we will have to face our denial and the there will be more fear/reaction than if we had dealt with it directly. What will you do today?

1/25/06 Report by the WHO Director-General to the Executive Board at its 117th session- the initial part of his speech deals with Avian Flu... and he talks about several improvements... quicker collection and transport (24 hrs), quicker reporting of results (24 hours via Britain), prompt transport of Tamiflu doses to the area, and WHO teams going to the area within hours. Notably, he also talks about how unexpected it was to have so many human cases so quickly, before there were widespread animal reports. We have to be ready for a variety of presentations.

1/24/06 Turkish bird flu outbreak shows speed the essence in pandemic: WHO- agreed, we need to be able to jump on cases ASAP after they are discovered. In addition, we need to be screening better and more efficiently. Countries without the disease need to be on the lookout. By the time it is in the newspapers, it is late to be getting a response together.

1/24/06 WHO denies exaggerating bird flu pandemic threat- obviously there are those who feel the concern for avian flu is over blown. Meantime, there is a new case in China, this is the 10th case there, and 6 of them have died to date. Notably, the cases have come from across the country. To me, this raises concerns about the ability of the health system to detect early cases.

1/23/06 Message from the Dean of Harvard's School of Public Health- the Dean discusses the need to be aware and prepared and discusses some of the experience from the 1918 pandemic.

1/23/06 Timeline for Kocyigit Ozcan Family Clusters in Dogubeyazit- this is an interesting bit of commentary and it is hard to know quite what to make of it. Dr Niman is very bright and an avid H5N1 follower. This time line is pieced together by a variety of reports and is not in the general media. Some of it is gathered by local reports, and others by "machine translations" of Turkish reports. I find it a bit hard to know how much of it is dependable and would prefer to see data from the "experts" who were sent there by the WHO. In general, there are some disturbing aspects to the whole situation in Turkey, but there is not the massive, explosive transmission that is supposed to be the hallmark of a pandemic. In a true pandemic, we would expect to see dozens of cases, followed by hundreds in a few more days. These would be expected to be happening in a variety of areas as people travel and then express the symptoms several days later. Personally, I think the cases there are related to severe exposure but to a bug that is mutating. The good news through all this is that the mortality rates seem to be dropping and hopefully that is related to earlier treatment with Tamiflu.

1/23/06 French woman free from bird flu: health ministry- This woman who had recently come from Turkey has tested negative for avian flu. They have done 2 sets of tests. It would be prudent to have her retested in a few days.

1/21-22/06 Offline secondary to computer issues. Not much new...

1/20/06 Alarms ring over bird flu mutations- analysis reported in "Nature" shows that there are 2 theoretically important mutations in the 2 cases that have been sequenced from 2 deaths in Turkey. One allowed the virus to bind to human cells better and one allows the virus to reproduce easier in humans. The later mutation was also seen in the 1918 version of the flu. The specific impact on humans has yet to be fully played out. There has not seemed to be a widespread outbreak of disease in people. It may be that the mutation will have died out with the cases, before it has had a chance to go to multiple other people. We will not know for a while. I should note, these teens died after exposure to sick birds. The critical question here is how well have the birds been culled in these areas, and are there any other carrier animals there. It is also not clear to me what efforts have been made to sterilize the areas. There have been cases in other countries where there was virus still detectable for as long as a month after the birds were removed from the area.

1/20/06 Six countries listed as priorities for bird flu grant funding and as expected they are all in Asia. It is interesting to note that Turkey is not listed here even though there are significant cases in the last few weeks. I suspect it is felt that the Asian countries have more entrenched disease as it has been there longer.

1/20/06 Elderberries 'may combat bird flu'- studies have shown that an extract from elderberries was effective in "neutralizing" H5N1 in Dog kidney cells. The ability to apply this to humans is totally unknown. I would not depend on this as your answer to the avian flu. You have to see how this works in people before you can depend on it. Tamiflu has been tested in cultures and generally works... but we are still not quite sure about how it affects the final outcome in people and what is the maximum amount of time allowable before treatment.

1/20/06 Summary of outbreaks in multiple countries As has been the almost daily occurrence, there are new reports of avian disease in Crimea and suspected cases in Turkey. Turkey has 13/81 provinces with confirmed disease and 19 more with suspected disease. Hong Kong has a reported positive bird case.

1/19/06 Are fears of a pandemic exaggerated? Honestly, this article and report on a new book are fairly sad. The author's argument basically is that it won't happen because it has not happened so far (this time). This is very similar to living by a volcano that has a history of periodic eruptions, and is now starting to rumble, and saying, "look, there is no hot lava so we have nothing to worry about". By the time there is rapid human to human spread, it will take incredible effort not to see what is happening. There have been 3 pandemics/century for at least the last 3-400 years. Do you think there might be some sort of pattern going on here? The last question here... will it come to the USA? Hello-have you ever heard of airplanes? The pandemic will start somewhere, and will spread from human to human, not from bird to bird. Remember, the Spanish Flu in 1918, actually is felt to have started in the US. I think this guy just wants to sell books and tell people what they want to hear, not explain what the science really shows.

No one knows for sure when and what the next pandemic will look like, we are waiting on mutations. At this point the leading candidate is H5N1, and it is of concern because it is clearly spreading and causing more cases, the death rate is unusually high and the situation is similar to 1918.

1/19/06 Bird flu: Lancet study cautious over drug-of-choice Tamiflu- as nations pledged almost 2 billion dollars to fight bird flu, researchers are worried that Tamiflu will make only a modest impact. Basic public health measures are critical. I would encourage you to understand good hygiene, concepts of isolation, and having food/water in case it is necessary to be self sufficient. See the official US recommendations at the top of the page.

1/19/06 Possible new case/death in new province in China. If confirmed, this would be the 6th death, and this one is in a new area.

1/19/06 Here is an excellent map of the situation in Turkey, including human and animal outbreaks. The images help make more sense of the situation. A new case is confirmed by local tests. This is the 21st case there and 4 have died so far. Notably, not discussed in these reports but discussed in prior papers last year was the expected increased transmissibility but decreased lethality as the virus mutates more toward a potential pandemic bug. Is this happening now. I don't know that we could say for sure but the pattern is there.

1/18/06 (Indonesian) Bird flu victims' father shows signs- hopefully this is still from common exposure. Note there is not formal test reports back yet. I suspect he will have the illness given the pattern of multiple family members with similar symptoms. His kids got sick earlier and now he has a high fever and breathing difficulties. One would expect that once the kids started getting ill that all poultry in the residence were culled and disinfectant sprayed all over the area. While his possible case can be from common exposure, this pattern tends to be seen more with human to human transmission. Further testing is necessary to try to determine the situation. It may not be possible to fully sort it out. Genetically the bug should be the same as what the kids had. It would be interesting to sequence this specific series and see if there are mutations compared with other samples from around the country.

1/18/06 Experts haggle over bird flu funding- as usual, there is always a lot of posturing over who should pay for what and who is or is not responsible for failures. Turkey says it has done a good job on avian flu. I respectfully disagree. Meanwhile, estimated costs for life insurance companies alone for a moderate outbreak are estimated to be 130 billion dollars. This does not take into account the financial impact on businesses, etc. Consider for a moment the impact of 9/11. How many people died versus the economic impact on the whole world (and we still feel in via airport security measures, etc) The amount of requested funds by the WHO is 1.5 billion dollars. This is a paltry sum in comparison to the potential impact of a pandemic.

1/18/06 More human H5N1 cases reported in Turkey, Indonesia- summary reports from Turkey and Indonesia. In essence, more new suspected cases and confirmations but all with direct exposure. Turkey has had poor surveillance that has allowed their outbreak to progress the way it has. This is important to emphasize. If you are not looking, you may well not see it. This is of concern in many parts of Asia and the Middle east. If it gets to Africa, there will be big problems.

1/17/06 Time of essence in bird flu fight, experts warn - the risk of a pandemic is considered great and money is urgently needed to combat the outbreaks. This is a familiar refrain. Time will tell if the nations will listen.

1/17/06 Experts Await Bird Flu Test Results on 3 children in Istanbul. This is the westernmost extent of possible cases at this time. In addition, there are 8 other cases across Turkey that are suspicious. One case is in serious condition. Test results always have to be watched with caution as they are not always accurate on initial testing. It is gratifying to see there is not an ever increasing surge in new/suspected cases. It appears to be slowing down at this point.

1/17/06 Jerusalem man does not have bird flu This report is pertinent in the negative report of disease. If it had been positive then it would mark infection in a whole new area.

1/16/05 Girl who died tests positive in preliminary test for H5N1 bird flu, raising human... - local tests are now positive making for 4 fatalities out of 20 cases in Turkey.

1/16/05 At least $1 billion will be pledged for bird flu preparedness: World Bank - the recent outbreaks around the world have stimulated countries to pledge dollars to help fight the spread of avian flu. Hopefully this aid will kick in promptly. Much of the aid offered to poor countries has come in the form of loan offers and the countries have not always been willing to take the loan. We would all be much better off if the funds were given as grants which did not have to be repaid. The economic costs of any outbreak far exceeds the costs of trying to stop it early.

1/16/05 Local testing shows Indonesian girl died of bird flu in family outbreak- there are two brothers who are also confirmed positive cases. The cases come from an area 110 miles from Jakarta. They have had exposure to birds that were ill but have not yet been confirmed as having H5N1. These cases need to be confirmed by the WHO but are clearly suspicious. Once again, it is concerning that the birds have been dying in this area and there was not any testing done before the children became ill. This argues that the Indonesian system is still unable to keep up with the outbreak.

1/16/05 Turkey Testing Girl's Body for Bird Flu, brother confirmed to have disease. this makes for at least the 19th confirmed case and possibly the 20th. The girl should be presumed to have the disease. They got sick at the same time in the same setting and he has confirmed H5N1. Both children were known to have contact and eaten a sick chicken. In this very poor part of the world, they have always had to make use of every little bit of protein available. Other reports are wondering what will happen to this area as chicken and poultry are removed from their livelihood. Around the world, people have used poultry as a very efficient means of increasing protein via eggs and meat. if the girl is confirmed positive, she would make the 4th fatality in Turkey.

1/15/06 H3N2 influenza has developed resistance to Amantadine and Rimantadine over the past 1 year- what a striking report. The common influenza has gone from 11% resistance to 91% in a single year. Clearly the virus mutates fairly quickly and clearly a dominant strain can take over very quickly. We do not see bacteria develop resistance and spread across the world with such speed. These drugs are not Tamiflu but the suspicion is that part of the resistance here is based on overseas use of Amantadine and Rimandtadine. This report clearly underscores the need to have rapid vaccine development/production capability available as soon as possible. If the H5N1 succeeds in going to a more rapidly transmitted form and has resistance to Tamiflu there will be even more problems.

1/15/06 Business in Britain bracing for bird flu: report- an estimated 80% of large companies in Britain are starting to ramp up their preparations- it would be interesting to see what the numbers are here in the US. At last check, not as many were ready. The other question is what the smaller businesses are doing. Companies like IBM can have workers telecommute. How about the local stores around you. Generally, the smaller companies are more direct service related.

1/15/06 WHO confirms 12 fatality in Indonesia- this case had been confirmed by local authorities earlier. The most significant point in this report is that there is no evidence of infection in any of her co-workers. She worked at a hospital but was also known to have purchased live poultry at a local market. Direct transmission still seems to be the dominant form of transmission throughout the world at this time.

1/14/06 WHO Seeks Blood Tests to Combat Bird Flu- the WHO wants to send teams in to go and see if there are people who have positive antibodies or throat swabs but who are without symptoms. This totally makes sense. We need to know more about the illness, it's transmission modes, incubation time and most importantly, if there are asymptomatic carriers. The surprising thing is that the WHO has not asked to do this in either China or Indonesia. It is not clear if there is something different about this outbreak or if China and Indonesia were doing this already, or if the Turkish system is just unable to deal with an outbreak like this. In any case, this is an important step in getting on top of the situation.

1/14/05 WHO heartened by lack of new bird flu cases - agreed. Given the incubation time seen in prior cases, if the original cases were highly infective we should have seen a run of new cases. Particularly those with bleeding in the mouth, a relatively rare event with most respiratory infections. We are not totally out of the woods but we appear to have dodged the bullet.

1/14/05 HHS Announces $100 Million to Accelerate State and Local Pandemic Influenza Preparedness Efforts. Washington state will receive about 1.9 million dollars to improve preparedness. This is very significant. I find it interesting that the US pandemic flu website released recommendations on what to do to get ready and there has been virtually nothing covered about it in the standard news releases here. Individuals and companies are viewing this as an issue that is over there, and clearly this is an issue that involves the whole world.

1/14/05 U.S. to send bird flu team to Turkey - obviously the US does not feel the outbreak has come to an end there. It is good to see that there is increased international cooperation on dealing with outbreaks. I am not sure what to make of the delay in sending a team. The outbreak started on 1/5/06 a full week earlier, and we just now decide to send a team. Usually, the experts are called in immediately. Besides, the WHO is already there. Is this just a PR move or are there more issues involved?

1/13/06 H5N1 virus change may ease jump from birds to humans, WHO says- the mutations seen are mild and of unknown significance. The article says the virus here is Amantadine and Tamiflu sensitive, which is good news. On the other hand, we do know that this virus is able to produce resistance in relatively short order after exposure to anti-virals. We see the same thing is anti-bacterials. Resistance can develop over a matter of days to weeks.

1/13/06 World Bank approves first bird flu funding There is and estimated $500 million to go to poor countries to support anti bird flu efforts. Clearly, authorities across the world are quite alarmed at what is going on. 6 months ago, this level of funding was unheard of. Hopefully the funding comes in time to make a difference in preventing the spread. If this amount of funds had been spent 9 months ago we might be in a very different situation now. The lack of adequate culls in Asia (Particularly Qing Hai, China and Indonesia) has ultimately really driven most of this years' outbreaks.

1/13/06 "Altogether, agricultural officials have confirmed poultry outbreaks in 11 provinces and are investigating possible outbreaks in an additional 14 provinces across the country.(Turkey)" Clearly, the outbreak is not well controlled at this point. It may take a few more weeks to see things settle down. I am happy to hear less reports of new suspected cases. Assuming the current trends continue, there does not seem to be the epidemiological evidence to support widespread human to human transmission at this time. In addition, Dr. Fauci says he does not know what to make of the mutations. He heads up the National Institute of Allergy and Infectious Diseases (US).

1/12/06 American Emergency Rooms are not up to desirable standards- see your state's situation. It is hard to ever say you are "there" but clearly there needs to be some work. Check it out...

1/12/06 Experts warn of bird flu risks with Lunar New Year- as the lunar New Year approaches, there is more risk for infection transmission as there are more birds being slaughtered. Historically, there has been a jump in cases at these times. Again, this does not mean there is human to human transmission but does increase the net risks somewhat as there is more risk for mutations.

1/12/06 Bird flu pandemic threat growing but stoppable - WHO- it depends on increased financial resources, better early detection, commitment, and rapid deployment of interventions. Our current performance is not considered adequate.

1/12/06 Indonesia's latest bird flu patient dies this is the woman reported a few days ago. She was confirmed by local authorities but not by the WHO. She and one other case would make for the 12th and 13th fatal cases but they are still considered unofficial by the WHO.

1/12/06 WHO says Turkish cases may yield new findings on H5N1 there are 2 boys who have tested positive for avian flu but have no symptoms. The question here is why don't they have symptoms? These cases in conjunction with the study about all the incidence of flu like syndromes in Asians who had handled sick birds, would suggest there are those with minimal or no symptoms. The good news with that would be that there is a lower death rate than currently seen. On the other hand, you could have a lot more cases than we are currently aware of. It is not really clear why these boys were tested. I would assume they were in families where there were siblings who were ill. It would also be interesting to see if there are any genetic patterns that allow for less symptoms. If you look at malaria, there is a genetic protection for those who have sickle cell anemia. The sickle cell condition lowers the amount of oxygen in the blood and that makes it harder for the malaria to live. If there is some similar trait in avian flu that provides protection, then that could be utilized to protect others. Please note, this is all a speculation at this time but points out why we need to know more about this illness.

1/11/06 The Canadian Broadcasting Corporation, the national public broadcaster in Canada, has put together an hour-long docudrama depicting the events of what might happen during the months of an H5N1 avian flu pandemic. The program airs Jan 11 @ 9 pm on CBC-TV (Canadian NPR). Honestly, I have not seen it but it might be interesting to check it out if you can. http://www.cbc.ca/fifth/

1/7/06 Pandemic Flu Planning Checklist for Individuals and Families- this is the official recommendation from the US Pandemic flu prep group. I would strongly encourage you to look at the list now and see about getting these supplies together. Once there is a major outbreak with rapid spread, everyone will head to the stores and there may be a run on supplies. A more orderly, purposeful and planned purchasing/planning program will be much less stressful and more successful. Buy items you know your family needs. It is like inexpensive insurance and you can use it later, even if there is no pandemic or emergency. The government does not have a formal recommendation about how long to plan for. I would suggest that you have enough supplies for a minimum 2-4 week time frame. This automatically means that there needs to be a lot of dry goods. You do not have to have super tasty items but they should be nutritious and easy to prepare.

1/7/06 Third Turkish Child Dies From Bird Flu The three dead children are all from the same family and there is a 4th who appears to be getting better at this time. The children apparently played catch with a dead chicken's head for days. Another child from another family has tested positive and it not clear if there has been contact between the two families. There are some 20 other cases suspected according to this report. The area is quite impoverished and medical care is sparse. This outbreak is surprising in that the number of cases in domestic poultry is quite small and out of proportion to the number of suspected cases. The next several days are pretty critical to see if there is human to human transmission or other aggressive spread. The incubation time is typically 2-5 days and occasionally out to 8 days. If we see a sudden mushrooming of cases in the next 72 hours that would be a bad sign. Remember, in Indonesia, there were a lot of suspected cases with a modest number of confirmed cases. At this time there has been an hiatus in human cases there.

1/7/06 Misc. Reports on avian flu outbreaks in Turkey- there are many reports of unclear dependability from Turkey. It apparently has been difficult to get good information from the area. There has been a quarantine of the area for a while. The outbreaks are understandably causing a lot of angst among locals and a rash of various reports. Given the inability to have rapid and accurate test reports, it is hard to know how many true cases there are. This could go either way with multiple under or over reported cases. In addition, Turkey's eastern neighbor Azerbaijan is to conduct tests to establish if bird flu caused the deaths of poultry in the south of the country.

1/5/06 Turkey's Bird-Flu Deaths Bring Virus Nearer to Europe- this article states that there are 6 suspected cases from the same town and that they all had contact will birds that died of "unknown causes". It is not clear if these include the 2 that died or not. As names are not used it is very hard to know exactly how many cases are there at this early juncture.

1/5/06 Bird flu claims 2nd Turkish child and another is in critical condition. A 4th child is ill with suspected flu but not quite as sick at this time. These cases have not been confirmed by the WHO yet but the Turkish lab is reportedly highly regarded.

1/5/06 Turkey confirms its first 2 human cases of avian flu- One of the two has died. This is just as I had discussed earlier, some preliminary testing can be wrong and this illness tends to turn positive later in the course of testing. The new cases are concerning for geographic spread. In addition, "an Agence France-Presse (AFP) report today said nine people have been hospitalized with a fever and cough in the city of Van, where the 14-year-old died." These cases have to be viewed with concern but not necessary alarm as the symptoms are too non specific at this time.

1/4/06 Officials could have avian flu- this title sounds much worse than reality. Nothing has been confirmed and we do not even know what symptoms they have. They were all exposed to sick chickens and it sounds like they were officials at a Hotel. If realm I would assume this is a common exposure source event rather than human to human exposure.

1/4/06 Bogus bird-flu drugs flood the Internet- beware of buying on line. The bogus drugs appear to be coming mainly from Asia but I am sure it is a matter of time till they come from anywhere. I would tend to avoid any website whose main focus is avian flu and selling drugs. If you buy from a big name brand pharmacy it is likely to be safer. They are in the business of trying to keep all of your pharmacologic needs met, not just for avian flu, and hence they are less likely to be willing to lose you for a one time profit.

1/4/06 China confirms new bird flu outbreak in southwest- more of the same. The major item to note is that this outbreak occurred on 12/22/05 and is just now being reported. This is slower than normal.

1/3/06 Another Indonesian dies of suspected bird flu- however, tests on a patient with suspected disease a few days ago have come up negative. This is why data counts! The difficulty in this disease process is that sometimes the tests have come back positive weeks later on a case that was considered negative. Despite this, you have to deal with issues with data that you have and keep the possibility of false negatives in mind. A lot of this deals with the type of test being used and when it was obtained. Each test, and test site has different accuracy rates.

1/3/06 Turkey rules out bird flu in boy's death after new outbreak- despite Turkey's assurances, I would not completely rule out this still being caused by H5N1. They have not identified what the agent is as yet and given the time it may take to turn positive, the verdict is still out. Other cases come to mind that later turned positive. Given the positive exposure to sick birds and lack of other identified cause, and that the symptoms are consistent with avian flu, I would still guess there is a 50/50 chance that one of the 6 will still turn out to have avian flu.

1/2/06 Scientists Cautious on Tamiflu's Impact on Bird Flu-"The strategy is ultimately to have 75 million treatment courses to cover 25 percent of the population," Fauci said. "We have assurances from the company that we will get to 20 million treatment courses by December of 06 and the 75 million by the summer or Spring of 07."- this is the first I have seen listed timing of getting more Tamiflu in this country. Currently we have somewhere around 4 million courses or so at the last report. Tamiflu needs to be taken early in the course. This article likely does not take into account the higher doses needed and hence reduction in people covered.

01/01/2006 WHO says China still not sharing bird flu samples - the practice of stonewalling continues despite their openness in other areas. It would appear there is not a clear consensus on how to deal with the flu. There have been a variety of issues in China over the last few years that the government is struggling with. The prior authoritarian approach clashes with the desires of the people to have more transparency. Hopefully, world opinion will sway the government to share their data.

01/01/2006 H5N1 avian flu viruses: What's in a name? CIDRAP has a nice article discussing definitions and significance of H5N1 names. Not all of them are the same. The article also talks about the risks of using a live virus avian vaccine like China has just announced. There are pro and cons to the argument. These viruses are notorious for their ability to mutate. They have for generations. How do you keep them from developing the ability to mutate? I would favor killed viruses as they are much safer. History is filled with examples of biological agents that were introduced to control an animal population and the purposely released agent ended up being worse than the problem being treated.

01/01/2006 Indonesian man dies of suspected bird flu- local tests are still pending.

01/01/2006 WHO warning after new China bird flu death- once again, the WHO is concerned about the lack of known source for the most recent case in China. The lack of reported cases in poultry around these human cases suggests that surveillance efforts are not adequate at this time. In addition, the WHO says China still not sharing bird flu samples. The reasons for this are unclear.