|
12/29/05 UN
vet dismisses fish farming as bird flu risk- I tend to disagree with the vet
in that there is known science to support the prior claims of transmissibility.
His main objection is that there would be too much impact on farming to be worth
changing how these farming practices are done. He states that surveillance
is the way to go. It would appear that surveillance is not work adequately
at this time as there are ever increasing outbreaks.
12/29/05 Chinese
scientists claim new bird flu drug better than Tamiflu- this is a hopeful
report. I doubt that there will be any drug to export as China has so many
people of its own. It remains to be seen if they will share the formula,
and also, if it is effective against avian flu. There is still not as much
open reporting and sharing of data as would be optimal for world
health.
12/29/05 Bird
Migration Not Spreading Deadly Flu- this is a very interesting
article. There are now more doubts as to whether migrating birds really
carry the virus or if it is via some other vector. The notable issue is
that months after the outbreaks, we still do not know for sure what is the
transmission vector. If you do not know what the mode of transmission, it
is really hard to stop it. Further investigation is necessary to determine
what is happening.
12/28/05 Fresh outbreaks of some
H5 variant have been reported in Vietnam,
Turkey,
and Romania
but I would emphasize that the "N" type has not been determined in
these cases yet. Malawi has claimed their birds died of a sudden downpour
(rain) but they are sending the birds for further just in case. Results
are still pending.
12/28/05
Chicken dung used to feed fish may help spread bird flu- this is an unproven
but potentially very significant article and the premise needs to be explored.
In essence, we know that poultry stool carries the virus. The stool is
commonly used to put into rice paddies and ponds to promote growth of fish which
are then harvested to eat. The H5N1 is known to be cold stable, that is to
say, it can survive in cold water for quite some time till it finds a new
host. Other birds that land in the water are then exposed to the virus and
the cycle continues. While this cycle has not been proven, it makes total
sense with the data we do have on the virus and this current practice is still
being promoted by the WHO's Food and Agriculture Organization (FAO). This
issue needs to be urgently addressed.
12/27/05 FDA
approves Tamiflu for flu prevention in children- this is not a huge surprise
medically but questionable to actually do on a regular basis. The regular
flu has a relatively low mortality rate, and there are already excellent
vaccines to use with very low side effect rates. For the average
youngster, that is a much better choice. For those who have a true chicken
egg allergy and are at high risk (getting chemo, severe asthma, AIDS, etc) then
this may be a reasonable option.
When you start talking about avian flu, you have a whole new
issue. There is no generally available avian flu vaccine, and prophylactic
doses of Tamiflu have been shown to induce resistance, thereby losing the best
weapon we have. If this practice becomes widespread then the general cases
of avian flu would be resistant and overall mortality rates would go up.
In essence, this recent approval should not be used much and will have little
impact overall.
12/26/05 Improved
farming key to fight bird flu: WHO- this is not any new information.
China has been moving more along the lines of vaccination rather than changing
fundamental farming/cultural techniques. That is probably most realistic
at this moment but the WHO is stating an ideal goal over time.
12/26/05 China
develops 1st live avian vaccine against bird flu/NewCastle disease- This is
an important development and would help to stem the surge in both animal and
potentially human cases. Animal cases by direct protection and human cases
by presumably less animal cases. It would be very interesting to know how
they have developed this vaccine and how it can protect against 2 different
species of viruses. In addition, it is important to know what safeguards
are in place to make sure that the virus does not develop it's own mutations
since it is a live vaccine that can be released into the wild.
12/23/05 New
England Journal of Medicine on Recent Cases of Flu Resistance- as discussed
in the last note, there were two options as to resistance in the 2
patients. Unfortunately, in at least one case, the answer appears to be
new mutation in the virus when exposed to standard doses of Tamiflu. This
unfortunate young woman's mom had the virus, and it was Tamiflu sensitive.
The patient came down with symptoms and was treated with standard doses of
Tamiflu (with the patient weighing only 66 pounds) within the recommended 24
hours of onset of symptoms. Initially she did well but then on day 4 she
took a turn for the worse and eventually died. The repeat cultured showed
resistance. This suggests that the virus developed resistance to currently
recommended doses of Tamiflu and that higher doses need to be used. The
other patient with proven Tamiflu resistance was only culture positive after she
completed treatment. Obviously the standard treatment doses did not work
adequately and presumably allowed the resistance to develop. Notably, 4/8
cases were treated and were virus negative after a few days and lived.
Those who died continued to be culture positive. The good/bad news,-
Tamiflu appears to work well in some, but the bad news is that it appears we
need to be using higher doses and for a longer treatment time. In summary,
we need more meds and even more importantly, a vaccine ASAP!
12/23/05 The
two Indonesian cases were confirmed by the WHO and this is pretty much as
expected.
12/22/05 2
Bird Flu Patients Who Died Were Resistant To Tamiflu "The experts
said the deaths were disturbing because the two girls had received early and
aggressive treatment with Tamiflu and had gotten the recommended
doses." The exact doses/duration of treatment are not reported in
this article. The New England Journal of Medicine called for double the
regular dose and for twice as long. It is not clear if these patients received
that or not. In addition, it would be important to know if the strain they
had was resistant on initial infection or if it developed over the course of
treatment. Either case is not desirable but the latter is more
worrisome. It may not be possible to know the answer in this case.
There have been reported strains of resistant organisms. Sometimes these
resistant bugs are not as aggressive and don't grow as well as the "wild
type". Additionally, it that strain never caught, then it might die
off on its' own and never get spread widely.
If on the other hand, the virus did indeed develop resistance
over the few days of treatment, then that is quite disturbing in that it would
suggest that other strains could do the same. If you take millions of
people simultaneously getting exposed, getting treated, and the bug rapidly
acquires resistance then a resistant type would rapidly take hold and spread
preferentially compared to the wild type.
12/21/05
Eighty Percent of Companies Worldwide Ill-Prepared for Business Continuity in
The Event of a Pandemic Type Event - This survey was provided by a business
evaluation collaborative. This is no surprise, in fact, I would be amazed
if truly 20% of companies are ready. I have talked with a number of
businesses and pretty much the answer is the same everywhere. "How do
you get ready for something of that scale? We just hope it won't
happen." Somehow, we need to expand the preparations. Part of
the problem is that it is expensive preparing for an infrequent event.
Whatever product you make, if you try to store 60 days of supplies, the carrying
costs and space requirements are huge. Each company has to first look at
whether they are likely to be staying open in a pandemic. Schools, movie
theaters, many shops will likely be told to close. They should not
stock up on general supplies. Critical infrastructure companies are
different. The power, gas, sanitation folks are essential services that
effect everyone and have a cascading effect. They need to figure out what
is needed, both physically and staff wise.
12/21/05 Sinovac
Biotech Ltd. Begins Pandemic Flu (H5N1) Vaccine Clinical Trials- the Chinese
are making headway on a vaccine, and presumably it uses some of the latest
genetic material. Clinical trials go in phases, with more people in each
trial phase. Phase I data will start to show up by March 2006.
12/20/05 US
health agency says China open on bird flu the NIH has said that China is
doing a great job and is very open and cooperative. This is important to
coordination of the WHO response. Some of my cynical friends will say this
is all PR. We will see. Sharing data on the current genetic code is
a good start.
12/20/05
China's CDC gives genetic information on 2005 avian flu to WHO. This
is very significant in that till now, they have not given anyone else the
genetic sequencing. The current limited production prototype is based on a
2004 version from Vietnam. There is usually antigenic drift so the more
current the information the better. China, Indonesia, and Vietnam are
considered the highest risk areas for developing a new mutation at this
time. This could change, for example if there is a outbreak in
Africa.
12/19/05 The next few months are the human
avian flu breakout months historically. This graph shows the overall
outbreaks by country and month over the last 3 yrs. You can see the trends
pretty clearly. Jan through March have the highest incidence of outbreaks and
there are more each year at present- consistent with the increased human
exposure. There is a new geographic map of outbreaks from Europa posted
under Outbreaks.
12/19/05
Indonesia says local tests show boy died of bird flu- this is a different
case than the 39 yr old man who also tested positive. These cases have
been confirmed in local labs. I can not remember any cases that were
positive in the local labs and negative in the WHO reference labs but I have not
been keeping a rigorous count. Other reports state the boy was 8 years old
and there are positive tests for flu in poultry around the case.
Currently the WHO mortality rate in Indonesia is 9/14 confirmed cases.
Once again, it is unclear if this most recent case had poultry
exposure. It is disturbing that there are positive tests in birds
around there and there is no report if these were in live or dead
birds. This has become a more common circumstance recently and
suggests the level of endemic exposure in Indonesia is quite high. It is
not clear why there is such a higher case mortality rate in Indonesia than in
other parts of the world. Here is the
official case count by areas.
12/19/05 House
of Reps. seeks $3.8 billion for avian flu- this is less than the White House
and the Senate had been requesting. At least there are some efforts to do
something. The House and Senate have to resolve their differences.
This item has been attached to the defense spending bill and there are all sorts
of other items on the bill. Hopefully, there will be a final resolution
before the Christmas break.
12/18/05 More
cases of bird flu detected in Romania the steady trickle of new cases
continues. Meantime, Britain
has confirmed the outbreak in Ukraine. Neither of these is a big
surprise.
12/18/05 NIH
Uses Live Viruses for Bird Flu Vaccine- MedImmune has been paid by the
National Institute of Health to develop a new vaccine that uses a genetically
modified form of avian flu and the spray is puffed up someone's nose. This
is a modification of a current seasonal vaccine. That seasonal
vaccine is currently licensed only for use in those to age 49. In essence,
what researchers are trying to do in to use a current vaccine backbone and to
make it "plug and play"... so that the new antigens can just be
inserted into the structure. Think of it like changing the socket on a
ratchet wrench. If successful, this would be a huge advance.
Human testing is due in April 2006. It should be noted this process still
involves using live chicken eggs in the process so it is not as direct as
synthetically manufacturing a vaccine.
12/17/05 Mutations
taking world closer to bird flu pandemic: official- The WHO Flu czar feels
the mutations are moving the virus closer to a pandemic type. The details
for why he feels this was are unknown. One would assume he should know,
and has reason enough to publicly comment on this.
12/17/05 Flu
fears as thousands of migratory birds die in Malawi- there is nothing known
for sure at this time but it is considered unusual for this many birds to die
suddenly. Malawi is in southern Africa. If they are positive for
H5N1 then one would have to assume there are cases in between. Zimbabwe
had a recent bird die off also but it turned out to not be H5N1.
12/16/05 Pandemic
Flu-Vaccine Prototype Promising- this adjustment- the addition of a
immunizing stimulant decrease the amount of viral antigen needed by 2/3s.
This is a huge step and very encouraging. In essence, there is effectively
triple the supply of just a few days ago! The supplies are still limited
and we need to get Congress to get moving on authorizing funding for newer,
faster production techniques. There is still a need for 2 shots over the
course of a few weeks.
12/16/05 Flu
pandemic could mean food shortages, peers warn-
British politicians warn of the potential for cascading effects of a pandemic,
including the loss of basic services and supplies. We have never been
exposed to that in western countries in recent history. This is related to
the nature of just in time shipping. We all need to consider our own personal
and work situation and consider how to have some extra supplies available to do
what is needed.
12/16/05 States
are urged to be ready for bird flu- this article was specific to Minn. but
the information applies to every state. Health and Human services says
that each state has to prepare on its own, or it will suffer the
consequences. There is a good list of thing to and not to do at the bottom
and I would encourage you to read them.
12/16/05 China
has a new outbreak in animals- after almost 2 weeks of no new
outbreaks. In addition there has been a 6th
human case in China. Like always, there is minimal information. It is
encouraging that the Chinese have not seen an outbreak for the last 15 days but
we will likely still see new cases pop up. It is relatively difficult to
completely eradicate the virus from the environment. There are cases of
the virus coming back after 10 months. The man and the poultry outbreak
are in the same county, which is a good thing... a single area is less
concerning that multiple sites at the same time. The man is said to have
had exposure to sick poultry.
12/15/05 Ukraine
confirms deadly strain of bird flu- the diagnosis is not a surprise as
Russian authorities had already confirmed the dx last week. 11/25
communities were positive. Hopefully control methods will successfully
contain the outbreak. China has gone 2 weeks with minimal new outbreaks after
their aggressive culls, showing that the basic cull approach works fairly well.
12/15/05 Vietnamese
boy, 3, dies of suspected bird flu- nothing proven, just suspected by local
officials.
12/15/05 Europe
will be prepared for flu pandemic by 2007: ECDC agency- cool. They appear to
be better prepared than the US at this point. We need to get moving.
Compare this with the article on how US states are doing. We don't have
funding much less tangible product in place.
12/15/05 First
US state flu meeting shows preparations slow- not enough hospital beds,
ventilators.... but honestly, I don't know if it is feasible to build enough
hospital beds to handle the surge capacity. These events happen on average
3/century with more cases than average. How do you build very expensive
beds for that occasional use, and more importantly, how do you staff them?
It is truly more efficient to be working on a rapid vaccine production
method. In the meantime, you can have emergency plans for how to convert
other facilities to urgent use. How about hotels. Beds and the
infrastructure are there. Perhaps you can have some semi trucks with
equipment on it to act as your central supply storehouse. These are the
issues that local and federal authorities have to grapple with. I think
the biggest issue is staffing. Doctors and nurses get sick just like everyone
else, and there is not a way to stockpile them. I would advocate some
preparation for mass education of the public. Most people in a flu
pandemic need the basics... rest , analgesics and fluids. Tamiflu as early
as possible. Oral antibiotics in case they develop a bacterial infection
on top of the flu.
12/14/05 Over
37 000 domestic birds confiscated in flu-stricken Crimean zone- multiple
areas in the Ukraine have been reporting unusual bird deaths. Russia labs
are confirming it as H5N1 but the British have not yet so technically these are
not official at this point. They are likely to be real, given the rate of
spread and mortality rates in birds. Romania has confirmed new areas of
outbreaks also.
12/14/05 FDA
Warns On Bird Flu Remedy Claims- very appropriately, the FDA is warning
various vendors that they need to cease with their claims. Very few people
have any idea how their products will help or hurt people in an avian flu
pandemic. The major exception to this is Roche with Tamiflu and even here
it is debated how helpful that will be. Vietnamese doctors feel it is not
helpful. Western physicians feel it will likely help but the treatment has
to be started much earlier- like within the first 48 hours of illness. At
present, cases are showing up at hospitals much later, commonly after they have
been ill for a while and may have been seen at another facility first. In
a true pandemic, will millions of cases all over, there will be much earlier
treatment of cases (assuming that medications can be properly
distributed). At present, each case of avian flu is the very exceptional
case in the midst of a large variety of respiratory illnesses. In a
pandemic outbreak, their is a huge surge in cases and there is a much higher
likelihood that the person with the sudden high fever, cough and aches is truly
a case of influenza, and doctors will be liberal in prescribing treatment.
Think of it this way, pre 9-11, we would not thought much of a highly
nervous middle eastern man on an airplane... maybe he is afraid of flying,
etc. Immediately after 9/11, everyone was hyper-vigilant and watching for
anyone who was the least bit suspicious. In the case of a pandemic, there
really would be more cases so it would be more likely to be
beneficial.
All the people who are promoting products to rev up the immune
system and the like are really out to make money. There is no way to know
if their products help or hurt. An highly active immune system may be good
and never let the virus get established, or it may be bad, and cause more
response to the virus than it should. In essence, kind of like using a
shot gun to shoot a mouse in the house. The collateral damage may be worse
than the original illness.
12/13/05 Indonesia
confirms ninth human bird flu fatality and the patient died on Nov.
19th. Once again, the turn around for cases from Indonesia is incredibly
slow. This makes you wonder how many others will turn positive
later. Obviously, he could not provide samples after the 19th so the rest
of the time is slack in the system. The article also states that 5 people
were admitted overnight with suspected bird flu. Realize, they could have
all sorts of different febrile lung infections. We urgently need a fast,
reliable test for H5N1 in early stages.
12/13/05 BIRD-FLU
DEATH: Thai Authorities unsure how dead boy, 5, got H5N1- this unfortunate
young boy contracted the illness from unknown sources at this point. The
people in closest contact to him have all tested negative and there have been no
reports of infection in birds close to them. They wonder if he was exposed
to some bird feces somewhere. In essence, who knows? This raises
concerns because if you can not identify what is the transmission source then it
is really hard to do much about it. If it is from a human source then you
have human to human transmission (but not too easy as no one else got it) and if
it is from an as yet unidentified bird source, then they are more likely to be
silent carriers as there have been no animal reports around there. The
bird feces story is hard to deal with. This seems to be the current
default explanation when no one has any evidence that is credible. While
it is possible, it is a very unsatisfying answer as no one is coming up with
reports of tests from random
12/13/05 Official
documents show (some type of) bird flu in Libyan farms- this is a report
found in Promedmail.org that alleges a positive test to avian flu- but there is
no subtype listed. This should not be construed as being H5N1 till
there is clear evidence as to what species it is. There are high and low
pathogenicity versions. The dangerous form is HPAI H5N1 and this is
usually manifest as seeing large numbers of wild or domestic birds
dying. At this time, we have no report of any of these. Stay
tuned!
12/12/05
Roche reports China pact to make flu drug- Roche is about ready to allow
China to produce its' own Tamiflu. For all those who say Tamiflu is of no
use, it is interesting to note that every country wants to buy/make it.
There are lots of bright and talented doctors and researchers who are studying
this issue. It is not perfect but till we have better vaccine making
capacity and speed, it is the best we have. The more countries that have
capability to produce Tamiflu, the better.
12/12/05 Japan
to grant 135 million USD to ASEAN to fight bird flu- Bravo Japan for being
proactive and helping other countries. President Bush has requested funds
to be used in fighting H5N1 overseas but to date, Congress has not been willing
to go ahead. The funds will go for both treatment and early detection.
12/12/05 Bird
Flu Seminar Panelists Say Panic Unnecessary- Exactly correct. Getting
prepared helps to take away the sense of uncertainty and panic. These
pandemics have occurred for centuries and they are nasty but survivable.
Those who are prepared will fare much better. Encourage local, state and
Federal officials to prioritize emergency preparedness. On a personal
basis, be informed, be flexible and wash your hands.
12/12/05 Ukraine
fears bird flu outbreak as fowl found dead in 21 locations- Russian labs
have confirmed this as H5N1 but the official results from Britain are
pending. This area seems to have fairly rapid spread. There are
local reports of the strain being different
and "unique". I have no idea why they say that and what the
significance of the alleged difference is. Hype or reality? Good
question. I think it best to wait and see.
12/11/05 Sen.
Bill F-He correctly states that while expensive,
developing plans for a pandemic is much less expensive than the estimated cost
of a pandemic. It must be noted however, that spending the funds does not
prevent a pandemic from happening, it just lessens the direct impact and it will
take several years to see the benefits of the plan. Never the less, I
totally agree with Sen. Frist, time is of the essence. Get the bill going!
12/11/05 State,
Local Governments Must Lead Flu Battle, White House Says this article is
worrisome. Till now, the Federal government has be assumed to take the
lead role in a battle with the state and local authorities following guidelines
established by the Federal planning. Now, all of a sudden, there is a
switch. Assumedly vaccine production and the like will still be
organized on a national level. The details of what is being suggested are
totally unclear but potentially represent a huge change. I would agree
that it is not realistic for the Federal government to be front and center for
all things but central coordination is critical. Each community knows their own
people better and should be working on how to mobilize local business and
individuals in case of any type of an emergency.
However, there are many things that cross
state boundaries and are beyond the control a single state. Rivers flow
across multiple states. Power is generated in one and shipped to
another. Who is making sure that the personnel at the plants are going to
work, or that there are vaccines to the critical infrastructure
people. What about nuclear power plants. Do we trust these to the
private operators that they can always get their staff there. What if
everyone is ill? There has to be coordination of all these
different issues.
I think they had this planning meeting and
decided that they were way behind in preparations and are trying to shift the
responsibility to some one else. In essence, when a problem develops, they
will say, " we told you that you had to take the lead on
this...". An alternate explanation is that they are concerned they
will not get the funding they need and are giving everyone an heads up.
The timing of this with the planning meeting yesterday and the announcement
right afterwards makes me favor the former interpretation.
12/10/05 China:
Bird flu virus in humans mutating- China states that there have been
unspecified mutations in the virus compared with those from Vietnam. The
US vaccine was geared around the virus seen in Vietnam in 2004.
Potentially this means the US prototype vaccine will not be as effective if an
outbreak developed in China.
12/10/05 Beijing has the 'virus in every corner of the country,' Hong Kong virologist says
- This very noted Chinese virologist says that China has been hiding
cases He has tested over 100,000 samples including some in areas where the
official party line is that there is no disease and he has evidence there is
disease there. China has limited who can publish about what is going on
and have put people is jail for publishing outside of the official
reports. A local farmer who reported the major outbreak in Anhui is
in jail and his lawyer has not been allowed to visit him. What's the issue
here? Only one lab in China is allowed to publish test results and that is
under government control. This doctor is announcing his findings at
considerable personal peril but he is very well known in avian flu circles and
he is likely counting on world sentiment to keep himself out of jail.
12/9/05 Bird
flu kills young Thai boy - deputy minister- the most notable issue here is
the the minister of health was unable to identify how the child caught the
illness. Usually there is some idea as to exposure. He is the 14th
death in Thailand by their report.
12/9/05 China
confirm fifth human case of bird flu "The latest
victim is a 31-year-old woman surnamed Liu from Heishan County in Northeast
China's Liaoning Province. She had symptoms of acute pneumonia, such as
high fever and breathing difficulty, on October 30. She later recovered and was
discharged from hospital on November 29...She tested negative for laboratory
tests before December 5 and then turned positive." This article, if
accurate is quite disturbing. It essentially says that using the testing
procedures/materials of the Chinese CDC, this woman was negative the entire time
she was ill and only turned positive a week after discharge from the
hospital. How many others are in this situation. There must have
been something about her case that made them suspicious to keep testing
her. I do not know what type of testing they were running for sure but
suspect that it was an antibody test. Antibody levels may take time to
develop. This is why one of the WHO criteria for recent infection is a
rise in antibody levels over time. I would note this case is reported in
the Chinese media, and not by the WHO at present. There is still the
possibility that the most recent test is inaccurate. The Chinese
government however has reported it and they do not like bad press so one has to
assume they take this case pretty seriously.
12/9/05 CORRECTION
- - RPT-Zimbabwe has outbreak of milder bbird flu strain- this is very good
news. H5N2 is not the same disease and is of little concern for human
transmission at present. As usual, details count!
12/9/05 Promedmail.org
reports on alleged seropositive prevalence of H5N1 in China- the second
article in this report is from Princeton, and they did a study on the alleged
reports of 35 million people in China being positive for H5N1. This number
has been tossed around by some saying that H5N1 is not new at all, instead it is
just more looked for and hence more discovered. These people claim that
the whole issue with H5N1 is a tempest in a teapot, that there really is not too
much to worry about. Here is a classic example of why you have to look at
the quality of data and reporters. Dr. Juliet Pulliam went back to the
original articles and dissected out the data. There were reports of about
2% H5 antibody positivity in certain areas but there was no annotation as to the
N type. Another study in the same article of disease in over 8000 animals
in China found no H5N1 but lots of H5N3. There was no H5N1. It would
seem that H5N1 is the newcomer on the scene.
12/8/05 US
gets failing
grades for health emergency preparedness
Trust for America rates the US preparedness for a variety of health emergencies
and overall the scores are not good.
12/8/05 Thailand
successfully produces anti-bird flu drug- this is positive. Countries
need to be empowered to be able to help themselves. It is interesting that
they have been able to produce results in a relatively short time. Either
they started much earlier (This appears to be the case) of the ramp up time
declared by Roche is inaccurate. Roche keeps saying it takes a year to
make. Indonesia has been planning the project for a year but production
has taken less time. Ironically,
in the US, we do not have any generic manufacturing going yet.
12/8/05 White
House to Hold Flu Response Exercise Federal level officials will hold a
"tabletop" response exercise- but it appears that state officials will
not be there. This is a useful exercise but would be better if there was
more funding. This also has to be brought to the basic response
level. Local officials have to know what to do, where to go for help, how
to approach an issue and an entire sequence of actions to implement in event of
an outbreak.
12/7/05 Chinese
girl is latest human bird flu victim- the 4th confirmed case in China. This
gal is said to have been exposed to sick chickens a few weeks before she got
ill. This is a little strange. Others around her have been fine. Why
did it take so long for her to get symptoms from those birds? Usually the
incubation time is measured in days, not weeks. Another Chinese website
says there have been no
cases of poultry avian flu in that county. Either there was a
different source or something else is going on. This does not necessarily
mean there is human to human transmission, but that is a possibility.
Alternatively there could be illness in the local animals that is non
fatal. Either case is somewhat disturbing.
This case does demonstrate how difficult it is to quarantine
everyone who has had contact with her over the last few weeks. When was
the exposure? Who did she have minor contact with over that time
frame? The report states there have been over 30 outbreaks in 11 provinces
in China recently. This case has not been confirmed by the WHO but the WHO
seems to accept China's declarations pretty readily.
12/7/05 China
urged to educate farmers in bird flu fight- Governmental attitude and
efforts are important but the biggest battle is for the minds of the local
people. This is where an outbreak is likely to happen, and hence, this is
the front line in the war to prevent an outbreak. The constant exposure of
animals to people markedly increases the risks. Chickens need to be raised
in set areas and sanitation needs to be taught. There needs to be
different methods of slaughter to prevent exposure. In addition, doctors
in China lack the tools to detect disease well. In personal communications
with Chinese doctors from local villages, they marvel at how medicine is
practiced here. In China they will see "2-3 times as many
patients" a day as here. High volume of patients combined with a lack
of testing materials translates into a high risk for unwitnessed disease.
Given that a pandemic will theoretically have an higher mortality rate, the
first evidence may be an outbreak of multiple deaths- and there may be may
people with lesser illness.
12/7/05 HHS
hopes pandemic preparations will ease flu vaccine supply kinks- in the text
there is mention that they will have 6 million doses of vaccine based on the
virus from 2004. This vaccine is beneficial for coverage of the virus seen
in Vietnam in 2004. Hopefully this will be helpful in a pandemic situation
but no one knows for sure. Money for a cell culture based vaccine is still
not available. This is unfortunate. It will take time to develop the
technology and then the vaccine production capability.
12/6/05 US
prepares for worst-case scenario with bird flu- the plan calls for dealing
with 92 million people getting ill over a 4 month span. This is mind boggling!
This translates into roughly 1/3 of the US populace. This is based on
extrapolations from the 1918 experience. These numbers would overwhelm the
medical system. Even if you could get in to be seen, there are not enough
supplies in clinics, hospitals and pharmacies at present to handle this crush of
people. To properly handle this type of volume, each medical facility
needs to pre-stock with extra supplies- masks, gloves, medications, IV fluids
and the like. I would encourage you to have your family and work to be
prepared... have extra supplies, essentials and be able to be flexible with
whatever situation arises.
12/6/05 States
support HHS plan for flu preparedness summits The Federal Government wants
to have a summit with state representatives there to coordinate care. This
does make good sense. Unfortunately, as always, funding is an issue and
there has not been a consensus on a federal budget. States have been
arguing about how much they should be paying for any program. Today, the
former 9/11 commission just gave the US failing grades on implementing the
recommendations from their bipartisan commission. Both Congress and
President Bush were faulted. In a similar fashion, pandemic planning runs
a very significant risk of being stuck in turf wars and arguments over funding.
12/6/05 New
animal outbreaks in Vietnam, Romania and probably the Ukraine.- Here is a
summary of reports from around Europe and Asia.
12/5/05
Doctor says bird flu drug is ‘useless’-
this article highlights the need to treat avian flu quickly within the first
24-48 hours of the illness. As the infection progresses, it starts a
cascade of immune reactions within the patient that causes lots of tissue
damage and scarring to the lungs. Once that has happened the Tamiflu does
not make much difference. Most likely, to be helpful, the virus has to be
treated early. Even in regular flu, it has been known that treatment has
to be quick. By the time someone has a high fever, abnormal chest xrays
and the like, it is probably of less benefit. The goal would be to snuff out the
infection before the severe immune response was fully launched.
12/5/05 Viet
Nam: Nurse Suspected of Contracting Avian Influenza- more unknowns... does
the nurse have the illness? She was caring for a H5N1 patient but the
other caregivers are ok. A family member of the original patient is said
to have had asymptomatic disease. These cases deserve careful following
and observation. If confirmed, these cases are the type that deserve
consideration for genetic analysis as there is question of unusual infection
patterns that suggests the potential for increased spread. Viruses that
can cause infection without symptoms are more worrisome as they allow carriage
in the human populace which can promote further infection. In essence, if
someone looks really sick, everyone stays away. If you look normal then
people assume you are not infectious.
12/4/05 Avian
influenza in Zimbabwe Suspected outbreaks- at this point, officials have
reported that there is H5 in their country but the N type is yet to be
determined as is the potency. Hopefully it is of a different type or
of LPAI. If this is confirmed as H5N1 and the high potency type, then it
will be more difficult to control in Africa as support services are
lacking. Notably, Zimbabwe is fairly far south of where there has been any
reported cases. If they have it, then presumably there are cases between
there and Europe also as that it was last seen coming down towards Africa a few
weeks ago. In a similar fashion, the
Ukraine has reported H5 but unknown N is a major bird die off. I am
suspicious for H5N1.
12/3/05
X-rays show shared symptoms among bird flu victims- the severity of chest
x-rays on presentation was a good predictor of eventual outcome. Common
signs were multiple areas of inflammation and development of fluid on the sides
of the lungs- a pleural effusion and commonly an infection in that fluid, called
an empyema. There also was "cavitation" i.e. parts of the lungs
were destroyed and formed holes in the tissue. These situations are hard
to treat and typically leave permanent damage even if the patient
survives. Now an interesting corollary may be this. If treatment has
no effect then it would not matter what the initial x-ray looked like. It
would either progress or not. Given that the authors say the initial x-ray
did correlate with survival, there is an implied suggestion that treatment does
help out. In essence, fire fighting is successful more if the house is not
fully engulfed in flames. Put out the fire while it is small, or better
yet, never let it get going.
12/3/05 Where
did the infection come from?-This is the question that experts disagree on
in Asia. There is a case where there are two people who were confirmed as
having disease without known exposure directly to poultry. One expert
thinks this is representative of human to human transmission, and others feel
this is related to unrealized exposure from the community as there are chickens
running around everywhere. What is the true answer? It is hard to
know and indeed, we may never know. How do you know everywhere a person
has gone over the last several days. Sometimes, there is gross
soiling with chicken manure. In othercases, it is more obscure.
There is little evidence for easy spread from dry inorganic surfaces over
time. I agree with the Promedmail.org moderator, more cultures need to be
done around the index cases but this takes time and money.
12/2/05 Ranbaxy
set to make large quantity of Tamiflu- this Indian company feels it should
be able to ramp up production quite quickly over the next few months. It
is trying to secure a solid supply of materials to do so. This is a very
positive development as many countries do not have as much Tamiflu as
desired. Ranbaxy says they can produce over 100 million courses of
treatment within the year so I would assume that production must be able to
start up soon.
12/02/05 Corporate
America is not prepared for avian flu- and according to this paper, not many
companies are sure if they want to even try. This approach won't work to
our advantage. On a most basic level, companies have to understand what
their work policy will be. If they encourage workers to come in while ill,
they will just keep passing it on. we must have a more intelligent way of
preventing illness. The basics still apply. Wash your hands, cover
your mouth if you have a cough, and stay home when ill...
12/2/05 Bird
flu quarantine lifted in NE. China's province this northeastern Chinese
province has been disease free for 21 days and would appear to show the benefit
of mass culls of birds in the affected area. This report is significant in
that if all the affected areas can do this the exposure of people to the illness
should be pretty minimal. Romania
just reported a new case but again the numbers are limited and infrequent
overall.
12/1/05 State
laws could hurt flu efforts, regulators say- at issue is thimerosal- and
there is no good data that using it in vaccines is problematic but many states
have laws going into effect that prevent it's use. "Making vaccine
mercury-free means packaging individual doses -- something that is not
necessarily easy for manufacturers to do." Having to make everything
single unit dose would decrease the ability to produce in volume. I have
not seen any good evidence that thimerosal causes autism.
12/1/05 Nearly
Vietnamese 200 communes with avian influenza- the title pretty much sums up
the article.
12/1/05 Regulators
cooperate in speeding bird flu vaccines- this is an important step in
producing more vaccine. This year, like last year, there have been
relative shortages of even the regular flu vaccine. We have to be better
about producing vaccines. In general, they are the most cost effective way
of treating an illness. Standardization/reduction of regulations will help
out.
12/1/05 Indonesian
woman dies of bird flu -health official- this case has been declared by
Indonesia officials but not confirmed by the WHO. This woman did have exposure
to sick birds before the onset of her illness. Another article on the same
woman describes over
a dozen suspected deaths from avian flu. As usual, there is no data on
those cases and what they turned out to be or if they just did not meet criteria
but have a high probability of having had the disease.
11/30/05 Wild
bird culls unlikely to help bird flu fight-UN- they have not elaborated on
details but I suspect it is because it is so hard to capture all the potentially
affected animals. They suggest an emphasis on the domestic birds in
captivity. Most human cases have been from exposure to domestic animals
which caught the disease from the wild birds.
11/30/05 Indonesian
President tells officials not to cover up bird flu
cases- quite correctly, he would rather have the truth
than false, bad information. They are mobilizing teams across the country
to monitor villages more closely. The young boy and his 2 brothers listed
below should have been caught much earlier. This will be necessary to get
on top of any rapid outbreak.
11/30/05 12th
Human case confirmed in Indonesia. This young boy is confirmed to have H5N1
and his 2 brothers died just a few days before he became ill. Their
chickens had died shortly before any of them became ill. The 2 brothers
were felt to have had typhoid. Obviously, the question now is whether they
really had avian flu instead. If they did, how did this boy get the
disease? From the birds or the brothers. There is no way to ever
know. There will not be further study of the two brothers as they have already
been buried and the WHO does not count those cases as they can not get the usual
definitive tests. This brings the Indonesian case count to 12 with 7
deaths by WHO count.
11/29/05 Virus
Mutation Found in Human Bird Flu Cases- in essence, this study shows that
the cases in China were different than the ones in Vietnam, but the both reflect
the local viruses found in the poultry of the area. There were not direct
changes seen in either locale. This is consistent with the idea that there
is constant mutation in the virus gene pool as opposed to a single strain that
is changing all across the world, i.e. multiple fronts as opposed to one.
As the virus spreads in animals across the globe, there are more chances for
mutation given the sheer number of viral particles involved.
The virus is not mutating in people themselves in this
study. That would be very worrisome. Mixing genes within an
specific person is one of the proposed mechanisms of developing a virus with
much more aggressive human to human transmission.
11/29/05 Study:
Bird Flu Vaccine Can Stop Spread- this study is suggestive that vaccinating
poultry is beneficial but it actually studied a different virus with 2 different
vaccines, and there were differences in results. This type of study needs
to be done carefully in a controlled environment with the H5N1 virus to see how
effective it is. The authors also suggest that each vaccine be tested
rather than to assume it is effective.
11/29/05 China
reports two more bird flu outbreaks- these birds were seen in an area with
previous culls on poultry.
11/29/05 Many
H5N1 cases bunched in families, report says- some 38% of cases in a recent
study were in a small number of families and in 3 families, the cases were
spread over time with at least a week in between the first and second
cases. This can be from 2 methods, either common exposure or potentially,
some limited human to human transmission. There is no clear evidence one
way or the other. The authors suggest careful monitoring of the
situation. These cases were through mid 2005. There is no listed
analysis of cases since then.
11/29/05 Possible
poultry outbreaks seen in Indonesia, Romania and now reports of disease in Chinese
tree sparrows . These outbreaks will continue and likely there will be
new species to track diseases in. They should not be considered a huge
surprise.
11/27/05 Case
of Human Infected with Bird Flu Virus Registered in Malaysia- details are
quite sparse, but the individual had just returned from China. It is not
clear what exposure route or diagnostic test was used to make this claim.
11/27/05 Viet
Nam: Avian influenza Situation - WHO Update 43- Vietnam has another human
case in a 15 y.o. boy who is recovering well. The current experience there
is a mortality rate of 22/66 cases while Asia in general is at 68/132. It
is not clear why some areas have a higher mortality rate... is it the treatment
or something inherent in the virus itself. There are different strains of
avian flu. The expectation is for the virus to become less lethal but more
transmissible as time goes on. A few years ago the mortality was commonly
100% but there were only a few cases a year.
11/26/05 Most
of China has had animal cases of avian flu outbreaks this year- piecing the
different reports together over time, most of China has had some form of
outbreak. Dr. Tashiro has described the cases seen as "the tip of the
iceberg" in prior posts. I would suggest health care workers to be on
the alert for patients returning from any of the areas to be on the alert for
febrile-respiratory illnesses. This is an unlikely issue for most people
as they are less likely to be near poultry.
11/26/05 Indonesia
to start producing Tamiflu soon- production will start in 3-5 months, and
presumably it will take some time for the product to come out. Roche has
come along way over the last few months. Bravo! Meantime,
Taiwan has decided to produce bird flu drug without license from Roche- and
production is schedule to start next year. In the meantime, they are still
working on purchasing more Tamiflu. I have not heard of anything specific
going on in the US except that talks were underway- and that was a few weeks
ago. The US still has not straightened out the funding issue either.
Congress and President Bush have not come up with a common package for approval.
11/26/05 Ongoing
questions about human deaths in China- this first link provides more of the
Chinese/WHO version of the alleged story and essentially says that there is no
story and tries to discredit Dr. Tashiro. He was not there, has not been
there with the WHO and WHO feels China is doing fine. Promedmail.org (an
arm of the International Society of Infectious Diseases) then asked Dr.
Tashiro for some clarifications and there are presented here. I feel
for poor Dr. Tashiro. He is trying to do his best be honest and to alert
the world about some questions and he is being criticized by certain
authorities. In view of China's recent history of cover ups regarding the
benzene spills over the last few weeks, where they lied and covered up as much
as possible till it was impossible to do otherwise, we have to be concerned
about the authenticity of Chinese claims. China has never been known for
openness and honesty. Unfortunately, this tends to backfire on people and
they can only imagine the worst. China needs to let the WHO fully examine
and pursue these questions and that will be the best way to determine what is
really going on. Dr. Tashiro, our thoughts and prayers are with you.
Thank you for being courageous enough to say something.
11/26/05 12th
Indonesian confirmed with avian flu.- this is more of the same an not a huge
surprise. Not much detail available.
11/25/05
Weighing pandemic's financial impact-
this article is written from a Wall Street Journal reporter and discusses some
of the impact across a variety of sectors and national economies. I would
encourage you to read the article. I can not profess to be able to
evaluate the business content!
11/25/05 Avian
Flu In Perspective: New England Journal Article Reviews 'Spectacular' Findings-
this short review of the NEJM article talks about some of the science behind the
current research and what it means. There are 2 major means for new virus
types to evolve, 1) direct mutation within the viral genetic material
(also known as recombination) and 2) reassortment- where the viral genetic
material is partially switched in a mixing animal- either an human or another
animal (like a pig). The author states that on his estimation of the rate
of genetic change, that the Spanish Flu virus was around for 18 yrs or so before
it became pandemic. This would suggest that there is more time for
researchers to develop a vaccine.
11/25/05 WHO
to send mission to China bird flu province- this is the second team mission
in recent weeks and they will be going to Anhui, where the second confirmed
human Chinese death has occurred. There has also been an outbreak in western
China, bringing the country to 21 animal outbreaks recently. The other
team went to Hunan and was the one that involved Dr. Tashiro.
11/24/05 Correction
from Dr. Tashiro Dr Tashiro states that the article below was
incorrect and he was misinterpreted. Please see the link in
Promedmail.org
This points out the need to make sure about the quality of
data and sources. There is a lot of emotions running out there.
In addition, see the 3rd report at the bottom of the
"correction article." A reporter who was there says that Dr.
Tashiro was quite clear in his presentation with charts and details. Is
this damage control or mis-interpretation? Who knows!
11/24/05 "Dr.
Masato Tashiro, a Japanese WHO consultant, believes that China has had 300 human
deaths from avian influenza and is hiding the true extent of the disease from
the rest of the world. "We are systematically deceived," he is
reported to have said.
Editor's Addendum, see article retraction above.
11/24/05 Indonesia:Infected
birds found in 7/20 tested subdistricts this is quite significant in
that there are so many other districts that were not tested for financial
reasons. There are 267 subdistricts in Jakarta. This is the area
where there have been the most human cases of avian flu. It is disturbing
they can not afford to test birds. If this is indeed the case, they will
have a hard time detecting what is going on and controlling it. Developed
countries need to step up to the plate and chip in promptly.
11/23/05 BusinessWeek:B - article deals with how various industries have been and might
be affected by an outbreak.
11/23/05 U.S.
to tighten sick passenger, quarantine rules- these rules make sense. It is
necessary to have rules in place before problems develop. There is a cost
to the industries involved. On the other hand, if people to not feel
comfortable traveling because of illness or if there is a massive shutdown of
traveling over fears of spreading illness then they would lose also.
Better to do it up front!
11/23/05 China's
plan to vaccinate billions of birds almost impossible: experts- this is as
discussed before. How can you vaccinate 13 billion birds? Who even
has that many syringes and needles? The experts feel it is not realistic
for them to be producing vaccine in the amount they say they are and that
spraying whole coops with the material has not been tested. I also wonder how
much of what is being published is really PR control. The Chinese have
always found it very necessary to maintain "face". In the
meantime, China
has reported 3 more outbreaks. Note the birds died last week.
There are more outbreaks expected as the weather gets colder.
11/23/05 One
of five Vietnamese suspected cases has been confirmed to be positive- he
appears to be improving and was moved to another hospital. This is
encouraging. I would assume he was treated with Tamiflu. Any
suspected case will automatically get treated to help cure as well as to
decrease the risk of spreading illness to others. Treatment with Tamiflu
is generally pretty safe. (Please note, I do not have stock in
Roche!)
There is no way ethically to really evaluate how effective
Tamiflu is... In the medical field you like to have a blinded study, where
half of the people are on active drug and half are not. The doctors do not
know who get the real drug and who does not. If you have 100 suspected
cases, can you ethically treat half and not treat half when you are dealing with
an illness with a 50% mortality rate? Who is going to sign up for
placebo? Who would sign up for a study if they thought they might
get placebo?
11/23/05 Discussion
of Tamiflu impact in standard flu- there have been questions as to Tamiflu
and deaths in Japanese children. The FDA has come out stating that it does
not appear to be related to the Tamiflu itself but the underlying disease
illness. There is a distinct incidence of encephalitis (inflammation of the
brain) with the flu and the incidence of this on Tamiflu and off it is the
same. This would suggest that the drug does not directly cause
confusion. This is good news that it is not a drug related side
effect. Death rates are listed as being 60-90% lower than without
treatment.
| 
