Same here TR - Mugwump very informative posts. It should make us think more about "were" we live. Funny (not really) how Americans don't think about the way they "travel" and what is "out there". Here in the Great USA you have it so well.

Thanx for the INFO

VG

"That the H5N1 virus may be able to be spread to humans drinking or swimming in contaminated water has now been officially recognised..."

http://www.who.int/water_sanitation_...background.pdf

This has implications in a variety of situations: drinking water from, or swimming in, bodies of water where migratory birds frequent (prior to any potential pandemic); hunting waterfowl (prior); or distancing-in-place during a pandemic (supply-chain disruption will almost surely stop chlorine deliveries and human H5N1 sheds huge quantities of viruses in feces -- a novel situation for influenza). Fecal contamination of water could prove to be a vector for past and future human cases.

[Our local Little League fields have an adjacent lake where large numbers of ducks and geese frequent and local dogs chase them into the water -- it's great sport for the dogs and fun to watch, geese are very scrappy and many dogs back down. I was at a game yesterday where a Golden Retriever did a coat-shake maneuver next to a viewing stand and got about 20 people wet in one go. That might be less funny if geese w/ avian flu migrate from Canada this fall.]

==============================================

About that new cluster in Surabaya, Indonesia. It is significant because it comprises a teacher and student. (No word on the 12 in quarantine reported earlier)

http://www.mediaindo.co.id/berita.asp?id=100362

"...a new cluster of confirmed or suspect H5N1 bird flu cases in Surabaya. The confirmed case (38F) was describe in the WHO update. She developed symptoms on May 2, was hospitalized on May 7, and died May 11. The above report indicates her child is now hospitalized with bird flu symptoms, consistent with human-to-human transmission within a family."

Another suspect case (20M) died today, but the same hospital has admitted two additional suspect cases, a teacher (30F) who died earlier, and her student (18M) who is in critical condition and on a respirator.

The geographical cluster in Surabaya thus has one confirmed and four suspect cases. Two of the suspect cases have died, and the student of one has been hospitalized. Similarly, the child of the confirmed case has also been hospitalized."

================================================

Finally, an article by Helen Branswell. She's a Canadian journalist who's won the Pulitzer for non-fiction. If it's under her byline, it's accurate and balanced.

"Bird flu cases in Indonesia raise questions about pandemic containment plan"

http://cnews.canoe.ca/CNEWS/World/20...590247-cp.html

.

Transmission and Transparency
 

There was a new death today (22May2006) in the original cluster chain from N. Sumatra. While transmission is far from "efficient" it isn't as inefficient as it once was.

The cite below is from Henry Niman, who is a somewhat controversial guy. His facts are always spot on but people sometimes (often) disagree with his interpretations. He is the consummate outsider whose "ridiculous" ideas become conventional wisdom with unnerving regularity (he was the first - in 1998? - to warn that wild waterfowl, specifically bar-headed geese, would carry H5N1 around the world; he was ridiculed for that). Someday I'll discuss reassortment vs. recombination vs. point mutations as modes of flu mutation. Niman was the pioneer of the recombination theory, which was originally scorned but is now one of those "well of course that's how it works" things.

Recombinomics

May 22, 2006

The growing H5N1 bird flu transmission in Medan, Indonesia has raised transmission and transparency concerns. The cluster has now grown to eight, and seven members of the cluster have died. H5N1 has been confirmed in all except the index case and the disease onset dates indicate there have been three generations of human-to-human (H2H2H) or possibly four generations (H2H2H2H).

Correlation vs Causation
 

Every lung cancer case in the US can be linked to poultry -- it's a fact. But that doen't mean poultry cause lung cancer.

"The WHO has been extremely concerned that none of China's 18 confirmed human cases to date have occurred in areas where outbreaks in poultry were previously reported. In most of the cases thorough investigations after the fact have pointed to some possible exposure to poultry. But the lack of obvious links disturbs international public health authorities."

Article from the great Helen Branswell

Watch what they do, not what they say...
 

GENEVA (Reuters) - The United States has sent a supply of Tamiflu to Asia to help the region prepare for a human outbreak of avian influenza, U.S. Health and Human Services Secretary Mike Leavitt said on Monday.

Leavitt did not say how much of the medicine -- recommended by the World Health Organisation (WHO) as a frontline treatment against a pandemic flu outbreak -- was sent, or where it would be stored.

"The United States government has just deployed treatment courses of Tamiflu to a secure location in Asia. The shipment is currently in transit and it will arrive later this week," he told journalists during the WHO's annual assembly in Geneva.

"I am not going to specify the amount or the location, but I want to make clear that we are beginning to deploy it," he said.

I want to make clear that we are beginning to deploy it
 

Sorry, I should have expanded, this is not the time to be cryptic or coy. First, let me say that I do NOT have any inside info beyond what I am gleaning from news reports. With that out of the way...

Mike Leavitt is the straightest shooter on this issue in the USGOV. NAMRU-2 is feeding sequence data and viral isolates back to facilities in the US -- don't know this for a fact but it's just common sense. If he says "..I want to make clear that we are beginning to deploy it" then he is telling us something, i.e. there has been a major uptick in the concern level by those in the know.

Couple this with recent comments from China's Vice premier Hui Liangyu 21May2006: "Summing up and analysing the epidemic's current development both inside and outside the country, the... situation is not optimistic." This is a very stark assessment for a high govt official.

We don't have enough TamiFlu for even a fraction of the US population, so if it's being sent overseas that's a pretty strong message.

If you've been sitting on the fence on this issue, well...let's just say I think I'd be much more comfortable right now having my preparations complete so I could watch events unfold. Even if we dodge this particular bullet this mess is going to go on for years. Get ready so you can forget about it and go on with your life.


.

Martial law has been declared in a European capital, 13,000 people have been quarantined, 40 streets have been blocked off and all businesses in the area shut down, there are reports of 4 people in quarantine, 2 are dead from H5N1 in Iran and an unspecified number are hospitalized and no report of it on the six o'clock news? Impressive journalism.

I did learn that Britney Spears almost dropped her baby recently (while holding an alcoholic beverage) and is apparently being visited by CPS.

Bucharest - About 13 000 people were quarantined in the Romanian capital Bucharest on Monday as troops and police sealed off streets in response to the city's second bird flu outbreak, officials said.

The mayor of the southern fourth district, Adrian Inimaroiu, said residents would be cut off and all businesses in the area would be closed during the quarantine period of up to three weeks.

The move came after the agriculture ministry earlier on Monday confirmed the presence of the H5 bird flu virus in dead chickens found in the neighbourhood, the latest of dozens of outbreaks of avian flu in Romania this spring.

"About 40 streets have been blocked" in the Luica quarter, Inimaroiu said, urging residents to stay calm.

He said the quarantine would last for a "period of a week to 21 days and all the institutions in this quarter will be closed".

"About 2 500 birds from this area will be slaughtered as rapidly as possible," the mayor said.
A neighbourhood on the northern outskirts of the capital was put under quarantine on Sunday evening with fences blocking a dozen streets and police preventing anyone from going in or out, except for medical emergencies.

US Tamiflu to Asia - Reading the tea leaves
 

This is a combination of news reports and Chatham House Rule emails:

Roche donated 3 million doses of Tamiflu, to be used as a fire break when a pandemic started. Half of this stockpile is in the US and half is in Switzerland. The deal is, it is only to be released under authorization of the WHO. The protocol for the release is detailed at the end of this message (sorry for the crappy formatting, it's from the WHO pandemic influenza draft protocol for rapid response and containment). This is all published fact.

Anyway, on to scuttlebutt, but informed scuttlebutt: Leavitt (USGOV HHS Secretary) is of the opinion that the pandemic has already started, or its start is imminent: "...the situation represents a transition in the behaviour of the virus likely to result in efficient and sustained human-to-human transmission" in the words of the protocol.

The word is that the WHO is in disarray -- it's top dog stroked out and died yesterday -- and Leavitt has taken it upon himself to release the Tamiflu. The strategy he is using: he is robbing Peter to pay Paul by sending US-purchased Tamiflu and withholding the Roche-donated Tamiflu. This pre-positions the stuff for rapid use (which he must think is worth a try -- lotsa luck) and still keeps the original amount of US stocks on hand. Slick. He's 1) sent a message 2) gotten the stuff where it might do some good 3) not really sent any of our very limited stock 4) called out Indonesia for lying about H2H.

Note that three of the four conditions in the protocol that presage "efficient and sustained human-to-human transmission" -- nos. 2, 3, and 4 -- have been met and there are rumors about no. 1.

mugwump

Containing the event

The rapid response and containment operation

The decision to launch a containment operation

An attempt to contain an emerging pandemic virus at its source is a demanding
exercise and a resource-intensive operation. Moreover, supplies of antiviral drugs reserved for use to support such an operation are finite and not easily replenished, and must therefore be used judiciously. For these reasons, the decision to initiate activities aimed at rapid containment should be triggered by compelling evidence that the situation represents a transition in the behaviour of the virus likely to result in efficient and sustained human-to-human transmission. Such evidence will derive from a combination of clinical,
epidemiological, and virological findings as guided by the following criteria:

1. Moderate-to-severe respiratory illness (or deaths) in three or more health care workers who have no known exposure other than contact with ill patients, and laboratory confirmation of H5N1 infection in at least one of these workers.

2. Moderate-to-severe respiratory illness (or deaths) in 5 to 10 persons with
evidence of human-to-human transmission in at least some, and laboratory
confirmation of H5N1 infection in more than 2 of these persons.

3. Compelling evidence that more than one generation of human-to-human
transmission of the virus has occurred.

4. Isolation of a novel virus combining avian and human genetic material or a
virus with an increased number of mutations not seen in avian isolates from one or more persons with moderate-to-severe respiratory illness (acute onset), supported by epidemiological evidence that transmission patterns have changed.

:)

"The chair is against the wall. The chair is against the wall."

Preamble to Stage 4?
 

In what some are calling a preamble to an escalation to pandemic Phase 4, the WHO have finally recognized that the Indonesian cluster in Sumatra was caused by H2H, and probably H2H2H transmission.

http://quote.bloomberg.com/apps/news...hK8&refer=home

Mugwump, thank you for the continued flow of information, but don't stop now please provide follow up to your last few threads.

The Chair
 

It's time to scream, shout and run about when mugwump posts "The chair is against the doorknob.":D

Not that any here would do that, or that any not here would notice.

But we will be ready.

Pete

First they insisted it wasn't human to human transmission. Thanks for the posts.

Not much new, awaiting test results on Iranian, Romanian, etc. samples and watching events unfold in Indo. I can give you some observations and my assessment of where we are right now.

People are really wondering about Romania's quarantine efforts. Shutting businesses, stopping food deliveries, using the army for coerced quarantine seem a bit extreme for bird infection, but maybe they are the ones who've got it right. Who knows, time will tell.

Europeans I work with think Leavitt is showboating by releasing the US Tamiflu. But, they truly hate us and would say something snotty regardless. Others think it's a smart gesture for signaling his opinion that we are in pandemic Phase 4, but doubt the Tamiflu will ever be used in Indonesia -- like pouring it down a rat hole. Personally, I hope it's being prepositioned for the military in Iraq, A'stan, Korea, Guam.

No one I know thinks that a breakout with an RO > 1 can be contained if it occurs in China, Indonesia, or India. Not even with boatloads of Tamaflu.

The WHO are playing a political game and are playing "parse the sentence" silly buggers in press releases. They know things have gone futher than they will admit. No one is willing to play hardball with Indonesia.

There is rank pessimism about the situation in Indonesia. A smart guy I know has said "notice how the flu cases are being reported by major medical centers?" His point is, it's like the drunk who lost his keys at night, somewhere between the bar and his car, searching under the streetlight because that's where he can see. There is a strong possibility that the same kind of clusters as those found close to primary med centers in Sumatra and Java are dotted all over rural Indonesia, "in the dark" so to speak.

The people in rural Indonesia are like people anywhere, I'm sure. The govt. is apparently held in very low esteem in the countryside and there is great distrust of health care workers (including from the WHO). Contrary to popular belief (and govt statistics) a large proportion of them are not Muslims but animists. They are not stupid but they are ignorant, and the govt. programs to spread the word about H5N1 have been pathetic.

There is so much dengue, TB, "normal" pneumonic disease, and chikungunya fever in Indonesia, India, etc. and the death rate from infectious disease is normally so high in these areas that it takes something truly extraordinary to create a stir. For example, there are estimates that 2 million Indians have contracted chikungunya and hundreds have died from it in the last several months. A few more flu deaths wouldn't be noticed.

My take? We are in Phase 4 and in retrospect have been since 2005. We are seeing inefficient H2H (and H2H2H) transmission of H5N1, and it is getting incrementally more efficient as time goes on. Birds have something to do with some cases, but very few.

I do not think we have reached the tipping point yet.

I think the breakout, if it occurs, will be heralded by a "bolt out of the blue" report of hundreds of seriously ill poor people in Nigeria, rural China or the sticks of Indonesia. The outbreak will only come to light when it is finally diagnosed in a privileged person in the middle/upper class.

It's possible that one of these clusters that are "under the streetlight" will be the one that goes ballistic, but pure probability argues against it. The breakout will probably be from that cluster cooking away out in the dark, in the poor slobs who have no access to health care.

I think the current press coverage is contemptible. The GW Bush administration has staked out a position on BF, so the liberal press (esp. the LA Times and NY Times) continue to pour out "Y2K with Feathers" stories. As an example, Robert Webster (a true expert) said he thinks that H5N1 **in birds** won't arrive in N America this year because he doesn't think the infection made it to Canada from Siberia or Nigeria this spring. Fine. But, that doesn't warrant "Expert Says No Bird Flu in US This Year" headlines. Very misleading. Right before the breakouts of avian H5N1 in Denmark, Hungary, Romania, Slovenia, etc. last week, the press was bugling that H5N1 was eradicated in Europe. WTF? Can't someone give a real expert a jingle before they publish this crap?

The only honest report will say nobody knows what is going to happen, because that's the truth. The risk is getting incrementally greater as time goes on, true, and that should be discussed. If it does hit, it could be horrendous. So, we should prepare. It's a given in crisis communications that people have to be frightened before they change their normal patterns of behavior. This constant drumbeat that people shouldn't be afraid is bullshit. It delegitimizes any climate for preparation as it mocks the few who do prepare. Jeez, only in America is it a God-given right to never be frightened by life.

I know some very gutsy people who are scared shitless by this virus.

I think the USGOV should spend less time and money on vaccines and more on food and fuel storage and infrastructure redundancy. Vaccines are critical, but there comes a point where more money doesn't help. Spend it on something useful.

mugwump out

That is such an inside joke that I am probably the only one who could get it. It's a line from a guilty-pleasure/crappy movie called Red Dawn where survivalist kids go up into the mountains following a Soviet invasion of the US and stage a guerrilla war. In the movie, the line I quoted is from a radio show on Radio Free America or some-such sending messages to the resistance.

I was making fun of myself.

I don't normally discuss my work or H5N1 with anyone in the neighborhood, most are flaming liberals ("HELP ME" signs) and I learned my lesson with my in-laws. I made an exception with my best neighbor-friend who moved to the other side of town. I voiced my concerns about the pandemic and infrastructure fragility and he came back with "So are you going up into the hills with a rifle to play Red Dawn? [holding nose and making static noises] 'The chair is against the wall. The chair is against the wall. John has a long mustache. John has a long mustache.' "

A-hole. He came around on his own -- he owns a food distribution company and he couldn't get his stuff to WalMart one week (HUGE $$$ loss) when congestion in the Texas rail network sidelined his product. That made him see the supply-chain light. Stubborn, maybe, but stupid he ain't.

I don't think we've reached a tipping point yet, but I do think that things have gotten a notch worse.