David Nabarro, Senior UN System Coordinator for Avian and Human Influenza, has some bad news, some good news and some more bad news. First (bolded mine):
Bird flu is a problem that will likely be with us for some years to come, according to David Nabarro, senior coordinator for avian and human influenza at the United Nations. [bad] But citing data on the spread of the H5N1 virus from 146 nations, Nabarro emphasized the positive. "The first thing to say is that the situation has changed, between 2004 and 2007, the rate at which new countries are being affected by H5N1 has reduced, we've got a bit of a plateauing [leveling out], the number of human cases, which act as a sentinel, has slightly decreased, and the human deaths have also decreased." [good] He said that broad epidemiological evidence suggests that the H5N1 virus situation is not quite so serious.
Not quite so serious in the sense that we are not seeing more cases and more countries compared to last year. Compare 2007's 77 human cases (so far – pending confirmation of up to 9 people from Pakistan with 2 deaths) with 2006's 115.
Note, however, the bad news. It's still here, still deadly, and still spreading.
The virus, however, is still being actively transmitted in at least six countries, and there are new reports (December 16) of human infection and death in Burma and Pakistan. At the Washington briefing, Nabarro stressed the importance of maintaining focus, funding and political will to keep H5N1 under control.
And John Lange, who leads the U.S. government's avian influenza program, told reporters that the global campaign to stop avian flu goes beyond dealing with individual outbreaks. "What we've really been trying to do, when possible," he explained, "is to build long-term capacity, both on the veterinary side and on the human health side, through increased levels of surveillance, training of veterinarians and epidemiologists, building up laboratories, etcetera."
And Lange observed that international cooperation on bird flu has already had a positive impact on overall public health preparedness. "If there were a new disease that just emerged tomorrow, but it was totally different from H5N1 — maybe something that came out and had the ability for sustained and efficient human-to-human transmission — the best entities able to cope with it in terms of the networks that have been built up would often be those that are now working on the avian and pandemic influenza threats."
Several comments to make about that. Lange is right that a focus on H5N1 and pandemic flu helps public health preparedness in general (and a point that I have been making all along). But the fact that there is now a sense that limited human-to-human transmission has taken place in the recent Pakistan (and maybe China) cases along with the continuing high fatality rates speaks to a continued issue. Some of the drop-off in cases may be to the generous use of 'tamiflu' blankets in exposed individuals and surroundings. That can cut off spread of illness (good) and also perhaps increase false negative testing (bad). Even if that happens on occasion, however, we are not currently seeing an outbreak that suggests the beginning of a pandemic. We are seeing continued (and deadly) outbreaks. In Indonesia:
In 2006, 20% of the confirmed H5N1 cases had no direct contact with poultry. In 2007, 30% of the confirmed cases have had no direct contact with poultry. Compared to 2006, Indonesia has had fewer confirmed H5N1 cases this year (40 vs. 55), but the cases have been deadlier -- the CFR has risen from 81.8% in 2006 to 87.5% in 2007 (link).
More worrisome is the Pakistan family cluster we described last week, including one US citizen who tested negative on Long Island (having returned here from Pakistan). Revere at Effect Measure summarizes:
The World Health Organisation (WHO) suspects there has been only limited human-to-human transmission of the H5N1 virus in Pakistan, but international test results are pending, an official said on Friday.
David Heymann, WHO assistant director-general for health security and environment, said no new suspect human bird flu cases had emerged in Pakistan since Dec. 6, signalling there had been no further spread.
[snip]
"The team feels that this could be an instance of close contact human-to-human transmission in a very circumscribed area and non-sustained, just like happened in Indonesia and Thailand," Heymann told a news briefing in Geneva. (Reuters)
To be clear about continued risk:
[WHO's] Doctor Heymann says H5N1 remains an animal disease. He says there have been only occasional instances where human-to-human infections have occurred.
The World Health Organization reports at least 209 people have died worldwide from the virus, most in Indonesia. Scientists fear the H5N1 or another as yet unidentified virus could mutate into a form that could easily spread the disease among humans.
Doctor Heymann says there were three avian flu pandemics in the last century and other pandemics before then. He says there is a clear understanding in the scientific community that there will be another pandemic of influenza.
"We do not know what virus will cause that, but we know there are avian influenza viruses out there and those viruses could cause a pandemic eventually," he explained. "As long as H5N1 is circulating anywhere in the world, there is a chance that that virus can, either through an adaptive mutation or re-assortment, cause a pandemic. The problem is nobody can quantify that risk."
Doctor Heymann says countries have to be prepared to take action when a pandemic strikes. He says the World Health Organization is stockpiling H5N1 vaccines.
Thailand (2004, .pdf), Indonesia (the Karo cluster in 2006), and now Pakistan represent accepted cases of limited human-to-human transmission (and for those who say it's never gone human to human, yeah, it has, three different countries). Revere (Effect Measure) asks:
Yes, sometimes there is human to human transmission. But it requires very close contact. Casual contact isn't enough. Sounds reasonable. But here's my problem. In a lot of cases there is no history at all of contact with sick poultry. Maybe theses cases came in contact with a virus shedding bird somewhere but was it similarly close contact? Or is casual contact with birds capable of transmitting infection but not from another person? Even more to the point, lots of people have close contact with sick poultry and they don't get infected. Only some people get infected. We don't know why that is, but it would seem more sensible to ask the same question about the rare human to human transmission. Why these people and not others?
As in much of the H5N1 story, many questions, few answers. Any one of those clusters could have been the beginning of the next pandemic. Or maybe, the next pandemic will be some other virus (an H7 or an H9, already known to infect humans). So, it'd be a good thing to continue to beef up surveillance and keep an eye on these emerging viruses, right?
While acknowledging the threats posed by war and global warming, Nabarro insisted that the biggest danger mankind faces today is almost invisibly small. "It's microbes, particularly microbes that come from the animal kingdom, that represent one of the greatest threats to humanity and certainly even to its survival as we know it."
Well, thank goodness, we're on the ball here in the US.
Congress slashes pandemic preparedness funding
Dec 20, 2007 (CIDRAP News) – The 2008 omnibus spending bill passed by Congress this week earmarks only $76 million for influenza pandemic preparedness funding, far below the Bush administration's $870 million request.
The President's advisors have indicated he will sign the bill when it reaches his desk, according to several media reports.
The reduction in pandemic preparedness funding appears to be the most significant cut to President Bush's spending proposals, Government Executive reported yesterday.
The House and Senate appropriations committees said their rationale for cutting the 2008 pandemic preparation budget was based on a $1.2 billion amount remaining from previous appropriations, according Government Executive.
However, Rich Hamburg, director of governmental relations for Trust for America's Health (TFAH), a nonprofit health advocacy group based in Washington, DC, told CIDRAP News that the $1.2 billion represents one-time funding that is mostly intended for buying vaccines and antiviral medications.
The 2008 omnibus bill contains no one-time spending items, he said. "The appropriations committees may have thought that this was a tough budget and that it was hard to make a case that all of the pandemic funding was needed right now," Hamburg said.
To maintain momentum on pandemic preparedness efforts, Congress could fold the funding into the 2009 budget or put budget requests into emergency supplements, Hamburg said.
OK, so this isn't a sexy program like troop funding or earmarks, but it is one of the few remaining bipartisan programs in DC. The funding went the way of SCHIP expansion.
To give you an idea of the importance of surveillance and the ubiquity of the problem, here's this week's bird flu (in birds) run-down (for H5 and H7 infection). Every bird infection is a risk for humans to catch the virus. Every human that gets the virus is a chance for mutation to take place that could enhance H2H spread:
Other Avian Influenza Outbreaks in Animals
- Benin: The H5N1 virus was confirmed on two poultry on farms, one north of the capital Porto Novo and one in the commercial capital Cotonou (Dec. 17).
- Canada: A Saskatchewan poultry farmer whose 50,000 birds were culled after an outbreak of H7N3 bird flu is asking for provincial and federal assistance to pay for the decontamination of his farm (Dec. 19).
- Germany (Brandenburg state): H5N1 was identified on a small poultry farm in Bensdorf in the Potsdam-Mittelmark district, about 85 km west of Berlin (Dec. 20).
- Poland: In the Warmia-Masuria province, the country's seventh outbreak of H5N1 in poultry virus was identified on a farm near the northern city of Olsztyn (Dec. 17). In the Masovian province, the country's eighth outbreak was confirmed on an egg-producing farm in the district of Zuromin (Dec. 22). This farm is within the contamination zone of a Dec. 8 outbreak in the village of Karniszyn, from where the virus is believed to have been transmitted.
- Russia (Southern Federal District): The country's third H5N1 oubreak this year has been reported in Shosseiny, 10 km from the poultry farm where the first case of bird flu was identified in the Rostov region in late November (Dec. 20).
- Saudi Arabia: The sudden death of 20 pigeons in the Al-Hudud ash Shamaliyah province (Northern border province) has raised bird flu fears in the provincial capital, Arar, located on the border with Iraq (Dec. 17). Concerned about a possible spillover of bird flu from poultry and wild birds in Saudi Arabia, Jordan has declared a maximum state of alert (Dec. 22).
- Viet Nam: Ducks in Go Cong Tay district of Tien Giang province that died are being tested for bird flu (Dec. 20).
The integrated and deliberate surveillance and prevention program in the US and overseas is part of the public health infrastructure that needs support, maintenance and (in some cases) rebuilding. Neglecting it is as dangerous as neglecting the levees in New Orleans. All the activity in the world won't help when the hurricane winds begin to blow.
The money cut (see above) would presumably be used for local preparations for humans. So, billions for Iraq, no money for public health. I'm so glad we have our priorities straight.
For other recent 2007 flu stories, see:
Time Cites Bird Flu Vaccine As Top Medical Development Of 2007
WHO says mass bird flu vaccinations not necessary
Pandemic Influenza and Pregnant Women
The Great Pandemic: The United States in 1918-1919
Blogging about Pakistan's bird flu
And, as always, you can check the Week In Review at Flu Wiki Forum.