H5N1: Another Country (Or Two) Heard From

Well, originally, the title (respectfully stolen from Effect Measure), referred to a new H5N1 human case in Burma, which joined Indonesia (two separate cases) and China (father-son) in reporting human cases this week. But, the big news is the breaking story in Pakistan.

Pakistan Has Eight Suspected Human Cases of Bird Flu (Update4)

By Jason Gale

Dec. 16 (Bloomberg) -- Five members of a family in Pakistan are among eight people who may be the country's first human cases of bird flu, the World Health Organization said. At least one brother died.

Pakistan's national laboratory found the lethal H5N1 avian flu strain caused the infections in three brothers and two cousins from the same family, according to information from a Dec. 15 WHO statement and Gregory Hartl, a WHO spokesman in Geneva. Another brother from the U.S., who attended a funeral for one of the victims, and his son tested negative for the virus at a hospital in Nassau County, New York, Hartl said.

Medical teams have been sent to Pakistan to assist local authorities in investigating the cases, in which two people had only mild symptoms, Hartl said. Doctors are monitoring for signs avian flu may be adapting to humans by killing fewer people, fostering its spread.

``It's too early to make any definitive conclusions'' about the outbreak, Hartl said in a Dec. 15 telephone interview. ``We are still in the middle of it.''

New York State health officials were informed Dec. 7 that a man from Nassau County who had returned from Pakistan told his doctor he might have been exposed to avian flu, said Claudia Hutton, director of public affairs for the state department of health in a telephone interview.

Pay attention to the bolded part, above (the NY State Health Department and CDC did). It represents both a familial cluster (raising the possibility of human-to-human transmission), and the speed at which a pandemic can spread worldwide. A more complete list of the outbreak and the large familial cluster it represents (a vet and 4 brothers, with a few cousins thrown in for good measure, spaced over 2 months) can be found at Flu Wiki's Forum. [Here's a summary from Effect Measure]. From Helen Branswell (CP):

Meanwhile, U.S. public health authorities have confirmed they conducted H5N1 testing on a man who had recently visited Pakistan and was complaining of mild respiratory symptoms. The man, who officials will only identify as having a link to the cluster, is said to have been concerned he might have been infected.

"The individual went to his private physician after returning from Pakistan, and discussed this with his physician," said Claire Pospisil, a spokesperson for the New York State department of health.

Pospisil said the doctor contacted the local health department in Nassau County, where the man lives, and they collected samples for testing. The tests came back negative.

David Daigle, a spokesperson for the U.S. Centers for Disease Control, said the CDC sent its plane to Albany on Dec. 8 to collect specimens for confirmatory testing. Within hours a CDC lab verified the state lab's findings.

"He was negative. There was no doubt about it," Daigle said from Atlanta on Saturday.

The idea that someone could be exposed to H5N1 in Southeast Asia and then fly to NY is completely plausible, and likely just happened. Some heads-up thinking by the local doc [and the patient] got the testing done in a timely manner, but had the testing been positive (and it could easily have been), there'd be quite a few headlines about this issue.

No headlines today? Well, let's use that as a teachable moment to cover two frequent criticisms of flu blogging: hype and fear-mongering.

Now, for all the concerns and accusations of media hype, there really is a paucity of news about H5N1 (Daily Kos excepted) and not a surfeit. Here is a google news search documenting that which used to be in 2005, and that which is now (click for bigger pic). Note that by region, this has overseas interest.

As for fear-mongering, as long as H5N1 remains in the environment, it will remain a threat to humans. And as long as that's so, we will report and write about it.This isn't fear-mongering (a term bandied about by folks who don't like to read about these things, for whatever reason), it's education. It is also prudent awareness of a candidate (H5N1) for a natural disaster (flu pandemic) that's as inevitable as the next "storm of the century", and as difficult to predict (both in timing and intensity). Hopefully, that will lead to some preparation steps (see below). And do note that the NYer tested above informed his doctor of his risk factors and got tested. Without that education (from news and elsewhere), you can't expect that level of public cooperation.

And, of course, thanks to the internets, there's more news to tell.

See Flu Wiki's Sunday wrap-up for the week's documented human and bird cases, courtesy of the wiki volunteers who track cases around the world - helpful to CDC and WHO and other public health officials as they do their work (more than a few have written me that they stop there to get the morning news - this is netroots activism applied to public health!). Not only are there new human cases scattered throughout Asia (including Pakistan, Burma, China and Indonesia, all of whom are less than than transparent about internal news), there are also new bird cases of H5N1 in Germany, Poland, Russia, Vietnam, and Saudi Arabia (and the hadj is soon, 1.5 million pilgrims expected).

This is not totally surprising, despite the paucity of news reports. Over the years, observational data suggests an upswing in reported cases between November and March:

Note that the line graph, the Case Fatality Rate (CFR), remains steadily above 60%.

So what do we take away from all of this? H5N1 is endemic in bird populations and will not simply go away. New outbreaks in new countries are likely part of the 'new normal', and we should expect a steady diet of news like this, particularly this time of year. In addition, the idea that "this will never be seen in North America" needs to be seriously rethought by anyone still holding on to that concept. We had a near miss last week, and  modern travel conditions make the possibility of a human case in NYC more than just science fiction.

So, as a reminder, here's what you need to know about pandemics (from the Citizen's Guide, foreword by David Heymann, WHO, .pdf):

Three prerequisites for the start of a pandemic

1. A new influenza virus is introduced to which humans have little to no immunity.

2. This virus must be able to replicate in humans and cause disease.

3. This virus must be able to efficiently transmit itself from one human to another.

Of the three requirements, the first two have been met by H5N1 and the third has not. There is no science that says it will, or that it won't. We do know pandemics are repetitive and inevitable.

Most public health specialists from around the world believe that there will be another human influenza pandemic, a pandemic caused by an avian influenza virus that can cause human illness and has mutated to a form that spreads from person to person. Such a random event has occurred three times during the past century, causing three different influenza pandemics.
David L. Heymann, Assistant Director-General
World Health Organization

But regardless of which virus the next pandemic comes from, pandemics are different than other disasters:

• Communities will be affected simultaneously.
• At least 30% of the overall population will
become infected.
• Absenteeism is expected to be upwards of 50%.
• A pandemic is likely to last for 12 to 18 months.
• Communities could be affected by several waves
lasting 6 to 8 weeks each.
• Vaccines and antiviral drugs for pandemic
influenza will be in short supply, may be of limited
effectiveness, and are not likely to be available to
most communities.
• Most of the ill will seek medical care.
• All healthcare systems will be overwhelmed.
• Health facilities are unlikely to be available to
most, and may be inadvisable to enter owing to
increased chances of exposure to the virus.
• People and communities will likely be on their
own without the help of mutual aid from other
communities, hospitals, or other public services.
• Those who take steps to prepare ahead of time
will be much more resilient as pandemic influenza
spreads.

Preparations to mitigate a pandemic need to be carried out beforehand, and are currently being done in many places throughout the United States and the world (for example, by groups as diverse as the American Red Cross, law enforcement, State Departments of Health, and many others). The ubiquity of the preparations, which may include your local school system, tells you something about the threat.

The next pandemic may not be H5N1, but H5N1 remains a candidate virus, and the planning to handle an event such as a pandemic will help with whatever comes (there's nothing wrong with an all-hazards approach to disaster preparation, as long as the all-hazards approach includes things as extensive as pandemics). Do yourself a favor and review your own family plans for natural disasters such as hurricanes, tornadoes and ice storms. Stock up on two weeks of food and water, and plan for power outages, if relevant to your community (it's very relevant in New England). You can rotate your stock and keep it fresh. It's time well spent and the effort will not go to waste.

Oh, and keep an eye on Pakistan. It's a big story, and political turmoil will not make the situation there any easier. For more details on an hourly basis, go here. And remember, when you start hearing about this in the media, if you ever do, it's not hype. It's news.