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Sunday, June 04, 2006

Ah, Bird Flu and Officialdom

I've been in a maze of bewilderment at the antics of bureacracy lately. This is not a Democratic bewilderment, or a Republican bewilderment, or a leftish bewilderment, or a rightwing bewilderment. The nature of the bureaucratic beast is pretty much the same no matter the genesis, I suspect. One of the hallmarks of the beast is the dedication to ignoring reality. Think of the Congress Critters' refusal to give up their pork as a huge chunk of the Gulf Coast lay devastated.

Last week WHO made official something that had been clear for some time. They are not going to raise their pandemic status alert for avian flu. It will remain at level three. The levels given below are from a WHO page which has now been removed from their website. These definitions were set in 2005:
Phase 1: No new influenza subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. The risk of human infection is considered to be low.

Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.

Pandemic alert period

Phase 3: Human infection(s) with a new subtype are reported. There are no instances of human to human spread, or at most, rare instances of spread to a close contact.

* Phase 4: Small cluster(s), meaning less than 25 people, lasting less than two weeks, with limited human to human transmission occur, but spread is still highly localized, suggesting that the virus is not well adapted to humans.

* Phase 5: Larger cluster(s), meaning between 25-50 people, lasting from two to four weeks, appear. While human to human transmission is still localized, the virus appears to be increasingly better adapted to humans. Though it is not yet fully transmissible, there is a substantial pandemic risk.

Pandemic period

Phase 6: Virus transmission increases significantly, and there is sustained transmissibility in the general population.human-to-human transmission.
It's clear from the medical data that we are no longer in stage three. WHO claims that the Indonesian cluster of eight began when the index case stayed overnight in a room with other family members through aerosol transmission. I think they are wrong, but according to an article in Nature the Indonesian cases showed more H5N1 than usual in their noses and throats. When questioned on the decision to stay at level three by scientists and reporters, some remarkable statements were elicited:
The difference between stages three and four hinges on how easily the virus can be passed between humans - a subjective call that in some cases may prove very difficult to make.

Examples of close contact include "staying close to the ill persons for hours or holding, touching, wiping the face, or kissing or speaking with the ill person at a close distance," according to Paul R. Gully, a senior advisor at the WHO in Geneva.

"By contrast, casual contact refers to a lesser degree of contact between the infected person and others. For example, being [within] a few to several feet away for shorter periods of time, but long enough for common respiratory infections such as regular flu or colds to be passed on through coughing or sneezing."
"We may not have done the best job of explaining what epidemiological signals we're looking for, what changes in the virus we're looking for, before we go up a level," Cheng told The Associated Press.
"If we saw a situation where somebody sneezed and there was somebody else on the other side of the room who happened to catch it, that would be a very significant change and that would be a good signal that we perhaps need to reassess where we are in the pandemic alert," Cheng said.
By the time someone on the other side of the room is catching H5N1 from a person coughing or sneezing, the pandemic will have already started. A pandemic occurs when a novel virus for which humans don't have immunities becomes efficiently transmittable between humans. What WHO announced last week was that they would consider convening a meeting of "experts" to change the pandemic threat level after it has begun, and not before. Take heed and be warned.

My company is finalizing our business continuity plan this summer, and we are planning for the possibility of a total quarantine forcing all of our employees to work from home, or the liklihood that employees' families will be ill and that we will have to have them work from home. It's possible for us, although it requires reworking management procedures totally. Because of the events of last spring (every single person at the place got sick, and the birds are still dying around us), we are already at our stage 5 precautions, which include mandated cleaning procedures several times a day for all contact points. That includes bathrooms, door knobs, etc. By the way, instituting those procedures cut all viral illness at the company, and it was the only thing that did.

I have read the reports and news accounts about the Indonesian cluster carefully, and I don't see any change. Clusters have not been exceptional for about six months, and I don't buy the theory that aerosol transmission was the main factor in this cluster. Other people, including one female neighbor of the index case, were in close, sustained contact with her while she was ill. This is being explained away as a family susceptibility, but barring actual evidence that there is some sort of genetic mutation unique to this one family in a remote village (and anyone who has any familiarity with such settings knows that the "everyone's your cousin" factor is likely to be true there), it is more likely that it spread through close contact (ie, shared toilet facilities) than through the air.

M-O-M, I've been thinking a bit about this, and I'd like to hear your opinion.

The "phases" outlined by the WHO sound reasonable enough, but I'm sure they were developed years ago.

By the time the big slow-moving institutions have official confirmation of "sustained, contagious, H2H transmission," won't the mutated virus already be all over the world? There are numerous flights from Jakarta to Los Angeles every day. Isn't it a bit silly to expect that we'll have a couple of weeks to prepare once "sustained" H2H has become a reality? By the time we hear of it confirmed in Indonesia, it's likely that it will already be in our own neighborhood, no?

I think the world may have gotten a bit too small for its own good. Al Gore, save us! (just kidding)
Pedro - that's exactly the point of this post. By eliminating the step stages, WHO has effectively announced that we won't be getting any warning.

By their old stages, we are in stage 4. That should trigger certain steps in individual disaster plans. Stage 5 should trigger final preparations and stockpiling, because some areas will only get a few days warning before they have to deal with stage 6. Sure, it could take a year or more for stage 5 to become stage 6, but the point is that once it does, time for planning is over, and we cannot know when stage 5 will turn into stage 6. Therefore, once we reach stage 5 we must be prepared to institute the steps necessary for stage 6 within a few days.

You are absolutely correct in what you are positing here. Once we have sustained transmission and efficient transmission, we cannot stop the pandemic. Whatever the virus is capable of, it will do.

Also, don't forget that the mutations and recombinations necessary to produce efficient transmission are more than capable of happening multiple times. We have already seen one of them occur multiple times (that is the acquisition of S227) in less than 300 documented human cases.

The odds aren't with us at all. And that is why for my company, this news produced the necessity to act as if we are in stage 5. We aren't, but what WHO told us last week is that we will likely never see an official stage 5. This is a purely political action - the fear of the countries affected is that they will be quarantined.
95% kill rate in this latest cluster.

I suspect we'll have about a billion dead and a billion more dying of this RL Captain Trips, and WHO will still be debating whether we're at Stage 3, 4, 5, or 6 -- must prevent panic, you know. (Though I suspect our WHO betters will already have themselves safely quarantined, so as not to disturb their debate.)
WHO will be drinking Tamiflu cocktails in the bar of an island resort, debating on what to name it!

There have been singleton cases (9) of idiopathic pneumonia with bleeding in Brazil. That was where they announced that a woman didn't have H5N1, but buried her in a closed casket anyway in May.
MoM, I read the definitions and remarked to DH Sunday that we were in Phase 4 no matter what WHO said. I feel really smart knowing I agreed with you! (I've tended to be an ostrich.)

I will pick up our turkeys soon. How many pounds do you want? ANd this year, I'm actually following the advice about not using raw egg whites, but the dried ones in my pumpkin chiffon pie.

I downloaded a 32 page pdf of recommendations by a doctor in Decatur. I don't remember his name, but he's a researcher for Emory & some drug manufacturers. Seemed to have good advice. I'm making a shopping list, and I'm going to Sams. Have you seen this? (If you don't know what I'm talking about, I'll link it for you.)
Carson, I have seen it. Crofsblog. GA actually isn't doing too bad on the preparation front.

Seriously - regarding turkey - I ate my last for this year about a month ago. I'm gonna have ham for Thanksgiving, and be thankful for it.

I might have definite info by next week, but I have an ugly feeling that we have a worse problem than we know in the US.
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