H5N1 in Indonesian pig population. Ideology to blame.

Great. H5N1 bird flu has jumped to pigs.  Just in case this gives you a So What? reaction, we are not talking here about the Swine Flu A(H1N1), which was all the rage in 2009, with huge vaccination and public health measures until it turned out to be quite minor, of interest now only to conspiracy theorists who think that it may have been dreamed up by Big Pharma as a measure to boost profits from sale of Tamiflu and vaccines.  (My opinion is that the response of the public health authorities was fairly correct, and that we should all count ourselves lucky that it turned out to be so mild).

No, we are talking about H1N1 Avian flu, which kills about 60% of the humans it infects. Luckily, it has great difficulty in spreading from birds to humans, and from human to human. You have to be pretty close to an infected bird or human to catch it. The epidemic of H5N1 in birds has been tailing off in Indonesia since 2007, but it is present in 7% of the pigs. Unfortunately they are mainly symptomless carriers, so we don't even get to identify which ones are infected without a test.Fortunately, it does not yet seem to pass from pig to pig.

So why is it significant that it has found its way into pigs? Pigs are a reservoir for the virus, and in pigs it can shuffle its genes around until it comes up with a winning combination that enables it to spread from pigs to human and between humans. Pigs are closer to humans than birds, physiologically. So far it has not done the transmission trick, and it has been in Indonesian pigs since 2005. It has so far developed the capability of binding to protein in the noses of both pigs and humans.

Maybe we will get lucky again, and by the time the H5N1virus overcomes its transmission problem,  it may hopefully have lost the virulence that gave it its 60% mortality rates.

If not, if it gives us another 1918 epidemic, at least we will have someone to blame - the free market fundamentalists.

How so?

Well, take a look here, at this WHO table of human deaths from H5N1.

Compare Indonesia and Vietnam.
Vietnam had a bad problem - the worst in the world - until 2005. Then they cracked it, and Indonesia took over as the main country of infection. The Vietnamese cases since 2005 were mainly from contamination from Indonesia.

How did Vietnam succeed in clearing the infection? Here's How.
After nearly two years of using mainly culling to control the virus, the Communist government last year adopted a combination of mass poultry vaccination, disinfecting, culling, information campaigns and bans on live poultry in cities.

Any rational world health organisation would have tried to replicate Vietnam's success in Indonesia. They did not.

Hans Troedsson, the UN's World Health Organisation representative in Vietnam, said the plan was "technically sound" but could not be copied or used as a blueprint by every country.
The cause of this irrationality, in my opinion, boils down to ideology. Vietnam's solution was deemed socialistic by some influential person within the WHO. Indonesia's sacred free market must not be contaminated with socialism. Instead, it remained contaminated with H5N1, which has passed into the pigs, and may pass thence to us, which may or may not have important consequences for human population numbers.


I am being very careful to remain scientific and objective here.

There is a remedy. Control the Indonesian outbreak with the Vietnamese model. Test all Indonesian pigs for H5N1 and slaughter out all the carriers. It's going to be expensive, far more expensive than applying the Vietnamese solution to the birds, but hey - that's the free market!

H1N1 Pandemic: Stay Calm, and Stay Home if Ill

Some quick notes on the A H1N1 pandemic declared yesterday by the WHO

The latest WHO figures give a total of 29699 confirmed cases af AH1N1 world wide, with 145 deaths.

This gives a case mortality rate of 0.5% - that is, you have a 0.5% chance of dying if you get it.

How does this compare with ordinary seasonal flu?
Here we are given a clinical attack rate (i.e. the proportion of the population that catches flu) of 5-15% for seasonal flu. Let's call that 10%, which would give 30,400,000 cases out of a total USA population of 304,000,000.

Annual death rates due to seasonal flu are around 30,000 in the USA, giving a case mortality rate of 0.1%.

Therefore case mortality rates are five times higher for pandemic flu.

Because less people have antibodies to the new strain, the clinical attack rate is higher with pandemic flu, 25-50% as against 5-15% for seasonal flu - 3-5 times. Let's take that as 4 times higher. That would give 5*4= 20 times the number of deaths that seasonal flu causes - 120,000 in the USA. I make that 0.04% of the US population. Individually each a tragedy (especially if pandemic hits younger people harder) but statistically the figures are not highly significant.

I stress that these are very crude calculations indeed, but they give us a ball park figure of what to expect. The actual numbers could be several times higher or several times lower.

The mortality rate for H1N1 may have been held down by the high level of vigilance and high use of antivirals in these early cases. Stocks are not infinite, so later on people may have to face the virus without support from drugs. In fact, their effect is to reduce the severity and duration of symptoms by a not very large margin. I would be very interested to see them compared with high dose Vitamin C and Zinc, which supports the immune system. There is some evidence for its efficacy. (I know, Dr Goldacre, not a lot, but this is because nobody gets a patent for vitamin C and Zinc).

Key messages are to reduce the case attack rate by emphasising the Stay Home If Ill message. Politically, employers are stupidly going to resist this message, on the grounds that absenteeism will increase. In fact, absenteeism in the longer run will be worse if ill people come in to work and spread it around. Government should help by abolishing the duty of GPs to issue medical certificates, since this drives infectious people out into the community to get their sick notes.

There should also be air quality monitors in civil airliners that could be tested and signal whether the aircraft was carrying H1N1. The passengers could be contacted, and advised to regard themselves as infectious for a week.

Government is deaf to these suggestions, just as they are deaf to the suggestion that we should find out if the effective masks that NHS staff will use can be sterilised in a microwave and re-used, which would save the NHS many millions of pounds a year in purchasing disposable masks. All of these suggestions have been put to Government and the NHS and have met with a complete ignoral.

Expletive deleted.

Hitchhiker's Guide to swine flu: Don't Panic

Useful CBC precis of the Center for Disease control here: Swine flu: FAQ

My reading of it is, on the small amount of data that we have at present is:
Don't Panic!
in big friendly letters.

This happens from time to time. 900 cases in Mexico, 6.6%% mortality. It looks as if it has human-human transmission, but outbreaks of swine flu seem to fizzle out. It is susceptible to common antiviral medication.

We can help all flu to fizzle out if we Stay Home if Ill!

Vietnam's success against avian flu may offer blueprint for others

Vietnam has succeeded in pretty much holding back Avian Flu, especially in comparison to Indonesia, where the disease is regarded as endemic (established) in its poultry.

After responding to its 2004 outbreaks mainly by culling infected flocks, Vietnam in 2005:

1. became the first country to institute mandatory nationwide poultry vaccination.
2. banned poultry rearing and live-market sales in urban areas;
   
3. restricted commercial raising of ducks and quail, which can harbor the virus asymptomatically;
   
4. imposed strict controls on poultry transport within Vietnam
   
5. clamped down on illegal cross-border trade
   
6. launched an aggressive public education campaign that deployed radio and TV advertising, neighborhood loudspeaker announcements, and outreach by powerful internal groups such as the Women's Union and Farmers' Union.

Nice work, no? No, not according to Dr. David Dennis, the Hanoi-based Vietnam influenza coordinator for the US Centers for Disease Control and Prevention, who whines "How much [of the reduction in cases] is due to the natural history of this organism in birds? We don’t know."

Oh dear oh dear. How backward and unscientific these Vietnamese are. How inconvenient of them to fail to do things one at a time, half heartedly, and ineffectively, all in the name of "science".

Ballcocks! Dr Dennis - and, sadly the WHO, who also have refused to learn from the Vietnam success - has his priorities all wrong. This is medicine we are doing here, which is the technology associated with medical science. Science can tag along and learn from the success, but all credit to the Vietnamese who have succeeded where Indonesia and other countries have so signally failed.

If people want to be scientific, let them repeat the Vietnam experiment in Indonesia (or, assuming that that country refused to play ball, some other more cooperative country), and leave out just one element - like the public education, or the market ban, and see if that works. Or, better still, let us forget the knowledge and go for the cure, and just do what worked in Vietnam, and let the anal retentive scientists go hang about by their empty viral specimen jars.

Of course, this aversion to learning from the Vietnamese could have nothing to do with what happened in April 1975. American defeat, ignominious exit, helicopters, Saigon.

Could it?

Avian flu: pointed questions.

It is most important to trace the source of the present outbreak of H5N1 Avian in Suffolk, in order to learn lessons that can help us to close that type of infection pathway. It is not good enough to say, as they are,"We may never know", and "Matthews tell us the eggs are not from Hungary".

Here are some lines of inquiry for some intrepid investigative journalist or researcher to follow up:

Do the DEFRA investigating teams have all the resources they need?

In the investigation, is enough attention being given to the possibility that the infection pathway could be the import of eggs already infected with H5N1?

Is it indeed the case (as reported) that the Holton (Suffolk) strain is similar to a Hungarian strain? How closely are they related?

Is it the case, as has been reported, that Matthews' Hungarian factory had an outbreak earlier this year?

Clearly there needs to be a stringent investigation of the provenance of all eggs brought into the Holton factory. The investigation must go beyond simple examination of the firm's records.

Without prejudicing any person or persons actually involved, it can be said that it is not unknown for records to be altered, particularly in circumstances of this type.

Smuggling is prevalent in the poultry business. http://www.nytimes.com/2006/04/15/world/europe/15bird.html?ex=1302753600&en=bc2640e1464f857a&ei=5088&partner=rssnyt&emc=rss

Eggs are presumably worth more in the UK than they are in Hungary.

It is possible that eggs bought in good faith as UK provenance might be foreign in origin.

Let us hope that DEFRA will follow these lines of inquiry. Let us hope that they have hearned from the 2001 foot & mouth outbreak. Let us hope. Or pray...

H5N1: Let us learn from Vietnam's success

New Zealand's source for World News on Stuff.co.nz: Vietnam to unveil advanced plan to fight bird flu

Vietnam, the country hardest-hit by avian flu but free of the disease for six months, will present a model plan on containing the virus at an Asia-Pacific conference next week, international officials said.

The "Green Book" outlines medium- and long-term strategies for fighting the deadly H5N1 strain of the virus among people and animals to help prevent a global pandemic.

It includes poultry and livestock production reforms, public awareness campaigns and tighter border controls to prevent illegal poultry trade... The H5N1 virus struck poultry and people in the Southeast Asian country of 83 million in late 2003. Vietnam, with 42 deaths out of 93 human cases reported, has the highest casualty rate but it has not had a human case of H5N1 since November. In recent weeks, neighbours Cambodia and China have reported infections in people and poultry.

The draft five-year plan will be presented at the 21-nation Asia-Pacific Economic Co-operation (APEC) avian flu meeting of ministers of agriculture and health in the central Vietnam city of Danang from May 4-6.
...

After nearly two years of using mainly culling to control the virus, the Communist government last year adopted a combination of mass poultry vaccination, disinfecting, culling, information campaigns and bans on live poultry in cities.

Hans Troedsson, the UN's World Health Organisation representative in Vietnam, said the plan was "technically sound" but could not be copied or used as a blueprint by every country.


Maybe not copied and pasted, Hans, but the WHO should definitely be looking with all due humility oat the facts of the Vietnamese case. Note especially that they stopped culling and started vaccinating, and they cut down on the poultry trade, which is now thought to be more of a risk for spread than wild bird migration. As an island, therefore, the UK could keep H5N1 Avian out if we stop bird imports.

Byt DEFRA is in charge, and DEFRA is short for DEaF to Reasoned Argument.

Preventing a Pandemic - in brief

I have just put this up on H5N1 - Wikipedia, the free encyclopedia
The probability of a "humanized" form of H5N1 Avian flu emerging through recombination in the body of a human co-infected with avian and seasonal influenza could be reduced by a programme of seasonal influenza vaccination of at-risk poultry workers. It is not clear at this point whether vaccine production could be stepped up sufficiently to meet this demand.

If an outbreak of pandemic flu does occur, its spread can be slowed by increasing hygiene in aircraft, and by examining airline cabin air filters for presence of H5N1 virus. Air transport out of infected areas must be reduced to the absolute minimum.

Social isolation is one of the most effective ways of limiting the spread of influenza in the local population. Although virus particles are shed in the 3 days before the patient becomes ill, it continues for a week or more once illness begins. The public should be taught that it is anti-social to go out of the house when ill. Frequent hand washing and the wearing of effective masks can also reduce transmission.

I find I have been advocating WHO policy

I have found that our proposal re vaccinating poultry workers with seasonal influenza in order to reduce the probability of recombination of H5N1 with human influenza is already WHO policy:


WHO global influenza preparedness plan:
The role of WHO and recommendations for
national measures before and during pandemics
WHO/CDS/CSR/GIP/2005.5


Countries with cases should:

... continue promoting vaccination with seasonal
influenza vaccine to limit risk of dual infection in
those most likely to be exposed to the animal
virus, and potentially decrease concurrent
circulation of human strains in the outbreak affected
area.
http://whqlibdoc.who.int/hq/2005/WHO_CDS_CSR_GIP_2005.5.pdf p27


So why is this not being done?

Poultry Worker Vaccination adopted by European Parliament

Press release from Caroline Lucas, Green MEP SE England:

EURO-MPs VOTE FOR MEASURES TO CONTROL BIRD ‘FLU
MEP WARNS: DON’T REPEAT FOOT AND MOUTH BLUNDERS OVER BIRD ‘FLU

THE European Parliament has voted to adopt a package of emergency measures prevent avian flu mutating and triggering an epidemic of human influenza in the EU.

MEPs have called on EU member states to co-operate on preparing for an avian flu outbreak, to share information and anti-viral drug supplies and to increase the level of ‘standard’ ’flu vaccination.

The Parliament also adopted Green proposals to offer all poultry farm workers standard ‘flu vaccines to reduce the risk of avian flu spreading to humans – but rejected calls for drug companies to relax patents on anti-viral drugs to allow production of generic alternatives in poorer countries, and systematic screening of air filters from flights originating in countries affected by the virus.

Green MEP Caroline Lucas said she was pleased the Parliament had accepted the Green proposal to offer ‘flu vaccines to all poultry workers, and to co-operate fully on planning and communication to avoid making the same mistakes as during the 2001 Foot And Mouth disease (FMD) outbreak.

“MEPs have today shown they are serious not only about trying to prevent an influenza pandemic but also about planning and communicating effectively to ensure the EU learns from the UK’s disastrous handling of the 2001 FMD epidemic.”

Dr Lucas, who was Vice-President of the European Parliament’s Committee of Inquiry into the UK’s handling of the FMD epidemic, added: “Millions of healthy animals were slaughtered needlessly and – some four five years later – many rural communities and farmers are yet to recover from the economic and psychological impact of the Government’s poor handling of FMD.

“The Government and EU must learn the lessons of recent history and make sure public health and the welfare of affected communities take precedence over market interests.”

She added that she was disappointed MEPs had rejected an amendment to call on the manufacturers of anti-viral drugs to allow the production of cheaper, generic alternatives in poorer countries and for the EU to provide greater support to developing countries affected by the virus.

She said: “I’m concerned that we are in danger of forgetting that the greatest risk for an influenza pandemic is from Asian countries, and that we should provide greater support for these countries – both because it’s in the EU’s own interests – but also, crucially, because it’s required in the interests of international solidarity.”


ENDS

Immunising Poultry Workers

BBC TV Points West news has reported tonight on my action as a General Practitioner who has just given his chicken farmer patient a shot of Influenza A vaccine.

I would like to explain the thinking behind my actions.

This will not stop my patients from getting Avian flu, but it will reduce the chance that this year's Influenza A virus will survive for long in their bodies. If Avian H5N1 virus should ever come to their farm, it is more unlikely that it would be able to combine with the human flu virus to produce the feared pandemic virus. To an infinitesimal degree therefore, my action has reduced the chance of a H5N1 pandemic. If this action were to be reproduced millions of times again in areas of high risk, it would give us a chance that the pandemic could be averted.

The Health Protection Agency has been reported as responding that my action was premature. I dispute this. It takes 10-14 days before protective antibody levels develop after vaccination. In the exceedingly unlikely event of a migrating bird infecting my patient's flock, vaccination would be too late.

It is absolutely true that poultry in the UK are not at risk of avian flu, at present. Our poultry farmers should be vaccinated at leisure, but the priority effort of immunisation should be targeted in South Asia, where experts agree the combination is most likely to occur. The UK Medical Research Council is flying experts to South Asia to boost flu surveillance programmes. It is good to monitor: but the medics should also be setting up vaccination programmes targeted on poultry workers.

I fully realise the logistical difficulties of vaccinating each and every last Chinese and South Asian chicken farmer, but it is well worth attempting.

I have today written to twenty vaccine manufacturers in the world to alert them to this possibility, and seek feedback on the feasibility of producing enough vaccine. I believe that the WHO could succeed in this project, given a major effort and adequate resources. The cost would be negligible compared with the astronomical cost and economic disruption caused by a pandemic of virulent influenza arising from a combination of Avian flu and common, seasonal Influenza A.

We do have time to do this. At present we know of only 120 people worldwide that have caught avian flu from their birds. As this number rises, so too does the probability of a new strain combining the virulence of avian flu and the infectivity of seasonal influenza: but it may need thousands of cases to produce a serious probability of this worrying combination.

The proposal is in line with WHO policy, which is to use influenza A vaccine widely, but the WHO has not yet gone the extra step of advising that poultry farmers and bird workers should be given front-line status. I have been writing to medical authorities including Dr David Nabarro, the WHO medical officer with responsibility for policy in meeting the challenge of the pandemic.

Pandemic flu is not inevitable. Given a major effort in immunising at-risk poultry workers, the probability of emergence can be reduced to a significant degree.

Avian Flu Proposals

I have put my avian flu proposals up on GreenHealth; they are
1 Prevent the emergence of pandemic flu by vaccinating poultry workers, starting in China and South Asia
2 Slow its spread via air travel by carrying out virological studies on airline cabin air filters.
3 Educating the public on self-isolation in the event of suffering any flu-like illness.

Campaigning Day

Have spent all day campaigning and lobbying on the Preventing Bird Flu question. Local virologist says yes, good idea, and no, there is no chance of the vaccine combining with H5N1 Avian by accident. Local Public Health Consultant says yes, sound idea, but they have to go with the protocols, and she will send me one. Email goes off to Prof Vivienne Nathanson at the BMA, trying to get them on board. Phone local chicken farmers trying to find a brave soul who is ready to go an TV having his arm vaccinated.

In between times write also to the UN special Representative to Somalia and the UK Representative at the UN asking what the we can do about Somalia (toughen the arms embargo, strengthen civil society, deny the warlords' freedom to travel).

Now it is Nicky's birthday party, so time to get off the keyboard.

The Human-Avian Flu Pandemic Can Be Averted

I have contacted my patients who are chicken farmers and offered them a regular influenza A vaccine - the one we offer annually to all over 65s, and those with chronic illnesses. This will not stop them from getting Avian flu, but it will greatly reduce the chance of it being in the bloodstream of my particular patients that the Avian flu combines with human flu to produce the feared pandemic.

If all chicken keepers in the UK were offered this service, the mutation would be most unlikely to occur in the UK. It might add perhaps 0.01% to the overall cost of the annual influenza vaccination effort. Compared to the cost of vaccinating the whole population of the UK against the H5N1 strain if and when it emerges, (which the Government proposes to do) the cost would be negligible. It is also easier than the alternative option of running chicken stocks down next spring.

If this policy were extended to chicken keepers throughout the world, the chance of the pandemic occurring at all might be averted.

Now for the job of trying to get a decision - maker to listen. Have sent to MP and Green Party media. WHO never answer emails. Try BMA next.

Quarantine that Virus

[apologies - this is a long one - 1119 words. Terrible stain on my claim to brevity. Worth serious study though. Could save your life.]

October 2005 – offices and public spaces are beginning to echo with the sound of coughing. Gp surgeries are beginning to silt up with people who seek advice, antibiotics and certificates for sore throats, coughs, and flu like illnesses. This will continue through the winter, culminating in the annual announcements of NHS overload due to the majestic annual global tour of the Influenza A virus. At the same time, public health physicians worldwide are pondering how to manage the global epidemic that would result if the H5N1 avian flu virus manages to mutate into a form that can pass from human to human. There minds are concentrated wonderfully by the knowledge that a particular variety of Influenza A killed 6 million people in 1918, and locked thousands more into a pathetic lifetime existence of Parkinsonian immobility. The risk of a global pandemic of this sort is always with us. This is not a cause for panic or scaremongering, but it should be a cause of careful consideration of how we respond to infectious diseases.
The SARS outbreak of 2002-3 gave us a foretaste of how we should respond. The success of the World Health Organisation. in dealing with SARS was due to not to high tech vaccines, but classic low tech quarantine and isolation measures. Doctors learned to isolate cases, to trace contacts and isolate them also. Many died, including many doctors, nurses and healthcare workers, but in the end it was successful. We should learn from that experience, and in particular should develop ways of limiting the spread of the virus through air travel. We should also develop strategies for responding to an epidemic should it break through our airports and other communication routes and become established in our country. This means that we must learn new measures for dealing with common conditions like influenza, so that when a serious outbreak occurs, isolation techniques will be familiar to us.
Isolation
People get infected by mixing with people who are already infected. Therefore, when we have an infectious viral illness we should put ourselves out of circulation. So far as is practicable, we should stay at home and rest. In particular, we should not try not to go to the shops, try not to go on public transport, and we should definitely not go to work.
There are sound theoretical reasons for resting a viral illness. I explain to my patients with flu-like illnesses that they feel tired and fatigued because their energy is being diverted to their defence system. They should therefore not try to divert blood away from their immune and back into their legs and brain by going to work. They should give their immune system a chance to do its job properly. This argument is effective, because the people who are most likely to carry on regardless tend to be conscientious perfectionists who set themselves high standards, and want to keep on going to work.
It is sometimes argued that much viral shedding occurs before the victims know they are infected. Quarantine cannot eliminate epidemics, because sometimes the infection is passed on by people who feel perfectly well. This is true, but not a reason to abandon isolation, since shedding certainly continues after symptoms appear, and isolation can therefore reduce the severity of the epidemic.
We have a triple line of defence against a global pandemic of the type which currently threatens us in the form of a H5N1 mutant: quarantine, vaccination and chemotherapy. All lines of defence must be used. The danger is that politicians will opt for vaccination and chemotherapy to the exclusion of isolation, because isolation involves much social inconvenience, and will be politically unpopular, unless it is correctly understood. It also runs counter to an ingrained management assumption that people should come to work when they are suffering viral illness, and that those who stay home are malingerers until proved otherwise.
Nevertheless, medical logic demands that the NHS and Health Protection Agency should lead a concerted “Stay Home if Ill” campaign to educate the population to recognise a flu-like upper respiratory tract infection, learn how to manage it at home without physically contacting a doctor, learn to stay home from work when ill, and learn to recognise symptoms that indicate complications that need treatment. They must start this campaign now, so that people are ready with the new strategy if a serious pandemic breaks out.
Not a Shirkers Charter
The key battle will be over changing the work ethos so that the default position is that an ill person should stay home, rather than struggle in to work.
All significant reforms will meet with resistance, and the key objection that the “Stay Home if Ill” initiative is likely to meet is that employers will argue that it will provide an inherently lazy workforce with a Shirker’s Charter. There are several answers to this assumption. We can look at the experience of other countries. In America, for instance some firms allow four days off a year, to be taken at a moment’s notice. They are called “duvet days”. Secondly, patients are often reluctant to stay off work because of the financial loss incurred, as well as the threat to job security. These factors will still counter any abuse of the system. Third, employers need to be educated about the workforce implications of dragging infected employees into work. Given the fact that most offices live on recycled, conditioned air, the products of one cough can be on every desk in the office within the hour. They should understand that an infected colleague cannot work efficiently, that an infected worker will be ill for longer than one who rests.
A sensible programme of health education could therefore overcome the objections from within commerce and industry, and indeed , bring them on side. The workers themselves will be happy to co-operate with the new scheme. Less incidence of viral illness, combined with less unnecessary consultations for viral infections will overcome the “winter pressures” that routinely overwhelm the NHS. This reform is one which could enjoy a rapid success. The country will gain improved productivity, and the NHS could gain a decreased workload, freeing up opportunities to improve the quality of medical care that we deliver. These are all immediate gains from this method: but the overriding gain is that it could vastly reduce the potential impact of the global epidemic that could result if the current avian flu virus does gain the ability to pass from human to human. And that could potentially save many thousands of lives in the UK alone.