Scott McPherson's Web Presence

This week has marked an escalation of sorts -- not regarding bird flu, but regarding the emergence of stories on bird flu, some of them second-guessing whether or not there will ever be a bird flu pandemic.  From blogger Orange and the site The Coming Influenza Pandemic?,  a link to the Cosmos story asking loudly if everyone overdid it when H5N1 was on everyone's lips from 2004 to 2006.  Orange also links to a Nature story via Effect Measure, written by the veteran Nature bird flu journalist Declan Butler.  Effect Measure's thoughtful analysis is here.

Allow me to weigh in on this topic.

Science has only recently been able to peek into the fascinating genetic makeup of influenza viruses.  The ability of scientists to unwrap and decode the actual genetic code of this viral killer has been prodigious over the past three or four years.  We all know the statements that knowledge will double every so many years, based on the accumulation of new knowledge and the ability of the Internet to make that knowledge available to yet even more scientists.

The one thing we cannot do except in very rare, Hultin-Taubenberg -esque circumstances, is to reconcile history with science.  On this score, we are as much in the dark as we have ever been.

Here's what I mean:  From an epizootic standpoint, our real, hardcore, boots-on-the-ground knowledge of past pandemic incubation is very, very limited.  We just don't have the data.  We still don't know how exactly how the 1918 Spanish Flu pandemic really started, although the evidence now points to Kansas, and not China, as the point of insertion.  Or maybe both:  Science is still debating whether or not Hope-Simpson's theory of a kind of viral spontaneous worldwide reveal is what actually happens.  Researching centuries-old historical accounts of viral activity flaring up pretty much simultaneously aboard ships at sea for weeks, all over the globe, simply does not match up with what science has uncovered about the virus thus far.

Want further proof?  Where is the thoughtful, detailed historical analysis of the 1957 Asian Flu pandemic?  It was not the killer 1918 was, but it nonetheless wrought economic calamity and did kill between one and two million people globally. Yet we know virtually nothing about where it came from, or what the spark was that sent the virus on its way across the planet.  We don't know how long it incubated, or where it made the species jump.  We can only guess.

So we think we know how the influenza virus evolves.  But we are far from certain about how it can do this within a limited time frame in various places, all at the same time.

Likewise, we do not know how long it takes for a virus to evolve to the point where it can make a major species jump.  Dr. Mike Osterholm recently made a huge point when he spoke of equine influenza.  Dr. Osterholm reminds us that it took forty years -- forty years! -- for equine influenza to make the species jump and show up in dogs in Florida.  That's forty years from when H3N8 was first typed.  Who knows how long it really took?  And it apparently accomplished this species jump without any major structural change in the virus' genetic footprint, according to a recent study I read.

So how did H3N8 equine influenza jump to, and kill, dogs in Florida and elsewhere without sacrificing a major change in its viral DNA?  Science has no answer.

Naysayers and critics point to the noticeable drop in the number of human deaths from H5N1.  And we all can certainly say that this is both welcome and unexpected news.  Surely we can chalk this up to better coordination, a Return on Investment of American and WHO dollars toward education of agrarian populations, poultry culling and other eradication efforts, and possibly (and I think in a very minor way) rudimentary poultry vaccination efforts.

For example: The minute India began experiencing its worst and massive H5N1 infestation in poultry last year, I said "Game over!" and refreshed my personal inventories of stuff.  I was more than surprised at the subsequent and apparent lack of human victims of H5N1 among cullers. I was downright shocked that a major outbreak of human H5N1 did not occur.  This prompted me to blog my speculation that Qinghai H5N1, as it exists today, might not be the pandemic strain after all, and wrote that the Fujian clade should get more attention.

We need to think more like the virus thinks and respect its patience.  H5N1 is now endemic in many areas and regions of the world.  Things may be calm now, but they can change with one day's notice.

As the Reveres did, let's turn to the topic of pandemic planning.  I believe we are worse off now than we were two years ago.  Why?  First, because pandemic fatigue has hit everyone, especially in the private sector.   Not to toot my own horn, but I am considered an expert in pandemic planning, and I am one of less than a handful of global IT pandemic planning experts.  I used to get several calls a day to lecture on panflu from all over the world.  

I have not gotten a call to do a bird flu lecture in months. 

Second, everyone has less money to devote toward pandemic preparedness.  Governments are broke all over the nation, and anyone who thinks things in the economy will be getting better anytime soon is living in a fool's paradise.  So no government has the money to buy antivirals, masks, hand sanitizer or anything else helpful.  This probably is why Roche decided to change its strategy with Tamiflu and sell it directly to businesses and corporations.  They realized governments were no longer able to spend taxpayer money on antivirals, and needed to change their business model to move product languishing in warehouses all over the planet.  Or to "lease" product, based on the releases I have read.  Kind of like buying gold stocks as a hedge against inflation.  Corporations would "reserve" their right to get Tamiflu in exchange for Roche warehousing the drugs and distributing them at a different pricepoint if the excrement hit the fan.

Likewise, knowledge will be much harder to impart.  Many governments have laid off their training departments or have made major cuts in personnel.  The focus of training will turn toward events that must be planned for, such as hurricane preparedness and the mitigation of other risks.  People in the Midwest, especially along the Mississippi River, have much more important things to attend to than pandemic planning.  And their real-time, immediate health care needs more closely resemble the health care needs of Indonesia than they do Indiana. 

Viruses have a tendency to kick humanity when it is down.  Bird flu has already deprived millions and millions of people worldwide of a primary and essential protein source.  The madness that is ethanol production from corn has raised food prices to an unconscionable level worldwide.  The combined loss of poultry to H5N1 eradication efforts, coupled with the increase in the price of everything, will reduce the quality of life for many poor nations and their residents.   Sick people get sicker; the pace accelerates.  This puts heavy pressure on the world's "haves" to help resupply starving people and offer compensation for culled birds, as well as putting enormous pressure on poor farmers to cover up their diseased flocks and keep their mouths shut if they don't get compensation.

Peering into this malestrom of uncertainty, protein deprivation, starvation, economic and political instability sits the H5N1 virus, along with many, many other "emerging" diseases.  Aided by these factors and the globalization and "flattening" of everything, these diseases bide their time, enduring setbacks here and advances there.  As Dr. Henry Niman says, H5N1 does not read press releases.  Nor does it read scientific journals.  And if it decides it will not be the next pandemic strain, another virus will come along to take its place.

When, where, and how severe will never be known to us.  We can only do what we can to prepare in this brave new world of ours.

In one 24-hour period, three people have died in Turkey from tick bites.  Apparently, these people self-removed argasid or ixodid ticks that were infected with a disease known as CCHF, or Crimean-Congo Hemorrhagic Fever.  This is based on proMED reports from the region.

According to the WHO, the viral disease CCHF was first discovered in 1944 in the Crimean Peninsula and named appropriately.  But in 1956, it was found that the source of the virus was a germ traced back to the Congo, which as we all know is a hotbed of one sort of hemorrhagic fever or another.  So the virus was renamed Crimean-Congo Hemorrhagic Fever.

From outbreaks in 2001 and 2003 in Mauritania and Kosovo to 2006's outbreaks in Turkey, the disease continues to expand its footprint.  Anyway, because of warmer-than-usual temperatures in the region that includes the border between Turkey and Greece, there have been many recent cases of CCHF. 

Here are the symptoms, according to the CDC:

The onset of CCHF is sudden, with initial signs and symptoms including headache, high fever, back pain, joint pain, stomach pain, and vomiting. Red eyes, a flushed face, a red throat, and petechiae (red spots) on the palate are common. Symptoms may also include jaundice, and in severe cases, changes in mood and sensory perception. As the illness progresses, large areas of severe bruising, severe nosebleeds, and uncontrolled bleeding at injection sites can be seen, beginning on about the fourth day of illness and lasting for about two weeks. 

In documented outbreaks of CCHF, fatality rates in hospitalized patients have ranged from 9% to as high as 50%.

Nasty stuff.  While currently limited to remote areas along the border between the two nations, a total of 2 cases with one fatality are currently reported in Greece, and more than 550 cases are currently reported in Turkey, with 37 deaths, including the three from Monday.

This serves as a stark reminder that while H5N1 has apparently gone underground from the moment, there are more than enough emerging diseases to keep surveillance crews busy.

And in our globalized world, a disease with a slow incubation period (such as CCHF, where it can stretch from one to nine days, according to the WHO) can mean trouble anywhere.

As you know all too well, I have not been blogging much on avian flu lately.  there are several reasons, the top three being the relative lack of news on the H5N1 front; the ability of my blogging colleagues to report on these in a timely and professional manner, rendering my posts on the same topics nothing more than redundant; and my focus on my "day job" as CIO for a Florida agency.

And let me assure you I am working on a very long and important series of flublogs. 

But occasionally things happen that just make me so mad, I have to speak out.  And so today, I am calling on the US Navy, the CDC and the WHO to get NAMRU-2 the Hell out of a clearly ungrateful Indonesia and get it to some place that welcomes it.  Like, ironically, Vietnam.  Or Australia, which would probably be easier to get samples to anyway. 

There is little doubt that Indonesia is politically sliding the way of pain-in-the-neck nations such as Iran, North Korea and Venezuela.  Now I know that the United States is a ripe target for ridicule.  We have done things around the world that the average American is not proud of.  But I am sick and tired of America being kicked in the groin by nations that we are trying to help.  From a health perspective, the nation doing most of the kicking these days is Indonesia. 

People have posted replies to my earlier blogs regarding Indonesia, asking me to be patient and to understand that if the US pulls out of any medical support for Indonesia, it will harm the Indonesian people.

Those pleas need to be vectored toward the real source of potential hardship:  The Indonesian government.  They are the ones harming their own people, and the United States cannot and should not be held responsible for what other nations deliberately do to their own people. 

Back to the title of the blog.  It is time to close the doors on NAMRU-2, and to relocate it somewhere else.  It is time to bring closure to this whole sad story.  Put NAMRU where it is appreciated, not condemned by some paranoid schizophrenic regime. 

Speaking of paranoid schizophrenic regimes: Last night, I watched the film The Last King of Scotland, and was mesmerized by the Oscar-winning performance of Forest Whitaker as Idi Amin.  Today, as I write this blog, I am haunted by that film.   How a charismatic person could lead a nation to ruin and mass death is so sad.  And we see several other nations and entire regions of the planet where government madness, fueled by anti-Western sentiment, is destabilizing this planet.  Supari and the Indonesian government overall would be wise to remember that the West wants to help, but its patience is not infinite, nor should it be. 

There was good news contained within the bad news coming from Indonesia this week.  The good news was that Indonesia will, indeed, continue to report bird flu deaths within some sort of usable timeframe.  As you recall, the Health Ministry had decided not to publish bird flu deaths within helpful timeframes but, instead, to roll up the death tolls and announce them on some sort of months-long schedule.

While I am not ready to call this week's announcements a reversal, it is welcome news and hopefully will eventually be proven to be a reversal of a disastrous policy.

The bad news, of course, was the announced new death toll, and in particular the deaths of two women.  The Health Ministry confirmed what we already suspected was an H5N1-related death -- a 16-year-old girl from South Jakarta  -- who was confirmed dead of H5N1 on May 14.  the second death was a 34-year-old woman from Banten province, who was pronounced dead on June 3.

The virus continues to strike lethally at younger persons, and women continue to be especially hard-hit.

The next story also confirms our deepening concern about the status of things in the archipelago nation of 18,000 islands.  A Reuters story of today validates/vindicates our belief that H5N1 is frequently and dangerously diagnosed as something other than flu.  Thus, we can assume rationally that the actual infection rates from H5N1 are many times higher than what has been reported.  Here's the story:

Bird flu mistaken as dengue and typhoid in Indonesia

Fri Jun 20, 2008 2:11pm IST

By Tan Ee Lyn

KUALA LUMPUR (Reuters) - Some cases of human bird flu in Indonesia have been variously misdiagnosed as dengue fever and typhoid, resulting in the late administration of drugs, a leading doctor in the country said on Friday.

Indonesia has had the highest number of human H5N1 cases in the world and while mortality rates are around 60 percent in other places, the figure is highest, or at 81 percent, in Indonesia.

Sardikin Giriputro, director of the Sulianti Saroso Infectious Disease Hospital in Indonesia, told an infectious disease conference in Kuala Lumpur that misdiagnoses and the late administration of drugs were partially responsible for the high mortality rates.

"It (H5N1) is misdiagnosed initially as dengue, bacterial pneumonia, typhoid and upper respiratory tract infection because of similar clinical features (symptoms)," Giriputro said.

Indonesia has had 135 confirmed human H5N1 cases from late 2003 to May 2008 and 110 resulted in deaths. The country reported two more confirmed cases this week, but these were not reflected in Giriputro's figures.

Oseltamivir, otherwise known by its brand Tamiflu, is considered the drug of choice against bird flu and Giriputro said fatalities mounted the later the drug was administered.

The survival rate was very high when Tamiflu was given less than 2 days after the onset of symptoms, but that plunged the later the drug was given.

"It's best if given less than 24 or 36 hours after the onset of symptoms," he told Reuters later.

While rapid test kits are now used to diagnose the disease in animals, Giriputro said these tools were much less reliable in people.

"It depends on the viral load (in samples taken from patients)," he said, adding that test results could turn out negative even if the person was infected with H5N1, simply because there was not enough virus in samples taken. (bold mine)

In a bid to reduce the death rate, the Indonesian government has begun distributing Tamiflu to health centers in areas where H5N1 cases have occurred.

"When doctors see influenza-like illnesses and where there is evidence of contact with sick poultry, then they give Tamiflu (without waiting for laboratory results)," Giriputro said.

© Thomson Reuters 2008. All rights reserved. Users may download and print extracts of content from this website for their own personal and non-commercial use only.

http://in.reuters.com/article/health/idINKLR31511520080620?pageNumber=2&virtualBrandChannel=0

Dr. Henry Niman and others have warned for years that the hasty administration of Tamiflu without first taking necessary samples causes false negatives and hinders accurate reporting of human H5N1 cases.  This new report from the Boots On The Ground confirms this in a decisive and final way.  It lessens the viral load and allows H5N1 to "fall under the radar" of reporting.  Likewise, Dr. Giriputro has also declared -- on and for the record -- that quick test kits are unreliable for use as the "last word" on whether or not H5N1 is present in someone.

So what can we deduce from all this? 

First, there are many, many, many more unreported cases of human H5N1 than we see in the press.  This may be a "DUH" to us, but it is important to see this in the global media.  And it is equally important that we are vindicated in that venue as well.

Second, we are unable to get some important viral changes mapped, because these people are getting Tamiflu and testing negative.  that may be good in terms of living, which is always nice, but it does mean that any genetic changes in the virus from these people are going undetected. 

Third, Indonesia is a human incubator of H5N1, and we must continue to monitor the situation there 24/7/365, preferably with the full assistance of the Indonesian government.

Screw it.

I am going to tell it like it is, and never look back.

The Indonesian government's self-inflicted death wish has reached intolerable proportions.  The most recent disclosure from Indonesian Health Minister and Court Jester, Siti Fadillah Supari, means Indonesia has reached the Tipping Point between political recklessness and geopolitical suicide.  Or maybe future homicide.

For those unfamiliar with recent developments:  Indonesia has announced it will no longer report bird flu deaths as they happen.  Instead, they will roll up the data and grace the rest of the world with reports every six months or so, or whenever the muse strikes them, or when a goat is slaughtered and the entrails are spread over the government's fax machines and computers.

This means Iran -- Iran! -- is more transparent than Indonesia.  It means China is more transparent.  It means Hell has frozen over.  It also means that for the rest of us, we will not know that an epidemic has started there until it is probably too late to do anything except batten down the hatches and pray.

It has gotten to the point that an ad hoc union of flu bloggers is trying to take more decisive action to bring someone -- anyone -- in the Indonesian government to his or her senses and stop this Supari woman before she dooms not just her nation, but the entire world, to disease and death.  Supari couldn't be jeopardizing the world's health any worse than if she bottled up a few sick people from Tangerang and flew them to Los Angeles.

So here are a few random ideas.  I appeal to my colleagues to use their resources to see if we can accomplish a few things and to add to this list within their own blogsites. 

1. First, let's have somebody ask John McCain and Barack Obama to sign a joint letter to the Indonesian president, expressing their regret and indignation at the government's policies.  If Indonesia knows that both presidential candidates will not stand for this Tomfoolery, and it is a bipartisan effort, it has to count for something. 
2. Second, let's start having some serious travel advisories about any travel to Indonesia.  The US, Britain, Australia (especially Australia, since Bali is to Australia what Disney World is to America) and other nations can all issue joint travel warnings, discouraging people from any travel to Indonesia.
3. Third, let's contact our local Congressman or -woman and Senator, asking them to write the White House and hammer for decisive action.  It is surprising just how few letters it takes to activate a slumbering Congressperson.
4. Fourth, and also within those letters, let's press for UN action against Indonesia.  A nicely-worded UN resolution should do the trick. 
5. Fifth, pull NAMRU the Hell out of Jakarta and put it where it is wanted.  Someplace like Vietnam or Thailand or South Korea would be just great.
6. Sixth, pressure American-led corporations to cancel all Indonesian conferences, including Bali.  Ask everyone to refuse to attend any multinational or multigovernmental conference that is booked in Bali or Jakarta.
7. Seventh, ask the WHO to begin applying the pandemic threat level to individual nations.  I have frequently called upon the WHO to raise the pandemic threat level from Phase Three to Phase Four.  Let's rethink this and take a Homeland Security approach to things.  As DHS applies the terrorism threat level to sectors such as the aviation sector, let's apply a Phase Four warning to Indonesia.
8. Eighth, let's do everything possible to empower doctors, scientists, researchers, reporters and bloggers to get the real story out of there.  Maybe we need a Bloggers Corps to go into Indonesia and teach bloggers how to post their stories and blogs anonymously and without detection by government censors.
9. Ninth, let's hope we have Boots on the Ground, James Bonds armed with Q-Tips and vials, ready to covertly swab the epithelial cells of suspected bird flu patients, and spirit the samples out of Indonesia via submarine.
10. Tenth, pull all US-bought antivirals out of the country.  Today. Save the Tamiflu for our own people.  After all, if the Indonesian government is willing to play Russian Roulette with a loaded gun regarding the health of the entire world's population, they obviously don't care one whit for the safety of their own people.

I am out of ideas.  Let's hear from you!