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The events of the past two weeks reminds us that H5N1 is the virus that will not go quietly into that good night.

A quick trip around the globe reveals new human infections in Indonesia and Egypt, and further research shows us that suspected influenza infections in both nations are many times higher than the official reports of confirmed H5N1.  Whether these are just precautionary tests ordered by suspicious and diligent health care workers, or truly worrysome symptoms from possible victims, or both, the simple fact is that across much of Asia and the Middle East, people are scared.

But the biggest news of the past two weeks is undoubtedly coming from the Czech Republic and Germany.  Wild birds and poultry in the Czech Republic are testing positive for H5N1, and German swans are dying again.  Unfortunately, some of those swans are dying in a lake in the middle of downtown Nuremberg!  Leipzig city workers are also finding dead wild birds.

Scientists speculate that Germany may become a host nation for H5N1, if the disease is not already considered endemic to the region.  It is only a short flight from the locations of the two cases to points in the Czech republic and Hungary, which has also had its share of H5N1 in wild birds and poultry this year.

The takeaway from this latest series of incidents is the incredible pervasiveness of the Qinghai strain (clade 2.2) of H5N1.  In just two short years, from its discovery in the thousands of dead birds at Qinghai Lake in China this time in 2005 to the present day, Qinghai has moved west across Asia where it infects poultry and kills humans regularly, to the north and the suburbs of Moscow where it infects poultry, to the Middle East where it infects poultry and kills humans regularly,  to sub-Saharan Africa where it infects poultry and has killed humans in Nigeria, and now returns to Europe, where an outbreak in poultry in France, Germany, and other nations in 2006 was especially worrysome.  What an amazing travelogue.

This virus is not going away. It is stretching itself further west and south, and it defies efforts to contain and eliminate it. 

Two recent stories regarding Indonesia share a common theme.  That theme appears to be the growing concern within the Indonesian government that the H5N1 that has killed so many of their young people is gaining Tamiflu resistance. 

The standard protocol for treating H5N1 patients is the same as for regular flu:  Two capsules daily for at least five days, administered within 48 hours of the onset of symptoms.  That regimen is continued until the patient either recovers or dies.  The concern is that H5N1 may be evolving to circumvent Tamiflu the same way it has circumvented amantadine and rimantadine, two M2 inhibitors (M2 is the surface protein of influenza A). 

Taking no chances, the Indonesian government is racing to create its own H5N1 vaccine, in partnership with US company Baxter.  Indonesia's stark change in attitude last January, to force the world community to earmark the first prepandemic and pandemic H5N1 vaccines for the island nation, therefore, comes more clearly into focus.  It would appear that the Indonesian leaders may have known of this change in sensitivity to Tamiflu and could see far enough down the road to know it needed vaccine NOW, rather than later -- and needed it based on its homegrown H5N1, not some other formulation.

The Indonesian health minister disputes the Australian claim of Tamiflu resistance.  Of course they will, because they do not yet have the vaccine, and they certainly do not want to shut off their access to the drug.  But actions speak louder than words.  The Indonesian diplomatic health crisis, therefore, appears to be less posturing and more of a desperate attempt to resolve a growing crisis within the country.

Taken in the larger context -- the activation of the Indonesian army to help with mass culls of poultry, the house-to-house sweep in Jakarta and other cities to test housecats, the reference to the Karo cluster of May, 2006 -- all of these actions speak much louder than words of reassurance that Tamiflu continues to be effective.

JAKARTA, June 22 (Reuters) - A vaccine to combat human bird flu could be ready as early as July, Indonesia said on Friday, adding it was prepared to use it immediately despite calls from the WHO to build up a stockpile first. Health Minister Siti Fadillah Supari said the World Health Organisation's advice was not realistic in the case of Indonesia, which has the highest number of bird flu deaths.  Read the full story at: www.alertnet.org/thenews/newsdesk/JAK138707.htm

Indonesian bird flu Tamiflu resistant

... and the world's "best practice" for bird flu eradication moves back three spaces.

The second death from H5N1 in Vietnam in the past ten days underscores the incredible difficulties in containing the H5N1 virus.  It was just this past November when President George W. Bush toured the Pasteur bird flu research facility in Ho Chi Minh City, and the WHO held Vietnam up as the best example of a nation's ability to eradicate bird flu.

Now, just a few months later and despite all the best practices Vietnam can perform, bird flu is back with a vengeance.  Several provinces are overrun with the virus in poultry, and now two people are dead -- the first and second deaths in over a year.

Vietnam is not necessarily to blame.  And we all agree that it is one heckuva lot easier to contain a virus in a totalitarian state than a democratic one!  But first: Vietnam has no control over its own borders (sound familiar?).  H5N1 has come across the border with China time and again, making a mockery of well-intentioned Vietnamese efforts at containment and eradication.  This is due to the smuggling of poultry INTO Vietnam, from China.  Chicken farmers found it was cheaper to smuggle poultry (photo at left) than to pay higher prices.  Market forces brought H5N1 back into Vietnam. 

Second, H5N1 is tough and stubborn.  These are important words when describing influenza.  As I explain it, flu plays "King of the Mountain."  The stronger strains survive, the weaker ones disappear or go to ground.  A perfect example is H2N2, the source of the 1957 pandemic.  It appeared, and H1N1 disappeared.  H3N2 appeared, and H2N2 disappeared. It was only since 1977 that two strains of influenza A (H3N2 and H1N1) have been able to coexist -- and that, at least explained via the rumour mill, was because of a Soviet mistake in a research lab.

There is no H2N2 anywhere in the world, except on ice in various research labs (remember the scare when H2N2 was sent out with a flu detection kit last year?) and in the belly of some birds somewhere.  Now, the theory that all pandemic viruses are "recycled" would hold that one day, H2N2 would reemerge.  But that is fodder for another blog.  Tests will tell us if the H5N1 that killed the two victims is the same strain as what has always been there (known as Clade 1), a different existing strain (Clade 2.3, also called Fujian, recently identified by Dr. Robert Webster and others and whose existence was denied by Chinese authorities), or a totally new clade that might have emerged via recombining with itself. 

But it allows us to draw several unsettling conclusions.  They are:

1.  H5N1 is nowhere near going away.  In fact, despite the fact surveillance has gotten magnitudes better in the past eighteen months, the virus continues to spread.

2.  H5N1 is one tough SOB.  It refuses to play king of the mountain.  It IS the mountain.

3.  However the virus is getting around, be it via migratory wildfowl, smuggling, current poultry factory practices or all of the above, it continues to spread and all attempts to beat it back fail eventually.

4.  We must keep beating it back, as a delaying tactic if for no other reason, to forestall the next pandemic. 

5.  Does Dr. Margaret Chan get ANY credit for delaying the pandemic back when she was Hong Kong health officer in 1997?  She may have single-handedly saved the planet with her decisive actions in the first outbreak of H5N1, ten years ago.  That is precisely why the WHO made her its head after the unfortunate and sudden death of the Korean guy.  I thought I would throw that one in as a shout-out to Dr. Chan.

From the ZImbabwean press:

Hanoi - A 28-year-old woman has died of bird flu in Vietnam, the second person there to succumb to the deadly H5N1 strain in just 10 days, after one-and-a-half years with no deaths, an official said on Thursday.

She died on Wednesday two weeks after being admitted to a Hanoi hospital that specialises in tropical diseases, said Nguyen Tran Hien, director of the state-run National Institute of Hygiene and Epidemiology.

Her death brings to 44 the number of people who have died of bird flu in Vietnam. Last weekend authorities reported the death of a 20-year-old man, who was the first fatality to be announced since November 2005.

Since last month, five human cases of bird flu have been reported in Vietnam, two of whom have died. Two others who had contracted the virus have already been released from hospital.

Communist Vietnam, once the nation worst hit by avian influenza, contained earlier outbreaks through mass vaccination campaigns, the culling of millions of poultry, and public education campaigns.

But the virus has come back strongly this year, hitting scores of poultry farms in an unusual summer-time outbreak.

Read the full article:  http://www.iol.co.za/index.php?set_id=1&click_id=143&art_id=nw20070621152503650C807795

And I nominate Admiral John Agwunobi.

Folks,

In July,1998, I was sitting in my office at the Republican Party of Florida when Jeb Bush's head appeared in the doorway -- followed by the rest of him, of course.  I had known Jeb since 1983, when I was one of the "dirty dozen" who conspired in Miami to get him started on his path to elected office .

Jeb said, "Scooter, what's Y2K?"  (Scooter is his nickname for me.)  I said I would give him a full briefing.  This was when he was running for governor again (this time successfully), and people were emailing him with concern about the Year 2000 issue.  I gave him regular reports on where Florida was vulnerable, using my syndicated weekly newspaper column as cover to get the information I needed.  In January, 1999, a week after he took office, Governor Bush commissioned me to set up a statewide Y2K awareness and preparedness effort, called Team Florida 2000.  It was a national model and was held up by Clinton's Y2K czar, John Koskinen, as a shining example of a partnership between government, the private sector and the service sectors.

I became Jeb's Y2K "czar," although he is loathe to use that term (using "czarina" instead).  I had the entire resources and gravitas of the governor at my disposal.  I had more money than time, so I tried to "buy time" whenever and wherever possible, including making heavy use of State aircraft (bumping Bobby Bowden occasionally!). 

The effort was incredibly successful.  The effort was "componentized," meaning sections of it were designed to be leveraged outside of Y2K.  And indeed two areas were heavily leveraged afterward; first, the Office of Information Security, which I built in early 2001; and the entire critical infrastructure monitoring effort, which we built to mitigate Y2K disruptions, but was made permanent the morning of 9/11.  So Y2K was, and is, a huge success, from many standpoints.

One of my favorite agency heads who I worked with closely during my tenure with Governor Bush was then-Department of Health Secretary, Dr. John Agwunobi.  John is, of course, now Admiral Agnuwobi, and he serves the people as Assistant Secretary for Health, U.S. Department of Health and Human Services.  John is a blogger on the HHS Pandemic Flu Blogsite, and I wanted to publish my response to his latest blog so you can read it here, as well as (hopefully) at http://blog.pandemicflu.gov/.

John,
We have known each other for some time, and we worked together during post-9/11 efforts for the Jebster. I am so very proud of the job you are doing in Washington, and I know you are a man of deep commitment and absolute professionalism. You are one of the “good guys.”

Please remind Secretary Leavitt that Y2K was a non-event because we planned and executed the largest successful IT project in the state’s/nation’s/world’s history. He has a tendency to speak of Y2K in disparaging terms. We “worked the problem” and solved the issues that I guarantee were NOT “non-issues”, had they been left unremediated.

Let me draw another parallel, to the effort we are involved in here in Florida. Having watched the pandemic preparedness situation for the past sixteen months, and having established relationships with some of the giants of the public health/policy and influenza sectors (Osterholm, Webby, Fineberg, et al), I am absolutely convinced that we are in dire need of a “pandemic czar.” We need someone who can address both the public health and economic/security calamities that will almost certainly occur if we experience a pandemic of any significant lethality in the near future. And that person needs the resources of the White House to be effective.

HHS is doing its job, but I do not see evidence at the local level that DHS is shaking the trees violently enough to force local domestic security committees to action. I speak nationally on the subject of pandemic preparedness and have probably given upwards of fifty speeches at state and national conferences in the past year. But I have given only two presentations at the direct request of law enforcement (Infragard chapters in Tallahassee, FL and Springfield, Illinois).

A pandemic is not just a public health event. The homeland security. public safety, supply chain and long-term economic ramifications both dwarf and substantially magnify the impact of a pandemic.

We cannot reasonably expect HHS to do it all. Someone in the White House needs to coordinate the total awareness and response efforts.

I hope we get the opportunity to see each other soon. Everyone in Tally says hello!

With a hat-tip to my friend and blogging veteran Michael Coston of Avian Flu Diary, who found this article and placed it on his excellent Blogsite.  The good news within the bad news is that we are getting anything remotely resembling good, defensible data from the Indonesian authorities, whose improvement in locating, diagnosing and ultimately dispensing of H5N1 in poultry is visible to all.

The bad news is that the disease is so endemic there.  Almost every province has H5N1 in poultry or humans or both.  Recent revelations from Indonesian authorities regarding asymptomatic (that's "no symptoms" to you and me), yet positive H5N1-infected poultry, and the disclosure that upwards of 20% of all wild cats in the island archipelago have H5N1 antibodies shows why this country is such a potential time bomb for a pandemic..

http://www.antara.co.id/en/arc/2007/6/20/tens-of-thousands-of-poultry-die-of-ai-in-e-kalimantan/

While you're at it, visit Michael "FLA_MEDIC" Coston's participation on the HHS Pandemic Flu leadership Blog at http://blog.pandemicflu.gov/?page_id=11 .