Scott McPherson's Web Presence

A few weeks ago, the trade publication Computerworld asked me to start blogging on their Website.  I blog over there for IT professionals who get the print magazine as well as those who surf the Website, and I focus mainly on IT and disaster recovery matters.  In fact, it was my frequent quotes regarding IT pandemic planning that got me the gig over there, although there is no compensation and there is a considerable draw on my time.

I wanted to vector you to that blog, titled "For hurricanes and pandemics, plan one category higher".  Just click on the link. 

I was daydreaming a bit this morning during a Gartner Group conference call on pandemic planning.  The speaker, Ken McGee, a VP of Gartner, was doing his usual excellent job of covering the situation. 

As I allowed my mind to wander, I came up with a metaphor for those of us whose mission it is to try and convince large numbers of people daily that a pandemic may be imminent.  I visualized a large symphony orchestra preparing to play something long and dramatic.  Perhaps an opera, or a Mahler symphony.  We'll use the opera comparison, as people may not be familiar with Mahler's symphonies, some of which required the construction of moveable sound baffles and entire rooms for extra musicians.  Besides, some of those had five movements, which destroys my metaphor.

But enough of Mahler.  Back to the metaphor.  Think of a pandemic as a kind of opera.  For our purposes, we'll call it an Opera in Three Acts, like Tosca or The Barber of Seville.  First, the orchestra shows up, begins to dress, grabs its instruments and occupies the stage.  This, collectively, comprises Phases One, Two and Three of the World Health Organization's numerically color-coded system deliniating where the world sits in regards to a pandemic.

During the end of Phase Three, the orchestra begins tuning its instruments and limbering up for the events that follow.  There is a delightful cacaphony of different strings, winds and brass, all playing their own little tunes, while the musucians are trying to adjust their instruments for humidity, temperature and environment.  This sound begins to build, and build, and build, until the conductor taps his baton on the music stand and the hall suddenly hushes. 

I believe we are at that exact moment with H5N1.  The room is hushed.  The orchestra is prepared and ready for what happens next.

What happens next, of course, is the Overture.  This is short and introduces us to the themes we will encounter during the opera itself.  What follows is the Opera in all its glory, usually spoken in foreign languages we wish we knew better (or knew at all), but the theme is universal:  Pain, suffering, heartbreak and usually, death. 

I cannot escape the feeling that the World Health Organization and the H5N1 virus itself may be preparing us for the Overture.  Look at the events of just the past week:  First, the WHO tells us that testing confirms the extreme likelihood of human-to-human (to human) transmission of H5N1 among four brothers last October and November in Pakistan.  If you look again at the onset dates, that conclusion was anectodal but strong.  Now it is confirmed.  And without saying specifically what changes (if any) in the virus itself may have occurred, the WHO speaks resoundingly about H2H in Pakistan, while revealing the confirmation of two other cases of H5N1 that had previously been undisclosed.  Give the WHO props for transparency but one demerit for tardiness.

Now, just today, the Chinese have come forward with conclusive evidence that the infection of a 24-year old Chinese man last November/December and the subsequent infection of the man's father was, indeed, another case of H2H.  As you might recall from my blog, Cones, umbrellas, Chinese fathers, and H2H, the Chinese were ready to explain the second infection as anything from both being exposed to common bird poop to the father chewing on the son's clothing while in hospital.  Here was a quote from a Chinese official:

Chinese health ministry spokesman Mao Qunan said Lu's infection was due to close contact with his son, but that the transmission was not technically "human-to-human".

"It has no biological features for human-to-human transmission," he told journalists.

Wrong!  Here is the Reuters story from today:

Chinese son likely gave bird flu to father: report

Mon Apr 7, 2008 6:32pm EDT

By Maggie Fox, Health and Science Editor

WASHINGTON (Reuters) - A 24-year-old Chinese man who died of bird flu in December passed the virus directly to his father in a rare case of human-to-human transmission of the virus, doctors reported on Monday.

Chinese officials had already said they believed the younger man infected his 52-year-old father, who survived, but genetic sequencing and other checks confirmed this was likely, the researchers said.

"In this family cluster of confirmed cases of infection with highly pathogenic avian influenza A (H5N1) virus in mainland China, we believe that the index case transmitted H5N1 virus to his father while his father cared for him in the hospital," they wrote in the Lancet medical journal.

H5N1 avian influenza is regularly breaking out in birds across Asia, the Middle East, Africa and Europe. It only rarely infects humans but has killed 238 out of 376 people known to have been infected since 2003.

Most have been directly infected by a sick bird, but in a few rare cases, one person appears to have infected another. These have been documented in Indonesia and, just last month, between two brothers in Pakistan.

Most have been among people who are genetically related and this also appears to be the case with the two Chinese men, the researchers said. Some experts believe there may be a genetic susceptibility to H5N1 infection.

The fear is that the virus will acquire changes that allow it to be passed from one person to another more easily. This could cause a pandemic that could kill tens of millions of people globally, so experts are carefully studying every case of transmission.

Yu Wang of the Chinese Centre for Disease Control and Prevention in Beijing and colleagues investigated the cases of the man and his son, who were diagnosed within a week of each other in December 2007 in Jiangsu Province.

They also tested 91 people the two men had come into close contact with. None of these people became infected.

The young man had a high fever, cough and watery diarrhea and his father nursed him intensively in the hospital.

The younger man died but his father got the flu drugs Tamiflu and rimantadine as well as serum from a woman inoculated with an experimental H5N1 vaccine and recovered.

"With the exception of occasional infection in health workers, all published incidents of possible or probable person-to-person transmission report transmission between genetically related individuals," Nguyen Tran Hien of Vietnam's National Institute of Hygiene and Epidemiology in Hanoi, and colleagues wrote in a commentary.

"Although this finding could be related to the intensity and intimacy of contact between family members, host genetic factors might also play a part in susceptibility to H5N1," they added. So anyone in close, prolonged contact with an H5N1 victim should get flu drugs just in case, they said.

Last week the World Health Organization said some human-to-human spread likely occurred when three brothers in Pakistan became infected with H5N1 last year.

The largest known cluster of human bird flu cases occurred in May 2006 in Indonesia when at least 7 family members died.

(Editing by Philip Barbara)

Interesting that the Chinese protocol entails the use of an M2 inhibitor, Rimantadine, in the course of treatment.  Also interesting that the Chinese experimented with the same serum that is now the basis for their new H5N1 trivalent vaccine, which I reported on yesterday.  Nice of the dad to "volunteer." 

The use of Rimantadine causes me to speculate the infection was Fujian, the strain Dr. Robert Webster and others discovered a couple of years ago.  I will rely upon others to correct me via comments if I am wrong.  The use of M2 inhibitors was pretty much rendered useless awhile back via the Chinese use of amantadine in the poultry vaccine for H5N1.  The virus mutated its way around amantadine as if it were an antiviral Maginot Line, and rendered the use of M2 inhibitors pretty much moot.

Perhaps Fujian H5N1 puts M2 inhibitors back into play. 

Someone out there, a poster on Flu Wiki or Flutrackers, is counting the number of suspected human clusters of H5N1,   I have lost count of the sheer number of human clusters that have occurred since 2003.  But I am betting that we are seeing a marked increase in these clusters.  

So the conductor is set at the podium; the orchestra has taken up its instruments; and the opera hall is hushed.

I'd find me a seat if I were you.  The overture to Phase Four is about to come.  This is gonna be one helluva show. And the fat lady's not gonna sing for awhile.

Last week's press release from the Chinese government regarding the so-far-succesful creation of a human vaccine against H5N1 avian influenza was picked up by China Daily and Reuters and broadcast to the world.  The Chinese were ready to manufacture some 20 million doses of a trivalent bird flu prepandemic vaccine.  This followed a test of 500 "volunteers" (I am sorry to be so cynical about how the Chinese categorize "volunteers".  

Now, I find it interesting that the Chinese were making a trivalent H5N1 vaccine.  Hypothetically, it would guard against Clades 2.1 through 2.3.  Or maybe it would guard against clade 1.0 and Clades 2.2 and 2.3.  I don't know, and I am counting on those who do know to post a response.  Of equal interest is the Chinese government's initial denial that Clade 2.3 (also called "Fujian") even existed.  But after they saw the evidence, they stomped off and started killing Tibetian monks in frustration, I suppose.

Anyway, the line I am most interested in comes toward the end of the news story. 

"It's also part of the task to secure an outbreak-free Beijing Olympics," she (SFDA spokeswoman Yan Jiangying) added.

I have speculated as early as last year that the Chinese government would go to extraordinary lengths to make sure H5N1 did not rear its beak during the ultimate sports spectacle.  Nothing like starting a pandemic at the javelin throw to draw bad publicity and start a worldwide economic depression.  So the Chinese will act quickly, decisively and without regard to consequence in order to keep H5N1 out of sight.  See my blog from last September, A problem of Olympic proportions, for refreshment. 

Here's the article about the vaccine:

Bird flu vaccine for humans approved

By Shan Juan (China Daily)
Updated: 2008-04-03 07:18

 

A homegrown vaccine for humans against the H5N1 influenza virus, commonly known as bird flu, was Wednesday approved by the State Food and Drug Administration (SFDA).

Worldwide, only the United States and the European Union have approved human vaccines against bird flu.

The SFDA approval follows two rounds of clinical tests involving 500 volunteers from 2005 to 2007.

The vaccine will enhance the country's capability to protect people from an influenza pandemic, said SFDA spokeswoman Yan Jiangying.

"Almost all known human bird-flu cases are caused by the H5N1 strain," said Yin Hongzhang, head of the biological product department of the SFDA.

But given the constant mutation of the bird-flu virus, it might be another strain instead that could trigger a pandemic, he added.

Yin Weidong, CEO of Beijing-based Sinovac Biotech and the vaccine maker, said in case of a pandemic, the WHO would offer the identified viral strain in three weeks for the producer to incorporate into the vaccine.

The production time for a vaccine against a new strain would take about four months, he said, adding that it takes two months for the H5N1 virus.

The vaccine-induced immunity lasts a year, similar to that of a seasonal flu shot, he added.

The company can churn out at least 20 million doses of the trivalent vaccines, Xinhua News Agency reported earlier.

Yan noted that the company will not sell the vaccine commercially.

"It will be purchased by the government for inclusion in the national strategic stockpile."

She said the SFDA streamlined approval procedures for the vaccine.

"It's also part of the task to secure an outbreak-free Beijing Olympics," she added. (bold mine)

Some 373 people worldwide have been infected with the virus since 2003, of whom 236 have died, according to the WHO. China has recorded 30 infections and 20 deaths.

To date, H5N1 influenza has remained primarily an animal disease, but experts fear the virus could acquire the ability for sustained transmission among humans.

http://www.chinadaily.com.cn/china/2008-04/03/content_6587926.htm

Despite the Chinese government's efforts, H5N1 is absolutely entrenched in the nation, and will not go quietly into that good night.  Three people have already died from H5N1 since January, and the virus' ability to mutate and kill evoked the famous Dr. Zhong Nanchan commentary of last month. 

Birds routinely test positive for H5N1 in southern China, including Hong Kong and the notorious Guangdong Province.  Now bird flu has reappeared in Tibet.  From today's Reuters:

China reports birdflu in Tibetan poultry

07 Apr 2008 13:14:13 GMT

Source: Reuters

 BEIJING, April 7 (Reuters) - China said on Monday that an outbreak of birdflu had killed 268 chickens at a poultry farm in the Tibet region.

 

Tests by a national laboratory showed the birds had died from the H5N1 strain of the virus, but it is now under control in the affected area, the Agriculture Ministry said in a statement on its Web site (www.agri.gov.cn).

 

Bird flu tends to be more active in low temperatures and since the start of this year China has reported three confirmed human deaths from the disease and several outbreaks in poultry.

 

With the world's biggest poultry population and hundreds of millions of farmers raising birds in their backyards, China is seen as crucial in the global fight against the virus. (Reporting by Emma Graham-Harrison; Editing by Jerry Norton)

http://www.alertnet.org/thenews/newsdesk/PEK137202.htm

Very quietly, the World Health Organization today confirmed what most of us had suspected all along -- that the Pakistani H5N1 human cases among family members in October and November of last year were, indeed, "likely" victims of human to human transmission. 

In the April 3, 2008 Update 2, three of the four family members (all male) were confirmed to have contracted H5N1, and the fourth is unconfirmed but "probable".  It is unknown if chain H2H2H transmission occurred, but judging by the onset dates, it is quite reasonable to assume this event is also likely.

Here is the WHO report, and a massive hat-tip to Crof for publishing this on his blogsite, H5N1.  And here's another sigh of relief that we dodged the proverbial bullet once again. 

Will our luck continue to hold out until we get real-time, global surveillance?  No one on Earth can answer that one.

Avian influenza – situation in Pakistan - update 2

3 April 2008

Two additional H5N1 cases were confirmed by serological testing, thus providing final H5N1 infection test results on a previously reported family cluster in Peshawar.

These tests were conducted by the WHO H5 Reference Laboratory in Cairo, Egypt and the WHO Collaborating Centre for Reference and Research on Influenza in Atlanta, USA. The table below summarises the testing results of the confirmed/probable cases in the family cluster.

• The preliminary risk assessment found no evidence of sustained or community human to human transmission.
• All identified close contacts including the other members of the affected family and involved health care workers remain asymptomatic and have been removed from close medical observation.

These laboratory test results support the epidemiological findings from the outbreak investigation in December 2007, and the final risk assessment that suggested limited human to human transmission likely occurred among some of the family members which is consistent with some human-to-human transmission events reported previously. This outbreak did not extend into the community, and appropriate steps were taken to reduce future risks of human infections.

 

 

 

Relationship	Onset Date	Outcome	Exposure	Status
Case 1 (Index case)	29 Oct 07	Fully recovered	Direct contact sick/dead poultry	Confirmed (serology)
Case 2	12 Nov 07	Dead (19 Nov 07)	Close contact with Case 1, no known direct contact with sick/dead poultry	Probable (No sample available)
Case 3	21 Nov 07	Dead (28 Nov 07)	Close contact with Case 1 and 2, no known direct contact with sick/dead poultry	Confirmed (PCR)
Case 4	21 Nov 07	Fully recovered	Close contact with Case 1 and 2, no known direct contact with sick/dead poultry	Confirmed (serology)

http://www.who.int/csr/don/2008_04_03/en/index.html

US steps up efforts to fight bird flu in SE Asia

The US government has recently stepped up efforts to combat a potential influenza pandemic whose origins are almost certainly going to be somewhere in Southeast Asia. 

I have always said that in the fight to contain pandemic influenza, as in law enforcement, Follow the Money.  And Follow the Tamiflu.  Nowhere was that more evident than in the efforts of the US, Indonesian authorities and the WHO to contain what appeared to be an outbreak of human H5N1 in Cikelet, West Java, in August, 2006.  More than 2,000 villagers from all adjacent hamlets were placed on Tamiflu as a precaution.  The story can be recalled by clicking on the reference at Crof's H5N1 blog entry from that time, "Drenching Cickelet in Tamiflu", here.

The US had shipped a substantial quantity of Tamiflu into the theater of operations some weeks before, which made quick distribution of Tamiflu possible. 

As we all know, Tangerang, Indonesia is just about the hottest spot in the world for catching bird flu, if you are a human being.  And there is precious little people know there about bird flu, despite the well-intended efforts of the Indonesian government to make them more aware.  I refer again to a blogger and respondent to one of my recent Computerworld.com blogs, a man known only as H&T:

I live in bird flu central (Indonesia). My wife is Indonesian and hails from a rural background in east Java. Traveling in that part of the world I am struck by two things related to bird flu:

1) Everyone keeps chickens and ducks in their yard;
2) Almost no one has any inkling about bird flu or what precautions to take (almost everyone is a subsistence farmer with little access to or interest about information on global events and concerns). (bold mine)

Bird flu is almost certainly coming soon to a theatre near you. It will almost certainly "made in Indonesia" stamped on the side.

Apparently that message is not lost on the US, which is acting to try and stamp out H5N1 in Tangerang before it is too late.  The United States has announced it is spending some $15 billion Rupiah, or roughly $1.7 million dollars US, to increase awareness of H5N1 in Tangerang Province alone.  The following news article is from Indonesia's Antara news service:

US envoy to give Rp15 bln to Tangerang to fight bird flu

Tangerang (ANTARA News) - US Ambassador to Indonesia Cameron R Hume is expected to hand Rp15 billion in humanitarian aid to the Tangerang administration to fight bird flu in the region, a local health official said on Tuesday.

"The grant will be presented by Ambassador Cameron Hume during his visit to Tangerang on Wednesday," a spokesman of the local health office, Aceh Kurniawan, said.

He said the funds would be used to control bird flu in the city and district of Tangerang by implementing a familiarization program.

The bird flu familiarization program would involve the local people and students in an effort to make them aware of the deadly disease.

Meanwhile, the chief of the Tangerang Health Office, Hani Heryanto, said the district administration already had a bird flu control program which could be implemented as soon as the US financial aid had been received.

Meanwhile, the chief of the National Committee on Bird Flu Control, Bayu Krisnamurthi said in Jakarta recently that Indonesia had suffered financial losses of Rp4.1 trillion due to bird flu (avian influenza/AI) outbreaks during 2004-2007.

Bay said in a statement that the losses were estimated based on the impact of bird flu outbreaks during 2004-2007 using the Computable General Equilibrium (CGE) model.

The impact calculated in the estimation was financial losses due to chicken culls, reduced demand for poultry products, lower chicken and egg consumption, costs incurred by farmers as well as the government for bird flu control, and the decline in the number of tourist visits.

According to Bayu, programs to control bird flu in Indonesia had shown progress, both in communication and surveillance, managing the spread of the virus in poultry and humans, as well as efforts to anticipate a possible pandemic.

The authorities would improve the control program from time to time, he said.

AI infection of poultry which was first reported in 2003 has spread fast and now poultry in 31 out of the country`s 33 provinces have been affected.

The disease has become endemic in Java, Sumatra, Bali and South Sulawesi. (*)

http://www.antara.co.id/en/arc/2008/4/1/us-envoy-to-give-rp15-bln-to-tangerang-to-fight-bird-flu/

Indonesia has lost a half-billion US dollars in the past four years, all because of bird flu.  And this half-billion dollars is almost wholly contained within rural, family farms.  Not to mention the loss of a major protein source.  When we talk about the threat of bird flu, we sometimes lose sight of the enormous financial toll this virus takes on the living.  This virus has become endemic to the nation's largest and most fertile areas.  Culling exacts a massive financial toll on the standard of living for those impacted by the disease's presence.  It is an extremely destabilizing and draining event for the nation, which has other things to worry about:  Volcanoes, earthquakes and tsunamis, Dengue fever, chikungunya virus, malaria, al Qaeda, and a paranoid health minister. 

The US is not limiting its most recent anti-bird flu efforts to Indonesia.  It is also building a significant depot of supplies in Thailand, to be used throughout the Southeast Asia region.  From news service AFP:

US officials launch bird flu stockpile in Thailand

Tue Mar 25, 12:16 PM ET

US officials on Tuesday officially opened a stockpile of equipment in Thailand designed to help Asian nations react rapidly to battle outbreaks of potentially deadly bird flu.

The US ambassador to Thailand Eric John presided over the Bangkok launch ceremony for the Regional Distribution Centre (RDC), which is located in Thailand's eastern province of Chachoengsao.

"The RDC will help ensure that countries in Asia will be able to take fast action to counter avian influenza without endangering the lives of rapid-response teams," John said.

"This centre will help ensure that avian influenza outbreaks can be contained safely and efficiently," he added.

The warehouse, funded by the US government's aid arm USAID, will initially stockpile 45,000 protective suits, 400 decontamination kits, 10 laboratory specimen kits and other equipment worth a total of 548,300 dollars.

John MacArthur, infectious diseases advisor with USAID, warned that bird flu remained a serious threat in the region around the Mekong river, and said the kits could be shipped to outbreaks within 24 hours.

Authorities in Laos earlier this month reported a fresh bird flu outbreak near its northwest border with Myanmar and China, while Vietnam has so far reported five bird flu deaths this year.

The World Health Organisation has confirmed that 236 people have died worldwide from bird flu since 2003.

The H5N1 avian influenza virus mainly kills animals but scientists fear it could mutate to easily jump from human to human, sparking a global pandemic.

http://news.yahoo.com/s/afp/20080325/hl_afp/healthfluthailandus_080325161612