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About two weeks ago, I wrote an open letter to Indonesian President Susilo Bambang Yudhoyono (or "SBY," as I understand he is called.  That reference comes from the always-welcome Blogsite of HHS Secretary Mike Leavitt).

The topic of my open letter was, of course, Indonesia's reluctance to participate in the community of nations.  The responses I received (not from SBY, but from faithful readers of this Blogsite)  were both welcome and interesting.  But they all had a common thread, which was:  Why spend good money after bad?  Why continue to accept Indonesia's pussy-footing on this important issue?  Haven't we done enough already?

Allow me to bring in a parallel:  Our Global War on Terrorism.  We have made it the stated policy of this nation that we will not wait for a terrorist attack to take place on American soil.  We will go after the terrorists wherever they are, whoever they are, and we will drive them into the ground.  We will gladly introduce them to whatever vestal virgins they may wish to visit  --  but on our terms, not theirs.

Let me say again: The global war on terrorism.  Now I want you to do a mental exercise:  Every time you read or hear the words "global war on terrorism," insert "fight against pandemic influenza." Or when you hear "the terrorists," think "pandemic flu."  Since homeland security experts (and the British government) have declared a pandemic to be as much of a risk as terrorism, we can substitute these expressions freely. 

Here we go:

We will take our Global War on Terrorism to all corners of the globe.  Anyone who is not helping us in this fight against The Terrorists is with the enemy.  We will defeat the terrorists because our fight is righteous and correct.  And woe betide anyone, or any nation, suspected of harboring the terrorists as a matter of national policy, or obstructing the Global War on Terrorism.  They will be dealt with.

We see the war in Afghanistan, the attempts to win the peace and build a new nation after winning the war in Iraq, and the efforts to wipe out individual al Qaida operatives via Predators, snipers, smart bombs (and occasionally some regrettably ill-placed bombs), and domestic arrests as evidence of the ongoing war against terrorism.

What we don't see are the deals, the secret agreements with nations such as Pakistan, and the flow of billions of dollars in aid (and other things) that allows us to continue to try and eliminate Islamic fascism's capacity to harm us.  That is both understandable and necessary; I am not sure I want to know how sausage and diplomacy are made, to paraphrase Mark Twain. 

You get the point.  If we are to remain consistent, we must engage bird flu as we also engage terrorism.  That means taking the fight to the enemy, no matter where it is.  It also confers a responsibility to other governments to be with us or against us.  "Us," in this case, is the WHO.  It is the UN.  It is 192 WHO member nation signees.  It is, quite simply, the rest of the planet.  In an ironic twist, it even includes some nations suspected of harboring terrorists!

We are dealing with an enemy -- the rise of pandemic influenza -- that is potentially a more indiscriminate killer of people than all the terrorist acts on the wish list of al Qaida combined.  It is amazing to me that various nations around the world are able to work cooperatively to ensure that the flow of information takes place to eliminate the spread of avian flu, despite their long-standing political and cultural differences.

As I mentioned in the open letter, we have nations such as Israel and the Palestinian Authority speaking regularly -- sometimes daily -- to corral H5N1.  India and Bangladesh are also working to try and contain bird flu, although things get mighty testy sometimes.

We even see transparency in the most unexpected of places.  Myanmar (Burma), arguably one of the most repressive regimes on Earth, is reporting its H5N1 problems.  China, which still "runs home to Momma" and reverts to secrecy at the worst times when it really needs openness and transparency, has improved its reporting of H5N1.  And Pakistan, which has almost as many geopolitical and geological problems as Indonesia, has the ability to welcome the WHO with open arms and securely move WHO lab workers into areas that are still crawling with al Qaida fighters.  We welcome these examples of transparency, even if we are not completely happy with the speed with which they occur.

In contrast, the nation of Indonesia has consciously decided to move into the opposite direction.  In fact, Indonesia has decided to become the bird flu equivalent of North Korea, becoming less and less transparent and trying to close off any attempt to determine its current status (NAMRU-2, WHO).

My goal -- and I am certain, the goal of HHS Secretary Mike Leavitt and his recent, unplanned and urgent trip to Jakarta -- was to try and get Indonesia to understand it has a global obligation in the fight against H5N1.  My open letter was certainly not intended to usurp or undermine Secretary Leavitt's diplomatic efforts, and I don't think anything I write could ever pack that much weight.  It was intended to show Indonesia that Americans care about what is going on in that nation, and that we all realize that this impasse could kill Indonesian and American children alike.  It was intended to show that Indonesia does not have to go it alone.  I also wanted to give some flexibility and options to both parties, and to show that some creative way might be found to end this impasse.

Part of the agreement signed between 192 nations and the WHO, as I understand it, makes viral strains the intellectual property of each nation.  That means Chinese H5N1 is the intellectual property of China.  But it also means that each signee nation must provide those samples in a timely manner to the WHO.  The WHO may or may not be allowed to release public sequences (which arouses the continual ire of Dr. Henry Niman and others), but at least someone gets to sequence those samples and look for mutations. 

Indonesia is a signee to that agreement.  Regrettably, Indonesia seems to have decided not to honor that treaty, and instead to continue to bicker and trivialize the situation.  By demanding some sort of vaccine guarantee in exchange for viral samples is the equivalent of cutting off one's nose to spite one's face.  No one knows if a Clade 2.1 mutation will spark the Next Pandemic.  No one knows if any currently-existing clade will trigger H5N1 H2H in humans.  And it is arrogant beyond words for Indonesia to think it should be guaranteed some sort of vaccine even when no one knows if it is their strain that will "go pandemic."

We already are shipping Tamiflu in prodigious quantities to Indonesia.  We are spending millions of American taxpayer dollars on preparedness in Tangerang province.  And only God and the OMB know how much in American taxpayer aid has already gone toward stomping out an Indonesian flu pandemic before it starts there.  In short, we are doing enough to help Indonesia.

By resolving to keep its H5N1 samples internal to Indonesia, and no matter how well-qualified its scientists are, it is playing Russian Roulette with the world's health.  This fact was underscored by the excellent recent editorial in the Wall Street Journal.  The Journal editorial also presented a political factoid; namely, that Health Minister Siti Fadilah Supari is courting Islamic factions in some bid for political office, and it always plays well in Jakarta and elsewhere to give the U.S. a hotfoot whenever possible.  this is confirmed by Secretary Leavitt's blog entry:

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

Except that this hotfoot will potentially burn everyone -- especially Indonesians.  Medical realities disclose that vaccine is an endgame strategy.  Vaccine will not be available until the second wave of a flu pandemic at best.  Maybe we won't see vaccine until the third wave.  No one knows.  But basing a global strategy on the basis of vaccine guarantees ignores the reality that most of Indonesia's population will be impacted well before a vaccine becomes available. 

The problem is, like the war on terrorism, we still have to work with recalcitrant nations.  We just cannot "write off" Indonesia.  We must convince this nation to cooperate with the United States.  This, too, was at the top of my list and the forefront of my consciousness when I wrote the open letter.

However, patience is a virtue that is not inexhaustible.  Secretary Leavitt underscored that thought when it gave Indonesia a time certain for a return to its treaty obligations.  Secretary Leavitt said in his blog:

I  have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable. 

Well said, Mr. Secretary.  We need to accept this worldview.  Indonesia needs to live up to its obligations. If not, move NAMRU-2 to a nation that would welcome it.  We'll get the Indonesian flu samples some other way.

And may God help us all if Supari wins any election for anything important. 

I got my usual ProMED alerts in today's email, and I was particularly interested in the update on the Peruvian situation.  You can read about it by scrolling down and reading my fifth installment in the series "It's not always influenza that kills."

Anyway, here is an extract from the ProMED report that I found quite interesting:

Given the long time since the vessel left China, the disease was mostb likely  introduced by one of the new crew members who went aboard in March 2008 (we are not told whether the fatal cases were those same 2). The adenovirus type is not stated, but the ProMED reader who contributed this report has suggested that it could be type 14, which has a 20 percent mortality rate -- see ProMED post Adenovirus 14-associated pneumonia - USA (OR) 20071010.3334. I quote Mod CP's comment on that report: "Human adenovirus 14 has not previously been regularly associated with human respiratory disease. It is perhaps too soon to designate human adenovirus 14-associated pneumonia as an emerging disease rather than perhaps a co-factor in an unusual disease situation." 

Of course, now we know that Ad14 has been associated with severe disease, even death -- a CFR that is alarming.  The world awaits the results of tests to determine if Ad14 was the culprit.

H5N1 avian influenza, which has run rampant in domestic poultry across the nation of South Korea in just a matter of weeks, has apparently just infected its first person.  That person is a South Korean soldier who was directly involved in the culling effort.

Some 14 other people (as of this Blog) were in hospital for symptoms of avian flu. 

The soldier was issued Personal Protective Equipment (PPEs) and was also given the antiviral Tamiflu as a preventive measure. 

For more on this development, check out these links:

http://www.flutrackers.com/forum/showthread.php?t=65451&page=2

http://www.recombinomics.com/News/04220805/H5N1_Korea_Transparency.html

http://www.recombinomics.com/News/04220804/H5N1_Korea_Mild.html

 

Over the weekend, a fascinating story crept up on us.  Down in the Southern Hemisphere earlier this month (April 9), a Chinese fishing vessel was surrounded by elements of the Peruvian Navy.  From news and Promed reports, two Chinese sailors died of a "strange mutant virus."  This virus has apparently proven itself to be Adenovirus, and i am betting something along the lines of Ad14. 

Veteran readers of this Blogsite should be lay experts on Adenovirus by now.  With more than 50 substrains, Adenovirus has been getting a lot of press lately.  Adenovirus is a culprit for "ILI," or Influenza-Like Illness.  It is also a culprit for "stomach flu," a term we all know is misleading and inaccurate but still out there, helped along by the medical community itself.

There may be "good Adenovirus."  Genetically-rendered Adenovirus promises to be the solution to everything from HIV/AIDS to bird flu itself, specifically by using Adenovirus as the agent to allow the respective vaccines to work their intended magic.

Whenever I read about adenovirus being used in a vaccine, I can't help but think of the new Hollywood  "imagining" of Richard Matheson's classic novel I Am Legend.  There is still no "true" and faithful film adaptation of the novel, but this is about as close as we're going to get.  Anyway, in the Will Smith movie, an uncredited Emma Thompson proclaims that a vaccine for cancer has been developed, using genetically-rendered measles virus.

Weeks later, the world has descended into chaos and murder.

Anyway, back to the Peruvian story.  This was picked up by Mike Coston in his Avian Flu Diary blog, and then Crof ran with it over at H5N1.  A short excerpt from Mike's posting of the story, translated from Flu Wiki:

This has raised the epidemic alarms. The health authorities of the country have imposed a quarantine and medical monitoring on 30 medical professionals and personal of the Navy that went to the aid of the fishing boat as a precautionary measurement. Until now none of them presents/displays symptoms of the disease.

Meanwhile, the fishing ship "Chan An 168" and its 22 surviving crew remain in quarantine, in an isolated zone to eight miles (10 kilometers approximately) off the port of the Callao, until it is determined how they acquired the disease. Patrol boats of Navy military watch that nobody boards nor leaves the boat.

DEADLY VÍRUS

The medical examinations have determined that eight of the other Chinese crew have the deadly virus, although they have not developed [symptoms]. Cook Jiang Dexin (40) and the crew member Che Caiqiang (38) of this boat died April 9th, after presenting/displaying high fevers during hours. No medicine could delay the advance of the disease.

The experts of the Legal Medicine Institute of the Public Ministry have determined that the cause of the death was "adenovirus" that has become extremely deadly.

The only Adenovirus that I can think of that causes respiratory symptoms -- and death -- on par with influenza is Ad14.  Search for my previous blogs on Ad14 for background.  The Case Fatality Rate for hospitalized Ad14 victims in the Pacific northwest was over 20%, based on a medical study.  For a refresh, here are some highlights from a news story about Ad14, published back in October, 2007 and also available on this Blogsite.

First encountered in 2005 in Oregon, the viral pneumonia frequently leads to hospitalization and has a 20% fatality rate, (bold mine) Paul Lewis, M.D., of the Oregon State Public Health Department, said at the Infectious Diseases Society of America meeting.

Recognition of the adenoviral pneumonia began with four patients hospitalized simultaneously at a Portland hospital. Upon comparing notes with physicians at area hospitals, Dr. Lewis and colleagues "almost fell out of our chairs because every hospital we called had recent severe and fatal cases of adenovirus disease."

Investigators followed up the informal communication with a systematic review of all cases of adenovirus disease identified by Oregon clinical laboratories from November 2006 to April 2007. Six months of active surveillance revealed what appeared to be a winter-spring predominant adenovirus disease, as the number of reported cases increased from January through April.

Isolates from the sickest patients were sent to the CDC, which found that almost all the cases involved adenovirus 14, a serotype identified more than 50 years ago but rarely detected since then and never in association with outbreaks.

Dr. Lewis and colleagues at the state health department reviewed analyzed specimens dating back to 1993 and found a few cases of adenoviral disease almost every year. Beginning in 2005 adenovirus 14 was the predominant serotype identified.

Comparison of 31 patients with adenovirus 14 disease and 14 patients with other adenovirus serotypes showed that adenovirus 14 tended to infect older men (median age 52.9), and almost half the cases involved smokers. Most strikingly, adenovirus 14 was associated with a hospitalization odds ratio of 15.9 compared with other adenovirus serotypes.

"This came out of nowhere in 2005 in Oregon," said Dr. Lewis. Acknowledging that almost all of the cases have involved severe illness, he agreed that the scope of the problem could be much larger and involve a broader spectrum of illness severity.

I have repeatedly called for a cheap, reliable Adenovirus 14 test, and for disclosure and record-keeping of this disease.  If it was enough to kill two Chinese sailors, cause the quarantine of some 30 Peruvian military personnel and create a public relations fiasco for the Peruvian government, it is serious enough to be documented.

CDC reports this year's flu season was worst since 2003-04 killer

The Centers for Disease Control has issued a report that confirms what many of us already suspected, based on the morbidity and mortality charts.  That is, this year's flu season has proven to be the worst in the past four years.  Plus, the season is not over yet.  It is still underway in some parts of the United States.

We knew this was shaping up to be a bad year, just by studying the reported cases and overlaying them against traditional epidemic thresholds. the Associated Press is reporting that this year's flu season topped the epidemic threshold for thirteen consecutive weeks, as opposed to the 2003-04 season, where the epidemic threshold was topped for nine straight weeks.

What made 2003-04 such a bad flu season was the combination of unusual virulence of the virus(es), coupled with a shortage of vaccine.  Reverse that order and you may have a better answer.  Entire books have been written on the fiasco that was the 2003-04 vaccine shortage debacle.

So this year's flu season was longer, but slightly less lethal than 2003-04's.  Why was the vaccine such a bad match?  readers of this Blog know of the A/H3N2/Brisbane appearance in Australia this past summer, which took place well after the vaccine targets were set (annually, in February).  Also, there were other problems, I think moreso with the B strain of the vaccine.  There was a lot of B this year, and I assume that was the other vaccine failure (CDC says the vaccine was only 44% effective this year).  In fact, the CDC says the B strain was typed and presumably hatched in -- FLORIDA!  NOT Guangdong.  And not Indonesia.  Guess those tourists took more than a sunburn home with them!  By the way, we love you dearly, tourists.  To steal a line from Carlos Mencia, what are cars to you people?   Tourist Kryptonite?  Geez!

Here is a link to the AP story:

http://apnews.myway.com/article/20080417/D903NHD81.html