Scott McPherson's Web Presence

The politics of going to Phase Four.

For the first time since H5N1 avian influenza has been tracked by the WHO, there is compelling evidence of simultaneous clusters of possible human-to-human transmission occurring in multiple nations with little physical proximity between them. 

Specifically, the locations are China, Indonesia and Pakistan.  In all three cases, people have died who were family members.  And what is equally distressing is that the third location -- Pakistan -- has previously never reported a confirmed case of human H5N1 infection.

We also know that on at least two different occasions within Indonesia, in the past 13 months, the WHO had vast quantities of Tamiflu distributed to thousands of villagers.  This was done in an attempt (so far successful) to prevent a cluster from growing into an outbreak.  Those two times were August, 2006 and September, 2007.  We all know of the August 2006 "blanket" of Tamiflu over four remote villages within a few clicks of each other; but we never heard about the results of the Palua Tabuan blanket.  Palua Tabuan is an island off the coast of Sumatra.  Every single villager on the island was given Tamiflu prophylactic ally last September as "fowl plague" and another undisclosed illness swept the island. 

Coupled with the simultaneous emergence of divergent familial clusters of H5N1-infected humans is the ongoing round of hostilities between the WHO and the Indonesian government.  Someone please tell me the difference between the Indonesian government's intransigence on the issue of sharing H5N1 virus samples and the Iranian government's refusal to cooperate on the topic of nuclear reactors.  Both situations are ticking time bombs that can spell doom for millions of innocent people if handled incorrectly.

Of course, we are more than willing to help out the Indonesian government when they come calling, as we did when it appeared Bali was fomenting H2H-capable bird flu last August and September.  By golly, the Indonesian government was more than willing to beg for help save the Global Warming Summit's location, hat in hand.  But once the virus had appeared not to mutate, the Indonesians assumed their previous defiant stance, with all the gratitude and credibility of Bobby Petrino.  I have dealt personally with Bobby Petrino, by the way, and I can tell you he is never to be believed and everything negative you ever heard about the man is probably true.  Now the entire nation knows his word is about as good as --well, as good as Mahmoud Ahmadinejad or Indonesian Health Minister Siti Fadillah Supari.

But I digress.  The point is, politics eventually comes into play, one way or another.  And the decision to raise the threat level from 3 to 4 will be a political one.

So I ask, in light of the above factors:  Is it time to raise the threat level for pandemic influenza from Phase 3 to Phase 4? 

Is the Indonesian government's refusal to help the global preparedness effort not as big a threat as the virus itself?  Have we not seen that this virus is a mutating fool and is steadily acquiring the genetic characteristics of human influenzas?  Have we not seen at least empirical evidence of H2H (and H2H2H in Indonesia in May, 2006) over and over again?

Let's threaten Indonesia with raising the threat level, if for no other reason than to get Indonesia (and the rest of the world) off its rear end.  Here's what raising the threat level would do:

• First, it would act as a catalyst for the governments of states, counties and cities to get moving with awareness and preparedness efforts.
• Second, it would prompt the private sector to finish its preparation efforts.
• Third, it would be a huge black eye to the economies of any nation that had an endemic bird flu problem and, for whatever reason, refused to take appropriate steps to contain or eradicate it.  Are you listening, Indonesia?  No more global conferences.
• It would help activists like us to get our message out more clearly and to more people.
• It would focus media attention on the issue.
• And it would remind families that they need to prepare themselves for a pending viral disaster.

We need to adjust our thinking and discuss the theory that the virus will mutate spontaneously and simultaneously in different locations due to some external influence or recombination event.  And our ability to identify and isolate this emerging virus will be totally reliant upon the levels of communication and cooperation between sovereign nations and between those nations and the WHO.  This means I do not hold out much hope that the WHO threat level phases will be able to maintain any semblance of real-world, real-time correlation with actual, evolving events.

Look at the mobilization of the Chinese military in Nanjing, the province affected by the latest suspected H2H event.  The Chinese military is wasting no time as it considers the threat of avian influenza in the province to be as great as the threat from SARS in 2003-04 (http://www.newfluwiki2.com/showComment.do?commentId=76347) .  Additionally, guards have been set up around the building where the latest H5N1 victim is said to be recovering.  They are clearly not taking any chances.

In Tangerang, Indonesia, the situation is much more dire.  I have blogged no less than four times in the recent past regarding the presence of H5N1 in Tangerang.  Family clusters are not uncommon there.  Just this past week, a 28-year old woman and a 47-year old man have both died in Tangerang. Causes are listed as anything from handling manure (the woman was a plant seller) to raising ducks (the man).

How about the more obvious thing:  Something big is happening in Tangerang province, and it is calling out for the world to investigate?  I am quoting directly from Dr. Henry Niman's commentary on the latest developments on his Website, recombinomics.com:

The two confirmed cases above extend the cluster of H5N1 cases in Tangerang.  Four of the five most recent confirmed cases in Indonesia have been from Tangerang and all but one died.  This clustering increases pandemic concerns.  Sequences from most of the human cases this year have been withheld, so tracking of H5N1 evolution in humans in Indonesia is not currently possible.  Bird sequences from Indonesia match earlier cases, but the most recent public human sequences from January had additional divergence not well represented in the public bird sequences.

H5N1 in poultry and wild birds in Indonesia has been widespread, but the recent confirmed human cases have been concentrated in Tangerang, adjacent to Jakarta, or Riau province in central Sumatra.  These two geographic clusters suggest that H5N1 in these regions is more efficiently transmitted to humans and raise concerns about unreported cases.  The vast majority of cases in Indonesia are confirmed when the patient is in critical condition and the case fatality rate in Indonesia is above 80%.  This high rate raises concerns that milder cases are not being reported, raising additional concerns.

WHO Pandemic Phase 4 is defined as "Evidence of increased human-to-human transmission."  So what constitutes evidence?  Is it a dramatic upswing of localized human H5N1 cases in a nation where no one can get their hands on virus samples?  If we limit this decision solely to scientific analysis and examination, at the end of the day it will still be up to a consensus of scientists to give their subjective opinion.  I said opinion.  That means a bunch of people in a room (or via videoconference) trying to come to a group decision on what to call things.

Meanwhile, in several remote (and maybe not so remote) corners of the planet, the virus mutates and causes more clusters.  The possibility for this to happen is upon us.

Look at what is going on around the world, as we speak.  There are multiple outbreaks of H5N1 in poultry in Poland.  Egypt just went on alert against H5N1, and no one would ever fault the Egyptian government to be digging in against this foe.  China goes on alert. Vietnam continues to wrestle with outbreaks.  Pakistan culls poultry and then two humans die.  Indonesia has no earthly idea how entrenched the virus is there.  Russia culls hundreds of thousands of birds. Saudi Arabia is reporting new cases in poultry, as is Bangladesh.  South Korea and China are battling localized outbreaks in poultry. And we haven't even gotten halfway through December!

The single biggest thing the WHO can do to raise awareness of H5N1's pandemic potential is to raise the threat level -- now -- from Phase 3 to Phase 4.  I am certain they can find sufficient justification, if said justification does not exist already.