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You know, the news on the bird flu front is kinda quiet right now.  Aside from Egypt, which has had a few cases and accompanying deaths over the past two weeks, and the expected weekly cases from Indonesia, things are relatively calm. 

We have come to expect daily stories of poultry culls in the third world, in this nation and that nation, and we are not surprised at all when a human case pops up, usually in Tangerang or West Jakarta or Vietnam or even China.  Just as H5N1 has become endemic in poultry and wild birds on every continent on Earth save the Americas and Australia, stories of H5N1 culls and human cases have become endemic to our consciousness. 

I guess this is the "New Normal" when it comes to H5N1. This is a dangerous phenomenon, because it is even more potentially dangerous than the phrase "pandemic fatigue," a phrase which I will attribute to Dr. Mike Osterholm until someone tells me otherwise.  "Pandemic fatigue" can be overcome with liberal doses of cluster cases, deaths in new nations, and positive tests of H5N1 in birds in nations where it is not supposed to be yet.  But the H5N1 New Normal is akin to the old story about boiling a frog in a pot.  You don't drop the frog in boiling water, so the story goes.  You put it in cold water and slowly turn up the heat.  By the time the frog realizes it is about to become a meal, it is too late for the hapless creature to do anything about it.

The drone of daily reports of individual human cases and poultry culls threatens to numb us to the continuing spread of the disease.  It also threatens the thoughts and actions of decision-makers, as they, too, run the terrible risk of suffering from the effects of this New Normal.  A drone of H5N1 news, without its culmination in catastrophe, can work against even the best-motivated efforts at preparedness. 

You will hear people say and write in the media, "H5N1 has been with us for ten years now, and there is no pandemic on the horizon.  Why should we continue to worry about this?"  The best example of this is Monsieur Vallat of the OIE, whom I have spanked enough on this Blogsite.  But everyone knows of their own personal Vallat, lurking somewhere in the corridors of power and influence.

Those personal Vallats point with specificity to the situation that may or may not be under control now in India.  Millions and millions of chickens culled.  Some suspected cases of human H5N1 infection, but none testing positive.  Heck, they say, even a small cull of H7 in Wales last year produced some human cases!  H5N1, they chant, will never become The Next Pandemic Strain.

So maybe it is time we refresh ourselves, gird ourselves with new arguments, and move out to fight this New Normal and recalibrate everyone to the facts as we see them.  And here's how I see things in early 2008, a pep talk to the faithful if you will.

State of Bird Flu H5N1, 2008

• H5N1 avian influenza continues to move across the planet.  It is now firmly entrenched on every continent except for the Americas and Australia (Antarctica does not count).  This can best be attributed to fantastic luck, coupled with the old Fortress America concept.  That means America has two natural barriers:  The Atlantic and Pacific Oceans.  A similar ditto to Australia for its relative isolation from other nations in the region with endemic H5N1.
• As I mentioned in a post recently, H5N1's Fujian clade is stretching its limbs further across Southeast Asia.  As it does so, it reinforces its reputation as a killer of humans, although it may still be relatively harder for humans to  catch than its siblings, Qinghai 2.2 and Indonesia 2.1 (with at least five distinct and identifiable subclades of 2.1).
• Qinghai 2.2, in the meantime, had settled into Egypt as a relatively benign version of H5N1, infecting but not killing in as great a percentage as it once had, nor as much as Fujian.  No more:  Almost all the 2008 Egyptian H5N1 cases have ended very badly for those infected.
• Additionally, there have been so many NAMRU-3 confirmed mutations and amino acid changes in Egyptian H5N1 poultry samples that the most logical conclusion is that bird flu has been able to mutate its way around poultry vaccines, which were a:) poorly matched to the virus, and b:) probably brought into Egypt from Asia.  This is because so many of the new Egyptian changes are mimicking their Asian counterparts, and in at least one case has brought back the "original" hemagglutinin cleavage site changes that marked the Karo, Sumatra human H5N1 cluster cases of May, 2006 (see http://www.recombinomics.com/News/02260801/H5N1_Gharbiya_Reversion.html ).
• Something has prompted Indonesia to start moving virus samples to the United States and the WHO, even though Indonesia's health minister just wrote a book condemning the US for trying to make H5N1 into a Weapon of Mass Destruction.  While the Indonesian government wipes the egg off its face and the health minister is measured for an Indonesian straitjacket, the WHO and the CDC rush back into labs to discern what it is about Clade 2.1 that makes Indonesia Ground Zero for human H5N1 cases.
• Look at the latest WHO stats and extrapolate them over a year.  By any yardstick, 2008 could shape up to be like 2005 or even exceed 2006. 
• Despite the warnings of medical professionals and public health experts across the globe, governments continue to try to place all their marbles in antivirals and an eventual vaccine -- even though H5N1 is the most heavily mutating influenza virus ever seen, and will theoretically drive around any vaccine barrier as easily as A/H3N2 Brisbane drove around WHO surveillance checkpoints in the summer of 2007 Down Unda.  A/H3N2 Brisbane, as we all know, is what is sickening millions of Americans as we speak.  And since a vaccine won't be available until Wave Two or even Wave three of a pandemic, regardless of which strain causes it, any vaccine will be too little, too late.
• The one thing that costs relatively little to do and has an ROI that is off the charts is education.  We need to teach people about influenza, pandemics, and preparedness.  We need to reach out to people now, not when the virus is at their airport. 
• Despite the facts and the ability of people to use this time proactively, there is less and less attention being paid to the issue.  Even though the longer we go without a pandemic actually brings us closer to the next one, we have not used our time well.  Time squandered is time lost forever. 

So it is time, troops, for us to redouble our efforts at awareness and education.  This flu season is a perfect time for us to remind people that a virus can, indeed, come to us out of left field and kick us when we least expect it. 

Reflect on this for a moment:  The WHO has the most sophisticated global influenza surveillance program in human history, yet a mutation of seasonal flu slipped past all the checkpoints and has sickened millions.  At last count, over twenty children were killed by influenza in Iowa alone this season.  Look at the national morbidity and mortality charts and say confidently that A/H3N2 Brisbane is a flu epidemic that the world was unprepared for.

We don't know how long it will take for H5N1 to become pandemic, if indeed H5N1 does eventually decide to make the move, head straight for those umbrella-shaped cells in our tracheas and knock the human race for a loop.  Maybe it will be an H2, or an H7, or H9.  But it will eventually come.  Look at what Dr. Osterholm said about H3N8 recently.  Mike reminds us that H3N8 was confined to horses for some forty years, until magically, it began infecting and killing dogs in Florida in the 1990s.  So why did it take forty years for H3N8 to move from killing horses to dogs? 

Influenza has its own timetable, and to paraphrase Dr. Henry Niman, it does not read press releases, nor does it keep Outlook calendars nor strategic plans.  It evolves at its own pace, despite all the barriers and agents we throw at it. 

I hope this helps.  Just writing this has helped me overcome my own personal New Normal.