INTERVIEWS WITH THE EXPERTS



Dr. Robert Webster
Director, U.S. Collaborating Center (WHO)
Rose Marie Thomas Chair
Department of Infectious Diseases, St. Jude Children’s Research Hospital
Memphis, Tennessee

Dr. Robert Webster is a world-renowned virologist, an expert in the structure and function of influenza virus proteins and the development of new vaccines and antivirals. He has spent more than 50 years studying influenza, and was the first to isolate and identify the strain of avian influenza that killed thousands of chickens in Hong Kong in 1997 (when it moved into humans, the virus killed a third of the people it infected).

Dr. Webster has traced the history of pandemics back through time, analyzing the descriptions of illness in the ancient medical records held at the Royal Society in the United Kingdom.

Dr. Webster’s laboratory contains more than 12,000 samples of avian influenza – a collection like no other in the world. There, he tracks new and emerging flu viruses and guides the development of vaccines to stop them.

He calls H5N1 the “scariest thing” he’s ever seen, and is currently working to pinpoint the threat of influenza transfer among migratory birds – something he thinks would be a primary source of the influenza’s spread.



The following is an edited excerpt from and interview with Dr. Robert Webster, conducted in late 2005...

Why should we be worried about influenza?

Many people in the world think it’s a big deal. Influenza is like taxes – it comes around every year whether we want it or not. And it is necessary to have vaccines for it. The truth of the matter is that influenza is much more serious than we realize.

The cost of influenza to the community runs into billions of dollars and occasionally, once or twice a century, we can have a pandemic that appears. And it’s the pandemics that we really worry about.

Tell me more about the pandemic of 1918.

The pandemic of 1918 is the worst pandemic in recent history. 1918 appeared at the end of WWI. In fact, it was the virus that finished WWI. Unwittingly, the Americans used biological warfare to finish WWI. They took the highly pathogenic, so-called “Spanish flu” with them to France. The virus blew across to the Germans. (It was called Spanish flu because neither the Allies nor the Germans wanted to acknowledge this virus was there, so they blamed it on the Spanish.)

This virus decimated the troops on the both sides and eventually the soldiers at the end of WWI brought the virus to the rest of the world: to the United States, Canada, New Zealand, everywhere in the world it was spread and it was absolutely devastating in its pathogenicity.

The 1918 flu was so pathogenic that people really didn’t believe that it was classical influenza. We can think about the very serious viral diseases that we know about. Ebola is one that everyone knows about. 1918, I can best describe it as ‘respiratory transmitted Ebola.’ The virus had the capacity to infect young soldiers in the morning, who died in the afternoon. They turned from white to black because there was no oxygenation of their blood.

This was a terribly disastrous virus. The total genome sequence of the 1918 virus has been established by Jeffrey Taubenberger, based on samples obtained from Alaska. In the beginning of October 1918, Alaska was under total quarantine. A mail ship arrived in Nome and there was no apparent influenza aboard on this ship. So they off-loaded the mail gave it to the dog sled.

The postman who carried the mail got very sick and it was apparent now that he had 1918 influenza. Unfortunately his dog team dragged him home to Brevig Mission. And the following week, 72 or 80 people of Brevig Mission died. That’s how severe this virus was.

How many people were killed worldwide by the 1918 pandemic?

The overall global death rate for 1918 was probably much closer to 100 million than 20 million. We really don’t know. The truth of the matter is we have no idea. If we go back to New Zealand, where I come from, whole villages simply disappeared. These figures never entered the tallies. So probably 100 million is a low figure.

Key points:

What are my chances of catching the flu if there's a pandemic?

How well prepared is the world for a pandemic?

How close are we to the development of a vaccine?

How do you think the virus would spread around the world?

Are you scared?

How likely do you think it is that something like the influenza virus could mutate into something like 1918 ever again?

Whether or not we could have another 1918-like outbreak? The answer is absolutely yes. The H5N1 virus that’s currently causing problems in Asia could easily mutate to produce a 1918-like pandemic. 1918 caused something like 2.5 per cent mortality globally. Lets look at what the H5N1 is doing in Asia at the moment. More than 50 per cent of people being affected are dying. Imagine what would happen if that was transferred to a global situation.

The only thing that this virus hasn’t learned yet is how to transmit between humans. If that happens, we are in great trouble in the world. 1918 would seem like a duck walk. This would be much, much more severe.

There are meteorites that have a 1 in 80,000 chance of hitting the Earth – where does this fit on that scale?

One of the questions that I’m frequently asked is how likely is this to happen. I spent my whole life working with influenza and I have never seen such a pathogenic virus.

Here in Memphis we sit on the Madrid fault, an earthquake fault line. The last major earthquake in Memphis made the Mississippi River flow backwards for a week and created a huge lake. When we plan for influenza we have to think about the planning for rare events like earthquakes.

The hospital at St. Jude’s Children's Research Hospital is built to stand a class 10 earthquake. And so we should be globally thinking about what would happen if this virus spreads. In other words, we need to think about the possibility that this virus will really happen.

Shouldn’t we plan the design of a hospital to withstand a force 10 earthquake? Of course we should. And of course we should prepare for this virus. We have to realize that influenza has been in the world forever, almost. It goes back to the time of the ancient Greeks.

This virus has always occurred. And it’s inevitable that there will be a pandemic. The most likely one at the moment is H5N1 and I tell you, you should prepare for it. It is probably the biggest threat to mankind at the moment.

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How good of a job have we been doing with preparations so far?

Are we prepared for this event? Hell no! We are not prepared. We’ve given a bit of lip service to having a pandemic plan. We have plans that sit on shelves and we are implementing the plan. This is the key issue at the moment. How much implementation of this plan have we done?

I think Canada is probably better prepared than most countries in the world. They have shown great wisdom in vaccine plans for influenza and antiviral planning. The rest of the world is way behind Canada. And so there are many things that can be done.

People are inclined to say ‘Webster, you are always calling wolf.’ But this time I really have to take the gloves off. It’s going to happen guys. But I hope I’m wrong.

What specific things should the world be doing right now?

We should be preparing vaccines that are suitable for H5N1. There is disagreements in the scientific community as to which will be the virus that transmits human to human. I would argue that any H5N1 vaccine is better than no H5N1 vaccine.

None of the people in the world have immunity to H5. We are totally susceptible. So if we make the vaccine against the current strain that we know about and stockpile it, we could use that as an interim vaccine until we make the perfect one. We know that it takes six months from the moment we decide that this virus that is going human to human.

But let me explain the difference between a vaccine that’s not a good match and one that is a perfect match. The vaccine that is currently available, and there is a vaccine that’s currently available for H5N1, this vaccine could protect you from death. If you’re vaccinated it would likely protect you from death. You may get sick. You may get deadly sick. But it will likely protect you from death. Such a vaccine is what I argue the world should be stockpiling.

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Where are we at right now in terms of vaccine production capabilities?

A vaccine has been produced; the new technology of reverse genetics permitted the preparation of this vaccine in about two weeks. And this vaccine has been growing and is in clinical trials in United States.

I have not heard the results of the vaccine – but on the other hand I have not heard any complaints about the vaccine. So the vaccine trial is clearly going on and we will get the answer within months of whether that vaccine is efficacious.

If you got a notice tomorrow that there was human-to-human transmission in several sites across Asia, can you describe how that six-month process would work?

My suggestion would be to immediately crank the handle for every vaccine company in the world to start making the currently available vaccine that’s been tested in humans in maximum amounts.

We know that there are not enough vaccine companies in the world to achieve this. But at least we should do our best to make the current vaccine – and at the same time develop the perfect match vaccine through the laboratories. Until the perfect one is ready, produce the vaccine that is currently available.

What can I do personally to protect myself right now?

The supplies that you would put in your house for an earthquake should be put into people’s houses for the event of this H5N1. Because if it is catastrophic or super catastrophic, all of the services as we know them are likely to collapse. Each household will be dependent on its self for water for food and so on.

I might be painting a black picture but I think we have to think in those terms.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

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What might be the progress of a pandemic H5N1 virus – how might spread around the world?

If we know where the index cases are occurring say in Vietnam, the World Health Organization has a contingency to use antivirals to slow the spread of the virus. And so that is a useful strategy to think about. If we are unlucky and we don’t know where this virus occurs – there are many areas in there where this could occur and we would not know. And so this virus could break out in an area where we don’t have good surveillance.

We have to look back at what happened with SARS and the initial cases with SARS and the spread from China to Hong Kong and from Hong Kong to Canada to many areas including Singapore, Vietnam and elsewhere. And that happened very rapidly with international transport on airplanes.

One of the things that one would think about would be stopping air travel. But if the virus is already transmitted, what is the point? But people will think about stopping international travel by air.

When this virus does transmit to Western countries and to the rest of the world, I think we have to look back at what happened in 1918. It would be a similar pattern to what happened in United States, Canada, New Zealand. The chances are we are not going to have enough facilities to bury the dead. That’s what we’re faced with.

Initially, this virus is going to go through a burst of causing enormously high pathogenesis – let’s hope it’s not 50 per cent lethal. Even down to 1918 levels, we know what 2 per cent mortality did in 1918. Humanity isn’t prepared for such an event. It’s almost as if we can’t be prepared for such an even.

People are going to survive of course. There is no doubt that society will survive. But it’s likely to be a catastrophic event. And then the finger pointing will begin. We saw this happen with SARS. In Hong Kong, the finger pointing of why we weren’t better prepared.

It’s human nature to have such an investigation. And so we should do what we can. The science is in place right now to make vaccines, to make antivirals and stockpile all these antivirals to limit the catastrophe. So lets do it, it’s the best we could do.

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You argue we could stop a pandemic at its source – what do you mean by that?

I wrote an article in ‘Nature’ about that, about ducks in particular. I still think that it’s possible to stop this virus before it learns to go human-to-human. If we look at what’s being done in Asia, what countries were successful, Thailand is one of those countries. In 2004, there were deaths going on in humans in Thailand. Are there deaths now? No. There are no more deaths in Thailand.

Thailand has understood the problem, and the problem is the domestic duck. This virus, the H5N1 virus came from the wild. From the migrating bird, it got into domestic ducks, then into chickens, and learned to be a killer.

In the past year, this virus has changed and evolved again in the duck so that it is no longer killing the duck - yet the duck is carrying this virus that is lethal for chickens and humans. The duck is the Trojan horse of influenza in Asia. The duck is the Trojan horse for H5N1. The duck looks perfectly healthy. It’s pooping out lethal virus in the poultry markets in Vietnam and it’s transmitted back to the wild migrating birds.

This is the real danger. It’s not the dead chickens. We know when the chickens are dead. There is a problem when ducks look perfectly healthy and are pooping out virus at levels that will transmit to humans and chickens. That’s the danger.

We have to do what the Thais have done, to understand that in every village where we have free reign ducks in Asia, that they are a risk. And we have to go and do surveillance. In Thailand, they sent 70,000 people to the villages. Every village was tested. We can do the same thing in Vietnam. Put in the infrastructure for the rest of the world and maybe we can still stop this thing.

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If the virus is now in multiple countries, Indonesia – South Russia, China – does it really matter what Thailand or Vietnam does?

It’s still not too late. China has been controlling this virus at least in part by using vaccine in poultry. Indonesia has been doing the same by using vaccine in poultry. And so the whole region can use poultry vaccines, better quality vaccines to control this virus at the domestic poultry level.

To get back to humans the virus has got to go through the domestic duck, back to the chicken, or the pig, to humans. We are still in a position to stop that. The first step is bio-security: keeping those wild birds out of the chicken houses and simple washing of the hands can prevent the transmission of most viruses to humans. And it’s still possible to do that.

How do you personally feel about the pandemic?

H5N1, I think, is the most dangerous, the most highly lethal virus that I have ever encountered. When you inoculate a chicken in the afternoon, and the next day, the chicken is dead – the virus has gone through this business of attachment, penetration, replication, and kills overnight – that’s an extremely lethal virus.

This is the hottest one I’ve ever seen. It terrifies me that the virus, if it ever learns to transmit from human-to-human, we are in terrible trouble. I know what this virus does in the chicken and in the ferret, and in the animal models, so don’t blame me if I am concerned about what is going to happen to you and me if it learns to transmit. I think we need to put every possible resource in place, to put our defenses in order, to do what we can to ahead of time, before this virus does learn to transmit in humans.
If you speak to the influenza community in the rest of the world, they may not be as scared as me, but there is general agreement that this is a virus that we have to take extremely seriously. There is not one scientist, influenza virologist, in the world who would dismiss this as something that we don’t need to be concerned about.

http://www.cbc.ca/fifth/nextpandemi...ws_webster.html

Dr. John Oxford
Scientific Director, Retroscreen Virology Ltd.
Professor, St. Bartholomew’s and Royal London Hospital
London, England

Dr. John Oxford is an expert in the study of viruses, and believes research and understanding of past epidemics are key to providing an early warning system against pandemics of the future.




What happened in 1918?

Toward the end of the First World War 1917-1918, and infection arose, probably here in Europe, and then spread around the world, most likely with the armistice, and four million young soldiers going home. Within 18 months, 50 million people had died. It was the biggest outbreak of any infection that the world has ever seen either before or since.
Is 1918 a fairly reasonable comparison for the potential pandemic?

1918 is very relevant to today’s situation with the chicken flu in Southeast Asia. We need to ask the questions: where is this next outbreak going to come from? How long is it going to take to explode, what is the generation time, and then how is it going to spread. All those very important questions are answered to some extent by forcing ourselves back to 1918… so I think 1918 is particularly relevant and it would we very unwise to forget about that outbreak and push it behind us, as people have done, and not try and learn from it.

One thing that I think we can think about and learn from the outbreak 1918 is the early generation. What happens at the beginning of a pandemic? There is always going to be that one case. I think we tend to forget that. And that one case turns into ten, into 100, into 1,000, 10,000, and before you know it, you’ve got as in 1918, 50 million deaths. So that generation, that explosion, that transmission is very important indeed.

Key points:

How did the 1918 virus infect the body?

What story from 1918 haunts you?

How might the coming pandemic differ from 1918?

Could we have another 1918?

What should we be doing to prepare for the pandemic?
What did the virus do to the body?

The pathologists who first began to record the outbreak towards the end of the First World War, they were recording a very unusual outbreak. They didn’t call it influenza; they called it “epidemic bronchitis,” occurring mainly in the army camps.

And what they began to notice was an entirely new disease. First of all, it was attacking young soldiers… it was giving them cough, upper respiratory problems, their temperature was shooting up, they were finding difficulty in breathing very quickly. And then, they’d either begin to get better, or they would sink into this profound pathology or this profound serious illness and then die.

I think some of the best descriptions of the early outbreak are from the British Army Medical Corp. Often they describe how the pathologists, the doctors, they don’t realize how ill they are. That’s pretty sad, to begin with. And some of them almost got a sense of euphoria and yet the medical team knew when they were going to die. They could predict they were going to die. They would start off with a cough and a temperature, quite a high temperature and quite a serious cough… then they’d get into difficulty in breathing.

Most of them would never recover. They would go downhill. They would become slightly euphoric, they would continue coughing, they would cough up blood, and some of them died very quickly indeed.

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Of all the 1918 stories that you have come across, is there any one that particularly sticks with you?

The example I like particularly, and I think it brings everything to the forefront for me, is that of Phyllis Burns, Now she was a young woman, in Edwardian England. She could drive a motorcar. That was extremely unusual. She could have sat it out in England and done nothing, but she volunteered to become a nurse, went out the Western Front, and she saw soldiers dying of the so-called Spanish influenza.

She came back to London after the armistice, as they all did. She got to Charring Cross Station and she was not feeling well. She had the aches and pains, the temperature, the flash, the difficulty in breathing – she realized she had caught the influenza. And she made another decision. It was to protect her mother. She wanted to go home to see her mother, but she thought she might infect her mother and that her mother might die. So she went off and sat by herself in a small room and tried to battle it out, and she didn’t succeed. She died.

To my mind, she represents the epitome of people that went through it, and made a huge sacrifice for other people. And every time there is an infection you get this.

What are the relevant comparisons between 1918 and what could happen with the current H5 virus?

I think the most single piece of information that is relevant to today is the question of how long these pandemics take to be born. Do they explode immediately? Does a virus suddenly emerge from a chicken or goose and explode into a killer virus, or is there kind of a gestation period.

I think that’s a very important question. And I think 1918 tells us quite clearly that there was quite a long gestation period; quite a long period when the virus was getting itself together. It did not explode immediately.

That’s a reassuring thing, because 1918 tells us that it pulled its forces together before it attacked. It took a year to do that. That’s not to say we should be complacent, but that is to say that just because this outbreak in Southeast Asia has not exploded around the world so far, does not mean we could relax our guard.

It might take a year; it might even take two years before it can get itself together.

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If it ‘gets itself together,’ what happens?

When the 1918 virus got itself together, it began to spread in the community. It broke out of the British Army camps, and began to spread in the community. It was aided fantastically, and perhaps uniquely, by the end of the First World War.

Suddenly, for the first time in history, you had five, six, seven million young people on the move. They were coming home from Europe, to Canada, Australia, South Africa, the world was their oyster, and the virus took advantage of that. It had a huge opportunity at that stage to spread and it took it.
Could we have another 1918?

I think we can and we must envisage a situation where a new pandemic could be worse than 1918. In spite of these new anti-viral drugs, which are pretty fantastic, in spite of new vaccines, we have immense traffic around the world.

In a day, I think 20 or 30 million people are moving. Once this new virus begins to break out, it will have opportunities, bigger than anything the 1918 virus could even have dreamt about. That’s why we have to be so careful. That’s why we have to be so guarded.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

Are we prepared for an H5 breakout?

We are spending a lot of time thinking about a lethal outbreak of H5N1 that would encompass the world, one that would give us a 1918 scenario, but in reality, when I wake up in morning, I think about what have we done, about what’s in the medicine cupboard, it’s pretty thin.

Science has progressed since 1918; there have been huge discoveries in anti-viral drugs for influenza. What we have not done, I would say, is press ahead and stockpile a sufficient quantity of either the anti-viral drugs, or vaccines, to give us any sense of preservation in the face of an outbreak. That is what worries me.

This pandemic virus is so threatening that we will have to throw the book at it. Everything will have to be thrown at this virus. Anti-viral drugs, vaccines, we’ll put people into quarantine. Everything will have to be thrown at this virus, to stop it spreading.

Now, how would society take all that? I don’t think we will. I don’t think we have a society now where you can tell people ‘Well, hang on a minute you are not going to go to a football match, you are not going to go to a cinema, you are not going anywhere for the next week because we are closing down everything.’

I think it will almost be like an Armageddon and people will find it very, very hard indeed to contend with that.

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How close are we really, right now?

It doesn’t matter how close we are. The important thing is to prepare, to stock up on the drugs and the vaccines. Then it will not matter if this outbreak begins tomorrow, or in two years time or in five years time. Because we’ll have our protection stocked away.

Can we actually have stockpiles built up in time for this onslaught?

We have the scientific know how now; we’ve made these anti-viral drugs. I think one now needs political will and commitment in cash to stockpile them. What we want is commitments from governments around the world, and realization that this is an important disease; this is not just something small here.

This could be the new beginning of an epoch, of a re-focus on infectious disease, a re-focus on the prevention of Mother Nature scenarios. Here is an opportunity that we’ve got now to apply new science, to apply new discoveries in preventing infectious diseases, so it could be a wonderful new epoch just beginning in the 21st century.

Can you walk us through the predicted phases of a pandemic?

I think, for the first time in human history, we’ve got a pandemic under a microscope. We are looking at the evolution of a pandemic. We are watching it almost on a day-to-day basis, as this virus is moving around in Southeast Asia, as it’s changing, as it’s moving from country to country.

What’s it going to do next? If it is going to break out from Southeast Asia, it’s going to have to have to decrease its killing power and increase its infectiousness. Once it does that, bang! It’s almost too late for any of us to do anything about it. That’s the kind of difficult situation that we are in at the moment.

The hospitals are going to be totally overwhelmed. You can get into an airplane in Southeast Asia and nine hours later you are in London, in a population of 12 million. You will be infecting people. They will be popping up everywhere. And then you are done for, unless you’ve got a plan, unless you are prepared. There will be complete and utter chaos. That’s what you’ve got to prepare for.

http://www.cbc.ca/fifth/nextpandemi...ews_oxford.html

The following is an edited excerpt from and interview with Dr. Michael Osterholm, conducted in late 2005...




Dr. Michael Osterholm
Director, Center for Infectious Disease Research and Policy
University of Minnesota
Minneapolis, Minnesota

Dr. Michael Osterholm is director of the Center for Infectious Disease Research and Policy (CIDRAP), associate director of the Department of Homeland Security's National Center for Food Protection and Defense (NCFPD), and professor in the School of Public Health, University of Minnesota. He is also a member of the Institute of Medicine of the U.S. National Academy of Sciences. In June 2005 Dr. Osterholm was appointed to the newly established National Science Advisory Board on Biosecurity.

Dr. Osterholm has been an international leader regarding preparedness for an influenza pandemic. His recent papers in the journals Foreign Affairs, the New England Journal of Medicine, and Nature detail the threat of an influenza pandemic and steps that should be taken in preparation for that event.
What is your sense of avian influenza as a threat to world public health?

One has to first understand that pandemics of influenza are like earthquakes, hurricanes and tornadoes. They will occur over some time, yet they’re unpredictable. We know we are overdue for another pandemic of influenza. There have been 10 in the last 300 years. Avian influenza clearly has to be at the top of the list right now of potential causes of that next pandemic influenza. For that reason, by itself we should be concerned.

But what’s making this particular avian influenza situation so serious is that it appears to be killing in a very similar way to that we saw in that 1918 pandemic flu virus, meaning that it actually uses the host immune response. When you combine that with the fact that we are overdue for a pandemic the potential for another 1918-like one is very real.

What was 1918 like?

The 1918 influenza pandemic began in the summer of 1918 and spread through the world over the next 24 months. It killed between 50 and 100 million people at a time when the world’s population was only 1.8 billion. (Today we have 6.5 billion people, you could understand the difference.)

Some may argue that today we have modern medical sciences and antibiotics and vaccines and therefore we would never experience another 1918-like experience. Unfortunately we don’t have the kind of vaccines that we need today to protect the world.

We don’t have antibiotics that would be effective against the primary way this virus kills. We might have an antiviral drug that might be effective, but it will be in very short supply.
The vaccine – how long is it going to take?

Ultimately, we must use the strain of influenza virus that begins to be circulated in the population and causes the pandemic as the new vaccine strain. We are prohibited from making an effective vaccine before the pandemic ever occurs. This means that we’re talking anywhere from five to six months after the pandemic begins that we will have our first vaccine available.

In addition, we can only really make about a billion doses of the vaccine a year given our current buildings, our current bioreactors, our current expertise. That means that if everyone needs at least two doses to be protected, only 500 million people in the first year would actually even have access to the vaccine. It’s not actually going to be there for us in a real meaningful way in those first days of the pandemic.

Key points:

How long will it take to develop a vaccine?

What would happen to our economy if a pandemic happened?

How prepared are we for a pandemic?

How worried are you?

People in public health say that in 1918 was little understood, that it was caused by a freakish combination of things like war, malnourishment and a virus that will never happen again – so it’s ridiculous to talk about 1918.

Pandemics of influenza have occurred dating back to antiquity and have been divided in two different camps. One camp of pandemics are those where a new strand emerges, but it typically kills the same way that the influenza seasonal virus kills (meaning that it does some damage to the lungs, but most of the deaths occurs as a result of secondary bacterial infections.)

On the other hand, 1918, which some describe to a unique situation will not occur again, actually has occurred in the past. We have evidence, for example, that in 1832 a pandemic of influenza even more sever than 1918 occurred. There is evidence dating back to the 1500 that this other type of pandemic occurs sporadically, where the virus actually does most of the damage by turning one’s immune system against the individual host.

So the idea that that couldn’t happen again is absolutely not correct, because it has happened multiple times in the past.

The second thing that people describe to 1918 is that there were these unusual conditions of crowding, that a war was going on. Well, that’s all true, but today when you look around the world you see first all the same kind of crowing for the vast majority of the population. Second we of all, we recognize that in 1918 that were many healthy individuals living in the rural areas of the modern and developed world who experienced the very same mortality rates that we saw for the soldiers in the battlefields or those whole lived in the concentrated and crowded areas. In that sense, there is no reason to think that that year was a unique factor.

In addition, there were 12 different studies that were done associated with the 1918 pandemic that looked at the actual deaths among pregnant women. There was a particularly high rate of deaths among these individuals. Studies showing between 35 to 70 per cent of women who died were pregnant. It did not differ whether you were in the United States or in Europe or even in Africa; whether or not you came from low, middle socio-economic classes; or whether you even had access to what was then called modern medical care.

And that’s why we are so worried today – because H5N1 in Asia has many of those same properties that the 1918 virus possessed.

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If something were to emerge today or tomorrow how would it spread around the world?

Today we are jetting around the world in almost unprecedented numbers. Wherever this influenza pandemic begins, it will be around the world in short order. We saw that with SARS, even though it emerged in the Guangdong province of China, it very quickly made it’s way out to Hong Kong. Just one visitor to one hotel sent it to six different countries and five different continents overnight. That type of spread will occur quickly with this and that is of great concern because it means we won’t have much time on a worldwide basis to prepare for the emerging pandemic.

What will be the effect on economies?

One of the most misunderstood aspects of a modern pandemic is not the medical side of the concern, but the social political economic side of it. One of the major differences between a potential impact of a pandemic today versus that of yesteryear is that of our global ‘just-in-time’ economy.

We all like to think that our borders will allow us some means to protect ourselves from the spread of the virus. What we fail to realize is the one global just-in-time economy has really eliminated those borders for all intents and purposes.

Today the critical goods and services that we enjoy in the developed world countries in many instances come from the developing world. If we were to put a rock in the gears of the global just-in-time economy, we would find many of the goods that we depend on every day for our daily lives would not be available. That in turn would create a spiral of other kinds of collateral damage problems.

Many of the medicines that we use in developed world countries would stop being shipping from one country to the other. Then there are critical medical devices: things like protective masks, or even machines that we use to keep people alive. We see that with our food supply. Today we have a global food supply and in many instances in Europe and in the United states the produce we eat comes from a developed country.

Suddenly the entire economy goes into a tailspin – when that happens, none of us have a clue as to what it might take as to bring that back out of that tailspin. I think that this is going to be an issue for economists, for policymakers, for leaders to begin to address because if we don’t the collateral damage from a pandemic could very well make the overall pandemic itself be just a small piece of the actual damage.

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How prepared are we for a pandemic?

Our group here in Minnesota has actually been on the leading edge of a number of emerging infectious disease issues dating back several decades. We were one of the first groups to actually sound the alarm back in 1981 around HIV/AIDS. We were early on into the area of antibiotic resistance; we were the ones talking about the problems with changing food supplies in the 1980s.

Every year we talked about pandemic influenza, particularly since 1997 and the first emergence of H5N1 in Hong Kong, we’ve recognized the potential for this virus to actually be the next cause of pandemic of influenza. And as each year has gone on since 1997, our lack attention as a world to preparing for this has become increasingly frustrating.

One day we will have a post pandemic commission looking at world leadership as to why we weren’t better prepared. I’m afraid that they will deliver a verdict that we were derelict in duty as public health officials, as government officials and even as a private sector in terms of getting prepared.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

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How have we been derelict?

We’ve been derelict in large part because of our lack of understanding of what this means and what we must do about it. The kinds of facts that we lay out as public health officials about the potential for a pandemic implication are not rocket science. When you understand the past and realize that we should have 20 years ago (after our first real scare with another pandemic and the swine flu situation) made a major investment into the vaccine development, procurement and delivery for flu. We didn’t do it. We just didn’t do it.

Today we live in a world with a 1950’s influenza vaccine technology supply chain. We also have to take head-on what kind of medications might we use if the flu were to occur and we weren’t able to get adequate vaccine supply. Our research and development around antiviral drugs for influenza has been miniscule. That’s why today we only have two drugs that could be potentially used, only one of them readily available and even that again in very short supply.

We’ve done very little. We’ve done almost nothing on our supply chain side to understand what are those critical goods or services that we must maintain during a pandemic. Today when we have a crisis, a bombing in the subway or we have a hurricane, any number of different things, we are able to respond because those are very limited interruptions in one given area for a very short period of time. We can bring in goods, we can bring in experts, we can bring in all kinds of services from other areas to help with that.

We are going to need those same kinds of goods, experts, or services and they won’t be there because we’ll be stretched so thin. It won’t last for a day, a week, or a month; it’s going to last for months and months and maybe several years. When we consider that we have done virtually no planning whatsoever as to how we may respond to that. How will we survive it?

One of the things I’m concerned about is influenza preparedness and planning. The Canadians are a good example. Two years ago they were given great credit for moving forward with vaccine production capabilities, to do the research necessary to find a better vaccine for influenza that could be utilized quickly in a pandemic situation. Virtually no funding was put forward for that and as such the Canadian research and development activity has gone nowhere. Why has that been allowed to happen? Why in the U.S are we investing so little into this particular situation when we look at all the money in many other areas in the world in many other issues?

I think it’s shortsightedness. We tend to be a reactionary world. We tend to not really think through what are those major causes of catastrophic damage that we cannot allow to happen. And what are those ones that if they do happen it’s unfortunate it’s sad, but we can get through it. We have never prioritized where our really most venerable spots are and what we must do about them. Influenza has to be at the top of the list.

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How worried are you?

Having been involved on an international level with issues like HIV/AIDS, antibiotic resistance, even terrorism, I am convinced that at the end of the day there is nothing that will equal that of pandemic influenza.

For many years I was asked ‘How do you sleep at night with all that you deal with and you know about and that you are trying to address?’ And to some embarrassment I would always say, I’m sorry but I do.
This is the one issue that keeps me up at night. I actually lay there thinking – my God, this is actually going to happen. I think about this from my own family stand point, not just as a professional and I get frustrated thinking that as a world we have had ample opportunities – we’ve had ample to time prepare, and each day each moment that ticks off that we’re still not better prepared for pandemic influenza is a day that we’ll regret later. That maybe is the thing I think about more than anything.

http://www.cbc.ca/fifth/nextpandemi..._osterholm.html

The following is an edited excerpt from and interview with John M. Barry, conducted in late 2005...



John M. Barry
Author, The Great Pandemic: The Epic Story of the Deadliest Plague in History

John M. Barry is the author of The Great Influenza: The Epic Story of the Deadliest Plague in History, which tells the devastating story of the 1918 flu pandemic, which killed more people in twenty-four months than AIDS killed in twenty-four years, and more in a year than the Black Death killed in a century. Barry has been watching the emergence of the most recent avian flu threat, and has suggestions for ways in which we might head off another flu pandemic.

Barry is the author of four previous books, including the highly acclaimed and award-winning Rising Tide: The Great Mississippi Flood of 1927 and How It Changed America.



What are the similarities between 1918 and the current avian flu?

All influenza viruses start out as bird viruses. There are two ways they become human viruses. It can, as happened in 1918, simply mutate its way into a human virus. But there is another way called re-assortment when, if an existing human virus infects a cell, and that same cell infects an existing bird virus, the two viruses can exchange genes. What emerges will be a new virus, combining the different elements of those two viruses. It will be seen as a new virus, so the immune system won’t be able to respond to it and it will spread explosively around the world.

How does a virus attack a cell?

Imagine a pirate ship with grappling hooks. The virus will throw a bunch of grappling hooks at a cell and bind to its surface. Then it will attack the cell, by working its way through the cell membrane. Once it’s inside the cell, it’ll make its way to the nucleus.

The virus then orders the cell’s machinery (every cell essentially is like a little factory) to make new virus particles. A single cell will produce between 100,000 and a million influenza virus particles. (However, the virus mutates so rapidly that 99 per cent of those virus particles will not work. They won’t be able to replicate themselves.) That still leaves between 1000 and 10, 000 viruses from a single cell that can work, that can infect another cell and start the process all over again.

That’s one reason why influenza seems to strike suddenly rather than gradually. With a bacterial infection, you’ll get sick gradually. But a viral infection, it has this logarithmic jump in the number of cells that are affected over a period of a few hours. The onset of the disease can be extremely sudden. You can be feeling fine when you go out to work in the morning, and by the mid-day coffee break you are virtually collapsed.

In 1918 there are reports of people who went out to work in the morning and were dead before they came home that afternoon. I’m not sure I believe some of those reports, but there are clearly cases where people died within 24 hours of the symptoms that are well documented by scientific observation.

Key points:

What is the influenza virus?

What drew you to focus on the 1918 pandemic?

In 1918, how did the virus kill people?

How did people try to protect themselves in 1918?

Who was most vulnerable in 1918?

What can we learn from 1918?

What would you do in the event of a pandemic?

How do you describe a virus?

Viruses are on the edge of life. I think most scientists believe them to be living organisms, but some don’t. They don’t do anything but reproduce themselves. They don’t eat, they don’t excrete waste, they don’t breathe, and they don’t have a metabolism. They are simply an invasion of genes into living cells.

Since they are not fully alive, it’s hard to target them. We understand a lot about how they function, and we certainly understand a lot about the influenza virus, but we have yet to figure out a way to cure the disease.

Our only real weapon against it is vaccination. There are viruses that we have developed very effective vaccines against, polio for example. And yet there are some influenza, or the common cold, or HIV, which we have not been able yet to develop a vaccine against despite intensive work.

What’s the relationship between birds, pigs, people and the virus?

All influenza viruses start out as bird viruses. It mutates very rapidly. This allows them to jump species – not only to people, but also to other mammals. In terms of pigs, some virologists refer to them as a ‘mixing vessel,’ because a pig’s cells actually have receptors on them, which make it easy for an avian virus to invade a cell.

Human cells do not have receptors that are naturally conducive to binding with a bird virus directly, although obviously it can happen, and it did happen in 1918 with H5N1 and it’s happening now.

Why were you personally drawn to studying the 1918 pandemic?

I was interested in the home front during World War I, which to me is always seemed like a crucible where a lot of pressures in American society came together and then exploded in 1919, right after the war. It was like a pressure cooker on the home front. The lid was being kept on during the war, but as soon as the war ended than all those pressures were just released.

I was also always interested in the influenza pandemic. There was a figure in the book, Oswald Avery, whom I identified with a lot. Avery was one of the greatest scientists in the 20th century. As a direct result of his studies, beginning on influenza, he discovered that DNA carried the genetic code. It took him 25 years of work to come up with that. And during much of that time he wanted to throw everything he was working on out the window. I identified with him a lot during at least half of the seven years that I worked on the book.

I wanted to toss the whole thing. But the last year and a half, it started to come together. And obviously I am happy with the book, and I’m glad now that I did it. Although it’s one of those experiences that you look back on and don’t want to go through again.

It was very difficult finding material, and it was very difficult making sense of the material that I did find. When I started writing the book, I expected to be overwhelmed with information, but as I started looking for this information, much of it that I expected to find easily, didn’t exists. Most of the scientists didn’t make laboratory notes, they were too busy to do any of the things they would do routinely. Or they were too sick. As a historian, and as a writer, you would want those things that they usually keep track of, but under the crisis, they didn’t.

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How did a person die with influenza in 1918?

The overwhelming majority of Westerners who got influenza in 1918 had exactly the same disease that you are familiar with today. You have a terrible three days, and a week later you are fine. But a minority, and it wasn’t a tiny minority, had an entirely different experience. Their symptoms were extraordinarily varied, and severe.

People could turn so dark blue from the lack of oxygen that physicians had reported they had difficulty distinguishing black patients from white patients. Some of the more horrific symptoms included bleeding from your nose and mouth, and from your ears and even your eyes. In some cases, literally, the floor would be covered in blood. It was an incredibly gruesome situation.

What did people in the communities do to protect themselves?

People isolated themselves. I think a lot of that was because we had two things going on. First, you had the government line. The Surgeon General of the United States said: “There is no cause for alarm.” There was cause for alarm, but his reassurances were repeated over and over by local officials practically everywhere. Meanwhile, people see their spouses die horribly, in less than 24 hours, and undertakers are not available, cemeteries are full.

People rapidly lost all faith in authority, and didn’t trust anything that they were told. This created a sense of alienation, and made it every person for himself, or herself. It spread terror and isolation.

The Red Cross reported that people were starving to death – not from lack of food, but because people were too frightened to go near the sick to bring them food. In most cases, you know, the communities began to fall apart.

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What seemed to work that we could look at now?

Nothing really worked in 1918, nor would it really work today. Cities passed ordinances against shaking hands, against spitting. Washing your hands constantly could work. Limiting your contact with people could obviously limit your chance of infection.

The streets in many cities around the world virtually emptied in 1918. It just froze society once it got going. Absentee rates were 40, 50, 60 per cent in some of the war industries.

In the army camps, scientists reported that in the camps that used quarantine rigidly, they did seem to have some effect on the course of the virus. But if the quarantine was not rigidly enforced, if there were any exceptions made at all, it didn’t seem to have any effect whatsoever.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

Who was at most risk to die in 1918?

If you were a healthy young adult, and you interacted with people, you were at the highest risk of dying. The one demographic subgroup was probably pregnant women – they are young adults already, and they have the additional burden and stresses of pregnancy on their body already. Pregnant women had the highest rates of mortality - sometimes extraordinary - mortality rates.

In 1918, how did they deal with the people dying so quickly in such a short period of time?

The ‘death system,’ the mortuaries, the cemeteries, and so forth, they were just overwhelmed. Bodies lay in homes for days at a time, sometimes more than a week. In Philadelphia, you literally had priests driving horse-drawn carts driving down city streets calling upon people to bring out their dead.

They were buried in mass graves, dug by steam shovels. It was a horrific circumstance. In some cases, where they had funerals, there were no coffins. They were, for each funeral, renting coffins. They would have a service with somebody in the coffin, and then the body would go to the cemetery without a coffin, and then that same coffin would be reused for another service 15 or 20 minutes later.

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What were the biggest mistakes in 1918 that made things worse?

Not taking influenza seriously. The second biggest mistake was that governments did not tell the truth to the public.

I don’t think that would occur now. Since 2003, and even more recently, influenza has gotten an enormous amount of attention and governments are taking it seriously now. At least Western governments are.

The second problem, not telling the truth to the public, I’m not so confident that that would not repeat itself. It’s already been demonstrated that governments in Asia haven’t entirely told the truth.

In the end, what can 1918 teach us? So much has changed scientifically, the general health of people, is it really useful looking at something from that long ago?

1918 teaches us how lethal influenza could be. It teaches us certain things about the importance of telling the truth when there is a major event of any kind. Even when the population was totally panicked, people who were trained did their jobs. Not just nurses and doctors, who behaved with unbelievable heroism and went into the worst areas and died in large numbers, but the police and volunteers who removed the bodies from homes. The lesson is that these people, if they have a sense of what they are supposed to do, they will do their jobs. If people are actually trained and know what to expect, they will continue to function.

But if there is no leadership and no preparation, you run the risk of a disintegration of services. It’s very important not just to have plan but also to practice that plan, and to prepare people.

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What would you personally do if H5N1 developed into a pandemic?

I think it’s important to recognize that any pandemic is a serious event. We are most worried right now about H5N1 because it’s been killing half of the people it infects. But, we don’t know that the next pandemic – and there will be another pandemic, the nature of the virus virtually guarantees it – we don’t know if it’ll come tomorrow, or if it’ll come in 20 years.

Our society has changed so much even since the last pandemic in 1968, which was so mild that most people who lived through it aren’t even aware that a pandemic occurred. Yet that mild virus, if it struck today, would today kill between 89,000 - 200,000 Americans. That’s a pretty severe blow.

And the impact on the economy would be even greater than it was in 1968, because our habits have changed. Businesses have become so much more efficient because there is no slack. You have just in time inventory, you more people more frequently eating out at restaurants, you have no excess hospital beds, you have all sort of things that mean even a mild pandemic would be more severe today than it was in 1968.

In terms of what I personally would do, frankly I would cut down on my contacts with people. I would sit at home as much as possible with my family. I certainly wouldn’t shake hands, and I would have a large store of canned goods and bottled water and hunker down.

Do you have your own personal supply of Tamiflu?

No. Tamiflu is not an answer. The virus is one of the fastest mutating viruses in existence. I don’t have any faith that this virus, once it got into the human population, wouldn’t develop resistance to Tamiflu, or any other individual antiviral. The real answer will be a vaccine that will work against all influenza viruses.

http://www.cbc.ca/fifth/nextpandemi...iews_barry.html

The following is an edited excerpt from and interview with Dr. David Butler Jones, conducted in late 2005...



Dr. David Butler Jones
Chief Public Health Officer
Public Health Agency of Canada
Ottawa, Ontario

Dr. David Butler Jones works on behalf of the public to inform and provide leadership to the government's efforts to protect the health and safety of Canadians. He also manages services, both laboratory and expert, to health officials across the country in order to support the public health system in Canada.

Previously, Dr. Butler Jones has served as Chief Medical Health Officer for the Province of Saskatchewan and Executive Director of the Population Health and Primary Health Services Branch for the province. He has worked in many parts of Canada and has experience with consultations and work exchanges in places as diverse as the Dominican Republic, Turkey, Scotland, Brazil, Kosovo, and Chile.


Why is the world concerned about H5N1 right now?

The main concern is that this particular avian flu has been going on, it’s not settling down. It’s spread to other bird flocks across Southeast Asia. It doesn’t seem to be slowing down. The concern is the potential for spread into humans. If that were to happen, it would be a very large concern.

Why should we be concerned about influenza?

Influenza itself, even in the in-between of pandemic years, kills thousands of people prematurely in Canada and around the world in larger numbers. It is a disease that is preventable through vaccination. It is easily spread from person to person and it is a disease that we can actually do something about.

How do you die from a type of influenza virus?

It’s a disease that starts off like a cold. You develop a cough, fever, muscle aches, etc. In some cases, that’ll go on for four five or more days and then you get better. In some cases you develop secondary pneumonias or sinus infections. Those are the secondary bacteria infections that are of concern and in those cases antibiotics can help.

How would you hear about a pandemic if it was starting to emerge in Southeast Asia?

There is surveillance going on. We are involved as public health agents working with these countries, providing technical support and being involved with them directly. We would get reports back either through WHO, through the country directly, or through the public health information network which constantly monitors media around the world looking for events of outbreaks, bio-terrorism, a whole range of things that then is that first alert. Once you get that alert, you investigate to see the extent of the problem.

Key points:

What are the strategies for slowing down a pandemic's spread?

What sorts of measures should Canadians expect to see?

Who gets the vaccine first? Who is the priority?

What can I do to protect myself now?

How seriously are Canada's political leaders taking the pandemic threat?

We would be involved with our counterparts both at WHO and in the affected countries to verify the problem. Then we would be informing public health authorities in Canada, bringing together expertise to assess our pandemic plan.

How would we slow down the spread of a pandemic?

There are a number of ways that you can slow it down. The use of antivirals may help, but there is no guarantee of that. Secondly, assessing the situation: what kinds of issues are there around travel? How do we monitor people, or give people information at border points to make sure that if they have symptoms they get appropriate medical attention? Making sure that people understand the importance of washing their hands properly.

Staying home if you are sick, covering sneezes and coughs, using the alcohol gels, washing of hands… All of these things we know, whether during the event of a pandemic or even now, can help prevent the spread of infection.

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At what point do you recommend to the government that travel to Southeast Asia gets suspended?

It really depends on the situation. The point at which you might consider that is where the spread is increasing, it’s infecting a number of communities, it doesn’t seem to be slowing down … at the same time you recognize the impact of suspending travel, so you don’t do it lightly.

How likely is it that if a pandemic broke out in Southeast Asia that you could stop from arriving in Canada?

The likelihood of being able to completely stop the outbreak of influenza is very small. Part of the difference between SARS and influenza is that we SARS carriers weren’t actually infectious until they had symptoms. Whereas with influenza, you could be infectious before you have symptoms.

I could shake your hand today. I rub my nose, I shake your hand, and you rub your nose. I have no symptoms. Tomorrow I come down with influenza, and the next day you come down with it. The potential of it to spread without being recognized early on is much easier and its ability to infect is much easier then many other diseases. That’s why the basic precautions, the frequent washing of hands, the covering of sneezes, the staying home when you’re sick, can slow it down. But could we say we’d ever be able to stop it? That’s unlikely.

What sort of measures will Canadians see once a pandemic emerged in this country?

The expectation is that businesses are planning for influenza as a potential threat to continuity in the business. What you would see is that each business would assess, depending on the situation, perhaps asking people to work at home, rather then coming in to work. In terms of schools, again depending on how its spreading, we might need to look at limiting school and other extra-curricular activities, to limit the spread. Or you may find that in terms of controlling it, it’s more effective to have the kids in school – but you have to have hand-washing programs and other things.

It would really depend on the scenario as it’s evolving, and that’s something that we will constantly need to assess to make sure that people have the best advice possible.

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You may have a large amount of deaths - what kind of problems might that pose for medical staff?

This is where the local planning around pandemic, not that you want to think about it, are the undertakers to deal with it. Maybe you’ll need to have a cool area to store bodies for a short period of time, to commandeer ice rinks and other facilities. That’s all part of the planning. While we may not like to think about it, these are important things to have in place. Hopefully we will never need them.

What sorts of preparations have been talked about in Canada?

Planning occurs at several different levels. At the national level we have a pandemic plan. We were the first in the world to have a national plan, and many other countries have been making use of it. At each provincial and territorial level there is a plan as it’s appropriate for their needs and for their situation. Local plans are also being developed with hospitals, family doctors and other practitioners, as with the local business communities, other providers, social services/.

Who gets the vaccine first?

The protocols continue to evolve around understanding the issue and that may change based on what the appearance of the virus is and who is most affected, and who is most at risk. Clearly you want to insure that there are some minimal essential services set in place: frontline health workers are there to provide care, as well as essential services. If you need a minimum of two people to run the water works, then you want to make sure they are immunized, and other sort of important decision makers, and then those who are at greatest risk of suffering in terms of their likelihood of dying.

There is a range of priorities, they may change and they continue to be re-evaluated as our understanding of the virus continues to improve.

And family members of people who are important?

Again, that depends on the situation at the time. If you only have a limited amount of the vaccine, then you need to protect those that will protect the integrity of the society and it’s a difficult challenge in terms of family members, if they are not engaged in that work then we may need to look at, where people for a period of time are not staying together in order to protect their family. All of these things are decisions that will be based on the issues that we face through the outbreak should it occur.

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What can I do to protect myself before the vaccine arrives?

There are two things. Clearly, the basic issues that we talked about in terms of the washing of hands, staying home if we are ill, the basic kind of things that reduce the spread of a whole range of infectious diseases, that’s one.

And two, keeping ourselves in good health. The more we can do to look after ourselves: basic nutrition, physical activity, and all those things that kind of keep us in good shape, that’s also essential in advance.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

Are we due for a pandemic?

Most experts would say you would see three or four pandemics in a century. The last one was in the late 60s, so we are 40 plus years since the last one. Could we see one next year? Or could it be five or ten years? Nature is quite unpredictable about these things. It could be a soon as a couple of years, it could be five, ten or 15 years.

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What is it like to die from influenza?

I haven’t done that yet. I may some day. For those who are affected, it’s a range. In most situations it’s the development of pneumonia, and the inability of the body to fight it off.

What was it like to die in 1918-19?

In 1918-19 you had the full range. You had those who died of secondary infections and you had those who died rapidly, unable to breathe. Much like SARS, much like some of the atypical pneumonias, that inability to catch a breath is kind of like drowning in the midst of air.

How seriously are politicians in Canada taking the threat of some form of pandemic?

I’ve been very impressed. They are concerned about this and we continue to develop the planning and processes that will help us as Canada to respond as effectively as one would hope in this kind of situation.

People are taking this seriously. It’s a tremendous challenge when it hasn’t happened yet, we don’t know when it’s going to happen. Some people are saying it’s imminent and then some months later WHO says that well maybe it’s not imminent once we reassess it.

There is a risk that being too negative, it sounds like the boy who cries wolf. Two or three years later, if haven’t seen it, people go away.

People shouldn’t be lying awake worrying about it, but people in public health and governments need to be worrying about it enough that we continue to plan to prepare to set ourselves in a situation where we will be able to respond as best as possible in a very difficult situation.

That’s kind of where we are at now. Nobody can predict exactly when we’ll face it, someday we will.

http://www.cbc.ca/fifth/nextpandemi...utlerjones.html

The following is an edited excerpt from and interview with Dr. David Fedson, conducted in late 2005...



Dr. David Fedson
Medical Director, Vaccines Division, Sanofi-Aventis (retired)
Fellow, American College of Physicians and the Infectious Diseases Society of America

Dr. David Fedson is an expert in vaccines of many kinds, including influenza. After spending 30 years as a clinician and researcher in the Universities of Chicago and Virginia, Dr. Fedson joined the Medical Department of Aventis Pasteur MSD, a vaccine company located in Lyon, France.

Since the mid-1970s Dr. Fedson's research has focused on adult immunization with influenza and pneumococcal vaccines. During this time he has published more than 100 scientific articles, chapters, and abstracts on the subject. Dr Fedson is a Fellow of the American College of Physicians and of the Infectious Diseases Society of America.




How close are we to this pandemic?

It’s really impossible to say how close we are to the next pandemic. Everyone who is knowledgeable about this will say the pandemic is inevitable; we know the pandemic clock is ticking, we just don’t know what time it is. As each day, week, month goes by we are getting closer to the inevitable next pandemic.

What’s is your hypothesis of how an influenza pandemic would spread in today’s world?

For me one of the important lessons to be learned from the pandemics of the twentieth century is that despite the enormous amount of international travel that we see today, we do not have to assume that the next pandemic virus, once it appears in a human community, is going to spread rapidly around the world and within a matter of a few weeks cause devastating disease world wide. This it not the evolution of the pandemics of the twentieth century.

In 1918 the first wave of infection occurred during the springtime, but the really deadly second wave did not occur until the following fall. If we look at our most recent pandemic in 1968-69 we find that the virus appeared in mid 1968 and caused pandemic disease in many countries including the United States and Canada in the fall of 1968-69. But in fact the excess mortality experience was worse the following year in the U.S., three provinces in Canada, and in France and Germany.

Now why did this virus, which was causing pandemic disease, why did it wait for more than a year to cause its real mortality impact in several countries? We have no idea why the virus behaved that way, but it did.

For me, the lesson that I take from that is that history tends to repeat itself and we should say that despite our international travel capabilities today the virus is not going to depend upon just 747s to move out – it’s going to behave in the way that it has behaved in the past and that means many parts of the world and probably billions of people will have time to prepare and to do things that will help protect themselves and help them to confront the pandemic experience once the virus arrives.

Key points:

What would happen to society if a pandemic struck?

Why is H5N1 so dangerous?

How are you and your family preparing for a pandemic?

What is the goal in developing a vaccine?

What would happen if there were news of an influenza pandemic outbreak today?

If the pandemic were to start today I think we would have tremendous confusion at the scientific level, at the level of the companies that make vaccines and antivirals and medical supplies. We would have extraordinary confusion at the public health at all levels: local, state, national, and international. Very quickly we would have an international political crisis, the likes of which we have never had to deal with in the past.

Very quickly it became evident to all those participating in this exercise that each country would tend to take care of its own people immediately. When you have a global epidemic and pandemic where people in all countries are involved, there has to be some sort of sharing of resources, sharing of expertise if these communities are to work together and survive. If the tendency politically for these communities is to look out for themselves, then that is going to create tremendous political pain. It’s something we have to anticipate and I don’t know to what extent any of the political institutions at the national or international level have even begun to map out what their behaviour is going to be once the pandemic appears.

I don’t think we have the international mechanism to deal with this. If we take a look at the AIDS epidemic, this is a horrific event that is devastating countries in sub-Sahara Africa and will soon devastate many other countries closer to Western Europe, North America in the developed world. How long has it taken for us to begin to build the international focus of attention and bring the resources to try to control HIV/AIDSs in the area of the world where it’s most devastating?

It’s taken 20 years. Why? What is it that takes people that long to pay attention to these kinds of events? We tend not to have the imagination – and even if we have the imagination, we don’t have the kinds of human institutions that are able to take a global event like this and come up with practical solutions and how to manage it.

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What is it about this particular virus that is so severe?

We don’t know what our pandemic virus is going to be. There is a lot of concern about the H5N1 virus in south East Asia now, the bird flu. Is the next pandemic going to be caused by the bird flu virus? We don’t know. Many people think that it’s certainly possible. Other people would say, ‘Well if it is possible, why hasn’t it caused a pandemic when this virus first appeared in 1997? Here we are eight years later, no pandemic. What’s going on?’ I don’t know.

We know that this virus can infect human beings. We know that when people are infected with this virus that many of them become very ill, and that this illness is particularly severe in younger people, and that it carries a high mortality in recognized cases. But the H5N1 virus is not the only virus that we need to think about as having pandemic potential.

There are viruses known as the H9 viruses. There is an H7 virus that caused outbreaks of disease in the Netherlands a couple of years ago. There is the H2 virus that caused the 1957 Asian influenza pandemic – if that were to come back again, two third of the world’s population living today would be totally susceptible to this virus. That’s all you need to have pandemic circumstances and allow this virus to spread worldwide.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

What is the worst-case scenario?

We have to believe that something like 1918 could occur again, because it’s occurred in the past. What would we do if we have a pandemic virus like that and it would have the potential to killing 175 to 350 million people? How would we respond in our communities?

I think that any scenario you choose to imagine. We live in a society in which everybody is playing some sort of a role in providing a service. What happens if all the people who supply cash to the cash machines are sick? We can’t go shopping we can’t even buy the little food that is of our shelves of our supermarkets because it’s all been bought and it’s not being delivered anymore. We have some potential for very serious breakdowns in the very fabric of our daily life if a pandemic comes and we have to prepare for that.

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What about your own preparations for you and your family?

I have done nothing. It’s a very difficult sort of decision. Some people would say you better go off and buy a supply of antiviral medication, which may help save the lives of your family and yourself, but in a situation like this where you have a stock of antivirals and nobody in your neighbourhood has a stock of antivirals and your neighbours begin to die and their children are dying – what do you do? Do you just lock the door? Do you get out your shotgun to defend yourself?

We are really talking about a situation of human survival and the ethical dimensions of the choices that will be faced are very hard to predict. Do I have a family supply of anti virals? No. It might make me feel safer in one respect, but it might make my life a lot more difficult to live in the face of pandemic moving through my community when I saw what it was doing to other people without antivirals.

What are the goals for developing a vaccine?

You want as much vaccine available as quickly as possible – if you get it there before the first wave and some parts of the world, great, but I think you can be fairly confident there will be more than one wave of the pandemic virus sweeping individual countries. You want to get as much vaccine out there as possible.

The criteria for developing the vaccine should be not to produce a vaccine that is optimally protected for an individual, but one that is acceptably immunogenic or protective for a population. That’s an entirely different perspective that we have had for any of the vaccines that we have produced for any disease up until now. The focus in vaccine production has always been to develop a safe and optimally protective vaccine for individuals. You have got time to produce as many doses of vaccine as can be sold, or purchased by public health authorities or bought by individual families. Here we have an entirely different situation.

We have got to find a formula for the vaccine that will be both safe and acceptably immonogenic so that we can produce the largest amount of doses as quickly as possible.

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Do you think there will be security issues around the transport of the vaccine once it’s available?

The issue of vaccine security when supplies are limited would be immense. You will find black-markets developing and people trying to profit from limited supplies of vaccine. Unscrupulous people in some states that were trying to sell bootleg vaccine or false vaccine for 10 times the price it normally would have obtained. We can expect to see activities like this spring up everywhere.

The security issues are going to be immense and I would think that there are a lot of countries that have already thought of the security and have plans for their military and their national guards on what to do. When supplies of vaccines begin to become available, protecting those supplies and distributing them in a coherent way that meets the needs of the population of public health is going to be a very large challenge.

http://www.cbc.ca/fifth/nextpandemi...ews_fedson.html

The following is an edited excerpt from and interview with Dr. Allison McGeer, conducted in late 2005...



Dr. Allison McGeer
Director of Infection Control
Mount Sinai Hospital
Toronto, Ontario

Dr. Allison McGeer is one of Canada’s foremost infectious disease specialists. At Mount Sinai Hospital, she has developed a clinical and epidemiologic research groups to conduct population-based surveillance for infectious diseases and to study infection risks, prevention and control in long-term care settings.

In addition to her position as director of infection control at Mount Sinai Hospital, Dr. McGeer is an infection control consultant to The Scarborough Hospital and the Baycrest Centre for Geriatric Care. She is also an Associate Professor of Pathobiology and Laboratory Medicine and Public Health Sciences at the University of Toronto.

If there were human-to-human transmission in Thailand, how would you as a doctor first hear about that in Toronto?

I’d likely first hear about it through a national notification plan that was developed post SARS called KIOSK but it would come simultaneously through that system through PROMED, probably on CNN, and through a variety of other public health notification systems that are active. I’d probably hear it simultaneously on the news, from PROMED and from all three levels of government in Canada.

The key question is when we move into World Health Organization Pandemic Level Six, which is a little beyond human-to-human transmission. The key timing issue is when we move from some limited human-to-human transmission to “we think the pandemic is starting.”

That’s not likely to be a single on/off switch. I think there’s likely to be a period of weeks, maybe months, of increased anxiety, of not being absolutely certain what has happened. I think there is likely to be a prolonged period of time where we’re starting to move into the pandemic mode and we’re not really sure it’s going to happen.

For that period of time there will be a lot of confusion, there will be a lot of disagreement about exactly how far we ought to be going. At the moment, at the ground level where I work, there’s also not really clear decisions made yet about what we’re doing at different stages.

The first thing that will happen when this notification comes is that there will be an immediate diversion of resources into working on the plan and trying to make it better and functional. And the important pieces of that plan are obviously how we’re going to manage patients who do have influenza, and how we’re going to manage patients who don’t have influenza.

Will every hospital in the country have its own pandemic plan?

Every hospital in the country has to have its own pandemic plan. Every hospital has a different population of patients, a different physical structure, a different management structure, and a different number of entrances to the building. We have templates for pandemic planning, but exactly how things are going to function is very hospital-specific.

Key points:

How prepared are Canada's hospitals?

Is it possible to prevent a pandemic from reaching North America?

How will hospitals deal with the crowds?

What can I do in the early stage of a pandemic to protect myself?

Is leaving town a good way to protect myself?

How often should I wash my hands? Should I wear a mask?
What should I be doing now to get ready for a pandemic?

Across the country, what’s the range for preparedness in healthcare institutions for a pandemic?

At this instant, most healthcare institutions have recognized the need for a pandemic plan; many have a pandemic plan in some stage of development. Very few have a pandemic plan that has been practiced at any level, and even fewer have a pandemic plan that they would say they were happy with, or that really makes them prepared for the pandemic.

Let’s say a pandemic has begun – what sort of things should governments be doing at that point to prepare people here or to prevent it from coming here?

We’re not preventing the influenza pandemic. There is no opportunity to prevent the influenza pandemic. We will attempt to do things that will slow the spread from country to country and prevent it from spreading. But what evidence we have is that none of those efforts will work, particularly if it’s a severe pandemic and people are very ill, we will close borders, we will attempt to stop movement.

But we know that those attempts will not be successful. Really, it’s about preparing for when it’s going to come and trying to minimize the damage when it arrives. The most important thing we’ll be doing is trying to make the decision at the right time to go for maximal vaccine production and hopefully we’ll have some more information about how to make vaccines and how much vaccine we can make.

If we’re talking about H5N1 as the next pandemic, those efforts will not get us anything like sufficient vaccine in time to protect even essential workers or very high risk patients.

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Once there’s sustained human-human transmission, how quickly might you expect it to make it to North America?

The situation could in some ways be similar to SARS where it was approximately two weeks from the time that people recognized that there was a significant problem to the time that we had sustained transmission in Toronto.

And it is not impossible – it’s unlikely, but not impossible – that the very earliest piece of sustained transmission would involve travelers to Canada, because you’re not going to detect sustained transmission at the moment of it happening.

How long would it take us to get vaccine ready to use or to manufacture?

Realistically, to have any amount of vaccine supply, we’re probably talking about a good deal longer than six months.

If the first wave of the pandemic happens in early 2006 and if it’s avian influenza, we will not have vaccine in Canada for the first wave.

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How on would you handle 1,000 people lining up to see a doctor the first day of the pandemic – perhaps even 10,000 the next day?

It’s not going to be easy, unless we do a lot of planning between now and then. It’s not going to be smooth; it’s probably not going to be particularly efficient unless we accomplish a great deal before the pandemic arrives.

But we have survived through previous pandemics; we will survive through this one. It requires as much organization as we can get to create efficient triage systems for identifying who the seriously ill people are, who the people are who need to be admitted to the hospital, and who the people are who can be sent home with instructions.

Would you set up tents outside the hospital?

Tents are probably pretty effective for a lot of hospitals as long as the weather’s good enough. If it’s a mild enough pandemic, some of us may be able to divert resources from other ambulatory care clinics so that we don’t need tents. If it’s a severe enough pandemic then we’ll be co-opting arenas, the Air Canada Centre, hotels…

Part of pandemic preparedness in that this is the kind of information that people will be supplied with is very specific about what to do with different types of symptoms, when you need to report to a doctor, where you need to go to do that.

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What is the basic message to give people in the early stages to a population?

The important thing is to be clear to people about when it’s safe for them to stay home and when they need to come into a hospital, when they need to see a physician. For example, children under six months of age need to be seen very quickly, no matter how ill they are because they can be very unstable very quickly.

For people who are older, it’s about understanding that if you develop acute shortness of breath or your fever’s not resolving after a period of time, that’s when there’s likely to be a complication that may become serious.

Some of those messages will change a little bit depending on the pandemic, because the pandemic may vary in severity, and because who gets sick quickly and who gets sick severely may be different.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

When it comes to the media, what’s irresponsible and what’s responsible, in terms of reporting?

I’m hoping before the pandemic that we have a discussion in Canada about media response and government messaging. What we saw during SARS, in general, the media were incredibly helpful. Partly because, media are organizations that are trained to move large amounts of information in very effective summary forms and get them to lots of people.

I think the danger Americans worry about more than Canadians is that in order to make a good story, the media will attempt to show kind of conflicting opinions and conflicting evidence. I am frankly not worried about that in Canada. We did not see that at all during SARS. It seems to me the media understands like everybody else that what we’re out there to do is to get the right information to the largest number of people

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I get sick, and I come to the hospital, isn’t that making the hospital a really dangerous place to be during a pandemic?

The risk of being infected during a pandemic is being alive. It doesn’t seem to matter a where you are. Attempts for people to isolate themselves and stay protected have historically not worked. They may work to some degree, but they don’t work very well.

One of the interesting things about influenza, unlike SARS, is that you’re most infectious with influenza just before you get sick or when you’re coming down with it. By the time you come to the hospital, which is likely to be three or four days later, you’re probably not very infectious any more. So, in fact, hospitals may be somewhat safer than other places.

If I try to protect myself by leaving town and going to a small town am I going to be safer?

We don’t know whether attempts at social isolation are effective. We do know that in previous epidemics they were not very effective. Everybody’s attempts to isolate their communities did not work. However, it’s reasonable to believe that basic precautions like hand hygiene and maintaining social distance will reduce your risk.

Unfortunately what we can’t tell you is how much it’ll reduce your risk. We don’t know how effective it is. We do know that in a setting of fear and uncertainty, with people getting sick, that people will not always believe even when there are things with solid evidence. Things like airport screening or closing the borders.

We know that airport screening will not be effective. We know that by the time we close the borders it’s not going to work. I think, have reasonable data about closing schools once a pandemic has established does not help. But we will almost certainly use a number of those interventions because we will be justifiably afraid and we will feel that we have to do everything we can.

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What can I do to protect myself once a pandemic has started?

I think the best that can be done at an individual level for protection from a pandemic is good hand hygiene – washing your hands, or using an alcohol hand wash at least five times a day, more often in a pandemic. Maintaining social distance from people – staying more than three feet away. Protecting other people if you get sick – making sure that you stay away from other people if you’re sick. And conversely, making sure that if you’re at work that people who are ill exclude themselves.

What sort of garb would you wear in a hospital to protect yourself from a pandemic?

In general, the two things that we know are effective and substantially infective are very good hand hygiene and wearing masks.

Why shouldn't I wear a mask?

There are a few difficulties with wearing a mask during a pandemic. The first is that we’re going to be short of supplies so it may be nice to say that you should wear a mask, but there probably aren’t going to be enough masks. And the difficulty with most masks is that after you’ve worn them for a while, they get moist they don’t work nearly so well anymore.

The second problem with mask use is that the circumstances where you most need it – close contacts with your kids, with your family members, with other friends – are the times when you’re least likely to wear it. If you’re going to wear a mask, it’s probably important that you wear a mask all of the time and that’s going to be very difficult for people to do, but maybe needed for effectiveness.

The third thing that some makes people a little nervous about masks is that when one of the consequences of wearing a mask – particularly for those of us who don’t usually wear masks – is that it draws your hands to the face. If your hands are not clean, and you keep putting your hands up around your face, you may actually increase the risk that you might get influenza despite the fact that you’re wearing a mask.

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What can I do now for myself to prepare for this pandemic?

The things that will protect you going into the next pandemic are getting your pneumonia shot if you’re at potential risk of pneumonia, stopping smoking if you smoke – because smoking presents a very clear increased risk for the setting of influenza or other pneumonias. Maintain a healthy lifestyle. The more physically fit you are going into any kind of illness, the better off you’ll be when you get there.

Training yourself and the people around you to wash your hands, or clean your hands with the waterless hand rinse, at least five times a day so you don’t have to re-train yourself during a pandemic.

Making sure that if you require regular medication that you have a set up with your physician that you know how that’s going to happen during a pandemic. Stock up on the kinds of supplies you need to have in your house for an influenza illness, so that even during the regular season if you get it you’ll have enough things to get through and manage appropriately. Things like having a thermometer at home at home and medication for fever. If you have small children you care for, make sure that if you get sick somebody you know is going to care for them while you’re sick.

It’s a short list, a perhaps somewhat irritating list, because in public health we’re always telling you to do those things anyway, but those are the things that will make significant differences to whether you get ill and how ill you get during a pandemic.

http://www.cbc.ca/fifth/nextpandemi...ews_mcgeer.html

The following is an edited excerpt from and interview with Dr. Ron St. John, conducted in late 2005...



Dr. Ron St. John
Director General, Centre for Emergency Preparedness and Response
Public Health Agency of Canada

Dr. Ron St. John is the Director General of the Centre for Emergency Preparedness and Response at Health Canada. Created in July 2000, the centre serves as the country’s coordinating point for public health security in Canada.

Dr. St. John has also served as director of the Office of Public Health Security at Health Canada where he was responsible for planning, programming and policy review for quarantine and migration health, travel medicine, the Global Public Health Intelligence Network, and counter-terrorism.

What is the mandate of the Centre for Emergency Preparedness and Response?

The protection of the health of all Canadians from the health impacts of disasters, whether they are natural disasters or whether they human caused disasters.

We have approximately 180 staff; they are spread across the country. It includes our quarantine service in eight major airports, regional emergency preparedness and response liaisons, and of course our major operation here in Ottawa.

Are you concerned about the flu virus in Asia right now?

The avian flu virus, the H5N1, is of some concern. It continues to change some of its characteristics in ways that are a little bit worrisome.

All organisms change their characteristics. It’s a matter of how often they do it and over what period of time. Even human beings are changing their characteristics over time. Because they multiply so rapidly in such large numbers, bacteria viruses have more opportunity to change their genetic make up more frequently.

Some people, when they hear that the flu is one of the biggest public health concerns, they say ‘the flu is just a cold, so what’s the big deal?’

Flu is traditionally thought of as just a bothersome disease; you get some aches and pains, and you have a fever and maybe some coughing a sneezing for three or four days. Then you recover and go about your business.

There are two aspects of ordinary flu that are worrisome or of some concern. One is that for people that are more advanced in age or have a chronic medical condition, the flu infections itself can aggravate those conditions and cause serious illness in an elderly person with say a heart disease or a lung disease problem.

The other aspect of flu that is of some interest is that it is hugely costly economically, because if you think of all the people that stay off of work for five days, and all the kids that get sick the amount of people that have to stay home to look after their children, the economic costs are quite large.

Key points:

Why are you worried about the avian flu?

Who's watching the flu in Asia?

How do you determine whether the flu has obtained human-to-human transmission?

How does influenza kill its victims? What are they symptoms?

How would we stop the pandemic from coming to Canada?

How can I protect myself?

Should everyone be taking Tamiflu?

Why are you worried about the flu in Asia?

The flu in Asia is an influenza virus of chickens, of avian species, of fowl. It’s not a virus of people, however, it has demonstrated that it can sporadically and under special circumstances infect some people. It is like a fish out of water; it’s a flu virus, but in the wrong species, it causes a very serious disease in humans with a very high fatality rate.

Fortunately, it doesn’t transfer from person-to-person as efficiently as the regular flu does. But if it happens to recombine with a human strain of the flu and acquire the characteristics of passage from person-to-person, then it might create a huge problem for us.

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What would be the concern about passage from human-to-human?

Influenza is a disease that passes from person-to-person, usually by what we call droplets -- the sneezing and the coughing. The degree to which it can cause an outbreak or widespread illness depends on the efficiency of that transmission. If the avian flu were to acquire the efficient transmission mechanisms of the normal flu, it could cause a serious epidemic.

To give you an idea, the H5N1 strain in Asia, when it did infect people, was initially causing a mortality rate of about 70 per cent. That has since fallen to about 50 per cent, which is still very dramatic. Among infectious diseases a mortality rate of 3 to 5 per cent is significant -- 50 per cent is huge. Would a recombined strain have that kind of mortality? We really don’t know. Obviously, if it did it would be an extremely serious problem.

Who is watching the development of the avian flu right now in Asia?

Most of the world is watching it vary closely. The WHO, our own scientists have been in Vietnam collecting samples, working with the Vietnamese government on analyzing those samples, looking at the genetic makeup of the virus, watching the changes that have taken place in that virus, trying to monitor its behaviour in the populations there is a lot of work going on right now.

They are looking for a trend, or the acquisition of characteristics that might be leading this virus down a path for efficient human-to-human transmission.

If that were to occur, what would your job be?

If the virus were to pick up the characteristics for efficient person-to-person transmission, we would obviously be concerned and we would try to monitor and gather as much information as we could: how efficient was it? What was the impact of the disease? How serious was the disease? How sick did it make people? What would be the mortality rate? This is a lot of information and data that would be collected early as possible and analyzed worldwide to come up with recommendations on how to intervene to slow or stop this virus down.

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What can you do to stop it once it becomes efficient as a transmittable virus?

The most efficient way of stopping something like this is with a vaccine. We would work very hard to obtain a sample of the strain very early on. It would then be put into the laboratories that specialize in identifying it and preparing it to be a candidate for a vaccine. We would then try and produce that vaccine as early as possible and make it available to the public in order to provide the level of protection.

What would show you that the virus was beginning to transmit from human to human?

The usual indication is what we call clusters. This is where groups of people get sick. What we see with the H5N1, the avian flu, is individual cases -- somebody that has been on a chicken farm, someone that has been with chickens that have been dying, has close contact because they look after the birds or they slaughter the birds. They are just solitary cases.

When you begin to see what we call clusters in a fairly short period of time, numbers of people coming down with the same disease, then you start to look at the relationship between those people and not all of them were chicken farmers. Let’s say you have the chicken farmer and his wife, but his wife went to the city and then her sister got infected, and then her sister’s kids were infected, that’s what we call a cluster. That’s when we say uh-oh, we are having some human-to-human transmission.

How does influenza kill its victims?

Influenza is an inflammation of the lungs. It begins to block the passage of oxygen into your blood, and you begin to have difficulty breathing. Then you begin to have a lot of fluid come out of your lungs, which is a little bit like having your lungs fill up from the inside with fluid. It can be so severe, making it very difficult to breath. Of course, without oxygen you run the risk of dying.

What symptoms might be exhibited?

Just like any other flu, you would start of with some general not feeling well -- some aching in your joints, and then you get a fever of 100 to 102 degrees. You don’t feel too well, you might start to sneeze, cough, have a runny nose. The trouble is that it doesn’t sound very specific. That can be one of a number of illnesses ranging from the common cold to other viruses. Sometimes it’s difficult to tell what is the flu and what is another respiratory virus.

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If a flu pandemic started in Asia, how realistic is it that we could prevent that flu from arriving in Canada?

If there were a true pandemic of influenza, and if we truly had efficient human transmission, there is global agreement that there is no real way to stop it. The global strategy is to try to slow it. The reason why we want to slow its spread is to have as much time as possible to prepare the vaccine.

The strategy is really not to stop it. There really isn’t a way to stop it given how infectious it can be. The strategy is to slow it down.

There are three measures for slowing down flu. One is the vaccine, to give you the best protection. But it’ll to take time to get that online because you can’t make a vaccine against a virus until you have a virus. That’s why there’s a lag time.

The second is anti-viral medications that are effective for decreasing the severity of illness and decreasing the mortality from flu.

The third is what we call increasing social distance, which means a lot of different things. For example, if you are having an outbreak in your community, you don’t want to go to gathering places with other human beings. Try to avoid going to shopping malls, movie theatres. Local public health authorities may decide to close public schools for a period of time. All of this increases the distance between people and makes it harder for the virus to jump from one person to another.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

How realistic is creating social distance in a major urban centre where we are so closely connected?

In a modern world it’s difficult. Yet it’s a matter of an average decrease in social connectivity, if you will. The sum total of moderate reduction will slow the virus. It won’t stop the virus, but it will slow it. If you don’t have to go to the movie, don’t go to the movie. Try to only engage in social conduct that is required. You have to go to the store to get food, but you don’t have to go to the movie.

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How do you imagine Canadians would react to the pandemic?

It’s always difficult to predict people’s behaviour in a crisis situation. One of the things in our field or emergency preparedness that we feel is exceptionally important is to maintain people’s confidence that the authorities are doing the right thing and that we are doing the best we can. If confidence is lost, things can degenerate.

The SARS situation gives us a little indication about how Canadians might behave because at any given point up to 8,000 were in a self-monitored quarantine. And from the information we have from Canadian health authorities, Canadians did follow the advice of the public health authorities and for the most part did comply to staying home if they had exposure to SARS.

How seriously do you take the 1918 pandemic as a potential model for what might happen to us?

It’s a model, and we take it seriously. We’ve just had a major meeting in London with some of the world’s best mathematical modellers looking at what might be the scenario for a pandemic strain and a lot of them have gone back to the raw data from the 1918 flu and have put that into their mathematical models, run it through their computers and analyzed that data…

One of the interesting outcomes was that the flu was perhaps not quite as infectious as we thought it once was. It’s not as infectious as let’s say the measles or the chicken pox. And that’s kind of good news based on analyses of 1918 data in a mathematical model.

In 1918, the virus spread around the world rather rapidly considering there were no airplanes for transcontinental travel. Did your model take that into account?

Yes, all the models nowadays are based on rapid air travel.

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What can I do to protect myself as an average citizen of Canada?

Two things. One is to be educated about influenza and about how virus spreads and what you can do to protect yourself, like washing your hands quite often. One of the ways the flu is spread is by hands. If somebody with flu is rubbing their nose, contaminating their hands with a virus, and then they shake hands with somebody and they then rub their eyes or their nose – that’s one way that the virus moves from person to person. The other way is caused by what we call droplets. You cough and some droplets of saliva come out with the virus and you inhale those. But hand washing is a very important method for prevention.

What about heading for the hills?

It’s one way to increase your social distance, but it’s not very practical for everyone to head for the hills.

There are stories from 1918 about towns having militias with guns blocking anybody from coming into the town, and they had no deaths from flu.

That’s not going to work too well in a modern society where we are much more connected by roads, by transportation, by other systems, compared to 1918. That was a long time ago. Just the food supply – so much of our food on our supermarket shelves is what’s called ‘just in time’ inventory. Tomorrow’s food arrives today, and if it doesn’t arrive today there won’t be any food tomorrow on the supermarket shelves. We live in that kind of a world where our commodities, our supplies, our way of living is totally dependent on transportation and interconnectivity. It’s almost impossible to visualize somehow shutting off a town so that nobody comes in or out.

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Can you talk a little bit about Tamiflu – its availability?

Tamiflu is the commercial name of a drug called Osoltamivere, which has been shown to be somewhat affective against flu viruses. It reduces the duration of your illness; it also reduces the potential mortality. But the caveat of the drug is that you have to take the drug within in 24-48 hours of the onset of your symptoms. That’s a little bit difficult because some of the flu’s symptoms are a little vague.

We have acquired a stockpile in Canada of Tamiflu, the provinces and the federal government have collaborated to build a stockpile. And this is for the nine priority groups identified in the Canadian pandemic influenza plan. And those stockpiles are in place. And then there are some additional stockpiles that are being built as we speak, so there will be some supply of Tamiflu in Canada.

Do you have a supply of Tamiflu?

Do I personally have a supply of Tamiflu? No I don’t.

Would you recommend to your loved ones that they get a supply of Tamiflu?

No I don’t recommend that at this time. First of all, if you have a supply of Tamiflu at home and you wake up a little achy, are you going to take your Tamiflu? If it’s not flu, how will you replace your supply? Are you going to take your Tamiflu today when you don’t need it and use it all up -- then when the flu virus does arrive you won’t have it?

It’s not very easy in the practical sense to figure out how useful Tamiflu will really be for you as an individual during a pandemic situation. Clearly if there is a pandemic situation arriving in the community, we would wand the healthcare workers to take Tamiflu. We want them to stay as healthy as possible so they take care of people that become ill.

Tamiflu sells for about $4 a tablet. If I buy $500 worth of tablets I could theoretically take it for three months while waiting for the vaccine to come.

You could. But there is no data on the safety and efficacy of Tamiflu for that period of time.

How much Tamiflu is there in the world? Is there enough if we could afford it?
In the entire world? No, I doubt it. There wouldn’t be enough Tamiflu for the whole world. There are six and a half billion people. Do a simple calculation. The best price you can possibly get with bulk purchases is about $2.50 a pill. If you just multiply that out, that’s about $18 billion for Tamiflu. When you think about what $18 billion could do for malaria, for tuberculosis, for other problems that are here now, not for a possible problem that we might have in the future.


http://www.cbc.ca/fifth/nextpandemi...ews_stjohn.html

The following is an edited excerpt from and interview with Professor Roy Anderson, conducted in late 2005...



Professor Roy M. Anderson
Chair in Infectious Disease Epidemiology
Imperial College
London, England

Professor Roy M. Anderson is head of the Department of Infectious Disease Epidemiology at the Imperial College Faculty of Medicine, University of London. His previous positions include the Linacre Professorship and head of Zoology, University of Oxford (1993-98), professor of parasite epidemiology and head of biology, Imperial College (1984-93) and director of the Wellcome Trust Centre for Infectious Disease Epidemiology, University of Oxford (1995-2000).

Professor Anderson is a fellow of the Royal Society and a foreign associate member of the Institute of Medicine at the U.S. National Academy of Sciences. His principal research interests are epidemiology, population biology, evolutionary biology, biomathematics, demography, and parasitology. He also has a keen interest in science policy and the public understanding of science.

How likely is human-to-human transmission of a lethal H5N1 virus?

It is quite difficult to estimate the likelihood of when it will happen. Bird virus has been around at least since 1996; we haven’t had that event despite very close contact between humans and birds in Southeast Asia and China. We have had a nine-year period where no event has occurred. Now, the next nine or ten years, the likelihood is that it will occur. But we are not certain what the product will be that comes out. It could have more pathogenicity and human transmissibility, or it could have high pathogenicity within humans, and very low transmissibility within humans. There is a great deal of uncertainty.

How would the virus become a pandemic?

The virus changes by two scientific prefaces. One is mutation -- a slow accumulation that points on this genetic code of small changes. That can make a bird virus transmissible to humans, but in the past major pandemics, we’ve had about three a century, the key aspect has been what is called “re-assortment.”

Re-assortment is if I acquire a human strain that is circulating, and at the same time acquire the bird virus. The two infect the same cell inside my body, their genetic codes get jumbled and something new comes out.

That new thing that comes out, there’s a small likelihood that what comes out has the high pathogenicity of the bird virus, and the degree of transmissibility within humans. But it is equally likely that what comes out has the low transmissibility of the current circulating human virus, and perhaps sufficient transmissibility within the human population. So there’s huge uncertainty, and very low probability of this re-assortment event occurring.

What would have to happen for the re-assortment event to occur?

Using myself as an example, I would have to have the current circulating human influenza virus, and then be exposed within 12 to 48 hours to the bird virus -- so I get dually infected during those first two days. That’s what’s required for re-assortment.

There is a great deal of uncertainty of the characteristics of the current bird virus with the human transmissibility capabilities.

Key points:

What is "re-assortment"?

How prepared are we for a pandemic?

How do you determine whether we've successfully fought the pandemic?

What do you tell your friends, about preparing themselves?

What would be the extreme outcome, if it were to obtain re-assortment?

A lot of figures have been bandied around about mortality rates, about the fraction of the population that would be infected. The truth is one doesn’t really know what is likely to happen. The question is how transmissible is it? Does it have a replication rate that takes it from human to human easily, or is it quite difficult to transmit? The worst scenario of course is high transmissibility. What typically happens with a new virus is that it starts off with low transmissibility and then as it circulates country by country, it improves its capability of transmitting from human to human

Another attribute which is hugely important is the pathogenicity. H5N1 is very pathogenic to humans, but subsequent epidemics after 1918 were of low pathogenicity to humans. The worst scenario obviously is something totally novel that the entire population has never seen, with high transmissibility and high pathogenicity.

^TOP

There are some figures that suggest it could be even worse than 1918, which indicates that its not only a scientific problem, but it would also become a social and political crisis. Can you talk about those two aspects?

Again, I stress that it is uncertain what the future holds, but if a highly pathogenic organism emerged, then we would have highly considerable problems. Influenza is unlike most other infectious diseases in two aspects. First, it tends to have a very short generation time. The generation time is the time from when I acquire it, to when on average I transmit it to somebody else. For influenza, that’s typically a few days, perhaps two to three days. Now by comparison, think about HIV -- the average time from when somebody acquires to when they transmit the virus is many years. The HIV epidemic develops on a time scale of decades, many, many decades, hundreds of years. The influenza pandemic will develop on a time scale from weeks to months.

Within a given country, the epidemic will probably be all over in about four to six months. Worldwide, the epidemic, or pandemic, will probably be over in about a year. Therefore, the first aspect is that speed of action is absolutely vital. We haven’t got time to ponder your contingency plans, you have to have them prepared and put them in place on day one when the infection arrives in your country.

What’s your appraisal of the current preparedness?

Clearly, there is quite a lot of variability between countries and how much they’ve taken this threat into account that relates to both the amount of anti-viral drug that they’ve ordered. There’s a lot of variability, a lot of differences of opinion in key areas. Do you restrict travel from certain countries to, say, Canada or the United Kingdom? Do you screen passengers on entry to an airplane? Do you then screen them again on exit? Quite a bit of scientific work has been done there. And they all point to one rather simple and stark observation: Once this starts, it’s almost impossible to stop from spreading from one country to another, unless your travel restrictions are 99.99 per cent effective. In other words, unless you totally close the borders down instantaneously you are very, very unlikely to restrict the entry.

That leaves you to two conclusions. One, your efforts should be totally focused on trying to help the country of origin of the new pandemic strain, whether that be southern China, Vietnam, Thailand… You help the World Health Organization with your own country’s stock of Tamiflu or an anti viral agent. The second point, since you are very unlike to stop it from entering, your country’s specific contingency plans should be orientated to: ‘how do I respond to when it arrives in a major city?’

Some experts suggest airlines could actually sterilize jetliners.

I think our experience from SARS and from a variety of other examples, is that screening passages at the entry to the airlines, the exits, sterilizing the airlines, is not a sensible expenditure of time and energy. The most sensible expenditure of time and energy is to work up a contingency plan of how you are going to control it when it arrives in the country. Ordering the anti-viral drugs, and preparation for rapid vaccine production, those to me are the most sensible expenditures.

Then there’s the more complicated set of contingency plans: Do you close schools? Do you restrict travel within a country? How do you ensure that the health care front line staff are protected and adequately informed about how to manage it with simple hygiene measures? How are you going to ensure the continued supply of fuel and food to a country which has a very threatening epidemic? These are the key issues, in my view.

^TOP

How would you prepare a country?

At the beginning you need very, very good surveillance so that you don’t find out about its arrival you know one to two weeks afterwards. Your surveillance has got to be exceedingly good.

Secondly, in an ideal world you need diagnostic services in a country, to be able to take a suspicious case, elevated temperature and fever and so on, and be able to diagnose whether that is an influenza virus very speedily, within a few hours. At the moment, these diagnostic tests, we still haven’t got that technology sorted out. That is another priority: getting rapid diagnostics developed in advance for influenza virus infections, so you can use your limited supply of anti-viral drugs very effectively by only treating those who have influenza.

I think my greatest worry is the origins of the epidemic may occur in some remote rural area of southern China, or perhaps Russia -- that it won’t be picked up for a number of weeks to a number of months. That because of some poor surveillance in the world, diagnosis will occur late and therefore it will explode on the world scene without adequate warning. That’s the real concern.

I am afraid that silent spread in rural regions is a possibility. Another thing that the WHO and international community can do is to try and improve surveillance capability in Southeast Asia, and in China in particular. And in Russia, so that the world has advanced warning and can try to help those countries suppress the epidemic in its point of origin.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

How will we be able to measure our degree of success against a pandemic?

Success is quite difficult to measure, because it’s only in retrospective analysis that you’ll be able to look at the mortality rate from the virus, and by comparison between countries how quickly you managed to suppress its spread.

How would cities, societies enforce quarantine?

My own view, in the case of an epidemic, is that you need tight government control: unified policy applied across all cities and all states. That will happen in the United Kingdom, but the U.K. is a small area in comparison with Canada and central government will play the central role in dictating policy, in different cities, in different health authorities.

President Bush has indicated that there will be military involved in his most recent plan, in your view, how might this look in the UK?

The question of military involvement is not something that is in the contingency plan for the United Kingdom. The Department of Health will take the lead in the case of an epidemic, and it will control the actions determining how to minimize spread, how to minimize mortality, and also with its interaction with other government departments: how to maintain education, fuel supplies, and so on.

^TOP

What do you say to the people who are the closest to you, friends, family, about how to cope with a pandemic?

People do ask questions. My initial response at the moment is the risk is low. Number two, keep separate in your mind the avian problem, which is a veterinary problem, keep that separate in your mind from the human problem.

We’ve had this avian virus spreading since 1996 and we’ve had no human problem, except for some direct transmission from birds to humans, but no onward human-to-human transmission. Keep that in your mind. There is no immediate threat at present.

If the worst happened, then a lot of common sense simple things would be important. Minimize your mixing. Perhaps work out a way with your employer where you can work at home via some broadband computer network. Do simple things like wash your hands.

People infected with a respiratory virus, when you blow your nose you contaminate your hands, then you shake hands or contact a door knob or a railing or whatever, you may be leaving virus on those contact surfaces. The virus will survive there from minutes to hours, depending on certain conditions. Try and minimize those sorts of contacts.

When should parents pull their children from school?

There will be guidance from central governments. It will depend very much on the transmissibility and the pathogenicity of the virus. For example, all these influenza viruses have different age specific pathogencities. They may or may not be pathogenic to the elderly or to the very young. Teenagers and young adults may be more resistant to sever effects of the virus. We won’t know that until the epidemic emerges. Guidance in central government about this will be crucial.

Having said that, what was so transparent from the SARS epidemic is that in respect of government guidance, people responded in a manner connected to the degree of hype that was presented to them in the media, sometimes accurately, sometimes falsely. Individuals will respond without government guidance. If you take, for example, Hong Kong during the SARS epidemic, their strong attendance in cinemas, or sporting events, dropped dramatically well before any government announcements.
Society and people will adapt their own behaviour in response to the perceived threat. Responsible handling by the media is an absolutely crucial part. Governments have to develop a communications strategy. They have to draw in journalists to this and make sure the quality of journalism is as well informed as possible about the issues, threats and reactions, so that accurate messages can be communicated to the public. People often underestimate the sheer power of the media, and it is crucial in the case of an influenza pandemic that accurate factual information is actually given to the public

http://www.cbc.ca/fifth/nextpandemi...s_anderson.html

The following is an edited excerpt from and interview with Major-General Lewis MacKenzie, conducted in late 2005...



Major-General Lewis MacKenzie
Armed Forces of Canada (retired)
Toronto, Ontario

Major-General Lewis MacKenzie spent 33 years in the Canadian military, performing nine tours as a peacekeeper and commanding ground troops in some of the world's most dangerous places: the Gaza strip, Cyprus, Vietnam, Cairo, Central America and Sarajevo.

General MacKenzie retired from the Canadian Forces in March 1993. He is the author of Peacekeeper: The Road to Sarajevo, a personal account of his peacekeeping experiences, and subject of a two-hour documentary, "A Soldier's Peace", based on the book, which has aired in over 60 countries and won a New York Film Festival award in 1996

If sustained human-to-human transmission of H5N1 happens, what do governments need to start thinking about?

First the government is going to have to deal with is the tremendous amount of interest by the Canadian public. Because unlike other natural disasters, there is so much pre-warning, so much hype, so much discussion that folks are going to be very, very reluctant to let folks outside of the country come back into the country from particular areas -- and pretty soon from worldwide. And therefore there is very much a security issue here.

Airports, ports, border crossings – there will be a call from the grass roots to shut down the borders. And I don’t think that there is any doubt certainly in my mind that that would immediately happen.

In 1918-19, the last great pandemic, the military suffered proportionately from the infection. What kind of challenges would there be as a commander if a large portion of your troops were getting sick?

Any organization that eats together, sleeps together, trains together, exercises together, operates together in close proximity is obviously vulnerable to any contagious disease. That was the problem in 1918.

That being the case, if we extrapolate that to today, they wouldn’t suffer as much by way of passing a disease in that these days not a lot of soldiers live in barracks, they live at home and they commute to work.

However, in the event of an emergency or a disaster, then they would concentrate in some of the few bases across Canada. No more than hospitals, no more than schools, no more than universities. The threat to them would not be any greater than those other organizations that gather together to do their day-to-day profession.

What happens to civilian leadership in a time of crisis?

The civilian leadership has been getting organized since 9/11. Within Canada we have the Department of Public Emergency Security Preparedness Canada. There is also a cabinet committee that looks after health and emergency preparedness.

Key points:

What is the Army's plan to keep soldiers safe?

How would you secure the borders if there was a pandemic?

What kind of law and order issues would we be dealing with?

How will the government respond to a pandemic?

Within that public security emergency preparedness is a military component and the military helps with some of the communication and obviously plays a role with all the other first responders.

9/11 created a impression within Canada that we’ve dodged the bullet, but we are going to have to deal with either a large natural disaster, pandemic, or terrorists attacks and therefore we are structurally much better organized.

The departments within provincial governments and the feds, for the first time in some of their lives, actually get together in the same room and talk these issues over where it used to be what’s commonly referred to as silos. Not so now -- the only way we can respond adequately is if all the departments work together.
^TOP

How would you go about closing the borders in Canada in the case of a pandemic?

We are talking about a pandemic here, so the idea of escaping across the border to another province, another country, doesn’t enhance your survivability. We are not going to be free of the pandemic in Canada if it happens in the United States or vice versa.

So you would need unmanned air surveillance, drones, that would identify groups of people if they were trying to cross the border and then you would launch the reserve forces so that you have standing by your rapid reaction forces to intercept them. The same thing on the coastline.

The way we are looking for drug runners coming on to the Nova Scotia coast now, you would just have to up the ante. It wouldn’t be haphazard; it would be 24 hours a day, and seven days a week -- extremely manpower intensive, very expensive.

How would you go about restrictions within Canada?

Within Canada, it is going to be extremely problematic because if my gut feeling is correct, the moment that there appears to be a really good chance of this becoming a pandemic in Canada, I would think a lot of folks would leave the densely populated areas assuming it would be safer to be out in the countryside. Would you rather be in Toronto, or in a ten in Algonquin Park in a tent somewhere?

I could see a mad rush from the large cities, from Montreal, from Vancouver, from Toronto to outlying areas and I can see the people in the outlying areas not being terribly welcoming. That sets up a security problem -- a law and order problem. And when you start using all your police forces and your military forces to cordon off certain areas, then you probably start getting looting and you have to redeploy your security forces. We’re not talking about large numbers here available to shut down a particular area and stop crime.

Under what scenarios does war start to break down in big centres?

I think it will be blatantly obvious when that happens. I think it will be very obvious when people’s reactions are observed by the government.

Now, maybe I am totally misreading Canadians. Maybe everyone will show up at work. Everyone in the medical system will show up to assist those that are ill. Schools will continue, universities will continues and life will go on as normal.

I personally don’t think that’ll happen, primarily because people are becoming more and more familiar with the threat and in fact have exaggerated it in some cases -- there is education that is being done for all the right reasons, but at the same time it is elevating the level of concern. I think the public will react in ways the will demand and enhance security within the country.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

^TOP

What would be some of the things that you worry about in terms of public reaction?

Traffic jams, disobeying of traffic rules, hording food, hording medical supplies, invasion, overwhelming smaller communities’ medical facilities, much the same as it would with a major terrorist attack.

We tend to look at enhancing the medical facilities within large cities, when in actual fact, people will leave the large urban centres and overwhelm the smaller centres.

How do you begin to coordinate a response to that?

You don’t fix it, you deal with it. You try and employ the resources that you have -- police, military, fire -- to establish a degree of normality and to show people that in actual fact, you are dealing with a situation. You’ve got to deal with it on the educational side, with propaganda -- because propaganda can be a positive thing -- get propaganda out and get folks to understand what the real threat is.
^TOP

On a national level, where is the nerve centre for response?

The PSEPC – Public Security Emergency Preparedness Canada has an operation centre in Ottawa, it reports to a cabinet committee. Deputy Prime Minister, Anne McClellan, is the key minister responsible, and here are representatives from the different departments at that operation centre.

Where would some of the fault lines be between what politicians think they need to do to satisfy voters, and what actually needs to get done to make Canada a safer healthier place during a pandemic?

I can’t think of another challenge facing the country where a political party would have to have a suicide death wish if it tried to play the political game and start throwing blame around. If they do, they deserve to be annihilated as a political party. It would be totally and absolutely inappropriate. There will be lots of time for that after the event; God knows we’ll have a royal commission to look at how we reacted, what went right and what went wrong.

But during the build up in particular and during the actual event then I think it would be the parties’ political interest of survivability to cooperate with each other.
^TOP

In terms of closing the borders, there are a lot of experts that say it’s useless, but that we need to do it to satisfy people.

Closing the border would be hurtful. We all know the figure – a million dollars a minute, 365 days a year, goes over the border into the United States. That’s our economy. It would have a horrendous impact on the economy; there would be great concern from the business community about shutting down the borders. It wouldn’t be an easy decision for the government to make.

What is your sense right now about how well prepared we are to maintain security in a pandemic?

My only concern is the amount of horsepower that is available – the limited amount of personnel to deal with security issues. So what do you do? You have to pick your priorities. And you have to assign your resources to your leading priorities.

In 1918, troops were used to do things like dispose of bodies because they were piling up in the big centres. What other things do you think troops might have to do in an extreme pandemic?

There are other areas where the military could contribute: moving supplies, trucking things around, communications, travel control, food preparation. The military has what we call ‘flying kitchens,’ where trucks have cooking facilities in the back and can move from point A to point B and can set up and be serving meals within an hour.

Personally, are you worried about the flu pandemic?

I’m concerned. Sure. But I am not losing any sleep over it and with some confidence say that, if nothing else, we are better prepared to deal with it now then we were five years ago.

http://www.cbc.ca/fifth/nextpandemi..._mackenzie.html

The following is an edited excerpt from and interview with Dr. Frank Plummer, conducted in late 2005...



Dr. Frank Plummer
Scientific Director General
National Microbiology Lab
Winnipeg, Manitoba

Dr. Frank Plummer is Canada’s leading virus hunter. He has spent much of his career working to develop an AIDS vaccine, focussing his research on African AIDS victims who appear to have a natural immunity. Dr. Plummer also led Canada’s effort to uncover the cause of the SARS outbreak.




Why is avian flu, or H5N1, why is that a concern right now?

There is a concern about the H5N1 virus because it has been on a few occasions, spreading from birds to humans. This had been happening since 1997. And the human infections have a very high fatality rate. Initially, about 75 per cent of people infected with Avian flu died.

The flu, it doesn’t seem like something we should be nervous about.

Influenza is a very important health problem on an annual basis. We have periodic epidemics that kill up to 5,000 or 6,000 Canadians and may more people globally. Periodically, the virus changes and causes what we refer to as a pandemic, which can result in much greater numbers of people infected and very severe illness with a lot of mortality.

What does the flu virus do when it attacks a cell?

A virus is a molecularly simple parasite. It is one of the simplest life forms known. But it can take over the replication machinery of a host cell and can ultimately kill people fairly rapidly.

All viruses replicate much more rapidly than humans do, and mutations occur in viruses pretty regularly. If one of those mutations make the virus less likely to be susceptible to the host immune system, that variant could be selected out by the immune system, and that’s one of the mechanisms that the flu virus uses to change and why it continues to be a problem annually.

Key points:

How does your job change once we know a pandemic has begun?

How would the work for a vaccine be conducted?

How might a pandemic today differ from 1918?

Are you afraid? What are you doing to prepare your family?

What's your nightmare scenario?

Why did the virus of 1918 mutate to the form that it did?

Nobody really knows why the 1918 flu virus was so highly pathogenic. We do know that if you take the hemoglutin gene out of that 1918 flu virus and put it into a lower pathogenic virus, that it becomes lethal for mice, so a part of that reason for its higher lethality is properties of the hemoglutin gene.

Why have we not seen another one since 1918?

I think its largely about the properties of the virus but it may also be about the conditions of the human population at the time. It was post World War I. People in Europe in particular were malnourished. Soldiers coming back from the war had nutritional problems; weakened hosts may have played a role as well.

What is the dialogue about the pandemic in the infectious disease community?

There is a lot of concern about pandemic influenza. It is the single most known threat that we face from infectious diseases currently, so the attention that its been getting over the last couple of years is certainly warranted.

Why is it the single greatest known threat?

Influenza is highly contagious compared to any other infectious diseases, and it can be lethal in some instances due to the properties of the virus or to the condition of the host.

^TOP

If human-to-human transmission is documented in Asia, what do you do when you get the call; what does your job become?

We would initially find out about human-to-human transmission from newspaper reports that we monitor using a system called GPHIN – Global Public Health Intelligence Network. Those reports would lead to counties investigating the problem and reporting to the WHO, who would then officially report to all its member nations that the phase of pandemic preparedness had changed – that there was sustained human-to-human transmission.

What we would do depends a bit on what the global response is. There may be efforts to try to contain a newly emerged pandemic virus within the country that it has emerged. There might be calls for teams to go to whatever country the problem has been recognized in. We would offer assistance there in the laboratory equipment in the field, so testing could be done.

In Canada, we would be trying to obtain samples of the virus so that we could work on characterizing it, making sure that our diagnostic tests were able to detect it, preparing diagnostic tests to equip laboratories on a provincial level to be able to test the virus, and then we would start developing a vaccine.

^TOP

Do you work 24 or 36 hours straight, when every hour counts?

I think we’d manage it quite a bit like we managed to squash the SARS epidemic. Essentially, you squash the hierarchy of the lab; form a number of different teams to look at different aspects of the science that is needed to produce a vaccine strain.

We would pull the people who don’t normally work on influenza onto the work we are doing to prepare a vaccine seed; most of the energies of the lab would be put into that project.

If everything goes very well it would take two to three months to produce a vaccine seed strain. If there are problems for whatever uncontrollable reasons, it could take a bit longer than that - but it is critical that we are able to do that as quickly as possible.

Does two or three months seem like a long time to wait for a vaccine?

I think any delay in having vaccines is a problem and we have to shorten the time as much as we can. That is why it is important for countries to work with the WHO to identify this problem as quickly as we can.

What are we not doing now in countries in like Vietnam and Thailand that we could be doing?

I think one of the problems with countries like Vietnam and others in the region is that surveillance systems and their border capacity are not very robust. We need to work with them to make sure they can detect a pandemic of influenza as quickly as possible.

We also need to make sure that the environment that we are in, in terms of trust, the emergence of a pandemic are minimized so that the situation that happened with SARS, where the government of China was slow to admit it had a problem, doesn’t occur again.

What kind of psychological pressure is there on the scientist who has to be as rational and scientific as possible when a society is in a fair bit of fear of the unknown?

There is tremendous pressure to produce results, to get diagnostics tests made, to get them validated, to produce vaccine seed strains as quickly as possible. There is tremendous pressure for information from the media and from the public.

Usually scientific results are subjected to peer review and validation by other scientists before they become widely known. That probably would not happen during a pandemic of influenza.

^TOP

If the virus were to be of 1918 proportions, some of the estimates say 60, 70 per cent of the population got it, what would that be like?

This isn’t 1918 and we are a lot better equipped to deal with a pandemic now than we were than in 1918, when we didn’t even know that influenza was caused by a virus. It didn’t have any kind of vaccine technology.

However, a virus that had the lethality of the 1918 pandemic would cause severe social disruption. That’s why the influenza plans have been put in place to try to figure out how we would deal with these things if there were huge numbers of people requiring hospitalization and medical care. And that's why we need to make a vaccine as quickly as we can.

It’s very important that we have contingency plans in place to ensure that critical systems, including laboratories, are functioning. You won’t be able to make an influenza vaccine if all your scientists are sick.

I would think that scientists would be among those as considered as priority for anti-viral use, and would be among the first to be vaccinated once vaccines are available.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

^TOP

You’ve worked with some of the worst viruses in the world, how do you personally rate the risk of pandemic influenza?

I’m certain that pandemic influenza is the greatest infectious disease threat that we know of right now. It’s much more likely to happen than small pox or anthrax, its much more likely to become a global problem, like a virus like Ebola or Marburg. It’s something we need to be concerned about and work hard at for preparing for.

What are you doing personally with your family, what do you tell your friends to prepare for this?

I haven’t touched it very much with my family. I think that we would not do anything other than what was recommended by the public health officials in Manitoba. Certainly I need to be here to make sure that the work that this lab needs to do gets done.

I don’t have a personal stockpile of Tamiflu, and I don’t have evacuation plans. I don’t think that I would be in a position to evacuate. And I don’t think you can escape this by barricading yourself at the cottage or something like that. You have to deal with it head on.

^TOP

How well is Canada prepared compared to other countries in the world?

Canada is in a better position than many other countries. Many countries have not even started to think about pandemic influenza, and have very limited capacities for surveillance or detection by their laboratories. That doesn’t mean that we have done everything that we need to do, you can never be fully prepared.

What’s your nightmare scenario?

I think a 1918 pandemic would be a nightmare, from my reading of the accounts. The rapidity with which it is spread, the fact that young people were affected, that people died very quickly, is very chilling when you read it.

The likelihood that we will have another influenza pandemic at some point in the near future is considered to be basically 100 per cent. How severe that would be, we don’t know. The 1918 flu seems to be an exception as to its severity, but most other pandemics have been considerable less severe than that. But it is a possibility that we could experience a problem of a similar nature in a future pandemic. It’s something that we need to be concerned about as a risk and be prepared for so we can deal with it when it emerges.

Although the 1918 flu was a very, very severe problem, a lot of people survived the pandemic as well. It’s not as if everyone in the world is going to die from this.


http://www.cbc.ca/fifth/nextpandemi...ws_plummer.html

The following is an edited excerpt from and interview with Dr. Margaret Chan, conducted in late 2005...



Dr. Margaret Chan
Assistant Director General
Communicable Diseases
World Health Organization

Dr. Margaret Chan began her career in public health in the People’s Republic of China, after obtaining her medical degree fro the University of Western Ontario. In 1994, she was appointed Director of Health of Hong Kong.

During her nine-year tenure in the position, Dr. Chan launched new preventative and promotive health care initiatives. She also developed new initiatives to improve communicable disease surveillance and response. Currently, she serves as Assistant Director General of Communicable Diseases at the World Health Organization.

During her time in Hong Kong, Dr. Chan successfully managed outbreaks of avian influenza and Severe Acute Respiratory Syndrome (SARS).




At the moment there isn’t the super lethal human-to-human form of H5N1 out there. Why all the fuss?

At this point in time, two of the three criteria for a pandemic exist. Number one: we have a new virus. Number two: this virus is able to jump to humans directly. The third thing we are waiting to see is if there is efficient human-to-human transmission. That would be the last criteria that would bring us into a pandemic.

It is important that we should act on early signals. If we are not prepared, clearly we will see huge health as well as economic impacts. If we are better prepared, we will reduce the health impact as well as the social and economic disruption.

Is there a gap between what the public understands to be the potential of this and the reality of what it could eventually be?

With the exception within certain communities, the awareness of the potential risk of a pandemic is not very high. There is still a lot of work that needs to be done to bring these communities into proper focus.

What would happen if several cities in Vietnam came down with major outbreaks of H5N1?

If what we are seeing is human-to-human transmission in several cities in a certain country, we need to do a very quick assessment to find out whether or not this is due to efficient human-to-human transmission. If indeed the cases are related to contact with sick poultry, the risk is less than if we have epidemiological evidence pointing to the fact that there is efficient human-to-human transmission.

If we are seeing several clusters demonstrating increased human-to-human transmission, the WHO will need to move very quickly and work with that country – we can ship antivirals into the first affected area, and use the antivirals to treat the people. What is more important is to treat the people that have been in contact with them; the contacts or the family members.

Key points:

When will the pandemic strike?

What are the preparation plans, for the WHO and member countries?

How close are we to a pandemic?

Nobody has the answer to this question. The unique nature about the influenza virus is its great potential for changes, for mutation.

We have learned from history that pandemic influenza in the past century took the world by surprise. This is perhaps the only time when we are beginning to see some early warning signals.

We are seeing avian influenza causing deaths in poultries in many countries in Asia; we are seeing some human infection. At this point in time they are very limited and we do not see strong evidence to support human-to-human transmission. But clearly the risk is there and we need to get ourselves prepared.

Some experts are predicting that the coming pandemic could be far worse than 1918. How would that change our lives?

I don’t really wish to paint such a gloomy picture. It is important for us to look at the evidence and not take the alertness attitude. Nor should we be complacent about getting prepared for a pandemic. We have been asked time and time again about how many people will get sick, and how many deaths there will be. But based on past sort of experience, we are seeing a lot of mortality and morbidity with the 1918 pandemic, but we are also seeing a less severe situation with the 1957 and the 1968 pandemics.

^TOP

If this strain breaks out in let’s say in Southeast Asia next fall, what could we expect to see here in North America?

There is a lot of attention focusing on countries in Asia. But I have to emphasize this point: the next pandemic does not have to start in Asia. It could start in any part of the world. In respect of which part of the world it is happening in, it will become a global problem, given the very high volume of international travel and the high population density compared to 40 years ago when we had our last pandemic.

How does influenza affect the body and how quickly it is transmitted?

The usual symptoms could include fever, cough, and muscle ache. The mode of transmission is by airborne droplets, and contact of body fluids. It can be quite mild, but in people with chronic disease or with a compromised immune system, the disease could be quite severe.

How prepared are governments at this stage?

At this point, we understand that there are about 50 countries that have pandemic influenza preparedness plan. But you know these plans vary in terms of their scope and in terms of their depth. We would be happy to work with member states to fast track this process.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

What would happen inside the WHO if the pandemic were to strike?

Within WHO head office here, we have the strategic operation centre. And this is the technology platform, and this is the place where all the technical people and other support departments would come together to examine the data that is being collected on a daily basis. That information and data is very useful to help us analyze what is happening on the ground. This is what we call doing the risk assessment.

Based on those risk assessments, WHO needs to come out with timely information, to help policymakers to make decisions. The WHO headquarters is very well connected with our regional offices, our country offices, and we could make connections with our member states to advise them on the latest position as the pandemic risk is concerned. This is the kind of thing that we would need to do on a daily basis, and we are already doing that. We have a daily meeting here, to analyze the intelligence and the information and send out the appropriate information.

^TOP

From a policy standpoint, how do you go on planning for the unimaginable?

Pandemic influenza is by nature an international issue; it requires an international solution. So the WHO and other UN organizations would need to work together with the countries that are being affected and with the support of developed countries to provide the necessary in-kind or in-cash support to mitigate or reduce the risk. These are the sorts of things that are ongoing now, and WHO is meeting with many partners to see how we can work together to rise above this challenge. It’s not an easy challenge.

What kind of powers does the WHO have for this possible situation?

The WHO is the lead agency in health in the United Nations system, and clearly we have very important functions to play. First, to provide timely and evidence-based advise, information and guidelines to help member states to formulate their policies. Second, we have an important role to play with our coordinating and convening power. In certain areas, for example, to fast track pandemic vaccine production, we would have an important role to play.
Another function for WHO is its operational and response function. We would be able to respond to countries in Asia who need technical assistance in public health, in virology, in laboratory science, to help them to investigate the situation on the ground and come to a very precise risk assessment.

http://www.cbc.ca/fifth/nextpandemi...views_chan.html

The following is an edited excerpt from and interview with Dr. Jeffrey Taubenberger, conducted in late 2005...



Dr. Jeffrey Taubenberger
Medical Pathologist
Armed Forces Institute of Pathology
Rockville, Maryland

Dr. Jeffrey Taubenberger is a pathologist at the Armed Forces Institute of Pathology in Washington, D.C., and heads the institute's division of molecular pathology.

Dr. Taubenberger’s hopes his research into the 1918 viral genome will help improve current systems for predicting future pandemics.

His aim is to bring the 1918 virus back to life by analyzing virus samples from victims of the virus, in the hopes of protecting the world from a repeat of the 1918 pandemic.




On the issue of human-to-human transmission, how would a human get a virus that they can pass on to another human?

One of the biggest questions facing us is to understand the basis for human-to-human transmission. Influenza viruses are viruses of a wide variety of animals, like wild birds, domestic birds, farm animals. These viruses have the ability to move around between species and adapt to new hosts.

But you know, we don’t actually understand the genetic basis of why this happens. We don’t know what has to change to allow a virus to not only infect a human being, but to acquire all the changes it needs to go from one person to another efficiently. Of course this is the key ultimately to understanding how pandemics form and might actually be the key to preventing a pandemic. Right now we don’t understand it so there’s no way to prevent it.

The last two pandemics, the 1957, and 1968 pandemics were actually mixtures in which a human acquired two or three new genes from a bird flu virus. This mixed virus, or ‘re-assortment virus’ as it’s called, was what led to the pandemic.

But in 1918, we think that something fundamentally different happened. We think that an entirely bird-like virus adapted to humans without mixing with a pre-existing human flu strain. That means that pandemic viruses can certainly do at least two different approaches to how they would become transmissible in humans.

What was known about 1918 when you started your work?

The 1918 flu was clearly one of the worst natural disasters of all recorded history, so there are probably millions of pages of scholarly work on the 1918 flu from physicians and public health officials describing what was happening in 1918 to historical analyses and economic impacts and so on.

Key points:

What happened to the virus between 1918 and now?

What have you learned about the 1918 virus?

How is it similar to the H5N1 virus we're familiar with today?

How dangerous are the H5 viruses?

If it makes human-to-human transmission, what happens next?

Would shutting the borders and halting travel stop the pandemic?

How can people protect themselves?

How did people die in 1918?

Are you worried?

What do you tell your friends/family?

But you know, fundamentally we knew very little about this virus. Of course, no virus was isolated in 1918. They didn’t even know influenza virus actually existed. Which meant there was no way to actually directly study this very lethal pathogen. People were not certain as to what kind of influenza virus it was, whether it was human-like, or bird-like, or pig-like. They didn’t understand what changes would be necessary to make this a lethal virus. So, really nothing was really known about the basic biology of the 1918 virus.

Could you describe the tissue samples that you studied?

When we started this project we were using autopsy tissues of U.S. soldiers that died of the flu at the end of World War I in 1918. Small snippets of lung tissue were fixed, and formulated, and embedded in paraffin wax, and stored at the warehouse at the Armed Forces Institute of Pathology for the past 80 years.

We were able to take tiny slivers of that tissue and isolate the genetic material of the flu virus using some molecular biology techniques to actually allow us to fish out very tiny fragments of the virus and characterize them. And we were able to find positive cases.

Then we were able to receive material from another location. A pathologist in San Francisco had been able to go up to Northern Alaska and do and exhumations of a number of bodies of 1918 flu victims that were interred in the permafrost.

He was able to send us frozen lung tissue from one case that still contained fragments of the virus. And that actually made it possible to sequence the entire gene structure of the virus.

Why did the virus disappear? Why was it not more easily accessible than these few samples?

I think it’s a common misconception that the 1918 flu disappeared very suddenly. People very often write that it appeared very suddenly and then disappeared just as suddenly. The 1918 virus actually never disappeared; it is still rotating in humans, just in a highly mutated form.

Here is a virus that emerged in humans sometime around 1918, spread and caused this enormous pandemic whereby practically everybody on Earth was exposed to this virus, something like a third of the world population was made ill, and tens of millions of people died. For this virus to survive inside the human population, it would have to mutate itself into a form that would be different from a pandemic form because everyone who survived the pandemic would actually have protective immunity.

Influenza viruses, in humans especially, do extremely well. They mutate extremely rapidly from one year to the next, which is why the vaccine needs to constantly be reformulated to keep with this really rapid evolution, and that’s exactly what happened in 1918. In the years after, viruses were mutating very rapidly away from the 1918 form and those that lineage of virus is still part of the virus circulation right now.

People are being exposed either with vaccines or through natural infections with influenza viruses today that are direct descendants of the 1918 virus.

^TOP

What did you learn about the 1918 virus?

Just this year we’ve been able to finish sequencing across the complete genome of the virus. While it’s a great sense of accomplishment to have finished sequencing across the virus, we don’t have really have all the answers that we want.

I think that the most fundamentally important thing that we have learned about the 1918 virus is that its origin is likely to be quite different than the two other pandemics that we know about, the 1957 and the 1968 viruses.

The 1918 virus was not a mixed human-bird virus but was an entirely bird-like virus that adapted ultimately to humans. How this process occurred is something that we are still trying to work out and we don’t fully understand, but I think has tremendous implications for the future and trying to prevent a pandemic like 1918 from happening.

^TOP

Why was it so lethal?

The lethality of the 1918 virus is still something that is not fully explained. In very recent work that’s been done in conjunction between my laboratory, and collaborators in Mount Sinai School of Medicine in New York City, and the Centers for Disease Control in Atlanta, we found that the entire 1918 virus when rebuilt and put into mice, was extremely virulent. It kills mice in just a couple of days. It kills fertilized chicken embryos.

But one of the biggest mysteries of the 1918 flu was the age group that was severely affected. Influenza viruses, normally when they do kill people, tend to kill people in the extremes of life: newborn infants or the elderly. Populations that have less than optimal immunity.

But in the 1918 virus, while those two populations also had very high mortality, there was this new peak of mortality in young healthy adults: 15 to 35 year olds. People in the prime of their lives were somehow specifically targeted for a lethal outcome with this virus.

I think that it’s very likely that there was a host factor involved -- that people of this age group may have had an extremely odd kind of immune response to this virus, perhaps because of the types of influenza viruses they were exposed to earlier in their lives.

Therefore, even having the complete sequence of the 1918 virus in front of us, we may not actually be able to explain one of the biggest mysteries of the 1918 virus without finding other pieces of information that are currently lost to us.

^TOP

You don’t buy the argument that the immune system just went into overdrive – that the healthier you were, the more lethal the virus could be?

It’s certainly possible that one of the explanations for high lethality in 1918 was the fact that there was such a robust immune response to the virus that the immune response in itself was damaging.

I still think that any number of possibilities is still open for discussion about what exactly happened in 1918. Until we can understand what influenza viruses circulated before 1918, unless we can analyze serum to look at the kind of antibodies that people had in their blood, of different age groups in 1918, unless that becomes possible by finding collections of serum, for example, from that time point, we may never be able to fully understand exactly what happened.

Could you compare the 1918 virus with the current H5 virus?

The 1918 virus is a different subtype than the current H5 virus. It’s an H1 subtype, which is quite different from the H5. But in general they have a lot of similarities.

They are both avian-like viruses. The 1918 virus has a handful of mutations in each of its genes that distinguish it from bird viruses, that are then maintained in all subsequent human viruses. And we speculate that this small number of changes, maybe around 30 or so in the whole virus, are crucial for this process of how a bird virus becomes a adapted to become a human virus.

The H5 viruses are actually beginning to show adaptations to humans in a way that parallels what happened in 1918. But whereas the 1918 virus may have had 30 changes, the H5 viruses that we see have no more than a small handful of these changes. Luckily, if this is the process that is going on, we are seeing a very early development. We are at a very early stage.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

^TOP

How deadly is the H5?

Currently the H5 viruses are quite deadly. We know that right now there have been about 120 documented infections and about 60 deaths, or 50 per cent mortality, which is an extraordinarily high mortality rate for any infectious disease. The 1918 virus had a fatality rate in North America of 2.5 per cent, meaning somewhere around two and a half per cent of the people who became clinically ill in 1918 ultimately ended up dying.

Of course I want you to remember that was at a time when there were no vaccines, no anti-viral drugs, no antibiotics, no respirators, no intensive care units. This was just general supportive care, or no medical care at all. In some parts of the world where there are other medical conditions, starvation, malaria, in the Third World, you saw much higher fatality rates.

I think that if a new pandemic were to emerge, I think it extremely unlikely that it would maintain the high fatality rate that we see now if it were to spread as a pandemic.

Do viruses become less lethal over time, or more lethal?

We don’t yet know the genetic basis of why one influenza virus is inherently more lethal than another, but we can say from general principles of infectious disease that highly lethal agents that kill their host very rapidly and at a very high percentage are unlikely to spread very well.

Ebola is a classic example. It’s an incredibly lethal pathogen with very high fatality rates, that does not spread efficiently at all among humans and is therefore unlikely to cause a widespread outbreak. Influenza viruses are spread very efficiently and I think one of the keys to their success, is that they cause relatively low mortality.

^TOP

When that first human-to-human case occurs, what would you expect to happen next?

The most important thing for the spread of a pandemic is for it to be able to go person-to-person. And the most important thing for pandemic preparedness would be to recognize that person-to-person spread of a new virus.

The key would be how quickly the surveillance network would actually pick up a new cluster of cases and how quickly an unusual outbreak among humans somewhere in the world would be identified as being unusual.

If it’s a virus that has unusual properties, that causes people to become fairly ill, if it has relatively high fatality rates, it’s likely to be detected fairly early. But this really depends on what part of the world you are in.

I would expect that once a new pandemic virus could get into humans, and could spread person-to-person efficiently, that there would be a small chance that this pandemic could be contained – if it were identified very promptly; if the surveillance network was close to real time; if you can come in and apply anti-viral drugs to try to wipe out the spread of the virus.

I am not so hopeful about that. Influenza is pretty infectious from person to person and the real problem about containing it is that a large number of people that are infected with viruses are shedding viruses before they are even symptomatic. The quarantine and containment strategies that worked with SARS, for example, are very unlikely to work with flu.

That means you would very likely see the rapid distribution of this virus, especially in a global society where tens of thousands of people move between continents every single day in airplanes, that it is likely to spread vary rapidly to other continents. We saw with SARS that within just a few weeks, it has spread from Asia, and to Europe and to North America.

^TOP

There would likely be a call to shut down travel almost immediately. How effective do you think that would be in slowing the spread?

When a pandemic first emerges, it will be very unlikely that there will be a completely matched vaccine available. The problem with influenza viruses is that because they are so variable, you can’t actually predict what the actual structure of the virus would be that might cause a pandemic. So there is no way to actually make a completely protected vaccine against a future unknown pandemic. Once this pandemic begins to spread, there would not be a vaccine available immediately.

There certainly will be some stockpiles of anti-viral drugs, which will likely be reserved for people who are critically ill, rather than for prophylactic treatment. What we are going to be left with is old-fashioned sort of public health control measures. To limit contact, to avoid crowds, I think there will be calls to close schools, to close public gatherings to limit spread of the virus. It’s likely that borders will close.

All of those things are likely to help a little bit. But ultimately, I think past experience suggests that none of those things will be very effective, and it’s likely that a pandemic virus will be able to spread, to all corners of the globe.

^TOP

What can we do to protect ourselves once the virus is out in the human population?

People can limit their contact as much as possible with other individuals. If they become ill themselves, they can try to either stay at home or go to hospital if that’s possible. Of course you can just do classic preventative measures: frequently washing your hands, wearing masks is somewhat helpful, for example.

At the public health level, countries are going to implement their pandemic plans which will try to quickly ramp up the availability of vaccines and the distribution of anti-viral drugs, the creation of emergency hospitals for example, so that patients who are critically ill can have beds in hospitals and be appropriately treated.

All of these things are going to have to happen. And of course people are going to have to listen to public health authorities about what is recommended, and follow those guidelines. But ultimately, all of those things that are going to react to a pandemic are not likely to prevent its spread or actually eliminate a pandemic.

The only thing that’s likely to eliminate a pandemic is actually finding a virus, and eliminating its circulation before it becomes transmissible in humans. That is something that might be possible in the future, but is not yet possible. We just don’t know enough to do that.

What worked in 1918?

In 1918 all the things that we just described were done. They recommended people to not gather in public places: they closed theatres, they closed schools. But ultimately, society was not shut down. Despite implications of future risk by public health officials, people did go on with their lives. Commerce occurred, people continued to move around to different parts of the country.

Of course, in 1918, World War I was still on. There was an effort of all the combatant countries to move troops, and personnel and supplies back and forth, between North America and Europe. The needs of the war effort, for example, were in a sense the complete opposite of the needs of public health officials to try to slow the spread of the virus.

Ultimately, none of the containment strategies that were attempted in 1918 worked. And ultimately this virus spread everywhere.

^TOP

There is a dispute about the numbers of people that died; can you talk about your views on that?

The number of people who are thought to have died directly of the virus, or as a secondary consequence of viral infection and then dying of bacterial pneumonia, or of heart failure, or of or some other medical problem but still directly linked to being infected with the virus has been growing steadily since 1918.

The earliest reports that have been compiled around 1920 or so, suggested that about 20 million people died. I think that that was ignoring much of the world. I think that was looking at North America and Europe, Australia and New Zealand predominantly. I think that scholars have looked at mortality rates around the world and have looked at the evidence that exists. I think that most epidemiologists and scholars would think that that number is much higher.

And a recent conference, in which all these data were pooled together, a best effort was made to come up with a better mortality figure. I think a number of 50 million is much more easily supported, although a number of members of this conference committee suggested that this number might even be double that, at almost 100 million.

What did death look like for people who died from the virus?

There were really two major ways in which people died. The first way was to die very rapidly, probably of the primary viral infection itself. And in those cases, people often basically drowned in their own blood or serum. You would get really severe damage into the lung, and you would actually leak blood into the air spaces of your lung. You would basically drown. And this happened in just a couple of days.

The majority of people however, probably three quarters of the people who died in 1918, actually died of secondary bacterial pneumonias. They had an initial viral infection that caused damage to their lung, and that set them up for infection with a colonizing bacterial agent. And because no anti-biotic were available in 1918, if you got a bacterial pneumonia, even as a young healthy adult, you had a 30 to 50 per cent likelihood of dying.

^TOP

How personally worried are you about the threat of a pandemic from this H5 virus?

I am certainly concerned what is going on with the H5 virus, but I would not be a person who would say that we are definitely going to see a pandemic or that it’s imminent. I think that it’s a virus that has a number of very concerning properties: it has a very highly pathogenic virus for domestic poultry, like chickens and other bird species, and so is a major agricultural and economic importance. This virus has the ability to completely devastate the farming industry in any country that it gets into. But in addition to that, there are some other features to the H5 virus that are unique and very worrisome.

One is that it has gotten into a small number of people. But it is a growing number. It’s a virus that is very pathogenic in other animals. It’s caused lethal outbreaks in tigers and other large cats in zoos. It has gotten into wild bird populations and gotten into wild birds, which is something that pathogenic chicken viruses have not been known to do in the past.

So this virus is spreading not only by the spread of agriculture and domestic poultry from one area to another, but now actually looks to be spread by wild bird viruses. These features are all really concerning.

But you know, ultimately there is no evidence that this virus has been able to be transmitted efficiently from person-to-person. And we don’t understand why that is.

What I am most concerned about is that we don’t have enough information to make an accurate prediction of what will happen.

The difficulty is trying to deal with something that occurs on a very irregular basis. We know that pandemics happen. Just like tsunamis happen, or earthquakes. But we don’t understand the rules governing the formation of pandemics.

They were certainly no periodicity to the emergency of pandemics, so to say that we are overdue, I think is a bit over-speaking what we actually face. We know, looking back in history, that on average, every 30 or 40 years you see a pandemic. Sometimes that may be as early as nine or ten years between pandemics, sometimes as large as 70 or 80 years between pandemics, but on average about every 30 years or so.

There is certainly no way to say we are due just by timing. It has been 37 years since the last pandemic. We are above the average now, but we could still go for a while. Unfortunately we just can’t predict. The only thing we can do is to say with some confidence that it’s quite likely that at some point in the future there will be a pandemic, and try to do what we can to prepare for it.

Trying to prepare for a very unlikely event, even if it’s one with devastating potential like a pandemic, is difficult. It’s difficult to apply money and planning at a governmental level and a political level to do something and to maintain the public interest in something that only occurs less than once a generation.

^TOP

When friends and family ask you what they should do to prepare for a pandemic what do you tell them?

I recommend that everyone that is able to get an influenza vaccine every year should do so, that having the vaccine is not only good for individual human health, but reduces the spread of the virus to other people, and to people that would have a very severe outcome with that infection – the elderly, or people with chronic illnesses. Reducing the spread of influenza in humans is quite positive.

People should take standard precautions. In the flu season, people should try to avoid crowds whenever possible. They should wash their hands frequently; they should seek medical attention if they get an influenza-like illness.

I think that it would be a mistake for people to think that they would need to have Tamiflu and any other anti-influenza drugs in their medicine cabinets, and at the first media reports that there might be a new pandemic to immediately take the drugs without any evidence of the virus spreading in their communities. I think that people have to be very cautious about this and people have to listen to what there local, national and public health officials say.

^TOP

People are saying that this could be one of the greatest risks facing humanity over the next few years. Where would you place that risk?

Pandemic influenza is clearly a very important and very serious public health problem. The sudden emergence of a virus that could make a quarter, or a third, or half of the world’s population ill within a year’s time and lead to millions of deaths and enormous economic impacts is very large. But there are so many risks that we all face, it is hard to know how to stratify an individual risk like a pandemic.
There are other risks of unusual but catastrophic events, earthquakes, tsunamis, hurricanes, at the pandemic level. There are all the chronic problems that are with us everyday that are enormous problems: starvation, chronic illness, malaria, TB, HIV, other things like that. These are all enormous problems, but just because things only happen on an occasional basis is not a reason not to do what we can to be prepared for it.


v

People should be aware that these interviews you are flooding the thread with were not part of the show. Or, if they were, only very small bits and pieces of them.

My overall impression of the show was that no matter what they (governments) try to do, nothing will stop it. That no matter what you do, including trying to isolate yourself, it won't help very much.

It made me think of something I read recently. Will have to ad-lib because I can't find it....

There was a study done that showed when a group of people were presented with what they perceived to be an impossible task, very quickly they stopped even attempting to solve it..

The following is an edited excerpt from and interview with Dr. Kulkanya Chokephaibulkit, conducted in late 2005...



Dr. Kulkanya Chokephaibulkit
Associate Professor of Paediatrics, Infectious Diseases
Zuhrat Hospital, Mahido University
Bangkok, Thailand




When did you first come across H5N1?

The very first case that I have seen was in January 2004; a case of a six-year-old child who had severe pneumonia. He started with a cold: running nose, some fever for a few days, and then coughing, high fever. He received some treatment from the paediatricians locally, but didn’t improve. The symptoms seemed to be more severe with more fever, more shortness of breath. Even the IV antibiotics could not contain the illness, then he came to see us.

The first time that I saw this child, I did not think of the virus - it was so severe that I didn’t think of the usual influenza virus. I was thinking about maybe some serious bacterial infection, or some serious a typical bacteria.

Avian influenza was at the top of my mind at the time - I think because there was some report of chickens and birds die from H5N1 and only a few days earlier. I saw the report from a WHO alert on the internet talking about a case that might be H5N1 in Vietnam.

So, with the clinical symptoms that were so severe in a normal healthy child, unresponsive to anti-biotic therapy, that let me to think of this unusual virus. I sent for the specific test.

Key points:

When you realized you had a patient with H5N1, what happened at the hospital?

How did you protect yourself and your family from being infected?

Why are people so worried about H5N1?

What should we be doing to prepare for a pandemic?

How did you tell the boy's parents that he had died?

What happened at the hospital - what sort of precautions were taken?

In the beginning there was no specific precaution procedures. Respiratory tract infections, or respiratory tract illnesses, do not require strict isolation, only droplet precautions, meaning that you be careful of the secretions and droplets that would produce from the patient.

The precautions that took place in this case were not special, it was routine for a respiratory tract infection. However, after we discovered that this is potentially a lethal virus, a very aggressive virus, we put this child is strict precaution isolation.

What were you thinking when you discovered that this child had H5N1?

We were quite scared. This is so new, not just to us, to human beings, to all mankind. It was the first time we experienced the virus we were so sure would never cause illness to humans – and here it actually can cause illness to human. Not just simple illness, not just a few fevers, but an illness that is so severe that it can kill you very fast.

We were quite scared about that. And not just the physicians, but also all of the health care workers working with the patients. We have 83 health care workers that had direct contact with the patients. We don’t know how contagious this virus would be.

Influenza, you can catch it easily. Once you have flu, you can spread the virus easily to your folks, to people around you very easily.

^TOP

You have a young child. Did you worry that you had gone home and perhaps had infected your family?

I’m not worried about that much because I an infectious disease expert. I know that direct contact is the most dangerous. Indirect contact can be prevented by good hand washing, by deliberate precautions. I am quite confident that I can clean myself up before I get home.

But at the very beginning, before we knew that my patient had H5N1, we didn’t take any special precautions, or more than the standard pre-cautions. At that time I was worried that I might get it, and if I might get it, then I get sick and might spread it to other folks around me. But after we know that this child has H5N1 we put the child in strict isolation.

What happened next for the boy?

The boy was intubated and the pneumonia progressed very rapidly. He came down with RDS, or Respiratory Distress Syndrome, and he died after that.

What did you have to do next?

There are many measures that you have to do simultaneously at the same time. The most important thing is to make public awareness of the potential of this virus to infect humans.

H5N1 is a bird virus, and therefore we think that it will not infect the human being. People are not worried about contact with chickens or birds. People don’t know that if they touch the very ill birds, or the chickens, or the dead bodies of the bird or the chickens, they might get the virus.

That’s why we have cases, because they aren’t aware of that. So public awareness is the most important thing. Once people know that they can get infections from the birds or the chickens, they are careful. Subsequent cases were less and less and finally disappear because people know how to protect themselves, not to touch the sick chickens.

^TOP

What is the state of H5N1 right now in the world? Where is the virus right now?

The virus is still circulating in many species of birds, in chickens and wild birds. H5N1 is not new. I think that it has been in this world for a long time.
H5N1 is not considered a pandemic virus at this time. There have been no human cases of H5N1 reported in Canada as of January 11, 2006.

Why are people concerned about H5N1 right now?

Because it can kill. It is not just a virus that will make you sick for a few days, like usual influenza virus.

Are you concerned about avian influenza?

We worry about avian influenza because it could happen at any minute, at any day, and if you are not well prepared, and if the virus infects human beings, and transmits easily from humans to humans, then it’s very scary.

I think it’s worrisome because the potential outbreaks of this deadly virus, it just could happen any day. But we don’t know how long it could be. It’s true, at the moment we have many other illnesses that we have to worry about -- malaria, tuberculosis, many other things -- but still H5N1 lives in the back of your head all the time. It’s like a bomb. You just wait for the time to happen.

^TOP

What kinds of things do you think we should be doing?

There are many, many things that should be done. Developed countries should be thinking about how to make a vaccine available if this virus has an outbreak. Developing countries need to think of how to contain the source of the virus. For example, right now, we know that the source of the virus is in chickens and birds, we should try our best to contain the virus, get rid of the infected birds, make the farm raising safe, so that we lessen the chance of having them spread to other birds.

In the medical setting, we need to make the preparedness plan: what should we do if one patient show up? What should we do if there is more than one, or a lot of patients show up at the same time? We need to prepare the stockpile of anti-viral and stockpile the personal protective equipments like masks, gowns. And it’s very important is to educate our people on every level.

Is there much that anyone can really do once it spreads?

If you might come down with the illness, focus on the prevention of spreading; cough etiquette, using a mask, washing your hands, all these things. Careful hygiene is very important. That’s on the personal level. If they can make themselves healthy, avoid getting the infection, that’s a very good role of them to prevent spreading.

For health care workers, we have to do our job, at best to contain the infection; we have to have good isolation systems, precaution systems. In terms of higher levels, the policy makers need to do their duties to contain the outbreak.

^TOP

What was it like, having to tell the parents of that little boy that he had died?

We explained to the parents that the child died from the avian influenza virus, and that he was very unlucky that he got it. The parents told me that if they had known that chicken could be this harmed, they would not have let the child touch the chicken. And if they knew that this virus was spreading among the chickens in the village, they wouldn’t let their children play with chickens at all.

A lot of Thai children grow up with chickens, because almost every single household has chickens in their house. They like to play with chickens. Chickens are part of their life. That’s why education is the most important thing. We don’t see new cases after you make public awareness.
However, this virus has not been able to adapt to infecting humans to humans. But if the virus adapts to be able to infect humans efficiently, and can transmit from one human to another human very efficiently, than this is another story. You don’t need to contact chickens before you come down with illness. That is a very scary situation and it is something that a lot of scientists have been worried about. It could happen any day. But we don’t know when.


http://www.cbc.ca/fifth/nextpandemi...phaibulkit.html

Thank you for pulling these together, Snowy Owl.

Historical evidence from both the dark ages and the 1918 pandemic show that's an incorrect assumption.

Strict self-quarantine is the ONLY thing that saved people.

Hey thanx for the bump. I'd completely missed this thread.

And um... the thread wasn't 'flooded' by interviews. It was set up specifically to contain them.

Looking forward to reading them - tomorrow - LOL.

__________________
Bunnies love me, this I know
'Cause Arubi tells me so.

Ummm, no, these were originally in the thread asking for viewers impressions of the recent Canadian Docu-drama about the bird flu. The person that split the thread didn't pull mine out, which leaves it out of context.

Bird Guano, I don't disagree with you, however, that was the message I felt was conveyed in that program.

Snowy,
A belated thank you. I missed this thread while away from home - haven't read it yet but certainly will.

__________________
Mat 24:24 "For false Christs and false prophets will arise and will show great signs and wonders, so as to mislead, if possible, even the elect."
"For the greater good, in a time like this it is better to be constant, alarmist and informative than piecemeal, confusing and late."-by Emmy Fitri, The Jakarta Post

Snowy,

Thank you for all the time and effort it took you to bring these most relevant documents to this site. I have read them, learned from them and will pass them on to key officials in my town.

Knowledge must be shared.

Thank You Snowy,

I value your insights and opinions.

B

Could someone please make this a sticky. This is the expressed opinion of the worlds foremost authorities in the field of interest and as such should be one of the first things read by everyone visiting this forum.

Thanks,
Brad Marsh

I second the motion.

Snowy, Great work . . Thank you so much. Having this as a resource will help greatly in sharing concerns regarding the BF with others.

Great stuff - mandatory reading for those that question.

Respectfully:
Admins, are you sure you don't want this stuff to be the first that people read when coming to this site?

These are the recent words of the worlds leaders in the relevant fields and I really feel they carry an authority beyond any of us amateurs. Surely they deserve 'sticky' status.

Having said that, it is your forum.

Best Regards,
Zapper

Good heavens - I DID mean to sticky this & for some reason I can't remember - I forgot.

Let me do it now.

__________________
Bunnies love me, this I know
'Cause Arubi tells me so.

Many Thanks Sue,
I refer a lot of people to this thread and in some ways I think it is the most valuable there is here. It shows clearly the unanimous opinion of the experts that this pandemic threat is quite real and needs to be taken seriously.

ATB,
Zapper

Why is it that I feel grossly overprepared? Most of the experts don't seem to be admitting they have stockpiled food, masks, or medications. They are saying this is important but are not explicitly encouraging people to stockpile. It seems some members here have more supplies than the experts.

Fredness,

Experts will have access to more tamiflu than we could dream about, because. . . well, they're experts. . . Think the boys and girls at the CDC, WHO and our (un)civil "servants" in Washington DC aren't going to get taken care of ???
.
.
Gilmore

Gilmore, amatures built the ark and experts built the Titanic
Big Grin