Saturday, November 27, 2004

The Next Big Thing

With retail season upon us, everyone is wondering what will be The Next Big Thing. The answer might have been anounced at a meeting of ministers from 13 Asian countries held over the last two days while Americans were chowing down on a Thanksgiving bird. Yes, it's H5N1 bird influenza and as many as 30% of the entire world might get this gift that keeps on giving. According to WHO, as many as 7 million might even be thrilled to death.

Haven't heard that WHO just announced it expects H5N1 to cause the next big flu pandemic? Maybe that's because US health officials have been taken up with even more important health issues. For example, the US Surgeon General wants us to trade family medical information at the dinner table so everyone is aware how their genes will doom them to serious disease (see post, The Surgeon General as Appetite Suppressant). Meanwhile the Director of CDC was busy explaining why she and her agency overstated the health impacts of obesity (see post below). In neither case was there any time for our nation's public health "leaders" to mention we are facing a threat that requires a change in farming practices, animal husbandry procedures, strengthening the public health system and the proper and timely provision of vaccines. Especially not the proper and timely provision of vaccines.

Influenza pandemics come around every 20 or 30 years, so we are due for one, as WHO pointed out at the meeting. Pandemics are caused when the influenza virus changes sufficiently that there is essentially no native immunity from past infection. And as far as anyone knows, humans have never been afflicted with an H5N1 virus before. It'll go through the world's population like a hot knife through butter.

The H5N1 influenza A virus has mainly affected birds, which are subject to many other influenza A viruses that don't seem to affect humans, although a few human cases have been reported in people in close contact with infected birds for some strains (H5N1, H9N2 and H7N7). In the three dozen or so cases where H5N1 has made the jump from birds to humans it has had a frightful 70% mortality, akin to Ebola and much higher than SARS. Human cases of H5N1 seem to occur unusually often in children. The real worry is that H5N1 will continue an already evident genetic shift and become adapted to person-to-person transmission. Already it has had an unprecedented geographic spread in birds and been found in tigers and domesticated cats. A likely scenario would be co-infection in pigs, often kept in close contact with humans in Asia. Pigs can also harbor human influenza A, which could allow a subsequent genetic recombination between the avian and human viruses with the worst features of each: extreme virulence and transmissibility between people.

Any protection must come from solid public health and other infrastructures to provide implementable contingency plans for dealing with transport and trade if the disease starts to spread, support for better agricultural practices, especially in the poorest nations and the stockpiling of affordable anti-influenza medication. Timely surveillance and warning and the ability to implement preventive and care-giving measures are needed not just locally, but globally. Too bad it's called influenza A. Maybe if we could rename it al-Qaeda we could find enough resources to bring "health democracy" to the rest of the world (giving new meaning to getting a "shot" from the US).

What about a vaccine? Two American companies are working on it, although nothing is expected during this year's flu season. With any luck we'll make it through without an H5N1 pandemic--this year. But what about next year or the year after? Two companies? Sounds familiar. Will they have exclusive licenses? Or will they distribute their technology globally, so that world public health authorities can set up half-a-dozen or a dozen production facilities with associated distribution networks throughout the world?

Oh well, not to worry. I'm sure our nation's public health leaders are doing their best. And they can't do everything (that's why they are urging us to take care of ourselves, after all). They have taken significant steps already, just announcing they are letting a contract to manufacture 75 million doses of vaccine. And at a bargain price: $877.5 million. Of course, it's a vaccine against anthrax, a non-contagious disease that only killed a handful of Americans when it got out of a government facility. But it's a matter of priorities and it's a start. First things first.

News reports about the Bangkok meeting with various slants can be found at AP via Newsday, CBC, The Standard of Hong Kong, The Nation and Reuter's Health. CBC has an "in depth" with a Canadian perspective and useful background on avian influenza viruses in general. So far no notice of the Bangkok meeting on the CDC site. WHO has a press release that adds nothing and is less helpful than the news stories, linked above.