CDC Director's missing intestinal tract

Just as Viet Nam reports another death in a nine-year old boy from avian influenza A(H5N1) (AP via USA Today), Thai investigators writing in CDC's scientific journal Emerging Infectious Diseases suggest that many cases of the disease might have been missed earlier this year. The Thai data also underline a persistent and worrisome feature of the cases to date: a predilection for the young (see post here). CIDRAP News has an excellent summary for those not interested in the technical details. Here is the gist.

Of 610 cases of illness suggestive of influenza that occurred in the January to March period of this year, twelve were confirmed as H5N1, seven under the age of fourteen. Because the symptoms of the disease are non-specific (literally "flu-like"), the investigators believe many cases go undiagnosed. CIDRAP summary:

The Thai investigators examined all cases in the first 3 months of 2004 in which patients were hospitalized with pneumonia or influenza after exposure to sick poultry. They classified cases with laboratory evidence of H5N1 infection as confirmed. Cases in which patients had been exposed to sick poultry and had either severe pneumonia or laboratory evidence of influenza A, but without confirmation of H5N1, were defined as suspected.

The researchers found 12 confirmed and 21 suspected H5N1 cases among the 610 potential cases reported from 67 of Thailand's 76 provinces. Eight of the 12 confirmed case-patients died. The median age of the confirmed patients was 12 years (range, 2 to 58) and that of the suspected patients was 33 (range, 1-67).

All the confirmed patients came from villages where abnormal chicken deaths had occurred, and nine lived in houses where backyard chickens had died unexpectedly, the article says. Eight patients had had direct contact with dead chickens.

More than 3 out of 5 of rural Thais live near backyard poultry flocks, producing hundreds of thousands of potential exposures. As noted in an earlier post, the chief worry is that co-infection of an H5N1 infected person with a human strain of the influenza A virus will lead to a reassortment of the segments of the genome of the H5N1 virus to produce a mutated H5N1 adapted to person-to-person transmission. Many experts believe this scenario is not only plausible but likely. Why American public health officials are not beating the "pandemic preparedness" drum remains a mystery.

Dr. Julie Gerberding is the CDC Director. She is an articulate public health professional able to communicate with the public accurately and credibly. All the more distressing that she is not using these skills to better purpose. Instead of a timely alert to state and local officials and the public that there is a looming health crisis, she has opined on the obesity epidemic and used the CDC platform for a pious reiteration of old news, that married people are healthier on average than unmarried people. There is an element of compliance and good old fashioned "brown nosing" here (see "Fulsome praise, as in . . . ").

What are the risks to sounding the avian flu pandemic alert? Certainly it isn't a fear of worrying people. After all, this is the Orange Alert Administration. Nor is it plausibly a fear of loss of credibility if a pandemic doesn't materialize (we should be so lucky). Many people already take the attitude that warnings from this Administration are of the "chicken little" variety. But that shouldn't deter any responsible official from sounding a genuinely warranted alert, which most experts believe this to be. Indeed it sould give CDC pause before pulling the "orange alert" lever or busily and visibly preparing for bioterrorist events with much less likelihood than a devastating influenza pandemic.

There will be no political points for publicly ratcheting up concern and no support (and possibly some resistance) from Administration apparatchiks already embarrassed over the flu vaccine screw-up. So a little resolve is needed. It seems to be missing.

Working diagnosis: Gutless leadership.

Update: Agence France Presse (via Channelnewsasia) is now reporting a second death from bird flu within a week in Viet Nam. A 6 year old boy died on December 30. This brings the total deaths from H5N1 in Viet Nam since January 2004 to 22. It is the third known case in the last month.