Thursday, December 07, 2006

The Flu Watcher’s Dilemma


While actual reports of human infections with the H5N1 bird flu virus have all but disappeared from the headlines, the actions of our governments, and the warnings issued by scientists continue to give credence to the idea that the threat of an Avian Flu pandemic has not gone away.

If anything, the warnings have grown more strident in recent weeks.

Counterintuitive, I know. You’d think, if the threat were ongoing, we’d be seeing more reports of human clusters; more outbreaks in birds, and news of quarantined villages and military cordons such as were so prominent in the news six months ago.

Of course, the news media in most of the countries affected by the bird flu are constrained by their governments, to one degree or another, as to what they can report. The level of transparency, and honesty in reporting bird flu cases varies considerably from one country to the next. And quite honestly, it’s impossible to know what we aren’t being told.

Up until a couple of months ago, we heard reports of hundreds, sometimes thousands of `suspected bird flu’ cases being screened, and proven to be negative in the press. It was comforting to hear that the authorities were being diligent, and that no new cases were being detected. When a patient died, we were assured they died of something unrelated to the H5N1 virus.

Last month, we learned that the most commonly used screening tests for bird flu are nearly 100% useless. That the nasal and throat swabs, and the ELISA tests, consistently failed to pick up the virus, even in patients known to be infected. Suddenly, we aren’t hearing about humans being tested, and their `negative’ results anymore.

So one has to ask. Are `suspected cases’ no longer showing up? Or, with the revelation that the tests are worthless, have authorities simply decided not to talk about them?

Frankly, I don’t know the answer. I wish I did.

Occasionally, we do hear about suspect cases in the foreign press. Flubies pour over foreign language newspapers, use translation software to convert the stories to a form of psuedo-English, and post the data on the Internet. Often, we never hear a follow-up report. Or if we do, it is months later.

So, while it is apparent no huge outbreak of avian flu is going on anywhere in the world, the suspicion is, scattered cases are occurring and are simply not being reported.

Against this background, we continue to hear warnings not to succumb to `bird flu fatigue’; not to become complacent. Countries like Switzerland, the UK, and the United States are spending hundreds of millions of dollars on vaccines and antivirals, in anticipation of a possible pandemic. Vaccines by the way, which have a very short shelf life, and would become useless in a matter of 12-24 months.

Massive, and very expensive drills and exercises are being held across the country and around the globe, in order for government agencies to be ready to deal with a pandemic. And the business community is being told of the necessity to prepare for absenteeism rates of 40% or more.

The State Department has announced that they will be unable to aid our citizens abroad should a pandemic erupt, and urge them to make their own plans to shelter-in-place. Buried in this announcement, this little tidbit caught my eye:

The Department of State has pre-positioned supplies of the drug Tamiflu at its embassies and consulates worldwide, for eligible U.S. Government employees and their families serving abroad.

Certainly a reasonable precaution, if one expects a pandemic to break out.

The level of concern seems to increase with each passing day, despite the lack of news in the media.

Part of this, no doubt, is due to the genetic changes we are seeing in the virus. It has changed radically since it first appeared in Hong Kong 10 years ago. It is becoming less avian in appearance, and is moving towards a more human pathogen. Over the past couple of years, it has shown the ability to infect a wide range of mammals, including some that normally are not susceptible to influenza.

As the virus has evolved, the lethality has not dropped as was predicted. In fact, it has gone up. During the Hong Kong outbreak in the late 1990’s, only 33% of the patients died. This year, in Indonesia, 76% have succumbed.

Again, a worrisome data point.

Although there are some who maintain that our government knows far more about the pandemic threat than they are letting on, I don’t subscribe to that conspiracy theory. I suspect the governments of the world, and the scientists following the bird flu, are as perplexed over the eventual timing of a pandemic as the rest of us.

They see the signs and portends, but like us flubies, have no way of knowing when, or if, a pandemic will break out. We’ve never watched the birth of a pandemic before; we have no benchmarks to tell us how fast things should evolve. There is no countdown clock to monitor. It will happen when it happens.

Frankly, I know of some scientists who are surprised it hasn’t already started.

There is danger in hyping a pandemic too soon, alerting citizens too far in advance, just as there is danger in waiting too long. And so governments are walking a tightrope, trying to convince citizens to prepare, without unduly alarming them.

As the drumbeats grow louder, however, it is only prudent that we in the flu watching community take heed. The virus is mutating, and expanding its geographic range. This time last year, it was in 15 countries. Today it has been detected in at least 55 countries. So the threat appears to be growing. More hosts mean more opportunities to pick up the necessary genetic changes to become a pandemic.

Just as governments are doing the prudent thing and preparing, so should all of us. When a pandemic does come, it will likely do so with little warning. It makes sense to be prepared well in advance.

But we also need to accept the idea that we could be in for an extended wait, that the next pandemic may not be imminent. While the next few months, being the peak of the flu season in the Northern Hemisphere, are perceived as being a high risk time period, the pandemic might not start this winter. It could come next summer, or next winter. It might not even come for years.

While many flu watchers expect a pandemic to start this winter, quite honestly, no one really knows how close we are to the next pandemic.

We simply have to wait and see.


BLITZEN said...

Amen, Medic. Patience is a virtue.

Anonymous said...

Should we go look, Uchitel?