Avian Flu Diary: 48 Months Later . . .

#17,843

Four years ago, a little before midnight on December 30th 2019, the dedicated newshounds at FluTrackers began posting the first of many reports out of China on an outbreak of an unidentified viral pneumonia in Wuhan; the capital and largest city (pop. 11 million) in Hubei Province.

Sharon Sanders sent me a head's up Skype message a little after midnight (which I did not read until I woke up about 2:30 am), but I had my first blog published before 4 am, which would be the 1st of three I would publish that day (see here, here, and here).

While none of us knew the world was about to change, it `felt' different and important. Reminiscent, in some ways, of the early reports of H7N9 emerging in China on March 31st, 2013 (see China: Two Deaths From H7N9 Avian Flu).

Within hours Crof (who is 3 hours behind on the west coast) had his first blog up (Hong Kong: CHP closely monitors cluster of pneumonia cases on Mainland), but it would literally be days before the mainstream media took notice.

It was - very much like today - during that quiet time over the holidays, where news bureaus and health agencies work short-staffed. People were more interested in ringing in the new year, and college football, than rumors of an epidemic in China.

Avian flu had gone quiet, and the big stories we were following that week involved a moderate H1N1 seasonal flu season and an unusual Outbreak Of Brucellosis Reported At Veterinary Research Institute - Gansu Province.

The WHO made their first public mention on Twitter 5 days later on January 4th, and two days after that the CDC Issued a Level 1 (Watch) Travel Notice For Unidentified Pneumonia - Wuhan, China. By then the official number of hospitalized patients had reached 59, and Hong Kong had gone into full alert mode, with PPEs flying off the shelf.

It would take China another 10 days to admit to the world that the virus was transmitting from human-to-human (see `Evidence of Limited Human-to-Human Transmission' - WHO WPRO) - something they must have known for weeks - but by that time the virus was already spreading silently in Europe and beyond.

Despite China's denials, the evidence suggested something serious. On January 7th, in a blog called Hong Kong: Caught With Their Masks Down, I described the run on PPE's in Hong Kong, and urged my readers that if they wanted N95s or Surgical masks, they'd better order them now.

The world may have felt blindsided by COVID, but this very scenario is one that had been discussed, analyzed, and had been the subject of numerous `tabletop' simulations over the years (see JHCHS Pandemic Table Top Exercise (EVENT 201) Videos Now Available Online).

Dire pre-COVID pandemic predictions by global health agencies include:

WHO/World Bank GPMB Pandemic Report : `A World At Risk'

WHO: On The Inevitability Of The Next Pandemic

World Bank: The World Ill-Prepared For A Pandemic

It was arguably the most anticipated crisis of the 21st century, yet despite plenty of warnings, the world went into it woefully unprepared.

Four-eight months ago, the world changed abruptly practically overnight. Millions have since died - likely far more than were ever counted - and many more had their lives dramatically altered by illness, disability, or the economic and societal impact of lockdowns.

The pandemic which was expected to last only 6 to 18 months, continued for 3 full years, despite a record setting vaccine development and deployment effort. The virus remains with us today, albeit significantly subdued, constantly evolving as it spreads.

Meanwhile, there are more than a few pathogens out there with pandemic potential that we continue to watch closely. While it might take years before it happens again, we could just as easily wake up tomorrow morning to vague reports of a mysterious disease spreading somewhere in the world.

You'd think that after being caught flat-footed at the start of COVID we'd have made pandemic preparedness a priority going forward.

Instead, we appear to have gone in the opposite direction. We've dismantled our COVID surveillance and reporting (see No News Is . . . Now Commonplace), and reporting of other outbreaks (as required by the IHR) seems to have taken a serious hit as well.

The WHO, in nearly every surveillance bulletin, reiterates the obligation for all nations to abide by the IHR (see below).

All human infections caused by a new subtype of influenza virus are notifiable under the International Health Regulations (IHR, 2005). State Parties to the IHR (2005) are required to immediately notify WHO of any laboratory-confirmed case of a recent human infection caused by an influenza A virus with the potential to cause a pandemic. Evidence of illness is not required for this report.

Yet China often goes 2 months or longer before releasing (very limited) data on human avian flu infections (see here, here, and here). China holds all infectious disease reports (in humans or in animals) very close to the vest for `national security reasons'.

In the 2 months following the end of their Zero-COVID policies, China reported roughly 84,000 deaths from COVID. But last August, an investigative report published by JAMA Open estimated 1.87 million excess deaths while another estimate from the EID Journal calculated 1.41 million deaths over those 60 days.

China isn't alone, of course. We rarely hear of MERS-CoV cases anymore from the Middle East, despite evidence of the virus still circulating in camels. The WHO has diplomatically cautioned:

The number of MERS-CoV cases reported to WHO has substantially declined since the beginning of the ongoing COVID-19 pandemic. This is likely the result of epidemiological surveillance activities for COVID-19 being prioritized, resulting in reduced testing and detection of MERS-CoV cases.

Harder to pin down are those sentinel events that are simply missed, or are deliberately covered up. There is very little that the WHO can do if a country decides - for economic, societal, or political reasons - to side-step the IHR.

Last April, in Lancet Preprint: National Surveillance for Novel Diseases - A Systematic Analysis of 195 Countries, we looked at an independent analysis which suggests that many nations have substantially overstated their compliance with the 2005 IHR regulations, and that surveillance and reporting are far less robust than advertised.

We like to pretend that there is plenty of time to prepare; that the next pandemic won't come for another ten or twenty years. But the clock is ticking, and we may have far less time than we hope.

In 2021's PNAS Research: Intensity and Frequency of Extreme Novel Epidemics, researchers estimated our pandemic risk may increase 3-fold over the next few decades.

And these are `extreme novel pandemics', which means there will likely be other - lesser - global health crises to deal with along the way. And we're not even well-prepared to handle those.

As we plunge headlong into 2024 we have a number of plausible pandemic/epidemic contenders to keep our eyes on. The `usual suspects' include:

Avian H5N1 (clade 2.3.4.4b & 2.3.2.1c), H5N6, and others including H3N8 and H9N2.
Several swine variant viruses.
MERS-CoV, or some other emerging coronavirus (possibly an offshoot of COVID).
And there are genuine concerns over the impact of recent sexual transmission of Mpox Clade I in the DRC.

This list could easily also include a hemorrhagic fever, Nipah, and even the Langya henipavirus (LayV). but the possibility exists that we could be hit by something entirely new, or at least something not on our radar:

Disease X. One that we don't currently recognize as a threat.

Whether from a new threat or old, another pandemic is inevitable. The only real questions are the timing, the severity, and the source.

In September of 2019, three months before the Wuhan outbreak, in a blog called `#NatlPrep: Personal Pandemic Preparedness', I quoted Michael Leavitt, Former Secretary of HHS: