Today I went to the Pandemic Influenza Conference in Texas

I guess I should start with the good news. The coming pandemic (whether it is Avian flu or a not yet known flu) is being looked at and discussed with all of the urgency it needs to be on a local and national level. Also, the public is becoming aware of the looming danger and are putting pressure on the various agencies to get their acts together. This has been fueled by the recognition that our government agencies failed utterly during and after Hurricane Katrina so perhaps some good has come of the incompetent way that awful disaster was handled. I got a lot of good resources that I will be further researching in the next few days. A web site I hadn't heard of www.pandemicflu.gov now has the National Strategy for Pandemic Influenza which was announced on 11/01/05 is on that site. It's supposed to be about 400 pages long. Needless to say, I haven't read it just yet so I don't know how detailed and comprehensive it is but it's surely got to have some detail if it's that long, either that or they have some verbose writers which is not out of the realm of possibility as we are talking about our government.

I wish the paragraphs on the bad news could be as short. Oh, my, where to start? I guess with the birds and Max Coats, DVM from the Texas Animal Health Commission. Good God, I wish I lived in his candy coated world. He isn't employed as a lobbyist for the poultry industry but the only way I would have been able to tell that is because it would have been required that it be disclosed. He runs the voluntary, yes voluntary, monitoring of poultry in Texas. The industry tests a very small portion of their flocks and eggs for avian influenza and then reports positive tests to his Commission. He is confident that the industry reps will not fudge on this because, well, I'm not exactly sure. I grilled him during question time, asking if this testing was random (who knows?),whether his Commission does the testing (that would be no), how it is enforced (honor system , :eyes: ),and most important of all, why would industry choose to report when it isn't in their financial interest to report (because Asia demands it, though how Asia would know if these were truly random samples and whether the industry in question was, um, lying wasn't spelled out). Yikes. We've had two incidences where it was reported (though not H5N1 in either case). I'm pleased that these two companies chose to behave appropriately but I am not overall reassured. The other little tidbit that was scary is that there are many, many undocumented small flocks throughout Texas and they aren't sure if they tested all of the birds in 10-30 mile buffer zone around these index flocks. Well, isn't that nice.

Next, Texas doesn't require nor do they want influenza to be a mandatory reportable disease. They don't have anywhere near enough staff to be able to process that much information. Increasing staff is not an option so we use a voluntary Sentinel Provider Surveillance Network or SPSN (these people live for three and four letter acronyms), a unwieldy but possibly workable system. We'll see.

Next, we should talk about the current situation with the H5N1 vaccine. We have a few problems there. The regular flu vaccine that gets developed every year requires about 15 mcg of inactivated influenza. The vaccine in its current iteration requires 90 mcg of inactivated avian influenza. So with current egg based technology, it will take six times as long to get the vaccine out to the public. So most of the first wave will have come, decimated the population and died out by the time the vaccine is available. They are looking at developing a cell mediated rather than egg mediated culture which will make things quicker by a couple of months. BTW, unless we are really, really lucky, the vaccine will have to be retooled once human to human variant is established so it will be 2-6 months from when the pandemic starts before we will have that form of vaccine. Not good enough, not nearly good enough. LAIV (live attenuated inactivated virus) or as it is known in the public, flumist or nasal flu vaccination may be one of the answers to that dilemma as it is more quickly developed and can be distributed and administered much more quickly. In that situation, people who have suppressed immune systems will not be able to take it and could even die from catching the flu from the vaccine snorters. Unfortunately, in that situation, pragmata will rule.

So, the vaccine will not likely be the first line of defense. Antivirals will be. Unfortunately, if H5N1 is our pandemic, tamiflu is the only one to have shown effectiveness and it has needed to be used in 2-3 times the normal dose. Also, some variants of this flu have shown resistance to tamiflu. If the variant we get is one of those, then prayer seems to be the back up plan. Or rather, we don't yet have a back up plan. Throughout todays discussion, a running theme was the lack of a plan B. At least we're talking about it.

We had a discussion about the disruption of critical workforce and supplies that would make Stephen King proud. If this flu or whatever is going to be our next pandemic gives us 3 - 5 years and the public and governmental sectors continue to see this as a high priority and if the Bush administration doesn't yank the money, we may well have better answers to these problems than stocking up on candles and canned goods. Right now, that's all we have folks. That, and a lot of worried discussion.

I don't think you even want me to go into the possible quarantine options.

Let's talk coordination between the various agencies who will be providing emergency management. Oh, wait, you've already seen examples of how that um, works. I am at least grateful that the various representatives had the ability to look contrite and sheepish and very, very willing to work on this issue. I guess the fact that it should already be working like a fine, oiled machine is neither here nor there. As you know, you go to the pandemic with the team you have. They’re not the team you might want or wish to have at a later time.

I really, really hate that our whole strategy relies on the Avian flu or whatever flu will be our next pandemic holding off for three to five years. I sure hope it got the memo.

One of my greatest fears is that the quarantine will be as bad as the disease.

Tucker

will quarantine themselves. That's actually one aspect of the larger problem. The electric company, the gas companies, the grocery stores and your neighborhood group health cooperative will not be able to keep enough workforce to run. Parents will, as they should, take their children out of school and in fact, the schools will close early in the pandemic because children are one of the largest vector pools. There goes nearly half your workforce to stay home with the kids. We certainly won't be sending them to daycare as that would defeat the purpose. As well, people will remove themselves out of fear.

Then, your government, whether out of malice (as in the case of the Bush administration) or out of political need to look like they are doing something, anything will resort to forced quarantine. I want to emphasize that military use was not discussed (though, I don't doubt that they will). The CDC and WHO will want quarantine, not because they believe they can stop the spread of the pandemic. They don't believe that for a second but a well run quarantine may delay the spread by a few days or in the best case scenario, by a few weeks. Those few weeks could mean the difference between getting a vaccine out in time to save a few million people.

The thing that wasn't discussed but was palpable was the awareness that our government doesn't have the ability to effectively mount a quarantine but they will die trying and so will many of us. We saw how well things went in New Orleans. I think the people at this conference recognize that quarantine will only work if those quarantined are supported with food, water and medical care and yet, none of those things will be forthcoming but not out of malice. The medical system will fail within about a month. Well before that, some very hard ethical questions will have been faced. Will they have been faced well? I personally doubt it.

care, but it won't be out of malice?

You mean, like the federal response to people dying of thirst in New Orleans wasn't murderous out of malice? You mean, like policies like keeping the Red Cross out of New Orleans because letting them in would "encourage people to stay there" weren't made out of malice? You mean, like corporate media's breathless reports of unconfirmed rumors about rampant violence and baby raping weren't aired out of malice?

There won't be any resources to call on, in this situation.

will be able to deliver 300,000,000 meals on wheels if it does happen?

effective, now would they?

We are talking about the POSSIBILITY of something with avian flu's (supposed) mortality rate somehow randomly mutating to become as contagious as the regular flu. But note that people with the regular flu are a lot more apt to leave their beds to infect other people. That's why highly lethal pandemics are more self-containing than less lethal ones.

though it likely won't work.

I know Rumsfeld has stock in the company that makes Tamiflu. I realize he is going to make bank on the new found need for Tamiflu. That said, this is a weak but necessary component of a very fragile attempt to save millions of lives. I think we're just going to have to get over the fact that the rat bastard will benefit.

Basically, what I'm saying is that Tamiflu isn't a right wing conspiracy drug. It just isn't. Many peoples lives may be saved by the use of it. Let's not throw the baby out with the bathwater.

Whether Tamiflu is a right wing conspiracy drug is not revelant. What is relevant is that Tamiflu has not been shown to have any positive effect on patient mortality outcomes in a clinical setting. The survival rate is far better for patients who aren't treated with Tamiflu than it is for those who are:

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=104&topic_id=5586251&mesg_id=5594017

Why would they give those patients Tamiflu and not give it to the others? Could it be because they were sicker and the doctors were throwing everything but the kitchen sink at them? It wasn't a double-blind study, which wouldn't be ethical in that situation. If the doctors involved still think Tamiflu is a decent tool to use, then I trust them--I seriously doubt they're tied to Rumsfeld.

given certainly did NOT prove to be effective. Even you have to admit this.

Have you read all of the research articles or only the two I managed to find and link here? Do we know what level those patients were? Do we know, from the article abstract, why they chose to give it to those patients, and why it might not have worked? We don't. Tamiflu isn't a magical cure and never has been. I don't know why everyone here seems to think it is. It's a tool doctors have that might make the influenza course shorter, and for a dying patient, that day or two might make a difference.

You might find it a whole lot better to actually talk with an infectious disease doc in your area about this rather than take on a nurse and a doctor's wife on a message board. You keep asking for research and more info (without looking for it yourself, apparently), so you should just go find someone in your area to interview and get back to us on.

Read this post:

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=104x5594266

I went and found two of the footnoted articles as you suggested. The one about the Thailand outbreak is here:

http://www.findarticles.com/p/articles/mi_m0GVK/is_2_11/ai_n11833869

The one about the Vietnam outbreak is here:

http://content.nejm.org/cgi/content/full/350/12/1179?ijkey=171d51f775eec28a47c5aabe85eed863238c3984

From the Vietnamese article:

Oseltamivir {Tamiflu} was administered to five of the patients, four of whom died. Treatment with the drug may have been started too late to be effective, although one of the two surviving patients did not start oseltamivir therapy until the 12th day of illness. ... Our experience suggests that supportive care may be the only option available. Controlled clinical studies are needed to assess the role of antiviral drugs and corticosteroids in the treatment of influenza A (H5N1) virus infections.


I happen to agree with the Vietnamese doctors who actually treated these patients. Do you?

There was a case in Vietnam. The sister was caring for her brother with the flu. They had her on a prophalactic dose of one pill a day. She caught the flu. They upped her dose and she survived. One case but it did work for her. Most people have gone in to the hospital after the recommended 24 to 48 hour window after exposure to take the drug. We don't have enough case studies to tell if giving it early will make any difference. It might be only a tiny help but that might be enough to make one survive or no. At any rate it is all that is available at this time besides relenza which has not been tested as far as I know in this flu.

http://www.commonvoice.com/article.asp?colid=3614

Dr Nguyen Tuong Van runs the intensive care unit at the Centre for Tropical Diseases in Hanoi, Vietnam and has treated 41 victims of Avian. Van says that she followed World Health Organisation or WHO guidelines and gave her patients Tamiflu, but concluded it had no effect on her patients' conditions. "We place no importance on using this drug on our patients," she said. "Tamiflu is really only meant for treating ordinary type A flu. It was not designed to combat H5N1 (Bird Flu) . . . (Tamiflu) is useless."

..

The WHO admitted Tamiflu had not been "widely successful in human patients."

"However, we believe in many Asian countries it hasn’t been used until late in the illness," a WHO spokesman said.

A Department of Health spokesman said: "While there is some anecdotal evidence of the build-up of resistance to antiviral drugs such as Tamiflu, at present the experience is that these drugs do work."


I'm happy to report that an anonymous DOH spokesman assures us that Tamiflu works, but I'm still looking for a shred of evidence to back his or her claim.

It was proven to work in the case I mentioned and in studies in mice for what that is worth. It remains to be seen whether it will work in the majority of cases. Some strains are responsive to cheaper flu drugs ie amantadine, some are resistant. It might depend on which strain wins out. It might end up being useless or wonderful mixed with other drugs. We don't really know yet. Not enough cases with a standardized protocol, not enough cases where it was started early enough after exposure. They have tried steroids to no avail also but perhaps with time a dosage regimen that works might be developed or a mix of drugs. Too early to tell but right now for the resistant strains to other drugs it is all that there is that can attack the N part of H5N1 of the flu.

and give the first Tamiflu shot 4 hours BEFORE any H5N1 exposure -- like they did with the mice -- then maybe it would be effective.

forget about the girl in Vietnam cause it does not fit into your preconceived notions?

That taking a prophylactic dose of Tami flu increases the likelihood of human to human avian flu transmission?

1) Why does the "current iteration of avian flu vaccine requires 90 mcg of inactivated avian influenza? What clinical trials have been run to suggest that this is a) necessary and b) effective?

2) You say that unless we are lucky, "the vaccine will have to be retooled once human to human variant is established." This statement seems to acknowledge the obvious problem of developing an effective vaccine against a virus variant that currently DOES NOT EXIST. What makes you certain that the sequence of random mutations that would be necessary to "establish" a human to human variant of avian flu (unless, of course, exactly such a virus has already been genetically engineered to order) are inevitably impending?

3) What leads you to believe that Tamiflu is effective in any way when it comes to humans who have somehow contracted an avian H5N1 viral infection?

4) Yes, I'd love for you to go into possible quarantine options as I believe that they, Tamiflu sales and the sudden necessity of creating millions of doses of a new, experimental vaccine (the effects of which will be shielded from legal redress) are all behind the "feverish" mainstream hyping of a currently far less than inevitable threat.

Perhaps you could step back a bit and reread my post, reframe your questions and we can have an actual conversation here.

Allow me to withdraw the fourth question since you already answered it, at least in part.

1) Why does the "current iteration" of avian flu vaccine requires 90 mcg of inactivated avian influenza? What clinical trials have been run to suggest that this is a) necessary and b) effective?

I don't understand what led you read any malicious intent into these innocent and perfectly reasonable questions, but let me assure you that I'm open minded to any scientific knowledge that you have on this subject.

2) What makes you think that the sequence of random mutations that would be necessary to "establish" a human to human variant of avian flu is inevitably impending?

I've altered this question so as to remove any possible impression of maliciousness.

3) What leads you to believe that Tamiflu is effective in any way when it comes to humans who have somehow contracted an avian H5N1 viral infection?

I don't understand what led you read any malicious intent into this question either, but let me again assure you that I'd sincerely appreciate any insights you'd be inclined to share.

I don't understand what led you read any malicious intent into these innocent and perfectly reasonable questions, but let me assure you that I'm open minded to any scientific knowledge that you have on this subject.

:rofl:

Once again, conventional "wisdom" is "supported" by conventional idiocy.

That's actually been used on the patients in Asia, and that's how we know that it takes at least twice the normal dose to work and that it doesn't always work. That was in my hubby's New England Journal recently.

Or lacking that, the title of the article?

There are posts with links downthread.

I'm a nightshifter and I just woke up from my "night".

After coffee, I will answer to the best of my ability and it will be mostly based on my memory of what was said.

1)The CDC is running the trials and using these vaccinated folks blood antibodies and mixing them with the current form of the flu and seeing if it can mount an effective response. They are using live volunteers but they aren't exposing them directly to the H5N1.

2)The WHO has a protocol in place to evaluate the liklihood of a given virus becoming a pandemic. They consider this strain to have a high liklihood of becoming a pandemic. They are worried enough about it to begin putting things in place on an international basis. Our scientific community is concerned enough about it to begin putting things in place on a national, state and local level. There is a consensus that we are way behind on this and that if this isn't the "one", there will be a one soon enough and having some protocols in place before the crisis might save some peoples lives.

3)It's been used with some mild success in the cases in Asia. It's also failed with some of the cases in Asia. This isn't the magic bullet by any stretch of the imagination but if there isn't a vaccine developed by then or it is so far off as to be useless, this will be a necessary though flawed part of the plan.

You said earlier that my statement about the current iteration of the vaccine not likely being fully right was tacit admission that this threat isn't credible. That's not true. Avian flu is enough of a credible threat that the scientific community in conjunction with our government (such as it is, in its current iteration) have decided that the risk is high enough to develop a vaccine now so that we will have something, albeit a flawed something to vaccinate huge swaths of humanity. If they "win the jackpot" and it is avian flu that mutates and if they have gotten the vaccine right enough, they will allow humanity to dodge the bullet this time. They aren't developing any other vaccines to other any others because none of the others currently show a credible threat.

from INEVITABLE.

And I agree that it's a great idea to plan for the next pandemic of some sort, which almost certainly is inevitable. This fact -- and not any specific supposedly inevitable specific strain of H5N1 -- is the reason that leading virologists have by and large towed the party line when it comes to the over-hyped threat of humanly transmissible avian flu. Yes, this hype is finally getting people to get off their asses and plan for the very real threat of SOME flu pandemic. However, you must forgive me if I disagree that "by any means necessary" equals good science.

Thank you for your report, bleak as it was. This information is not to be taken lightly; our lack of national preparation is absolutely disgusting. Perhaps our problem with preparedness lies in the fact that legislation is not based on scientific observations and logistical population growth models, but rather political expedience.

In recent months here on DU, I've witnessed a disturbing recalcitrance towards discussion of an impending pandemic. In the scientific community, the Avian Flu is not discussed as a right-wing plot to fatten Rumsfeld's wallet while he gorges at the Tamiflu troph (although that may be a convenient by-product of having insider knowledge - but that's neither here nor there). Rather, it is - at least from my limited knowledge - consiered somewhat of an inevitability.

I am glad that you are taking the time to don a plastic shovel in an attempt to dig a hole through the dense political rhetoric of our times. Incessant, polarized blather from FOX often evokes rebuttals and angry responses from the thinking community - as it should. However, it is not wise to use a political filter to screen out facts which should truly be of great concern to anyone interested in living out the decade.

sequence of genetic mutations necessary to create a variant of avian flu that is highly contagious through human to human contact to be "somewhat of an inevitability."

I'm completely serious about this. I keep hearing this claim repeated like some sort of Orwellian mantra, but it makes NO SENSE WHATSOEVER. We can't even identify which random, naturally likely genetic mutation sequences would be necessary to create such a virus, much less how likely it is that any of these putative unknown mutation sequences would actually occur in the wild, much less which of these potential future genetic pathways would/could result in the creation of new H5N1 variant with both the contagiousness and virulence to guarantee an immediate pandemic. Given these facts, the only way human pandemic of avian flu could possibly be considered scientifically inevitable is if it has already been genetically engineered to order and tested in secret.

But please, feel free to keep common sense from confusing your admittedly limited knowledge of this subject.

That's why the internation medical community is seriously monitoring Asia, especially China and Vietnam, for influenza. Many thousands die every year from the "normal" strains, but the more lethal strains could cause something on a horrible scale.

They're watching Asia because the virus seems to need three things all living in close proximity: birds, pigs, and humans. They still live in close proximity in many rural parts of China, Vietname, and Thailand, so their hospitals are watched as closely as possible.

We already know that H5N1 can pass to people (through consumption of infected bird products, like meat and blood, or living close enough to the birds to inhale something), as it already has. People have died from it in much larger numbers than we're used to seeing. We know that the influenza virus is extremely adaptable--mutates very quickly and very easily compared to other viruses. That means, it is merely a matter of time for someone infected with a more lethal strain directly from a bird or pig to then pass on one that has mutated. If it mutates to have easy human-to-human transmission (something that hasn't happened yet) and keeps its lethal kick, that's when we're in trouble, and that's what we're watching and planning for.

My hubby's an internist, and he's very worried about this--has been for years. The medical system in our community (small hospital, small ICU, only two pulmonary/critical care groups (one of which isn't very good), and a limited number of internists and nurses) just won't be able to handle an epidemic very well. That means that many good people will die needlessly because we won't have the resources to keep them alive. My husband has already lost patients to "normal" strains of the flu, and he doesn't want to see others die from something worse.

is that the small hospitals will not be the only ones overwhelmed. They all will. And there is way too much that isn't in place yet. That we are just starting on these things when the threat has been around all along and the higher threat since 1997, it's pretty appalling that we are this far behind. OTOH, at least we are starting now and not when a pandemic is already underway.

We usually lose around thirty to forty thousand patients a year to the "normal" strains of influenza, but we lose many, many more than that in epidemic years. There has been much interest in the 1918 strain for years (I first heard about it when my husband was a pre-med in the early nineties), as that was a horribly lethal one.

I understand the need to question what we read, but your angry and defensive tone is a bit grating. Perhaps you could find some evidence to back up your position?

As far as I can tell, this claim appears to based entirely on the examination of exactly two tissue samples, one that was supposedly stored at an old Army hospital for almost 100 years, and the other that was supposedly buried under Alaska permafrost for almost 100 years.

Is there any other corroborating/disputing evidence of which I'm unaware? It would seem to me that an at least slightly more comprehensive assay of historical tissue samples might be in order considering the importance of this question.

It was caused by a similar avian strain. I've seen a number of your posts have less than perfect comprehension of what people have posted.

I guess you're unaware that they have isolated and replicated the 1918 flu strain? That one made me clench my butt cheeks but it is important information. That was how they found out that it was an avian strain rather than a swine strain which is what they had believed for some time.

buying into the company line on this subject?

I think his questions have shown only strong cynicism, with which I personally definitely agree, as well as intelligent, and probing if skeptical questions.

I don't think there's going to be a pandemic. Perhaps not at all, but certainly not this year with the avian flu virus. They couldn't make the West Nile Virus into a pandemic either.

The very biggest red flag, btw, is that George W. Bush showed keen interest and prior concern about this as a subject matter for his governance. That would be about the first things EVER, aside from wrecking-ball legislation aimed at destroying this country, its people and economy on the one hand, and all the power-grabbing Executive Orders, gutting of rules and regulations, and other similar stunts on the other. There's a reason he's interested, and it isn't because he has an altruistic bone in his body, anywhere. No, more likely because it offers yet another path to full dicatorial power he has yearned for -- aloud, even! -- since his first installation.

No, I'm not saying the Avian flu and talk of a pandemic is all a rightwing plot. OTOH, they (this administration) really are promoting it about how they promoted the "economy's going to be in recession" prior to taking office, which is yet another thing that raises a red flag. Further, a fully objective pursuit of an answer to the question cui bono? leads one down some interesting paths.

It's the tone he tends to use that I find grating and a bit annoying. He's questioning everything, but only asking questions is easy. There's tons of research out there to back up what we're saying, and it's easy to find, especially when we even link it and copy it out.

I don't know why Bush finally listened to the medical community, and I don't know why there's all the hype. I do know that I've been hearing about this as a strong possiblity since starting to date my husband when he was a pre-med in the mid-nineties, and that was coming from the medical community, which was seriously frustrated in how no one seemed to agree that it's a bad thing that we need to prepare for.

Even a stopped clock is right twice a day, and I think that might be the case with Bush. Maybe Rumsfeld got through to him, maybe his doctor got through, maybe someone he knows battled a less-lethal influenza strain. Frankly, I don't care. I don't think that the question right now is who benefits but more like, "Are we prepared?" The answer to that is no.

A review article in this week's New England Journal of Medicine (definitely not a right-wing mag--too many articles and essays against the administration in the last couple of years) cites research that says that the normal strains we deal with every year are the most lethal for babies under the age of six months. After that, it's all children under the age of four--over half of whom had never had any previous diagnosis of anything wrong with them and were known to be healthy prior to infection. That's with the normal influenza we deal with every year. This latest strain is far more lethal, and it is killing previously healthy young people, just like in 1918.

We need to prepare for this epidemic--any and every epidemic. The reality is, our medical system is so broken, that we are barely treading water as it is. Shove another five percent of the local population into already over-crowded hospitals, make them need to be on ventilators within the first 48 hours and have multiorgan failure, and too damn many will die. This isn't some far-off thing: all it takes is one good bioterror attack or one infected person on a crowded plane into a crowded airport. The reason why the medical community is scared is that they know with good certainty that they cannot handle anything like that without a higher death rate than they're comfortable with.

Everyone brings up SARS. We were damn lucky SARS hit Toronto and not NYC or LA. Canada has a national health care system that could respond to the crisis well and had the tools it needed to contain the outbreak. We don't. We can't even keep 36,000 babies, children, men, and women from dying from influenza every year, a higher rate than other countries with national systems.

avian flu, and the lack of clinical evidence for Tamiflu's effectiveness against it?

I would put money on it that if you got influenza really badly, enough to be hospitalized for it, you'd be the first to get angry if your medical team didn't do absolutely everything in their power, including try Tamiflu, to save your life. You wouldn't be lying there, going on and on about the "overhyped threat" and "the lack of clinical evidence." :eyes:

I'm sorry I can't read the original articles in Chinese (as many are) on the clinical evidence for you. How about you actually try looking for the evidence you need yourself?

work.

And if I had terminal cancer, I'd even try laetrile. Does that mean the US government should stockpile it?

unless they come up with something better. We need our arsenal to be as full as possible while we prepare a vaccine. Wouldn't you rather they had a method (however flawed) to "quarantine" the virus instead of the people.

a nonexistent virus?

possibly (hopefully) not this virus. Yes, I actually want them to stockpile all of the antivirals. It's a much better investment than bombing Iraq into the stone age. I suspect they could do it with far less than 500 billion dollars.

us from studying/learning about the situation, however

anytime W gets interested in something, my first thought is 'what benefit does he think he'll get from this?'

And the WHO has a protocol in place for monitoring likely candidates. Avian Flu fits that protocol perfectly and it's spreading rapidly in bird populations. It has also easily crossed into other species, species that to their knowledge have never gotten a bird flu. I can't remember off the top of my head which species they were (one was a large cat species but again, I can't remember and I didn't jot it in my notes). There isn't another one as concerning as the avian flu so that's the one they are concentrating on and they are concerned enough that they are making plans. If this one isn't the one, they will have the plans in place.

Who do not consider a flu pandemic as inevitable. There are also those who believe that this strain may have reached its genetic dead end, given that it has been in the wild for 8 years or more and has not made that leap. It is also true I believe that there has never been a known pandemic H5 strain. Some are coming to the opinion that H5 may not be able to cause one.

As to the mortality statistics they may be misleading. My understanding is there has been no attempt to do a serasurvey in the region to see how many are actually infected. It is not inconceivable that many have contracted the flu but were not sick enough to report it. The mortality rate of any flu strain would look bad if you only counted those sick enough to be in the hospital.

Comparisons to the 1918 flu may be invalid as the conditions which may have led to that strain becoming lethal do not exist now, even in the crowded cities of Asia.

Most viral strains become less lethal as they gain the ability to move easily from host to host. Killing the host is not conducive to spread of the virus. Even the 1918 strain weakened as it moved into the countryside.

I'm not saying there isn't reason for diligence, there definitely is, but I think all possibilities must be acknowledged...it is usually the most dire that gets the press unfortunately (though there have been more balanced articles recently).

Can you provide some links to your sources?

I'll dig em up and put them up here as soon as I can.

I mentioned in my first post. It has a lot of the stuff around planning.

The New England Journal of Medicine had the article sited by another poster. It is from the September 2005 issue. I haven't researched that one yet so I don't have anything to site from it.

NEJM September 29, 2005 review article: http://content.nejm.org/cgi/content/full/353/13/1374?hits=20&where=fulltext&andorexactfulltext=and&searchterm=H5N1&sortspec=Score%2Bdesc%2BPUBDATE_SORTDATE%2Bdesc&excludeflag=TWEEK_element&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

I know that's with a subscription, so if that free thingy doesn't work (what's the name of that site that helps you get around subscriptions?), here are some more parts of that article:

"Human-to-human transmission of influenza A (H5N1) has been suggested in several household clusters16 and in one case of apparent child-to-mother transmission (Table 3).20 Intimate contact without the use of precautions was implicated, and so far no case of human-to-human transmission by small-particle aerosols has been identified. In 1997, human-to-human transmission did not apparently occur through social contact,8 and serologic studies of exposed health care workers indicated that transmission was inefficient9 (Table 2). Serologic surveys in Vietnam and Thailand have not found evidence of asymptomatic infections among contacts (Table 2). Recently, intensified surveillance of contacts of patients by reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay has led to the detection of mild cases, more infections in older adults, and an increased number and duration of clusters in families in northern Vietnam,21 findings suggesting that the local virus strains may be adapting to humans. However, epidemiologic and virologic studies are needed to confirm these findings. To date, the risk of nosocomial transmission to health care workers has been low, even when appropriate isolation measures were not used10,11 (Table 2). However, one case of severe illness was reported in a nurse exposed to an infected patient in Vietnam."

snip

"The clinical spectrum of influenza A (H5N1) in humans is based on descriptions of hospitalized patients. The frequencies of milder illnesses, subclinical infections, and atypical presentations (e.g., encephalopathy and gastroenteritis) have not been determined, but case reports12,21,22 indicate that each occurs. Most patients have been previously healthy young children or adults (Table 3)."

snip

"The virologic course of human influenza A (H5N1) is incompletely characterized, but studies of hospitalized patients indicate that viral replication is prolonged. In 1997, virus could be detected in nasopharyngeal isolates for a median of 6.5 days (range, 1 to 16), and in Thailand, the interval from the onset of illness to the first positive culture ranged from 3 to 16 days. Nasopharyngeal replication is less than in human influenza,27and studies of lower respiratory tract replication are needed. The majority of fecal samples tested have been positive for viral RNA (seven of nine), whereas urine samples were negative. The high frequency of diarrhea among affected patients and the detection of viral RNA in fecal samples, including infectious virus in one case,22 suggest that the virus replicates in the gastrointestinal tract. The findings in one autopsy confirmed this observation.41

Highly pathogenic influenza A (H5N1) viruses possess the polybasic amino acid sequence at the hemagglutinin-cleavage site that is associated with visceral dissemination in avian species. Invasive infection has been documented in mammals,28,29,39,40 and in humans, six of six serum specimens were positive for viral RNA four to nine days after the onset of illness. Infectious virus and RNA were detected in blood, cerebrospinal fluid, and feces in one patient.22 Whether feces or blood serves to transmit infection under some circumstances is unknown."

snip

Their conclusion set: "Infected birds have been the primary source of influenza A (H5N1) infections in humans in Asia. Transmission between humans is very limited at present, but continued monitoring is required to identify any increase in viral adaptation to human hosts. Avian influenza A (H5N1) in humans differs in multiple ways from influenza due to human viruses, including the routes of transmission, clinical severity, pathogenesis, and perhaps, response to treatment. Case detection is confounded by the nonspecificity of initial manifestations of illness, so that detailed contact and travel histories and knowledge of viral activity in poultry are essential. Commercial rapid antigen tests are insensitive, and confirmatory diagnosis requires sophisticated laboratory support. Unlike human influenza, avian influenza A (H5N1) may have higher viral titers in the throat than in the nose, and hence, analysis of throat swabs or lower respiratory samples may offer more sensitive means of diagnosis. Recent human isolates are fully resistant to M2 inhibitors, and increased doses of oral oseltamivir may be warranted for the treatment of severe illness. Despite recent progress, knowledge of the epidemiology, natural history, and management of influenza A (H5N1) disease in humans is incomplete. There is an urgent need for more coordination in clinical and epidemiologic research among institutions in countries with cases of influenza A (H5N1) and internationally."

studies and research are necessary.

They made it clear that it is a big threat, that what we know shows that we could be in trouble, and that yes, we do need to do a lot more research to learn more about this particular manifestation of the virus (from how to detect it earlier to how to treat it better).

I don't see how it can't be inevitable. Humans are not that far removed from the gene pool that they will be spared a lethal flu. It just doesn't make any sense.

I didn't go to a public forum. This was geared toward those in the community who will be directly responding to the eventual crisis.

There were a number of people who felt strongly that the avian flu H5N1 was going to mutate and there were a number of people who were less sure but they all said that we just don't know. They all said that what we do know is that a pandemic is coming, that H5N1 is a very credible threat and that we are woefully unprepared for any pandemic. They all said that if this is the one, we don't know its lethality hence we don't know how many people will die and how disrupted our society will be or for how long. There are many unknowns but that we will have another pandemic is a known.

Your understanding about the survey of the region is wrong. The WHO has descended upon these areas with a vengeance. Our own CDC is getting into the act now. This is a very credible threat and it has exposed huge holes in planning. Heck, it's exposed that there is next to no planning on a local level, minimal planning on a state level, a little more on a national level and a fair amount on an international level but the WHO isn't at all sure that their prep is enough.

That is obvious...and I am not saying that diligence is not warranted. If there has been a serasurvey done are the results posted somewhere?

And I do not discount that a pandemic is highly possible. But I have done some reading on this, and have read the opinions of a number of virologists and immunologists who say that this strain is not really a good candidate to cause the pandemic we worry about. That it appears to be perfectly suited genetically to kill birds. It does seem in an area with almost half the world's population, and 8 years to spread with only 160 known infections that this may be the case.

Also I am confused as to how a random mutation can be considered inevitable with regards to a specific strain

Isn't it more accurate to say that the worry over this strain is because of its apparent lethality, and not that it is necessarily more likely to become pandemic? I listened to an interview with Dr. Fauci who made this point. He noted he viewed the likelihood of this particular strain becoming the pandemic strain as low, but that diligence is required because of its deadliness in birds.

I heard no less than half a dozen times that they believe (one said hope) that the lethality will decrease from its current 50% if it makes the jump. The WHO scientists, the CDC scientists, Rumsfeld (I'm kidding on that one. He wasn't part of the conference. With the exception of one state communications director, it was populated with Phds, MDs, RNs and public health officials)all feel this is a very credible threat.

So I would say the concern expressed was the complete lack of immunity to this strain and that it is continuing to spread through bird populations and that it has already made a number of species jumps. They are trying to make plans based on many unknowns including whether this is the strain, what its lethality will be and what we have in place now to combat a pandemic and what we still have to implement.

I would suspect it would be on the WHO website.

I think it's safe to say that most of us are happy to hear a relatively calm voice providing some facts. Facts that could prove more useful to me than dark forebodings of being abandoned to my fate by my own feckless government. Keep up the good work.

Someone else on this thread would do well to stop nipping at your heels and go read the 400-page document for himself. He could even give us a review -- which I, for one, would be glad to have.

Hekate

"Honor system," eh? Sounds a bit like their approach to mad cow - allow the beef industry to ignore the mandated precautions and keep the head firmly in the sand. At least unlike with BSE, the government isn't FORBIDDING testing of animals by those who want to do it.

Yet.

In my darker moments I do wonder if the Bushies are eagerly anticipating the aviian flu epidemic because it will be their next 9/11 - this time a chance to finally implement the martial law that they've been planning for years and partially implemented after the hurricanes. Northcom was set up in 2002 (under the command of the guy who had been in charge of Norad on the day of the 9/11 attacks) with one of its missions being to administer martial law in the US once it was declared.

The Pentagon has made plans for martial law too...
http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=104x5582171

If the avian flu doesn't come fast enough, why, I'll bet there will be another 9/11-style attack.

worth reading, thanks.

times the normal amount per dose or 2-3 times longer than the usual course?

I'll check NEJM for that, as I remember reading it in there.

Patients with suspected influenza A (H5N1) should promptly receive a neuraminidase inhibitor pending the results of diagnostic laboratory testing. The optimal dose and duration of treatment with neuraminidase inhibitors are uncertain, and currently approved regimens likely represent the minimum required. These viruses are susceptible in vitro to oseltamivir and zanamivir.46,47 Oral osel-tamivir46 and topical zanamivir are active in animal models of influenza A (H5N1).48,49 Recent murine studies indicate that as compared with an influenza A (H5N1) strain from 1997, the strain isolated in 2004 requires higher oseltamivir doses and more prolonged administration (eight days) to induce similar antiviral effects and survival rates.50 Inhaled zanamivir has not been studied in cases of influenza A (H5N1) in humans.

Early treatment will provide the greatest clinical benefit,15 although the use of therapy is reasonable when there is a likelihood of ongoing viral replication. Placebo-controlled clinical studies of oral oseltamivir51,52 and inhaled zanamivir53 comparing currently approved doses with doses that are twice as high found that the two doses had similar tolerability but no consistent difference in clinical or antiviral benefits in adults with uncomplicated human influenza. Although approved doses of oseltamivir (75 mg twice daily for five days in adults and weight-adjusted twice-daily doses for five days in children older than one year of age — twice-daily doses of 30 mg for those weighing 15 kg or less, 45 mg for those weighing more than 15 to 23 kg, 60 mg for those weighing more than 23 to 40 kg, and 75 mg for those weighing more than 40 kg) are reasonable for treating early, mild cases of influenza A (H5N1), higher doses (150 mg twice daily in adults) and treatment for 7 to 10 days are considerations in treating severe infections, but prospective studies are needed.

High-level antiviral resistance to oseltamivir results from the substitution of a single amino acid in N1 neuraminidase (His274Tyr). Such variants have been detected in up to 16 percent of children with human influenza A (H1N1) who have received oseltamivir.54 Not surprisingly, this resistant variant has been detected recently in several patients with influenza A (H5N1) who were treated with oseltamivir.21 Although less infectious in cell culture and in animals than susceptible parental virus,55 oseltamivir-resistant H1N1 variants are transmissible in ferrets.56 Such variants retain full susceptibility to zanamivir and partial susceptibility to the investigational neuraminidase inhibitor peramivir in vitro.57,58

This is from "Avian Influenza A (H5N1) Infection in Humans: The Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5" in the September 29, 2005 issue of the New England Journal of Medicine.

The article also had this to say about the patients who have already had the virus:
"Most hospitalized patients with avian influenza A (H5N1) have required ventilatory support within 48 hours after admission,15,16 as well as intensive care for multiorgan failure and sometimes hypotension. In addition to empirical treatment with broad-spectrum antibiotics, antiviral agents, alone or with corticosteroids, have been used in most patients (Table 3), although their effects have not been rigorously assessed. The institution of these interventions late in the course of the disease has not been associated with an apparent decrease in the overall mortality rate, although early initiation of antiviral agents appears to be beneficial.1,15,16 Cultivable virus generally disappears within two or three days after the initiation of oseltamivir among survivors, but clinical progression despite early therapy with oseltamivir and a lack of reductions in pharyngeal viral load have been described in patients who have died."

This is why the medical community is concerned. We don't have that many vents or unit beds.

though they didn't go into detail like you just did. Thanks.

I'm serious. I sat there with my mouth open as I read it through. We're in deep trouble if the virus stays this lethal through the next mutation. I can tell you I won't see my hubby for weeks, that's for sure. He'll be living at the hospital.

and I am not sure it is worth it to let him go to work. He will go anyway but I hate the idea of it.

We are talking about a virus that has been recognized in far less than 500 total patients.

So how many human H5N1 victims have been given oseltamivir and at what stages of the illness's progression? How many have survived compared to patients for which oseltamivir was not prescribed? Basically, how well can we quantify the statement "early initiation of antiviral agents appears to be beneficial" when it comes to oseltamivir?

I'd bet that you could find a copy of the article at your hospital's library if you can't get it online. The footnote list is extensive, and the tables are pretty big.

They were doing a review article, which means that they take all of the many, many articles published on the topic and distill them down into what doctors need to know as of the latest research.

If you want the actual science, it's not hard to find.

17 of the 22 avian flu patients treated with Tamiflu are now dead and buried! That's avian flu 17, Tamiflu 5. Further proof that when it walks like a neoCON and talks like a neoCON and enriches a neoCON, it's generally just another big CON.

Here's a chart from your NE Journal of Medicine article ( http://content.nejm.org/cgi/content/full/353/13/1374 ) that's been widely distributed and quoted from to "prove" that oseltamivir (Tamiflu) is a clinically effective treatment for humans infected with the avian flu (H5N1) virus.

This chart suggests that a total of 25 H5N1 patients have been treated with oseltamivir (Tamiflu), but it doesn't give a breakdown of how many of these lived or died. However, all 10 of the patients in the Ho Chi Minh City were treated with Tamiflu, and these patients had an 80% mortality rate -- which is much higher than the average mortality rate for all clinically documented human cases of H5N1.

Further, when the NE Journal of Medicine article claims that "early {Tamiflu} treatment will provide the greatest clinical benefit," it cites a medical article concerning the Thailand outbreak ( http://www.findarticles.com/p/articles/mi_m0GVK/is_2_11/ai_n11833869 ) in its footnotes. The cited article states:

Seven patients were treated with the neuraminidase inhibitor oseltamivir (Tamiflu) at various stages of illness. Treatment tended to have been started earlier in those who survived (a median of 4.5 days from onset compared with 9 days for those who died), and both survivors who were treated received the complete 5-day course of drug, whereas 2 of 5 patients who died received the complete 5-day course.

In addition, when this prestigious journal mentions that the "early initiation of antiviral agents appears to be beneficial," it references another medical article concerning the Vietnam outbreak ( http://content.nejm.org/cgi/content/full/350/12/1179?ijkey=171d51f775eec28a47c5aabe85eed863238c3984 ). From the cited article:

Oseltamivir was administered to five of the patients, four of whom died. Treatment with the drug may have been started too late to be effective, although one of the two surviving patients did not start oseltamivir therapy until the 12th day of illness. ... Our experience suggests that supportive care may be the only option available. Controlled clinical studies are needed to assess the role of antiviral drugs and corticosteroids in the treatment of influenza A (H5N1) virus infections.

So let's add up the bottom line:

8 out of 10 patients treated with Tamiflu in the Ho Chi Minh City outbreak died. 5 out of 7 patients treated with Tamiflu in Thailand died as well. Finally, 4 out of 5 patients treated with Tamiflu in Vietnam died, with only the patient whose treatment was started the latest (in the 12th day) surviving!

For those counting at home, that works out to a whopping 77.3% mortality rate for avian flu patients treated with Tamiflu! To put this in clinical perspective, just 21 of the 37 other avian flu victims died -- resulting in a far less severe mortality rate of 56.8%.

In summary, there is no evidence for widely repeated claim that Tamiflu is a clinically effective treatment for humans infected by the avian flu virus.

I read the same stuff and came to a similar conclusion. First of all, there's not much data, but secondly, it looks like Tamiflu has about the same effectiveness as it usually does.

Tamiflu has to be taken at the onset of symptoms for best effectiveness (which is only shortening the duration of the illness), and it almost never is, as the symptoms often look just like the regular cold. That's why I never take it and why my husband never takes it. It really is more about getting over the infection sooner, as it's not a vaccine to prevent infection or like an antibiotic or antiviral to help the body kill off the infection.

The reason they used it in those cases is because it's one of the few tools we have to even deal with influenza beyond support measures. Tamiflu is often used in patients in the hospital in hopes that it will help their bodies get better sooner, but I don't know any doctors who have all that much faith in it. When my husband read their Tamiflu treatment plan, I believe his words were something to the effect of, "We are soooo screwed."

I was just explaining why they were saying that we need twice the amount of Tamiflu than normal (I agree that it's a shaky case) and citing the articles that the WHO used to make that decision. I think our problem in communication is that I trust the CDC and WHO, and you don't. Mine comes from my experience as an internist's wife, and yours comes from whatever your experiences are.

Neither one of us thinks Tamiflu has been proven effective against human H5N1 infections in a clinical setting.

Both of us think some sort of influenza pandemic is likely over the next 25 years, and that we should prepare better for it.

I think we may disagree on how likely it is that avian flu will randomly mutate in such a way to cause a human pandemic, but I'm not even sure about that. I feel that this is a credible, but far from inevitable threat. How about you?

I think Tamiflu should be used when the doctors think it should be used, as I sure as heck didn't go to med school and can't make that kind of call.

I think that this strain is being watched for a reason, and that it's very likely that it could mutate to be easily transmitted amongst humans and then break out of its local area and spread. I don't know if it'll be this year or next or in five years, but I think it is inevitable for another more deadly version of influenza to make its way through the human population.

I don't think that the doctors are in some conspiracy with the neocons to overhype the threat, and I don't think that our medical system can handle an epidemic at all. Why that is, I have my theories, but then, I only know the system from my experiences and watching my husband deal with it. I would bet that I trust doctors more than you do and that I trust that they will do their darndest to save as many lives as possible. I see that everyday, and I've lived with that, so that's why if the World Health Organization sends a memo to my husband telling him which treatments to follow and what to look out for, I tend to trust that, as does my husband.

relieve her tremors so she could feed herself. She was a brilliant and determined woman, but we were far too poor to afford a nurse. We felt that if only she could manage to feed herself lunch, she could remain at home with my brothers and me (who all both went to school and worked), and we could manage the rest.

So I talked to the doctors and they told me that since they were freezing nerves in the medulla region, the worst that could happen was that her already deteriorated motor skills would further deteriorate. On the day of the operation she talked about chickening out, but I gave her a pep talk. She was such a trooper that she would have crawled over glass on her hands and knees if she thought it would help her family.

Long story short: I lost the mother I knew that day. She was replaced by a ghost version who could never again form complete sentences and who always kept the TV on channel 7, both day and night. However, since she could raise her arms and count nearly as well both before and after the operation, it was clinically recorded as a successful outcome. To cap it off, she still needed someone to feed her lunch, and it turned out that -- unbeknownst to us -- there had been a local program of volunteers who did just that the whole time.

This experience taught me to research the ACTUAL medical DATA rather than simply buy whatever some doctors are selling. It's not a case of trusting or not trusting. 98% of doctors are doing their best, but when it's your life or that of a loved one, sometimes that just ain't enough.

Those doctors didn't tell you all of what could happen. Brain surgery is never an easy thing, and it is never something to enter into lightly. (Don't get me started on how brain surgeons can be the worst jerks around.) The hospital social worker should've found that volunteer group as well. It is horrible that everything went wrong for your mother and your family, and I'm very sorry you went through such a painful experience. My grandmother had MS, and it was very hard to watch her go through that.

It's still hard to expect that you'll be able to find and understand every single bit of research in any one area of medicine, though. At some point, you will need to trust the experts. That's what I've learned in my endometriosis--I almost went crazy trying to find and read all of the available research and then figure out what was the best course for me. Finally, I put it in the specialist's hands and made my husband stop researching it as well. Does that mean that I've given up power over my body and my life? No, but it means that I am admitting that I cannot know as much as someone who has dedicated his life and career to this disease. I have my second and third opinions, and I weigh what I know with what I've heard from everyone, and I go from there.

for the anger I'm seeing from stickdog. Who knows? However, I find it ironic that you and I are completely on the same page and yet my level of distrust and frankly personal betrayal by the CDC is profound and yet, I think they are putting together a reasonable (albeit flawed and incomplete because of the very limited data they have) plan. I do wish they had started earlier but the fact that they are pushing to get a plan together now rather than in the middle of the pandemic (which will come with or without the avian flu, as you and I and all the people at the conference are fully aware) is a blessed event. It's one of the few good pieces of information to come out of the conference. I'm nowhere near forgiving them for destroying my child and my religion but that doesn't mean I can't recognize what they're doing here that's right.

avian flu jumping the species boundary to become highly contagious among humans (while still retaining an unheard of mortality rate) is as natural and inevitable a biological process as continual unprotected sex leading to procreation.

It's simply not so, and the fact that everybody from the CDC to the WHO to the AP to Bush himself is falling over themselves to get all of us to believe that it IS so makes me a little suspicious.

and we have stockpiled no where near enough. And the money that the Bush administration will only cover 25% of our population for a treatment, not a prophylactic dose. I don't have any idea what a prophylactic dose would be though I'm guessing that healthcare providers will be provided with prophylactic doses (that would be smart and might well keep that workforce working).

effective against H5N1 illnesses in humans -- at ANY dosage?

Leneva IA, Roberts N, Govorkova EA, Goloubeva OG, Webster RG. The neuraminidase inhibitor GS4104 (oseltamivir phosphate) is efficacious against A/Hong Kong/156/97 (H5N1) and A/Hong Kong/1074/99 (H9N2) influenza viruses. Antiviral Res 2000;48:101-115

Abstract here: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11114412&dopt=Abstract

Monto AS, Fleming DM, Henry D, et al. Efficacy and safety of the neuraminidase inhibitor zanamivir in the treatment of influenza A and B virus infections. J Infect Dis 1999;180:254-261.

Abstract here: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10395837&dopt=Abstract

These are good starts, as there is much, much more out there in the medical literature.

is that treating avian flu patients with Tamiflu DECREASES there chances of survival. 17 of the 22 patients treated with Tamiflu DIED:

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=104&topic_id=5586251&mesg_id=5594017

conclusion. You are confusing proximity with causality. It clearly needs more research and it would be great if they came up with another drug that worked more effectively because we've got to find a way to get through those first few months before we have a vaccine. There is an awful lot of death between the start of a pandemic and having a vaccine.

If you disagree with this statement, please produce the clinical evidence.

What the evidence says so far is that 20% FEWER of the patients given Tamiflu have survived. That's hardly a resounding endorsement.

I would suggest reading the 400+ page document at the WHO site and getting to your hospital's library before deciding you know more than all the infectious disease specialists working on influenza or the doctors who actually treated those patients. You're taking one chart and one article and extrapolating from there, which is bad medicine and bad science.

that it does NOT support the contention that Tamiflu is an effective treatment against the avian flu.

You have read only the ones I've cited here. You have not read the Infectious Disease journal lately or read any of the Asian clinical journals. You cannot take the couple in English I found as the entirety of the clinical findings and then twist them to prove what you want. You only had the abstracts, not the originals, and that's just not enough to prove your point.

Maybe you need to:

http://content.nejm.org/cgi/content/full/350/12/1179?ijkey=171d51f775eec28a47c5aabe85eed863238c3984

http://www.findarticles.com/p/articles/mi_m0GVK/is_2_11/ai_n11833869

And 8 of the 10 Tamiflu patients in the Ho Chi Minh city outbreak died, so we can safely assume more of the same for that population.

In the Hong Kong outbreak, nobody was given Tamiflu and in the Cambodia outbreak, there was no mention of Tamiflu. So, pray tell, what other clinical evidence have I missed, knitter?

Man, you are fast. I haven't even scratched the surface yet. I figure I'll be at it for months.

However, as this topic winds down, as all topics do, I wanted to take a moment to thsnk you for making this one of my highest post count postings. And I'm not being snarky.

And an overall upgrade of our health care system would be useful. Not just in case of a pandemic.

Sounds like most of the people on your level are doing what they can. Too bad about the idiots on top.

though some of those 400 were attending via webcast. It was a huge conference area though, and they had to bring in other chairs to line the back. Most of the people (I'm not. I'm a staff nurse at a local hospital) were people who are the emergency planners for public health, various hospitals, first responders etc. A number of people there were from the political side. I helped to translate some of the more obscure medical terminology for a person from that sector who was sitting beside me.

This is the header for an article which appeared recently in Canada's Globe and Mail. (Unfortunately, it's now in their pay-to-download archives ... but as I recall from reading it when it came out, he argued that the best defense lies in a strong, accessible public health care system ... people would be less vulnerable, and diseases could be detected and treated much more quickly. He was highly critical of any attempt to rely on military-enforced quarantines, of the type proposed by Bush.)


We should be talking prevention, not reaction
ANDRÉ PICARD
Today's Paper: Thursday, October 6, 2005 12:00 AM Page A19
George Bush says he would impose sweeping quarantines and call in the military to help enforce them during an influenza pandemic.A fat lot of good that will do.The ''kill bugs dead'' machismo is no doubt motivated by domestic political concerns, but the U.S. President's comments demonstrate a fundamental lack of understanding of public health that is all too common in political circles.

Hope we're not looking at a situation that dire. But I fear we may be. There is no way I can trust Team * to do what needs to be done to protect US. That was Barry's concern also (he didn't mention * though). The government in 1918 covered up the crisis and refused to act even when people were dropping like flies, AND when the medical community was pleading and begging that the necessary measures to protect the public be taken. Why should we believe anything is different now?

Will you give a thumbnail synopsis?

I'll try though. :D He discusses so many aspects of the pandemic. One was a comprehensive look at the state of medicine in America right before and after the pandemic hit. You will be amazed at how backward this country was by comparison with the rest of the world. He gave an incredibly intimate description of the researchers who worked at an insane pace to track down the microscopic mass murderer. His descriptions of viruses and antibodies in the human body was absolutely amazing. One was of an antibody that carries the body of it's viral prey over it's "head", displaying it to other antibodies (there are many different types) so they can recognize it, if it crosses their paths! He talks about the origins and spread of the disease. Interestingly, it appears to have begun in rural Kansas. Of course he gives all the horrendous and gory details of how this disease killed people, and believe me, it sounds like real torture. A major part of the book involves the incredible stupidity and indifference/callousness of the government and military. In addition to other outrages, they were so determined to get soldiers into Europe that they ignored all the warnings of the medical community to isolate those with the virus. The tales of what happened to cities under siege from this monster is bone chillingly terrible. The public was lied to about how bad the pandemic was, constantly being told to "not get scared", while whole families were being wiped out all around them. As a result paranoia took over, and people who normally were the first to help their neighbors, shut their doors and neither let anyone in nor left. So, many people, including children, who didn't get the flu, but who were in homes with those who did, literally starved to death.

That just scratches the surface of the book. I HIGHLY recommend reading it.

I would say, "heckuva job", except that the expression seems to be a bit of a hex these days!

Re: the virus getting the memo (and the 400-page report) -- I would say that there's a better chance of IT reading the material, than President Bush. But I live in hope.

From the Baltimore Sun last week: http://www.baltimoresun.com/news/health/bal-te.nat06dec06034742,1,724258.story?coll=bal-nationworld-headlines">HHS chief urges states to prepare for bird flu

...Dr. Susan Allan, Oregon's public health director, cautioned against what she called "the disease-of-the-month plan."

"I do have a concern about the focus on a single disease, when other diseases may pose an equally severe risk," she said.

"I'm afraid that everybody will drop what they're doing on other and a lot of good activity will be undercut."...

Dr. Allen is spot on. And the problem is not just a "disease of the week" focus. Crisis preparation continues to be exclusively top-down and focused on preparation for the "disaster of the moment."

A believe it is critical for every state and community to establish rational plans for civil emergencies. But the plans should not be narrowly focused on the "emergency of the moment." Certain crises require specialized action, but planning must account for a variety of emergencies. Planning should not be exclusively "top down." Citizens have no idea what they should do in any given crisis. This state of affairs is dangerous and unnecessary. There are actions and roles that can be defined in advance (e.g., designated emergency centers for every locality, neighborhood leaders trained to provide crisis-specific support services, citizen volunteer recruited to form contact "trees" that can be employed to disseminate information if standard avenues are disrupted.).

Perhaps the powers-that-be know something they are not telling us (e.g., a mutated form which is deadly and highly contagious in humans has already been identified), but I just don't get it. Unless they "know something" the risk of the specific mutations that would lead to an Avian flu pandemic does not seem high enough to justify the massive level of attention it is getting. I am plagued by the suspicion that the alarm is being used to force states to shovel cash into pharmaceutical coffers.

There's a real reason the medical community is as concerned about this as they are. Heck, they have been for years--this is no "disease of the moment." This is a real problem, and preparing for H5N1 will help us prepare for any major epidemic, really, as it means beefing up intensive care units and other resources around the country.

by our so-called medical experts about both the inevitability of avian flu mutating to become contagious via human to human contact AND the supposed effectiveness of Rumsfeld's Tamiflu antiviral against it!

in asia and it is continualy mutating. The first of the year we have tet, chinese new year, and the haj at mecca. With so many large groups of people together the chances of it combining with someone who has a normal flu are enormous and it just might hit the jackpot and be able to spread easily. Ukraine is slaughtering fowl right and left in the news today as it has spread in birds all over the country. We are just getting into flu season. I am looking at probabilities and it scares the pants off of me.
My bottom line is, I am prepared. If it does not happen good. If it does I won't have my family looking at me wondering what they are going to eat.

who already has the normal flu?

Wow! Why have we spent so many billions developing biological weapons when that's all it takes to make the superbug of all superbugs?

and I am sure we have also weaponized several nasty bugs in our labs using lab techniques too.
Here is an article http://www.arabnews.com/?page=1§ion=0&article=74573&d=12&m=12&y=2005 on what saudi arabia is doing to get ready for haj

monkeys in a room typing for a million years is one possible way of writing Hamlet.

I hate Rumsfeld as much as the next person. I would like to see him go to jail and lose all of his money. That said, your position on Tamiflu is absurd.

and note that the survival rate of the patients treated with Tamiflu is 20% LOWER than that of the patients not treated with Tamiflu?

That is so full of shit that it must be oozing onto your keyboard.

My husband was horrified when he saw that it would need twice the dosage to have the same effect, as the usual effect isn't all that much to begin with. The reason they even used it is that it's one of the only things known to have any effectiveness at all against influenza.

I'm not sure: do you think that the medical community is lying about the possibility of an influenza pandemic entirely or that they're being used by the administration to make money off of it or both? I don't know why you're so angry at all those doctors and researchers frantically trying to help people and doing their best, but being an armchair quarterback doesn't give you the right to call the plays bullshit.

showed that those that received tamiflu for I think it was eight days instead of the normally prescribed 5 had a greater survival rate. We do need case studies of how the survivors in asia were treated though... to see what worked and what did not. A lot of the people admitted were admitted after they were in pretty bad shape and had been sick for several days.

It remains to be seen if getting the drug into them early makes a difference.Information is not coming out from asia like it should. I hope the WHO is getting some of this info cause the docs here will need it to establish a treatment protocol.There has been a lock down of info coming out of China the past few days after they admitted their fifth case. They have declared that anyone who talks to the press without state ok will be arrested.

Most of the people who have got in in Indonesia have been small clusters and many had no obvious contact with fowl. Yesterday there was a news article out of Jakarta of new cases and it said there were six people who had been admitted with sx and they were in worse shape than those who were already in the hospital. http://dnaindia.com/report.asp?NewsID=1002109 and http://www.thejakartapost.com/detailnational.asp?fileid=20051214.C02&irec=1

New Zealand is the place to be if this hits. They are getting their population ready, are having their pharmacies stockpile Insulin and other critical meds, and having the people stockpile enough food to weather six months at home. They are aggressively getting ready.

spreading this disease. Until there is, I suggest that the best way to protect yourself against it is to refrain from raising birds and/or drinking their raw blood.

Most of the cases in Indonesia were clusters and many with no known exposure to birds. It is still limited human to human. It has mutated to do this but still has not hit the jackpot to go easily human to human. It has jumped to felines and pigs. THe RNA in a flu virus is naturally unstable allowing it to recombine or reassort easily. Look it up.I am following each new case closely. Wild birds are spreading it throughout asia and there has been one case in Israel which survived. The reporting from asian countries suck as they are censoring their news as this causes an economic hit esp with tourism.


Here is a paper that China did which shows that the heamagglutinin protein of this specific virus has acquired the ability to better bind to both Avian and human surface proteins. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16342757&itool=iconabstr&query_hl=9l


As for your comment to another post of mine, yes a virus usually will give up some of it's virulence to go pandemic. This one has around a 50 percent death rate. If it went down to twenty percent it still would be a catastrophe. I think the 1918 flu had a 2 to 5 percent death rate.I am looking at probabilities. If you do not want to prepare for the possibility that is your choice. I have made mine.

Where is the evidence that most have been in clusters and many with no known exposure to birds?

An example. One of the latest cases. A 35 year old father in hospital as well as his 2 yr old child. His other child has already died. There are several cases where one member of a family falls ill after another has died and only one gets tested as positive. The other members of the family are not counted as they were not tested. This is happening in Vietnam and Indonesia. On the national geographic special last sun as well as the cnn special on sun there was the case of a woman who became ill and died but her nephew caught it and survived. In her case it was traced to fertilizer containing chicken waste she had bought and used on her plants in pots on her porch.

THere are many other cases of clusters. I don't have time to look them up for you. The info is out there.
THis family had contact with poultry. You will see in the article that they say they have had 5 case clusters.
http://www.tempointeraktif.com/hg/jakarta/2005/12/13/brk,20051213-70530,id
Translation of article
RSPI treated the Patient was expected by the Case Cluster birds Flu

http://www.tempointeraktif.com/hg/j...051213-70530,id

Tuesday, December 13 2005 | 13:44 WIB

The TIME Interactive , Jakarta :Ny. Najiha (35) the citizen Street Kampung Baru No. 20 RT04/10 Kembangan North Jakarta West, and his son, Kafi (2) since struck 22.35 last night was treated in in isolation space Cempaka the Infection Hospital (RSPI) Sulianti Saroso.

Both of them could be treated in RS Republic of Indonesia State Police Soekamto Jakarta East for three days. “Keluhan him was similar, that is hot, the cough, crowded, also diare,” said the Spokesperson KLB birds Flu RSPI A.M. the Patu Inspiration, Tuesday (13/12).

According to the Inspiration, a day before the two patients were treated in RS Soekamto, one of the children Najiha died, after the fever and the cough for several days. Around their residence, diketahu had the neighbour who maintained the poultry like the chicken and birds.

“Hasil the serology test and the PCR test did not yet be, but this ought to be suspected as the case cluster,” added the Inspiration.

The case cluster was the spread of the virus H5N1 the cause of birds flu accompanied humankind that happened in the scope of the family or the certain environment. “Di Indonesia has had 5 cases cluster. That finally was the Endang case in Bandung, that by WHO was stated as the case cluster,” he revealed.

About the condition for the two patients, the Inspiration explained that the level of Kafi leucocyte, continued to descend in three taking times of the sample of blood in RS Soekamto. Initially totalling 10.820, afterwards to 65.000, and on Sunday (11/12) only remained at 3,500.

Normal him, the level of leucocyte in blood, revolved between 5.000 and 10.000 per milligram blood. The decline in leucocytes was one of the indications of birds flu.

Najiha leucocytes could personally show the figure 8.800, but on Monday (12/12) increased to 15.300. Ibnu Rusydi

"look it up" but you're the one who brought it up.

I have read upteem translations of news reports from all over asia. I have not kept a spreadsheet. If I have time I will look up some cases for you but I assure you there have been cases with no known exposure to poultry. You said there were no clusters. I showed you that there are reports there are clusters.

It is an ugly and very scary scenario if it happens. It is something I hope never happens but the whole world is mobilizing for it and for good reason. This particular virus has a good chance to go the distance but it might not. As I have said before, I am ready just in case.

You have the choice to either ignore it or make at least minimal preparations. It is your choice. I live in Florida. For twenty years I prepped for hurricanes every season. Nothing ever happened till last year. Then I had three hit me in six weeks. I was ready. If nothing else I know my family won't suffer because I did not put in the effort to be prepared.

By the way, I am a retired nurse and my hubby is a family physician. If this does happen I stand a good chance of losing him as I sure as hell know that there is nothing that is available that will help prevent him from being infected if this does go pandemic and he goes to work to try and help people. Dr Webster said on the tv specials last Sun that the vaccine they are testing will not keep one from getting the flu but might keep you from dieing from it. That remains to be seen and I don't think there will be enough available for all the health care workers being that the military wants half of it.So I am pissed at the whole situation and have a good reason for following this thing so obsessively.

just like I'm now asking for the evidence that people with no exposure to birds have gotten it.

I think you need to channel some of that into research.

:-)

if you die in the coming pandemic. ;)

2004
Studies at the genetic level further determined that the virus had jumped directly from birds to humans. Limited transmission to health care workers occurred, but did not cause severe disease.
http://www.who.int/csr/don/2004_01_15/en/

http://www.who.int/csr/don/2004_02_02/en/
In the absence of evidence of direct exposure to poultry in these two cases, WHO
epidimiologists are considering various alternative explainations. Both sisters are known to have provided health care to their brother....

2005
http://www.recombinomics.com/News/10150501/H5N1_H2H_Tamiflu.html
This discusses the vietnamese girl I mentioned earlier and goes into how all cases are not recorded plus health care workers getting the flu.
I found these three on a simple google search. There are many more and better examples actually, and I am sure you can find them.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15668219&dopt=Citation

Another citation

http://www.who.int/csr/don/2004_01_15/en/

Extensive investigation of that outbreak determined that close contact with live infected poultry was the source of human infection.

http://www.who.int/csr/don/2004_02_02/en/

However, contact with an infected bird, or some other environmental source of the virus, is another possible route of infection that has not been ruled out. Outbreaks of H5N1 in poultry are widespread in Viet Nam. Large amounts of the virus are excreted in bird droppings, and can survive for some time in the environment.

http://www.recombinomics.com/News/10150501/H5N1_H2H_Tamiflu.html

The above comments from a pre-released Nature paper raise serious questions about the prophalactic use of Tamiflu and human-to-human (H2H) of H5N1. The sister, Nguyen Thi Ngoan, of the index case, Nguyen Si Tuan, was taking the FDA approved prophylactic dose of Tamiflu, 1 pill per day. However, even while on Tamiflu, she developed H5N1 bird flu symptoms. Genetic analysis of the virus suggested that she was infected by her brother, even though she was taking Tamiflu.

...

Thus the proper dose of Tamiflu and the frequency of resistance in Vietnam remains unclear. Similarly, the impact of wider use of Tamiflu in Indonesia is another area of concern.

http://www.recombinomics.com/News/10150501/H5N1_H2H_Tamiflu.html

http://content.nejm.org/cgi/content/full/352/4/333



We believe that the most likely explanation for the family clustering of these three cases of avian influenza is that the virus was transmitted directly from the infected index patient to her mother and to her aunt. Person-to-person spread of avian influenza A (H5N1) strains has been the focus of intense concern. Ongoing surveillance for such an event across Asia has so far yielded no evidence of efficient person-to-person spread. In this context, it is reassuring that no further transmission of the virus has been detected and that the available characterization of the virus from this cluster showed no adaptive change in the receptor-binding site from the avian 2,3-linked pattern toward the 2,6-linked pattern of the human sialic acid receptor. Furthermore, phylogenetic analysis of all the genomic segments showed that the H5N1 virus from this family cluster belongs to the prevalent genotype Z and that there was no reassortment with human influenzaviruses. These findings confirmed that the virus was not a new variant that has gained the ability to transmit itself from person to person more efficiently.

Other explanations for this cluster are possible, although we believe they are less likely. The diagnosis in the index patient could not be confirmed virologically, but the clinical features — pneumonia with lymphopenia and thrombocytopenia and rapid progression to the acute respiratory distress syndrome and death — and the exposure to sick and dying poultry correspond to all the cardinal features of previously reported cases in humans.11,12 Antibodies to H5 were not detected but would not yet be expected in serum collected six days after the onset of illness.21 The confirmation that the clinically similar illnesses that followed in her mother and aunt were caused by influenza A (H5N1) provides strong support that this pathogen also caused the disease in the girl.

...

The illness in the aunt also probably resulted from transmission from the index patient. Her last recognized exposure to poultry was 17 days before the onset of her illness — a period that is longer than the accepted incubation period, which ranges from 2 to 10 days.


Only the last article provides strong scientific evidence of human to human transmission and as it states, the "findings confirmed that the virus was not a new variant that has gained the ability to transmit itself from person to person more efficiently."

it was a quick google search and I got these before I hit half the first page of links.There were a ton more.
The nurse in the first link got it from a patient and had no exposure to poultry. I remember the case. I am sure you can find more info on it if you like.

You wanted some examples and I found a few. And no one has said the virus has gone efficient human to human. If it does the world will know about it in short order.
I am done debating the issue. I am tired and going to bed.

but if the pandemic comes, remind him to always wear an N-95 particulate filter mask. I'm also a nurse and had a patient who was being ruled out for TB just yesterday and I spent quite a bit of time behind one of those. I had forgotten just how awful they are to wear. That said, if a pandemic hits our shores no one will ever see me without one.

of a pandemic of some sort.

first Tamiflu injections exactly four hours BEFORE they were infected with H5N1.

Talk about a joke experiment!

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/tb2/1374

possibility of SOME SORT of influenza pandemic over the next 25 years. Like you, they don't really care that the over-hyped threat of avian flu has led to increased public support for their efforts. Like you, they don't really care if we stockpile Tamiflu or not. They are out to save lives, and a stockpile Tamiflu might be of some help when it comes to saving lives.

Personally, I think the denizens of DU can handle the truth. And the truth is that while the threat of ANY flu pandemic has been dangerously under-hyped, the threat of a human avian flu pandemic has been seriously over-hyped* and there's no clinical evidence for the claim that Tami flu is an effective treatment against it.



*unless it's already been created to order in a lab somewhere

I'm so glad that over the course of a day or two and after reading a couple of articles you have found out the complete and total truth of the entire influenza situation and have shared that amazing truth with us.

Forget what the MDs have learned, forget what the World Health Organization has learned and it telling everyone in the medical community, forget the CDC involved in influenza monitoring in Asia. They've got nothing on you, do they?

If you are so quick to believe that an easily transmissible avian strain has been created in a lab somewhere to create the influenza pandemic and so quick to dismiss all research as crap, then you already have your biased answer, don't you?

:sarcasm:

I'm so tired of trying to find articles for you only to have you latch onto one small part and blow it out of proportion while ignoring the salient parts of the research. Tamiflu is known to have little effect, and I never said it was the wonder pill to save us all. I simply shared what the international medical community is saying about it, and you grabbed onto one thing you could and ran with it into tin foil land.

We're bound to "blown it out of proportion."

I have no problem with beefing up capacity in our medical system in a way the prepares us for a variety of health crises -- and a related effort to insure all and prevent the 18,000 unnecessary deaths that devastate families every year because so many of our citizens have no health insurance.

But, the dangers of antibiotic-induced mutations that result in highly contagious, resistant strains of any disease agent may well pose a far greater risk of future pandemic. Apparently threats caused by pharmaceuticals just don't merit the level of attention that threats supposedly "solved" by pharmaceuticals get.

I remain suspicious of shifting tax dollars into pharmaceutical coffers to produce a single drug that could ultimately prove ineffective against a mutated form the avian flu. When we use a vaccine against the current form of any virus, we make it more likely that a mutated form will be resistant to that drug. It's a simple issue of selection for survival.

In any case, if the public health threat is serious, the production of the treatment ought to be nationalized. Private entities should not be raking in profits on volume production required to address any major public health crisis.

He's adamant that we cannot overuse antibiotics, and he is very cautious with his patients, even when they ask for them. We tend not to take them in our family unless we really need to (UTIs, known infections with known cultures, that sort of thing). He constantly talks with other PCPs in our area about it, too. Most agree with him and have cut back on prescribing them.

As for needing a national health care system and getting the private entities out of it, amen! Pharma disgusts me half the time and makes me nauseated the other half, and don't get me started on insurance companies.

Same thing in our family. It's a rare thing that we even choose to see a physician for cold like symptoms and even less often do we actually choose to use the too easily proffered antibiotics.

It is great that some people are gettng the message. But until national, and international, policy puts an end to the casual use of antibiotics, all the people demanding, and getting, antibiotics for every sniffle are serving as resistent strain incubators -- and the resulting strains are a danger to us all.

against bacterial agents, not viruses. The antibiotic resistent bacteria is scary but I just don't see the potential for a pandemic unless bacteria gets much better at spreading through droplets as the various forms of flu do.

I should have said "treatment-induced highly-resistent variations" pose a risk as high, or higher (both antibiotic and antiviral treatments exert selective pressure).

Vaccines induce the production of antibodies. Viral agents that mutate in ways that allow them to survive antibody attack can then spread to all those who recieved the original vaccine.

It is not a nice thought, but the massive vaccination programs are putting selective pressure on the bird flu virus. Mutations that allow the virus to survive vaccine-induced antibody attack are the survivors in a vaccinated host. So, when some random mutation results in a variation capable of passing from person-to-person, the vaccination program itself increases the probability that the variation will also carry a mutation that allows it to survive antibody attack.

Making birds a hostile environment through vaccination does cut down on the spread, and with fewer cases, there are fewer opportunities to mutate. But, if the disease agent is not completely erradicated (and they never are) vaccination creates conditions that select for resistent strains. When possible, public health measures that separate host and disease agent are most effective in eliminating threat. If, instead of improving sanitation, Cholera had been treated by antibiotics, public health officials may have had some success in the short run, but in the long run, they would have been faced with ever more intractable strains.

I did misunderstand. Thanks for the clarification.