Opinion article from Jakarta Post -Avian influenza risk: A reality check

[Christian Rivers]

I post this opinion piece from a Jakarta paper in the psychosocial section as a point of discussion. Two items strike me. The tone of the article may generate distress and turmoil even if we agree with many of the facts. Second, he states that only 400 actual tests for H5N1 have been conducted in Indonesia and explains that is the reason for not knowing the true fatality rate for avian flu in humans. That figure is far below what I would have expected based on the certainty of statements published in other settings.

In order to address the fear of pandemic flu, the principles of risk communications and the posts in flutrackers.com about Dr. Sandman’s work are most helpful. An important key in risk communication is compassionate competence. Maybe a good exercise is to try to take the facts in this article and re-write it constructively.

CR


http://www.thejakartapost.com/detail...718.E02&irec=1


Avian influenza risk: A reality check
Jakarta
Bird flu kills people, and does so with frightening alacrity. More than half of those infected with the H5N1 strain of influenza died, despite good clinical care. We know that one of its predecessors killed 40 million people around the globe long before the age of commercial aviation, automobiles, and mega cities. That virus killed only 1 to 2 percent of those infected.
Imagine H5N1 infecting far more people with far greater speed and very high mortality rates -- it is an apocalyptic vision. Such an event would turn the course of human history in a few short, terrifying months. Or we could see a super volcano that causes an ice age, or a massive meteorite strike that does much worse.
All of these scenarios have two things in common: They are science fact, not fiction, and they are very unlikely across the extremely brief span of time represented by a hundred years (less than a blink of the eye in geologic time). Defining significant as sufficient to change the course of biological history, the last significant super volcano was 70,000 years ago (go see its footprint at Lake Toba), and the last significant meteor strike was 65 million years ago. Pandemic influenza is no geological event. These occur every 30 years or so, and we are overdue.
A pandemic will happen, and H5N1 is a good candidate -- with some important and often overlooked caveats. In providing consulting to corporations preparing for a pandemic, I have been surprised by the expectation of calamity and the consequent extreme measures being planned.
When pressed for a rationale to justify these measures, they explain coping with a virus that kills most of the people it infects -- like Ebola or some other super deadly microbe. What most of these lay planners fail to grasp is the extremely low probability of the virus causing a pandemic to be as deadly as H5N1 now appears to be.
There are two compelling reasons for this optimism:
First, H5N1 itself may not be all that deadly.
Sec0nd, Darwin would object to a virus that rapidly kills most people and yet manages to spread around the globe. Health officials around the globe have done a horrendously poor job in getting this hopeful and truthful message across to the public.
On the first point we should all understand that H5N1 virus may well have a mortality rate far below the roughly 50 percent death rates seen among those diagnosed. Why? The diagnosis of H5N1 is extremely challenging.
It requires highly skilled scientists equipped with very expensive gear and extremely carefully chosen reagents. Only two laboratories in Indonesia are capable of doing it reliably, and between the two of them they have examined about 400 people since the middle of last year.
People with fever and the sniffles will not get this diagnostic testing. They must be severely ill. Absolutely no one knows how many people have been infected by H5N1 and recovered after a completely unremarkable illness. It is too difficult and expensive to screen the tens of thousands of people needed to come up with a true fatality rate for this infection.
On the second point, Darwin's natural selection is at work. Viruses have to obey these rules, too. Humans and viruses have been around long enough for us to have a grip on what is likely or not. There are well known examples of viruses that rapidly kill most people they infect -- smallpox, Ebola, Lassa, Marburg, to name just a few.
These awful viruses have more than high mortality in common -- they do not cause pandemics. They erupt periodically in pockets of outbreaks or epidemics, and then vanish. In stark contrast, the most widespread viruses -- infecting us day in and day out, like a cold virus, or cold sore virus -- also happen to be the most benign.
That contrast is no accident. Viruses that kill efficiently severely limit their own ability to proliferate. Their severely ill host inspires fear among potential new hosts, and the rapid death of the host further limits the chances of transmission. A rapidly lethal virus capable of causing a pandemic would have to possess an array of characteristics currently unknown to science. HIV comes close, but its success hinges upon the fact it is very slowly lethal.
Responsible scientists could not reasonably allow for a forecast of pandemic with a virus killing more than half of those infected. It is possible, but it is in the realm of probabilities found in geologic time and events. If it has happened in human history, we don't know of it.
When pandemic influenza finally occurs, and it will, we are not likely to see mortality rates going much higher than 1% of those infected. Yes, that will kill many millions of people and it will be very unpleasant -- but it will not be a human calamity that changes the course of our biological history. That is, unless we let it do so.
If people do not come to work for fear of a deadly infection (that in reality is not so deadly), we face far greater risks as a species by loss of the thing that sustains almost all of us: our economically woven society. Food appears on our table because we buy it from people who go to work. Electricity comes into our homes because people go to work to provide it for a fee. We fly in airplanes managed by people who go to work. People who go to work provide us security in maintaining law and order.
Franklin D. Roosevelt said it best, "We have nothing to fear but fear itself." Organizations planning for the pandemic should focus on getting the workforce to come to work. It is the failure of workplaces that poses, by far, the greater danger to us all.
Employers should address fear of this virus because it is more dangerous than the virus itself. Governments should make the investment needed to gauge the real danger of a virus like H5N1, rather than simply put out the death toll among the most severely ill. People need to go to work, even if there is some biological risk -- and they will if they know what they are facing and have the tools needed to minimize that risk.

[Shannon Bennett]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

This is the stick your head in the sand approach to pandemic flu. His reasoning is flawed as is his science.

[snip]
First, H5N1 itself may not be all that deadly.
Sec0nd, Darwin would object to a virus that rapidly kills most people and yet manages to spread around the globe.
[snip]

First:
The WHO have gone in after a family member has become ill and tested all those around the patient. They show no signs of the disease, neither do they show antibodies later. If there were silent or almost silent cases of H5N1 infected out there, we would have seen them in those most likely to harbor the disease. The WHO would have immediately released this data to calm people and stabilize markets. It is wishful thinking and flawed reasoning to maintain there are silent cases immersed in the population.

Second:
There is no pressure on this virus to protect those it has infected. It is an avian virus not a human virus, we are already a dead end. We are also only an opportunity for replication. This beast can't think, it can only react to stimulus.

[snip]
When pandemic influenza finally occurs, and it will, we are not likely to see mortality rates going much higher than 1% of those infected. Yes, that will kill many millions of people and it will be very unpleasant -- but it will not be a human calamity that changes the course of our biological history. That is, unless we let it do so.
If people do not come to work for fear of a deadly infection (that in reality is not so deadly), we face far greater risks as a species by loss of the thing that sustains almost all of us: our economically woven society.

[snip]
Using his flawed reasoning he then makes the statement there is no reason to suppose we cannot go to work. He is obviously arguing from a business perspective and is willing to ignore fact to perpetuate profits. Even if the scenario was reduced to that of 1918 it would cause a vast interruption in business. It would also be in direct opposition to governments objectives of maintaining a quarantine to reduce morbidity and mortality. There is absolutely no evidence to support his guess that this is a minor disease and we should carry on as usual. I do hope someone with a bit more integrity clarifies his deadly message.

[sharon sanders]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Thank you Joe for this important exercise.

It is critical that we develop the skills, as one of the premier H5N1 information sites on the internet, to correctly present information.

We must strive to present factual information in a calm and reasonable manner to help the world's citizens respond in a productive and measured way.

Many individuals from over 100 countries log in to view our posts. We have a responsibility to provide the facts, to the best of our ability, and to remain aware of the social consequences of what we publish here.

I encourage all members to post on this thread their thoughts about the article above.

[JJackson]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Here is an alarmist re-write (not my view of what will occur but as valid a take on the available data)

H5N1 is an avian flu virus which can infect humans, when it does so it has a CFR in excess of 50%. Fortunately its binding site is not optimised for attaching to mammalian cells, at present, so infection is rare.

Flu viruses mutate rapidly due to there sloppy single strand RNA gene structure and there ability to leap-frog the usual incremental accumulation of mutations by swapping longer genetic sequence during dual infections.

If this happens, as it has done may times before, between a human adapted flu and the HPAI H5N1 there is no good reason to believe it will be accompanied by a reduction in the CFR, logically it should make the infection worse as the virons being produced in the infected individual should no longer have any difficulty infecting more of their host?s cells; being mammalian optimised.

Following standard Darwinian evolution and the ?herd immunity? protection provided in wild waterfowl we can see H5N1 following all the usual ?rules?. The wild waterfowl population appear to be able to tolerate infection moderately well having some fatalities and some mildly infected carriers - as you would expect from a population with some exposure to assorted H5Nx and HxN1 serotypes. When the HPAI H5N1 enters a immunologically na?ve chicken shed the mortality rate approaches 100% and if left as a closed system this would act as a dead end for the virus. If, and when, a pandemic strain emerges with a2,6 (human) binding and enters a target rich urban environment a similar event should occur, the difference being the system is not closed and the virus is free to find new hosts. In past pandemics this pattern has been followed until the density of individuals who still have no antibodies is so low the pandemic dies out due to a lack of naive victims (Ro < 1).

Of the two main variables in a calculating fatalities in a flu pandemic CAR (the proportion of those exposed who become ill) and CFR (the proportion of the ill who die) the CAR is fairly predictable at ~ 1/3 but the CFR can vary by orders of magnitude from 1/1000 to close to > 1/2. A virus with a very high CFR will tend to deplete its host population and die out but in the case of flu, which has an infective period prior to symptom on set, this is not a major evolutionary draw back until it has decimated its host population and certainly does not stop it killing all the chickens in a shed. Viruses do not plan ahead they will adapt to a reduced host population density once they have created one, not because they know that high morbidity is going to cause them problems at some point down the line.

[sharon sanders]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

JJackson - I do not think your post is alarmist.

I think words like frightening, apocalyptic, and terrifying, that are in the above article are alarmist.

What do you think? Do you see any others?

[JJackson]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Alarmist not in its use of adjectives so much as a scenario with a more alarming outcome.

[sharon sanders]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Yes, but your observations are based on current and accurate data. You also acknowledge at the beginning of your essay that these observations may not become reality.

We never promised a rose garden. Even roses have thorns.

[Snowy Owl]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

I post this opinion piece from a Jakarta paper in the psychosocial section as a point of discussion. Two items strike me. The tone of the article may generate distress and turmoil even if we agree with many of the facts. Second, he states that only 400 actual tests for H5N1 have been conducted in Indonesia and explains that is the reason for not knowing the true fatality rate for avian flu in humans. That figure is far below what I would have expected based on the certainty of statements published in other settings.

In order to address the fear of pandemic flu, the principles of risk communications and the posts in flutrackers.com about Dr. Sandman?s work are most helpful. An important key in risk communication is compassionate competence. Maybe a good exercise is to try to take the facts in this article and re-write it constructively.

CR

OK I will give it a try, excuse my english since it is not my first language, but still, this is a good exercise IMHO.

SO

Avian influenza risk: A reality check
Jakarta

Bird flu can kill people, more than half of those infected with the H5N1 strain of bird-influenza died, despite good clinical care. We know that the so called Spanish Influenza at the beginning of the 20th century killed over 60 million people around the globe long before the age of commercial aviation, automobiles, and mega cities. That influenza virus, have killed more than 2% of those infected.

Imagine the avian H5N1 virus, after some transformations becomes pandemic, it could spread fast and infect more people in high density cities.

It is a perspective that prompt preventive actions. Such an event could turn the course of human history in a few short, suffering months.

Human pandemic occur every 30 years or so.

A pandemic will happen, and H5N1 is a good candidate -- with some important and often overlooked caveats. In providing consulting to corporations preparing for a pandemic, I have been surprised by the expectation of the anticipated calamity and the consequent extreme measures being planned.

When pressed for a rationale to justify these measures, they explain coping with a virus that kills most of the people it infects -- like Ebola or some other super deadly microbe. What most of these lay planners fail to grasp is the 'transformed H5N1 pandemic virus' might not be as lethal than the Avian H5N1 virus is and that is actually infecting humans.

How could a virus that rapidly kills most people, and thus reducing the infectuous time, can manage to spread fast and wide around the globe. Health officials around the world have done a poor job in getting this hopeful and truthful message across to the public.

On the first point we should all understand that Avian H5N1 virus may well have a mortality rate far below the roughly 50 percent death rates seen among those diagnosed. Why? The diagnosis of Avian H5N1 is extremely challenging.

It requires highly skilled scientists equipped with very expensive gear and extremely carefully chosen reagents. Only two laboratories in Indonesia are capable of doing it reliably.

People with fever and the sniffles will not get this diagnostic testing. They must be severely ill. Absolutely no one knows how many people have been infected by H5N1 and recovered after a completely unremarkable illness. It is too difficult and expensive to screen the tens of thousands of people needed to come up with a true fatality rate for this infection.

Humans and viruses have been around long enough for us to have a grip on what is likely or not. There are well known examples of viruses that rapidly kill most people they infect -- smallpox, Ebola, Lassa, Marburg, to name just a few. These awful viruses have more than high mortality in common -- they do not cause pandemics. They erupt periodically in pockets of outbreaks or epidemics, and then vanish. In stark contrast, the most widespread viruses -- infecting us day in and day out, like a cold virus, or cold sore virus -- also happen to be the most benign.

That contrast is no accident. Viruses that kill efficiently severely limit their own ability to proliferate. Their severely ill host inspires reactions among potential new hosts, (social distancing, protective equipment, prophylactics), and the rapid death of the host further limits the chances of transmission. A rapidly lethal virus capable of causing a pandemic would have to possess an array of characteristics.

Responsible scientists could not reasonably allow for a forecast of pandemic with a virus killing more than half of those infected. It is possible, but it would have to include a high collateral damage caused by the dislocation of Society and of our dependancy towards produced goods and services.

When pandemic influenza finally occurs, and it will, it certainly will kill many millions of people and it will be very unpleasant -- but it will not be a human calamity that changes the course of our biological history. That is, unless we let it do so, or we provoke it.

If people do not come to work for fear of a deadly infection (that in reality is not so deadly), we face far greater risks since we have become dependants of the thing that sustains almost all of us: our economically woven society. Food appears on our table because we buy it from people who go to work. Electricity comes into our homes because people go to work to provide it for a fee. We fly in airplanes managed by people who go to work. People who go to work provide us security in maintaining law and order.

Franklin D. Roosevelt said it best, "We have nothing to fear but fear itself." Organizations planning for the pandemic should focus on getting the workforce to come to work. It is the failure of workplaces and the fact that we have lost the know how and the routine to produce our own food and our dependance to energy that poses, the second collective stress in a pandemic.

Employers should address the unpreparedness towards this virus because it is more dangerous than the virus itself. Governments should make the investment needed to gauge the real danger of a virus like H5N1. People need to go to work, even if there is some biological risk -- and they will if they know what they are facing and have the tools needed to minimize that risk.

[Christian Rivers]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

I share the range of sentiments above.
Snowy ? good reframe, excellent English.

I ?ll take a try at a couple of points.

Let me accept a couple of the writer's basic points: the current case fatality rate (CFR) of 0.5 for avian flu is probably much greater that the expected CFR for pandemic flu (lets say 0.025). Therefore the world is at danger if we all behaved as if the CFR were 0.5 when the evolving pandemic is announced.

Reality Check
?.
Officials worldwide generally agree that the world will face a pandemic and the most likely near term candidate agent is the avian influenza H5N1. In projecting the potential impact of the next pandemic, health officials have relied on models of the 1918 Spanish flu pandemic as a extreme example. In the US, health officials in a worst case scenario are looking at the possibility that 35% of our 300 million population will become ill (105 million ill) and for a possible case fatality rate of 2.5% approximately 2.5 million dead.
The purpose of the world wide effort for pandemic preparation is to mitigate against the rates of illness and death and to maintain the essential infrastructure of society.

Our social dilemma is the same as the prisoner?s dilemma. If we all maximize efforts at individual survival by social isolation, we decrease the ability of society to survive ( ie. collapse of the infrastructure from loss of healthcare capacity, transportation of goods, loss of power, loss of food production and distribution, and social unrest). As an individual I also need society. Society has a vested interested in survival of its members but no real investment in me as an individual.

Businesses and social agencies must negotiate a new social contract with its members, customers and suppliers now. We need to work within our immediate social groups as participants to collectively assess our individual risks and how we mitigate those risks as a group. In times of crisis we extend ourselves for those we trust. Trust is built on relationships which are built through communications. The reality is we all have the responsibility to speak up, speak out, and speak now. Then listen.

CR

[JJackson]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Bravo Snowy & Christian.

One thing that has troubled me greatly from the start of my interest in H5N1 as a possible pandemic candidate is its virulence. As the article argues disease which quickly kill of their hosts are at an evolutionary disadvantage and I have always assumed that the CFR would not be as high in the pandemic form. My reasons were much the same as his; firstly that testing has been selective leading to an inflated CFR and secondly historical precedent, this is just not normal behaviour I can not point to examples of human or animal example of successful diseases which have emerged and promptly killed such a high proportion of their hosts.

One closer inspection there are flaws in his, and my, argument. The ?common diseases are mild diseases? argument is correct but for diseases that have reach equilibrium with their hosts. H1N1 is taken as the planner & modellers bad scenario and was the agent in the worst flu pandemic of modern times but is also ? now it has reached equilibrium ? one of the ?most benign? examples he quoted i.e. one of the serotypes in seasonal flu. Historically there have been examples of extreme pandemic fatalities but we probably need to look back to 1347 for one. In Europe fatalities are thought to have been > 1/3, I have no idea what the CAR rate was but as deaths = CFR * CAR for a typical pandemic flu CAR of 1/3 that would equate to a CFR of 100%. So if flu pandemics are a 1 in 30 year events and 1918 type pandemics are 1 in 100 year events perhaps events with CAR = 50%, CFR = 50% occur once a millennium ? not exactly geological time but we would be extremely unlucky to have one occur on or watch

Apologies to all for not sticking strictly to Christians brief in my previous post and hat tip to Snowy for doing so beautifully ? I am in awe of how well you must write in French and sad, and ashamed, that my French is not good enough to appreciate it.

[Snicklefritz]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

The argument that the current CFR for avian flu is inflated, that there are many more individuals that have become infected and recovered strikes me as odd.

Individuals will argue that the risk of acquiring infection directly from fowl is very low, except for individuals exhibiting certain high risk behaviors, and that the virus is not easily transmissible from one human to another.

But, in order for the current CFR to be mathematically reduced to 'seasonal flu' values it seems to me there would have to be thousands of individuals infected.

Either the virus is easily transmissible, and thousands have acquired hidden infections, resulting in an inflated CFR. Or, the virus is not easily acquired from fowl, and not easily transmissible, but the CFR is very high.

I hope that makes sense.

[Thinlina]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

Didn't the black death and the spanish flu come in many waves? Like three? Every wave more deadly than the one before? So it would make a little different equation of the CFR and CAR.

[JJackson]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

1918 flu came in three waves with the bulk of the deaths in the second. The first was in the spring and the second in the traditional flu season.

The Black death crept slowly from Asia into the Mediterranean ports and then from village to village as a rolling pandemic and - as I understand it - most of the the deaths occurred at that time but it kept re-appearing for decades but with lesser death counts; presumably due to some level of immunity in the population.

[Laidback Al]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

The fact is that a serological study in Cambodia indicates that mild cases of H5N1 are not being overlooked.

from about 3/20/2006

Alohamora, here's the article I was looking for...
Cambodian study suggests mild bird flu cases aren't going undetected

ATLANTA (CP) - New data from Cambodia presented at an international conference Monday suggest mild or symptomless human cases of H5N1 avian flu may not be occurring.

Many have hoped that the world is overestimating the virulence of the H5N1 virus, based on an assumption the disease surveillance systems in affected countries might not be sensitive enough to pick up mild infections. But if the work presented at the International Conference on Emerging Infectious Diseases is borne out by additional larger studies, it would suggest the current case fatality rate of roughly 54 per cent might indeed be close to reality.

Lead researcher Dr. Philippe Buchy of the Institut Pasteur in Phnom Penh put a positive spin on his findings. "In our experience, it seems that the virus still has difficulty jumping from avian to humans," he said in an interview.

But the head of the influenza branch at the U.S. Centers for Disease Control said the findings have both positive and negative implications. "You can look at it in the way that it's encouraging because it means that the virus is not jumping to humans very readily. And that of course is very important and that's a positive thing," said Dr. Nancy Cox. "But on the other side of the coin, it means that the case fatality rate is still very high. And that is a negative thing."

Cox said it will be important to do this type of work on a larger scale, to get a more definitive picture of whether mild or asymptomatic H5N1 human cases are occurring. She said some larger studies are planned.

Buchy and his colleagues reported on work they conducted last spring in a Cambodian village that had H5N1 outbreaks in poultry and where one of that country's four recorded cases lived. (All four Cambodians known to have been infected with the virus died.)

The researchers tested blood samples from 351 of the villagers looking for the antibodies to the virus that would be proof of mild or asymptomatic infections. They found no signs of additional infections - this despite the fact that many of the villagers had significant exposure to infected poultry.

Even a doctor who was involved in a difficult process to insert a ventilator tube into the windpipe of an H5N1 patient did not became infected, said Buchy, who noted the doctor wore no protective gear because he didn't realize what his patient was suffering from.

"We didn't find any case of H5N1," Buchy said in an interview. "So nobody seems to have been asymptomatic or with mild symptoms during this outbreak in Cambodia. It was also true with several other doctors and nurses and none of them were positive."

Buchy said blood samples taken from two veterinarians who had autopsied birds that had died from H5N1 showed no sign of antibodies to the virus either. Like the doctor, the veterinarians hadn't taken any precautions; they hadn't realized the birds had been killed by H5N1.

After the first human cases of H5N1 were reported in Hong Kong in 1997, so-called serological surveys - checking blood samples for antibodies - were done to see if all the cases had come to light. At that time, a small number of people, mainly health-care workers, were found to have developed antibodies without having become sick enough to be diagnosed with the disease.

But the virus has changed a great deal since then and the virulence of current circulating H5N1 viruses has risen. And experts have called for more of this work to be done to ensure that the world gets a better handle on what is actually happening with the virus.

Cox suggested the Cambodian study is a start. "The work in Cambodia is extremely important because it shows that we really aren't missing that much," she said.

Source: Telus

http://www.cidrap.umn.edu/cidrap/con...2706cases.html

[Mingus]

Re: Opinion article from Jakarta Post -Avian influenza risk: A reality check

First, H5N1 itself may not be all that deadly.
Sec0nd, Darwin would object to a virus that rapidly kills most people and yet manages to spread around the globe. Health officials around the globe have done a horrendously poor job in getting this hopeful and truthful message across to the public.

I hope so, but sadly don't beleive it.
The 1347 plague and the 80ies seal H7N7 are two examples of high fatality/case disease that spread despite their virulence rate.

reached equilibrium

I must agree with JJackson on that... until the time the virus has reach his equilibrium with our species, anything can happen.

Sorry, I won't try to re-write it, my foreing english would make this thread moves to the comedy room...:p Que voulez-vous? la plusse belle langue du monde c'est celle de ma m?man!