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New ladder to a pandemic alert

Shiloh

Editor, Senior Moderator
Source: http://www.todayonline.com/articles/260862.asp

June 21, 2008

New ladder to a pandemic alert
WHO?s six-step proposaloffers greater clarity infight against flu infection


Tan Hui Leng in Kuala Lumpur
huileng@mediacorp.com.sg


THE World Health Organisation (WHO) has released details of a new flu pandemic alert system to replace its existing one, which has been criticised for lacking clarity.
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Currently, the world is in phase 3 of the alert system, which is defined as ?no or very limited human-to-human transmission?. The six-step, three-layer alert system is a ladder going from ?low risk of human cases? in phase 1 to ?efficient and sustained human-to-human transmission? in phase 6, the pandemic phase.

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Last year, a cluster of eight Indonesian family members who were infected through human-to-human H5N1 transmission sparked confusion over WHO?s flu alert level, with some calling for it to be raised to phase 4; that is, ?evidence of increased human-to-human transmission?.
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WHO?s new system addresses such issues of interpretation with three layers. The first comprises phases 1 to 3 and is defined as ?predominantly animal infections; limited transmissibility among people?.
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Phase 4 would be ?sustained human-to-human transmission of animal or hybrid animal-human influenza virus, able to cause sustained community-level outbreaksthat have been verified? ? this is when health authorities can consider issues such as rapid containment, discussion of phase changes, and switching to a pandemicvaccine.
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Phases 5 and 6 would comprise the ?geographical spread? of flu. There is also a post-pandemic phase.
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Dr Nahoko Shindo, the medical officer at WHO?s Epidemic and Pandemic Alert and Response department, said the final version of the phases would be available by year?s end.
She announced this on Friday during the 13th Congress of Infectious Diseases in Kuala Lumpur.
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Infectious disease experts at the conference also warned that although the worst of the bird flu threat is over, the fight to eliminate the disease from poultry is weak.
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The head of the United Nations? Food and Agricultural Organization, Dr Juan Lubroth, said that ?drawbacks and weaknesses? remain in the battle to eliminate the H5N1 strain from the poultry sector. The virus is now active in 10 countries and is endemic in the poultry population of some.
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Infectious diseases experts fear that H5N1 could mutate into a form that spreads easily among humans and trigger a deadly flu pandemic.
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He said the death of poultry especially affects the poor, 80 per cent of whom own livestock for their livelihood. As poultry is an important, inexpensive protein source, Dr Lubroth warned that failure to protect their food sources could worsen the global food crisis.
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Veterinary services around the world need to be strengthened and more experts trained, while reporting must be more transparent,
he said, adding that countries have to use more surveillance and implement policies to deal with the disease.
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?We fail to see that political commitment,? he said.
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This is of concern especially as H5N1 in humans exhibits a high fatality rate and unlike seasonal human flu, H5N1 spreads to the various organs.
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On Thursday, Indonesia reported another two human avian flu cases, bringing the total number of infected humans worldwide to 385 since 2003. Of these, 243 have died.
 
Re: New ladder to a pandemic alert

> Last year, a cluster of eight Indonesian

was this already announced/established in 2007 ?
 
Re: New ladder to a pandemic alert

Looks like old 3 and 4 are being combined into 3 and old 5 and 6 are being combined into 4. The new 5 and 6 are pretty much irrelevant because they will quickly follow 4 (its the 1,2,3,6 system).

http://www.who.int/csr/disease/avian_influenza/phase/en/

New system will allow WHO to admit that there are dozens of H2H clusters, but hold off on vaccine creation and distribution until it is too late to have much of an effect. The new system is a "reactive" as the old, but will dispose of the issue of many examples of H2H among family members and close contacts.
 
Re: New ladder to a pandemic alert

Looks like old 3 and 4 are being combined into 3 and old 5 and 6 are being combined into 4. The new 5 and 6 are pretty much irrelevant because they will quickly follow 4 (its the 1,2,3,6 system).

http://www.who.int/csr/disease/avian_influenza/phase/en/

New system will allow WHO to admit that there are dozens of H2H clusters, but hold off on vaccine creation and distribution until it is too late to have much of an effect. The new system is a "reactive" as the old, but will dispose of the issue of many examples of H2H among family members and close contacts.

This will have the effect of keeping the apparently evolving epidemiology of H5N1 out of the international media spotlight. I see that the world stockmarkets are apparently the paramount consideration of WHO, not human health.

At best, this type of recategorization will only delay the inevitable panic (as you say the 1,2,3,6 system) of an uninformed public. This approach has the potential to make the long term global financial effects much worse than if we all made a calm, concerted and focused effort to prepare now.

Which state/corporate entities are putting the political pressure on WHO to recategorize the alert levels?
 
Re: New ladder to a pandemic alert

When was the earliest known h2h transmission?
From a epidemiological and serosurveys point of view, the first instance of unsustained human-to-human transmission of H5N1 avian influenza virus was in Hong Kong, 1997.

The most clear, and accepted, instance of h2h transmission was the so-called Karo Cluster, Sumatra Island, Indonesia, May 2006 (http://www.who.int/csr/don/2006_05_23/en/index.html)
 
Re: New ladder to a pandemic alert

From a epidemiological and serosurveys point of view, the first instance of unsustained human-to-human transmission of H5N1 avian influenza virus was in Hong Kong, 1997.

The most clear, and accepted, instance of h2h transmission was the so-called Karo Cluster, Sumatra Island, Indonesia, May 2006 (http://www.who.int/csr/don/2006_05_23/en/index.html)
There have been dozens of examples of H2H. In fact most of the first cases of confirmed H5N1 have been in clusters and most of the clusters have been H2H (Cambodia, Indonesia, Turkey, Iraq, Azerbaijan, Nigeria, Pakistan). H2H has also been written up in peer reviewed journals for Thailand and Indonesia, with a "can't be excluded" in Azerbaijan.
 
Re: New ladder to a pandemic alert

There have been dozens of examples of H2H. In fact most of the first cases of copnfirmed H5N1 have been in clusters and most of the lcusters have been H2H (Cambodia, Indonesia, Turkey, Iraq, Azerbaijan, Nigeria, Pakistan). H2H has also been written up in peer reviewed journals for Thailand and Indonesia, with a "can't be excluded" in Azerbaijan.

I agree. I don't want to hide nothing. Only, the most explosive case, Karo Cluster highlight.
 
Re: New ladder to a pandemic alert

they decrease the information content of the phases.

we need more phases, not fewer.


best would be to give a number for the estimated
pandemic probability, (-say for the next 12 months) of course.
 
Re: New ladder to a pandemic alert

When was the earliest known h2h transmission?

Within the first batch of human infection cases reported between May and August 1997.

Isolation of Avian Influenza A(H5N1) Viruses From Humans—Hong Kong, May-December 1997. Vol. 279 No. 4, January 28, 1998.
http://jama.ama-assn.org/cgi/content/full/279/4/263

"The other possible case-patient (of 2 discussed in this paper) is the 3-year-old sister of patient 7 and cousin of patient 6. She lived in the same apartment as patient 7 and had onset of fever on December 13 and was hospitalized in good condition. Preliminary laboratory results were positive for influenza A(H5N1) virus; confirmation of these results by virus isolation is pending.

Patient 6
On December 7, a 5-year-old girl developed fever, rhinitis, cough, sore throat, and vomiting. As of December 17, she remained hospitalized in satisfactory and stable condition. A nasopharyngeal aspirate collected on December 10 yielded influenza A(H5N1).

Patient 7
On December 12, a 2-year-old boy developed fever and was admitted to the hospital in good condition. The child is a cousin of patient 6, who frequently visited him and his family at their home. On December 16, a culture from the child was reported positive for influenza A(H5N1) virus."

Right from the get-go, we have probable family clusters reported in the initial 18 cases of avian H5N1 infection in humans. A telling comment in the paper:

" because influenza surveillance in Hong Kong has been conducted primarily in hospitals, milder cases may not have been recognized, and the severity of infections identified to date may not be representative of the spectrum of illness caused by A(H5N1) infection in humans."

A later article (BMJ 10 Jan 1998;316(7125):91) reported that follow-up contact investigation of the initial cases (15, 4 died and another 4 in critical case at the time of publication) showed that 9 out of 502 contacts were positive (antibody assay for H5N1) for exposure but did not develop severe symptoms.

http://bmj.bmjjournals.com/cgi/content/full/316/7125/91
 
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Re: New ladder to a pandemic alert

Within the first batch of human infection cases reported between May and August 1997.

Isolation of Avian Influenza A(H5N1) Viruses From Humans—Hong Kong, May-December 1997. Vol. 279 No. 4, January 28, 1998.
http://jama.ama-assn.org/cgi/content/full/279/4/263

"The other possible case-patient (of 2 discussed in this paper) is the 3-year-old sister of patient 7 and cousin of patient 6. She lived in the same apartment as patient 7 and had onset of fever on December 13 and was hospitalized in good condition. Preliminary laboratory results were positive for influenza A(H5N1) virus; confirmation of these results by virus isolation is pending.

Patient 6
On December 7, a 5-year-old girl developed fever, rhinitis, cough, sore throat, and vomiting. As of December 17, she remained hospitalized in satisfactory and stable condition. A nasopharyngeal aspirate collected on December 10 yielded influenza A(H5N1).

Patient 7
On December 12, a 2-year-old boy developed fever and was admitted to the hospital in good condition. The child is a cousin of patient 6, who frequently visited him and his family at their home. On December 16, a culture from the child was reported positive for influenza A(H5N1) virus."

Right from the get-go, we have probable family clusters reported in the initial 18 cases of avian H5N1 infection in humans. A telling comment in the paper:

" because influenza surveillance in Hong Kong has been conducted primarily in hospitals, milder cases may not have been recognized, and the severity of infections identified to date may not be representative of the spectrum of illness caused by A(H5N1) infection in humans."
Yes, H2H is not new. Most cases involve 2 or 3 family members (or other close contacts), and there were also clear examples in Vietnam and Thailand in 2004.

WHO uses many techniques to exclude H2H clusters, but those methods really have lost credibility, so the new systen will allow WHO to admit that there are dozens of small H2H clusters, and still keep the level at 3.
 
Re: New ladder to a pandemic alert

do the phases count for H5N1 only ?

will they establish phases for -say- H7 also, when the human cases
increase a lot -more than with H5N1 ?

what phase would they have been in in 1976 ?
in 1977 ?
 
Re: New ladder to a pandemic alert

do the phases count for H5N1 only ?

will they establish phases for -say- H7 also, when the human cases
increase a lot -more than with H5N1 ?

what phase would they have been in in 1976 ?
in 1977 ?
I think 1976 was limited to a few cases in NJ.
 
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