Weekend jaunt

Off to Las Vegas, to leave some money and have some fun. Back to posting on Monday. Keep an eye on Indonesia. Nancy

Nurse ill in Indonesia

[1] Indonesia - West Java
Date: Fri 2 Jun 2006
From: Cat Bachman
Source: Antara News, Indonesian News Agency, Fri 2 Jun 2006 [edited]



A 25-year-old nurse is currently being treated at the Hasan Sadikin
Hospital here for bird flu-like symptoms. She was admitted to the
hospital which has been treating a number of bird flu patients on
Thursday evening [1 Jun 2006].

"When she arrived at this hospital last night, her body temperature
was very high, namely 39.6 degrees Celsius [103 F], but now it has
decreased to 37 degrees Celsius [98.6 F]," Hadi Jusuf, head of the
bird flu medical treatment unit of the hospital, said here on Friday
[2 Jun 2006]. The hospital was planning to send the patient's blood
sample to the laboratory of the Health Development and Research Body
in Jakarta on Friday [2 Jun 2006]. The result of the laboratory test
is expected within the next 3 days, he said. "We could not confirm
[that she had contracted H5N1 avian influenza], although she had
earlier had contacts with 18-year-old and 10-year-old siblings, who
died of avian influenza recently," he said.

The ailing nurse had never had contact with poultry, but she had
treated [her?] sibling at Ujungberung Hospital, where she worked as a
nurse. If she is confirmed of being infected by bird flu virus, it
would be the first case of human-to-human transmission of the virus
[i.e. transmission from patient to nurse - Mod.CP], he said.

Meanwhile, the UN World Health Organization (WHO) announced recently
that international health investigators were finding no evidence that
efficient transmission of the highly pathogenic avian influenza virus
has emerged from [i.e. spread beyond] a family cluster of cases in
Indonesia's province of North Sumatra.

As of 29 May 2006, according to the WHO the H5N1 virus has caused 127
deaths in 224 cases worldwide since it was detected in humans in late
2003. In all but a handful of cases, humans have become infected
through direct contact with ailing birds, their feces or blood.
Indonesia has detected 48 cases of H5N1, 31 of those appearing since
January 2006, and ending in 36 fatalities.

--
Cat Bachman

Living in chicken sheds

Merlin, the British medical aid charity working in the earthquake zone in Java, has warned of disease risks to survivors taking shelter in chicken sheds.

Dr Yolanda Bayugo, Merlin's health director in Indonesia, raised concerns today with the Ministry of Health and the World Health Organization in Yogyakarta and has asked for more tents to be supplied.

"We are concerned that people using poultry sheds as shelter are at risk from avian flu and salmonella," said Dr Bayugo.

"In Pundong sub-district of Bantul, where about 35,000 people are homeless, we found more than 100 people taking shelter in six large poultry sheds," she continued. "The sheds, built from bamboo, are each about 200 metres long and are the only surviving structures in the area. One shed was new and had not yet been used to keep chickens. Others, which had been cleared recently, were only partially cleaned and still had chicken droppings lying on bamboo slats."

The avian flu virus is known to be present in poultry farms across Java and can be spread through contact with fresh or dried chicken droppings. Last year, the World Health Organization identified the virus in parts of Java now affected by the earthquake.1There were no reported cases in Pundong, but it was identified in Yogyakarta, Sleman and Klaten districts.

The virus has claimed the lives of 36 people in Indonesia since the beginning of 2005. Last month, an outbreak on the neighbouring island of Sumatra, killed six people.

British nurse Paula Sansom, who is leading Merlin's emergency response team, said: "It's tragic that people who have lost their homes have no option but to take shelter in places where they could catch a deadly virus. In such over-crowded conditions the risk of contamination with avian flu and salmonella will increase."

"We have requested that the supply of tents is prioritised for people in these communities," she continued. "Where poultry sheds are the only means of shelter, Merlin is helping affected families to clean the sites properly and follow appropriate hygiene precautions."

Merlin arrived in the Yogyakarta region on Sunday - a day after the 6.3 magnitude earthquake killed more than 6,000 people and left around 200,000 homeless. The team has been operating mobile clinics in the Bantul area and distributing emergency medical supplies, including intravenous fluids, antibiotics and water purification tablets.

For more information, contact: Jacqueline Koch Merlin Indonesia Mobile: +62 (0)813 813 11 436 comms@merlin-indonesia.org

Jonathan Pearce Head of Communications, Merlin London Office: +44 (0)20 7014 1701 jonathan.pearce@merlin.org.uk

Ju-Lin Tan Senior Communications Officer, Merlin London Office: +44 (0)20 7014 1702 ju-lin.tan@merlin.org.uk

Out of office hours: +44 (0)7092 382 421

Notes 1. Communicable Diseases, risks and interventions. Indonesia earthquake-affected areas, 2006, May 31, 2006

Photographs are available on request.

Merlin is the only specialist UK charity which responds worldwide with vital health care and medical relief for vulnerable people caught up in natural disasters, conflict, disease and health system collapse.

[ Any views expressed in this article are those of the writer and not of Reuters. ]

Avian flu news

Bird Flu Explodes in Indonesia May 31 8:15 PM US/Eastern Email this story

By MARGIE MASON
AP Medical Writer

JAKARTA, Indonesia

Indonesia averaged one human bird flu death every 2 1/2 days in May, putting it on pace to soon surpass Vietnam as the world's hardest-hit country.

The latest death, announced Wednesday, was a 15-year-old boy whose preliminary tests were positive for the H5N1 virus. It comes as international health officials express growing frustration that they must fight Indonesia's bureaucracy as well as the disease.

"We're tying to fix this leak in the roof, and there's a storm," World Health Organization spokesman Dick Thompson said. "The storm is that the virus is in animals almost everywhere and the lack of effective attention that's being addressed to the problem."

Indonesia, an archipelago of 17,000 islands with a population of 220 million people, has a patchwork of local, regional and national bureaucracies that often send mixed messages. The impression, health officials said, is often that no one is truly at the helm.

"I don't think anyone can understand it unless you come here and see it for yourself," said Steven Bjorge, a WHO epidemiologist in Jakarta. "The amount of decentralization here is breathtaking."

He said Health Ministry officials often meet with outside experts to formulate plans to fight bird flu, but they are rarely implemented.

"Their power only extends to the walls of their office," Bjorge said, adding that the advice must reach nearly 450 districts, where local officials then decide whether to take action.

Indonesia has undergone a sometimes rocky transition to democracy since dictator Suharto was ousted in 1998, with many powers held by the central government being transferred to regional and community control.

But the process has been haphazard, and funding and policy decisions are often at the whim of inexperienced officials, mayors and village heads.

National government officials concede there is a problem.

"The local government has the money, thus the power to decide what to prioritize," said Hariyadi Wibisono, director of communicable disease control at the Ministry of Health. "If some district sees bird flu as not important, then we have a problem."

Indonesia has logged at least 36 human deaths in the past year _ 25 since January _ and is expected to soon eclipse Vietnam's 42 fatalities. The two countries make up the bulk of the world's 127 total deaths since the virus began spreading in Asian poultry stocks in late 2003.

Attention has been fixed on one village on Sumatra island where six of seven relatives died of bird flu. An eighth family member was buried before samples were collected, but the WHO considers her part of the cluster.

Experts have not been able to make a direct link between the relatives and infected birds, which has led them to suspect limited human-to- human transmission. But no one outside the family of blood relatives _ no spouses _ has fallen ill and experts say the virus has not mutated.

Scientists believe human-to-human transmission has occurred in a few other smaller family clusters, all involving blood relatives. Experts theorize that may mean some people have a genetic susceptibility to the disease.

On Wednesday, WHO said 54 uninfected relatives and contacts of the Indonesian family cluster are under quarantine and are taking the antiviral drug Tamiflu and being monitored by health workers. The quarantine is voluntary and the teams are also visiting all the homes in the 400-household village in North Sumatra to look for signs of illness. It said there are no signs the disease has spread since May 22.

Bird flu remains hard for people to catch, and most human cases have been traced to contact with infected birds. Experts fear the virus will mutate into a highly contagious form that passes easily among people, possible sparking a pandemic.

Experts say the best way to battle bird flu in Indonesia is to tackle it in poultry. But that message is not always getting through. Many local governments have refused to carry out mass poultry slaughters in infected areas, and vaccination has been sporadic at best.

Such measures helped other hard-hit countries like Vietnam and Thailand curb outbreaks. Both have strong central governments that have taken a leading role in the effort.

The U.N. Food and Agriculture Organization has been working with officials to improve poultry surveillance in Indonesia and quicken response times to outbreaks.

But public awareness and bio-security standards remain low in the densely populated countryside, home to hundreds of millions of backyard chickens.

"It's not quite so easy here, where you have to have the local authorities and provincial authorities and national all on board," said Jeff Mariner, an animal health expert from Tufts University working with the FAO in Jakarta.

"We find outbreaks every week scattered throughout Java. It's a diffusely endemic disease. In most districts, you can find it at any time," he said. "It's a staggering undertaking in a decentralized country."

___

Associated Press writers Zakki Hakim in Jakarta and Alexander G. Higgins in Geneva contributed to this report.

MORE BIRD FLU THAN WE KNOW

NewsTrack

Bird flu may be underreported

ROME, May 31 (UPI) -- The World Organization for Animal Health says lack of funding in China, Indonesia and Africa may result in underreporting of cases of bird flu.

"Farmers will probably not report sick animals" in Africa because of inadequate funding, education, time and distance, the group's avian flu coordinator, Christianne Bruschke, said at an international conference of more than 300 scientists from 100 countries in Rome Wednesday.

"Their veterinary services are very weak and many countries do not have laboratory facilities" to track the disease.

Bruschke urged industrialized nations to provide adequate funding to monitor infected poultry in developing countries, the BBC reported.

The animal health organization suspects avian flu virus may now be endemic in poultry flocks in Indonesia, where 36 people have died.

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WHO UPDATE ON INDONESIA 5/29/06

Avian influenza – situation in Indonesia – update 15

29 May 2006

The Ministry of Health in Indonesia has confirmed an additional six cases of human infection with the H5N1 avian influenza virus. Three of these cases were fatal.

None of the newly confirmed cases is associated with the family cluster in Karo, North Sumatra. The cases are widely dispersed geographically (see map below).

One newly confirmed case is an 18-year-old man from East Java Province. He developed symptoms on 6 May and was hospitalized on 17 May. He is now recovering. The investigation found a history of exposure to dead chickens in his home within the week prior to symptom onset. No further cases of influenza-like illness have been identified during the investigation and monitoring of his close contacts.

Two additional cases occurred in a 10-year-old girl and her 18-year-old brother from Bandung, West Java. Both children developed symptoms on 16 May, were hospitalized on 22 May, and died on 23 May. Both children had a history of close contact with sick and dying chickens at their home in the week before symptom onset. The identical onset dates strongly suggest that they acquired their infection following a shared exposure to poultry, and not from each other. Follow-up of contacts has not identified further cases of influenza-like illness.

An additional case occurred in a 39-year-old man from West Jakarta. He developed symptoms on 9 May, was hospitalized on 16 May, and died on 19 May. The investigation determined that the man cleaned pigeon faeces from blocked roof gutters at his home shortly before symptom onset. No further potential source of exposure was identified.

The remaining two patients are a 43-year-old man from South Jakarta, who developed symptoms on 6 May, and a 15-year-old girl from West Sumatra, who developed symptoms on 17 May. The 43-year-old man has recovered and been discharged from hospital. The 15-year-old girl remains hospitalized. The sources of exposure for these two cases are under investigation.

The newly confirmed cases bring the cumulative total in Indonesia to 48. Of these cases, 36 were fatal.

Maps showing the location of Indonesia’s H5N1 cases can be found on the WHO Indonesia avian influenza web site .

Memories of all the fallen. I honor you. Thank you.

Who gets treatment?

Who lives? Flu crisis may make us pick

Experts are divided on who gets the limited vaccine in case of a pandemic.

By LISA GREENE, Times Staff Writer
Published May 28, 2006


Imagine the worst: A deadly new strain of flu speeds across the globe, and as it approaches the United States, the reality is grim.
There isn’t enough vaccine to prevent people from getting the virus. Not enough medicine, hospital beds or even ventilators to treat the sick.

Whom do you save?

What was once an abstract philosophical dilemma has become an urgent health policy question. The most immediate danger, Asia’s killer bird flu, hasn’t turned into a worldwide epidemic because it hasn’t yet developed the ability to spread easily from person to person.

But public health officials must prepare for the threat of a disease that could spread with explosive speed. A global epidemic could kill nearly 2-million people and hospitalize nearly 10-million just in the United States. If a pandemic hits any time soon, scientists estimate that there may be only enough vaccine for about 10 percent of the population during the first year of the illness.

“In a situation like that, we will have to choose,’’ said Dr. Greg Poland, director of the Mayo Clinic Vaccine Research Group and a member of the advisory committee on vaccines for the federal Centers for Disease Control and Prevention. “We’re not used to that. We want everyone to get on the lifeboat.’’

But in this instance, most people won’t fit. And already, some of the nation’s top ethicists and flu experts disagree about who should go first.

“I’m not a fan of the rules as they’ve been presented,’’ said prominent bioethicist Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. “I’m not sure they’ve explained why they’re doing what they’re doing.’’

The priority vaccinations

The guidelines now listed in the federal pandemic flu plan call for health care workers and vaccine producers to be vaccinated first. Few argue with that; without them, there will be nobody to care for the sick.

“If you have doctors and nurses that don’t come to work, you have nobody taking care of flu patients,’’ said Dr. Bruce Gellin, director of the National Vaccine Program Office for the federal Department of Health and Human Services.

After that, the guidelines call for certain vulnerable groups to be vaccinated, such as pregnant women, and then people older than 65. Healthy children would come last, along with other healthy people ages 2 to 64.

It’s more than an abstract policy for LeeAnne Cochran.

The 27-year-old Tampa resident was watching her three kids make their way to a park play gym one afternoon last week. She had a quick reaction to who should get the first vaccine: “The kids, I think.’’

But her youngest child, 6-year-old Chelsey, was listening.

“No, you should get it first,’’ she told her mother.

“But I don’t want my kids to die,’’ Cochran said.

“We don’t want you to die!’’ Chelsey said.

“But you have a whole life ahead of you.’’

Is it that easy? Should Chelsey, Marissa and Devin get vaccine before, say, the elderly? Before their grandmother?

“I don’t know,’’ Cochran said. “It’s a hard decision. Yeah. I’d have to say the kids. It’s kind of selfish. But I have three kids.’’

That question has been a key point of contention for scientists as well.

“There was substantial discussion of priority for children,” Gellin said. “It’s not as if they were ignored … healthy children have been at low risk in prior pandemics.’’

Does age matter?

It’s the age question that has incited the most debate. In setting the guidelines, the federal group assumed that this pandemic would be similar to earlier ones in 1957 and 1968, and that the elderly would be among the most at-risk for severe illness and death.

But others question whether that’s true. In the worst flu pandemic, the 1918 Spanish flu that killed more than 40-million people around the globe, the most deaths occurred among healthy young adults.

What would really save the most lives?

“Government policies have been, the people most likely to get sick, the people most likely to be in danger,’’ Caplan said. “But you could argue that in real scarcity, it makes sense to take into account the best chance of surviving. Instead of the 85-year-old with pneumonia, you could say you’re going to treat the 30-year-old.’’

Caplan and colleagues recently put together a group, the Ethics of Vaccines Project, to discuss such questions.Protecting children makes medical sense, Poland said. Some studies show that vaccinating children for regular flu decreases the spread of flu in the whole community. Children gather together in school, swapping homework, hugs and germs at a rapid rate.

“Children tend to be super-spreaders,’’ Poland said. “So in reality, if I give it to a 2-year-old, I’m protecting the 2-year-old, the parents, the sibling, the grandparents. If I give it to an 80-year-old, I’m probably not going to protect the same number.’’That depends on the nature of the pandemic, Gellin said. Who gets vaccinated could change depending on who gets sickest.

“All this is shaped by how a pandemic looks,’’ he said. “You need to have a process that would allow that kind of flexibility — to have some understanding of how it’s playing out.’’

Also, studies that show vaccinating children provides a protective effect on the community reflect situations when enough vaccine was available to cover all the children, Gellin said. In a pandemic, that might not happen.

Underlying the medical questions are more philosophical choices. Whom do you want to save? How do you decide which lives have the most value? Dr. Ezekiel J. Emanuel, chair of the Department of Clinical Bioethics at the National Institutes of Health, recently upped the debate with a provocative essay in Science magazine.

Federal guidelines suggest saving the most lives, rather than giving people a chance to live more years or their natural lifespan, wrote Emanuel and a co-author, expressing their personal opinions, not federal policy.

The two propose giving younger people higher priority based on that idea, then combining it with what they call an “investment refinement.” They would give a higher priority to 13-year-olds than 2-year-olds, balancing the teenagers’ “more developed interests, hopes and plans” that have not yet come to fruition.

The federal guidelines follow the same philosophical principles as vaccination for a normal flu season, Emanuel said.

“It’s a completely different situation,’’ he said. “The potential for mortality is high. The potential for social chaos is completely different … the principles underlying pandemic flu (vaccination) need to be realigned too.’’
Some say protect children

Others also argue for protecting children as a philosophical choice.

“The thing that would make the most sense to me, is not to prevent deaths, but to preserve as many quality years of life as possible,’’ said Dr. John Sinnott, clinical director of the Signature Program in Allergy, Immunology and Infectious Disease at the University of South Florida College of Medicine.

How choices are made is an essential part of the equation, too, Caplan said. Although there have been some government-sponsored forums on the topic, Caplan said there hasn’t been nearly enough public debate.

“The person who’s more informed is more likely to comply,’’ he said. “Part of the reason to have a discussion of the rules is so people will follow them. It’s all the glue you’ve got.’’

Other hard decisions would have to be made as flu spread. Who would get flu medicine, such as Tamiflu? Ventilators? Beds in hospitals’ intensive care units?

Some of those decisions would be similar to those made with vaccine, doctors said. Health care workers, once again, would be high priorities for getting Tamiflu, an antiviral medicine that could reduce the severity of the flu. But other decisions might mean uncomfortable choices: giving beds to the extremely sick — but not the frailest of all.

“When you’re really overwhelmed, you start to ration by triage,’’ Caplan said. “Let go of the people so injured and sick that you don’t know if you can help them. Like on a military field … we do it a lot in war.’’

And that, doctors say, is what a true pandemic would be.
http://www.sptimes.com/2006/05/28/Worldandnation/Who_lives_Flu_crisis_.shtml

reassuring consumers from UPI

McDonald's advertises it's bird flu-free

May. 27, 2006 at 6:57AM

McDonald's Corp., of Oakbrook, Ill., plans an advertising campaign to inform customers its chicken is safe from bird flu, the Wall Street Journal said.
McDonald's has ads ready to launch should the deadly H5N1 strain of avian flu reach the United States or another country where the fast-food chain operates.
Humans cannot contract bird flu by eating chicken that has been cooked and prepared properly, the Wall Street Journal reported.
McDonalds -- which made its name in hamburgers -- is increasingly dependent on sales of meals made with chicken.

H5N1 cases rise in Indonesia

WHO confirms two more bird flu cases in Indonesia

JAKARTA (Reuters) - Two more Indonesians have been confirmed as infected with the H5N1 bird flu virus, a health official said on Monday, citing results from a World Health Organisation-recognised laboratory in Hong Kong.

Samples from an 18-year-old male, from Bandung in western Java island, tested negative earlier in Hong Kong but the latest result would classify him as a H5N1 case, said I Nyoman Kandun, director-general of communicable disease control.

A 15-year-old girl from Solok in western Sumatra, who is fighting for her life, also tested positive, he said.

Time to rewrite the rules of the pandemic

Sunday, May 28th, 2006
WHO to rewrite pandemic staging descriptions in wake of Indonesian cluster

n

(CP) - The World Health Organization plans to redraft the descriptions of its pandemic phases, a task triggered by the confusion provoked by the recent large cluster of human cases of H5N1 avian flu in Indonesia.

The acting head of the WHO's global influenza program says the rewrite will spell out more clearly how the agency thinks a novel influenza virus would behave during the different phases leading up to a pandemic.

The redraft should also help people understand why the WHO doesn't believe the Indonesian cluster - which killed seven of eight infected members of a family in at least three waves of illness - signifies a change in the level of pandemic risk.

"What we're hoping to do is clarify what are the differences between phases and make it more easily understood by everyone what we're actually looking for," Dr. Keiji Fukuda said in an interview with The Canadian Press.

"There's clearly so much confusion both about what is Phase X or what is Phase Y, how do we go from it, what is the role of the pandemic task force and what is the process for deciding whether there should be a phase change.

"And so I think that what we will try to do is address those issues specifically and get it posted on the web," said Fukuda, noting he hopes the work will be completed in the next week or two.

The worrisome Indonesian cluster - the largest to date and the first time person-to-person-to-person spread of the virus is believed to have taken place - has provoked calls from some quarters to change the global pandemic alert level to Phase 4 from the current Phase 3.

Before it could consider making that change, the WHO would have to convene a panel of experts - the task force Fukuda mentioned - to comb through the accumulated scientific data looking for evidence H5N1 viruses are becoming more transmissible to and among people and therefore pose a greater pandemic risk.

The task force would advise the WHO. But the final decision rests with the Geneva-based global health agency.

The current pandemic phasing document is a six-step ladder going from no known pandemic threat (Phase 1) to a full-blown pandemic (Phase 6). Many experts admit it's hard to see the difference between Phase 3 (no human-to-human spread or rare instances where a person has had close contact with an infected person), Phase 4 (small clusters of limited and localized person-to-person spread) and Phase 5 (larger but still localized clusters of human-to-human spread).

Fukuda agrees the descriptions of the phases are ambiguous, acknowledging that "it drives people crazy because we can't say precisely: 'Look for three of these or 10 of those or 13 minutes of this."'

The revised version will likely key in on the type of activity that allowed the virus to jump from one person to another - prolonged close contact with a sick individual or more fleeting or incidental exposure.

It's been known since the first H5N1 outbreak in 1997 that the former could trigger human-to-human spread. The latter, though, would be a signal of a significant shift in the virus's transmissibility - and would likely prompt serious consideration of a phase change.

"That's a little bit hard to describe for people. It's easier to say we're looking for 10 people or 15 people," Fukuda said. "But in truth, what we're really looking for is what's the kind of contact between the source of infection and the people who become infected."

Redrafting the language may pose challenges. After all, the emergence of a pandemic flu virus is an uncharted process, one which science has never had the capacity to watch.

"No one has a black-white answer because we've never done it before," said Lance Jennings, a virologist and epidemiologist at Christchurch Hospital in New Zealand who helped draft the current pandemic phasing document.

Exacerbating the situation is the fact that determining whether human-to-human spread has taken place is an inexact science. Most clusters to date have occurred in families, where cases almost invariably share experiences and exposures.

Unless the genetic blueprint of the virus takes on some signature changes, in many such cases it's almost impossible to say with certainty that the source of infection was another person, not an infected bird.

Still, infectious disease experts believe the scientific world will be able to tell when the pattern of transmission has sufficiently changed - though how quickly the change will be noted is anybody's guess.

"I think we'll know it when we see it," said Dr. Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy, reaching for the famous phrase coined to describe pornography - "I can't define it, but I can tell you when I see it."

But that phrase, often cited by experts attempting to describe the next phases in the pandemic alert scale, highlights how challenging it may be to put into words a clearer picture of what the stages of an emerging pandemic might look like.

A lot rides on the process. Pandemic planning by governments and multinational companies is geared to the level of the global pandemic alert. An upward shift in the level kicks pandemic preparedness activity into higher gear.

"There are major multi-national companies in this world that are prepared to evacuate expats out of certain areas of the world if the staging goes from 3 to 4," noted Osterholm, who cautioned major U.S. business leaders in New York last week against tying responses too closely to the WHO pandemic staging document.

"To try to distil down the current status of where we're at is like trying to give the world economy a one number grade," he said, but added the phases are useful "to help us organize our thinking."

Fukuda agreed that changing the alert level would likely have a domino effect on international trade, travel and economies.

"It would be perceived as countries as a signal that something significant had changed," he said. "I think it's quite likely that we would see an increase of action in all areas. Certainly an increase in concern. Certainly there would be a lot of media attention. Certainly countries would probably really look at their pandemic planning . . . and try to identify what gaps that t - hey might fill. It's highly conceivable that it would have a big effect on travel."

-

(CP) - The World Health Organization's current pandemic phase scale is divided into six stages. They are:

Phase 1 - No new influenza virus subtypes detected in humans. An influenza virus subtype that has caused human infection may be present in animals, but risk of human infection considered low.

Phase 2 - No new influenza virus subtypes detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.

Phase 3 - Human infection(s) with a new subtype occur, but no human-to-human spread, or at most rare instances of spread to a close contact.

Phase 4 - Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting the virus is not well adapted to humans.

Phase 5 - Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible.

Phase 6 - Pandemic: increased and sustained transmission in general population.

CDC UPDATE ON AVIAN FLU

Indonesia Situation Update - May 25

There is an ongoing WHO investigation into a family cluster of H5N1-infected persons in Indonesia. According to the latest information from WHO, 8 members of the family have contracted avian influenza, 7 have died and 1 has survived.

A WHO team, including one of our foremost CDC influenza experts, is on-site and collaborating with the Indonesian Ministry of Health on this investigation. At this time, limited human-to-human transmission has not been established definitively, but it is the leading hypothesis. If true, it would be consistent with findings for earlier clusters in Hong Kong and Thailand.

However, genetic analyses by WHO reference laboratories at CDC and the University of Hong Kong indicate no evidence to date of evolution in the virus that would enhance it's transmissibility between humans. There are no changes in the virus in Indonesia compared with other H5N1 viruses isolated recently.

There is no evidence of community spread beyond the family cluster and no infections in health care workers. We are, however, continuing to monitor the situation.

All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a severe phase of illness.

While this is a very sad situation for the family involved, and of concern to all of us, the evidence does not suggest that the virus has become more virulent or that a pandemic is imminent.

Tamiflu is being used as prophylaxis for people in the community who may have come in contact with family members, and the evidence suggests the virus remains susceptible to Tamiflu.

Human-to-human transmission can range along a continuum, from occasional, dead-end human-to-human transmission, to efficient (easily transmitted) and sustained human-to-human transmission.

It is important to distinguish the limited human-to-human transmission that may have occurred in this family from efficient (easily transmitted) and sustained human-to-human transmission that would represent a pandemic risk. Efficient and sustained transmission means that the virus is easily passed from person to person. It is a characteristic of annual influenza and pandemic influenza viruses, but is not something we have seen in the Indonesia or other clusters.

Rare instances of probable human-to-human transmission associated with H5N1 viruses have occurred in the past. In addition, previous family clusters of H5N1 infections have been reported in Indonesia and other countries. Specific instances of suspected transmission include:

• In 1997 in Hong Kong, there was evidence of limited transmission of H5N1 virus to health care workers and household contacts of patients. These contacts exhibited mild or no illness and did not transmit the disease to others.

• In 2004 in Thailand, there was evidence of probable human-to-human transmission in a family cluster. Transmission was associated with prolonged very close contact between an ill child and her mother. Transmission did not continue beyond one person.

• It is possible that other cases of human-to-human transmission have occurred in association with the H5N1 epizootic that emerged in Asia in 2003. There is no current evidence that transmission has continued beyond one person.

So far, the spread of H5N1 virus from person to person has been rare, inefficient (not easily transmitted), and unsustained.

It would not be surprising to see limited human-to-human transmission during the current H5N1 outbreak in Indonesia, as has been seen in the past.

These events remind us that we cannot be complacent in the face of this highly fatal virus and the threat it poses to the world community. They underscore the importance of continuing preparation.

LA TIMES OFFERS THIS OPINION ON BIRD FLU

What Darwin has to say about bird flu
Can the disease mutate into a widespread threat to humans? Possibly, but it won't happen overnight.

By Wendy Orent, WENDY ORENT is the author of "Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease."May 28, 2006

THERE'S A LOT OF bird flu virus out there. Despite encouraging news from Vietnam and Thailand, neither of which has reported any bird or human cases of the lethal H5N1 strain this year, the situation in Indonesia continues to worsen. Eight members of a family contracted the disease, and seven of them died this month. The timing suggests person-to-person transmission. Although not the first instance of such transmission, it's the single largest cluster that has been seen, according to virologist Earl Brown of the University of Ottawa. Indonesia appears to lack the resources to combat the disease.The virus is also active in Egypt and has spread to Israel, Jordan and the territories where Palestinians live. Africa has a wide belt of infection. With the disease spread over so much of the world, more people in contact with sick birds means more opportunities for humans to catch the virus. This appears how human influenza pandemics have begun — through human contact with sick birds.

But the factors that set off a pandemic remain unknown. No one has ever tracked the evolution of a new pandemic. All we have seen — in 1918, 1957 and 1968 — is the aftermath of that evolution. Still, we are told that all it would take for H5N1 to become a pandemic would be for the virus to mutate so it could spread in a sustained way from person to person. This is known as "mutation to transmissibility." This phrase has appeared countless times in news reports. It's a warning. It's also boilerplate. What does it really mean?Part of the problem is that "mutate to transmissibility" means different things to different people. To Peter Palese, chairman of the department of microbiology at Mount Sinai School of Medicine, who has studied influenza viruses for 35 years, the phrase makes sense. "These mutations [to make the disease transmissible from human to human] could happen in a chicken. It's not likely, but it cannot be excluded."Palese recognizes that many mutations would be necessary for a virus to switch from a chicken virus to a human one. But, he adds, the genetics of transmission are "one of the black boxes of human influenza research."The H5N1 virus faces several barriers in jumping to and transmitting among humans. The most important is its ability to replicate in and adapt to human tissues, specifically the upper respiratory tract (not in deep lung tissue, where it now seems to grow). In the windpipe, the virus would be more likely to spread in a cough or sneeze, infecting other humans.Palese thinks that bird flu mutations are sitting in the evolutionary driver's seat — that a combination of the right host switches in this most mutable of viruses could set things off. Still, that's a long way from a single mutational switch — say, from chicken to human — triggering a pandemic. But things may be more complicated.To Brown, H5N1 mutations are not enough. They have to occur in the right context. "It's hard to get infected with this [H5N1] virus," he said. "You need a large dose of it to ensure the presence of some mutant strains suitable for growing in mammals." According to Brown, several different mutations on different genes seem to be involved in a virus moving from one host to another. Bird flu strains he's passed through laboratory mice have changed in ways similar to what has been seen in certain cases of the human H5N1 virus, suggesting that the changes may be significant for the strain's adaptation to mammals. Some mutant strains have appeared repeatedly and independently in different humans infected with the bird flu virus. In one patient in Turkey, about half the H5N1 strains detected appeared to be viruses that had adapted to humans. But, as Brown points out, the changes were a dead end — the victim died without passing on the disease.Brown recognizes what seems to elude most people who worry about pandemic outbreaks: What's necessary to produce a human-adapted virus is humans — a series of person-to-person infections. Without that chain of transmission, any human adaptation of H5N1 is difficult to imagine. Here is where communication between those who fear an overnight pandemic and those who believe the process will be longer, slower and more controllable breaks down. If we think H5N1 mutations alone drive escalation to a human-adapted virus, all that's necessary for a pandemic is for the right combination of genes to line up in a sort of viral slot machine.IN A CASINO, the house usually wins, but occasionally someone hits the jackpot. It's the law of large numbers — given enough time and enough opportunity, viral mutation will toss up a deadly combination. No one wants to win the bird flu slot-machine game. If the genes happen to line up and a vulnerable human happens to be the host in the right place, the disease takes off and a pandemic explodes. Given how mutable the H5N1 virus is, the thinking goes, at some point this is inevitable.But as Brown knows, evolution doesn't work this way. Gene mutation isn't in the driver's seat. Rather, it's Darwin's charioteer — natural selection — that drives evolution. Mutations are the raw material of evolutionary change. They don't determine which direction the chariot will go.Any successful H5N1 mutation must interact with other viral genes in a human host to improve its ability to infect the host. This is an adaptive process — and it is true whether the new virus arises directly through mutation or even through recombination with a common flu strain. H5N1 is beautifully, tragically adapted to chickens and has proved a monstrous predator. It evolved this way by preying on chickens packed into huge commercial chicken farms in Asia.The bird flu virus is still at the starting gate when it comes to humans. But should any strain of H5N1 manage to survive many sequential transmissions, Darwin's charioteer may drive off. The best transmitters will be favored by selection, as evolutionary biologist Paul W. Ewald of the University of Louisville contends. The process will continue, human by human, until a fully human-adapted, explosive strain emerges.This process of adaptation is probably how pandemics begin. The World Health Organization recently proposed a plan to move experts and resources to any area afflicted with clusters of viral infection; a plan that, given this evolutionary logic, makes eminent sense. At the beginning, viral adaptation to a host is slow. A disease just beginning to transmit is controllable. Surveillance, flexibility, willingness to impose or undergo quarantines, along with international cooperation, will be necessary to stop pandemic flu — or any other disease moving from animals to humans — before Darwin's driver gets ahead of us and nothing can be done.

COMMENTARY FROM RECOMBINOMICS

Commentary H5N1 Bird Flu Onset Dates Confirm Human TransmissionRecombinomics CommentaryMay 25, 2006Fuelling the suspicion hanging over person-to-person transmission is the unusually long time lag of 15 days between the first and the last person in the cluster falling ill.The incubation period for the H5N1 is usually no more than seven days and if the family had been exposed to the same source, they would all have fallen ill at about the same time."You want to look at the dates of onset of the disease. If they are close together they may have had the same exposure," Thompson said.The above comments by WHO on the importance of disease onset dates in determining to source of H5N1 bird flu are also used to identify human-to-human transmission clusters. The onset dates are the most important data point because most H5N1 infections have an incubation time of 2-5 days as indicated in the New England Journal of Medicine review of H5N1 cases, authored by physicians who are WHO consultants. The 2-5 dates contradict recent comments to the New York Times that the incubation time for H5N1 was normally 7-10 days. The shorter time explains why most of the H5N1 clusters reported since 2004 have a 5-10 day gap between the index case and other family members. Half of the gap is due to the incubation time in the newly infected patients, and half is due to the time it takes for the index case to be optimally contagious.Because of the importance of disease onset dates, they are usually included in WHO updates. They were withheld from descriptions of the Turkey clusters involving the two largest families, who were cousins and also withheld in the Sumatra cluster. Although onset dates were given for the first and last victim, there were no dates for the other H5N1 confirmed cases. Recently, the number of suspected human-to-human clusters acknowledged by WHO has been rising. However, the vast majority of prior clusters have the 5-10 gap in disease onset dates, indicating most are due to human-to-human transmission, since bird to human infections are very rare and two independent infections from birds are unlikely. Authors from the WHO and the CDC wrote a report on the first 15 clusters, and most had the 5-10 day gap. The report was on cluster through there first cluster in Indonesia. Subsequent clusters have shown the same pattern, and clusters are common in Indonesia.However, WHO investigates these cases, focusing on non-human sources and if found assuming the non-human source infected all family members, instead of just the index case. Thus, the presence of infected birds in the area does not explain the time gap, which is most easily explained by human-to-human transmission..