The Avian Influenza: Dying to Kill

"The reality is...pandemics happen. When it comes to a pandemic, we are overdue and we are under-prepared," the Secretary of United States Department of Health and Human Services, Mike Leavitt, solemnly addresses to the press in Nashville on April 11, 2006. He later adds, "The H5N1 virus we are concerned about currently resembles the triggering virus in 1918." He is referring to the Spanish influenza pandemic that occurred right at the end of WWI and killed more than half a million people in the United States, as well as more than twenty million people worldwide.

Countless post-mortem exams reveal lungs full of fluid and blood. Scientists first foresaw that there may be cause for concern when wild birds in Hong Kong were documented to be dying of pneumonia back in 1997. Starting again in 2003, cases of tens of millions of diseased birds have been found for the past five years. These dead birds are being found in an increasing amount of territory, spreading throughout Asian countries, Eastern Europe and most recently, Africa. The numbers of dead geese and swans are continuing to rise. In some instances of severe disease outbreak, entire flocks of chicken are being wiped out in less than 48 hours. Currently, over 100 billion birds have been killed.

The ducks effortlessly flying above do not appear to be affected by any of the lethal avian disease that looms below. However, worried biologists and lab scientists know that these ducks represent their primary cause for concern. This is because they have discovered that both wild and domestic ducks are now acting as a silent reservoir for a highly pathogenic virus known as H5N1 Influenza type A, or more commonly known as the avian flu. This virus is the culprit behind the severe illness affecting all the birds. Infected birds are leaving behind highly contagious trails of the flu virus in their saliva, nasal secretions and feces. This H51 virus enters the ducks without causing any apparent symptoms and is then able to use the ducks as a natural passenger.

Veteran emergency responders in New York fume with frustration as they walk away from their pandemic planning meetings. Officials in London quietly search for extra morgue space. The emergence of this H5N1 influenza virus has not only caused severe distress within the avian family, but it has also led to disarray within scientific communities, the media, and groups of health officials. Debates within the public have already begun to arise concerning issues such as how expensive quarantines should be and which government agency should lead the response to a pandemic, which they have overheard from excited health officials, "will kill millions". The primary reason for this public alarm is that there is now scientific reason to believe that the H5N1 influenza virus type A has found a way to transfer from birds to humans. According to the World Health Organization, birds have carried various influenza viruses for centuries. The difference now is that there is now evidence that migratory birds can introduce the usual low pathogenic H5 and H7 viruses to poultry flocks. Once the virus resides within the poultry flocks, it is then able to mutate into a highly pathogenic form that can transfer to humans through direct contact.

Health officials have publicly stated that they do not believe there to be a high risk of people becoming infected with the avian flu in the United States and other developed countries. According to the officials, the people who are at risk for becoming infected are those who are in one of the ten countries where there are heavy outbreaks of the H5N1 virus in birds, or who are directly exposed to birds such as farmers or slaughters.

Despite the rare possibility of an avian flu outbreak occurring within a developed country, alarming statements by the media and government officials are continuing to be made. President Bush addressed world leaders in a speech, saying that "if left unchallenged, the virus could become the first pandemic of the 21st century." In 2005, Bush suggested the possibility of using the military to enforce quarantine.

Dr. Salme Taagepera, a biologist who teaches a class called Diseases in the 21^st Century at the University of California, Irvine, says that out of all the diseases that she has lectured about in class, the avian flu is the only disease that has kept her up at night worrying. Considering the possibility of an avian flu pandemic and quarantine here in the United States, she says that one thing we have learned from Katrina is that you do not put a bunch of people in stress together in one place. However, she does feel that quarantine would be more effective now than during the Spanish pandemic of 1918, because we currently have better all-around health conditions. Still, she believes that quarantining would also pose a new problem. Travel has increased since the time of post WWI, and thus, viruses and infections are more easily spread. She thinks that developing countries will be especially wiped out if a pandemic were to presently occur, because they have no choice but to go out to get food supplies and risk being exposed to the virus.

Karen Shore is an important member of the UCI Avian Flu Planning Pandemic Committee, specifically, in the UCI Department of Environmental Health and Safety. She explains that her role in the Committee is predominately administrative and vital to keeping the group meeting regularly and staying on task. She is a nurse practitioner as well as a public health nurse. She says that college students are at a much greater risk of becoming infected if an avian flu pandemic were to occur in the United States, due to the fact that students are in very close contact with each other, in the classroom, dorms and during group meals. As she ponders upon the matter, she adds that there is also the factor that younger people tend to believe that nothing will happen to them or that they are "invincible", so some students may not take the precautions that would be given to them during an outbreak. She also said that in the case of a pandemic, UCI would experience a 40% absenteeism rate, and precautions such as distributing vaccinations, teaching students to practice good respiratory hygiene, and social distancing would be implemented. She explains that social distancing includes two concepts. First, there would be a cancellation of public events such as sports, plays and classes, and secondly, students would be told to keep a minimum of three feet distance from one another. She says that a pandemic is not something that will hit us like an earthquake, but rather that we will know the alert is one the rise because it will be a hot topic in the media. However, she predicts that with a 50% mortality rate from the avian flu, there will be many student deaths before a vaccine becomes available.

Karen Shore explains that if the avian flu virus were to progress to World Health Organization phase of alert level 6, the Campus Emergency Operations Committee would be activated. Level 6 is the highest level of alert, known as "Pandemic alert", which means that new avian flu viruses are causing human cases of the flu to appear. Currently, UCI is on the WHO phase of alert level 2, which means that there is believed to be a higher risk of human cases. This is known as the "Inter-pandemic phase", meaning that new avian flu viruses have been found, however there are no human cases.

Linda Bogue works alongside Karen Shore in the UCI Environmental Health and Safety Department, and has been involved in emergency management for years. She explains that the UCI Pandemic Planning Committee practices "emergency management", which has been around for decades, however, the actual profession of emergency management is fairly new. She says that success in the field requires familiarity with 4 aspects, which are known as mitigation, preparedness, response and recovery. Two especially useful resources that the UCI Pandemic Planning Committee uses for planning are the Department of Homeland Security, which is at the federal level, and the Office of Emergency Services, which is at the State level. She says that colleges and universities are all pretty generous with sharing resources so that they are not all 'reinventing the wheel'. Linda Bogue believes that if a pandemic were to occur in the United States, there would be an increased anxiety among some of the general public. She states, "As with any emergency, people who prepared in advance will weather the outbreak better than those who don't take the time to get themselves educated and prepared." She continues to speculate on what may occur in the face of a pandemic, and says that hospitals are now including morgue activities along with their other planning activities.

The main thing currently preventing the avian flu from causing a pandemic is that the H5N1 influenza virus type A does not spread easily to people. It is very rare for a person to catch the virus from a bird, and there have only been one or two instances where a person infected with the avian flu may have spread the virus to another person.

On June 28^th, 2005, an eight-year-old girl died in the Banten province of Indonesia, after becoming severely ill. She started out with a fever, diarrhea and cough. However, her symptoms progressed so rapidly that four days later, she died of respiratory distress. Her 38-year-old father died just a month earlier, along with her one-year-old sister, who also died of severe pneumonia illness. This case was reported to the World Health Organization in 2005. The father was documented to be the first laboratory-confirmed human case of avian influenza. Based on reports such as this, respiratory complications are a common, and deadly, component in human cases of the avian flu. Health experts have stated that a human case of avian influenza starts out like any other flu would; however, after a few days, people start to have trouble breathing. It is therefore possible that a person would not know for sure that he has contracted the avian flu until he had become life-threateningly ill.

According to leading health experts, one of the few medicines believed to be effective to provide relief from the avian flu is known as Tamiflu. The label attached to Tamiflu states that it is "for the treatment of uncomplicated acute illness due to flu in patients 1 year and older who have shown symptoms for no more than two days." This drug is made by the Roche pharmaceutical company in Switzerland. There is a huge demand for it and a critical shortage because scientists have only recently realized the potential of the drug. The current stockpile for the drug is 2.5 million, yet, according to officials, the ideal stockpile is 20 million. It is not likely that UCI would have a supply of Tamiflu on campus if a pandemic were to occur, however, as Karen Shore mentioned, vaccines would be available. These vaccines are also being stored in Orange County for the general public in case of a pandemic.

However, there may be a real danger associated with Tamiflu. In Japan, a young teenager jumps over the fence of her backyard and runs wildly into the street, where she is killed by smashing into a moving car. This incident was one of the two apparent suicides of teens in Tokyo, according to an excerpt from Japan Today. In Japan, the label attached to the Tamiflu container warns against possible side effects, which include, "impaired consciousness, abnormal behaviors, hallucinations and other psychological symptoms." Until just recently, these side effects were not made commonly known to the public in the United States. Finally, after receiving 103 reports of "injury and delirium" among the millions of flu patients taking Tamiflu, the majority being from children in Japan, the Food and Drug Administration decided to change the Tamiflu label in the United States. Just this last Monday, November 13^th, 2006, the Food and Drug Administration announced that they have updated the Tamiflu label with a warning that "close monitoring begin immediately after starting treatment with the drug". The issue that complicates the situation is that both Roche and the Food and Drug Administration have stated the possibility that the abnormal behavior being reported could actually just be a symptom associated with severe influenza. Therefore, there is no definite way to know whether the abnormal behavior seen in the flu patients is a result of taking Tamiflu, or if is simply derived from the flu itself. According to documents released this last Monday, the Food and Drug Administration staff announced that stopping treatment of Tamiflu could be very harmful if it turns out that the medicine is not the cause of the abnormal behavior. Furthermore, if Tamiflu proves to be necessary for the treatment of the avian flu, UCI, as well as the entire United States has cause for concern- considering that it is no where near the top of the waiting-list for the medicine.

The current report given by the World Health Organization shows that between the years of 2003-2006, there have been 256 total laboratory-confirmed human cases of avian influenza in the world, and 152 resulting deaths to date. This H5N1 influenza virus is considered to be the most lethal flu in history, in that, of those infected, there is a 55% mortality rate. The largest increase of human contracted avian influenza occurred between the years 2003 and 2004, during which 42 additional cases were documented. The outbreak of the H5N1 virus has thus far occurred in 10 countries, including Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Thailand, Turkey and Vietnam. The most human cases have been seen in Vietnam, with a total of 93, and the majority of avian flu inflicted deaths have occurred in Indonesia, with 55. Officials from the World Health Organization believe that the risk of a pandemic is more serious now that the virus has entered large parts of Asia, and they expect that there will be a further spread of this highly pathogenic form of the H5N1 influenza virus to new areas.

Health officials estimate that if an avian flu pandemic were to occur, the situation would be much worse than Hurricane Katrina's impact on New Orleans. Dr. Salme Taagepera cannot imagine anything but people in the United States being selfish and taking care of themselves during a pandemic, which she fears may not be for the total good. Experts predict that during the early stages of the outbreak, there would be very little effective therapy for those infected. It is imagined that there would be no place for the dead and that caskets would be used up within days. It is also predicted that at least 200,000 Americans would die from the avian flu within a few months. The enormity of this death rate is equivalent to the amount of deaths that occurred during the September 11th tragedy multiplied by 666. The amount of deaths that have resulted from smallpox, AIDS and anthrax would be nothing in comparison the amount expected to occur in an avian pandemic.

However, as Dr. Salme Taagepera puts it- from a strictly human standpoint, worrying about the possibility of an avian flu pandemic is not something that an individual can afford to do on a day to day basis. Marie Curie once said, "Nothing in life is to be feared. It is only to be understood." Perhaps fear is our true pandemic.