I attended a conference for emergency response & health planners on the avian influenza pandemic several days ago. The presenters were all top-flight, well-recognized, well-credentialed state and local public health, medical and emergency services experts. In addition to the flu itself (at no extra charge!) (a-choo! – please pass the NyQuil), I picked up the following notes:

-----

pandemos – of all the people

50-100 million died in the 1918 pandemic (called the “Spanish Flu” because Spain was a neutral country during World War I and thus had the only uncensored news, and was responsible for the early reports of the outbreak).

influenza -- medieval Italian for “influence of the stars”

The world suffers from “cultural amnesia” (Mike Davis, 2005) about the 1918 pandemic because there are few alive today who were alive then. This is also relevant in terms of immunity.

In addition to death and disability, pandemic flu shortens life spans among survivors by as much as 10 years.

The H5N1 virus will impact young and middle-aged healthy individuals far more
than normal seasonal flu due to the severity of the inflammation or cytokine storm it induces in healthy lungs.

Because of this abnormal and obverse peak of mortality across the demographic curve, the pandemic threatens social paralysis and disruption, will have a severe impact on familial and daily care (esp. for toddlers and the elderly), have a severe impact on the functionality of industry, government, health care et al, and will generate significant issues surrounding burial practices, social gatherings, and more.

The Top Ten Things You Need to Know…

1) Avian flu is not necessarily pandemic flu. The development of a pandemic is dependent on the degree of pathogenicity in the virus.
2) We are globally interdependent.
3) Flu pandemics are recurring events; we are on the brink of one now.
4) When a pandemic arrives, there will be widespread illness and death,
5) Current medical supplies are inadequate or insufficient.
6) Economic and social disruption will occur.
7) We need to build “surge capacity” into our health care systems.
8) Education is critical and will generate trust and confidence in government, planners, medical care providers, etc. Such trust and confidence will emerge and sustain itself only if there is “transparency in communications”.
9) All planning must be local.
10) A rejuvenation of the public health system is required.

The H5N1 virus is highly pathogenic and has the potential to create a pandemic if:
· A new sub-type will emerge (this has occurred);
· It will infect humans (133 documented human deaths thus far as of 12/5/05);
· It spreads easily and sustainably (this has not yet been confirmed) as a result of viral reassortment, adaptiveness and mutation.

The current situation is the most severe poultry outbreak on record, already resulting in the deaths of 150 million birds (directly or through preventive culling) in five Asian countries. Vietnam is the epicenter, where probable human-to-human transmission has been reported.

The 1918 pandemic killed approximately 25-30% of the population.
Mortality occurs in about 25-55% of those infected.

[Take a moment to mentally walk through your locale or community and see one out of every four individuals falling sick with 48 hours of onset, and one-quarter to one-half of those dying over the course of a week. In a city of 100,000 people, 25,000 will likely not report to work, and 6-12,000 will die.]

The World Health Organization is conservatively estimating that 2.0-7.5 million will die worldwide. In the US, the worst-case scenario is that 1.9 million will die, and that 8.5 million will require hospitalization.

There will be high rates of absenteeism, and the disruption of essential services.

Businesses are urged to undertake immediate continuity of operations planning.
There is a need to build strong social capital.

Planning must proceed on the basis of “space, staffing and supplies”.

Every home should develop an emergency plan.

Education about cough etiquette, the necessity for respiratory and hand hygiene, and the use of “increased social distance” must be undertaken.

Infection occurs before symptoms present themselves.
Infected individuals remain contagious for 2-7 days (longer in children!).

There is scientific unanimity about the fact that we are overdue for such a pandemic.

The disease will spread rapidly and affect an entire nation pretty much at the same time. Thus the ability to call on outlying regions for support, supplies, manpower, etc. will not exist. We live in a Just-in-Time distribution economy, and this distribution chain will be affected by absenteeism etc.

Urban crowding drives up the attack rate of the disease.
Low socio-economic status also drives up the attack rate of the disease.

The SARS virus, a relative slow-mover, moved from Honk Kong to Vancouver in one month.

Preparedness

1) Get the right people involved.
2) Define how coordination among entities will occur.
3) Move beyond “planning to plan”.
4) Define who is in charge.
5) Review legal authority as pertinent.
6) Think through whether the plan addresses the entire population.
7) Consider special ways to deal with the isolated, chronically ill-at-home,mass child care needs, and more.

There are a large number of unknowns with regard to this disease:
· Epidemiology;
· Demographics;
· Severity;
· Absenteeism rates across demographics;
· The effectiveness of vaccines and anti-virals;
· The production/supply/distribution of vaccines and anti-virals;
· The possible effect of the use of adjuvant extenders in vaccines.

Prioritization for the Use of Vaccines and Anti-Virals
(current draft working plan in the US):

1A Manufacturers and Distributors of Vaccines and Anti-Virals
1B Highest Risk 16 million (age 65+ with chronic disease, < age 65 with two or more chronic diseases)
1C Pregnant Women and their Household Contacts;
1D Public Health Emergency Responders; Key Government Officials
2A High Risk 58 Million
2B Personnel from Public Safety and Critical Infrastructure
3 Other Key Decision-Makers; Funeral Officers
4 Healthy Children and Adults

This is a critical and difficult social triage question, given the unknowns, given the debatable effectivnesss of vaccines and anti-virals, given the expected high fatal impact on young health adults due to cytokine storms, and given the lack of supplies and resources to handle intensive health care needs (esp. acute respiratory issues). Many “first responders” and health care personnel feel that they and their families must be far higher on the prioritization list.

If the pandemic is of a moderate to severe nature, our response to it will be “qualitatively different”.

The challenges:
· The magnitude;
· The severity;
· Staff shortages;
· Limited ability to call in extra-regional resources;
· Other services will be disrupted.

The disease characteristics:
· a short incubation period (1-4 days, 2 on average),
· abrupt onset, with peak infection curve arriving early, and
· the clinical illness from flu infection is non-specific.

There is a great deal of attention and energy being focused on the ability of the world to contain or slow down the spread of the pandemic at its source.

Planning must and will consider:

· School closures (to prevent spread and incubation);
· The cancellation of all large gatherings;
· “Snow Days” (or asking businesses to allow workers to stay home from work)
(though this has serious implications re: timing, loss of service/income,
the effect on the business and the economy, etc.)
· Deferring travel to involved areas;
· The widespread use of masks (? Effectiveness, ? supply);
· Communications (the development of phased messaging to the public);
· Risk Communication to the public.
· The best role for those who have survived the illness (the “deployment of the immune”).

What and where is the triggering point or mechanism that will swing planning into action?

A Massachusetts public health expert looked at the newspapers in Boston from the 1918 pandemic, factored in the population data from today, and said that “The Boston Globe will run 12-14 pages of death notices for weeks”. In 1918, on one day in Philadelphia, over 700 people died.

If we ask major segments of the population to stay home for days on end, Who will provide the services? Who will provide day care to the children if they are not in school and Mommy is sick or dying?

· There will be very little warning.
· There will be simultaneous outbreaks.
· There will be a shortage of supplies of all types.
· Facilities will be overwhelmed.
· Health care workers et al will be at highest risk.
· There will be widespread illness and a shortage of workers.
· There may be more than one wave of infection.
· All planning and response will have to be local. (You’re on your own.)
· Critical attention must be paid to the legal, public health and scoio-psychological aspects of the collection, identification and disposal of bodies.


Planning should seek to improve health care systems and public health “surveillance” through monitoring of data, etc. Clinicians at all locations and levels will be “sentinels”. Syndromic surveillance should be improved and extended.

“Exercises and simulations are a very good way to elicit critical ideas and suggestions.”

More specifically, business continuity planning must address:

· Forecasting of employee absences;
· The dissemination of information to employees;
· The establishment of policies for employees who
Have been exposed;
Are expected to become ill;
Become ill at the worksite.
· The impact of the pandemic on the business;
· The impact on employees and customers;
· The allocation of resources to protect employees and customers;
· Communication and education for employees;
· Connection with external organizations and communities.

“Destiny should not be confused with poor planning.”

Fellow CGCS member Gabrielle must be acknowledged as the genesis of this report. Either she or I may add more information in the near future.

---
“As concern mounts over the potential spread of avian flu to humans, researchers believe they've discovered one reason why the infection can prove so deadly. Experiments with human cells have found the H5N1 virus can trigger levels of inflammatory proteins called cytokines and chemokines that are more than 10 times higher than those that occur during a bout of the common flu. This massive increase in cytokine and chemokine activity can inflame airways, making it hard to breathe. It also contributes to the unusual severity of the avian flu, which can result in life-threatening pneumonia and acute respiratory distress.” [Medicine.Net “Health Day”]

“The study, published in the online journal Respiratory Research, might suggest that if H5N1 does cause a pandemic, it could disproportionately affect the young and healthy as compared with seasonal flu, which kills many elderly but few young adults.” [MS-NBC ]

“A recent laboratory study has produced more evidence that infection of human lung cells with the H5N1 avian influenza virus leads to intense inflammation similar to what was seen in victims of the 1918 Spanish flu pandemic….The H5N1 viruses were "more potent inducers" of cytokines and chemokines—chemical messengers that trigger inflammation—than H1N1 viruses were, says the report by a team led by J.S.M. Peiris of the University of Hong Kong. A flood of inflammation-triggering chemicals released by the immune systems has been referred to as a "cytokine storm." Autopsies of H5N1 avian flu victims in Vietnam and elsewhere have revealed lungs choked with debris from the excessive inflammation triggered by the virus. Similar severe lung damage was frequently reported in victims of the 1918 pandemic, which disproportionately killed people with the strongest immune systems—young, healthy adults”. [CIDRAP News]

"This study confirms earlier work that H5N1 induces a cytokine 'storm,'" said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota School of Public Health, in Minneapolis. "It helps us understand the pathophysiology of the disease."

The noted increase in cytokine production is what distinguishes avian flu from other flu, Osterholm said. "The hyperproduction of cytokines is very relevant. It points out that the way people actually experience severe illness with this virus is different than what we see with other influenza viruses."

"This is basically a cytokine storm induced by this specific virus, which then leads to respiratory distress syndrome," Osterholm said. "This also makes sense of why you tend to see a preponderance of severe illness in those who tend to be the healthiest, because the ability to increase the production of cytokines is actually higher in those who are not immune-compromised. It's more likely in those who are otherwise healthy." [Medicine.net]


Sources:

General News

http://www.cidrap.umn.edu/cidrap/content/i...05cytokine.html

http://www.medicalnewstoday.com/medicalnews.php?newsid=34202

http://www.medicinenet.com/script/main/art...rticlekey=55295

http://www.medicalnewstoday.com/medicalnews.php?newsid=34202 [See this link for information and further links to GenoMed.]

http://msnbc.msn.com/id/9994455/

http://abcnews.go.com/Health/Healthology/story?id=1305156

http://www.michnews.com/artman/publish/article_10676.shtml


Related Medical Studies:

http://www.biomedcentral.com/1471-2180/4/28

http://www.blackwell-synergy.com/doi/full/...5.x?cookieSet=1

Thanks for sharing the info.

So did they say whether or not masks helped at all?



Is there any OTC medicine that we can take that might help the inflamation or at least make us feel a little better? What supplies did they suggest people have on hand for their emergency kit?



What kind of an emergency plan? Does this refer to what you will do if you can't go to work...who will help you, how you will pay bills, etc?

Are there any OTC medications that we might try other than:



Do we have any docs on this website? Would something like this have anything to do with easing symptoms?


CYTOKINE MODULATORS AS NOVEL THERAPIES FOR ASTHMA

Peter J. Barnes­
Department of Thoracic Medicine, National Heart and Lung Institute, Imperial College, London SW3 6LY, United Kingdom; e-mail: p.j.barnes@ic.ac.uk


Cytokines play a critical role in orchestrating and perpetuating inflammation in asthmatic airways and several specific cytokine and chemokine inhibitors are now in development for the treatment of asthma. Inhibition of IL-4 with soluble IL-4 receptors has shown promising early results in asthma. Anti-IL-5 antibody is very effective at inhibiting peripheral blood and airway eosinophils but does not appear to be effective in symptomatic asthma. Inhibitory cytokines, such as IL-10, interferons, and IL-12 are less promising because systemic delivery produces intolerable side effects. Inhibition of TNF-α may be useful in severe asthma. Many chemokines are involved in the inflammatory response of asthma, and small-molecule inhibitors of chemokine receptors are in development. CCR3 antagonists are now in clinical development for the treatment of asthma. Because so many cytokines are involved in asthma, drugs that inhibit the synthesis of multiple cytokines may prove to be more useful. Several such classes of drug are now in clinical development, and the risk of side effects with these nonspecific inhibitors may be reduced by the inhaled route of delivery.

Acronyms
Terms
http://arjournals.annualreviews.org/doi/ab...alCode=pharmtox

Oh boy, this doesn't sound good -- neither does this.

htm

Ok, I've frightened myself enough for tonight.

Ok, I'll end this on a positive note. This was from 2003 so maybe they have done the clinical trials? Maybe, just maybe, this will be available before the pandemic hits and it will work.

Cure for flu found?
BUPA investigative news - 28 October 2003
written by Rachel Newcombe, reporter for BUPA's Health Information Team

As the colder weather descends, the annual UK flu season begins. For many people it is an unpleasant, but ultimately harmless illness, while for others can lead to serious conditions, such as bronchitis or pneumonia. And, for 3,000 to 4,0000 people in the UK each year, it causes their death - usually amongst the elderly. British researchers have been investigating the most deadly form of flu- strain A - and have come up with a potential treatment that minimises the worst symptoms of the disease. So, how far have they got with their research?

What were the headlines?
Details of the flu research appeared in a range of UK newspapers and websites, gaining headlines such as, "Cure for killer flu 'discovered'", "Scientists develop novel flu strategy", "New flu drug calms the 'storm'", "Scientists hope to end flu misery within five years" and "Brits cure 'flu!".

Some reports were detailed and informative, whereas others provided a brief overview and appeared to imply that a definite cure is ready and waiting to be given to humans, which isn't quite the case just yet.

What is the bigger picture?
The study was carried out by researchers from Imperial College London and published in the Journal of Experimental Medicine.

They investigated the influenza A virus - the type responsible for pandemics such as the 1919 Spanish flu outbreak which killed more than 20 million people worldwide - and developed a way of eliminating symptoms in mice by reducing the response of active T white blood cells by one third. Some experts believe that it is the body's response and not the virus that causes the damage. By reducing the body's response, it is hoped that the harmful effects of flu will be reduced too.

The body's immune system consists of two major types of white blood cells: T and B cells. B cells produce tailor-made antibodies that help the body remember and quickly respond to invaders, and T cells are responsible for patrolling the body, seeking out and destroying diseased cells.

When the lungs are infected with the flu virus, the T cells release chemical signals that cause them to stay longer in the lungs. However, more T cells are always arriving, and they in turn release more signal and stay longer in the cells, leading to a build up of T cells and chemical signals. This is called a "cytokine storm" and it is thought that this causes damage to the lungs.

Senior author of the paper, Dr. Tracy Hussell, from Imperial's Centre for Molecular Microbiology and Infection, said, "During flu infection the immune system has an 'all hands on deck' attitude to the viral assault. But it's this that causes most of the damage. The exaggerated immune response produces inflammatory molecules that lead to what's known as a 'cytokine storm'. Essentially too many cells clog up the airways and prevent efficient transfer of oxygen into the bloodstream."

Ways to stop the cytokine storm have focused on blocking all T cells, but this stops the patient's immune system from clearing the virus and leaves the body open to other infections. The goal is to prevent the storm forming without stopping the T cells attacking the flu virus. To acheive this, the researchers developed a way of down-regulating one of the T cells signalling chemicals (called OX40).

"OX40 sends out a survival signal instructing activated T cells to remain in the lungs for longer to help fight the infection," explained lead researcher, Dr. Ian Humphreys. "Inhibiting this signal therefore allows T cells to vacate the lungs earlier whilst leaving behind a sufficient immune presence."

The researchers blocked the action of OX40 by using a fusion protein (OX40:Ig) supplied by the pharmaceutical company Xenova Research. It was found that six days after infection with flu, mice treated with OX40:Ig were indistinguishable from uninfected control mice. In contrast, infected mice that had not been treated lost 25 per cent of their body weight, lost their appetite and looked withdrawn and hunched - aspects the researchers say are characteristic of flu symptoms. Even when treatment was delayed for several days after infection, when the mice had lost 20 per cent of their body weight, treatment with OX40:Ig reversed the symptoms.

In theory, this treament could be given after symptoms are known to present, unlike yearly vaccinations that rely on predicting how the virus might mutate, or antiviral drugs that have to be given as soon as contact is made with the virus.

Dr. Hussell also believes that the treatment could have "tremendous scope" for aiding other diseases "characterised by excessive T cell inflammatory response," such as bronchitis, asthma, pneumonia, SARS or rheumatoid arthritis.

The next stage is a clinical trial, which may be started next year, involving the use of OX40:Ig in nasal spray or inhaler form. If this proves successful, it may be developed as a treatment.

What does this mean?
Dr. Alan James Hay, a flu expert from the National Institute for Medical Research, was interested in the findings. "Flu is a serious disease," he told BUPA. "It may be that in the last year or two we've had very mild winters in terms of the attack rate of flu, but one doesn't have to go too far back [for another picture]. The last major epidemic was probably in 1989 when we had in excess of 20,000 deaths due to flu, and there are several thousand deaths each year in the UK."

"The experiments that have been done at Imperial College relate to the fact that a lot of the symptoms you have following flu infection are due to the immune response, the inflammatory response, to the infection. We know from other studies that the severity of the disease in animals and in humans is related to that immune response," he explained.

"As far as I understand it, what these people have done is to use the protein to reduce the immune response to an experimental infection in mice to a level such as they can reduce the symptomology - the pathogenic consequences of the infection - but have not eliminated the beneficial effects of the immune response in removing the virus following the infection," he continued. "This is where it seems optimistic that some therapeutic way of reducing the symptoms without reducing the ability of the immune system to combat and get rid of the virus infection could be developed."

However, he added that, "It's important to remember that this has been done in mice, not humans. The principle is quite attractive, but it's important to stress that this does not prevent virus infection, but rather simply treats the symptoms. What we really want is something that can prevent you from being infected by the virus in the first place."

What does this mean to me?
With no cure available at the moment, vaccination for those most vulnerable to flu infection is the best choice. For those aged 65 and over, plus younger people considered at high risk, yearly flu vaccinations are free through the NHS and are recommended.

Dr. John Watson, from the Health Protection Agency, said, "For most people flu is an unpleasant rather than dangerous illness. However, for the at-risk groups, such as the elderly and patients with heart problems, diabetes or asthma, it can be much more dangerous. This is why it is important for those in the at-risk groups who are recommended for vaccination take up the opportunity."

He added that, "In recent years the strains in the flu vaccine have been a good match with those circulating and the vaccine has therefore offered good protection."

If you do end up succumbing to flu, the symptoms - a high temperature, headache, muscle aches and pain, weakness and loss of appetite - normally begin after an incubation period of one to four days and last for an average of one week. The virus is spread through coughing, sneezing and skin contact, so if you do have flu, it's important to regularly wash your hands and cover your nose and mouth when coughing or sneezing.

Existing treatments include painkillers, such as paracetamol, to relieve muscular aches and pains and fever, fluids to prevent dehydration, and steam inhalation to aid stuffy blocked noses. In certain circumstances, two antiviral drugs, zanamir and oseltamivir, may be prescribed to at-risk children and adults who have had flu-like symptoms for less than 48 hours. Antibiotics are only prescribed when a secondary bacterial infection, such as pneumonia, is present.

Summary
Although common and generally not dangerous, flu can be nasty and cause disruptive symptoms. This research finding offers an interesting new approach to the illness, but more research and clinical trials are needed before the drug can be fully developed for use by humans.

http://www.bupa.co.uk/health_information/h.../281003flu.html

What I am most interested to know is---

the flu is a virus, the avian flu the same.

HOWEVER-pnemonia can be treated with anti-biotics, and many people especially the elderly have bacterial pnemonia shots.

Has anyone said whether pnemonia shots or anti-biotics for the sever pnemonia will help lessen the chance of death?

It appears this pnemonia is what kills you in the flu, and people in the far-east do not have access to quickly having pnemonia. By the time they are seen it might be too late.

Anybody know?

It would be nice if this could be permanently pinned

Thanks, folks, for adding to this thread...

The British study noted above is the one that Gabrielle found about two weeks ago and which jump-started her thinking and further inquiry about cytokine storms. (She is a physician.) I asked the associate director of the Harvard School of Public Health about this issue and he did not offer any thoughts or news, but the studies cited in the news were breaking as he spoke. I think I will be invited to be a part of the planning process for a major city near where I live which has a large Southeast Asian population and I shalll endeavor to keep you posted.

There are two thoughts I'll add at the moment: One is the expression of the former director of public health in Massachusetts who said "Everyone is a public health practitioner." The other is a re-iteration of the theme of the conference: "All planning must be local." So start in the home and move out. Contact your employer, your city public health department, and stay tuned.

Home emergency planning will be detailed in good time. I think there are several issues you can and should begin to think about immediately. First, are there kids and/or elderly and/or ill people in your household? Second, the employed individuals in your household will have to consider what the issues are around their not being able to go to work for 4-10 days. Third, there is likely to be a break-down in materials and supplies distribution to some extent, so it makes sense to stockpile critical items (foods, medicines, etc.). When the virus comes to your area, you will not be wanting to go out for days... Fourth, if you have existent respiratory or other chronic disease in one or more individuals, it makes sense to have a good chat with your doctor. Fifth, it makes sense to get to know your neighbors and their situation (kids, elderly, shut-ins, etc.) and it makes sense to have a meeting of some sort after you've checked in with public health officials. Build that social capital. Sixth, start practicing cough etiquette, good hand hygiene, and increasing social distance. Seventh, raise the question with any schools that any of you attend. Child care for toddlers whose parent(s) are ill, or child care for toddlers who themselves are ill, may be a critical issue requiring some creative thinking and some neighborhood planning.

The H5N1 virus is highly pathogenic, unlike any normal flu virus, and as noted in the studies above, will cause excessive inflammation of lung and respiratory channel tissue, exacerbating pneumonia and other respiratory problems. It is the cytokine storm that will kill because the body cannot clear or block the inflammation and its debris. This is why Gabrielle has indicated the possibility of a cytokine blocker which might be developed.

More to follow...

Big question-

How in the world will anyone know when NOT to let anyone out of the house?
For all the good of everything is, when you have a family and a routine,
the only theortical way to beat this would be to lock yourself up from the outside world until a vaccine is readily available, and until you could get that vaccine, without coming into contact with someone infected, who would pass it to you before the vaccine will work (doesn't it take 2 weeks for a vaccine to work?)

So, a vaccine will not be available for some 6 months at least ...

BUT WHEN IS THE FIRST DAY YOU STAY HOME?
By the time anyone knows it is there, it is already too late to hide

That's funny that we would both find the same study.

Thanks for all of the info and thanks for agreeing to keep us updated. I have been tracking this flu for quite some time and I am very concerned about it. I'm not too confident about us having any vaccines for this flu but if there are any medications that might help alleviate the symptoms I would really like to make sure that I have those at hand. I was curious if getting the regular flu shot would in any way help alleviate some of the symptoms of the avian flu? I know the regular flu is not the same but I thought there might be some ingrediant in the regular flu vaccine that might help with the avian flu symptoms as well.

Who knows maybe if we have another infection at the same time that we get the avian flu we won't have the cytokine storm because our immune system's attention will be divided between the two different infections.

When is the first day you stay at home?

This is the issue the planners presented as: "What and where is the triggering point or mechanism that will swing planning into action?"

This entire set of problems is very difficult for planners. (Infection occurs before symptoms present themselves.)

Planners will have to engage in some very deep and detailed thinking. Models and simulations will play a role. Late-breaking scientific research will play a role. There is some concern and debate as to whether existing vaccines and anti-viral agents will offer any value. There are ongoing clinical trials to see if different routes of delivery (ex: injection vs. trans-dermal) will allow more efficient use of limited supply. There is research on the possible use of adjuvants to extend the vaccine supply.

The simplest answer to all your questions is to tap into your local public health department and other sources for news and information, and to pay attention to "the man in the white lab coat". In other words, in public pronouncements, it is wisest to find and trust a credible spokesperson who is coming from a medical, public health and science-based background. At the moment, I know of finer resource that the CIDRAP program run by Michael Osterholm. The web site is noted above. The WHO and the CDC remain key international and national government agencies spear-heading this issue.

Serious local and state planning will kick into a much higher gear soon. Check for state government health department web sites, plans, public pronouncements, etc.

As always, if you have any underlying health issues, the advice of your own physician is suggested.

From the US CDC Clinician Outreach Program:


Pandemic Influenza

Information for Health Professionals:

A compilation of resources and information provided to clinicians for their use in discussing pandemic influenza with patients and providing care in case of spread of this agent to the United States.

http://www.cdc.gov/flu/pandemic/healthprofessional.htm


Business Pandemic Influenza Planning Checklist

http://www.cdc.gov/flu/pandemic/pdf/businessChecklist.pdf


State and Local Pandemic Influenza Planning Checklist

http://www.cdc.gov/flu/pandemic/pdf/PandemicFluChecklist.pdf

Anything new officially or unofficially?

G4A, nothing new from here... but stay tuned.

I've recently finished writing a 66-page white paper entitled "Coalescing Effective Community Disaster Response: Simulations and Virtual Communities of Practice".

If you are interested in reading it, drop me an e-mail at Magmak1@AOL.com.

What follows is the abstract and the first four paragraphs:

Coalescing Effective Community Disaster Response: Simulation and Virtual Communities of Practice

Abstract

This paper discusses the inclusive blend of simulations, models and games and other digital and/or online technologies with local/regional “virtual communities” and communities of practice as a potentially powerful and effective approach to comprehensive community emergency preparedness. It broadly scans a range of important theories, publications, software tools, commercial products and prototypes.

In a scanning overview, it looks at people, organizations, disaster event characteristics and some pitfalls in disaster response, multi-organization networks and learning within and among them, communication and information issues, simulations and games, spread-sheet modeling, “virtual reality” and synthetic environments, table-top exercises and drills, de-briefing issues, virtual communities, online learning, virtual conferences, concept mapping, state-of-the-art ‘socio-technical systems’ for emergency management, intellectual capital, social capital, social translucency, and ‘cascade thinking’ (or forecasting 2nd- and 3rd-generation consequences) as they apply to emergency management and disaster preparedness.

The first four paragraphs:

"Our mindset with regard to disaster is book-ended by two phenomena: the Katrina experience in New Orleans, and the projection of pandemic flu.

John Harrald, co-director of the Institute for Crisis, Disaster, and Risk Management at George Washington University, spoke of the Katrina response: "… we are seeing a failure of imagination."

According to the World Health Organization, “Countries around the world need to start rehearsing plans for tackling a flu pandemic to identify hidden obstacles and ensure the best response once the virus arrives”.

How does a multi-organization network rehearse plans effectively?"

Well...I guess moving further toward being reclusive...
working three days a week in an office with one other
and being able to communicate with the telephone,
email and fax may help...as well as living in a
less than population intensive neighborhood.
Having retirement payments that cover the basic
expenses whether I can work or not is also helpful.

I guess I could move to a snow-bound location,
rather than a heavily humidified climate. But,
oh well, no use in going nuts over it at 56.

Sounds like we're in for some death...but typing
while Forrest Gump plays on TBS in the background
reminds me how God has blessed this idiot time and
time again. If my clock runs out...well it could have
been much earlier...if a bullet went a few inches to the left...
or if I'd been a little further up front in the column
when the booby-trap went off. I'm a simpleton,
without the knowledge to get very fearful.

I greatly respect ya Mag for moving to the front on this.
People are gonna need ya there. Heros take so many
different forms. But, they are always needed by The People.

Whether war, poverty and starvation, or pandemic...we need
heros to respond. Step up and step out my brother.
I'll await any requests for help you may convey...
command has nothing to do with rank or wealth- it's heart.

Salute. ...and Merry Christmas.

Thanks, Indianhead... I appreciate the tip of the cap.

But, as noted above, "we are all public health practitioners". If the pandemic flu comes to the US, the effects on all of us will be significant. Thus, all of us have to become involved, if only at the family and neighborhood level. Even the simplest level of neighborhood organizing in advance will be necessary in order to insure that no one is overlooked.... that the kids are taken care of, that the elderly and infirm are looked after, that folks work together to insure that basic needs are taken care of (food, water, meds, etc.), and that people have the latest and most up-to-date information. Lastly, establish key contacts with your local government, especially its public health department.

If you are sufficiently interested to move beyond concern for those immediately around you, I recommend you ask about local planning efforts and perhaps join in somewhere to play a role in both planning and perhaps even response. Check with your local emergency management director, work with the Red Cross, join a CERT team or the Medical Reserve Corps (you need not be a clinician), or work through some other community group.

Everyone will have to be involved, because this event, if it comes to pass, will impact everyone.

According to the American Lung Association (http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35692)

""Pneumonia" encompasses many different diseases that involve infection or inflammation of the lungs.

"Pneumonia is mainly caused by viruses, bacteria and mycoplasmas. Pneumonia can also be caused by the inhalation of food, liquid, gases or dust, and by fungi."

So, only bacterial pneumonia can be cured with antibiotics. If your immune system is compromised by something like the bird flu, then I would guess (and I admit, I'm not a medical professinal) it stands to reason that you could get a secondary infection that is bacterial, viral, or fungal that could cause pneumonia.

Ed

Bird flu kills second Turkish child


Thursday 05 January 2006, 10:30 Makka Time, 7:30 GMT


A pandemic among humans would kill millions worldwide



Related:
Turkey reports first bird flu death
Turkey acts to curb bird flu spread
Turkey slaughters birds amid flu fears
Bird flu strikes Turkey, Romania



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A second Turkish child from the same family has died from bird flu at a hospital in eastern Turkey where she was being treated, a regional governor said.


Her brother, 14-year-old Mehmet Ali Kocyigit, had already died of the H5N1 strain of bird flu, officials said on Wednesday, confirming the first human death from the disease outside China and southeast Asia.

"We lost Fatma Kocyigit this morning," Niyazi Tanilir, governor in the eastern province of Van, said on the CNN Turk news channel. Newspapers said Fatma was 15 years old. She died at around 6:30am (0430 GMT) on Thursday.

The governor said one patient was in a critical condition and another in a less serious condition.

A World Health Organisation (WHO) official said the boy had probably died from H5N1, which would mark a dramatic shift westwards for the disease.

Recep Akdag, the Turkish health minister, gave no specific details about the boy's death, but said samples had been sent to the WHO and Britain for more tests.

If the boy's death is officially confirmed as being the result of H5N1, it would be the first outside eastern Asia where more than 70 people have been killed by the disease since 2003.

The virus remains hard for people to catch, but there are fears that it could mutate into a form easily transmitted among humans. Experts say a pandemic among humans could kill millions around the globe and cause massive economic losses.

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January 5, 2006
Bird Flu Found in Three More in Turkish Family
By THE NEW YORK TIMES
By The New York Times

ISTANBUL, Jan. 4 - Bird flu has been diagnosed in three people in eastern Turkey, officials announced late Wednesday.

All three are members of the Kocyigit family in Van, who were in close contact with birds, the director of the Van public hospital, Huseyin Avni Sahin, said in an interview on NTV Istanbul. The three were being treated, Bloomberg News reported.

Turkey's health minister, Dr. Recep Akdag, said Wednesday that the disease had been diagnosed in another member of the family, Mehmet Ali Kocyigit, 14, who died Sunday, contradicting earlier reports that denied a connection.

Also, 10 people who had become ill but had not been confirmed to have avian influenza were being treated at the hospital in Van, Mr. Sahin said. All developed high fevers, coughing, and bleeding in their throats before admission to the hospital.

"We're following the correct treatment," he said. "However the risk of death is very high in bird flu cases."

Local officials have forbidden moving poultry in or out of the district where the cases were confirmed, the state run Anatolia Agency reported.



Copyright 2006The New York Times Company

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January 7, 2006
New Bird Flu Cases in Turkey Put Europe on 'High alert'
By ELISABETH ROSENTHAL
By ELISABETH ROSENTHAL

ROME, Jan. 6 - Health officials in Europe said Friday that they were on "high alert" as a third child in eastern Turkey was confirmed to have bird flu and more than two dozen people there were under observation at a local hospital, an unusual cluster of human cases that raised the possibility that the virus had become more contagious to humans.

The officials have watched with concern over the last four months as the strain of bird flu known as H5N1 has moved steadily from East Asia to the edge of Europe, first in birds and now probably in humans. A laboratory in England confirmed for the first time on Friday that the three children in Turkey, two of whom died, had had the H5N1 virus. The tests pointed to the most serious N1 strain, health officials said. Further testing on samples from them and other patients was under way.

"I'm not sure we've seen a cluster like this in terms of numbers, and certainly it's a concern," said Maria Cheng, spokeswoman for the Division of Epidemic Preparedness at the World Health Organization. "Is the virus being transmitted more easily from birds to humans, or even from humans to humans? We need to put all the pieces together before we can come to conclusions."

International health authorities say the Turkish victims - the first outside of East Asia - probably became ill after close contact with sick or dead chickens infected with the virus. Reports in the Turkish press said that two siblings who died, Mehmet Ali Kocyigit, 14, and his sister, Fatma, 15, had been playing catch with the heads of dead chickens.

While the H5N1 virus does not now readily infect humans or pass between them, scientists worry that it may acquire that ability through naturally occurring processes, a development that could ultimately set off a worldwide flu epidemic.

Scientists point out that the cluster of cases in Turkey does not indicate that such a mutation has occurred. Even if additional cases of bird flu are confirmed there, some scientists say, they probably stemmed from people handling the same sick birds - not from a mutated virus that passed between humans.

Still, the W.H.O. and the European Commission were alarmed enough to dispatch a joint team of scientists to eastern Turkey this week. Both entities also said they did not believe that people in Europe were at risk, unless they had had contact with poultry in disease zones.

"Europe is on high alert," said Christine McNab, a spokeswoman in the Director General's office of the W.H.O. "But unless there is new information, the risk still lies with people who are in contact with sick birds." In Europe, Romania and Croatia have reported outbreaks.

The full extent of the cluster is unclear because tests for H5N1, which are difficult to perform, are still under way in England. Beyond the Kocyigit siblings, another unrelated boy was also found to be infected. He is severely ill in the same hospital where the siblings were treated, in the city of Van.

Two other children in the Kocyigit family were also recently hospitalized with severe respiratory disease. One died Friday, and the other is recovering, although tests have not yet confirmed their diagnoses.

An additional 26 people are in the Van hospital under observation for possible bird flu, the Turkish Anatolia news agency reported, though many will presumably turn out to have lesser ailments.

"There is naturally panic among locals who believed for many years that there was no harm in eating dead poultry," Prof. Ahmet Faik Oner, head of the Van University Hospital child care unit, said in a telephone interview. "Now is the time to change their habits without any delay in light of these casualties."

Until now, all known 142 cases of human bird flu have been in East Asia. Most have been lone cases in families, and about half of those infected have died.

Scientists in Cambridge, England, are examining virus samples from Turkey for genetic changes from the Asian variant that could make the virus more capable of jumping from birds to humans. The European Commission, which banned poultry imports from Turkey in October, after the first outbreak in chickens there, said that it was "closely monitoring the situation."

Dr. Jeremy Farrar, director of the Oxford University Research Unit in Ho Chi Minh City, Vietnam, who has treated more than a dozen people with bird flu, said the Turkish cluster was "worrying" but in no way meant that a flu pandemic was imminent or inevitable.

Dr. Farrar said that he, too, had seen a few tiny clusters of people with H5N1 in Vietnam and had concluded that they were probably caused by "common exposure" to the same infected birds.

"In rural communities, whether in Vietnam or Turkey, people live very close to poultry," Dr. Farrar said. "When a bird is prepared for a meal, the whole family is involved."

He also said that many patients now in Turkish hospitals would ultimately test negative for the disease.

"It's a horrible virus, but in the early stages it's like any pneumonia," he said. "When people are scared they have a lower threshold for going to the hospital. It's a natural reaction."

At the very least, the outbreak underscored serious gaps in the world's strategy for addressing this emerging disease. For one thing, even though chickens were dying, there were no reports of H5N1 in the remote village of Dogubayazit when the Kocyigit children fell ill.

"Especially in rural areas, we need to do more to get the message out," said Ms. Cheng, the W.H.O. spokeswoman.

Sebnem Arsu contributed reporting from Istanbul for this article.



Copyright 2006The New York Times Company

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January 6, 2006
Turkish Family Loses 2nd Child to Avian Flu
By ELISABETH ROSENTHAL
ROME, Jan. 5 - A second child of a farm family in rural Turkey has died of avian influenza, Turkish health authorities said Thursday, sounding alarms about the capacity of the worldwide reporting system to track the spread of the disease.

In recent months, there have been a number of outbreaks of bird flu in poultry in Turkey, including confirmed and suspected outbreaks in provinces adjacent to where the children lived, in Van, a town near the Iranian border.

The child, Fatma Kocyigit, 15, died Thursday, four days after her 14-year-old brother, Mehmet Ali Kocyigit, the Turkish Anatolia news agency reported. Their 11-year-old sister, Hulya, and some neighbors are being treated in the hospital, the agency said.

[On Friday, Reuters cited a report from the Anatolian state news agency that said Hulya Kocyigit had also died.]

The children, the first human victims of the disease outside of China and Southeast Asia, had close contact with sick poultry, the route by which virtually all human victims have become infected. About 140 people in Asia, where the deadly H5N1 bird flu virus was first detected, have been stricken. About half of them have died.

The discovery of human bird flu far removed from previous cases shocked international health officials, who said they had assumed that countries like Turkey, Romania and Croatia, all of which reported modest bird flu outbreaks in animals late last year, could contain the disease and prevent human infections.

"We are very much worried and surprised, since we thought Turkey had the capacity to respond," said Joseph Domenech, chief of veterinary services at the United Nations Food and Agriculture Organization in Rome. He noted that, even in Asia, bird flu had rarely infected humans despite hundreds of millions of bird deaths from the disease.

Dr. Domenech said that it was unclear if there were far more cases of H5N1 in birds in Turkey than had been reported, or if the virus had changed in some way so that it could more easily infect humans.

A United Nations team from Copenhagen has been dispatched to Turkey to study the deaths, and a lab in England is studying virus samples from the two dead children. "Today there are far more questions than answers," Dr. Domenech said.

Despite the worrisome developments, World Health Organization officials in Geneva reaffirmed that the risk to the general population is negligible.

"What's happened here is what we have already seen in Asia," said Christine McNab, a spokeswoman for the organization. "These children were infected by infected poultry, so it doesn't change our assessment of risk for the general population in Europe."

In many ways, the most troublesome aspect of the announcement was that the children were from Agri Province in Turkey, where bird flu had not previously been reported, in birds or in people. This suggests that outbreaks of the disease are not always being reported to international health authorities, as is required. The authorities have long been concerned that local officials in Asia lack the expertise to detect the disease and may be reluctant to report it because of its devastating effects on the incomes of farmers.



Copyright 2006The New York Times Company

Thanks, Snuffy, for keeping up up to date on the breaking news from Turkey. [It will be interesting to see how the march of avian influenza in humans affects foreign policy and military initiatives and capabilities.]

---

Here are the first three of twelve extracts from the paper I wrote recently entitled "Coalescing Effective Community Disaster Response: Simulations and Virtual Communities of Practice".

“How can we combine and coordinate the multitude of disciplines and organizations— such as businesses, agencies, schools, universities, hospitals, fire and police—and connect across local, state, and federal levels where needed? How can we build a sufficient practice repertoire that must include new databases, protocols, technologies, simulations, standards, case studies, and research?”

“Communities of Practice: A New Tool for Government Managers”, William M. Snyder (Managing Director, Social Capital Group) and Xavier de Souza Briggs, (Assoc. Prof. Of Public Policy, Harvard University), IBM Center for Business and Government (Collaboration Series), November 2003. (http://www.businessofgovernment.org/pdfs/Snyder_report.pdf)


What is implied is the creation of a system that has high visibility to all, allows for a great degree of awareness about both content and process, and maintains a high degree of accountability among those involved. As a critical part of a community, it becomes “socially translucent”.

“Social translucence: An Approach to Designing Systems That Support Social Processes”, Thomas Erickson and Wendy Kellogg, IBM T. J. Watson Research Center (http://www.pliant.org/personal/Tom_Erickson/st_TOCHI.html).


Leonard Marcus, Ph.D., at the Harvard School of Public Health’s Center for Public Health Preparedness, notes that, in any preparedness effort focused on public health issues, we will need the combined skills of the following:

· scientists (to assemble, test for, and verify evidence of disease/spread);
· clinicians (to understand, assess and map out plans for disease spread);
· strategists (to assess options);
· ethicists (to grasp and communicate the human dimension);
· planners (to chart what must be done);
· organizers (to marshal and link people and resources);
· risk assessors (to appraise choices and consequences);
· politicians (to grasp decision-making dynamics);
· financial officers (to manage money and spending); and
· prophets (to be able to see into the future and plan accordingly).

How can all these people share a common goal, a common context, a common picture? Where is the structure and facility through which they can come together at a local level? How will they find common ground and agreement? Dr. Marcus says that “One of the major sources for conflict in any system, but especially those preparing to or actually responding to an emergency, is the conflict between power and expertise.”

"There is a tendency in organizations and among people working in them to think in narrow and self-protective terms. The silo mentality refers to a perspective that is insular, parochial, isolationist, and tilting toward the close-minded…. Training and career development occur in silos, knowledge tends to organize itself in silo-oriented literature, and budgets, space, and departments are bunched and distinguished into silos for ease and efficiency of management. The silos offer a reinforcing zone of familiarity that encourages silo-reinforcing pursuits. Connectivity acknowledges the effects and inevitabilities of silo thinking and counters it by constructing explicit, robust, and purposeful bridges that … link and re-motivate preparedness efforts."

Leonard Marcus, Ph.D., Harvard/MIT Conference on Bioterrorism Preparedness, JFK School of Government, Harvard University, June 2003.

There are deeply-rooted frames of reference which create traps
for organizations responding to crises:

· The inability to detect, or search for, “signals”;
· Laborious or hesitant mobilization;
· Divisions, partitions & demarcation lines that isolate [what Marcus calls silos];
· Vertical isolations between layers of bureaucracy;
· Dramatic errors in communication;
· Scape-goating;
· Inadequate mindsets;
· Noisy context;
· Unusual geographical patterns;
· Monitoring difficulties;
· Inadequate data monitoring;
· Unusual data;
· Inadequate focus of attention;
· Stealth problems; and
· Scientific gaps.

“Understanding the French 2003 Heat Wave Experience: Beyond the Heat, a Multi-Layered Challenge”, Patrick Lagadec, Journal of Contingencies and Crisis Management (Volume 12, Number 4, December 2004). ( http://www.blackwell-synergy.com/doi/abs/1...79.2004.00446.x )


“Do you have a meeting with 500 organizations to put together a revised emergency response plan? Of course not. Not if you want to get anything accomplished. But you do begin to form new networks between these organizations or begin to think about how existing networks can be utilized in the disaster context…. Certainly, these groups may be very willing to become involved and help in a disaster response, but putting organizations in touch in the midst of a crisis can prove quite a challenge. It is preferable to know the organizations and the people who work with them beforehand. Indeed, they may have resources and skills to offer that don’t immediately come to mind. Knowing each other, keeping organizations informed of emergent needs: these efforts could lead emergency managers to resources they didn’t know existed in a timely manner and allow for successful improvisation when established systems are overwhelmed.”

“Considering Convergence, Coordination and Social Capital in Disasters”, Tricia Wachtendorf and James Kendra, Canadian Risk and Hazards Network (1st Annual Symposium), November 19, 2004 ( http://www.crhnet.ca/docs/presentations/T-Wachtendorf.pdf )


“I think the ultimate possibility of computerized conferencing is to provide a way for human groups to exercise a "collective intelligence" capability. The computer as a device to allow a human group to exhibit collective intelligence is a rather new concept. In principle, a group, if successful, would exhibit an intelligence higher than any member… Attempts to design computerized conferencing structures that allow a group to treat a particular complex problem with a single collective brain may well promise more benefit for mankind than all the artificial intelligence work to date.”

Murray Turoff, noted in The Virtual Community by Howard Rheingold
( http://www.rheingold.com/vc/book/intro.html ).


“Under the pressure of an extreme event, decisions will be influenced by social, professional, socioeconomic and political relations, organizational structures, and prior experiences. In other words, decisions, like the extreme events themselves, are highly contextual, and understanding context will be central to understanding decisions. For example, the willingness of decision makers to act on new information may strongly depend on the level of trust they have for those who deliver the information, which may in turn reflect a history of prior interaction [emphasis mine]. And even the concept of a “decision maker” is inherently complex and nuanced. In any organizational context, decisions are usually “made” through complex interactions among a variety of participants, few or none of whom will have a comprehensive view of the entire situation.”

“Extreme Events: A Research and Policy Framework for Disasters in Context”, Daniel Sarewitz and Roger Pielke, Jr.,
( http://www.cspo.org/products/articles/xepaperfinal.pdf )


“This technology is enabling people to engage in complex, socially contextualized activities in ways not possible before. While it used to be that geography determined the boundaries of a group and the possibilities for collective action — I had to be near you to join you — now technology is revolutionizing our capacity for purposive collective action with geographically remote actors. This evolution toward technology for groups is evident from Meetups, wikis, LiveJournal, peer–to–peer, groupware, virtual worlds, GRID computing, a wide range of so–called “social software” tools…. New social and visual technologies are emerging to facilitate the work of groups. What was an “information revolution” is becoming a social revolution.”

“A Democracy of Groups”, Beth Simone Noveck, First Monday,
Volume 10, Number 11, November 2005
( http://www.firstmonday.org/issues/issue10_11/noveck/ ).

“Communities of practice— collaborative action-learning networks— can combine disciplines, interests, and capabilities across boundaries to take on national priorities…. A “community of practice” is a particular type of network that features peer-to-peer collaborative activities to build member skills as well as organizational and societal capabilities. Education and public safety communities of practice generally involve organizations from the private and nonprofit sectors, even when they are primarily sponsored by public agencies. Organizations and researchers use a variety of terms to describe similar phenomena, such as “learning networks,” “knowledge communities,” “competency networks,” “thematic groups,” and others.”

“Communities of practice also provide a living repository for ideas, information, best practices, directories of experts and resources, and the rest of the requisite repertoire that civic leaders will need. The amount of information to absorb just to keep up with an established professional discipline can be overwhelming. Member relationships provide a network for finding out quickly which information is most important to pay attention to and where to get the knowledge you need “on demand,” instead of piling it up on your desk or storing it in an obscure folder somewhere in your computer’s hard drive ‘just in case’.”

“Communities of Practice: A New Tool for Government Managers”, William M. Snyder (Managing Director, Social Capital Group) and Xavier de Souza Briggs, (Assoc. Prof. Of Public Policy, Harvard University), IBM Center for Business and Government (Collaboration Series), November 2003.
( http://www.businessofgovernment.org/pdfs/Snyder_report.pdf ).

“Today’s technologies make the world’s libraries accessible to anyone with a wireless PDA. A vast social network is literally at the fingertips of anyone with a cell phone. As a result, people have unprecedented freedom to bring resources together to create their own learning trajectories.”

“Video Games and the future of learning”, David Williamson Shaffer, Kurt P. Squire, Richard Halverson, and James P. Gee, University of Wisconsin-Madison and Academic Advanced Distributed Learning Co-Laboratory, December 2004
( http://www.academiccolab.org/resources/gappspaper1.pdf ).


One of the new tools available for the creation of social capital is the web site i-neighbors.

[See http://i-neighbors.org/index.php.]

“The idea of combining a way to support the people around me and link to local government while developing a platform for people to do some basic sharing of opinions, knowledge and giving them a way to communicate…” has arrived in the US.

See the blog by James Burke at www.ifccc.org.


“We know the rules of community; we know the healing effect of community in terms of individual lives. If we could somehow find a way across the bridge of our knowledge, would not these same rules have a healing effect upon our world? We human beings have often been referred to as social animals. But we are not yet community creatures. We are impelled to relate with each other for our survival. But we do not yet relate with the inclusivity, realism, self-awareness, vulnerability, commitment, openness, freedom, equality, and love of genuine community. It is clearly no longer enough to be simply social animals, babbling together at cocktail parties and brawling with each other in business and over boundaries. It is our task – our essential, central, crucial task – to transform ourselves from mere social creatures into community creatures. It is the only way human evolution will be able to proceed.”

M. Scott Peck, “The Different Drum: Community-Making and Peace”, in The Virtual Community: Homesteading on the Electronic Frontier, Howard Rheingold ( http://www.rheingold.com/vc/book/intro.html )

http://news.ft.com/cms/s/f1f0bee2-8065-11d...00779e2340.html
Human bird flu spreads to western Turkey
By Vincent Boland in Ankara
Published: January 8 2006 16:46 | Last updated: January 8 2006 22:36

The Turkish health ministry confirmed on Sunday that five more people have contracted the deadliest strain of bird flu as the disease spread westward reaching Ankara.


With seven cases of the H5N1 strain of the virus now confirmed, news that the deadly flu had reached the outskirts of the capital added to the growing sense of crisis gripping the country after the deaths of three children last week.

The latest cases are likely to raise fresh concerns about the government’s handling of the outbreak. Opposition leaders have demanded the resignations of the health and agriculture ministers and media reports have been critical of what they claim is the country’s lack of preparedness despite the known dangers.

Iran on Sunday began restricting the movement of people and vehicles across its border with Turkey, and a senior Russian epidemiologist advised against travel to the country because of the outbreak.

The health ministry said on Sunday, two children and an adult had tested positive for the H5N1 strain of the bird flu virus in the capital Ankara, and two children in the eastern city of Van, where the city’s university hospital has been inundated with claimed or suspected cases of the disease.

Two other people in Van, about 1,000km east of Ankara, had already tested positive for the virus, and at least 40 people, many of whom are children, remain under observation there and elsewhere with bird flu symptoms. All leave has been cancelled for medical personnel around Turkey.

Officials from the government and the World Health Organisation battled severe winter weather as they attempted to reach an isolated area of eastern Turkey, near the borders with Iran and Armenia. The three dead children – two sisters and a brother aged 11, 14 and 15 – were contaminated there after apparently playing with the head of a chicken that had died of the disease.

The state-run Anatolian news agency reported that Iran, which borders western Turkey, has closed at least one border crossing

Tests in Turkey and at a WHO laboratory in London confirmed that at least two of the three children died from the H5N1 strain of the virus, the first fatalities in Europe. The strain has killed at least 74 people in Asia in the past three years.

A cull of domestic poultry was still under way late on Sunday in the area around Dogubayazit, the village where the children lived, and in other parts of the country where dead birds have been discovered. Eastern Turkey has many mountain lakes where migrating birds stop, and poor families in the region bring their poultry into their homes in winter.

The three cases in Ankara were announced hours after authorities in the capital set up “bird flu crisis centres” at two hospitals. Doctors said that “all the necessary measures” were being taken to deal with the outbreak, but there were fears that Turkey’s health system could be overburdened if people continued to turn up at hospitals out of panic, fearing that they might have the disease, as appears to have happened in Van.

Turkey first reported incidents of bird flu at a poultry farm in the west of the country in October, and the latest outbreak began in late December.

http://news.bbc.co.uk/1/hi/health/3422839.stm

Q&A: Bird flu


The virus is contracted through
close contact to poultry

The spread of bird flu - also known as avian flu - which has led to human deaths in South East Asia, is causing concern.
But what is the disease and what are the possible risks to humans?

Q: What is bird flu?

Like humans and other species, birds are susceptible to flu.

There are 15 types of bird, or avian, flu.

The most contagious strains, which are usually fatal in birds, are H5 and H7.

The type currently causing concern is the deadly strain H5N1.

Even within the H5N1 type, variations are seen, and slightly different forms are being seen in the different countries affected in this outbreak.

Migratory wildfowl, notably wild ducks, are natural carriers of the viruses, but are unlikely to actually develop an infection.

Domestic birds are particularly susceptible in epidemics.

This is why the confirmation of H5N1 in birds in Turkey and Romania is causing concern.

Pakistan has seen cases of the H7 and H9 strains of bird flu in poultry, but no cases of these strains have been passed to humans

Q: Is it possible to stop bird flu coming into a country?

The fear, after the Turkish and Romanian findings, is that H5N1 will spread across Europe.

Because it is carried by birds, there is no way of preventing its spread.

But that does not mean it will be passed to domestic flocks. Experts say proper poultry controls - such as preventing wild birds getting in to poultry houses - which are present in the UK, should prevent that happening.

In addition, they say monitoring of the migratory patterns of wild birds should provide early alerts of the arrival of infected flocks - meaning they could be targeted on arrival.

Q: How do humans catch bird flu?

Bird flu was thought only to infect birds until the first human cases were seen in Hong Kong in 1997.

Humans catch the disease through close contact with live infected birds.

Birds excrete the virus in their faeces, which dry and become pulverised, and are then inhaled.

Symptoms are similar to other types of flu - fever, malaise, sore throats and coughs. People can also develop conjunctivitis.

Researchers are now concerned because scientists studying a case in Vietnam found the virus can affect all parts of the body, not just the lungs.

This could mean that many illnesses, and even deaths, thought to have been caused by something else, may have been due to the bird flu virus.

Q: How many people have been affected?

As of 20 October, 2005, there had been 118 confirmed cases of avian flu in humans in Indonesia, Vietnam, Thailand and Cambodia, leading to 61 deaths.

In comparison, Sars has killed around 800 people worldwide and infected at least 8,400 since it first emerged in November 2002.

Q: Can avian flu be passed from person to person?

There are indications that it can, although so far not in the form which could fuel a pandemic.

A case in Thailand indicated the probable transmission of the virus from a girl who had the disease to her mother, who also died.

The girl's aunt, who was also infected, survived the virus.

UK virology expert Professor John Oxford said these cases indicated the basic virus could be passed between humans, and predicted similar small clusters of cases would be seen again.

It is not the only instance where it has been thought bird flu has been passed between humans.

In 2004, two sisters died in Vietnam after possibly contracting bird flu from their brother who had died from an unidentified respiratory illness.

In a similar case in Hong Kong in 1997, a doctor possibly caught the disease from a patient with the H5N1 virus - but it was never conclusively proved.


Q: Does this mean there is likely to be a large outbreak of bird flu?

Experts are concerned that this could happen. But in the Thai case, the virus was only passed to close relatives and spread no further.

In addition, it had not combined with a form of human flu.

This is the real fear. Experts believe the virus could exchange genes with a human flu virus if a person was simultaneously infected with both.

The more this double infection happens, the higher the chance a new virus could be created and be passed from person to person, they say.

Concern has also been raised by research which showed that the virus which caused the 1918 pandemic was an avian flu virus.

Q: What would be the consequence if this did happen?

Once the virus gained the ability to pass easily between humans the results could be catastrophic.

Worldwide, experts predict anything between two million and 50 million deaths.

Q: Is there a vaccine?

There is not yet a definitive vaccine, but prototypes which offer protection against the H5N1 strain are being produced.

But antiviral drugs, such as Tamiflu which are already available and being stockpiled by countries such as the UK, may help limit symptoms and reduce the chances the disease will spread.

Concerns have been prompted by news a Vietnamese patient has become partially resistant to the Tamiflu, drug experts plan to use to tackle a human bird flu outbreak.

Scientists say it may be helpful to have stocks of other drugs from the same family such as Relenza (zanamivir).

Q: Can I continue to eat chicken?

Yes. Experts say avian flu is not a food-borne virus, so eating chicken is safe.

The only people thought to be at risk are those involved in the slaughter and preparation of meat that may be infected.

However, the World Health Organisation recommends, to be absolutely safe all meat should be cooked to a temperature of at least 70C. Eggs should also be thoroughly cooked.

Professor Hugh Pennington of Aberdeen University underlined the negligible risk to consumers: "The virus is carried in the chicken's gut.

"A person would have to dry out the chicken meat and would have to sniff the carcass to be at any risk. But even then, it would be very hard to become infected."

Q: What is being done to contain the virus in the countries affected?

Millions of birds have been culled in an attempt to stop the spread of the disease among birds, which would in turn stop it being passed on to humans.

--------------------------------------------------------------------------------

January 9, 2006
Bird Flu Reports Multiply in Turkey, Faster Than Expected
By ELISABETH ROSENTHAL
ISTANBUL, Jan. 8 - A flurry of new reports of avian influenza in humans and animals emerged Sunday from various parts of Turkey, and international health officials said they had come to believe that the disease had been simmering in the eastern part of the country for months, even though it was reported there only in late December.

A team of experts, including representatives of the World Health Organization, accompanied by the Turkish health minister, was scrambling to determine the full extent of the outbreaks. The group was heading by bus on Sunday to the worst-hit areas in and around the city of Van, where the airport was closed by severe weather.

Four children from villages near Van, in remote eastern Turkey, have now been confirmed by the W.H.O. to be infected with the H5N1 strain of avian influenza, the first human cases outside of East Asia. Like many people in those poor villages, the four had had close contact with birds, health officials said, and probably were infected as a result.

Turkish officials announced Sunday that tests had confirmed five new cases of H5N1, two more in Van and three around Ankara - two young brothers and an elderly man, according to Turan Buzgan, the Health Ministry's basic sciences director.

The Ankara cases have the most alarming implications because bird flu had not been previously reported in that part of the country, and it is a relatively well-off area, where it is not the norm for humans and animals to live under one roof. The infected boys had contact with dead wild ducks, and the man with a dead chicken, said a ministry spokesman.

In addition to the confirmed cases, some 50 other people suspected of having the disease have been hospitalized, at least 30 in the Van area and about 20 in Ankara, a Health Ministry spokesman said.

The W.H.O. said it had not been notified of the latest test results, and so could not confirm the new cases, said Maria Cheng, a spokeswoman in Geneva. But she added that international scientists studying the H5N1 virus samples from Turkey had detected no changes that might make it more contagious to humans. "It seems very much like the virus we've seen in Western China," she said.

The cluster of cases in Turkey is extraordinary and a cause for concern, scientists said. In all of East Asia, where the disease has been running rampant in birds for years, only about 140 people have been infected.

New reports of outbreaks among animals across Turkey were also rapidly increasing. By evening, the Agriculture Ministry said 10 of 81 provinces were reporting the disease in birds, up from 3 just a few days ago.

"Things are unfolding quickly, but we do not yet know how extensive the outbreaks are," said Juan Lubroth of the United Nations Food and Agriculture Organization.

"But we now believe and expect they have been going on for some time," he said, starting perhaps as early as October or November.

In light of the nine human cases confirmed in the last four days, the failure of the Turkish officials to detect and publicize animal outbreaks quickly could have been a deadly oversight.

Humans almost always acquire bird flu through close contact with sick birds. In areas with known outbreaks, all domestic birds are supposed to be culled quickly, and farming families in the surrounding area must take extreme precaution in handling poultry to prevent human infections. Because there were no earlier reports of bird flu in the area, the patients in Van and Ankara had no way of knowing they were at risk.

In one village near Van, Dogubayazit, four children from the same family have apparently come down with the disease after playing with chicken heads. Among the six cases in the area confirmed to have H5N1, two have died. A third also died, although her first test was negative. Ms. Cheng of the W.H.O. said the test was being repeated because it is "complicated and sometimes falsely negative," and circumstances implicate the H5N1 virus.

Although H5N1 does not now readily spread between humans, scientists are worried it may obtain that ability through biological processes, setting off a worldwide pandemic.

The international health officials said that while Turkey had responded swiftly to its first outbreak of bird flu, which occurred in the more developed western part of the country, in October, government officials had been far less efficient in dealing with the disease in the impoverished east.


Sebnem Arsu contributed reporting for this article.



Copyright 2006The New York Times Company

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January 8, 2006
New Reports of Avian Influenza Emerge in Turkey
By ELISABETH ROSENTHAL,
International Herald Tribune
ISTANBUL, Jan. 8 - As a flurry of new reports of avian influenza in humans and in animals emerged today from disparate parts of Turkey, international health officials said that they now believed that the disease had been simmering in the eastern part of the country for months, even though it was only first reported there in late December.

A team of experts, including specialists from the World Health Organization and accompanied by the Turkish health minister, was scrambling to determine the full extent of the outbreaks. The officials made their way by bus today to the worst-hit areas in and around the city of Van, whose airport was closed by severe winter weather.

Four children from villages near Van in remote eastern Turkey have now been officially confirmed to have been infected with the H5N1 strain of the flu by the W.H.O., and at least 30 people are hospitalized in Van City as possible victims. Like many people in these poor villages, the four children - two of whom have died - had close contact with birds, health officials said, and probably become infected as a result. A sibling of the two victims has also died, although tests for the virus have so far been negative.

In addition, Turkish officials announced today that tests had confirmed five more cases of H5N1, two in Van and three from around Ankara - two young brothers and an elderly man, according to the Health Ministry's basic sciences director, Turan Buzgan.

The Ankara cases have the most alarming implications since bird flu has never been reported in that part of the country. It is a relatively well-off area, where it is not the norm for humans and animals to live under one roof. The boys infected had contact with dead wild ducks, said a ministry spokesman, and the man with a dead chicken.

The W.H.O. said it had not yet been notified of the latest test results, and so could not confirm the cases, a spokeswoman in Geneva, Maria Cheng, said. But she added that international scientists now studying the H5N1 virus samples from Turkey had so far detected no changes that might make it more contagious to humans. "It seems very much like the virus we've seen in Western China," she said.

New reports of animal outbreaks across Turkey were also rapidly increasing with 6 of 81 provinces now reporting ongoing disease in birds, up from three just a few days ago. By this evening, the Agriculture Ministry said the count was up to 10.

"Things are unfolding quickly, but we do not yet know how extensive the outbreaks are," Juan Lubroth of the United Nations Food and Animal Organization said. He added that the organization now believed that they had been occurring "for some time," starting perhaps as early as October or November.

In light of the nine human cases over the last four days, the failure of the Turkish officials to quickly detect and publicize animal outbreaks could have been a deadly oversight.

Humans almost always acquire bird flu through close contact with sick birds. In areas with known outbreaks, all birds are supposed to be quickly culled to contain the disease, and farming families in the surrounding area must take extreme precaution in handling poultry to prevent human infections. Because there were no reports of bird flu in the area, the patients in Van and Ankara had no way of knowing they were at risk.

In one village near Van, Dogubayazit, four children from the same family have apparently come down with the disease, after playing with dead chicken heads. Two, confirmed to have had H5N1, have died. A third also perished although her first test was negative. Ms. Cheng said it was being repeated because the test is "complicated and sometimes falsely negative" and circumstances implicate the H5N1 virus.

Although H5N1 does not now readily spread between humans, scientists are worried that it might obtain that capability through biological processes, setting off a worldwide pandemic.

The officials said that while Turkey had responded swiftly to its first outbreak of bird flu, which occurred in the more developed western part of the country in October, government officials had been far less efficient in dealing with the disease in impoverished eastern regions.

"The veterinary structure is weak there," said Mr. Lubroth, who added that the United Nations had offered its assistance. "I'm not sure if officials in the capital were even aware for a long time that there was a problem."

A total of 50 patients are in hospitals in Van and Ankara with possible bird flu, said a Health Ministry spokesman, all of whom had close contact with birds and all of whom have respiratory symptoms, coughing and a fever.

Many "are not highly suspected cases, but giv