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US Readiness for Flu Outbreak "Spotty"

Putting aside for a moment whether an outbreak of Pandemic avian flu (H5N1) is on the horizon or not, the recent outbreaks in China (where no concrete connections have yet been proven) and in Pakistan (where a small chain of human to human transmission has occurred according to the World Health Organization) raise the concern level.

Keiji Fukuda, coordinator of the WHO's global influenza program, told Reuters this week that the Pakistan cases probably represent a mix of poultry-to-human infections and human-to-human transmission resulting from close contact when people cared for infected relatives. "We don't have any indication of a broader health threat, other than poultry outbreaks" in the area, WHO spokesman John Rainford told CIDRAP (Center for Infectious Disease Research & Policy - University of Minnesota) news today. "Our risk assessment suggests no evidence of sustained transmission. All the close contacts and involved healthcare workers remain asymptomatic and have been released from close medical observation."

At the same time, CIDRAP is also reporting that the origins of the more recent outbreak in Indonesia in which five members of one family have been infected are unknown (see also from CIDRAP: CIDRAP News story "Possible H5N1 family cluster probed in Pakistan” and CIDRAP News story "Reports suggest common source in family H5N1 cases"

Therefore, despite explanations, there is a possibility that in both Pakistan and China (and maybe Indonesia), we are seeing both human-to-human and bird-to-human transmission. The question of human-to-human transmission, and whether that jump can or will turn into a pandemic has to be considered. In fact, the World Health Organization, in its latest reports said that there is a possibility that the reported Bird Flu in Pakistan might be spreading both from person to person and from poultry to humans. Additionally, the U.S. State Department this week began a series of articles on the bird flu preparations in Vietnam

Vietnam's Vaccination Effort Helps in Fight Against Avian Flu Vaccinating its highest-risk populations of chickens and ducks has been an expensive and logistically complex effort for Vietnam’s central government, but animal health officials say it has slowed deadly outbreaks of highly pathogenic H5N1 avian influenza among birds in the Southeast Asian nation and, critically, among people. Also see: The State Department’s Bird Flu website is found here, Bird Flu (Avian Influenza) and National Strategy for Pandemic Influenza

Why make this point (over and over again)? It’s all about preparedness. Based on a report from Trust for America’s Health (tagged as a “watchdog” group by some local media), "Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism," we remain unprepared. The report indicates that a “number of critical areas of the nation's emergency health preparedness effort still require attention.” More on point:

Thirteen states don't have adequate plans to distribute vaccines and antidotes in the event of a flu pandemic or a bioterrorism attack. Among the findings outlined in the report:

● Flu vaccination rates decreased among the elderly in 11 states during the past year.
● Six states cut their public health budgets between fiscal 2005 and fiscal 2006.
● Thirteen states do not have adequate plans to distribute emergency vaccines, antidotes, and medical supplies from the Strategic National Stockpile
● Twenty-one states do not have statutes that allow for adequate liability protection for healthcare volunteers during emergencies
● Twelve states do not have a disease surveillance system compatible with the Centers for Disease Control and Prevention's (CDC) National Electronic Disease Surveillance System
● Seven states have not purchased any portion of their federally-subsidized or unsubsidized antivirals to use during a pandemic flu
● Seven states and D.C. lack sufficient capabilities to test for biological threats

"There is little doubt that emergency health preparedness is on the national radar," Levi added. "But until all states are equally well prepared, our country is not as safe as it can and should be."

All fifty U.S. states and the District of Columbia (D.C.) were graded based on publicly available data. The results? Thirty-five states and D.C. scored eight or higher on the scale of ten indicators. Illinois, Kentucky, Nebraska, New Jersey, Pennsylvania, Tennessee, and Virginia scored the highest with 10 out of 10. Arkansas, Iowa, Mississippi, Nevada, Wisconsin, and Wyoming scored the lowest with six out of 10.

We are dealing with the potential onset of a naturally borne medical disaster. I believe that it is important to recognize that the question of the “jump” to human-to-human transmission is one that could be “only one mutation” (of the virus) away. This was discussed back in October in The “Next” Step in Bird Flu Mutations. While "some" people may argue that "human-to-human" transmission is not occuring (or at least not yet on a large scale), or even that if an outbreak of H5N1 occurs in the United States, it might not become a pandemic, I blieve that the saying that "a chain is only as strong as its weakest link" holds true here.



The Boston Globe reported that MA is one of only 7 states that haven't yet bought a single dose of drugs to combat a global flu epidemic.

H5N1 avian flu: Spread by drinking water into small clusters:

Human to human and contact transmission of influenza occur - but are overvalued immense. In the course of Influenza epidemics in Germany recognized clusters are rarely (9% of the cases in the season 2005).
In temperate climates the lethal H5N1 avian flu virus will be transferred to humans strong seasonal in the cold via cold drinking water, as with the birds feb/mar 2006.
Recent research must worry: So far the virus had to reach the bronchi and the lungs in order to infect humans. Now it infects the upper respiratory system (mucous membranes of the throat e.g. when drinking and mucous membranes of the nose and probably also the conjunctiva of the eyes as well as the eardrum e.g. at showering). In a few cases (Viet Nam, Thailand) stomach and intestine by the H5N1 virus were stricken but not the bronchi and the lungs. The virus might been orally taken up, e.g. when drinking contaminated water.
The performance to eliminate viruses of the drinking water processing plants in Germany regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Even ground water used for drinking water is not free from viruses.
In temperate climates the strong seasonal waterborne infections like norovirus, rotavirus, salmonellae, campylobacter and - differing from the usual dogma - influenza are mainly triggered by drinking water dependent on the drinking water temperature (in Germany minimum feb/mar – maximum august). There is no evidence that influenza primary is transmitted by saliva droplets. In temperate climates the strong interdependence between influenza infections and environmental temperatures can’t be explained with the primary biotic transmission by saliva droplets from human to human with temperatures of 37.5°C. There must be an abiotic vehicle like cold drinking water. There is no other appropriate abiotic vehicle. In Germany about 98% of inhabitants have a central public water supply with older and better protected water. Therefore in Germany cold water is decisive to virulence of viruses.
In hot climates/tropics the flood-related influenza is typical after extreme weather and natural after floods. Virulence of Influenza virus depends on temperature and time. If young and fresh H5N1 contaminated water from low local wells, cisterns, tanks, rain barrels or rice fields is used for water supply water temperature for infection may be higher as in temperate climates.

Dipl.-Ing. Wilfried Soddemann
eMail soddemann-aachen@t-online.de
Epidemiological Analysis:

While noting the vast publishing of the article you posted here, I thank you for the clarifying nature of the information you provided.

So, by your analysis, the impact of human-to-human transmission is being overblown. Further, your statement is that it is water-borne? I'll be checking with some of my water utility people after the holiday.