Avian Flu Information
What You Should and Shouldn't Worry
About: Putting Avian Flu in Perspective
Wall Street Journal
November 1, 2005
How do you catch flu from a chicken? That is one of many questions on the minds of Americans who aren't sure how to react to scary headlines and ominous warnings about avian flu.
World health officials say we may be on the verge of a bird-flu pandemic, but so far, the disease has killed fewer than 70 people since it emerged as a threat eight years ago. The disease is found mostly in Asia, but it is carried by migrating birds and it is certain to spread everywhere, including the U.S. Today the Bush administration is expected to unveil its strategy for a flu pandemic.
So what do we do next? Here are some answers to common questions about avian flu and what you can do to protect yourself.
The disease hasn't arrived on our shores yet, but experts predict it probably will arrive here as early as the spring, when infected migrating birds on their way to the Arctic mix with North American birds.
Will that put humans at risk?
Right now, the bird-flu virus doesn't move from bird to human very easily, requiring very close contact with an infected bird, feces or blood. In Asia, most of the people who have become infected are those who have raised poultry, killed and plucked birds, or worked closely with infected domestic or wild birds. For instance, in a few cases, handlers of fighting birds got sick after giving mouth-to-mouth resuscitation to an injured bird, notes Suresh Mittal, a Purdue University virology professor working with the Centers for Disease Control and Prevention on a vaccine.
The disease also isn't very contagious among humans. There may be one case of a mother contracting the illness from her child, but it isn't clear if she was exposed from the child or a bird. At least 100 million birds likely have been infected, but there are just 121 documented cases of human infection, so the odds of catching flu from a bird are clearly very low.
Then why is everyone so worried?
The worry isn't today's bird flu but what it might become tomorrow. We already know this flu is deadly, killing about half the people who catch it. The fear is that it will become more contagious, which could happen if it mutates or combines with a human virus. The risk is especially worrisome as infected birds migrate to Africa. There people live in close quarters with animals and a large percentage of the population has HIV, possibly making them more vulnerable. All of this increases the risk that bird flu will combine with a human virus, and once that happens, the disease will likely spread quickly.
So when should I start to worry?
Right now, only isolated cases of avian flu have been reported. If a cluster of cases emerges, that suggests the virus has changed and has begun to spread by human contact. Once that happens, the virus could show up in the U.S. within two months, Dr. Mittal says.
Should we stop eating chicken and eggs?
It is safe to eat cooked poultry and eggs. The risk of infection appears to come only from live birds as well as slaughtering and plucking birds and exposure to blood or feces. There are no reported cases of bird flu being transmitted through eggs, but even if the risk exists, the pasteurization process likely would kill the virus, as would cooking. Use common sense and protect cooking surfaces, cutting boards and counters from exposure to raw poultry and raw eggs, which also carry risk for salmonella.
Should I cancel plans to travel to Asia?
The CDC hasn't recommended that people cancel travel plans as a result of the avian-flu outbreak. If you plan to go to Asia or a country with bird-flu cases, stay away from live-food markets, wash hands frequently and make sure your food is well cooked.
Should I cancel plans to buy a pet bird?
Most pet birds sold in the U.S. are bred here and haven't been exposed to avian flu. Imported canaries and finches are quarantined for a month under federal law; that is twice the time needed to detect bird flu. Retailers such as PetsMart quarantine birds for two extra weeks, so it is unlikely a sick bird would end up in a legitimate store. Don't buy birds from an individual or at a swap meet. And don't put your pet bird outside in a cage, as wild birds can steal food or leave droppings, putting the bird at risk, says PetsMart veterinarian Michael Staitman.
Will a flu shot lower the risk of bird flu?
No. The vaccine developed for the current flu season battles an entirely different variety of flu. Two other flu drugs, amantadine and rimantadine, right now are ineffective against bird flu. Two antiviral drugs, Tamiflu and Relenza, might work to reduce symptoms of bird flu and shorten the duration of the illness. The prescription drugs must be taken within 48 hours of exposure.
Some panicked consumers are stocking up on the drugs, though the practice is discouraged. Improper use could render the drugs ineffective, plus they can't be used by everyone, says Marc Siegel, associate professor at New York University's School of Medicine and the author of "False Alarm: The Truth About the Epidemic of Fear."
Is there an avian-flu vaccine?
A potential vaccine is being tested in humans in the U.S., according to the CDC. The problem is that the version of the bird-flu virus we are worried about hasn't emerged yet, so it isn't known if the vaccine being developed now will ever work.
AVIAN FLU: PREVENTING A PANDEMIC
On the front line
Specialists risking their lives to save ours
By KEVIN VOIGT
Staff Reporter of THE WALL STREET JOURNAL
October 28, 2005
It's called H5N1 and it's on the move.
Better known as avian flu, it has just reached Europe, thought to be carried by migratory birds from Asia.
More than 120 human cases have been reported world-wide in the latest wave of outbreaks, beginning late 2003 -- all of them in Asia. So far, half of the victims have died. Cases have been traced to humans having close contact with infected poultry, with no known cases of human-to-human transmission. But the potential mutation of the virus into one that can jump from person to person has scientists and government officials around the world on red alert.
The H5N1 avian flu virus (CORBIS)
Virologists say the way avian influenza attacks the human body sets it apart from other influenzas. Symptoms include fever, coughing and vomiting as the virus first attacks the lungs, replicating in the cells of the lungs as the lining of the air sacs inflame and fill with water. Then unlike other common forms of influenzas, the virus moves on to attack the liver, the kidneys, the pancreas and in some rare cases, the brain, shutting down organs one by one.
PREVENTING A PANDEMIC
- Inside the Race to Find Vaccine for Avian Flu1
- Follow the Avian Flu News Tracker2
See complete coverage of avian flu, including a map of H5N1's reach3, plus an in interactive graphic on the science of the virus4 and a look back at major flu epidemics5.
Southern China has been the birthing grounds of most known emerging diseases in the past century, which puts researchers here on the front line to stop the next outbreak, says K.Y. Yuen, head of infectious diseases at the University of Hong Kong. "The 1957 and 1968 pandemic, the first case of avian flu, SARS -- they all started here," he says.
Weekend Journal talks to four infectious-disease specialists -- all veterans of the 2003 outbreak of severe acute respiratory syndrome -- who are now active in battling what may become the next global pandemic. They talk not only about what attracts them to working in this dangerous field, but about the challenges they regularly face.
The early warner: Yuen Kwok-yung
In Asia, it's experts like K.Y. Yuen whom the region's health authorities count on to spot when a new disease has hit the human population. "I never do pure (lab) research ... my research always starts with the patient," says the 49-year-old chairman of infectious disease research and the head of the microbiology department at the University of Hong Kong, who gets two or three calls a day from physicians at various Hong Kong hospitals stumped by a patient's symptoms.
It's tricky work, because the way the body reacts to a new virus can mimic many known maladies. Once a new disease is recognized, Dr. Yuen begins his detective work involving epidemiologists, virologists and others on his team to find and isolate where the contagion began, as his team did in 1997 when the first known human cases of the H5N1 avian influenza anywhere were found in Hong Kong. That outbreak killed six people and led to the mass extermination of all poultry in the territory.
"Hong Kong is a very important health sentinel post for the rest of the world," Dr. Yuen says. It butts up against southern China, which has proved itself to be a breeding ground for new, infectious diseases that can jump to humans from animals because the close proximity of ducks, chickens, pigs and humans creates a chain of transmission that epidemiologists blame for two of the major influenza outbreaks of the past half-century.
Dr. Yuen was among the first consultants called to Hong Kong's Kwong Wah Hospital to see a patient with pneumonia in late February 2003 who wasn't responding to treatment. The patient was a doctor from Guangdong province across the border in China. Both his lungs failing, the dying man had told doctors at Kwong Wah that he saw patients in Guangdong who died of a mysterious pneumonia.
The first thing Dr. Yuen thought: "This is really serious." The second thing was that he should be wearing more than his paper surgical mask. He immediately called the city's public health director and warned that a new infectious disease had arrived in the city. Later, researchers in his department would isolate the virus and give it a name: severe acute respiratory syndrome, or SARS, which crossed the globe in weeks, infecting more than 8,000 people and killing 800.
In late 2003 and early 2004, when there were SARS outbreaks in research laboratories in Beijing, Singapore and Taipei, Dr. Yuen often woke up, sweating in his bed clothes after nightmares of a similar leak in his labs. "It's one of the biggest responsibilities on my shoulders -- these things can kill myself and my staff," he says. "That's why I'm losing my hair so rapidly."
For Dr. Yuen, whose father was a dentist and grandfather practiced Chinese traditional medicine, medicine seemed a natural career path. He worked as a surgeon patching up gunshot victims and removing inflamed appendixes for seven years before he got the urge to do "something that lasts, that has more of a big impact."
Being in his line of work keeps Dr. Yuen vigilant about habits that could make him sick, or bring disease home to his wife, a now-retired intensive care nurse whom he married in 1988. "I never eat raw meat; generally everything except for fruit is cooked," he says. "I do tai chi one hour a day, a half hour before sleep and early in the day," he says. "I jog in the countryside each week."
"Three things are essential for good prevention: rest, exercise and diet. If you don't have appropriate rest, stay active and have a balanced diet, you are in trouble."
Besides getting annual flu booster shots, he keeps alcohol swabs in his pocket for constant disinfection. "The fingers are the most dangerous instruments in the world; you touch something, then you're constantly touching your mouth or rubbing your eyes," common entry points for infection, he says.
The provocateur: Guan Yi
"My personal belief is that if (avian flu) goes to human-to-human transmission, it will be too late to do anything," declares Guan Yi, a 43-year-old flu scientist who says he's becoming increasingly shrill out of frustration with the situation.
"It's true, we can't answer if or when it will spark a pandemic. But I know the reasons why it's emerging and re-emerging in the animal population, I know the mechanism behind that," he says. "The virus, as I expected, has gone to Europe. The thing here is, based on the calendar, we have a very limited time, so I'm quite worried," he adds. "If the number of animal cases increases, the human cases will increase."
'We have personally prepared a vaccine,' says Dr. Guan. 'If there's an outbreak, I will first use it on myself.'
Dr. Guan has his own survival plan if the flu strikes. "We have personally prepared a vaccine," he says. "If there's an outbreak, I will first use it on myself. If I'm okay, then I'd ask our whole medical group to be vaccinated. We can make a small quantity for ourselves. If there is enough, maybe then we would give it to friends and family."
A native of Jiangzi province in China, Dr. Guan went to university to study medicine at age 16 -- the same year his father was struck with a respiratory infection and chronic bronchitis. "I thought maybe I could help him," he says of his decision to study medicine. "Unfortunately, he didn't live until I finished medical school." His father died in 1981 at the age of 54.
Initially, Dr. Guan was drawn to pediatrics, spurred by the job satisfaction that "with a lot of children's diseases, they can completely recover." His interest in viruses was sparked while treating children in hospitals in Beijing and Shantou. "Influenza virus commonly caused problems in children, but often what we could do was very limited," he says. "Every winter, it's a big threat."
The viral fascination led him to the University of Hong Kong in 1991, where he studied under famed researcher Robert Webster, who first posited in the 1960s that the great pandemics of the 20th century sprang from bird flus. An outbreak of flu among race horses in Hong Kong in 1992 fueled his interest in viruses that could jump to humans from animals.
Then, in 1992 and 1993, Dr. Guan studied an outbreak of flu among race horses in Hong Kong that infected 300 head and closed the Hong Kong Jockey Club for 10 weeks. The episode fueled his interest in viruses that could jump to humans from animals. "At that time, a generation had already passed since the last pandemic," he says.
Next, he began jetting between Hong Kong and the St. Jude Children's Research Hospital in Memphis, Tennessee, doing stints studying animal-borne viruses. He had just returned to Tennessee on Nov. 28, 1997, when he received a call from his Memphis supervisor who said: "Don't unpack your bags -- we're sending you back to Hong Kong."
For the next few weeks, Dr. Guan was part of the team that explored the bird markets of Hong Kong and rushed back to the labs, where they learned that 20% of the city's poultry population was infected by an avian flu that would claim six human lives. "The question then waiting for me was how was H5N1 generated, and where did it come from?" he says. It's a question that has defined his research for the past seven years, as the disease became endemic in bird populations stretching from Southeast Asia to South Korea.
Not one to shy from confrontation, Dr. Guan in June got embroiled in an acrimonious dispute with Chinese officials when he published a paper in the journal Nature that showed H5N1 had appeared in migratory birds in China's Qinghai Lake -- a key stopping point for wild geese and ducks heading into Europe. Chinese officials disputed his findings, which indicated the virus might be wider spread in China than previously acknowledged.
"How many people will die if H5N1 becomes a pandemic? I don't know, and no one knows," says Dr. Guan, who is smoking more these days due to stress and whose only vacations the past four years have been annual three- or four-day visits to his mother in China. "The virus keeps growing, it keeps adapting ... we're always one step behind the virus." And given the level of probable contagion, Dr. Guan fears that its even odds that "if just one person escapes and lands in Europe, it will be too late" to avert a pandemic.
His work has led to the culling of poultry populations in Thailand and Vietnam after outbreaks infected human there. Still, he is worried that lack of political willpower generally will prevent adequate intervention. "Control measures are decisions made by politicians, and they might not particularly have the full picture, which makes me feel despondent," says Dr. Guan, who is married to an anesthesiologist in Hong Kong, and has one son studying biology at a U.S. university.
He, his wife, an anesthesiologist, and their son were unscathed by SARS. But Dr. Guan worries that his own odds of escaping another kind of outbreak are shortening. "With direct exposure, there are many opportunities for infection," he says of his trips into the field gathering animal samples. "I am exposed too frequently, God help me. Each time you feel nervous."
The medical diplomat: Jeremy Farrar
In a world where diseases don't respect borders, Jeremy Farrar is a medical diplomat. The British national was born in Singapore. His father was a globe-trotting teacher who kept the family moving around Asia and North Africa while he grew up. A foreign service career was considered, "but I would rather do that sort of work through medicine and science rather than diplomacy," Dr. Farrar says. "It's very exciting to be part of an international collaboration, built on real friendship, training doctors here in their home country rather than flying one or two to Oxford."
'I have three small children and this is a very big worry for the world,' says Dr. Farrar, who lives in Ho Chi Minh City.
Married to a fellow physician, he studied to be a neurosurgeon, then noticed that the doctors in the malaria unit next door to his Oxford digs were having more fun, so he switched to infectious diseases.
Dr. Farrar, now 44, came to Ho Chi Minh City in Vietnam to head the Oxford University Clinical Research Unit at the Hospital for Tropical Diseases nearly 10 years ago. He has watched it grow from a staff of five to more than 60, focusing work on malaria, Dengue fever and typhoid, and was part of a team that first decoded the typhoid genome. His lab is one of several in the country that does genetic testing for avian flu.
Treating avian flu is among the most difficult work for doctors anywhere to diagnose, particularly in rural countries, he says. "(Avian flu) tends to be more widespread in the body, does much more damage, the range of symptoms are much broader," he says.
In 2004, on the eve of Tet, the Vietnamese New Year, Dr. Farrar received a call from a doctor with some troubling news. A six-year-old girl was ill and not responding to treatment. He learned that the girl, like many children in Vietnam, had a pet duck which had died. She was so distraught over the pet's death, she even dug the duck back up after its burial. Soon after, she fell ill. After Dr. Farrar reviewed the test results in his laboratory in Ho Chi Minh City, it was clear human avian flu had come to Vietnam.
At 91 confirmed cases, Vietnam has by far the highest number reported in the latest outbreak; it has recorded 41 deaths.
"We've had probably 100 suspected cases in our hospital and 20 confirmed patients. "It's an incredibly horrible infection," says Dr. Farrar. "I haven't experienced the same degree of destructiveness; it's really damaging to the lungs and very quickly damaging to other organs. Once you get into that cascade of damage, it's difficult to treat." Although the number of cases has dwindled to a trickle -- the last known bird flu victim died in September -- Dr. Farrar and other researchers at the center have been working with Vietnamese doctors to prevent avian flu's spread.
The fear of its rapid spread worries him at a personal level, too. "I'm a human being like everyone else; I have three small children and this is a very big worry for the world, but it joins a list of other big worries, such as TB and HIV," he says. Other than maintaining good hygiene and "avoiding chickens ... there aren't many tools out there to fight it," he says.
Meantime, his wife Christiane, who studies typhoid fever at the hospital, says "we really don't do anything differently from other families."
Dr. Farrar says it is government officials at all levels around the world who have the harder job. "What I do is very simple," he says of diagnosing and treating the disease. "What they have to do is change human behavior in a time of crisis, and that's a very difficult thing to do."
The impact of Hurricane Katrina in New Orleans provides a good illustration, he says; while officials there had difficulty getting people to leave, if bird flu strikes the difficulty will be getting people to stay. "You wouldn't want those people to be traveling," he says.
Personally, it's difficult for him to predict what he would do with his family if avian flu reached pandemic stage. "You just have no idea until faced (with) the situation. Of course, the children have no need to be here. We might send them away if it was safe to do so and if they could leave."
The fact gatherer: Hitoshi Oshitani
For the past six years in his job at the World Health Organization, Hitoshi Oshitani has been on the frontline of emerging diseases from Asia, such as the Nipah virus that killed more than 100 people in Malaysia and Singapore in 1998 and 1999.
'If you make the wrong decision, it may affect many people,' says the WHO's Dr. Oshitani, who lost a colleague to SARS.
Based in Manila, his office covers a wide swath of the world, including nations with world-class disease response systems such as Japan and Australia, and some with the worst, such as Laos and Papua New Guinea. He both supports local medical officials of member nations with technical advice as well as serving as a conduit to spread information about infectious diseases that threaten to spill across borders. These days he gets as many as 150 emails a day from WHO colleagues and health officials around the region. The bulk of them are about avian flu, such as "unusual patient cases, how to test for it, where to send samples, what precautions to take, what sort of masks to use," he says.
If the disease takes hold in the region like SARS did, Hitoshi Oshitani is the man the World Health Organization will count on to sound the alarm of a global pandemic threat. He's regional adviser for infectious disease for the WHO in 37 Asian-Pacific nations.
From his base in Manila, Dr. Oshitani says: "My job is to provide the right information, the most updated available to policy makers and senior (WHO) management. If you cannot provide such information, they may end up with the wrong decision."
And the wrong decision could have big consequences. A false alarm could damage local economies, spooking the public and halting travel. An untoward delay could allow the disease to spread. "It's actually a big challenge to balance these two things," says the Japan-born 46-year-old who wanted to be an anthropologist. "It's very stressful because we don't know what's going to happen, nobody knows."
Drawn to developing countries, Dr. Oshitani decided to go into medicine and specialize in the infectious diseases that are a common problem in young nations. After three years in Zambia with a nonprofit Japanese agency and a stint as a university professor, he took a job at WHO attracted by a mandate to work on emerging diseases. He's been there six years.
The work has constant challenges. "You are getting pressure from the press, the government, senior management, the country officers -- it isn't easy to deal with all these people. They are also under terrible pressure," he says.
But despite his work days regularly stretching to 14 hours, Dr. Oshitani stays in his job because "dealing with these issues on the front line, nobody else can have access to all this information, and I can provide some of the answers."
Like for most infectious disease researchers in the Asian-Pacific region, it was the 2003 outbreak of SARS that has defined his work in recent years. In the early days of the outbreak, Dr. Oshitani and others feared it may have been the first cases in the long awaited outbreak of H5N1 avian flu in humans. "At this stage, we really didn't know," he says.
After a meeting with health officials in Beijing attempting to assess the situation in China, he flew to Hanoi to meet with WHO colleague Dr. Carlos Urbani. Dr. Urbani was treating patients in Vietnam with symptoms similar to victims in China. "I went there to help him out, and we were together for about 24 hours before he left for a conference in Bangkok," Dr. Oshitani recalls. When Dr. Urbani landed in Bangkok on March 11, he was ill and immediately hospitalized. He died from SARS less than three weeks later.
Soon after, WHO issued a global alert that brought regional travel to a standstill, hitting local economies hard. Dr. Oshitani, who still hasn't gotten around to writing a will, penned a letter to his wife, Yuko, who moved back to Japan two years ago with their three school-age children. "I told her if I was infected with the virus and died, I wouldn't regret the work I did."