New ladder to a pandemic alert

[Shiloh]

Source: http://www.todayonline.com/articles/260862.asp

June 21, 2008

New ladder to a pandemic alert
WHO’s six-step proposaloffers greater clarity infight against flu infection


Tan Hui Leng in Kuala Lumpur
huileng@mediacorp.com.sg


THE World Health Organisation (WHO) has released details of a new flu pandemic alert system to replace its existing one, which has been criticised for lacking clarity.
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Currently, the world is in phase 3 of the alert system, which is defined as “no or very limited human-to-human transmission”. The six-step, three-layer alert system is a ladder going from “low risk of human cases” in phase 1 to “efficient and sustained human-to-human transmission” in phase 6, the pandemic phase.
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Last year, a cluster of eight Indonesian family members who were infected through human-to-human H5N1 transmission sparked confusion over WHO’s flu alert level, with some calling for it to be raised to phase 4; that is, “evidence of increased human-to-human transmission”.
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WHO’s new system addresses such issues of interpretation with three layers. The first comprises phases 1 to 3 and is defined as “predominantly animal infections; limited transmissibility among people”.
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Phase 4 would be “sustained human-to-human transmission of animal or hybrid animal-human influenza virus, able to cause sustained community-level outbreaksthat have been verified” — this is when health authorities can consider issues such as rapid containment, discussion of phase changes, and switching to a pandemicvaccine.
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Phases 5 and 6 would comprise the “geographical spread” of flu. There is also a post-pandemic phase.
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Dr Nahoko Shindo, the medical officer at WHO’s Epidemic and Pandemic Alert and Response department, said the final version of the phases would be available by year’s end. She announced this on Friday during the 13th Congress of Infectious Diseases in Kuala Lumpur.
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Infectious disease experts at the conference also warned that although the worst of the bird flu threat is over, the fight to eliminate the disease from poultry is weak.
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The head of the United Nations’ Food and Agricultural Organization, Dr Juan Lubroth, said that “drawbacks and weaknesses” remain in the battle to eliminate the H5N1 strain from the poultry sector. The virus is now active in 10 countries and is endemic in the poultry population of some.
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Infectious diseases experts fear that H5N1 could mutate into a form that spreads easily among humans and trigger a deadly flu pandemic.
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He said the death of poultry especially affects the poor, 80 per cent of whom own livestock for their livelihood. As poultry is an important, inexpensive protein source, Dr Lubroth warned that failure to protect their food sources could worsen the global food crisis.
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Veterinary services around the world need to be strengthened and more experts trained, while reporting must be more transparent, he said, adding that countries have to use more surveillance and implement policies to deal with the disease.
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“We fail to see that political commitment,” he said.
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This is of concern especially as H5N1 in humans exhibits a high fatality rate and unlike seasonal human flu, H5N1 spreads to the various organs.
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On Thursday, Indonesia reported another two human avian flu cases, bringing the total number of infected humans worldwide to 385 since 2003. Of these, 243 have died.

[gsgs]

> Last year, a cluster of eight Indonesian

was this already announced/established in 2007 ?

[HenryN]

Originally Posted by gsgs

> Last year, a cluster of eight Indonesian

was this already announced/established in 2007 ?

Karo cluster was discussed in real time.

http://www.recombinomics.com/News/05...a_H2H2H2H.html

[HenryN]

Looks like old 3 and 4 are being combined into 3 and old 5 and 6 are being combined into 4. The new 5 and 6 are pretty much irrelevant because they will quickly follow 4 (its the 1,2,3,6 system).

http://www.who.int/csr/disease/avian...enza/phase/en/

New system will allow WHO to admit that there are dozens of H2H clusters, but hold off on vaccine creation and distribution until it is too late to have much of an effect. The new system is a "reactive" as the old, but will dispose of the issue of many examples of H2H among family members and close contacts.

[rymich13]

When was the earliest known h2h transmission?

[Farmer]

Originally Posted by niman

Looks like old 3 and 4 are being combined into 3 and old 5 and 6 are being combined into 4. The new 5 and 6 are pretty much irrelevant because they will quickly follow 4 (its the 1,2,3,6 system).

http://www.who.int/csr/disease/avian...enza/phase/en/

New system will allow WHO to admit that there are dozens of H2H clusters, but hold off on vaccine creation and distribution until it is too late to have much of an effect. The new system is a "reactive" as the old, but will dispose of the issue of many examples of H2H among family members and close contacts.

This will have the effect of keeping the apparently evolving epidemiology of H5N1 out of the international media spotlight. I see that the world stockmarkets are apparently the paramount consideration of WHO, not human health.

At best, this type of recategorization will only delay the inevitable panic (as you say the 1,2,3,6 system) of an uninformed public. This approach has the potential to make the long term global financial effects much worse than if we all made a calm, concerted and focused effort to prepare now.

Which state/corporate entities are putting the political pressure on WHO to recategorize the alert levels?

[ironorehopper]

Alert Phase system (http://www.searo.who.int/LinkFiles/C...ion-update.ppt)

[ironorehopper]

[ironorehopper]

[ironorehopper]

Originally Posted by rymich13

When was the earliest known h2h transmission?

From a epidemiological and serosurveys point of view, the first instance of unsustained human-to-human transmission of H5N1 avian influenza virus was in Hong Kong, 1997.

The most clear, and accepted, instance of h2h transmission was the so-called Karo Cluster, Sumatra Island, Indonesia, May 2006 (http://www.who.int/csr/don/2006_05_23/en/index.html)

[HenryN]

Originally Posted by ironorehopper

From a epidemiological and serosurveys point of view, the first instance of unsustained human-to-human transmission of H5N1 avian influenza virus was in Hong Kong, 1997.

The most clear, and accepted, instance of h2h transmission was the so-called Karo Cluster, Sumatra Island, Indonesia, May 2006 (http://www.who.int/csr/don/2006_05_23/en/index.html)

There have been dozens of examples of H2H. In fact most of the first cases of confirmed H5N1 have been in clusters and most of the clusters have been H2H (Cambodia, Indonesia, Turkey, Iraq, Azerbaijan, Nigeria, Pakistan). H2H has also been written up in peer reviewed journals for Thailand and Indonesia, with a "can't be excluded" in Azerbaijan.

[ironorehopper]

Originally Posted by niman

There have been dozens of examples of H2H. In fact most of the first cases of copnfirmed H5N1 have been in clusters and most of the lcusters have been H2H (Cambodia, Indonesia, Turkey, Iraq, Azerbaijan, Nigeria, Pakistan). H2H has also been written up in peer reviewed journals for Thailand and Indonesia, with a "can't be excluded" in Azerbaijan.

I agree. I don't want to hide nothing. Only, the most explosive case, Karo Cluster highlight.

[HenryN]

Commentary

http://www.recombinomics.com/News/06...New_Alert.html

[gsgs]

they decrease the information content of the phases.

we need more phases, not fewer.


best would be to give a number for the estimated
pandemic probability, (-say for the next 12 months) of course.

[Oracle]

Originally Posted by rymich13

When was the earliest known h2h transmission?

Within the first batch of human infection cases reported between May and August 1997.

Isolation of Avian Influenza A(H5N1) Viruses From Humans—Hong Kong, May-December 1997. Vol. 279 No. 4, January 28, 1998.
http://jama.ama-assn.org/cgi/content/full/279/4/263

"The other possible case-patient (of 2 discussed in this paper) is the 3-year-old sister of patient 7 and cousin of patient 6. She lived in the same apartment as patient 7 and had onset of fever on December 13 and was hospitalized in good condition. Preliminary laboratory results were positive for influenza A(H5N1) virus; confirmation of these results by virus isolation is pending.

Patient 6
On December 7, a 5-year-old girl developed fever, rhinitis, cough, sore throat, and vomiting. As of December 17, she remained hospitalized in satisfactory and stable condition. A nasopharyngeal aspirate collected on December 10 yielded influenza A(H5N1).

Patient 7
On December 12, a 2-year-old boy developed fever and was admitted to the hospital in good condition. The child is a cousin of patient 6, who frequently visited him and his family at their home. On December 16, a culture from the child was reported positive for influenza A(H5N1) virus."

Right from the get-go, we have probable family clusters reported in the initial 18 cases of avian H5N1 infection in humans. A telling comment in the paper:

" because influenza surveillance in Hong Kong has been conducted primarily in hospitals, milder cases may not have been recognized, and the severity of infections identified to date may not be representative of the spectrum of illness caused by A(H5N1) infection in humans."

A later article (BMJ 10 Jan 1998;316(7125):91) reported that follow-up contact investigation of the initial cases (15, 4 died and another 4 in critical case at the time of publication) showed that 9 out of 502 contacts were positive (antibody assay for H5N1) for exposure but did not develop severe symptoms.

http://bmj.bmjjournals.com/cgi/content/full/316/7125/91

[HenryN]

Originally Posted by Oracle

Within the first batch of human infection cases reported between May and August 1997.

Isolation of Avian Influenza A(H5N1) Viruses From Humans—Hong Kong, May-December 1997. Vol. 279 No. 4, January 28, 1998.
http://jama.ama-assn.org/cgi/content/full/279/4/263

"The other possible case-patient (of 2 discussed in this paper) is the 3-year-old sister of patient 7 and cousin of patient 6. She lived in the same apartment as patient 7 and had onset of fever on December 13 and was hospitalized in good condition. Preliminary laboratory results were positive for influenza A(H5N1) virus; confirmation of these results by virus isolation is pending.

Patient 6
On December 7, a 5-year-old girl developed fever, rhinitis, cough, sore throat, and vomiting. As of December 17, she remained hospitalized in satisfactory and stable condition. A nasopharyngeal aspirate collected on December 10 yielded influenza A(H5N1).

Patient 7
On December 12, a 2-year-old boy developed fever and was admitted to the hospital in good condition. The child is a cousin of patient 6, who frequently visited him and his family at their home. On December 16, a culture from the child was reported positive for influenza A(H5N1) virus."

Right from the get-go, we have probable family clusters reported in the initial 18 cases of avian H5N1 infection in humans. A telling comment in the paper:

" because influenza surveillance in Hong Kong has been conducted primarily in hospitals, milder cases may not have been recognized, and the severity of infections identified to date may not be representative of the spectrum of illness caused by A(H5N1) infection in humans."

Yes, H2H is not new. Most cases involve 2 or 3 family members (or other close contacts), and there were also clear examples in Vietnam and Thailand in 2004.

WHO uses many techniques to exclude H2H clusters, but those methods really have lost credibility, so the new systen will allow WHO to admit that there are dozens of small H2H clusters, and still keep the level at 3.

[gsgs]

they could go back to

1) no pandemic
2) pandemic

[gsgs]

do the phases count for H5N1 only ?

will they establish phases for -say- H7 also, when the human cases
increase a lot -more than with H5N1 ?

what phase would they have been in in 1976 ?
in 1977 ?

[HenryN]

Originally Posted by gsgs

do the phases count for H5N1 only ?

will they establish phases for -say- H7 also, when the human cases
increase a lot -more than with H5N1 ?

what phase would they have been in in 1976 ?
in 1977 ?

I think 1976 was limited to a few cases in NJ.

[HenryN]

Commentary

http://www.recombinomics.com/News/06...ert_Panic.html

[ironorehopper]

Originally Posted by gsgs

do the phases count for H5N1 only ?

will they establish phases for -say- H7 also, when the human cases
increase a lot -more than with H5N1 ?

what phase would they have been in in 1976 ?
in 1977 ?

Yes. The Canadian H7 case

''Avian influenza A(H7) human infections in Canada

5 April 2004

The first human case of avian influenza A(H7) in British Columbia occurred in a person who was involved in culling of infected birds on 13-14 March. On 13 March, he may have been accidentally exposed in the eye. On 16 March, the individual reported conjunctivitis and nasal discharge. Treatment with oseltamavir, an antiviral drug active against influenza A viruses, began on 18 March. On 30 March, Health Canada concluded that this case was caused by avian influenza A(H7). Health Canada informed WHO of this case on 31 March. The patient's symptoms have fully resolved.

On 2 April, WHO was informed by Health Canada of a second poultry worker in British Columbia identified with avian influenza A(H7). This worker developed conjunctivitis in March 25 after close contact with infected birds. He was treated with oseltamivir on 25 March and his symptoms resolved.

Based on this epidemiological information provided by Health Canada, the World Health Organization today raised the global pandemic preparedness level from 0.1 to 0.2 for the Canadian outbreak.

Global pandemic preparedness levels are dictated by the epidemiological situation for each local event. Level 0.2 means that more than one human case caused by a new subtype of influenza virus has been identified in the local event.

In Asia, another avian influenza virus, A(H5N1), has been responsible for 34 reported human illnesses and 23 deaths. The existing global preparedness level of 0.2 for the avian influenza in Asia remains unchanged.

Preparedness levels have been organized into a matrix established by WHO in 1999(WHO Influenza Pandemic Preparedness plan). When a preparedness level is raised to 0.2, affected countries are advised to step up their surveillance in persons exposed to affected poultry, to organize special investigations to better understand the new virus, to advise persons at risk to wear protected clothing, and to consider the use of antivirals and normal human influenza vaccine.

WHO has been informed that Canada has taken all required actions in response to the current avian influenza A(H7) outbreak in British Columbia.

The new pandemic preparedness level for avian influenza A(H7) also means that WHO will begin a series of activities to obtain the virus, characterize it, and assess the needs for diagnostics and vaccine development.

-

http://www.who.int/csr/don/2004_04_05/en/index.html

------

(OLD WHO Pandemic Phase Level, http://www.who.int/entity/csr/resources/publications/influenza/whocdscsredc991.pdf)

-------''

[gsgs]

wow, they even had fractional levels in 2004 and for 2 strains
separately !

I once proposed 60 fractional levels 0.0,...,5.9 but everyone
ridiculed or said I were posting nonsense or such

reducing the number of levels=phases is not good, IMO.
The more the better, the more informative.

[Oracle]

If HPAI H7 was going to make a 'bid for pandemic power', it could have done it, neatly, in Abbottsford. It started out innocuously as LPAI in late February.

Four prisons. Thriving Asian immigrant population. First Nations reservation. Major continental flyway intersection with major river valley with areas of local wetlands. Large, densely-packed poultry operations.

If it had been an Asian H5N1 strain, it would have worse than nominal conjunctivitis in humans.

Who Pandemic Alert Phases and Levels are IRRELEVANT for H5N1. This is an AVIAN disease. Humans and assorted mammalian and avian scavenger species reported to date are accidental victims.

If this strain wished to mutate to move into humans as a specialty virus of our species, it would have done so by now.

[rymich13]

So as I see it we have had limited h2h transmission all along. But the question is, has it become more easily transmitted as time goes on? Also it seems that this virus may take some to become pandemic because it seems to be adapting to humans, but at a slow and steady rate which leads me to beleive that we may still be a few years away from a pandemic. But anything can happen it may happen next week, next month, next year, 10 years from now, etc. We just do not know.

[Sally Furniss]

Originally Posted by ironorehopper

From a epidemiological and serosurveys point of view, the first instance of unsustained human-to-human transmission of H5N1 avian influenza virus was in Hong Kong, 1997.

The most clear, and accepted, instance of h2h transmission was the so-called Karo Cluster, Sumatra Island, Indonesia, May 2006 (http://www.who.int/csr/don/2006_05_23/en/index.html)

FT thread on the Karo cluster Indonesia - Family in Karo suspected of having bf

FT threads on Pakistan Cluster
http://www.flutrackers.com/forum/showthread.php?t=62591
http://www.flutrackers.com/forum/showthread.php?t=46327
http://www.flutrackers.com/forum/showthread.php?t=45631

[rymich13]

I read that the new system would be completed by years end but when do they plan on implementing it fully?

[Commonground]

Originally Posted by rymich13

So as I see it we have had limited h2h transmission all along. But the question is, has it become more easily transmitted as time goes on? Also it seems that this virus may take some to become pandemic because it seems to be adapting to humans, but at a slow and steady rate which leads me to beleive that we may still be a few years away from a pandemic. But anything can happen it may happen next week, next month, next year, 10 years from now, etc. We just do not know.

In my opinion, we can not judge the rate of the spread, because it is stifled by Tamiflu. Although I do agree it is not efficient transmission, I do wonder exactly how efficient it is? As Dr. Niman has noted many times in the past week, our latest outbreaks this year have included 3 clusters, albeit with different diagnoses, but circumstances point to H5N1.

[Sally Furniss]

Originally Posted by rymich13

So as I see it we have had limited h2h transmission all along. But the question is, has it become more easily transmitted as time goes on? Also it seems that this virus may take some to become pandemic because it seems to be adapting to humans, but at a slow and steady rate which leads me to beleive that we may still be a few years away from a pandemic. But anything can happen it may happen next week, next month, next year, 10 years from now, etc. We just do not know.

Length of transmission chain is a significant measure of transmissibility. Tamiflu is rightly given to contacts of a case. Use of the Tamiflu blanket can mask transmission events.

[Commonground]

Originally Posted by Oracle

If HPAI H7 was going to make a 'bid for pandemic power', it could have done it, neatly, in Abbottsford. It started out innocuously as LPAI in late February.

Four prisons. Thriving Asian immigrant population. First Nations reservation. Major continental flyway intersection with major river valley with areas of local wetlands. Large, densely-packed poultry operations.

If it had been an Asian H5N1 strain, it would have worse than nominal conjunctivitis in humans.

Who Pandemic Alert Phases and Levels are IRRELEVANT for H5N1. This is an AVIAN disease. Humans and assorted mammalian and avian scavenger species reported to date are accidental victims.

If this strain wished to mutate to move into humans as a specialty virus of our species, it would have done so by now.

I thought this was interesting

WHO: on pandemic influenza you need to know 10 things
2008-01-07 China CDC website read 262 times

1. Pandemic influenza and avian flu different.

Avian influenza refers to a group mainly affected birds of different influenza virus. Is extremely difficult these bird viruses transmitted to other species, including pigs and humans. The vast majority of the avian flu virus will not spread to people. When a spread in humans has never been a new subtype of virus can occur when the influenza pandemic.

Therefore, H5N1 avian influenza virus is a potential for a pandemic strain, because it eventually could mutate into a human transmission of the virus. Once the mutations, it will no longer be a bird virus, which will become a human influenza virus. Influenza pandemic is a human disease can make a new influenza virus triggered.
-snip-
10. When the threat of a pandemic, the World Health Organization to increase global warning.

World Health Organization and the ministries of health and various public health organizations in close cooperation to support countries in monitoring the spread of influenza virus strains. One able to identify influenza virus strain of influenza monitoring system for rapid detection of a pandemic virus is essential.

In order to promote pandemic preparedness plans, provides for six different stages and to determine the government, industry and the World Health Organization duties. The current situation as the third stage: a new virus to humans is causing infections, but does not spread easily in the world.
-snip-
http://64.233.179.104/translate_c?hl...px%3FId%3D2779

[Oracle]

H5N1 lacks more than half of the sequence markers for pandemic human disease, according to articles posted here recently.

The real danger in H5N1 lies in the continued spread, reinfection of migrating waterbirds and episodic infection of passerines, and viral transmission to highly susceptible domestic poultry.

The danger to the global food source posed by H5N1 was also noted in a commentary article posted today (and previously noted in other threads).

In the last 20 years, global industrial-scale poultry production has increased by thousands of percent, particularly in Asia and more recently in Africa - it's the new, cheap protein source to feed a hungry, overpopulated planet.

The match between migration patterns, Niman's molecular travel logs, and recent adoption of large-scale poultry operations in specific countries and outbreaks:

Priceless.

I concur with Henry: the so-called pandemic experts simply don't 'get it'. The necessary molecular markers for pandemic aren't acquired by ressortment, nor by 'random mutation'.

But at least we understand why Webster was 'far less concerned' about H5N1 than he had been several years ago.