Facing the flu

"Human influenza is coming, we know that, and no government, no leaders can afford to be caught off-guard."

"So far it is crystal clear what H5N1 could do. There is a clock ticking, we just don't know how long we have got."

It has already fulfilled two of the three conditions for creating a human flu pandemic: it is a novel virus that humans have no or little immunity to and it can replicate in humans, causing serious illness.

The third condition will be met if it learns to transmit between humans efficiently.

"There have been continual avian-flu outbreaks around the world in poultry; in fact there have been 20 such outbreaks since 1959, but always the birds are slaughtered and the progression is stopped," Harris says.

"In this case it hasn't been able to be contained. Millions of birds throughout Asia and Russia are infected ... and now we have a huge reservoir of the virus. It's too late for that first phase of slaughter to stop the spread."

With migratory birds carrying the virus farther abroad and international travel so prevalent, Harris says conditions have never been so good for a pandemic.

"So far it is crystal clear what (H5N1) could do. There is a clock ticking. We just don't know how long we have got.

"(Pandemics) always come from avian flu and we have never had such a large reservoir before so the chances of it could not be higher."

Harris says the pandemic outbreak would come if a person was infected simultaneously with the easily transmitted annual influenza bug H3N2 and H5N1. The two flu bugs could merge, rearrange themselves and become an easily transmitted virus.

Experts cannot guarantee this will happen but admit all factors have combined to give this virus "a very strong chance" of going to a pandemic level.

Harris says the virus "could evolve into a monster", and warns people should start preparing for the worst.

Harris says an outbreak will most likely hit New Zealand in autumn or winter because H5N1 survives best in cold, humid conditions.

The best protection in an H5N1 pandemic will be to avoid public outings, stock up on food and water, and if necessary isolate yourself in your home and get a prescription for the anti-viral drug Tamiflu.

"Preliminary tests show the drug is likely to be effective against all strains of H5N1 if taken within two days of symptoms developing," says Harris.
- Anna Claridge

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Planning for a flu pandemic began at the Health Ministry in the late 1990s but efforts have stepped up dramatically in recent months.

Twenty-six Health Ministry staff are now fleshing out precise details of a response. The Health Ministry is the lead agency although almost every other ministry is involved in pandemic planning.

Police, customs, welfare and education agencies are considering non- health issues such as school closures, border management and the maintenance of critical infrastructure, such as the supply of food and water, and law and order.

The director of public health, Mark Jacobs, describes it as "potentially the country's most serious crisis".

Minimising the spread of the virus will be critical.

It is likely that all but the most seriously ill will be asked to stay at home. Public events will be cancelled and childcare facilities, schools, and tertiary institutions closed. The public will be advised against unnecessary travel.

Hospitals and general practices are likely to be overwhelmed.

High levels of absenteeism are expected at many workplaces as people fall ill, or stay home to care for others. Food, water, gas and electricity supplies are all likely to be affected.

Advice to the public on how to care for family and friends at home will be available through a national pandemic hotline.

Hundreds of children could be orphaned and health boards and other agencies have been advised to make plans for their care.

Deaths are expected to peak in the fourth week of a pandemic. The ministry believes existing morgues at hospitals, undertakers and funeral directors have the capacity to cope. A key group, the Officials' Committee for Domestic and External Security Co-ordination (ODESC), will be charged with minimising social disruption and the economic impact.

The Health Ministry has already committed $26 million to buy 835,000 doses of anti-viral drug Tamiflu, enough for one in five New Zealanders. Health workers and other essential staff are likely to be first in line. It is also buying enough infection-control equipment, such as masks and gloves, to equip frontline health staff for several months.

It is "exploring options" for supplies of any bird flu vaccine, if one becomes available, but global demand would be high and supplies limited.

In Canterbury, pandemic planning is being led by the medical officer of health, Mel Brieseman, DHB chief medical officer Nigel Millar, and Pegasus Health managing director Paul McCormack.

McCormack says a key recommendation from Canterbury's pandemic planners will be the need to keep bird-flu sufferers away from other patients. It is likely patients will be asked not to just turn up to their usual GP or hospital, but to ring for an assessment. People will then be sent to designated centres for bird-flu sufferers.
- Kamala Hayman

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Start thinking about it. Start talking about it.

"We know there is going to be a pandemic but we don't know when, what strain or how bad," says the director of public health, Dr Mark Jacobs.

The Government has secured some of the anti-viral drug Tamiflu for targeted use among key groups.

Individuals can also get Tamiflu prescribed but it is expensive ($75 for a course of 10 tablets), it needs to be taken consistently throughout disease outbreaks (meaning an individual's needs might cost hundreds of dollars), and recent heavy demand has depleted available stocks. Authorities are urging people to rely on simpler measures to cope: staying away from the sick (or from the well if you are sick), maintaining good hygiene, and being prepared.

Authorities say households should have a survival kit, similar to those for other civil disasters, including measures to cope if essential services are affected. "We need to think about a pandemic the same way we think about earthquakes and floods. We need to be ready," Jacobs says.

The kit should contain:

• At least two weeks supply of water.
• Two weeks supply of canned or dried food (and a can opener).
• A battery-operated radio with spare batteries.
• A first-aid kit.
• Protective clothing including gloves and face masks.
• Paracetamol to reduce fevers.
• Warm clothing and sleeping bags.

Jacobs says taking basic precautions during a pandemic could reduce the rate of infection.

Individuals should take extra care to wash and dry hands after going to the bathroom, make sure their faces are properly covered when they sneeze, use tissues to sneeze in, and stay more than one metre away from people who are sick.

Health authorities are asking everyone to have an influenza jab when the annual vaccine for conventional flu becomes available, so if patients have flu-like symptoms, doctors will be able to rule out the usual flu strains.

Depending on the severity, a pandemic could hit in as many as three waves of up to six weeks each over the course of almost a year.

Mark Jacobs' best advice for a nervous public? "The bird flu may be the start of the next pandemic but it may well not be. We just don't know. People do need to be concerned but keep it in some perspective. Either way, we are going to have an outbreak and this is a good opportunity to review how prepared we are."

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KEEPING FEAR IN CHECK

Dr Peter Marsh of Oxford University is a world expert on social behaviour and says scientific advice describing a virus as a "time bomb" or talk of it "mutating" provides a picture that inevitably creates public alarm.

"Once you have that kind of imagery," says Marsh, "then rational consideration, rational decision-making, really goes out of the window." He adds: "Humans tend to worry more about the unfamiliar and the improbable."

While New Zealand experts spoken to will not be drawn on the likely social fallout during a pandemic, health authorities are urging calm.

The Ministry of Health says New Zealand has one of the most advanced pandemic plans in the world, authorities are prepared and the threat of outbreak must be kept in perspective.

While Kiwis may pride themselves on taking a level-headed approach to crises, the deserted foodcourts and palpable suspicion of all things Asian during the 2003 Sars scare suggests the population is not immune to over-anxious reactions.

A worst-case scenario presented as part of the United States Government pandemic plan gives a taste of how an outbreak could create social panic.

The model traces the possible course of a pandemic from initial outbreak in a small village in Asia, spreading through the continent to densely populated East Asia, and then into the West.

As it spreads into the United States, "rates of absenteeism in schools and businesses begin to rise. Exaggerated accounts of illness are reported by the media. Citizens begin to clamour for vaccine but only 10 per cent of the estimated need is available. Hospitals and outpatient clinics become severely short-staffed when the majority of doctors, nurses and health-care workers become ill. Intensive-care units at local hospitals become overwhelmed and soon there are widespread shortages of mechanical ventilators for treatment of patients with pneumonia.

"Family members become distraught and outraged when loved ones die within a matter of days. Looting becomes a serious problem in major metropolitan areas due to shortages of police officers.

"Further deterioration in health and other essential community services occurs over the next six to eight weeks as illness sweeps across the country."

Dr Michael Osterholm of the University of Minnesota's School of Public Health – a prominent voice in the warnings of potential virus-spread catastrophe – says the closest the world has come to this scenario in modern times was the Sars crisis.

And his conclusion: "Even with the relatively low number of deaths it caused compared to other infectious diseases, Sars had a powerful negative psychological impact on the populations of many countries."

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ECONOMIC EFFECTS

"It would certainly throw us and the rest of the world into a recession."

The probable closure of New Zealand's borders during a bird-flu pandemic would create an unprecedented economic shock. And that may only be the start of it.

The $6.3 billion tourism industry, which brings 2.4 million tourists to the country each year, would be decimated. Many small businesses would close, possibly for good, as staff chose to stay home and avoid contact with the public.

"That is what we saw in Asia during Sars and that's the advice coming out of Indonesia now," BNZ chief economist Tony Alexander says. "That kind of blow would force downward pressure on the New Zealand economy and secondly, confidence would be shattered domestically so there would be reduced spending and we could expect a recession."

Production capacity would slow as the workforce wilted, although Government plans already in train would ensure basic infrastructure, including water and power supply, could still operate.

Some overseas economists are predicting an even grimmer reaction, with one British model pointing to economic turmoil unseen since the Great Depression of the 1930s, with massive unemployment and national economies slashed.

Tony Fenwick, of the Ministry of Economic Development, says contingency plans have been put in place with energy providers, the information and communication sector (from phone lines to TV), the transport sector and water and waste.

"We have worked with each sector to ensure business continuity (in a worst-case scenario). In this event the human-resource issue will be key."

Fenwick says it is almost impossible for the Government to put a figure on the possible economic impact of an outbreak.

Alexander says the potential economic impact could not be compared to any other event in New Zealand history. "It's different from foot and mouth, different from Sars. In the 1918, '57 and '68 pandemics it wasn't the modern world economy that we know today so we can't measure against those events. It would certainly throw us and the rest of the world into a recession. It would be a short, sharp shock."

Based on the experience of other recent global shocks, a select few businesses would benefit from an outbreak – supermarkets are an obvious one – but less predictable is the suggestion of a boon for craft shops. After the September 11 attacks in America, orders to craft-supply shops soared as Americans chose to isolate themselves in their homes. But they would be small oases in a ravaged economy.

"The Reserve Bank would ease monetary policy sharply," Alexander says. "The New Zealand dollar would plummet because our biggest export earner (tourism) would be decimated and investors would want their funds closer to home so they would pull their money out of foreign markets and bring it back here. It would be devastating."
- Anna Claridge

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For those seeking some relief from the gloomy talk of pandemics and mass death, there are various voices arguing that we're getting a bit carried away. True, some are conspiracy theorists, some are probably being a little bloody-minded, and they are all in a decided minority, but they do have some points to make.

Setting aside those who insist the current scenario is being driven by shadowy interests determined to inflict new vaccines on the population, one of the more level of the cautionary voices is Marc Siegel's, an associate professor of medicine at the New York Medical School.

Rather than poo-poohing the bird-flu risk, Siegel has written of the part that fear plays in skewing people's response. There are plenty of killer bugs around, he points out, but only a few – usually minor threats – that captivate the media and hence trigger widespread anxiety.

"The mass media tend to magnify the latest health concern and broadcast it to millions of people at once. This has the effect of provoking panic way out of proportion to the risks. I call this phenomenon the `bug du jour'," Siegel wrote in the Washington Post recently. The irony, he adds, is that the resulting panic leads to real illness – as in depression and stress-related disease.

Many commentators point to past epidemic warnings which have spectacularly failed to live up to their apocalyptic billing: Sars, mad-cow disease, smallpox, Ebola virus, West Nile virus.

Wendy Orent, writing in the New Republic, has pointed to some of the same doomsayers cropping up in the bird-flu hysteria as those who have previously seen armageddon coming in the form of other bacteria and viruses.

Another popular doubters' argument, particularly in Asia, questions why the enormous effort has gone into fighting an as-yet-phantom disease when real ones – such as tuberculosis – mow down millions of their kin each year.

Ross Clark, a columnist in the conservative British magazine, The Spectator, wonders whether the wave of panic being generated in his country has its origins in a deeper suspicion of the East; whether bird-flu hysteria "like Sars before it, is really just the latest version of the yellow peril".

Much of the current sceptical commentary takes place on weblogs; for those seeking more words of comfort, try a Google search on bird-flu hysteria.
- Geoff Collett

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Two factors combine to make winter the perfect breeding time for the H5N1 virus in South-east Asia.

Come November the temperatures drop and the humidity increases, an ideal environment for bird-flu survival.

Come December the buildup to the Lunar New Year, known as the Tet Festival, sees poultry overload the dinner plates and backyards of Vietnam and Thailand.

Millions of poultry farmed in the boundaryless backyards are herded to open-air markets for sale, and closer to home, families slaughter their own flocks in often unsanitary conditions.

Among the poultry feasting during the Tet Festival months is a dish that scientists have linked to some of the early bird- flu deaths: duck's blood pudding. This soup is a Tet Festival staple, made from simmered duck innards and raw duck's blood, and provides ample opportunity for the virus to jump from bird to human in the often bloody, unsanitary preparation and consumption conditions.

The bird population in Asia (a figure for the region is impossible to calculate, but authorities estimate China's poultry population is 13 billion) means the region plays host to a huge reservoir of H5N1.

"Within a country, the disease spreads easily from farm to farm," World Health Organisation experts say.

"Large amounts of virus are secreted in bird droppings, contaminating dust and soil. Airborne virus can spread the disease from bird to bird, causing infection when the virus is inhaled."

The virus was first discovered in Hong Kong in 1997. It infected 18 people, killed six and forced the slaughter of more than 1.5 million birds over three days.

Authorities believed they had beaten it until mid-December 2003 when H5N1 re- emerged in birds in Korea and has since spread throughout Asia and most recently to Alaska and Siberia.

The first human infection since the Korean outbreak was in Vietnam in January 2004, in the middle of the Tet Festival.

Almost two years on and despite the culling of millions of birds in Asia, the virus has not been stopped.

At least 120 people have contracted the disease, of whom 63 have died. So far, deaths have been reported in Cambodia (four), Thailand (12), Indonesia (six) and Vietnam (41).

The WHO has launched an international appeal to get resources into poverty-stricken Asian nations with large bird-flu outbreaks.

"WHO is fully aware that governments in several countries with serious poultry outbreaks do not have the resources needed to introduce recommended protective measures for cullers or carry out the very rapid destruction of poultry flocks," the organisation says. "In some of these countries, the practice of raising poultry on backyard farms in remote rural areas, which may not be registered with agricultural authorities, further complicates rapid and systematic elimination of the animal reservoir."

In the interests of protecting international public health, WHO is asking for resources and support from the international community.

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KEEPING BIRDS FLU FREE

New Zealand has just over three million layer hens and 87 million broiler chickens contributing to an annual $800 million poultry industry.

Chicken is our No. 1 choice of meat – we each eat an average of 40kg a year – and the industry is confident the bird flu sweeping Asia poses little threat to that consumption.

Michael Brooks, of the Poultry Industry Association, says that according to MAF advice and monitoring, the chance of bird flu breaking out among poultry in New Zealand is slim.

The poultry industry in New Zealand claims a "world-class" track record of keeping out infectious diseases, thanks mainly to a "no imports" rule on foreign poultry.

"What we are saying is that we don't have bird flu now. We are doing all we can to keep it out and New Zealanders should feel confident consuming poultry products," Brooks says.

"The threat of introduction into New Zealand birds comes from migratory birds. But surveillance of migratory patterns shows it is not seen as a major concern."

He adds: "The potential threat to the industry seems to be minimal ... It appears if avian flu comes to New Zealand it will come through a person."

About 200,000 migratory birds arrive in New Zealand during spring, primarily godwits and knots which have travelled 11,000km from Alaska and Siberia – both are known to have H5N1 in limited areas.

On their return the birds stop in the tidal mudflats of Asia where the risk of exposure to infected domestic fowl or ducks and geese is considered slight.

MAF spokesman Ron Thornton says international experts, migration studies and MAF surveys point to a "low risk (of bird introduction) ... but we can't say anything is zero risk".

If there was an outbreak, MAF would quarantine any affected poultry, trace their movements to detect any further virus cases and most likely kill the infected birds.

However, MAF says it will not adopt a more aggressive policy, of pre-emptive slaughter or suppressive vaccination among bird flocks.

Thornton adds that New Zealand's endangered bird species is unlikely to be at risk of catching H5N1 if there is an outbreak in New Zealand poultry, because of their isolation.

If a native bird – a kiwi, for example – was to contract H5N1, Thornton says it would likely be left to self-cure because it had little chance of transmitting the virus any further.
- Anna Claridge

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"Panic isn't an option ... But I think it is probably just more media overkill."

"Don't paint me as one of these loonies with an underground bunker in the mountains," says Alistair Kinniburgh, a 50-something Christchurch-based photographer. When it comes to bird flu, Kinniburgh is no camo-clad survivalist – but he aims to survive.

"I've been aware of H5N1 for some time now. I'm no longer worried, because I've got my plan set and ready to go." There's no mountain bolthole, but he's got the Tamiflu; his extended family has an action plan ready to go into effect once the first cases are reported. "My attitude is take some precautions, get on with life, but know that at some stage, these things are likely to happen."

Laurel, a Christchurch mother and wife, doesn't want her surname used because she fears people reading this will think her paranoid. She's not paranoid, but she's nervous. A recent round of surgery got her wondering about her vulnerability. Reports that Australian customs were searching Asian visitors' bags because of bird flu upped the angst. Then her son announced his plans to travel through Asia.

Suspicion that it might be a drug company beat-up has faded with each minute searching the web. She's got the Tamiflu. "You just can't afford to be complacent about this."

Labour's Banks Peninsula MP, Ruth Dyson – a Cabinet minister in the last government – takes the view that people should be aware but not panicked. "The most important thing is that New Zealanders recognise that any such threat is a possibility. We need to make sure we're prepared." She hasn't taken any steps to protect herself, but she has confidence in the inter-agency response – in that regard, she says, we are better prepared than Australia.

Of course, it may be that, as in Britain, government MPs are at the front of the queue for State-issued Tamiflu. New Zealand's emergency schedule hasn't been disclosed. Are MPs in line? "I'm not aware of that. We might be."

David Geraghty is a fatalist when it comes to bird flu. He works at what would be close to ground zero in the event of a pandemic: an Auckland tertiary institution with a large number of Asian students.

"Panic isn't an option. I see no other course than to wait and see. If it comes it will likely mutate faster than the mid-'80s Bowie, so loading up on flu medication now might not achieve much. But I think it is probably just more media overkill."

As for one of those who may be faced with staring the disease in the eye, Dr Paul McCormack – the managing director of Pegasus Health and one of Christchurch's lead planners for the possible pandemic – reflects: "Bird flu is very frightening. It is difficult to know how real it is, but my assessment is that it is very real and any sensible person would be frightened by the threat.

"The only way we can respond is to look at protecting ourselves and producing a credible plan."
- Matt Philp

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No human-to-human transmissions of bird flu have been confirmed by the World Health Organisation (WHO), however two cases are suspected. All other cases have been confirmed as bird-to-human transmission.

In September 2004, Thai health authorities investigated the first possible case of after a mother who had cared for her infected eight-year-old daughter fell ill.

Authorities found the woman either contracted H5N1 from her daughter or another environmental source but could not come to a definitive conclusion.

In January this year, a 47-year- old Vietnamese man died in Hanoi after twice testing negative for H5N1. A third test, done after his death, found the strain.

The man was retested only because his younger brother, who had been caring for him, had also fallen ill. The brother's initial test for H5N1 also came back negative but two subsequent tests were positive.

Doctors say that in both cases, it was impossible to rule out another environmental source. Even if the cases were proved, evidence to date indicates the transmission of the virus among humans has been limited to family members only and that no wider transmission in the community has occurred.

"It's almost definite that there have been clusters of people who passed the virus human to human," says Christchurch microbiologist Ben Harris. "But what we do know is it won't transmit easily in its current form."

WHO says the lack of transmission between humans is heartening, but adds: "The situation could change quickly, as the H5N1 strain has been shown to mutate rapidly and has a documented propensity to exchange genes with influenza viruses from other species."

As Harris says: "The thing at the moment is that it's not very good at transmission. If it can learn to do that rapidly then we are in significant trouble."

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World Health Organisation figures show the current mortality rate for bird-to-human transmission of the H5N1 virus to be about 51 per cent – one in two of its victims have died.

However, Ministry of Health figures taken from a United States pandemic model show the likely infection and mortality rate in New Zealand to be much lower should bird flu become easily transmitted human to human.

The director of public health, Mark Jacobs, says under a model developed in the US, an H5N1 outbreak among New Zealand's 4.1 million population would result in:  

• Between 1600 and 3700 deaths. 
• Between 6900 and 15,200 people requiring hospitalisation. 
• Between 325,000 and 759,000 requiring a doctor's consultation.

During the peak week of an eight- week pandemic wave, 35per cent of the population would be infected and a general practitioner would on average be consulted by 80 people with H5N1.

Jacobs says all figures surrounding possible infection and mortality rates are based on a model, and the actual incidence could be much higher or lower depending on the strength of the virus.

"The truth is it could be worse, it could be better, we just don't know."

Compared to the 1918 pandemic which killed 8250 New Zealanders (745 per 100,000), the model shows a worst-case scenario H5N1 pandemic in New Zealand would kill 91 people per 100,000, or about 3700 in total.

Canterbury would have about 400 deaths and 1800 cases in hospital.

New Zealand's normal death rate is about 28,000 Kiwis dying each year, of all causes.

The most common causes – statistically far more likely to kill you than bird flu – are cancer (7810 deaths a year) and heart disease (7618 deaths).

But the projected bird-flu toll would be higher than the road toll (435 deaths a year – 0.01 per cent of population) or those killed by diabetes (782 deaths a year – 0.02 per cent of population), for example.

Globally, WHO models suggest that, in the less-devastating models, a pandemic of H5N1 would kill between two million and 7.4m. Up to 1.2 billion people would get sick and 28 million would be hospitalised.

This compares to:

• The Sars outbreak which infected 8100 people, killing 774 of them.
• 2.9 million deaths from Aids each year (25 million deaths to date).
• 2 million deaths from tuberculosis each year.

• 1 million deaths from malaria

– Anna Claridge

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- © Fairfax NZ News