H5N1

Indonesia: Still quiet

It's 9:30 pm in Vancouver, and almost noon Thursday, July 24, in Indonesia. Here is the next-to-last Antara story I can find about avian flu: Bird Flu Cases Declining In Indonesia, But Prevalence Still Seen High Internationally.

You'll notice that the date is June 23, a month ago. Since then, Antara has published just two flu stories, on July 22 and July 24. Both have to do with international discussions, not with local H5N1 cases.

The other Indonesian media have been equally silent: Emmy Fitri's last Jakarta Post flu story appeared on June 20.

Bidang Komunikasi Komnas FBPI, a bilingual website, hasn't updated since June 18. An earlier site, Komnas FBPI, went silent after June 19.

I can't even find the last flu report on the English page of the Indonesian ministry of health.

WHO's avian influenza page hasn't been updated since June 19, except for a timeline dated July 14, which has no human cases more recent than two Indonesian women who died in May.

For a country that can barely hold itself together in the face of natural and man-made disaster, this is quite an achievement. Indonesia has shut down reports and discussion on a disease that has killed four out of five Indonesians who have contracted it.

The absolute numbers of avian flu cases, of course, are very small. But the whole point of H5N1 is its potential for catastrophically exponential spread, and that is why people worry about it in Egypt, run pandemic drills in Hawaii, and publish big reports in London and Washington.

You would think that every country with an embassy in Jakarta would be on the phone to its ambassador: "What are these people thinking? What's going on there?" That would be especially true of neighbours like Vietnam, Australia, the Philippines, and Malaysia.

Yet the media of other countries seem as quiet and serene as those of Indonesia itself. Maybe it's the excitement of the Olympics, or the US presidential race, or it's the vacation break for all the editors from Reykjavik to Christchurch. The H5N1 experts, from Dr. Nabarro on down, have said nothing.

Maybe, at the end of the month, Dr. Supari will condescend to formally advise the world of the death of Asnawi Sandri on July 10. Or maybe she won't.

Whether we like it or not, the Indonesian government's silencing of news about H5N1 is a remarkable stunt. If the rest of the world goes along with it for another month, we will have effectively lost track of events. If we lose track of events, we lose hope of smothering a pandemic in its cradle.

South Korea: Cat may have died of H5N1

Via Chosun Ilbo: Cat may have died of bird flu. Excerpt:

Quarantine authorities are investigating whether a cat died of bird flu in Gimje, North Jeolla Province, where a highly pathogenic strain of the disease broke out in April.

If the cat is found to have died of avian influenza, it would be the first mammal to die of the disease in Korea.

Dr. Kim Chul-joong, a professor at the College of Veterinary Medicine at Chungnam National University, said Wednesday, “We isolated the highly pathogenic strain of avian flu from the dead cat found along the Mangyeong River in Gimje and have asked the National Veterinary Research and Quarantine Service to confirm the cause of death of the cat.”

The strain of bird flu found in the country in April and May is known to infect not only poultry but also mammals such as rats and ferrets.

If the cat is confirmed to have died from bird flu, quarantine authorities may have to order a cull of dogs, cats and other mammals in the wild.

A casting call for a pandemic drill

Via The Marysville Advocate in Kansas: Crowd needed for flu testing at health office. Excerpt:

Sue Rhodes is expecting chaos on Aug. 4, and she welcomes it.

Rhodes, Marshall County public health nurse, and staff members at the Marshall County Health Department are planning a pandemic flu training exercise, and they want Marshall County people’s help — the more, the better.

All residents are invited and encouraged to take part in the exercise, which will be from 6 to 9 p.m. Aug. 4 at St. Gregory’s School, 207 N. 14th, Marysville.

Rhodes said the health department has been preparing for several years for pandemic influenza, which is a global outbreak caused by a new influenza virus.

“Despite our best effort, the effects of pandemic influenza could bevery severe,” she said. “Federal, state and local governments all have plans in place that can help in responding to pandemic influenza.”

The Marshall County Health Department has decided to simulate and test its plan to administer a mass quantity of flu vaccine in a brief time.

“In a true pandemic, the state and federal governments will expect us to administer flu vaccine to everyone in our county within approximately one week,” Rhodes said.

Rhodes said she is asking that “anyone and everyone come forward and act as citizens walking through the clinic to get vaccinated.”

“We would like to simulate vaccinating as many people as possible in a trial three-hour period,” she said. “While you are there, register for a drawing and pick up your free family preparedness guide.”

US: Healthcare workers to get first pandemic vaccinations

Via Reuters: US vaccination plan puts health care workers first. Excerpt:

Essential health care workers would be immunized first if a flu pandemic broke out in the United States, the government said on Wednesday.

The Department of Health and Human Services released long-awaited details on who would get vaccinated and when if a serious global influenza epidemic emerged.

The plan put a million health care workers, such as emergency room staff and nurses skilled in vaccinating others, at the top. Next were military and "mission critical" personnel, public health workers and hospital and nursing home staff.

All of these play a "critical role in providing care for the sickest persons; highest risk of exposure and occupational infection," the plan read.

"This guidance is the result of a deliberative democratic process," HHS Secretary Mike Leavitt said in a statement. "This document represents the best of shared responsibility and decision-making."

Here's the news release from the Department of Health and Human Services.

Hawaii: Teams use airport to stage bird flu drill

Via the Honolulu Star-Bulletin: Teams use airport to stage bird flu drill. Excerpt:

Local, state and federal workers and military and civilian health care personnel worked as a team in a bird flu drill yesterday at Honolulu Airport.

The drill, Lightning Rescue '08, simulated what would happen if an airliner from Asia arrived at Honolulu Airport bearing more than 300 passengers with some experiencing symptoms of avian influenza or "bird flu."

"We take it very seriously," said Dr. James Ireland, medical director at Honolulu Airport. "It's unlikely that something like this would happen but we want to be ready."

Dozens of emergency response personnel from different agencies, clad in protective masks and gear, administered first aid to mock patients who were civilian or military volunteers.

The simulation included setting up an emergency intensive care unit in the airport gate called an "Isolation Treatment Facility," with full emergency care facilities designed to run continuously for up to five days, at which time any patients requiring further care would be transferred to a hospital.

ASEAN plans assessment of pandemic preparation

Via Vietnam News Agency: ASEAN to boost bird flu pandemic control. Excerpt:

Bird flu chiefs from across Southeast Asia have agreed to assess the ability of their governments to respond to a deadly human pandemic of the H5N1 virus, reported foreign media on July 23.

The Association of Southeast Asian Nations (ASEAN) agreed that its member countries must be better organised to tackle a human-to-human outbreak of H5N1, Bayu Krisnamurthi, the head of Indonesia’s National Committee for bird flu control and Pandemic Preparedness was quoted as saying.

Many of the 10 states lacked organised bureaucracy or infrastructure to tackle a pandemic, which could kill millions if it mutates into a more easily transmittable form, Krisnamurthi said, adding that Indonesia, Thailand and Vietnam have experienced human cases but others have not.

Therefore, ASEAN countries are expected to finish assessing their preparedness by January or February next year, Krisnamurthi said.

Australia faces "Papal flu"

Via The West Australian: WA health authorities warn of Papal flu spike. Excerpt:

WA health experts are steeling themselves for a potential spike in influenza cases, as World Youth Day pilgrims infected with respiratory viruses, gastroenteritis and chickenpox leave Sydney this week.

With many young worshippers diagnosed with flu, WA Health Department head of communicable disease control Paul Van Buynder urged people who had not had a flu shot, particularly young children, to be vaccinated because it was likely young pilgrims returning from the festivities would help spread it around the country.

“WA has had very little influenza so far this year,” Dr Van Buynder said.

“Many of the pilgrims will leave Sydney after the papal Mass and travel around the country, including to WA, and it is likely they, or other visitors, will bring influenza with them.”

In particular, he advised parents of children who were eligible for free vaccines this year to ensure they had received their second shot.

During the six-day event, NSW Health reported 153 pilgrims were struck down with influenza, 23 were isolated with gastroenteritis and one was infected with chickenpox.

I wonder about the surge capacity of Beijing's hospitals.

US: Nursing homes unready for pandemic

Via Yahoo News: Nursing Homes Unprepared for Pandemic Flu Fallout. Excerpt:

If an influenza pandemic swept through the United States, nursing homes might not be prepared to deal with patient overflow from hospitals, say researchers who looked at more than 400 nursing homes in Michigan and Nebraska to come to this conclusion.

Of those nursing homes, only 23 percent had a specific pandemic influenza plan, 23 percent had a pandemic response incorporated into an overall disaster response plan, and 52 percent had no pandemic plan.

The researchers also found that less than half of the nursing homes had provided pandemic education to staff members, and just 6 percent had conducted pandemic influenza outbreak exercises. Half of the nursing homes had stockpiled commonly used items such as gloves and hand products.

The original report is in The Journal of the American Medical Association. But it doesn't provide even a free abstract, so I won't bother linking to it.

Vietnam: H5N1 hits third province

Via Xinhuanet: Bird flu hits one more Vietnamese province. Excerpt:

Bird flu has stricken Vietnam's central Nghe An province, raising the total number of affected localities in the country to three, according to a local veterinary agency on Tuesday.

Bird flu has, since July 18, killed 30 chickens and 160 ducks raised by a household in Nghi Loc district, the Department of Animal Health under the Ministry of Agriculture and Rural Development said, adding that Nghe An and the two southern provinces of Dong Thap and Tra Vinh are being hit by the disease.

Korean H5N1 strain can infect mammals

This isn't exactly news, but here's the story in The Korea Times : `Bird Flu Strain Can Be Transmitted to Mammals'. Excerpt:

Quarantine authorities said Tuesday that the virus strain of avian influenza that swept the country in April could be transmitted to mammals, but not necessarily to humans.

The Ministry of Food, Agriculture, Forestry and Fisheries sent samples from infected birds to the U.S. Center for Disease Control and Prevention for detailed analysis.

The U.S. agency concluded the virus from the sample could be transmitted to mammals but that there was no proof it could infect humans, an official from the ministry said.

"It was impossible to directly test if it can cause illness in humans. Alternatively, we chose a weasel for testing and when it was infected, it showed similar symptoms to bird flu,'' the official said at a news briefing.

He declined a "yes or no'' answer over the possibility of the virus infecting humans, citing the lack of human testing.

Several years ago, after a B2B outbreak in Korea, some of the cullers were found to have H5N1 antibodies—though they had shown no symptoms. That in itself makes the Korean H5N1 interesting.

H5N1: Here, there, and everywhere

When I ran across this report, I thought it was brand-new. As a commenter has pointed out, it was actually published in 2006. I'm going to let it stand; it's still worth reading and considering. Via PLoS Medicine: Pandemic Influenza: Risk of Multiple Introductions and the Need to Prepare for Them. Excerpt from the conclusion, re-paragraphed:

We conclude that the benefit of a strategy to contain pandemic influenza at its source will be to postpone the time to the next pandemic, not to prevent a pandemic from ever occurring.

If at least one containment attempt of an introduced pandemic-capable strain will be necessary, it is likely that multiple containment attempts will be necessary. Richard Danzig has made a similar point about preparations for bioterrorist events. Because terrorists using biological agents could “reload” with relative ease and strike multiple times in multiple locations, Danzig cautions that we should “plan to defend against a campaign, not an isolated attack” [19].

Even if we had the capacity (i.e., stockpiles, resources, and manpower) to undertake multiple containment attempts, each introduction of a pandemic-capable strain offers a new chance for containment to fail, and subsequent introductions would likely be harder to contain than the first.

Thus, containment is likely to “buy” time, but the amount of time will depend on the capacity for multiple containment attempts and the success probability of any given containment attempt, among other factors.

For most realistic scenarios, containment provides only a small expected gain in time to a pandemic. The expected gain is generally less than the expected time to the next pandemic.

Because of its potentially limited impact, we therefore conclude that containment should not form the centerpiece of a pandemic control policy.

Moreover, to maximize the benefits of any delay achieved by containment, any containment plan should include an additional action plan to be implemented rapidly and concurrently with the first containment attempt.

Central to this action plan should be a series of measures to drastically reduce the risk of introduction of a pandemic-capable strain, including widespread culling of exposed or potentially exposed poultry and changes in agricultural practices to reduce ongoing risk of exposure [20].

Significant poultry culling in and around the site of introduction would shrink the animal reservoir population and would limit bird–human contact. Culling in more distant sites would be warranted if the pandemic-capable strain or related strains were widely distributed. Vaccination of avian populations might be an option in areas where the risk is less, or where culling is not practical.

Such measures, the most extreme of which may not be politically or economically viable at present, would take on additional urgency and perhaps become possible following the introduction, and successful containment, of a pandemic-capable strain.

In other words, no one's going to take H5N1 really seriously until half the staff of Sulianti Saroso Hospital have died from avian flu in three or four days.

At that point Hanoi, Beijing, New Delhi, Islamabad, and Cairo realize they have some unknown length of time to try to save themselves. And so do the rest of us.

Antara awakes

Just 27 days after its last mention of H5N1, Antara brings up the subject of avian flu again: Indonesia, China sign minutes of the meeting. Excerpt:

Indonesian and China`s Health Ministers respectively Siti Fadila Supari and Chen Zhu signed Minutes of the Meeting prior to signing a Memorandum of Understanding about bilateral cooperation in the healthcare sector.

The signing function which was among others attended by Mohamad Oemar, deputy head of Indonesian representative in Beijing, took place at the Chinese Ministry of Health in Beijing on Monday.

"The signing constitutes an initial step of the bilateral healthcare cooperation which will be followed by the signing of an MoU," Minister Supari said, adding that a further step of the cooperation would cover political and economic health affairs.

Before signing the Minutes of the Meeting, the two health ministers who were accompanied by their delegation exchanged views on health problems in the respective country.

"Bird Flu cases apart from the bilateral cooperation become a hot issue during the exchange of views," Supari said.

"We hope the health sector cooperation between Indonesia and China can be stepped up considering that each country has the same problem of diseases like the bird flu," she said.

Meanwhile, China`s Health Minister Chen Zhu said his government hailed Indonesia`s wish to establish health cooperation including exchange of information.

Chen Zhu said further that China had encouraged Indonesia to conduct research and development of the health sector, for instance on bird flu.

Now I feel like one of those old Kremlinologists, trying to track Soviet policy by the neckties worn by Politburo members watching the May Day parade.

So bird flu was a "hot issue"—in what way? Evidently Minister Chen wasn't backing Dr. Supari's position, or she would have said so. Had he been twisting her arm? Was his encouragement "to conduct research and development" a hint that he thinks the Indonesians have been sleeping on sentry duty?

Your guess is as good as the next Kremlinologist's. But it took an international agreement to bring H5N1 back into Indonesia's English-language media, and I don't expect a new torrent of flu stories.

But I would like to think that China and other countries are reviewing the "hot issue" of bird flu with Dr. Supari, even if only in quiet meetings where the handshakes are warm and the smiles are cold.

The Lords on WHO

I've had a chance to look at the House of Lords' report, at least on the chapter dealing with WHO and other intergovernmental agencies. It's very informative, especially about the mandate of WHO and the constraints it operates under. Here's a longish excerpt about the organization's structure and resources, re-paragraphed and with citations removed:

More B2B H5N1 in Vietnam

Via Nhan Dan: Bird flu diseases reoccurs in Dong Thap.

A new outbreak of bird flu disease has occurred in Dong Thap province, the Veterinary Department announced on July 20.

On July 18, right after receiving information about 350 dead chickens that were suspected of suffering from bird flu disease, out of a total number of 500 chickens raised by one household in Tan Hoa hamlet, Tan Nhuan Dong commune, Chau Thanh district, the local veterinary service culled the remaining number of chicken immediately.

After that, the chickens were tested positive to virus H5N1.

At present, the local authority is taking urgent measures to prevent the disease from spreading.

UK: World warned over killer flu pandemic (updated)

Via The Independent: World warned over killer flu pandemic . Excerpts:

The world is failing to guard against the inevitable spread of a devastating flu pandemic which could kill 50 million people and wreak massive disruption around the globe, the Government has warned.

In evidence to a House of Lords committee, ministers said that early warning systems for spotting emerging diseases were "poorly co-ordinated" and lacked "vision" and "clarity". They said that more needed to be done to improve detection and surveillance for potential pandemics and called for urgent improvement in rapid-response strategies.

The Government's evidence appeared in a highly critical report from the Lords Intergovernmental Organisations Committee, which attacked the World Health Organisation (WHO) as "dysfunctional" and criticised the international response to the threat of an outbreak of disease which could sweep across the globe.

The Government said: "While there has not been a pandemic since 1968, another one is inevitable." Ministers said it would could kill between two and 50 million people worldwide and that such an outbreak would leave up to 75,000 people dead in Britain and cause "massive" disruption.

Peers joined ministers calling for urgent action to build up early warning systems across the Third World that can identify and neutralise outbreaks of potentially deadly new strains of disease before they are swept across the globe by modern trade and travel. Peers also called for new action to monitor animal diseases, warning of the potentially disastrous effects of conditions such as the H5N1 bird flu virus jumping to humans and demanded that Britain step up funding for the WHO to tackle the threat.

With international tourist journeys now reaching 800 million a year, giving unprecedented potential for epidemics to spread across borders, and many cities rapidly growing in developing countries, which would provide "fertile ground" to spread disease, peers on the committee warned that conditions such as Sars, avian influenza and ebola "have the potential to cause rapid and devastating sickness and death across much of the world if they are not detected and checked in time".
...
The report called for a fundamental overhaul of the WHO's regional offices around the world. "Given the threats to global health that we face from newly emerging infectious diseases, a dysfunctional organisational structure within the world's principal policy-making, standard-setting and surveillance body simply cannot be afforded."

That "dysfunctional" remark is going to cause some unhappiness in the UN bureaucracy, but maybe it will bring Margaret Chan and David Nabarro out in the open to demand a stronger mandate—especially in regard to virus samples and prompt reporting of human H5N1 cases.

It's already Monday in Britain, but I can't find the original report. When it turns up, I'll post about it and include it in the H5N1 Special Reports list.

In the meantime, you may enjoy Lord of the Blog, the blog of Lord Soley—the chair of the Intergovernmental Organisations Select Committee of the House of Lords.

Update: The Guardian now has a story about the report, and includes a link to it. I've added a link to the report in the H5N1 Special Reports list, down near the bottom of the right-hand column.

Macao warns about flu

Via Xinhuanet: Macao's health authority warns of rising flu cases. Excerpt:

The health authority of Macao Friday issued a warning of increasing local flu cases which may lead to a small outbreak in July.

Between the 25th and 28th weeks of this year, local patients with symptoms of respiratory infection has increased significantly, as 290 to 330 of every 1,000 outpatient visits to local hospitals concerned respiratory infection, according to a press statement from the Health Bureau of the Special Administrative Region.

Based on years of observation, the outbreak of flu usually peaks in March each year, however, the number of flu cases will also surge in July, the Bureau said in the statement.

Global catastrophic risks

It's another glorious summer morning here in Vancouver, so what better time to consider an Oxford conference concluding today on Global Catastrophic Risks.

The risks are far-ranging, from gamma-ray bursts to nanotechnology, but pandemics get attention too. Here's the abstract from Professor John Oxford's paper "Social, Scientific and Medical Lessons from the Great Influenza Pandemic of 1918":

As we are approaching the 90th anniversary of the Spanish influenza there is a realization that much can be learnt to help us face the first global outbreak of the 20th century.

SARS does not provide a realistic model, the virus being controlled by quarantine. Influenza is a much more dangerous virus.

There was advance warning from small outbreaks in 1916 of a newly emerging infection but this information was ignored. The great wave in the autumn of 1918 saw acts of heroism in health care workers and in the community whilst the scientific community struggled to use masks and vaccines. Unexpectedly some quarantine studies were started in the USA to deliberately infect volunteers.

With all this in mind, are we ready now to confront the most vicious virus known to us?

I know, it reads more like the blurb for a thriller than a proper abstract, and he means the 21st century, not the 20th. But it's the best I can find on the site. If Professor Oxford publishes his full paper, I'll be glad to link to it.

Encouragement from the grassroots

Via The StarPress.com in Indiana, an op-ed by a local doctor, Daniel House: Pandemic flu event best battled by honest communication. Excerpt:

For the past few months, I've joined other members of the Henry County medical community in mapping out plans to combat a pandemic.

This Henry County Hospital effort began at the request of the board. All of the current board members are businessmen, and they had all read an article about the impact of a pandemic and how, in these circumstances, you could expect one-third of your staff not to show up for work.

Needless to say, that caught everyone's attention.

Pandemics seem to happen in thirty year cycles. Pandemics occurred three times in the last century -- 1918-19; 1957-58; and 1968-69. Many scientists believe it's just a matter of time before it happens again.

A pandemic would have tremendous economic impact on a community, and not only on those who become ill. Everything would be affected - from the availability of food and supplies to the cancellation of school and church services to even a disruption of funerals.

An award-winning book, The Great Influenza - The Epic Story of the Deadliest Plague in History, describes in vividly painful detail the struggles early 20th century Americans dealt with when the pandemic struck. John M. Barry's book has become a curriculum of sorts for my colleagues and me.

Our goal, if disaster strikes, is to achieve an "ordered chaos." Barry's book has helped us develop and plan for various scenarios.

We have a tremendous advantage over the people of that earlier time. It's called the Internet.

But we will face the same kinds of human emotions that have made pandemics of the past so painstakingly difficult. Family members will likely be separated and quarantined, perhaps for long periods of time. The quality of health care people have gotten used to will be compromised by the sheer volume of those who are ill. People are going to be upset, even combative, on behalf of their loved ones.

So we hope you'll join us in this pandemic preparedness journey. Just by reading this article you're helping us. If you haven't already, we encourage you to read Dr. Bowers' opening article in this series about hand washing -- a simple act that could be a powerful deterrent to the challenges ahead.

The articles also can be found at Henry County Hospital's Web site, and archived under news.

This kind of quiet, local communication and planning is critical, and not just for pandemic flu. Good communication between healthcare workers and their communities can reveal other problems and open the way to their solution.

Hong Kong: Girl treated for Influenza-A

Via the Hong Kong government website: Girl treated for Influenza-A. The girl's a 6-year-old, and it doesn't sound like a serious case.

And via the same source: Summer flu season caution issued. The Hong Kong authorities really don't like it when people get sick.

Philippines planning for H5N1

Judging from the steady trickle of stories like this one, the Philippines isn't procrastinating. Via the Sun.Star Pampanga: Minalin poultry trade ready vs bird flu . Excerpt:

Dr. Analeah Venturina, municipal health officer, said the municipal plans are in place, especially during the [time] of the migratory birds' season.

Venturina said aside from Candaba, this town is also visited by migratory birds.

"Our plans are in place, we have orders here prohibiting the hunting and shooting of wild birds," she said.

Concerns over Minalin's preparedness came after reports that the AI virus infects mostly poultry animals like chicken and ducks.

Minalin is credited as the "Egg Basket" of Central Luzon, and supplies most of the egg requirements of Metro Manila and other provinces. The town's poultry industry plays host to a million egg layers and around 100,000 local ducks.

According to Venturina, migratory birds usually land at the four coastal villages of the town. She, however, clarified that no poultry business are within the vicinity of the area.

Furthermore, local ducks are also prohibited to go to the fields and swamps visited by migratory birds.

The health official advised that physical contact should not be made on sick or dying birds without protective clothing. She said that sanitary procedures should also be considered when handling fouls like constant hand washing.

The Municipal Health Office, she said, is also conducting educational campaign to educate people on the effects and threats of the AI virus.

The Provincial Veterinary Office (PVO) meantime warned that smuggled exotic birds pose might spread the dreaded AI virus.

Hawaii plans pandemic exercise

Via The Garden Island on Kauai: Traffic advisory for medical exercise convoy today. Excerpt:

An eight-vehicle convoy with police escort will be on the road between Nawiliwili Harbor and the Pacific Missile Range Facility today between 9 a.m. and 10 a.m.

The convoy of three Army Humvees, four trucks, and a large tractor-trailer are bringing communications gear and other large equipment from O‘ahu to be set up for a pandemic flu exercise on Thursday.

Civilian and military personnel will be preparing for the exercise through next week. Next Wednesday, two large tents will be set up near the emergency entrance to the Kaua‘i Memorial Veterans Hospital.

Most of the equipment, however, will be set up at the Navy’s Pacific Missile Range Facility at Barking Sands, where the majority of the exercise activities will take place.

Branswell on dengue fever

Via The Belleville Intelligencer, a CP story by Helen Branswell with relevance to flu watchers: Travellers beware: Keep dengue prevention in mind. Excerpt:

It goes by the nickname "break bone fever." And after his brush with dengue, Phil Day knows why.

Day, an expatriate Canadian living in Singapore, contracted the mosquito-borne viral disease in 2007 after years of working in cities across Asia. He and his wife, Karen, were both afflicted, struggling through an illness that left them exhausted and in pain.

While they were sick, they needed to be monitored for signs they were developing the severest form of the disease, a life-threatening hemorrhagic fever. (Neither did.) That monitoring required them to go to hospital for daily blood tests. On one of those trips, Day saw a sight that embodied how he was feeling.

"We were waiting at a traffic light and this old guy, probably 90 years old or so, crossed the street with a cane. He was moving very slowly and every step looked painful," he recounts via e-mail.

"And I turned to my wife and said: `That's it. That's exactly how I feel."'

Dengue is a disease of warm climes; Canada's cold winters deter the virus from setting up shop here.

But the thousands of Canadians who travel to the wide swaths of the world where the virus does spread are at some unquantifiable risk of getting infected with a virus that can trigger symptoms that range from flu-like fatigue and aching joints to a hemorrhagic fever that can kill.

A newly published study looking at trends in dengue infections in travellers notes the past 20 years have seen a marked expansion of dengue's turf, from Southeast Asia to the islands of the South Pacific, the Caribbean and the Americas. There have even been domestically acquired infections in some of the southernmost U. S. states.

Dengue has become a more common diagnosis than malaria for ill travellers returning from tropical regions except Africa, notes the study, published in the July issue of Emerging Infectious Diseases.

Solomon Islands farmers learning about H5N1

Via Solomon Star: Poultry farmers to learn about bird flu. Excerpt:

Poultry farmers will soon learn about what Avian Influenza, also known as bird flu, is.

The Ministry of Agriculture and Livestock will be providing awareness programmes on the disease. Bird flu is a disease of birds that usually attacks wild ducks and geese as well as domestic poultry.

Already, it has affected hundreds of poultry farms mainly in Asia, that resulted in huge losses of income for farmers.The disease is yet to be recorded here.

But the Ministry of Agriculture and Livestock officials are taking no chance. Their awareness programmes are part of efforts to combat the disease should it gets here.

The ministry launched its awareness programme on the bird flu during the recent National Trade and Agriculture Show in Honiara.

With the launch, they are now taking the programme right to poultry farmers. This will be done through the media, field visits and on pamphlets. Information would be distributed to farmers on how the disease affects domestic poultry.

Nepal identifies flu-vulnerable areas

Via The Rising Nepal: Siraha prone to bird flu. Excerpt:

The District Livestock Service Office, Siraha has announced ten VDCs of the district as bird-flu vulnerable areas.

The areas adjoining the Indian border and known for commercial poultry farming were declared dangerous after chicken started dying.

The 10 vulnerable areas include Siraha municipality, Lahan municipality, Sonmati, Majhaura, Bariyapatti, Itatar, Nawarajpur, Madar, Chikana, Lagadigoth and Inarwa VDCs.

Around 250 samples have been sent for examination to the Regional Laboratory in Biratnagar.

Reports have however been received of poultry and eggs being smuggled into the country, taking advantage of the absence of government officials in the bordering areas.

CIDRAP on the death of Asnawi Sandri

Via CIDRAP: Another H5N1 death reported in Indonesia. Excerpt:

Lily Sulistyowati, a health ministry spokeswoman, told the AP she couldn't confirm the man's death. "But we'll let the public know when we release our report at the end of the month," she said.

Under the International Health Regulations, countries are obligated to promptly report human H5N1 influenza cases and other diseases regarded as a potential global health threat to the World Health Organization (WHO), which posts announcements about them and keeps an official count of illnesses and deaths.

However, it's not clear if Indonesia's health ministry has informed the WHO of the case. If the WHO recognizes the man's infection, it will be listed as Indonesia's 136th H5N1 case and 111th death.

WHO's June 19 update on Indonesia, and on the latest total of cases and deaths, hasn't been updated yet. The latest WHO timeline of major events is dated July 14, but again the most recent human deaths on the timeline are those reported on June 19.

So I assume WHO has not yet been officially notified of Mr. Sandri's death. The end-of-the-month report will be a very interesting document, I'm sure.

By the way, 111 deaths out of 136 cases gives us a case fatality ratio of 81.6%.

The recent report from Sulianti Saroso Hospital says most cases arrive in hospital late, which is why the CFR is so high.

But if the local media aren't talking about H5N1, it doesn't seem likely that families will bring their sick kids to a doctor at the first cough or headache, when diagnosis and treatment might be effective.

Bangladesh: Scientist invents quick H5N1 detector

Via The Daily Star: BAU teacher invents easy device to detect bird flu. Excerpt:

A scientist at Bangladesh Agricultural University (BAU) has developed a cheap and easy device for detection of avian influenza (bird flu).

The inventor, Dr Md Alimul Islam, a professor of Microbiology and Hygiene Department of BAU Veterinary Science Faculty, said the bird flu virus has been isolated and it is possible to go for production of its vaccine if they get patronisation from the government.

The low cost device will detect the virus within a few hours, Prof Alimul said, adding that 'per bird per course vaccine' imported from foreign countries costs Tk 100 while it will cost only Tk 30 to 40 if it is produced in the country.

He expressed hope that the new method of bird flu detection and consequent production of low cost vaccines will help to save the promising poultry sector as well as the people related with it.

He conducted his research at the laboratory of F n F Pharmaceuticals in Jhenaidah for a year to develop the 'Molecular Detection Method' as BAU has no laboratory with adequate facilities for such research.

For detecting bird flu, the samples are tested at Savar in Dhaka and for confirmation of the infection, the samples are generally sent to National Institute of Animal Health in Thailand and Way Bridge in England and it takes several days to receive the report.

“Although 229 farms were detected with H5 virus positive in 48 districts of the country during the last several months, chickens of 474 farms were culled on suspicion due to lack of proper detection system. Farm owners faced a loss of Tk 4,500 crore. Tk 10,000 crore was invested in this growing sector,” he said.

Meanwhile, the paper also reports that low-income Bangladeshis can't afford protein these days:

Almost all protein sources are becoming unreachable to limited income group as well as the middle-class people as their prices have marked a sharp rise in the city markets and elsewhere in the country.

With the soaring price of the protein-rich items like fish, meat, pulses, chicken, egg and milk, many people have resorted to cut consumption of these items causing malnutrition among a large section of the populace.

Mostly, women and children are bearing the brunt of the situation.

The prices of protein-rich items, being dearer for the last few years, surged by 20 to 30 percent in the last one month.

It has become tough to purchase two kgs of beef and two chickens with Tk 1000. Moreover, it takes at least Tk 500 to Tk 600 to purchase a kg of fresh fish whereas it was possible for a five-member family to run a week with this money, said market sources.

Vietnam: H5N1 kills "vaccinated" chickens

Via AsiaOne.com: Mystery of 'vaccinated' chickens dying of bird flu. Excerpt:

Chickens that are vaccinated against bird flu are supposed to be immune to the disease.

But hundreds of chickens at a poultry farm in southern Vietnam have died of avian influenza - even though the farm owner had earlier reported that the birds were vaccinated against the disease, an official said yesterday.

Since late last month, several hundreds of the 3,000 chickens in the flock have died at the farm in Tan Lan commune in Long An province, 50 km west of Ho Chi Minh City.

Last week, they were tested positive for the H5N1 avian-influenza virus, said Mr Dinh Van The, head of the province's Animal Health Department.

The farm owner reported to the department that all birds in the farm had been vaccinated against bird flu, he said.

"We suspect that he was not honest in his report, or that the vaccine used at the farm was of bad quality," he added.

"We are investigating the case."

Nigeria pays compensation to poultry farmers

Via The Tide: Avian influenza: FG pays N626m as compensation. Excerpt:

The Federal Government has paid N626 million [US$5.318 million] as compensation to poultry farmers and individuals, whose birds were culled following the Avian influenza (AI) outbreak in 2006.

Mr. Banji Akeredolu, Communication Component National Coordinator, Avian Influenza Control and Human Pandemic Preparedness and Response Project, disclosed this on Wednesday in an interview with the newsmen in Abuja.

Akeredolu said that the compensation was made possible with the assistance of the World Bank, adding that the country’s AI control project had one of the best compensation modalities and rates around the world.

“In countries in South East Asia, they don’t pay compensation, especially to those who have backyard poultry, because they expect you to have taken insurance.

“But in Nigeria, we paid those who lost one chicken and those who lost thousands. The rate now is much better, between N800 and N1,000, depending on the type of bird, compared to the old flat rate of N250 [US$2.12] per birds,” he said.

The Coordinator said it was difficult to quantify the losses resulting from Avian Influenza outbreak.

“It is not just the loss of birds but also loss of jobs and loss of interest in the poultry business.

“A lot of people who lost all their birds have not returned to business. A lot of people who were previously employed are now unemployed,” he said.

Australia: Flu plagues Pope's pilgrims

Via the Sydney Morning Herald: Flu plagues Pope's pilgrims. Excerpt:

The number of pilgrims diagnosed with influenza across Sydney has reached 139, with a total of 70 pilgrims staying at Oakhill College in the western Sydney suburb of Castle Hill now having the disease.

20 pilgrims have also been diagnosed with influenza at the Thomas Moore School in Campbelltown.

The number of pilgrims with gastroenteritis is diminishing though, with 23 pilgrims from St Therese's Primary School at Denistone the only ones infected.

There is one pilgrim from the Sydney Olympic Park site at Homebush with suspected chicken pox who has since been isolated.

NSW Health has confirmed that 79 people have been taken to emergency departments in hospitals around Sydney in the last 24 hours.

The total number omitted to hospital since the start of World Youth Day on July 13 now stands at about 242.

I mention this only to observe that any very large gathering of people is a bonanza for viruses and bacteria. The Globe and Mail says Beijing "is being sanitized and sterilized within an inch of its life." But some Olympic visitors are sure to bring illness with them, and others will find illness waiting for them.

And we lucky Vancouverites get to host the 2010 winter Olympics.

Guerilla epidemiology

At the end of the third week in June, the Indonesian government seems to have effectively shut down most domestic news of avian influenza. The official sites like Komnas FBPI and the ministry of health have been silent. Metro TV Online, an Indonesian television news source, has been equally silent.

A few reports have appeared in Bahasa Indonesia media, duly translated by the flu forum newshounds. They gave us the news about Asnawi Sandri, who appears to have died of H5N1 on July 10, though we had to wait until today, July 17, to get some kind of rough confirmation.

We've also had the all-H5N1 issue of the Annals Academy of Medicine Singapore, with its argument for withholding H5N1 samples co-authored by Dr. Supari herself. I've read the article. It has an excellent summary of the impact of H5N1 up to December 2007. If only for that, you should read it.

But even making allowances for the lack of editing by a fluent English speaker, it doesn't make much sense as an argument for "mutual trust, transparency and equity."

The authors assert that the International Health Regulations (2005) can be interpreted in two ways: to share biological samples, or simply to share "public health information." Indonesia evidently chose the second way after various failures in etiquette by WHO and the authors of scientific papers using samples supplied by Indonesia.

Perhaps these were genuine gaffes by Indonesia's foreign colleagues. If so, they could have been remedied by shouting, screaming, and kicking over furniture in the offices of a few scientists and bureaucrats.

Instead, Dr. Supari and her government chose to engage in a collective sulk. They withheld samples; then they released some; then they withheld some more. It was a passive-aggressive game, played by powerful people more concerned about their own egos than about the potential disaster of a pandemic.

For the time being, Jakarta can win this game. Their English-language media lack the independence to publish and be damned, and the foreign media are too stupidly ignorant of Bahasa Indonesia to go to the sources. The country's medical experts are too few and too cowed to raise a stink, or to bully the government into behaving sensibly. The country has plenty of other miseries to distract both its own people and the rest of the world.

But Asnawi Sandri was not the last Indonesian casualty of H5N1. Maybe this summer, likely by autumn, and certainly by December, more Indonesians will die of avian flu. Dr. Supari may do her considerable best to suppress the news, but it will leak out. A reporter here, a frustrated doctor there—pretty soon, you're talking about a whole new underground information network.

It will have to start from scratch. I spend too much of my dwindling life expectancy surfing the web in search of Indonesian bloggers and news sites that might carry some mention of H5N1. I recall the good old days of SARS, when even nurses in Singapore and English teachers in Harbin were reporting the epidemic in hair-raising detail. Nothing like that seems to be operating now in Indonesia or the other hot-zone countries.

But I'm confident that doctors in Java and Sumatra have colleagues and former med-school classmates elsewhere in the world. Reporters in the west must have friends in Indonesian media. Diplomats in Jakarta are doubtless telling their governments more about Dr. Supari and H5N1 than you or I will ever know.

Somehow, we need to recruit guerilla epidemiologists who can pick up information, make sure it's credible, and pass it on the world. They don't even have to be medically trained, as long as they can recognize factual information and draw the right conclusions. Confronted with that information, our own media might finally see a story, and go after it.

The hot zone is teeming with enterprising folks who can smuggle chickens and ducks through any frontier from Nigeria to Siberia. Surely we can find some equally enterprising people who can smuggle information out of a country like Indonesia.

Turkey: No more B2B H5N1

Via Turkish Press.com: Turkey Says Bird Flu Cases Disappear.

Turkey officially informed the World Organization for Animal Health that avian influenza disappeared from the country.

A senior official from Turkish Ministry of Agriculture & Rural Affairs sent a letter to Paris-based international organization and said that 7 cases were seen in different parts of the country between January and April 2008.

Muzaffer Aydemir, Director-General of Protection and Control, said in his letter that necessary precautions were taken to fight the disease that ended in Turkey.