Still Waiting for Avian Influenza The traditional November-March flu season is coming to a close.

This season was noteworthy for its apparent mildness and an adequate supply of vaccine. Also, there seems to be less talk and less news about that viral bogeyman, Bird Flu. Can we relax now and watch for spring? No. Avian influenza is still on the loose. If you haven’t heard much about it lately it’s because it has been driven off the front page by election news, war stories, and the usual holiday inattention. And to be perfectly honest, it’s hard for health officials to sustain public and media interest in a catastrophe that never materializes. Fortunately, there are a number of agencies and scientists who have not ignored the possible, but unpredictable, threat of pandemic influenza. For example, on February 2, the Federal government triggered a legal provision giving drug and vaccine companies protection from lawsuits related to any emergency products for avian flu. Trial lawyers may not like it, but the provision may be a useful means of encouraging companies to manufacture and stockpile antiviral drugs and vaccines. The Centers for Disease Control and Prevention (CDC) also released its “Interim Prepandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States.” At a 108 pages, no one is likely to read it, but it does have four extremely obvious and mercifully short paragraphs about isolating and treating flu patients; using voluntary home quarantine; closing schools; and using social distancing or “personal space” as a means of reducing person-to-person virus transmission. At the end of January, the World Health Organization issued another warning about avian or H5N1 influenza following two more human deaths in Egypt and Indonesia. Those deaths

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bring the total number of human H5N1 cases to 274. Of those, 167 have died, making the fatality rate for avian influenza around 60 percent. What makes H5N1 so deadly? Some clues are emerging from the 1918 pandemic H1N1 flu strain that scientists recently resurrected from genetic fragments, and from the current H5N1 avian strains circulating among birds. Some of these very dangerous experiments are showing how and where these viruses attach in the lungs to promote person-to-person transmission. Other experiments suggest these viruses kill partly by over-stimulating a patient’s immune system much like a serve allergic reaction. Can the spread of H5N1 be stopped? No. Wild aquatic birds are the source of influenza viruses. They spread H5N1, as do many species of domestic birds. Wild birds migrate over great distances, and domestic poultry and pet birds are transported by truck, train, and plane all over the world. The virus is a frequent flyer; it has moved from China and Southeast Asia, across Asia, into Europe and Africa. It also infects other species, including cats and people. Can we prevent a repeat of the devastating 1918 pandemic? Maybe. Antiviral drugs such as Tamiflu are being manufactured and stockpiled. Vaccines also may play a crucial, if imperfect, role in blunting a pandemic. Several companies are making vaccines against the H5N1 virus. But making a flu vaccine is a complex “Rube Goldberg” process involving worldwide surveillance, interagency guesswork, thousands of chickens, millions of eggs, capable manufacturers, and reliable distribution. Even then, the resulting vaccine may not be a good match against the currently circulating virus. Many viruses are sneaky microscopic shape-shifters and the influenza virus is the shiftiest sneak of them all.

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Still, there are candidate vaccines being tested against H5N1 strains. The problem is there may not be enough to go around. As of last November, the federal stockpile contained enough vaccine for about 3 million people. Now the government is spending about $133 million to see if pandemic flu vaccines can be diluted to stretch the supply. Not only is the vaccine “watered down”, but an adjuvant is added to stimulate the immune system in the same manner that a large concentration of regular vaccine would be expected to do. Adjuvants may stretch the supply to 150 million doses. In the meantime, it may be a good idea to continue getting the regular flu vaccine. Not only will it keep you from getting the regular flu, it may also provide some protection against bird flu. Recent experiments showed that immune responses to this year’s flu vaccine (which consisted of H1N1- and H3N2-like viruses) also reacted against the H5N1 bird virus. That cross-protection might mean the difference between getting sick with bird flu and dying from bird flu. We don’t know when or where a flu pandemic will begin. Robert Webster, one of the world’s great flu experts, recently wrote, “H5N1 is the most virulent virus I have encountered; if it does acquire consistent human-to-human transmissibility—it will likely be catastrophic.”

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