*Dr. Greger's Pandemic Update: February 2007*
Michael Greger, M.D.
Dr. Greger's Pandemic Update: February 2007
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CONTENTS
I. Bird Flu Scandal in Britain
II. Taking All Nine Lives: Bird Flu and Cats
III. U.S. Federal Guidelines on Pandemic Response Released
IV. Should We All Stockpile Tamiflu?
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I. Bird Flu Scandal in Britain
Evidently, bird flu is seasonal like the regular flu--and flu season
seems in full swing. Ten new human cases have followed new outbreaks
in birds in Asia, the Middle East, and Africa, with 90% mortality.
This flu season was the first to bring H5N1 into the British poultry
industry, with the virus struck an industrial facility, not a free-
range flock. Indeed, contrary to popular assumptions, a recent Food
and Agriculture Organization of the United Nations research report out
of Johns Hopkins University found that industrial-scale chicken and
egg operations in Asia were proportionally four-times more likely to
suffer outbreaks than backyard flocks.[1]
In England, nearly 160,000 turkeys confined in sheds at a single
facility died or were "depopulated" at an operation owned by Bernard
Matthews, the largest turkey producer in Europe with an annual
turnover of nearly a billion dollars.[2] Predictably, fingers were
quick to point to wild birds as the culprits. The corporation denied
any culpability and the government backed them up. It was later
exposed that Bernard Matthews was importing more than 40 tons of
poultry each week into the facility from Hungary--a country actively
stricken with H5N1. Not only did the corporation continue the imports
even after thousands of turkeys started dying, but it was revealed
that British agriculture officials knew about the shipments but kept
this information from the public, the Parliament, and the Food
Standards Agency, even though some of the infected meat might have
made it into the food supply. The memo was labeled "commercial in
confidence."[3]
The poultry industry has played the key role in the spread of this
virus around the world. A 2006 international scientific conference
sponsored by the world's leading veterinary and agriculture
authorities came to the consensus that the main means of spread of
this disease was the commercial trade in poultry products, not wild
birds.[4] As one biologist remarked, the reason the focus seems to
have remained on wild birds is that "[c]orporations pay more taxes
than migratory birds do...."[5]
The globalization of the industrial poultry industry has not only
facilitated the spread of deadly viruses like H5N1, but may have
played a role in their emergence in the first place. This seemed no
surprise, given Britain's prior experience with epidemics of foot and
mouth disease and mad cows, leading to a new spate of articles
questioning the "Horrific price of food on the cheap."[6]
Peter D. Zimmerman, Chair of Science & Security in the Department of
War Studies at King's College, London, and former Chief Scientist of
the U.S. Senate Foreign Relations Committee, wrote an editorial in The
Wall Street Journal: "The process that produced H5N1 is at work every
year, and the more intense the agribusiness of raising chickens in
China becomes, the more rapidly new viruses can spread and mutate."[7]
The English outbreak led a group of influential intellectuals,
including a Nobel Peace Prize winner and former UN Assistant Secretary
General, to openly called for "the elimination of large-scale
intensive livestock farming, which is accelerating the development of
new pandemic viruses."[8]
As we approach the centennial of Rachel Carson's birth (April 20,
2007), I am reminded of a quote from her introduction of the
influential 1964 book ANIMAL MACHINES: "The modern world worships the
gods of speed and quantity, and of the quick and easy profit, and out
of this idolatry monstrous evils have arisen." [9] In this case, the
"monstrous evil" may be H5N1.
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II. Taking All Nine Lives: Bird Flu and Cats
The U.S. Embassy in Indonesia, the country worst hit with human H5N1
fatalities, recently started advising Americans to avoid contact with
stray cats.[10] This follows a report that 100 cats out of 500 sampled
in Indonesia showed evidence of contact with the virus. The UN Food
and Agriculture Organization gave this a positive "glass-half-full"
spin, declaring it "rather encouraging" that "80 percent of cats in
outbreak areas have not been infected."[11]
H5N1 started killing cats in 2004. Fourteen out of 15 cats in a
household in Thailand grew weak, started coughing up blood, then died.
Tigers and leopards in zoos had already started dying after being fed
infected chicken meat.[12] This was the first time on record that cats
had ever come down with the flu. Cats had always been considered
resistant to getting the disease.[13] The World Health Organization
wrote, "The reported infection of domestic cats with H5N1 is an
unusual event in what is an historically unprecedented situation."[14]
An additional wrinkle was added in this month's issue of Emerging
Infectious Disease. An Austrian study showed that cats may be able to
harbor the disease without showing overt symptoms. In a city southwest
of Vienna, a sick swan was brought to an animal shelter where the bird
infected 13 ducks, chickens, and other swans. By the time cats were
found infected too, two dozen had already been adopted out into homes.
[15] None of these cats showed any signs of sickness, but when cats do
fall ill, H5N1 doesn't limit itself to the lungs. The virus can spread
to every major organ system in the cat's body, including the brain and
heart, and is excreted through the saliva, mucus, urine, and feces.
[16] This has raised the specter that cats, along with other
susceptible animals kept as companions, such as ferrets, mice, and
hamsters, could play a role in H5N1 transmission. The European
Commission has called for all cats in affected areas to be kept
indoors.[17]
So far there's only been one confirmed case in a canine, a young dog
in Thailand who spiked a high fever five days after contact with an
infected duck carcass. The virus spread to the animal's lungs, liver,
and kidneys, and the dog died the next day.[18] In the South Korean
outbreak last year, both dogs kept as pets and those raised for meat
were reportedly exterminated by the hundreds as a precautionary
measure. The slaughter did elicit some concern: "It's just too cruel
to indiscriminately kill other livestock [like dogs] when there is
obviously no proof these animals can transmit the bird flu virus to
humans," said one young villager. "I have little puppies that are as
small as my palm. How can they have the heart to kill those small
things?"[19]
Following the discovery of an infected stray cat in Germany, the head
of a German poultry trade association called for cats to be shot on
sight.[20] Noting that there have been no known cases of cat-to-human
transmission, the United Nations has advised "against killing cats as
a virus control option...."[21]
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III. U.S. Federal Guidelines on Pandemic Response Released
In BIRD FLU, I directed people to the official pandemic preparedness
guides for businesses, schools, and places of worship on the CDC
website PandemicFlu.gov. These were largely pre-pandemic
recommendations, though, rather than what to do once a pandemic is
upon us. This month, the U.S. federal government released its
guidelines on what communities should do to "limit the spread of a
pandemic; mitigate disease, suffering, and death; and sustain
infrastructure and lessen the impact on the economy and the
functioning of society."[22]
The federal strategy focuses on isolation and home quarantine of those
in contact with suspect cases, as well as social distancing measures,
such as closing daycare centers and schools for up to three months.
Children are considered by World Health Organization as the primary
vectors for the spread of pandemic influenza.[23] Children shed more
virus and over a longer period and, as the CDC delicately puts it, are
"not skilled at handling their secretions...."[24]
Speaking to 350 of the world's flu experts earlier this month, Dr.
John Bartlett, chief of infectious diseases at Johns Hopkins, tried to
convey how these measures might impact society: "When you start
closing schools, closing businesses, and closing subways, it brings
cities or communities to a standstill," he said. "That's to me one of
the issues in this planning that people have not completely
grasped...They sort of assume that the rest of life would go on."[25]
Prize-winning author of THE GREAT INFLUENZA, John M. Barry, warned
hundreds of business leaders earlier this month that planning
documents, however well-intentioned, are not enough. As a resident of
New Orleans, he used Katrina as a prime example: "If there was an
event more planned for than a hurricane hitting New Orleans, I don't
know what it is."[26]
Irwin Redlener, director of the National Center for Disaster
Preparedness at Columbia University, calls the federal plan the
"mother of all unfunded mandates." Of President Bush's proposed $7
billion, 95% is intended for pharmacological interventions. Although
our vaccine and antiviral capacity certainly needs to be bolstered,
this only leaves 5% to support local public health systems. Dr.
Redlener points out this comes out to be about $35,000 for each U.S.
hospital and public health department--not even enough to cover the
salary of a single additional nurse.[27]
Complicating the lack of funding, Dr. Bartlett called the U.S.
healthcare system "fragmented, competitive, disorganized, and broke.
We are about the only country in the developed world that doesn't own
its healthcare system," he said, "and therefore trying to organize
this becomes almost impossible at a central level."[28] Bush's budget
for fiscal year 2008 would allocate about another billion towards
pandemic preparedness, but actually proposes to cut $185 million from
funds earmarked for upgrading local public health readiness, leaving
local preparedness funding more than 25% below 2005 levels.[29] This
highlights the need for individuals to take steps on their own to
safeguard their families and communities.
The U.S. Council for Excellence in Government recently released a
report entitled, "Are We Ready?" The council concluded that less than
10% of Americans had taken the recommended steps necessary to prepare
for disaster.[30] Vice Admiral Richard H. Carmona, the last Surgeon
General of the United States, has emphasized personal responsibility:
"You are obligated as a citizen to have some knowledge as to how to
protect yourself and your family. The government will help you, and
provide you with information, but don't blame the government if you
fail to act."[31]
In a Reuters article entitled, "U.S. not scared enough of bird flu,
Senate told," the director of the CDC reportedly made it blunt at a
Senate hearing last month: "People who fail to prepare for a flu
pandemic are going to be tragically mistaken."[32]
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IV. Should We All Stockpile Tamiflu?
If we are to take seriously these admonitions to prepare, what should
we do? Stockpiling weeks of essential supplies to be able to
effectively shelter-in-place during a pandemic, as I profiled in last
month's Pandemic Update, is the standing recommendation of the CDC and
is relatively uncontroversial. The most contentious issue may be
private stockpiling of antiviral drugs like Tamiflu. In the sections
"Get It Now While Supplies Last" (http://birdflubook.com/a.php?id=91)
and "Crash Course" (http://birdflubook.com/a.php?id=92). I discuss the
basic ethics and specifics of obtaining a personal stash.
In their article "The Dilemma of Personal Tamiflu Stockpiling" (http://
www.psandman.com/col/tamiflu.htm), risk communication specialists
Peter M. Sandman and Jody Lanard characterize many of the arguments
against personal stockpiles as specious, illogical, and disrespectful.
[33] An argument they find persuasive, though, is that by centralizing
control over Tamiflu, governments can best ration the limited supply
to protect the most vulnerable and safeguard the infrastructure. In
light of Katrina, though, U.S. critics are skeptical that a government
monopoly is the best model to efficiently and equitably distribute the
medication, especially since, ideally, the drug should be taken within
hours of the onset of symptoms. In its February 2007 guidelines, the
federal government admits that a mechanism for distribution has yet to
be developed.[34] To protect against resentful mobs during a pandemic,
one medical ethicist recently was reported to suggest doctors be given
guns.[35]
Robert Webster is perhaps the world's leading authority on bird flu,
and, as such, his two cents may be worth quite a bit. In a recent
interview, he recommended that we should indeed try to get hold of a
supply of antivirals to have on-hand to safeguard ourselves and our
families for when the time comes.[36]
In BIRD FLU, I only detailed adult antiviral dosing regimens. Tamiflu
is not approved for use in children under one year of age (given that
their blood-brain barrier may not be fully mature), but older children
can be dosed based on weight. Children under 15 kg (33 lbs) are
typically treated with 30mg twice a day, those between 15-23 kg (33-51
lbs) get 45mg twice a day, those 23-40 kg (51-88 lbs) get 60mg twice a
day, and children over 40 mg (88 lbs) get dosed as an adult at 75mg
twice daily. To facilitate pediatric dosing, Tamiflu is available as a
"tutti-frutti" flavored powder that is mixed with water at the
pharmacy. Unfortunately, the liquid suspension is too unstable for
stockpiling purposes, and pharmacists will not dispense the dry powder
alone. This week the manufacturer of the drug filed for permission to
produce 30mg and 45mg capsules in addition to 75mg,[37] but until then
physicians may instruct caretakers stockpiling the drug for their
children to break open the adult 75mg capsules and mix the dose
themselves.
For example, to make a 30 mg dose, your physician may advise you to
dump all the powder from one 75mg capsule into five spoonfuls of a
soft food like applesauce, mix well, and then feed two of the five
spoonfuls to the child (2/5 of 75=30). For a 45mg dose, one could do
the same thing except feed three of the five spoonfuls, and a 60mg
dose would be four out of five. Caretakers should consult their
children's physician about this and all prescription drug decisions.
One might also consider asking their physician about stockpiling the
older class of antivirals as well. In "Bitter Pill" (http://
birdflubook.com/a.php?id=29), I bemoaned the fact that H5N1 had become
resistant to the amantadine class of drugs as a result of Chinese
farmers feeding it to their chickens. While the strains of H5N1 in
much of Southeast Asia remain drug-resistant mutants, the so-called
"second clade" of H5N1 escaping out of Asia may be sensitive.[38] An
editorial published this month in the British Medical Journal
suggested countries should start stockpiling these drugs, suggesting
that under certain circumstances a drug cocktail strategy containing
both classes might be preferable to using the Tamiflu class alone.[39]
All these drugs require prescriptions from your doctor. Internet sites
that don't require prescriptions should be viewed with great
skepticism; U.S. Customs seized hundreds of parcels of counterfeit
Tamiflu last year.[40] Internist and clinical researcher Grattan
Woodson, M.D., compiled a set of internet resources to facilitate
obtaining antiviral prescriptions, including an insightful essay into
physician psychology, "Enlisting Your Doctor's Help" and a "Dear
Colleague" letter you can respectfully present to your family doctor.
These are currently available at http://tinyurl.com/vp3ve.
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[2] Business in the Community. 2007. Bernard Matthews Ltd.
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[3] Revill J, Barnett A, Khan U, and McLaughlin D. 2007. Grubby
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[4] Normile D. 2006. Wild birds only partly to blame in spreading
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[5] Horner N. 2006. Genetic diversity keeping the bird flu at bay.
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[29 Trust for America's Health. 2007. Cuts Proposed in the President's
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[35] Lawson, A. If bird flu grips the nation, doctors will need guns.
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[37] F. Hoffmann-La Roche Ltd Corporate Communications. 2007. Roche
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[39] Tsiodras S, Mooney JD and A Hatzakis. 2007. Role of combination
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