*Dr. Greger's Pandemic Update: June 2007 *
Michael Greger, M.D.
Dr. Greger's Pandemic Update: June 2007
*******************************************************
CONTENTS
I. "Bird Flu" Book Receives Academic Acclaim
II. Unmasking Our Ignorance: CDC Releases Mask Guidelines
III. Live Bird Market Moratorium Legislation Introduced in New York
IV. Homeland Security Plans for Population Home Quarantine Up to 90
Days
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I. "Bird Flu" Book Receives Academic Acclaim
Though the poultry industry wasn't very receptive to my book,[1] this
is not surprising given intensive poultry production's starring role
in the emergence of highly pathogenic strains of avian influenza. The
opinions that count most are those of scientific colleagues, some who
have devoted their lives to the study of influenza--the luminaries
like Kennedy Shortridge and John Oxford, both of whom were very
generous in their support of the project.[3,4] The most recent
scientific journal review of "Bird Flu" was published in "Virology
Journal," written by two virologists at the Chinese Academy of
Military Medical Sciences' Institute of Microbiology and Epidemiology
in Beijing.[5] Here's a snippet:
"Greger's superb story-telling ability makes every page of the book
interesting and fascinating for both specialist and
layperson...Numerous quotes, pretty illustrations, vivid titles and
clear writing make reading really a pleasure...Dr. Greger's simple and
practical suggestions are invaluable for both nation and
individual...Greger's book is the best of its genre and deserves to be
read by anyone who is concerned about human and animal health. This
book is a must read for government and enterprise officials who are
advocating and advancing poultry industry standards...I highly
recommend it." The full review is free for download at
http://www.virologyj.com/content/pdf/1743-422X-4-38.pdf.
I am very pleased to say that "Bird Flu" is currently being translated
into Chinese in hopes of further opening the dialogue in a country
that has historically played a key role in the emergence of pandemic
strains of the virus. I address our current understanding on why this
may be the case in my contribution--"Why do so many global flu
pandemics come from eastern Asia?"--in the upcoming book "Seventy
Great Mysteries of the Natural World" to be published by Thames &
Hudson.
-----------------------------------------------------------
II. Unmasking Our Ignorance: CDC Releases Mask Guidelines
Last month, the U.S. Centers for Disease Control and Prevention (CDC)
released its long-awaited interim guidance on the use of masks for
personal protection during a pandemic.[6] In "Masking Our
Ignorance" (http://birdflubook.com/a.php?id=97), I laid out the basic
principles (such as the differences between cheap drugstore surgical
"facemasks" and the more expensive hardware-store N95 "respirators")
and noted the paucity of real data on the effectiveness of masks. Not
much has changed.
The CDC emphasizes that during a pandemic, we should avoid crowded
public settings unless "absolutely necessary," but if we have to
venture out, then along with proper cough etiquette (http://
birdflubook.com/a.php?id=94) and hand hygiene (http://birdflubook.com/
a.php?id=95), "[f]acemasks should be considered...." According to the
guidelines, we should also consider wearing a surgical mask to protect
others if we fall ill or have recently been exposed to someone who may
be sick. N95 respirators should be considered if we need to have close
contact (within about six feet) with someone suspected to be infected.
In a case such as this, when, for example, we might be caring for a
fallen family member, we might want to duct-tape the entire periphery
of the respirator to our (clean-shaven, if appropriate) face, as tiny
gaps between the face and the respirator can undermine its
effectiveness.
According to "The New York Times," the language released to the public
was changed at the last minute from "wear a facemask" to "consider
wearing a facemask."[7] This intentional vagueness arose both from
scientific uncertainty and a concern that mask-wearing might actually
increase risk under certain circumstances. Although wearing a mask
might act as a reminder not to touch one's face and, therefore,
theoretically cut down on transmission, it's also possible that the
discomfort of wearing a mask might lead to more face-touching, if
folks slip contaminated fingers under masks to scratch or wipe away
sweat.[8]
One thing seems clear: Evidence is lacking to support mandating public
mask-wearing by law, as was done in a number of municipalities during
the pandemic of 1918. Hundreds of so-called "mask-slackers" were
rounded up and arrested in cities like San Francisco. This may be good
news. Jail is not a place you want to be during a pandemic.
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III. Live Bird Market Moratorium Legislation Introduced in New York
The Director-General of the World Health Organization continues to
call bird flu the greatest global health threat of the 21st century.
[9] As of June 14, 2007, with the deaths of a pregnant 15-year-old[10]
and a young man who reportedly both cooked and ate infected chicken,
[11] Indonesia now reports 80 human deaths out of 100 cases.[12] This
represents a case fatality rate exceeding that, on average, of Ebola
virus.[13] In recent weeks, we've seen a resurgence of H5N1 in
Vietnam[14]--a country in which we thought the disease controlled--and
its incursion into Ghana, the ninth African country so far affected.
[15] "It's sort of like a big witch's brew," characterized one public
health professor recently. "It's bubbling away--will it boil
over?"[16]
Following the lead of many Asian nations--China,[17] Vietnam,[18]
Japan, Singapore[19]--one of the steps Ghana is taking to control the
virus is to shut down all live bird markets in the country.[20] In
Egypt, for example, selling live poultry may soon carry a six-month
jail sentence.[21] Starting in 2008, even in a country like Taiwan
(which has yet to suffer an outbreak), those found publicly
slaughtering birds may face a fine of $500,000 NTD (~$15,000 US).[22]
The chair of Taiwan's National Science Council explained the reasoning
behind the ban on live markets: "We can't foresee whether an outbreak
of bird flu will happen in Taiwan, but every nation in the world is
obligated to take part in the prevention of the epidemic."[23]
Bird flu is not just a problem in Asia and Africa. Before the
emergence of the highly pathogenic H5N1 in China, the largest recorded
outbreak of bird flu was here in the United States in the 1980s, an
outbreak in Pennsylvania that led to the deaths of 17 million birds.
[24] Both the Asian H5N1 virus[25] and the Pennsylvania H5N2[26] have
been linked to live bird markets.
The U.S. Department of Agriculture estimates that more than 20 million
birds of various species pass through 150 known live bird markets in
northeast metropolitan areas of the United States every year.[27] The
concern is that these storefront slaughter facilities may act as
veritable viral swap meets where infections with potential human
implications like avian influenza can multiply and spread. (More at
"Made in the USA" (http://birdflubook.com/a.php?id=77) and "Viral Swap
Meets" (http://birdflubook.com/a.php?id=59).)
The two cases of human infection in the United States were both caused
by H7N2, the strain that continues to circulate in live bird markets
both in New York City and surrounding states.[28] Last month, four
individuals in Wales and northwest England were found infected with an
H7N2 virus traced back to a public market in Chelford, England selling
birds for slaughter. Three were hospitalized but all recovered.[29] "I
thought I was going to die," one victim reported.[30]
Leading Flu scientist Robert Webster concluded a landmark article on
the emergence of pandemic viruses with these words: "An immediate
practical approach is to close all live poultry markets...." He goes
on to note that with refrigeration systems widely available, it is no
longer necessary to sell live birds. "The reality is that traditions
change very slowly," he said, but "a new pandemic could accelerate
this process."[31]
New York State Assemblywoman Barbara Clark is not waiting until
disaster strikes before shoring up the levees. Assemblywoman Clark
introduced this year a package of legislation that would declare a
moratorium on the licensing of new live bird markets[32] while a task
force investigated their public health and safety implications.[33] At
her press conference, I debuted investigative footage from The Humane
Society of the United States that was recently filmed at live bird
markets in six cities across the country. Compiled footage can be
viewed in a two-minute video at http://tinyurl.com/2er2u7 and New York
State residents can contact their elected officials here:
https://community.hsus.org/campaign/NY_2007_bird_markets.
-----------------------------------------------------------
IV. Homeland Security Plans for Population Home Quarantine Up to 90
Days
This year the U.S. Department of Homeland Security released a guidance
document for public service agencies entitled, "Pandemic Influenza:
Best Practices and Model Protocols." In it, Homeland Security urged
stakeholders to ask many of the hard questions, such as "Will society
experience a breakdown?" "Will vigilantes develop in neighborhoods or
communities?" and urged the development of civil unrest protocols.
(For my review of the social chaos that can result from plague
situations, see http://birdflubook.com/a.php?id=102.)
One of the "planning assumptions" Homeland Security is using is that
"[t]he population may be directed to remain in their homes under self-
quarantine for up to 90 days per wave of the outbreak to support
social distancing practices."[34] To recap from my January 2007
Pandemic Update (http://tinyurl.com/25vj4l), the State Department
suggested U.S. families abroad be prepared to "shelter-in-place" for
12 weeks and Dr. Webster suggested 3 months. All of these
recommendations are at odds with the current U.S. Department of Health
and Human Services (HHS) recommendation that families and individuals
need not stockpile more than two weeks of food, water, and other
essential supplies in preparation for the next pandemic. This month,
an interactive online forum presented an unprecedented opportunity to
question these discrepancies directly.
On June 13, 2007, Health Secretary Leavitt convened a leadership forum
on pandemic preparedness. As an adjunct to the forum, the Department
of Health and Human Services is hosting a companion five-week Pandemic
Flu Leadership Blog to run until June 27 in a commendable attempt to
increase transparency and dialogue--and difficult questions are being
asked of our leaders.
On the blog, Admiral John O. Agwunobi, the Assistant Secretary for
Health, was taken to task for sticking to the weeks (versus months)
stockpiling recommendation. His reasoning seemed to imply that
Americans couldn't handle the truth. "Naturally," he wrote, "the more
time and effort that you put into preparing a stockpile, the more self-
reliant you will be." He notes, though, that few seem to have taken
even modest measures to prepare. "We at HHS believe that two weeks is
an effective compromise that can get all American families thinking
about their own needs." Many took this explanation to be patronizing.
To read the storm of comments this unleashed and to make your own
voice heard, go to http://blog.pandemicflu.gov/?p=43.
For the remainder of the month, I'm off to Europe to present at a
number of venues including the Scottish Parliament and the House of
Commons, as well as to meet with Members of the European Parliament in
Brussels. It will be interesting to get their perspective on what
global policy initiatives may reduce the pandemic threat. I'll let
everyone know what I find.
*******************************************************
REFERENCES
[1] Smith R. 2007. Avian flu message seems odd. Feedstuffs, January
29.
[2] LeSure E. 2005. Low-carb pioneer Atkins files for bankruptcy.
Associated Press, August 1, 2005.
[3] Shortridge K. 2006. Forward. In: Greger, M. Bird Flu: A Virus of
Our Own Hatching (New York City: Lantern Books). http://birdflubook.com/a.php?id=115.
[4] Oxford J. 2006. The Next Pandemic. Nature 444:1007-8.
http://birdflubook.com/resources/NatureReview.pdf.
[5] Qin C and Qin E. 2007. Review of "Bird Flu: A Virus of Our Own
Hatching" by Michael Greger. Virology Journal 4:38.
http://www.virologyj.com/content/pdf/1743-422X-4-38.pdf.
[6] United States Centers for Disease Control and Prevention. 2007.
Interim public health guidance for the use of facemasks and
respirators in non-occupational community settings during an influenza
pandemic. http://www.pandemicflu.gov/plan/community/maskguidancecommunity.html
[7] McNeil DG. 2007. U.S. issues guidelines on use of face masks in
flu outbreak. New York Times, May 4.
[8] Branswell H. 2007. Should people plan to wear medical masks during
a pandemic? CDC says maybe. Canadian Press, May 04.
[9] Engeler E. 2007. Chan: Bird flu huge global health threat.
Associated Press, May 16.
[10] Indonesia Center for Public Communication. 2007. AI has killed 79
People. June 4. http://www.depkes.go.id/en/0406ai.htm
[11] Mandari P. 2007. Indonesia confirms 80th bird flu death. Agence
France-Presse, June 14. http://news.yahoo.com/s/afp/healthfluindonesia;_ylt=AnVm9XZmtFFaPosPAsBj2C2TvyIi
[12] Indonesia Center for Public Communication. 2007. Eighty people
die for AI. June 14. http://www.depkes.go.id/en/1406ei.htm
[13] United States Centers for Disease Control and Prevention. 2003.
Ebola Hemorrhagic Fever. November 26. http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebotabl.htm
[14] 2007. Bird flu spreads in Vietnam. Australian Broadcasting
Corporation, May 28. http://www.radioaustralia.net.au/news/stories/s1934488.htm
[15] 2007. Ghana reports its first H5N1 outbreak. Center for
Infectious Disease Research & Policy News, May 2.
http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/may0207ghana.html
[16] Smith S. 2007. As deadly as ever, avian flu proves a persistent
foe. Boston Globe, May 28.
[17] 2006. Beijing closes live poultry market permanently.
ThePoultrySite.com December 18.
http://www.thepoultrysite.com/poultrynews/10522/beijing-closes-live-poultry-market-permanently
[18] Environmental News Service. 2005. Beijing halts poultry trade to
guard against bird flu. November 7. http://www.ens-newswire.com/ens/nov2005/2005-11-07-05.asp
[19] 2006. Law to ban slaughtering live poultry in markets. Taiwan
News, August 31. http://english.www.gov.tw/TaiwanHeadlines/index.jsp?print=1&categid=10&recordid=98885
[20] Dovi E. 2007. Ghana reports first case of bird flu. Accra, May
2.
[21] Johnston C. 2007. Egypt seeks to bar live bird trade over H5N1
fears. Reuters, March 28.
[22] Chuang J. 2006. Anti-bird flu plan will cost poultry vendors
jobs. Taipei Times, August 31, p. 1.
[23] 2006. Law to ban slaughtering live poultry in markets. Taiwan
News, August 31. http://english.www.gov.tw/TaiwanHeadlines/index.jsp?print=1&categid=10&recordid=98885
[24] Brown C. 1999. Economic considerations of agricultural diseases.
Annals of the New York Academy of Sciences 894:92-4.
[25] Perez DR, Nazarian SH, McFadden G, and Gilmore MS. 2005.
Miscellaneous threats: highly pathogenic avian influenza, and novel
bio-engineered organisms. In: Bronze MS and Greenfield RA (eds.),
Biodefense: Principles and Pathogens (Norfolk, UK: Horizon
Bioscience).
[26] Alexander DJ. 2000. A review of avian influenza in different bird
species. Veterinary Microbiology 74:3-13.
[27] Shane S. 2004. Live-bird markets are under the microscope: as the
United States battles new outbreaks of bird flu, the role and
necessity of live-bird markets must be examined. National Provisioner
218(4):38. http://www.findarticles.com/p/articles/mi_hb314/is_200404/ai_hibm1G1117180028
[28] Centers for Disease Control and Prevention. 2006. Past avian
influenza outbreaks. http://www.cdc.gov/flu/avian/outbreaks/past.htm
[29] United Kingdom Health Protection Agency. 2007. Confirmation of
avian influenza H7N2 infection. May 25.
http://www.hpa.org.uk/hpa/news/articles/press_releases/2007/070525_avian_flu_H7N2.htm
[30] Traynor L. 2007. We thought we would die from bird flu. Liverpool
Echo, May 31. http://tinyurl.com/3dldb5
[31] Webby RJ and Webster RG. 2001. Emergence of influenza A viruses.
Philosophical Transactions of the Royal Society of London 356:1817-28.
[32] New York State Assembly. 2007. Bill summary A08540.
http://assembly.state.ny.us/leg/?bn=a08540
[33] New York State Assembly. 2007. Bill summary A08541.
http://assembly.state.ny.us/leg/?bn=a08541
[34] United States Department of Homeland Security. 2007. Pandemic
Influenza Best Practices and Model Protocols.
http://www.usfa.dhs.gov/downloads/pdf/PI_Best_Practices_Model.pdf