Harvard Public Health Review
Summer Fall 2006

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HSPH Update: Avian Flu

Bird Flu: Now, All Too Human

An outbreak in Sumatra shows the world is ill-prepared

As of September 1, Indonesia held the world's record for the greatest number of human deaths from bird flu: 46. In April and May, the virus, H5N1, struck eight members of a family in Sumatra, killing seven. DNA analyses provided strong evidence of limited human-to-human virus transmission--and the world experienced an important test of its master plan for quashing a possible pandemic.The verdict?Indonesia's response was "disorganized and underfinanced," said World Bank officials. "Not satisfactory," charged members of the World Health Organization (WHO).At the Harvard School of Public Health, Associate Professor of Epidemiology Marc Lipsitch says the response "gives reasons for worry." News reports, including one in Nature, bear him out:

It took eight days for government officials and a WHO representative to get to the Sumatran village after the first person died, on May 4, and another week for a larger team to appear;
A body was buried before it could be tested;
Some villagers hospitalized for observation fled home.
Beyond the cluster of new cases, there were other problems: H5N1 is endemic in poultry in Indonesia, yet according to the World Organization for Animal Health, the country is no longer counting many outbreaks in poultry;

Although culling birds is the first line of defense in containing outbreaks, according to WHO, Indonesia has refused to slaughter flocks on a mass scale, as other countries have done. In part, the government lacks funds to adequately compensate bird owners;

Many Indonesians appear ill-educated about bird flu. Some have resisted requests that they and their fowl be tested for H5N1.

WHO's preparedness plan, unveiled in 2005, reflects a strategy called containment--spotting human transmission, then striking back with antivirals and measures such as quarantine and vaccination. Some plan elements were implemented in Indonesia: WHO tapped pharmaceutical company Roche for drugs, while some villagers agreed to be quarantined and accepted antivirals.

Lipsitch supports containment, but observes that "the Indonesian situation suggests containment will be very difficult if serious human-to-human spread occurs because there, where the virus moved slowly and the family cluster remained small, it was nonetheless hard to respond quickly and persuasively."

According to a study published in Nature in September 2005, if a pandemic-capable strain evolves, WHO will have at most three weeks to quarantine people and to treat infected patients to prevent a human pandemic. In Indonesia, it took nearly that long for officials to arrive in the Sumatran village.

On May 30, WHO unveiled a revised draft protocol for rapid response and containment. The protocol worries Lipsitch because it has two phases, which could slow the response time overall. The first phase focuses on confirming and isolating human cases and administering antivirals; the second phase advises "exceptional" measures, such as closing workplaces.

"Transitioning from the first phase to the second could waste valuable time," Lipsitch warns. "The worst could be happening and you may not know it for days--or weeks. Under-responding now may doom any full-scale response you may hope to take later."

His advice? Employ a many-pronged response that anticipates multiple introductions of human-to-human transmissible strains of H5N1 over time, in various locations. Educate the population about bird flu. And offer powerful incentives to report sick fowl and to cull poultry, especially in areas where humans have fallen ill or died from H5N1.

"In responding to a potential pandemic, you have to assume the worst--guilty until proven innocent--and react accordingly," Lipsitch says.

Christina Roache is the editor of Harvard Public Health NOW, the biweekly newsletter of HSPH, published online at www.hsph.harvard.edu/now.html.

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