June 05, AU Edition

Bird flu: It’s on the rise in Asia, and experts agree it’s only a matter of time before it – or another killer flu – shows up in Australia. How ready are we? Is any preparation enough? As SHAUN DAVIES discovered, the world is overdue for a flu pandemic, and even the best preparations could leave Australians
For post-war generations unused to death on a global scale, it’s not easy to comprehend the enormity of a disaster like the Spanish Flu. The worst health disaster since the Black Plague, in 1918 and 1919 it killed an estimated 40 million worldwide – more than twice as many people as died in World War One – and infected around twenty per cent of the global population. Originating in the US, the virus spread to every corner of the globe. In India alone it killed seventeen million, while in Fiji fourteen per cent of the population was wiped out in two weeks. Australia got off comparatively lightly with 12,000 deaths, but there were still massive disruptions to everyday life. Authorities closed cinemas, schools, public transport and churches.
One town in the US even banned its citizens from shaking hands.
The Spanish Flu was not the only influenza pandemic of the twentieth century. The Asian Flu of 1957, which started in China and spread to every continent, killed at least one million worldwide. Just 11 years later, in 1968, the Hong Kong flu caused a relatively mild pandemic that killed 750,000 people.
In fact, for at least the past 200 years we’ve averaged an influenza pandemic once every 20 to 30 years. Seeing as it’s more than 40 years since the Hong Kong Flu, experts are worried that the world is overdue. The World Health Organisation’s regional director for the South Pacific, Dr Shigeru Omi, warned this year that ‘the world is now in the gravest possible danger of a pandemic’.
The reason for all this alarm is a deadly strain of avian influenza called H5N1. This is the virus that has devastated Asia’s poultry industries. More than 140 million birds have died or been destroyed and the combined losses to GDP in affected nations is estimated at between US$10 billion to US$15 billion so far.

But H5N1 also has a nastily efficient knack of killing humans, and that’s what’s got authorities in a spin. Through unsanitary wet markets, undercooked food and other means, the virus is known to have made the leap from bird to human 89 times since January 2004. In 52 of these cases the infection was fatal – a kill rate of 58 per cent.
At present, H5N1 can’t jump from human to human. But in a process called ‘antigenic shift’, it can exchange genetic information with other influenza viruses, forming completely new strains. If H5N1 came into contact with another virus in a human host it could potentially gain the ability to move easily from one person to another. And if that happens, a new pandemic on the scale of the Spanish Flu could be imminent.
Dr Ian Gust is the chairman of the WHO Influenza Collaborating Centre in Melbourne. He would play a vital role in co-ordinating the global response to a pandemic, tracking the progress of the virus, advising the director-general of the WHO and providing governments around the world with up-to-date information.
‘The reason many people are concerned about the current situation is that something very unusual has happened in the bird population,’ he says. ‘We’ve seen almost simultaneously in Asia major outbreaks of highly pathogenic avian influenza, killing initially thousands, then millions and now probably tens of millions of birds. It’s become endemic, certainly in ducks, in much of Southeast Asia.’
H5N1 is asymptomatic in ducks – and Professor Gust says this is a big problem. Because people can’t tell which birds are infected and which are healthy, the risk of a viral leap is greatly increased. The more times H5N1 crosses to a human host, the more likely it is to swap proteins with an ordinary influenza virus.
If the virus did gain the ability to jump from human to human, modern transportation would spread it around the world far more quickly than in 1918. ‘Then it essentially went at the speed of individuals, horses, trains and ships. Now infected individuals are likely to be moved around the world quickly by aeroplane … so one would guess that the spread is likely to be quite brisk.’
But just how likely is this much-feared mutation or recombination in H5N1? Are we a hair’s breadth away from disaster? Or are the scenarios being played out in the media exaggerated?
‘The answer is we don’t know, other than that the probability is low,’ Dr Gust says. ‘Over the last 15 months you’ve had tens, maybe even hundreds of millions of people living closely beside infected birds, which you would think gives a significantly increased risk of this rare event occurring… This tells you that it is a low-risk phenomenon.’
Even if a worst-case outbreak of avian flu is statistically unlikely, Australian authorities are on high alert. Australia’s Health Minister Tony Abbott recently said that an H5N1 pandemic could be a ‘worldwide biological version of the Indian Ocean tsunami’, and the Federal Government has dedicated $133.6 million over five years to preparing for a pandemic.
birdflu3.jpgOver the past year, Australia has amassed the single largest stockpile of antiviral drugs in the world. These ‘neuraminidase- inhibitors’ prevent infection in healthy people and cure infected people if administered during the onset of symptoms. They’d be our frontline defence in the event of an outbreak, administered to essential service workers and groups deemed most at risk from the virus.
The government has also entered into contract with pharmaceutical companies CSL and Sanofi Pasteur to supply 50 million doses of any pandemic flu vaccine that became available – enough to protect every Australian citizen. However, it would take up to six months for a vaccine to be produced and distributed in large numbers, and some experts say that by that stage the virus will have already worked its way through the population.
The director of the communicable diseases branch of NSW Health, Jeremy McAnulty, would help co-ordinating the health response to an influenza pandemic in NSW.
He says that the states have been hard at work creating influenza pandemic action plans that complement the national approach.
‘Early on what you’d do is try to identify each case individually, rapidly if possible, and isolate them and then identify their contacts to try and prevent further spreads’, he says. ‘We’d be looking out for cases as they came into the country, you’d be sending out communications to all doctors, and we’d put people in isolation and we’d have certain powers that allow people to be held for certain diseases.’
There would also be attempts to trace the networks of people the infected individual had been in contact with. Double-checks to ensure correct diagnosis would be mandatory, and infected people would be interviewed and counselled. But the strategy would change if the situation became worse.
As numbers increase further you use other strategies such as looking after people at home and community caring for people. At some stage, depending on the numbers involved, it would involve cancelling routine operations in hospitals.
There could also be closures of football stadiums, cinemas and schools, as well as cancellations of public events. The states would be required to keep essential services running as absenteeism shot through the roof. Hospitals would be overloaded and community centres converted into isolation wards.
‘If it does happen it will be something that our country will not forget in a hurry’, Tony Abbott said at a recent press conference. But he also claimed that Australia is ‘better prepared than probably any other country in the world.’
Professor Peter Curson, director of the Health Studies program at Macquarie University, does not share Mr Abbott’s confidence. He has just completed a paper for the Australian Strategic Policy Institute, which sharply criticises the government’s pandemic action plan on numerous points.
‘There is no comment anywhere [in the action plan] about how they’d handle fear, panic or public reaction’, Professor Curson says. ‘I’ve spent 25 years looking at public reaction and human behaviour in previous epidemics in Australia and there’s no doubt that people have an underlying fear of contagion, of infection, particularly when there’s no specific cure or specific treatment.’
‘Official measures put in place like increased surveillance, quarantine, limited supplies of antivirals, masks, restricted travel and so on will heighten public fear and panic, and that’s not mentioning the role of the media of course, who undoubtedly would play a major role.’
The government has a basic duty to protect Australians from outbreaks of disease, says Professor Curson, pointing out that in the event of a major pandemic there would be nowhere near enough antivirals to protect all Australian citizens. It would be six months before a vaccine became available – leaving a huge proportion of the population unprotected.
‘The priority plan says antivirals will be delivered to high risk groups, and by that they mean the old, the young and the people suffering from chronic illness’, he says. ‘But if you take out the one million health-cum-service workers, there are about two million people aged over 65, there are one million kids aged under two or three, well that won’t leave anything.’
But a spokeswoman for Australia’s Chief Medical Officer, Professor John Horvath, rejects Professor Curson’s criticisms. She says a revised action plan, which will soon be released by the Federal Government, does contain provisions for the handling of public fear and the other matters that Curson raises.
The Health Department also points out that there are limits on the global production of antivirals, which means the government can’t provide protection for every Australian, even if it wants to. ‘With current technology and manufacturing processes, obtaining enough antivirals to protect 20 million people for six months would be almost impossible at any price’, Tony Abbott said at an infectious diseases conference in May.
There’s another ethical issue at stake in the bird flu debate – what level of support should Australia provide to its neighbours in the event of a pandemic? On one hand we have the world’s largest stockpile of antivirals; on the other there’s not enough to go around. Would we be generous to our neighbours, as we were during the Indian Ocean tsunami? Or do we only give when we have nothing to lose?
‘Should a pandemic occur next year or this year, only those countries that have got either a national manufacturer or have a guaranteed supply agreement with one of the existing manufacturers would be able to access vaccine’, says Dr Gust from the WHO. ‘For most countries in the world, vaccines and antivirals are only something they can dream of and they’d have to rely on conventional public health measures.’
birdflu1.jpgThe WHO will soon broker a meeting where countries with large stockpiles of antivirals (including Australia, Japan, the US and the UK) will be asked to make their drugs available to stamp out a small outbreak of a novel virus in small village in Cambodia, for instance.
‘My hope is that (these countries would) make a tremendous effort to put out that spot fire, to prevent it becoming a bush fire that spreads widely, so there would be a major attempt to quench the infection using international stockpiles’, Professor Gust says.
‘Clearly Australia is a key participant in that discussion and has an opportunity to take a lead in that area. I can’t foreshadow what the government’s view would be, but I hope they would be generous.’
Whether H5N1 is the culprit in the next global outbreak of influenza remains to be seen. But experts agree that it’s only a matter of time before the world faces a new pandemic. If the outbreak is severe enough, no amount of preparation would be enough to prevent a disaster – and that’s a frightening thought.
SARS killed just 770 people. But it did an estimated $15 billion worth of damage to the economies of Southeast Asia. In a worst-case scenario, H5N1 would cause tens of millions of deaths. What damage would that do to the global economy? Could we ever be ready for the devastating effects of a pandemic?
‘We’ll never be able to sit back and say, “Well, we’ve done it now, let’s bring it on”,’ says NSW Health’s Jeremy McAnulty. ‘Unfortunately it will never go away and our preparation will always be there, and if a pandemic hits then we’ll have to start preparing for the next one. It’s an ongoing process.’
But Professor Gust from the WHO believes that it’s too early to start panicking. He says that to have a doomsday scenario, the virus ‘has to escape and retain its existing virulence’ – a fairly unlikely prospect.
‘In North Vietnam the virus has already become less pathogenic for birds and less pathogenic for humans,’ he says. ‘A mutation or a recombination that enabled the virus to spread could equally, easily, result in a virus which spread rapidly but had relatively low pathogenicity.’
‘The scenarios that you keep seeing painted in the newspaper are absolutely worst case scenarios. And as we know from history, the most probable scenario is rarely the worst case scenario.’
While the world waits for the next flu crisis, JENI PAYNE meets an Australian on the frontlines of another age-old epidemic
On a visit to the US to see her host families and life-long friends she made as a high school exchange student, Jenny heard about the massive worldwide scheme known as PolioPlus. ‘Then when I became a member back in Australia, I decided that’s what I wanted to get involved in.’
India gave Jenny her first taste of work as a volunteer and she returned three times to help immunize its population. Then followed holidays spent working with communities in Ethiopia, Botswana and this year, Pakistan.
‘Two drops on the tongue is all it takes. A child can be protected against polio for as little as sixty cents worth of vaccine.’
In 1985, Rotary International launched the PolioPlus program to protect children worldwide from the cruel and fatal consequences of polio. Since that time, Rotary’s efforts and those of partner agencies, including the World Health Organization, the United Nations Children’s Fund, the United States Centers for Disease Control and Prevention, and governments around the world, have achieved a 99% reduction in the number of polio cases worldwide.
From the launch of the global initiative in 1988, to the eradication target of 2005, Rotary’s Centenary Year, five million people, mainly in the developing world, who would otherwise have been paralyzed, will be walking because they have been immunized against polio. More than 500,000 cases of polio are now prevented each year.
But complacency is the enemy. According to the UN, the number of polio cases has been reduced from an estimated 350,000 cases in 1988 to just under 700 reported cases at the end of in 2003 – a greater than 99% reduction. At the same time, Indonesia has just suffered its first polio outbreak in ten years, and UN officials suggest that worldwide eradication this year may in fact not be possible.
Poliomyelitis (polio) is a highly infectious disease caused by a virus. It invades the nervous system, and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. It spreads rapidly by unsafe water and hand-to-mouth contact, especially in overcrowded conditions where sanitation is poor and faecal contamination prevalent. Houseflies also contribute, by transferring virus from faeces to food. Toddlers not yet toilet-trained transmit polio readily even in hygienic environments. Initial symptoms are fever, fatigue, headache, vomiting, stiffness in the neck and pain in the limbs.
One in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralysed, 5% to 10% die when their breathing muscles become immobilized.
The tragedy is, polio mainly affects children under five years of age and there is no cure, it can only be prevented. Polio vaccine, given multiple times, can protect a child for life.
‘Polio is generally caused by poor sanitation, so kids in underdeveloped countries are most as risk’, says Horton, adding that currently, the coalition against polio is facing a crucial time in the program.
In 2004, there was a cessation in the immunization program in Nigeria, due to political circumstances. It led to a blow-out in numbers locally and threatened to spread to neighbouring Sudan.
‘Polio is passed on so easily. Only 1% will catch it, but the rest are carriers.’
It was this exposure to the poignant plight of third world children that inspired Jenny to save all year for working holidays as part of Polio Plus. ‘It’s lucky I have a supportive boss! I never want to see children suffering. In India I saw children with flaccid legs.
Sometimes it’s too much. It’s an awesome, terrible reminder of the disease. No child deserves to live like that. If we can do something to help, why wouldn’t we?’
As part of a so-called ‘STOP team’, consisting of 36 people from 22 countries, including medical professionals and Rotary volunteers, Jenny makes a difference in countries that are desperately in need, most recently Pakistan.
‘Pakistan has never broken transmission. There were 103 cases in 2003 and now there are 46. There’s a new government now and it’s supporting the initiative, working very hard with immunisation campaigns every six weeks.’