- The Washington Times - Monday, October 4, 2004

John Zarocostas in Geneva interviewed Dr. Klaus Stohr, 45, coordinator of the World Health Organization’s Global Influenza Program, for The Washington Times Saturday on the current outbreak of avian flu in Southeast Asia, and the threat of a global influenza pandemic.

Question: What’s the latest on the bird flu outbreak in Thailand and in neighboring Southeast Asian countries?

Answer: The first official report on the outbreak came in January and February of this year. Now we know the outbreak started much earlier, presumably in the beginning of 2003. Currently, there are ongoing outbreaks in Indonesia, Malaysia, in Thailand and in Vietnam. The disease has occurred during a period that is normally relatively quiet for avian H5N1 virus outbreaks in poultry.

Normally, you see these outbreaks flaring in winter or spring. Now we have widespread outbreaks in at least three countries, and small outbreaks in Malaysia, and we fear when winter comes there will be a further increase … .

Q: There have been about 30 deaths in Vietnam and Thailand combined, and in the recent case of the woman that died in Thailand, there are fears there was a human-to-human transmission [following a] mutation from the animal strain. How serious is the threat of a global pandemic or was this a single-time mutation?

A: Avian influenza viruses are new pathogens for humans. In humans [such mutations] normally cause a single case of the disease — the person dies, and the virus [does,too] with him or her, and that’s what’s normally happening.

We know that in rare circumstances, this virus can also be transmitted from the initially infected person to the next person. That’s not new. That happened in Hong Kong in 1997. We have seen this with other avian influenza viruses in the Netherlands last year. Now the cluster in Thailand appears to be one of these rare events where normal A(H5N1) influenza virus is spreading in a very unsustained way from one person to the next. So we might not see a new feature of the A(H5N1) virus.

However, we are very concerned that a pandemic would look exactly the same. Namely, we have a small cluster of cases for which contact with poultry cannot be fully established. Therefore, it is very important to investigate this cluster to see if there is any further spread. It does not look like it. The Thai colleagues have a very intense surveillance in the village, as well as in the vicinity.

The second important thing when those clusters occur is to analyze the virus, because the virus cannot hide whether it has changed or not when we investigate its genetic makeup …

Q: Is the Centers for Disease Control and Prevention in Atlanta close to finding out exactly what sort of strain it is?

A: The samples arrived at CDC last week. They are in rather good shape, and the analysis is ongoing … and we are confident the results will be forthcoming relatively shortly.

Q: Is the world prepared, given that only about 50 countries have a national strategy for a pandemic?

A: Preparedness for an influenza pandemic includes a large range of measures. One of them is to have a vaccine available and to have antivirals. Others are to have thought through who should receive this vaccine and who should receive the antivirals.

[Editor’s note: Vaccines are injections designed to stimulate the body to fight a specific virus. Antivirals are nonspecific medicines that are swallowed and designed to help the body resist viruses it may encounter. They are soon excreted from the body and must be taken again.] …

There’s a large diversity in national pandemic preparedness. And, principally, there are only a handful of countries that have gone through the complete thinking of pandemic preparedness.

Q: Are countries in Asia that have gone through a rough two years with the severe acute respiratory syndrome (SARS) outbreak, and now Avian flu — have they got adequate national strategies in place?

A: The level of preparedness is behind schedule in Asia. There are certainly many reasons. One is that influenza is not ranking very high on the list of priorities. For good reasons, perhaps, because of AIDS, tuberculosis and other infectious diseases.

Aging, diabetes and other noncommunicable diseases are presumably causing more death and disease than influenza. In addition, an influenza pandemic is something that is not predictable … .

Q: How long would it take to develop a vaccine for the avian influenza H5N1 strain, the one that is the current threat?

A: Vaccine development, or normal vaccine development, takes three to seven years. Influenza-vaccine development goes through various stages: Development of a prototype strain, organization of clinical trials, and then large-scale production.

They’re currently in the second step, where two companies have started with these clinical batches, as we call it. They produce a small amount of vaccine and will shortly begin human trials. …

Q: How long would it take?

A: Two to four months.

Q: So, there is a risk there could be a pandemic outbreak and the world could be without sufficient vaccines to combat it. What are your scenarios?

A: It’s extremely likely there will be gaps in vaccine supply, as well as in antiviral supply. No country will have enough when a pandemic starts. That’s the case now; where there is no vaccine available whatsoever, and that will also be the case next year if there are no major steps taken by all the partners who are involved — governments, companies, as well public health organizations, such as WHO. Pandemic virus traveled around the world in six months during the last pandemic, and it will be much quicker this time.

Q: When was the last influenza pandemic? The Hong Kong flu of 1968?

A: Yes, in 1968. But there are good data also for 1957, when it took six months for the virus to reach the United States after it started in Asia. [The CDC estimates that the Hong Kong virus, A(H3N2), caused about 34,000 deaths in the United States.]

Q: How many fatalities in these two outbreaks? We know that in the big one in 1918-19 about 40 million to 50 million people died.

A: It has been estimated that [in the 1968 pandemic] between 1 million and 4 million people died in a relatively short period of time — less than a year. Mainly in developed countries, because data for developing countries are just not there. So one has certainly to accept that.

… The influenza pandemic virus — when it emerges — there is no hope that we can stop it from travelling around the world, and attack rates as a percentage of people who are going to be affected will range between 25 percent, up to 40 percent.

Now, the world population is around 6.3 billion people, so we would [hope to have] about 2 [billion] to 3 billion vaccine doses shortly after the beginning of a pandemic.

This is completely unrealistic at the current stage, when we have not even clinical trials started. Two companies out of nine major companies are now developing small amounts of vaccines, and many companies do not have anything … .

Q: Can existing antivirals be adequate as a stopgap until there is a vaccine that works?

A: Antivirals, there are two groups, are excellent tools. These drugs are used during the normal influenza epidemics, on a very small scale. But the production capacities are limited and the price is high.

One country — Australia — has established a stockpile sufficient for 5 percent of its population, and France is in close discussions with the producer to establish a stockpile. …

Q: The global health alert system under the umbrella of the WHO — can it coordinate effectively something on the scale of hundreds of millions?

A: Yes, the global alert and response mechanism the WHO has established was found to be very useful in detecting the outbreak of other infectious diseases, to mount a national and international response to control them. …

An influenza pandemic cannot be halted. We can slow its spread, but controlling a pandemic is not possible. It’s always damage control.

Q: If a pandemic takes place, what does your alert system foresee?

A: To slow the transmission, social distancing might be useful. That would be closing schools, suspending public gatherings, shutting down factories — these are all means countries have at their disposal.

It depends on the objectives … in any given country, and economic capacities as well as political stability, and the will to implement these measures.

To prevent international spread, we would not recommend travel.

At the current stage, as a useful means, WHO has drawn up a list of 140 possible interventions, such as social distancing, entry screening, exit screening — all these measures have been looked at. … But most of these measures cannot prevent the global spread. They can only slow it down.

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