Bird Flu

Overview written by Daniel Mark Norris Newton Davis

Last Updated:7-8-07

Several years ago when I first started studying pandemics I found it curious that they expected the next one to start in Asia. I wondered how they could predict what part of the world a pandemic would emerge from. Then the Bird Flu started emerging from Asia. Having run across Bird Flu several years ago, during the course of my research, it seemed nobody was paying attention to it as it evolved.

A book called 'Bird Flu: A Virus of Our Own Hatching' is the most accurate documentation of Bird Flu. Public health expert Dr. Michael Greger shows how animal factories have become incubators for viruses. His entire book can be read online at http://birdflubook.com/g.php?id=5

I feel Dr. Michael Greger to be the best source of information regarding the Bird Flu Pandemic. Following are the E-Mails sent to me from his site, with many links to get you the information needed to have the most accurate information available.

E-Mails from Dr. Michael Greger

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Dr. Greger's Pandemic Update: January 2007

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Happy New Year and my apologies for the delay in sending out this
update. December was an especially busy month for me on the road
(speaking schedule updated weekly at http://birdflubook.com/events.php
), and I was just unable to stay on top of this rapidly mutating field.
I don't know how all the flu bloggers are able to keep up!

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CONTENTS

I. Help New Bird Flu Video Go "Viral"
Exploring primary pandemic prevention

II. Sixty-Two Million Lives at Stake?
New study estimates potential human toll

III. Flu Year's Eve?
Why has bird flu been off the news radar?

IV. Stockpile Weeks of Essential Supplies
How much food and water should we squirrel away?

V. It's Alive!
Up to citation 3,172: http://BirdFluBook.org as a living document

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I. Help New Bird Flu Video Go "Viral"

More than 20 years ago, Imperial Chemical Industries invented National
Breast Cancer Awareness Month to encourage women to get mammograms with
the mantra, "Early Detection Is Your Best Prevention." Mammograms, of
course, don't really prevent breast cancer. They may mediate the impact
of the cancer (what we call in medicine "secondary prevention"), but
mammograms don't prevent the disease in the first place ("primary
prevention"). Getting at the root causes may not be something in which
Imperial Chemical Industries (a leading manufacturer of petrochemicals
and pesticides) is particularly interested.

Similarly, with the unprecedented spread of a truly unprecedented
virus, H5N1, current pandemic preparedness efforts are understandably
focused on secondary prevention, mediating the impact of the next
pandemic, with less public emphasis on trying to understand and prevent
the emergence of hypervirulent flu viruses in the first place.

I did my postgraduate medical work at a Boston public health hospital
awash with victims of AIDS. When most of us were growing up, there was
no such thing as AIDS, and now, 25 million people are dead. I began
thinking to myself, where did this virus come from? In light of the
threat of H5N1, I wrote BIRD FLU to try to answer that question. From
where do emerging diseases emerge?

Our new bird flu video, online at http://birdflubook.org/g.php?id=6 ,
attempts to encapsulate in four minutes the central thesis of my book:
The intensification of the global industrial poultry industry may be to
blame for the dramatic escalation of outbreaks in recent decades of a
variety of concerning bird flu viruses, including H5N1. I'm hoping the
video will spark interest and discussion, and encourage people to dig
deeper. For an exploration of the various lines of evidence used to
support the argument, the entire book is available free full-text
online at http://BirdFluBook.org .

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II. Sixty-Two Million Lives at Stake?

The December 23-January 5 issue of the medical journal "Lancet"
featured a study predicting that a 1918-like pandemic today could kill
between 51 and 81 million people, with a median estimate of 62 million
dead.[1] This result surprised the lead Harvard researcher: "We
expected to end up with a number between 15 and 20 million," he said.
"It turns out we were wrong."[2]

The estimate was based on the lethality of the 1918 virus, which had a
human case mortality rate of around 2%. Quoting from the study: "In
most discussions of influenza, the 1918-20 pandemic sets the upper
limit, in terms of mortality, on what might occur in future pandemics.
However, there is no logical or biological reason why that
pandemic--albeit very severe--should represent the maximum possible
mortality in a future pandemic."[3] Indeed the current case mortality
rate of H5N1 is more than 20 times that of the 1918 virus, officially
killing about 60% of confirmed cases. People don't even seem to get a
coin toss as to whether or not they live through the disease.

It's hard to believe a flu virus could be that deadly, though. The 60%
figure is calculated by taking the number of people who have died and
dividing by the total number of cases. But what if we're missing a
large number of cases? What if there are people who have gotten
infected, but were missed because they showed few or no symptoms? In
that case, the 60% mortality could be a gross overestimate. The results
of an investigation to help answer this question were recently
published by the CDC.[4]

In the Cambodian province of Kampot, dozens of chicken flocks were
dying from H5N1, but there was only one reported human case, a young
farmer who subsequently died. This was the signal for researchers to
swoop in and try to take blood from every family in the area to
determine the actual human infection rate. How many cases were we
missing? They analyzed blood work from 351 area villagers. Not a single
person showed evidence of present or past infection.[5]

There are two tentative conclusions we can draw from this study. First,
H5N1 remains at present almost exclusively a bird virus. In the ten
years since it was discovered, though it's led to the deaths of
hundreds of millions of birds, only a handful of people seem to have
even become infected. The concern, of course, is that the virus will
mutate into a human form, easily transmitted from one person to the
next, thereby triggering the next pandemic. This leads us to conclusion
number two. If this study is an accurate reflection of what's happening
on the ground, then the human case mortality rate may really be on the
order of 60%. Based on this study, we don't seem to be missing many
cases.

Even if H5N1 does indeed currently have Ebola-like human lethality, for
it to be able to mutate into an easily transmissible human form, many
assumed the virus would necessarily have to ratchet down its ferocity.
A panel of experts recently convened by the World Health Organization
(WHO), however, has brought that assumption into question.[6] Pandemic
influenza has the potential to infect billions of people. If H5N1
retained its ability to kill half of its victims, "it could be more
lethal than anything we've ever seen in history," said one WHO
scientist.[7] Or as another flu expert remarked, "All bets would be
off."[8]

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III. Flu Year's Eve?

One of the most common questions I get asked on the road is what ever
happened to bird flu? To quote my favorite public health blogger,
"[A]sk the people in Vietnam, South Korea and Nigeria. The virus
doesn't care if you know where it is or not."[9] (For my pick of the
flu-blogger litter, see the Resources section at
http://birdflubook.com/links.php ). Whether or not H5N1 ever arrives on
U.S. soil as a bird virus, should it mutate into a pandemic virus,
geographic borders would be essentially meaningless. Indeed, in the
just-released "Global Risks 2007," the World Economic Forum lists
pandemic flu as one of the greatest risks of global "major systemic
disruption" for the new year.[10]

If anything, the risk may be growing. According to the World Health
Organization, more people died in 2006 from bird flu than did in the
three prior years combined--most under 20 years old.[11] "It's still
smoldering," said Dr. Anthony Fauci, who heads U.S. scientific efforts
to combat bird flu.[12] "The danger of a pandemic is as profound now as
it was a few years ago," reiterated David Nabarro, flu czar for the
United Nations.[13] In regards to the threat of pandemic flu, the new
Director-General of the WHO who just took office said, "Complacency is
our biggest enemy."[14]

2007 marks the ten-year anniversary of the first human death from H5N1.
If H5N1 were able to trigger a human pandemic, wouldn't it have done so
by now? Some evidence suggests that the 1918 flu virus--which triggered
the greatest medical disaster in history--was "smouldering" for at
least 11 years before it went pandemic.[15] We simply don't know enough
about the biology of these viruses to accurately estimate a timeline.
H3N8, for example, circulated in horses in North America for nearly 40
years before jumping into dog populations and triggering the canine flu
that grabbed headlines in 2005.[16] With regard to H5N1, a World Health
Organization and USDA research team has concluded, "It is probably
dangerous to rely on the 'if it were going to happen it already would
have' argument."[17]

John Oxford wrote the book on influenza--literally, co-authoring the
standard textbook, "Influenza: The Viruses and the Disease" (along with
the more general textbook "Human Virology"). In his generous review of
BIRD FLU in the December 21 issue of the prestigious science journal
"Nature," he answered why we should concern ourselves with the 150 or
so human deaths to date:

"Well, go back to 1916, to Etaples in northern France, where a form of
flu causing heliotrope cyanosis (a characteristic lavender coloration
of the face) with a case fatality of 60% was beginning to spread. There
were 145 cases. At some point in the next two years it mutated to
become more infectious and 30 times less virulent. Then it killed 50
million people. Doesn't this ring a nasty bell?"[18]

According to the director of the National Center for Disaster
Preparedness at Columbia University, most scientists remain convinced
that "we most certainly will encounter a deadly H5N1 global pandemic at
some time in the future."[19] Why then the loss in media interest?

One intriguing possibility is that reporters have intentionally been
trying to downplay the pandemic threat. On behalf of Trust for
America's Health and Columbia University's School of Public Health,
researchers conducted one-on-one interviews with TV, radio, and print
journalists who cover public health issues. Numerous respondents said
that they have purposefully toned down their coverage or passed on
pandemic flu stories altogether so as "to present the news without
inducing panic." The study suggested that the reporters were very
knowledgeable but "fear that passing along too much of this knowledge
to their readers will lead to panic."[20]

Public complacency, according to the Dean of the Harvard School of
Public Health, is the biggest roadblock to pandemic preparedness.[21]
The American public wants to see more in depth reporting on the
subject.[22] This patronizing attitude revealed in the study suggests
that some journalists may be holding back instead of providing the full
story that might otherwise motivate people to action.

One media participant in the study explained their dilemma:

"I don't want to panic anyone, but I do want to prepare my audience. I
have personally told my family to get 90 days worth of supplies
together, in case they need to stay away from other people for a while.
I don't tell my readers that, because our editors think that may be
ineffective and will cause panic. But the world is a scary place.
People need to understand what could happen so that they can be
ready."[23]

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IV. Stockpile Weeks of Essential Supplies

Whichever estimate one uses, 62 million deaths,[25] 150 million
deaths,[26] or 360 million deaths,[27] WHO flu coordinator Keiji Fukuda
hit the nail: "Speculating about the possible numbers is an interesting
exercise, but the really important thing is, what do we do about it?"

The advice on the CDC website http://www.pandemicflu.gov focuses on
stockpiling weeks of essential supplies so that we can effectively
"shelter-in-place" during a pandemic. Like a snow emergency where we're
told not to go out unless it's an emergency, we may be asked to
self-isolate ourselves and our families in our homes until the danger
passes. Although globally a pandemic might last 12 to 18 months, it is
expected to come in waves, and in any particular locale, the wave may
only last a few weeks, hence the CDC's recommendations. If we have to
go out to the corner store to buy toilet paper or something during a
pandemic, we may be bringing back more than just groceries to our
families.

For how many weeks should we prepare, though? The U.S. State Department
recently sent a cable out "to all diplomatic and consular posts"
explaining that "current guidance notes that families should be
prepared to 'shelter-in-place' for up to twelve weeks, and maintain
sufficient food and water supplies to accommodate that entire
period."[28] After flu bloggers pointed out the discrepancy between
this three-month stockpiling recommendation and the two weeks cited by
the Department of Health and Human Services,[29] the two month
guideline inexplicably vanished from U.S. consulate websites.[30]

Robert Webster, arguably the world's leading bird flu expert, also
recommends three months. In a recent interview, he was asked what
people could do to protect themselves before a vaccine were available.
"If they have a house in the hills, then go for it--and stay there for
three months. And have enough food there already so you can stay as far
away from your neighbors as possible."[31]

To follow the State Department's advice to stockpile a gallon of fresh
water per person per day in case of "complete infrastructure
breakdown,"[32] for a family of three that would involved storing a ton
of water--literally. Webster has a better suggestion: "One bottle of
Chlorox is enough to purify all the water you need out of the local
river."[33]

The recipe for water purification I give in my "Be Prepared" section (
http://birdflubook.com/a.php?id=103 ) recommends 10 drops of unscented
liquid household chlorine bleach per quart (liter) of water. This
admittedly is an oversimplification. Most "regular" chlorine bleach on
the market is so concentrated (around 5% sodium hypochlorite), a mere 2
drops of fresh bleach should be sufficient for a quart of clear (and
not overly cold) water. But there are 1% chlorine products on the
market as well, requiring 10 drops. So instead of recommending everyone
read the small print on the bottle and advise 1 drop per quart for 7 to
10% bleach, 2 drops for 4 to 6%, and 10 drops for 1%, I just tried to
simplify with one number, erring on the side of caution. One purpose I
see of these monthly updates, though, is to expand beyond the basics,
particularly when it comes to concrete, practical measures families can
take to prepare. Next update, I'll cover the ethics and particulars of
obtaining and maintaining personal stashes of antiviral drugs such as
Tamiflu.

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V. It's Alive!

Not only is the entire text of BIRD FLU online free, but the electronic
format allows for easy updating so I don't have to wait for the next
edition to add new material (softcover expected in fall 2007). It also
allows for an informal global peer review to make the work as robust as
possible. Graeme Laver, for example, whose landmark experimental work
(along with Webster) established the very origin of influenza in the
avian world, kindly corrected my mischaracterization of the H spike on
the virus as an enzyme, and Jan de Jong of the Dutch National Influenza
Centre clarified his lab's role in the identification of the first
human isolate of H5N1 in 1997.

The most important change so far, though, is the rethinking of Dr.
Woodson's "Tamiflu Re-Administration Strategy." Tamiflu is normally
given as a ten-pill course, two pills a day for five days. In the
section "Stretching the Stockpile" ( http://birdflubook.com/a.php?id=9
), I posed a question: If a family of five is privileged enough to have
a single pack of ten pills, how could one possibly make such a Sophie's
Choice? Enter Woodson's creative (though erroneous) "Tamiflu
Re-Administration Strategy." Assuming that Tamiflu was excreted
unchanged by the kidneys, he figured that if each family member were to
take two pills and then drink his or her own urine for five days, the
entire family could, in theory, be saved. Do try this at home, said
Woodson, but only under medical supervision to ensure proper hydration.
Woodson listed in his book ways to improve palatability--chilled,
preferably, and flavored with citrus.

Unfortunately (or, perhaps, fortunately), this strategy won't work.
Tamiflu is altered by the liver such that urinated Tamiflu would not be
readily re-absorbed by the intestine. Dr. Woodson has since stripped
this recommendation from the latest edition of his work, "Good Home
Treatment of Influenza," generously available free for download at
http://BirdFluManual.com

Please do keep questions, comments, and corrections coming:
mhg1@cornell.edu; (206) 312-8640.

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REFERENCES

[1] Murray CJ, Lopez AD, Chin B, Feehan D, and Hill KH. 2007.
Estimation of potential global pandemic influenza mortality on the
basis of vital registry data from the 1918-20 pandemic: a quantitative
analysis. Lancet 368(9554):2211-8.
[2] Cheng M. 2006. Flu pandemic could kill up to 81 million people.
Associated Press, December 21.
[3] Murray CJ, Lopez AD, Chin B, Feehan D, and KH Hill, op. cit.
[4] Vong S, Coghlan B, Mardy S, et al. 2006. Low frequency of
poultry-to-human H5N1 virus transmission, southern Cambodia, 2005.
Emerging Infectious Disease 12(10).
http://www.cdc.gov/ncidod/EID/vol12no10/06-0424.htm
[5] Ibid.
[6] Branswell H. 2006. If bird flu virus becomes pandemic, high death
rates possible: WHO report. Canadian Press, November 2.
[7] Ibid.
[8] Cheng M. 2006. Flu pandemic could kill up to 81 million people.
Associated Press, December 21.
[9] "Revere." 2006. What happened to bird flu? (partial answer, here).
Effect Measure, December 22.
http://scienceblogs.com/effectmeasure/2006/12/what_happened_to_bird_flu_answ.php
[10] World Economic Forum. 2007. Global Risks 2007.
http://www.weforum.org/pdf/CSI/Global_Risks_2007.pdf
[11] World Health Organization. 2007. Avian Influenza Update Number 76.
January 2.
http://www.wpro.who.int/NR/rdonlyres/AF22747B-5AB5-4CBE-99E2-B770DBD6B76F/0/AIWeekly76WPRO.pdf
[12] Hellerman C. 2006. Bird flu virus 'still smoldering,' U.S. expert
says. CNN. December 11.
[13] Gale J and Lauerman J. 2006. Bird Flu Cases Decline, Raising New
Risk: Complacency (Update1). Bloomberg, December 29.
[14] Altman LK. 2207. New UN health chief sets her priorities. New York
Times, January 5.
[15] Shortridge K. 2006. H5N1 "bird flu"-some insight. New Zealand
Pharmacy, April, pp. 23-7.
[16] Branswell H. 2006. Decade after H5N1 virus emerged, experts ponder
best-before-date question. Canadian Press, April 15.
cnews.canoe.ca/CNEWS/Canada/2006/04/15/1535656-cp.html.
[17] Perdue ML and Swayne DE. 2005. Public health risk from avian
influenza viruses. Avian Diseases 49(3):317-27.
[18] Oxford J. 2006. The Next Pandemic? Nature 444:1007-8.
[19] Redlener 2006. Americans at Risk (New York: Alfred A Knopf).
[20] Peter D. Hart Research Associated, Inc. 2006. Gauging the Threat:
Media Coverage of Pandemic and Avian Flu. April 26.
http://healthyamericans.org/reports/flumedia/GaugingReport.pdf
[21] Editorial. 2006. Shrugging at a pandemic. Boston Globe, November
5.
[22] Southwell BG, Hwang Y, and Torres A. 2006. Avian influenza and US
TV news. Emerging Infectious Diseases 12(11)
http://www.cdc.gov/ncidod/EID/vol12no11/06-0672.htm
[23] Peter D. Hart Research Associated, Inc., op. cit.
[24] Ibid.
[25] Murray CJ, Lopez AD, Chin B, Feehan D, and Hill KH, op. cit.
[26] Associated Press. 2005. WHO: Mutated bird flu could kill up to 150
million people. September 29.
[27] Center for Infectious Disease Research and Policy. 2005. Foreign
Affairs focuses on pandemic threat. CIDRAP News, June 10.
[28] Screenshot of google cache archived at
http://ryanschultz.vox.com/library/post/us-consulate-in-hong-kong-backtracks-on-bird-flu-warning-why.html
[29] Department of Health and Human Services. 2006. Pandemic Flu
Planning Checklist for Individuals and Families. January.
http://pandemicflu.gov/plan/pdf/individuals.pdf
[30] Baum D. 2006. State Department simply offers good advice.
Greenhammer. November 11 http://www.greenhammer.net/2006/week45.htm
[31] Dreifus C. 2006. Bird Flu and You. AARP Magazine,
November-December. 34-5.
[32] Deutsche Presse-Agentur. 2006. Stockpiling suggested for possible
bird flu. Bangkok Post Breaking News, November 7.
http://www.bangkokpost.net/breaking_news/breakingnews.php?id=114048
[33] Dreifus C, op. cit.


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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]

-----------------------------------------------------------

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]

-----------------------------------------------------------

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.

*******************************************************

REFERENCES

[1] Otte J, Pfeiffer D, Tiensen T, Price L and Silbergeld E. 2006.
Evidence-based Policy for Controlling HPAI in Poultry: Bio-security
Revisited. FAO Living from Livestock Research Report, December.
http://www.fao.org/ag/againfo/projects/en/pplpi/docarc/rep-hpai_biosecurity.pdf
[2] Business in the Community. 2007. Bernard Matthews Ltd.
http://www.bitc.org.uk/membership/directory_of_members/bernard_matthews.html
[3] Revill J, Barnett A, Khan U, and McLaughlin D. 2007. Grubby
scandal shames our poultry industry. The Observer, February 11.
[4] Normile D. 2006. Wild birds only partly to blame in spreading
H5N1. Science 312(5779):1451.
[5] Horner N. 2006. Genetic diversity keeping the bird flu at bay.
Parksville Qualicum News, May 9.
[6] Lean G. 2007. Horrific price of food on the cheap. Daily Mail,
February 5.
[7] Zimmerman PD. 2007. From Bird to Person. Wall Street Journal,
February 7, p. A15.
[8] 2007. Global poor most at risk from bird flu. The Guardian,
February 5. http://www.guardian.co.uk/birdflu/story/0,,2006021,00.html
[9] Harrison R. 1964. Animal Factories (Ballantine).
[10] Associated Press. 2007. Embassy: Indonesia cat may spread bird
flu. February 7.
http://seattlepi.nwsource.com/health/1500AP_Indonesia_Bird_Flu_Cats.html
[11] Food and Agriculture Organization of the United Nations. 2007.
Avian influenza in cats should be closely monitored. February 8.
http://www.fao.org/newsroom/en/news/2007/1000490/index.html
[12] Kuiken T, Fouchier R, Rimmelzwaan G, Osterhaus A, and Roeder P.
2006. Feline friend or potential foe? Nature 440(7085):741-2.
[13] Kuiken T, Rimmelzwaan G, van Riel D, et al. 2004. Avian H5N1
influenza in cats. Science 306:241.
[14] World Health Organization. Avian influenza A(H5N1)--update 28:
Reports of infection in domestic cats (Thailand), situation (human) in
Thailand, situation (poultry) in Japan and China. February 20.
http://who.int/csr/don/2004_02_20/en/
[15] Leschnik M, Weikel J, Mostl K, Revilla-Fernandez S, Wodak E, et
al. 2007. Subclinical infection with avian influenza A H5N1 virus in
cats. Emerging Infectious Disease 13(2). http://www.cdc.gov/EID/content/13/2/242.htm
[16] Rimmelzwaan GF, van Riel D, Baars M, Bestebroer TM, van Amerongen
G, Fouchier RA, Osterhaus AD, and Kuiken T. 2006. Influenza A virus
(H5N1) infection in cats causes systemic disease with potential novel
routes of virus spread within and between hosts. American Journal of
Pathology 168(1):176-83.
[17] Thiry E, Zicola A, Addie D, Egberink H, Hartmann K, Lutz H,
Poulet H, and Horzinek MC. 2007. Highly pathogenic avian influenza
H5N1 virus in cats and other carnivores. Veterinary Microbiology
(publication pending).
[18] Songserm T, Amonsin A, Jam-on R, Sae-Heng N, Pariyothorn N, and
Payungporn S. 2006. Fatal avian influenza A H5N1 in a dog. Emerging
Infectious Diseases 12(11). http://www.cdc.gov/ncidod/EID/vol12no11/06-0542.htm
[19] Xinhuanet. 2006. Bird flu: S Korea slaughters dogs, cats, pigs,
mice. China View, November 29. http://news.xinhuanet.com/english/2006-11/29/content_5406728.htm
[20] Duke BK. 2006. Germany says people in areas with bird flu should
keep cats indoors.
British Medical Journal 332:568.
[21] Food and Agriculture Organization of the United Nations. 2007.
Avian influenza in cats should be closely monitored. February 8.
http://www.fao.org/newsroom/en/news/2007/1000490/index.html
[22] Centers for Disease Control and Prevention. 2007. Interim Pre-
pandemic Planning Guidance. February. http://pandemicflu.gov/plan/community/community_mitigation.pdf
[23] World Health Organization. 2005. Avian influenza: assessing the
pandemic threat, January 1. http://www.who.int/csr/disease/influenza/H5N1-9reduit.pdf
[24] Centers for Disease Control and Prevention. 2007. Interim Pre-
pandemic Planning Guidance. February. http://pandemicflu.gov/plan/community/community_mitigation.pdf
[25] Childs D. 2007. Life in the Time of a Pandemic, ABC News,
February 2. http://abcnews.go.com/Health/story?id=2842630&page=1&CMP=OTC-RSSFeeds0312
[26] Roos R. 2007. Notable quotes from business summit on pandemic
issues. CIDRAP News
February 8. http://www.cidrap.umn.edu/cidrap/content/influenza/biz-plan/news/feb0807quotes.html
[27] Redlener I. 2006. Americans at Risk (New York: Alfred A Knopf).
[28] Roehr B. 2007. US expert warns interdependence of countries makes
world more vulnerable to flu pandemic. British Medical Journal
334:281.
[29 Trust for America's Health. 2007. Cuts Proposed in the President's
Budget to Disease Prevention and Bioterrorism Preparedness Programs
Jeopardize the Health of Americans, TFAH Warns. February 5.
http://healthyamericans.org/newsroom/releases/release020507.pdf
[30] Council for Excellence in Government. 2006. Are We Ready?
December 14. http://www.whatsyourrq.org/PRI_report.pdf
[31] Redlener I. 2006. Americans at Risk (New York: Alfred A Knopf).
[32] Fox M. 2007. U.S. not scared enough of bird flu, Senate told.
Reuters, January 24.
[33] Sandman PM and J Lanard. 2006. The Dilemma of Personal Tamiflu
Stockpiling. January 10. http://www.psandman.com/col/tamiflu.htm
[34] Centers for Disease Control and Prevention. 2007. Interim Pre-
pandemic Planning Guidance. February. http://pandemicflu.gov/plan/community/community_mitigation.pdf
[35] Lawson, A. If bird flu grips the nation, doctors will need guns.
The Sunday Times, February 11. http://www.timesonline.co.uk/tol/news/uk/health/article1363825.ece
[36] Dreifus C. 2006. Bird Flu and You. AARP Magazine, November-
December. 34-5.
[37] F. Hoffmann-La Roche Ltd Corporate Communications. 2007. Roche
Files Application in Europe for Tamiflu 30 and 45 Mg Capsules.
February 16. http://www.roche.com/med-cor-2007-02-16
[38] Cunha BA. 2006. Amantadine may be lifesaving in severe influenza
A. Clinical Infectious Diseases 43:1372-1373.
[39] Tsiodras S, Mooney JD and A Hatzakis. 2007. Role of combination
antiviral therapy in pandemic influenza and stockpiling implications.
British Medical Journal 334:293-294.
[40] Barnes K. 2006. Counterfeit Tamiflu surfacing across America.
January 13. http://www.in-pharmatechnologist.com/news/ng.asp?n=65017-roche-tamiflu-bird-flu-pandemic


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*******************************************

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

*******************************************************

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.

-----------------------------------------------------------

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.),
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[26] Alexander DJ. 2000. A review of avian influenza in different bird
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[27] Shane S. 2004. Live-bird markets are under the microscope: as the
United States battles new outbreaks of bird flu, the role and
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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
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[30] Traynor L. 2007. We thought we would die from bird flu. Liverpool
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[31] Webby RJ and Webster RG. 2001. Emergence of influenza A viruses.
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[32] New York State Assembly. 2007. Bill summary A08540.
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[33] New York State Assembly. 2007. Bill summary A08541.
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[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


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Dr. Michael Greger's book: Bird Flu: A Virus of Our Own Hatching