.Over the last year, it has been impossible to watch TV or
read a newspaper without encountering dire reports about bird
flu and the possibility of a pandemic, a worldwide epidemic.
First Asia, then Europe, now Africa: like enemy troops moving
into place for an attack, the bird flu virus known as A(H5N1) has
been steadily advancing. The latest country to report human
cases is Azerbaijan, where five of seven people have died. The
virus has not reached the Americas, but it seems only a matter
of time before it turns up in birds here.
Even so, a human pandemic caused by A(H5N1) is by no
means inevitable. Many researchers doubt it will ever happen.
The virus does not infect people easily, and those who do contract
it almost never spread it to other humans. Bird flu is what the
name implies: mostly an avian disease. It has infected tens of
millions of birds but fewer than 200 people, and nearly all of
them have caught it from birds.
But when A(H5N1) does get into people, it can be deadly.
It has killed more than half of its known human victims—an
extraordinarily high rate. Equally alarming is
that many who died were healthy, not the frail
or sickly types of patients usually thought to be
at risk of death from influenza.
The apparent lethality of A(H5N1), combined
with its inexorable spread, are what have made
scientists take it seriously. Concern also heightened
with the recent discovery that the 1918 flu
pandemic was apparently caused by a bird flu
that jumped directly into humans.
In addition, A(H5N1) belongs to a group of influenza
viruses known as Type A, which are the
only ones that have caused pandemics. All those viruses were originally bird flus. And given the
timing of the past pandemics — 1918, 1957, 1968
— some researchers think the world is overdue
for another. It could be any Type A, but right
now (A)H5N1 is the most obvious.
The virus lacks just one trait that could turn it
into a pandemic: transmissibility, the ability to
spread easily from person to person. If the virus
acquires that ability, a pandemic could erupt.
Everything hangs on transmissibility. But it
is impossible to predict whether A(H5N1) will
become contagious among people. The virus has
been changing genetically, and researchers fear
that changes could make it more transmissible,
or that A(H5N1) could mix with a human flu
virus in a person, swap genetic material and
come out contagious.
But most bird flu viruses do not jump species
to people. Some experts say that since A(H5N1)
has been around for at least 10 years and the
shift has not occurred, it is unlikely to happen.
Others refuse to take that bet.
The A(H5N1) strains circulating now are quite
different from the A(H5N1) strain detected in
Hong Kong in 1997, which killed 6 of 18 human
victims. Over time, A(H5N1) seems to have developed the ability to infect more and more species
of birds, and has found its way into mammals—specifically, cats that have eaten infected
birds.
The actual number of human cases may well
exceed the number that have been reported, and
may include mild cases from which victims recovered
without even seeing a doctor. If that is
true, the real death rate could be lower. But no
one knows whether mild cases occur, or whether
some people are immune to the virus and
never get sick at all.
In the absence of more information, health
officials must act on what they see — an illness
that apparently kills half its victims.
Q. How will we know if the virus starts
spreading from person to person and
becomes a pandemic?
A. If there is a pandemic, it would be everywhere,
not in just one city or one country. To
detect such an event as early as possible there is
an international surveillance system, involving
more than 150 countries, that searches for signs
that a new flu strain is taking hold in humans.
One hallmark of a pandemic flu would be an
unusual pattern of illnesses — lots of cases, possibly
cases that are more severe than normal
and, possibly, flu infections outside the normal
flu season.
Ordinary human flu viruses, for reasons that
are not entirely understood, circulate only in
winter. But pandemics can occur at any time. A
pandemic would also involve a flu virus that
was new to humans, meaning that no one would
have immunity from previous infections.
Q. If bird flu reaches the United States,
where is it likely to show up first?
A. Although health officials expect bird flu to
reach the United States, it is impossible to
predict where it may show up first, in part
because there are several routes it could take.
If it is carried by migrating birds, then it may
appear first in Alaska or elsewhere along the
West Coast.
But if the virus lurks in a bird being smuggled
into the United States as part of the illegal trade
in exotic birds, it could land in any international
airport. Bird smuggling is a genuine problem:
in 2004, a man was caught at an airport in Belgium
illegally transporting eagles from Thailand,
stuffed into tubes in his carry-on luggage.
The birds turned out to be infected with
A(H5N1), and they and several hundred other
birds in a quarantine area at the airport had to
be destroyed.
In theory, an infected human could also bring
bird flu into the United States, and that person
could fly into just about any international airport
and go unnoticed if the virus had yet to produce
any symptoms.
Q. Does bird flu affect all birds?
A. No one knows the full story. Scientists
say A(H5N1) is unusual because it can infect
and kill a wide variety of birds, unlike a vast
majority of bird flus, which are usually found in
wild birds, not domestic fowl, and which cause
few symptoms.
Some researchers suspect that wild ducks, or
perhaps other wild birds, are impervious to
A(H5N1), and may be the Typhoid Marys of
bird flu — getting the virus, spreading it to other
birds but never becoming ill themselves. No one
has good evidence of this yet, but that may be
because the way scientists discovered A(H5N1)
infections was by finding birds that had gotten
the flu and died.
As virologists like to point out, dead birds
don't fly. So migratory birds cannot spread the
virus if they are dying shortly after being infected.
That is why some researchers say that if
wild birds are spreading the A(H5N1) virus, it
must be a bird species that can be infected but
does not become ill.
Q. When people die from avian flu
contracted from birds, what kills them?
A. Like victims of severe pneumonia, many
patients die because their lungs give out. The
disease usually starts with a fever, fatigue,
headache and aches and pains, like a typical
case of the flu. But within a few days it can turn
into pneumonia, and the patients' lungs are
damaged and fill with fluid.
In a few cases, children infected with
A(H5N1) died of encephalitis, apparently because
the virus attacked the brain. A number of
people have also had severe diarrhea — not usually
a flu symptom — meaning that this virus
may attack the intestines as well. Studies in cats
suggest that in mammals the virus attacks
other organs, too, including the heart, liver and
adrenal glands.
But more detailed information about deaths in
people is not available because very few autopsies
have been done. In some countries, like
Vietnam, where many of the deaths occurred,
autopsies are frowned upon. Researchers say
they may glean useful information from autopsies,
but fear that pressing for them would alienate
the public in some areas.
Q. If I got bird flu, how would I know?
A. There is no reason to suspect the disease
unless you may have been exposed to it.
Since the virus has not reached North America,
doctors do not look for bird flu in people unless
they have traveled to affected regions or have
been exposed to sick or dead birds.
The early stages of the illness in people are
the same as those of ordinary flu: fever, headache,
fatigue, aches and pains. But within a few
days, people with bird flu often start getting
worse instead of better; difficulty breathing is
what takes many to the hospital.
In any case, patients with flulike symptoms
that turn severe or involve breathing trouble
are in urgent need of medical care.
Q. Can I be tested for avian flu?
A. There is no rapid test for bird flu. There
is a rapid test for Type A influenza viruses, the
group that A(H5N1) belongs to, but the test is
only moderately reliable, and it is not specific
for A(H5N1).
State health departments and some research
laboratories can perform genetic testing for
A(H5N1) and give results within a few hours,
but they do not have the capacity to perform
widespread testing.
Because of the limited availability of testing
and the extremely low probability of A(H5N1)
in people in the United States, the test is recommended
only for patients strongly suspected of
having bird flu, like travelers with flulike symptoms
who were exposed to infected birds.
Q. Do any medicines treat or prevent
bird flu?
A. Two prescription drugs, Tamiflu and Relenza,
may reduce the severity of the disease if
they are taken within a day or two after the
symptoms begin. But Relenza, a powder that
must be inhaled, can irritate the lungs and is not
recommended for people with asthma or other
chronic lung diseases.
Both drugs work by blocking an enzyme —
neuraminidase, the "N" part of A(H5N1) — that
the virus needs to escape from one cell to infect
another. But just how effective these medicines
are against A(H5N1) is not known, nor is it clear
whether the usual doses are enough. Also unknown
is whether the drugs will help if taken
later in the course of the disease.
Although government laboratories and other
research groups are trying to develop vaccines
to prevent A(H5N1) disease in people, none are
available yet.
Q. If there is an epidemic of flu in
humans, how can I protect myself?
A. If there is a vaccine available, that would be
the best option. But if there is no vaccine it may
be hard to avoid being infected. Flu pandemics
spread quickly, even to isolated regions. The
1918 flu reached Alaskan villages where the only
way visitors could arrive was by dog sled.
The vaccines produced every year to prevent
seasonal flu are unlikely to be of any use in
warding off a pandemic strain. But a flu shot
could provide at least some peace of mind, by
preventing the false alarm that could come from
catching a case of garden-variety flu.
Similarly, people over 65 and others with
chronic health problems should consult their
doctors about whether they should be vaccinated
against pneumococcal pneumonia, a dangerous
illness that can set in on top of the flu. Again,
that vaccine will not stop bird flu, but it may
prevent complications.
Some health officials have recommended
stockpiling two to three months’ worth of food,
fuel and water in case a pandemic interferes
with food distribution or staffing levels at public
utilities, or people are advised to stay home.
Many health experts have advised against
stockpiling Tamiflu or Relenza, the prescription-only antiviral drugs that may work against
bird flu. Doctors say the drugs are in short supply
and hoarding may keep them out of reach of
people who genuinely need them.
Also, they say, self-prescribing may lead to
waste of the drugs or misuses that spur the
growth of drug-resistant viruses. But people
may not trust the government to distribute
these drugs, and may want their own supplies.
Doctors say people can take precautions like
avoiding crowds, washing their hands frequently
and staying away from those who are sick. Masks may help, but only if they are a type
called N-95, which has to be carefully fitted. So
far, masks and gloves have been recommended
only for people taking care of sick patients.
Avoiding the flu can be hard because it is not
always possible to spot carriers. Many people
get and spread flu viruses and but never know
they are infected.
Q. Is the government prepared for a
bird flu pandemic?
A. No. The nation does not have an approved flu
vaccine for people or enough antiviral drugs or
respirators for all who would need them. The
best protection in any flu pandemic will come
from a vaccine, but scientists cannot tell ahead
of time what strain the vaccine should protect
against.
Efforts are under way to make a vaccine for
A(H5N1). But the virus could mutate in a way
that makes experimental vaccines ineffective,
requiring more than one vaccine.
Moreover, there is no assurance that the next
pandemic will even involve A(H5N1). It may involve
a different strain of bird flu, and an
A(H5N1) vaccine would not work for it. Recent
efforts to develop a sort of universal flu vaccine
that would work across strains have failed.
For now, the hope is to spot a pandemic early
and quickly make a vaccine. Investigators are
developing new and better ways to make vaccines
— a bird flu, for example, cannot be grown
in fertilized eggs like other flu viruses because
it kills the chicken embryos — but these new
methods must first be approved by the Food
and Drug Administration.
Preparations also include government plans
to stockpile drugs to protect people who were
exposed to the flu and to reduce the severity of
the disease in those who are ill. But the one antiviral
drug that everyone wants to buy and stockpile,
Oseltamivir, also sold by Roche as Tamiflu,
is in short supply.
In retrospect, scientists say, maybe the nation
should have started preparing sooner. But
until the current bird flu appeared, there was
little interest in such expensive and extensive
preparations.
Q. If bird flu reaches the United States,
will it be safe to eat poultry or to be
around birds or other animals?
A. Poultry is safe to eat when it is cooked thoroughly,
meaning that the meat is no longer pink
and has reached a temperature of 180 degrees
Fahrenheit. The risk is not from cooked meat —
cooking kills viruses. Instead, it is from infected
birds that are still alive or have recently died.
So the person who killed an infected chicken,
butchered it or put it in the pot would be at greater risk than the one who ate it.
It's not clear how long the virus lives on a
dead bird, but it is unlikely to survive more than
a couple of days. And it seems unlikely that infected
chicken will find its way to supermarkets.
If the bird flu strikes poultry farms, the
farmers will know there is a problem. Before
they die, the birds develop major hemorrhages,
with blood streaming from their cloacas and
beaks. When the flu gets to a poultry farm,
farmers have to destroy their flocks, and poulgreater risk than the one who ate it.
It's not clear how long the virus lives on a
dead bird, but it is unlikely to survive more than
a couple of days. And it seems unlikely that infected
chicken will find its way to supermarkets.
If the bird flu strikes poultry farms, the
farmers will know there is a problem. Before
they die, the birds develop major hemorrhages,
with blood streaming from their cloacas and
beaks. When the flu gets to a poultry farm,
farmers have to destroy their flocks, and poultry
from infected farms cannot be sold for meat.
As for contact with healthy birds or animals,
there is no need to panic. The A(H5N1) virus is
a nasty one. If chickens or other animals became
infected they would get sick and die, and
you would know the virus was present.
But animals can carry many diseases besides
influenza, and whenever you are around animals
it is a good idea to wash your hands afterward.
Because cats in Europe have caught
A(H5N1), apparently from eating infected
birds, health officials there advise keeping pet
cats indoors, but no such recommendation has
been made in the United States.
For now, officials at the Centers for Disease
Control and Prevention say it is safe to have
bird feeders, and they note that even if the virus
does arrive here, the kinds of birds that perch at
feeders are far less likely to carry A(H5N1)
than are aquatic birds like ducks and geese.
Q. Is it safe to buy imported feather
pillows, down coats or comforters and
clothing or jewelry with feathers?
A. Imported feathers may not be safe. There is
a risk to handling products made with feathers
from countries with outbreaks of bird flu, according
to the Centers for Disease Control and
Prevention.
Feathers from those countries are banned in
the United States unless they have been processed
to destroy viruses.