Fwd: Re: [FoRK] avian flu/home grown/PastFutureTense

Tracie K Meyer con10gent_sentience
Sat Oct 15 21:29:45 PDT 2005

[dwalker at childrenscentralcal.org: [ccm-l] Scientists say they have found
Tamiflu-resistant strain of bird flu]

Now what are we going to do, since the entire world is stocking up on
Sell Roche stocks?


Scientists say they have found Tamiflu-resistant strain of bird flu

PARIS - Researchers have identified a mutated form of H5N1 bird flu that
is resistant to Tamiflu, the drug being stockpiled around the world to
counter a feared influenza pandemic, a study released on Friday said.

The strain was found in a case in Vietnam involving a 14-year-old girl
who may have caught the flu from her brother rather than directly from
infected birds, it said.

Sequencing of the virus showed that it had a mutation that made it
resistant to oseltamivir, the lab name for Tamiflu.

However, tests on lab animals showed that the resistant virus is
sensitive to another drug called zanamivir, commercialised as Relenza,
the research said.

The study was due to be published next Thursday in Nature, the British
science weekly, but the journal decided to bring forward its release
because of its importance.

The findings "raise the possibility that it might be useful to stockpile
zanamivir as well as oseltamivir in the event of an H5N1 influenza
pandemic," said the authors, led by Yoshihiro Kawaoka of the University
of Tokyo and the University of Wisconsin at Madison. - AFP/ir

David H Walker MA RRT RCP
Children's Hospital Central California
9300 Valley Children's Place 
Madera, CA 93638
Voice: 559-353-5575
Pager: 559-262-8049

"We will have to learn, before understanding
any task, to first ask the question, 'What information
do I need, and in what form, and when.
'"  We should begin thinking about the delivery system
for the information only when this is clear.
Peter Drucker 1990

>>> "Wax, Dr. Randy" <RWax at mtsinai.on.ca> 10/14/05 8:00 AM >>>
I would also like to emphasize the importance of sketching out the
plans in advance as much as possible.
We have learned from disaster simulations here in Toronto (non-Avian flu
scenarios but still helpful) that there needs to be multiple levels of
triage for conditions where the patients will arrive in a steady stream
rather than rapid bolus.
1.  Field Triage (EMS)
2.  Hospital Triage (Emergency department intake)
3.  ICU Triage Intake (who gets into the expanded ICU +/- on a
4.  ICU Triage Exit (after intervention which could be hours/days, who
becomes considered unsalvagable-->withdraw life support and go to the
with palliation)

EMS and Emergency Departments in many cases have more experience and
training in triage (although we have seen many discussions on CCM-L
about flaws in these systems evident in the Katrina response and other
recent disasters).  Many ICUs perform some sort of entry/exit triage,
the rules will have to change dramatically during a pandemic.
Most ICU physicians and staff (in my opinion) have minimal training in
understanding the shift to a disaster triage mode.  Many will have
shifting from looking after the individual patient to viewing the
from a system-wide level.  Some will also worry about their liability
making decisions to withdraw support on patients who would have been
salvagable under normal circumstances.  Considerable training needs to
done in advance, and policy-makers must clarify what protection
have to make these difficult decisions.

I am very interested to hear what has been done in Hong Kong and other
locations to help sort out these difficult issues.  We are working on
plans here in Ontario and I will certainly share our thoughts once


Randy Wax, MD, MEd, FRCPC
Staff Intensivist, Medical/Surgical Critical Care Unit
Medical Director, MSH Program for Resuscitation Education and Patient
Mount Sinai Hospital
Toronto, Ontario, Canada
Assistant Professor, Division of Critical Care, Department of Medicine,
University of Toronto
rwax at mtsinai.on.ca

-----Original Message-----
From: David Walker [mailto:dwalker at CHILDRENSCENTRALCAL.ORG] 
Sent: October 12, 2005 11:08 PM
To: ccm-l at ccm-l.org
Subject: Re: [ccm-l] Avian Flu contingency planning

Dr. Kelly, we have spent the greater part of the last two years working
how we will handle an Influenza Pandemic specific to H5N1.  This virus
you know currently has a mortality that exceeds 50% generally from ARDS.
The virus that caused the 1918 pandemic had a mortality of ~ 5%, so what
learned from the last great pandemic could possibly be much different
H5N1 from a patient care perspective.  In addition, if you check out the
CDC's website of the autopsy of a 6 year old male, the report describes
H5N1 destroys the Type II Pneumocytes as well as it can create a form of
meningitis.  Therefore, we could face a large number of patients not
Respiratory Distress of all levels, but also may present with
failure.  However, current lessons from Hanoi and Jakarta show that
Respiratory Distress could be the greatest problem we would need to
and as you mention, how do we ventilate large numbers of ARDS patients.

Dr. Tom Buckley described last April, that the use of a simple CPAP
may perhaps be an option since there is not enough ventilators in the
to ventilate the projected numbers of patients that may require
ventilation (recently described by the "Foreign Affairs" paper).  Unless
are now stockpiling large numbers of disposables, I seriously doubt you
be intubating these patients; therefore, the use of mask CPAP may be
somewhat useful. From a triage perspective, one goal may be to set up
clinics" outside your hospital so that patients' would be assessed away
your ED so that you are not overwhelmed within your health care
In here lies the ethical issue of at what level of respiratory distress
you admit and when do you determine the patient is not sick enough, or
is so
sick they will not survive?  If you do place many patients on a simple
CPAP system what do you do when they stop breathing and you are the only
clinician caring for 20 or more patients? 

You also mention as one of your concerns is pediatric patients that
need to be admitted to your adult facility.  I understand this fully
having the appropriate disposables and clinicians that are comfortable
taking care of the kids will be a challenge to say the least.  One
suggestion would be to work with your nearest Children's Hospital and
for their input as you work on your plan so that you could be consitent
their procedures so that you could share
equipment and personnel if the need arises.   

Next week the USA will have a pandemic plan in place that I hope will
address some of these issues for us here in the States (as your country
done), but I have a strong suspicion that we will have to make many of
ethical decisions on our own.  Therefore, we are also trying to learn
that we can on how best to prepare for the pandemic that would some how
us through this terrible disaster.  It appears however, that as one
pandemic preparations it is important to remember that this thing may
happen, at least in the worst case scenarios and makes preplanning even
important to keep from making very costly decisions for stockpiling
etc .  

I hope this helps in some small way, but I commend you and your fellow
citizens for placing these issues on the table for discussion and

David H Walker MA RRT RCP
Children's Hospital Central California
9300 Valley Children's Place 
Madera, CA 93638
Voice: 559-353-5575
Pager: 559-262-8049

"We will have to learn, before understanding
any task, to first ask the question, 'What information
do I need, and in what form, and when.
'"  We should begin thinking about the delivery system
for the information only when this is clear.
Peter Drucker 1990

>>> daniel kelly <kelly246 at btinternet.com> 10/12/05 2:47 PM >>>
Dear all,
We are about to try and determine what on earth we are going to do when
hits.I feel it poses special challenges because as the number of victims
increases the number of staff available to treat them diminishes.In
it is clear from Flu Surge that the number of cases requiring
will outstrip any ventilatory capacity.As a director of an adult ICU I
actually more concerned about how we will manage the rise in paediatric
admissions. Generally we transfer out to a regional center but I guess
they will fill up very quickly. When disasters occur in the field it is
accepted that triage determines who gets treated because this is the
way to deal with overwhelming demand.

Does Avian Flu demand that we use the principles of Triage within

All thoughts welcome as I think conventional hospital responses will be
flawed in this context.

Dan Kelly
Clinical Director
Critical Care
Blackpool UK

Children's Hospital Central California
A Great Place to Get Better
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On Fri, 14 Oct 2005 19:37:41 -0400, "Stephen D. Williams" <sdw at lig.net>
> I thought I clearly alluded to those complications in my later paragraph.
> Possibly our disagreement, or your missing piece of knowledge, is that 
> everyone's immune system is different.
> I can't do it justice (see http://en.wikipedia.org/wiki/Immune_system ), 
> but I was taught in medical school (Mini-Medical School that is) that 
> the immune capabilities include a fixed number of molecular patterns 
> that are derived from mixing and matching from the parental sets.  This 
> means that only a finite set of molecular patterns can be matched and 
> that finite set is different for each person.  (I can't remember if this 
> concerns cytokines or T-Cell matching.)
> I believe I've heard estimates that 5% of humans are immune to HIV.  
> This is the kind of thing I was referring to.
> To wit:
> http://www.aidsinfonyc.org/hivplus/issue3/ahead/genes.html
> http://my.webmd.com/content/article/97/104268.htm?z=1624_00000_0000_f1_07
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8918278&dopt=Citation
> sdw
> Kevin Elliott wrote:
> > At 23:42 -0400  on  10/13/05, Stephen D. Williams wrote:
> >
> >> To answer the immunity comment: I was referring to "natural 
> >> immunity", i.e. the capability >of someone to A) avoid noticable 
> >> infection and/or B) to survive infection either because
> >> their immune system reacts quickly enough or they just don't have the 
> >> protein structure for
> >> a particular virus to bind to.  Those kinds of immunity ARE 
> >> inherited, with lots of random
> >> exchanges and "mutations", and are said to be the whole point of 
> >> dual-sex reproduction.
> >>
> >> The presence of particular antibodies is not passed on (except some 
> >> mother->child), but the >ability to make those antibodies to a 
> >> particular response definitely is inheritable most of >time.
> >
> >
> > I think what's missing from your analysis is the very complicated 
> > issue of exactly how a given person at the time developed 
> > immunity/survived:
> >
> > Were they exposed to the "full strength" variant or a weaker mutation 
> > that their body fought off and in the process developed antibodies 
> > that were also effect against the full strength variant?
> >
> > Did they ever have the disease at all or did the merely avoid exposure?
> >
> > Even if they survived the full strength virus was this because of a 
> > superior immune system or simply because their immune system tripped 
> > over an effective antibody earlier than "normal"?
> >
> > My impressions is that for most viral infections the body is CAPABLE 
> > of synthesizing effective antibodies.  The issue of survival comes 
> > down to a race between the bodies ability to adapt and the viruses 
> > ability to mutate and/or kill the host.  I actually think this bodes 
> > well for the first world in the case of a catastrophic avian flu 
> > epidemic- at the turn of the century 1st and 3rd world medicine were 
> > much closer to each other than they are today.  With the life support 
> > mechanism available today, I would think we'd be much more capable of 
> > sustaining life long enough for the bodies natural antibodies to win 
> > the battle.

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