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

Justin Mason jm
Sun Oct 16 15:33:54 PDT 2005

Hash: SHA1

This is pretty old news btw ;)  It is significant that it's being
published in Nature, though.  

Here's the source Reuters story that channelnewsasia is probably
working from:


The report's authors still advise stocking up on *both* Tamiflu and
Relenza, but not amantadine.  This is only one strain -- the one found in
the Vietnamese case.

BTW the report also talks about observed human-to-human transmission:
'evidence she was directly infected by her brother and not by chickens, a
rare case of human-to-human transmission of the virus.'

(PS: Also, the Bebergian depression cloud isn't entirely correct: it's
worth noting that Tamiflu has been part of the WHO's arsenal in Vietnam
and elsewhere treating H5N1 cases for a while, so that resistance
selection has been taking place there already.)

- --j.

Tracie K Meyer writes:
> [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
> Tamiflu?
> Sell Roche stocks?
> Dave
> http://www.channelnewsasia.com/stor.../173522/1/.html
> 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
> triage
> 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
> ventilator)
> 4.  ICU Triage Exit (after intervention which could be hours/days, who
> now
> becomes considered unsalvagable-->withdraw life support and go to the
> ward
> 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
> recently
> about flaws in these systems evident in the Katrina response and other
> recent disasters).  Many ICUs perform some sort of entry/exit triage,
> but
> 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
> trouble
> shifting from looking after the individual patient to viewing the
> situation
> from a system-wide level.  Some will also worry about their liability
> for
> making decisions to withdraw support on patients who would have been
> salvagable under normal circumstances.  Considerable training needs to
> be
> done in advance, and policy-makers must clarify what protection
> clinicians
> 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
> triage
> plans here in Ontario and I will certainly share our thoughts once
> better
> established.
> Randy
> Randy Wax, MD, MEd, FRCPC
> Staff Intensivist, Medical/Surgical Critical Care Unit
> Medical Director, MSH Program for Resuscitation Education and Patient
> Safety
> 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
> on
> how we will handle an Influenza Pandemic specific to H5N1.  This virus
> as
> 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
> we
> learned from the last great pandemic could possibly be much different
> with
> 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
> how
> 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
> only
> Respiratory Distress of all levels, but also may present with
> multi-organ
> failure.  However, current lessons from Hanoi and Jakarta show that
> Respiratory Distress could be the greatest problem we would need to
> treat
> 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
> system
> may perhaps be an option since there is not enough ventilators in the
> world
> to ventilate the projected numbers of patients that may require
> mechanical
> ventilation (recently described by the "Foreign Affairs" paper).  Unless
> you
> are now stockpiling large numbers of disposables, I seriously doubt you
> will
> 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
> "fever
> clinics" outside your hospital so that patients' would be assessed away
> from
> your ED so that you are not overwhelmed within your health care
> facility.
> In here lies the ethical issue of at what level of respiratory distress
> do
> 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
> mask
> 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
> would
> need to be admitted to your adult facility.  I understand this fully
> since
> 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
> ask
> for their input as you work on your plan so that you could be consitent
> with
> 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
> has
> done), but I have a strong suspicion that we will have to make many of
> the
> ethical decisions on our own.  Therefore, we are also trying to learn
> all
> that we can on how best to prepare for the pandemic that would some how
> get
> us through this terrible disaster.  It appears however, that as one
> makes
> pandemic preparations it is important to remember that this thing may
> not
> happen, at least in the worst case scenarios and makes preplanning even
> more
> important to keep from making very costly decisions for stockpiling
> supplies
> 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
> preplanning. 
> Dave
> 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
> this
> hits.I feel it poses special challenges because as the number of victims
> increases the number of staff available to treat them diminishes.In
> addition
> it is clear from Flu Surge that the number of cases requiring
> ventilation
> will outstrip any ventilatory capacity.As a director of an adult ICU I
> am
> actually more concerned about how we will manage the rise in paediatric
> admissions. Generally we transfer out to a regional center but I guess
> that
> 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
> only
> way to deal with overwhelming demand.
> Does Avian Flu demand that we use the principles of Triage within
> hospitals?
> 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>
> said:
> > 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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