A doctor at Hanoi’s infectious diseases hospital in Vietnam has reportedly claimed the deadly bird flu virus has started to change its form, amid fears it is only a matter of time before human-to-human infections occur.
The BBC’s 'Panorama' program reported that the Hanoi hospital sent samples of the H5N1 virus for overseas testing at the end of last year, with the results showing that the bird flu had mutated.
The likelihood of avian influenza changing to make it easier for the disease to pass directly from one person to another has sparked a massive international effort to contain outbreaks and step up vaccine production.
"I really do hope that the pandemic will not break out this winter because we have not gone through, in our planning machinery that we’ve got in the world at the moment, we’ve not gone through the contingency planning that is necessary," United Nations Flu Co-ordinator, Dr David Nabarro, told 'Panorama'.
Japan’s Yomiuri Shimbun newspaper reported that Tokyo is considering whether to release 300 million yen (A$3.52 m) in additional funding to help the World Health Organisation (WHO) battle the virus.
Already, Japan has committed A$1.84 m in the fight against fresh infections, while China has also earmarked A$331 m towards health measures.
Girl infected
Beijing has invited the WHO to investigate what could be the country’s first case of human bird flu infection after initially finding that the death of a 12-year-old girl in late October was due to pneumonia.
He Yin was among three people in the village of Wantang, in central Hunan province, believed to have suffered pneumonia.
The girl died but her nine-year-old brother and a school teacher both recovered.
China’s health ministry has issued a statement saying that although initial tests proved negative to bird flu it "cannot rule out the possibility of human infection of H5N1 avian influenza."
China has had several cases of the flu outbreaks among bird flocks but no human cases have yet been confirmed.
In the northern Liaoning province, officials have culled 370,000 chickens after a fourth outbreak in three weeks killed nearly 9,000 birds.
Indonesia, one of four Southeast Asian nations where human infections have occurred, authorities have confirmed a fifth fatality from the H5N1 virus.
More than 60 people have died since late 2003 among a total 122 cases across Indonesia, Vietnam, Thailand and Cambodia.
SOURCE: World News
One of the reasons why the 'Panorama' team were so keen to go to Vietnam was so that they could meet the healthcare workers who have had direct experience of treating patients suffering from the H5N1 virus, which is currently endemic in poultry in parts of South East Asia and has proved capable of jumping species and infecting humans as well.
Vietnam has had more human cases of H5N1 than any other country and in Hanoi and Ho Chi Minh the team met doctors and nurses in two infectious disease hospitals. When they visited there were no H5N1 patients in the country and the hospitals were mainly treating patients suffering from diseases like malaria, dengue fever, tuberculosis and HIV.
However, this does not mean that H5N1 has gone away. Flu is seasonal. The majority of cases in Vietnam have occurred in colder weather and the hospitals they visited were gearing up for the possibility that the same would happen this year.
In Hanoi the team met one doctor who had actually caught H5N1 himself. This was discovered not because he became severely ill with the flu but because they decided to screen all the medical staff in the department which treated flu patients, in order to gauge the transmissibility of the disease.
The doctor had had a cough for a couple of months, but other than that had not suffered from the virus. He believes that he caught the virus from a patient because, although his family does keep poultry, the birds all tested negative for the virus.
A health worker who catches the flu are likely to be one of the early warnings that the virus is developing into an easily transmittable 'human' form. As yet it has only displayed very limited ability to do so, but the more cases there are, the more chances there are for the virus to mutate into a 'humanised' form.
In Vietnam, as in other South East Asian countries, live poultry is a common sight even in the centre of cities. In Hanoi caged birds were for sale in a market, which also sold butchered meat. People buy live animals and bring them home to slaughter them there.
Because of the avian flu outbreak, the government has issued numerous directives to try and stop the selling of live birds but some parts of the country have not cracked down on the practice effectively enough.
A Food and Agriculture Organisation (FAO) official, based in Vietnam explained to the team that wet markets can lead to the spread of disease because of the contact between dead and live birds. There is a worry that live birds which are not sold at the end of the day will be brought home and then back to the market the next day, when they could have picked up the virus.
It also worries officials that the birds are transported live to the market, sometimes on the back of motorbikes. The droppings which carry the virus are therefore being spread on tyres and onto roads.
In Ho Chi Minh the situation was different. Markets where months ago you could easily buy live ducks and chickens were selling only butchered meat when the 'Panorama' team visited in October. There is now a rule that all poultry should be slaughtered before it is brought into the city.
From Ho Chi Minh the team travelled South West to the Mekong delta and a province called Ben Tre. Here they travelled to the home of Nguyen Thi Thanh, a 35-year-old widow whose husband, Phan Van Luu, died from H5N1. It was the most recent fatal case of the flu in Vietnam.
Thanh has a six-year-old daughter to support who has just started school. The daughter, Phan Thi Thach Thao is pictured along with Thanh's mother-in-law who lives with them in this roadside house. Thanh and her husband used to work together to sell a breakfast broth to village residents and people driving through. She continues this work alone now.
She believes her husband was infected by a fighting cock which he butchered. He became ill very quickly afterwards. She tried to nurse him at home but his fever kept getting worse and eventually he had to be brought to hospital. He is buried just down the road from their house.
No one else in the family caught the disease and no other bird in the area was found to be carrying it.
Vietnam is in the process of trying to vaccinate all domestic animals in order to get rid of H5N1. The vaccine they are using comes from China and every bird has to get two shots, the second a month after the first.
In Ben Tre farmers are generally happy to have their animals vaccinated to prevent H5N1 coming back. In the past few years when the virus broke out locally their ducks and chickens had to be culled.
Culling was vastly expensive for the farmer as the government only compensated them for a quarter of the market price of each bird. Animal health workers told us that during culls farmers would sometimes try and hide their flocks so they could keep them.
The FAO supports the vaccination strategy as the only way to prevent the spread of the disease in animals in Vietnam. If you can wipe out or curb the disease in poultry, then the chances of it ever mutating into a human form are greatly reduced.
Reporter Jane Corbin is pictured (photo ommitted) in front of a statue of Ho Chi Minh, after whom the city formerly called Saigon was renamed in 1975 following the unification of the country. This statue is outside the 'Peoples Committee Building' in Vietnam. Vietnam is a communist country and we were accompanied by an official from the ministry of foreign affairs throughout our trip, who helped set up our filming.
Panorama's "Bird Flu - Facing the Pandemic" is broadcast on Sunday 6 November 2005, at 22:15 GMT, on BBC One and online at bbc.co.uk/panorama where it is also available on demand and in broadband.
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by Laurie Garrett
In February 2003, at a time when the world was focussed on containing Sars, the Netherlands was battling a different infection: bird flu.
A highly pathogenic strain of avian influenza began to spread through chicken flocks in one of the country's densest poultry farming areas.
It spread very quickly through farms and caused real alarm in a country where the export of poultry and eggs brings in 284m euros a year.
As well as concerns for the economy, there were fears for human health: in 1997, in the first outbreak of H5N1 in Hong Kong bird flu had managed to infect humans who had come into contact with birds. In that outbreak 18 people had been hospitalised and six had died.
Knowing what had happened in Hong Kong, the Netherlands did undertake to protect all those who they charged with the culling of infected birds by distributing masks, eye protection, gowns and caps. But this strain had never infected humans before and the risks were thought to be low.
Taken by surprise
Despite the precautions, human cases were being anecdotally reported within a week.
The symptoms were mild, in most cases it caused conjunctivitis, but health protection units were suddenly alert to the possibility of a flu pandemic developing through mutation or a mixing of the virus with a human flu already in circulation.
Human health protection teams soon joined their veterinary counterparts on the ground but the measures they enacted were not enough to prevent one person, a 57-year-old veterinarian named Jan Bosch, from dying as a result of the disease.
Four months after the outbreak began it was brought under control. 30m chickens had been killed to curb the disease's spread. 89 humans had been infected by the virus and one person had died.
Since then scientists and policy makers have been looking at the outbreak in order to understand exactly what happened.
A key question for scientists was: why did a disease which gave most humans a mild conjunctivitis, lead to a person's death?
'What made it a human killer?'
Influenza viruses are highly unstable; as they reproduce, they can mutate.
The virus which killed Jan Bosch was H7N7 but it had mutated and become more virulent.
The first symptoms appeared just two days after the 57-year-old had visited an infected chicken farm and spent just two hours screening flocks.
He got a headache and a fever. The family doctor took swabs in case it was H7N7 but for reasons which are unclear the results he got back were negative.
Six days later his condition had deteriorated and he was taken to hospital. Chest X-rays showed pneumonia. He was moved to intensive care and put on a ventilator, but it wasn't possible to save his life.
He died just two weeks after first becoming ill. H7N7 was discovered at autopsy: there was a lot of the virus in his lungs.
The way in which H7N7 attacked, in this case, is similar to the way in which H5N1 - the current strain of flu affecting chickens, ducks and wild birds - has attacked humans in the cases where it has jumped species: it is the lungs which the virus attacks.
No one surrounding the vet caught the virulent form of H7N7 from him. However no one can say categorically whether it could have transmitted or not.
Indeed in some families in the Netherlands the milder form of H7N7 was transmitted from one person to another, so that people who had not had direct contact with chickens nonetheless caught the illness.
This transmission was limited but of it course if it had been able to spread further and faster we would have been looking at a much more dangerous situation and potentially a new pandemic starting on European soil.
Where did it come from?
A team in the Netherlands had already been monitoring low-pathogenic, avian influenza in wild birds.
Avian influenza is always present especially in waterfowl like wild ducks but it is not usually something which kills.
However, when a low-pathogenic virus finds its way into domestic chickens, it spreads fast and furiously and can mutate into something much more virulent. This appears to be what happened in the Netherlands.
A low pathogenic avian influenza which had been circulating in wild birds bears a close genetic resemblance to the highly pathogenic H7N7 which later emerged.
Furthermore, the outbreak began on a free-range farm where chickens were more likely to come into contact with germs shed by wild birds.
The virus was most probably carried by migrating mallard ducks. They would have had no symptoms themselves but when the flu was picked up by domestic chickens it mutated into a deadly form.
The same process would have occurred with H5N1, the strain currently affecting poultry in South East Asia though in this case the transmission between wild and domestic birds has gone one step further.
Probably the low-pathogenic flu was transmitted from wild to domestic birds and became highly pathogenic back some years ago. This year it was discovered that the highly pathogenic form, which developed in chicken flocks, has been passed back to wild birds.
Why the Dutch are nervous
This is something which has never been documented before and it makes farmers and scientists in the Netherlands particularly nervous.
In the Netherlands poultry farming is particularly dense. There are about 90m chickens and a human population of just 16m.
An outbreak of this virus, which would not even have to mutate to start killing poultry, would be very hard to contain and likely result in another massive cull.
In October 2005 Panorama visited one of the farms which was affected by the 2003 outbreak. The farmer there, Jan Van Kampen, was already keeping his flocks indoors as a precautionary measure to reduce the risk of them catching H5N1.
Normally his flock is free range and would be out in the fields. He told Panorama that after the 2003 outbreak he did not have any income for a year, because he was not allowed to keep chickens in the same barns until they could be sure they were free of the virus.
The outbreak in the Netherlands shows the significant advantages which a Western European county has when it comes to tackling outbreaks of avian influenza.
The method of killing birds using CO2 gas pumped into the barns (which has also now been tested in the UK), contrasts with some of the slower culling methods used in South East Asia and ultimately the cull was very effective.
However, despite the distribution of goggles and masks and an advanced public health system, people still caught the flu from the birds and one person died.
The fact that the symptoms which developed were mostly mild forms of conjunctivitis perhaps meant that poultry workers were not that worried about the virus and were not careful enough.
As one public health official put it, the workers did not understand 'the big picture' that the virus could mutate in humans to become more virulent or mix with a human flu to form a pandemic strain.
If called upon to tackle an outbreak of bird flu in chickens in the UK, government ministers and officials will have the threat it poses to human health at the front of their minds.
FURTHER READING:
Transmission of H7N7 avian influenza A virus to human beings during a large outbreak in commercial poultry farms in the Netherlands - M. Koopmans et al, Lancet, Vol 363, February 2004
Avian Influenza A virus (H7N7) associated with human conjunctivitis and a fatal case of acute respiratory distress syndrome. - R. Fouchier et al, PNAS, Vol.101 no.5, February 2004
'The Monster At Our Door'
Panorama's "Bird Flu - Facing the pandemic" was broadcast on Sunday 6 November 2005 on BBC One and online at bbc.co.uk/panorama
'Is Tamiflu A Prescription For Survival?'
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