Reem Leila reports on preparations to contain the impact of an Avian Flu pandemic Prime Minister Ahmed Nazif has approved the allocation of LE240 million ($42 million) to combat bird flu. The money is to be shared between the ministries of agriculture and health and will be used, says Ayman Al-Qaffas, spokesman for the Supreme Committee for Combating Bird Flu (SCCBF), to help the Health Ministry produce vaccines. "The Agriculture Ministry will use the money to develop labs, train 1,200 vets and vaccinate poultry against bird flu," said Al-Qaffas. Thirty-four cases of bird flu in humans have been reported in Egypt since February 2006 of which 20 made a full recovery. The remaining 14 cases ended in fatalities. The H5N1 virus has claimed the lives of 172 people worldwide. According to the SCCBF spokesman, attempts to combat bird flu in Egypt have been severely hampered by the continued practice of raising poultry domestically in rural areas. In a report prepared by the US Health and Human Services (HHS) department Stephanie Marshall, director of Pandemic Communications, writes, "bird flu virus presents a massive challenge to the government across many levels. Uncertainty about the course of a possible pandemic and unknown scientific factors, as well as unforeseen and unintended outcomes with respect to governmental actions and statements make this a communication management issue of epic proportion. The economic and societal effects of such a pandemic could have significant detrimental impact on the country." A critical component of national preparedness for an influenza pandemic is adhering to transparency in government communications and actions, in order to maintain public confidence and trust, to inform the public about the potential threat, and to provide a solid foundation of information upon which future actions can be based. Al-Ahram Weekly was among an Egyptian delegation, headed by Abdel-Rahman Shaheen, official spokesman at the Ministry of Health and Population (MOHP), invited by the US State Department for a one week reporting tour in the United States that focussed on the deadly bird flu virus and the precautionary measures that should be followed should the H5N1 virus turn into a pandemic. The delegation visited the offices of the HSS, USAID, the National Institute of Health (NIH), the US Department of Agriculture (USDA) and the Centre for Disease Control and Prevention (CDC). USAID officials were content with the levels of transparency adopted by the Egyptian government in dealing with issues arising from the spread of the H5N1 virus. Accordingly, Dennis Carroll, senior infectious diseases advisor and director of the Avian and Pandemic Influenza Preparedness and Response Programme, said Egypt will be eligible for financial aid to help contain and combat the virus. "The actual sum has not yet been identified, but within a month this allocated amount will be acknowledged during USAID officials' visit to Egypt," explained Carroll. Many scientists believe it is only a matter of time before the H5N1 virus mutates into a strain capable of human-to-human transmission. It is the timing and severity of the ensuing pandemic that cannot be predicted. Anthony Fauci, director of the NIH's National Institute of Allergy and Infectious Diseases, points out that influenza pandemics have occurred three times in the past century. In 1918-19, 40 million people died and in 1957-58 an estimated 7.4 million people fell victim. The 1968-69 outbreak of influenza resulted in significantly fewer deaths. While stressing that there are as yet no reported cases of sustained human-to-human passage of H5N1, Fauci warns that as the virus mutates it could become capable of passing from human to human and as a consequence will spread quickly. "Accordingly different governments, including the US, are focussing on comprehensive public health efforts -- increasing surveillance, monitoring outbreaks in order to be alert to any slight change in the virus, international cooperation, increasing anti-viral stockpiles, and building more robust capacity for vaccine production -- that will help protect different nations no matter what pandemic strain emerges or where." The Egyptian government, says Shaheen, has prepared a detailed national plan to be implemented in case of a pandemic under which half of Egypt's 150,000 hospitals beds will be reserved for Avian Flu patients. "Patients with minor ailments will not be admitted to hospitals," says Shaheen. "Egypt has also considered medicating people in their homes and providing them with the necessary health and medical care since thousands are expected to contract the virus." During an influenza pandemic, people will likely look for several sources for information about the status of the pandemic, what to do to stay healthy and where to go to obtain medical services. In such a situation, says Shaheen, the media, ranging from TV and Radio to newspapers and magazines, will play a crucial role. "Campaigns to increase people's awareness and furnish accurate information will be crucial." Any pandemic, says Shaheen, is expected to last between six and eight weeks. Egypt's national plan to face an outbreak, therefore, is not limited to the Health Ministry but includes the ministries of communication, environment, education, electricity and interior. Each of the concerned authorities will assign an official to identify reliable sources of information and watch for early public health warnings about the possible mutation and spread of the virus. "The Egyptian government will designate the prime minister, health minister or the head of the State Information Service (SIS) to address the public on developments." Meanwhile, the US Food and Drug Administration (FDA) announced its initial approval of a human vaccine against the H5N1 virus two weeks ago. "The vaccine," reports Andrew von Eschenbach, commissioner of food and drugs at the FDA, "could be used in the event that the current H5N1 avian virus develops the capability to efficiently spread from human to human, resulting in the rapid spread of the disease across the globe. Should such an influenza pandemic emerge, the vaccine may provide early limited protection in the months before a vaccine tailored to the pandemic strain of the virus is developed and produced." "The threat of an influenza pandemic is, at present, one of the most significant public health issues our nation and the world are facing. The approval of this vaccine is an important step forward in our protection against the pandemic." The vaccine, intended for immunising people at increased risk of exposure to the H5N1 influenza virus aged between 18 and 64, is administered in two intramuscular injections, given one month apart. It is, says Fauci, generally well tolerated, with the most common side effects reported as pain at the injection site, headache, general ill feeling and muscle pain. The initial study, according to Fauci, showed that 45 per cent of individuals who received the 98 microgramme, two-dose regimen developed antibodies at a level that is expected to reduce the risk of contracting influenza. Although the level of antibodies seen in the remaining individuals did not reach that level, current scientific information on other influenza vaccines suggests that less than optimal antibody levels may still have the potential to reduce disease severity and influenza-related hospitalisations and deaths. In a statement issued last week, the World Health Organisation (WHO) said countries and vaccine manufacturers had agreed it may be feasible to create a stockpile of H5N1 vaccine and to separately develop a mechanism to ensure broader access to pandemic influenza vaccine for developing countries in the advent of a pandemic. While "meeting at WHO headquarters on 25 April, countries that have experienced human H5N1 infections, donor countries, and vaccine manufacturers from industrialised and developing countries agreed that both scientific evidence and international political commitment support further efforts to examine whether and how to establish a stockpile of H5N1 vaccine and a mechanism for broader access to pandemic vaccine when the next influenza pandemic occurs." "We have taken another crucial step forward in ensuring that all countries have access to the benefits of international influenza virus sharing and pandemic vaccine production," said Margaret Chan, director- general of WHO. "All countries will now be better placed to protect the public health security of their people and the world at large. Such cooperation is welcome and is consistent with the International Health Regulations, which will soon come into force." Marshall warns, however, that the influenza vaccine production process is long and complicated, the production technology labour-intensive, taking up to nine months from start to finish. Vaccines thought to be effective against a pandemic virus are not yet available to Egypt. Vaccines produced each year for seasonal influenza outbreaks will not protect against pandemic influenza and according to the report released by the US FDA, although a vaccine against the H5N1 virus is under development in several countries, no vaccine is ready for commercial production and no vaccines are expected to be widely available until several months after the start of a pandemic. "Egyptian vaccine-maker Vacsera is seeking to team up with the French Pasteur Institute to produce vaccines, the human vaccine against bird flu included," explained Shaheen. The vaccine, though, will need to closely match the pandemic virus and large- scale commercial production will, as a consequence, not start until the new virus has emerged and a pandemic has been declared. "Producing a new vaccine will take at least one month. Should the pandemic appear first in a country other than Egypt this will give us more time to act," says Shaheen. In the case of a pandemic it is estimated that at least 30 per cent of Egypt's health workers will contract the virus. School teachers and children have been identified as the group next at risk. "Sterilised masks, of which Egypt has stockpiled nearly 20 million, will be distributed first among health workers, children and teachers, and then the remaining population," said Shaheen. The influenza virus already infects animals and birds, including ducks and pigs, and has developed resistance to Tamiflu. In Egypt two cases in humans, both resulting in death, were a result of transmission from ducks. "The patients were treated with Tamiflu and Adamine but still they died," says Shaheen. NIH officials recommend the use of Rimantadine rather than Adamine, which contains "toxic substances that badly affect human health," warns Fauci. Egypt's Ministry of Health, however, argues there is no significant difference between the drugs and Adamine can be safely used. Pigs also constitute a potential reservoir for the H5N1 virus. Michael Bell, head of the CDC's Division of Healthcare Quality Promotion, National Centre for Preparedness, Detection and Control of Infectious Diseases recommends the removal of pig populations from inhabited areas to lessen the risk of virus mutation. The density of the settlement pattern in Egypt, where 95 per cent of the population is concentrated on five per cent of the land, has serious ramifications for any pandemic outbreak. The virus has been found at 270 sites and is now "totally rooted in the Egyptian environment" says Shaheen, who believes that following the first incidents of Avian Flu Egypt should have radically culled all poultry and taken draconian measures to stamp out the continued domestic rearing of birds. Egyptian and US health officials are currently advising people to stock at least three weeks supply of food and water as well as essential drugs since "many pharmacies could be subject to limited working hours during the pandemic," according to Shaheen.
