The Fatal Strain Page 44

  255 “does not encourage immediate openness”: Angus Nicoll, “Human H5N1 Infections: So Many Cases—Why So Little Knowledge?” Eurosurveillance 11, nos. 4-6 (Apr.-June 2006): 74-75.

  255 fewer than a dozen victims: One of the few autopsies was performed on Captan Boonmanut, the Thai boy whose admission to Siriraj Hospital in Bangkok helped alert Dr. Prasert Thongcharoen to the spreading virus. See Mongkol Uip rasertkul et al., “Influenza A H5N1 Replication Sites in Humans,” Emerging Infectious Diseases 11, no. 7 (July 2005): 1036-41.

  256 Rini Dina: Her case is discussed in: I. Nyoman Kandun et al., “Three Indonesian Clusters of H5N1 Virus Infection in 2005,” NEJM 355, no. 21 (Nov. 23, 2006): 2186-94.

  258 on the afternoon of Tuesday, June 14: The account of this meeting is based primarily on an internal WHO account, “Notes of Avian Influenza Meeting, Tuesday, June 14, 2005.”

  260 when Troedsson reported back: Personal notes of call, June 14, 2005.

  260 Stohr and his colleagues in Geneva: Personal notes of discussion, June 14, 2005.

  260 sent an e-mail: E-mail from Yan Li, June 13, 2005.

  261 Kinsmen Place Lodge: The details in this account are drawn from extensive press coverage of the episode in August and September 2003, including multiple articles written by Helen Branswell of Canadian Press; Pamela Fayerman, Kim Pemberton, and Nicholas Read of the Vancouver Sun; Mark Hume of the Toronto Globe and Mail; and Lawrence K. Altman of the New York Times. See also Wayne Kondro, “Canadian Officials Watch SARS-like Mystery Bug,” Lancet 362, no. 9385 (Aug. 30, 2003): 714.

  262 without his permission: Nicholas Zamiska, “Avian Flu Puts WHO in a Bind,” Wall Street Journal Asia, Oct. 18, 2005.

  263 Khai signaled his government’s good intentions: For Ellen Nakashima’s full interview with Khai, see “Transcript: Interview with Phan Van Khai,” washingtonpost.com, June 16, 2005.

  264 “They should be from different backgrounds”: Personal notes of discussion.

  264 say as little as necessary: Personal notes of call.

  264 without actually lying to them: For WHO’s vaguely worded, four-paragraph press release about the mission, see “International Team of Avian Influenza Experts Visits Viet Nam,” June 24, 2005.

  266 rogue bits of genetic material: Several members of the WHO mission, including Tashiro, told me that the Canadian primers were at fault. Plummer later told me that he did not dispute the findings that the tests conducted with the Canadian-supplied primers had yielded false positives. But he added, “Given that both our lab and the CDC have concluded that our primers are effective, we remain confident that they were not the cause of the false positives.”

  266 French press agency reported: “Top Scientists Downgrade Risk of Imminent Bird Flu Pandemic,” Agence France Presse, June 29, 2005.

  Chapter Ten: Let’s Go Save the World

  269 more people had died: On the stream of Indonesian cases in late 2005 and early 2006, see Endang R. Sedyaningsih et al., “Epidemiology of Cases of H5N1 Virus Infection in Indonesia, July 2005-June 2006,” Journal of Infectious Diseases 196, no. 4 (Aug. 15, 2007): 522-27.

  269 keeping her identity confidential: Though I continue to honor this request, the victim’s name was disclosed in Indonesian press reports.

  273 humming with questions: On the key steps and objectives of an avian flu investigation, see “WHO Guidelines for Investigation of Human Cases of Avian Influenza A (H5N1),” WHO, Jan. 2007.

  274 A study of Indonesia’s first 127 confirmed cases: I. Nyoman Kandun et al., “Factors Associated with Case Fatality of Human H5N1 Infections in Indonesia: A Case Series,” Lancet 372, no. 9640 (Aug. 30, 2008): 744-49.

  277 deadliest outbreak of Marburg hemorrhagic fever: Accounts of the Angola outbreak can be found in John Donnelly, “Deadly Virus, Anger Take Hold in Angola,” Boston Globe, Apr. 12, 2005; Sharon LaFraniere and Denise Grady, “Stalking a Deadly Virus, Battling a Town’s Fears,” New York Times, Apr. 17, 2005; and M. A. J. McKenna, “CDC Team Sees Small Advances Against Disease,” Atlanta Journal-Constitution, May 25, 2005.

  277 a flare-up in southern Sudan: A good account is David Brown, “U.N. Team Studies Sudan Outbreak,” Washington Post, Oct. 21, 1998.

  278 the mountains of Afghanistan: For details, see WHO press release, “‘Influenza-like’ Acute Respiratory Infection Behind Deadly Afghan Outbreak,” Mar. 2, 1999.

  280 suddenly erupted in Azerbaijan: Some of the details in this account come from internal WHO situation updates, field reports, and notes of conference calls in March 2006. The outbreak is described in “Human Avian Influenza in Azerbaijan, February-March 2006,” Weekly Epidemiological Record, no. 18, May 5, 2006, 183-88; A. Gilsdorf et al., “Two Clusters of Human Infection with Influenza A/H5N1 Virus in the Republic of Azerbaijan, February-March 2006,” Eurosurveillance 11, nos. 4-6, Apr.-June 2006, 122-26; and Caroline Brown, “First H5N1 Outbreak in Humans Associated with Dead Wild Birds: Azerbaijan, February-April 2006,” paper presented at FAO/OIE International Scientific Conference on Avian Influenza and Wild Birds, Rome, May 30-31, 2006.

  282 rumors and emerging reports: See Gina Samaan et al., “Rumor Surveillance and Avian Influenza H5N1,” Emerging Infectious Diseases 11, no. 3 (Mar. 2005): 463-66.

  285 Five South Koreans: “Five More in S. Korea Infected by Bird Flu,” Agence France Presse, Sept. 15, 2006.

  285 Hong Kong’s mass slaughter: C. B. Bridges et al., “Risk of Influenza A (H5N1) Infection Among Poultry Workers, Hong Kong, 1997-1998,” Journal of Infectious Diseases 185, no. 8 (Apr. 15, 2002): 1005-10. This article also reports that 10 percent of 1,525 poultry workers tested in Hong Kong were positive for H5N1 antibodies.

  285 In one telling study: Sirenda Vong et al., “Low Frequency of Poultry-to-Human H5N1 Virus Transmission, Southern Cambodia, 2005,” Emerging Infectious Diseases 12, no. 10 (Oct. 2006): 1542-47. A pair of studies that looked at Nigerian poultry workers with widespread exposure to likely infected poultry and Chinese workers in live poultry markets at the time of a human infection possibly contracted in a market also showed minimal evidence of antibodies to H5N1. See J. R. Ortiz et al., “Lack of Evidence of Avian-to-Human Transmission of Avian Influenza A (H5N1) Virus Among Poultry Workers, Kano, Nigeria, 2006,” Journal of Infectious Diseases 196, no. 11 (Dec. 1, 2007), 1685-91; and Ming Wang et al., “Food Markets with Live Birds at Source of Avian Influenza,” Emerging Infectious Diseases 12, no. 11 (Nov. 2006): 1773-75.

  285 A subsequent study: Sirenda Vong et al., “Risk Factors Associated with Sub-clinical Human Infection with Avian Influenza A (H5N1) Virus—Cambodia, 2006,” Journal of Infectious Diseases 199, no. 12 (June 15, 2009): 1744-52.

  285 enigma of the cullers: There’s a similar puzzle for health-care workers. Studies of health-care staff in Vietnam who treated avian-flu patients also found no evidence of exposure to the virus. This is in marked contrast to the experience with SARS, which took a heavy toll on health-care workers. See Nguyen Thanh Liem, World Health Organization Avian Influenza Investigation Team Vietnam, and Wilina Lim, “Lack of H5N1 Avian Influenza Transmission to Hospital Employees, Hanoi, 2004,” Emerging Infectious Diseases 11, no. 2 (Feb. 2005): 210-15; and Constance Schultsz et al., “Avian Influenza H5N1 and Healthcare Workers,” Emerging Infectious Diseases 11, no. 7 (July 2005): 1158-59.

  286 unable to identify a possible source: Endang R. Sedyaningsih et al., “Epidemiology of Cases of H5N1 Virus Infection in Indonesia, July 2005-June 2006,” Journal of Infectious Diseases 196, no. 4 (Aug. 15, 2007): 522-27.

  286 were ruled inconclusive: Bayu Krisnamurti, head of Indonesia’s National Avian Influenza Committee, quoted in “Indonesia Investigating Suspicious Bird Flu cases: Official,” Agence France Presse, Dec. 18, 2007.

  286 behavior of the virus in Indonesia “mysterious”: “Mysterious Bird Flu Baffles Indonesian Scientists,” Agence France Presse, Feb. 6, 2008.

  286 the country’s first human case: It is described in I. Nyoman Kandun et al., “Three Indonesian Clusters of H5N1 Vir
us Infection in 2005,” NEJM 355, no. 21 (Nov. 23, 2006): 2186-94.

  287 a quarter of all confirmed cases: Writing Committee of the Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Influenza A (H5N1) Virus, “Update on Avian Influenza A (H5N1) Virus Infection in Humans,” NEJM 358, no. 3 (Jan. 17, 2008): 261-73. On case clusters, see also Sonja J. Olsen et al., “Family Clustering of Avian A (H5N1),” Emerging Infectious Diseases 11, no. 11 (Nov. 2005): 1799-1801. On Indonesian clusters specifically, see discussion in Endang R. Sedyaningsih et al., “Epidemiology of Cases of H5N1 Virus Infection in Indonesia, July 2005-June 2006,” Journal of Infectious Diseases 196, no. 4 (Aug. 15, 2007): 522-27.

  289 made some people susceptible: See, for example, WHO, Report of WHO Working Group, “Influenza Research at the Human and Animal Interface,” Sept. 21-22, 2006.

  289 statistical chance alone: V. E. Pitzer et al., “Little Evidence for Genetic Susceptibility to Influenza A (H5N1) from Family Clustering Data,” Emerging Infectious Diseases 13, no. 7 (July 2007): 1074-76.

  Chapter Eleven: The Lights Go Out at Seven

  294 despite some projections: Hitoshi Oshitani, Taro Kamigaki, and Akira Suzuki, “Major Issues and Challenges of Influenza Pandemic Preparedness in Developing Countries,” Emerging Infectious Diseases 14, no.6 (June 2008): 875-80.

  295 “He just knows everybody”: Interview with Dr. Megge Miller.

  296 The health workers at the two local clinics: Interviews with Ly Lai and Dr. Ou Sary, Kampot province.

  297 it went a long way: Interviews with current and former WHO officials in Cambodia, including Drs. Michael O’Leary, Isabel Bergeri, and Megge Miller. See Richard Stone, “Combating the Bird Flu Menace, Down on the Farm,” Science 311, no. 5763 (Feb. 17, 2006): 944-46.

  298 a surprising item: William Prochnau and Laura Parker, “The Waiting Plague,” Vanity Fair, Nov. 2005.

  298 had pledged $2.3 billion: UN System Influenza Coordinator (SIC) and World Bank, “Responses to Avian Influenza and State of Pandemic Readiness, Third Global Progress Report,” Dec. 2007 (1st printing, released Nov. 29, 2007). The total figure increased modestly to $2.7 billion in 2008. See UN SIC and World Bank, “Responses to Avian Influenza and State of Pandemic Readiness, Fourth Global Progress Report,” Oct. 2008.

  299 ninety-one-page progress report: UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (1st printing).

  299 a new version of the report: UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (2nd printing, released Dec. 18, 2007), 8-9.

  299 would decline even further in 2008: UN SIC and World Bank, “Responses . . . Fourth Global Progress Report,” Oct. 2008. The report warned, “There is a risk that this decline in resources pledged, especially for countries with the greatest remaining needs, could undermine the sustainability of the investments made to date.”

  299 warned of growing “flu fatigue”: Paula Dobriansky, undersecretary of state for democracy and global affairs, “Remarks at the International Partnership on Avian and Pandemic Influenza Ministerial, Sharm El Sheikh, Egypt,” Federal News Service, Oct. 25, 2008.

  299 the World Bank had helped estimate: World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework,” Nov. 30, 2006. The original estimates were in World Bank, “Avian and Human Influenza: Financing Needs and Gaps,” Jan. 12, 2006.

  299 sector after sector: UN SIC and World Bank, “Responses . . . Third Global Progress Report,” Dec. 2007 (1st printing).

  300 “Adequate financial support”: Ibid.

  301 Yet the obstacles are many: An excellent examination of the challenges facing the development of a pandemic vaccine is the seven-part series “The Pandemic Vaccine Puzzle,” written by Maryn McKenna for the Center for Infectious Disease Research and Policy and posted online beginning October 25, 2007. The articles are available at www.cidrap.umn.edu. Another fine overview is Joost H. C. M. Kreijtz, Albert D. M. E. Osterhaus, and Guus F. Rimmelzwaan, “Vaccination Strategies and Vaccine Formulations for Epidemic and Pandemic Influenza Control,” Human Vaccines 5 (Mar. 2009): 3. See also WHO, “Global Pandemic Influenza Action Plan to Increase Vaccine Supply,” Oct. 23, 2006; and National Institute of Allergy and Infectious Diseases, “Report of the Blue Ribbon Panel on Influenza Research,” Sept. 11-12, 2006.

  301 research into any kind of flu vaccine: See, for example, a pair of studies by the Institute of Medicine. Kathleen R. Stratton, Jane S. Durch, and Robert S. Lawrence, eds., Vaccines for the 21st Century: A Tool for Decisionmaking (Washington; National Academies Press, 2000); and Institute of Medicine staff, New Vaccine Development: Establishing Priorities (Washington: National Academies Press, 1985).

  301 An analysis in 2007: Aeby Thomas, Niels Guldager, and Klaus Hermansen, “Pandemic Flu Preparedness: A Manufacturing Perspective,” BioPharm International, Aug. 2, 2007. For further discussion of the delays inherent in developing a pandemic vaccine, see Jesse L. Goodman, “How Fast Can a New Vaccine for an Emerging Respiratory Virus Be Developed and Available for Use?” Presentation at the International Conference on Emerging Infectious Diseases, Atlanta, GA, Mar. 22, 2006.

  301 confound efforts to develop a single vaccine: See, for example, WHO, Report of WHO Working Group, “Influenza Research at the Human and Animal Interface,” Sept. 21-22, 2006; Steven Riley, Joseph T. Wu, and Gabriel M. Leung, “Optimizing the Dose of Pre-Pandemic Influenza Vaccines to Reduce the Infection Rate,” PLoS Medicine 4, no. 6 (June 2007): e218; and G. J. D. Smith et al., “Emergence and Predominance of an H5N1 Influenza Variant in China,” PNAS 103, no. 45 (Nov. 7, 2006): 16936-41.

  301 unusually resistant to experimental vaccines: See, for example, Karl G. Nich olson et al., “Safety and Antigenicity of Non-adjuvanted and MF59-adjuvanted Influenza A/Duck/Singapore/97 (H5N3) Vaccine: A Randomized Trial of Two Potential Vaccines Against H5N1 Influenza,” Lancet 357, no. 9272 (June 16, 2001): 1937-43; Jean-Louis Bresson et al., “Safety and Immunogenicity of an Inactivated Split-Virion Influenza A/Vietnam/1194/2004 (H5N1) Vaccine: Phase I Randomised Trial,” Lancet 367, no. 9253 (May 20, 2006): 1657-64; Isabel Leroux-Roels et al., “Antigen Sparing and Cross-Reactive Immunity with an Adjuvanted rH5N1 Prototype Pandemic Influenza Vaccine: A Randomised Controlled Trial,” Lancet 370, no. 9587 (Aug. 18, 2007): 580-89; and Nega Ali Gogi et al., “Immune Responses of Healthy Subjects to a Single Dose of Intramuscular Inactivated Influenza A/ Vietnam/1203/2004 (H5N1) Vaccine After Priming with an Antigenic Variant,” paper presented at Third WHO Meeting on Evaluation of Pandemic Influenza Prototype Vaccines in Clinical Trials, Geneva, Feb. 15-16, 2007.

  302 This could cut the production time: Peter F. Wright, “Vaccine Preparedness—Are We Ready for the Next Influenza Pandemic?” NEJM 358, no. 24 (June 12, 2008): 2540-43.

  302 Initial clinical trials: Hartmut J. Ehrlich et al., “A Clinical Trial of a Whole-Virus H5N1 Vaccine Derived from Cell Culture,” NEJM 358, no. 24 (June 12, 2008): 2573-84.

  302 than even seasonal flu shots: David Brown, “Bird Flu Vaccine Shows Promise,” Washington Post, July 27, 2006; Leroux-Roels, “Antigen Sparing”; and Suryaprakash Sambhara and Gregory A. Poland, “Breaking the Immunogenicity Barrier of Bird Flu Vaccines,” Lancet 370, no. 9587 (Aug. 18, 2007): 544.

  302 could radically increase: WHO, “Projected Supply of Pandemic Influenza Vaccine Increases Sharply,” press release, Oct. 23, 2007.

  302 “can’t provide vaccines to the world free”: Wayne Pisano, quoted in a Council on Foreign Relations letter from Laurie Garrett, senior fellow for global health, June 20, 2007.

  302 a local vaccine against hepatitis B: Tini Tran, “Vietnam Struggles to Rein In Hepatitis B,” Associated Press, July 17, 2000.

  302 a new generation of vaccines: “Health: Vietnam Successfully Produces Second Generation Hepatitis Vaccines,” Vietnam News Briefs, Apr. 11, 2002.

  303 “future availability to Vietnam is doubtful”: “Report of WHO Mission to Support Influenza A/
H5N1 Vaccine Development in Vietnam,” 2005.

  303 “serious ethical reservations”: Ibid.

  304 “the volunteer ‘spirit’ may not be universally shared”: Internal WHO document, 2005.

  304 monkey kidney cells: “Vietnam-made Bird Flu Vaccine Proves Effective,” Vietnamese News Agency, Aug. 22, 2008.

  304 on researchers at the institute: “Volunteers for H5N1 Vaccines Get Second Injection,” Vietnamese News Agency, May 17, 2008.

  304 student volunteers: Ibid.

  304 “Good results”: Tranh Dinh Lam, “Vietnam: Bird Flu Vaccine for Humans May Be Available by 2009,” Interpress Service, June 4, 2008.

  304 mass production by late 2009: “Vietnam-made Bird Flu Vaccine Proves Effective,” Vietnamese News Agency, Aug. 22, 2008.

  304 30,000 Vietnamese dong: Ibid.

  304 Siti Fadilah Supari was far less patient: The accounts of Supari’s political rise, her battle over the sharing of viruses, and the wider international dispute over samples and benefits are drawn from interviews with Supari, current and former officials of the Indonesian health ministry, and other Indonesian public health officials and political figures. It also draws on interviews with WHO officials and public health and diplomatic officials from the United States, Australia, and other countries, as well as documents from the Indonesian health ministry, WHO, and the U.S. Department of Health and Human Services.

  305 Her scheduled flight: Details of Supari’s trip to Geneva are drawn from Siti Fadilah Supari, It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza (Jakarta: Sulaksana Watinsa Indonesia, 2008), 112ff.

  306 “We do not really know”: Statement by the Minister of Health of the Republic of Indonesia H. E. Dr. Siti Fadilah Supari at the Inter-Governmental Meeting for Pandemic Influenza Preparedness, Geneva, Nov. 20, 2007.

  307 her cell phone rang: Yanto Soegiarto, “Diving into the Deep End,” Globe Asia, Oct. 2007.