This is not a COVID essay, not directly. It’s an avian influenza essay. I have been watching the bird flu news with a lot of concern. Here are some samples:

Eagles Are Falling, Bears Are Going Blind

Will bird flu spark the next pandemic?

Global H5N1 bird flu outbreak so bad many countries are now considering vaccination

In my next essay I’ll unpack why the news worries me so much. In this one, I want to share a chapter from my global health book, condensed to fit here1. TED is no longer publishing the ebook, so I guess this is your once chance to read it.

Influenza, or flu, is a viral infection that causes a cluster of symptoms including fever, sore throat, weakness, fatigue, and body pain. Most influenza is easily transmitted from person to person through the air or via bodily fluids. Adding to its infectiousness, it’s a tough virus: many strains can stay alive on surfaces for a week at room temperature or indefinitely at very low temperatures.

The most recent influenza pandemic was the 2009 H1N1 epidemic (known as swine flu), which spread through 214 countries in a single year and killed just over 18,000 people (Roughly half the number who die from seasonal flu every year in the US alone). At the other extreme, the 1918 flu pandemic killed at least 40 million people; some estimates go as high as 100 million.

HPAI H5N1 is the virus that causes bird flu, or avian influenza. It is highly lethal when it infects human beings, and it’s very infectious among birds. So far, though, it’s not that dangerous to birds and doesn’t spread easily to people. It doesn’t spread among people at all.2

Avian influenza is difficult to fight because wild birds are a reservoir for the disease, and they infect domestic birds. In many countries, especially in Southeast Asia, people live in close contact with farmed poultry like ducks and geese, which makes them a prime target for transmission of avian influenza.

If the infection begins to spread more easily among people, this will be an extremely dangerous virus.

If you’re in a hurry just read this part:

HPAI H5N1 is the virus that causes bird flu, or avian influenza. It is highly lethal when it infects human beings, and it’s very infectious among birds. So far, though, it’s not that dangerous to birds and doesn’t spread easily to people. It doesn’t spread among people at all.
Avian influenza is difficult to fight because wild birds are a reservoir for the disease, and they infect domestic birds. In many countries, especially in Southeast Asia, people live in close contact with farmed poultry like ducks and geese, which makes them a prime target for transmission of avian influenza.
If the infection begins to spread more easily among people, this will be an extremely dangerous virus.

Influenza mutates rapidly. There are hundreds of types of influenza, and each year’s seasonal flu vaccine is based on the best guess of public health officials and vaccine manufacturers as to which strain will dominate the year’s flu season.

The 2009 influenza strain that went pandemic was very contagious, but it didn’t kill that many people. Its mortality rate was relatively low. Avian influenza has a mortality rate of about 60%[i], but so far has not been highly contagious among mammals.

Sooner or later, avian influenza will mutate into a form that will spread not just to people, but from person to person. It’s just a question of when, and how prepared we’ll be when it happens.

Surviving pandemic influenza, as a planet, requires preparation. The 2009 swine flu pandemic was a natural experiment, and what it revealed was important. We are not ready for an epidemic of dangerous flu. We were basically helpless against the travel of swine flu. If we are just as helpless in the face of a flu with a high mortality rate, the results are going to be ugly.3

Preparing properly for an influenza pandemic is going to be costly, but the good news is that it’s not influenza specific. Preparation will help us be ready for other pandemics and strengthen health systems overall. It has three components: reporting and infrastructure, pharmaceutical preparedness, and putting global controls in place.4

Reporting and infrastructure are the keys to tracking flu epidemics. Reporting includes surveillance - effective local and national reporting of influenza cases, to catch flu clusters as they occur. Infrastructure entails the ability to quarantine flu cases, produce vaccine and antivirals, and get health care providers in place as needed. Effective reporting is what makes sure that preparedness succeeds.

Pharmaceutical preparedness means stockpiling vaccines and antiviral drugs in useful ways and ensuring that we have the capacity to produce them in necessary amounts. Antivirals must be stockpiled for three purposes. First, they are necessary to treat the initial cases of influenza and the health care providers whom they will likely infect. Remaining antivirals can be used to slow the spread of the virus by treating whole communities where there are clusters of outbreaks. Finally, if there are enough, the antivirals can be used to treat the general population when they are infected with influenza. We need to purchase and safely store as many antivirals as possible for these three uses. That means money to buy them, and sufficient manufacturing capacity to produce them.

Vaccines are tricky to get right, but they play an important role in slowing the spread of pandemics because flu vaccines need to be manufactured once a flu virus is identified. Otherwise, the vaccine will not be effective against the specific mutation of the virus causing pandemic. However, you can manufacture a vaccine against your best guess for pandemic. Even if you’re not quite right, if you pick the correct influenza subtype for the vaccine, it will still have some effectiveness.[ii] We also need to expand our ability to formulate and deliver vaccines; right now, the flu vaccine is still grown in eggs, which limits manufacturing capacity.5

Finally, we need global regulations to make sure that all countries act together, in useful ways, when a pandemic occurs6. That means coordinating travel policies, sharing information, and finding scientific and medical consensus. The World Health organization currently leads these kinds of efforts, but it needs financial and logistical support to do it effectively. Coordination also means sharing and distributing vaccines and antiviral drugs, something that currently happens on an ad hoc basis through bilateral treaties and discussions with drug companies. It doesn’t always work. In 2006, for example, Indonesia refused to share samples of the avian flu virus with the WHO. Their argument was that pharmaceutical companies would use Indonesia’s public health work to develop vaccines or treatments that would be priced beyond what Indonesia could afford to pay.

Note to readers: I am now working on Turkiye earthquake response and it takes a lot of time. I can sustain this newsletter at a every-other-week pace but not weekly. If you have a paid subscription, please feel free to drop down to unpaid if the value isn’t there for you.

[i] http://www.cdc.gov/flu/avian/gen-info/facts.htm

[ii] http://www.who.int/csr/disease/influenza/A58_13-en.pdf

1

And edited slightly because I am a perfectionist.

2

Probably the most important sentence in this essay.

3

I wrote this originally in 2011. COVID bore out that prediction pretty brutally. I have never been so miserable to be correct.

4

Imagine how minor COVID could have been if we’d done this.

5

COVID vaccine manufacturing went way better than this - RNA vaccines have been a game changer.

6

Do you prefer the sigh or the gusty weeping?

Last Mask Standing

Avian Influenza