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Bird Flu Hanky Panky in Asia

By Grattan Woodson, MD, FACP

Indonesia, Vietnam, and Thailand

One measure of how well adapted H5N1 bird flu is becoming to humankind is the growing ease with which people contract the disease from birds, other people, or animals like swine. ² Prior to the summer of 2005 when the first human cases of bird flu were confirmed in Indonesia, it behaved differently. What made the Indonesian index cases so unique compared to the earlier ones in Vietnam and Thailand was the lack of especially close contact with infected birds. But now things may be changing.

In June 2005; the first cluster of human-to-human transmission of bird flu was identified in Indonesia. ³ A cluster is defined as a distinct outbreak of the same illness within a specific group of people that all share contact with a single infected individual known as theiindex case. Since June 2005 in Indonesia there have been dozens of unconfirmed clusters associated with 2 or 3 secondary cases. In May of 2006, the largest confirmed cluster was observed in Sumatra when six associated cases developed.

There are several criteria used by epidemiologists to establish a cluster of human-to-human spread. The first is timing of the secondary cases. The incubation period for flu is 2 to 3 days in adults but can be much longer in children and immuno-compromised persons. For human-to-human spread of the disease to be a possibility, the patients must have a flu-like illness. The time between exposure to the index case and the first sign of symptoms must be at least 48 hours but could be much longer. The H5N1 bird flu virus must be detected unequivocally within the index and secondary cases. The cluster’s secondary cases must have no exposure to infected birds or swine. A large number of the Indonesian clusters satisfy 3 out of 4 of these criteria. The problem has been the inability to obtain samples properly for definitive diagnosis of the virus. These sampling errors have resulted in false negative findings that prevent the cases meeting the stringent WHO influenza criteria. This means that the WHO has not recognized these clusters that document limited human-to-human spread of bird flu. If they had been recognized, the WHO pandemic alert phase would have been moved from level 3 to 4 before now. The criteria for this change in status is:

Small clusters with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.

The first documented case of person-to-person transmission of bird flu occurred in Thailand during 2004 and was reported in the New England Journal of Medicine.⁴ That strain did not spread further in people but was a significant development in the evolution of bird flu all the same. There have been many other examples of probably person-to-person spread of bird flu but for one reason of another the WHO has not recognized them. In fact, the first human bird flu infections since the 1997 Hong Kong cases occurred in 2003 and were consistent with a human-to-human transmission of the H5N1 virus.⁵ At that time, several members of a family developed an influenza-like while visiting China. They had no known contact with poultry or infected birds. Two out of three of these patients died but H5N1 was confirmed as being present in only 2 of the three cases. Another case of human-to-human spread of H5N1 occurred in Vietnam in February 2005. It was reported recently in a December 2005 medical article focusing on bird flu resistance to Tamiflu in the journal Nature. The sister of an index case contracted bird flu while caring for her brother. She had no contact with infected poultry. The virus was resistant to Tamiflu and on analysis was proven to be identical genetically to the strain her brother was ill with.

Until the Indonesian outbreak in June 2005 and those listed above, all previous documented human cases of bird flu have been among those who had intimate contact with sick poultry during processing, cooking, eating, or caring for them. In contrast, many of the index cases developing in Indonesia during the summer of 2005 caught the disease after the briefest exposure to the vicinity of infected birds. For instance, many people became ill while visiting a zoo in Jakarta where they simply walked past the sick animals in birdcages. They had no direct contact with the birds what so ever. After becoming ill with bird flu, some of these Indonesian index cases passed the virus along to others who they came into close contact with them leading to the formation of a at least a half-dozen small clusters. The other members of the cluster had no known sick bird exposure. Most of those secondarily infected were close household contacts of the index case. While these clusters are evidence that the H5H1 avian influenza is adapting to humans and is becoming more contagious, transmission of the virus between persons is still not easy enough to say that bird flu has achieved efficient human-to-human transmission. All in all it seems to me that it is high time for the WHO to increase the pandemic alert phase to level 4.

China
What happened at Qinghai Lake China in May 2005?

On May 4, 2005 wild birds began dying in the Qinghai Lane Nature Reserve in Qinghai Province, China. The reserve is China’s largest inland saltwater lake and occupies the northeastern part of Qinghai-Tibetan Plateau. The official brochure for the reserve provides the following information:

Qinghai Lake Nature Reserve “The Qinghai Lake Nature Reserve is located in the bound of 3 counties, Gangcha, Haiyan, Gonghe, covering an area of 4,500 square kilometers. Except for the Qinghai Lake itself, the reserve's landform is characterized with lakeside plains, swamp meadows, hilly meadows semi-desert steppes and sand dunes successively. There are 200 species of birds and animals, among which animals have 36 species in 15 families and 6 orders; birds have 164 species in 35 families and 15 orders. About 114 species or 69.5% of the birds of birds [found there] propagate in this nature reserve. There are 4 species water birds under protection. They are bar-headed wild geese, fish gulls, brown-headed gulls and cormorants, amounting to over 400,000. The Qinghai Lake Nature Reserve is an important region for migratory birds to propagate and live through the winter in the high inland area, as well as a post house for those migrants.”⁶

 

Worldwide wild fowl flyways are interconnected

The Qinghai Nature Reserve is an important stopping off point for long-range migratory waterfowl that travel back and forth each year along the East African West Asian Flyway. This route covers thousands of miles. Beginning in Africa the birds fly northeast through India over the Himalayas with a stopover in Qinghai then on to Siberia. The track swings around in Siberia moving southwest crossing the Middle East before returning the Africa. Along this route, the birds cross paths with others birds migrating from Siberia to Europe, the Middle East, and Africa. These others cross paths with migrating birds that travel from Siberia to Alaska who meet up with others that fly down and then back up the Pacific coast of the Americas. Those flying from Europe to Western Africa mix with birds migrating from there to Nova Scotia on the Atlantic coast of North America. These birds interact with those that travel annually south across Canada and the US down into the Caribbean and then to South America.

Outbreak at Qinghai

In late May 2005 Chinese press reports announced that 178 migratory geese had been found dead in a bird sanctuary on Qinghai Lake in the far western provinces of Xizang (Tibet) and Xinjiang (Uygur Autonomous Region). ⁷ The deaths were investigated and found to be due the highly pathogenic H5N1 strain of bird flu. The sanctuary was sealed to all outsiders and from about May 23, 2005 forward, the Chinese story becomes murky due to a press censorship and tight control by the authorities. Several official reports and most importantly the actions of the Chinese from here on until the present time provide some interesting insights. For the most part though we have to rely on unofficial news sources and statements by individuals for the story.

Just before the Chinese clamped down on the flow of bird flu news from Qinghai, the Agriculture Minister made a telling comment to the press. He said the Qinghai Lake H5N1 strain “possibly contains a gene for human contraction”
Qinghai Lake Nature Reserve This suggests that there may have been human cases of bird flu contracted after being exposed to the sick and dead birds. The Chinese Ministry of Health issued a nationwide alert and sent medical teams into Qinghai Province to screen people for bird flu.

A spokesman for the Health Ministry, Mao Qunran said to the China Times on May 23, 2005 that the outbreak was confined to wild birds only with no cases in humans or domestic poultry. Three million doses of H5N1 poultry vaccine were “rushed” to the Qinghai, Xizang, and Xinjiang Provinces by the Agriculture Ministry.

Dead birds at Qinghai Lake: Boxun News Service⁸ On May 23, 2005 the Chinese Ministry of Agriculture made its initial report to the Paris-based OIE, the UN agency that is responsible for keeping track of infections among animals. In the report, the Chinese officials speculate that the outbreak began at the Qinghai Lake Nature Reserve in mid-April 2005. The report goes on the say:

“The location of the outbreak was: Niannaisuoma village, Quanji town, Gangcha county, Qinghai province. The place is an important rendezvous of migratory birds on one of their Asia-Europe route. The migratory birds found dead, including bar-headed goose (Anser indicus), great black- headed gull (Larus ichthyaetus), brown-headed gull (Larus brunnicephalus), ruddy shelduck (Tadorna ferruginea) and great cormorant (Phalacrocorax carbo). The total number of birds found dead: 519.”

On May 25, 2005 the first reports of human infections and deaths in Qinghai Province surfaced on the Internet from an unofficial source, The Xining News. ProMED-mail, an Internet site sponsored by the International Society for Infectious Diseases also published these reports. The ProMED translation of the original report in Chinese is reproduced here:

“Recently, many people died of avian influenza in Qinghai province. The affected localities reveal that, as of early April 2005, there have been several deaths of migratory birds. Because of lack of reporting, the news has not traveled widely. Toward the end of April 2005, cases of human infection started to emerge. After 1 May 2005, some tourists who visited the areas were severely affected, and 6 of them died.”

Dead birds at Qinghai Lake, Boxun News Service In an accompanying comment, ProMED states: “This report suggests that during the month of April 2005, a large-scale dissemination of the infection took place involving both humans and domesticated animals. The affected area is vast but sparsely populated. Thus, the problem of infection involving both humans and domesticated ‘animals is relatively unnoticeable.’ The feral birds migrate freely and so expand the area of transmission. The Chinese authorities have admitted the outbreaks and started to seal of the affected area. Because of this, Mrs. Yi Wu (Chinese Minister of Health) has cut short her visit to Japan and returned home. According to the local news in the affected locality, the number of human casualties is higher than 6. The deceased persons are all foreign tourists (i.e. not local residents): 2 (a man and a woman) from Chengdu and one man from Chongqing, Sichuan province. It is unknown from where the remaining casualties come. The information was provided by someone who has visited the area of the outbreaks.”

On the same day, a second Xining News reports the number of confirmed human deaths in Qinghai has risen to 11 from 6 and that the Chinese Government had instituted a news blackout on all aspects of the infection. This is closely followed by another report, this time from the Boxun News Service on the Internet that the human death toll in Qinghai had now been raised to 121.⁹ The Boxun story was based upon “data reported by the government on 24 May, provided by an individual on the inside.” This story, originally published in Chinese was machine-translated and republished in English by Henry Niman, PhD on his www.Recombinomics.com website. ¹⁰, ¹¹

 

Human Bird flu cases reported from Qinghai Province China on May 25, 2005
Location: City	Infections to date	Deaths to date	Case Fatality Rate
Yongfeng	14	8	57%
Hongshan	15	6	40%
Zheyiguodong	21	12	57%
Zheyiguodong	21	12	57%
Shangyou	14	11	79%
Yikekulan	14	11	79%
Maiduosaizhe	13	6	46%
Zhihema	12	9	75%
Quanji	15	9	60%
Gangcha dasi	11	8	73%
Shairiniang	9	6	67%
Nanbiquguo	5	3	60%
Qiankuoer	12	9	75%
Zhanjiang	9	11	78%
Haowuluo	11	7	64%
Legemurinaqiong	4	1	25%
Qiejijiangkeri	5	3	60%
Xima	9	3	33%
Xiaobeihu	5	1	20%
	198	120	61%

In the table above, the location, number of cases of flu and deaths taken from the Recombinomics article is reproduced along with an analysis of the case fatality rates to that time. In addition to people becoming ill, there are also reports of many deaths among poultry, swine and sheep.¹²

On May 25, 2005 a group of Hong Kong Chinese scientists and their American collaborators published a paper in the journal Nature announcing the cause of the deaths of the bar headed geese at Qinghai was H5N1 bird flu. The Minster of Agriculture’s Veterinary Bureau roundly criticized these findings.¹³ One week later, the Ministry of Health citing “safety concerns” closed the Hong Kong lab. ¹⁴ No foreign or domestic press our outside public health organizations have been allowed into the affected areas of China.

On May 26, 2005, the Chinese Ministry of Health reported that an expert team had been sent to the Quanji Township of Gangcha County in Qinghai Province to investigate the outbreak of H5N1 in birds. The team reported no human infections had occurred as of May 24, 2005.

The Qinghai story abruptly ends at that point with no new information being reported by official or unofficial sources. But on June 10, 2005 The Chinese Daily, an officially sanctioned publication, reported that the Chinese Ministry of Agriculture announced a new wild bird die-off had been discovered in the far western Xinjiang Province. ¹⁵, ¹⁶ The story reports the following:

“A new outbreak of avian flu has been confirmed in Tacheng, Northwest China’s Xinjiang Uygur Autonomous Region, the Ministry of Agriculture (MOA) said yesterday. More than 2,000 geese at a Tacheng farm have shown signs of avian flu, and half of them have been confirmed infected, according to a MOA report. The National Avian Influenza Reference Laboratory confirmed that 460 geese had died from the deadly H5N1 strain of the virus.”

The report went on to say that there were no human cases of bird flu.

The “Swine Streptococcus” outbreak in Sichuan China:
Summer of 2005

On June 24, 2005, the first patients began arriving at the hospital in Sichuan China suffering from a rapidly fatal pneumonia.¹⁷ Several weeks after these first reports reached the west the Chinese confirmed that there was a “mystery illness” in the Sichuan region of the country. Hundreds of people were affected. When pneumonia developed in these cases, it was fatal in more than half the patients.¹⁸ The story for the officially sanctioned Xinhua press provides the following details:

“An unknown disease has stricken 20 villagers and killed nine of them in southwest China’s Sichuan Province over the past four weeks, the provincial health department confirmed Saturday. A team of experts from the Ministry of Health and Ministry of Agriculture are in Sichuan to provide medical aid and conduct epidemiological investigation.
 
Between June 24 and July 21, three hospitals in the city of Ziyang received 20 patients with similar symptoms. They all started with a high fever, fatigue, nausea and vomiting and became comatose later with bruises under the skin.
 
By July 21, nine patients had died and one had recovered and been discharged from hospital. Ten more were still being treated, six of whom in critical condition, the provincial health department said.
 
The patients, 19 men and a woman, are all farmers aged between 30 and 70. They are from 15 villages in Yanjiang and Jianyang and they all butchered sick pigs or sheep before coming down with the strange disease, a preliminary investigation has found.”

In a Boxun News Agency report, some of the patients were described as becoming dark blue in color over a few hours from cyanosis (loss of blood oxygen), having widespread bleeding, and as dying very quickly from pneumonia.¹⁹ These descriptions together with those reported by the official Xinhua report are frighteningly similar to the medical history of patients during the 1918 pandemic who died from pneumonia and secondary adult respiratory distress syndrome induced by cytokine storm. In a letter to a colleague, a US Army doctor serving at Fort Devens in Massachusetts described the clinical course of some of the young soldiers he was treating. An excerpt from this letter follows:

“These men start with what appears to be an ordinary attack of La Grippe or Influenza, and when brought to the Hospital they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the colored men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate.”²⁰

When the Chinese finally confirmed the presence of a widespread and highly lethal pneumonic illness that had become epidemic in the region, they attributed it to Swine Streptococcus, an unlikely human pathogen. ²¹, ²² This infection can spread to man from swine but rarely does so and when this happens is readily treatable with routine antibiotics like amoxicillin²³, ²⁴,²⁵. Prior to the release of this cover story by the Chinese authorities, Boxun published reports from the hospitals treating the patients that indicated the cause of the infection was a virus. Sichuan Province is located to the east and adjacent to Qinghai Province where the Qinghai Lake bird flu outbreak occurred in May 2005. The geographic and temporal proximity to Qinghai together with the clinical presentation of the patients in Sichuan with the “mystery disease” certainly suggests that bird flu could have caused this infection rather than swine streptococcus. The official Chinese story has been and remains that swine streptococcus caused the human disease outbreak in Sichuan.

On July 22, 2005 a Boxun report translated and reprinted on Recombinomics.com stated that bird flu had caused illness among ethnic Tibetans living in western Qinghai Province.²⁶ Teams were sent it to identify those sick with the virus that were then taken away to an undisclosed location. Fighting broke out between the local Tibetans and Chinese team members in response to the teams aggressive culling of the Tibetan’s poultry.Some Chinese were killed during the unrest and the Peoples Liberation Army (PLA) was sent to the area to restore order and enforce a quarantine that was placed around the affected areas. There are reports that in the countryside several entire villages were literally bulldozed into no-existence overnight with all their people being taken away by the PLA. Journalists and outsiders in general, even Chinese were forbidden to enter the area.

ZIYANG, CHINA - July 26: A patient suffering from a mysterious disease is moved to an isolation ward at the Ziyang First People's Hospital in Sichuan Province, southwest China. While official reports cite a swine bacterium as the probable cause, circumstantial evidence and lack of independent confirmation cast doubt on the verdict. (China Photos/Getty Images)²⁸
The Sichuan Public Health Ministry announced that 82% of the patients admitted to the hospital in China died of the “swine streptococcus” infection as of July 26, 2005.²⁷ This high case fatality rate for these patients surely overestimates the true lethality of bird flu from this outbreak because it does not take into consideration the cases who were not ill enough to be admitted to the hospital and who recovered.

To this day, the Chinese continue to maintain their original story. The Chinese refuse to allow any external inquiry into the incident by WHO or any other outside independent agency. There are also reports of medical personnel being imprisoned for trying to get this information to the outside world.

In August 2005, the Chinese government claimed in a report to the WHO that the swine streptococcus disease had been brought under control.²⁹ As of August 16, 2005 there had been 215 cases and 39 deaths with no new cases reported since August 5, 2005 and that everything was returning to normal. By September 2005, the story withered with no new information getting out of the region. Infectious disease specialists’ and public health officials never considered the explanation the Chinese gave for the cases, swine streptococcus, reliable but the matter was dropped as their attention moved elsewhere.

The Chinese stopped sharing bird flu viral cultures with public genetic databases in May of 2005 after the Qinghai Lake outbreak. In early 2006 they agreed to provide some genetic sequence information. These were confined to strains that infected birds but not humans.³⁰, ³¹, ³² Then, in the spring of 2006 in response to growing international pressure, the Chinese turned over several H5N1 viral cultures to the WHO with the understanding that they would be held within WHO’s restricted database and not made available to the general research community.

Unconfirmed reports of human bird flu China during 2005

On November 15, 2005 came a very detailed report from Boxun that there was an ongoing and very serious bird flu infection in people living in the China. The unofficial report claimed the present cases were a continuation of those that had begun in May 2005 in Qinghai. Apparently the disease had been smoldering in rural China for 6 months before this report with the human death tolls reaching 310 through November 12, 2005.³³ Government health workers had quarantined several thousand people. The format of the actual report contains medical details that suggest that it had been prepared for epidemiologic purposes. The English translation of the Chinese version of the Boxun News story is reproduced below in its entirety and is followed by the chart that was the subject of the report and that was smuggled out of China by an unnamed official from the Ministry of Health.

“China has been continually plagued by Avian Influenza outbreaks of varying degrees and unverified reports of infection. In 2005, some of these outbreaks attracted the attention of the outside world. However, these outbreaks are not as straightforward as what is perceived by the world at large. Due to the deployment of the PLA to the epidemic zones, the Chinese Ministry of Health has been able to gain some form of control and organization over the dissemination of information to the rest of the world. And although they have ostensibly allowed the entry of external health experts into the epidemic zones to conduct their investigations, they will still be bound by arrangements and rules dictated by the Chinese and hence their perception of the situation there would not accurately reflect the actual events that had occurred.
 
Currently, the Avian Influenza problem in China is very grave. Over the course of the outbreaks, Chinese officials have been briefed on the procedures to follow in order to control the outbreak and the spread of information. The Chinese Central Military Committee has directed that all suspect and confirmed cases of Avian Influenza infections be sent to specialized hospitals. Notifications must be sent to a higher centralized authority. They have also strictly prohibited any Chinese health officials to privately speak to the foreign media. If it is discovered that they have done so, they will be sacked immediately. There must be no mention made of the H5N1 virus in the cause of death of those who have succumbed to the virus. Patients who seek treatment for respiratory problems in non-designated hospitals will not be allowed to claim insurance or medical expenses. Although accurate till 12th November, these case figures are constantly changing. Also,since the cases figures have been collated by the Central State Council, they would have reduced it somewhat, and hence, the actual figures may be higher.”
The Boxun story concludes with these remarks: “Currently, the situation in China is severe. Human to human transmission has occurred and affected personnel have been quarantined for long periods. Death figures are noticeably higher in B-H transmission regions. The situation has been gradually brought under control although it still remains critical.”

Human Bird flu deaths reported in China in 2005
Province	Number Deaths	Number Infected	Number Quarantined	Number Disappeared	Mode of Transmission
Qinghai	143	131	961	13	B-H, H-H
Xinjiang	18	35	340	6	B-H, H-H
Inner Mongolia	28	9	149	2	B-H, H-H
Xichang	7	15	177	9	B-H, H-H
Sichuan	0	12	39	0	B-H
Hunan	8	4	17	0	B-H, H-H
Hubei	25	297	1,524	4	B-H, H-H
Guangdong	6	47	66	6	B-H
Fujian	2	13	9	11	B-H
Jiangxi	1	0	7	0	B-H
Zhejiang	0	0	13	0
Jiangsu	0	0	21	0
Hunan	0	0	57	0
Hebei	0	0	21	0
Liaoning	69	237	2,076	2	B-H, H-H
Jilin	0	19	30	0	B-H
Heilongjiang	0	23	9	0	B-H
Hainan	0	0	6	0
Yunnan	0	3	0	0	B-H
Gansu	1	0	7	0	B-H
Ningxia	0	3	0	0	B-H
Shaanxi	2	0	0	0	B-H
Shandong	0	0	4	0
Anhui	0	6	21	0	B-H
B-H (Bird to Human transmission) H-H (Human to Human transmission)

It is interesting that the chart includes so few bird flu cases from Sichuan since it is my presumption that the “Swine Streptococcus” outbreak there was actually caused by H5N1 influenza. If is it true that the Ministry of Health produced this document and intended it for internal use only, the lack of cases bird flu in Sichuan Province weakens the case that they were due to influenza.

Analysis of the data in the table above reveals that there were 1164 cases of influenza with 310 deaths in China in 2005 through November 12, 2005. This translates into a case fatality rate of 27%; a statistic that is substantially lower than the widely reported 50% plus rates published from form the cases of hospitalized patients in Southeast Asia and Indonesia. The Chinese epidemiologic methods and tactics while heavy-handed, appear to be more effective at identifying less severe cases of bird flu infections than is the case in the other countries. Even if the 212 cases and 39 deaths from Sichuan attributed to Swine Streptococcus are added to the above chart, it has no material effect on the case fatality rate.

On November 18, 2005 an interesting report was published in the China Daily, an official news source, about the exploits of a team of urban doctors and nurses charged with managing a major bird flu outbreak in Liagoning.³⁴ This curious story provides the following description:

“Unaffected areas of the province have supplied 1,000 medical workers in 65 teams to Heishan County providing health checks and direct epidemic prevention work. ‘We have mobilized all localities and departments at various levels to take part in the battle against bird flu. We will try out best to prevent it from spreading and from being passed to humans.’ said Dong Degang, deputy director of Liagoning Health Department. Medical teams have checked around 450,000 villagers living in and around bird-flu hit areas, according to the Liagoning Bird flu Prevention and Control Office. All 72,000 villagers in Heishan are receiving check-ups twice a day. Around 1.32 million villagers’ houses have been disinfected and residents have also been given bird-flu education and anti-viral drugs, Zhao said.”

What intrigues me about this report is the unprecedented and extensive use of medical personal and the their attention to people. For instance, in early 2006 when bird flu arrived in Europe and outbreaks developed in wild and domestic birds, the response has involved culling all the infected birds and those within several kilometers of the infected farms. There was no medical response as this was not required. Medical responses were undertaken only when human cases developed in Turkey. China does not provide medical care for its citizens and the vast majority of people in rural China have no access to care. The use therefore of scarce medical personnel and resources on this scale certainly suggests more than a poultry culling agricultural operation. Frankly, the facts provided in the article are most consistent with a massive public health response necessary to contain a large outbreak of human bird flu.

At about the same time that the above reports were appearing, China officially admitted for the first time that there had indeed been 3 human cases of bird flu in this region and 2 deaths. They claim that all 3 cases were the result of bird-to-human transmission. Since then, the Chinese have been reporting about 1 new case of human Bird flu each week with some additional deaths but assiduously denies that there is any truth to the stories leaking out of the China.

77 deaths among Chinese poultry cullers in Liagoning

On November 19, 2005 The Boxun News agency reported the deaths of 77 agricultural workers in Liagoning who were infected with bird flu while culling poultry.³⁵ The 69 deaths in Liagoning reported in table above are similar to the Boxun report and may explain the majority of the cases in that city. As you recall, the Chinese Daily news report cited above was about a medical team working to stop bird flu in Liagoning. It is reasonable to assume that most of the infections in these agricultural workers are examples of bird-to-human transmission, a significant detail not included in the report. While many millions of birds have been culled throughout Eurasia since bird flu was first recognized in 1997, it is very rare for workers employed in this activity to contact it although a few show serologic evidence of having had the infection. ³⁶ This report is important because it adds to the growing evidence that the virus has changed its behavior by being able to transmit itself much more easily from birds to humans. This is an important step in the bird flu’s human adaptation process and is one that is being seen in the Indonesian and Turkish outbreaks as well.

A private communication on the situation in China goes public

Masato Tashiro, MD is the Director of the WHO Collaborating Center on Influenza at the National Institute of Infectious Diseases, Tokyo, and head of the Department of Virology of the National Institute of Infectious Disease (Japan). After returning from an official WHO visit to China, Dr. Tashiro made an informal presentation to group of intimate colleagues while attending a retirement party for one of their WHO co-workers in Germany. What is remarkable is that Dr. Tashiro showed a slide that contained a handwritten chart in Chinese that had the same information contained in the Boxun report including the number of 2005 Chinese deaths of 310. When he speaks, his colleagues listen. Apparently, one of them decided that the information he shared with them privately at that party was too important to keep quite. The next day, an account of Dr. Tashiro’s comments was reported on the front page of the German newspaper, Frankfurter Allgemeine Zeitungand immediately picked up by the world press.³⁶

The good doctor is quoted as saying, “we have been systematically deceived” by the Chinese. Describing the chart he said “What you see here, is an unofficial, unpublished report from China for the H5N1 infection situation with humans” He said that there had been “several dozen” human outbreaks of bird flu in 2005 that were responsible for “at least three hundred proven deaths in China” and some 3000 people placed in quarantine. Again referring to the chart he pointed out that there were seven outbreak instances where the notation “human-to-human transfer probable” was made. Again he said to his colleagues, “We are systematically being lied at” by the Chinese who are keeping the world in the dark over the actual situation in China. He indicated that this was a reckless course for them and the world. Dr. Tashiro told the group that at least five of their WHO medical co-workers in China had been arrested caught trying to report the Chinese bird flu endemic and other medical researchers had been threatened with punishment if they published any findings that were inconsistent with the Ministry of Health statements.

When asked where he got his information, Dr. Tashiro said that he was given the chart from a trusted source while visiting Hunan Province for the WHO in early November where he and Chinese public health officials were investigating an H5N1 outbreak there among domestic poultry.

When the press contacted the WHO about Dr. Tashiro’s statements, Dick Thompson, a WHO spokesman said, “These rumors have been investigated, and we’ve been told by the Chinese Ministry of Health that there’s no foundation to them.” The US Government issued a similar statement in support of Chinese cooperation in the bird flu effort at the same time.

Three days later, Dr. Tashiro publishes a retraction. A copy of his statement to ProMED-Mail, a publication of the International Society of Infectious Disease who had republished the story first printed by the Frankfurter Allgemeine Zeitung is printed below.

I am surprised to read the report. First of all, it is not correct. Therefore, I would ask you to correct it. In my presentation at the meeting in Marburg, I stated that WHO’s official numbers of H5N1 human cases are only based on laboratory confirmed cases. It should be therefore an iceberg phenomenon. Due to poorly organized surveillance and information sharing systems in many affected countries including China, it is reasonable to consider that more cases have occurred actually. We have heard many ‘rumors’ or unauthorized information, which we cannot confirm. In this context, I talked about a few examples of non-authorized information and rumors about Asian countries, which I received through private channels. I clarified that I do not know the original sources and I cannot confirm whether they are true, how these numbers were derived and what laboratory tests and epidemiological investigation were done. Therefore, the article cited in ProMed-mail is incorrect and misleading. I did not receive any interview during my stay in Germany. I did not say anything that I believe the figures of the unauthorized information.
My message at the meeting was that international societies should help China to establish and perform nationwide surveillance and information sharing systems. I do not think that the Chinese Authority will conceal the facts from the world. Since the SARS event, they are collaborative to WHO. But they may have still limited capacity to monitor all human cases particularly in rural areas. --
Masato Tashiro, NIID JPN WHO Collaborating Center for Reference and Surveillance on Influenza, National Institute of Infectious Diseases, Tokyo”

Dr. Tashiro’s letter was closely followed by a denial of the story by the Chinese government going so far as to say that no Japanese WHO official had even visited the country recently. ³⁷

Certainly these are interesting developments. For these two different sources to independently report the 310-death figure from bird flu and each reported 7 regions with presumed human-to-human transmission of the virus had occurred. It is plain to see that the chart Dr. Tashiro showed in Germany is exactly to same as the one reported by Boxun that they attributed to an unnamed Chinese official within the Ministry of Health.

A Hong Kong virologist speaks out

In December 2005, at great risk to himself and his career, Guan Yi, a highly respected virologist at the University of Hong Kong and a veterinary bird flu researcher released an unapproved report on over 1000 viral samples he had received from all over China that were positive for the Highly Pathogenic Avian Influenza (HPAI) H5N1 strain.³⁸ Dr. Yi stated that the bird flu is widely spread in poultry and wild birds in every region of China and that the government is suppressing the extent and intensity of these avian outbreaks.

Official dissimilation of bird flu information emerging from China

In my opinion, a pattern is emerging that suggests the Chinese Government has engaged in widespread suppression of facts about human bird flu in China. This is not unprecedented for this government who practiced this policy in 2003 during the SARS epidemic. They were able to hush-up that public health emergency for months before the outbreak and its cover-up was reported to the world press by the Boxun News Agency. Nevertheless, the official denials and lack of credible reports from outside agencies regarding the bird flu situation in China leaves us uncertain.

The Chinese really have the upper hand. They control all the media in the country and publish the “facts ” they want published irrespective of the truth. There is no free press in China. The control access to the areas where the outbreaks have been reported and do not allow the WHO or any outside agency into any area it wants to keep them out of. Until the spring of 2006, they withheld all information about the bird flu virus strains they had collected since May 2005. Analysis of the genetic changes in these H5N1 strains provides virologists with a “road map ” that permits them to “see ” where the virus has been and how long it has been there. These analyses are also the best way to understand how the virus is adapting to humankind. They can inform us what pathways it is taking during its evolutionary journey and what traits it is picking up along the way. These traits are called polymorphisms and determine how the virus behaves. One reason that the Chinese may have sat on these specimens for so long is that they know this information can be deduced from analysis of the viral genome and don’t want any facts to get in the way of their cover-up.

Chinese insecurity and paranoia

It is very obvious from comments made by WHO and US Government who have reliable sources and means of determining the actual facts in China that we will never have, that they have closed ranks with the Chinese government. This is a very delicate issue politically for those charged with working with China and I think that they have made a strategic decision that it is critical, in this instance, that the Chinese boat not be rocked with the truth because there was more to be gained by the world as a whole tolerating their actions than outing their deceptions.

For all the economic progress China has made of late, we must not forget that this is not a stable democratic country. It is remarkable that the Chinese government reported over 70,000 instances of public rioting and disorder for that year 2004. China’s domestic and foreign policy is the best evidence of just how insecure its leaders feel. Their approach to Tibetan and Uygur autonomy and Mongolian and Taiwanese independence are the consistent with the actions of a threatened adolescent not a great world power. On the world stage, China acts like a country that feels under attack from every corner of the globe. They have a long memory despite the attempt by their 1960s Cultural Revolution to wipe it out. That history is replete with attacks from outside and domination for centuries by invading hordes of Mongols, Europeans, and Japanese. So, in some respects their xenophobia is probably justified.

Domestically the government is a totalitarian dictatorship with no democratic legitimacy. There is widespread official corruption. While their economy is growing at a 10% annual rate and has recently risen to become the world’s fourth largest, the government has very little control over this leviathan. The Chinese banking system is weak and has many poorly performing loans made to government-owned entities that can’t be foreclosed due to political considerations. Regulators have lost control of the flow of funds into and out of the country explaining in part why they cannot control their economy except by use of heavy-handed methods like currency valuation and interest rates.

The Peoples Liberation Army has many and varied business interests that compromise its national defense mission by producing massive conflict of interest among its officer corps. The PLA probably is the biggest conglomerate in China. Imagine for a minute what would happen if the US Defense Department owned factories, farms, hotels, and businesses throughout the county and that these enterprises had become enormously successful with the profits being accruing to the benefit of the general staff and all field-grade military officers? Talk about your $7,000 toilet seats!

A huge wealth and education gap has emerged between the 300 million Chinese living in the cities and the 1 billion living in the country. Internal travel restrictions, the one child policy, lack of religious and political freedom, and widespread worker exploitation are all very destabilizing factors for the government. So why shouldn’t they be paranoid and insecure?

Transmission of H5N1 bird flu

The situation in China sounds very similar to the cases reported on more openly from Indonesia, Turkey, and the Middle East where bird flu remains endemic with both bird-to-human and human-to-human transmission seen in multiple clusters in several regions of the country. At this point in June 2006, there is no sign that bird flu is being transmitted easily between people because while the clusters of cases have been getting larger, they all burn out after affecting less than 10 people.

Bird flu is one polymorphism away from gaining pandemic status

Scientific studies of the H5N1 virus published in the spring of 2006 revealed that the virus lacked a necessary receptor on its hemagglutinin surface protein needed to attach itself to the human upper airway. The investigators surmise the absence of this essential receptor explained why bird flu had not become pandemic already since it already had all other essential elements. Every human flu strain causing pandemics or seasonal flu during the 20^th century has this essential receptor. Without it, the virus cannot be transmitted through the air by coughing or sneezing.

I was surprised that these research reports were played up in the press so positively when first reported. If they had read the articles more closely they might have seen that in addition to reporting about the absent receptor, they also found that H5N1 had all the other pieces of the genetic puzzle it needed for pandemic spread. To me this meant that bid flu was just a hop, skip, and a jump away from efficient human-to-human transmission. Of course, this is too simplistic. Dr. Webster, the noted influenza virologist and researcher with St. Jude Hospital in Memphis has stated that H5N1 needed 10 mutations to obtain this receptor. Since mutations occur at random, this would be a pretty formidable barrier for the virus to cross. On the other hand, this could happen in one step by the process of reassortment or recombination with a strain that possessed the receptor. Since there is a large pool of potential donor influenza strains with the hemagglutinin upper airway receptor currently residing in humans and swine, the chances for reassortment or recombination between H5N1 and one of the other strains looks pretty likely to me. It would be a lot quicker than the time required for 10 mutations to occur.

One of the conclusions from these studies of H5N1’s lack of a receptor for the human upper airway receptor is that most of the human bird flu cases seen to date are probably the result of infection by ingestion of the virus rather than by inhaling it. This is suggested by the 40% incidence of diarrhea seen in the cases reported in 2005 from Vietnam by the WHO Writing Group in the New England Journal of Medicine. The H5N1 has a receptor for the human intestinal tract so it can easily gain entry via that pathway. Seasonal flu can present as an intestinal illness to begin with that then involves the lungs, which is the preferred site of influenza reproduction. If H5N1 gains the receptor for the human nose and throat then it will probably be transmitted most commonly by that means person-to-person rather than through ingestion but that route will still occur in some folks.

Swine-to-human transmission of bird flu?

The largest confirmed cluster of bird flu was reported to date occurred in Sumatra, Indonesia in May 2006. ⁴⁰ This cluster went to three generations of human-to-human spread before dying out. In Indonesia, there is growing evidence that birds may not be the only source of infection in people including this large cluster. Public health officials have begun looking at the possibility that some of the cases of human bid flu were contracted from swine. In the spring of 2005, it was confirmed that highly pathogenic avian influenza H5N1 had infected just about all the domestic and feral swine in Indonesia.⁴¹, ⁴²As reported above, during the outbreak of “ Swine Streptococcus” in Sichuan in the summer of 2005, the official Chinese media reported that the farmers became ill after slaughtering sick swine and sheep. In the anonymous reports posted on the Boxun Bulletin Board during that period there were comments not just about sick and dying poultry. There were also posts about many sick and dying swine, cattle, and sheep. One post reported seeing large numbers of dead large animal carcasses floating down the river.

“Don’t tell your mother”

⁴³

Obviously, one conclusion that can be made from an analysis of these confirmed and unconfirmed reports is that there may well be a lot of information about the bird flu virus that is being held close to the vest by national public health authorities and the WHO. The reasons for this are varied and probably even justified in some instances. They want to protect the public from becoming panky and fearful. “Why upset them when a pandemic might not even happen?” “Little white lies never hurt anyone.” “It is for their own good”. The problem with dissimilation and cover-up is that when the truth comes out, as it surely will, latter during a pandemic or other crisis the individuals and agencies participating in these unsavory activities will loose credibility in the eyes of the public. They will not be seen as reliable sources of information or guidance. This is very serious because we need reliable official sources of information and guidance in times of crisis. Another important consequence of these acts is that they serve to lessen public awareness of the risk of pandemic. This predictably reduces the incentive for the public to prepare for the pandemic and to the extent that one can prepare for an event like this, will reduce their ability to successfully cope with it. While some policy makers may think they are being responsible by playing down the risk we face from pandemic, in fact these actions are more likely to exacerbate the disaster.

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• ²Indonesian tests confirm five people from one family died of bird flu AFP 14May2006
• ³Niman H, Bird Flu Cases in Jakarta Indonesia Grows to Six Recombinomics July 25 2005
• ⁴K Ungchusak etal., Probable person-to-person transmission of avian influenza A (H5N1) N
  Engl J Med 2005;352:333-40.
• ⁵Avian Influenza: assessing the pandemic threat. January 2005 – WHO/CDS/2005.29
• ⁶Qinghai Lake Nature Reserve Website http://www.qhnews.com /1028/2005/01/18/35@84450.htm
• ⁷Oon C., Beijing rushes vaccine to bird flu zone., The Straits Times, 24May2005
• ⁸Boxun News Service 3Jun2005 Photos of dead bird at Qinghai Lake www.Boxun.com
• ⁹Boxun (Abundant News) is located outside of China and is run by Chinese expatriates and dissidents. They publish their reports on the Internet and host bulletin boards and chat rooms, all in Chinese. They seem to have good contacts within the medical community in China. They share the credit with another news agency for breaking the SARS story at a time when the Chinese had kept a tight news blackout in place for months. The part they played in getting the SARS story out gives them some credibility with respect to their Bird flu reports.
• ¹⁰Dr. Niman is highly respected although somewhat controversial scientist and virologist who has made, in my opinion, many important contributions to the Bird flu story. His Recombinomics Commentary is an especially rich source of information and interpretation of the data coming out of Asia, Europe, and elsewhere-concerning Bird flu.
• ¹¹Niman H, Human Bird flu Deaths Increase to 121 in Qinghai China www.Recombinomics.com 25May2005
• ¹²Niman H, 8000 Bird flu Deaths in Gangcha County Qinghai., Recombinomics Commentary 2Jun2005
• ¹³Niman H., China Closes Lab Isolating and Sequencing H5N1 Bird flu Recombinomics Commentary July 26 2005
• ¹⁴Drukier C, Jekielek J., The Politics of Pandemic Is the Bird flu Already Spreading in Asia The Epoch Times Jul 27 2005
• ¹⁶Zhe Z, Bird flu outbreak in Xinjiang confirmed., China Daily 10Jun2005
• ¹⁷Niman H, Symptoms in Sichuan China Resemble 1918 Flu Pandemic Recombinomics Commentary 24Jul2005
• ¹⁸Unknown disease claims 9 lives in Sichuan Xinhua 24Jul2005
• ¹⁹Mysterious Shenzhen deaths due to ebola Boxun 25Jul2005
• ²⁰First Published in the British Medical Journal, December 22, 1979
• ²¹Experts pinpoint virus in unknown disease in SW China Peoples Daily 26Jul2005
• ²²Lyn TE., Experts puzzled by China’s swine flu outbreak., Reuters 28Jul2005
• ²³Florence Berthelot-Hérault,Corinne Marois, Marcelo Gottschalk, and Marylène Kobisch1,. Genetic Diversity of Streptococcus suis Strains Isolated from Pigs and Humans as Revealed by Pulsed-Field Gel Electrophoresis JOURNAL OF CLINICAL MICROBIOLOGY, Feb. 2002, p. 615–619 Vol. 40, No. 2
• ²⁴Luque, I.1; Tarradas, C.1; Borge, C.1; Perea, A, etal., :Efficacy of amoxicillin in the control of a challenge with streptococcus suis.laboratorios hipra, S.A. - e-mail: email me hipra@hipra.com - www.hipra.com
• ²⁵Comment provided by From Patricia Doyle, PhD from a text on Swine Strep as a cause of human disease: “Streptococcus suis, an important pathogen of pigs, is endemic in most pig-rearing countries of the world, including the UK. The organism is carried in the tonsils of pigs, and pig-to-pig spread is mainly by nose-to-nose contact or by aerosol over short distances. Human infection with Streptococcus suis is rarely reported and only about 150 cases have been reported from the world literature. Two serotypes have been implicated in human infections; S. suis type 2, an established zoonotic human pathogen and more recently S. suis type 14. Human infection may be severe, with meningitis, septicaemia, endocarditis, and deafness. People in direct contact with pigs or pig products are considered at risk. Asplenic patients are known to be at greater risk from the disease. Human infection is thought to occur mainly via cuts or abrasions when handling infected carcasses.”
• ²⁶Niman H, Military Enforcing Quarantine in H5N1 Pandemic in China Recombinomics Commentary July 22 2005
• ²⁷Niman H., Case Fatality Rate of 82 percent for Mysterious Illness In Sichuan China Recombinomics Commentary July 26 2005
• ²⁸Drukier C, Jekielek J., The Politics of Pandemic Is the Bird flu Already Spreading in Asia The Epoch Times Jul 27 2005
• ²⁹Outbreak associated with Streptococcus suis in pigs in China: WHO Update 16Aug2005
• ³⁰China urged to share bird flu data country claims better antiviral and avian vaccine CIDRAP News 27Dec2005
• ³¹WHO Urges China to share Bird flu samples., Reuter., 27Dec2005
• ³²Revere., Chinese viruses not available to other scientists 19Nov2005 EffectiveMeasure.com
• ³³Official from Ministry of Health Reveals 2005 Human Case Figures for Avian Influenza Outbreak in China Boxun 15Nov2005
• ³⁴Yong W., City doctors in villages fighting epidemic., China Daily 18Nov2005
• ³⁵77 H5N1 Fatalities in Liaoning Province Boxun 19Nov2005
• ³⁶Olsen SJ, Ungchusak K, Sovann L, etal,. Family Clustering of Avian Influenza A (H5N1) Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 11, No. 11, November 2005
• ³⁷MacKenzie D., Expert says bird flu has killed 300 people in China NewScientist.com news service 24Nov2005
• ³⁸China refutes rumor on death toll from bird flu., Xinhuanet 27Nov2005
• ³⁹York G., China hiding bird flu cases., The Globe and Mail 9Dec2005
• ⁴⁰Gale J Indonesian Bird Flu Cases Raise Transmission Fears Bloomberg 18May2006
• ⁴¹Bird flu spreads among Java’s Pigs, Nature Vol 435|26 May 2005
• ⁴²Niman H., H5N1 in Indonesian Pigs Confirmed Recombinomics Commentary 25May2005
• ⁴³On December 7, 1941 Joseph Goldstein, the American Buddhist author and co-founder of the Insight Meditation Society in Barre, MA, tells a story about riding with his father in their car when the attack on Pearl Harbor was announced on the radio. After listening to the report, Joseph’s father turned to him and said, “don’t tell your mother”.