Avian Influenza

AVIAN INFLUENZA

Mr. BURGESS. I thank the Speaker for that consideration.

Mr. Speaker, I wanted to come to the floor tonight to speak just a little bit about a situation that we have had to address here in Congress, and we likely will have to think about it some more over the coming year or years, and that is the issue of avian influenza.

The important thing to remember when we talk about bird flu, or avian influenza, is, there are different types of flu. We are all familiar with the common type of influenza, the one that we all get a flu shot for or should get a flu shot for every year. And the reason we have to be vaccinated every year is because there are modest changes that occur in the genetic makeup of this virus year in and year out, a so-called genetic drift.

Avian flu refers to a virus that is currently present only in birds, but has on occasion made the transition to a human host with rather significant effects. This reflects a bigger genetic change than can occur in the flu virus from time to time, a so-called genetic shift. This could become a major health threat to humans.

As of June 20, 2006, the World Health Organization has confirmed 228 human cases with 130 deaths. It doesn't take much to do the math to see that that is a mortality rate in excess of 50 percent for this virus.

Now, the trouble signs that are already present. We do have the virus present in birds; there is a wide geographic setting with involvement of other animals, including cats and tigers. Bird-to-human transmission has occurred, but it has occurred only with inefficiency; and there has been on occasion, through close household contact, inefficient human-to-human transmission.

Steps one through four have occurred since 1997, and I must stress, they have occurred in the Eastern Hemisphere of the world. There have been no reported cases in birds or humans in the Western Hemisphere.

The last step in this process, the efficient human-to-human transmission of this virus, has not occurred. If that step does occur, and it is certainly not certain that it will, but if that step does occur, that would trigger the onset of the possibility of pandemic flu.

One of the big problems that we have with this virus, as humans, is that we have no underlying immunity to this virus, so that if the virus is introduced to the community where it can spread easily from person to person, it could progress very rapidly through the population.

Now, pandemics are not new phenomena; they occur and have occurred over the centuries. They happen about every 35 years, approximately three per century. And, indeed, in the 20th century there were three such epidemics. In 1918, the so-called Spanish flu killed 50 million people worldwide. In 1957, the Asiatic flu killed 170,000 people in the United States. And, in 1968, the Hong Kong flu killed 35,000 people in the United States.

What would happen if a pandemic flu were to reemerge? The Department of Health and Human Services estimates that for a moderate outbreak like the Asian flu pandemic in 1957, we could see over 200,000 deaths in this country. In a worst-case scenario, such as the Spanish flu pandemic in 1918, almost 2 million deaths would be estimated to occur in the United States.

Mr. Speaker, I have a couple of maps that show some of the progression of this illness across the globe. Looking here at this first map, the eastern part of the world, avian flu cases are depicted in blue, human cases in black. On this map you will see almost 50 countries that have been involved with avian flu in bird populations and a smaller number, 10 countries, have reported human cases which have moved with some difficulty from birds to humans.

Looking at a map that shows the progression of this illness in birds, we see that in Hong Kong in 1997 when the disease was first reported, there has been a gradual progression westward since that time. June of 2004, the disease had progressed to Vietnam. June of 2005, the disease was reported in Iraq. In 2006, Turkey. In March of 2006, it had made an appearance in Egypt, and the progression is westward.

This inset map on the bottom, the orange lines, and it is difficult to see, but that outlines the places where bird populations, domestic bird populations, poultry populations and human populations tend to overlap. You can see in the areas in China and Vietnam and Southeast Asia where that appears to have been a significant issue, and you can see some areas of the United States that would be at risk if bird flu actually spread to this country.

To date, the disease has been endemic in birds and over 200 million birds have been culled in the last 3 years. This is significant in that there are many parts of the world that rely on poultry as literally a means of currency, and this has been a very difficult thing for some countries to accomplish. But a critical aspect of the prevention of the disease is if we can stop it in birds and never have to worry about it in humans, it is going to be much, much better for us as a people.

Let me take these out of the way for a moment and demonstrate one of the issues that is so striking about this illness because it does occur in wild birds. This is a map that shows the migratory flyways across the world. It is thought that this virus is spread by migratory birds to poultry populations. The countries with outbreaks in general have a high concentration of poultry. There is some concern because there are two of these flyways, as you can see, the East Atlanta Flyway which goes from the African continent up into the polar regions of Canada, and then the East Asia Flyway which comes up through Australia and comes into Canada and Alaska.

Now, it is unknown whether the virus will make a transition to the Western Hemisphere by these routes, but the routes suggest there could be some risk. And for that reason, there has been increased testing across the United States starting in Alaska with nearly 100,000 samples taken from live and dead wild birds, and 50,000 samples from water from high-risk waterfowl habitats to be tested in 2006 alone.

The World Health Organization has identified six levels of pandemic alert, and we are currently at level 3 with limited human-to-human transmission. As of June 20, 2006, the World Health Organization has confirmed 228 human cases, 130 deaths. The disease was first found in Hong Kong in 1997, and 18 human cases were encountered in that outbreak, six of whom died, and there was significant poultry culling from that population. The disease was almost arrested at that point.

There is a high incidence of the disease in a few countries. Vietnam has had 40 percent of the human cases, and Indonesia has had 20 percent of the human cases. The problem is in Indonesia, the virus has not been contained compared to Vietnam. And Indonesia has had outbreaks since early 2004, and new outbreak reports occur with some frequency. As of June 20, the 51st case of human infection, which was fatal, was confirmed.

Let's look at a map of Indonesia. There has been a steady rise of reported cases and a high correlation between poultry populations and human outbreaks.

The little triangles on the map represent human cases. It is misleading because the triangles overlap so there are more case than there are actually triangles because some of these cases do occur in clusters and are very close in a geographic footprint.

In some of the larger cities, notice how close some of the triangles occur. Indonesia is the fourth most populous country. In many ways Indonesia is still suffering from the tsunami that hit there the day after Christmas in 2004. In May they had a major earthquake in the central Java region with as many as a million and a half people left homeless, and Indonesia raises about a billion and a quarter chickens per year. That is about 7 percent of the global total. It has 70,000 villages spread across its 17,000 islands. Many of the poultry raised in Indonesia are raised in the backyards of people's houses, and about 80 percent of the country's 55 million households actually have close proximity to poultry. And that makes the presence of the disease in Indonesia a little more troubling.

A chart that is fairly busy but I think important to look at depicts some of the cases that have occurred in Indonesia. This is information that has been confirmed by scientists and field researchers from the World Health Organization. This is a recent family cluster that occurred in the Kubu Simbelang village in North Sumatra.

Many of the recent news headlines had to do with the fact concerning the avian flu virus may have become efficient in going from human to human, but the outbreak investigation showed that this is indeed, although there is a high number of cases, it is indeed what is known as a contained cluster, meaning no others, no health care workers, no neighboring villagers, were being infected.

The initial case, the index case of a 37-year-old woman, was most likely infected by her sick and dying backyard chickens. She kept them indoors at night. No specimen was taken from this patient before she was buried so it cannot be confirmed that she was infected with the H5NI virus. However, seven of her relatives did test positive for the virus. The relatives most likely became ill because of close contact with the initial illness. Six of the seven relatives have died, so currently limited inefficient human-to-human transmission of the H5N1 virus that causes the avian flu.

Another thing that is striking about this, we all think of flu as being an illness that strikes the very young or very old. But look at the age distribution in this family, in this village. Basically young healthy people were the ones that were infected. Now, it is not known whether that is significant or that just was the cluster that unfortunately got infected by that incident of infection, but it is striking that so many people were in the age group where you would think they would be young and healthy with a good immune system that could ward off this virus.

In general, 3 to 5, 10 days elapse between the time of symptoms to death with this illness.

Now several things separate the situation that is present today from that which existed in this country in 1918, and the first has been the introduction of antivirals and vaccines. Antiviral agents are able to actually attack part of the virus itself and work like an antibiotic and prevent the virus from replicating, and prevent the viral infection from being so severe.

Antivirals do have to be administered within the first 24 hours of the onset of symptoms in order to be effective. For that reason, we have to have an adequate stockpile of antiviral medications, and there has to be the distribution network to get the antiviral medications to the areas where they would be required should an outbreak occur.

Tamiflu is probably the most famous of the antivirals. Relenza is another one proprietary name for one of the antivirals. Again, if administered during the first 12 to 24 hours, these have the possibility of not stopping the illness, but moderating the course of the disease.

Vaccines are historically our major line of defense against viral illnesses. One of the problems we have is we have not had a great deal of secure vaccine manufacturing within our borders for a number of years. We have to have that ability to manufacture the vaccine within the United States.

One of the other problems is this virus is constantly evolving. It has not yet evolved from a state where it can go easily from human to human. There has been a vaccine developed to the current H5N1 virus, but if it changes yet again to the efficient human-to-human form, the vaccine may not be as effective. To some degree, you almost need to wait until the pandemic occurs before you can actually develop the vaccine.

But the good news is that there has been a vaccine that has been developed that seems safe. It does seem effective against the current strain of bird flu. One of the difficulties occurs, since we have no native immunity to this virus, it does take a lot of this vaccine to render someone immune to the virus. Normally you take a flu shot that is 15 micrograms of material to develop immunity. With this vaccine, it requires two doses of 90 micrograms in order to get someone to develop the appropriate immunity.

The other thing that has to happen, vaccine manufacturers that do exist manufacture vaccines by an old method, an egg-based method. If the disease is in chickens and we are having to cull poultry from the population, you don't want to depend upon an egg source for your vaccine, and newer cell-based technologies certainly need to be developed.

Surge capacity within the health care system is going to play a key role. We are going to have to be certain that we protect first line responders with whatever vaccine is available. If the virus hits, antivirals have to be available for first line responders. It is going to be important to rotate health care workers so they don't become overwhelmed in dealing with the disease, and we are going to have to offer mental support services, not just for health care workers, but for patients and their relatives who are charged with caring for them. This could be a disease that will take a very heavy emotional toll on the population.

In order to minimize the economic impact, we have to implement business continuity plans. This is being done in many communities. Certainly my communities back in Texas have looked into how they will handle some of the other things that local and county and State governments are supposed to do if faced with a pandemic outbreak.

Mr. Speaker, I will wrap this up. I do want to mention that I spent a day last week in Geneva with some individuals at the World Health Organization. Dr. Michael Ryan was kind enough to spend some time talking with me on the global perspective. I have been focused primarily on preparedness within this country, and Congress appropriately has been focused on preparedness in this country. But I want to make mention of some of the things being done by the World Health Organization in order to make certain that the virus is either arrested in its initial outbreak or that the disease is mitigated because people have been on top of it.

Dr. Ryan works at a place called the Strategic Health Operations Center that is part of the World Health Organization in Geneva. The purpose of that organization is to provide strategic support, in this country to provide that strategic support to the Department of Health and Human Services, but they also have a global response network that is responsive to the World Health Organization as well as the CDC and Health and Human Services Department here in this country.

The concept is to control this virus at the source, and that is really what is one of the critical features of this. That is how they were able to gain control in Vietnam and Hong Kong. To some degree, culling of poultry populations is something that we may see more of as time goes by, as well as isolation and quarantine of infected individuals coupled with vaccination and antivirals.

Intelligence is of course a key to this whole process. And then verification of that intelligence, assessment of the situation on the ground and then a response to the situation as it occurs. All of these are parameters that the World Health Organization is monitoring through the Strategic Health Operation Center in Geneva.

Countries need to know that they just are not able to hide a problem like this and that officials at the World Health Organization consider this a reportable illness with or without the permission of the host government of the country. That, I think, is a terribly important step.

We have a lot of work yet to do in Congress as far as national preparedness. A good deal of work has already been done as far as the request for proposal for vaccines that went out earlier this year through Secretary Leavitt and the Department of Health and Human Services. A lot of preparatory work is taking place on the State, local, and county levels.

Every one of our committees in Congress has a role to play in preparedness for the possibility of this pandemic.

In the final analysis, is a pandemic going to occur? No one knows the answer to that question. It could be an illness of such severity that preparedness is something we are all going to wish we spent more time doing.

Or it may have come across as something more like the Y2K phenomenon where nothing much happens.

It will be in our best national interest, though, to focus on some of these preparedness aspects to work with some of our partners at the World Health Organization, be certain that we keep this virus under surveillance, be certain that we develop the vaccine capability, the surge capacity within our health care system and the development and stockpiling of antivirals within our country.

Mr. Speaker, you have been very indulgent.

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