Alan Sipress - The Fatal Strain

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 Virus 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.

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.