Effect Measure

WHO [World Health Organization] is now saying that human to human (H2H) transmission has not been ruled out in China or Pakistan:


The World Health Organization said Friday it was impossible to say whether a case of bird flu in China involving a 52- year-old man was due to human-to-human transmission – but, even if it was, it was down to very close contact between the victims.

The Assistant Director-General for Health Security at WHO, Dr David Heymann, said the only proven transmission of this nature so far, in Indonesia and Thailand, had been as a result of very ‘close contact’ in a ‘very circumscribed area.’ (via Monsters and Critics)


The World Health Organisation (WHO) suspects there has been only limited human-to-human transmission of the H5N1 virus in Pakistan, but international test results are pending, an official said on Friday.

David Heymann, WHO assistant director-general for health security and environment, said no new suspect human bird flu cases had emerged in Pakistan since Dec. 6, signalling there had been no further spread.


“The team feels that this could be an instance of close contact human-to-human transmission in a very circumscribed area and non-sustained, just like happened in Indonesia and Thailand,” Heymann told a news briefing in Geneva. (Reuters)

This is the new line. Yes, sometimes there is human to human transmission. But it requires very close contact. Casual contact isn’t enough. Sounds reasonable. But here’s my problem. In a lot of cases there is no history at all of contact with sick poultry. Maybe theses cases came in contact with a virus shedding bird somewhere but was it similarly close contact? Or is casual contact with birds capable of transmitting infection but not from another person? Even more to the point, lots of people have close contact with sick poultry and they don’t get infected. Only some people get infected. We don’t know why that is, but it would seem more sensible to ask the same question about the rare human to human transmission. Why these people and not others? Instead of asking that question, they are falling back on the “close and heavy exposure” explanation.

I guess they don’t want to alarm us. Or something.


  1. #1 herman
    December 22, 2007

    WHO representatives can no longer be trusted, and have lost credibility. They constantly report birds as somehow the cause of human bird flu infection, even when there is no contact with birds; and they conceal facts regarding human to human contagion. They do this to protect governments from the negative economic consequences of notifying the world of the presence of human to human transmission. This means public health departments all over the world will not be informed in time of the increase in human to human transmission to do anything the prepare for it. And if the fatality rate stays at 60%, this will result in massive human death all over the world.
    The recent human chain of bird flu in Pakistan is the longest ever recorded, and WHO has not released the information regarding the age, gender, disease onset dates, hospital admission dates, dates of death, and the relationship between the confirmed cases.
    To spin and conceal information regarding human bird flu infections is more than just a word game, it is a crime against humanity for economic reasons.

  2. #2 M. Randolph Kruger
    December 22, 2007

    Revere, the genetic predisposition thing of course comes to mind here but to get sick your receptor bases have to be a match or a close one.

    With that in mind I question the WHO for the following reasons. If the bug is now “limited human to human” transmission it would appear at least to me that the bug by whatever method has mutated to a more human pattern and continues to gravitate so. The Chinese had that deal in July of 2005…Over 1000? Did it mutate in and then the Chinese stamped it out and by doing so get lucky?


    Very interesting if you take the current events and start extrapolating. It would seem that someone is holding onto their toys and hoping that the outcome will be different even though they keep trying the same thing. It stands to reason that if its learned that particular receptor part, that it will learn even better on how to match it in the future. I know that its possible that it might not, but the case descriptions, numbers and in particular the outcomes dont bear the best case out.

    Time and again we have seen experts from around the world stating that this is mutating, its picking up this and that receptor base, its shifting and drifting or if you ascribe to Dr. Henry Niman-recombining. Whatever the case for the lay guys like me there is smoke coming from the building and the fire department says there is no cause for alarm as they ring in the 4th and 5th call for assistance. Can someone legitimately say to me that we are NOT in Pan Level 4 or really 5?

    I know you have friends in CDC and WHO. I know a few too. But as a group they are as political as the Democrats and Republicans. Geneva saw that and its based in a endless loop of economics, healthcare, bragging rights and patents. Neither the CDC or WHO would cause a panic until they were sure. But sure for me isnt so much in the very opaque to near black for surveillance information, but more in the carefully couched words of both. Not to mention the locals such as Supari and the goof ball in Pakistan who says there is no need for alarm as they spread almost 300,000 Tamiflu tablets intot he population. NO CAUSE FOR ALARM? Prophylaxis is Pan Level 4-6 type stuff. They put this stuff into the pandemic plans and do it by stages. Its Pan4!

    Then there is the drivel about the Pakistan case being B2H as it would appear at least to me that the simple definition of time prevents this. Just as it was in China between father and son prohibits the idea of B2H but maybe more B2H2H=>. Pakistan is more interesting but about the same.

    I spoke of time. IMO the time that it takes for the various bozo’s to get in place, change the diagnosis which is always B2H and no further transmission by the local authorities we are going to be in deep, deep shit. It took the Paki brother of the sickened family there approximately 28 hours to make it into the States. He wouldn’t have under current criteria for onset of symptoms been sick. Maybe have a few aches and pains clearly attributable to jet lag. All the while he could have been virus as he went across the planet. He had to hit either Athens, Rome, Frankfurt, Brussels, Amsterdam or Paris coming back through to the US. Our flying non-index index case would by transiting even one of those highly interconnected EU airports spread it like dust in a high wind. Then he lands in JFK, Newark or Boston. The process repeats itself to Chicago, Miami, South America, Canada.

    My point is simple, if we get the fully H2H case anywhere and they get onto a plane there simply will not be any way to contain it. Our suggested National Pandemic Flu Plan (NPFP) would not have time to go into action much less move up the step list from Pan Level 3 to 4, much less the 3-6 which is what it would be. Widespread off antigen vaccinations would be worthless or nearly, they wouldnt even have time to deploy it. Sudden surge at days 3-4-5 would doom us. No containment possible.

    I truly fear what could be happening and they are not telling us. The transparency of the WHO is as bad as anything you have touched upon in the past with the CDC and budget cuts. But to what end are we moving. They should be spreading the alarm I think rather than trying to limit the news on it. Its not like Swine Flu of 76. We have the equivalent of the first cases of H5N1 popping up in birds all over this planet now. Whats it going to take?

  3. #3 revere
    December 22, 2007

    Randy: I wouldn’t count too heavily on the receptor match. Humans have both receptors (I’ve written about this a lot here). The genetic predisposition is still controversial and I am not convinced it is a major factor. We’ve also discussed this here. We don’t know why some people are infected and not others. It is a major mystery. It could be a host factor or purely viral or a combination. The environment may or may not be involved in some cases. It is much to easy to take an isolated laboratory finding and speculate and extrapolate. The danger in this is that it will lead you to spend a lot of effort in the wrong direction. As far as I can see, the only sure investment at this point in our knowledge is investment in a sound public health and social service infrastructure, which covers all disasters to a community, including a pandemic.

  4. #4 Tom DVM
    December 22, 2007

    Let’s see…for ten years H5N1 has been highly lethal to humans consistently…for ten years, H5N1 has been transmissible from human to human…Recently, H5N1 has become transmissible in diverse and distinct, geographical environmental niches…

    and now we are clearly seeing clusters upon clusters…the cluster frequency is increasing.

    Given this is an ‘animal’ disease and humans are after all, just another animal…the trend line seems pretty obvious.

    Once again, the World Health Organization clearly demonstrates that it is a political organization and is a ‘poor excuse’ for a scientific agency…and why would it be any different…according to the experts, the WHO did a perfect job in responding to SARS…and they are continuing that good work with H5N1.

    We have already seen how this story will end…unfortunately.

  5. #5 Tom DVM
    December 22, 2007

    The World Health Organization can dance on the head of a pin all they want: if you listen really carefully you can hear the sound of H5N1 laughing.

    Epidemiologists say: Thin out sick chickens.

    Virus says: Thin out stupid people

    Racter (Mar. 2006)

  6. #6 Dr Michel S.F. Vermeulen
    December 22, 2007

    Follow-up on H5 antibody levels in the country’s different persons would be useful for determining the extent of H5N1 spread among patients and contacts.

    This remark is valuable for the low symptomatic patients, and why not, for the atypical symptomatic patients, and those in good health.

    Only a significant pattern is necessary, abble to express or to eliminate a reality.

    All sorts of flu’s nuisance aren’ t the same because patients and virus characteristics are fluctuating, for exemple, let us remember the seasonnal flu’s cases.

    This reality can mask the H5N1 spread , but …., to say is easy, but the feasibility and the cost is an other story.

  7. #7 revere
    December 22, 2007

    MSFV: We and many others have been calling for seroprevalence surveys for years. Those that have been done show no evidence of inapparent or asymptomatic infections, a surprising and unsettling thing, although the evidence is sparse. I believe it is now customary to do serologic contact testing for H5 convalescent antibody titers.

  8. #8 SusanC
    December 22, 2007

    Well, we’ve had millions of people in contact (close or not) with infected poultry by now. All indications are that the number of people who get infected is a minuscule fraction of those exposed. Why? It would point to some host mechanism, IMHO.

    I don’t think environmental factors nor viral factors play a big part in determining who gets infected because either one of those is likely to cause far larger numbers of infections in unique locations compared to neighboring localities than the current clusters spread out over many countries. Sure, we are seeing more cases in Indonesia than other places, but if environmental play a bigger part than host factors, then we should be seeing more pockets of much higher infection rate in some areas than others.

    Check out these 2 maps of Indonesia, showing recent case reports, and from earlier this year, and notice how they are rather too evenly spread to suggest environment as an important issue.



    IF the major issue lies in host factors, the next question becomes What host factors?

    I see 2 distinct patterns that may be significant: age, and the fact that the overwhelming preponderance of clustering occur among blood relatives.

    This may not be enough for any firm conclusions, but I’m more inclined towards believing in the genetic predisposition angle than ever.

  9. #9 revere
    December 22, 2007

    Susan: You make some excellent points. However we know that environmental factors are important for either infectivity or transmissibility of this virus (seasonality) and environmental factors also refer to specific other exposures an individual might have (e.g., other infections, occupational factors, the micro-environment of exposure, etc.). So I wouldn’t dismiss non-host non-viral factors too easily, as they probably modulate the risk of transmission and/or infection, in ways we don’t understand. It is a complex mix. The blending of host and environment is seen in the question of gene-environment interactions, a major area of current research in biology. Focusing on the virus, alone, however, doesn’t seem reasonable to me. The “close contact” sotry is basically a virus only tale.

  10. #10 herman
    December 22, 2007

    Recent information indicates the total number of victims in the Pakistan cluster could be as high as 10. Could this indicate there have been further genetic changes in H5N1, making it easier for the virus to infect humans? Will WHO try to find this out during their investigation, and if they do, will they release the information; or will they instead store the data in a secret data base?
    In spite of what WHO representatives constantly state, that all human bird flu infections result from contact from birds, except for a few rare instances; the reality does not support this.
    Human to human contagion with H5N1 is actually very common, and happens frequently. Usually the index case is infected by birds, and then family members begin to get sick through human to human transmission. WHO constantly insists in the case of human clusters, they all became sick from a common bird source. But this is nonsense. If they had all become sick from a common source, they would have all become sick within 2 to 4 days. But in these clusters, the index case becomes sick, usually after contact with sick birds, and then, over days or even weeks, other members of the family or friends,become sick. This is clear evidence of human to human transmission because of the time gap.
    And in the Pakistan cluster, the time separation is almost 2 months. In other words, the index case became ill from H5N1 after exposure to sick birds, and then others became sick through human to human transmission over a 2 month period, until the total number reached about 10 people. This is a new record.
    Sooner or later, the virus will adapt to humans, and the pandemic will begin. Stage 4 should now be declared, before whole villages become infested with human H5N1 infections.

  11. #11 anon
    December 23, 2007

    maybe it’s just bad luck ?
    many different factors for the virus must all match
    so it can successfully start replicating in another host.

    this could involve weather,host-genetics,host-nutrition,
    location of immune patrol cells, location of entry,
    breathing cycle, prevalence of some gases or bacteria,
    smog, wind,…

  12. #12 herman
    December 23, 2007

    If this virus ever gets into your lungs, and destroys them, perhaps you will, with your last breath, no be so stupid, when you encounter eternity.
    I will never forget the photograph of a young girl in Vietnam that died of bird flu. Her death made a imprint in my mind I will never forget.
    Please concentrate on the wisdom of Revere. I am sure he has seen people die. This is not a joke.

  13. #13 revere
    December 23, 2007

    herman: I think anon was making a different point (not a frivolous one). He is suggesting that there is a certain small probability of transmission in each case, which accounts for the infrequent occurrence.

  14. #14 RobT
    December 23, 2007

    My take on the question of why only some get infected is not so much finding that answer, but taking the precuationary principle to heart. Yes, it will be extremely important to tease out whatever factors are at play with curent H5N1 infectivity NOW, but shouldn’t we be ASSUMING that H5N1 will change, and in the process get much better at the H2H game? Whatever the mechanism of mutation it hits upon, shouldn’t we be ASSUMING that it WILL happen, and prepare our health care systems, food distribution, and vaccine production systems, accordingly.

    It seems to me from examining the activity in Australia, that we are assuming it WON’T go pandemic. And if it does, certainly not at anything like the current CFR. What is it about the precautionary principle that we find so difficult?

  15. #15 herman
    December 23, 2007

    I apologize. I did not understand the meaning of your statement.

    I want to thank you for assisting me in understanding what anon was communicating.

  16. #16 revere
    December 23, 2007

    RobT: I agree with ou, of course. We need to focus on managing the consequences. I was focussing on the way they framed the H2H scientifically.

  17. #17 M. Randolph Kruger
    December 23, 2007

    Since Tan06 and I have been pouring over info that was available from the EU, Central Asia and Eastern Asia we have pretty much came to the conclusion and its definitely not based in any study that “something” was going on in the about 10-12 years ahead of the 1918 flu. There were many, many cases of people dying of pneumonia in Belgium, France, Italy, Netherlands, Germany and Prussia. But records keeping sucked at best. Lots of pneumonia though and no definition of viral or bacterial in any cases.

    Here is a heart stopper. I found ten cases in about 8 news papers where whole families were sickened with varying results in those countries. Panflu on the run? Other buggies running thru them? I dont know anything other than they had pneumonia. That little fact has taken almost a year and a half to produce. I had to pick up a little French and a little Italian to get that figured out.

    Then there are the pneumonia’s recorded by the mandarin war lords of turn of the century China. Yes, some cases where whole families became sick and one or two where the whole family died. Strange, but not so strange in China then. Was it bird flu getting started… Now theres a reach but how far is that reach? Perhaps not far? .

    Tom has posited that this is becoming more efficient. Indeed, it would seem that if you just take your crystal ball out and forget the hard cold facts of science and how we track these things, its repeating itself. In fact it screams of coincidence. I fully appreciate the dilemma which by definition offers up two or more solutions but none are acceptable to the science types. Could we be sitting in the middle of the start of a pandemic and the WHO/CDC or whomever is sitting on their asses and assessing a couple of hundred RT-PCR’s and still not conclusively say its BF?

    I think this is where Tom and I are coming from. The situations in China, Egypt, Turkey past, Pakistan, Indonesia do not add to the answer, only more to the question. We all want to know the answer and if we get the answer that we all suspect, it means a shit load of us are about to die. The WHO and its vaunted bureaucracy has made them politicians and not doctors and thats as bad as anything that Revere has ever posted about the CDC under the Gerberdinator. The difference? The difference this time is that its not just the US, its the world. I know they mean well and they dont want to start a panic, but if they jack around to the last minute there will be a panic, a planet wide one and it will kill thousands if not hundreds of thousands in its own right.

    If we have it and people were not warned to prepare AS IF IT WERE AROUND THE CORNER then the survivors will look like scarecrows and fight over food like they do in Bangladesh after a storm. This would be a worldwide event.
    Now I know they want to err on the side of caution but in the last two weeks two major nations have started moving their people into greater than Pan 3 status on their own. Startng with the UK they have ordered enough stuff to screw the budget for some years to come. Revere posted about the budget cuts to DEFRA there. His assertion? Its madness…. Of course it is but I wonder if its now a reallocation that acknowledges bird flu is here and about to hit? I would assert that the question begs another question and that is if they are cutting the buget when they have already had human cases of a type of bird flu, does it make sense? Well of course not…But it sure as Hell does if they know its coming.

    We are all conspiracy theorists at heart, ever since Julius Caesar. We want our governments to be transparent and sane. We rarely get it. The UK may have been telegraphing what they think by action rather than statement. The same could be said for the WHO. By making the statement that the Paki situation was contained is one thing, but they threw the Pan Level 4-6 anti-viral blanket which indicates to me that 300,000 tablets were either used pre-emptively or prematurely. So you tell me….use the above paragraph… Does it make sense?

    Only if they know its coming.

    Again, we are supposed to decide this based upon WHAT? Certainly nothing the WHO gives us. Carefully worded statements that give them the outs they need if it breaks high path or in any manner into humans.

    We can rag on the Indons about sequences all we want. Revere and others have posited that not releasing the sequence data and samples to the world ensures that we wont have the whole picture if it comes. I would submit that we wont have the picture at all. It will likely based upon the lack of data, information, and science come like the proverbial thief in the night. That equates to even more lives. We are driving in a tunnel with sunglasses on that have only a little point which you can see thru. We are doing about 100 mph. We could thread the eye of the needle, but that only happens to Tom Cruise in a MI movie.

    So with the actions of now five nations being much higher than Pandemic Level 3 can anyone tell me what makes them believe the WHO and their rhetoric? Nbarro says that the risk has been reduced on the same day that the WHO is announcing limited human to human transmission which they say isnt sustained.

    According to who?

    So what are we to believe? I am simply not sure any longer and I learned in the military that when the orders conflicted with the reality that I did something about it. That something was to lock and load. Gimme Jimmy was the last one to issue orders about something like this… Do not use your M-16 in a firefight and thats an order.

    We field modified that. Use your M-16 with discretion and if caught by a news person doing it, shoot the newsie before he can report it. Sounds like the order of the day at the WHO only they are doing the shooting this time. They are being outed at each turn by the newsies and the result is even less useable information coming out. They put out crap to the newspeople and they are now starting to call them on it as we are in the information age and they bring in expert this and that. I will know its close, very close when the disinformation is equal to the obvious facts. Keep that in mind.

    IMO, the newsies are the only ones getting it right and they are coming up day after day with stuff the healthcare people in these various nations cant. They also are much better at collecting info than the WHO. So again, Tom is IMO right. We are animals. The bug is attacking now with most of the criteria that defines a PANDEMIC! Neither he or I wrote this stuff. We are using their playbook but now even the gamers arent using their own book. The bug was resident for at least 15 years in 1918 if you read the news accounts and then it attacked in full force. That is if you buy that it was there for years. We know in 2007 that BF is in many places and it has been around for 10 years at least.

    Again, what are we to believe?

  18. #18 Jonathon Singleton
    December 23, 2007

    Howdy Randy,

    I must say, your above posting reads pretty much like an historical H1 pandemic overview vis a vis an analysis of current H5 events… The situation at present reminds me of how I felt ten years ago — a disconnect between planet changing events (Hong Kong 97) and mainstream AmericanOz media culture (us sitting at home laughing at Bill Clinton being crucified for lying ’bout getting a blowjob)!

    Recombinomics Commentary — “WHO Hoarding of H5N1 Sequences Raises Pandemic Concerns” (December 23, 2007)

    Niman is reflecting your concerns, Randy! What the frack is going on!?! How much time is left to prepare for that which we know will occur as a result of pattern-analyzing the last ten years!?!

    Why are we “frontliners” always right but never listened to?

    Happy holidays (ooooops) Xmas ’07

  19. #19 RobT
    December 24, 2007

    Revere, and all board members;

    It’s off topic, but as Christmas eve settles in here in Oz, I just wanted to thank you Revere for all your diligent and edifying work, and to the contributors to this blog who each add their own value.

    May we all have a pandemically uneventful 2008. I sincerely wish.

  20. #20 anon
    December 24, 2007

    I meant, there is maybe not just a single factor which would make H5N1 go
    efficiently h2h, but rather many smaller factors (mutations?) which are necessary
    to increase its chances of spread. Only if all factors are favourable, the virus will
    infect the next human host.Each factor itself could be 50% likely to match but
    due to the multitude of factors the overall probability is low.
    One mutation improving on one factor may reduce on another one, so it’s hard
    to improve all factors simultaneously and can only be done with special,
    human-targeted evolution through h2h2h2..2h

  21. #21 kyangadac
    December 24, 2007

    you note newspaper reports of families going down with flu prior to 1918. I saw a similar report in a local history about the first Lake Grace show(fair) in 1890(IIRC) – this report commented that influenza had killed a number of white people in this isolated community. By this time, influenza epidemics had already decimated Aboriginal communities in the South West but this report made the paper because of the white families involved.
    The point is – lack of transport and community isolation prior to WW1 (and probably up until 1919) meant that flu epidemics didn’t spread with the same facility as they can today. Although it is possible to identify epidemics in the 19th Century spread by sailing and steam ship movements (1830).

    This doesn’t really detract from your point though.

  22. #22 M. Randolph Kruger
    December 24, 2007

    I saw the Aussie accounts for the Lake Grace deal and I couldnt add it because of the criteria I was looking for. Dead birds and then WITHIN six months (seems to be the far end of when it would happen), dead people. Pretty simple…couldnt find dead birds Lake Grace. As a result there wasnt a bird link that I could establish. Wish I had though. I am sure its in there but most of bug tracking is finding commonality and I am a novice at it at best. Dont know what else to look for

    Then there is this. Endemically infected is also a term that I couldnt find a start date for in history. So maybe native peoples got it from meteors, or croc meat. Something would have had to have been endemically infected other than people for this to work. See my “dilemma”?

    The sailing ships I had a little problem with but only by the onset dates. If there were a lot of people on a tub heading back and forth along with crew it was like long chain transmission from person to person. Lots of people died at sea and there sure as hell werent birds on board. So it was easy to confirm H2H=>. But I wanted the origins. I found stuff on how mandarins dealt with the bodies by incinerations in China, I found how many families just up and died basically overnight and their homes were simply burned with them in it. But again, its the winged chain converting to the two legged or four legged one that I was looking for. Missionaries noted that pigs died in and around Hong Kong in great numbers back then…BF? Who knows? Bird kills back then were simply not reported except in the most elite of states (countries) and even then only as a footnote. Germany and Hungary had a few, but no human deaths until well after whatever it was got them. Well after was in both cases two years later. So its very coincidental with what we are seeing here. Science….shit no and any epidemiological guy would stomp all over it. Coincidental? Very.

    Longest article I was able to find was about 40 sentences…. Long hard dig to find these things. Its like what we are getting now only a little better reported. They simply passed these things off as normal back then. I hope we dont find the smoking gun connection in the manner they did in 1918.

    Hiya Jonny! Merry Xmas old son.

  23. #23 Library Lady
    December 26, 2007

    Dear MRK,
    “Lots of people died at sea and there sure as hell werent birds on board.”
    You cannot assume that. The lack of refrigeration would require that there were crated, live chickens, ducks, geese, pigs, etc. on board as provisions, sharing the same space with humans. The crew and passengers would consume those first, consume the salted stores next, and then new provisions would be procured at the next island or port known to be well-supplied with live and/or salted provisions.
    Library Lady

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