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What is Avian Influenza and why should we be worried

about it?(1)<a name="whatis"></a>

Many influenza experts agree that an influenza pandemic is ‘inevitable and possibly imminent’.(2) Some experts predict that the chance of a world-wide pandemic of avian influenza in the human population occurring in the next 12 months is around 10 per cent.(3) In the face of increasing public concern about the prospects of a pandemic, Health Minister Tony Abbott has cautioned that while a ‘severe pandemic’ is a ‘distinct possibility’, it is ‘by no means a certainty or even a probability’.(4)

Avian influenza is an infectious disease of birds caused by particular strains of the influenza virus. The disease occurs worldwide, and is most commonly found in migratory water birds. Water birds are generally resistant to infection caused by avian influenza, but the virus can cause severe disease when it spreads to poultry and other birds. In rare cases, avian influenza can infect humans.

There are 15 different types of avian influenza virus. The types that cause the most deaths are known as highly pathogenic avian influenza (HPAI). There is currently an outbreak of an HPAI strain called H5N1 in birds in several countries in Asia and parts of Europe. The first cases of humans being infected by H5N1 were detected in Hong Kong in 1997. Eighteen people were affected, six of whom died. In that instance the virus did not spread from person to person. There have since been more outbreaks of human infection, including one in Vietnam in 2004, and others in Thailand and Indonesia more recently. To date, there have been no confirmed cases of human-to-human transmission into the general community, although there have been ‘family’ clusters of avian influenza in Vietnam, Thailand and Indonesia. These cases have involved very close contact with an infected person and, as the family members were all exposed to the same potential animal and environmental sources of infection as well as to each other, it is impossible to know whether transmission was human-to-human.

The major cause for concern arising from the current outbreak of H5N1 is that the more the infection spreads in birds, the greater the opportunity for infection in humans. Not only has H5N1 shown a capacity to be deadly once it infects humans (to date about half of all confirmed human cases of H5N1 have resulted in death), but if an HPAI virus such as H5N1 infects humans who also have human influenza, it could mutate into a new sub-type of influenza virus which could be transmitted easily from person to person.(5) This could mark the start of an influenza pandemic.

An influenza pandemic would likely lead to high rates of morbidity (sickness) and mortality (death). The <a href="http://www.un.org/News/briefings/docs/2005/050929_Nabarro.doc.htm">Senior United Nations System Coordinator for Avian and Human Influenza, David Nabarro</a>, has said that, depending on a range of factors including the location of an outbreak, and the speed and quality of a response, the death toll from a human pandemic of avian influenza could be anything from 5 to 150 million’. According to the <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pandemic-plan.htm">Australian Management Plan for Pandemic Influenza</a> (discussed <a href="#_Australian_preparations_for">below</a>), it is estimated that an avian flu pandemic could lead to at least 2.6 million people seeking medical attention, 58 000 people being hospitalised and between 13 000 and 44 000 deaths.(6)

     ==E-brief outline==

This E-Brief provides links to information and key resources on avian influenza and the potential for an avian influenza pandemic, including:

  • <a href="#generalinformation">general information</a> on avian influenza
  • information about <a href="#australianpreparations">Australia’s preparations</a> for an avian influenza pandemic
  • information about the<a href="#theinternational"> international response</a> to a potential pandemic, including <a href="#australianassistance">Australian assistance</a> to the Asia-Pacific region
  • information about <a href="#preventionand">prevention of and treatment for avian influenza</a> in humans, including debates over the most effective uses of available resources
  • information on <a href="#australianresearch">Australian research on influenza</a>
  • <a href="#commentary">commentary</a> in the public domain on avian influenza and the prospects of a pandemic
  • <a href="#parliamentarylibrary">Parliamentary Library publications</a> related to avian influenza
  • news websites containing information on the <a href="#keepingup">latest avian influenza developments</a>.

The E-Brief will be updated regularly.

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<a name="_General_information:_avian"></a>General information: avian influenza <a name="generalinformation"></a>

The following websites provide general information on avian influenza and the risk of an influenza pandemic:

Maps<a name="maps"></a>

The following sources provide maps showing locations of avian influenza outbreaks:

Timelines<a name="timelines"></a>

The <a href="http://www.who.int/csr/disease/avian_influenza/Timeline_28_10a.pdf">WHO website</a> contains a timeline of the emergence of H5N1. <a href="http://www.nature.com/nature/focus/avianflu/timeline.html">Nature magazine’s website</a> contains a more general timeline of influenza pandemics, starting with the first recorded influenza pandemic in recent history in 1890.

How many people have been infected so far?<a name="howmany"></a>

The WHO’s Regional Office for the Western Pacific has compiled a series of <a href="http://www.wpro.who.int/sites/csr/data/graphs1.htm">graphs of human cases of avian influenza</a>: including by onset date and country, by age group and country, by outcome and date of symptoms onset, and by outcome and age group.

The website of the <a href="http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/case-count/avflucount.html">Centre for Infectious Disease Research and Policy</a> at the University of Minnesota contains a table showing all laboratory-confirmed human cases of H5N1 avian influenza since December 2003 (updated regularly).

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<a name="_Australian_preparations_for"></a>Australian preparations for a flu pandemic<a name="australianpreparations"></a>

In June 2005 the Federal Government released the <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pandemic-plan.htm">Australian Management Plan for Pandemic Influenza</a>, which provides information on national plans in place for an Australian response to an influenza pandemic should an outbreak occur. The Plan includes:

The Management Plan is currently being revised, with a view to finalising the next version of the Plan by the end of 2005.

A key component of Australia’s preparation for a possible pandemic outbreak is the <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-bio-factsht_stckpile.htm">stockpiling of essential medicines,</a> including anti-viral drugs. The use of anti-viral drugs (and vaccines) in a pandemic response are discussed further below under <a href="#_Treatment_and_prevention">‘Treatment and Prevention’</a>.  

The Department of Health and Ageing’s website also includes information for <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pubhlth-pandemic-gp.htm">medical practitioners</a> and <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/pubhlth-pandemic-healthcare.htm">health care workers</a> on preparing for an influenza pandemic.

The <a href="http://www.affa.gov.au/content/output.cfm?ObjectID=293EBA9F-3684-4F01-B848A1EAC9B1D0D9&contType=outputs">Department of Agriculture, Fisheries and Forestry website</a> also includes information on Australia’s preparations for responding to an outbreak of avian influenza in the animal population, including <a href="http://www.animalhealthaustralia.com.au/aahc/index.cfm?E9711767-B85D-D391-45FC-CDBC07BD1CD4">AUSVETPLAN—the Australian Veterinary Emergency Plan</a>.

The Australian Quarantine and Inspection Service (<a href="http://www.daff.gov.au/content/output.cfm?ObjectID=3E48F86-AA1A-11A1-B6300060B0AA00014">AQIS</a>) has an <a href="http://www.affa.gov.au/corporate_docs/publications/pdf/animalplanthealth/avian_influenza_paper.pdf">Avian influenza plan</a> and is already implementing border protection measures including screening all flights, passengers and baggage from high-risk countries.

A national exercise to test the preparedness of Australia’s health and emergency response systems for an outbreak of avian influenza, <a href="http://www.maff.gov.au/releases/05/05159wtj.html">Exercise Eleusis</a>, will be held on 29 November–1 December 2005.

Recent statements by the Health Minister and the Chief Medical Officer <a name="recentstatements"></a>

The following links are to major statements made recently by the Health Minister, Tony Abbott, and the Chief Medical Officer, Professor John Horvarth on avian influenza:

For more statements by Mr Abbott and Professor Horvarth see the <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-health-emergency-media.htm#avian">Department of Health and Ageing’s website</a>.

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<a name="_The_international_response"></a>The international response<a name="theinternational"></a>

The WHO continually monitors infectious diseases around the world, including the evolving avian influenza situation. For example, the WHO’s <a href="http://www.who.int/csr/disease/influenza/en/index.html">Global Influenza Programme</a> closely monitors influenza developments all over the world. 

In 2000 the WHO established the <a href="http://www.who.int/csr/outbreaknetwork/en/">Global Outbreak Alert and Response Network</a>—a collaboration of institutions and networks who pool human and technical resources for ‘the rapid identification, confirmation and response to outbreaks of international importance’. The Network provides an ‘operational framework to link this expertise and skill to keep the international community constantly alert to the threat of outbreaks and ready to respond’. The WHO, through the Network, would play a major role in coordinating the international response in the event of an outbreak of pandemic influenza.

There have been a series of major international meetings on avian influenza recently:

  • on 25 October 2005 an international meeting of health ministers was held in Ottawa, Canada, to discusses global influenza pandemic preparedness. The key principles and recommendations agreed to at the meeting are included in the <a href="http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/2005/2005_fin_e.html">official communiqué</a>. The meeting was attended by the Health Minister Tony Abbott, who gave a <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2005-ta-abb251005a.htm">country report </a>on Australia’s preparedness
  • on 31 October–1 November 2005 <a href="http://www.dfat.gov.au/apec/fs1.html">a high level meeting</a> of principal pandemic/disaster management coordinators from the 21 Asia-Pacific Economic Cooperation (APEC) countries was held in Brisbane. The meeting was aimed at identifying ways APEC countries might further cooperate in responding to a pandemic outbreak. (No communiqué was made available from this meeting)
  • on 7–9 November 2005 a meeting entitled <a href="http://www.who.int/mediacentre/events/advisories/2005/ma28/en/index.html">‘The H5N1 Agenda: Towards a global strategy’</a> will be held at WHO headquarters in Geneva. The meeting will aim to put together a comprehensive assessment of the global challenge presented by the threat of avian influenza, and identify the next steps in controlling current avian influenza outbreaks in animals and preparing for a human influenza pandemic. (Communiqué to be added as soon as it is available.)

<a name="_Australian_assistance_in"></a>Australian assistance to the Asia-Pacific region<a name="australianassistance"></a>

The issue of avian influenza was also discussed at the <a href="http://www.scoop.co.nz/stories/WO0510/S00396.htm">Pacific Nations Forum</a> held in Papua New Guinea in October 2005. Prime Minister John Howard <a href="http://www.pm.gov.au/news/media_Releases/media_Release1657.html">announced</a> at the Forum that Australia would contribute $8 million to strengthen regional and national capacity to respond effectively to avian influenza and other infectious diseases.

In September 2005 the Federal Government announced an <a href="http://www.ausaid.gov.au/media/release.cfm?BC=Media&ID=1604_6389_233_4094_4794">avian influenza assistance package for Indonesia</a>, including the provision of 50 000 courses of Tamiflu to help combat the recent outbreak of avian influenza in Indonesia.

In June 2005 the government announced a <a href="http://www.ausaid.gov.au/media/release.cfm?BC=Media&Id=2681_1882_1465_5412_3249">$6 million package of measures</a> to help combat avian influenza in South-East Asia, focusing in particular on assisting Indonesia, Vietnam, and China with influenza surveillance, emergency preparedness and response capabilities.

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<a name="_Treatment_and_prevention"></a>Prevention and treatment <a name="preventionand"></a>

Anti-viral drugs<a name="antiviral"></a>

Currently, there are two anti-viral drugs which can be used as protection against disease caused by avian influenza (that is, as prophylactic, or preventative medicine), and in the treatment of symptoms of flu victims: these are <a href="http://www.fda.gov/cder/drug/infopage/tamiflu/default.htm">oseltamivir</a> (sold as Tamiflu), manufactured by Swiss pharmaceutical company Roche, and <a href="http://www.fda.gov/cder/news/relenza/default.htm">zanamivir</a> (sold as Relenza), developed by Australian biotechnology company Biota and manufactured by Britain-based pharmaceutical company GlaxoSmithKline.

In Australia, Tamiflu and Relenza are available as prescription-only medicines. The recommended retail price for one ten-dose course of Tamiflu is $49.20. The recommended retailed price for one four-dose course of Relenza is $49.95.(8)

The National Medicines Stockpile<a name="thenational"></a>

As part of its preparations for an avian influenza pandemic, in 2004–05 the Federal Government allocated $123.8 million to <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-bio-factsht_stckpile.htm">stockpiling</a> anti-viral drugs for use in the event of a pandemic influenza outbreak. Australia’s stockpile contains enough anti-viral doses for about 20 per cent of the population—this is one of the biggest per capita stockpiles in the world.(9) According to <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2005-ta-abbsp020505.htm">Health Minister Tony Abbott</a>, ‘with current technology and manufacturing processes’, obtaining enough anti-virals to protect the entire Australian population for six months (the anticipated time it would take to develop a vaccine—see <a href="#_Vaccines">below</a>) would be ‘almost impossible at any price’.

According to the <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pandemic-plan.htm">Australian Management Plan for Pandemic Influenza</a>, in the event of a pandemic outbreak, 10 per cent of the anti-viral stockpile will be earmarked for treatment of people with flu symptoms, and 90 per cent would be reserved for prophylaxis (preventative treatment). According to Health Minister Tony Abbott, the current supply of anti-viral drugs in Australia’s <a href="http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-bio-factsht_stckpile.htm">National Medicines Stockpile</a> would be sufficient to protect 1 million essential service workers for about six weeks. The Chief Medical Officer, in consultation with the Australian Health Disaster Management Policy Committee (AHDMPC), would advise government on when and to whom anti-virals should be released.(10)

Generic anti-virals?<a name="genericanti"></a>

There is currently a worldwide shortage of anti-viral drugs. Global supply of both Tamiflu and Relenza is controlled by the patent owners, Roche and GlaxoSmithKline, which limits overall manufacturing capacity and therefore overall supply.(11)

In October 2005, however, <a href="http://www.newscientist.com/channel/health/mg18825224.100">New Scientist magazine</a> reported that the Indian company Cipla will begin making a generic version of Tamiflu, and that Roche, who had previously opposed any moves to manufacture generic Tamiflu, has decided that ‘it would not oppose companies that want to strike a licensing deal’.

There has recently been some debate in Australia about the manufacture of generic versions of anti-viral drugs. In an article published in the <a href="http://mja.com.au/public/issues/183_11_051205/lok10852_fm.html">Medical Journal of Australia</a> in October 2005, Australian National University academics Buddhima Lokuge, Peter Drahos and Warwick Neville urged the Australian Government to consider enacting compulsory licensing provisions to allow generic manufacturers to start producing anti-virals locally, or to import them from generic manufacturers overseas.

<a name="_Vaccines"></a>Vaccines<a name="vaccines"></a>

The most effective defence against influenza is vaccination. However, most experts agree that in the event of a pandemic of a new strain of highly pathogenic influenza, it would probably take scientists at least six months to develop and produce a vaccine.

The Federal Government has entered into contracts with the Australian company <a href="http://www.csl.com.au/">CSL Ltd</a> and <a href="http://www.sanofipasteur.com.au/avpi-australia/front/templates/vaccinations-travel-health-vaccine-aventis-pasteur.jsp?codeRubrique=60&lang=EN">Sanofi Pasteur</a> (which has a Sydney-based Australian operation) for vaccine supply in the event of a pandemic. In July, the government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2005-ta-abb089.htm">announced</a> that it would provide CSL Ltd with $5 million to fast-track the development of a pandemic influenza vaccine in Australia.

<a href="http://www.mcri.edu.au/Downloads/Media_Releases/BirdFluTrials_4-Oct-2005.pdf">Clinical trials</a> of a bird flu vaccine being conducted by the Murdoch Children’s Research Institute and the University of Melbourne (and sponsored by CSL Ltd) commenced in Melbourne and Adelaide in early October 2005.

<a name="sideeffects"></a>Vaccination side-effects

Influenza vaccination does carry a small risk of side effects. For example, according to the <a href="http://www1.health.gov.au/immhandbook/">Australian Immunisation Handbook</a>, fever, malaise and myalgia occur commonly after vaccination. The Immunisation Handbook also notes that an association between an influenza vaccine used in the Northern hemisphere from 1992–94 and Guillain-Barré syndrome (GBS), a rare neurological condition, has been shown, with one to two cases of the syndrome occurring per million people vaccinated. However, according to the US <a href="http://www.cdc.gov/nip/vacsafe/concerns/GBS/3">Centers for Disease Control and Prevention</a>, reports of GBS after the administration of flu vaccines are extremely rare. In most cases where GBS developed after an immunisation, proof that the vaccine caused GBS has not been established.

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<a name="_Australian_research_on"></a>Australian research on avian influenza <a name="australianresearch"></a>

On 28 September 2005, the Federal Government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2005-ta-abb117.htm">announced</a> that funding for research into pandemic influenza would be fast-tracked by the National Health and Medical Research Council (which oversees the administration of funding for health and medical research).

There are several highly regarded institutions conducting influenza research in Australia, including:

See the following articles discussing research into influenza currently being conducted in Australia:

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Commentary <a name="commentary"></a>

The threat posed to Australia by an outbreak of pandemic influenza and the adequacy of Australia’s preparedness have been the subject of much public debate over recent months. The following is a brief selection of opinion pieces, articles and other commentary on some of the key issues.

The adequacy of Australia’s preparedness for an influenza pandemic has been the subject of debate. For example:

  • in October 2005 the Australian Labor Party released a detailed critique of Australia’s pandemic management plan (Julia Gillard, Shadow Minister for Health, <a href="http://parlinfoweb.parl.net/parlinfo/Repository1/Media/pressrel/GWFH63.pdf">‘Preparedness of the Australian Health Care System for an Avian Flu Pandemic: No room for complacency’</a>, September 2005)
  • flu experts such as researcher Professor Graeme Laver have also argued that Australia’s plans for responding to a pandemic are flawed. Professor Laver argues, for instance, that the government should allow Tamiflu to be sold over the counter to make it more widely available to the general public (see, for instance, <a href="http://parlinfoweb.parl.net/parlinfo/Repository1/Library/Jrnart/SL1H61.pdf">‘Avian flu: are we prepared?’</a>, Australian Science Magazine, vol. 26, no. 6, July 2005)
  • Professor Peter Curson, Director of Health Studies at Macquarie University, has argued that Australia needs to be better prepared for the public fear and panic that could occur in the event of a pandemic outbreak (Peter Curson, <a href="http://parlinfoweb.parl.net/parlinfo/Repository1/Media/npaper_5/YBCH60.pdf">‘Pandemic threat demands the truth: there is something to be afraid of’</a>, Sydney Morning Herald, 20 September 2005), and
  • on the other hand, some commentators such as WHO flu researcher Ian Barr have argued that the threat of an avian flu pandemic in Australia has been greatly over-stated (see Lisa Macnamara, <a href="http://parlinfoweb.parl.net/parlinfo/Repository1/Media/npaper_0/08OH60.pdf">‘Bird flu risk here “almost non-existent”’</a>, The Australian, 22 October 2005).

As mentioned above under the <a href="#_Treatment_and_prevention">prevention and treatment</a> heading, there has been some discussion about the potential for manufacturing generic anti-viral drugs. See:

The likely economic fallout from a flu pandemic has also been the subject of some discussion. See:

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Parliamentary Library publications<a name="parliamentarylibrary"></a>

The Parliamentary Library has produced the following publications related to the threat of pandemic influenza:

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