The Fatal Strain

(Nov. 15, 2002): 77, 381-88.

18 At Imperial College London: Neil M. Ferguson et al., “Strategies for Containing an Emerging Influenza Epidemic in Southeast Asia,” Nature 437 (Sept. 8, 2005): 209- 14.

18 A separate team: Ira M. Longini Jr. et al., “Containing Pandemic Influenza at the Source,” Science 309, no. 5737 (Aug. 12, 2005): 1083-87.

19 “No attempt has ever been made”: “WHO Activities in Avian Influenza and Pandemic Influenza Activities, WHO, Jan.-Dec. 2006, 16. The approach was quickly embodied in WHO planning. See “WHO Pandemic Influenza Draft Protocol for Rapid Response and Containment,” updated draft, WHO, May 30, 2006.

19 WHO’s emergency containment plan: The strategy is described in the finalized WHO protocol. See WHO, “WHO Interim Protocol: Rapid Operations to Contain the Initial Emergence of Pandemic Influenza,” updated Oct. 2007.

20 “It will require excellent surveillance”: WHO, “WHO Activities in Avian Influenza and Pandemic Influenza Activities: January-December 2006,” p. 16.

25 by the time Puji was buried: A local account of the cases and grassroots response is “Report Regarding Bird Flu Disease in Karo Regency, from the Karo Regent Daulat Daniel Sinulingga to the Governor of North Sumatra in Medan, Kabanjahe,” May 31, 2006.

28 According to Batak lore: Interview with Juara Ginting, an anthropologist who grew up in Karo district and studied Batak belief and superstition at North Sumatra University before pursuing a master’s degree at Leiden University in the Netherlands.

29 beheaded a chicken: Margie Mason, “Officials Backtrack Bird Flu Cluster,” Associated Press, May 26, 2005.

29 scores of poultry traders: Jason Gale and Karima Anjani, “Indonesian Bird-Flu Victim Sought Witchdoctor, Shunned Hospital,” Bloomberg, May 26, 2005.

29 “significantly delayed”: WHO, “Avian Influenza Cluster, Karo, North Sumatra, May 2006, WHO Interim Report.”

30 “universally refused”: Ibid.

38 senior Indonesian officials: See, for instance, Health Minister Siti Fadilah Supari, quoted in Tubagus Arie Rukmantara, “Awareness and Prevention Key in Bird Flu Fight,” Jakarta Post, July 28, 2006.

38 “From the lessening of the tension”: Siti Fadilah Supari, It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza (Jakarta: Sulaksana Watinsa Indonesia, 2008), 23.

38 Supari would continue: See, for example, “Minister Denies Bird Flu in RI Spreading by Human-to-Human Transmission,” Antara news agency, Sept. 3, 2007.

38 were quickly convinced: Georg Petersen, “Investigative Report of a Cluster of Human Avian Influenza Cases, North Sumatra, May 2006,” WHO.

39 “If he turns out to be positive”: Internal WHO communication from Jakarta, May 21, 2006.

39 “In response to the possibility”: Ibid.

40 tested positive for the virus: The specimens collected by Uyeki and his colleagues later showed that the virus had been aggressively mutating as it moved from son to father. See, for example, Santoso Soroeso, “Epidemiology and Clinical Features of Avian Influenza in Indonesia, Questions and Lessons Learnt,” presented at Australia-Indonesia Symposium in Science and Technology 2006, Sept. 13-14, 2006, Jakarta; and also Declan Butler, “Family Tragedy Spotlights Flu Mutations,” Nature 442 (July 13, 2006): 114-15. Initial analysis of the specimens at Hong Kong University also showed that Dowes’s sample had the same signature mutation as the sample from his son. This seemed to be further evidence that Dowes caught the virus from his son, marking the third generation of transmission. This finding was reported at the time by several media and cited by U.S. Secretary of Health and Human Services Michael O. Leavitt. See, for example, Department of Health and Human Services, Pandemic Planning Update II, a report from Secretary Michael O. Leavitt, June 29, 2006. But researchers familiar with the results later said the initial findings regarding a signature mutation were not as conclusive as at first thought. The case for third-generation spread still rests on the case histories of the Ginting family members and the timing of their illnesses.

42 also onto a third: Politics long prevented researchers from publishing their analysis of human-to-human-to-human spread in the Sumatra cluster. But half a year later, another instance of third-generation transmission was confirmed in Pakistan and later described in a publication. See: “Human Cases of Avian influenza A (H5N1) in North-West Frontier Province, Pakistan, October-November 2007,” Weekly Epidemiological Record, no. 40 (October 3, 2008): 359-64.

Chapter Two: A Visitation from Outer Space

This chapter draws on interviews with current and former public health, infectious-disease, and laboratory specialists at the Hong Kong Department of Health and the CDC, as well as animal health researchers in Hong Kong and the United States.

45 a three-year-old boy: The case is described in J. C. de Jong et al., “A Pandemic Warning?” Nature 389, no. 6651 (Oct. 9, 1997): 554; and in Kanta Subbarao et al., “Characterization of an Avian Influenza A (H5N1) Virus Isolated from a Child with a Fatal Respiratory Disease,” Science 279, no. 5349 (Jan. 16, 1998): 393-96.

48 far more than a runny nose and chills: A thorough overview of the clinical spectrum is provided in J. S. Malik Peiris, Menno D. de Jong, and Yi Guan, “Avian Influenza Virus (H5N1): A Threat to Human Health,” Clinical Microbiology Review 20, no. 2 (Apr. 2007): 243-67; and in K. Y. Yuen and S. S. Y. Wong, “Human Infection by Avian Influenza A H5N1,” Hong Kong Medical Journal 11, no. 3 (June 2005): 189-99. WHO has described the symptoms and clinical course of the disease in reports by the agency’s writing committee. See 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. The cases in individual countries have also been surveyed and described. See, for example, Hongjie Yu et al., “Clinical Characteristics of 26 Human Cases of Highly Pathogenic Avian Influenza A (H5N1) Virus Infection in China,” PLoS One 3, no. 8 (Aug. 21, 2008): e2985; and Sardikin Giriputro et al., “Clinical and Epidemiological Features of Patients with Confirmed Avian Influenza Presenting to Sulianti Saroso Infectious Diseases Hospital, 2005- 2007,” Annals of the Academy of Medicine (Singapore) 37 (2008): 454-57.

49 a counterattack so furious: This aggressive response has been much discussed. The following is a sampling of the research: M. C. W. Chan et al., “Proinflammatory Cytokine Responses Induced by Influenza A (H5N1) Viruses in Primary Human Alveolar and Bronchial Epithelial Cells,” Respiratory Research 6 (Nov. 11, 2005): 135; C. Y. Cheung et al., “Induction of Proinflammatory Cytokines in Human Macrophages by Influenza A (H5N1) Viruses: A Mechanism for the Unusual Severity of Human Disease?” Lancet 360, no. 9348 (Dec. 7, 2002): 1831-37; Menno D. de Jong et al., “Fatal Outcome of Human Influenza A (H5N1) Is Associated with High Viral Load and Hypercytokinemia,” Nature Medicine 12, no. 10 (Oct. 2006): 1203-07; J. S. Malik Peiris et al., “Re-emergence of Fatal Human Influenza A Subtype H5N1 Disease,” Lancet 363, no. 9409 (Feb. 21, 2004): 617-19; Ka- Fai To et al., “Pathology of Fatal Human Infection Associated with Avian Influenza A H5N1 Virus,” Journal of Medical Virology 63 (2001): 242-46; and Jianfang Zhou et al., “Differential Expression of Chemokines and Their Receptors in Adult and Neonatal Macrophages Infected with Human or Avian Influenza Viruses,” Journal of Infectious Diseases 194 (2006): 61-70.

50 inviting a suicidal counterattack: There has been debate about whether the immune response or the virus itself is more directly responsible for death. See, for instance, Kristy J. Szretter et al., “Role of