11/28 | H5N1 _ Doctors Could Abandon Their Flu Patients

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<B><center>Professors sound-off on bird flu

<font size=+1 color=red>Possible pandemic has scientists, health officials, politicians scrambling for a plan</font>
By: Melissa Patterson
Issue date: 11/28/05 Section: News
<A href="http://media.www.ucfnews.com/media/paper174/news/2005/11/28/News/Professors.SoundOff.On.Bird.Flu-1113965.shtml?sourcedomain=www.ucfnews.com&MIIHost=media.collegepublisher.com">Central Florida Future</A></center>

Though it has recently received more attention, the bird flu isn't new. There are more than a dozen strains of avian influenza that frequently sicken birds around the globe. They do not, however, frequently spread to humans and kill them within days.</b>

The current threat is known as H5N1, a highly contagious and rapidly fatal strain of the bird flu. Once contracted, rapid deterioration of the lungs is common, with pneumonia and multi-organ failure usually following. The World Health Organization attributes nearly 70 deaths to H5N1, and, based on the current mortality rate, almost half of everyone infected will die.

In the case of a pandemic, WHO gives a conservative estimate of 7.4 million deaths, but it warns the toll could be much higher. Many wonder: if the avian flu has always been such a common bird illness, why are people suddenly becoming infected?

The avian flu is an RNA virus, much like AIDS, which means it is prone to frequent and rapid mutations, according to Debopam Chakrabarti, assistant professor of molecular and microbiology at UCF. After innumerable useless copies, the virus randomly replicated itself into a version humans are susceptible to.

This is the version that has infected about 130 people, according to WHO - but it's not the one scientists are dreading.

Now that H5N1 has mutated into a form humans are susceptible to, the next step toward a pandemic would be the last step: to have a person already infected with the human flu also contract the bird flu. In a process known as "reassortment," the two viruses would recombine inside the victim's body, producing a deadly hybrid.

This highly fatal hybrid virus, easily passed between humans, would be the harbinger of chaos so many fear. Governments around the globe, including the U.S., have already begun manufacturing vaccines against the current bird flu strain, but some say it's too little, too late.

"I don't think world leaders are doing enough," Annette Khaled, assistant professor of the Biomolecular Science Center at UCF, said. "It takes time for these things to develop, and you have to invest in research. You can't just do things quickly."

President George W. Bush outlined a $7.1 billion strategy Nov. 1 to prepare for the danger of a pandemic, hoping to stockpile enough vaccine to protect 20 million Americans against the current strain of bird flu. But because of the high frequency of mutation, many scientists call this a futile venture and a waste of money.

"Viral vaccinations generally work well as long as the parent virus strain has not mutated," Alexander Cole, assistant professor of molecular and microbiology at UCF, said. However, "Once the virus mutates to the point that the protective antibodies can no longer recognize the virus, the vaccine is no longer effective."

But it's not all bad news. Antiviral drugs like Tamiflu and Relenza are being used as damage control in humans infected with the virus, and in many cases have proved effective. They wouldn't treat the pandemic form of the virus, scientists warn, but they could prove useful in preventing the "reassortment" process that would lead to the pandemic.

Nations and private buyers are rushing to stockpile Tamiflu, seen as the superior antiviral by many, but there is simply not enough to go around. Tamiflu's exclusive manufacturer is already battling a backlog of orders due to the drug's lengthy manufacturing process. At present capacity, it would take 10 years to produce enough for 20 percent of the world's population. Also, is should be emphasized that there is currently no form of the avian flu that is easily transmissible from human to human.

Meanwhile, two of the countries hardest hit by the bird flu, China and Vietnam, took extreme measures to fight the disease on Nov. 15. China promised to vaccinate its entire poultry stock of 14 billion birds, paying all fees involved. Vietnamese officials ordered farmers in its two largest cities to kill or sell all poultry by today.

That may take care of poultry's threat, but it doesn't protect against wild waterfowl, where H5N1 is thought to have originated. WHO believes the spring 2005 die-off of 6,000 migratory birds in Central China may be a signal that the virus is becoming more deadly.

Chakrabarti fears that birds may not be the only threat. There is a possibility that other animals, not just birds, are already silent carriers of the avian influenza, he said.

"I think this virus is showing a little broader host range than the earlier forms," Chakrabarti said. "Some of the disease could be asymptomatic; maybe other animals are getting it [and not showing symptoms]. Then they could pass it through their fecal matter and spread it all over."

There have been several publicized cases of avian flu-related death that could support Chakrabarti's theory. The most recent one involved two Indonesian women this month who died after having no known contact with flu-infected birds, according to a doctor who treated one of the patients.

WHO still maintains that, "though rare, instances of limited human-to-human transmission of H5N1 … have occurred in association with outbreaks in poultry and should not be a cause for alarm. In no instance has the virus spread beyond a first generation of close contacts or caused illness in the general community."

At a Nov. 7-9 meeting in Geneva at WHO headquarters, more than 600 delegates from over 100 countries laid the foundation for worldwide cooperation against the virus. In his conclusion, WHO director-general Lee Jong-wook said, "We have plans on paper, but we must now test them. Once a pandemic virus appears, it will be too late."

Many of those plans include faster and less-expensive vaccine methods. Bush's administration plan, for example, stresses the cell culture method: growing the virus in easy-to-handle cell cultures instead of the current, cumbersome process requiring millions of chicken eggs.

Cell culture vaccines aren't the only contender, as scientists from around the world announce new methods each week. Russia announced Nov. 15, in collaboration with Vietnam, that it could release a new vaccine involving mutations of the virus's cloned DNA by February.

Whatever the method, many scientists agree that it's important to keep researching new possibilities, since chicken eggs might become scarce if many countries are forced to slaughter their poultry populations.

"As the current methods of generating vaccines are laborious, and output is not sufficient for global immunization, it would be prudent to continue our search for alternative vaccine sources and methodologies," Cole said.

Other scientists, including Khaled, are stressing funding for a broader range of research.

"We need to invest a lot more in basic science research," Khaled said. "A lot of research dollars are going into specific diseases … and not enough money is being spent on the basic workings of the human body." She added that this won't immediately yield a cure, "but it will give us more information about how our immune system works."

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<B><center><font size=+1 color=brown>Govt confirms new human bird flu case in Bandung </font>

By Arie Rukmantara
<A href="http://www.asianewsnet.net/level3_template1.php?l3sec=15&news_id=48923">The Jakarta Post</a>
Publication Date : 2005-11-28</center>

A 16-year-old boy has been confirmed as the country's 12th human bird flu case, as the government said Indonesia was ready to start producing the antiviral drug Tamiflu within three to five months to help fight the disease.</b>

Health ministry official Hariadi Wibisono was quoted by AFP as saying that the condition of the boy, who was admitted to the state hospital in West Java's provincial capital Bandung on Nov. 15, was good but he was infected.

"Tests (on blood) taken from the 16-year-old boy, both locally and by the World Health Organisation (WHO), show that he is a bird flu patient," he said.

"We have received news that his condition is quite good and it is hoped that he can survive," he added.

Seven fatalities from the H5N1 strain of avian influenza have been confirmed in Indonesia by the WHO, but more than a dozen suspected bird flu deaths have been reported.

Health officials are waiting for WHO confirmation of local tests which showed that a 35-year-old man who died Nov 19 was the country's eighth fatality.

Four other Indonesians have been confirmed as carrying the virus but have either recovered or are still receiving treatment.

Meanwhile, health minister Siti Fadilah Supari said on Saturday (Nov 26) that the mass production of Tamiflu in the country would start in three to five months.

The minister said the government would appoint state-owned pharmaceutical companies to make Tamiflu under the generic name oseltamivir phosphate.

"It could be Kimia Farma or Indofarma," she said.

Siti said Indonesia had obtained permission from the distributor of Tamiflu, Swiss pharmaceutical giant Roche AG, which holds the patent for production, to produce the drug only for the domestic market.

The government will produce about 20 million Tamiflu tablets, she added. "The drug will only be produced according to our needs or a minimum of 10 per cent of the country's population (of around 220 million people)."

"At present, we have 800,000 tablets provided by donor countries such as Australia, Japan and Singapore," Siti said.

Siti said her office had discussed with India, China and South Korea the possible provision of raw materials for Tamiflu production here.

"We'll get confirmation from them within two days," she added.

The money to produce the drug would be allocated from the 2006 state budget, as well as coming from donor countries, the minister said.

"It's a testament of our seriousness in fighting bird flu. We do not want Indonesia to become the world's source of bird flu," Siti said.

Kimia Farma president director Gunawan Pranoto said his company was ready to produce Tamiflu, should it be appointed by the government.

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<B><font size=+1 color=green><center>Livelihood of millions of Chinese farmers at stake from bird flu </font>

28 November 2005 1043 hrs
<A href="http://www.channelnewsasia.com/stories/afp_asiapacific/view/180808/1/.html">Channelnewsasia.com</A></center>

HEISHAN COUNTY, China : Feng Xiao's simple brick henhouse stands empty except for stacks of unused cages. An outbreak of bird flu has wiped out his flock and those of other farmers across this entire county in north China. </b>

There's little the 40-year-old farmer and others like him in many parts of China can do. Their livelihood is ruined indefinitely.

"I hope to get back into raising chickens immediately after the outbreak is cleared," says Feng. "In this area, we depend on poultry raising for 100 percent of our income."

With insufficient land to earn a good living from growing crops, farmers throughout China raise poultry to feed their families and supplement their income.

For counties such as Heishan, where 90 percent of the farmers raise poultry, when the disease strikes the entire community is devastated.

Even farmers living in areas not yet hit by bird flu are affected, with poultry in nearby areas also having to be culled.

The government has culled at least 21.1 million poultry amid 27 reported bird flu outbreaks across China this year.

China this month confirmed its first three human cases of bird flu, including two who died. The disease has killed more than 60 people in Southeast Asia since 2003.

Although many countries are battling bird flu, China -- the world's biggest poultry producer -- could suffer the biggest impact.

Although the value of poultry production amounts to only about two percent of annual GDP, the industry employs some 14 million farmers and workers.

The government has agreed to give farmers 10 yuan (1.23 dollars) for each grown bird culled and half that amount for chicks and ducklings. But 10 yuan is just half the cost of raising a chicken and does not cover the lost earnings from selling eggs.

Despite getting a lump sum of 38,000 yuan for his 3,800 poultry culled, Feng is still faced with a 20,000 yuan loss.

He says he, his wife and teenage son will need a government loan if they want to raise chickens again.

"When I found out my flock of chickens had bird flu, I felt terrible," Feng says. "We're just waiting for the government's help now."

Farmers in another village in Heishan county complain that it is unfair that the government has refused to compensate them for chickens that died before it confirmed bird flu outbreaks.

"They started culling in late September but a lot of chickens began dying in mid-September. The government at the time said it was not bird flu, but now everyone is saying the government was simply late in reporting the disease," says farmer Lu Hongjun.

"They should pay us for those chickens as well. There are families that lost so much money."

Experts say countries must compensate fairly to encourage farmers to report diseased birds, and also think of a longer term solution.

"Often it's a livelihood. It means that they will lose a livelihood for a considerable amount of time," says Henk Bekedam, the World Health Organization's China representative.

"Normally before people can do some restocking, it takes two months and farmers might be out of business for three months.

"So we should also look not only at the replacement value of the ducks and chickens that have been killed or culled, but we also have to think of the business for the two or three months that they are losing."

A longer-term issue is the need to overhaul China's poultry farming practices, which even Chinese officials admit are backward.

Most of the poultry are raised in farmers' backyards. Many are mixed with livestock and the chickens and ducks run around inside farmers' homes.

The mixed raising of animals and close proximity between animals and humans could give the avian influenza virus an opportunity to mutate into a form that is more virulent and transmittable between humans -- potentially causing a pandemic that could kill millions of people.

"The government will have to gradually standardize poultry raising such as by building bigger, better, isolated facilities," says Fu Jingwu, deputy director of the Liaoning province animal health inspection and management bureau.

This could mean raising poultry in modern buildings constructed to keep out migratory birds, blamed for spreading the virus. However farmers lack the money to do this.

"Some people will have to switch to other occupations," Fu says.

This will not be easy. If farmers want to raise pigs, for example, they will need several thousand yuan -- a substantial amount for them -- to buy piglets and food to feed them.

Farmers who spoke to AFP anxiously awaited word on when they could raise poultry again. Some, like Lu, fear they won't be able to pay their children's school tuition if the epidemic drags on.

"For now, we can survive. In the long term, we don't know," says Lu.

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<B><font size=+1 color=blue><center>Vietnam City Poisons Pigeons to Prevent Bird Flu </font>

VIETNAM: November 28, 2005
<A href="http://www.planetark.com/dailynewsstory.cfm/newsid/33673/story.htm">www.planetark.com</a></center>

HANOI - Vietnam's commercial hub Ho Chi Minh City has begun poisoning pigeons and other wild birds as it moves to prevent avian flu from spreading into the crowded city, an official said on Friday.</b>

The H5N1 bird flu virus has flared in 19 of the country's 64 provinces, the most recent cases being in the northern provinces of Quang Ninh and Nghe An, the Agriculture Ministry said in a report on Friday.
The World Health Organisation (WHO) said another human case was confirmed in the northern Hai Phong province. The infected 15-year-old boy had recovered and been discharged from hospital, the WHO said in a statement from its headquarters in Geneva.

The H5N1 virus has killed 68 people in Asia, including 42 in Vietnam, since late 2003. Experts fear the virus could mutate into a form that passes easily among people, triggering a global pandemic of killer flu.

The virus has this week also surfaced in the south where Ho Chi Minh City, a centre of 10 million people, is located.

"We will make sure that no birds are left in the city to minimize the risk of bird flu," Huynh Huu Loi, Director of Ho Chi Minh City's Animal Health Department, told Reuters.

Some international experts have said that pigeons appear to be resistant to the deadly H5N1 virus, but the city authorities are taking no chances.

Loi said beside the poisoning campaign, authorities would also move pet birds outside the city until Vietnam is free of bird flu.

The southern city, the country's largest, has banned poultry farming even though it has had no human cases since December 2004.

Most of the outbreaks in recent weeks have been in the cooler north. But the virus has spread to the south with the province of Long An reporting its first flu outbreak in poultry this week.

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<B><font size=+1 color=purple><center>Doctors 'could abandon flu victims'</font>

00:24am 28th November 2005
<A href="http://www.dailymail.co.uk/pages/live/articles/health/thehealthnews.html?in_article_id=369893&in_page_id=1797&in_a_source=">dailymail.com.co.uk</a></center>
Concerns that health workers could abandon their posts in the face of a flu pandemic, leading to a shortage of staff to care for the sick, have been raised by experts. </b>
Governments and planners around the world need to prepare for the impact of a flu pandemic on staffing levels and other issues of ethical importance, a report warned.

It follows the predictions of doctors that a flu pandemic is inevitable, although it is not possible to say when it will strike or where it will start.

The latest report, by the Influenza Pandemic Working Group at the University of Toronto, looks at the ethical issues that need to be considered in advance of a widespread flu outbreak.

The four key issues of ethical importance outlined by the experts include the duty of health workers to provide care during an outbreak, and restricting liberty in the interest of public health, such as quarantines.

Their report also outlines how ethical considerations impact on decisions over the allocation of scarce resources, such as medicines, and implementing travel bans to slow the spread of flu.

The experts based their predictions in part on the experience during the outbreak of severe acute respiratory syndrome (Sars) in 2003, which affected nations including Canada. They said that during the Sars crisis, some medical workers were afraid they would be infected while caring for patients, and would infect their families and friends.

During Sars, a large number of health workers were infected because of their work and some died. Others were dismissed for failing to report for duty.

The experts said that workers generally showed heroism and altruism in the face of danger during Sars, but some "balked" at caring for those who were infected. Afterwards, many raised concerns about the level of protection to themselves and their families, with some even leaving the professions.

The experts said a flu pandemic would put far greater pressures on health services around the world and that ethical codes should be produced to provide guidance on issues such as professional rights and responsibilities.

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<B><center>Sunday, Nov 27, 2005
<A href="http://www.mytelus.com/news/article.do?pageID=ontario_home&articleID=2102999">www.mytelus.com</a>

<font size=+1 color=red>Public debate needed on ethics behind tough choices a pandemic would force </font></center>

TORONTO (CP) - It's time to engage the public in open and frank debate over the excruciating choices a flu pandemic could force governments and health-care delivery systems the world over to have to make, a new report suggests.</b>

Governments need to throw open discussions already well underway to determine who gets first crack at eventual vaccine and who won't get limited antiviral drugs, so the public can be assured those decisions are being based on an ethical foundation that reflects shared values, the authors suggest.

Such deliberations should address what societies can reasonably ask of health-care workers, who could be risking their own lives during a pandemic, and what protections societies are willing to offer them in return, notes the report, written by ethicists from the University of Toronto's Joint Centre for Bioethics.

"The time to figure out what roles, responsibilities and expectations are going to be is now. Not when the emergency rooms are starting to fill up. Not when we're trying to deal with intense numbers of very sick individuals," one of the authors, Dr. Ross Upshur, said in an interview.

But one of Canada's leading infectious diseases experts warned it is easier to call for such deliberations than to actually have them.

Planners in the health-care arena shudder at the thought of having to decide what to do when they've run out of life-saving mechanical ventilators and a gravely ill 15-year-old comes through the emergency department door, Dr. Allison McGeer admitted.

Do they take the oldest person on a ventilator in the hospital off it? Do they call around to other hospitals to see if someone older still can be removed from a ventilator across town?

"I think, at least among health-care workers, to even have the discussion somehow creates a sense of playing God," she said.

"People know if they get in the situation where the decisions will have to be made, they'll have to be made. But to overtly have a discussion ahead of time about making them? . . . The general response up till now among health-care workers is that people really don't think they can do that."

She's not certain the public wants to contemplate the scenario underlying the tough choices either, noting a rising chorus of criticism that those warning of the dangers of a pandemic are being unduly frightening.

"It's hard to have these discussions without being scary," said McGeer, head of infection control at Toronto's Mount Sinai Hospital.

She pointed to the dilemma of deciding priority lists for pandemic flu vaccine - should adults go before children? - to illustrate her point.

"That's only an important question, really, if there is a risk of probably, realistically, death associated with making the wrong decisions. And in a fairly mild pandemic, that's not really on the table," explained McGeer.

"As soon as you start the process of 'If it's severe enough that we really need to have this discussion,' that's looking at a situation that none of us want to look at."

None of the 100-plus national pandemic plans that have been written to date have a dedicated section aimed at helping people make ethical decisions should an influenza pandemic trigger a public health crisis, noted Dr. Peter Singer, another of the authors.

"That's really sort of ironic because the ethical issues are . . . going to be the glue that holds a society together when it's struggling through a very, very tough time if the pandemic in fact is severe," said Singer, director of the bioethics centre.

The report lays out four key issues the authors think require an ethics-based debate: the duty of health-care workers; the use of liberty-restricting measures like quarantine; the implementation of international travel bans and the setting of priorities for rationing scarce medical resources such as antiviral drugs.

A senior official said the Public Health Agency of Canada wants to put out parts of the Canadian pandemic plan for public deliberation, including its policy on who should get drugs like Tamiflu and under what circumstances.

"We have to further refine that, but then state it in such a way that we can go out to Canadians and say: 'This is our position. What do you think of it?' " said Dr. Paul Gully, deputy chief public health officer.

"It is not good enough to have these (ethical) issues in the back of the mind. One actually has to demonstrate absolutely clearly that one had actually taken them into account."

The duty of health-care workers to provide care is a key area that needs clarification, according to the report, which raises a spectre few planners like to acknowledge but many fear - the prospect of some health-care workers refusing to work during a pandemic.

It happened during SARS, Upshur admitted. While many hospital workers performed heroically, some overtly refused to treat SARS patients or "distanced themselves from engagement."

"The distribution of risk was by no means equitable within health-care institutions," Upshur said. "And that's probably not the best way to think about how to staff an infectious disease emergency."

The report notes that after the devastating Spanish Flu pandemic of 1918-19, the Canadian Medical Association wrote into its code of ethics that "when pestilence prevails" doctors have a duty to "face the danger . . . even at the jeopardy of their own lives."

That code has since been rewritten. And there is a general lack of guidance from the organizations governing the medical professions as to how far the "duty of care" extends, the report warns.

It calls on these groups to spell out clearly what members's responsibilities would be in a major infectious disease outbreak. And it calls on governments to do as much as they can to protect health-care workers and to offer disability insurance and death benefits for those harmed or killed while performing their duty.

The authors acknowledge the discussions won't be easy and they won't make the news any less devastating at the individual level if, during a pandemic, a doctor informs a person his mother can't be put on a ventilator because someone else needs it more.

"It may not take the sting out of it. But where it might lead us to is a situation that people recognize that some of those really tough choices that we will be faced with are perhaps unfortunate, but not unfair," said Singer.

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<B><font size=+1 color=brown><center>Fatal H5N1 Case in Beijing?</font>

<A href="http://www.recombinomics.com/News/11270501/H5N1_Beijing.html">Recombinomics Commentary</a>
November 27, 2005</center>

It is reported this patient is a male, the about 35 years old, the family lives in the Beijing stability gate in the avenue side alley, is the Beijing local inhabitant. In this sickness others raises has the pigeon, is a pigeon amateur, has many years to raise the pigeon history.</b>

It is in 24th after the peaceful outside earth temple morning calisthenics suddenly faints the stable gate hospital which is escorted to by the periphery person approaches, in diagnoses is forced after the pneumonia by the hospital to shift to the Chinese and Japanese friendly hospital. Afterwards several will guard against the personnel once to have been to in the dead family to possess the pigeon to carry off and to carry on the strict disinfection, the personnel which the family member and once sent to hospital has also carried on the strict inspection. At present the hospital to the dead family member's death diagnosis is the acute pneumonia, official to has already carried on the serious political warning with the dead concerned personnel.

The above machine translation describing a fatal pneumonia case in Beijing is cause for concern. Although H5N1 test results have not been disclosed. The sudden death of a young man (35M) who raises pigeons needs to be investigated further. The number of outbreaks linked to wild birds in areas near Beijing has been steadily increasing (see map) and H5N1 in pigeons has been detected in other areas.

In addition to the bird deaths, H5N1 involvement in fatal human cases has been acknowledged and independently confirmed, increasing concern levels. Similarly, there are also reports of pigeon deaths in Beijing.

More information on H5N1 in humans and pigeons in Beijing would be useful.

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<B><font size=+1 color=green><center>Ethics in a Pandemic</font>

28 Nov 2005
<A href="http://www.medicalnewstoday.com/medicalnews.php?newsid=34025#">medicalnewstoday.com</a></center>

Coping effectively with a predicted influenza pandemic that threatens to affect the health of millions worldwide, hobble economies and overwhelm health care systems will require more than new drugs and good infection control.</b>

An international medical ethics think-tank says that all-important public cooperation and the coordination of public officials at all levels requires open and ethical decision making.

The Influenza Pandemic Working Group at the University of Toronto Joint Centre for Bioethics today recommended a 15-point ethical guide for pandemic planning, based in part on experiences and study of the Severe Acute Respiratory Syndrome (SARS) crisis of 2003.

The report says plans to deal with a flu pandemic need to be founded on commonly held ethical values. People need to subscribe in advance to the rationale behind such choices as: the priority recipients of resources, including hospital services and medicines; how much risk front line health care workers should take; and support given to people under restrictions such as quarantine. Decision makers and the public need to be engaged so plans reflect what most people will accept as fair and good for public health.

"A shared set of ethical values is the glue that can hold us together during an intense crisis," says Peter Singer, M.D., Director of the University of Toronto Joint Centre for Bioethics (JCB), which undertook the advisory report. "A key lesson from the SARS outbreak is that fairness becomes more important during a time of crisis and confusion. And the time to consider these questions and processes in relation to a threatened major pandemic is now."

The report concludes that flu pandemic plans universally need an ethical component that address four key issues:

1. Health workers' duty to provide care during a communicable disease outbreak.

2. Restricting liberty in the interest of public health by measures such as quarantine;

3. Priority setting, including the allocation of scarce resources such as medicines;

4. Global governance implications, such as travel advisories.

Health care workers duty to care

The SARS crisis exposed health care systems to hard ethical choices that rapidly arose. Dozens of health care workers, for example, were infected through their work and some died. Other failed to report for duty to treat SARS patients out of fear for their own health or that of their family. A flu pandemic, where there may be no absolute protection or cure, would put far greater pressures on health care systems around the world.

"Workers will face competing obligations, such as their duty to care for patients and to protect their own health and that of families and friends," says JCB member Ross Upshur, M.D., Director, Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre. “Medical codes of ethics in various countries provide little specific guidance on how to cope with this very real dilemma. Professional colleges and associations need to provide this kind of particular guidance in advance of an infectious disease outbreak crisis.”

Governments and hospitals also need to provide for the health and safety of workers, and for the care of those who fall ill on duty. This might include an insurance fund for life and disability to cover health care workers who become sick or die as they place themselves in harm's way.

The Human Costs of Restrictive Measures

Officials need to provide support for those in quarantine, cut off from family, friends, work, shopping and possibly medical care for other aliments, the report says. The public should also be made aware of the need for quarantine and the consequences of non-compliance.

"The decision to use restrictive measures need to be made in an open, fair and legitimate manner. The public has a right to know the compelling public health reasons for curtailing rights and restricting normal activities. If quarantines are used, those affected need adequate care and job protection. Preventing financial hardship is important to obtaining full compliance from the public," says Dr. Upshur.

Measures to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by quarantine also should be part of pandemic preparedness plans the report recommends.

Allocating Scarce Resources, Medicines

All countries will face scarcities of medicines, equipment and health care workers during a pandemic, according to the group. Governments, hospitals and health regions should publicize a clear rationale for giving priority access to anti-viral medicines and vaccines to particular groups (e.g., front line health workers, children, decision-makers).

Advance planning ought to include criteria for resource allocation decisions, created in consultation with the general public.

Travel Bans

The World Health Organization (WHO) has warned that if the H5N1 strain of bird flu mutates and infects people it could reach all continents in less than three months. The WHO would likely impose regional travel restrictions in hopes of slowing the spread of the disease.

However such decisions can have major economic impacts. Canada, and Toronto in particular, suffered millions in economic losses when the WHO advised international travelers against all nonessential travel because of SARS.

Decisions about travel restrictions need to be clearly justified and the process must be transparent the report says.

At the same time, the WHO relies on individual countries for reporting disease outbreaks. Such surveillance may be beyond the capacity of many developing countries. The developed world should continue to invest in the surveillance capacity and the overall public health infrastructures of developing countries.

The WHO recommends that ethical issues be a consideration in the planning process for an influenza pandemic. Canada's province of Ontario has incorporated this framework into its plan.

“Other jurisdictions and nations should assess their pandemic plan against this ethical framework and these recommendations,” says Dr. Singer.

“Looking ahead, we can say that if the pandemic strikes it will cause great hardship, but societies will struggle through. They will be better able to do so if they have general agreement on an ethical approach. Afterwards, history will judge today's leaders on how well they took decision on the ethical challenges they faced in the midst of the crisis.”

Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak

Individual liberty

In a public health crisis, restrictions to individual liberty may be necessary to protect the public from serious harm. Restrictions to individual liberty should:

- - Be proportional, necessary and relevant.

- - Employ the least restrictive means.

- - Be applied equitably.

Protection of the public from harm

To protect the public from harm, health care organizations and public health authorities may be required to take actions that impinge on individual liberty. Decision makers should:

- - Weigh the imperative for compliance.

- - Provide reasons for public health measures to encourage compliance.

- - Establish mechanisms to review decisions.

Proportionality

Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community.

Privacy

Individuals have a right to privacy in health care. In a public health crisis, it may be necessary to override this right to protect the public from serious harm.

Duty to provide care

Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability and workplace conditions.

Reciprocity

Reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families.

Equity

All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of the health crisis, this could curtail not only elective surgeries, but could also limit the provision of emergency or necessary services.

Trust

Trust is an essential component of the relationships among clinicians and patients, staff and their organizations, the public and health care providers or organizations, and among organizations within a health system. Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during an evolving health crisis. Trust is enhanced by upholding such process values as transparency.

Solidarity

As the world learned from SARS, a pandemic influenza outbreak, will require a new vision of global solidarity and a vision of solidarity among nations. A pandemic can challenge conventional ideas of national sovereignty, security or territoriality. It also requires solidarity within and among health care institutions. It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services or institutions.

Stewardship

Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour and good decision-making. This implies that decisions regarding resources are intended to achieve the best patient health and public health outcomes given the unique circumstances of the influenza crisis.

Five procedural values to guide ethical decision-making for a pandemic influenza outbreak

Reasonable

Decisions should be based on reasons (i.e., evidence, principles and values) that stakeholders can agree are relevant to meeting health needs in a pandemic influenza crisis. The decisions should be made by people who are credible and accountable.

Open and transparent

The process by which decisions are made must be open to scrutiny, and the basis upon which decisions are made should be publicly accessible.

Inclusive

Decisions should be made explicitly with stakeholder views in mind, and there should be opportunities to engage stakeholders in the decision-making process.

Responsive

There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis. There should be mechanisms to address disputes and complaints.

Accountable

There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of actions and inactions should be grounded in the 14 other ethical values proposed above.

Summary of Recommendations

An ethical guide for pandemic planning

1. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should ensure that their pandemic plans include an ethical component.

2. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should consider incorporating both substantive and procedural values in the ethical component of their pandemic plans.

Four key ethical issues

Issue 1: Health workers' duty to provide care during a communicable disease outbreak

1. Professional colleges and associations should provide, by way of their codes of ethics, clear guidance to members in advance of a major communicable disease outbreak, such as pandemic flu. Existing mechanisms should be identified, or means should be developed, to inform college members as to expectations and obligations regarding the duty to provide care during a communicable disease outbreak.

2. Governments and the health care sector should ensure that: a. care providers' safety is protected at all times, and providers are able to discharge duties and receive sufficient support throughout a period of extraordinary demands; and b. disability insurance and death benefits are available to staff and their families adversely affected while performing their duties.

3. Governments, hospitals and health regions should develop human resource strategies for communicable disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution of risk among individuals and occupational categories.

Issue 2: Restricting liberty in the interest of public health by measures such as quarantine

1. Governments and the health care sector should ensure that pandemic influenza response plans include a comprehensive and transparent protocol for the implementation of restrictive measures. The protocol should be founded upon the principles of proportionality and least restrictive means, should balance individual liberties with protection of public from harm and should build in safeguards such as the right of appeal.

2. Governments and the health care sector should ensure that the public is aware of:
a. the rationale for restrictive measures;
b. the benefits of compliance; and
c. the consequences of non-compliance.

3. Governments and the health care sector should include measures in their pandemic influenza preparedness plans to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by quarantine or other restrictive measures.

4. Governments and the health care sector should institute measures and processes to guarantee provisions and support services to individuals and/or communities affected by restrictive measures, such as quarantine orders, implemented during a pandemic influenza emergency. Plans should state in advance what backup support will be available to help those who are quarantined (e.g., who will do their shopping, pay the bills and provide financial support in lieu of lost income). Governments should have public discussions of appropriate levels of compensation in advance, including who is responsible for compensation.

Issue 3: Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines

1. Governments and the health care sector should publicize a clear rationale for giving priority access to health care services, including antivirals and vaccines, to particular groups, such as front line health workers and those in emergency services. The decision makers should initiate and facilitate constructive public discussion about these choices.

2. Governments and the health care sector should engage stakeholders (including staff, the public and partners) in determining what criteria should be used to make resource allocation decisions (e.g., access to ventilators during the crisis, and access to health services for other illnesses), should ensure that clear rationales for allocation decisions are publicly accessible and should provide a justification for any deviation from the pre-determined criteria.

3. Governments and the health care sector should ensure that there are formal mechanisms in place for stakeholders to bring forward new information, to appeal or raise concerns about particular allocation decisions and to resolve disputes.

Issue 4: Global governance implications, such as travel advisories

1. The World Health Organization should remain aware of the impact of travel recommendations on affected countries, and should make every effort to be as transparent and equitable as possible when issuing such recommendations.

2. Federal countries should utilize whatever mechanisms are available within their system of government to ensure that relationships within the country are adequate to ensure compliance with the new International Health Regulations.

3. The developed world should continue to invest in the surveillance capacity of developing countries, and should also make investments to further improve the overall public health infrastructure of developing countries.

University of Toronto Joint Centre for Bioethics

Innovative. Interdisciplinary. International. Improving health care through bioethics.

The JCB is a partnership among the University of Toronto and 15 health care organizations. It provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.

-

http://www.breitbart.com/news/2005/11/10/D8DPJGGOE.html

=


<center>

Gotta Bump it - to find it on the board
Again!</center>

Shakey said:

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<B><font size=+1 color=blue><center>Vietnam City Poisons Pigeons to Prevent Bird Flu </font>

VIETNAM: November 28, 2005
<A href="http://www.planetark.com/dailynewsstory.cfm/newsid/33673/story.htm">www.planetark.com</a></center>

HANOI - Vietnam's commercial hub Ho Chi Minh City has begun poisoning pigeons and other wild birds as it moves to prevent avian flu from spreading into the crowded city, an official said on Friday.</b>

The H5N1 bird flu virus has flared in 19 of the country's 64 provinces, the most recent cases being in the northern provinces of Quang Ninh and Nghe An, the Agriculture Ministry said in a report on Friday.
The World Health Organisation (WHO) said another human case was confirmed in the northern Hai Phong province. The infected 15-year-old boy had recovered and been discharged from hospital, the WHO said in a statement from its headquarters in Geneva.

The H5N1 virus has killed 68 people in Asia, including 42 in Vietnam, since late 2003. Experts fear the virus could mutate into a form that passes easily among people, triggering a global pandemic of killer flu.

The virus has this week also surfaced in the south where Ho Chi Minh City, a centre of 10 million people, is located.

"We will make sure that no birds are left in the city to minimize the risk of bird flu," Huynh Huu Loi, Director of Ho Chi Minh City's Animal Health Department, told Reuters.

Some international experts have said that pigeons appear to be resistant to the deadly H5N1 virus, but the city authorities are taking no chances.

Loi said beside the poisoning campaign, authorities would also move pet birds outside the city until Vietnam is free of bird flu.

The southern city, the country's largest, has banned poultry farming even though it has had no human cases since December 2004.

Most of the outbreaks in recent weeks have been in the cooler north. But the virus has spread to the south with the province of Long An reporting its first flu outbreak in poultry this week.

Click to expand...

THIS BRINGS NEW MEANING TO THAT BOOK TITLED "SILENT SPRING"

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<B><font size=+1 color=green><center>Ethics in a Pandemic</font>

28 Nov 2005
<A href="http://www.medicalnewstoday.com/medicalnews.php?newsid=34025#">medicalnewstoday.com</a></center>

Coping effectively with a predicted influenza pandemic that threatens to affect the health of millions worldwide, hobble economies and overwhelm health care systems will require more than new drugs and good infection control.</b>

An international medical ethics think-tank says that all-important public cooperation and the coordination of public officials at all levels requires open and ethical decision making.

The Influenza Pandemic Working Group at the University of Toronto Joint Centre for Bioethics today recommended a 15-point ethical guide for pandemic planning, based in part on experiences and study of the Severe Acute Respiratory Syndrome (SARS) crisis of 2003.

The report says plans to deal with a flu pandemic need to be founded on commonly held ethical values. People need to subscribe in advance to the rationale behind such choices as: the priority recipients of resources, including hospital services and medicines; how much risk front line health care workers should take; and support given to people under restrictions such as quarantine. Decision makers and the public need to be engaged so plans reflect what most people will accept as fair and good for public health.

"A shared set of ethical values is the glue that can hold us together during an intense crisis," says Peter Singer, M.D., Director of the University of Toronto Joint Centre for Bioethics (JCB), which undertook the advisory report. "A key lesson from the SARS outbreak is that fairness becomes more important during a time of crisis and confusion. And the time to consider these questions and processes in relation to a threatened major pandemic is now."

The report concludes that flu pandemic plans universally need an ethical component that address four key issues:

1. Health workers' duty to provide care during a communicable disease outbreak.

2. Restricting liberty in the interest of public health by measures such as quarantine;

3. Priority setting, including the allocation of scarce resources such as medicines;

4. Global governance implications, such as travel advisories.

Health care workers duty to care

The SARS crisis exposed health care systems to hard ethical choices that rapidly arose. Dozens of health care workers, for example, were infected through their work and some died. Other failed to report for duty to treat SARS patients out of fear for their own health or that of their family. A flu pandemic, where there may be no absolute protection or cure, would put far greater pressures on health care systems around the world.

"Workers will face competing obligations, such as their duty to care for patients and to protect their own health and that of families and friends," says JCB member Ross Upshur, M.D., Director, Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre. “Medical codes of ethics in various countries provide little specific guidance on how to cope with this very real dilemma. Professional colleges and associations need to provide this kind of particular guidance in advance of an infectious disease outbreak crisis.”

Governments and hospitals also need to provide for the health and safety of workers, and for the care of those who fall ill on duty. This might include an insurance fund for life and disability to cover health care workers who become sick or die as they place themselves in harm's way.

The Human Costs of Restrictive Measures

Officials need to provide support for those in quarantine, cut off from family, friends, work, shopping and possibly medical care for other aliments, the report says. The public should also be made aware of the need for quarantine and the consequences of non-compliance.

"The decision to use restrictive measures need to be made in an open, fair and legitimate manner. The public has a right to know the compelling public health reasons for curtailing rights and restricting normal activities. If quarantines are used, those affected need adequate care and job protection. Preventing financial hardship is important to obtaining full compliance from the public," says Dr. Upshur.

Measures to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by quarantine also should be part of pandemic preparedness plans the report recommends.

Allocating Scarce Resources, Medicines

All countries will face scarcities of medicines, equipment and health care workers during a pandemic, according to the group. Governments, hospitals and health regions should publicize a clear rationale for giving priority access to anti-viral medicines and vaccines to particular groups (e.g., front line health workers, children, decision-makers).

Advance planning ought to include criteria for resource allocation decisions, created in consultation with the general public.

Travel Bans

The World Health Organization (WHO) has warned that if the H5N1 strain of bird flu mutates and infects people it could reach all continents in less than three months. The WHO would likely impose regional travel restrictions in hopes of slowing the spread of the disease.

However such decisions can have major economic impacts. Canada, and Toronto in particular, suffered millions in economic losses when the WHO advised international travelers against all nonessential travel because of SARS.

Decisions about travel restrictions need to be clearly justified and the process must be transparent the report says.

At the same time, the WHO relies on individual countries for reporting disease outbreaks. Such surveillance may be beyond the capacity of many developing countries. The developed world should continue to invest in the surveillance capacity and the overall public health infrastructures of developing countries.

The WHO recommends that ethical issues be a consideration in the planning process for an influenza pandemic. Canada's province of Ontario has incorporated this framework into its plan.

“Other jurisdictions and nations should assess their pandemic plan against this ethical framework and these recommendations,” says Dr. Singer.

“Looking ahead, we can say that if the pandemic strikes it will cause great hardship, but societies will struggle through. They will be better able to do so if they have general agreement on an ethical approach. Afterwards, history will judge today's leaders on how well they took decision on the ethical challenges they faced in the midst of the crisis.”

Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak

Individual liberty

In a public health crisis, restrictions to individual liberty may be necessary to protect the public from serious harm. Restrictions to individual liberty should:

- - Be proportional, necessary and relevant.

- - Employ the least restrictive means.

- - Be applied equitably.

Protection of the public from harm

To protect the public from harm, health care organizations and public health authorities may be required to take actions that impinge on individual liberty. Decision makers should:

- - Weigh the imperative for compliance.

- - Provide reasons for public health measures to encourage compliance.

- - Establish mechanisms to review decisions.

Proportionality

Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community.

Privacy

Individuals have a right to privacy in health care. In a public health crisis, it may be necessary to override this right to protect the public from serious harm.

Duty to provide care

Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability and workplace conditions.

Reciprocity

Reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families.

Equity

All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of the health crisis, this could curtail not only elective surgeries, but could also limit the provision of emergency or necessary services.

Trust

Trust is an essential component of the relationships among clinicians and patients, staff and their organizations, the public and health care providers or organizations, and among organizations within a health system. Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during an evolving health crisis. Trust is enhanced by upholding such process values as transparency.

Solidarity

As the world learned from SARS, a pandemic influenza outbreak, will require a new vision of global solidarity and a vision of solidarity among nations. A pandemic can challenge conventional ideas of national sovereignty, security or territoriality. It also requires solidarity within and among health care institutions. It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services or institutions.

Stewardship

Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour and good decision-making. This implies that decisions regarding resources are intended to achieve the best patient health and public health outcomes given the unique circumstances of the influenza crisis.

Five procedural values to guide ethical decision-making for a pandemic influenza outbreak

Reasonable

Decisions should be based on reasons (i.e., evidence, principles and values) that stakeholders can agree are relevant to meeting health needs in a pandemic influenza crisis. The decisions should be made by people who are credible and accountable.

Open and transparent

The process by which decisions are made must be open to scrutiny, and the basis upon which decisions are made should be publicly accessible.

Inclusive

Decisions should be made explicitly with stakeholder views in mind, and there should be opportunities to engage stakeholders in the decision-making process.

Responsive

There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis. There should be mechanisms to address disputes and complaints.

Accountable

There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of actions and inactions should be grounded in the 14 other ethical values proposed above.

Summary of Recommendations

An ethical guide for pandemic planning

1. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should ensure that their pandemic plans include an ethical component.

2. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should consider incorporating both substantive and procedural values in the ethical component of their pandemic plans.

Four key ethical issues

Issue 1: Health workers' duty to provide care during a communicable disease outbreak

1. Professional colleges and associations should provide, by way of their codes of ethics, clear guidance to members in advance of a major communicable disease outbreak, such as pandemic flu. Existing mechanisms should be identified, or means should be developed, to inform college members as to expectations and obligations regarding the duty to provide care during a communicable disease outbreak.

2. Governments and the health care sector should ensure that: a. care providers' safety is protected at all times, and providers are able to discharge duties and receive sufficient support throughout a period of extraordinary demands; and b. disability insurance and death benefits are available to staff and their families adversely affected while performing their duties.

3. Governments, hospitals and health regions should develop human resource strategies for communicable disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution of risk among individuals and occupational categories.

Issue 2: Restricting liberty in the interest of public health by measures such as quarantine

1. Governments and the health care sector should ensure that pandemic influenza response plans include a comprehensive and transparent protocol for the implementation of restrictive measures. The protocol should be founded upon the principles of proportionality and least restrictive means, should balance individual liberties with protection of public from harm and should build in safeguards such as the right of appeal.

2. Governments and the health care sector should ensure that the public is aware of:
a. the rationale for restrictive measures;
b. the benefits of compliance; and
c. the consequences of non-compliance.

3. Governments and the health care sector should include measures in their pandemic influenza preparedness plans to protect against stigmatization and to safeguard the privacy of individuals and/or communities affected by quarantine or other restrictive measures.

4. Governments and the health care sector should institute measures and processes to guarantee provisions and support services to individuals and/or communities affected by restrictive measures, such as quarantine orders, implemented during a pandemic influenza emergency. Plans should state in advance what backup support will be available to help those who are quarantined (e.g., who will do their shopping, pay the bills and provide financial support in lieu of lost income). Governments should have public discussions of appropriate levels of compensation in advance, including who is responsible for compensation.

Issue 3: Priority setting, including the allocation of scarce resources, such as vaccines and antiviral medicines

1. Governments and the health care sector should publicize a clear rationale for giving priority access to health care services, including antivirals and vaccines, to particular groups, such as front line health workers and those in emergency services. The decision makers should initiate and facilitate constructive public discussion about these choices.

2. Governments and the health care sector should engage stakeholders (including staff, the public and partners) in determining what criteria should be used to make resource allocation decisions (e.g., access to ventilators during the crisis, and access to health services for other illnesses), should ensure that clear rationales for allocation decisions are publicly accessible and should provide a justification for any deviation from the pre-determined criteria.

3. Governments and the health care sector should ensure that there are formal mechanisms in place for stakeholders to bring forward new information, to appeal or raise concerns about particular allocation decisions and to resolve disputes.

Issue 4: Global governance implications, such as travel advisories

1. The World Health Organization should remain aware of the impact of travel recommendations on affected countries, and should make every effort to be as transparent and equitable as possible when issuing such recommendations.

2. Federal countries should utilize whatever mechanisms are available within their system of government to ensure that relationships within the country are adequate to ensure compliance with the new International Health Regulations.

3. The developed world should continue to invest in the surveillance capacity of developing countries, and should also make investments to further improve the overall public health infrastructure of developing countries.

University of Toronto Joint Centre for Bioethics

Innovative. Interdisciplinary. International. Improving health care through bioethics.

The JCB is a partnership among the University of Toronto and 15 health care organizations. It provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.

Being one of the front line health care workers, I am very interested in the articles written regarding medical ethics and the duty to serve, etc. I found that the writers of the ethics questions were very good at words, but it all seemed so vague. Are these questions going to be debated ad nauseum and nothing "real" accomplished? Probably. There are too many questions to adequately answer.

Look at what happened after Katrina. Rescues came too late for many gravely ill patients despite heroic efforts by staff. Then when all was said and done, those health care workers came under fire for not doing enough, even though they themselves went without food, water and shelter as well while trying to care for the sick. It seems like we are in for a real ride if this thing really goes pandemic. May God have mercy on all of us.

response

Dixielee, I understand what you are saying. We have been looking at the day to day dilemma's that will present themselves if quarantine takes place....covering laundry issues for staff; food needs; additional beds for quarantined staff; additional beds for families of staff who refused to be separated; etc., etc., disposing of trash. All of these things and many, many more will create terrible bottle necks should a true pandemic occur.

As another front line healthcare worker, I pray we don't have to go through this.

Keep up the great work Shakey! The piece above on all wild birds being poisoned to avert the threat of bird flu in Vietnam's largest cities especially deserves everyone's full attention.

On the subject of health care workers going awol...John Barry's book describes this in detail for the 1918 flu. If more had been known about the flu symptoms and severity and if it were not so lethal and if there were more medical resources available, perhaps it would not have been such a problem. There were regions of the country in 1918 which needed a massive influx of volunteer HCWs which never materialized because people were too scared. Even just the traditional neighbor-helps-neighbor when another family is sick was missing - e.g., by delivering meals or helping with the children, many of whom were orphaned by the 1918 flu.

If a pandemic reaches the point where those choices have to be made, is it possible we'll already be past the point where they can be made? IOW, hospitals will be overwhelmed, overrun, and perhaps even under siege by panic-stricken people. Look what happened during Katrina, when several hospitals in NOLA had to plead for police protection to keep the mobs out of the emergency rooms. At some point early in a pandemic, assuming one of the severity contemplated here, hospitals will just have to turn everyone away because they will have no more capacity. Telling people there's no more room is much easier than choosing which patient gets taken off the ventilator to make room for someone more deserving.

CW

Shakey, keep up the good work.

somewherepress said:

Keep up the great work Shakey! The piece above on all wild birds being poisoned to avert the threat of bird flu in Vietnam's largest cities especially deserves everyone's full attention.

Click to expand...

I know it's tacky, but now I can't help thinking of that Tom Leher song "Poisoning Pigeons in the Park'.

Hey, a bit of gallows humor..sorry..

That may take care of poultry's threat, but it doesn't protect against wild waterfowl, where H5N1 is thought to have originated. WHO believes the spring 2005 die-off of 6,000 migratory birds in Central China may be a signal that the virus is becoming more deadly.

Click to expand...

Remember all those dead birds on the Oregon coast this summer?

http://www.msnbc.msn.com/id/8796487

http://www.orednet.org/~rbayer/j/j601.htm

http://www.dailykos.com/storyonly/2005/8/1/114820/7173

http://newportnewstimes.com/articles/2003/12/03/general/news-01.txt

http://www.sciencedaily.com/releases/2005/08/050819123253.htm

dayummm..now there is putting two and two together..wonder if this has occurred to anyone else???

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I am linking this thread to Lady Nuthatch's thread on China admitting that H5N1 is MUTATING in human victums....

I am running into several sourses which are saying the dame thing - too many for this subject to be ignored by us....

http://www.timebomb2000.com/vb/showthread.php?t=177702

This is perhaps the most important (as well as dangerous) developement that H5N1 is made; or is making . It is with out a doubt the most foreboding...

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<B><font size=+1 color=red><center>28 November 2005
Flu Threat to Farm, Animal Workers Might Be Increasing</font>

<A href="">USINFO.STATE.GOV</a></center>

This population could be leading edge of pandemic, study finds</b>

Workers routinely in contact with pigs are more likely than the general populace to be infected with viruses that originate in swine and other animals, according to new research sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), one of the National Institutes of Health.

This finding needs to be taken into account in pandemic influenza planning, the organizations say.

The research, conducted at the University of Iowa Center for Emerging Infectious Diseases, found that pig farmers had a sharply higher level of exposure to animal virus than control groups, as much as 35 times higher.

Pigs also can be infected by avian viruses. If pigs, chickens and humans live on the same farm, there is potential for a “mixing bowl” effect, in which new dangerous viruses could form, according to a November 25 NIAID press release.

This makes farm workers, veterinarians and meat processors more vulnerable to animal diseases than the population at large, and more likely to become carriers who could spread a new virus into the nonagricultural population, setting off a pandemic.

“Not protecting agricultural workers could amplify influenza transmission among humans and domestic animals during a pandemic and cause considerable damage to the swine and poultry industries, as well as the U.S. economy,” said Iowa University’s Gregory C. Gray.

The H5N1 virus that has stricken Asian birds and given rise to warnings of a human influenza pandemic has infected some swine, but the virus has not become contagious among pigs.

For additional information on the avian influenza and efforts to combat it, see Bird Flu.

(begin text)

National Institute of Allergy and Infectious Diseases (NIAID)
[Bethesda, Maryland]
Friday, November 25, 2005

Agricultural Workers at Increased Risk for Infection with Animal Flu Viruses

Findings May Have Implications for Pandemic Flu Planning

Farmers, veterinarians and meat processors who routinely come into contact with pigs in their jobs have a markedly increased risk of infection with flu viruses that infect pigs, according to a study funded in part by the National Institute of Allergy and Infectious Diseases (NIAID), one of the National Institutes of Health (NIH). While the findings are not entirely unexpected, the strikingly higher risk of infection coupled with the fact that pigs can be infected by swine viruses, bird (avian) viruses as well as human flu viruses — thereby acting as a virtual virus “mixing bowl,” especially on farms where pigs, chickens and people coexist — is a potential public health concern, the study authors assert. The paper appears online this week in Clinical Infectious Diseases.

“Pigs play a role in transmitting influenza virus to humans,” says NIAID Director Anthony S. Fauci, M.D. “The worry is that if a pig were to become simultaneously infected with both a human and an avian influenza virus, genes from these viruses could reassemble into a new virus that could be transmitted to and cause disease in people.”

The study results strongly suggest that occupational exposure to pigs significantly increases the risk of developing swine influenza infection. Agricultural workers should, therefore, be considered in developing flu pandemic surveillance plans and antiviral and immunization strategies, according to the study’s co-investigator, Gregory C. Gray, M.D., director of the University of Iowa Center for Emerging Infectious Diseases.

“If migratory birds introduce the H5N1 bird flu virus into swine or poultry populations in this country, agricultural workers may be at a much greater risk of developing a variant H5N1 and passing it along to non-agricultural workers,” Gray says. “Not protecting agricultural workers could amplify influenza transmission among humans and domestic animals during a pandemic and cause considerable damage to the swine and poultry industries, as well as the U.S. economy.” While swine in other countries have been infected by the H5N1 virus, to date, the virus has not become readily transmissible between swine.

Swine influenza infections generally produce mild or no symptoms in both pigs and humans. However, exposure to swine flu virus at a 1988 Wisconsin county fair resulted in serious illness for 50 swine exhibitors and three of their family members; one previously healthy woman who became infected died.

The U.S. swine industry, which employs about 575,000 people, has shifted during the past 60 years from primarily small herds located on family farms to large herds maintained in expansive but confined agricultural facilities. Crowded conditions coupled with the constant introduction of young pigs to existing herds have made swine flu infections among pigs a year-round occurrence rather than the seasonal event they once were. As a result, there is a constant opportunity for people who are occupationally exposed to pigs to become infected with influenza viruses and, conversely, a continual opportunity for human flu viruses to mix with swine or bird flu viruses.

To determine the prevalence of swine influenza infection among swine-exposed employees, the researchers, led by Dr. Gray and graduate student Kendall P. Myers, examined serum samples taken from four adult populations in Iowa between 2002 and 2004. Three populations were occupational groups exposed to pigs: 111 farmers, 97 meat processing workers and 65 veterinarians. The fourth control group included 79 volunteers from the University of Iowa with no occupational pig exposure.

The researchers tested the serum samples for antibodies to several then-current swine and human influenza A viruses. The results showed that all three occupational study groups had markedly elevated antibodies to swine flu viruses compared with the control group. Farmers had the strongest indication of exposure to swine flu viruses, as much as 35 times higher than the control group. Similarly, comparable values were as much as 18 times higher for veterinarians and as much as 7 times higher for meat processors than the control group. In contrast, exposure to human flu virus in the occupational groups was not significantly different than that of the control group.

To date, the H5N1 avian virus has not appeared in the United States in any animal population or in humans.

NIAID is a component of the National Institutes of Health, an agency of the U.S. Department of Health and Human Services. NIAID supports basic and applied research to prevent, diagnose and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism. NIAID also supports research on transplantation and immune-related illnesses, including autoimmune disorders, asthma and allergies.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U. S. Department of Health and Human Services. It is the primary Federal agency for conducting and supporting basic, clinical, and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.

My S.W.A.G. is this will be a full blown pandemic in the next 2-3 months.

I think it very unlikely that anyone, esp SE Asian nations, could reverse engineer Tamiflu and have it in production without help from Roche. This is either wishful thinking or a snow job to placate the rising masses and buy a little more time, maybe both.

As for healthcare workers sitting this one out:

See:

Half of health care workers may not show up to work during Flu Pandemic

--------------------------------------------------------------------------------

The Mailman School of Public Health at Columbia University in New York City set out to look at how many healthcare workers said they would show up for work, depending on the type of emergency. There was some good news: 87 percent of 6,000 workers surveyed in 47 facilities in and around New York said they would be able to go to work in the event of a mass casualty incident, and 81 percent for an environmental disaster.

Only 61 percent, however, would show up for a smallpox epidemic, just 48 percent during a SARS epidemic and 57 percent during a ‘radiological event.’

That’s a problem, isn’t it? Less than half of healthcare workers expect to work during a SARS [or bird-flu] epidemic, and less than two-thirds if terrorists set off a so-called dirty bomb in the financial district.

Full article posted 11/21/05 is at:
http://www.avoidbirdflu.com/article.php?id1=5107

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<font size=+1 color=brown><B><center>Is It Time To Push The Panic Button?</font>

November 29 2005
John Roughan - Honiara
<A href="http://www.scoop.co.nz/stories/HL0511/S00330.htm">Scoop.com.co.uk</a>

*******</B></center>
Solomon Islands leaders normally wait until the last minute before 'leaping' to action. This is especially true when it comes to preparing for major national disasters. Recall the Level 5 cyclone which roared through Tikopia a few years back. A few New Zealand pilots and some other countries nationals knew more about what was happening to our people on Tikopia than our leaders did. Almost a week went by before government leaders knew whether any one on Tikopia was still alive or not? National response to that disaster, unfortunately, was pityingly late and sparse.

Of course cyclone preparation is a long term sort of thing and over the years, thank goodness, we've built up expertise. We have become sort of ready for them. But there are two disasters waiting to hit us at this very moment and we continue to be woefully unprepared. There is modest preparation in place, for instance, for the AIDS/HIV epidemic but hardly anything for the Avian Flu bug. This last mentioned disaster deeply worries the rest of the world but we hardly seem concerned. Countries in our region are putting their people on disaster alert in case the Avian Flu hits them. They take the threat quite seriously. While our AIDS/HIV preparation is spotty at best, national preparation for Avian Flu hasn't rated a mention in the current seating of parliament.

This current Avian Flu, probably began in China or another part of Southeast Asia, is a serious disaster waiting to happen. Some rate its destructive power as bad as an atomic attack. This sickness is much more deadly than a serious cold, a blocked nose or cough and sneezing bouts. The world has never experienced this kind of flu before and it's waiting in the wings to happen. More than half the people who contracted
Avian Flu in Southeast Asia over the past two years died and the rest needed days of hospital care.

Nations across the globe--China, Vietnam, Indonesia, Taiwan, etc. to stop the flu bug in its tracks from taking hold of their people, are slaughtering tens of thousands of chickens, ducks and other bird species. National governments greatly fear that this deadly flu could wipe out millions of their people, if they don't do some seriously radical destruction of their bird populations. The last time the world witnessed so dangerous a flu was in 1918 when it killed millions in a few months. Doctors, scientists and politicians are now fearful that this newest Avian Flu which now attacks people's poultry might leap into human beings. Once that happens, the world is looking at massive death rates the like it has never seen.

Last week, fortunately, the Minister of Finance informed parliament members that he had wisely salted away about $40 million, earmarking funds for a possible disaster emergency. No, he never mentioned Avian Flu, but I'm sure that thought wasn't far from his mind. Hopefully not a penny will be used to fight the Avian Flu. However, if needed, at least, we have stored up funds to jump start a response to fight this disease if it ever did hit our shores.

But money alone, as necessary and needed, is simply not enough. Serious health planning measures including public awareness campaigns are a necessary first step to prepare people about this sickness. Secondly, medical plans--pre-ordering vital medicines, hospital preparation and staff training--should be already well known to our medical people.

In many other nations, the Avian Flu seems to infect local flocks of chickens and ducks through wild bird passage. The Solomons does not lie in the path of big flocks of migratory birds which yearly make their continental-spanning journeys. Some bird spices cross Southeast Asia to travel to the warmer climates of Indonesia, Australia, etc. These birds could infect local birds with the sickness. But this sickness, if it did jump into humans, could come to us in other ways.

Back in the early 1960s, for instance, a Solomons protectorate High Commissioner and his party paid a visit to Hong Kong before returning to the Solomons. In their visit, didn't one of them pick up another flu bug. He brought it back with him on his returning here. Within a few weeks, that flu infected a number of our people. Fortunately, although serious, did not kill anyone but it did show how quickly the flu could travel around Solomon Islands.

Whether we should push the panic button is an open question. But certainly more must be done to alert out people and get in place plans to care for them just in case. That's the least that government owes its citizens.

Yeah, the NOLA/Katrina experience and the hospitals does make one cringe at thinking on how services would be allocated and the triage process under those circumstances.

Bump

Thank-you very much,Shakey for all of the info you have shared. Being a front line hospital worker makes me a little nervous. I have family to care for-some very elderly and if I go to work and couldn't get home-well, they could die.Family should come first. Plus, our institution has no plan to have extra food,supplies or medicines.

Most of our ER docs already have said they will be staying/going home if the bird flu starts to appear in a large number of patients. Because our hospital (and those in the surrounding area) only care about the bottom line-MONEY!!!!

The nurses have talked this to death and we don't know what to do. We are torn between our families and our patients.

Scarier and scarier!!!

Maranatha

Shakey said:

-


I am linking this thread to Lady Nuthatch's thread on China admitting that H5N1 is MUTATING in human victums....

I am running into several sourses which are saying the dame thing - too many for this subject to be ignored by us....

http://www.timebomb2000.com/vb/showthread.php?t=177702

This is perhaps the most important (as well as dangerous) developement that H5N1 is made; or is making . It is with out a doubt the most foreboding...

Click to expand...

Agreed Shakey, back to work in about two weeks and will post any developments I come across in B.S. I have connections but would like to see it for myself.

herbgarden said:

Thank-you very much,Shakey for all of the info you have shared. Being a front line hospital worker makes me a little nervous. I have family to care for-some very elderly and if I go to work and couldn't get home-well, they could die.Family should come first. Plus, our institution has no plan to have extra food,supplies or medicines.

Most of our ER docs already have said they will be staying/going home if the bird flu starts to appear in a large number of patients. Because our hospital (and those in the surrounding area) only care about the bottom line-MONEY!!!!

The nurses have talked this to death and we don't know what to do. We are torn between our families and our patients.

Click to expand...

If the ER Docs plan to stay home, and Nurses are torn, what about the aides, and techs who make very little money, and do most of the actual care.....?
I'm basically in the same place you are, herbgarden.
If I stayed true to my moral convictions, I'd without a doubt stay...
Realisticly, I'm not sure.

Dixielee, and other front line medical staff:

Have you decided what you will do? Hospital policies be damned. I just hope I have a 2 week window from what I consider the sentinal event and the arrival of the pandemic in my area so Ican turn in my letter of resignation. I would like to keep my license, but I see no advantage in throwing myself on the sword.

I have the ability and desire to shelter in place until the worse is over. The way I look at it, there will be at least one well trained, healthy nurse to help with the reconstruction. May not get the job back at the hospital I now work at, but IMHO, the administrators will not be too picky hiring nurses after.

I may be old, but I am not that much of a risk taker.

DM

Actually, you might consider this, most Counties and cities have an ordinance that requires county employees to report for duty as disaster workers. It is a condition of employment. Not only that, it allows certain officials - including the Public Health Officer, to draft any civilians to work in a disaster. Your choice may be to serve or spend the epidemic in a crowded jail.

Only if they can find you Marsh.

Yes, I have decided what to do. I, too hope and expect there to be a window of opportunity as we watch this thing unfold. I am currently a travel nurse with 13 week contracts. The worst that could happen, job wise, is that I would not complete a contract and may be subject to paying back my housing allowance for the remainder of the contract. That is a small price to pay for my life.

I will work until I am sure it has gone H2H efficiently anywhere in the world. Then we will shelter on our little homestead with as many relatives as will show up. There will be plenty of work to keep everyone busy for the duration of the pandemic.

As far as being drafted to work, well, I think I will conveniently have the flu if any one comes around to ask. We will have our own little quarantine going.

Jumpy, you are right....they will have to find me first! Then they have to get past my dogs.

Dixielee said:

Yes, I have decided what to do. I, too hope and expect there to be a window of opportunity as we watch this thing unfold. I am currently a travel nurse with 13 week contracts. The worst that could happen, job wise, is that I would not complete a contract and may be subject to paying back my housing allowance for the remainder of the contract. That is a small price to pay for my life.

I will work until I am sure it has gone H2H efficiently anywhere in the world. Then we will shelter on our little homestead with as many relatives as will show up. There will be plenty of work to keep everyone busy for the duration of the pandemic.

As far as being drafted to work, well, I think I will conveniently have the flu if any one comes around to ask. We will have our own little quarantine going.

Jumpy, you are right....they will have to find me first! Then they have to get past my dogs.

Click to expand...

I hesitate to inject this.

BUT

Any person who is infected with H5N1 will not show symptoms for between 3 to 14 days (this is the period that they will be CONTAGIOUS - but not feel ill).

The bottom-line is this; The first person who is admitted to any hospital inside the United States, will have passed along thier illness (the H5N1) to others...

Conclusion (mine) that when a person is dianosed as being an H5N1 victum. It is a reaonable asumption there forth, that nearly every major city has been exposed to it (by those persons which the infected person came into contant with.....

Dear DRs, Nurses and HealthCare Workers on TB2K:

I understand your ethical dilema about duty vs family.

Just posting to add that given that there is very littel surge capacity in today's health care, the phyiscal hospital is not goindg to be able to care for many incremental patients above current work loads.

Meaning that the hospitals could quickly be overwhelmed. Meaning you will be more useful to a Recovey effort if you maintain you and yours during the onset and duration of a pandemic.


Shakey,

That is the Crux of the dilema. The pre-symptom shedding of virus has got to be controlled if the pandemic is to be stopped. The only apparent method is quarentine and anti-viral prophylaxis on the front lines, at ports of entry, in the ER, etc.

I suppose a major ethical dilema for TPTB is when to initiate the first quarentines and isolations. Too early and you have economic consequences that could make you look stupid. Too late and you have piles of dead bodies. Prudence suggest that sooner is better than later. I would hope we ground planes and quarentine ships as soon as H5N1 reaches a WHO scale of 5 when H2H is proven efficient - hopefully this first occurs somewhere other than in our backyards. Even so I doubt that will stop the spread - it may delay it so a vax can be deployed after the current 6+ month lead time.

Bill P said:

My S.W.A.G. is this will be a full blown pandemic in the next 2-3 months.

I think it very unlikely that anyone, esp SE Asian nations, could reverse engineer Tamiflu and have it in production without help from Roche. This is either wishful thinking or a snow job to placate the rising masses and buy a little more time, maybe both.

As for healthcare workers sitting this one out:

See:

Half of health care workers may not show up to work during Flu Pandemic

--------------------------------------------------------------------------------

The Mailman School of Public Health at Columbia University in New York City set out to look at how many healthcare workers said they would show up for work, depending on the type of emergency. There was some good news: 87 percent of 6,000 workers surveyed in 47 facilities in and around New York said they would be able to go to work in the event of a mass casualty incident, and 81 percent for an environmental disaster.

Only 61 percent, however, would show up for a smallpox epidemic, just 48 percent during a SARS epidemic and 57 percent during a ‘radiological event.’

That’s a problem, isn’t it? Less than half of healthcare workers expect to work during a SARS [or bird-flu] epidemic, and less than two-thirds if terrorists set off a so-called dirty bomb in the financial district.

Full article posted 11/21/05 is at:
http://www.avoidbirdflu.com/article.php?id1=5107

Click to expand...

Pardon my ignorance, but what is "S.W.A.G."?

and I don't know about two to three months..will give it more like six to nine months myself, but that's just me..and then no telling how fast it will spread across the world....and don't forget that they say this will come in 'waves', either..

The good news is, I am NOT a city/county/state employee. The hospital I work at is a County Hospital, but is its own taxing district. My letter of resignation is already written just needs a date and delivery. (I am using 'personal reasons' and am establishing a tract of still not recovering from the death of my husband).

Sentinel events include, not only H5N1 going WHO Phase 5 but also an unexplained diagnosis of Dengue Fever in the US. H5N1, according to posts by Shakey, can mimic Dengue Fever, and in the south, Docs are more likey to call those symptoms Dengue than H5N1, since Dengue is endemic in the area. And, yes we are still seeing mosquitoes and flies around.

Just heard on the news that Common Flu has been diagnosed in Bexar County (San Antonio, TX) DUH!!!!! We have been getting patients in the ER with flu-like symptoms for a couple of weeks. Mostly health care workers who are working in SA hospitals.

Remeber that Flu is not "diagnosed" unless tests have been run and then the samples are serotyped by the Health Department. That hardly ever happens. ER and Primary Docs just treat the symptoms, and if appropriate, Rx Tamiflu. ALERT: Our hospital is out of Tamiflu and there is no known delivery date for restocking.

I always worry when health care workers who have been in the field for a few years pick up 'bugs' from the patients. Our immune systems have been exposed to so many pathogens, we tend to have a fairly high resistance. Anything that breaks through and gets the Nurses--I consider it quite a strong little bugger.

Lovely!

DM

The doc can stuff it anyway

Docs can't do anything about the flu since it's a virus.

Realistically, I don't expect to survive a severe flu bug because of my respiratory disease, and I sure ain't gonna kick off lying in a concrete-slab hospital bed with tubes up my nose, down my throat, in my arms, and trailing out of every other orifice just so some greedy doc can make some extra $ off my insurance company that refused to pay for the asthma protocol I need and probably use me as a drug experiment for other patients.

Screw that!

I'll gasp my last breath in front of the tv with "Star Wars" running on the tv, a hot buttered rum in one hand and a great sci-fi novel in the other with Pink Floyd's "Dark Side of the Moon" playing on the stereo.

http://www.canada.com/ottawacitizen...111&k=24590&p=2

Prepare public for bird flu, experts urge governments
Ethical guidelines must be set up, understood to avoid panic, chaos

Mark Kennedy
The Ottawa Citizen


Monday, November 28, 2005


Governments preparing for a flu pandemic should develop ethical guidelines for their plans that include health and disability insurance for health workers and special assistance for people forced into quarantine, says a new report released yesterday.

The report, prepared by the University of Toronto's Joint Centre for Bioethics, warns governments throughout the world -- including Canada -- are not doing enough to engage the public in discussions about the ethical values that should underpin pandemic preparedness plans.

Last year, the federal government released a plan that spells out how it will prepare for, and respond to, a flu pandemic that experts say could kill millions of people worldwide. But the detailed blueprint, although prepared with the assistance of provinces and public health authorities, has not had much input from the Canadian public.

That has raised questions about whether the public would panic in a pandemic and reject government decisions about how to deal with the crisis.

The report, released yesterday by the medical ethics think-tank, casts a spotlight on that shortcoming.

"When an influenza pandemic strikes the world, many people, ranging from government and medical leaders to health care workers, will face a host of difficult decisions that will affect people's freedoms and their chances of survival," says the report.

"There will be choices about the level of risk health-care workers should face while caring for the sick, the imposition of restrictive measures such as quarantines, the allocation of limited resources such as medicines, and the use of travel restrictions and other measures to contain the spread of the disease.

"Governments and health-care leaders need to make the values behind their decisions public. They should discuss the values with people who could be affected. ... They need to do this in advance of a health crisis, not when people are lining up at emergency ward doors."

Among the report's recommendations:

- Professional colleges and associations for health workers should provide, through their codes of ethics, "clear guidance" on the "expectations and obligations" about their duty to provide care during a pandemic.

- Governments and the health sector should ensure disability insurance and death benefits are available to health workers and their families adversely affected while performing their duties.

- Governments should ensure the public is aware of the rationale for restrictive measures such as quarantine and the "consequences" of non-compliance.

- Governments should offer backup support for people who are quarantined, such as providing them financial support in lieu of lost income and arranging for basic needs such as grocery shopping and paying their bills.

- Governments should publicize a clear rationale for why medicines such as antivirals and vaccines are to be given first to a priority list of people, such as health care workers.

Dr. Peter Singer, director of the centre for bioethics, said in an interview Canadians learned some critical lessons from the SARS crisis of 2003 -- notably, fairness is important during a time of confusion.

"SARS was a dress rehearsal for what a bad pandemic flu could be," he said. "It's sort of the waves splashing on the shore, where the pandemic flu is the health tsunami. It's the ethical values and framework that's going to be the glue that holds together a society in an intense crisis. This is, to my way of thinking, the foundation of the house."

Without that ethical framework, he said, the public simply won't be as likely to accept the controversial measures taken by government in a pandemic.

"What you'll have is erosion of public trust in the decisions of leaders at a whole variety of levels," said Dr. Singer. "From the directors of intensive care units, through the CEOs of hospitals, through the heads of public health authorities, through health civil servants and health ministers. Right up to the head of state."

In recent months, world leaders have begun ramping up preparedness measures for a flu pandemic because of the fear the H5N1 bird flu virus, which has been raging in southeast Asia, could soon turn into a strain that is easily transmissible among humans. Once that happens, a pandemic could circulate throughout the world in weeks.