Dr. Alan Hampson of the Pandemic Taskforce of the World Health Organization (WHO) and an adviser to the Australian government on influenza, said, “This study has looked at the dynamics of the spread of the virus in the family environment … and has come down with the conclusion that it clearly does show person-to-person transmission.”

Hampson said the infections had the potential to ignite a pandemic.

If that’s the case, then it’s only a matter of time before another and another and another human-to-human transmission occurs—eventually resulting in a pandemic.

As this report was being prepared, WHO and other authorities were hurriedly investigating a suspicious H5N1 transmission between members of a family in China. A 52-year-old man from Nanjing, the capital of the eastern province of Jiangsu, was confirmed to have the virus in his respiratory tract just days after his 24-year-old son died from the virus on Dec. 2. The father recovered following administration of the antiviral Tamiflu at the onset of symptoms.

“The possibility of human-to-human transmission cannot be ruled out,” said Joanna Brent, a Beijing-based WHO spokesperson.

The case was disturbing because neither father nor son could be found to have had any contact with infected poultry. Furthermore, WHO and the Jiangsu Animal Husbandry and Veterinary Bureau said there have been no reported H5N1 outbreaks in poultry in the province. A mandatory order to vaccinate poultry has been in effect in the province since 2003, and a recent survey revealed all poultry had been vaccinated and that 92 percent of it had developed antibodies.

Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) and the National Institutes of Health-supported Center of Excellence for Influenza Research and Surveillance within CIDRAP, explained to HSToday that the dramatic spread of “active” virus strains in birds around the planet has become a veritable biological soup for mutations.

“There’s a teeming mass of constantly mutating viruses” within the bird population today, any one of which could make the jump to humans, agreed vaccine expert Dr. Gregory Poland of the Mayo Clinic.

H5N1 and related strains are now circulating in birds in 60 countries, but the virus is entrenched in several countries, including Indonesia, Egypt and Nigeria. Consequently, Dr. David Nabarro, senior United Nations system influenza coordinator, said at an influenza conference in India in December that the potential for a pandemic “is a problem that will be with us still for some years to come.”

H5N1 has already mutated into a form that is able to infect people much more easily than previously known. These mutated viruses have been found to be able to live and thrive in the human nose, throat and upper respiratory tract, like the H5N1 strain found in the man and his son in China.

The discovery was made by a team of researchers led by internationally recognized influenza virologist Yoshihiro Kawaoka of the University of Wisconsin-Madison School of Veterinary Medicine. His team discovered that by adapting to the upper respiratory system, the virus is capable of infecting a wider range of cell types and more readily spread, needing perhaps only another mutation or two to potentially set off a pandemic.

“The viruses that are in circulation now are much more mammalian-like,” Kawaoka explained. “The viruses that are circulating in Africa and Europe are the ones closest to becoming a human virus.”

“Let me make this very clear - it’s no longer a question of whether” there’s going to be a pandemic—“it is going to happen,” Osterholm declared.

“It’s going to happen,” agreed Dr. Sandra Schneider, professor and chair of the Department of Emergency Medicine, University of Rochester [New York] Medical Center.

“We think it will happen sometime, but we don’t know when or where,” confirmed Nabarro.

“The risk of an avian influenza pandemic is still with us,” WHO Director General Margaret Chan warned at a conference in China in November.

Chan urged public health authorities to “not let your guards down.” She, like other pandemic authorities, was worried about the creeping complacency toward the threat since the blitz of attention it was given in 2005-06.

“We can’t let pandemic fatigue get the best of us,” even though “there will be days when people look at you as if you were one brick short of a load,” Osterholm said.

Shortchanging care

“Certainly progress has been made, but we’ve still got a long way to go,” said Richard Hamburg, director of government relations for Trust for America’s Health.

At the apex of concern, the Bush administration proposed $7 billion for preparedness. Congress responded with less than half that amount in an emergency supplemental spending bill. Congress appropriated another $2.3 billion in another supplemental spending bill in June 2006.

Another $650 million for pandemic preparedness was included in an emergency spending bill Bush vetoed last spring because it included a timetable for withdrawal from Iraq. Congress came up with compromise legislation the president signed, but without the additional funding for pandemic readiness. The money was to aid in buying vaccines, antivirals, other medical supplies and diagnostic and surveillance tools.

Hamburg is “concerned … there will be no additional funding” for pandemic preparedness. “Unless Congress acts, there’s no more money for pandemic preparedness” in the pipeline. “What we’ve got may be what we’ve got!” Hamburg told HSToday.

Less than half a billion dollars of existing pandemic preparedness funding initially was earmarked to help states prepare. Another $250 million was designated for state and local capacity-building last year in a compromise bill between the Senate, which proposed $300 million, and the House, which proposed nothing.

Many state homeland security and health department directors have complained that the appropriations they received amounts to a pittance. For example, out of the original $300 million in Virginia, Loudoun County received $48,000, Prince William County $66,000 and heavily populated Fairfax County $125,000. In those three counties, the money did little other than buy materials to educate the public.

Vaccine assurance

A vaccine is the closest thing to salvation from a pandemic. But because the only reliable vaccine must be made from the pandemic flu strain, the first batch—an estimated 600 million to 1 billion doses for the entire planet if a pandemic were to occur today—won’t be available until, at best, six months into the pandemic, long after the first, maybe even the second, wave of infections.

Nabarro said it’s likely there will be “three to six monthly interval waves,” causing reinfection in previously infected areas.

The Department of Health and Human Services’ (HHS) Pandemic Preparedness Plan outlines a goal to establish pre-pandemic influenza vaccine stockpiles for 20 million in the critical workforce and the expansion of domestic pandemic vaccine manufacturing surge capacity for 300 million persons within six months of the onset of a pandemic.

The efficacy of a pre-pandemic vaccine, though, is uncertain. According to a CDC statement, “There is no guarantee [a pre-pandemic vaccine] will be effective against the emerging pandemic strain.”