In late May 2008, the summer Olympics in China were officially canceled, and in the beginning of June, the first cases of the new H5N1 strain started to surface internationally. The first significant virus clusters appeared nearly simultaneously in Siberia, Mongolia, India, Japan, Korea, Singapore, Indonesia, Australia and other countries along the western Pacific Ocean rim. However, hundreds of confirmed and suspected cases, or contained mini-clusters had already been reported worldwide.
The world braced for the seemingly unavoidable pandemic. New cases and confirmed virus clusters continued to appear worldwide, starting and spreading mostly in Southeast Asia during June and July, and eventually surfacing in the Americas, Africa and Europe by early August. Although isolated cases or mini-clusters appeared on all continents during late May and June, the spread of significant virus clusters progressed slowly over the summer, reaching all corners of the globe by early August. These significant clusters of flu cases represented the largest virus footholds and posed the greatest pandemic containment challenges. Consequently, these clusters received the bulk of WHO resources and attention.
However, as nations scrambled to contain the growing threat within their own borders, resources began to focus inward, leaving less fortunate nations with a drastically reduced capacity to handle the containment and treatment of the H5N1 pandemic.
Despite these shortcomings, the avian flu of 2008 was marked by a strikingly lower case fatality rate than expected, exhibiting a lower virulence than the previously seen strains. Additionally, it proved to be less contagious. These two key features, combined with both an effective international response and expansive vaccine program, produced a lower than expected worldwide transmission rate.
Nature’s gifts aside, contingency plans had been formulated by the WHO and funded by the international community since 2006, providing several key safeguards that mitigated the deadly effects of the 2008 H5N1 virus. Most effective were the severe and strictly-imposed travel bans with known or suspected areas of infection. The initial restriction against Chinese travel, imposed and robustly enforced by major world governments, made later restrictions throughout the world easier to impose and execute.
With the taboo broken, long-term diplomacy and inaction were set aside in the interest of international safety and security. Even the smallest and least influential nations had little trouble denying travel from areas with known or suspected avian flu virus. The United Nations fully supported any such measures with the immediate promise of military enforcement and indefinite sanctions, providing the needed leverage to ensure compliance and ultimately preventing a true decimation of the world’s population.
Simultaneously in early May, the WHO implemented an ardently proactive system of detecting, tracking and responding to suspected avian flu cases, sending vast resources across the globe to meet the pandemic threat.
The WHO pandemic surveillance and response plans proved effective throughout the summer and fall, however, completely containing the virus proved difficult even in the best of situations. H5N1 virus continued to propagate in a limited capacity, frequently escaping one containment zone (usually before full containment was imposed) and starting another cluster of cases in a nearby, geographically accessible area. Sometimes, the virus managed to travel much further, due mainly to the very devious nature of the flu virus. Infected individuals often showed no signs of infection or remained asymptomatic for 2-3 days after infection, but could be highly contagious to anyone that came into close contact with them. In this way, infected individuals shed the virus, while appearing perfectly healthy, and could often slip out of containment zones without knowledge of the danger they posed to their surroundings.
Despite these difficulties, WHO response procedures, combined with an aggressive vaccine program, kept the pandemic from achieving anything close to its full deadly potential. By early September, vaccine production exceeded expectations, and vaccine shipments followed two distinct patterns:
(1) routine and planned distribution according to pre-2008 WHO-sanctioned rationing guidelines.
(2) hot-zone containment distribution, where excess shipments were directed to areas with very high potential for an uncontrollable outbreak. These locations were identified early, and vaccinations commenced immediately for high-risk population groups and essential service personnel. Since the H5N1 vaccine required nearly 4-6 weeks to provide complete immunity, hot-zone vaccination procedures commenced early in high-risk zones.
The fall of 2008 proved to be tense worldwide. While most of the significant clusters were controlled and contained by WHO procedures, a few notable exceptions occurred, providing chilling insight into the potential of the H5N1 virus. In early September, avian flu virus massively broke free of containment in Karachi, Pakistan, and spread like wildfire throughout the country. The breakout resulted from overcrowding under dismal health conditions combined with a dysfunctional government-provided healthcare system. Pakistani residents began to flee toward the Indian border, fearful that the outbreak would escalate even further beyond government and WHO control.
Unsurprisingly, tensions mounted with India, where several large cluster outbreaks had already taxed the Indian system to the brink of failure. In late September, when massive waves of Pakistani refugees swarmed the Indian-Pakistani border, mostly via land, a brutal and severe Indian military response kept the pandemic refugees from overwhelming India’s own desperate situation. The ensuing hostilities between India and Pakistan were immediately addressed by the United Nations Peace-Keeping Arm, with the aim of preventing both a conventional or nuclear escalation. By the end of the pandemic in late spring of 2009, 6.8 million Pakistanis died from pandemic-blamed causes. Relations between Pakistan and India remain tense to this day.
In October, the pandemic situation in Mexico City failed. WHO teams and Mexican health officials were overwhelmed by the sheer volume of cases spreading among the most densely populated and poverty-stricken areas of the capital city, where containment, social distancing and quarantine procedures proved impossible. Fortunately, strict and effective containment efforts outside of the Valley of Mexico kept the severe outbreak contained within the Mexico City Metropolitan Zone. Sadly, flu casualties in Mexico City reached an estimated 1.5 million. In 2008, the Mexico City Metropolitan Zone had a population of nearly 21 million people.
Simultaneously in October, a nearly uncontainable outbreak erupted in Serbia, due mainly to the near impossibility of cooperation between Serbian national government officials and the UN-backed WHO teams. Negative Serbian nationalist sentiment toward major UN charter members, stemming mainly from UN charter member support of Kosovo’s declaration of sovereignty in February 2008, stalled the timely activation of WHO plans within Serbia.
Once it became clear to the international community and surrounding Balkan states that this outbreak posed a serious threat in several geographic directions, the United Nations coordinated a mobilization and deployment of Balkan military forces to push well into Serbian borders, on all fronts, to assist with the formation of an effective containment zone. Once this zone was established, WHO teams, backed by UN security, entered the zone and started the long process of reestablishing control of the pandemic situation. Estimated losses in Serbia hovered near 545,000. The population of Serbia prior to the 2008 pandemic was approximately 10 million.
In each of these cases, outbreaks reached near full epidemic levels in the cutoff hot zones, with a 6-10% case fatality rate among those infected with the H5N1 virus. Interestingly, in each of these cases, a near complete loss of national and local government control ensued, catapulting each area into complete chaos. Nearly all services ceased to exist, including electricity, food, water, police, and health care services. As a result, civil disobedience, rioting, looting and general disorder reigned, requiring large-scale military and civil affairs interventions from neighboring countries. These cases were frightening glimpses of the true devastating potential of a pandemic.
In stark con
trast to these situations, pandemic chaos was prevented in the most unlikely and unstable area of the world, Iraq. Positive, unexpected gains materialized in Iraq during the pandemic. As part of the U.S. vaccine rationing protocol, all forward-deployed members of the military received the earliest available H5N1 vaccine, with a higher priority classification for the units already deployed, or soon to be deployed to combat zones in the Middle East or Afghanistan. Additionally, coalition forces in Iraq and Afghanistan were given WHO authority to receive, stockpile and distribute WHO vaccine allotments to the local populations, in response to the present pandemic threat. Coalition forces received detailed WHO pandemic containment training, widely disseminating this training to civil affairs and medical assets throughout Iraq.
As a result, an extremely effective vaccination and pandemic containment policy was established and executed in Iraq and Afghanistan, effectively blunting the spread of H5N1 in these areas. In both cases, the presence of an organized, disciplined and capable force, with an established and effective command and control (C2) network, resulted in the effective implementation of promulgated WHO procedures. The coalition mission in both nations transformed within weeks from a robust anti-insurgency and democratization campaign to one of the most successful humanitarian operations in history.
In Iraq, at the beginning of this transition, Al-Qaeda-backed insurgent groups escalated the level of violence against coalition forces, civilians and healthcare providers, in the hope of fomenting a final and overwhelming revolt against the coalition forces. Their timing could not have been worse. The attacks, clearly aimed at disrupting the coalition and government efforts to safeguard Iraqi lives, immediately erased all remaining tolerance of insurgent violence toward civilians and pandemic containment efforts. Tribal leaders, militia commanders, and local Iraqi leaders, both Sunni and Shiite, joined together in a rare and momentous condemnation of Al-Qaeda. Immediately following, a representative delegation of these leaders reached a tentative cooperative agreement with leaders of the coalition forces and the Iraqi government.
While the war against the pandemic raged throughout the world, a new war against Al-Qaeda-backed insurgents mounted in Iraq. Coalition forces, backed by Iraqi military forces and guided by a new army of local tribal militia, routed insurgent forces from all of their strongholds, sending the few survivors scurrying toward either Iran or Syria, where little refuge awaited them. By late spring of 2009, the Iraqi insurgency was declared dead by coalition commanders, the Iraqi president, and major Iraqi tribal leaders.
Afghanistan’s Al-Qaeda-backed pro-Taliban elements were similarly driven from all major strongholds back into the mountains bordering Pakistan, where they would remain in obscurity. During late July of 2009, the U.S. administration, with the full backing of the senior U.S. commander in Iraq, declared that U.S. troops would begin a significant redeployment from Iraq by early in the fall of 2009. These troop withdrawals would coincide with the 2009 presidential election, which been delayed due to the state of worldwide and national emergency caused by the pandemic.
The WHO plan routed the H5N1 strain by late December 2008, and wave 1 of the 2008 avian flu pandemic disappeared in January 2009. Vaccination production continued at an unprecedented pace, with nearly 2 billion doses distributed by the beginning of February 2009. By May 2009, wave 2 of the deadly H5N1 strain was declared ineffective and unlikely to further cause pandemic illness. By this point, roughly 40% of the world’s population had either been vaccinated or exposed (survived and now immune) to the avian flu, and the strain could no longer succeed at large-scale epidemic levels. The vaccination, surveillance and containment plans set forth by the WHO successfully met the challenge of the H5N1 virus. Most importantly, faced with an undiscriminating worldwide threat, the international community rapidly assembled and decisively acted to implement a plan to prevent the virus from reaching its true pandemic potential.
Still, worldwide death figures were grim. Nearly 49.8 million people died directly from flu-related causes, with another estimated 500-600 thousand deaths blamed on indirect causes such as rioting, starvation and famine. Southeast Asia accounted for a vast majority of the deaths, with China alone losing nearly 25.1 million of its citizens. Other highly-populated areas of Asia suffered high death counts, including over 4 million in India, 3.5 million in Pakistan, and at least 8 million spread throughout the western Pacific Rim (Koreas, Vietnam, Malaysia, Indonesia, Japan and Australia). The remaining 7-9 million deaths were spread among the Americas, Africa and Europe.
U.S. deaths remained relatively low considering a population of more than 300 million. For 2008 and 2009, within the U.S. and its territories, close to 112,000 deaths were officially attributed to the H5N1 virus. As a comparison, in any typical year, nearly 35,000-50,000 people die from seasonal flu-related complications in the U.S. Most of these deaths were geographically clustered in highly-populated regions along the west coast, particularly around San Diego, Los Angeles, San Francisco and Seattle. Several other major U.S. cities, including Dallas/Fort Worth, Atlanta, Chicago, St Louis, Denver, and the New Jersey/NYC metro area, suffered medium-sized cluster outbreaks, spreading to nearby communities and towns in the form of small cluster outbreaks. Fortunately, containment and vaccination efforts within the U.S. kept all major outbreaks from uncontrolled spread into the general population stream.
Despite these casualty figures, the WHO declared the international community’s handling of the 2008 avian flu pandemic to be a success, but not all members of the international community were immediately included in this celebration. Several countries blamed China’s cover-up as the main culprit for the pandemic outbreak, proposing that if China had immediately cooperated with the WHO at the outset of their epidemic, the virus could have been mostly contained within China.
WHO officials were reluctant to support this claim, fearful of pushing the Chinese away from future cooperation. In a summary report, WHO officials admitted it was likely that the H5N1 virus would have eventually escaped even the tightest containment efforts within China, regardless of WHO involvement. However, their report did draw attention to the 3-4 week delay to international pandemic response time caused by the Chinese cover-up. The report even speculated that millions of lives may have been spared if earlier notice of the pending pandemic had been released by the Chinese government, regardless of whether China accepted international assistance.
To underscore the serious threat posed by China’s actions, WHO officials theorized that given the avian flu’s deadly characteristics, the final estimated death figures represented a fraction of the pandemic’s potential killing capacity, and that without the quick international implementation of the WHO plan, casualties rates could have been multiplied tenfold. Their remarks were carefully crafted to put China on notice. This proved to be an incendiary comment, and parts of it were soon to be retracted by the WHO.
The Chinese decried the report, attempting to reinforce the position that their containment procedures and tactics should serve as a future WHO model, and that 100% containment remains impossible given the unpredictable nature of flu transmission. Addressing the issue of their reporting delay, they also dismissed the notion that lives could have been spared, as an anti-Chinese, non-scientifically based hypothesis. A feeble attempt to explain the delay followed, citing confusion between widespread swine strep cases and the H5N1 virus hiding in its shadows.
The WHO, CDC and most nations’ health and disease organizations continued to declare the cooperative international response to the H5N1 pandemic as a model of success. Similarly, most scientific experts in related fields of study agreed that the system and protocols activated in 2008 by the WHO, if supported by the global community, would adequately prevent a future worldwide pandemic disaster. These experts, whose ranks were filled by government scientists, government health officials, government planners, and leading scientists in disease/virology, further forwarded a hypothesis that if a future pandemic threat is reported early enough to the WH
O, the next threat could be more effectively handled at its point of origin.
These experts acknowledged that even the quickest and most effective containment could not completely prevent a pandemic threat from escaping into the world. However, they theorized that with a rapid and overwhelming international response at the point of origin, the pandemic would spread at a very slow and controlled rate, similar to the cluster outbreaks seen outside of China, and arguably on a much smaller scale.
With an overwhelming consensus of the international scientific community’s support, the WHO requested additional resources from member nations. The requested resources included increased funding, enhanced vaccine research and production capability, and the augmentation of personnel to support nearly a 30% organizational expansion. The WHO received unfettered access to what it requested, and by the beginning of 2010, boasted an even more robust and effective capability to handle future pandemic threats. Throughout 2010, the specter of a global pandemic threat quickly faded from the world’s general consciousness.
However, not all scientists were convinced that the threat of a devastating pandemic had been vanquished. From early 2009, skeptics quickly highlighted that the avian flu pandemic of 2008 only yielded a quarter of the deaths caused by the Spanish flu of 1918. Casualty estimates for the 1918 flu range from 50-120 million deaths worldwide. For many, this comparison served as a basis for declaring the pandemic efforts of 2008 to be an unqualified success; however, a smaller group saw the 1918 figures as cause for further alarm.
These skeptics, comprised of a small number of virologists, epidemiologists, public planning experts and assorted international academia, championed a minority opinion, casting serious doubt on the capability of the WHO and the world community to handle the next pandemic. Needless to say, their views were not popular in the WHO-dominated aftermath of the 2008 pandemic. Their theories were similarly unpopular with most national governments and public officials, due to the alarmist and potentially panic-inducing nature of their scientific claims. With little official support, these experts cast their lots together and formed an organization dedicated to educating the public, further promoting international pandemic awareness and lobbying major governments to increase preparation for a deadlier, more difficult pandemic.
The Jakarta Pandemic Page 51