Six years after the Covid pandemic began, we are still locked in three of the five phases of the so-called typical response to the pandemic, as described in one. Recent Opinion Articles. Those three stages are: ignoring and denying (Stage 1), getting angry and finding a scapegoat (Stage 4), and forgetting (Stage 5). The authors belatedly call for a national commission to examine the COVID experience, which is unlikely to happen in our politically divided world.
But I couldn’t agree more that we are completely unprepared for the next pathogen. For now, one threat remains: bird flu.
I want to ask senior public health leaders to discuss the feasibility of a robust response strategy based on accurate point-of-care testing for new bird flu strains and using the ring strategy to reduce the spread. Our current single warning and response system, while necessary, is inadequate.
bird flu situation
We should all worry about this 200 million domestic poultry Are affected from 2022; including mammals elephant sealshas been destroyed; And That dead swans washed ashore On the Long Island coast, most likely died from highly pathogenic avian influenza (H5N1 or bird flu).
to date, infection in humans Most have been “mild”. But not all. More than 70 cases of bird flu have been reported since 2024, including two deaths. and this The virus keeps mutating.
So far, we have been lucky.
testing and feedback
What is our current strategy to screen bird flu patients? CDC recommends In an effort to look for bird flu or other new variants, a more detailed analysis of patients hospitalized with influenza A has been completed at the State Virology Reference Laboratory. This is a highly accurate form of testing, but time consuming. I think some academic medical centers are also testing the H5 novel strain.
Meanwhile, rapid point-of-care tests are generally being used only in a limited way. While the science of rapid testing has progressed and now includes more sensitive antigen tests – and also more rapid molecular and PCR tests – there has been only limited deployment of these, as far as I know. Perhaps in the future there will be a possibility of a handheld device that incorporates molecular amplification, but we are not there yet.
Is our current first line of defense – the only line – sufficient?
If bird flu mutates, expands, and spreads more effectively to humans, it will likely occur near poultry farms, dairy cow herds, or pig farms located in rural areas. However, hospitals, medical clinics and state virology laboratories today, especially in those places, are more under-resourced than in 2020 and even last year. Our current first line of defense, while necessary, is inadequate.
Why wait for a declared emergency and then activate the Emergency Use Authorization (EUA) process, with its inherent chaos, when we are only a few molecular variations away from the possibility of a pandemic? There are several US companies that have rapid point-of-care H5N1 tests in advanced development (One has been approved by the FDA) and a growing number of free-standing laboratory-based instruments capable of 1-hour molecular or PCR testing are available.
One Ring Strategy for Bird Flu
A rapid deployment team can be organized by Epidemic Intelligence Service infectious disease detectives and deployed in two different scenarios: 1) an outbreak that begins within the US and/or 2) an outbreak outside the US
In the first case, rapid point-of-care tests will be deployed in a “ring” around the patient’s “zero”. Essentially, the concept of the ring strategy is to stop the spread of the disease by isolating, testing, monitoring or vaccinating close contacts of infected individuals to create a buffer of immunity around the outbreak. ring strategy It has been used for diagnosis, treatment and vaccination. But, to the best of my knowledge, this has not been fully implemented as part of the pandemic strategy.
Point-of-care testing kits will be distributed to all emergency departments and clinical sites within a radius around the initial areas of concern (usually work and home). Another ring may be needed if the patient is transferred to a regional medical center. A free-standing rapid PCR testing equipment can be deployed at the nearest regional facility to confirm the diagnosis. Coordination with local public health, state virology reference laboratories, and the Governor’s office will be necessary. Early mitigation is the goal. therapy with antivirals Starting at the point of diagnosis. Those who test negative will remain in self-quarantine and will be given two additional point-of-care tests to be used later that day and the next morning. They will get the results through smartphone app.
In the second scenario, the team will be deployed in a semi-circle at entry points at international airports, cruise ship landing ports and border entry points. Rapid tests will be conducted on all flights going to America. The rapid test will include influenza A, B and H5 (bird flu). To reduce false negatives, tests will be run 90 minutes before landing. Helicopters will deliver testing kits to cruise ships. People with positive screening tests will be isolated before passport control. Those who refuse testing will be denied entry, and given a second chance to test. Then, to reduce false negatives, people who tested negative from all sites will be discharged, given two additional test kits to be used later that day and the next morning while they self-quarantine. They will call their results case officer or use a smartphone app.
A few possible triggers will initiate this event. A hospitalized patient with influenza A who is positive for H5 and whose immediate contacts are developing respiratory symptoms. Another would be if a farm or wild animal has a local cluster of flu-like cases outside of flu season. A third reason would be large numbers of domestic mammals falling ill or dying, especially in dairy herds and pig farms.
Once bird flu is diagnosed, the deployed team will focus on initiating dual therapy. Fortunately, two anti-influenza, oral medications are FDA approved and available. The target will be all influenza patients in the area, and all people in close contact with the patient of concern, as determined by the rapid response team.
We need federal leadership to create such a program. Regional state coalitions will not have the organizational or coordination capabilities to do this. Such a warning and intervention system would require significant work and resources, including formal FDA approval for more rapid tests, funding for manufacturing start-up supplies, real-world field testing, and development of rapid data systems. I think the medical community will support this initiative to create a second line warning system and will “flock” to help.
Daniel Terrace, MD, is a retired faculty member of Tufts University School of Medicine in Boston and a critical care physician.
