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Last Updated: Monday, 7 November 2005, 18:26 GMT
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The following is a transcript of Panorama's "Bird Flu - Facing the pandemic", first broadcast on 6 November 2005 on BBC One at 22:15 GMT

NB: THIS TRANSCRIPT WAS TYPED FROM A TRANSCRIPTION UNIT RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT: BECAUSE OF THE POSSIBILITY OF MIS-HEARING AND THE DIFFICULTY, IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS ACCURACY.


JANE CORBIN: There's a country in the Far East which is living through what we all fear. Panorama has been to Vietnam to meet the families of bird flu victims. We hear from the British doctor who's treating patients with the disease, and the health worker who caught it and survived. Only 62 people worldwide have died from bird flu, so should we be scared it could spark a global outbreak, and if it does, how well prepared is Britain? How will we all react facing the spectre of a flu pandemic?

Dawn in the Mekong Delta. The start of a journey to discover what the family of Vietnam's latest victim of bird flu have been through. This virulent disease has killed 41 people in this country, more than anywhere. Experts fear this could be the place which sparks off a global pandemic. Nguyen Thanh and her mother-in-law still run a roadside stall selling food to travellers. Mrs Thanh's husband helped her run the business until the day he was suddenly taken ill this July. Phan Van Lieu had butchered a chicken at home that day, a cockfighting bird. Afterwards he invited two friends to eat it with him.

NGUYEN THI THANH

That day he had a party at home. I wasn't there. He ate chicken. Over the next 5-6 days he developed a fever, cold and headache. He felt pain throughout his body. I said you wont get better unless you go to hospital.

CORBIN: Neither of the other men who had eaten the bird was affected. No one suspected the cockerel was the source of Phan Van Lieu's mystery illness which rapidly grew worse.

THANH: In the middle of the night he started deteriorating, so I called the doctor and he put him on oxygen. The next morning they gave him an injection. Sometimes he was exhausted, sometimes a little better. CORBIN: Mrs Thanh began to realise her husband's life was in danger, he needed specialist care.

THANH: But when I asked to transfer him to the city, the doctor said it's a race against time. In the afternoon I watched him grow weaker and weaker. He lost his life that day.

CORBIN: Three quarters of the cases of bird flu in people worldwide have occurred in Vietnam. Many of the victims have been brought to one hospital in the southern city of Ho Chi Minh. I went there to meet a British doctor who's lived and worked here for ten years. Jeremy Farrar has witnessed the devastation caused by the H5N1 bird flu virus. We have no natural defences against it and the body's immune reaction literally destroys the lungs. JEREMY FARRAR: So this is the chest X-ray of a normal patient. You can see the ribs here, and if you can see the black areas in between, this is where we breathe through, this is where we take in oxygen and breathe out carbon dioxide and we need this, of course, to live.

CORBIN: And then what happens in the patient with H5N1 virus?

FARRAR: So this is now a patient who was admitted in January with H5N1 and you can see that on admission to this hospital, already you can see the vast difference. The black areas of the right lung have now been completely destroyed by the virus, and so there's very little gas exchange, very little oxygen exchange going on in this lung. CORBIN: This bit.. the dark bit over here?

FARRAR: You can see this patient still had a little bit of lung that was working okay, and in fact this patient came into hospital breathing on their own, without any assistance from us. But you can see about two days later you can see there's an horrendous progression of the disease. So by now the whole of the lung tissue is destroyed, so both the right lung and the left lung now are completely damaged by the virus.

CORBIN: So essentially this patient is now.. the lungs have been destroyed. FARRAR: So there is essentially no lung there and the patient now is no longer able to breathe for themselves.

CORBIN: And what happened to that patient?

FARRAR: And this patient died about a day after this X-ray was taken. CORBIN: All serious influenza viruses originate in birds. In Vietnam the poultry population has exploded in recent years, a cheap source of protein in this fast developing nation. People live cheek by jowl with their poultry. Cockfighting is just one way in which humans and their birds are brought into close contact. The greatest danger is when butchering birds infected with the flu virus. People can breathe in droplets of blood, saliva or faeces. It's thought eating infected poultry that's not properly cooked can be a way of catching the disease. Ducks in particular are reservoirs. They often carry it without showing any signs of ill health. This new virulent strain of bird flu has become endemic in flocks in Vietnam.

Winter is approaching and the flu season is about to start. At present Dr Farrar and the medical staff are caring for patients with malaria and dengue fever but they expect to soon see a new wave of bird flu cases. Dr JEREMY FARRAR Director, Clinical Research Unit Hospital for Tropical Diseases, Ho Chi Minh

I think we have to assume it's going to happen and in Hanoi and in Hiroshima city the various authorities and we in the clinical and research community are assuming it's going to happen and are trying to prepare for that. CORBIN: This lethal flu strain first jumped from bird to human in Honk Kong 8 years ago. It died down but then re-emerged in China. There have been 122 confirmed cases in Vietnam, Cambodia, Thailand and Indonesia in the past three years. They raised the spectre of 1918. The last great pandemic sparked by a virulent bird flu infected half the world's population during the First World War. It killed up to 50 million people in three distinct global waves of disease. Flue pandemics are natural phenomenon, there have been two lesser outbreaks last century. Professor John Oxford has researched the origins of the virus that caused the 1918 pandemic. He's exhumed bodies preserved in the permafrost of Norway, to take samples of lung tissue to isolate the bird flue strain that began in an army camp in northern France. PROF. JOHN OXFORD : We think it broke out in the camp, and it started slowly, that's why we have to be so careful now, you know.. in the first months there were 50 cases. It had, in the near vicinity, geese, swans, ducks, chickens.

CORBIN: So those are soldiers.. what, buying geese to eat?

OXFORD: Yes, in the live goose market.. chicken market in the nearby village.

CORBIN: And of course geese have been carriers of this avian flu virus.

MAN: Yes.

CORBIN: Like the flu bird today, the 1918 strain took its heaviest toll on young healthy adults, not the elderly who had better immunity.

Professor JOHN OXFORD Virologist Queen Mary's School of Medicine, London

These samples were taken, it's a piece of lung from a victim from the 1918 pandemic. So we can come along all these years later, my colleagues in the United States, have reconstructed the virus totally from those genes.

CORBIN: And when you look at the genetic footprint of the 1918 virus in that, and you look at the virus today that we're so concerned about, do you see similarities? OXFORD: Unfortunately you do see similarities. I say unfortunately because it's again another warning. This H5N1 has a little too likeness, to my way of thinking, to the 1918 virus.

CORBIN: So far the H5N1 bird flu virus has only infected a person on 122 documented occasions, it hasn't spread beyond those people. Global pandemics occur when a flu virus finds a way to transmit easily from person to person. To do that the H5N1 virus either needs to change gradually, as happened in 1918, or to mix with a seasonal human flu virus inside a person. Either route could create a highly contagious and deadly strain.

Sir LIAM DONALDSON Chief Medical Officer Department of Health

It has been around for 5 or 6 years. We've had 60 deaths, probably a billion people have been exposed to it, so at the moment it's not showing any signs of mutating into a human strain, or mixing with a human flu virus, but it could happen in the short-term or it might be quite a long time before it happened, or even a third scenario it could be an entirely different bird flu strain that we don't yet know about. So all of those scenarios are possible.

CORBIN: An epidemiologist at Oxford University, Professor Angela McLean, has studied the pattern of infectious diseases and their effect on society. The longer between flu pandemics, the less immunity there is in the population. Professor McLean plans to send her children to the country, to try and protect them from the first wave of infection if a pandemic breaks out.

Professor ANGELA McLEAN Epidemiologist University of Oxford

The first wave of the epidemic is a bad one, and you'd expect it to be quite short. You expect it to last about 3 months and then things to go quiet again, for reasons that aren't entirely clear, and then for there to be other waves later. The pandemic could last for several years in different ways, but hopefully, as you get further into the pandemic, control will be much, much better. So yeah, I'm prepared to take three months out of my kids' education in order to protect them.

CORBIN: But isn't this all scare mongering? People are very afraid of this and it might not happen. It's been about to happen for some time with the warnings, but it might not happen at all.

McLEAN: I think it will happen, the question is when. It might not happen soon, that's right, but the problem is, if it does happen, it could be so bad. I hate scaremongering, I really do, but the fact is that very often with emerging infections, we've been in denial actually, and then things have turned out really bad.

CORBIN: Vietnam with 80 million people, and a huge reservoir of H5N1 in poultry is at risk of a serious outbreak. Each new case of bird flu in a person gives the virus a new opportunity to change into something able to pass easily from person to person, the pre-condition for a pandemic and what's been happening in this population in recent months raises the disturbing possibility that the virus is mutating. We visited Hanoi's Infectious Diseases Hospital where doctors saw 33 bird flu patients last year from across northern Vietnam.

DOCTOR: [giving tour of hospital] This area for isolation special. CORBIN: So far the medical staff haven't considered there's a high risk to them from nursing such patients. But now they worry, there are signs the virus is evolving.

Dr NGUYEN DUC HIEN Director, Institute of Tropical Diseases Bach Mai Hospital

The virus which causes this illness can change its form, and it's strain. Sometimes it makes the disease worse, sometimes less severe. We already sent our samples to some other countries to test, and the results show that the virus had changed at the end of last season's epidemic.

CORBIN: In the past year nearly three times as many Vietnamese have caught the bird flu virus as in the previous year, but more are surviving. But to the British doctor who has watched it spread here in the past two years, that is hardly reassuring.

Dr JEREMY FARRAR Director, Clinical Research Unit Hospital for Tropical Diseases, Ho Chi Minh

In this virus, so far, 50 or 60 percent of people who get the infection die, and of course that virus dies with that patient, and it's absolutely tragic for the patient and their family but in terms of spreading the virus to other people, it's actually very good news at a population level because that virus can't go on The worry would be if the virus started killing slightly fewer people, but infected more, then we have what we had in 1918 and then we have the chance for a global pandemic. CORBIN: As I found out, travelling around Vietnam, there are now what doctors call cluster cases, groups of survivors. These are human hosts which give the virus a chance to live on, and in the process change to become better at infecting other people. South of Hanoi in the rice growing district of Tai Bin, I met a family, some of whom had suffered from bird flu but lived to tell their story. It's been 9 months since Nguyen Sy Tuan was well enough to carry out simple household tasks. Not since the night in February, he arrived home to celebrate a family holiday with his parents and his sisters.

NGUYEN SY TUAN

On about the 4th, the Chinese New Year, I'd been out with some friends. When I came back I saw my parents slaughtering chickens. They'd almost finished but I helped them, since on that day we had our ancestor worshipping ceremony. Then on the 5th, I had a temperature.

NGUYEN THI NHAM

When we were at home in the evening he said: "Mum I have a fever and it's almost unbearable. There is pain throughout my whole body." I saw his face and his body turning red.

CORBIN: Tuan was taken to the local hospital and then to Hanoi where he grew worse.

TUAN: I found it difficult to breathe. I had a high fever and a feeling of tiredness in my arms and legs.

CORBIN: Then Tuan's younger sister, Nguyen, fell ill, though with less severe symptoms. In Vietnam the H5N1 virus, like the 1918 one, has attacked more young healthy adults than the old and children.

NGUYEN THI NGOAN

In the night, as soon as my brother, Tuan, came to Hanoi, I too had a fever.

CORBIN: Perhaps surprisingly, their older sister, Nhung, pregnant at the time, was unaffected, though she nursed Tuan in hospital.

NGUYEN THI NHUNG

When Tuan got the fever and was taken to the hospital, I went there to help him, and all during the time he was in the hospital I was there with him, but I didn't get sick.

CORBIN: And Tuan's parents were unaffected by the virus, though they'd been involved in slaughtering the sick chicken, and the whole family had eaten it.

NGUYEN SY NHAM

Before what happened to my two children, people ate chicken, ducks, all sorts of poultry, but afterwards people were more alert. They put dead chickens in sacks, dug deep holes to bury them. Around here, some families even bury chickens alive, they didn't eat them. Now time has passed and people see nothing happening, so they eat chicken as usual.

CORBIN: No one can say for sure if Tuan's sister caught bird flu from him, or if the chicken was the source, but this cluster case and similar ones in neighbouring countries in the Far East has the experts worried.

Do these cluster cases give us perhaps a clue as to whether or not this virus is more likely to jump human to human and that we should therefore worry about that?

Dr JEREMY FARRAR Director, Clinical Research Unit Hospital for Tropical Diseases, Ho Chi Minh

Yes, I think if you were guessing what would happen with an avian influenza coming across into a human population, I think you would predict that you would have lots of chickens, lots of ducks, dying of an avian influenza spread over a very large geographical area. And then within that geographical area occasionally you would see a human case, on its own, isolated, maybe in a family and no other family members affected. The next stage would be you would maybe start to see clustering occur, and by that I mean more than one patient occurring within a family. At the moment that may well represent common exposure to a virus.

CORBIN: Rather than one human being catching it from another.

FARRAR: Rather than one human being¿ but I'm a natural optimist and you could interpret the same data and say this is inefficient, limited, human-to-human transmission, and you cannot tell the difference at the moment.

CORBIN: In one Hanoi hospital they have already had a case of a doctor catching H5N1 even though he hadn't been exposed to an infected bird. In March Dr Hoi developed a nasty cough which persisted for two months. Tests on him proved positive for the H5N1 virus. But samples taken from his poultry at home proved negative.

Dr NGUYEN THANH HOI Bach Mai Hospital I think my only contact was with the bird flu patients on the ward. At home we have several chickens and one duck for eggs, and all the time they had no symptoms of bird flu. When I discovered I had the symptoms, I asked our authorities to test my family and the neighbours. All were negative. In my case it's hard to say what was the source of transmission, it's also hard to confirm that it was human-to-human transmission. But if it can be transferred between people, then it really is catastrophic and it will become a pandemic.

CORBIN: If a pandemic started in a Far Eastern country, it would very quickly spread beyond the region to threaten the whole world. Dr DAVID NABARRO Avian and Human Influenza Co-ordinator United Nations

From the start of the pandemic, which means the first appearance of the changed virus, through to it getting out of control, becoming like a forest fire, that's about 3-4 weeks. I mean it depends of course on the circumstances within which it happens, the location where it starts, and it also depends on the degree of crowding that there is. But that's the sort of time interval that we have. We will need to move very, very quickly in that time interval, and we have to also recognise that it will take possibly about a week to get the identity of the virus confirmed, so we may well have an even shorter timeframe in which we can actually get mobilised.

CORBIN: Internationally Britain is recognised as one of the countries best prepared to face a pandemic. The UK government has put a pandemic top of its list of threats, on a par with terrorism.

Sir LIAM DONALDSON Chief Medical Officer Department of Health

We need to be constantly alert and vigilant. It remains a realistic threat and it will remain a realistic threat, even if its five years away.

CORBIN: The Government is planning for 14 ½ million people, a quarter of the UK population, falling sick in the first three months wave of a pandemic. At it's peak, hospitals would have to deal with 20,000 new patients a week.

Dr Iain Stephenson, consultant in infectious diseases, is already seeing suspected cases of bird flu in travellers returning to the Midlands.

If you would like t put your questions on Bird Flu to the experts in next week's Panorama text us on 07736 100100

STEPHENSON: So you have a large number of people who come to the Far East and return often with respiratory symptoms.

CORBIN: Dr Stephenson showed me the precautionary procedures Leicester Royal Infirmary has for nursing patients in quarantine.

STEPHENSON: .. and then buy protection¿

CORBIN: Because this is a very virulent virus.

STEPHENSON: Avian influenza that we may have seen cases come back are a highly pathogenic and highly virulent virus, and so it's important to be protected if you're seeing patients that are just suspected or confirmed with the condition.

CORBIN: Leicester's 12 special negative pressure rooms serve a population of almost a million. They'd soon be full if a pandemic flu hit the Midlands, as with such beds across the country.

Dr IAIN STEPHENSON Infectious Diseases Consultant Leicester Royal Infirmary

If Pandemic flu arrives into the UK every hospital would be involved with patients are likely to be in such large numbers and we would not be able to isolate everybody in such facilities as this. The hospitals would have to put together plans as to how to cope, and so people will need to look at the organisation of triaging and keeping people out of hospital, you don't need to be here. But there's going to be a proportion of people who develop complications and become sick enough to require hospitalisation and we're going to need intensive care units respiratory wards and infectious diseases units to cope with that.

DONALDSON: In the last few years, as everybody is aware, a great deal of extra investment has gone into the NHS, building up to giving us one of the best publicly funded services in Europe, so the infrastructure of the NHS has expanded enormously in the last few years.

CORBIN: There's no extra money for the pandemic?

DONALDSON: Well no, but it will be a question of priorities within the existing NHS resources. If the pandemic comes, it will be a public health emergency, it will be an emergency for the NHS, and some of the work will need to be re-prioritised, and obviously some non-essential procedures would not take place on the time scale that they were originally scheduled, and the NHS would switch over into emergency mode, and it would deal with a public health emergency just as it would deal with any other sort of emergency that led to many more people becoming ill. CORBIN: Under the pandemic plan, the government assumption is that just under 54,000 would die but they estimate it could be as high as 750,000. Many of them would be under 65.

DONALDSON: The upper limit is, as you'll see from the plan, it's 750,000, it could be a lot lower than that. Our planning assumption is 50,000 or so but we work very flexibly, and if, when the virus emerges, the strain is more virulent than that and would lead to extra cases and deaths, then we will take that into account at the time.

CORBIN: Panorama brought together Dr Farrar from Vietnam with other British experts featured in this programme, to discuss the government's contingency plans and how we all might react in a pandemic.

Is there the risk that the NHS will be overwhelmed if it arrives on our shores?

Dr IAIN STEPHENSON Leicester Royal Infirmary

I think if the pandemic virus occurs this year, I think¿ in the next season, I think people are likely to agree that we are going to have major problems, it depends on how virulent the pandemic is, quite which age groups its particularly affecting. But there are certainly going to be problems with the NHS coping with cases coming into hospital with this.

Dr JEREMY FARRAR Hospital for Tropical Diseases, Ho Chi Minh

Of all the infectious diseases we know about, influenza is the one really that can cause a global pandemic which will affect everybody whether they're rich or poor, whether they live in London or whether they live Hiroshima City or Jakarta, we don't know how to stop it, we don't know how to prevent ourselves getting it and that's what makes a big worry.

CORBIN: With flu people can spread the virus without realising it. They're infectious for several days before they have symptoms. Computer models predict how a 21st century pandemic could spread through the world's major airport hubs in days.

D. Brockmann Maximum-Planck Institute [computer model]

FARRAR: Somewhere in the region of 150 to 200 thousand people daily fly to every major city in North America and Europe, and the risk there is that you're not just going to carry one person but you're going to potentially have multiple outbreaks in multiple cities.

CORBIN: So should we shut down our transport systems?

Professor ANGELA McLEAN University of Oxford

I think everyone who's looked at that has come to the conclusion that you might be able to slow things down rather marginally that way, and against that you have to balance the huge economic cost.

CORBIN: So you wouldn't actually stop it.

McLEAN: Oh no, you wouldn't stop it.

Professor JOHN OXFORD Queen Mary's School of Medicine, London

If and when this flu virus gets moving we're really going to have a problem, a medical and social problem, and we're going to have a panic problem, and that's the main reason for stocking up, for governments to prepare now is to stop panic actually. We do not want a New Orleans situation, and we saw what happened there. We don't want that all around the cities of the world as everyone gets into a flap. CORBIN: Have the government been slow to let people know, or do they risk raising a panic if they do inform them?

McLEAN: I don't think there's any harm in explaining to the people the difference between what we all think of as flu, and the proper viral infection is not like a bad cold, and it needs to be treated with real respect. People should understand that when they're told to stay at home when they have flu, it's to protect other people. It's because they represent a threat to others and that it's really your responsibility, once you're infected, to stay away from other people. CORBIN: And should schools be closed for example?

McLEAN: I think that rather depends on how badly whatever arrives. Remember we don't know what's going to come, how badly it affects children.

OXFORD: The thing about the children is, and this business of closing down schools, you have a huge then wave of other problems. You know, the schools close down, the mum has to stay home, the dad has to stay home, and so you're getting people ill in the work force but mum's home.. you know.. the thing gradually, the country gradually comes to a halt in¿. McLEAN: I agree. Children can do another thing as well of course which is that they can act as a focus for disseminating infection.

OXFORD: Oh yes, they can, yes, they can.

McLEAN; So I mean it think certainly, and it is already in the plan that the closure of schools would have to be considered.

CORBIN: Although cases of bird flu infecting humans have so far been limited to the Far East, the H5N1 virus itself has spread steadily westwards via migrating birds. This raises the fear a pandemic could start nearer home. Dutch virologist, Albert Osterhaus, first warned three years ago that bird flu would spread to Europe along flight paths used by migrating water fowl. ALBERT OSTERHAUS: We know that the big problem is here in South East Asia, and from here we saw that the virus spread probably through migratory birds, it spread all the way here to Mongolia, Siberia and also to Kazakhstan and.. well this is quite a move, and of course if the virus can come all the way from here to there, it's just a little hop to Western Europe.

CORBIN: Two years ago someone died in Holland when migrating birds infected domestic poultry and animal health workers with bird flu. Another strain as virulent as the H5N1 arrived via water fowl wintering in quiet canals in Gelderland.

How many chickens do you have, Jan?

JAN: Five and twenty thousand.

CORBIN: Twenty-five thousand.

The canals cross the heartland of the country's free range chicken industry where 90,000 chicken roamed in fields which brought them into contact with infected migratory birds. In February that year, an outbreak of bird flu began on Jan Van Kampen's farm. JAN VAN KAMPEN Poultry farmer

You could see they were ill. They were all hunched up, their feathers all ruffled. But most of all with this illness they were hawking, making a funny noise from their throats because their lungs were badly affected.

CORBIN: As chickens began to die, the authorities ordered a cull of 30 million birds. But it wasn't just chickens who got ill - 90 poultry workers and members of their families began to suffer, most with conjunctivitis, but some with mild flu-like symptoms. Most worrying of all, a vet who'd been taking samples from the chickens developed acute respiratory distress. Two weeks later Jan Bosch died raising the fear that once birds in Europe were infected, they could spread the disease to people.

Professor ALBERT OSTERHAUS Director, National Influenza Centre Erasmus University There was a lot of virus in his lungs, and this was this particular virus that had been seen in the chickens as well, although it had accumulated a number of mutations which we suspect, or actually we have evidence, that these mutations actually transformed the virus from a relatively low pathogenic virus for humans into a very pathogenic virus.

CORBIN: Three months ago, as concern grew that another virulent bird flu strain was moving westwards, the Dutch ordered all free range chickens to be kept indoors away from wild birds. OSTERHAUS: It only needs one bird to infect one flock of free range chickens in Europe to spark an outbreak, so I think there is a risk, we cannot estimate the risk at this moment, but the risk of something very terrible to happen, a draconic situation as we've seen it two years ago in the Netherlands where we had to cull more than 30 million chickens, yeah, that was a nightmare and we don't want that to happen again.

If you would like to put your questions on Bird Flu to the experts in next week's Panorama text us on 07736 100100

CORBIN: In the UK there is still no order from the government to bring free range chickens indoors. But the Dutch believe the precautions they've taken to protect their poultry industry and those who work in it have been vindicated. Three weeks ago the H5N1 virus was found in birds in Eastern Europe and Turkey. JAN: You can well imagine that people are scared that it could easily come here again and so you decide to minimise the risk and you keep the chickens inside.

CORBIN: Have recent events closer to our own shores, the appearance of the virus in migratory birds in Europe, the existence of dead parrots here in the UK, is it inevitable that this will end up on our own shores via birds?

Sir LIAM DONALDSON Chief Medical Officer Department of Health

Well I don't think it's inevitable that that will be the route, and indeed it's rather ironic given the billions of people living in the Far East and the much larger outbreaks there that everybody should be thinking that these recent events mean that the pandemic will start in Europe. It could but I think it's far more likely that it will start in the Far East. CORBIN: In 1918 they didn't have the vaccines and other drugs that modern medicine has given us, but how prepared are we to produce enough of them in time. The only real long-term protection against a pandemic is to develop a vaccine for the whole population, but current production methods using hen's eggs are slow and limited. So far the government's ordered only 2 ½ million doses of a vaccine against the current H5N1 virus but it almost certainly wont be the right vaccine for the pandemic. Because the flu virus is likely to change, ordering 120 million doses of the most suitable vaccine wont happen until the actual pandemic flu strain is identified. It will then take at least six months to produce two shots for everyone.

Dr IAIN STEPHENSON Leicester Royal Infirmary

Current manufacturing capacity is around 300 million doses a year, that's the current production, so it's a small percentage of the world population in global terms, and come a pandemic everyone is going to be straggling around looking for their vaccine and so manufacturing capacity is certainly limited and that needs to be built up over a period of time, but there has to be investment to do that.

Professor JOHN OXFORD Queen Mary's School of Medicine, London

I don't really understand why we're all hesitating with this vaccine. I mean the technology is there, you know.. in this country and every country in Europe can make vaccines, the technology has been going for 50 years. There's nothing new. We need to get.. we need to just decide which virus we're going to use and grow the stuff up.

McLEAN: But what vaccine would you make?

OXFORD: H5N1

McLEAN: This year's.

OXFORD: Yes. I would go for the one we've got, I don't see why we're hesitating at this stage investing a miniscule amount of money using the technology we just have to press the button and five weeks later the vaccine starts coming off the shelf.

CORBIN: So better something than nothing is what you're saying.

OXFORD: Yes, it's better something than nothing. I'm sure I think you would agree, it might not be perfect, we might not quite appreciate how people are responding to this vaccine and so on and so forth, but you might bet your bottom dollar that it's going to have some effect, and I would take it like a shot.

CORBIN: Whilst an H5N1 vaccine might afford some protection in a pandemic, the government is worried that billions could be wasted on the wrong vaccine.

Sir LIAM DONALDSON Chief Medical Officer Department of Health

We have already ordered 2.5 million doses of the H5N1 strain but we cannot have tunnel vision with this, we've got to recognise that the flu strain that emerges is likely to be different to the exact strains that are around at the moment which are in any case viruses that affect birds, they haven't yet mutated or mixed with the human flu virus and gone into a human strain that's easily transmissible from person to person.

CORBIN: If it breaks out this winter you've got about two million doses on hand, are you worried there will be difficulties in prioritising who gets that limited amount? DONALDSON: Having a vaccine of the H5N1 is very much a long-shot and a contingency but that's what we've ordered for essential workers.

CORBIN: In Vietnam the search for a vaccine is urgent as winter and new cases of bird flu loom. At Hanoi's research institute they are hoping to begin human trials of an H5N1 vaccine next spring. It's in everyone's interest, not just Vietnam's, to develop vaccines for both people and poultry to contain the virus and stop it spreading.

Dr LE THI QUYNH MAI Deputy Director, National Institute Of Hygiene and Epidemiology

We need a vaccine urgently to protect both those who raise poultry and the general community, that's why we'd like to get help, assistance with finance and technology from other countries in order to vaccinate poultry and find a way of preventing the transmission of the virus from poultry to humans.

Dr DAVID NABARRO Avian and Human Influenza Co-ordinator United Nations

I believe that the situation with regard to avian influenza in Vietnam is very serious indeed. This is an environment in which a mutation or a reassortment of the genetic material in the H5N1 virus is quite probable, and it therefore seems to me important that we not only do our best to help control the influenza but also we try to reduce contact between humans and birds which is very difficult given the role of backyard birds in local society. The Vietnamese government does seem to be seized with the issue but it's going to be a huge and continuing battle, and one that we must all support, all of us.

CORBIN: A succession of international VIPs have visiting Hanoi, urging the Vietnamese to be open about the scale of their problem, and to do all they can to contain the bird flu. Natural catastrophe's can become tests which undermine governments. In the wake of hurricane Katrina, a shaken President Bush has sent his Health Secretary, Mike Leavitt, to see what America can now learn from Vietnam and what help it can offer too. It's in the interests of rich nations to give money and expertise to stave off the threat to their own communities. At 6am next morning and a dressed down Mr Leavitt is paying what he hopes will be a surprise visit to one of Hanoi's so-called "wet markets". The Vietnamese government claims these markets where live birds are sold and slaughtered on the spot, have been closed down. But clearly live chickens, ducks and other birds are still available in Hanoi. These conditions heighten the risk of the H5N1 virus in blood and droppings being spread or transported elsewhere on shoes or wheels. Some market sellers refuse to talk to the American visitor, and those who do are defensive. UN officials told us that local authorities tried to keep sellers bringing live birds from the provinces out of the market while Mr Leavitt was there. Despite the clear risks of spreading bird flu, traditional markets like this will never be entirely stopped.

Mr Secretary, what's been your reaction to coming to the market, what have they been telling you this morning?

MICHAEL LEAVITT US Secretary of Health and Human Services

Well it's confirmed that there is a lot of cultural momentum behind the way they interact with animals and birds and people, it's just the way they live and have for centuries, and so expecting that that will change is probably not realistic.

CORBIN: Some would say you woke up to it late and in fact you should have been across this some time ago and it's only things like Hurricane Katrina that have focused the mind of the Bush administration on what could be a huge problem.

LEAVITT: Well actually the administration has been working on this issue in a very prominent way for months. For example, we now have a vaccine that we started working on more than a year ago by being able to get an isolate here in Vietnam, that kind of activity takes time and lead time and we've also been doing what the rest of the world has been doing. The truth is there's no one in the world that's very well prepared for this.

CORBIN: And inevitably there's going to be a time lag, isn't there, before America.. before all nations in the West are prepared.

LEAVITT: Inevitably, but the chances of this flu erupting into a highly efficient virulent strain of flu like the 1918 in the course of a month or two or three are very low scientists tell me, and while it's a great concern we need to act in a very deliberate and measured way and that's what I think the health ministers around the world are doing and I feel confident that we'll have a comprehensive approach to this.

CORBIN: Mr Leavitt's banking on the more reassuring view that the virus will only evolve slowly, but there's an equally valid possibility it could suddenly take off this winter if it mixes with the human flu virus.

If a pandemic was to break out this winter, is the world ready for it?

Dr DAVID NABARRO Avian and Human Influenza Co-ordinator United Nations

No. No, no, no, we're not. I really do hope the pandemic will not break out this winter because we have not gone through in our planning machinery that we've got in the world at the moment, we've not gone through the contingency planning that is necessary to consider how we might deal with the kinds of changes in the way the world works would be provoked by the pandemic itself and by the reaction of our different global institutions to the arrival of pandemic influenza.

CORBIN: Vietnam's only hope of slowing the virus is to tackle the avian carriers. It's an enormous task for animal health workers. One in four poultry in Ben Tre Province was found last year to be infected. Half a million birds were culled, but owners only received a third of their value and many infected birds were hidden. Now the aim is to vaccinate 90% of ducks, but it's not yet known if the new Chinese vaccine will just delay the onset of disease in a bird which already has the virus, or even if it will go on shedding virus in its droppings. No one knows if the poultry vaccination programme will prevent new human cases of bird flu.

NGUYEN VAN THOI District Communist Party official

There have been epidemics of this new disease in Ben Tre for the past three years. The vaccine has been newly introduced so we don't know how effective it will be. For us, prevention is the main aim and we need to give it time, but we can't guarantee that it will stop the epidemic.

CORBIN: In Ho Chi Minh City Dr Farrar is expecting to see new cases of bird flu any day now. three have already been identified in two nearby countries, and the UN has warned the world must provide funds and know how to help the Far East keep a close watch out for each new case, and new mutation of the virus.

Is it realistic that we could contain an outbreak here in South East Asia and prevent it ever reaching Western Europe, America, etc?

Dr JEREMY FARRAR Director, Clinical Research Unit Hospital for Tropical Diseases, Ho Chi Minh

I really honestly am an optimist, but I think if there were a cluster of cases in any country, it doesn't matter that it's Vietnam. It could be Edinburgh or Bristol or London or San Francisco. If there is a cluster of cases which spread beyond a few cases, and by that I mean ten or twenty or thirty cases of flu that goes from one person to another, once you've got to that stage, I think it's impossible to contain it, yes, I think once it spreads beyond 20, 30, 40 cases, it's going to be incredibly difficult to control, even in a highly developed country with unlimited access to money and resources. CORBIN: Until a vaccine is developed, the only hope of controlling a pandemic are antiviral drugs like Oseltamivir, Tamiflu, it prevents the virus spreading from cell to cell around the body. But Tamiflu needs to be taken quickly. Patients treated with it in the Far East have still died and there have already been cases of resistance to it. The government has ordered nearly 15 million courses of Tamiflu, enough for a quarter of the population they expect to fall ill, but the stockpile wont be complete until next September. Sir LIAM DONALDSON Chief Medical Officer Department of Health

This is one of the key strategies and we can't deny the public the opportunity to benefit from it, even though we're not 100% sure of what it's full impact will be in a pandemic situation.

CORBIN: But again there's a time lag here. We wont have a sufficient stockpile of Tamiflu for some months yet, not till getting on towards the end of next year. I mean how will you tell some people they can have it and others that they can't? It's going to be tough. DONALDSON: There will have to be prioritisation but we are further ahead with stockpiling than many other countries of the world. We will be ready by September 2006, we will have our full stockpile in place. It's coming in at a rate of 800,000 a month at the moment, it will be going up to closer to a million a month nearer to the time. So obviously at any point, if the pandemic should come sooner rather than later, we will have to prioritise and people at the highest risk and frontline NHS workers will be the priorities.

CORBIN: For every family in the UK, a pandemic will raise questions of who gets priority when only one in four people may have access to antiviral drugs. Dramatisation [News]

There's been an angry response the government's announcement that the UK's stockpile antiviral drugs to combat the new strain of Avian flu will only be given to those who develop flu symptoms. Top priority will go to healthcare workers and other emergency respondents.

MAN: Well that leaves us nothing, nothing at all.

If you would like t put your questions on Bird Flu to the experts in next week's Panorama text us on 07736 100100

WOMAN: Yes, but Meg's mum got antiviral drugs for her family, she got them on the internet. Well I tried but there was nothing left.

MAN: Well what I don't understand is why they couldn't provide enough antiviral drugs for everybody.

WOMAN: Well I suppose they have to decide on the most important people like the nurses and the government. But where does that leave us, eh? Dr IAIN STEPHENSON Leicester Royal Infirmary

Well clearly there's going to have to be rationing if the pandemic comes and that's going to be part of the strategy that healthcare workers and key workers are going to have to be prioritised.

McLEAN: Do you think 25% is not enough?

OXFORD: I think it's a good start and I think it needs to be increased quite a lot on that. Dr JEREMY FARRAR Hospital for Tropical Diseases, Ho Chi Minh

We're essentially relying as a drug, for a single drug in a viral infection, and resistance is inevitably going to develop. In fact there's already evidence¿

CORBIN: It might not work.

FARRAR: It probably would work and it is the right thing to buy it¿

CORBIN: But we don't know.

FARRAR: ¿ because that's all we've got. But if we rely on our whole global strategy on a single drug to treat a viral infection which is going to become resistant, and there already is evidence of that, then we're going to end up in a very bad situation.

Professor JOHN OXFORD Queen Mary's School of Medicine, London

Most people in the community, you know, will not have access to these drugs, and when this thing comes, some people have more access than others, and I imagine every politician in the world will have a little access to it, and that's the sort of thing that really gets a society into an unpleasant situation, people in the know, doctors and biologists, are stacking up on these drugs for themselves.

CORBIN: Have you got antivirals stashed away at home? What are you doing?

STEPHENSON: A number of people I'm sure have got Tamiflu stashed at home just in case.

CORBIN: Have you?

STEPHENSON: I've got some Tamiflu stashed at home, yes.

CORBIN: Professor McLean?

Professor ANGELA McLEAN University of Oxford

No, my prescription is sitting in Boots waiting to be filled.

OXFORD: I've got.. you know.. three packets. I did have six but everyone who comes into the office wants a packet and now I've got three. But that's not going to be enough, you see, and that's why you need to carefully plan it and that's where the governments need to take these decisions, it shouldn't be left to people like us getting things on the internet or cadging the stuff or borrowing it, it really shouldn't.

CORBIN: Dr Farrar, you're in the hot seat, living in Vietnam as you do, right in the middle of where these outbreaks have occurred, I mean what precautions are you taking? What can you do?

FARRAR: Personally I don't have a stockpile at home of Tamiflu, of Osi Tamiflu, no. There are small amounts in the country. I personally don't have a stockpile at home, no.

CORBIN: Scientists and governments have been given for the first time a chance to chart a pandemic in the making through Vietnam's experience with bird flu. It's an unprecedented opportunity to harness the political will and energy generated by fear to try and contain a force of nature. But history tells us that though infrequent, pandemics are inevitable. For all our sakes we can only hope the next one wont come this winter.

If you have any questions about bird flu and the threat of a pandemic, please send them to us via the Panorama website or text us at 07736100100. We'll contact as many of you as possible, and next week, in a special programme, we'll have answers to your questions and let as many of you as we can quiz experts from around the world.



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