Opinion: Gambling with bird flu is asking for trouble — and another pandemic

The warnings are increasing. Infectious disease researchers, virologists, veterinarians, and occupational health specialists around the world are sounding alarms.

The stories of wild birds, mammals, poultry, cattle, and other farm animals with "bird flu" (H5N1) keep coming. The real infection numbers are greater than official reports, but no one knows by how much. Meanwhile, decision-makers and other authorities seem intent on repeating the same mistakes made with COVID-19 and SARS.

Now, it has spread to people.

Stories of dairy and poultry workers in the U.S., with largely "mild" infections so far, seemed distant — until news broke about a case in Canada. In early November, a B.C. teen made international news fighting for their life with a mutated version of the virus. They're still in intensive care, unable to contribute information about a possible source of their infection.

At her Nov. 26 update, B.C.'s public health officer (PHO) Dr. Bonnie Henry tried to reassure the public with news that an “extensive public health investigation” revealed no known source. The only possibility found before closing the investigation was two dead geese infected with a virus version that may be related to the sick teen’s.

While not having to deal with a specific source might make life easier for public health leaders, it’s not at all clear how that’s good news for the rest of us. It’s a lot harder to protect yourself when you don’t know where the infections are coming from.

Why worry?

In B.C., the perfect storm is brewing. The wild bird migratory season is happening along the Pacific flyway. With them — like the geese that may be behind the teen's infection — comes H5N1. In the Fraser Valley, so far, 64 operations have had poultry flocks infected with H5N1 since October, and scientists have found an “unprecedented amount of environmental contamination” of area wetlands with avian flu — where it may survive for months.

Worse, the mutations found in the virus that infected the teenager show it’s adapting to humans and is more likely to affect the lungs - possibly explaining why the teen became so sick.

This all is happening in the midst of respiratory viral season — on top of COVID-19 that just won’t go away, no matter how determined we are to ignore it. Sluggish and opaque responses to H5N1 outbreaks in the US are provoking international concern. The highly-respected American virologist David O’Connor says, “It seems that the United States is addicted to gambling with H5N1. But if you gamble long enough, the virus may hit a jackpot.”

"A jackpot for the virus would fuel a pandemic", Tulio de Oliveira, South Africa’s director of the Center for Epidemic Response and Innovation, wrote in the New York Times, despairing at the lack of timely and complete sharing of information about the virus' evolution. His warning provides a frustrating echo of the un-learned lessons of the COVID-19 pandemic raised by the 2022 international Lancet Commission. Amongst other lessons, it highlighted "the lack of timely, accurate, and systematic data on infections, deaths, viral variants, health system responses, and indirect health consequences".

Canadian authorities seem to be making the same gamble, unwilling to learn from their own past mistakes, or the collective wisdom of everyone from occupational health and safety experts to scientists, engineers, historians, and front-line healthcare workers.

Based on initial symptoms alone, H5N1 can’t be distinguished from more familiar influenza strains, COVID-19 or the common cold. In the case of the infected BC teen, even asking about their poultry farm exposure would not have raised any alarms at their first ER visit. BC got lucky, and no H5N1 transmission occurred. The question is what happens next time?

Researchers using ferrets to study an H5N1 strain isolated from a dairy farm worker found it could be transmitted via the air, as well as by direct contact and on contaminated cages and bedding material. Like the SARS-CoV-2 virus that causes COVID-19, the seasonal flu virus and many other disease-causing microbes, H5N1 can travel in tiny aerosol particles. They float in the air like smoke for hours, travelling significant distances, riding on air currents, and sneaking through the gaps around medical masks. Through the simple act of breathing, those infected with H5N1 risk unknowingly exposing everyone in that B.C. ER waiting room, and possibly dozens of healthcare workers.

Even if we didn’t have the evidence of those ferret studies, the need for a precautionary approach is clear — especially when we have non-invasive, cost-effective tools like air cleaners and N95 respirators that dramatically reduce risk of spread.

Public health leaders gambled against airborne transmission in COVID, and in SARS before that - and lost both times.

We cannot afford to get this wrong yet again. Beyond the harm done to individuals, every new human infection produces billions of copies of the virus. With a high mutation rate, this allows nature’s evolutionary engine to roll the dice over and over — each one giving the virus another chance to hit the pandemic jackpot.

For us, the only way to win is not to play.

The good news is that with a precautionary approach, it not only can be done, but it has been done.

Many people are familiar with the outbreaks that occurred when SARS arrived in Toronto in 2003 — far fewer know of Vancouver’s “outbreak that didn’t happen.” When a patient returning from Hong Kong arrived at the Vancouver General Hospital ER on March 7, 2003, the emergency team applied the precautionary principle. They placed the patient in respiratory isolation, before any laboratory confirmation. In contrast, Toronto hospitals were late to initiate airborne precautions to prevent the short- and long-range spread of the SARS virus in shared air - an error that led to many more people getting infected, and more deaths.

The SARS Commission was crystal clear about the lessons public health leaders needed to learn from B.C.’s success and Ontario’s failure, presciently writing...

"If the Commission has one single take-home message it is the precautionary principle that (health and) safety comes first: that reasonable efforts to reduce risk need not await scientific proof… Until this precautionary principle is fully recognized, mandated and enforced in our health care system, nurses and doctors and other health workers will continue to be at risk from new infections like SARS."

Justice Campbell’s inquiry into the mismanagement of SARS-CoV-1 laid out the information we needed to do better when SARS-CoV-2 came along. He explicitly specified that “...the precautionary principle that reasonable action to reduce risk, like the use of a fitted N95 respirator, need not await scientific certainty.”

Backed by decades of rigorous science and real-world experience in occupational health and safety (OHS), and very specific directions in the Canadian national standard (CAN/CSA-Z94.4), there is simply no ambiguity about how to handle novel respiratory diseases with any potential to transmit via aerosols.

This SARS lesson was unfortunately ignored. Thus the 2022 Lancet Commission's number two COVID-19 pandemic lesson was the...

"costly delays in acknowledging the crucial airborne exposure pathway of SARS-CoV-2 … and in implementing appropriate measures at national and global levels to slow the spread of the virus."

In late 2022, almost two years into the pandemic, the retiring Chief Scientist of the World Health Organization publicly regretted the WHO's failure to accept and act on airborne transmission early on as their biggest mistake that has cost an enormous number of lives.

We cannot make the same error again with H5N1. At her last update, it was a relief to hear BC PHO, Dr. Henry, confirm that the B.C. teenager with H5N1 has been on airborne precautions in the ICU.

Unfortunately, both Vancouver Island Health Authority and Vancouver Coastal Health Authority put out clinical guidance stating that "droplet" precautions are sufficient when assessing and testing suspected bird flu patients. They are not, given that once the teen’s suspected H5N1 infection was confirmed, 60 healthcare workers had potentially already been exposed. Luckily for them and for us, this time, no one got infected.

The August 2024 BC CDC version of Management of Specific Diseases, Interim H5N1 Avian Influenza Outbreak still defines “exposures of concern” as “within 2 meters to a bird, animal or other human with confirmed avian influenza A virus infection.” This fails to acknowledge that H5N1 can be spread much further through aerosol transmission, and will miss people who have been exposed. It also is counter to the precautionary principle.

The path forward

We do not know how rapidly H5N1 will evolve and spread — but there is a realistic possibility an H5N1 pandemic could be as bad as the COVID pandemic, or even worse. We might get lucky — but to rely on that happening is a gamble, not a strategy.

No one discipline can claim to have all the answers to dealing with infectious diseases. Public health and infection control policies must be rewritten to adopt the practical, proactive, evidence-informed approaches used by OHS experts. We also need the deep understanding of engineering controls, like fresh and filtered air, along with the “societal memory” of historians and those who study human behaviour, and the lived experience of those harmed by past failures.

Scientific understanding may not be able to perfectly predict the future, but it’s better than waiting until there are bodies to count before we act.

So what does the precautionary principle (aka “better safe than sorry”) tell us we should be doing differently?

First and foremost, those present in environments where there is a risk of H5N1 — especially in healthcare, or working with animals — must immediately be provided with the N95 respirators required to comply with basic health and safety standards, along with the training and policies needed to maximise their effectiveness. This is no more negotiable than protections against asbestos or toxic chemicals. The effective exemption of hospitals from workplace health and safety requirements cannot be permitted to continue.

Secondly, public education and policies about transmission and contact tracing must be based on the physical realities of aerosol behaviour. There is no magic two-meter (or six foot, or 1-3 foot) boundary beyond which infectious particles somehow refuse to travel. A “potential exposure” is anyone who shared air with an infected person, who may or may not have symptoms. While the story of how those mistaken assumptions came about is entertaining, they are decades out of date - and lacked scientific justification in the first place.

Thirdly, as Florence Nightingale recognized over a century and a half ago, places where diseases may be transmitted need clean air. Whether it’s SARS-CoV-2, H5N1, or something new a decade from now, if a pathogen can’t get to you, it can’t make you sick.

While new technologies are being rolled out, we have effective options ready to go today, ones that are well-understood by the engineering experts who design and oversee their installation.

Air filtration units — portable and fixed — provide a rapid way to remove contaminants and improve air quality in crowded spaces like hospitals, schools, other workplaces and indoor public spaces. Upgrades and new-build ventilation systems take longer to implement, but provide built-in filtration and fresh air delivery for the life of the building. Updates to legislation — an “Indoor Clean Air Act” as the one promised in New Brunswick — can help ensure the benefits are for everyone, not just the wealthy few.

As a bonus, they can also remove other contaminants like wildfire smoke, dust and pollen.

The best time to upgrade ventilation may have been years ago — but the second-best time is today.

The history of major infectious disease outbreaks in Canada is one of missed opportunity after missed opportunity, betting against the house in nature’s casino. With growing awareness of the danger from H5N1 — and the damage already being done by long COVID — decision makers face a clear moral, scientific, and legal requirement to face the reality of airborne disease transmission, and act immediately.

Enough is enough.

Lyne Filiatrault, MDCM, FRCP EM (retired)

Canadian Aerosol Transmission Coalition member