From Flu Wiki 2

Forum: WHO Containment Protocol March 17 Draft

tamiflu resistance

anon_22′s scenario for pandemic ‘containment’

17 March 2006

anon_22 – at 23:08

I’ve just had a quick read (it being 3am here and I just walked in the door) of the new WHO draft protocol for containment just out today. Very scary, very interesting:

I think anyone who reads this would immediately notice the word ‘imminent’ in the very first sentence. WHO being a UN entity, is not an organization that uses words casually: it is almost certain that such an important word would have been hotly debated. Even though it is softened by ‘may be’, the fact that this word is used at all, and right at the beginning, tells me the degree of undeniability (of the evidence they have) if not consensus among the 70 international experts at the technical meeting.

It is also truly historic that such an attempt is being made at the global scale. I feel humbled both by the enormity of the task and the collective will of such a large number of people from all corners of the world: not just the top people at the conference, but everyone all the way down to the village health visitors, and of course all of us here at the fluwiki either contributing or learning or observing or encouraging each other. Makes me proud for once to be a citizen of this planet.

OK, starry-eyed aside, a few things I want to point out because they are useful to learn:

  1. recognizing the event – Notice that they are using respiratory symptoms as the primary marker, not fever or other flu-like symptoms.
  2. epidemiological signals as the most sensitive and reliable indicators – you know we have been having such vigorous debates about whether there is any ‘proof’ that the virus is likely to go pandemic, and whether such proof is possible. Well, here is the answer for you: epidemiological data is not proof, but it is as good as its going to get if we want to be able to pick out h2h transmissions early enough to do something about it. Changes in viral sequences are important as supportive evidence of possible change of transmission mechanism, among other things, but viral signals on their own do not give us an accurate enough warning or prediction of the behavior of the virus.
  3. WHO criteria for clusters that need immediate investigation: 3 or more cases with onset within 7–10 days PLUS history strongly suggestive of exposure. This seems to me a pretty low threshold, which is a good thing. Shows me they are really serious about trying to catch this early.
  4. It is important to do urgent veterinary investigations to exclude common or ongoing avian sources of infection. Plus of course to collect the avian sequence cos a big red flag would be raised if that is significantly different from the sequence from patients.
  5. responsibility for reporting is put squarely onto the countries: “national authority is expected to provide WHO with all relevant information, including clinical, epidemiological, and laboratory data”. No more if’s or but’s. Just do it, guys!
  6. Probably the most important paragraph IMHO is ‘the decision to launch a containment operation’ – they are looking for signs that indicate ‘a transition in the behavior’ likely to result in efficient h2h. Well, aren’t we all.

These criteria are important enough for me to quote them here:

1 Moderate-to-severe respiratory illness (or deaths) in three or more heath care workers who have no known exposure other than contact with ill patients, and laboratory confirmation of H5N1 infections in at least one of these workers

I get goose bumps when I read this cos this was exactly what I wrote the other day in the ‘other shoe’ thread.

2 Moderate-to-sever respiratory illness (or deaths) in 5 to 10 persons with evidence of human-to-human transmission in at least some, and laboratory confirmation of H5N1 infection in more than 2 of these persons.

Notice again the use of respiratory symptoms, NOT fever, as something to look out for. Useful.

3 Compelling evidence that more than one generation of h2h transmission has occurred. eg the family of HCW, like I said the other day

4 Isolation of a novel virus combining avian and human genetic material or a virus with an increased number of mutations not seen in avian isolates from one or more persons with moderate-to-severe respiratory illness (acute onset), supported by epidemiological evidence that transmission patterns have changed.

Notice that viral data needs to be supported by epidemiological evidence to trigger action, but not the other way round. ie an outbreak satisfying epidemiological criteria even if there is no new discoveries in the viral sequence would still be enough to warrant action.

That’s as far as I’ve gotten and its 4am, so I better post this and go to bed :-)

Maybe Part 2 tomorrow, or later today.

Humble – at 23:40

Anon-22: Thank you for summarizing this report for us. We will be able to use this information as we look at the news reports (go MaMa!)and perhaps have a jump start on when h2h starts. (Okay…fess up…are you secretly on the WHO consulting team? :-) <just kidding>. I can imagine how strange that was for you to see them come up with the same trigger points. Interesting stuff. Good work.

Layperson Indeed – at 23:40

UUMM, I noticed on page 7 under heading-Deployment of international field teams— International field teams, drawn from institutions in the WHO Global Outbreak Alert and Response Network (GOARN), can be rapidly deployed --- following —reciept of a request from the affected country.

 Does this sound a little scary or familar?

Maybe I am just tired and not reading things right.

18 March 2006

anon_22 – at 05:17

bumped for comments

Grace RN – at 05:22

Sounds like they’re laying the groundwork for announcement of Level 4.

anon_22 – at 05:30

I am only picking out a few points for discussion. The document is long but well worth reading. Here’s the link

NotParanoidButat 05:59

Thanks Anon 22 your insights are wonderful please keep them up and keep sharing NPB, Australia

anon_22 – at 19:39

The next question of course is is it going to work? I guess the best way is to test it with some scenarios. Here I have made up a scenario that would fulfill the first criterion for containment according to WHO:

Moderate-to-severe respiratory illness (or deaths) in three or more heath care workers who have no known exposure other than contact with ill patients, and laboratory confirmation of H5N1 infections in at least one of these workers


SCENARIO

Municipal No1 Hospital in small town India, Turkey, Indonesia, China, Nigeria, Greece, or Azerbeijan, population approximately 38,000. Nearest major city 92 miles away with population 3.2 million.

Day 0 - onset of symptom of index case, 14M, family had poultry deaths, H5N1 confirmed in farm 6km away.

Day 8 - admission for acute respiratory distress and delirium, high suspicion, all infection control precautions started and in place after first 3 hours, died Day 10, samples sent, initial positive H5N1

Day 12 - hcwA 22F, nurse assistant – feverish feeling, headache, abdominal cramp, diarrhea x2 sees Municipal No1 hospital doctor, reassured, given sick leave

Day 13 - hcwB 29F, registration clerk – fever, bone pain, this is her regular day off, stays home, cares for 3 children aged 4–10.

Day 13 - Index case tissue samples confirmed H5N1 positive.

Day 14 - hcwB now has dry tight cough, sees herbal practitioner, calls work to say she has a cold, worried because 4 year old son has fever and cough, takes child to local private doctor, spent 45 min in waiting room, child given an injection, B stays home to care for child

Day 14 - hcwA now has chest pains on coughing and some difficulty breathing, goes to Municipal No1 hospital, ‘walk-in’ case 11am, very anxious, has trouble convincing doc that she is really having difficulty breathing, no fever recorded initially, sent to x-ray and routine blood tests, waits at ER for test results, X-ray ?chest infection, gets admitted to general ward at 5pm after 6 hours in ER, seen by chest physician at 11pm, x-ray ‘unsatisfactory quality’ but H5N1 suspected, repeat chest x-ray and isolation ordered, patient taken to x-ray wearing surgical mask, finally isolated at 4am, ‘throat swap’ sent, put on tamiflu, oxygen

Day 15 - hcwC 31M, ICU nurse - fever, cough, slight bleeding from throat, (had seen patient die of bleeding) worried about isolation, self treatment with own tamiflu standard dose, calls in to request 2 days off for ‘family emergency’

Day 17- hcwA gets worse, put on ventilator, first tests negative,

  (no suspicion yet, cos they don’t know about B & C)

Day 19 - B collapses while getting out of bed, neighbour brings B in taxi to nearest hospital, not Municipal No1, delirious, rapid shallow breathing, cold sweat and slightly cyanotic, no family member present to say that she was hcw, initial diagnosis ?food poisoning ?chest infection, suffers convulsion and cardiac arrest while waiting at x-ray, intubated and hand-bagged for 2 hours while waiting for transfer due to lack of ICU facilities, some hcw present had use of surgical masks loosely covering face, but not any of the radiology staff or clerk or porters or patients waiting, transferred to Municipal No1, 2nd cardiac arrest en route, arrived at No1 dead, certified ‘dead before arrival’, not ‘admitted’ into hospital records, body sent to morgue to be collected by family next day, autopsy refused on religious grounds, cause of death – ‘dengue fever’. All 3 of B’s children now have fever and cough. Father called from work, was out all day with B at hospitals etc so children left in care of neighbour, family of 3 adults and 6 children aged 2–17.

Day 20 – epidemiology team begins to hear through grapevine of increasing number of patients with fever and some ‘bad chest infections’. Health visitors sent to do home visits of selected cases.

Day 21 – hcwC attends No1 hospital with respiratory distress, volunteers history of caring for BF patient, response team activated, patient put into isolation, all staff alerted to use highest level of PPE available, but still only 1/2 have access to N95 masks and gowns, hcwC condition serious but stable, put on oxygen and CPAP, initial test negative

Day 24 – hcwA dies, autopsy refused, but samples of lung aspirates, CSF and blood sent for urgent tests. Repeat PCR for hcwC now positive for H5N1, urgent roll call of all hcw initiated, heads of departments required to submit all staff absences or sicknesses by 10am next day.

Day 25 – B’s boss reports at 2pm inability to get in touch as no one answering the phone. Several more attempts made. At 6pm, decision made to send staff out to home visit the next morning.

Day 26 – home visit revealed death of B plus all 3 children admitted to private hospital for ‘typhoid’.

Full alert for ‘suspected hospital outbreak of H5N1 with possible efficient h2h transmission.

END OF SCENARIO


Using the WHO draft protocol of March 17th as response plan, please comment on:

  1. the likelihood of such a scenario happening in any of those countries or in any country.
  2. whether ‘western’ countries like the US would have been able to get alerted sooner.
  3. whether containment is now possible, and why
  4. if containment not successful, what are the chances of the world benefiting from a ‘significant’ (according to your own definition) delay in spread of the virus to make the exercise worthwhile

Finally, what are the chances of massive and haphazard use of tamiflu in containment-gone-out-of-control causing a significantly increased chance of tamiflu resistance in the virus?


Now, I’m going to be very mean, and tell you guys that I’m going to get on a flight in a few hours and probably won’t get online much in the next 24 hours. I’ll leave y’all to thrash this out and see what conclusions or lessons can be drawn.

Over and out.

<evil grin>

Melanie – at 19:58

Jeez,

Anon_22, highly believable scenario.

Pun Intended – at 20:18

That’s terrifying! So based on that scenario, does anyone have any idea how many people would have been exposed before the alert is official?

Thanks for the scenario.

food storage nut – at 20:28

I keep trying to get into the link which anon-22 put above and can’t get in. I tried getting in by going through the WHO website and still cannot get in. Anybody else having the same problem?

Kat – at 20:32

I got in. Once on the Who site, click on the “Full text” link.

Kat – at 20:40

….and it came up on my Adobe Reader.

Tom DVM – at 20:51

Has anyone heard a clear statement from an expert that he or she believes that containment is remotely possible?

kristikaylene – at 21:01

I believe that the doc on Oprah mentioned 40 being the magic number…that is, if efficient h2h is recognized and contained by the 40th person, it can be contained…beyond that, it all officially hits the fan.

It’s been awhile since the show, so feel free to correct me if that is not what was said…I’m too tired to review the show right now!

Medical Maven – at 21:07

Tom DVM at 20:51: As remotely possible as containing a fart in a windstorm. : )

Seriously, I have read a lot of hemming and hawing about how it needs to be tried. And that they could not live with themselves if they did not try, blah, blah, blah.

Tom DVM – at 21:14

Medical Maven It seems to me that as it becomes more and more apparent that past mistakes make us helpless to do anything to prevent it now…it is more important that those who made the mistakes have clear initiatives to ‘stop it in its tracks’.

A little attention in 1997–2003 would have made a big difference.

Medical Maven – at 21:24

Tom DVM at 21:14: As usual Mankind needs a “time machine” to correct its mistakes.

“And the moving hand having writ, moves on”.

Tom DVM – at 21:28

Medical Maven. What frustrates me is we never learn from our mistakes. SARS was recent history.

Grace RN – at 21:37

anon_22-completely believable scenario, and scary as hell. All in all, I’d guess 100+ exposed by day 4.

Containment? about as believable/realisitic as the Tooth Fairy and the Easter bunny.

19 March 2006

anon_22 – at 02:10

Hey, you guys, you are supposed to make a SERIOUS EFFORT to contain this! Your government signed up for it, and if you request containment WHO is going to give you LOTS OF TAMIFLU! Come on, get with it!


Part of what this exercise is about is to show that real life is messy and cannot be ‘modelled’. Patients like hcwB fall through the cracks and disappear into the black hole, and if it wasn’t for the fact that this was a hospital outbreak and the boss starts calling around, one would probably never found out about this case. Without extremely stringent supervision and repeated drills, hospital practices almost never work the way they are supposed to.


Now we are at Day 26, or 26–8 = 18 days from detection of first case. The WHO protocol says it is still ok to try containment cos it’s less than 21 days. Also there are no contraindications to containment because (page 9)

  1. there is lab confirmation
  2. the geographical area is apparently small and population not very big

And yet almost everyone on this thread thinks it’s not going to work. Why?

You guys HAVE TO MAKE THE CASE, whether you think it’s going to work or not, and why.

Anybody want to have a go analyzing this? I assure you the rewards are immensely educational.

Meanwhile, I’ve got a flight to catch….. :-)

Humbled – at 03:05

“…heads of departments required to submit all staff absences or sicknesses by 10am next day.” If hospitals started reporting this NOW, then we might have a chance of catching this as it starts…

Given the scenario outlined by Anon_22 above, I do not think containment is possible at all. (Disclaimer: I am not a health care professionl…just a person with an opinion. :-) Containment went out the window before it even started because there is no reason for any HCW to report their illnesses and nobody is monitoring employee absences. The ability to spread the disease as stated above increases exponetially with each missed case. Giving a false diagnosis of Typhoid or Dengue fever to those clearly displaying H5N1 symptoms further delays proper containment and isolation.

I think waiting for “official” lab results will make containment ineffective. One should assume it is h2h bird flu until proven otherwise. Anon_22, I know you are probably looking for something much more indepth than this, but I wanted to give my very first impression before I thought about it too much. Sometimes gut reactions can be more useful than well thought out ones. (And sometimes not. :-)

I am very interested to see what others have to say. Thanks for the great work.

kk – at 04:42

Does the “answer” have something to do with no one following up on the index case and his contacts, and then their contacts? Or that we don’t know whether these three workers had, in fact, contracted H5N1 from the boy?

The index case may have become infected with H5N1 from another person, but if attention is focused on the health care workers, the days before their infection might be overlooked, especially with a quickly growing cluster of new infections. Those days could go back to, like, days −15 to −100, depending on what/who the virus was up to, while it got cozy in people.

Re anon’s ? 4 - if containment isn’t successful, then there really isn’t a delay, not with this scenario. Still, it probably makes people feel better to try to exert some control, right?

It seems that, in the story anon gave us, and with the assumed “control” measures, not enough focus has been placed on the index case, to determine whether it truly is an index case. If it’s not, then the containment in this community may be pointless if the flu is busy branching out somewhere else for twenty plus days.

I agree that the only way to have containment efforts work is to have health care workers already trained, and have them already taking precautionary measures before the flu hits. Routine monitoring of hospital/clinic employee health, like a check in when they report to work, and procedural alerts when they fail to come in to work, would probably be a good idea for those areas with lots of culling going on.

More measures should go into effect now so that, when the official scary-signs appear, no one will overlook them. Like, before bad things happen that no one can deny, there should be double checks and triple checks.

Right now, it’s sorta like…how people act in horror movies. When they go into the old barn, alone, with no shoes, to see what that chopping noise was. The WHO plans aren’t bad, but they = neighbor calling the police when girlfriend of barn-explorer shows up on doorstep covered in blood. The WHO can’t be in everyone’s barn, but people don’t seem to take extra precautions until they have been scared into it, or until everyone around them is doing it.

Maybe some PR firm could turn H5N1 into the next cool thing.

If only H5N1 could go H2H in Toronto…I bet they would catch it.

kk – at 04:46

Yes, that’s the answer - Toronto must save the world.

kk – at 05:02

Sorry - one more - re delay - again, I think in this story, there wouldn’t be any real delay, but there might be other stories where the WHO measures, even if they didn’t stop pandemic flu, would create a delay. Any delay, so long as it’s recognized by the appropriate authorities, is a good delay. For one, it gives the rest of the world a chance to take the situation more seriously. And, if you add a bunch of delays together, spread out over time or geographically, they could make a difference of at least weeks. Three weeks closer to a vaccine is better than nothing.

The levees managed to hold back the water in NO during Katrina. That delay would have, should have, made a big difference, in a nicer story, where govt authorities took some action as soon as the water started coming in.

I think there should be a whole bunch of flu levees, and I don’t think FEMA should be in charge of monitoring the flu levee breaches. They’re not, are they? Can it be Toronto instead, or maybe that dreamy Gajdusek?

Harriet – at 10:59

I have been following FluWiki for about six months and I want to thank everyone for their input and knowledge. Containment is worth trying. However, I really can’t imagine it working. I have travelled extensively thoughout the developing world,mostly in Asia and Africa. Most recently, I spent a month in a subsaharan county in West Africa. Most of the people in this African county are not literate. Outside of the city and biggest towns, most people do not have electricity, many do not even have clean running water. People live spread out over large tracks of land, many are still nomadic, and most everyone lives with chickens. Most people have no access to health care at all. I have visited clinics in small communities and hospitals in towns and cities and they are already totally under staffed, crowded, and in most cases filthy. I have seen used syringes lying in dirty sinks. When there is a “trained” health care worker, the lines form hours before the clinic opens with most people not seen that day, and this is for regular heath care. Perhaps if H-2-H starts in a Western nation, and if everyone is on top of it,we may be able to slow the spread of the flu. I am most concerned if it starts in most of Asia or Africa.

crfullmoon – at 11:15

I don’t think containment is possible.

We don’t know who the contacts have contacted, but influenza is very contagious. Air travel, other travel, is unrestricted. The US wouldn’t have been any more on the ball, if that scenario happened here; the US has outdoor chickens, people without health insurance, sending sick kids to school so they don’t miss work and lose their job, most hospital/office people not wearing PPE since they aren’t expecting a problem, aren’t ready to test for H5N1, think “it isn’t human-to-human yet” so they don’t have to take initiative until someone orders them differently…

:-/

Allquietonthewesternfront – at 11:51

Harriet - you should post more often. Important if disturbing insight, thanks.

kk – at 16:09

I agree with moon re US, if it happens anytime soon - say, from a soldier on leave. Whenever I mention H5N1 to anyone, they say, “Y2K,” and then they roll their eyes. Or, they sigh.

There is a greater chance of catching something before the whole situation slips through the cracks, however, since we have a stronger infrastructure than many places, more access to medical care (even without health insurance), and a stronger peer pressure incentive (imagine how neighbors would react to someone home-treating bleeding-through orifices family members, or any healthy, young person who is suddenly dying in the home. Not as common around these parts.). Still, though, given that influenza is so contagious, the stronger chance might not be enough, especially if people don’t stop with their “Y2K” mentality.

It’s been starting to change in recent weeks - people’s awareness level. Not quite as much eye rolling. I’m not sure what’s doing it. It didn’t change much once H5N1 hit Western Europe, as I thought it would. Maybe it’s from the news picking it up? Is the meme of H5N1 pandemic flu is beginning to infect the US population?

AnnieBat 16:44

Harriet has given a clear picture of the situation in countries where this H-2-H is first most likely to go - or in a country that does NOT invite WHO to the party!

If EVERY COUNTRY has the information and resources to immediately isolate all people (radius of affected area unknown) the moment someone sneezes or a bird dies (don’t wait for test results - act immediately), and contain them for a minimum of 21 days from onset of last symptoms (being extra cautious?) then containment can work.

So, like so many others, I do not believe containment can work because the above just won’t happen.

22 April 2006

anon_22 – at 09:38

(this was posted on the news thread but I thought I should put it here for completeness of discussion.)

This new paper in Science addresses the question of whether the use of tamiflu for prophylaxis during a pandemic, as proposed by the WHO would result in the appearance of a tamiflu-resistant strain. The results from this model are very disquieting.

1 The incidence of naturally occurring tamiflu resistance is low but significant.
2 Experience with M2 inhibitors and anti-infectious agents in general tells us that resistance can happen quickly and usually faster than expected when a new drug is widely used.
3 Current data suggests that NA inhibitor resistance depends on several different mutations. Two of these, R292K & H274Y, appear to reduce the fitness of the virus for transmission. However, there is at least one E119V which in animal models does not reduce transmission fitness compared to the wild type.
4 In a pandemic, if one were to give prophylaxis to all exposed subjects, the ability of the wild type (which is sensitive to tamiflu) to spread is effectively curtailed by the drug. Any resistant strain particularly one which does not lose its fitness significantly, will be able to infect these subjects.
5 The total number of infected people may be reduced by widespread prophylaxis, but in the small number of symptomatic cases that will still occur, the percentage of drug resistant strains may rise rapidly.
6 Whether this will then result in a pandemic will depend on whether the virus retains its transmission fitness to produce an R0>1.

In other words, if we use the WHO containment protocol and give out tamiflu to everyone in an area where efficient h2h is starting and where it is feared that a pandemic can start, you may reduce the number of cases significantly (and thereby reduce the chance of a pandemic, since fewer cases increase the chance of the virus getting to a ‘dead-end’.) but if a drug resistant strain appears, you may end up favoring its selection over the wild type.

That is in contrast to the theoretical models proposed by Ferguson (and Longhini, I think) where they say that resistant strains will lose out cos they are weaker. To be fair, Ferguson did give a caveat that a containment exercise should be abandoned as soon as a resistant strain appears. All that, however, is theoretical. In actual practice, if one is operating in underdeveloped countries in rural areas, how much extra resources would we need for such timely epidemiological surveillance, especially since determining drug resistance is even more complex and time consuming than viral culture or sequencing, and we are woefully slow in getting these done even now?

gs – at 10:28

why are they using prophylactic Tamiflu instead of evacuating/quarantining areas ? You could still give Tamiflu on first onset or high suspicion of symptoms. You could also first give Relenza and later Tamiflu, or even combine with adamantanes - the required resistance-mutations are probably independent. Can’t we test the whole thing with normal flu ? Is it possible to contain an outbreak of normal flu, if we _really_ try ? How much does it cost ?

anon_22 – at 11:18

gs “why are they using prophylactic Tamiflu instead of evacuating/quarantining areas ?”

Because it would be logistically impossible and politically suicidal, unless riots (by those being quarantined) and/or mutiny and AWOL’s (by those who are supposed to impose it) are what you want.

“You could still give Tamiflu on first onset or high suspicion of symptoms. You could also first give Relenza and later Tamiflu, or even combine with adamantanes - the required resistance-mutations are probably independent.” Yes, of course. But that would not contain the virus.

“Can’t we test the whole thing with normal flu ? Is it possible to contain an outbreak of normal flu, if we _really_ try ? How much does it cost ?”

Not all problems are due to lack of effort or money. Normal flu is normal flu, drug response and the spread would be different, a significant proportion of people would have immunity, etc. That’s why they have to use mathematical models.

28 April 2006

Many Cats – at 03:20

bump.

23 May 2006

anon_22 – at 14:17

There are signs that WHO is considering moving ahead with containment response in Indonesia. This is a summary of where we are:

To summarize, a cluster of human H5N1 cases were recently evolving in Sumatra. The index case developed symptoms on April 27th and died on May 4. Other family members started falling ill some time early May (exact dates unknown) and at least six of them died from around May 8 - 14. Now we have another confirmed case who was the father of a boy who died May 13. He developed symptoms May 15 and died May 22.

From the disease onset dates, unless they are all infected from ‘common source’, which is highly unlikely as they live in different houses, it would appear that we have a CONFIRMED CLUSTER OF H2H2H.

This fulfills the WHO criteria (first post here) 3 Compelling evidence that more than one generation of h2h transmission has occurred

The US has announced that they have sent out a stockpile of tamiflu to Asia. This stockpile according to sources is part of the 3 million dose WHO stockpile earmarked specifically for containment.

Let’s keep discussions on containment here, and discussions on Indonesia here, discussions on sending tamiflu here, and breaking news here.

anon_22 – at 16:52

close thread for length. New one here

Kathy in OR – at 16:54

From the WHO Avian Influenza – situation in Indonesia- update 14 dated May 23, 2006 Analysis of viruses Full genetic sequencing of two viruses isolated from cases in this cluster has been completed by WHO H5 reference laboratories in Hong Kong and the USA. Sequencing of all eight gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations. The viruses showed no mutations associated with resistance to the neuraminidase inhibitors, including oseltamivir (Tamiflu).The human viruses from this cluster are genetically similar to viruses isolated from poultry in North Sumatra during a previous outbreak.

Would some one please explain to me if the above is true how are they accounting for the H2H2H transmissions? What if anything from their perspective is different to cause this?

Retrieved from http://www.fluwikie2.com/index.php?n=Forum.WHOContainmentProtocolMarch17Draft
Page last modified on September 12, 2006, at 11:34 PM