Richard Knox, NPR
Nguyen Thi Anh sells poultry at the Tangh Kong Market in Hanoi. Many of the ducks and chickens sold there can carry the H5N1 bird flu virus without showing symptoms. Health experts worry that mixing species "silently" spreads the virus.
Nguyen Thi Anh sells poultry at the Tangh Kong Market in Hanoi. Many of the ducks and chickens sold there can carry the H5N1 bird flu virus without showing symptoms. Health experts worry that mixing species "silently" spreads the virus. Richard Knox, NPR
Richard Knox, NPR
Nguyen Thi Duyen, 24, works in a Hanoi street market, slaughtering chickens and ducks. She worries about bird flu, but doesn't think her risk is high enough to require protective equipment, such as gloves and masks.
Richard Knox, NPR
In a vaccination station set up in a parking lot in Ha Tay Province, veterinary technician Luong Van Tien inoculates a baby chick. Vietnamese officials are trying to vaccinate all chickens and ducks against H5N1 bird flu by the end of this year.
Richard Knox, NPR
Nurse Nguyen Duc Tinh, left, came down with avian flu after caring for a patient who got the disease from contact with sick poultry. Health officials feared it was a case of human-to-human infection, but now believe Tinh was also exposed to sick birds.
Experts have dreaded the next flu pandemic for years. But only in the past month have most people focused on the frightening possibilities: Hundreds of millions sick; dire shortages of medicine and hospital beds; millions dead; and little prospect of a vaccine in time for an expected second wave of deadly flu.
It's a picture not too different from 1918, when a new strain of flu quickly spread to every corner of the planet. Then, something like 40 million people died.
But there is one big difference. This time public health officials have the luxury — and the curse — of foresight. They see clear signs of an impending flu pandemic. That means they can plan and prepare, if they can figure out what to do.
Ground Zero for a Pandemic
Experts in human and animal health say Vietnam is the perfect incubator for the next pandemic. That's mainly because the Vietnamese have intense, daily contact with poultry — in traffic-clogged cities, remote villages and everywhere in between.
In Hanoi, Dr. Marie Sweeney takes us on a tour one of the city's many open-air markets. She's the health attache at the U.S. embassy here.
"Not only do you have live poultry, you have freshly killed dressed poultry," she says. "People can buy the whole bird, buy the gizzards and the liver; you can buy chicken feet."
When Sweeney looks out over the hundreds of birds for sale here, she sees things most people don't: billions of viruses. Or at least she sees the perfect opportunity for flu viruses to flourish, mutate and spread.
She watches as one butcher cuts the throat of a chicken and drains its blood into a bowl. "She's doing this without any protective equipment," Sweeney notes. "No gloves on her hands. Nothing on her face. No mask."
Nguyen Thi Duyen, the poultry butcher, is 24. She's been slaughtering and plucking birds since she was 14. So she knows about "chicken flu," or "cum ga," as the Vietnamese call it.
"I have heard of the bird flu but there haven't been any cases here," she says. "There were chicken deaths, but not because of the bird flu."
Through a translator, Duyen says she's worried about the disease. "But I work on the chickens that are still alive. If they're already dead, I won't work on them. I'll take them to the market. I won't work on dead chickens."
That won't necessarily protect her. Vietnamese ducks are often infected with the bird flu virus without showing symptoms. And now studies show chickens can be silently infected, too.
A Crash Vaccination Campaign
That means Vietnam can't stamp out bird flu just by killing sick birds. So it's trying to give flu shots to every last chicken and duck. The idea is to reduce the chance that the bird flu virus will jump from poultry to humans.
You can see the crash vaccination campaign in full swing by taking a short drive out of Hanoi, into the densely populated countryside. Serene rice paddies are dotted with bustling towns and tightly clustered hamlets.
Luong Tan Tien stands in a vast parking lot in front of the People's Committee headquarters of Ha Tay Province, southwest of Hanoi. He's a veterinary technician, and he's a surreal figure, wearing a blue plastic gown, goggles and a plaid cloth tied over his mouth. As he lifts a big syringe, vaccine bubbles out in milky drops.
"We vaccinate the chicks here from 20 days to two months," he explains. "This is part of the national program here to provide the vaccination for all chickens, with international support."
Tien pinches the skin of a bird's naked belly and pumps in vaccine. He does this again and again and again for hundreds of squawking chickens.
Next in line is farmer Dong Van Tho. He patiently waits his turn, carrying a bamboo basket full of chickens.
"I heard from radio and also from TV and newspapers, that H5N1 is very dangerous," he says. "And therefore we have to bring all the chickens here to be vaccinated. I'm worried about getting the infection myself, and also members of my family."
Vaccinating chickens is only part of Vietnam's crash program to head off a pandemic.
Changing a Way of Life
Bui Quang Anh is in charge of animal health in Vietnam's Ministry of Agriculture. When he talks about the live poultry markets, urgency is written all over his face.
"We cannot continue this kind of reckless slaughtering and buying and selling of potentially infected poultry," he says.
Anh says Vietnam is imposing a number of revolutionary measures — a national moratorium on duck production and a ban on poultry-raising in cities. The government is also prohibiting the sale of a delicacy called duck blood soup, which has been linked to human cases of bird flu. And most startling — for a society that insists on fresh-killed meat — Vietnam plans to centralize the slaughter of poultry in factories and sell it in plastic-wrapped packages.
"By 2006, the Vietnamese people will be going to the grocery store to buy their poultry," Anh says. "We can get it done."
But Anh is frustrated. Local governments aren't eager to destroy the livelihood of farmers and butchers.
The virus, however, isn't going to wait around for all these things to work. It's out there busily mutating. Whether it happens in Hanoi or in a rural area, a pandemic strain will emerge if the bird virus acquires the changes it needs to spread freely among humans.
Vaccinating poultry might slow that process, but not prevent it. So Vietnam will soon release another plan aimed at stopping the spread of H5N1 after it becomes a human virus.
This is called "pandemic containment": stopping the pandemic at its source. Nobody's ever tried that before. Nobody's ever been in a position to. Previous pandemics came unannounced.
Dr. Peter Horby is with the World Health Organization's office in Hanoi. He says everything depends on spotting the very first cases, fast.
"The thought has been around the area of 20 to 50 cases occurring over a period of several weeks would be the kind of alarm bell," he says.
Earlier this year, World Health Organization officials thought an outbreak actually was happening in Thai Binh province, a couple of hours southeast of Hanoi. It started with a 21-year-old man named Nguyen Sy Tuan. He helped his parents slaughter chickens. Then he fell ill. His 14-year-old sister became sick, too.
Tuan's mother and aunt took him to the Thai Thuy District Hospital. A nurse named Nguyen Duc Thinh helped him to his bed and took care of him through the night.
"First, because we didn't have an X-ray, I was just thinking it was fever, high fever. We were thinking of pneumonia," he says.
It wasn't pneumonia. It was bird flu. Then a few days later, something alarming happened. Nurse Tinh fell ill himself, with high fever and difficulty breathing.
"I thought I might die," he says. "I was in crisis. I am frightened at that time. Spiritually, yes, I'm afraid."
Experts feared the virus had learned to spread from person to person.
But no more cases occurred in Thai Thuy. Investigators say the nurse might have been exposed to sick poultry. But the possibility of human-to-human transmission galvanized officials here. Now they know they have to watch for signs of flu not just in birds but in people.
"We need to have medical workers at the grass roots level so that when there are some cases, they will be able to detect [them] at the very beginning, you know?" says Dao Chung Binh, an administrator at Thai Thuy's hospital.
Preparing for a Human Outbreak
Binh would also like to have a stock of Tamiflu, a drug that can save lives if given early and sometimes prevent the spread of flu. His hospital has enough Tamiflu to treat only two patients.
The government of Holland did give the hospital a respirator recently to treat patients with failing lungs. "But it doesn't work yet, because we still need oxygen before it works," Binh says.
Those kinds of problems make Binh skeptical that a pandemic could be stopped. "If the scientists prove that H5N1 [has been] transmitted human to human, then it would be a disaster. And once it is a disaster, it is really out of our control," he says.
A few miles from the hospital, in an office at the Thai Binh Provincial Health Department, Dr. Nguyen Van Thom unlocks two suitcases. "These are cases of the medicine, ready for when the epidemic occurs here," he says. Inside the suitcases are precious boxes of Tamiflu. He thinks a pandemic can be stopped, and says he's ready to try.
"This is like for quick reaction," he explains. "So even the most distant places we are able to bring this medicine in 45 minutes time. We have Tamiflu here, 1,000 tablets and also antibiotics and some other medicine needed in case."
If H5N1 breaks outs, it's going to take a lot more than 1,000 doses of Tamiflu to stop it. That's because experts think everybody within a few kilometers of the first cases will have to get the drug to stop the spread of the new virus. And they'll need to keep taking it until no more new cases appear.
Studies say that would take several million doses of Tamiflu. Right now Vietnam has a tiny fraction of that, and it's scattered around the country. The WHO has enough Tamiflu for 3 million people. It's sitting in a warehouse a few hours away by jet.
Once experts decide a pandemic strain is really circulating, the WHO would rush its stockpile to the outbreak. But that assumes the killer virus pops up in a single place. And "it may not happen that way at all," says the WHO's Peter Horby. "We may start to see multiple small fires bursting out over a wider area."
In that case, the supply of Tamiflu could run out fast.
And besides blanketing the area with Tamiflu, authorities will have to do other things: isolate flu patients, protect health care workers, and seal off the affected area so people don't flee, spreading virus as they go. Officials would also have to close schools and ban public gatherings.
In short, a lot has to go very right in a very short span of time. And flu planners hope the first outbreak doesn't happen in or near a city — where the virus would spread too fast to contain it.
It's a tall order. But the WHO's Horby says it's necessary to give containment a try — or forever regret it. "I think everybody realizes that it's probably a long shot, but it could be one of the most important public health shots ever. It may be unsuccessful but if it was successful you'd have a huge impact."
Back in Ha Tay Province, technicians on motorbikes go house to house, making sure every chicken is vaccinated. And a set of loudspeakers broadcasts messages about chicken flu to the residents of Huong Son Commune. "Make sure your poultry gets vaccinated," says the voice. "Report all suspicious cases of bird flu."
NPR's Rebecca Davis produced this report.