A ‘Ring Strategy’ for Bird Flu

Six years after the COVID pandemic began, we are still locked in three of the five stages of a so-called typical response to a pandemic, as described in a recent opinion article. Those three stages are: Ignore and deny (stage 1), anger and search for scapegoats (stage 4), and amnesia (stage 5). The authors call for a much-belated national commission to investigate the COVID experience, which, in our politically divided world, has a low probability of happening.

But I cannot agree more that we remain wholly unprepared for the next pathogen. Right now, one threat stands out: bird flu.

I’d like to call on senior public health leaders to discuss the feasibility of a robust response strategy based on accurate point-of-care testing for novel bird flu strains, and to use a ring strategy to mitigate spread. Our current single alert and response system, while necessary, is simply insufficient.

The Bird Flu Situation

We should all be concerned that 200 million domestic poultry have been affected since 2022; that mammals, including elephant seals, have been decimated; and that dead geese have washed ashore along the Long Island coast, likely killed by highly pathogenic avian influenza (H5N1 or bird flu).

To date, infections in humans have mostly been “mild.” But not all. Since 2024, there have been more than 70 cases of bird flu, including two deaths. And the virus keeps mutating.

So far, we have been lucky.

Testing and Response

What is our current strategy to screen patients for bird flu? CDC recommends that patients hospitalized with influenza A have a more detailed analysis completed at a state virology reference lab, in an effort to look for bird flu or other novel variants. This is a highly accurate form of testing, but time-consuming. I imagine that some academic medical centers are doing H5 novel strain testing as well.

Meanwhile, rapid point-of-care tests are generally being used in only a limited way. While the science of rapid testing has progressed and now includes more highly sensitive antigen tests — and also more rapid molecular and PCR tests — these have had only limited deployment, as far as I know. Perhaps further in the future there will be a possibility of a handheld device that incorporates molecular amplification, but we’re not there yet.

Is our current first line — only line — of defense sufficient?

If bird flu does mutate, spill over, and spread to humans more effectively, it will likely occur near poultry farms, dairy cow herds, or pig farms, all located in rural areas. However, hospitals, medical clinics, and state virology labs are more under-resourced today, especially in those locations, than they were in 2020 and even last year. Our current first line of defense, while necessary, is insufficient.

Why wait for a declared emergency and then activate the emergency use authorization (EUA) process, with its built-in chaos, when we are only a few molecular shifts away from a pandemic possibility? There are several American companies with rapid point-of-care H5N1 tests in advanced development (one has been FDA approved) and an increasing number of free-standing laboratory-based instruments available, capable of 1-hour molecular or PCR testing.

A Ring Strategy for Bird Flu

A rapid deployment team could be organized by the infectious disease detectives from the Epidemic Intelligence Service and deployed in two different scenarios: 1) an outbreak that starts within the U.S. and/or 2) an outbreak outside the U.S.

In the first case, rapid point-of-care tests would be deployed in a “ring” around patient “zero.” Essentially, the concept of ring strategy is to contain the spread of a disease by isolating, testing, monitoring, or vaccinating close contacts of infected individuals in order to create a buffer of immunity around the outbreak. Ring strategy has been used for diagnosis, treatment, and vaccination. But, to my knowledge, it has not been fully implemented as part of a pandemic strategy.

Point-of-care test kits would be distributed to all emergency departments and clinical sites in a radius around the initial areas of concern (generally work and home). Another ring might be needed if the patient is transferred to a regional medical center. A free-standing rapid PCR testing instrument could be deployed to the nearest regional facility to confirm diagnosis. Coordination with local public health, state virology reference labs, and the governor’s office would be essential. Early mitigation is the goal. Therapy with antivirals would start at the point of diagnosis. People who test negative would self-quarantine and be given two additional point-of-care tests to be used later that day and the following morning. They would call in results via smartphone app.

In the second scenario, the team would be deployed as a semi-circle at entry sites at international airports, cruise ship landing ports, and border entry locations. Rapid tests would be placed on all flights heading to the U.S. The rapid test would include influenza A, B, and H5 (bird flu). To minimize false negatives, the tests would be run 90 minutes before landing. Helicopters would deliver test kits to cruise ships. People with positive screening tests would be separated before going through passport control. Those who decline testing would be denied entry, and offered a second chance at testing. Again, to minimize false negatives, people discharged from all sites with negative tests would be given two additional test kits to be used later that day and the following morning while they remain under self-quarantine. They would call in their results to the case officer or use a smartphone app.

A few potential triggers would initiate this program. One is a hospitalized patient with influenza A who is positive for H5 and whose immediate contacts are developing respiratory symptoms. Another would be if there is a local cluster of flu-like cases outside the flu season near a farm or wild animals. A third trigger would be large numbers of domestic mammals getting sick or dying, particularly among dairy herds and pig farms.

Upon diagnosis of bird flu, the deployed team would focus on starting dual therapy. Fortunately, two anti-influenza, oral drugs are FDA approved and available. Targets would be all influenza patients within the zones of interest, as determined by a rapid response team, and all those in close contact with a patient of concern.

We need federal leadership to build such a program. Regional state coalitions would not have the organizational or coordination capabilities to do so. Such an alert and intervention system would require significant work and resources, including formal FDA approval of more rapid tests, funding for manufacturing a start-up supply, real-world field testing, and development of a rapid data system. I imagine the medical community would endorse this initiative to build a second line alert system and would “flock” to help.

Daniel Teres, MD, is a retired faculty member of Tufts University School of Medicine in Boston, and a critical care physician.

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