The following is an edited excerpt from and interview with Dr. Kulkanya Chokephaibulkit, conducted in late 2005...

When did you first come across H5N1?

The very first case that I have seen was in January 2004; a case of a six-year-old child who had severe pneumonia. He started with a cold: running nose, some fever for a few days, and then coughing, high fever. He received some treatment from the paediatricians locally, but didn’t improve. The symptoms seemed to be more severe with more fever, more shortness of breath. Even the IV antibiotics could not contain the illness, then he came to see us.

The first time that I saw this child, I did not think of the virus - it was so severe that I didn’t think of the usual influenza virus. I was thinking about maybe some serious bacterial infection, or some serious a typical bacteria.

Avian influenza was at the top of my mind at the time - I think because there was some report of chickens and birds die from H5N1 and only a few days earlier. I saw the report from a WHO alert on the internet talking about a case that might be H5N1 in Vietnam.

So, with the clinical symptoms that were so severe in a normal healthy child, unresponsive to anti-biotic therapy, that let me to think of this unusual virus. I sent for the specific test.

What happened at the hospital - what sort of precautions were taken?

In the beginning there was no specific precaution procedures. Respiratory tract infections, or respiratory tract illnesses, do not require strict isolation, only droplet precautions, meaning that you be careful of the secretions and droplets that would produce from the patient.

The precautions that took place in this case were not special, it was routine for a respiratory tract infection. However, after we discovered that this is potentially a lethal virus, a very aggressive virus, we put this child is strict precaution isolation.

What were you thinking when you discovered that this child had H5N1?

We were quite scared. This is so new, not just to us, to human beings, to all mankind. It was the first time we experienced the virus we were so sure would never cause illness to humans – and here it actually can cause illness to human. Not just simple illness, not just a few fevers, but an illness that is so severe that it can kill you very fast.

We were quite scared about that. And not just the physicians, but also all of the health care workers working with the patients. We have 83 health care workers that had direct contact with the patients. We don’t know how contagious this virus would be.

Influenza, you can catch it easily. Once you have flu, you can spread the virus easily to your folks, to people around you very easily.

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You have a young child. Did you worry that you had gone home and perhaps had infected your family?

I’m not worried about that much because I an infectious disease expert. I know that direct contact is the most dangerous. Indirect contact can be prevented by good hand washing, by deliberate precautions. I am quite confident that I can clean myself up before I get home.

But at the very beginning, before we knew that my patient had H5N1, we didn’t take any special precautions, or more than the standard pre-cautions. At that time I was worried that I might get it, and if I might get it, then I get sick and might spread it to other folks around me. But after we know that this child has H5N1 we put the child in strict isolation.

What happened next for the boy?

The boy was intubated and the pneumonia progressed very rapidly. He came down with RDS, or Respiratory Distress Syndrome, and he died after that.

What did you have to do next?

There are many measures that you have to do simultaneously at the same time. The most important thing is to make public awareness of the potential of this virus to infect humans.

H5N1 is a bird virus, and therefore we think that it will not infect the human being. People are not worried about contact with chickens or birds. People don’t know that if they touch the very ill birds, or the chickens, or the dead bodies of the bird or the chickens, they might get the virus.

That’s why we have cases, because they aren’t aware of that. So public awareness is the most important thing. Once people know that they can get infections from the birds or the chickens, they are careful. Subsequent cases were less and less and finally disappear because people know how to protect themselves, not to touch the sick chickens.

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What is the state of H5N1 right now in the world? Where is the virus right now?

The virus is still circulating in many species of birds, in chickens and wild birds. H5N1 is not new. I think that it has been in this world for a long time.

Why are people concerned about H5N1 right now?

Because it can kill. It is not just a virus that will make you sick for a few days, like usual influenza virus.

Are you concerned about avian influenza?

We worry about avian influenza because it could happen at any minute, at any day, and if you are not well prepared, and if the virus infects human beings, and transmits easily from humans to humans, then it’s very scary.

I think it’s worrisome because the potential outbreaks of this deadly virus, it just could happen any day. But we don’t know how long it could be. It’s true, at the moment we have many other illnesses that we have to worry about -- malaria, tuberculosis, many other things -- but still H5N1 lives in the back of your head all the time. It’s like a bomb. You just wait for the time to happen.

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What kinds of things do you think we should be doing?

There are many, many things that should be done. Developed countries should be thinking about how to make a vaccine available if this virus has an outbreak. Developing countries need to think of how to contain the source of the virus. For example, right now, we know that the source of the virus is in chickens and birds, we should try our best to contain the virus, get rid of the infected birds, make the farm raising safe, so that we lessen the chance of having them spread to other birds.

In the medical setting, we need to make the preparedness plan: what should we do if one patient show up? What should we do if there is more than one, or a lot of patients show up at the same time? We need to prepare the stockpile of anti-viral and stockpile the personal protective equipments like masks, gowns. And it’s very important is to educate our people on every level.

Is there much that anyone can really do once it spreads?

If you might come down with the illness, focus on the prevention of spreading; cough etiquette, using a mask, washing your hands, all these things. Careful hygiene is very important. That’s on the personal level. If they can make themselves healthy, avoid getting the infection, that’s a very good role of them to prevent spreading.

For health care workers, we have to do our job, at best to contain the infection; we have to have good isolation systems, precaution systems. In terms of higher levels, the policy makers need to do their duties to contain the outbreak.

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What was it like, having to tell the parents of that little boy that he had died?

We explained to the parents that the child died from the avian influenza virus, and that he was very unlucky that he got it. The parents told me that if they had known that chicken could be this harmed, they would not have let the child touch the chicken. And if they knew that this virus was spreading among the chickens in the village, they wouldn’t let their children play with chickens at all.

A lot of Thai children grow up with chickens, because almost every single household has chickens in their house. They like to play with chickens. Chickens are part of their life. That’s why education is the most important thing. We don’t see new cases after you make public awareness.

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