Why I'm Paranoid About the H5N1 Flu...and You Should Be Too.

[liz_marcs]

First off, I must give massive props to my Red State political soul sistah ad_kay for helping to kick me in the ass on this matter.

Generally, when flu season comes around, I'm somewhat blase about it. I know I shouldn't be, especially since one of my historical insterests happens to be the 1918 Spanish Flu pandemic and the World War I era. I also know that history has a nasty habit of repeating itself.

For the past two years, I've been nervously watching the H5N1 flu, aka the Avian Flu, march across Asia. It has all the earmarks of frightening world pandemic once the virus mutates enough to allow human-to-human transmission. Thus far, the transmission is still bird-to-human, which is why the infection and mortality rate is (relatively) low.

It isn't a matter of if this will change. It's a matter of when.



At first I was tempted to go into the whole scientfic rigamorole on what makes H5N1 so very special (and inspires flashbacks to the 1918 flu pandemic in me), but you're better off reading the experts as they explain science behind the difference between the usual flu and a flu with the potential to be a deadly pandemic.

The fact is, we already know what a flu pandemic looks like. During the 1918 pandemic, 20% of the global population became ill and the mortality rate was estimated to be 2.5% to 5% (I've seen arguments that it was as high as 12.5%). The global deaths during the 1918 pandemic are estimated to be between 25 million to 50 million people (some estimates run as high as 100 million). The reason for the uncertain numbers is because at the time, influenza was not reportable and there were no international health organizations monitoring the emergency or tracking the influenza. (Let's leave behind a moment that World War I was raging across Europe and much of the media in the combatant countries were under wartime censorship.)

During the 1918 pandemic in the U.S. alone, 28% of the American population fell ill and an estimated 1.5 million Americans died. That's more than the number of people killed in a single year by heart disease, cancers, strokes, chronic pulmonary disease, complications of AIDS, and Alzheimer's disease combined. (Source: Flu, Kolata, 1999, p7)

What also makes the 1918 flu pandemic unique is that it didn't kill the "usual suspects:" the elderly, young children, the immunocompromised, or people with chronic respiratory conditions. It killed people in the prime of their lives (age 20 to 50) and (theoretically) at the height of health.

The H5N1 virus is now emigrating across the globe via migratory birds. The H5N1 virus has left its Southeast Asian confines and within the past month or so has appeared in western Russia, Romania, Turkey, and Greece.

There have been documented cases of bird-to-human transmission and the virus has already adapted itself to attack pigs and large wild cats. It has not yet achieved human-to-human transmission, but because the virus is transmissable between birds and people, H5N1 is at Phase 3, which is the first step in a Pandemic Alert.

Remember, due to the nature of how viruses adapt and evolve, it's not a matter of if, it's a matter of when human-to-human transmission will occur.

Although only 60 people are known to have died from H5N1, it's not the overall death toll that makes flu a potential killer, it's the lethality. Approximately 50% of the people who contract H5N1 die.

I'll be the first to say that the high lethality of H5N1 in Southeast Asia may have secondary reasons: access to healthcare and medicines being two major factors contributing to the lethality. Even if we take those into account, if we use the 1918 flu pandemic as a model, H5N1 could achieve 12.5% rate of global lethality. In a world with an estimated population of 6.6 billion people, that translates to a lot of dead bodies. The economic impact ranging from hard-hit families to entire nations could be devastating.

Scared yet? If you know history, you should be.

I could jump up and down right here and mention that we've known for 2 years that H5N1 is a monster just waiting to be unleashed. I could also mention that the U.S. preparedness for a true flu pandemic is about on par with our hurricane preparedness.

At least some governmental agencies (aside from the CDC) are finally getting with the program, although it seems to be more on the local level as opposed to a nation-wide plan to respond to a pandemic. My home state of Massachusetts, for example, is already pushing people to get their flu and pneumonia vaccines and to put aside an emergency stash of nonperishable foods and bottled water. (The exact phrase from our governor is, I believe, "Prepare like you're going to be in a winter-long nor'easter.")

However, I won't get into the screaming bit. Instead, culled from various sources, I will point out that western industrialized nations do have tools that its citizens can use.

Let me jump back a moment and say that the historical record of the 1918 pandemic shows that people died for several reasons: no resistance to the either the regular or pandemic strain, pneumonia, constriction of the bronchial tubes, fluid in the lungs, and dehydration and high fevers that caused physical damage, such as the breakdown of critical organs and tissues.

Let's hear it for the 21st century. We have some defenses today that the people of 1918 didn't have.

1. Get your flu shot
I'm a two-minded person when it comes to the flu shot. I'm not 100% convinced it actually helps and I've not seen any difference between years I've gotten it and years I haven't. However, on the off-chance that I've just been lucky, I got jabbed today and will suffer being under-the-weather for the next few days.

The flu shot (live virus version) will not protect you from H5N1 because there is no vaccine yet available for it. What it will do is protect you from the usual flu strains. It has been suggested that part of the high mortaility rate in 1918 was because people would get the "normal" flu, and then get hit with the pandemic flu while their immune system was still recovering and resistance to new infection was low. The same principal applies. Protect yourself from what's known, and you have a better shot at avoiding or lessening the impact of what's unknown.

Most U.S. states reserve the first wave of flu vaccines for populations considered at high risk, such as (again) the elderly, very young children, people with chronic respiratory conditions (asthma counts, which is how I got mine so early, even if my asthma less than Type 1), and the immunocompromised. However, most states declare "open season" (that is, everyone can get a shot) after October 24. Check with your state department of health to determine the cut-off date and the locations, dates, and times of flu clinics.

2. Get your pneumonia shot.
Merck's Pnemovax 23 is good for 5 years.

Bacteria are sneaky little bastards and they will take advantage if your immune system is compromised or too weakened to fight back. In a pandemic flu like H5N1, it's a very plausible scenario. Again, looking back to 1918, a certain percentage of the dead actually died as a result of bacteria-causing pneumonia that colonized the lungs while the immune system was too weak. The vaccine will strenthen your defenses and help keep the little bastards in check.

You will have to go to your physician to get it, since I don't know of any public health clinics that give these shots out.

3. If you smoke, quit. Now.
This should be pretty obvious. Tobacco smoke constantly irritates the lungs and mucus membranes, making them more hospitable to bacterial and viral infections. Tobacco also increases blood pressure, inflames the bronchial tubes, and increases heart rate, all conditions that can hinder body functions (like breathing) and distracts the immune system from fighting an infection.

4. If you're asthmatic, keep your bronchodilator supply at a high level.
Bronchodilators help open up the bronchial tubes, which brings more oxygen into the lungs. This isn't going to be a huge help if your lungs are full of fluid, but it should ease breathing.

5. Gatorade for dummies.
I say "for dummies," because I usually forget how wonderful Gatorade can be when you need to get fluid in you very fast. Keep a supply on hand. If you're losing fluid from both ends of the digestive tract, this might be your best bet to stave off dangerous dehydration. It's not just fluid loss, it's also electrolyte imbalance that's a problem, since electrolytes ensure that cellular activities continue. Water, juice, tea, and broth might not be enough to restore all the fluids you need. Remember, dehydration was a huge problem in the 1918 flu epidemic and was partially responsible for some of the deaths.

6. Your friends, acetaminophen and iboprofen.
This is something I didn't know until I read through Flu Wiki, but in case of high fevers (and fevers can run dangrously high at 104 degrees F), it is perfectly acceptable to take acetaminophen (Tylenol) and iboprofen (Advil) concomitantly. The two agents have different mechanisms of action, but they both fight fevers, bring down swelling, and relieve the usual flu symptoms. It's sort of like getting a two-fer: double the benefit, but not double the potential adverse side effects.

7. Tamiflu.
Tamiflu from Roche Laboratories is by prescription only in the U.S. Ask your physician for a prescription and then go and buy it so you'll have it in your medicine cabinet. You have 48 from the onset of flu symptoms to take this drug. Reports are that it is very effective.

8. Get informed. The information is out there, but you have to get it.
If you're interested in the H5N1 flu and how you can protect yourself in the case of a pandamic, here are some places you surf to:

Flu Wiki is such a wealth of information that it'll make you dizzy. And paranoid. However, it offers a fantastic overview of what we know, and what we don't know, about the flu, and especially H5N1.

For some commonsense advice on what to do to prepare for a pandemic, check out Dr. Grattan Woodson's article on Flu Wiki.

The Wikipedia entry on influenza offers an embarassment of links to additional information and is worth the visit.

In the U.S. The Centers for Disease Control has an Avian Flu page that is chock full of information.

For a more international view of H5N1, the World Health Organization page on the avian flu is a damn fine place to start.

Books I highly recommend (especially since I've read them and can say they're very good) if you're looking for a historical perspective:

Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It by Gina Kolata

The Great Influenza: The Epic Story of the Deadliest Plague in History by John M. Barry.

Stay healthy, everyone.

Comments

[midnightsjane.livejournal.com]

I'm of two minds about this. On one hand, it is good to be prepared, and doing the things to keep yourself healthy is important. Getting a flu shot is a good idea, because right now people are more at risk from current strains of human flu than they are of getting avian flu. The Chief Medical Officer of Vancouver's Public Health Dept. says that he would advise those at risk to get flu shots for sure: the elderly, the infirm, those who are immunocomprimised, health care workers, etc. He feels, and I agree, that stockpiling Tamiflu is not necessary for the average person; indeed it increases the risk of it being misused and thus creating a strain that is resistant to it.
Your advice about quitting smoking, keeping hydrated, and the use of ibuprofen and tylenol are well taken.
It really is a very good thing for everyone to be well informed. However, it is less helpful for people to focus overly on the possibility of an avian flu pandemic to the detriment of other health issues.

[liz-marcs.livejournal.com]

Oh, agreed. Very much agreed.

Hmmmm on the Tamiflu (thanks for the info). I honestly don't know much about it and have never used it. I tend to avoid using medications (if possible, I avoid use of antibiotics) as much as possible. Stupid me, I didn't read the product information closely and so wasn't 100% aware that Tamiflu overuse or inappropriate use could lead to resistant strains.

Keeping other health issues in check is much more important, I agree. Chances are, you're more likely to die from other chronic condition (cardiac, respiratory, etc.) than the flu. Plus, if you're healthier to begin with (keeping properly hydrated, eating properly, etc.) you're more likely to fight off an illness, ranging from the common cold to the flu.

Plus there are a lot of commonsense things people can do. Washing hands is a big one. Covering your mouth when you cough or sneeze, that's another. Some people I work with are even more paranoid about bacteria, over and above what I personally think is necessary if you're not working in a health care facility.

That said, the Avian Flu does worry me because of the close historical parallels. One thing we can hope for is that when it does mutate to allow human-to-human transmission that it might be less lethal and/or virulent.

Plus, I don't know about Canada, but awareness of the Avian Flu is almost nil among the general population south of you guys. Awareness is slowly picking up, but it's either nothing or hysteria (like our governor recommending the equavelant of a winter's worth of food).

[midnightsjane.livejournal.com]

I think the thing with Tamiflu is like antibiotics. More exposure can increase the likelihood of the virus or bacteria mutating to become a resistant strain. Kind of like what's happened with the superbugs that are resistant to most forms of antibiotics. The paranoia about bacteria that leads people to use antimicrobial soaps etc. really does increase the possibility of resistant bacteria. Viruses are more complex, but the flu virus mutates very quickly, so there is even some chance that Tamiflu might not be adequate down the road.
I think we're a little more prepared here. The government has stockpiled enough tamiflu for those at risk, and have plans for covering the health care and emergency forces in the event of a pandemic.
It's always a good thing to be aware of the risks, and prepare as best we can.

[liz-marcs.livejournal.com]

Sadly, our government as stockpiled enough for 2% of the population. Guess which 2% is going to get it.

Plus, it's slowly dawning on people down here that we've let our healthcare infrastructure deteriorate to a dangerous degree and that we have a dangerously large percentage of the population with no health insurance at all. We're unprepared for even a heavy "normal" flu season, let alone a pandemic.

Sadly, most of us in the U.S. are pretty much on our own.

[taerowyn.livejournal.com]

but it's either nothing or hysteria (like our governor recommending the equavelant of a winter's worth of food).

I've actually been warned through contacts with non-MA local-level health people that stocking up on a few weeks' to a month's worth isn't such a bad idea. I don't think it's hysteria so much as being prepared for the hysteria that will hit when the pandemic does.

[liz-marcs.livejournal.com]

A month's worth of nonperishables makes a lot more sense to me. Certainly heading into the winters here in New England most people have at least a couple of weeks' worth of canned goods on hand in the cabinets.

Granted, this means I'll be eating a lot of soup...but...hey, at least it's Progresso.

But you make a very good point.

[norwegianne.livejournal.com]

There's currently a debate about this in Norway and Denmark. One health official in Norway was on a newspaper-forum, answering questions from the public, most of which went: Are we going to die tomorrow from this?

His answer: The media has blown it out of proportion. It's good to be prepared, though. Which is why the Norwegian government have gotten in line at a Dutch factory that is preparing to make the vaccine if/when the Avian flu mutates, and have 4 million vaccines on preorder.

The Danish politicians are rallying to do the same thing. Of course it gets a bit different when you're looking at vaccines for a small country, rather than a gigantic one. Also, it is unfortunate that it is the wealthy countries who can afford to give the vaccine to its citizens, which means that the less wealthy countries in the world, again, take the back seat.

[liz-marcs.livejournal.com]

As I pointed out above, people are starting to realize that the healthcare infrastructure in the U.S. is dangerously deteriorated. In some ways, I'm lucky. I live in the northeast and you can't swing a dead cat without hitting a major academic healthcare center, but even so, those palaces would get overwhelmed in a pandemic.

It's a difficult line to walk between concern and panic. The problem is, the U.S. press is mostly silent about it, so we're talking almost no awareness at all among the general population. There's almost a mindset that with two oceans on either side, we're "safe." Never mind that we get the normal flu season and never mind that it didn't help us almost 100 years ago.

But on the other hand, once the press wakes up, you will have that panic-y overreporting. There's some theory that this winter won't be the big one, but next winter might be. If people are innundated with panic too soon, and nothing happens, people won't prepare when the threat is real (see: hurricanes, Katrina, Rita).

Speaking of less wealthy countries taking a back seat, look at what's happening in the wake of the South Asian earthquake. It's devastating and winter is coming. Those governments are strapped and it seems that there's little help coming their way.

[iyalode.livejournal.com]

This issue has dominated our news for some time. There's hardly a day goes by that we don't read or hear something about it. And today my ISP ran a poll on their webpage about it.

As you mentioned the secondary issues are a great concern for countries who do not have good healthcare. And when it crosses over it is here that the fatality rate is expected to be highest.

[liz-marcs.livejournal.com]

Not suprised H5N1 is dominating your news. I'd be more surprised if it wasn't. You Assies are right on the frontline of any flu roaring its way out of Southeast Asia.

There is one hope, and that is, when the virus mutates enough for human-to-human transmission, that it might be less lethal. *fingers crossed* I know I'll be hoping for that.

[anelith.livejournal.com]

While it might be possible for healthy adults to get a flu shot after October 24th (although it will require some calling around to find a drugstore offering a clinic, since my doctor's office has for some mysterious reason decided to *stop* having shot clinics!), my kids will not be able to get them. That's because my pediatrician refuses to give flu shots to healthy kids.

I don't know of any healthy kids who get flu shots, actually. I believe that it requires 2 shots, spaced apart by some days or weeks, up to a certain age (8 or 12?). So the recommendation to get your whole family vaccinated, while it sounds good, might be very difficult to follow.

[liz-marcs.livejournal.com]

Hunh. That I didn't know.

If you click on the Flu Wiki link, it appears they're starting to do research on immunizing school-aged children to help prevent the spread of flu. I definitely saw on the "high risk" form I signed that caretakers for young children also get high priority. Since I don't have children, I had assumed that children could get them.

Good point. And thanks for pointing that out.

[smhwpf.livejournal.com]

Agree it's a serious threat, and all good advice above. Things may not be quite so bad though. Here in Britain they're estimating around 50,000 deaths (though possibly as high as 750,000 in the worst case), though they reckon a quarter of the population could fall ill, so clearly a much lower lethality rate than the present - I guess any mutated strain that could spread person-to-person would be likely to have a lower lethality rate than the current version. Still decidedly worrying, mind.

There's also the question of a vaccine. Of course at the moment the mutated pandemic strain doesn't exist, hence no vaccine, but the Chief Medical Officer here is saying that they should be able to get one up and running and out in the population within 4-6 months of the pandemic starting.

Mind you, different picture in different countries. I'm reasonably confident over here that the government (loathe and despise them as I do in most respects) is making a reasonable amount of preparations, but I shudder to think of how the Bush regime will handle things over your end, and with the lack of universal health care too. Though of course it's likely to be even worse in poorer countries.

The only other slightly optimistic thing is that, again the UK top medical people are saying they expect the pandemic to come more likely next winter rather than this one, which at least gives a little more time to prepare.

[liz-marcs.livejournal.com]

I'm with you in hoping that mutation to allow person-to-person will also cut the lethality. Also, here's another thing: how many people who get the flu actually go see a doctor? There maybe some element to the idea that reporting actual infections results in a "higher" lethality rate. The numbers of deaths though, that oculd be real.

At least in the U.K. you have a health system that's working. Our healthcare infrastructure in the U.S. has been deteriorating for years because the government has left "market forces" completely in charge of the healthcare system. In the northeast where I am, the healthcare network is actually in good shape, if expensive if you lack insurance (which a frightening percentage of our population does).

The other issues is that the ones who'd be hit the hardest by a pandemic are the ones who are most likely the most vulnerable: people without health insurance, working poor, the elderly, etc. Even the middle class would be pretty much on their own if a pandemic hit. Even so, what we've got is better than nothing at all, and poor countries would be doubly hit.

Let's drink to worrying over nothing. Or barring that, a year delay so we can be better prepared.

[stephanierb.livejournal.com]

Thanks for posting all of this. I had been reading a bit about the avian flu in the news, but nothing this indepth. My doctor has suggested that I get a flu shot every year(I have an autoimmune disease and take immunosuppresants to treat it), but I've never bothered. I've never gotten the flu, so each year that I don't get it, I feel less inclined to get one for the coming year. After reading this, though, I'm rethinking that position.

[liz-marcs.livejournal.com]

Yike!

A friend of my brother's takes immunosuppressants because he's a heart transplant patient. He's pretty religious about getting his vaccinations and remains *knock on wood* healthy as a horse, borrowed heart aside.

But I comply sympathize with not wanting a flu shot. Like I said, I rarely get the flu to begin with and I've seen little difference between the years on or the years off. I just went the better safe than sorry route.

[caille.livejournal.com]

I found this article at Acid-Test. It's both scientific and practical. I don't think you have it linked in your post, although I confess I just moused over your links (I will go back to check 'em out.)

The article discusses a number of aspects about a possible pandemic. It tries to put things in perspective while still recognizing the terrible risks. More important, I think, is the way in which it warns that some of the counter-measures being discussed could make things worse. You should definitely read the whole article. Here's a bit:

....Fiction 2. Quarantine outbreak areas to contain the disease.

You feel the first twinges of something that could be bird flu. Imagine two different scenarios. In the first, you go to the hospital, get tested, receive free medication, your whole family and all your contacts are tested and also receive any necessary medication. In the second, you go to the hospital, get tested, are quarantined for an unspecified length of time, your family is quarantined and unable to go to work, pay the rent, go to school, or do anything they have to do. The money spent on finding and quarantining you and yours is not available to provide an adequate supply of drugs. It's a no-brainer that in the second case you'll rush to the hospital and turn yourself in. Not.

Non-punitive quarantine is an essential public health measure. Punitive quarantine just makes people hide disease symptoms, infecting other people the whole time, until they physically collapse. What's true on an individual level is also true on a national level in that governments try to cover up problems, citizens try to evade border controls, and the spread of the disease becomes unknowable and can't even be tracked....

One thing for sure is that we have to pay attention. We also have to be prepared for serious disruptions in the infrastructure, even if we don't get sick ourselves.

[liz-marcs.livejournal.com]

Awesome! Thanks for the link.

This is why I shuddered when he-who in the White House started making noises about using the military to enforce a quarantine. It sounded a lot like pouring gas on the fire to me and with something so easily transmissable as a flu virus, not terribly effective. By the time you have sick people, you're already too late to stop the spread.