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The Coming Pandemic?

The United States is woefully unprepared for the next likely disaster: an avian flu pandemic.
Health officials at the Centers for Disease Control and Prevention, and at the World Health Organization, are urgently warning governments and public health officials that a deadly avian influenza virus may soon spread rapidly across the globe, overwhelming unprepared health systems in rich and poor countries alike. The lethal Type A strain of influenza virus, known as H5N1, first emerged in Hong Kong in 1997 and has since been responsible for the deaths of hundreds of millions of chickens, ducks, and other water fowl, and increasing numbers of mammals. As of July, over 100 people in Southeast Asia have been infected, most from contact with infected birds, and 60 have died.

This is a powerhouse virus. Infectious disease experts are warning that it is only a matter of time before the virus mutates to become more easily transmittable among humans. Once it does, it will spread quickly, and the global death toll will likely be in the tens of millions. Despite these warnings, local, state, national and international preparedness is entirely inadequate to the potential threat. As one health expert said recently, "avian influenza is a viral asteroid on a collision course with humanity".

H5N1 is the most lethal strain of influenza ever seen. Since appearing, it has killed 100 percent of the domesticated chickens it has infected. Over the past 9 months, avian influenza has evolved to become heartier and deadlier, and has jumped the species barrier to kill a wider range of species including mammals such as tigers, horses, pigs, mice, and humans. Most alarming is that since the beginning of the year, several human-to-human cases have occured.

Thus far, the disease has been limited to Southeast Asia, the Korean Peninsula, Indonesia, and China, but Russian health authorities in recent days have confirmed H5N1 as the cause of death in large numbers of migratory birds and poultry in six separate regions east of the Ural Mountains, which are all that now stand between the virus and Europe. Experts are almost certain that the virus will arrive in Europe and the Middle East as early as this fall.

If (and many say when) the virus mutates or acquires just a few new genes, it will travel the world at a deadly velocity. The havoc such a disease could wreak will exceed that of the Spanish flu of 1918-19, which killed at least 50 million people worldwide over a period of 18 months, including 6 percent of the U.S. population. Almost no one will have natural immunity, no matter whether they've received influenza vaccinations previously.

It is also possible that nothing will happen. The virus may not acquire the capability for easy human-to-human transmission. It may lose some or all of its extraordinary virulence. No one can predict with certainty what H5N1 will do. But the risk of danger is profound, and we are quite simply terribly unprepared.

The CDC and WHO predict that an avian influenza epidemic could kill between 2 and 10 million Americans, hospitalize millions more, and sicken one-third to one-half of the U.S. population. The entire world would experience similar levels of carnage, with higher death tolls expected in regions with poorer general health and higher numbers of HIV-infected individuals, such as in Africa. A global death toll in the hundreds of millions is not out of the question.

Unlike the typical yearly influenza virus epidemics, it will be the young and healthy who suffer the most, because it is not so much the virus that kills, rather the overwhelming immune response of the body against it. In what is known as a cytokine storm, the body quite literally destroys itself. Young healthy bodies with healthy immune systems will mount the most overwhelming immune response, and experience the highest mortality.

Aside from the tremendous loss of life, the effect on the global economy would be catastrophic. Profound work stoppages would occur. Borders and airports would be closed for months. Trade and travel would virtually cease. The world's stock markets would undoubtedly crash. Aside from economics, the disease would affect global security, reducing troop strength for all armed forces, UN peacekeeping operations, and civil police worldwide.

Local, state and federal governments are simply unprepared for the massive social disruption and panic that would result from an avian flu pandemic. And the federal government knows this. Outgoing Health and Human Services Secretary Tommy Thompson, when asked what worried him most, stated last December that the threat of a avian flu pandemic was a "really huge bomb that could adversely impact on the healthcare of the world", killing 30 to 70 million people. One would assume that he spoke with the authority of someone with access to the best medical information in the world.

If a pandemic happened in the near future, U.S. hospitals would quickly be overwhelmed. They would also quickly become understaffed, as many medical personnel would be afflicted with the disease. Disruptions in the supply of medications would occur. Hospitals would be overwhelmed with both the sick and the worried well. Many times more people infected with avian influenza would need ventilator care than there exists ventilators in the U.S. How would they deal with the large numbers of patients? How would hospitals make decisions on rationing?

Critical community services would be immobilized, including fire, police, and community government. Workplaces would grind to a halt. Shortages of food and other essentials would occur. Places where people gather - malls, cinemas, theaters, churches, sporting events - would be shut down to limit human spread of the virus. The resulting social breakdown would be unlike anything seen by living Americans.

A vaccine was only very recently developed, and is on the FDA fast-track for approval, however just two million doses are expected to be produced in the U.S. over the next four to six months. The United States would probably only have about a month or less of warning before a pandemic became widespread, therefore there would simply not be enough time to produce a vaccine against H5N1 on a large enough scale to immunize the entire U.S. population. Moreover, unlike the usual single yearly vaccination administered in the fall and winter months against the usual strains of influenza, immunization against avian influenza would require a series of two vaccinations. We simply cannot count on vaccines.

We will also face the dilemma of who to vaccinate. The usual candidates - the very young, the elderly, and the immunocompromised - were actually the ones most likely to survive during the Spanish flu pandemic of 1918-19. As is expected to happen with an avian flu pandemic, it was the young and healthy who suffered the highest mortality during the Spanish flu pandemic. So do we immunize the young and healthy with our limited avian influenza vaccines? Or do we immunize those who society traditionally considers its most vulnerable? Or do we give priority to health care workers, civil servants, and those in the military? How will we decide?

As for treatment, only one antiviral, oseltamivir (Tamiflu), is known to be at least somewhat effective against avian influenza. However, no one knows exactly how effective it will prove in the event of a pandemic.

Only one company, Roche of Switzerland, produces Tamiflu. Its production is slow and difficult, and could not be greatly accelerated in the event of an avian flu pandemic. Countries in the developed world, including Johnny-come-lately the United States, are beginning to stockpile the drug, but if a pandemic were to hit in the next one to two years (and many say it likely will) there simply will not be enough Tamiflu to go around. Great strife would ensue as the limited supplies of this expensive drug were allocated to those in health care and other essential services. Everyone else, and everyone in the underdeveloped world, would simply be out of luck.

The Bush administration since 9/11 has spent billions of dollars on what it terms "biodefense", and has established priorities in inverse relation to actual probabilities. The risk of an avian influenza pandemic, and the potential for massive death and disruption, far exceeds the risks and potentials of outbreaks of anthrax, or smallpox. As one member of the government's advisory panel on vaccinations recently said: "It's too bad that Saddam Hussein's not behind avian influenza. We'd be doing a better job".

What can we do? We can no longer ignore the warnings. Local and state governments, as well as the federal, must move avian influenza pandemic preparedness to the top of their domestic public health priority list. Hospitals and local and state public health officials must do likewise. Citizens must be informed of the brewing threat, and demand immediate attention be given to community preparedness.

While a global pandemic cannot be stopped once it starts, its impact, and its death toll, can be greatly reduced by immediate dedication to preparedness. We might get lucky, and an avian flu pandemic might never materialize, but should we leave it to chance?
realistically, are we faced with home remedies? 16.Sep.2005 14:11

theresa mitchell

Suppose, Doctor, that this virus appears before sufficient stockpiles of Tamiflu and vaccines are available...it seems to me that we would be left to watch our young perish of the 'cytokine storm.' Surely there are actions we can take to mitigate that. If inflammation results from t-cell oversupply, should over-the-counter anti-inflammatories (such as naproxen and ibuprofen) be taken? If so, what dosage should be used?

Moreover, isn't it true that l-ascorbic aids in scavenging of damaged cells? Would that reduce the overall inflammation? I have had good results taking l-ascorbic when my body is damaged by overwork or surgery (7-10 grams per day). I seem to recall reading that l-lysine has a broad antiviral effect, as well; and it would seem that some form of chelated zinc is useful. What do you think of these approaches? Are there other mitigating treatments? Also, how should hydration be maintained in the event of nausea?

The real WMD 17.Sep.2005 10:02

Anarchy-nonymous

The CDC believes that as many as a dozen nations currently possess smallpox, as it was distributed to allies by the Soviet Union in the 1980s. North Korea, Iran, Syria, and other "rogue states" currently possess the ability to smuggle smallpox into the US and start an epidemic that would be as catastrophic as a nuclear attack. The USSR would maintain stockpiles of 4,500 metric tons of weapons-grade, inhalation anthrax. The technology to create this deadly bacteria is common to virtually all nations.

The whole WMD thing is a ruse.

A Scary Tale 19.Sep.2005 11:23

Tom

If we can believe in early indications, the H5N1 virus will dwarf the spanish flu pandemic. Among those victims who have contracted it, had suffered a 55% mortality rate. Please dear reader, pause for a second and let it sink in. The only constrain remaining for the virus is, to jump the 'species barrier' and be communicable between humans, (so far it is contracted only between animal to human and not human to human) Soon as that mutation will occur, we will have a pandemic at hand, like we have not seen, since the bubonic plague of the Dark Ages.
The way I knew it, that the vaccine Tamiflu is highly effective, to the point of providing virtual immunity for the patient. However there is no chance to make more than a tiny fraction of the needed dosages, with the present arrangement of only one supplier for all of Humanity. (Why not licence it?)

avian flu 22.Sep.2005 09:24

karl roenfanz ( rosey ) k_rosey48@hotmail.com

of course congress, the prez, supreme court, and the military would get the secrete stash. the rest of us would have to wait untill the fda would approve the tamiflu after adequit testing. ( five to ten years )

PBS Mentions 22.Sep.2005 15:28

Arizona PBS Watcher

PBS "Newshour" does frequent stories about the Bird Flu,so it most be a serious issue.

Intellectual Property Rights Kill 23.Sep.2005 09:19

CatWoman

Every time this story is told, there is mention of the fact that Tamiflu might help and that only Roche of Switzerland makes the drug and therefore, there will almost certainly be only a very tiny, limited supply. (A very cynical side of me wonders whether Roche has anything to do with the hype surrounding the bird flu. But a more paranoid side is as scared as anyone about the possibility of such an epidemic.)

It surprises me, though, that no one has made the leap here, between the scarcity of a possibly lifesaving drug in the face of a possibly devastating outbreak, and the implications for intellectual property rights. If this epidemic is feared to be so severe, and if Tamiflu could save people, why in the fuck do we allow one tiny company to keep a lid on the antidote? Why isn't every lab in the world brewing up a batch of tamiflu? Oh. Right. Because Roche owns the intellectual property rights to the formula, and of course their company profits are worth more than tens of millions of lives. Just like the way AIDs drugs that could save thousands of lives in Africa are being denied to mothers and babies there, because the people can't afford to buy them and the companies that make the drugs refuse to allow cheaper knock off drugs to be manufactured. And the world courts affirm the value of company profits over human lives, every time.

Fuck that. If tens of millions of people die because they did not have access to this drug, then it will be Roche and intellectual property right who are to blame. And both should be hung.