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Phase Seven
The Makings of a Super Flu
Blue in the face, gasping for air, and fighting for life, the clinical picture of a super flu is not pretty. It starts like ordinary flu, the seasonal nuisance that causes fever, joint pains, malaise, and coughing. But this one is different. It progresses fast with a high fever and piercing headache. As your temperature rises, blood heats in the body core, muscles contract, and violent chills occur. You cannot get warm despite piles of blankets.
Once in the respiratory tract, the preferred ground for human influenza infections, the virus triggers a massive inflammatory reaction. Tissues die, blood vessels leak, and the lungs become filled with fluid. Coughing is violent and blood-tinged phlegm bubbles up into your throat and mouth. You gag and cough, and choke. In the end, viral pneumonia sets in; your lungs fail and you suffocate to death, choked by your own secretions.
WHAT'S A PANDEMIC?
The term pandemic refers to a global disease outbreak. In comparison, an epidemic is a fast-spreading disease that affects a group of people in a limited geographical area but doesn"t affect global health.
A flu pandemic is a worldwide outbreak of a new strain of influenza virus that no one has immunity against and so it causes widespread sickness and loss of life. It?s so contagious that the number of new cases increases exponentially.
The reason we don?t have immunity to a newly emerging influenza strain is because our immune systems have not developed antibodies to that particular strain. Antibodies are special proteins that remember an infection?s genetic signature or code and alert the immune system to mount a defense to fight the virus.
Technically, anti-influenza antibodies circulating in the blood recognize a specific protein, called a viral antigen, and chemically attach or bind to it. In the case of the flu, they bind to hemagglutinin, HA for short. It?s called this because HA causes red blood cells, which contain hemoglobin (where the "hem? part of the term comes from), to clump together or agglutinate. HA plays the crucial role of helping the virus dock onto a host cell. By binding to HA, antibodies and other immune substances inhibit the virus from attaching to and infecting healthy cells.
But influenza is a smart virus. It continuously rearranges itself chemically and genetically so our immune system can?t recognize it. Then the virus has full reign in virgin territory.
Eventually, our immune system mounts a defense, but only after the virus has made us sick. Sometimes the immune system goes too far. If it overreacts, which is often the case in younger healthy adults, a cytokine storm occurs in which the body?s own disease-fighting chemicals set off a self-destructive cycle resulting in explosive tissue damage. In a matter of hours, you can be dead.
In a pandemic, death rates are high. In the twentieth century, there were three flu pandemics. Between 50 and 100 million people died of Spanish flu in 1918, two million from the 1957 Asian flu, and one million in 1968 from Hong Kong flu.
During the 1918 flu, 60 percent of the people of Nome, Alaska, died and some Eskimo villages were entirely wiped out. In Samoa, 20 percent of the population died, and many other South Pacific islands fared much worse. In some British boarding schools, up to 90 percent of children were sick and many died. Death rates were particularly high among pregnant women, with 70 percent succumbing to the illness. The highest rate of infection, however, was among the young and healthy. The disease spread particularly fast among enlisted men in the armed forces on both sides of the Atlantic during World War I.
Pandemics, like hurricanes, move faster than government aid workers or medical bureaucracies can respond. Though viruses are far less predictable than a hurricane, we have come to understand some of their patterns. With foresight, we might avoid the worst. That?s the good news. The bad news is we?ll get hit.
The flu season comes every year, as it has for thousands of years. That?s ordinary flu. Epidemiologists, scientists who track diseases and study epidemics, agree that we are overdue for a viral pandemic of plague proportions. The most likely candidate is our old nemesis, influenza?nature?s way of thinning the herd.
Experts believe that the current avian H5N1 influenza strain, ?bird flu,? has the potential to become a human pandemic in proportions that could dwarf the Spanish flu of 1918, which killed millions and is, to date, the deadliest influenza outbreak in modern history.
Flu hunters, influenza experts who follow viral outbreaks, identify hot spots, study the disease in the laboratory, investigate its genetic code, and create theoretical worst-case scenarios in order to understand the disease and predict its path, all agree on one thing: It?s only a matter of time before the next outbreak happens. The question no one can answer is how severe it will be and when it will come. The experts hope that a pandemic influenza will be nothing more than a more severe version of seasonal nuisance flu, but they?re not betting on it. Viral dynamics are a mystery. We could be in for a super flu.
During a pandemic, symptoms may not follow the usual course. If the coming one is anything like the 1918 influenza pandemic, inflammation may not be confined to the lungs, like regular flu, but could affect the brain, liver, and other body tissues. The virus could even bypass the respiratory system entirely. Entering the bloodstream, it could cause the liver and kidneys to fail, damage nerves, and rupture muscles. Many of the people who survive this flu may never fully recover. Signs that H5N1 is not like ordinary flu are already here. Infected with bird flu, one Vietnamese boy died in a coma, days after he was infected, with an inflamed brain but with clear lungs.
The World Health Organization (WHO) Global Influenza Preparedness Plan lays out six pandemic phases and recommendations for public health responses. In September 2005, WHO issued a Phase 3 warning declaring that a virus new to humans was causing infection, but had not yet reached a stage where it easily spread between people. It?s the lowest rung of the pandemic alert ladder. Only a few months before, they thought we were at the tipping point, but flu officials pulled back from declaring Phase 4 (at which human-to-human transmission occurs) because, although they found clusters of human cases in Vietnam, they were unable to positively identify them as H5N1 influenza.
Meanwhile, bird flu had become endemic in large parts of Asia and it was making its way to Turkey. By March 2006, it exploded into Africa and Europe, infecting chickens, swans, and cats, but few humans. The flu hunters were close behind. They claimed that, though humans were becoming infected, the virus was still too inefficient to warrant escalating the alert. Phase 5 is marked by rapid spread of infection, and the last rung, Phase 6, is when it goes global. There is no Phase 7; beyond Phase 6 is apocalyptic.
THE INFECTION OF THE WORLD
Viruses respect no boundaries. They recognize no international borders or time zones. They have no obligation to country, race, social status, gender, or age. Rich and poor alike become victims. They infect the young and the old. If given the opportunity, viruses travel long distances, circling the globe in days. They are everywhere and infect everything from bacteria to whales, and kill plants as well as people. No one has bulletproof immunity.
For a flu pandemic to occur, at least three concurrent if not simultaneous events are necessary: (1) a new highly aggressive virus has to appear with the ability to infect humans; (2) a vulnerable population must be available without previous exposure and no immunity to the new virus; and (3) infection has to spread readily and rapidly from person to person.
If a pandemic influenza strain like a human version of bird flu were to emerge, experts agree that global spread is inevitable. What makes this virus particularly ominous is that it travels on the wings of migratory birds and can be transported to market in live chickens and ducks. Once infected, people could carry it to other countries in a matter of hours when flying by airplane or traveling by bus or train.
Pandemic flu tends to spread in two or three waves in the course of a year. The first wave introduces the virus into a host population. Some people get violently sick and many die. The second wave, which follows three to nine months later, tends to be more deadly than the first or third, and many people get sick and die. By the third wave, our immune systems have developed specific antibodies and faster recognition occurs. It can defeat the virus before it invades too deeply in our tissues, and thus the virus is not as deadly. By the end of a year to a year and a half, it?s over.
Medical scientists are as certain as they can be that, at some time in the future, we will experience another pandemic. It could be this year, next year, or in ten years. We don?t know when it will come, but it is imminent.
Early detection and control are important to contain contagion and slow down the spread of infection. That may be only possible in the developed world where sufficient infrastructure, staff, equipment, communications, and medicines to cope with large numbers of sick people are available. Smaller countries like Switzerland are better off in this regard. The United States, though the richest country in the world, is a large country with pockets of high density where people live in Third World conditions, making inner cities and poor rural areas likely to be hit hardest. What transpired in New Orleans after Hurricane Katrina was an example of the poorest being most victimized. Lesser developed nations are even more vulnerable because of overcrowding, unsanitary personal hygiene, lack of medical services, and inadequate public health measures.
Of the three components necessary for a pandemic, the first two are nearly in place. H5N1 bird flu is a lethal virus that has the ability to become a human infection to which no one has immunity. To make matters worse, many social and economic conditions are in place for an epic disaster. Poverty and malnutrition caused by poor diet weaken immunity, and massive overcrowding in Third World slums makes for a perfect target. Widespread infection is certain to occur.
WHAT MAKES A SUPER FLU?
Infection from influenza virus is simple, effective, and universal. If you breathe, you can catch it. If a strain of influenza emerged that retained these traits and added others like resistance to antiviral drugs and the ability to outsmart vaccines, we?d be in big trouble.
A super flu is a viral infection that has all the ancestral traits of influenza, is drug-resistant, has undergone genetic mutations that make it possible for it to spread from human to human, no one has immunity to, and is extremely contagious and virulent. Pandemic influenza, like the Spanish flu of 1918, is much more virulent than regular flu. As if it is in a hurry to bypass the usual incubation period, it spreads readily and rapidly from person to person, and the infected individual can die within 48 hours after primary infection.
When recreated in the laboratory, the 1918 flu virus was found to be 50 times more prolific than ordinary flu on the first day of infection, and 39,000 times more virus particles were released four days later. This is an astounding rate of replication and beyond what even the strongest of human immune systems can keep up with. It?s no wonder that all of the mice used in the experiment died within six days. This is a forewarning of what a super flu pandemic would be like in humans. Almost no one infected would survive.
Were a super flu to attack, it is conceivable that more than half the population of India and regions of China and Southeast Asia would get sick. Japan, being an island and having the wealth to pour into medical resources, would fare better. Much of the Caribbean, Mexico, and many parts of Latin America would be infected. Countries like Haiti would be devastated. Africa, already suffering from AIDS and malaria, could receive a deathblow overshadowing famine and genocide. Western Europe, geographically close to Africa and contiguous to Russia, which in turn borders Asia, could be hit very hard. Many European countries, however, are preparing for the worst by stockpiling supplies of antiviral and other drugs to treat flu and secondary infections.
North America will not be spared. American bureaucracy will slow relief efforts, and politicians, unfamiliar with public health crisis, will be powerless. Centralization of resources will prevent rapid distribution of food and medicines. Natural disasters have been low on federal priorities. Hurricane Katrina showed us that nature is more powerful than terrorists and more unpredictable, even if we know the trajectory.
A tear in the fabric of society is upon us. With the breakdown brought about by a super flu, borders would be closed and international flights suspended. Schools and other places where people come in close contact, like theatres, would also be closed. National security may become vulnerable; insurgency and terrorism might escalate. Entire cities may need to be quarantined. The estimated costs of a flu pandemic in the United States alone are 70 to 165 billion dollars. The global economy, so much a part of the twenty-first century, would shut down.
In fact, super viral diseases are historically real. During the conquest of the Americas, upward of 95 percent of indigenous people in North America, Mexico, the Caribbean, Central America, and South America were wiped out by smallpox and influenza. The last major killer pandemic, the Spanish flu of 1918, caused an estimated 50 million deaths and possibly as high as 100 million in a single year. It reached even remote corners of the globe.
The 1918 Spanish flu pandemic was more like a Biblical prophecy come true than a medical disease. Almost a century later, epidemiologists still study this worst of modern influenza pandemics for clues to help them understand and prepare for the next big one. What they have found has them scared: The 1918 flu was a type of bird flu.
Among domestic poultry and some wild migratory waterfowl, bird flu is devastating. It kills almost all birds infected and it?s spreading around the world at an alarming rate. Of humans who have contracted the bird flu directly from handling sick chickens or ducks, half have died. It?s no wonder flu experts are concerned.
A human flu pandemic would be as devastating but on a global scale. Contagion would be spontaneous. Infection would be swift and deadly. More than half of its victims would die painfully. In pandemics, an estimated 25 percent of the work force is unable to work. During a super flu pandemic, 30 to 50 percent of the population could become ill with influenza. World leaders, generals, and heads of corporations would become sick, just as would ordinary people including firefighters, police, and healthcare workers. The economies of some countries would be shattered.
Schools would close. Public transportation would grind to a halt. Store shelves would be empty and not be restocked for weeks. Martial law could be needed to control rioting and looting. Local police would not have adequate manpower to maintain law and order. Troops might be used to enforce quarantines and curfews.
Wall-to-wall cases would swamp hospital emergency rooms. To prevent overcrowding, triage hotlines may be used to sort the most serious cases from the merely sick and disabled. MASH-type field units would be set up in hospital and shopping mall parking lots and temporary influenza hospitals would have to be created in public buildings when hospitals overflow with patients. Many people would receive no formal medical care and would suffer and die in their homes. It?s conceivable that entire families could die without anyone knowing. Rescue workers would have to go house to house, recovering bodies.
In some cities in poor states and in many small poor countries, the number of sick and dying people could reach catastrophic levels, totally outstripping city and governmental resources. Disposing of the dead would become a nightmare.
ARE WE PREPARED?
The prospect of catastrophic sickness is frightening. The scale of damage that nature can inflict is beyond what policy makers care to imagine. There are many questions, but few clear answers. How can a nuisance illness rise to plague proportions? When it arrives, will we be prepared? WHO experts inform us that we are not well prepared.
The United States has no wide clinical use of rapid in-office testing for flu as do the Japanese. We don?t have enough antiviral drugs as does Hong Kong. We?re not as organized as the Swiss. Even if we had sufficient antiviral drugs, they don?t work that well and if improperly or overused could trigger a super flu mutant strain worse than the original one. There won?t be enough vaccine to go around. Even if we make a safe and effective vaccine in time, it won?t completely halt the spread of infection. There are not enough respirators and other medical supplies to assist the breathing of the most seriously ill.
American doctors aren?t prepared. They have little training and almost no experience with severe infectious disease. They rely on symptom discrimination to diagnose and treat disease rather than cutting it off at the root. Many don?t bother differentiating between a cold and the flu. Most consider the flu a self-limiting, nuisance illness that has no cure. Seasonal upper respiratory cases are so common that professional apathy is high. Antibiotics are indiscriminately prescribed. But antibiotics, designed to kill bacteria, don?t touch viruses.
A pandemic tends to kill people at the extremes of the life span and persons with underlying chronic disease. In the elderly, who have the highest mortality rate from seasonal influenza, secondary infections like pneumonia are treated with antibiotics and lung inflammation with steroids. Comfort measures like oxygen are given to ease congestion and help breathing, and ventilators are used to assist failing lungs, but the elderly die anyway. Nursing homes, where aged people are warehoused, are particularly vulnerable, as are the healthcare workers who tend to our frail seniors. During a super flu pandemic, we could lose up to 90 percent of our elders.
If we are not prepared now, will we learn so we are ready the next time? Pandemics behave as unpredictably as the viruses that cause them. In previous pandemics, great variations were seen in mortality, severity of illness, and patterns of spread. During a pandemic, there is a huge surge in the number of cases, with an exponential increase over a very brief time, often in a matter of weeks. A pandemic strain?s capacity to cause severe disease in traditionally unaffected age groups, namely, young adults, is a major determinant of a pandemic?s overall impact. For example, firefighters and nurses tend to be younger, and if they become sick, emergency response is compromised.
In the best-case scenario, we?ll see it coming, identify it early, and slow it down at the source. Asia is the most likely starting place, but it could happen anywhere or even in multiple places simultaneously. If we are lucky, the flu strain will be vulnerable to existing antiviral drugs and there will be enough supply. If we are lucky, we?ll get the vaccine right the first time and there will be enough shots at the right dosage to inoculate key people and the most vulnerable groups, reducing the overall death rate. I?m sorry to say that this is overly optimistic and perhaps fantasy thinking.
Given time, an influenza virus will outsmart antiviral drugs. Many have done so already. When a virus becomes impervious to drugs, no one is immune. It may mutate so fast, scientists aren?t able to keep up. A super flu could spawn multiple variant strains appearing simultaneously in different parts of the world. A super flu pandemic will not only kill animals and individual humans, but infect modern civilization. It will stop only when our immune systems learn to normalize it.
Your best bet to beat pandemic influenza is to educate yourself, develop a personal preparedness plan, protect your family, use prescription and over-the-counter drugs wisely, and learn to beat the flu naturally when it comes.
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