One way to connect the dots of H5N1 outbreaks in widely separated areas is the infection of wild birds. It's been said that “dead ducks don't fly,” and human activities such as the poultry trade are responsible for the spread of the virus. Evidence that certain wild birds might carry a strain that is much more pathogenic in chickens (Science 2005;310:426-428) is very worrisome. Such viruses do not pass readily to humans; however, their widespread prevalence over a prolonged time increases the probability of a mutation leading to greater transmissibility.
Some predict that the next pandemic will involve one of the subtypes of influenza (H2, H3, and H1) that keep recurring cyclically in humans, and will be more like the 1957 outbreak, which caused 2 million deaths worldwide, or the 1968, which caused 1 million.
The unprecedented mortality of the 1918 “Spanish flu,” which killed more than 40 million, was attributed to the trench warfare of World War I, and the movement of sickened soldiers in crowded conditions, in which they exposed hundreds or thousands of others (Science 2005;310:1112-1113). American troops from Camp Funston, KS, probably brought the epidemic to Europe. There was virtually no response or acknowledgment to the epidemics in military camps in early 1918 ( www.stanford.edu/group/virus/uda/index.html). Country doctor Loring Miner of Kansas warned national public health authorities of his alarming experiences, but was ignored (John M. Barry, The Great Influenza, Viking 2004).
Compounding the problem, the War destroyed the economic and social structure of Europe. Famine swept across central and eastern Europe; 1 million German civilians died of starvation, while the Allies continued a food blockade until 1919, 6 months after the Armistice was signed (Chronicles, January 2004).
Viruses circle the globe faster now than in 1918, and the Bush Administration has called for $7.1 billion to help avert a pandemic. The biggest chunk, $2.8 billion, would be spent on a crash program to speed cell-based vaccine technology, replacing cultures in eggs, so that a vaccine for all Americans (600 million doses, 2 per person) could be manufactured within 6 months of an outbreak. The Administration is pushing for legislation to shield vaccine manufacturers from lawsuits (Sciene 2005;310:952-953).
To meet the goal, it may be necessary to reduce the amount of antigen needed per dose 20-fold. This would require the use of adjuvants such as alum or squalene (Nature 2005;438:23). Some believe that squalene in anthrax vaccine caused or contributed to Gulf War syndrome (www.autoimmune.com). To stretch scarce supplies of Tamiflu, probenecid could be used to slow urinary excretion, doubling the time that the drug stays in the blood. During World War II, probenecid was used to extend precious supplies of penicillin, and is still used to increase blood levels of penicillin in the treatment of syphilis and gonorrhea (Nature 2005;438:6).
Huge stockpiles of antiviral drugs will be useless if the virus develops resistance. The CDC is discouraging the use of amantadine and rimantadine this season because up to 90% of viral isolates are resistant. While the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) are less prone to select for resistant viruses, resistance is emerging in Japan. Officials worry that private stockpiling may result in inadequate doses or shortened courses of treatment, especially if shortages inspire people to share their personal supplies. Public health personnel and some professional societies urge physicians to put the good of society first and not to accede to patients' requests for supplies to store ( N Engl J Med 2005;353:2633-2637;2667-2672).
The inclination to push universal vaccination reminds some of the 1976 outbreak of swine flu. The CDC director said that “if we believe in preventive medicine, we have no choice” but to try to immunize the entire country. Vaccine was rushed into production, but insurers refused to cover it. No new cases of swine flu occurred, and it appeared that the program might die. Then Legionnaire's disease broke out. Panic about swine flu revived before the responsible bacterium was isolated, and Congress hastily passed a bill providing that all lawsuits would be defended by the federal government. No jury trials or punitive damages would be allowed. A third of the adult U.S. population received the vaccine. Swine flu lay dormant, but dozens of cases of Guillain-Barré syndrome (GBS) were reported, with an occasional fatality (Wall St J 11/28/05).
The role of influenza vaccines in causing GBS is controversial. A review of the Vaccine Adverse Event Reporting System (VAERS) data revealed 382 cases of GBS reported following influenza vaccine between 1991 and 1999, with the median time of onset being 12 days. Acute GBS was 4.3 times as likely to follow influenza vaccine as tetanus-diphtheria vaccine, and severe GBS 8.5 times as likely (Clin Immunol 2003;107:116-121). Underreporting is likely to be quite significant.
David Fedson, formerly of Aventis Pasteur, suggests that statin drugs might prevent the most severe complications by suppressing inflammation ( Science 2005;310:429).
Preventing transmission is obviously an imperative. Frequent handwashing and keeping 3 to 6 feet away from a potentially infected person are recommended. Virus can survive in bird droppings for a week in warm weather and more than a month in cold weather, according to the World Health Organization (My Way News 1/20/06).
Hospitals may not be well equipped to contain respiratory diseases. When the new university hospital opened in Tucson, it could not accept a patient with tuberculosis because air circulation went from room to room. Older hospitals had ultraviolet lights in the isolation rooms. Very little information about this was retrieved on a MedLine search, but one article suggested that UV air disinfection might be effective in interrupting airborne transmission of influenza (Johns Hopkins Medical J 1977;140:25-27).
Just-in-time inventories make U.S. hospitals especially vulnerable to interruptions in supplies of essential items like insulin, anesthetics, and blood products if absenteeism closes factories or if transportation is halted (Wall St J 1/12/06).
British businesses are urged to develop contingency plans for continuing to function with absenteeism of 25% (Sunday Times 1/22/06).
Web sites to watch: promedmail.org (reports and maps of avian flu) and www.cdc.gov. The U.S. national strategy is found at www.whitehouse.gov/homeland/pandemic-influenza.html, and state plans at www.pandemicflu.gov/plan/stateplans.html.
The 24th annual meeting of DDP will be held at University Place, Portland State University, Portland, OR, on August 5-6, 2006. A breath-taking tour of Mt. St. Helens is planned for Friday, August 4. The bus trip will take about 9.5 hours.
While the media focused on government failures, one of the largest rescue operations in history saved more than 50,000 lives by boat and helicopter. The Coast Guard claimed more than 24,000 rescues. Local first responders launched 100 to 200 boats within the first 24 hours. The National Guard, Wildlife & Fisheries, and many others worked heroically– without press or central command and control (Lou Dolinar, realclearpolitics.com 9/15/05).
DDP, 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, (520)325-2680, www.oism.org/ddp