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Bird flu facts and fiction

From a biologist, a rant on what works and what doesn’t for H5N1. Below: fiction, then fact, then what to do. I apologize in advance for the hectoring tone, but I’m fed up with the balderdash I keep hearing. Eat tamiflu, and barricade yourself into Fortress Wherever with a gun to keep out the feverish hordes. I mean, honestly.

(Nov 1, update, at end)

Fiction 1: We’re all going to die.
It makes for a good movie script, but this is not the way diseases work. The most lethal disease on record, Marburg hemorrhagic fever, causes death in over 90% of patients in the worst outbreaks. Ebola’s rate hovers around 80%. (Aids, a long-term illness, is in a different category, but even untreated Aids is not 100% fatal. See the research on prostitutes with immunity in Nigeria.) Both Marburg and Ebola are very different from flu. Sars is more closely related, and it had a fatality rate of around 15%.

Obviously, these are all very high fatality rates, and the only good rate is zero. The point I’m trying to make is that exaggerating risk does not help anyone to deal with it.

There is some early data coming out of Indonesia that suggest 100% fatalities. What the number means is that 100% of the people diagnosed as definitely having H5N1 virus have died. These tests are done at hospitals. People don’t normally go to hospital for flu, certainly not in the Global South. The people seen at the hospital are in a very bad way when they’re brought in, and many fatalities are expected in a group in that condition. But in order to know what the chance of surviving the disease is, you’d need to know the total number of people who have the virus. You’d need to know how many carry the virus without symptoms, how many recover, and how many die. We know none of this, so we have no idea what the rate is. It could be 100%, it could be 5%. H5N1 is a very bad strain of flu with pandemic potential. The intelligent thing would be to deal with the real threat (more on that below), and the stupid thing would be to do nothing but stock up on tamiflu. [Update Oct 8, below, on antivirals. [1]]

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.

None of this is smart. It satisfies the need to spend money on oneself rather than others, but unfortunately that’s the only thing it accomplishes. In the case of flu, quarantine doesn’t achieve containment of the disease, and it doesn’t stop an ever-widening number of people from getting sick. It does, however, cost lots of money. Spending the same amount of money on an actual solution would be smarter, even if it meant we had to donate to others.

Fact 1. Flu viruses mutate.
Flu viruses mutate a lot. There are uncountable trillions of them, all changing in various ways. Some of those changes make them able to infect bats, or civet cats, or Canada geese, or humans. The way they do this is the same way spaghetti sticks to the wall when you throw it to see how done it is. Most of it slides off, but a few noodles hang on. In the case of viruses, the ones who manage to hang on have a whole new defenceless host to grow in. After a few years, the host learns how to unstick that particular kind of virus, and the hunt is on for yet another new home. The point of all this is that sooner or later, any flu virus will have a mutation that allows it to pass between humans. If one outbreak of lethal human flu is stopped, that’s not the end of the danger. A few months later, there will be another outbreak.

That’s another reason why quarantine, by itself, doesn’t solve the problem. All you’re doing–if it works!– is putting out brush fires, while the viruses keep pouring on fuel just out of reach.

Fact 2. Flu and cold viruses are transmitted mainly by touch. (Some recent work on that reported in the BBC Oxford & Lambkin [2], 2005, Journal of Infection, August 2005, pages 103-9)

A small amount of cold and flu transmission is by the dreaded droplet infection and inhalation of the virus. The risk is especially high for air travellers because the airlines save money by recirculating air without filtering it well enough, by keeping the air too dry because that’s cheaper, and by keeping its oxygen content too low, likewise because that’s cheaper. Airlines should be kicked, repeatedly, until they do what is necessary for the safety and health of their passengers and flight attendants, especially so since air travel is the best way for the virus to hop continents.

For the rest of us, however, the most effective flu prevention is washing hands or using alcohol wipes after touching doorknobs, phones, toilet handles, and anything else touched by many different people. Basically, you should be cleaning your hands about six times a day. The next most important thing is cleaning and disinfecting surfaces that are touched often (counters, phones, desks, etc.). The virus is activated when virus-laden fingers touch our mouths, nose or eyes. It is truly amazing how difficult it is not to touch one’s face, and how unconscious and automatic the process is. One of the interesting effects of wearing rubber gloves is that you find out how often you touch your face.

Most face masks are useless for stopping viruses. Viruses are *tiny*. They’re just big molecules, after all. Any face mask that is easy to breathe through has a pore size that looks like chicken wire to a virus. However, what face masks can do, and do very effectively, is stop you from touching your nose or mouth.

Fact 3. The public health system in the US has become inadequate to deal with a flu pandemic.
Any system will be stressed by a big outbreak of flu, but ours has fallen down on three important counts. The first is vaccine production. Production has been allowed to concentrate in very few plants. Problems at even one plant, as in the 2004 flu season, then cause nationwide problems. The second issue is vaccine distribution. This is part of the great nationwide infrastructure decay that makes it difficult to provide any emergency supplies to where they’re needed. We’ve had all the proof we need of how bad the situation is during the 2005 hurricane season. Vaccine distribution is bad, too. The 2004 season proved that.

The third issue is tailoring vaccines to current outbreaks. The approved method involves sterile incubation of virus in chicken eggs and takes months. A flu season gears up around November and extends into spring. About nine months earlier, scientists have to *guess* what the next epidemic strain will be, and then start the months-long process of designing a vaccine for it. It then takes a couple of months, at best, to distribute it. For decades, there was no alternative.

Now, DNA-based methods could make a tailored vaccine in *weeks*. There are valid reasons to make sure the method is safe enough to apply to millions of people, so it should have been pushed through testing at the earliest opportunity and the fastest speed. It hasn’t been. It’s still sitting on the shelf. If it wasn’t, we wouldn’t have to guess about the right vaccine to use for the current flu season. And if a new strain showed up suddenly, we could deal with it right then and there. As for distribution, I’d bet UPS could give the government a hint or two that would get that time down to weeks as well.

Take home message: Vaccines are the best personal preventive measure. Get shots if you can. Assume government response to a pandemic will be reasonably useless.

Some links for more information:
Dr. Charles [3] paints a plausible doomsday scenario if we do everything wrong.

Centers for Disease Control [4] “what’s new” page with links to other CDC info on transmission, vaccines, and prevention.

The 2005-2006 flu season US vaccine contains two A series elements (related to H5N1): A/New Caledonia/20/99-like (H1N1) and A/California/7/2004-like (H3N2). The third element is from B, the other major group, B/Shanghai/361/2002-like viruses.
Update Oct 11: Dr. Chris Grant, writing in comments on the excellent BBC article on bird flu [5]: “H5N1 is a description of two tiny virus peptides (H = hyaluronidase type 5 and N = Neuraminidase type 1). (Fun factoid: Hyaluronidase is the same stuff on the surface of sperm to help them make a way into the egg.)

World Health Organization [6], data on confirmed cases and transmission.

Wikipedia [7], facts and figures about avian flu and its history.

Things to do:

[Update, Oct. 8.] More on tamiflu, and flu antivirals. They are not useless, but:

Tamiflu (oseltamivir phosphate) reduces the severity of flu and/or shortens its duration IF treatment is started within hours of the first symptoms. It does not work against colds. When self-medicating without positive diagnosis, you need to differentiate between cold and flu symptoms within the first 4-12 hours of onset. Tamiflu can have side effects, the main ones being nausea, vomiting, stomach pain, diarrhea, bronchitis, or dizziness. Relenza (zanamavir), the other major antiviral, is likewise strong medicine.

Flu viruses are growing resistant to antivirals [8]: “…in a special online edition of The Lancet, scientists at the Centers for Disease Control and Prevention reported that 12% of influenza A strains worldwide have developed resistance to the most widely used flu medications.” Bird flu (H5N1) has already shown some resistance to tamiflu. Whether the strain that mutates into human-to-human transmission will be susceptible or resistant can’t be known until the strain actually evolves. Resistance is arising the same way antibiotic resistance did. Amantadine and rimantadine are apparently ineffective against H5N1, and many other flu viruses, some say because the drugs are widely used to medicate poultry in China. Tamiflu is widely prescribed in Japan for any flu-like illness.

Stockpiling and self-medicating with tamiflu will likely exacerbate viral resistance. Anybody who doesn’t take the full course will help the evolution of resistant viruses. There are always plenty of people who “save some for next time.” So, by trying to take care of number one, instead of everyone, we’ll end up breeding resistant disease, potentially in a matter of weeks, and we’ll all be defenseless.

When is it sensible to take an antiviral? When it is part of the public health measures to contain an outbreak, (or, on an individual level, when you or someone you live with has a diagnosed case of flu). This is the main reason why there aren’t enough doses of antivirals for everyone. We don’t need enough for everyone. We need enough to blanket regions with outbreaks, and we need those viruses not to be already resistant to the only drugs available because people have been using them wrongly. Outbreak regions involve a few million people at most. This is not to say our current public health system has enough doses even for that, but the shortfall is nowhere near as stark as the scaremongering about, “There’s only two million doses for three hundred million Americans!”

Update, Oct 11. My earlier information was too sanguine. The WHO recommends enough antivirals to cover 25% of the population. In the US, that’s closer to 80 million than a few million. So we have a BIG shortfall. As I said, expect the government response to be pretty useless. The shortfall doesn’t change all the other points made about incorrect usage, viral resistance, and promoting the spread of the virus, potentially to yourself.

Containing outbreaks is better for everyone than stockpiling drugs uselessly, depleting supplies until outbreaks are uncontainable, or, worst of all, breeding resistant strains. Getting yours while you can could be worse-than-useless by making it MORE difficult to contain an outbreak, an outbreak just as capable of infecting you as anyone else.

This is one of those difficult situations where, if we’re all sensible and unselfish, there won’t be a problem, but if we try to take care of ourselves, we’ll end up hurting ourselves. A minute’s thought shows how stupid selfishness is in this case, but it feels so right, people will invariably do it unless there is strong leadership to the contrary. I think part of the reason there is so much pressure for self-centered (and useless) actions is the assumption of an adversarial, or at least uncaring, relationship between people and government. The sad thing is that unless the government is doing its job, there is no way for an individual to solve the problem. It would be like trying to have a mass transit system all by yourself.

[Update: Nov. 1 2005]
File this under “OMIGOD, I can’t bel-eeeeve it!” I wonder what the CDC threatened them with to make them listen? Or is the Shrub’s popularity so low, somebody in the Administration decided they can’t be complete screw-ups about absolutely everything? Somebody’s even figured out that cell culture-based vaccine-making methods are Important. I am shocked. Shocked!

From the BBC [9]:

“Bush unveils bird flu action plan

“…At the heart of the plan is a request for $2.8bn to accelerate development of vaccines using cell-culture technology. …

“The strategy entails:

  • $1.2bn for the government to buy enough doses of the vaccine against the current strain of bird flu to protect 20 million Americans
  • $1bn to stockpile more anti-viral drugs that lessen the severity of the flu symptoms
  • $2.8bn to speed the development of vaccines as new strains emerge, a process that now takes months
  • $583m for states and local governments to prepare emergency plans to respond to an outbreak

“To equip Americans with accurate information on how to protect themselves and their families, the government is launching a website: www.pandemicflu.gov.”

Technorati tags: bird flu, avian flu, H5N1, pandemic, epidemic, public health

13 Comments (Open | Close)

13 Comments To "Bird flu facts and fiction"

#1 Comment By mistah charley, ph.d. On 07 Oct, 2005 @ 07:01

Very sensible and good advice. I’d add one more general category of actions to take in anticipation of a possible pandemic:

Prepare for an interruption of commerce – in other words, have enough food, water, etc. on hand to last for several weeks (or more), just in case the stores are closed or empty if this turns out REALLY bad.

#2 Comment By EZSmirkzz On 07 Oct, 2005 @ 09:36

I’ve enjoyed you reasonable and sensible posts since I first read one at Deepaks place on ID. That was why I linked to you, and this post is another reason why I am glad I did.

#3 Comment By quixote On 07 Oct, 2005 @ 13:22

I think the interruption of commerce is going to be the major damaging effect of any flu pandemic, bird or otherwise. Fatalities are tragic, but, *by themselves*, their effect is devastating only on those immediately concerned. The economic effect of SARS, for instance, was humongous.

The suggestion to make sure you have canned goods and clean water for several weeks is a good one in general these days, given our chickenhawk-without-a-head that passes for an Administration.

#4 Comment By Rich Puchalsky On 12 Oct, 2005 @ 18:44

Fiction 2 about quarantine is fine, but Fiction 1 is not really reassuring. If the avian flu mutates to easy human-to-human transmission with a 2% death rate, and 30% of people catch it, that’s quite enough to be concerned about.

Fact 1 and 3 are fine, but for Fact 2, I don’t know whether face masks are really so useless. Flu doesn’t just float on flu-sized particles through the air; it’s in water droplets. The water droplets might be caught by the mask even though a bare virus would not.

#5 Comment By quixote On 16 Oct, 2005 @ 16:21

I agree that if even a few people die, that’s something to be concerned about. The only good fatality rate is zero. I’m not saying we shouldn’t be *concerned*, I’m saying we shouldn’t race off and do stupid things that feel good (punitive quarantine, taking tamiflu incorrectly) and actually make the problem worse. It’s one of those situations where to do right by ourselves, we have to do right by everybody.

The problem with face masks is analogous to that with Star Wars missile defense: sure, even a dust mask will trap the odd virus + something particle, but thousands can get though, so it’s really irrelevant. However, as I said, even though they don’t stop viruses, they stop you from touching your face, and that DOES stop viruses.

The BBC has a whole series of informative articles:
Quick Guide: Bird Flu
Corporate effects: Firms brace for possible pandemic
and global impact, showing flyways of migratory birds.

Remember that the bird flu virus has NOT yet mutated to a human-to-human transmissible form, and that there is no way to know what that form will look like. It doesn’t exist yet. That’s why appropriate public health measures (ability to produce and distribute vaccine in weeks, enough antivirals to stockpile and ability to distribute in days) are so important. That’s why our frazzled public health system is so dangerous. And why tamiflu producer’s Roche’s arrogance in putting its monopoly ahead of public health is so criminal.

#6 Comment By Yusuf Smith On 16 Oct, 2005 @ 22:20

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.

Is anyone really talking about doing such a thing? During the 1665 London plague it was called “shutting up”, and was acknowledged to have increased mortality rates by ensuring that members of infected people’s families got the disease. No doubt it’ll do the same with bird flu.

#7 Comment By quixote On 18 Oct, 2005 @ 09:33

Oddly enough, given how stupid it is, the answer is yes. US may use military quarantine to contain flu – Bird Flu – MSNBC.com. (Just one of dozens of links by searching on ‘Bush flu quarantine’) This is the Shrub’s idea of the best course of action. Maybe somebody at the CDC can find out what his phone number is and get him to listen, but the track record on reality-based interventions with this administration are not good.

#8 Comment By quixote On 21 Oct, 2005 @ 11:39

Oct 21, update re Roche, flamed above (approx. Oct. 15th) for arrogance. Two or three days ago, bad PR and the ability of governments to force compulsory licensing on grounds of national need, forced Roche to begin discussing licensing. Better late than never? Don’t know. I’ve certainly lost all respect for them. Lots of other people probably have too.

#9 Comment By Bob Payne On 22 Oct, 2005 @ 17:50

“The risk is especially high for air travellers because the airlines save money by recirculating air without filtering it well enough, by keeping the air too dry because that’s cheaper, and by keeping its oxygen content too low, likewise because that’s cheaper.”

Follow up: We live at high altitude, Lake Tahoe–7,000 feet to be exact. We have found that virus born sickness (colds and flu) are not as frequent up here. Are we just dreaming or does high altitued offer protection? Is it better to have dry air in an airplane with a flu case or two aboard?

#10 Comment By quixote On 24 Oct, 2005 @ 10:18

7,000 feet … We have found that virus born sickness (colds and flu) are not as frequent up here

Interesting. No, I’ve never heard of any preventive effect of high altitude. My guess would be that folks living at Lake Tahoe don’t live in high densities, and are also healthier and fitter than the average.

#11 Comment By Sanjay On 29 Oct, 2005 @ 13:48

With some certainity, it can be said that bird flu is in the incubating stages here in India.

I’m not sure why people are so paranoid about bird flu. Bird flu is *far* more fatal to birds than humans. Calm down, take a step back and breathe.. and stop hoarding tamiflu.

#12 Comment By Anonymous On 18 Nov, 2005 @ 12:22

I’m surprised that no one is “walking on the sunny side of the street” (US slang for being optimistic) with regard to bird flu–every time you look at the papers, the governments of the Western world are “whinging” (how I love that word) about how the old pensioners are dragging down their economies by being such a drain on Social Security, Medicare, etc.
If the bird flu rips through the population and kills off all these old farts, the economic effects will be POSITIVE rather than negative.
As you do your holiday shopping this year in the crowded malls and terrible traffic, imagine how nice it would be if half of all these people cluttering up the landscape would go away.
The only way commerce will take a blow is from the panic caused by bird flu; the long term beneficial effects of gettting rid of surplus population will more than make up for it.

#13 Comment By quixote On 19 Nov, 2005 @ 13:49

(Hmmm. A tad heartless, but I gather that some historians think the Black Death may have helped bring in the Renaissance for exactly that reason.

Of course, in the interests of promoting the subsequent Enlightenment, all readers of this blog should be among the survivors….)