|Issue #118 • July/August, 2009|
Do we have anything to worry about the reemergence of Swine Flu — Novel Influenza A (H1N1) — this fall? The short answer is: Probably not. There are some dangers as there would be from any potential pandemic, but the dangers are not always medical.
What are the dangers of flu?
First let me say that flu or any other illness should be taken seriously. However, in any given year about 1,000 people die of influenza. In a bad year, 3,000. The media is reporting that the Centers for Disease Control (CDC) says 35,000 people die each year of flu. It’s not true. The CDC lumps flu and pneumonia deaths together. The overwhelming number of those deaths are pneumonia, plain and simple. In BHM’s issue 97 (Jan/Feb 2006), I wrote an in-depth article putting the Avian Flu, our last big pandemic scare, in perspective. So this issue let’s put the danger from Swine Flu in perspective.
There are about 41,000 traffic deaths each year. That means you are anywhere from 14 to 41 times more likely to die in a given year from a traffic accident than you are from flu. Even in a terrible flu season, such as the Hong Kong flu of 1968-69, you were more likely to have been killed in a motor vehicle accident. On top of that, you are also some 700 to 2,000 times more likely to be badly injured (whiplash, brain injury, paralysis, etc.) than to die from flu.
Think about what you do to reduce your chances of getting killed or disabled in a motor vehicle accident. You drive carefully, wear seat belts, don’t drive drunk, walk in the left-hand side of the road facing traffic, etc. After you take all these precautions, influenza is still a much lesser threat to you than the thing sitting in your driveway. And, as you’ll see, you can further reduce the threat of contracting influenza—and dying of it—by following the simple steps listed below.
The first way to protect yourself from flu is to do what your mother always said: “Wash your hands!” It sounds so utterly simple, but the best defense you can take against any contagion is sanitation. I once asked a doctor how he could treat so many infected people without getting sick himself and he said, “I wash my hands after every patient.” He didn’t feel the need to elaborate.
This past spring I visited a friend in Massachusetts and I noticed that whenever he enters his house from the outdoors the first thing he does is go to his sink and wash his hands. The act is so automatic, it’s like a ritual with him. But he assured me he rarely gets sick. After a minute of reflection, he said, “It’s been over two years since I’ve been sick. And it’s not like I haven’t been around sick people.”
The second way to protect yourself is, if you must touch your eyes, nose, mouth, or any other bodily orifices, wash your hands first. Contagions need a way to get access to your body and those are the avenues of entry.
Third is to avoid infected people. This isn’t always easy, especially if you work in an office or, worse yet, where you constantly meet the public as in a supermarket or restaurant. And worse, it’s difficult to tell when someone’s contagious because they can be contagious a day before they manifest symptoms. So, whenever you’re out meeting the others, commit yourself do doing steps one and two, above, frequently.
Fourth, get a flu shot. If the virus going around this time is particularly bad, and if a vaccine has been developed for it, get it when it’s available.
Fifth, if this year’s flu is a particularly bad strain, get treatment as soon as you manifest any symptoms. There are now prescription drugs such as Tamiflu and Relenza that are effective against flu viruses.
What if the worst happens?
The flu outbreak of 1918-19 (the Spanish flu) was, in absolute numbers of people killed, the worst pandemic in human history. But, as bad as it was, that season’s flu was different only in degree but not in kind from any other flu outbreak before or since. So it’s possible we could see such a pandemic strike again this year or in any future year. Just how bad was it? Conservative estimates have put the death toll at 20 million worldwide, but more recent estimates say as many as 100 million people may have died. That many deaths is so mind numbing, and so hard to comprehend, it brings to mind a quote from former Soviet dictator Josef Stalin who said, “The death of one man is a tragedy. The death of millions is a statistic.”
Another take on that pandemic is to realize the mortality rate of most influenza epidemics is less than 0.1%, or fewer than 1 person in 1,000 who contracts it. But in the United States, the mortality rate of the 1918-19 pandemic was 2.5%, meaning roughly 1 person out of every 40 who contracted it died. Worse, the span of time between onset of symptoms and death was often mere hours. People got up, went to work, started feeling sick, and were dead of it before nightfall. We haven’t seen anything like that before or since.
And no one knows why the Spanish Flu of 1918-19 was so deadly while all of its ancestors and descendants have had markedly lower death rates. It’s been speculated that the mutation of the virus that was so virulent back then no longer exists except in mutated forms that aren’t as deadly. Like the Spanish Flu, this year’s Swine Flu are subtypes of the H1N1 virus. It is conceivable that a similar form of deadlier virus could reemerge with this year’s flu season — or some future year’s. And that is why we must look at each and every flu season with some trepidation.
So, what if this flu resembles the flu of 1918-19. What then? Again, we can be cautiously optimistic.
We are vastly more prepared to deal with a pandemic than at any other time in history. Not just because we have better drugs, but because we have a better understanding of how flu pandemics spread.
Past pandemics have tended to come in waves with the first wave being a relatively mild flu season in the spring. The following summer, the disease abates. But they were each followed by a second wave the following fall and winter of particular virulence. This was true in the flu pandemic of 1889-90, which apparently started in Uzbekistan and came to be known as the Russian flu; the 1918-19 flu which may have started in Kansas but came to be known as the Spanish flu because of the incredibly high death rate it brought on in that country—as many as eight million Spaniards died as a result of it; the 1957-58 Asian flu which was first identified in China; and the 1968-69 Hong Kong flu which was first identified in that city. This is good news because, unlike the deadly pandemic of 1918-19, today we have the means of creating vaccines, and the race is currently on to develop one that will be effective against the strain currently working its way around the world.
Another reason is that we now know that nonpharmaceutical interventions (NPIs), including isolation and quarantine, can be very effective in stopping the spread of the disease. A proposed strategy to combat this strain of flu, if it turns deadly, is to isolate and treat those who contract it and to treat all those around them with vaccine and the flu treatments listed below.
Treatment of the flu
The drugs useful in combatting the virus include Tamiflu (whose generic name is oseltamivir), Relenza (generic name zanamivir), Flumadine (rimantadine), and Symmetrel (amantadine). The Centers for Disease Control has already announced there are adequate supplies of these drugs with more than 44 million treatments of it on hand. However, the CDC has also announced that some of the virus strains currently circulating are showing resistance to Tamiflu. Their advice: “When influenza A (H1N1) virus infection or exposure is suspected, zanamivir or a combination of oseltamivir and rimantadine are more appropriate options than oseltamivir alone.”
Flu viruses mutate so fast that it’s inevitable that they will evolve to circumvent any treatments we have today, and other treatments will have to be developed in the future to combat new strains. Which drug or combination of drugs will be used will depend on the variant of the virus infecting you.
Unlike vaccines, which are a preventative, the way the above medications work is they interfere with the virus’s ability to reproduce. They don’t stop it, they don’t kill it, but slow it down thereby allowing your body’s own immune system to develop defenses to kill the infection off before the virus has a chance to overwhelm you. Because of this, these medications must be taken only after the onset of symptoms, or you are otherwise sure you’ve been exposed and will manifest symptoms presently. They will reduce both the severity of the disease and its duration. But they are not preventatives. If you take them when the viruses are not present, your body will not produce the necessary antibodies.
Vaccines work differently. A vaccine is a weakened or dead version of a bacteria or virus. When it is introduced into the body, your body has no way of knowing these are weakened or dead. It nonetheless musters its defenses and develops antibodies to counteract the foreign invader. This takes time to happen, but once your body can manufacture antibodies for a particular pathogen, when it meets that pathogen again it’s defenses now knows how to make those antibodies and it can now quickly create them and overwhelm the pathogen. This is why there are so many diseases you can only catch once: measles, chicken pox, small pox, polio, even particular strains of past influenza viruses — once you’ve contracted one of them, your body has learned to quickly make antibodies to fight it the next time it encounters it.
I know you’ve heard about people who got their flu shot and got the flu anyway. Well, they did and they didn’t. When we say someone has the flu, it’s because their body manifests all the symptoms associated with it. If someone’s reaction to a dead or weakened flu virus is so severe that they seem to have “caught” the flu, imagine how violently their body may have reacted to a viable virus. Perhaps he or she is one of the people whose body would have reacted so violently that they’d have become one of the mortality statistics.
So, with all the good news, why all the ballyhoo about the flu? The problem is that we, as humans, are lousy at assessing risks, and that includes you and me. Take this simple test: If you had a choice between letting your child go down the block to play at the house of someone you know has firearms or go to the house of someone you know has a swimming pool, which one would you feel safer letting your child go to? The gut reaction of most people is to say, “Let him go swimming.” But according to the book Freakonomics, by University of Chicago economist Steven Levitt and New York Times journalist Stephen J. Dubner, your child is 111 times more likely to drown at the house with the pool than get shot and killed at the house with the gun. In other words, the soccer mom with a swimming pool is a greater hazard to your children than the self-reliant mom packing a .45. But we hear guns villainized almost daily in the mass media, while swimming pool accidents and even traffic fatalities barely get notice. Thus we form our opinions.
And this leads to another danger of the flu: hysteria.
With all the hubbub over a possible flu pandemic, and the public’s horrible ability to assess risk, the initial hysteria over the Swine Flu flooded emergency rooms as people who were not even displaying symptoms of flu showed up demanding screening and treatment at the expense of others who had real illnesses and traumas.
Another danger is government’s response to hysteria. John Stossel, the journalist, recently made the statement that, “Crisis is the friend of government.” What he meant is that anytime the public feels a threat, those people “in charge” — who can’t balance the budget, keep us out of wars, or lower the crime rate — step in and promise a solution. And their solutions invariably mean more government intervention and bureaucratic meddling, and more intrusions on our freedoms. The Massachusetts House of Representatives has already unanimously passed, and sent to the Massachusetts State Senate, a bill that would allow the state in any perceived health crisis to enter private property without search warrants. The problem with laws such as this is that they are so vaguely worded that they become vehicles for abuse. (Who would have guessed when it was passed under Nixon that the RICO Act, sold to a gullible public as a means to bring drug kingpins down, would actually be used 5,000 times a week against average citizens for crimes such as having too much money on you at the airport?)
So, calm down, get on with your life, practice sanitation, get a flu shot when it’s available, go for treatment if you believe you are really manifesting symptoms, and keep a wary eye on your politicians.