Swine Flu Spreads Like Wildfire

H1N1 Spreads Like Wildfire!!!

This is the type of hype we are seeing on websites, and reading in news papers. But - CGS member Paul sends us a report from the World Health Organization (WHO) which reads as follows:

5 May 2009 -- As of 06:00 GMT, 5 May 2009, 21 countries have officially reported 1124 cases of influenza A (H1N1) infection 12 May 33 countries 5728 cases of H1N114 May 33 countries 6497 cases of H1N115 May 2009 34 countries have officially reported 7520 cases of influenza A(H1N1) infection18 May 2009 -- As of 06:00 GMT, 18 May 2009, 40 countries have officially reported 8829 cases of influenza A(H1N1) infection, including 74 deaths19 May 2009 -- As of 06:00 GMT, 19 May 2009, 40 countries have officially reported 9830 cases of influenza A(H1N1) infection, including 79 deaths. 20 May 2009 -- As of 06:00 GMT, 20 May 2009, 41 countries have officially reported 10 243 cases of influenza A(H1N1) infection, including 80 deaths3 June 2009 -- As of 06:00 GMT, 3 June 2009, 66 countries have officially reported 19,273 cases of influenza A(H1N1) infection, including 117 deaths8 June 2009 -- As of 06:00 GMT, 8 June 2009, 73 countries have officially reported 25,288 cases of influenza A(H1N1) infection, including 139 deaths 10 June 2009 -- As of 06:00 GMT, 10 June 2009, 74 countries have officially reported 27,737 cases of influenza A(H1N1) infection, including 141 deaths

This data is very useful in terms of giving a sense of the communicability of H1N1, the so called Swine Flu. It is spreading fast, and though this is not good news, there is evidence from two sources that suggest this is not, overall, the end of the world.

The mortality rate so far suggests the flu is less lethal than ordinary strains. The Type A flu's that we are so familiar with have a death rate of .1 percent. This is one death in every thousand cases. And though that is not good - it is typical. The high risk groups for typical flu are the very young and very old.. But lets do the math for this flu. As of June 10, 2009 27,737 cases are reported and there are 141 deaths. We assume this anyway. There is evidence that in Britain, the numbers may be skewed - as the cause of death- in some cases - may be from other things. (story from London Times) But, the math is here:

141/27,737= x/100 and this works out to .05 percent. One in 2000 deaths. (Assuming my math is not hopeless. )

(Update: the math is wrong see below, and note, the virus is slightly more lethal than type A seasonal which means the .1 for type A is wrong, the current eval as of May is qouted...this doesn't change the point of the article. Here is the mortality rate as of MAY which from one source says: "The estimated fatality rate is 0.4% -- this virus is considerably less lethal than the virus that caused the 1918-1919 pandemic but somewhat more lethal than usual seasonal flu viruses.")

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The risk groups though are lopsided. The age range for increased morbidity and severity of infection is day 1 – age 19. And the reason is young immunity. That group is prone to hyper immune response known as “cytokine storms.” a mad of rush of white cells to the site of the infection which does not shut down normally as a part of a feedback loop..This means that because the bug tends to settle a little lower in the respiratory tract, the lungs fill with fluid from inflammation. The bug must have new features the very young have not been exposed to, and the old must have some immunity to parts of this virus. Also, the young have smaller lungs, and a narrower airways.

( There are ways to deal with this too. Utilize the labs and rule out other causes. And then focus on that airway, keeping it patent, and mitigate the inflamatory response. The labs and the ER people have to be the best and no expense is to be spared..)

Meanwhile, realize this, the death rate from SARS was 10%. And the bug was stopped cold. We haven't heard from it since. And part of the cause is prevention. The Chinese had no inhibition about wearing masks in public. Part of dealing with bugs like this is to prevent their spread. And the score card on this bug is very poor, especially when we have so much hype about a 1918 style killer flu being on the horizon. A bug that has a bad effect on anybody, like Bird Flu, but spreads like Swine Flu, is a big concern. And so, the time to be prepared by institutionalizing prevention is NOW.

I

n 2006, I attended a lecture on the subject of bird flu. And was surprised by the potential impact of such a disease. But, if there was a bird flu pandemic , it would not be bird flu with the current genetic structure of bird flu. It would be amalgam of current flus infecting humans, by way of infecting animals who have bird flu. A hybrid of bird flu and human flu. We discussed the modes of mutation. One mode being natural (very slow), and the other being a product of human activities

(Much faster)

The model that was suggested for the latter mutation was that pigs or farm animals would get infected with both types of flus, a bird flu and human flu, and both flus would combine - the worst case scenario being the bird flu would pick up the "catchyness" of a human flu. The result would be potentially devastating. As, a bug slightly less lethal than bird flu (very high mortality) with the virulence of type A strains, could trigger an epidemic on par with the Spanish flu of 1918.

But imagine a bird flu combining with a swine flu? taking into account how fast swine flu has spread

This thought exeriment does not paint a pretty picture. And so some of this hype may be helpful, because it would prepare us for such a mutation.

But, when I suggested that it would be helpful if habits in the orient changed where it regards interactions between humans and farm animals, there was an uproar of objection.

It is isn't appropriate to suggest changes in habits that people have had for centuries. The argument was around cultural sensitivity. Apparently farmers infected with human flu could sleep with their animals as they have always done, and continue to keep chickens near pigs who walk through bird droppings and catch bird flu. This mechanism is how the pigs could be infected with both strains. The big issue was "cultural sensitivity." But there are ways to deal with these habits that are culturally sensitive and so, we need to move beyond that reflex of culture worship to address them.

For example: We could ask the governments in the orient to intervene with incentives for farmer to facilitate the necessary rearrangements. This is a constructive avenue for prevention. And, in our own cultures in the west, wearing masks unselfconsciously in markets and even in schools could help.

One thing is clear though, we do not have our ducks in a row to cope with an epidemic of super flu. And, that is why we need to think in these terms now by formulating prevention agendas such as: organizing adequate supplies of antivirals, circle immunizations in the absence of adequate supplies of vaccine (immunizing those exposed to an infected person.) And drills following critical pathways which are standardized plans for those entering the ER with high fever, sore throat, and respiratory distress. Ruling out other causes is also key, as we should not rely on clinical judgment alone. Many bacterial agents could be causing the symptoms and deaths if not ruled out by mircobiology and treated. Many viral infections result in secondary bacterial infections, and so, they need to be ruled out. if cost is a concern bacterial culture of nasopharynx could be justified by something as cheap as a "Gram Stain." with CBC and differential. (What white blood cell lines are proliferating? Lymphocytes - Viral, or Neutrophils - Bacterial. These tests can be done for 30.00 dollars. Otherwise, the treatment could be wrong, and so is the Epidemiology ( the study of infectious disease.) Unfortunately, we will always be in competition with bugs that use us to survive, and we can't live in harmony with all of them, some are too virulent, and so - we need less hysteria and a definite plan to win this type of battle.

As an after thought on this article I would hope that in health care systems such as the British system which are currently taxed, I would hope that cheap diagnostic tests be done on acute cases on admission for suspected H1N! cases, to rule out secondary bacterial infections, they should be done, during the course of the hospital stay, especially if the patient is not responding to treatment. They should be done on readmission, if the patient is discharged and comes back sicker. This because secondary infections can occure post viral. I think this is a good strategy because many lives could be saved, and money would be saved, as the use of antivirals and antibiotics would be focused. Come fall, when eveyone is driven in doors, and the flu season begins, concerned british citizens could insure that these checks would be done, at local hospitals if anyone gets sick, this preemption would lessen some anxieties during flu season.

Here are some stories about bacterial illnesses being misdiagnosed as swine flu in Britain. They are simply not ordering tests and they are not treating bacterial infections which invariably become fulmanent when not treated with antibiotics. And this because the health care system is broken. There will be many more stories like this in Britain this fall. Below one had strep, another bacterial meningitis, and another a kidney infection (bacterial.) We will probably get this cost cutting behavior in the US too if the Obama NHC plan passes (these stories really make me mad) :

http://www.guardian.co.uk/uk/2009/aug/08/swine-flu-misdiagnosis-death

http://www.telegraph.co.uk/health/swine-flu/6040395/Dead-girls-family-misdiagnosed-with-swine-flu-start-petition-against-telephone-diagnosis.html
http://news.bbc.co.uk/2/hi/uk_news/england/bristol/somerset/8184506.stm

Here's another, a misdiagnosed appendicitis in Britain, again a bacterial issue:

http://www.telegraph.co.uk/health/swine-flu/5979182/Girl-with-appendicitis-misdiagnosed-with-swine-flu.html

There are probably many more on the internet for Brits not diagnosing bacterial infections, "swine flu," (viral) being the coverall for their lack of using lab tests to differentiate. I do know of two people a mother and a child who were turned away from a scottish ER three times, when they had strep throat. They were told it was "viral" The mother went "private" for both and was treated immediately, a few weeks later, another went to the same ER with same symptoms, and was turned away, also told it was viral, she died of strep septicemia. It's up to the Brits to demand more from there health care system this flu season. (these episodes were in March 2007.)

Note: The British NHC was one of the finest health care systems in the world. Sometimes these systems work well in small countries. But the system is now crushed and over taxed. And for reasons that have less to do with the system and more to do with the economics of so many accessing it (some of whom are illegals). In the US. an analogous the plan would cover a massive amount of territory, and a much larger population, and would meet a similar fate. Decreased quality of care. There is nothing said here that the Brits could not fix, and still maintain their system, but the answer is standards of care, backed by a strong economy. And by decreasing the tide of immigration.

Update: Since in the US strep pneumonia is a common post viral infection, it is probably a good idea to get a Strep pneumoniae vaccine this flu season. This is the most likely cause of secondary pneumonias developing in H!N! cases. Many of those who have died in the US from what appeared to be H1N! had strep pneumoniae - this is a bacteria similiar to strep pyogenes, but this one has an affinity for the lower respiratory tract. This will be the bug to watch in other countries too. (source: http://www.reuters.com/article/domesticNews/idUSTRE58T52D20090930?feedType=RSS&feedName=domesticNews&rpc=22&sp=true)

Update: WHO worries about mutation as the virus spreads worldwide:

http://www.reuters.com/article/marketsNews/idUSLO6472720090724

There is an update on flu from the daily express about what appears to be a new virus, if the swine flu is not the big super flu, there is a reason to keep an eye on this situation. A flu reported in the Ukraine.