A New Flu Pandemic

By John McCormick

THE NEW H7N9 BIRD flu strain, is it hype or a real threat?

An intelligent reader always treats disaster reports with a large grain of salt. Sadly, very early in the course of this particular influenza spread, it appears to be a real threat but sometimes it takes a scientist to know if the latest big scare being pushed by the mainstream media is real or just another Shark Week/silly season threat to keep people watching the news.

Someone suggested I lead off this article with a warning that half of you reading this won’t be around to read anything next year. While that is a bit of hyperbole, history as recently as just 100 years ago shows that pandemics can be that deadly so, although that comment is premature, some flu event will eventually come along which could kill off half the population.

Although people still learn about the Black Death that ravaged Europe in the Middle Ages, and because plagues are caused by bacteria instead of a virus, today most incidents of either pneumonic or bubonic plague are simple matters for doctors to treat with modern antibiotics.

The reason a deadly flu outbreak is of such major concern is simply because, as with the common cold, influenza is a viral infection and there isn’t any treatment for a virus-caused illness other than supportive measures such as putting patients on a ventilator to keep them alive until their immune systems fight off the infection.

In this article I'll be looking at the actual threat level of this newest virus threat, what could raise or lower the degree of threat, what treatments may work, how to protect yourself, and also at the actual virus itself.

The newest flu scare certainly deserves to be taken seriously and the fact that the last big scare (over H1N1 swine flu) turned out not to be the big one, doesn’t negate the fact that it certainly could have been a major pandemic—in a word, we just lucked out.

Sort of. Actually, although today people have forgotten everything except the fact that it was a big scare and they weren’t infected, the 2009 H1N1 influenza eventually infected about 60 million people and killed upwards of 12,000. (At this point it is important to note that reported numbers early in any flu epidemic are only those proven by laboratory tests to be a certain strain—actual numbers are always much larger, especially in third world countries.)

The last big swine flu threat was shortly before 1920 and killed so many people that the government had to resort to mass burials.

In fact, the social result of the 1918 influenza combined with the deaths in WWI was similar to that of the black plague—a significant reduction in the population and a period when people went a bit wild with relief that they survived.

The latest threat is also from a Type A flu strain, this time H7N9, and, as I write this we still don’t know how it is transmitted, but there are strong indications that it has characteristics which make it likely to be transmissible between humans.

Human transmission is the critical factor when considering whether or not a specific disease is likely to pose a serious threat. While birds get around either by flying or by being turned into buffalo wings, while alive they don’t actually mix with people in large crowds. Strains of swine flu are also unlikely to cause major human casualties for the same reason.

The big concern in the medical community is whether one of the animal borne infections will mutate into a strain that can pass from one human to another, especially via airborne mechanisms.

While people will die from bird or swine flu if they come into direct contact with live infected animals, fortunately every known virus is rendered inactive when heated sufficiently and that temperature threshold, 160 degrees F (70C) is quite low by modern cooking standards.

A piece of pork or poultry cooked properly will be safe to eat even if the animal was infected.  By contrast, a rare steak or bloody hamburger would not be safe, something to remember if/when a serious viral infection appears in the beef industry. (By the way, Mad Cow or Creutzfeldt-Jakob Disease is not viral, it is a prion disease and cooking won’t kill it because it isn’t really alive.)

So, while an avian or swine flu may become dangerous to humans, extreme measures are not required to avoid infection—discovering you have eaten infected meat isn’t a death sentence, although it is certainly something to be avoided.

What the H Do Those H and N Numbers Mean?

The flu, which every year causes millions of people to have a miserable week or two and which actually kills tens of thousands of people, mutates every year, which is why it can spread. If the strain were stable then once you caught it you would be safe every following year.

Sub classification of flu viruses are based on two varieties of protein (often referred to by researchers as “spikes”) which are found on the surface of the virus. These proteins are varieties of H (hemagglutinin) and N (neuraminidase). There are 16 H type proteins and 9 N type proteins found on flu viruses. Hence, common swine flu H1N1 has the first type of hemagglutinin and first neuraminidase protein types.

Type A viruses are surrounded by a capsid or protein coating.

The hemagglutinin protein variety determines how the virus attaches to a cell and neuraminidase is an enzyme which will release the virus from the host cell. In other words, variants in the H protein spikes allow a virus to attach to the surface and penetrate different kinds of cells while the variety of the neuraminidase enzyme determines whether a mature virus which has multiplied in a cell can get out of the cell and spread to other cells.

A more detailed description of a recent flu variant would be A-H1N1/09 indicating that it was an A strain of influenza first described in 2009.

[Right, a 3D graphical representation of a generic influenza virion’s ultrastructure, and is not specific to a seasonal, avian or 2009 H1N1 virus. Source: CDC. Drawing by Dan Higgens.]

While most cells, and even bacteria, contain both DNA and RNA, a virus will only contain one, but not both kinds of nucleic acids. Both RNA and DNA viruses can attack human cells.

RNA viruses affecting humans include influenza, SARS, polio, West Nile, and measles. The life cycle of these RNA viruses do not involve DNA at any point.

Retroviruses are RNA viruses which also have a reproductive phase which includes DNA—HIV is an example of a retrovirus.

The reason it is important that influenza is an RNA virus is simply because that class of viruses has a very high mutation rate. Thus we have HIV-1 and HIV-2 viruses which cause AIDS and don’t change much despite infecting a large number of humans. Influenza, on the other hand mutates every year or even more often.

An RNA polymerase replication process does not involve any “fact checking” or verification step, unlike that which is included in animal DNA. That is the reason rapid mutation is possible for influenza. Any change is passed through to the next generation, while DNA polymerase replication tends to reject any alteration in the duplicate, otherwise animal life would be nearly impossible because cells would mutate too quickly to be survivable.

Type A influenza can infect many mammals including humans, horses and swine as well as birds—this is the source of all previous  flu pandemics.

Type B flu viruses affect humans and seals.

Type C flu only affects pigs and humans.

These three types of viruses, antisense (negative) single strand RNA, are sometimes referred to as Orthomyxovirus, a Greek language term meaning (loosely) mucus causing virus.

The serotypes (classification based on immune responses) included in Type A viruses are H1N1, H1N2, H2N2, H3N1, H3N2, H3N8, H5N1, H5N2, H5N3, H5N8, H5N9, H7N1, H7N2, H7N3, H7N4, H7N7, H7N9, H9N2, H10N7.

That is more than you probably ever wanted to know about how viruses are classified.

H7N9

This is a bird flu type of virus. The main mutation required for an avian influenza to infect humans is in the growth temperature. Many viruses will only multiply and spread in a very narrow temperature range. Since birds have a higher body temperature than humans, the virus usually doesn’t cross species lines.

What is dangerous about this new variant first discovered in the Shanghai market is that it will grow in the same environment found in the human upper respiratory system.

Masato Tashiro of the Influenza Virus Research Center, National Institute of Infectious Diseases, and Yoshihiro Kawaoka, a faculty member in the UW-Madison School of Veterinary Medicine, report studies have shown medicines known as ion channel inhibitors block the ability of the neuraminidase enzyme to break out of a cell after the virus has multiplied. The virus may therefore be treatable by the antiviral drug oseltamivir. It is important to remember that this is only theoretical at this stage and not shown in any human trials as of the middle of April.

Mild Cases Mean More Danger

Jeremy Farrar, director of the Oxford University Clinical Research Unit in Ho Chi Minh City, Vietnam, pointed out that the increasing number of mild cases of H7N9 in mid-April is actually a bad sign, especially when combined with the sudden increase in hot spots. Over a single weekend cases appeared in central and northern China, widely separated from the initial Shanghai incidents.

Within a few weeks the first infection was found outside China in Taiwan—very bad news, and just a month after first being identified, the H7N9 virus had been proven to infect more than 100 people and kill more than a dozen. More would almost certainly die because they had just acquired the infection.

During the same time frame (essentially the month of April, 2013) a number of cases were found to be relatively mild, which counterintuitively means the virus is becoming more dangerous and a greater threat to become a pandemic. This is because milder cases indicate rapid mutation and a virus can’t spread if it kills the host too quickly.

Compared to the previous years’ concerns about the H5N1 flu, the new infection is spreading incredibly rapidly. In five years there have been 45 confirmed H5N1 cases, but in only two weeks since the first report of an H7N9 infection on March 31, there have been 63. Some of that may be due to increased surveillance, but would not account for more than a few additional reports.

Another reason this latest virus poses a great threat is that the earlier bird flu killed infected birds while the new H7N9 spreads through flocks but doesn’t make the birds obviously ill. That means that it can spread rapidly and undetectably through many flocks and therefore expose many humans to it even if it doesn’t transmit between humans.

Specific Pandemic Threats

If you are keeping track online, the major authority is the World Health Organization (WHO) in Geneva, Switzerland, that posts daily pandemic updates.

The influenza virus itself doesn’t kill. It is important to understand the fatality mechanism if you are to make intelligent decisions.

One threat is to the elderly or those with compromised immune systems who are weakened by the flu and die from other causes such as pneumonia.

The other big threat is, ironically, to those with strong immune systems. In a pandemic, people have no defenses built up and when infected the body's own defensive systems are triggered to a powerful extent.

Babies and older adults have weak immune systems which is why they are vulnerable to complications from the usual yearly flu. Those are the groups which tend to get pneumonia and other opportunistic infections after being weakened further by the yearly flu. They don't have systems which react strongly to the flu itself, either because they are young and have weak immune systems, or are older and have many past flu infections to strengthen the specific immunity factors which are the same for many flu strains.

What happens with young and healthy patients is that their immune systems react so strongly that they can trigger something known as a "cytokine storm."

When this happens the person’s immune system overreacts to the totally new flu virus and actually attacks the body’s healthy organs and systems—that makes the healthy, approximately 15 to 60 year old individual the most likely to actually succumb to the flu.

Because this cytokine storm phenomena is generally rare it is also not well understood. Cytokines are similar to hormones and are used by the body to communicate between cells, mostly on a local basis.

A cytokine storm can overwhelm the nervous system and cause breathing problems which is why hospitals put critical flu patients on assisted breathing machines.

The fact that most hospitals only have a few of these and they are often in use for surgical or other critical patients is what really frightens experts in the pandemic field.

New Threat—Will People Avoid Getting Vaccinated?

There are two major barriers to stopping the spread of a pandemic. First, the virus must be isolated and a vaccine produced in huge quantities. Second, you have to get people to voluntarily accept vaccination for themselves and their relatives.

Unfortunately, because everyone has slightly different DNA, every vaccine which is safe for most people will have some bad side effects for a portion of the human population. When this happens people panic and refuse vaccinations. All of us probably know people who refuse the yearly flu vaccine because one time they got it and still caught the flu—it was likely a different strain as every year there are multiple strains around, but the one bad outcome now stops them from ever getting protection.

Very unfortunately there is strong emerging evidence that the 2009 H1N1 vaccine has caused a number of cases of narcolepsy in young patients. This demands serious study before the next pandemic flu scare and vaccination drive.

There are always side effects to any medication or medical procedures. But risks must be balanced against the threat, something lay people have great difficulty doing, and that includes the many television talking heads who sensationalize the threat but seldom mention the risk from not getting vaccinated.

This common human reaction sometimes causes the medical establishment to avoid telling the general public about some rare but known risks and can even lead to self-delusion, leading some supposed dispassionate scientists to ignore early evidence of dangerous side effects.

Of course this danger is much worse when drug companies’ profits are involved, but it also occurs when doctors decide they know best and, often with excellent cause, worry about how many deaths will result from public panic over some relatively rare risk.

Personally, I can’t walk because of a rare side effect of a very necessary medication, which led in part to my interest in such events.

A major reason the medical establishment doesn’t say much about side effects is because most prescribed medications are really necessary—one additional reason to avoid unneeded medicines such as the antibiotics in meat and poultry.

Unfortunately a very necessary vaccine, the one for pandemic flu, often causes a number of problems. Because even a normal flu year sees about 100,000 deaths worldwide, a few incidents of bad reactions should be ignored, or a great many people who don’t understand the balance of risks will refuse the vaccine dramatically increasing the danger.

A recent well-known example is the parental concern over the risk of a preservative compound in vaccinations causing autism. This was a major concern among parents for years and has only recently been completely disproven, so epidemiologist’s concerns are certainly justified.

This fear and consequent reluctance to allow inoculation is incredibly important in the case of a pandemic threat where, not hundreds of thousands but tens or even hundreds of millions will die if even a small percentage of the population refuse vaccination.

I brought all that up as a preface to this unfortunate fact which I have recently learned from an issue of “The Lancet.”

The H1N1 Pandemrix swine flu vaccine given in 2009 to prevent an H1N1 swine flu pandemic has now been statistically proven to cause a sevenfold increase in incidents of narcolepsy, not in everyone, but in children and teens of northern, western European ancestry.

This correlation was suspected and ignored by many researchers for several years, probably blocking a number of labs from studying the problem with an eye to determining if it could be avoided in future vaccines. That is one big downside of scientists ignoring evidence.

[Left, microbiologist using an electronic pipetter to extract reconstructed 1918 Pandemic Influenza Virus from a calibrated vial. Source: CDC. Photograph by James Gathany.]

Groups trying to keep secrets, whether for selfish or altruistic reasons, is the other big downside of such willful ignorance. Just as with Washington politicians who always think they can keep something secret, eventually everyone learns of the deception and people become even more distrustful of the special interest group involved in the deception whether it is a small group of politicians and bureaucrats, or the entire scientific community.

Why do people always forget that the deception is always discovered and then the fact that the deception occurred is always worse than the actual event being hidden? Human nature almost always overcomes common sense even in scientists.

The reluctance to even consider this category of medical threats is amply illustrated by this quote from “The Lancet Infectious Diseases,” Volume 13, Issue 5, Pages 396-397, May 2013:

“Terhi Kilpi, director of the department of vaccination and immune protection at Finland’s National Institute for Health and Welfare (THL) told TLID that the first thing we met was a huge silence from the scientific community, and we had a feeling that no one wanted to hear about this.”

Initially the link to narcolepsy was found only in Nordic countries, but a recent study published in the British Medical Journal shows that it also affects children in the UK, western Europe in general, and the U.S.

In this case the studies show that the risk of giving the trivalent flu vaccine to pre-20-year-olds probably outweighs the benefits in this age group. In Finland about 80 lives were saved in the entire population by the massive vaccination drive, but nearly 100 new narcolepsy cases in teens and children likely resulted from the vaccination.

This should lead epidemiologists to question the wisdom of giving flu vaccinations to this age group and merits serious study by the medical community.

Threat Level High or Zero?

It is too early to tell whether this will be a bad flu year or even a pandemic. There are some indications supporting either scenario, but with an early mortality rate of 20 percent or so, it is instructive to recall that the 1918 swine (Spanish) flu had a similar mortality rate and modern medicine wouldn’t have made much difference.

Even that is probably very low. It is reckless to attempt to assign a mortality rate to a virus based on a handful of patients, especially when a large number of them are still being treated. What we actually know at the end of April is that the mortality rate is at least 20 percent, and not that it is only 20 percent.

The spread of a virus is actually closely related to the nuclear physics problem of whether enough slow neutrons are produced in nuclear decay to sustain a chain reaction.

In medicine the number is known as R-0, the reproduction rate, or how many people are infected by one sick person. For H1N1 R-0 was about 1.5, so 100 infected people would infect 150 more.

Some reporters are saying that for H7N9 R-0 is zero because there is no case of human to human spread. But they are saying this only 3-4 weeks into the illness, far too early in my opinion, to reach any conclusion, especially since mild cases have already been reported which usually indicates rapid mutation.

Another factor which makes this a virus to watch carefully is the likely complete lack of natural immunity for a class of virus which has never been seen in humans before.

In other words, H7N9 is not likely to be a problem but if it is a problem it will become a very big problem.

Bottom Line

This year’s pandemic threat is still at the earliest stage, barely on the radar of many mainstream media groups but it will get a lot more attention, possibly by the time you read this in a week or two.

You will have to decide for yourself just how concerned you need to be and what steps if any you take to protect yourself and your family. This article should give you some additional ammo to help you make logical decisions, separate the facts from the hype, and understand when government agencies might not be telling the whole truth.

Will this be the year’s silly season media threat of the week, or not? Or, will it be a real threat, in which case the media may actually underplay it at the behest of government agencies wanting to avoid panic?

If you have children, then you will need to weigh the threat against the possibility that a new vaccine will pose the same narcolepsy danger or perhaps have some other side effect on children.

You also need to consider that the flu often kills younger people with strong immune systems, and the elderly (which actually means those over about 60), along with the fact that vaccines are never 100 percent effective and that they do almost no good for those over 60 or 65. Of course the elderly may already have significant protection because they have immunity from so many earlier strains.

If you decide this is a significant risk, there are steps you can take. Scheduling sick days to fall during the worst flu season is important. Getting your business to tell people with the flu to take days off can help, and so can working from home for short periods. Stocking up on basics to reduce the number of trips to stores during the worst of the epidemic in your area is a good idea.

Keeping a small stock of protective masks can be important—they won’t be available during a major event, but having a few around can be a lifesaver and you can always use them when working on some dusty project.

Simple dust masks aren’t effective. You need something known as an N-95 class medical mask—disposable and not particularly expensive, but they may be in short supply. Most of the year they are easy to find either online or locally.

These masks do not filter out something as small as a virus, instead they block most of the larger droplets from coughing or sneezing and these droplets are what carry the flu virus into your respiratory track.

This Just In

An important new way to save lives in a flu outbreak involves eritoran, a compound that blocks TLR4 and is now in clinical trials as a sepsis drug. According to an article in the May 1 online issue of “Science NOW” (AAAS), of mice given eritoran injections, 90 percent of treated mice survived, compared with only ten percent of those not given the drug.

Because the majority of deaths from influenza are due to overactive immune
systems, selectively suppressing the patient’s own reaction to the virus is
an important step in reducing mortality, letting the virus run it’s usual
course.

A major pandemic on the scale of the one which occurred at the end of WWI would cause extreme social disruption, delaying shipments of everything from food to medicine, but even a mild flu season can be disruptive on a personal level. For the latest information on influenza outbreaks start with the World Health Organization’s Disease Outbreak News page. 

John McCormick has been a rancher, mechanic, radiologic monitor, and an emergency management coordinator. He is a trained physicist, science/technology journalist, and widely-published author with more than 17,000 bylines to his credit. He is a member of The National Press Club and the AAAS. His full bibliography is online.