Avian Flu Hysteria
For a long time now I have been meaning to post my thoughts on what I see as overhyping the avian flu situation. Luckily, a reader of Instapundit beat me to it and summed up nicely a lot of my thoughts.
As a medical researcher, I want to make a gentle but sincere plea to the blogosphere to calm down this flu hysteria just a bit. The main way that flu kills is by predisposing its victims to “superinfection” by bacterial illnesses – in 1918, we had no antibiotics for these superimposed infections, but now we have plenty. Such superinfections, and the transmittal of flu itself, were aided tremendously by the crowded conditions and poor sanitation of the early 20th century – these are currently vastly improved as well. Flu hits the elderly the hardest, but the “elderly” today are healthier, stronger, and better nourished than ever before. Our medical infrastructure is vastly better off, ranging from simple things like oxygen and sterile i.v. fluids, not readily available in 1918, to complex technologies such as respirators and dialysis. Should we be concerned? Sure, better safe than sorry, and concerns about publishing the sequence are worth discussing. Should we panic? No – my apologies to the fearmongers, but we will never see another 1918.
This MD hit almost all of the doubts I had: much better (and more sanitary) medical practices and supplies, the wide-spread use of antibiotics, and better general health of the populace.
But, this made me examine why there is this hysteria, and I think two points need to be raised about this. Researchers and medical doctors who study these diseases become convinced that their disease of interest is much more of a threat than any others. Be it pride, tunnel-vision, or a subconscious desire to attract more publicity or grant money to their area of research, these medical professionals have a general bias towards their particular virus or bacteria. Personally, in the two dozen virologists I have spoken too, I have seen this general propensity. I am not arguing they are wrong or corrupt, just that their dire warnings need to be considered in context.
Another factor to this hysteria concerns the general public and their view of viruses. Today the most talked about and intimidating virus, to laypeople, on the planet is HIV. A virus that people know has been around for at least two decades, is growing in total number of infections, and seems to mutate so fast that therapies become eventually useless against it and infected persons whither and die. But the comparison between HIV and avian flu is a flawed one.
When a virus, any virus, infects the body a “battle” is started between the virus transforming the infected person’s biomatter into duplicates of itself and the bodies’ immune system creating and mobilizing enough of the correct antibodies to combat it. If the virus wins, the immune system is decimated, secondary infections take over, and death is likely; if the body wins, the virus is generally defeated, and an immunity to that virus is set up. Avian flu falls into this model but HIV does not. The insidious nature of HIV is that it can survive the immune assault (by “hiding out” in the eyeballs) and has a high mutation rate, so the body is never rid of it.
This is where all the concern about the avian flu going through so many mutations to make it both transferable from human to human and airborne. Combine with that the previously detailed persistent nature of HIV, and you have a mental model of viral infection in the common person’s mind that leads to hysteria.
Now, don’t get me wrong, I am not arguing that everything will be perfectly fine, I am not that Pollyannaish, there will be infections. But, either most will recover, or few deaths will happen in segments of the population who are immune-compromised (the already ill, the elderly, the very young) or who do not have adequate access to antibiotics (the very poor). But our society has advanced to a point that these deaths will be few and far between.
If you want to talk about how to reduce even those few deaths, that is something to discuss, but we should stop the over hyping of this microorganism.
Update from Razib: Welcome Corner readers, and thanks for the link John.
IIRC, the 1918 epidemic hit young, otherwise healthy people the hardest.
True, but healthy for the times. Also, you have to consider what the good doctor said in his email I linked to above, that they had poor sanitary measures, limited antibiotics, and tended to crowd all the infected into poorly-ventilated areas.
“they had poor sanitary measures”
Yes, and that was important for bacterial, yeast, and parasite transmission. I donÂ’t know that present sanitary practices are better at preventing viral transmission. High flu infection rates are common today.
“limited antibiotics”
True, and that is important if secondary infections are doing the killing. If the virus itself is deadly, then antibiotics donÂ’t help.
My guess is the young people of that time were on the whole healthier than the young people today. (Much more physical activity, much less obesity and low nutrient snacks.)
“crowd all the infected into poorly-ventilated areas”
More of our population lives in major cities now than at any other time in history. Not many live in cramped quarters but there would be ample opportunities for exposure.
Today we have rapid, worldwide transportation. If an epidemic takes hold anywhere in the world, it will be difficult to contain it.
I do believe that a pandemic is a real danger. I do believe plans should be made and much more effort put into fast vacine development. I donÂ’t view such concerns as irrational, nor such actions as hysterical.
Fly,
from the email by the MD specialist:
The main way that flu kills is by predisposing its victims to “superinfection” by bacterial illnesses -
It seems to me that I explicitly set out that the main danger of the flu virus was a secondary bacterial infection taking over after the decimation of the immune system. I am guessing you just sped-read the post and missed that part.
Also, you wrote,
I donÂ’t know that present sanitary practices are better at preventing viral transmission.
Sure they are, both in hospitals and in general society. Simple things such as better general cleanlisness stops a lot of viral transmissions.
Finally, you have to consider the starting point of individuals immune system. If it is weakened by repeated chronic illnesses (such as TB), poor nutrition, etc. Our immune systems are far healthier than 87 years ago.
And, as I have spoken to a lot of viral researchers on these subjects, I have no doubt that it is hysteria.
AIDS hides out in the eyeballs? Man, that’s disturbing.
Damn your eyes!!!
I think the table below supports the argument that the 1918 epidemic was in fact an influenza + TB epidemic. The TB mortality rate today is a tiny faction of what it was a century ago. And while modern transportation is often portrayed as the “weak link,” the vector by which an epidemic would spread, such interconnectedness also makes far less likely the emergence of relatively isolated populations immunologically unprepared for a highly contagious disease that is still “in the wild” and that’s been regularly infecting people for millennia. It’s an ongoing and worldwide chicken pox party.
Death Rates by Cause of Death, 1900 – 2002
http://www.infoplease.com/ipa/A0922292.html
A lot of people crave the adrenaline rush of a massively fatal die-off from a flu pandemic. News organizations thrive on the morbid fascination. Viral researchers will overhype the threat to get more funding through the legislature.
When people spend all their time worrying about this type of remote threat, it is a sure sign that they have nothing important to do.
“My guess is the young people of that time were on the whole healthier than the young people today. (Much more physical activity, much less obesity and low nutrient snacks.)”
Not to mention a certain culling effect. Chronically unhealthy people in 1918 were less likely to make it to adulthood, indeed out of infancy, than they are today.
My guess is the young people of that time were on the whole healthier than the young people today. (Much more physical activity, much less obesity and low nutrient snacks.
I don’t agree with this statement, I think you are confusing percieved physical fitness (i.e. a high muscle/fat ratio) with immunological and physiological fitness. Remember, people of those times did not have childhood vaccines, so the ones who made it to adulthood suffered (but survived) many kinds of illnesses and infections which are not present in the first world today. This had the effect of: stunting growth, damaging internal organs (heart, lungs, kidneys, livers), and making their immune system less vital. Just because they survived to adulthood and to pass on their genetic material does not mean they remained paragons of health; on the other hand, a genetic profile probably allowed them to just barely survive, with severe damage which made them more susceptible to new infections.
And the TB + influenza connection is strong, as I pointed out in my post.
Sorry, “Implied” in my post
ScottmÂ’s quote: “The main way that flu kills is by predisposing its victims to “superinfection” by bacterial illnesses”
That is why the very young and the old are the most at risk from seasonal flu. Their immune systems are too weak to fight off the secondary infections. Modern antibiotics definitely help. That is not what happened in 1918.
http://www.stanford.edu/group/virus/uda/
“The flu was most deadly for people ages 20 to 40. This pattern of morbidity was unusual for influenza which is usually a killer of the elderly and young children. It infected 28% of all Americans (Tice). An estimated 675,000 Americans died of influenza during the pandemic…”
“People were struck with illness on the street and died rapid deaths.”
Scottm: “I am guessing you just sped-read the post and missed that part.”
No. IÂ’ve followed this topic closely for some time. IÂ’m aware that very knowledgeable people are concerned about this danger.
“Simple things such as better general cleanlisness stops a lot of viral transmissions.”
If that were true, why do flu viruses spread so quickly and so far every year? Yes, we know how to slow viral transmission. But that requires preparation such as stockpiling masks and planning so that major transmission nodes such as schools are closed. It also requires having sufficient time to develop and manufacture effective vaccines. It requires that people be aware of the danger and what steps they can take to reduce their risk.
Common sense is the first line of defense against the flu. Handwashing comes second. Third, for me, is jalaneti, a simple and benign form of nasal lavage. For six years I have been washing out my nose daily with a mild saline solution using a neti pot, and have had only one cold/flu in all that time. If you are reading this, then do an internet search on nasal lavage, jalaneti and neti pots. It’s not voodoo, it’s not hype, it’s about keeping the nose and nasal passages clean on the inside, so they work at peak efficiency.
Be it pride, tunnel-vision, or a subconscious desire to attract more publicity or grant money to their area of research, these medical professionals have a general bias towards their particular virus or bacteria.
Why are HIV researchers exempt from this danger? The parallels between the current HIV-AIDS theory – announced not by peer-reviewed research but by press release – and Japan’s SMON debacle, where a mysterious virus turns out to be nonexistent, are striking.
http://www.virusmyth.net/aids/data/besmon.htm
Kiume: “emergence of relatively isolated populations immunologically unprepared for a highly contagious disease that is still “in the wild” and that’s been regularly infecting people for millennia”
The problem isnÂ’t with an old contagious disease that suddenly infects a new population. The danger is a new deadly, highly contagious flu evolving.
There are already outbreaks of avian flu that are deadly in humans. Humans catch the disease from birds and then die. If a human catches both a human contagious flu and the avian flu, then a recombinant flu that is both deadly and highly contagious could result. There is evidence that this has happened in the past.
In a world where travel is limited then either the local population would die out or a weaker form of the virus would evolve. In either case, the danger from a pandemic was slight.
When travel is common, then any outbreak of disease could rapidly be transmitted worldwide.
Fly:
If young people were healthier then they they are today then we would expect that they would have a higher life expectancy then today. We know that is a false statement ergo they were not healthier then young people today.
Bird flu has been around for a while. If it’s so virulent why is it just now becoming a danger? IIRC, only 60 people world-wide have died from it. That’s fewer than legionnaire’s disease, cobra bites, lightning, heck, probably meteorites. I don’t get it. And as to AIDS, read Duesberg and Kary Mullis and keep an open mind.
Actually, as I recall HIV hides out in the CNS (not sure if this includes the eyeballs) and the lymphatic tissue.
Let me retort by changing the subject.
The main negative effect of an avian flu pandemic (which more likely than not will happen) is not the primary effect of mortality, but the economic collapse that will come from fear of infection.
It doesn’t matter if the flu kills 2 million or 200 thousand or just 20 thousand, it’s going to throw the ecnonomy into a tail spin.
So while people shouldn’t necessarily be fearing for the personal safety*, we should all be afraid about the possiblity of economic hardship.
*I did buy a pack of N95 masks.
“If young people were healthier then they they are today then we would expect that they would have a higher life expectancy then today. We know that is a false statement ergo they were not healthier then young people today.”
Life expectancy was lower in 1918 than it is today primarily because of high infant and childhood mortality back then. If you looked at the remaining number of years which a 20-year-old could expect to live in 1918 vs. 2005, there would be much less pronounced of a difference, and much of that probably would be due to the lower survival rates for the various maladies of old age. But if you compared the typical 20-year-old in 1918 to the typical 20-year-old today, I would imagine that the 1918 individual would be just as healthy, if not healthier, than his or her present-day counterpart.
“Bird flu has been around for a while. If it’s so virulent why is it just now becoming a danger?”
It is becoming a danger because the birds are carrying a form of the flu that can infect humans and kill them. The next step is for the bird flu virus to infect a human cell that is already infected with a human virus, i.e., a virus capable of human-to-human transmission. Inside the infected cell the bird flu and the human flu can exchange genetic material. The result could be a new flu strain which is both deadly and highly contagious and for which humans have no prior immunity.
This danger of such an epidemic has existed for some time. (See Spanish Flu.) You are hearing warning now because there have recently been more outbreaks of deadly avian flu across the world.
As Rikurzhen stated there is a good chance that an avian flu epidemic will not occur in the next few years. But there was also a good chance that New Orleans could dodge the hurricane for another season. We should balance the cost of preparation against the potential cost of not preparing.
rik’s comment is down the line of what i was thinking. the verbal arguments need to be decomposed and explicitly framed in terms of their background parameters/assumptions.
1- is the danger couched in terms of short-term first order threat to mortality via infection? or, is the danger couched in terms of instability due to psychological stress?
2- the parameters vary as a function of space. to put it less ostentatiously, much of africa and south asia is packed with people whose immune systems are less than stellar, embedded in societies where public health is a myth. granted, there is a possibility that we could insulate (the west) ourselves from the fall out, but i’m not totally sure.
3- has anyone offered an explicit model with nicely digestable parameters that try to gauge the probability of a pandemic at any given time? for example, to simply one could assume that you have an expectation of one “jump” between bird to human in n pairwise interactions between birds and humans. that expectation is subject to variance, but as t approaches infinite obviously a “jump” will happen…are the bird-human interactions less than in 1918 (because animals don’t live as close to people), or more than in 1918 (because there are more domestic birds and humans than there were then?). there are also a shit-load of other parameters at play, from transportation and social networks to the interaction of birds with birds (the rise of mass chicken farms). i’m not holding out the hope that these models are a strong signal in the noise, but, they can clarify the debate a bit and expose starkly everyone’s background assumptions.
4- some of the hysteria might just be due to the fact that the public is insensative to non-hysterical pleas for planning.
my understanding is that sequencing (e.g. of the 1918 strain) gives us some data on the extent of mutation that is sufficent to change a bird-to-human trasmitted flu into a human-to-human flu. however, we don’t really have enough data points to say what is necessary; and thus we may not be able to make reliable estimates on how long it will likely take for the human-to-human transmitting avian flu to evolve.
but given the bird+human population of SE asia with the living conditions there, i would guess (off the top of my head) that we’re looking at years rather than decades.
well, is there any insight that can be offered by archeo-epidemiology? obviously our species has been hit by pandemics periodically, probably at least since the neolithic. we might not be able to pin down the probability of a neo-flu pandemic, but perhaps we could construct some sort of prediction equation using historical and archaeological data points to infer parameters?
to be explicit about what i’m thinking of (and this speaking as one of the ignorati), imagine that archaeologists manage to extract samples from individuals across europe between 10 and 6 K BP when agriculture swept over the continent, and population densities rose (via endogenous increase and the demic diffusion wave). if we could pin down the number of individuals who died because of pandemics that would give us some insights into the relationship between novel pathogens and changing population dynamics. perhaps the plague that wracked the byzantine empire during the reign of justinian, and later the medieval era plague, could also help.
People have been dying of this bird flu for many generations. The ability to specifically type and diagnose infections by type is fairly recent in that part of the world. This is very slow transformation on the part of the avian flu virus. Watching paint dry would be more exciting.
I would suggest that natural disasters of most varieties including disease outbreaks are usually logistically distributed in terms of the probability that any given person will die divided by the probability that they will survive. Our data points for flu outbreak magnitude suggest that the distribution for this outbreak associates the vast majority of the aggregate expected mortality in the most severe cases. However, the majority of moderately severe cases are still not catastrophic. It seems reasonable to assert that the empirical evidence contradicts any assertion that extremely serious pandemics have become more likely, as moderately serious ones have not become more common and both should be generated by similar factors.
This remains the case even when terrorism is taken into account. Spreading ordinary diseases is easy and terrorism is old. There is no reason to think that terrorists have recently become more inclined to spread diseases, (even the biotech required is old) so historical data on total disease includes disease due to terrorism.
It is only too human to crave for the End of the World. It is not coming yet, and certainly not through bird flu.
well, is there any insight that can be offered by archeo-epidemiology?
might be hard to get that DNA
http://www.sciencefriday.com/pages/2005/Oct/hour1_101405.html
follow the money:
http://www2.bmo.com/bmo/files/news%20release/4/1/Avian%20Flu.pdf
The classic case of medical alarmism is the panic over variant CJD (human Mad Cow Disease) in Britain a few years ago. The doom-sayers were predicting deaths in the hundreds of thousands, if not millions.
In the event, total deaths over the ten years or so since variant CJD was indentified now come to about 150, and have been on a falling trend for about 5 years. Deaths so far this year (up to 4 October) come to precisely 3. My guess is that total deaths for the ‘epidemic’ will be less than 200.
Home heating has come a long way since 1918.
So, how many of the people who have died of the avian flu in Asia died of secondary bacterial infections? It seems like that’s a critical question, right? Certainly, once it was realized that they were sick, they would have been given antibiotics if necessary. (But perhaps by then the infection had already done too much damage for many of them to live.)
Michael Vassar: ?However, the majority of moderately severe cases are still not catastrophic. It seems reasonable to assert that the empirical evidence contradicts any assertion that extremely serious pandemics have become more likely, as moderately serious ones have not become more common and both should be generated by similar factors.?
I?m not so sure about, ?both should be generated by similar factors?.
The usual method that a new flu evolves is that an existing human flu virus undergoes a mutation causing the surface markers of its viral capsule to change enough that antibodies to the prior form are no longer able to prevent infection. My guess is that such viral changes would fit a curve as Michael suggests and the curve should give a decent prediction of the severity of future pandemics.
Another method by which a new flu virus can evolve is recombination between a bird-to-human virus and a human-to-human virus. This method is far less common and is not the source of most flu outbreaks. The severity of pandemics of this type needn?t be predicted by curves based on the first mechanism.
If there is a flu pandemic I don’t think there will be enough hospital beds to supply oxygen and IV fluids, much less respirators and dialysis. Especially if a substantial fraction of the medical community succumb. I even wonder if there will be adequate distribution of antibiotics for those with pneumonia who can’t get into hospitals. And that’s for the US/Europe/Japan. What about China, India, et. al. and Africa and Middle East?
I think the MD is too optimistic, perhaps a bit hubristic himself.
Robert,
It’s the constant “if” factor that is the weakness of your argument and the avian flu alarmists. A similar “if” factor ocurred during the BSE episodes of a few years back; an “if” factor that caused them to cull thousands of animals, go into hysteria, and damage their economies and we still cannot determine how efficiently BSE transfers to humans, if at all.
Don’t go throwing links at me on this BTW, I’m writing a post on this subject and the BSE/alzheimers’ ambiguity
shoot,
I clicked too soon. I meant to conclude with: and you can discuss that there.
Scottm: ?It’s the constant “if” factor that is the weakness of your argument and the avian flu alarmists.?
What steps are justified when risk is unknown? At what point is one person?s rational concern, another?s hysteria? (Labeling people as ?alarmists? does little to refute their claims.)
How does one estimate the probability? Use history? There has already been a major flu pandemic in 1918. Depend on experts? Experts in this field are saying that recent avian flu outbreaks indicate that a flu pandemic is likely.
If the risk is significant, what policies are rational? (Yes, there is an ?if? in that statement. Prevention and preparation require handling both low probability events and high probability events.) Should the US government be stockpiling masks and buying vaccines? Should more money be spent on research and development of vaccines? Are these ?hysterical? or ?alarmist? reactions?
“Experts in this field are saying that recent avian flu outbreaks indicate that a flu pandemic is likely.”
Thsi makes me a little sceptical as well. From a follow the money perspective. If there is increased interest/ hysteria about avian flu. It will translate into more funding for research, epidemiology , vaccines etc etc etc. Now guess who would be the beneficiaries of this dole. You guessed it- the very experts talking about a likely pandemic.
Big science in academic institutions – long ceased to be about science. It is all about funding, overinflated egos, and empire building. So let me say, i take claims by experts with apinch of salt.
There may or may not be a pandemic coming, but the experts cannot be counted on to be unbiased. Most Dept heads that i have known came to be that way by being the most effective charlatans and money launderers, not the best scientists.
DNA vaccine could help save lives, slow spread of ‘bird flu’
http://www.eurekalert.org/pub_releases/2005-10/acs-iac101905.php
?A DNA vaccine could be produced in as little as two or three weeks, Dunnill says. To do it, scientists would create a “loop” of DNA that contains the construction plans for a protein on the outer surface of the H5N1 virus. When that DNA is injected into cells, it would quickly reproduce the protein and trigger immunization in much the same way as a conventional vaccine.?
?
?Although no commercial influenza DNA vaccine is currently available, these vaccines have worked well in animals. However, human trials are still in the early stages so the safety and efficacy of these vaccines isn’t fully established in people. But these trials could be accelerated, Dunnill says, particularly if the H5N1virus eventually causes large numbers of human deaths and out paces the supply of conventional vaccine. In the worst case scenario, he suggests, using a DNA vaccine could be a “stop-gap” measure until enough conventional vaccine is available to corral the pandemic.?
Vic: ?There may or may not be a pandemic coming, but the experts cannot be counted on to be unbiased.?
I agree. Even if they believe themselves to be totally unbiased, their intense life focus on the single issue will give it unwarranted importance in their worldview.
That leaves open the question of how society should weigh such risks and what an appropriate response should be.
To counter that, if their lifes focus is this very subject, and their reputation in the field makes up a large portion of their esteem and standing (personal as well as professional, as you would expect from such consuming commitment and sacrifice), then I’m sure any contemplated warnings would have been given equally intense consideration before they were put out.
Redd: ?I’m sure any contemplated warnings would have been given equally intense consideration before they were put out.?
No doubt. Especially considering the bad publicity surrounding the Swine Flu vaccination program.
But intense considerations don?t negate bias. Even a person?s choice to enter a world health field reflects a worldview that may differ from the general society. So I believe it is wise to look for bias and conflict of interest in policy statements. However, that doesn?t mean the policy recommendations are wrong or should be ignored.
It’s also worth pointing out that positive claims (this has happened, this will happen, I have done this) are a lot easier to get published and get attention for than negative claims (this hasn’t happened, this probably won’t happen, I tried this and it didn’t work). And both politicians and the media are much more likely to pay attention to the people who say “the sky is falling” than the people who say “it looks like rain.”
Fly mentions that one might estimate the probability by looking to history. This just tells us that p is above 0. When conditions change profoundly, it’s shaky to compare the past to the present. If we were to judge from the recent past, it would appear that we’re long overdue for another epidemic of dysentery and cholera. However, these only become epidemic when environmental conditions are met, such as contaminated public water systems. Prevent those conditions (by modernizing the water system), and you prevent further epidemics.
If funds were invested to mosquito-proof indoor areas in s-S Africa, that would greatly cut down on the malaria epidemic. Years down the road they would not be justified in worrying that they’ve enjoyed too much malaria-free time, and that this is just the calm before the storm of another epidemic. That storm would only come if they threw away their mosquito-proof housing. Same goes for STDs: safe sex prevents an epidemic, and only abandoning these practices will favor further epidemics.
Paul Ewald talks a bit about 1918 in _Plague Time_, and he concludes that, in addition to obvious culprits like unsanitary conditions, it was the mass poultry-farm-like conditions of crowding in the WWI trenches & makeshift hospitals that favored increased virulence on the Western Front. People were so tightly packed together that the virus could be both highly virulent and not incur fitness costs since the host wouldn’t have had to move around to pass it on — the next host was right by his side.
Those conditions were the oxygen to its fire: once the war was over, or once the virus left the area, it sputtered out. That’s the take-home message — prevent mass poultry-farm-like crowding, and it won’t become both widespread and very harmful (among humans or birds). Even densely populated urban areas apparently aren’t dense enough — they favor increased virulence compared to rural areas, but if they supported highly contagious and highly virulent strains, one of these strains would’ve emerged as epidemic during the last 100 years since they mutate so rapidly.
well said agnostic
I couldnt have said it better.
WRT bias
I would like to point out that the amounts of funding devoted to the HIV problem ios far in excess of its public health impact or potential public health impact in the united states. A vocal group with their own institutional or other biases can and does use a media generated hysteria to obtain disproportionate public and other funding. HIV research became sexy. maybe avian flu will become sexy as well.
It’s my understanding that the recent deaths from avian influenza have been due to direct viral damage (to the lungs, mostly), not secondary infections. The argument that ‘ordinary influenza kills by secondary infections, therefore avian influenza will as well’ is not well founded.
The Great Influenza Epidemy of WWI did not die out because the war ended but becouse survivers developed immunity to the virus. Avian influenza may never mutate to acquire human to human infection cpability, and specifically transmission through the air. I dont even see it disrupting the poultry industry. Are we going to tremble all the time thinking that some animal virus may develope air human-to-human capability? If so, why bird influenza and not say HIV?
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