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Plan for the Worst, Hope for the Best

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Plan for the Worst, Hope for the Best

SPECIAL WEB SNEAK PEEK! Swine Flu is sweeping the news, and maybe the nation. Scientists don't know whether we're looking at 1918, when 21 million people died worldwide, or at 1976, when one case of swine flu led to a disastrous vaccine program. Here's what you should know about swine flu, pandemics, staying healthy and funding for public health.

Editor’s Note: Covering an emerging story that can evolve even more rapidly than the virus it’s talking about is an impossibility for a monthly publication. Therefore we are making this story available now online (before the print version hits the streets) and will update it as new information becomes available.

It’s 2009, and a flu virus that makes its home in pigs when not infecting humans (influenza virus A (H1N1) has demonstrated we are, indeed, a global village. Initially emerging in Mexico, it was identified by the CDC in April after cases appeared in California and Texas.

Viruses begin with some tremendous advantages: the first is takes us a while to figure out what’s there.

It was April 6 when local health officials reported a respiratory disease outbreak and issued a health alert in La Gloria, Perote, Veracruz, Mexico. Sources there reported a health official had been seeking help for the town since February.

It was ten days later, April 16, when atypical pneumonia cases were reported in Oaxaca. It was almost another four days before CDC identified swine influenza A (H1N1); and it was identified in California and possibly Texas. By April 27 cases had been confirmed in Europe, Asia and New Zealand. WEB UPDATE: On Wednesday evening, April 29, the Washington Department of Health announced there are six probable cases of swine influenza A H1N1 in the state, including one case in Spokane County. The six people infected are exhibiting flu symptoms but did not test positive for the flu. The current H1N1 test available will not react to the swine flu creating concern; therefore, the non-responding samples have been sent to the CDC for further testing as probably swine flu samples. Read about it here.

(Web update: 30 April - First probable case in North Idaho (read)

On April 22 Canada issued an ‘alert’ for all travelers returning from Mexico, and that’s the second advantage viruses hold—the amount of time it takes to determine whether or not a particular virus is going to turn into a major threat. Does the virus cause death? If it does, does death occur in previously healthy patients, or only those whose immune systems were somehow compromised? How quickly does the virus progress to death? Are secondary infections involved? What is the incubation period, the amount of time it takes to develop symptoms after exposure (the amount of time a patient is unknowingly spreading virus)? Does a prior flu shot offer any protection? Is the virus susceptible to treatment? It’s the answers to these questions that determine whether a particular virus has the ability to become a pandemic (causing serious illness and/or death to people throughout the globe) and these questions can only be answered with data... data which comes from infected patients.

Testifying in 1982 at a congressional  hearing on AIDS, Dr. Richard Krause of the U.S. National Institutes of Health noted, “Nothing new has happened. Plagues are as certain as death and taxes.” That is still true today.

Especially plagues of influenza. Global flu pandemics, affecting millions of people throughout the world, occurred in 1732, 1781, 1830, 1833, 1889, 1918-1919, 1846, 1957, 1968-1970 and 1977. It’s believed that deadly pandemics potentially have occurred at least once every generation.

Although it might be easy to assume that “it’s better safe than sorry,” in responding to the threat of a potential pandemic, the U.S. was burned by that philsophy in 1976 when a young, previously healthy soldier at Fort Dix, New Jersey died just a few hours after being hospitalized with what turned out to be swine flu—specifically swine influenza A/New Jersey/H1N1. The government’s response led to a massive and disastrous immunization program—disastrous because that version of swine flu never made it off the army base and never killed another person, yet 4,181 people sued the government (who had agreed to be legally liable for vaccines manufactured in the face of a potential epidemic) after receiving the flu vaccine and then developing Guillain-Barre syndrome. Twenty-five died.

Dr. Harvey Fineberg, Dean of the Harvard School of Public Health, explained the government’s response to the influenza outbreak at Fort Dix: “... it’s hard to separate likelihoods from consequences,” and suggested in 1976 that policy makers were “overwhelmed by the consequences of being wrong.”

Those consequences are illustrated by the 1918-1919 flu epidemic. Over one billion people worldwide were made ill and 21 million died—including half a million in the U.S. alone. Although no tissue and blood samples were kept from the patients of that epidemic, tests in 1932 showed that people alive during 1918-1919 had antibodies to swine flu, while those born in 1920 did not. The virus suspected for causing the worst flu outbreak in American history was a swine influenza A (H1N1), a virus so virulent there were reports of people dying within 45 minutes of first feeling ill.

But this is not 1918, which offers good news and bad to the American public.

First, the good news. The swine flu virus currently circulating can be identified by a blood test. Although it now takes a couple of days for tests to confirm the presence of swine flu, scientists in Hong Kong are working to develop a test that can drop that time to hours. They expect to have it ready within a week. An accurate test prevents not only patients receiving inappropriate medication, but can also prevent panic.

In addition, the swine flu circulating is currently susceptible to two established antiviral treatments (it is resistent to the other two available). In 1918, there were no treatments available for those infected.

And while there are flu deaths reported in Mexico, to date not one confirmed swine flu case in the U.S. or elsewhere has progressed to death. ONLINE UPDATE: The U.S. reported on April 29 the death of a 23-month old in Texas due to swine influenza A H1N1 infection. The child had recently arrived in the U.S. from Mexico. (See story here.) ONLINE UPDATE - the first US patient with swine flu died today. Julie Trunnell of Harlingden, Texas died in hospital; while health officials confirmed she was hospitalized with swine flu, they have not listed that as a cause of death, saying she had "chronic, underlying health conditons." Trunnell was pregnant, and when she slipped into coma, the baby (a healthy girl) was delivered by Cesarian section.

Other good news? Eat all the sausage, bacon and pork chops you want (or that your doctor will allow). Swine flu is not transmitted by eating pork. But consider buying it from a local producer, like Woods Meat, as large-scale Controlled Animal Feeding Operations are implicated in the creation and spread of harmful viruses and bacteria. (Read here.)

The bad news? Flu viruses mutate rapidly. The swine influenza A (H1N1) in the news today is technically not a swine flu - or not just that - as it contains genetic material from pigs, birds and humans—as Pulitzer Prize-winning health author Laurie Garrett points out, it could just as easily be called avian flu or human flu. Influenza is “a microbial chemelion that [has] thrived over millenia by rigorously adhering to a single maxin: adapt or die,” Garret wrote in “The Coming Plague.” This current virus is a brand new entity on the virus scene, and we don’t yet know its tendency to mutate. That could be a problem if this particular flu ends up in a host also infected with the human influenza (H1N1) that is resistant to the antiviral drug Tamiflu, and picks up that resistance, which it currently does not have. Garrett says she is “very, very worried,” that this might happen.

In addition, borders are simply imaginary lines on a map that viruses don’t recognize. We have already seen that it took only ten days for swine flu cases to be reported throughout the world. Containment is not really an option. “The world really is just one village,” said premiere virologist Joshua Lederberg in the late 90s. “Our tolerance of disease in any place in the world is at our own peril.” Americans tend to grumble at providing foreign aid for health care (and provide it in paltry amounts because of that), yet what this virus might illustrate is that helping Mexico with health care, for example, ultimately helps us. And it goes without saying that helping our own poor with health care can protect the rest of us—viruses don’t check to see if there’s money or a health insurance card in your wallet before invading your body. (Editor’s note: the assumption is that this virus began in Mexico, yet there have been some reports that U.S. cases in California and Texas may have occurred before the Mexican outbreak. In addition, in many ways Mexico has a better public health infrastructure than we do.) Web update 4/30: CDC reports onset of symptoms in two California children as March 28 and March 30. Onset of symptoms began in Mexico around March 15.

More bad news can be found in current headlines: in today’s world the global market, already reeling, is ill-prepared to face further threats. The peso is in the basement, oil futures are falling, stock markets are dropping... risk aversion is not going to improve our economy, yet fearful investors may find themselves crawling under the bed to hide along with their money. And by the way—it generally takes a year or more for a flu pandemic to work its way through the populace, so recovery could take a while.

There is other bad news tied to money, and that concerns the ability of the federal government to provide needed help to the states in the event this epidemic grows. Testing kits and treatment drugs cost money, as do the personnel and equipment necessary to identify, track and respond to public health threats. Yet public health has been slowly strangled almost to death through lack of funding over the last few decades. Take a minute to feel sorry for poor Senator Susan Collins of Maine, who just two months ago led the GOP insistence on stripping all state and local pandemic preparedness dollars out of the stimulus bill, “What does that have to do with an economic stimulas package?” she asked. We can only hope we’re not getting ready to have that question answered.

So what can you do? First, look for credible information on what’s going on. News today tends to sensationalize—check for updated reports with the Centers for Disease Control and Prevention and at the Pandemic Flu website; for local information with Idaho’s Panhandle Health Department  and the Montana Department of Public Health and Human Services .

You can also practice basic hygiene—wash your hands frequently and if you must sneeze, do so into your arm, not your hands (which, even with tissue, can spread any virus you might harbor). By the way, you need to wash your hands long enough to sing the Alphabet Song in order to remove harmful bacteria and viruses.

Finally, we should take note of a statement by Univ. of Chicago historian William McNeill: “We are caught in the food chain, whether we like it or not, eating and being eaten.” Perhaps the best consequence of the spread of swine flu would be a recognition of that fact that leads to greater support for public health.

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Landon Otis

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health, H1N1, swine flu

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