Surprise!

People are always surprised when things go really wrong. When Katrina struck New Orleans and flooded the city, shocked surprise was written on everybody’s face. I heard “I can’t believe this is happening” from countless people on television.

People were surprised even though they’d been warned. Predictions about what would happen to the levees in a catastrophic hurricane had been made for years. A century ago, the nearby town of Galveston, Texas, had been wiped off the map by a monstrous hurricane. There were more timely warnings too, like the evacuation order ignored by so many because they couldn’t leave or decided not to. I remember hearing one guy responding to a reporter who asked if he would leave saying “Hell no! Me and my buddies are going to hole up, drink some beers and ride ‘er out.”

When the city flooded, I wondered whether he and his friends had survived or if they were wading through the city with disbelief on their faces. I wonder if we’ll have the same stunned look when the next influenza pandemic hits.

I first started reading up on avian influenza – bird flu – a few days ago, when a report on H5N1, a particularly virulent strain of it, caught my eye. H5N1 has already infected humans as well as birds. There have been 122 confirmed cases in people outside of China, including 62 people who have died.

The report I read dealt with cases inside China. China has confirmed only three cases of H5N1 in people. But according to a researcher who has been investigating bird flu in China on behalf of the World Health Organization (WHO), these cases represent only the “tip of the iceberg”. Masato Tashiro, head of virology at Tokyo’s National Institute of Infectious Disease, has listed “several dozen” outbreaks including almost 300 deaths and 3000 people quarantined.

He has also documented seven human-to-human transmissions. This is frightening. Bird flu is only bird flu until it starts passing between humans. Then it’s just the flu, in this case, a lethal version of it. So far, there are no confirmed cases of human-to-human transmission of bird flu, although there are a couple of suspected cases. If Tashiro’s report is correct, we are much closer to a pandemic.

In 1918 and 1919, a worldwide epidemic of influenza killed between 25 and 50 million people. It was caused by H1N1: bird flu. The effects of this new strain were severe:

The strain was unusual in commonly killing many young and healthy victims, as opposed to more common influenzas which caused the bulk of their mortality among newborns and the old and infirm. People without symptoms could be struck suddenly and be rendered too feeble to walk within hours; many would die the next day. Symptoms included a blue tint to the face and coughing up blood caused by severe obstruction of the lungs. In further stages, the virus caused an uncontrollable haemorrhaging that filled the lungs, and patients would drown in their own body fluids.

The last two influenza pandemics, in 1957 and 1968, both originated in Asia, just like H5N1. One of the reasons for this is the living conditions in these areas. In parts of China, some people raise pigs in their homes. Pigs are like a “mixing vessel” because they can get bird flu and human flu at the same time. When this happens, the viruses can swap genetic material – and thus genetic traits – with each other like trading cards. If a bird flu virus gets dealt the “human-to-human-transmission” card from a human flu virus, we have a nightmarish problem.

Many people and pigs in Asia also come in close and daily contact with poultry, creating what one researcher calls a “genetic-reassortment laboratory — the mix of an unprecedented number of people, pigs, and poultry.” He goes on:

It is sobering to realize that in 1968, when the most recent influenza pandemic occurred, the virus emerged in a China that had a human population of 790 million, a pig population of 5.2 million, and a poultry population of 12.3 million; today, these populations number 1.3 billion, 508 million, and 13 billion, respectively. Similar changes have occurred in the human and animal populations of other Asian countries, creating an incredible mixing vessel for viruses. Given this reality, as well as the exponential growth in foreign travel during the past 50 years, we must accept that a pandemic is coming — although whether it will be caused by H5N1 or by another novel strain remains to be seen.

Add to this mixing pot the Chinese government’s legendary reputation for secrecy and deceit (they hid SARS too) and we have a volatile combination, one that the WHO says the world is “ill-prepared” to deal with. The WHO has “urged all countries to develop preparedness plans, but only 40 have done so”. Is Canada one of those countries?

The answer is a qualified yes. There is a plan, but its adequacy is questionable. And if you’re not a medical professional or an essential service provider, you might find it particularly un-reassuring. (Speaking of which: one part of the plan is headlined Guidelines for the Management of Mass Fatalities During an Influenza Pandemic.)

Other than quarantines, which are especially difficult to enforce in free societies, the main weapons against an influenza outbreak are vaccines and antiviral drugs. The problem with the vaccine approach is that you can’t make vaccines for a pandemic virus until it starts to spread and researchers get their hands on it. In other words, people need to start getting sick before a vaccine can be made.

Canada has a $325 million, ten-year contact with ID Biomedical in Vancouver to produce vaccines for an influenza pandemic. The problem is that it would take the company seven months to produce its first batch of the vaccine, which doesn’t include clinical trials, and even then it could only produce about eight million doses a month. As of the beginning of 2005, ID did not even have a manufacturing plant with a level of biological containment high enough to allow it to manufacture the vaccine.

Antiviral drugs are also available, but they are in worldwide demand as governments seek to stockpile them. According to Canada’s plan, “current supplies of antivirals, both within and outside of Canada, are very limited”. This means that the supplies of vaccines and antivirals need to be rationed, and they are, in order of importance: health care workers, then essential service providers, then high-risk individuals, and finally healthy adults and children.

That order might be logical, but it’s certainly not reassuring. Remember that the outbreak in 1918-19 was unusual because it killed “many young and healthy victims”. Given the limited amount of drugs, the young and the healthy who find themselves at the end of the treatment list might not get treated at all.

So what can you do? Standard survival preparedness, like a stash of food, water and fuel, is always a good idea, although I’m the first to admit I don’t have one. There’s also a booming online trade in antiviral medicines, if you wanted to stock up on those: search for Tamiflu on the Internet and you’ll find plenty of places to buy it, although it’s really expensive and who knows if you’ll ever get it.

Government officials tell people not to stockpile these drugs even as they work to do just that. There’s no guarantee they’ll work against whatever virus triggers the next pandemic anyway, so it might just be best to save your money and buy a supply of surgeon-style face masks. And hope that you can avoid going out in public for as long as possible.

It all sounds crazy, I know. Just like the environmentalist loonies who warned that Katrina would come, sooner or later. You might be shocked when an influenza pandemic strikes and you find yourself at the bottom of a list of priorities. But if you’ve read this far, you can’t be surprised.

————
More reading:
H5N1 on Wikipedia
Official Chinese bird flu deaths could be ‘tip of iceberg’
Most Canadians don’t feel avian flu is a threat: poll
Bird Flu, Liberty, and Quarantine
Canadian Pandemic Influenza Plan
World Health Organization: Avian influenza FAQ
Preparing for the Next Pandemic
Countries ill-prepared for influenza pandemic