Siege of Disease
Are we just one flu virus mutation away from another killer epidemic?
By Joan Trossman Bien 03/07/2013
Veteran TV journalist Kris Knutsen of Pasadena believed she was doing everything right. She had gotten a flu shot and, by her own admission, is sort of maniacal about cleanliness, using hand sanitizer throughout the day. Still, she recently lost a week to illness.
“The first day I felt kind of ‘off,’” Knutsen recalls. “The next day, I got this heaviness in my chest and didn’t feel great. By that afternoon, I went home from work, because I felt terrible. My nose was running and I was starting to get a cough. By the next day, I felt horrible. I had a temperature, was all congested, had a massive headache, body aches and a little bit of chills.”
Welcome to a typical episode of Flu Lite 2013.
Because she’s been vaccinated, Knutsen is lucky enough to know how it feels to acquire a less severe form of influenza. However, this recent bout of illness knocked her completely off her feet. With a fever of 102 degrees and unable to do much of anything, Knutsen isolated herself from her family, stayed in bed for several days and waited until she was no longer infectious before returning to work.
The Centers for Disease Control and Prevention (CDC), which tallies the effects of influenza in the United States, reported that, as of Feb. 22, there had been 64 pediatric deaths associated with pneumonia and the flu. The agency also found that more than half of all hospitalizations due to flu involved people over 65.
The CDC declares an epidemic when the death rate reaches 7.3 percent of the population, a threshold crossed late last year. In early January, that number shot up to 9.3 percent. Although the pneumonia- and flu-related death rate is just beginning to decline, the CDC declared on its Web site that the United States is still far above the epidemic rate, at 8.4 percent.
As for the spread of this year’s influenza, the CDC, as of early February, reports it remains widespread in 38 states, including California. Just a few weeks ago, seven more states reported widespread infections. While there has been a decline in flu cases in the eastern US, the virus appears to be getting stronger in central and western states.
Need a shot?
The official line from Dr. Jonathan Fielding, Los Angeles County director of public health, recommends that everyone over 6 months old get a flu shot. The vaccination’s success rate is at a modest 62 percent, making Fielding less enthusiastic about requiring all health-care workers to get a flu shot, something he has not done, and will not do absent a true medical emergency. However, he says there still is time to be vaccinated for those who want a shot, as flu season lasts until spring.
“One must be measured and use discretion in terms of what is mandated,” Fielding said. “On the other hand, do I think that hospitals have a right to mandate that their health-care workers be immunized? Yes, at that level of the individual hospital.”
If a patient gets sick and feels they need to go to a hospital, they can’t take it for granted that all of the workers with whom they come into contact will be vaccinated. Fielding said there is only one way to be certain. “You would have to call the hospital and get the policy.” He added that he must balance the benefit to public health against individual freedom. But the message clearly is that getting the flu shot will do more to keep you healthy than not getting it.
The question is why so many people are avoiding getting a flu shot. Even health-care professionals, including doctors and nurses, are inoculated at the modest rate of 60 percent.
No one’s immune
Influenza is unpredictable. When a strain of the virus suddenly swept through the world’s population in 1918 — as the First World War was coming to a close and the Russian Revolution was just getting started — no one was prepared. With nations recovering from global war, public health officials wanted as little attention as possible paid to the flu, urging newspapers to censor the true scope of the crisis. Public officials then made erroneous decisions based on the censored information and lifted quarantines just as the virus was losing steam. And the ill-timed public celebrations over the end of the Great War metaphorically poured gasoline on the smoldering embers of the virus, which then exploded across the country.
In modern times, there have been four pandemics of influenza: the Great Influenza Pandemic of 1918; the Asian Flu in 1957-58; the Hong Kong Flu in 1968; and the 2009 Swine Flu, also called H1N1. But the truth is, nothing compares to the 1918 pandemic in its near-total sweep of the globe — from villages in the Arctic to isolated islands in the Pacific Ocean. Virtually every city on the planet hosted human influenza, and it circled the Earth inside of just a few months.
A lot of famous people and their family members died from the 1918 pandemic. Neither fame nor wealth offered protection. Sigmund Freud lost his daughter, Sophie. William Randolph Hearst lost his mother, Phoebe. Donald Trump lost his grandfather, Frederick. Sen. Robert Byrd lost his mother, Ada Mae Kirby.
Artists who perished before their time included painter Gustav Klimt, playwright Edmond Rostand (“Cyrano de Bergerac”) and Chicago theater innovator Kenneth Sawyer Goodman of the Goodman Theater. Also taken by the flu was the daughter of Buffalo Bill Cody.
Despite the effects on high society and politicians, the history of influenza, particularly that of the 1918 flu, has been treated by the educational system as an event best forgotten. When children are taught about the Middle Ages, there is often a recitation of the numbers of people who died from the Black and the Yellow plagues. Yet, even though one-quarter of the population of Europe was wiped out by those plagues over the course of four years, the 1918 flu killed many, many more people in the space of just eight months. That flu infected roughly one-third of the Earth’s population.
The past 100 years have been peppered with epidemics, and the 1918 Influenza Pandemic was estimated to have been the worst siege of disease in the history of humankind, killing up to 100 million people.
Life in 1918 bore little resemblance to conditions of the 21st century. Life expectancy for men back then was 53. One in five infants did not live to see their fifth birthday, partially due to childhood diseases, which included measles, diphtheria, scarlet fever and pertussis.
The concept of cleanliness leading to better health was well known by then. Vaccines for some illnesses — smallpox, typhoid and typhus — were commonly given to children at school. And sewer systems had been built in cities, which went miles toward lowering mortality rates.
The magnitude of danger was not readily apparent when the first wave of virus hit in the spring of 1918. People got sick, and then they recovered within a few days. They called it the “three-day flu.”
The first death was noted at a US Army base in Kansas, after which hundreds of healthy young men suddenly got sick. That summer, as GIs were shipping out to fight overseas in World War I, the flu virus went with them. In the filthy and wet trenches of war, influenza flourished. By July, it had infiltrated the civilian population of Europe.
In late August 1918, researchers believe the virus mutated when three port cities around the world simultaneously erupted in a deadlier form of the flu: Brest, France; Freetown, Sierra Leone; and Boston. During the last week of August, 5 to 10 percent of those in Boston with the flu died as a result of secondary respiratory infections.
Only two weeks after the flu arrived in Boston, it found its way to the West Coast. By late September, there were 35,000 known cases of flu in California. The number hit 115,000 in early November, but record-keeping was spotty. In Los Angeles, schools remained closed for four months.
A third and final wave of a most virulent form of influenza crested in spring 1919. By then, the flu had morphed into a fearsome force, terrifying to see. For some, the illness attacked their lungs with such ferocity that the person would turn blue or black as they were being starved of oxygen. One early symptom was a nose bleed with incredible force. Blood would flood the lungs, mix with desperate attempts at getting air and emerge as a bloody froth as victims suffocated in their own fluids.
There are many reports of people dropping dead within hours of the first symptoms. Researchers now believe that the heavy death toll was partly due to secondary respiratory infections occurring in a time before antibiotics.
An unusual aspect of the 1918 flu was how hard it hit healthy young people. In a typical seasonal flu, those least able to overcome the illness are the very young and the very old. However, in 1918, and then again in 2009, the healthiest young people often had the most severe cases and were most likely to die. Doctors say that was because their own immune systems went into overdrive with the afterburners on, a “cytokine storm,” in which the immune system overwhelms the body.
The war in Europe took the majority of doctors and nurses away from America, leaving the civilian population in the hands of medical and nursing students. Public health departments were aware of the rising panic and pressured newspapers to not report on the epidemic. As a result, after it was reported that there was a drop in influenza cases by November 1918, quarantines were lifted. In fact, this happened at a critical point in the pandemic. Massive public celebrations marking the end of the war only heightened the spread of the infection, and soon the flu had spread from coast to coast.
When the pandemic ended in summer 1919, some 675,000 Americans had died. Worldwide, estimates run as high at 100 million deaths. Life expectancy in the US had dropped by 12 years.
A bad year
Not only did the flu hit America a month earlier than usual this year, the most serious of the circulating strains and subtypes, Type A H3N2, “a moderately severe strain,” as Fielding calls it, is the dominant flu.
Thousand Oaks pediatrician Dr. Ken Saul, however, has a different opinion. “My experience is this strain of flu is just average from my objective assessment,” he says. Saul has so far seen 43 cases of influenza, and 18 of those patients had been vaccinated. Not one case was serious enough for hospitalization to even be considered, he says. Although Saul strongly recommends getting the flu shot, he is not leading the parade.
“I don’t beat the drums, pull out the banners and scare people. I tell people that if you weigh the risks and benefits, it is better to get the flu shot, because nothing terrible is going to happen from the flu shot and something terrible could happen from the flu.”
As Saul points out, vaccination is no guarantee that you will be immune from the flu. But if that happens, you will likely get a milder form of it.
Summing up her experience with influenza, Knutsen recalls, “I had a flu shot. If this was supposed to minimize your flu, I understand why people were going to the hospital. This was brutal.”
Nevertheless, a lot of people have been going to work sick — and highly infectious. Influenza viruses can live on surfaces for a few hours. The virus is also airborne. Each time an infected person sneezes, coughs or speaks, tiny droplets of virus are expelled into the air. An adult sneeze can propel a virus six feet.
Knutsen, an assistant news director at KTLA, Channel 5, remembers watching as flu swept through her newsroom, starting at one end and moving to the other, then back down the far side of the room until almost everyone got ill. Most of the sickest people did not get the flu shot, even though the company had offered it at no charge last fall.
Today, we quibble over the value of a vaccination. We may acknowledge the terrible toll taken by the virus in 1918 but act as if that could never possibly happen again. Yet, all of the pandemics of the past century were caused by direct descendants of the 1918 flu virus. Doctors cannot predict when or whether a flu virus will eventually mutate into a deadly scourge or become innocuous. But there is always the fear that one year the flu will mimic the 1918 pandemic and mutate into a beast that devours families and communities.
And yet, 40 percent of health care professionals chose not to get their flu shots. That number includes doctors and nurses who work closely with the most vulnerable and weakest patients. Some hospitals require workers to get immunized or lose their jobs, but most do not have such a policy.
Race to the end
Peering into the future, we are left to wonder which one of two possibilities will occur: The appearance of a novel virus to which there is no existing immunity, or the development of a universal vaccine that needs to be renewed only once or twice a decade.
There is some very good news in the way the vaccine is manufactured. Because flu strains change, until recently, scientists had to take their best guess at which strains would be dominant in a coming year. Once decided, nearly all of the manufacturing took place outside of the US. Eggs were used to incubate the virus for the vaccine. This took several months. When flu season arrived, it was hoped that the viruses were the right ones and that enough vaccine had been made. If there was not enough, it would take too long to make more batches. If too much was made, the financial losses would be enormous. Manufacturing the flu vaccine has never been profitable.
Now, the FDA has approved a completely new approach to the manufacture of seasonal flu vaccine — the first made by using an insect virus and DNA technology called Flublok, manufactured in Connecticut. Other vaccines already have been made using this technology. It uses neither the influenza virus nor eggs and still protects against the three dominant strains of flu.
An actual universal flu vaccine is about 8 to 10 years away, according to researchers. It would require a booster every 5 to 10 years after that, instead of an annual vaccination.
On the flip side of this progress is the unknown answer to how any of the influenza viruses will mutate at any given time. For several years, researchers have sounded the alarm that the Avian Flu, the Swine Flu and SARS (a deadly respiratory disease which spread into Asia a few years ago) were just one mutation away from becoming highly infectious. Right now, it takes close contact with infected animals or people to transmit those flu viruses. If any of them were to become airborne, these viruses could fly through the population at great speed, similar to what occurred in 1918.
And so, the race is on. If such a mutation occurred, and if that happened after development of a universal vaccine, it is possible that the world would be divided into two camps: The living, who were vaccinated, and the seriously ill and dead, who were not.
With everything we now know about mercurial, fast-moving and potentially virulent flu viruses, this scenario is not difficult to imagine.