flu - my research and thoughts on it

[muldoon]

I am not a doctor, nor before about a week ago did I have any particular interest in influenza.  However, I have been reading and educating myself on this topic pretty hardcore for the past week and want to write this email with what I found, what everyone should be aware of, and a hint at what to expect.  (I say email, but I will post to a few boards I frequent as well).

Flu background,
very important to understand that the flu is common, and already causes problems around the world.  In the US, 36,000 people a year die from the flu every year.  or roughly 100 a day.  A total of 60,000 die from influenza/pheumonia every year.   Pneumonia is a bacteria infection, and the flu is viral; it is quite common for a virus to start an illness, only to have bacteria set in.  So we can reasonably conclude that more than 100 people a day die from the flu. 

virus's have a rating scale, to determine how much of a threat they can provide.  Keep these numbers in mind later.
CFR - Case Fatality rate.  the rate of which an infected person will die from it.  regular flu is 0.10%
CAR - Clinical attack rate.  the amount of people who will get inflected and are symptomatic.  regular flu, 10%
(to doublecheck these numbers, 300million americans * 10% infected * 0.1% fatality rate = 300000000 * .10 * 0.0010 = 30,000 as expected)


virus's in general have some common traits, virus's mutate.  This occurs by the virus literally decomposing and breaking down within the cell.  Other virus's within the cell can then combine and a new virus is created.  This is how influenza spreads, and why after 2000 years on this planet there is not a single "cure" for it.  It changes.  This change is called reassortment.  This particular flu everyone is scared about is half USswine based and half eurasia swine based.  Because it is swine based it has bird and human properties in it, thats part of the swine lineage.  This means that some of the DNA for it is from pigs, hummans, and birds.  It is not clear to me if all of these are carriers, or get sick.  I cannot find an answer to this. 

Whats different about this virus?
It tolerates heat well.  Flu season is in november, for the northern hemisphere.  Inluenzas like cool damp weather, and one of your bodies natural defenses - vitamin D, which you get form the sun - is lowest at that time.  The ONLY flu outbreak I can find reference to in April/March is from 1918.  It's unique. 

Because it is literally brand new, with no real close relatives in the virus family, there is zero immunity to it.  Above there was a reference to the attack rate, and how it is generally low with regular flu.  One of the main reasons for that is because once your body defeats a virus, it remembers how to beat it and you are "immune" to it.  This applies to measles and mumps and other virus's as well.  So, in a given population, some percentage has already been exposed to most virus'es.  No one has been exposed to this, we are very susceptible because it has never existed before. Likewise, there are no immuninizations for it because you have to have the DNA to make immunizations.

Thats enough basic background.  Here are two interviews/links/emails I have verified and think are important to the discussion.   I have read hundreds, some are so off the charts rediculous I wouldnt repeat them, these are credible and informative and illustrates the key points people should be aware of. 

http://blogs.sciencemag.org/scienceinsider/2009/04/exclusive-cdc-h.html
--Everyone should try to read it, it's technical, some of it I dont understand and never will, but I want to point out this is the head CDC virus guy talking; he is supposed to be clinical and precise.  He does give some good information tho

April 29, 2009
Exclusive Interview: CDC Head Virus Sleuth

Virologist Ruben Donis, chief of the molecular virology and vaccines branch at the U.S. Centers for Disease Control and Prevention, spoke with ScienceInsider at length last night about the swine flu virus causing the current outbreak. CDC's early analysis raise several provocative possibilities. The stage appears to have been set for this human outbreak by an outbreak over the past decade of flu viruses in swine that combine strains from several species. The first infected human may not even have been in North America, let alone Mexico. Patient samples from Mexico taken over the past several months reveal that this swine flu clearly exploded in late March, suggesting that it was not rapidly spreading in that country, undetected, for very long.

Donis discussed the genetics of the virus—the clues in this mystery—in detail. These include several of its eight genes, which code for surface proteins hemagglutinin (H) and neuraminidase (N), the matrix that surrounds the nucleus, the nucleoprotein itself, and three polymerase enzymes called PA, PB1, and PB2.

A few exerps from it:

Q: How close is it to the closest strain you know of?

R.D.: Depends which genes. You have similarities of about 94% in the hemaggluttinin [H] to the nearest strain we know.

Q: Is it of swine origin?

R.D.: Definitely. It's almost equidistant to swine viruses from the United States and Eurasia. And it's a lonely branch there. It doesn't have any close relatives.

Q: How about the neuraminidase gene?

R.D.: It has close relatives in Asia. It's also swine.

It's new, never seen before. 

Q: Have you been to Mexico yet to study this outbreak?

R.D.: No. CDC sent a group of scientist and epidemiologists, laboratory folks that went over there to set up diagnostic labs. One is in Yucatán; one in is in D.F. [Distrito Federal, which includes Mexico City].

Just something that has been bothering me.  All these reports of people being sick coming home from cancun.  Yet, the news has ZERO reports of any illness from the tourist town.  The CDC sent a team to the Yucatan, that explains it to me.  It also explains some of the recent actions by Mexico in shutting down huge sections of the country over this.  The numbers they are reporting are politicized in my opinion.   You can draw your own conclusions, but the CDC shouldnt be sending a team to a city with zero infections.  Much like case after case shouldnt be coming home sick from a trip to cancun either. 

R.D.: I saw figures that do scare you. We've received 300 samples from Mexico, and these cover the span of February, March, and April. And you look at flu A, traditionally it's A/H1 or A/H3 or it's B up until the end of March. There are two or three cases up to [the] last days of March that are swine. Then in April they skyrocket. So all the cases in the D.F. areas, where most samples came from, it really transmits very efficiently.

Q: What is the date of first sample?

R.D.: I think it's the end of March, the first positive specimen.

What scares you?  it transmits very efficiently.  That directly ties to that CAR number noted above.  Were going to get to that in a bit. 

---
Now, here is an email I was forwarded.  It was originally from a Doctor in Texas, from New Braunfels. 

Anyone who knows me would know that anytime I see an email or post like this I immediately look for ways to discredit it.  I looked for the post on google, sure enough 255 hits, it's been reposted all over the internet in the past two days.  It is attributed to a doctor, he signed a copy of it on the internet.  Some sites say the doctor is real (or at least that town has a doctor by the same name). and yes - there is a doctor,
http://www.vitals.com/doctor/profile/1144278326  he's a real person.  I called the number they have for him, and got an afterhours recording for an emergency clinic.  I called the other number and got a tired sounding receptionist.  I asked to talk with the doctor and was told he was not available for phone calls; she then asked me if this was about the email.  I said yes and she said he sent it out to family and friends and if I wanted to question the statistics I could contact the health department.  I asked her to clarify that he did indeed send it and was told yes, but only to friends and his family members. 

- So the email is real, in the sense that a real doctor less than 200 miles form the boarder wrote it.  I am not a doctor, I can not claim it is valid, I cannot claim it is not a hoax.  But the latter seems unlikely if he put his name on it.  New Braunfels is a small town, a doctor in a small town sends something alarming like that and is wrong he kills his career.  I dont know if it is accurate but I believe he thinks it is.  You can call if you want, but I did, this is not a forward; its is not friend of mine did, I did. 

So what was in his email afterall?

"After I returned from a public health meeting yesterday with community leaders and school officials in Comal County, Heather suggested I send an update to everyone, because what we are hearing privately from the CDC and Health Department is so different from what you are hearing in the media. Some of you know some or maybe all of this, but I will just list what facts I know..

- The virus is infectious for about 2 days prior to symptom onset

- Virus sheds more than 7 days after symptom onset (possibly as long as 9 days) (this is unusual)

- Since it is such a novel (new) virus, there is no "herd immunity," so the "attack rate" is very high. This is the percentage of people who come down with a virus if exposed. Almost everyone who is exposed to this virus will become infected, though not all will be symptomatc. That is much higher than seasonal flu, which averages 10-15%. The "clinical attack rate" may be around 40-50%. This is the number of people who show symptoms. This is a huge number. It is hard to convey the seriousness of this.

- The virulence (deadliness) of this virus is as bad here as in Mexico, and there are folks on ventilators here in the US, right now. This has not been in the media, but a 23 month old near here is fighting for his life, and a pregnant woman just south of San Antonio is fighting for her life. In Mexico, these folks might have died already, but here in the US, folks are getting Tamiflu or Relenza quickly, and we have ready access to ventilators. What this means is that within a couple of weeks, regional hospitals will likely become overwhelmed.

- Some of the kids with positive cases in Comal County had more than 70 contacts before diagnosis.

- There are 10-25 times more actual cases (not "possible" cases -- actual), than what is being reported in the media. The way they fudge on reporting this is that it takes 3 days to get the confirmatory nod from the CDC on a given viral culture, but based on epidemiological grounds, we know that there are more than 10 cases for each "confirmed" case right now.

- During the night, we crossed the threshold for the definition of a WHO, Phase 6 global pandemic. This has not happened in any of our lifetimes so far. We are in uncharted territory.

- I expect President Obama will declare an emergency sometime in the next 72-96 hours. This may not happen, but if it doesn't, I will be surprised. When this happens, all public gathering will be cancelled for 10 days.

- I suggest all of us avoid public gatherings. Outdoor activities are not as likely to lead to infection. It is contained areas and close contact that are the biggest risk..

- Tamiflu is running out. There is a national stockpile, but it will have to be carefully managed, as it is not enough to treat the likely number of infections when this is full-blown. I don't think there is a big supply of Relenza, but I do not know those numbers. If I had to choose, I would take Relenza, as I think it gets more drug to the affected tissue than Tamiflu.

- You should avoid going to the ER if you think you have been exposed or are symptomatic. ER's south of here are becoming overwhelmed -- and I mean that -- already. It is coming in waves, but the waves are getting bigger.

- It appears that this flu produces a distinctive "hoarseness" in many victims. The symptoms, in general, match other flu's; namely, sore throat, body aches, headache, cough, and fever. Some have all these symptoms, while others may have only one or two.

- N-Acetyl-Cysteine -- a nutritional supplement available at the health food store or Wimberley Pharmacy, (Whole Foods or Sun Harvest) has been shown to prevent or lessen the severity of influenza. I suggest 1200mg, twice a day for adults, and 600mg twice a day in kids over 12. It would be hard to get kids under 12 to take it, but you could try opening the capsules and putting it on yogurt. For 40 pounds and up, 300-600 mg twice a day, for less than 40 pounds, half that.

- Oscillococinum, a homeopathic remedy, has been vindicated as quite effective in a large clinical trial in Europe, with an H1N1 variant. You can buy this at (Whole Foods, Sun Harvest) Hill Country Natural Foods, or the Wimberley Pharmacy.

The CAR is 40-50%.  This is the infection rate, or more accurately the rate of people who are symptomatic.  Typical flu has people who carry it but never show symptoms.  50% of the contacts will show symptoms. 

infectious 2 days before symptoms, and for 7-9 days after getting sick.  people can seem fine and be contagious.  there is zero immunity to it because no one has ever seen it.  given the continued contagious for over  a week, it is a given that hospitals or clinics will be overwhelmed with this.

wow
..
from the cdc guy above we know it started in march.  My best guess is that this has been with us for some time, and is just now reaching critical mass and getting attention.  I have heard comments from people saying they just got over the flu, and I think that it is entirely possible they just had this. 

--

The fatality rate is all over the charts.  The rates coming from mexico do not reflect the rates coming from the US.  The US numbers to date show a 0.1%ish fatality rate- much inline with a normal flu.  Mexico on the other hand has been reported around 6%, and I saw some reports as high as 12%.  A few possibilities to explain the gap between us and mexico. 

1) Mexico is underreporting illness, through politicizing, or through people not going to hospitals, or not enough hospitals to hold the real numbers.
2) hospital equipment; an example, lets say you have 10 patients and 20 oxygen respirators - fatality rate is 0.  you have 100 patients and 20 respirators, fatility is 80%.  with mexico hospitals being overran and us hospitals able to provide medicine and care - this holds some validity. 
3) mexico did not get out in front, they did not know what they had and treated with antiviral which did not work, while the us started with tamiflu and relenza immediately some success.
4) mexico is 10-14 days ahead of us on this and when they were where were are now they didnt show as big of a problem either.
5) not enough data points have come in to really get an idea.

-probably a combinatoin of all of those.  We wont know until we know. 


Even though we do not know the CFR, clinical fatlity rate, we can still make some projections.  These are not wild speculation, it is mathematical models. 


0.1%) normal flu fatality rate.  40% car means 120 millions americans in the continental states will get sick, this is 120,000 dead.  this is 3-4 times normal flu season numbers.  This may be reasonable, we dont know because we dont know the real fatality rate, and we dont know how that fatality rate will change when we get to the peak of 5million new cases a day with this model.

1%) this is mostly where we are now in terms of official confirmed cases to confirmed deaths in the us so far.  Assuming the rate holds, and given the spike were talking about - it cant, this number works out to just over 1 million dead in the united states.  This is 1.2 million americans dead in the next 3 months. 

5%) this is mexicos number.  Hopefully they are reporting the real numbers.  5% means 6 million dead americans. 

I dont want to look any higher than this.  From my textbook reading and understanding - it could potentially be higher.  I will not do that math, there is nothing to indicate it is on the horizon based on what we know today.  keep this part in your prayers.



------------------------------------------------
Now what.  Here's my take on it. 
It's here, it cannot be put back in the bottle. 
It is not a mexican problem, it is now a global problem.
I would say that there is near a 100% chance everyone in the US will get exposed to this.  based on what we know, 40-50% will get sick with it. 
It is now part of the flu world.  you cannot hide from it, it wont go away.  just as our modern day flues come from spanish flu in some ways,
this one will spread and mutate as well.  if you hide for 3 years, you stand a chance of getting hit with this and the mutations of it. 

Alot of people will get sick, some will die.  just as with a normal flue, however the amount of people sick and zero background immunity to
it will make it hit hard.  But people will get better, getting sick is not a death sentence.  remember that, getting sick just means you
get sick.  getting sick is NOT the danger as I see it. 

THE DANGER IS PANIC.

Looking at what is going on in mexico, and reading the WHO and CDC and NIH playbooks for pandemics, no one is going to like what is coming.
locking down of roads.  closing schools, businesses, quarantines, potentially martial law.  If you are not prepared for extended outages, you will be caught in the panic.
Dont have a reason to leave your house while things are in panic mode.  Stay safe, keep yourself protected.  Have your medicines at home, have your
food and water.  Speaking of medicines, go ahead and plan for everyone in your house having the flu for 14 days.  Have cold medicine and paper plates,
water gatorade, have food you can cook fast and easy.  Right now looks like media blackout to me.  I would act as soon as possible if you find yourself lacking. 

By this time you may all think I'm crazy.  We'll know by this time next week if that is the case, my best guess is we know by Sunday. 

ED: increased font size in quotes for easier readability - MD

[MountainDon]

Thanks Muldoon, Like you said, we'll know when we know. 

[apaknad]

good research muldoon. let's hope it will be a better result than some of what is in your posting. i could see the shut down problems, but not quite as fast as sunday. hope i'm wrong. will do the grocery shopping i have been putting off tomorrow. nice work.

[peternap]

As always Muldoon...good post.
Like I said earlier, a lot of mixed signals

[MountainDon]

Thing is that there's no point in heading for the hills and hiding. It'll come and get you eventually, or you'll have to come to town and it'll bushwhack you. Best thing is to stay calm, stay healthy... eat right and all that, pray daily and see what happens.

Washing your hands frequently as they advise may help. NOT touching your face, the nose and eyes is a very difficult thing to develop, but likely a big help. Start being aware of those unconscious habits. I hope K and I have honed our awareness enough from years of working with preschoolers to help make a difference. We manage to avoid colds and whatnot pretty good, even though there are runny noses about from time to time.

We are watching what's going on in the neighborhood as best as we can. Our preschool year ends May 22. If the public schools pull the plug, we'll be right in there with them.