Outlook: Flu Threat Exaggerated?
Monday, October 17, 2005; 12:00 PM
Feeling afraid? Feeling very afraid? That would be reasonable given the recent outbreak of apocalyptic warnings from health officials and experts about the specter of a world-wide flu pandemic. But in Sunday's Outlook section, science writer Wendy Orent says that much of the warnings are overblown -- and many of the discussed preparations wouldn't do much good anyway. President Bush has raised the possibility of calling in troops to enforce a quarantine. But Orent says it isn't clear what kind of quarantine he's talking about and how the military would go about enforcing it. Above all, she notes, quarantines work well at controlling the spread of some types of disease. But there isn't any quarantine that would help stop pandemic flu.
Wendy Orent is an Atlanta-based writer and author of "Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease" (Free Press). She was online Monday, Oct. 17, at noon ET to discuss her Sunday Outlook article, The Fear Contagion .
The transcript follows.
Wendy Orent: Thanks for talking to me today. I'll be discussing bird flu and quarantine.
Arlington Va.: I am a lawyer specializing in health-care and public health regulation. I smell a rat.
The so-called "bird flu epidemic" is a completely human-caused, human-promoted group of related but non-identical pathogens which result from the stressful and unnatural conditions of factory farming and mass, high-speed slaughter. The enforcement of laws which have been heavily resisted by the poultry industry could prevent any significant further flock exposure within a very few months at relatively low cost.
The administration seems to want this epidemic-risk to capture the public's imagination, and to provide useful fodder for the repeal of the "posse comitatus" doctrine, which prevents the use of troops as domestic police. Bush has announced that, in effect, he wants troops to carry out the mass-slaughter and cleaning of most of the U.S. factory-farm bird population.
Why is every scientist and lawyer in the U.S. not condemning this?
Wendy Orent: Bird flu ought really to be called "poultry flu" as one of my birder correspondents from Korea, Nial Moores of BirdsKorea, has pointed out. The entire bird flu problem comes from the conditions - really, we could call them disease factories - in which chickens and other birds are raised. In SE Asia and China, some of the poultry farms are enormous. I read of one which housed five million chickens packed together - that's a very good way to start growing a virulent disease. Only good biosecurity regulations (keeping wild birds, the original source of strains of avian flu, away from domestic poultry) and keeping poultry in cleaner, safer, and less crowded conditions can prevent the evolution of highly pathogenic bird flu. I hear the conditions at the big farms are improving in China - but the genie is already out of the bottle, and even birds in small family farms have caught the disease. I agree with you that the bird flu epidemic is completely human-caused and promoted. I hope we are not going to see the military involved in this way.
Washington, D.C.: As I understand it, the reason the H5N1 virus poses such a threat to humans is that we have no history fighting it and thus no built up defense against it. Yet, by now, there are a few people who have contracted the disease and survived. Do those people now have a defense against the illness (e.g., could they catch it again?) and if so, can that defense be harvested for other humans to use?
Wendy Orent: We don't really know how many people have actually contracted the disease and suffered mild or subclinical (so mild you don't know you're sick) infections. Since no chicken farmers or slaughterers in Thailand have apparently gotten sick from the disease, and since many if not most have undoubtedly been exposed to the virus, it is quite possible that they are immune. We could have thousands of immune people and SE Asia - no one has done the testing that could show this. Yes, anyone who has gotten sick and survived is immune - and no, I don't see how this immunity could be "harvested" - certainly not in large doses.
Clifton, Va.: Does anyone remember the Swine Flu pandemic? No, because it didn't happen. Millions were supposed to die according to the WHO and U.S. health officials. Swine flue just didn't pan out like they thought. There is no guarantee when the bird flu mutates and it transferred from human to human that it will be deadly to humans. However planning and vaccine is needed just in case it does. D---d if you do and dead if you don't?
Wendy Orent: It's incredibly important to remember the Swine Flu pandemic. The decision to vaccinate people was a rational one at the time, given the state of knowledge. Scientists at that time, including Dr. Edwin Kilbourne whom I quote extensively in my article, believed that pandemic flu returned periodically - they thought it came back once every eleven years or so. When that young soldier at Fort Dix (who went on a long march carrying a heavy pack despite his illness) died of a strain of influenza that seemed to be related to the 1918, flu experts were very concerned. About 40 million people were vaccinated, and a few hundred were paralyzed. At least 25 people died.
In the face of a clear and present danger, we might as a society be willing to assume those kind of risks. But in the absence of a clear danger - and remember, avian flu is just that - it's avian flu, and not a human disease, we should not be thinking about pre-vaccination. There is no pandemic, and no clear signs that one is developing. We should not be vaccinating people. Stockpiling vaccines? It's a reasonable approach. But that's all we should be doing. I should also add that we don't actually know, if the disease does become a true human disease and starts spreading easily, whether the vaccines we've developed now will work.
Fairfax, Va.: I feel very dumb asking this question, but... can you get the bird flu from eating/handling chicken or eggs?
Wendy Orent: It's actually a very good question. Yes you can - but not at the moment, not in the United States. If you went to Asia, though, or anywhere H5N1 has been detected, I certainly would recommend you not handle any birds! Quite likely chicken farmers are widely immune in Asia. But you aren't!
Nashville, Tenn.: Hello Ms. Orent. You say in your article, "there isn't a shred of evidence that a pandemic is actually on the way." What about the fact, "At least four of its eight genes now contain mutations seen in the deadly strain that circled the globe during and after World War I." as reported in The Washington Post?
Wendy Orent: Really, this is a misunderstanding of what the authors of the article in Science which described the resurrected virus actually intended - I spoke to two of the authors at length. The 1918 flu virus was an extremely well-adapted virus. It was very good at spreading among people and killing them. It was a human virus, even though its genes apparently originally came from birds. The fact that there may be some similarities means nothing for the potential of H5N1 to turn into a lethal human disease. Right now it is a lethal chicken disease, which evolved in the chicken farms of Asia under conditions not all that dissimilar to the conditions under which the 1918 flu evolved in the trenches, trucks, and railroad cards of the Western Front. Both of these sets of conditions are disease factories. We would need another Western Front, and to let H5N1 loose in it, to see anything like the same evolution of virulence. The best source on this is Paul Ewald's book "The Evolution of Infectious Disease."
The fact remains that H5N1 is NOT spreading in long chains person to person - there have been perhaps two instances of person-to-person transmission in two years. That is not a pandemic. It's not the start of a pandemic.
Tamiflu: I was advised by a friend to get a prescription for Tamiflu in advance, fill it and keep it in case of exposure - is this a good idea, in your view? Seemed problematic to me on a number of levels.
Wendy Orent: Seems problematic to me too. I can't see any reason for doing this. If and when there's a pandemic virus evolving, vaccination will protect you best. You don't want to be popping Tamiflu for nothing. It's never been used on a mass basis, and we don't know what side effects will crop up - nor how long people would have to use it to stay safe. There is no Tamiflu in my medicine cabinet!
Clifton, Va.: How many people who died in 1918-19 from the flu would be saved today because of advances in modern medicine? If this flu does mutate is the risk higher is less developed countries than here in the U.S.? We have no guarantee that when the flu mutates and can be transmitted between humans that it will be a particular virulent strain and it may be a strong as a cold virus. How many people die from the flu in the U.S. in a bad year and how does this compare to the predictions with the Kentucky Fried Flu?
Wendy Orent: According to the CDC, 36,000 people die a year in the United States from flu or its complications. Compare this to the 34,000 people who died from the 1968 pandemic known as the Hong Kong flu. Not all pandemics are particularly deadly. if and when the disease begins to transmit person to person, its virulence will drop - flu strains are generally mild to moderate, as they depend on mobile hosts to transmit them through coughing and sneezing. The predictions for Kentucky Fried Flu (that's great!) are completely out of whack. The worst we may see would be something like the 1957 pandemic, which killed about 70,000 in the US. But as you point out, medicine is better now - so probably there would be a lower level of mortality, taking into account the population increase.
Minneapolis, Minn.: When will we know if this is going to turn into anything? Does it spread quickly, or is it something that would take until next flu season to show itself in people?
Wendy Orent: It doesn't spread at all - there have been only two apparent cases of person to person transmission - the last was last January or February. I don't know when it's going to become generally apparent that a new pandemic is not on the way. (It may still come,but there are NO signs of it now.)
Pittsburgh, Pa.: I keep hearing 60 people have died from bird flu in Asia. Asia is an awfully big place with lots and lots of people and 60 fatalities doesn't like a huge deadly epidemic. Your thoughts?
Wendy Orent: My thoughts are the same as yours. 60 people over two years and how many square miles? - is not impressive. It's a tragedy for those people and their families, but I don't think it represents a major threat to the rest of the world.
Phoenix, Ariz.: If the vast majority of Asian chicken/poultry farmers are immune then why is the number of mortalities so high?
Wendy Orent: Well, that's the point, it isn't high. We have no idea how many people have actually acquired some form of H5N1. That poultry workers do develop antibodies to bird flu has been proven by earlier research. But no one has tested these farmers yet.
Washington, D.C.: As I understand it there was a recent publication (in Nature) of the 1918 flu virus structure. Charles Krauthammer last Friday noted the danger involved with this, namely that this virus could be ordered from a commercial laboratory and leaked out into the public. How much of a threat is this?
Wendy Orent: I am not happy about it. There is no threat from the people who actually did this work. Nothing will get past them. The CDC has shown itself extremely capable of guarding the most dangerous disease strains. but could someone else now make the virus, now that the techniques and the genome sequence have been published? Why not?
Nashville, Tenn.: In March of 2003 we sent our troops into Iraq expecting them to perform the rigors of combat for up to a year under conditions of biological warfare just as severe as avian flu. I don't accept your statement, "Indeed, a strictly enforced quarantine could do more harm than good." Why can't we just outfit our citizens with the same protective gear that we gave to our military and then request people to stay put for 40 days?
Wendy Orent: Because flu is too explosive to be quarantinable. That's not true for most bioweapons agents - though the only ones which probably would really need to be quarantined would be smallpox and plague. And quarantine would work for those diseases quite well.
Anonymous: What family-level preparations do you recommend now?
Wendy Orent: STay home if you're sick. Wash your hands. If a pandemic breaks out, immunize your children; if you can't,keep them home from school. It seems that children may be the chief disseminators of flu, as a recent study in Japan has shown. But all this is theoretical - no genuine threat exists as of now. But these rules apply to all contagious diseases. Keep your kids home if they are feverish, coughing, or sneezing - no matter what bugs they've got!
Nashville, Tenn.: Could you discuss the impact of air travel and the fact that for the first time in history in 2007 a majority of the world's people will be living in cities, two drastic changes from 1918 that would have on the spread of a pandemic? Don't these more than make up for the fact that we are not fighting in the trenches? Thanks.
Wendy Orent: No. I was talking about the evolution of virulence. Air travel could send a disease around the world more quickly, as we saw with SARS. But that has nothing to do with the disease evolving greater virulence, which requires a disease factory like the Western Front. Mere crowding in cities won't do it - you need the transmission of disease from people immobilized by illness to healthy people - repeatedly.
Silver Spring, Md.: Dear Ms. Orent,
I have read your article but find some of your statistics not as well articulated as they could be. For example, citing the 60% fatality rate from H5N1 you state that 25 people died from the swine flu vaccine. With over 40 million doses given out, this corresponds to a mortality percentage of .0000625%. When given the option of fighting the bird flu unvaccinated versus receiving a new vaccine, I'll play the odds and get the vaccine.
Wendy Orent: Well, I would play those odds too if there were actually a pandemic virus threatening me - which there is NOT. Think about polio. There is about one case per million (or fewer) of paralysis from the live virus. But in the absence of wild polio, that's too high a risk, which is why now people in the US are given the killed virus instead. It's the same thing. 25 people dead in a condition of no risk is 25 people dead who shouldn't be.
Arlington, Va.: How do people die from the flu? Flu happens all the time and people generally don't die from it. Where's the lethality?
Wendy Orent: The people who die from flu, under normal circumstances, are elderly, immuno-compromised, pregnant, people with cardiac conditions, or sometimes the very young. That's the worst-case "normal" pandemic scenario - as happened in 1957. Under non-pandemic conditions (every year) it's typically the elderly or very young. Flu just isn't that deadly a disease - the need to keep the host mobile ensures that.
Alexandria, Va.: Let's say that something does hit the U.S. - how would the average office worker, commuter, shopper, etc protect oneself? Masks? Gloves? Hibernation?
Wendy Orent: Masks won't really help - the flu particles are too small. Stay home as much as you can - and more important, don't go out if you get ill, pandemic or not. That's the best way to minimize transmission of even ordinary flu. If you're sick, stay home!
Boston, Mass.: Wendy, all this flu talk has me a bit nervous. As a regular commuter on Boston's public transportation (or cattle carts as I call them), I am wondering if there are any tips for staying away from the flu, avian or otherwise, during a daily dose of people-packed, rush-hour exposure? Thanks.
Wendy Orent: Wash your hands when you get home, I suppose, and use a hand sanitizer. But flu is mostly airborne. You're at the mercy of those people who think that working while they're ill is heroic. I repeat - if you're sick, stay home! Please!
Bethesda, Md.: Hi Wendy,
Where is the Surgeon General on this topic? I don't recall seeing anything coming from that office. It worries me when the President is talking about using the military against a pandemic. Considering his management of FEMA I do not want the President making medical judgments, such as quarantines, without the Surgeon General's advice or advice from other medical sources within the government.
The lack of a medical lead on this in the U.S. government leads me to suspect there is some politics of fear being employed.
Wendy Orent: I was not happy to hear that the President was thinking of using the troops to enforce quarantine. It just wouldn't work - and things could get out of control very quickly...I don't know what some nervous soldier would do it if a kid broke quarantine. I believe everyone would be sane and reasonable - but you never know. I think quarantine for flu should be taken off the table.
Seattle, Wash.: To add to my previous question submission, which was something like" What family-level preparation would you suggest now?"
I've been telling people that panic is completely inappropriate, that calm and rational emergency preparation should be directed to the highest risk in each region. Here in Seattle it is clearly earthquake. Preparing for earthquake is preparing in important ways for all risks.
"Any preparation,... is some preparation,... and some preparation will give you the confidence and ability to make clear decisions for your family at a time when those decisions will make an important difference." - JSE
The big difference with something like flu is TIME. Instead of days, it will be weeks and months.
So what are you recommending people add to their "earthquake kit"? What needed or very useful items will "disappear" when Public Health says that the risk is real? Hand soaps (what kind)? N95/Surgical Masks (what kind)?
Wendy Orent: Dr. Kilbourne doesn't believe in masks against flu - the particles are too small, and the mask gets charged with moisture and turns useless. Soap is soap - stay away from the antibacterial stuff, which can help grow resistant strains. Alcohol-based sanitizers are useful. But don't worry too much about preparation for bird flu in particular. There really isn't any reason to do so.
Rolla, Mo.: I can't help but think that this may be the latest attempt at distraction from the Bush administration's current demise in public approval ratings. Enough hype could change the subject for a while.
Wendy Orent: I have certainly heard a lot of people saying that.
Nashville, Tenn.: Why don't we just kill off all the domestic birds and poison the food on the migratory bird routes? Scientists claim that this virus is evolving so fast that they can't inoculate domestic birds. In birds we are not as concerned with the safety of a vaccine as its efficacy.
Wendy Orent: I do hope you are kidding. Poisoning the wild birds would be the worst kind of wickedness and waste, in my opinion. And they aren't much of a threat - more victims than vectors. Remember, sick birds don't fly far - and dead ones don't fly at all.
Washington, D.C.: Follow-up question: given the possibility that the 1918 flu virus will be re-released, should we prepare a vaccine for this?
Wendy Orent: I think that's actually a good idea. But of course, there would be no need to distribute it.
Chevy Chase, Md.: What's the basis for your statement that "there isn't a shred of evidence that a pandemic is actually on the way"? I don't know how many times I've read in the paper that a humanly transmissible version of bird flu is virtually certain to develop. Are all these scientists blowing smoke?
Wendy Orent: Virtually certain to develop. No. I don't think most scientists have thought about what transmissibility really is - it's how the virus gets out of one host and into another. Right now, thee's no sign of this - the virus in autopsies shows up only deep in lung tissues. It can't be coughed out that way. We're a long way from transmissibility!
Alexandria, Va.: It might help clear up some confusion if you define virulence and how it differs from contagious. Virulence means how sick a disease makes a person; contagious means how easily it spreads. When you talk about how the crowded conditions of 1918 led to the virulence of the strain, many laymen assume you referring to how quickly and easily the disease spread; then you get people comparing things like air travel now and seeing the same threat when it is really different.
Wendy Orent: Virulence is deadliness - how thoroughly a germ exploits a host's tissues, how likely it is to kill. Transmissibility is how it gets from one host to another. ,...it has to be shed in some way. Human flu is highly transmissible, but not very virulent. 1918 flu was both virulent and transmissible. Bird flu is virulent, at least sometimes (and very virulent for chickens) but not transmissible. Thanks for this question - hope this helps.
Nashville, Tenn.: "Flu just isn't that deadly a disease." Didn't you mean to say that normally flu isn't that deadly. Sixty deaths of 117 for H5N1 sounds pretty deadly to me.
If masks don't work, why are these poultry workers wearing them in Asia?
Wendy Orent: Well, I'd wear a mask in Asia too, around chickens. It might help for a while. Remember, it isn't 60 deaths out of 117. We don't know how many thousands of people have actually contracted H5N1 - we don't know the denominator.
Englewood, Fla.: Why don't we secure our borders for a start?
Wendy Orent: How?
Washington, D.C.: Ray Kurzweil and Bill Joy wrote an excellent article in today's NYT regarding the dangers of publishing the genome of the H5N1 virus. The gist of it is that doing so is effectively publishing the plans of a weapon of mass destruction that is far more dangerous and far easier to manufacture than a nuclear weapon.
What restrictions do you feel are appropriate for the control of this sort of information?
Wendy Orent: An excellent and very difficult question. I don't know the answer. I think it's a dangerous situation. Is the game worth the candle? There are a lot of conflicting opinions on that. The most I can say here is that I think the jury is very much out on that one.
Rockville, Md.: I wonder if we are getting a bit too excited. After all, the 1918 flu has not been repeated since then. Why should bird flu gain the capacity for human to human transmission now? But my question is about how to stay safe. Perhaps the best way to stop the problem is to let healthy people stay home. What would that cost? How long would they stay? A week? Two?
Wendy Orent: There's nothing to worry about at present. And if a pandemic comes, this would be a great over-reaction. You can't keep the whole society at home - the economy, for one thing, would come to a crashing halt.
Wendy Orent: OK, thank you all very much for participating. I enjoyed the opportunity to answer your questions.
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