The
facts about Bird Flu
by Prof. BM Hegde
New
Delhi: "Fear always springs from ignorance," said Ralph
Waldo Emerson. Nothing could be more true than this in the
case of bird flu. This is another type of influenza. The
symptoms are runny nose, headache of varying severity, body
aches and pains, high fever, with or without pneumonia presenting
as cough and breathlessness with scanty sputum. In severe
cases, signs of respiratory failure set in rapidly and might
end up with bleeding and disseminated intra-vascular coagulation
and multi-organ failure. Bleeding is more common in those
with gastric type of 'Flu. Those suffering from gastric
'flu will have severe loss of appetite, diarrhoea, vomiting
and even bleeding per rectum and occasionally haemetemsis.
Many will have sub-clinical infection in any epidemic. The
causative organism is a variant of the influenza virus-H5N1
variety for this pandemic, if ever it happens-hope it doesn't
happen as predicted! It was predicted to start sometime
between November 2005 and March 2006.
So
far no authentic human to human transmission has been
reported. The deaths so far have all been in those in
close proximity to infected birds. Influenza is endemic
in many places in the winter season. Many a time it could
reach epidemic proportions. Epidemic is where the disease
spreads exponentially, so fast that the incidence doubles
every few days. Pandemic is a global epidemic. In most pandemics
there are almost an equal number of people infected but
do not show clinical signs severe enough to be noticed by
doctors. The latter could only be diagnosed by anti-body
titers before and after the pandemics! They could, however,
spread the virus around. The history of influenza pandemics
in the past could teach us a lesson or two if another one
comes along. In the last 400 years there were 12 pandemics,
roughly three per Century. We had three in the last Century,
Spanish 'flu of 1918 where there were a total of 640 million
clinical attacks, 50 percent of the then population of 1.2
billion with 12.5 percent case fatality ratio with 80 million
dead. The variant was H1N1 type. Next was the Asian 'Flu
of 1957 with H2N2 type. The last was the Hong Kong 'Flu
of 1968 due to H5N2 variety. 1918 pandemic had three separate
waves with a gap of three months and the last one in 1968
had two waves.
If
that trend persists in 2006, we should expect total deaths
of 2-3 billion (case fatality multiplied by clinical
attack rate compounded by the population) what with the
population now at 6.6 billion. It could throw all our systems
out of gear. The worst would be that all our hospitals,
put together, would not be able to cater to even 10 percent
of the patients! This virus spreads even without contact
with patients. Their coughing into the air will disseminate
the virus in the atmosphere. Touching a patient, his clothes,
or even shaking hands, and staying in the vicinity could
all spread the disease. Doorknobs and counter tops can harbour
the virus for days! Medical care workers are at a great
risk. Crowding and slum dwelling could increase the incidence
and case fatality. Society will have to take the responsibility
of looking after the sick in the eventuality of the hospitals
getting clogged. Patients with respiratory failure will
have to be made comfortable to meet their maker in heaven,
as there will not be enough respirators to go round. They
could be made as comfortable as possible, though.
I
had personal experience of the 1968 pandemic. I was
working in London and for the Xmas weekend I was the only
junior doctor on call. Others were celebrating Xmas. In
three days we had as many deaths as to get me cremation
money of 490 Sterling pounds at four pounds per cadaver.
This was in one small sub speciality (cardiology and pulmonolgy)
teaching hospital in London, when there were 12 medical
schools with thrice that number of hospitals those days.
The horrible sight was people in their prime of youth just
coming in and dying. The old elderly with respiratory and
cardiac ailments simply perished, many of them in their
own homes before help could arrive because of dehydration
compounded by the winter dry heating systems in their homes.
Thank God, by February it had eased a lot. You will not
believe if I told you that the vaccine arrived only in February
and we were inoculated then. We were lucky to be alive,
thanks to God and our immune systems. Despite all our nano-technology
claptrap and claim for advances in medical sciences the
situation is no way better than in 1918 or 1968. We have
come back one full circle to the days of Hippocrates - "cure
rarely, comfort mostly, but console always".
Educated relatives will have to take charge. Home remedies
include basically keeping the hydration of the patient,
making him comfortable with pain-killers and tepid sponging
to get the fever down. Helping them with cleaning and feeding
is additional responsibility. Many of them will have no
appetite. That should not be a worry if they recover, but
fluid loss is so great that dehydration could kill very
fast. Oral re-hydration fluids are better made at home as
they require much more salt than the one's available in
the market: four cups of boiled cooled water, two tablespoons
of sugar and one level spoon of salt. To be mixed and kept
ready for use, patient must be fed continuously in small
amounts. Even if they vomit one could feed them by the spoon.
If they have appetite liquid food could be given. Hot food
is taboo if the temperature is high, but sore throat gets
better faster with sips of hot water or hot saltwater gargles.
Where the weather is dry humidifiers will help. Relatives
could bolster their immune systems by eating plenty of fresh
fruits and vegetables and nutritious diet, avoiding the
junk food and cooked meat. Vitamin supplements are useless.
There have been three large studies published this week
in the best science journals showing that multivitamins
and B complexes given as tablets are useless and could even
be dangerous. Unlike the claptrap, they do not seem to prevent
stroke, heart attacks etc. according these studies.
Vaccine
against the disease is ready but already doubts are
cast on its validity, as the virus seems to have mutated
a bit. This is an egg embryo vaccine and takes up to six
weeks to prepare and cannot be prepared on mass scale. It
is only 70 percent effective, anyway, even when it is good.
A total of 300 million does are expected and the G8 countries
have already placed orders for 90 percnet of the stocks.
We may have to ration the vaccine only for the very young,
old elderly, people above 50 years, the infirm and the health
workers. There is a possibility of doubling the capacity
by mixing an adjuvant that might stimulate the immune system
along with half dose of the vaccine! Oseltamivir
is a new antiviral drug that might have an effect on this
H5N1 virus. It is called Tamiflu. Two tablets a day for
five days is the recommended dose but some people believe
it might have to be given for ten days. As of now, it costs
25 dollars for ten tablets. As a prophylactic it will have
to be once a week for the duration of the epidemic. We do
not know much about its side-effects. Another drug that
might be useful in the event of Tamiflu being unavailable
is Zanamivir (Relenza is the trade name).
The sad part of the story is that 90 percent of these drugs
are bought by the G8 countries. The rest of the world will
have to make do with the remaining 10 percent. Really Mathew
Law is working here: "He who hath shall be given". This
is the level playing ground in globalization that our political
masters are trying to push down our throats!
For
the medical profession that wants to know more about this
threat there is a nice monogram-THE
MONSTER AT OUR DOOR-threat of avian 'flu- by Mike Davis.
I am grateful to Mike for the material for this write-up.
I have been very generous in drawing information from there.
"Courage is resistance to fear, mastery of fear, and
not absence of fear." Mark Twain.
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