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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