by Larry Smith
"The year 1918 has gone...a year in which developed a most fatal infectious disease. Medical science for four and one-half years devoted itself to putting men on the firing line and keeping them there. Now it must turn with its whole might to combating the greatest enemy of all--infectious disease."
1919 edition of the Journal of the American Medical Association.
Ever since the Huns crashed the Roman Empire’s 800-year party in the 5th century AD, Europeans have been terrified of invaders from the East.
But today’s invader could be even deadlier than Attila the Hun. It’s name is H5N1. It is an avian flu that has already caused the death of millions of birds – and about 60 people - in the Far East. And it has now spread to Turkey, Romania and Greece.
It is not just Europe that is threatened. Experts say the world could soon face another pandemic on the scale of the Spanish Flu (or Purple Death) of 1918 which - according to latest estimates - killed more than 50 million people in a few months at the end of the First World War.
That’s because scientists have found that the 1918 virus was also a bird flu, one that had mutated so that it could pass from person to person. They discovered this by actually reconstructing the extinct virus out of bits of tissue from 87-year-old autopsies.
This alarming discovery led health experts from 65 nations to meet in Washington DC earlier this month to discuss ways of containing another worldwide epidemic that some say could kill as many as 150 million people today.
American officials say they are taking the possibility of a bird flu pandemic “very seriously”. Meanwhile, Bahamian health officials have heightened their surveillance of hospital admissions and reportable illnesses. According to Public Health Director Dr Baldwin Carey: “We are following trends on a daily basis.”
The World Health Organisation says the spread of the bird flu to poultry in new regions raises the chance of more human infections. Experts add that controlling the virus in animals is the most cost-effective way of cutting the risk of a human pandemic.
US Agriculture Secretary Mike Johanns said recently that governments had to promote widespread awareness of the issue: “If we fail to act decisively, the repercussions will be significant on many levels.”
Avian flu was thought to infect only birds until the first human cases were reported in Hong Kong in 1997. Currently, the virus does not spread easily from one person to another. People catch it from direct contact with live infected birds, or their droppings. There is no risk from eating cooked poultry or eggs.
The latest strain was first noticed in birds in Southeast Asia two years ago and has since spread to at least 10 countries with no sign of slowing – causing heavy losses in livestock and poultry along the way. Now experts are saying it could be carried by migratory birds into Europe and Africa.
The common flu that we are all familiar with kills more than 30,000 people a year in the US alone – but it is tame as killer viruses go. The 1918 Spanish Flu was worse than even the fearsome Black Death, a plague which killed a quarter of Europe’s population in the middle ages.
In fact, this was the most devastating epidemic in recorded history - more people died in the influenza pandemic of 1918-19 than were killed by the Great War. The virus affected one third of the global population, with death rates about 50 times higher than those from seasonal influenza.
"Nobody can say with certainty that there will be another pandemic, but if you go back in history it looks like, on average, a pandemic emerges every 30 years," according to Jeffrey Taubenberger, a top expert on the 1918 virus. “The last pandemic was in 1968 -- 37 years ago.”
So far there have been 117 confirmed cases of avian flu in humans in Indonesia, Vietnam, Thailand and Cambodia, leading to 60 deaths. This virus kills half of those who catch it. Seasonal flu isn't nearly so lethal. And even in the 1918 pandemic, the death rate was less than 5 per cent.
By way of comparison, SARS (a form of pneumonia) has killed around 800 people worldwide and infected at least 8,400 since it first emerged in November 2002 in Hong Kong. And while AIDS killed 25 million people in its first 25 years, the Spanish flu killed more in only 25 weeks.
Today, the fear is that a flu pandemic will stall the global economy, overwhelm hospitals, and produce chaos in local communities. Bahamians rely on cross-border travel to make a living, for example, and it was only two years ago that Toronto’s tourist business collapsed overnight during the SARS outbreak. The US is now considering the use of troops to enforce quarantines in the event of a bird flu outbreak.
Nassau suffered its worst outbreak of infectious disease in the mid-19th century, when the arrival of a ship from New York sparked a cholera epidemic. Historians say a tenth of the island’s population was affected, of whom a quarter died, and the disease spread to nearly every out island. This dramatic experience led to the Quarantine Act of 1905 and construction of an isolation station on Athol Island which operated until the 1920s.
Little information is available on the impact the 1918 flu had on the Bahamas or the region, but recent estimates put the death toll throughout the Caribbean at about 100,000 between October 1918 and March 1919, with nearly 30,000 deaths in British territories. Jamaica, Belize and Guyana suffered most, with heavy mortality among the poor. No flu deaths were officially reported here, but researchers say 60 people may have died. The total Bahamian population at the time was only 53,000.
According to Dr Harold Munnings, who is researching a book on the history of hospitals in the Bahamas, the potential consequences of a bird flu pandemic are horrifying: “In 1918, influenza was not a reportable disease, so no statistics were kept.
“The quarantine station was still in operation, however, and a health officer was supposed to board every vessel entering the harbour from overseas. While they were primarily looking for cases of smallpox and cholera, people with respiratory illness may well have been detained there.”
But this was before air travel became commonplace. Nowadays, infected people who are not obviously sick can get on an airliner and be on the other side of the world in a few hours. And humans have no natural immunity to the virus that is spreading from Asia today.
And bird flu symptoms are much worse than the seasonal variety. The Spanish Flu began with a cough and a headache. Temperature, breathing and heart rate increased rapidly. Pneumonia came next, filling the lungs with liquid and drowning the patients, turning them blue from lack of air.
Patients bled from mouths, noses, ears and eyes. Those who survived often suffered temporary or permanent brain damage. Several million developed encephalitis lethargica, in which victims were trapped in a permanent sleep-like state, as portrayed in the 1990 movie "Awakenings."
“The challenge is to develop a vaccine for a virus that has not yet emerged, though we reasonably anticipate that it will,” Dr Munnings said. “Laboratories need the (human-transmissable) virus in order to make a vaccine.
And if a vaccine were to become available but was in short supply, how would we figure in terms of priority? Does it make sense for people to get a seasonal flu shot in hopes of simulating immunity that could cross protect against bird flu? Are anti-viral drugs being stockpiled by the government? Do we have an emergency plan for the country?
“There are no particular measures being directed against the flu at this time other than heightened surveillance,” Dr Carey said. “If an epidemic were to occur our main defence would be to screen people coming from certain points of origin. There is recommendation that existing vaccines may be helpful and we do have supplies of these.”
Could the virus infect local birds? There are only three poultry farms here (on New Providence, Abaco and Grand Bahama), processing a total of about 30,000 chickens a day. They import chicks from the United States, the world’s largest poultry producer. But although there were isolated outbreaks of avian flu in North America as recently as last year, experts say it would be highly unlikely for an infection to enter the country this way - there are too many industry controls. The possibility of an infected migratory bird passing on the virus to poultry in an enclosed farm is also considered unlikely.
But while controlling the disease in animals is the first line of defence, the WHO is urging governments to cover a quarter of the population with anti-viral drugs to prepare for a flu pandemic. Lately, there has been a worldwide run on Tamiflu, which is considered effective against bird flu, and production of other anti-viral drugs is being ramped up. The two biggest local wholesalers told Tough Call they had no stocks of Tamiflu and were finding it difficult to source the drug.
Dr Carey said that while the government was not stockpiling anti-viral medicines, there were provisions for the Pan American Health Organisation to release supplies to countries affected by a flu outbreak. He also indicated that India and possibly Brazil would soon be producing cheaper generic versions of drugs like Tamiflu.
In addition to millions of dollars in aid to affected countries and health organisations, the United States has already approved spending of $3.9 billion on vaccines and antiviral drugs, and the Administration is preparing a request for billions more.
The British estimate that a flu outbreak could affect a quarter of their population, with possibly 50,000 deaths. Doctors have been advised on how to manage an outbreak, including the priorities for who should receive anti-viral drugs.
Australian Health Minister Tony Abbott said recently that no one who lives through such a pandemic will forget it: “If it happens, ordinary life as we know it will cease, probably for about six months....New Orleans on a massive scale. Now that is a very scary prospect.”
A recent article in the New England Journal of Medicine asked what would happen if the pandemic started tonight: “The global economy would come to a halt, and we could not expect appropriate vaccines to be available for many months, and we have very limited stockpiles of antiviral drugs.
“We have no detailed plans for staffing the temporary hospitals that would have to be set up in schools and community centres - and that might need to remain in operation for one or two years. Healthcare workers would become ill and die at rates similar to, or even higher than, those in the general public. Judging by our experience with SARS, some healthcare workers would not show up for duty. “
The article ended with a call for a detailed operational blueprint of the best way to get through a two-year pandemic.
But there’s no denying that it’s hard for officials to know just how aggressively to sound the alarm. After all, they don’t want to be accused of needlessly frightening the public. But they also don’t want to be accused later of leaving us under-prepared for a disaster.
According to the Pan American Health Organisation, “governments face a host of policy dilemmas both before and during an outbreak. Good risk communication means sharing those dilemmas and letting the public help you decide.”
The major factors include: the time it will take for an effective vaccine to be available; decisions on the allocation of vaccine; the capabilities of healthcare systems; how national and international economies will cope; and the reaction of ordinary people to such a massive social crisis.
These are questions that must be raised and discussed openly. There are few warning signs before a pandemic strikes – except a large and rapidly growing number of new and unrelated cases every day. The WHO says that the global spread of a pandemic can't be stopped – but preparing properly can reduce its impact.
As US Health Secretary Mike Leavitt said: "We must have complete transparency (and) commitment from the highest political levels in countries around the world.”