The Spanish flu pandemic in 1918, attributed to a form of bird flu known today as AH1NI, killed around 100 million people globally and significantly decreased the life expectancy of Americans. During the war, soldiers lived in close quarters with other soldiers and their movement to the war zone where they were in touch with other soldiers and civilians facilitated the spread of infection. Currently, with population density higher and air travel practically eradicating boundaries, the specter of a pandemic grows chillingly more real.
Today, any sick person presenting with minimal symptoms who travels and coughs within a plane or a place with heavy density or foot traffic can be “Ground Zero” to another worldwide pandemic. In fact, even one sick migratory wild bird or poultry cooped in commercial houses or backyard farms can be the root of the infection. Of prime importance is to protect against the mutations of the AH5H1 virus which could make air-borne transmission easier, cause worse symptoms and result to more deaths. Unfortunately, it takes months for scientists to come up with a vaccine effective against the AH5N1 strain which mutates faster than the slower swine and seasonal flu.
Table By Earthsound (Own work) [CC-BY-SA-3.0 (www.creativecommons.org/licenses/by-sa/3.0)Governments, scientists and medical organizations are vigilant over monitoring what could be the next bird flu pandemic – this time with the more virulent AH5N1 virus as the causative agent. Though the virus is not easily passed between humans, infected bird to human transmission is deadly with mortality rate likely to be greater than the reported 50%. The first known cases of avian flu caused by H5N1 were reported in Hong Kong in 1997. Recent cases in several Asian countries reported a fatality rate between 50-83%.
The usual causes of death are respiratory failure, cardiac failure and renal failure with death occurring from as short as 4 days after onset of symptoms to as long as 30 days. On the average, death occurred 9-10 days after the onset of symptoms. The patient manifests signs and symptoms similar to the ordinary flu. The patient rapidly gets worse and complains of breathing difficulties. Viral RNA can be detected in nasal samples 2-15 days after the onset of illness. The patient may have bloody sputum and progressively develop bilateral lung findings consistent with ARDS or acute respiratory distress syndrome. There are two kinds of avian flu with one strain more virulent but presenting with similar symptoms such as:
- High fever (usually more than 38 degrees)
- Cough and sore throat (indicates upper respiratory tract infection)
- Pulmonary infiltrates (lower respiratory tract infection, pneumonia)
- Lymphopenia (decreased white blood cell count in the presence of infection means depletion or an immune-compromised state)
- Generalized body ache, stomach ache, watery diarrhea, vomiting and occasionally bleeding from nose and gums.
- Medical treatment of choice is still Amantadine and corticosteroids such as methyprednisolone and dexamethasone. Broad spectrum antibiotics and other antiviral like Ribavirin and Oseltamivir were also tried. Therapeutic drugs are helpful when started early in the course of disease – started late, even shotgun therapy will not ease severity of symptoms. Patients would usually need assisted ventilation within 48 hours after admission.
How the Avian Bird Flu Spreads
A sneeze releases droplets that can be inhaled by an unsuspecting victim or the carrier may touch surfaces with unwashed hands, releasing pathogens lying in wait for another victim. According to the World Health Organization (WHO), poultry-human and human-to-human transmissions occur through:
- Droplet inhalation
- Direct contact/unprotected contact with an infected person
- Through self-inoculation (when hands in contact with the virus makes its way to the mouth, nose or eye conjunctiva)
- Indirect contact (fomite or any object like a dish, glass, clothes or beddings that can transmit infection on contact)
- Occupational exposure
- Environment transmission through drinking or swimming in contaminated water, using untreated poultry feces as fertilizer etc. The AH5N1 virus can survive long periods of time outside the host, making other modes of transmission theoretically possible.
Particularly at risk are those who work in poultry farms or those who get to handle sick birds such as those who work in slaughter houses and breeding farms. Playing with asymptomatic ducks and handling seemingly healthy roosters can also cause transmission. Since 2003, avian influenza incidents were reported in Vietnam, Thailand, Cambodia, Indonesia, Mongolia and Russia. Jackie Chan as spokesperson for the United Nations hyped awareness regarding avian flu in a video created to increase awareness in children – one of the groups highly at risk.
According to the University of Maryland, consuming undercooked chicken parts, including blood and raw eggs increases the risk for contracting the disease. Researchers speculate that the 1997 outbreak was due to fecal contamination since infected birds can spread the virus through feces and saliva.
Viruses have a “protein spike” on their surface which literally serves as the key to their entry into the cells of the human respiratory tract. The virus contains genetic material which upon entering the human cell “dictates” the nucleus to clone or replicate the virus. When this cell dies, it releases more of these deadly viruses whose RNA or genetic material are constantly mutating. This sneaky entry into a host cell results in more viruses which can attack other host cells. Though the symptoms itself can be mild, it causes serious illness like pneumonia and organ failure.
The human immune response which detects the “invasion” by foreign protein (virus) releases cytokines. However, this protective response causes massive inflammation. In the human lung, this means rapidly progressing pneumonia. An inflamed lung collects fluid which makes effective air exchange impossible; the lung literally drowns in its own blood and fluids. Coughing, sneezing, talking or touching people and surfaces with virus contaminated hands causes spread between humans.
There are numerous pathogens but few that truly strike fear such as the Ebola virus and Human Papilloma Virus – however the death rate for a single epidemic of Avian Flu is much higher than the total mortality rate for HIV over the last 25 years!
What makes the AH5N1 far more virulent and deadly are:
- Enhanced replication
- Increased resistance to inhibition by cellular immune defenses like interferon and tumor necrosis factor which enables it to replicate, mutate and expand “infectiousness” to other avian species and other animals.
It would seem like the Black Plague multiplied a thousand times since transmission is easier, reach is wider and the number of would-be-hosts could be expanded to practically any animal species including small animals in the wild and our own domesticated pets. The rapidly-changing antigenicity makes it difficult to create vaccines specific for the AH5H1 strains.
Another “what if” scenario imminently possible according to scientists is rapid spread when a person infected with human strain flu gets attacked by avian virus. The RNA of these two viruses will recombine in the host’s cells and possibly come out with a deadly strain that the human body has not developed immunity to. This new variant can spread easily since it has already crossed the inter-species barrier and may trigger a pandemic which like the 1918 Spanish flu killed millions.
Research abounds with evidence that commercially raised poultry is responsible for the outbreak of this oftentimes fatal disease. However in March 2011, joint researchers from the United States Geological Survey, United Nations Food and Agriculture Organization, and the Chinese Academy of Sciences reported that by using satellites and genetics they were able to uncover a definite link between Tibetan wild geese, a species that migrates across Asia and domestic poultry. Bird flu virus is common among wild birds and most developed some immunity so they are largely asymptomatic. However, during migration, they can infect domestic fowl causing disastrous results. In 2005 bird flu outbreak in Qinghai Lake, China killed thousands of these migratory geese. Asymptomatic carriers soon infected domestic poultry in many parts of Asia. According to Diane Prosser, a USGS biologist, “The telemetry data also show that during winter, wild geese use agricultural fields and wetlands near captive bar-headed geese and chicken farms where outbreaks have occurred.” These Tibetan birds migrate not just throughout most of Asia but also to Europe and Africa.
To date, 16 countries have reported H5N1 outbreaks in poultry. Fortunately, no migratory bird had ever tested positive in North America. Clearly, global transmission is possible through two main pathways:
- Global human air travel and
- Migratory birds.
- Once identified in backyard and commercial flocks, the birds are destroyed and the farms are disinfected and quarantined.
Therapies and Remedies for Avian Bird Flu
Flu is treated symptomatically at the onset of symptoms. Ibuprofen or acetaminophen is used in the presence headache, muscle pain or fever. Meclizine is given at a dose of 25-50 mg. every 4-6 hours as needed when the patient is nauseous or vomiting. The importance of correctly rehydrating the patient cannot be overemphasized since fever, vomiting, and diarrhea can cause dangerous dehydration and electrolyte imbalance. Ice packs can be used to further cool the fever. Warm tea and other liquids should be pushed if the patient can tolerate drinking.
Unless there are contraindications, diarrhea can be treated with loperamide at a dose of 2-4 mg. every 4-6 hours. Diarrhea can be watery and at times bloody and may cause anal lesions. The buttocks and anal area should be gently washed and swabbed with petroleum jelly to prevent sores or soothe existing ones. Abdominal cramping can be alleviated by diphenhydramine given at a dose of 25-50 mg. every 4-6 hours. Loperamide and diphenhydramine are both anti-histamines so care should be taken if considered since drug effects are additive.
People who belong to the high-risk population of avian bird flu like young children, geriatrics, the sickly, the immune-compromised, those who had been exposed to affected people 7-14 days prior to onset of symptoms, people who travelled to affected countries prior to onset of illness, those who are exposed due to their occupation to fowl and those who work in health-related facilities providing care and treatment to patients should be treated right away with neuroaminidase inhibitor such as oseltamivir. Chemoprophylaxis with oseltamivir (Tamiflu) can begin without waiting for positive laboratory results since otherwise healthy patients respond well to early treatment (e.g. 24 hours after onset of symptoms). The drug prevents the replication and slows down the release of the virus from the cells. Started early, it can alleviate symptoms within .5-1 day. However, if the disease has advanced to the point where the virus cells have been released, oseltamivir will have limited use, if at all.
It should be given when there is an outbreak or following close contact with an infected person or anima. Available as tablet or suspension, the prophylactic dose is 75 mg. once a day for patients 13 and older for six weeks. During an outbreak, CDC or the Centers for Disease Control and Prevention recommends that these “highly at risk” groups be given prophylactic treatment within 48 hours:
- Hospitalized patients
- Children below 2 years old
- Adults over 65 years old
- Pregnant women
- Immuno-compressed people and
- Patients under treatment with aspirin.
Unfortunately, H5N1 seems to be more resistant so dosage and duration of therapy should be increased. During outbreaks, oseltamivir may be in short supply and can be extended with probenecid.
Amantadine (Symmetrel) is one of the earliest ani-virals recommended to ward off influenza. Approved for use in 1966, it is also prescribed as an anti-Parkinsonism drug. Research shows it is no longer effective for H1N1 influenza and colds but was found effective for H5N1 (especially the strain from Qinghai) which showed sensitivity to amantadine. It acts as an M2 inhibitor, an ion channel inhibitor that prevents mutation of the virus. It is given to adults at a dose of 100 mg. once or twice a day for ten days. The dose is adjusted for children and those with kidney malfunction.
Amantadine should only be considered as first line defense if other neuroroaminidse inhibitors are available. However in the absence of such drugs, amantadine can be used as firt-line therapy for confirmed or strongly suspected cases. Another drug to consider when neuroaminidase inhibitors are not available is rimantadine (Flumadine).
Clinicians have put a lot of premium on preventing death in this disease of extremely high case fatality; so even though there are some side effects, zanamivir is given to confirmed or highly suspicious cases resistant to oseltamivir. Zanamivir (Relenza) is available for oral inhalation using a diskhaler device and CDC recommends a dose of 10 mg. twice a day in adults and children 7 years old and above. CDC does not recommend using a combination of neuroamidase and M2 inhibitors except in cases where avian bird flu is confirmed or highly suspected because of a strong tendency to quickly develop resistance to the drugs.
Other Medical Interventions
The question whether to routinely give prophylactic antibiotics to an existing case of viral pneumonia is a medical decision that plagues doctors. However, because of the deadly course, some doctors prefer to give antibiotics in case secondary bacterial infection gets superimposed on the avian bird flu. Ordinarily, a “watchful waiting” stance is taken for the usual cough and colds. However, the fast progression and deterioration (morbidity) of affected patients necessitates definitive action because any delay might mean that the patient might have taken an irreversible turn for the worse. Hospitalized patients also run the risk of superimposed iatrogenic infections so antibacterials are recommended. The drug of choice is based on the most likely bacterial pathogen because of drug resistance issues. (Refer to http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf) When assisted ventilation is required, antibiotics are routinely given since there is a greater chance of developing hospital-acquired pneumonia. Tailor-fitting the choice of antibiotics to the likely organisms should always be a guidepost in treatment.
Corticosteroids have also been used in the treatment of H5H1 but the jury is still out on whether to include the practice is mainstream interventions since the results are varied. Other staples of anti-viral therapy like ribavirin, interferon and immunoglobulins are ineffective and may cause dangerous side effects like anemia, leucopenia and birth defects (when administered to pregnant women).
Fever, difficulty of breathing and congestion, hallmarks of avian bird flu are best treated medically because of the imminent danger because of the virulence. However, ice-pack on the face, steam inhalation to break down mucus and oral rehydration ease symptoms. If commercially prepared oral rehydration fluids are available, the patient must be encouraged to sip in small increments throughout the course of disease. A home-made solution made from 1 liter purified water, ½ teaspoon salt and 2 tablespoons sugar can be mixed. The goal is to be able to drink 2 liters of water or at least until eyes are no longer shrunken and skin elasticity returns to normal.
Studies are ambivalent on the effects of Echinacea but many naturopaths are firm believers of its antioxidant properties. Thumb-sized ginger can be steeped with green tea, chamomile or Echinacea and sweetened with honey. Tea can be alternated with the rehydrating fluid. Ginger can also ease a queasy stomach. One tablespoon of honey can be taken with ¼ teaspoon cinnamon and 1tbsp. of freshly squeezed citrus to promote immune function. If preferred two drops of lemon balm can be added to green or oolong tea.
Healing soup could be prepared by boiling minced garlic, grated ginger, sliced dried mushrooms with a bit of soy sauce to taste. Another alternative is to boil broccoli and kale (rich in B vitamins) with a bouillon cube. All these have immune-boosting properties. Fresh garlic or ginger or oral supplements of the same should not be taken when there is evidence of bleeding since garlic and ginger have blood-thinning properties.
Whole-food supplements like spirulina and chlorella with zinc should be taken aside from regular multivitamins and minerals supplement. If the patient cannot tolerate solid food, meal replacement using powdered wheat grass and soy can be given four times a day.
The body fights back by producing antibodies that neutralize the virus. One effective way to do this is to include probiotics (Lactobacillus acidophilus) in the patient’s diet. If patient can tolerate a semi-soft diet, a cup of yogurt can be used as one meal replacement. Intestinal absorption may be affected by the antibiotic treatment; inclusion of probiotics in the diet ensures that the intestinal flora balance is restored.
For sore throat, there are probiotic lozenges that can be tried. These do not have the drying effects of alcohol and do not contain added sugar. Simple gargling with salt solution can be done at least three times a day.
Other therapies like acupressure and aromatherapy may ease aches and congestion. The former can also assist with lymphatic drainage. A few drops of lemongrass oil or oil lavender in a base of easily absorbed virgin coconut oil does wonders.
The Food and Drug (FDA) first approved a vaccine for human use against H5N1 in 2007. Produced by Sanofi Pasteur Inc. this inactivated influenza virus vaccine is indicated people 18 – 64 years old who are at risk (occupational, exposure to sick patients etc.). A 90 mg intramuscular dose given twice at 28 days interval, produced the most antibodies and is said to reduce the risk of acquiring the disease by 45%. The figure is low but research done by the FDA suggests it is effective even if the antibodies produced don’t seem substantial. However, CDC or the Centers for Disease Control and WHO do not advise routine vaccination for bird flu.
In isolated cases (non-pandemic) patients should be isolated with precautions for droplet and contact spread. In the hospital, single room occupancy with a steel door or negative pressure is suggested. Health care workers must wear masks and long sleeves. They should also be monitored for fever twice a day. Household members who may have been exposed to the virus must undergo mandatory testing and prophylactic treatment.
Travelers must be immunized two weeks prior to travel and must observe hand washing procedures strictly. He/she must not eat or handle poultry at any time or eat undercooked or raw eggs. When hand washing is not possible, alcogels must be on hand. Always use tissue or handkerchief to prevent droplets from spreading the airborne virus every time you cough, sneeze or wipe secretions. When it can’t be helped, cough or sneeze onto the inside of your elbow or sleeve.
Last but not least, just as CDC advises, “Don’t get, don’t spread.”
- Keawcharoen, J., Broek, J., Bouma, A., Tiensin, T. , Osterhaus, A. , & Heesterbeek, H. (2011). Wild Birds and Increased Transmission of Highly Pathogenic Avian Infl uenza (H5N1) among Poultry, Thailand.Emerging Infectious Diseases, 17(6), Retrieved June 20, 2011, from http://www.cdc.gov/eid
- (2003, November 1). Production of pilot lots of inactivated influenza vaccines from reassortants derived from a. World Health Organization. Retrieved June 10, 2011, from http://www.wpro.who.int/internet/resources.ashx/CSR/Publications/production+of+pilot+lots+of+inactivated+influenza+vaccines.pdf
- (2005, May 01). H5N1 Influenza Virus Vaccine Questions and Answers. U.S. Food and Drug Administration . Retrieved June 15, 2011, from http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm080753.htm
- (2006, August 14). The Race Against Bird Flu.IDEAS From IBM. Retrieved June 15, 2011, from http://www-935.ibm.com/services/uk/gts/pdf/avian-influenza.pdf
- (2011, April 11). Influenza at the human-animal interface Summary and assessment of April 2011 events. World Health Organization. Retrieved June 12, 2011, from http://www.who.int/csr/disease/avian_influenza/Influenza_Summary_IRA_HA_interface.pdf
- Beigel, J. H., Farrar, J. D., Han, A. M., Hayden, F. D., Hayr, R. , & De Jong, M. D., et al. (2005). Avian Influenza A (H5N1) Infection in Humans. N Engl J Med, (353), 1374-85.