Swine flu has been the latest health scare to grip the world. Our trusted health officials have warned that millions of us could die from the H1N1 virus as the pandemic sweeps the globe. In the UK alone, it is expected to kill around 750,000 of us, and a further 1.2 million Britons will develop severe symptoms, warn government sources.
This latest health panic coincides almost exactly with when vast consignments of Tamiflu-bought to fight against avian or bird flu (caused by the H5N1 subtype of the influenza A virus), another epidem-ic that never happened-are coming to the end of their shelf life. Without the latest scare, billions of dollars of Tamiflu stock would have to be discarded-with our health guardians forced to have to explain themselves to their governments in these cash-strapped times.
As it now is, health officials can instead say that they are well prepared for the swine flu epidemic, which also may never happen, and can start handing out those Tamiflu supplies to schoolchildren, travel-lers and key personnel.
The UK and US governments alone have more than three billion dollars' worth of old Tamiflu stock that they must use within the next few months, and virtually every country in the developed world bought sizeable stocks of Tamiflu during the avian flu frenzy of 2005. The US government has announced a state of emergency, and released 12 million doses of its 20 million stockpile for immediate use in areas where there have been cases of swine flu infection.
Nevertheless, there have always been swine flu infections, albeit not on the scale that we are currently seeing. Between 2005 and February 2009, and before the latest outbreaks, 12 people had been infected in the US alone (Lancet, 2009; 373: 1495).
Experts reckon that the current outbreak has been caused by a new strain of the influenza A virus referred to as 'H1N1'. No one is sure how the existing virus trans-muted into this novel strain, but conspiracy theorists have latched onto comments from Indonesia's health minister, Siti Fadilah Supari, who believes it could even be man-made.
"I'm not sure whether the virus was genetically engineered, but it's a possibility," she has told reporters (Agence France-Presse, April 28, 2009; www.blogcatalog.com/topic/agence+france+presse+supari/).
Whatever the virus' provenance, it seems to have started around March 18 in Mexico, although the authorities there were alerted to the possibility only after two cases were reported in California on April 21. Mexico's health officials confirmed three days later that the new virus had been detected in victims of an influenza outbreak that was sweeping the country.
Meanwhile, while the world blames Mexico for starting the swine flu outbreak, the Mexicans are blaming a local pig farm and its poor levels of hygiene. Several of their newspapers are pointing the finger at local plants of Smithfield Foods, the world's largest pork packer and hog producer. Mexican journalists report on the concerns of the local residents in the town of Perote, in the state of Veracruz, Mexico-where the outbreak was believed to have started-that the pig-breeding farm there has polluted the atmosphere as well as local water supplies.
A municipal health official apparently supports the locals' concerns, and says that the outbreak may have been started by flies reproducing in pig waste.
Not many dead
Health officials and epidemiol-ogists have for the longest time been anticipating a pandemic that would kill many millions of people, so it's not surprising that they went into immediate overdrive once Mexican officials confirmed cases of infections with the new virus. Predictions of 750,000 deaths in the UK alone were soon being made, and the media quickly latched on to the figure of 159 deaths in Mexico as a result of the swine flu outbreak.
But where did this figure come from? Only two groups could possibly have any real grip on the situation: Mexico's own Ministry of Health and the World Health Organization (WHO). At that time, both of these organizations were consistently stating that only seven people had been confirmed as victims of the H1N1 virus.
Mexico's health minister Jose Angel Cordova confirmed the seven swine flu deaths on April 28, as did Vivienne Allan, from the WHO's patient safety programme.
"Unfortunately, that [the press claims of 150-plus deaths] is incorrect information and it does happen, but that's information that's not come from us. The death toll is seven and they all come from Mexico," said Allan.
The UK's health minister Alan Johnson appeared to be equally as happy to ignore the WHO and Mexico's own health minister when he spoke to the House of Commons the previous day, on April 27. He told the House that there had been 89 deaths in Mexico from swine flu, although only 18 of these had definitely been confirmed-but even this more conservative estimate was still more than double the actual number. Johnson also told MPs that the symptoms were mild and that, in the UK, "all patients have made a full recovery".
Yet, despite his statements, and just a day after he said them, his own department was quoted as declaring that 750,000 people in the UK could die from the swine flu pandemic, even though the symptoms were mild.
In fact, the Department of Health made this calculation in November 2007, when a possible avian flu pandemic was still the scare of the day-and a full 18 months before the first swine flu infection was reported. In its report entitled Pandemic influenza: surge capacity and prioritisation in health services - provisional UK guidance, officials were calculating the likely impact of a worst-case scenario of any highly infectious and virulent pandemic.
The figure had first been mooted by the UK's chief medical officer Sir Liam Donaldson in 2005, when he was predicting the likely effects of an avian flu pandemic while, in the US, the then President George W. Bush was saying that two million Americans would die.
Scares are us
Epidemiologists are convinced that the human race is overdue a virulent pandemic that will kill millions of people, just as the Spanish flu outbreak did in 1918. In a recent calculation, academic Christopher Murray and his colleagues at the Harvard Initiative for Global Health at Harvard University in Cambridge, MA, have predicted that 62 million people would die in the next global flu pandemic. He based his calculations on data from the Spanish flu pan-demic (Lancet, 2006; 368: 2211-8).
In 2003, virologist Robert Webs-ter and Elizabeth Walker wrote an article entitled The world is teetering on the edge of a pandemic that could kill a large fraction of the human population (Am Sci, 2003; 91: 122; doi 10.1511/2003.2.122).
In part, they based their predic-tions on a pattern that had been established over the past 300 years and, because they have convinced themselves that a pandemic is imminent, epidemiologists and health officials see every flu contagion as the next 'big one'.
In 1976, health officials in the US announced that one million fellow citizens would die from a swine flu virus-but they were out by 999,999 as it claimed just one victim, a young soldier. In 2003, we were told that SARS (severe acute respiratory syndrome) would claim millions of lives, yet the current death toll stands at 251. Two years later, we were warned by the United Nations, in a press conference on
29 September 2005, that avian (bird) flu-more correctly known as 'influenza A virus H5N1'-would kill up to 150 million people. As of April 2008, 257 people had died from avian flu, and 421 H5N1 infections have been identified around the world, according to WHO reports.
Epidemiologists calculate that there are four major flu pandemics every century. There were serious outbreaks in the 20th century in 1918, when the Spanish flu (H1N1) killed around 40 million people-although modern estimates reckon that the true figure could be as high as 100 million deaths-and in 1957, when the Asian flu (H2N2) claimed around one million lives. More recently, in 1968, the Hong Kong flu (H3N2) killed a similar number of people.
However, it's important to bear in mind that the annual seasonal flu kills around 500,000 people every year. An outbreak is classified as 'pandemic' when an existing virus strain infects people across differ-ent countries and regions.
The WHO had calculated that the next pandemic would occur in 2005, which is the reason for the panic over the avian flu virus, and it still maintains that a pandemic is imminent. While it's true that we shouldn't be complacent, what is the evidence to support the idea that four pandemics occur every 100 years?
The Spanish flu outbreak has been likened to the Black Death, and has even been described as the "greatest medical holocaust in history". But it happened at the end of World War I, when levels of the general public health and sani-tation were at a very low point.
By comparison, the Asiatic flu outbreak of 1889, 29 years earlier, claimed a relatively few one million lives. Similarly, the two pandemics that occurred more recently tended to claim the lives of the elderly and the poor. Indeed, epidemiologists agree that these two populations would be those hardest hit in any new outbreak, and especially in the developing countries.
This suggests that there is a correlation between nutritional health and good sanitation, and virulence. However, in historical terms, as our nutritional and sanitation levels are arguably at the highest they've ever been, is it possible that epidemiologists have got it wrong because they haven't corrected for this confounding factor in their calculations?
No vaccine, no problem
A vaccine is the only supposed antidote to a flu virus, and there isn't one yet for the swine flu virus, and there probably won't be for six months or so. Despite this, drug companies-and especially those that can offer an antiviral-have fared well from the latest scare.
In the week that the swine flu panic was at its height, the share price of GlaxoSmithKline, manu-facturer of the antiviral Relenza, jumped 60p, adding lb1.3bn to the company's wealth, while Roche, which makes Tamiflu, saw its share price rise 8p, adding Sfr3.4bn to its value.
Over the past 40 years, the drugs industry has produced four antivirals to combat the worst effects of flu. Amantadine was created in 1966 and was eventually followed by rimantadine in 1993. Today, doctors are reliant on Relenza (zanamivir) and Tamiflu (oseltamivir), both of which were approved by America's drugs regulator, the Food and Drug Administration (FDA), in 1999.
The leaps in their share prices are perhaps surprising as, at best, the two antiviral drugs can treat only symptoms to make the patient feel more comfortable. It is even more surprising that, despite its limited benefits, Tamiflu was ordered by most of the developed countries during the avian flu scare even though it has no potency against either the H5N1 avian virus or the H1N1 swine flu virus.
In fact, Roche makes no secret of Tamiflu's limitations, and states that it can reduce the duration of flu symptoms by one day, provided that it's given within the first 48 hours of symptoms appearing.
The emergence of viral resistance to these antiviral agents has also been highlighted in studies of patients who develop flu (Lancet, 2000; 355: 827-35; J Infect Chemother, 2003; 9: 195-200).
However, even if they are not effective, the antivirals are at least considered to be relatively safe-or 'well tolerated', to use pharma-speak.
But this was not the experience in Japan, one of the first countries to use Tamiflu to counter the avian flu. Japanese health authorities reported eight deaths related to the drug during the bird flu scare, and all of the victims were aged between two and 17 years, said Dr Rokuro Hama, head of the non-profit Japan Institute of Pharmacovigilance based in Osaka. Two of the victims were boys who were reported to have been behaving abnormally after taking the drug.
A similar response was seen in two other adolescents who, in each case, had taken just one Tamiflu capsule. One was a 14-year-old boy who either jumped or fell from the ninth floor of an apartment building in 2005 and, a year earlier, a 17-year-old boy had jumped in front of a truck after taking the drug (see www.voanews.com/english/archive /2005-11/2005-1).
According to the FDA's Patient Information Sheet (December 12, 2006), more common reactions to the drug include nausea, vomiting, diarrhoea, bronchitis, stomach pain, dizziness and headache.
Not surprisingly, the safety of Tamiflu as an anti-flu therapy has never been established in patients under the age of 18 years, or among 13-year-olds as a preventative. In 2003, the FDA issued an alert that Tamiflu should not be given to any child under the age of one year, as a reaction to it could be fatal.
Doctors are hoping that the latest swine flu virus is susceptible to Tamiflu and Relenza, although virologists were shocked to discover that even the standard H1N1 virus had spontaneously developed a near-total resistance to Tamiflu during the most recent flu season (New Sci, April 29, 2009; www.newscientist. com/article/dn8509-new-tamifluresistant-bird-flu-cases-stir-fears.html).
Just one shot
Each year, drug companies produce a vaccine to counter the season's flu virus, and they take their guidance from the WHO, which lists the flu viruses it believes will be prevalent that year.
For 2009, for example, the WHO has recommended that vaccines should be produced to counter the H1N1 virus-a mutated strain of which is causing the current swine flu outbreak-and the influenza A/H3N2 virus.
Both the National Health Service in the UK and the Centers for Disease Control and Prevention (CDC) in the US claim that the side-effects of any flu vaccine are rare and mild, with cold-like reactions being typical.
Nevertheless, the vaccine that was produced in 1976 to counter the expected swine flu outbreak in the US was anything but benign.
On instructions from his health advisors, the then President Gerald Ford launched a mass immunization programme, costing $135m, with the ambitious aim to "inoculate every man, woman and child in the United States"-220 million people in all.
The programme was abandoned after just two months, when doctors finally discovered that the vaccine was dangerous-by which time, 40 million Americans had already been vaccinated. More than 500 people given the vaccine suffered from the paralyzing nerve disease Guillain-Barr'e syndrome, and more than 30 people died. The US govern-ment then had to pay out $93 million in compensation to the victims or their survivors because the vaccine's manufacturers had refused, from the outset, to accept any liability for any harmful side-effects.
Vaccine manufacturers are also faced with the challenge of trying to hit a moving target. Each year's flu vaccine is a 'best-guess' scenario, as a flu virus is constantly changing its antigen shape ('antigen shift') to evade recognition by the host's immune system, and can mutate up to a million times more often than a DNA virus (Vaccine, 2002; 20: 3068-87).
This means that it is almost impossible for a vaccine to achieve an exact fit with a flu virus every year, and why even the annual flu shots are a year out of date by the time they reach the general public.
Another problem is production speed. Only 19 countries around the world have production facilities that are capable of manufacturing flu vaccines. The WHO estimates that only 750 million doses a year can be produced, which is not enough to go round, especially if it's decided that the more vulnerable should be given two shots each.
Most manufacturers still cultiv-ate the virus in chicken eggs, which is a time-consuming process. So, one radical new vaccine-manufac-turing technology is being pioneer-ed by the pharmaceutical company Baxter International. Instead of using eggs, Baxter is working with the actual virus, which doesn't need to be modified, and is developing its own avian flu vaccine, called Celvapan, using this method.
Last year, the vaccine passed the first two phases of safety trials, and Baxter announced that "Celvapan combines innovative science and breakthrough production technol-ogy with the aim of protecting people against an H5N1 (avian flu) pandemic flu infection" (N Engl J Med, 2008; 358: 2573-84).
Earlier this year, Baxter almost became the source of a major avian flu pandemic when some of the live viruses it has been working with found their way into a consignment of seasonal flu vaccines, which were due to be circulated to 18 European countries (Toronto Sun, February 27, 2009; www.torontosun.com/news/canada/2009/02/27/8560781. html).
Had the contaminated batch not been discovered just in time, avian flu would almost certainly have entered into the human race as a transmissible disease, and would have finally proved right the gloomy predictions of the epidemiologists.
Baxter has now requested a sample of the latest swine flu virus (Bloomberg News, April 26, 2009; www. bloomberg.com/apps/news?pid=20601087&sid =aD0VK0_oNmw4&refer=home).
There are plenty of groups that benefit from a pandemic scare. Drug companies always do well out of any health epidemic-real or imagined-and those that are producing antivirals have seen their company stocks rise in value. Health authorities are glad of it as they can get rid of the stockpiles of antivirals left over from previous scares, and they also won't look so stupid for crying wolf the last time. The media also benefit, as scare stories sell newspapers. Perhaps there is also something about us that likes to be scared-at least, just a little.
But there is no biological evidence or need for pandemics to be cyclical. Viral outbreaks aren't triggered by blind forces that are out of our control. On the contrary, we-the general population-have a pretty big say in whether or not another pandemic will happen.
Yet, surprisingly, how we can avoid one through better hygiene and nutrition is the only thing that is not mentioned by our health guardians or drug companies.
Don't be a victim
For the millions of pounds and dollars that health authorities have spent in warning us about an impending swine flu pandemic, not a penny or cent has been used to tell us how we can protect ourselves against the virus.
The UK's Department of Health has leafleted every home with a Swine Flu Information newsletter, but nowhere in its 12 pages does it offer advice on nutrition and hygiene beyond using a tissue when we sneeze.
As we've seen from the statistics for the previous pandemics, a healthy immune system and good public sanitation are key in determining the virulence of a flu virus. Of all the nutrients, vitamin A is one of the most important for maintaining a healthy immune system. Aside from supple-ments, vitamin A is also found in cod liver oil, oily fish, cheese, whole milk and eggs.
Other important nutrients are the other antioxidant vitamins, C and E, and the latter can reduce susceptibility to infection.
Zinc is a natural antiviral and, in one study, a zinc nasal gel reduced the duration of a cold (Ear Nose Throat J, 2000; 79: 778-80).
A chinese takeaway
While the UK and US health guardians are despatching Tamiflu from their vast stockpiles, their Chinese counterparts are recommending that their countrymen buy star anise (Illicium verum), an important ingredient in Chinese food that is also a natural antiviral.
Star anise, a herb that is used as a flavourant, is one of the raw ingredients in Tamiflu, and was also used by the Chinese during the avian flu scare of 2005.
But, as with Tamiflu, star anise can produce serious reactions, especially in the young. In 2000, 23 babies aged three months or less needed hospital care after developing serious gastrointestinal and neurological symptoms after having been given a star-anise infusion (An Esp Pediatr, 2002; 57: 290-4), while 63 people were treated for malaise, vomiting and nausea soon after drinking a herbal tea that contained star anise (Ned Tijdschr Geneeskd, 2002; 146: 813-6).
If you are unfortunate enough to catch the flu, there is a range of alternative remedies you could try instead of Tamiflu.
- High-dose vitamin C is an effective fighter of flu viruses (J Appl Nutr, 1971; 23: 61-8), as is vitamin A, lysine and ultraviolet therapy (Int J Biosocial Med Res, 1996; 14: 115-32).
- Elderberry is another successful antidote. In one study of 60 flu victims, who were given either 15 mL of elderberry extract or a placebo four times a day for five days, the elderberry group reported that their symptoms cleared up four days sooner than those in the placebo group (J Int Med Res, 2004; 32: 132-40).
- The perennial herb pokeweed (Phytolacca americana) can stimulate the immune system, and is especially effective against flu viruses (Antimicrob Agents Chemother, 1980; 17: 1032-3), although it shouldn't be taken over a long period of time as it can be toxic.
- The herbal remedy Echinacea (purple coneflower) is considered an effective immune booster, and can also help to ward off the worst symptoms of flu if taken early enough (J Fam Pract, 1999; 48: 628-35).