How likely is it that H1N1 will pick up some Asian avian bit before all is said and done?

Factual Questions
1

Honestly I do not know if this belongs here, or in GD, or where, as I am sure that there is not any real answer … but boys and girls, as a pediatrician I am getting more and more scared as Summer winds down, and I need a place to vent. Maybe someone can talk me off the ledge.

To bring all readers up to speed - influenza viruses have different little rings of DNA that they can exchange when the same individual (be it a human, a pig, or a bird) are infected with more than one strain at the same time. That’s how the mogrel that is Pandemic A/H1N1 came to be: it is 1/3 North American Swine, 1/3 North American Avian, and 1/3 that is half European Swine and human influenza. Strains can also accumulate spontaneous mutations which can do nothing, or add resistance, or make it more or less infective, or more or less deadly, along the way. Greater numbers reproducing mean greater chances for getting one or more or those mutations.

I’ve been scared already for several reasons. Selfishly as a pediatrician because this particular bug seems to target my population group; even if it is an average year overall it will be heavy hitting in my segment of the world at large. And that will start soon, as it is out there is sizable enough numbers that it will begin to erupt within a few weeks of school starting back up. Still each case is currently no more likely to be dangerous than regular seasonal flu, albeit 4x as many cases is 4x as many serious complications and may overwhelm healthcare systems. But I’ve been much more scared that as H1N1 goes on its world tour through China, Egypt, Thailand, and Indonesia - regions where humans catch Asian Avian every year - that some humans will be infected with both at the same time and that a H1N1-Asian Avian hybrid Son of Satan will be created with the infectivity of H1N1 and the morbidity and mortality of Asian Avian. And that we (whoever “we” are) won’t be well enough vaccinated to be protected by then.

So okay, that nightmare has been enough to keep me up at night, reassured only by one ID expert who tells me that he thinks that if Asian Avian could intermingle with a human to huma transmissible bug, it already would have by now, so the fact that we have not already had an Asian Avian pandemic by now makes him think that we won’t … of course anther ID expert posits that H1N1 should be able to swap out North American Swine for Asain Swine “… like Mr. Potato Head swaps noses.”, so small comfort was obtained.

NOW there is this! H1N1 in birds. Sure, tell me that this “should not be a cause for alarm” all you like, but I am alarmed! It can go directly into birds … and as it builds in regions with endemic Asian Avian, that means a large number of birds that will have H1N1 and Asian Avian at the same time, that many more coinfection and hybridization opportunities. Damn.

So boys and girls I am out here on the ledge … is there anyone willing to try to talk me back in? Or do I stay in my state of anxiety until Spring (or disaster) hits? (Whichever comes first?)

By the way, if your state does not bring the H1N1 vaccine to your kids in school (and I doubt most will, although it makes the most sense to do it that way) PLEASE call your pediatrican in early October to get signed up to come in a flu shot Saturday (or however they do it in your office) to get vaccinated as soon as these vaccines get in, probably mid-October, and for the follow-up shot too. Getting the school age population to 90%+ immunized is our single best defense as a society. Pretty please.

2

As this is in GQ, this feels like an odd response, but you have convinced me to ensure my kids get the flu shots.

Will the Flu Shots be for H1N1?

3

There is a vaccine for seasonal influenza. Most of us docs are getting our deliveries now and in our office at least we are starting our vaccination programs as soon as we get them in.

There will be a vaccine for H1N1. How much and exactly when is still up in the air. We are currently told sometime in October for the first load but that the first load will be only a third of what they were hoping to have available by then. The rest will be coming but over the next month or so.

Both will be available as a killed injectable vaccine and as a live weakened nasal vaccine. The live weakened nasal version of H1N1 actually grew better than expected while the one for the injectable grew slower than expected, but the manufacturer cannot get their supplier to keep up with the damn little plastic delivery devices. Each form has its advantages and disadvantages. The nasal one in general works better but really can make you mildly fluish (People often claim the injectable does but it does not, can’t, killed virus, they just got something else and blamed the shot).

Regular seasonal is one thing, and I’d do it (and of course will do it), but odds are that H1N1 will be the big player and obviously is the one that I’m watching like a New Orleanian watches a Cat 5 in the Gulf. Can’t do much about it except keep watching the weather channel …

4

DSeid, of what value is it for a physician to spread alarm about something that is bound to happen sooner or later anyway (as it has throughout human history)? Encouraging people to get vaccinated is a good idea, but not sure how it helps to get shrill about it. Viruses are combining and recombining all over the world. We do what we can do, but we can’t completely prevent this from happening.

5

“Shrill”?

Nah.

I was actually honestly hoping that someone had some knowledge to share that would make me a bit less anxious about the risks than I am. No such luck here or elsewhere. Generally I have found that those who are not worried are pretty ill informed. And that includes quite a few MDs.

Look I am ready to deal with a very long season in our office. If all that happens is that we peds are swamped then I will be a very relieved person. I am even accepting that there is a significant risk that while most kids will be just fine the pediatric numbers may still exceed our “surge capacity” for pediatric hospital beds and in particular for critical care spaces - IOW that I may have a critically ill child in my office or in the ER and no floor beds let alone any regional ICUs with spaces. And I can’t do much about that. But I cannot but worry about it. And while it will suck to be that kid the risk of that kid being your kids is tiny indeed.

As to my greater worries … well, there is no value to me sitting on my concerns quietly either. I will feel as if one bullet is dodged at least if we get past the next two months without an H1N1/H5N1 hybrid showing up in Egypt. Egypt is endemic with H5N1 with 34 human cases reported this year so far and a presumed large wild bird reservior. Reports of human co-infection occurring there already may or may not have been specious but they will occur and they will also occur in unreported numbers in birds given that H1N1 can go directly into them as well. If a new H1N1/H5N1 hybrid is birthed in Egypt in October and someone infected with it but not yet ill makes the Haj in November then India, Africa, the MENA region, and to some degree much of Asia is in very big trouble. Us a bit less so.

Maybe I just want some others to appreciate the value of what we do not hear over these next weeks. Assuming that we do not hear it.

6

Make sure to explain to parents that the needles used for vaccination are so much thinner than the ones used when they were kids that it is far less painful. And use the “on the count of three cough” trick. But you knew both those things.

7

Well in terms of my attention to Egypt and the risk of a potential H1N1/H5N1 hybrid and in particular the risk of it spreading by way of the Haj … there is this which comforts me some.

8

I wish I had an answer for you, but I’ve been reading these guys. They’re epidemiologists who have been writing a lot about H1N1. The blog is well written and backed up with solid data, was particularly informative back in April. I just searched and couldn’t find much mention of another recombination event with the current H1N1 swine flu virus. My impression is that while there is a finite probability, right now it looks low. It appears to be crowding out the seasonal H1N1 and H3N1 viruses that have been circulating for years, but they’re not sure how. That phenomenon might make the probability of a recombination event with H5N1 less likely in a human host, but perhaps slightly more likely in a bird. So far, Hong Kong has not turned out a new recombinant.

Vlad/Igor

9

Vlad/Igor, thank you for the link. Yes, an interesting blog.

A comment on the 9/4 post does little to reassure me re surge capacity. Some real concerns expressed there.

And the post commenting on the ferret study was informative, explaining it well enough that I understand the study more clearly than I had on my own. Certainly the data from Australia is that H1N1 did crowd out the seasonal bugs there. I also do not clearly understand why this happens but it does with influenza with some regularity - we also rarely see an influenza peak and an RSV peak at the same time - something seems to allow a particular influenza to not have to share the stage much while it is on. It is odd. Of course that does not rule out multiple separate peaks…

What is your basis for your impression that the probability looks low right now? This really is the discussion I was hoping to have with this thread. We know from other ferret studies that H5N1 can reassort with H3N2, at least in the ferret model. We know from the mere fact that this H1N1 has a mongrel genetic past (part North American Swine, part North American Avian, part half European swine and half human influenza) that it has reassorted readily previously. Please convince me that your impression is correct. Really. I want someone to show me the information that I just have not been aware of that makes such an eventuality unlikely with a pandemic H1N1 that can mix it up in all of the big three organisms (humans, pigs, and birds) in the same season, in areas which have H5N1 endemic. Never in my life have I wanted as much to be wrong and for someone to be able to point out my idiocy.

10

My impression came from one of the Effect Measure entries regarding reassortment opportunities in North America, but at this point, I don’t remember. It is of note that even though 2009 H1N1 has spread world-wide now, it still hasn’t picked up or developed resistance to Tamiflu.

There is this paperthat puts the reassortment probability as “significant” if/when H1N1 makes a run through Viet Nam. The journal has an Impact Factor of 3.3, FWIW. Then there’s this one that seems to indicate that the “cytokine storm” associated with H5N1 would be altered (decreased?) in a reassortment event with H1N1 based on an in vitro model. This one indicates that reassortment is more likely to take place in pigs than in humans or birds, which if true, would make detection of such an event a little easier (as long as pigs don’t fly). I think we don’t really know the probability of reassortment at this point, and the best strategy is to put effort and resources into surveillance of human and swine populations. This doesn’t exactly help you in your practice or for your peace of mind, but you can reassure parents and patients that using a modified form of universal precautions will go a long way toward protecting them from whatever is out there.

Vlad/Igor

11

Actually there have been multiple case reports of Tamiflu resistance. That resistance has not yet become widespread is all. We know from past experience that such can occur in a blink of an eye.

And of note they explicitly excluded infection within animal vectors; their model was exclusively looking at the risk incurred with humans becoming coinfected as a result of catching H5N1 from an animal vector - not the risk of H1N1 going into an animal vector and reassorting there. And they are placing the risk “significant” looking at only a single Asian country. Reassuring this aint.

This kind of thinking has been my best reassurance. Along those lines is the fact that the H5N1 endemic in pigs at least has become a bit less virulent as an adaptation for evolutionary success. It simply is a better tactic to keep your host alive long enough to pass more of our progeny on to other organisms. The fact that swine and birds with H5N1 now do not always die, and may even have mild disease, has made survelliance more difficult but it makes the possibility of an H1N1/H5N1 hybrid having less than horrific virulence more probable. I can hang on to that to keep myself from drowning in my anxiety.

Not sure I read that the same way as you do. I just read it that the risk of reassortment within pigs is significant as it has happened multiple times before; not that within birds is not. And as far as “pigs don’t fly”, well that swine flew already! :slight_smile:

Agreed that we really do not know. As far as modified universal precautions … I am a pediatrician. My patients are girls who squeal and hug each other; boys who wrestle each other down and drool in each others faces, teens who share sodas and well, other things. Modified universal precautions? Not too likely. Seriously.

Thank you for sharing those cites. Believe it or not it really does help.

12

As a poor person not over 65, I think it’s interesting with all this “panic” over the flu, I’ve yet to see anyone offering free or true low cost (I don’t call $30 for a shot low cost though my Walgreens will give it to you at this rate for qualified people) shots.

Since poor people are more apt to get the flu, less likely to get the shot and will have to go into work and be more apt to spread it, this is why I question if it is as serious where is the outcry to vaccinate everyone?

13

As someone over 65, poor or otherwise, you are not on the priority list for H1N1 vaccination in any case.

As for other populations, the feds are providing most of the H1N1 vaccination for free.

Administration costs depend on who is doing it. Does the state provide the staff and bring it to the schools? Public health departments? Or doctors offices (which then shifts the costs to insurers and Joe Blow)? There is also a plan for differential pricing for developed vs emerging and underdeveloped economies.

14

As someone over 65, at least be relieved that you’re not as likely to have severe reactions to swine flu. So far it seems, as in the 1918 pandemics, that those with healthy immune systems (ie the young) are more likely to have severe symptoms.

15

Well, it happens to me. Last year I got 10 days of fluish fatigue. My immune systems response causes this. I dont think its in my head or unrelated. Happens every time.

16

Just want to mention that from the government statistics I’ve seen, there have been only 25 cases of bird flu in Thailand since 2004, most of them occurring in 2004. The last reported case was in January 2007.