A New Pandemic Threat On the Horizon: H7N9, by TXnurse

Influenza A viruses originate from various avian species, and almost exclusively begin in China. Influenza A viruses have always infected many different species of birds. Often initially seen in one species, they frequently cross over and cause illness in another species, this is called mixing, mutation or antigenic drift. This is how new subtypes of viruses are created. Eventually these viruses progress until they mutate enough to become infective to mammalian hosts (us). These viruses can be highly infective, easily transmissible and very lethal in humans. Most of us have probably heard of the H1N1 virus that took a substantial toll on the world’s population in 2009, and continues to be a threat during flu season. Many still may be familiar with H5N1. This subtype appeared around 1997 in China and has made slow progress to become more adaptable with human to human transmission (H2H). In the last 10 days China has made announcements (almost daily) of cases of severe influenza that has been subtyped as H7N9. This particular strain has been known to infect birds, but up until this point not humans. The number of cases daily, including deaths has been alarming. The World Health Organization (WHO) and the Centers for Disease Control (CDC) are taking this new development very seriously. What the 3 subtypes mentioned above have in common is that when they first appeared they are what scientists and virologists call Novel subtypes (meaning new to humans). Depending on the way they have mutated and adapted to become infective to humans has a lot to do with how lethal they are to us. The unique genetic sequences of these viruses also give virologists insight into how lethal they may be, and what their “case fatality rate” (CFR), may be on the general population.

My intent on writing this article is to make it as easy as possible for everyone to understand the importance of how serious a novel pandemic can be to us without getting bogged down with the scientific terms, and how important it is for us as prepared individuals to know how to handle and stockpile for a pandemic with a high CFR. My background is in critical care. For the past 24 years I’ve worked in an Intensive Care Unit, and have taken care of numerous influenza patients. We had quite a few patients on ventilators in 2009, and we lost some young people with serious pneumonias and multi organ failure. I have always been interested in epidemiology and in the mid-1990s began researching influenzas extensively. What has me particularly worried about H7N9 is the rapid development of this novel subtype, and the possibility that there is already human to human transmission. As of 4/12/13 China has reported 49 cases, 11 deaths, many remaining critical and only two recoveries. This may not sound worrisome to most people, but if you knew how difficult it is to get accurate information and numbers out of China, it is quite astounding that they are admitting to these cases so quickly! This leads me to believe that there are many more still unreported. We do not have a complete picture yet, with possible “mild” cases factored into the numbers, but the numbers we do have show an extremely high CFR (probably greater than 50%). In comparison the last great pandemic in our recent history was the Spanish Flu of 1918, it had a CFR of 2% and it killed approximately 50 – 100 million people world wide. The World Heath Organization, CDC, and much of the scientific community believe it is only a matter of time before another novel pandemic virus hits the world again. Normally in each century the world has approximately three flu pandemics, this was the case in the last century, we had two mild pandemics in 1957 and 1968, which increased the overall mortality rates throughout the world, but not significantly, and still had the elderly and infirm as its primary victims. The Spanish Flu in 1918 was quite different in the fact that its primary victims were young and healthy people in their prime. Scientists believe this was primarily due to something called a “cytokine storm”, which occurs most frequently in the young healthy population, allowing a person’s own immune system to over react and attack vital organs, especially the lungs. This is also what we saw to some extent with the H1N1 virus in 2009. Currently with H7N9 victims the reports have stated that most became very hypoxic (short of breath) fairly soon, and most progressed rapidly to multi organ failure.

Effects of Past Pandemics on the United States
Pandemic    Estimated U.S. Deaths      Influenza A Strain     Populations at Greatest Risk

1918-1919       500,000                            H1N1                      young, healthy adults
1957-1958         70,000                            H2N2                      infants, elderly
1968-1969         34,000                            H3N2                      infants, elderly
2009-2010         18,300                            H1N1 (swine)         young, healthy adults

Please note that all these recent pandemics had a CFR of 2% or less. World wide the current CFR for the slow adapting H5N1 virus is greater than 60%, which means that every 6 out of 10 people who have caught the H5N1 virus have died! I shutter to think what the CFR will be for the H7N9 virus that appears to be adapting to humans at a much faster pace.

Seasonal Flu vs. Pandemic Flu what is the difference?

The seasonal flu is the normal flu we see arrive every year usually starting sometime in the fall and lasting until sometime in the spring. Each year we see slightly different variations of influenza virus subtypes that have been around for awhile, and most of us have some antibodies and immunity to some of these subtypes. So when it comes time to look at making the next season’s flu vaccine our influenza specialists usually look at the three most prevalent subtypes we just had and begin to culture these viruses in fertilized eggs (scientists are working on cell based vaccines now for faster deployment of vaccines, soon to be common place I hope) and then combine them to come up with our new vaccine for the coming flu season (this is the simple version). The process to make a new vaccine usually takes about 6 months. The seasonal flu can target 5 – 30% of the population, and usually makes you feel horrible for about a week or so. Complications arise in people with compromised immune systems and in the very young and elderly. Deaths occur usually from a secondary pneumonia infection. Getting your flu vaccine every year greatly reduces your chances of getting the flu. The experts who just made the new vaccine are hoping the new subtype out for the season will at least be partly covered by the vaccine. I’ve heard many people say they “got the flu” from the shot. That really is not possible as the vaccine is made from a “killed” virus, your arm may hurt and some people may have a slight fever, with minimal other discomforts, but I believe you are better off being vaccinated.

A pandemic flu occurs when we have an avian species coming up with a new subtype that we have no antibodies or immunity to. The virus goes through several stages until it mixes and mutates to become easily transmissible to humans. This novel strain can possibly be very lethal. “Pandemic” simply means it will become a global problem (because of the newness). A global pandemic flu will likely target greater than 50% of the world’s population due to the fact that none of us has any immunity.

Consequences of a Global Flu Pandemic

In a typical disaster which usually happens to a localized area or country, resources are mobilized to help with the recovery. In a global flu pandemic there are no resources from unaffected regions to mobilize, it will be every region, every country, every family fending for themselves. In a global pandemic the disaster is unrelenting (up to 12 – 18 months), which will thwart any effort to recover. Hospitals will be overwhelmed in days to 1 – 2 weeks. Because of our “just in time delivery systems” that every corporation now uses, medical supplies will become nonexistent in days. The hospital I work in usually has a pharmacy delivery twice a day. As an example of the systemic system weakness people will walk off their jobs and go home due to the fear of catching the flu and bringing it home to their loved ones. This will greatly affect our supply chains for all our resources; groceries, medicines, fuel, etc. Hospitals are not just made up of Doctors and nurses, we have ancillary departments that are fundamental in the care and operation of our hospitals. Suppose just one department, like Nutritional Services is affected first, either by fear of coming to work, or by people who have caught the flu, how do our patients get fed? Within days many departments in the hospital will be depleted of personnel, again either by not coming into work, or becoming victims of the flu. Emergency Room departments will be completely over run very quickly, and unfortunately in most cases there is not a whole lot we can do medically for people with a viral infection. Flu usually has to run its course, and if we do not have IV fluids for hydration and any antivirals left, how do we care for these people? People requiring a ventilator for lung support will be out of luck, as this number could be in the thousands, or worse, millions. Our hospital has 5 ventilators at any given time, in times of extra need we can rent maybe 1 or 2 more in our area. It is my firm belief that if we had a global pandemic occur with a high CFR we will be taking care of our own sick, at home. The smartest way is to prepare ahead of time with supplies at home, and be prepared to quarantine your family during the event.

What are the Symptoms of the Flu?

Pretty much what we are already familiar with: sore throat, cold, fever, chills, nausea, vomiting and muscle aches. Warning signs for an immediate Doctor or ER visit would include severe acute shortness of breath, bluish skin (fingers, lips, etc.), seizures and dehydration.

What is the incubation period for catching the flu?

The time between human exposure and onset of illness (incubation period) is usually 2 – 4 days, sometimes up to 7 days. (If I had my family in isolation/lock down for a pandemic and another family member came, I would quarantine them for up to 14 days).

How long does a Pandemic last?

Generally flu pandemics come in three waves, with the second wave usually being the worst. For a global pandemic you are usually looking at up to possibly eighteen months for the three waves to have made their rounds and begin to subside. Currently the CDC has stated that in the recent past they have tried to make a H7 vaccine “just in case” and have had difficultly with it conveying immunity. This may be a big problem for us, as it could take up to a year or more to have a vaccine available to vaccinate our total population.

How contagious is the flu?

The influenza virus can live on an inanimate surface for up to 48 hours; it can live on your clothes for up to 8 hours.

How is the flu spread?

The flu can be spread by droplet infection: coughing, sneezing, bodily fluids. It can be spread by direct contact: shaking hands, door knobs, computer keyboards, shopping carts, etc. The flu can also be airborne, and many influenza experts call for social distancing during a pandemic while out in public or at work (6-10 feet), and if you are out in public during a pandemic you should be wearing personal protective equipment  (PPEs).

What can I do to prepare my family for a pandemic?

Make sure your family members are up to date on their vaccines, such as the annual flu vaccine (this could possibly convey some immunity to a new virus, not really sure if it would or not). The pneumovax vaccine is also very important, this protects against 23 types of bacterial pneumonia. Hepatitis A is not a bad idea if our utilities are not working and we are forced to drink or eat questionable water or food. A tetanus vaccine is also important, as everyone should have one every 10 years. Be sure to contact your own Physician and discuss these maters with her/him.

The single most important thing we can do during a flu pandemic while at home, work or in public is practice good hand washing skills. This means using plenty of soap with warm to hot water and scrubbing 30 – 40 seconds, remember to get the back of your hands and in between your fingers, under your nails and up your arms. Rinse thoroughly and dry with a paper towel and then turn off the water with the paper towel, so as not to contaminate your hands on the dirty faucet handle. Using a alcohol based hand sanitizer is also recommended (not a antibacterial soap that is not alcohol based). To use this thoroughly wet your hands with the sanitizer and let air dry, do not towel dry. If you are sneezing or coughing be sure to use Kleenex, and properly dispose of them, if Kleenex is not available sneeze into the fabric of your shirt sleeve. I think sneezes have been clocked at 200 miles/hour, that can really travel some distance! Frequently clean your work surfaces at home and at work with either germicidal wipes or a weakened bleach solution (one part bleach to 4 parts water), don’t forget your telephones and computers!

Medicines and Personal Protective Equipment (PPEs)

Let's talk about antivirals first: Neuraminidase Inhibitors have been proven to be effective for some people during normal flu seasons and also with the 2009 H1N1 pandemic, and for some of the unfortunate people who contracted the H5N1 subtype, these antivirals may not prevent the flu, but they can lessen the severity and duration of the flu. Some of these antivirals are Tamiflu, and Relenza and the M2 inhibitors Amantadine and Rimantadine. If you have an understanding physician try talking to them now and see if you can get some prescriptions for these drugs. The first two listed have proven to be the most effective, but depending on the specific subtype, some of the viruses have become resistant to the antivirals. Please be sure your home is stocked with plenty of pain and fever reducers. Also be sure you have working thermometers on hand. Have a blood pressure cuff at home and learn how to use it properly; low BP can be one of the first signs of complications.

Particulate Respirator Masks – these ideally should be “fit tested” to be worn properly, you could try going by your local hospital and see if they could show you the proper way to wear the mask. If that is not possible be sure the mask fits snuggly around your face covering your nose and mouth without leak areas (guys….this means no mustaches or beards). These masks must be NIOSH approved N95 rating or higher. A surgical mask is a second (although poor) alternative if respirators are unavailable. One mask can usually be worn for approximately 8 hours, if it has not become soiled, contaminated (taking off and on), or becomes too moist. Nitrile, latex, or vinyl (if you have a latex allergy) single use exam gloves. These come in boxes of 100, you can find them cheap at Sam’s or Costco. The masks can be ordered from places like medical supply companies. You need to have a lot of these on hand, try to get appropriate sizes for your kids if you can. You also need eye protection, wear goggles or a face shield. Goggles should have the side protectors, these can be found at medical supply companies and stores like Lowe’s or Home Depot. Often I have seen pictures of people in the world wearing only masks and not goggles during a pandemic, this was especially evident during the SARS out break. With droplet infections you are contaminated by coughing and sneezes into your mucous membranes…..that includes your eyes! Don’t forget your alcohol based hand sanitizers, and germicidal wipes.

Gowns – a long sleeved cuffed disposable gown may be needed for direct care for an infected person.
 If you are caring for an infected person at home in the case of a severe pandemic and hospitals are closed or full be sure to isolate and quarantine this person to a separate part of the house if at all possible, and have only one primary care person who always wears their PPEs. Keep all materials to care for the infected also separate. Be sure to dispose of  any items that may be soiled or contain bodily fluids very carefully, and away from other family members.

Hydration of the person with flu is extremely important, especially if a hospital is not available. This can prove daunting for someone with nausea and vomiting, but it is imperative if you are the care giver to keep trying to push fluids.

Electrolyte drink
½ tsp. baking soda
½ tsp. table salt
3-4 tbsp. sugar
1 quart water
Mix well, flavor with lemon or sugar free Kool Aid.

Keep a daily record of the person who is ill, include temp, blood pressure, and respirations. Also take daily temps of other members of your family (with a separate thermometer), and be prepared to separate and isolate any additional family members who you believe may be becoming ill. Make sure the infected person is urinating regularly, and in good amounts, if they aren’t this is the first sign of dehydration, or worse, possible kidney failure.

As preppers we all strive to protect our families and loved ones as best we can, a pandemic with a severe CFR would be devastating to the world. Personally this would be one of my tipping points in calling all family members home and staying home, no one in or out for the duration. I would be praying that they come up with a vaccine within a year.

I sincerely hope none of us has to deal with a pandemic with a high CFR in our future, but if we do please prepare now with the items you may need. I will never forget watching scenes from Toronto, during the SARS epidemic, of people selling simple surgical masks on street corners for $10 each! Like with everything else we prepare for now, this is just another possibility in the crazy, crowded world we live in.

Please stay healthy and God Bless.

Disclaimer: This information is not intended to replace the advice of a doctor. The author and web site disclaim any liability for the decision you make based on this information.