Where Will the Swine Flu Go Next? By JOHN M. BARRY

[Guest guest]

Where Will the Swine Flu Go Next? By JOHN M. BARRY. April 28, 2009

M. Barry is the author of " The Great Influenza. "

New Orleans - AS the swine flu threatens to become the next pandemic, the

biggest questions are whether its transmission from human to human will be

sustained and, if so, how virulent it might become. But even if this virus were

to peter out soon, there is a strong possibility it would only go underground,

quietly continuing to infect some people while becoming better adapted to

humans, and then explode around the world.

What happens next is chiefly up to the virus. But it is up to us to create a

vaccine as quickly as possible.

Influenza viruses are unpredictable because they are able to mutate so rapidly.

That capacity enables them to jump easily from species to species, infecting not

only pigs and people but also horses, seals, cats, dogs, tigers and so on. An

avian virus responsible for the 1918 pandemic jumped first from birds to humans,

then from humans to swine (as well as other animals). Now, and not for the first

time, pigs have given a virus back to humans.

Mutability makes even existing, well-known flu viruses unpredictable. A new

virus, formed by a combination of several existing ones as this virus is, is

even less predictable. After jumping to a new host, influenza can become more or

less virulent — in fact, different offshoots could go in opposite directions —

before a relatively stable new virus emerges.

Influenza pandemics have occurred as far back in history as we can look, but the

four we know about in detail happened in 1889, 1918, 1957 and 1968. The mildest

of these, the so-called Hong Kong flu in 1968, killed about 35,000 people in the

United States and 700,000 worldwide. Ordinary seasonal influenza, in comparison,

now kills 36,000 Americans a year, because the population has a higher

proportion of elderly people and others with weak immune systems. (If a virus

like the Hong Kong flu hit today, it would probably kill more people for the

same reason.)

The worst influenza pandemic, in 1918, killed 675,000 in the United States. And

although no one has a reliable worldwide death toll, the lowest reasonable

number is about 35 million, and some scientists believe it killed as many as 100

million — at a time when the world's population was only a quarter of what it is

today. The dead included not only the elderly and infants but also robust young

adults.

What's important to keep in mind in assessing the threat of the current outbreak

is that all four of the well-known pandemics seem to have come in waves. The

1918 virus surfaced by March and set in motion a spring and summer wave that hit

some communities and skipped others. This first wave was extremely mild, more so

even than ordinary influenza: of the 10,313 sailors in the British Grand Fleet

who became ill, for example, only four died. But autumn brought a second, more

lethal wave, which was followed by a less severe third wave in early 1919.

The first wave in 1918 was relatively mild, many experts speculate, because the

virus had not fully adapted to humans. And as it did adapt, it also became more

lethal. However, there is very good evidence that people who were exposed during

the first wave developed immunity — much as people get protection from a modern

vaccine.

A similar kind of immune-building process is the most likely explanation for

why, in 1918, only 2 percent of those who contracted the flu died. Having been

exposed to other influenza viruses, most people had built up some protection.

People in isolated regions, including American Indian reservations and Alaskan

Inuit villages, had much higher case mortality — presumably because they had

less exposure to influenza viruses.

The 1889 pandemic also had a well-defined first wave that was milder than

succeeding waves. The 1957 and 1968 pandemics had waves, too, though they were

less well defined.

In all four instances, the gap between the time the virus was first recognized

and a second, more dangerous wave swelled was about six months. It will take a

minimum of four months to produce vaccine in any volume, possibly longer, and

much longer than that to produce enough vaccine to protect most Americans. The

race has begun.

M. Barry, a visiting scholar at the Tulane/Xavier Center for

Bioenvironmental Research, is the author of " The Great Influenza. "

http://www.nytimes.com/2009/04/28/opinion/28barry.html