This H3 N2 Flu Season Could Be The Worst For U.S. Since 1968 Hong Kong Flu Pandemic

Electron micrograph of the H3 N2  influenza virus, largely responsible for most deaths and hospitalizations this flu season.

As the tally of pediatric deaths reaches a high not seen for nearly a decade, and flu is now wreaking medical havoc in all of the contiguouos states, one wonders if this scourge could rival the Hong Kong flu pandemic of 1968-69.

As I wrote earlier (December 11, 'The H3N2 Flu  - Are We Ready For The Onslaught?')  citing a Wikipedia reference:

"The Hong Kong Flu was a category 2 flu pandemic caused by a strain of H3N2 descended from H2N2 by antigenic shift, in which genes from multiple subtypes reassorted to form a new virus. This pandemic of 1968 and 1969 killed an estimated one million people worldwide"

But could this flu season be as bad? What we do know is what began as "the Aussie flu" last summer (the Australian winter)  has now metastasized to cause over 14, 000 hospitalizations and nearly 60 pediatric deaths. The hospitalization rate, according to one WSJ article ('Flu Hospitalizations Highest Since 2010' ) has now reached 51.4 per 100,000 or the highest since the  2009 H1N1 pandemic flu. That  strain "led to more than 60 million flu cases in the U.S".

Less noted is that the current hospitalization rate now compares to that (43.5 per 100,000) in the 2014-15 flu season - also dominated by H3 N2. Less known is that flu season saw 56,000 die from flu or even more than the Hong Kong flu killed in the U.S. (34,000).  In a blog post I wrote on Dec. 22, 2014, it was interesting to read how I suddenly came down with that flu while watching a football game. (My wife got it 3 days earlier).  That holiday season turned out to be a total wipe out but we were both glad we got our flu shots!

I also got the Hong Kong flu - the first  known appearance of H3 N2  -  so why didn't I have any immunity when the 2014 H3 N2 flu struck?  Well, likely because that was actually a variant strain, e.g. H3 N2v - where more Avian or swine contributions factored in.  It elicits the question of whether the current ferocious flu season is dominated by a similar H3 N2 variant, and in fact whether it could be as bad as the 1968 pandemic.

Soon after the Aussie flu struck the UK,  Professor Robert Dingwall, a public health expert at Nottingham Trent University, told the UK Daily Express  the oncoming H3 N2 season is expected to be the most serious flu outbreak since the 1968 pandemic that started in Hong Kong and killed more than a million people world wide. 

In a number of respects he's correct as this flu season further plays out, and it is clear we haven't even hit the peak yet.  See e.g.



There is also the chance this flu season could go on much longer than the (normally)  expected end in May. The Hong Kong flu swept the world infecting hundreds of millions for almost 2 years. Such freak pandemics seem to occur every 50 years, with the 1968 pandemic striking 50 years after the deadly Spanish flu - which killed up to 100 million - arguably a worse  human health catastrophe than  the Black Death. See also:

https://www.cnn.com/2017/04/07/health/flu-pandemic-sanjay-gupta/index.html

In their book, 'The End of Epidemics', authors Jonathan D. Quick and Bronwyn Fryer argue that the most frightening future risk is the potential for a new, highly contagious and deadly flu to arise from a "viral stirring pot".  Such a pot would include avian, animal (e.g. swine) and human-infecting viruses.  They also note the opportunity for such mixing abounds as beasts, birds and humans rub shoulders in places like factory farms.  Like Sanjay Gupta (earlier link) Dr. Quick's take is this is not a matter of if but "when".

My bet, as I've written before, is the new deadly pandemic will be a hitherto unseen form of Avian flu.   Cue then the date September 29, 2005, when David Nabarro, the newly appointed Senior United Nations System Coordinator for Avian and Human Influenza, warned the world that an outbreak of avian influenza could kill anywhere between 5 million and 150 million people. The reported mortality rate of highly pathogenic H5N1 avian influenza in a human is high; WHO data indicate 60% of cases classified as H5N1 resulted in death. My take, given the H5N1 would incept a "cytokine storm"  similar to what the H1N1 Spanish Flu did, is that at least 500 million would perish, and possibly as many as 1 billion.

So, we infer that what kills most humans - apart from the secondary infections, e.g. pneumonia  - is the immune system's hyper response to the virus invasion of our lung cells. This hyper reaction is what induces the cytokine storm.   Research into the Spanish flu victims discloses that death likely arrived via a cytokine storm, i.e. the victim basically "drowning" in their own lung fluids. The alveoli or air sacs of the lungs become basically incapable of gas exchange, e.g. between oxygen and CO2 and the victim suffocates as the cells burst - responsible for many of the victims having blood spurting from eyes, ears, nose etc.  Also, the effort to summon oxygen from elsewhere leaves the victims with a bluish or cyanotic facial appearance.

Contrast this with a number of  documented Asian cases,  where victims with H5N1 experienced diarrhea followed rapidly by a coma without developing respiratory or flu-like symptom. This shows that one can perish that suddenly, and with no evident breathing problems. 

More distressing, genetic sequencing of avian influenza A (H5N1) viruses from human cases in Vietnam, Thailand, and Indonesia shows resistance to the antiviral medications amantadine and rimantadine, two of the medications commonly used for treatment of influenza. This leaves only two remaining antiviral medications (oseltamivir and zanamivir) that should still be effective against currently circulating strains of H5N1 viruses.

If and when the next influenza pandemic strikes we better have our anti-viral weapons ready along with every available resource to care for the millions of victims. The current scenes, with hospitals having to set up triage  tents outside of main facilities and ERs flooded, shows we are nowhere near ready when the "big one" strikes. Which could, I say could...be at the tail end of this current H3 N2 season.

We will also have to drop the obsession with "diminished hospital profit margins" during flu outbreaks. That should be the least concern if millions of our fellow citizens are infected by a killer flu variant or totally new strain.

The H3 N2 Flu - Are We Ready For The Onslaught? What About An Avian (H5 N1) Pandemic?

Electron micrograph of the H3 N2  influenza virus.


My first introduction to the H3 N2 flu virus arrived in December, 1968, after I'd just flown home to Miami from New Orleans for the Christmas holidays.   Within 2 days of my arrival I was hit by one of the nastiest flu viruses,  called "the Hong Kong flu".   A micrograph of the virus is shown below:


I was basically laid up in bed with body aches, chills, severe nausea and fever for 8 days, and could not partake of any Christmas dinner. Since I was unable to do so, my parents decided to visit my younger brother, John, at his Naval Air base in northern Florida.  They asked if I'd be ok alone, and I assured them I could tough it out. There were plenty of cans of chicken noodle soup, as well as bread (for toast) and other assorted stuff - even some slices of spiral ham -  if I was able to consume such later.

Most of my time was spent just watching the tube, and reading - when I could. I was perhaps 90 percent better by the time I returned to New Orleans but within two days had to take extra time off from the oil company I worked at - after a relapse. (At that time, most proper companies gave employees 2 weeks sick leave, unlike the penny pinching, greedy rats today.)

We now know the arrival of the Hong Kong flu in 1968, started with a half million cases in Hong Kong. This was also the first (then known) arrival of the H3 N2 flu virus.   From Wikipedia we learn:

"The Hong Kong Flu was a category 2 flu pandemic caused by a strain of H3N2 descended from H2N2 by antigenic shift, in which genes from multiple subtypes reassorted to form a new virus. This pandemic of 1968 and 1969 killed an estimated one million people worldwide"

We also learn:

"Both the H2N2 and H3N2 pandemic flu strains contained genes from avian influenza viruses. The new subtypes arose in pigs coinfected with avian and human viruses and were soon transferred to humans. Swine were considered the original "intermediate host" for influenza, because they supported reassortment of divergent subtypes."

And:

The Hong Kong flu strain shared internal genes and the neuraminidase with the 1957 Asian flu (H2N2). Accumulated antibodies to the neuraminidase or internal proteins may have resulted in much fewer casualties than most pandemics.The Hong Kong flu was the first known outbreak of the H3N2 strain, though there is serologic evidence of H3N? infections in the late 19th century. "

This is useful to know now as the medical gurus are warning of a new onslaught and incarnation of this flu - after it literally tore through Australia during the Aussie winter. Even two months ago, because of our ages - we were warned by our PCP to not miss the flu shots this year. Not long after we each got the  quadrivalent recombinant flu vaccine, as well as the special   PCV13   pneumonia vaccine. Given severe flu can easily lead to pneumonia (and my dad died from pneumonia in 2009) this was a no brainer.

What we know already is that the the flu vaccine is only about 10 percent effective, and the quadrivalent vaccine may be slightly better. Each year matching the vaccine to the projected influenze virus to emerge is a literal crap shot, because the virus mutates so easily.. So what might have worked 8 or 9 months ago now no longer does.  Like other life forms, viruses adapt as well to external conditions and even to other flu viruses.  As noted earlier, one can have an antigenic shift, in which genes from multiple influenza subtypes reassort to form a new virus.

Professor Robert Dingwall, a public health expert at Nottingham Trent University, told the UK Daily Express it is expected to be the oncoming H3 N2 season is expected to be the most serious flu outbreak since the 1968 pandemic that started in Hong Kong and killed more than a million people world wide.

From 2003 to 2013, the three flu seasons that were dominated by H3N2 strains of the flu had the highest mortality rates - causing more deaths on average than other years (excluding the 2009 H1N1 pandemic flu).  All this is happening - with the new H3 N2 outbreak almost upon us - as we near the 100th anniversary of the Spanish Flu pandemic. This was estimated to have wiped out nearly ten percent of the global population at the time - or up to 50 million.

Coincidentally, the World Health Organization is closely monitoring a new strain of H7 N9 in China, also known as Avian flu. To be sure this is a cross species form or Avian flu and not anywhere as deadly as the H5 N1 which is keeping researchers like Pardis Sabeti of Harvard up at night.  Why? Because it holds the greatest potential for human annihilation.

In 2003, world-renowned virologist Robert G. Webster published an article titled:  "The world is teetering on the edge of a pandemic that could kill a large fraction of the human population" in American Scientist. He called for adequate resources to fight what he sees as a major world threat to possibly billions of lives. 

On September 29, 2005, David Nabarro, the newly appointed Senior United Nations System Coordinator for Avian and Human Influenza, warned the world that an outbreak of avian influenza could kill anywhere between 5 million and 150 million people. The reported mortality rate of highly pathogenic H5N1 avian influenza in a human is high; WHO data indicate 60% of cases classified as H5N1 resulted in death. My take, given the H5N1 would incept a "cytokine storm"  similar to what the H1N1 Spanish Flu did, is that at least 500 million would perish, and possibly as many as 1 billion

Electron micrograph of H5N1 influenza virus particles. 

Research on genetically restored Spanish flu discloses that death likely arrived via a cytokine storm, i.e. the victim basically "drowns" in their own lung fluids. the current Avian flu cases.  In a number of  documented Asian cases, victims with H5N1 experienced diarrhea followed rapidly by a coma without developing respiratory or flu-like symptom. This shows that one can perish that suddenly, and with no evident breathing problem.  The inflammatory cascade triggered by H5N1 has been called a 'cytokine storm' by some, because of what seems to be a positive feedback process of damage to the body resulting from immune system stimulation. H5N1 induces higher levels of cytokines than the more common flu virus types.

There have been studies of the levels of cytokines in humans infected by the H5N1 flu virus. Of particular concern is elevated levels of tumor necrosis factor-alpha, a protein associated with tissue destruction at sites of infection and increased production of other cytokines. Flu virus-induced increases in the level of cytokines is also associated with flu symptoms, including fever, chills, vomiting and headache.

Genetic sequencing of avian influenza A (H5N1) viruses from human cases in Vietnam, Thailand, and Indonesia shows resistance to the antiviral medications amantadine and rimantadine, two of the medications commonly used for treatment of influenza. This leaves only two remaining antiviral medications (oseltamivir and zanamivir) that should still be effective against currently circulating strains of H5N1 viruses.

Highly pathogenic H5N1 symptoms in people can include:


• Fever and cough

• Acute respiratory distress

• Shortness of breath/difficulty breathing

• Abdominal pain

• Diarrhea

Complications:

• Pneumonia

• Respiratory failure

• Shock

Will next year, the 100th since the Spanish Flu pandemic,  usher in a killer flu pandemic of its own? We don't know, but as Prof. Pardis Sabeti pointed out on a recent CBS Early Show health segment, the virus does keep changing, mutating - adapting. This is why she's "kept up at night"  pondering the consequences if it seized on the right confluence of factors to trigger another deadly pandemic. And the next one - possibly of H5 N1 - may also eliminate 10 percent of humans...or more.  There is little pre-existing natural immunity to H5N1 virus infection in the human population. If H5N1 viruses gain the ability for efficient and sustained transmission among humans, an influenza pandemic could result, with potentially high rates of illness and death worldwide.  Let us hope we dodge that infernal
"bullet" with Avian flu on it.