A balanced Perspective

Our national (and international) culture(s) have become very focused on immediate gratification.  Any news cycle that does not keep up with “Breaking News” each and every day is soon relegated to the back.  It is no wonder we have cynical exploitation in tabloid style hyper sensationalism as well as apathy and lack of reasonable action on part of the public. 

Here then is my honest take on what is at stake when this virus comes back this fall during our peak flu season.  Notice I said “when“, not “if”.  Most if not all experts agree H1N1 will be the driving force behind the 2009 flu season.  No ifs or buts about it. Flu Pandemics tend to happen in waves, a relatively “easy” early summer wave followed up by  a fall wave that is much more devastating. See the classic 1918 flu waves below, for the United States.  There is some concern that with the speed and frequency of air travel in our modern world there may not be the “breathing time” between successive waves that we saw in 1918.

Flu and common cold: very different beasts

Almost all of us have had head colds at one time or another.  But if you have been fortunate enough not to have had full blown flu until now and assume it is like a bad head cold, please think again.  My family (my Mom, brother and I) got the 1957 pandemic flu.  I was 9 years old and I felt I was dying.  I almost did. Raging high fever, loss of consciousness, deliriums, unmitigated projectile vomiting that left us seriously dehydrated – it was very frightening experience.  It left me and my brother weak as kittens for many weeks after we recovered.  Flu is like a common cold?  Not on you life!  When you get the flu you will surely know the difference.

What makes H1N1 different from last year’s flu?

Flu viruses circulate through their human hosts for many years, changing out bits of themselves as they mix and match snippets from different strains.  It has been a while since there has been a truly novel flu strain that majority of us have not seen at one time or another.  The “bird flu” (H5N1) that created a stir a couple of years ago was one such.  Since our bodies had no experience of this particular flu virus, an alarming number of people who got infected with it died. The latest tally on WHO H5N1 site lists 262 deaths in 433 confirmed human infections.  Fortunately for our species, this bird virus was not very good at infecting humans.  As we discussed in a prior article, bird viruses are used to the higher temperature of birds and have a tough time thriving in our colder human bodies.

But the H1N1 flu virus getting WHO’s  Pandemic 6 status is a very different beast.  For starters, it seems to have originated in pigs (with a few bits of DNA thrown in from human flu viruses and bird viruses as well).  This promiscuous virus has proven to be able to infect anyone it comes into contact with at will.  Dozens of countries have documented cases of human-to-human transmission.  People sitting a couple of rows ahead of an infected passenger on airplanes have come down with the same infection – proving droplet transmission (brought about by sneezing and coughing) happens all too easily with this virus.  As for schools, day care centers and other similar germ factories, this virus is very good at passing from child to child with little hindrance.  The CDC has declared that just about all of the flu cases in the USA during this otherwise off season (our flu season typically ends in late April) represents H1N1 infections.  So much so that most states have stopped bothering to test and confirm for H1N1. Take a look at chart below from the CDC and you can see how the dark blue (novel H1N1) dominates the picture starting around week 17.

Folks, this virus is not going to go away.  It will infect more and more people until our species gradually develops familiarity with it, just as we did with all previous varieties, over a matter of a few years.  The trick is getting from here and now to then and there, in one piece.

One-Two Punch

What made the 1918 flu virus so very dangerous with millions of people getting killed around the world? There are two things that a dangerous killer virus has to do.  First, it must be able to pass from person to person (human-to-human transmission) with relative ease.  H5N1 could not do that and we dodged a bullet.  But H1N1 has proven itself to be quite able to spread easily.  In a matter of a couple of months it has literally circled the globe and infected thousands (most likely hundreds of thousands) of people in almost all countries.

The second thing that a killer virus has to be able to do is be so devastating in its effect on the host that it kills a large percentage of the people it infects.  As I mentioned above, H5N1 killed more than half of the people it infected.  Fortunately for us, thus far the CFR (case fatality rate or the number of cases that died) is still quite low for H1N1.  Neither H1N1 nor H5N1 have learned both of the tricks needed to have massive human casualties.  The nightmare scenario that no doubt keeps up public health officials from getting a good night’s sleep is the possibility of these two viruses meeting up in some Asian countries where H5N1 has become well entrenched. If the two viruses share (exchange DNA snippets) and the trick each one has learned, thereby spawning a new version that knows both tricks, we will be in for a very bad time indeed.

The Optimistic Scenario

For the sake of argument let us assume we luck out, H1N1 continues to infect human populations across the world as it has already shown itself capable of doing, but it does not learn massive killing capability.  Experts project roughly one third of the human population (6 billion, give or tak a few hundred million) will get infected.  That is 2 billion people getting quite sick.  How will our healthcare systems handle that kind of patient load? How will poor countries handle it?  How about groups of people with chronic health conditions that require frequent access to healthcare resources?

If we get lucky and the case mortality remains low, say a mere 0.1%, or one person out of every 1,000 infected people, we are talking of  “only” 2 million people dying worldwide. No doubt, the actual death toll will fall much more heavily on poor and crowded countries with scarce medical resources and poor hygiene. Mind you, this is the optimistic scenario.  A mere two million people dead, many of them people in the prime of their lives, individuals who were bread winners and home makers.

Implications for CLL Patients

Let us continue with the optimistic and hopeful scenario I suggested above, but see if anything changes when we drill down and look at our patient community as opposed to the general healthy public.

What is the single characteristic reported about the deaths we have witnessed thus far with H1N1?  Health officials have been quick to point out that many of the victims had underlying health conditions.  Here is the list of risk factors CDC has on their site:

  • chronic cardiovascular disease (congestive heart failure and cardiomyopathies)
  • chronic pulmonary disease including chronic obstructive pulmonary disease and emphysema
  • diabetes mellitus
  • alcoholism
  • chronic liver disease, including cirrhosis
  • cerebrospinal fluid leaks
  • functional or anatomic asplenia including sickle cell disease and splenectomy
  • immunocompromising conditions including HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome; those receiving immunosuppressive chemotherapy (including corticosteroids); and those who have received an organ or bone marrow transplant
  • I have highlighted some of the more obvious risk factors our guys are likely to have, both because of the CLL and the age group we are likely to be in. You may argue with me about some of the ealrier bullet points, but there is no way of avoiding a whole host of risk factors listed under the last bullet.

    What does that mean?  Well, even if swine flu H1N1 retains its low case fatality rate that we see right now in the general public and does not learn any new tricks along those lines between now an d the fall flu season, the case fatality rate is likely to be much higher in at-risk populations.  That means CLL patients are at much higher risk of dying if they get the H1N1 flu, compared to the general otherwise healthy population.

    Killer Pneumonia 

    Just about all the case fatalities in the USA had been on ventilators for massive pneumonia prior to death.  Unless you are new to CLL Topics and Updates, you are by now familiar with my often repeated statement: the single biggest cause of death in CLL patients is pulmonary infections and pneumonia. Put these two pieces of the puzzle together and you understand why I am deeply concerned about the risk posed by H1N1 pandemic to our patient community.  Unless you are extra vigilant about avoiding infection in the first place, there is a one in three chance you will get infected.  Once infected, you are much more vulnerable to viral pneumonia. Given our sleeping-on-the-job immune systems, there is much higher chance that the viral pneumonia due to H1N1 can pick up addition life threatening bacterial pneumonia.  Have I scared you sufficiently?  I hope so.  Rather that than you walking into this fall’s flu season blissfully unaware of your particular risk status.  Mind you, the scenario I have considered is the optimistic one.

    Pneumonia Vaccinations

    The CDC has a full section recommending pneumonia vaccinations.  Here is link to the section, please visit it and read all the details.  Below is a quote:

    “During influenza outbreaks, pneumococcal vaccines may be useful in preventing secondary pneumococcal infections and reducing illness and death. Currently, two vaccines are available for prevention of pneumococcal disease, a 23-valent pneumococcal polysaccharide vaccine (PPSV23) and a 7-valent pneumococcal conjugate vaccine (PCV7)”

    CDC’s Advisory Committee on Immunization Practices (ACIP) recommends a single dose of PPSV23 for all people 65 years and older and for persons 2 to 64 years of age with certain high-risk conditions (listed above). People in these groups are at increased risk of pneumococcal disease as well as serious complications from influenza. A single revaccination at least five years after initial vaccination is recommended for people 65 years and older who were first vaccinated before age 65 years as well as for people at highest risk, such as those who have no spleen, and those who have HIV infection, AIDS  or malignancy.”

    Do you know when you got your last pneumonia vaccination?  Was it longer than 5 years ago? Did you know which type of vaccine you got, the PPSV23 or the PCV7?  Did your spouse get the shot too? If you are not sure how to answer any of these questions, I strongly urge you to talk to your GP about getting a PPSV23 shot right away.  Yes, there is ALWAYS the question about whether or not your immune system is still able to mount much of a response to any vaccination, but I think it is prudent to get whatever help you can get. And the CDC advisory committee’s recommendation of PPSV23 for at-risk populations like CLL patients is very compelling.

    The other obvious action item is to make sure your immediate family and those around you stay as healthy as possible – a case of “herd immunity” protecting you as well.  If your spouse is over 65 or has any of the risk factors listed above, it is important to get him / her to get the shot as well.


    Normally “Updates” software does not let through live links in the comments section – a way of avoiding spam and links to sites peddling Viagra, cheap knock-off watches and degrees, or free money from Nigeria. But for this article I will allow comments with live links to go through (provided they are related to the topic under discussion and not blatant marketing ploys). It means a lot more admin work for me (or Radha, our webmaster).  But I think it is worth the extra work to make sure we get access to all the credible information out there.  I am hardly an expert on this subject, I defer to people like Peter Carpenter on it.