This combination of things got me interested in both epidemiology and immunology, and I’ve been studying it (and teaching the topics) since then.

Do you remember the H1N1 pandemic of 2009? Compared to our current pandemic, it was minor. But it wasn’t nothing. There were a half million lab-confirmed cases, which is probably a fairly small percent of acutal cases, with the real number being up to 1.4 billion. The estimated death toll was well over a quarter of a million. My memories of that pandemic are sharp, because my son was born right in the middle of it. The Maternity Ward was on lock down. But, the vaccine was around and nobody in our extended family actually got sick.

Also at that time, epidemiologists and other infectious disease experts were doing a lot of talking-head work, and among them, was Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. (See for example: H1N1 could overwhelm U.S. in the next two months).

I remember at the time, or probably a year or two later, Osterholm was on a talk show with two or three other experts, including one who had written a recent definitive history of the 1918 pandemic. At one point, each of the experts had a chance to opine about the next version of such a pandemic. Interestingly, they were all fairly up beat. We have, after all, vaccines, something not really developed in 1918. And great doctors and medical ablities and stuff. There really can’t be another pandemic like 1918.

Then, Osterholm spoke. He said this: The next pandemic may be worse than 1918. It will be harder, not easier, to deal with. Yes, we will have a vaccine for the next pandemic virus, but it will take at least a year, maybe a couple of years, to get it. The virus will not wait. It will ravage our population. There will be, plain and simple, a major pandemic with no vaccine for it, for a very long time, many months at least. Meanwhile, the virus will be worse than 1918, because in 1918 we had far more hospital beds per person than we do now. Basic nursing, in a hospital, will be what will save lives, more so than fancy medical stuff.

We have transformed our medical system today to one in which people spend very little time in hospitals, and hospital stays have become something for the very sick or the very rich. Note that the first thing sane US states did (the ones run by Democratic governors, and a couple of others) when Covid-19 emerged was to figure out how to build out hospital capacity at lighting speed. That was because of Osterholm and a few of his colleagues, and their predictions of what would happen. The response plan was already in place, and has been for years. Something like this state level response was also in place at the federal level, until the Trump Crime Family dismantled it early in Trump’s term.

A bunch of smart people had studied past epidemics and pandemics. A bunch of smart people had studied epidemiology and immunology, and viruses. A bunch of smart people described what a pandemic would look like. All you had to do was to be one of the few people who happened, by chance or circumstance, to have read that literature and listened to those individuals, to remain today pretty much unsurprised by everything that has happened over the last year, and that will happen over the next year. Nobody knew the timing, but this one corner of science and public health knew this would happen, and what it would look like.

One thing none of these smart people expected was that the US would be taken over by a nefarious anti-science political party (Republicans) that would set us back decades in our ability to manage a pandemic, just when the big pandemic came along.

And, there is one other unexpected surprise, and this is surprisingly little talked about. The vaccines that are now being distributed are nothing like vaccines have ever been before. In fact, they only barely fit the definition of a vaccine. Vaccination normally involves introducing substances into the body that cause an immune reaction that doesn’t make you sick, or not too sick, but that cause the adaptive immune system to prepare for a future infection by a specific pathogen. The new RNA technology does not do that. Rather, it programs a few thousand cells in your body to produce a molecule that is the substance that causes the immune system to react. The vaccine factory is in your cells.

That is new.

The new Swine Flu has now been verified in nineteen US states, with 141 cases. Technically there is 1 death, but since the young girl who died actually caught the flu in Mexico (and came to Texas for treatment) it is hard to say how that should be counted.

WHO characterizes the global spread of the flu as a “rapidly evolving” situation. As of an early morning update from WHO, the swine flu has been confirmed in Mexico (156 confirmed cases) as well as Austria, Canada, Germany, Israel, Netherlands, New Zealand, Spain, Switzerland and the UK. Each of these countries has between 1 and about a dozen cases, except Canada which has 34.

My comments:

1) I’m annoyed at the playing around with the name of the flu. The Israeli Government was wrong to insist on not calling this Swine because of the kosher-pork issue. Nothing about that makes sense. The Minnesota Government led by Republican “I’m not very smart but I won’t raise your taxes” Pawlenty is also wrong in insisting that it be called the H1N1 flu. Pawlenty has stated that we should not call it the “swine flu” because that is disparaging of the pork industry (which is reasonably important here in Minnesota).

That is utterly stupid because you can eat pork chops, ham,and bacon all day, from swine who have the flu, and never get it. There are times when it is appropriate to adjust the name of a disease for various social or political reasons, but it is wrong to do so in response to utter ignorance. Instead, deal with the ignorance. Pawlenty will not deal with the ignorance directly because he is a Republican and, quite honestly, Republicans prefer to foster, and when convenient use, ignorance for their own monetary and political gain.

2) There is no validity whatsoever to the idea that the swine flu is more deadly in Mexico than elsewhere, or that Mexicans are somehow more likely to die of it. Well, the latter may ultimately be true because of health care differences. It may turn out that people in Mexico and Panama will be more likely to die of this flu than people in Sweden and France, owing to disparities in health care across countries. It may also be the case that people in Louisiana will be more likely to die of this flu than people in Minnesota or Massachusetts for the same reason. However, it is also true that the data that are currently available are not sufficient to say anything other than this, and only in a very preliminary way: The current swine flu outbreak seems to have a mortality rate that is roughly similar to the seasonal flu, at present. (But see below.)

3) It s not true, as is reported again and again by reporters who should really stuff a sock in their mouth on waking and keep it there all day, that the swine flu is “mild” in the United States. This misconception and mis statement comes from an illogical extension of number 2 above. This is a serious flu. You get sick as a dog for a week or so, and it can kill you, just like the seasonal flu.

4) Regarding the spread of this flu: More and more people who know what they are talking about are saying that the spread of this flu is similar to that of seasonal flu. In the same way that we can characterize the mortality rate as similar to seasonal flu, we can probably say the same regarding the rate of spread. However, both characterizations are subject to change as data become more available.

There are two separate issues here. On one hand, we have the accumulation and verification of case by case data, and on the other hand, we have the spread of the flu. Over time, the quality of the data will become good enough to make longer term projections and to make assumptions about the missing or lower quality data areas of the world. So, right now, as we see reports of more states in the US or more countries across the world reporting cases for the first time, are we watching the actual spread of the flu, or the improvement of data? Answer: Both, and we can’t separate the two right now with any degree of reliability.

5) Regarding the flu’s virulence and mortality: Good news and bad news. I have one piece of good news and two pieces of bad news.

First the good news: It does seem (see above) that this flu is not extra deadly.

Now the first bit of bad news: The seasonal flu is deadly. This new flu … the swine flu … is like the seasonal flu. It is also deadly. It might be that the currently spreading strain of Swine H1N1 ends up being less deadly, it might end up being more deadly, but if it turns out to be about the same as the seasonal flu and goes though a similar cycle, you can expect several tens of thousands of Americans to die of it.

Maybe thats a good thing. Maybe killing 38,000 Americans twice in one year instead of once will result in a change in attitude towards both the flu and towards vaccination in general. Maybe I’m too cynical. Maybe I’m not.

Now the second piece of bad news, and this is the scary bit. This flu may be worse than a regular flu in that more people will get it … there is not vaccine available now, so it’s initial spread will be unchecked compared to a normal seasonal flu for which vaccines may have been distributed. There is probably not as much of an immunity to this flu as for the seasonal flu (this has yet to be determined but is likely true) so it may be that more people will end up getting this flu.

Fine. But that’s not the real bad news.

The real bad news is that since this is a new flu part of which (flu has different parts that may have different histories) only recently entered the human environment, there might be a slightly higher than we would like to have chance that this flu, while it swaggers around the human population making people sick, will recombine with one or more other flu viruses that are already out there with very nasty results.

This flu could spread around the world as a regular flu, making lots of people sick but not being overly deadly. Then, some time during its spread, or even after it has largely abated, it could mutate through recombination (of some of its parts) and come back as a much more severe flu, causing a truly deadly world wide pandemic.

How possible is this? We have no way of knowing, but that scenario has happened before. From a paper by Taubenberger and Morens:

Historical records since the 16th century suggest that new influenza pandemics may appear at any time of year, not necessarily in the familiar annual winter patterns of interpandemic years…. Thereafter, confronted by the selection pressures of population immunity, these pandemic viruses begin to drift genetically and eventually settle into a pattern of annual epidemic recurrences caused by the drifted virus variants.

In the 1918-1919 pandemic, a first or spring wave began in March 1918 and spread unevenly through the United States, Europe, and possibly Asia over the next 6 months … Illness rates were high, but death rates in most locales were not appreciably above normal. A second or fall wave spread globally from September to November 1918 and was highly fatal. In many nations, a third wave occurred in early 1919 … Clinical similarities led contemporary observers to conclude initially that they were observing the same disease in the successive waves. The milder forms of illness in all 3 waves were identical and typical of influenza seen in the 1889 pandemic and in prior interpandemic years. In retrospect, even the rapid progressions from uncomplicated influenza infections to fatal pneumonia, a hallmark of the 1918-1919 fall and winter waves, had been noted in the relatively few severe spring wave cases. The differences between the waves thus seemed to be primarily in the much higher frequency of complicated, severe, and fatal cases in the last 2 waves.

That paper characterized the pattern of the 1918 flu well, but was written before some key findings in the nature of flu evolution, so I won’t pass on the speculations those authors provide for why this pattern developed.

Taubenberger, Jeffery, & Morens, David (2006). 1918 Influenza: the Mother of All Pandemics Emerging Infectious Diseases, 12 (1)