An Influenza Pandemic is Inevitable. It’s Time to Prepare.

An influenza pandemic is inevitable. It’s time to prepare.

I had a little bird

Its name was Enza

I opened the window

And in flew Enza.

– Children’s song from the 1918 influenza epidemic

Years ago, I had pertussis. It wasn’t fun. I am reasonably sure I caught it sitting next to someone on an international flight who spent the duration with a hacking, wet cough which I now understand was likely the classic whooping cough of pertussis. It wasn’t long after I developed the same months-long, miserable whoop myself.

And so it goes with the global, ready-dissemination of other infections, too, including Ebola, Zika and…severe influenza strains: “An infection in all but the most remote corner of the world can make its way to a major city in a day or less.” Says Michael T. Osterholm, Ph.D., director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Of those listed, the greatest concern is with influenza.

And yet we are utterly unprepared for an influenza pandemic.

Osterholm writes from his 2017 book Deadliest Enemy: Our War against Killer Germs, “As infectious disease epidemiologists, we all know that pandemic influenza is the one infectious disease that will happen. It has happened at least 30 times since the 16th century and our modern world presents all the ingredients for an imminent return.”

And this pandemic might be just around the corner. An aggressively virulent strain, the Asian H7N9, an avian influenza virus, jumped to infecting humans in China in 2013. Annual epidemics of H7N9 have been reported in China ever since, with this year’s being the worst.

40 percent of individuals infected with H7N9 have died, usually from rapidly-progressing, severe pneumonia. (Incidentally, mortality from this year’s flu, as is true with most years, is most commonly due to the development of secondary bacterial respiratory infections. Scroll to the end of this blog for treatment considerations for influenza.)

From the CDC: Asian lineage H7N9 virus is rated by the Influenza Risk Assessment Tool (IRAT) as having the greatest potential to cause a pandemic, as well as potentially posing the greatest risk to severely impact public health.

I am not by nature an alarmist. Even as social media demands the creation of clickbait content with alarmist headlines, I resist it. In fact, I loathe it.

But here is the undeniable truth, which we’ve not adequately metabolized: We are vulnerable to being hit HARD with a severe influenza pandemic. Here’s why:

1. The flu vaccine continues to be inadequate, and yet we put all of our medical eggs into this basket. Even in its best years, it may be about 60% effective. This year, it’s estimated that vaccine efficacy may be a woeful 10%. Osterholm wrote in 2012: “The perception that current vaccines are already highly effective in preventing influenza is a major barrier to game-changing alternatives.” And“We have over-promoted and overhyped this vaccine. It does not protect as promoted. It’s all a sales job: it’s all public relations.” 

Why? 

1. Microbes out-evolve us on an order of about 40 million to one (from this Time article– I wasn’t able to corroborate with a peer reviewed resource. But we can comfortably say they’ve got us over an evolutionary barrel). With that ability, we will never achieve a viable vaccine using the methods currently employed which are based chasing and guessing what the new strains will be. As Osterholm writes, “It is the range of possible results from the changeability and mixing of influenza strains that makes it the king of infectious microbial beasts.”
2. As I’ve blogged about, the more flu vaccines one receives, the less effective they become: In a review of 5 years of historical vaccination data, vaccine effectiveness for influenza A in those with no prior vaccine history was 65%, whereas effectiveness was reduced to 24% in those with a frequent vaccination history.
3. Dollar investment into next-generation pharmaceutical treatments lags well behind other areas of R&D: influenza doesn’t make money.
4. Climate change influences the severity of influenza: warmer winters tend to be followed by severe epidemics with earlier onset.
5. Our crowded population combined with living closer to poultry and pigs creates the opportunity for viral mutation, allowing the expedited spread of animal-only infections to humans.

WHO IS MOST VULNERABLE TO FLU-RELATED COMPLICATIONS?

As usual, the youngest and oldest in our population have the highest rates of flu-related mortality, along with those who have chronic health conditions. Reprinted (abridged) from the CDC:

• Asthma
• Neurological and neurodevelopmental conditions
• Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
• Heart disease
• Blood disorders (such as sickle cell disease)
• Endocrine disorders (such as diabetes mellitus)
• Kidney disorders
• Liver disorders
• Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
• Weakened immune system due to disease or medication
• People younger than 19 years of age who are receiving long-term aspirin therapy
• People with extreme obesity

BUILDING RESILIANCE WITH FUNCTIONAL MEDICINE

In functional medicine, we are best-prepared to support those individuals with the above conditions in building resilience against the 2018 flu and any forthcoming pandemic. It’s essential we rely on a full functional (i.e. systems) approach, leaning on the tools of functional medicine including a careful history and physical, dietary prescriptions and specialty testing we’re familiar with, along with nutrients and lifestyle interventions. Mapping our findings to the IFM’s Matrix will guide us in administering an efficacious plan over the long haul. Here’s a case report mapped to the Matrix.

Sleep, exercise, meditation have all been shown as beneficial in preventing the flu.

Here’s a nice study looking at berries and their anti-influenza effects.

As a teacher in functional medicine, I hit this home over and over again to those training in our Clinical Development Program: I cannot underscore enough how a careful, system-wide investigation followed by the enactment of an equally careful plan is the best chance of restoring and building resilience.

A FEW EASY MUST-DO-NOWs FOR INFLUENZA PROPHYLAXIS AND TREATMENT

Don’t forget vitamin D!

This seems so obvious, but judging from the recent labs in in my practice, people are indeed…forgetting. Even those of us who are regular D supplementers: If you slip out of the habit even shorter term your D levels will drop. In cold, darker climates, supplementation is essential.

“Reduced exposure to solar radiation, leading to a deficiency of vitamin D and hence impaired innate immunity, has been suggested as a trigger for influenza viral replication and as an explanation of seasonal influenza.”

Could it be so simple?

A recent meta-analysis published by British Medical Journal looking at vitamin D supplementation (both D2 and D3 studies were included) and risk of acute respiratory tract infection identified a significant risk reduction overall, but particularly in those with D deficiency at the start of a study (<25 nmol/L or 10ng/ml) who experienced a whopping 50% reduction in risk with supplementation. Authors noted benefits occurred in those taking vitamin D daily or weekly, rather than those who received a single, high-dose bolus, where no benefit was noted, even in individuals with very low levels of vitamin D.

From BMJ: “Why might use of bolus dose vitamin D be ineffective for prevention of acute respiratory tract infection? One explanation relates to the potentially adverse effects of wide fluctuations in circulating 25-hydroxyvitamin D concentrations, which are seen after use of bolus doses but not with daily or weekly supplementation.”

Palmitoylphospoethanolamide (PEA): Six randomized control trials you’ve never heard of with outcomes besting estimates of influenza vaccine efficacy.

 

With over 350 peer reviewed papers and a Nobel Prize all devoted to PEA and its many indications, it’s a remarkably underappreciated molecule. Note the significantly favorable outcome in 5 of 6 DBPC trials looking at acute respiratory disease/influenza listed above. PEA was marketed for the treatment of influenza as prophylaxis and treatment for the common cold under the brand name Impulsin in the 1960’s and 1970’s. Dosing was generally 600mg TID for up to three weeks; some studies continued with 600mg QD longer term. There are multiple mechanisms associated with this potently anti-inflammatory palmitic acid derivative, from inhibition of TNF-alpha and NFKb, to mast cell stabilization. In influenza, it is thought that PEA works by attenuating the potentially deadly cytokine storm. I encourage you to dive into the research. I suspect you’ll start using this molecule in practice, as we are.  Note that we are only purchasing PEA manufactured in Europe.

And vitamin C…are you prescribing enough?

Vitamin C, possessing a long, rich traditional history as playing a strong role in preventing infections, is a wise and affordable addition to an influenza protocol. A 1999 study looking a C in preventing and relieving acute respiratory illnesses (ARI) showed remarkable benefit (85% reduction in reported ARI as compared to controls receiving pain relievers and decongestants) in those treated with hourly doses of 1 gram of vitamin C over six hours, and 1 gram three times per day thereafter.  The University of Helsinki analyzed findings in two older randomized trials looking at various doses of C on the duration of the common cold: the finding was clear: more IS better. Those taking 8 grams of vitamin C on the first day of the cold only, reduced the duration by 20%. These studies need to be repeated, but the safety record of vitamin C means that we can and should be using it now.

And finally…it’s time to wash your hands. Practice “targeted hygiene” in flu season

Wash hands more often in flu season. Use a triclosan-free sanitizer if need be when near sick people (FDA literally JUST banned triclosan). That’s right. This is a low-hanging fruit in flu prevention. We want to be rational in our interpretation of the hygiene hypothesis always, but especially in flu season. The use of “targeted hygiene” is important in preventing influenza.

For the 2018 influenza, antivirals are working. Tamiflu will help wipe out the flu, especially if it’s started immediately, based on clinical presentation.

Here’s a link to a treatment table I created previously. It’s not exhaustive, but provides a useful start. Add and subtract as appropriate. There are plenty of immune boosters I’ve not included. Choose those you like. Access it here: Treatment Ideas for Influenza and Influenza

As an aside: was the astonishingly high rate of fatalities in the 1918 influenza a result of salicylate toxicity?

Published in the journal Clinical Infectious Diseases in 2009, a compelling hypothesis was posited by Starko suggesting the extremely high fatality rate, especially among young adults, associated with the 1918 influenza pandemic had something to do with salicylate toxicity. Physicians were routinely prescribing daily massive loads of aspirin- 8 to 31 grams per day (not aware of the possibility of hemorrhagic lungs, increased lung fluid and impaired mucociliary clearance. The marked October 1918 spike in death rates just preceded the JAMA, the US Navy and US Surgeon General’s recommendation of using aspirin for treatment.

Salicylate toxicity

The maximum adult dose of aspirin per 24-hour period is 4 grams; at 6.5 grams, referral to the emergency department is recommended. “A lick” of oil of wintergreen, at 98% methyl salicylate is toxic to a child 6 years or younger. 4mL or more in anyone 6 years or older may result in systemic salicylate toxicity. Of course, we know even a baby aspirin (81mg) is too much in some vulnerable individuals and has been associated with bleeds. We need to be careful here.

Related Reading:

Fire Cider Recipe
New Data Suggests More is not Better with Regards to the Flu Vaccine
OMG  – I Have the Flu!