[Paleopsych] WP: The Fear Contagion
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Mon Oct 17 02:06:05 UTC 2005
The Fear Contagion
A Flu Quarantine? No, Sir
By Wendy Orent
Sunday, October 16, 2005; B01
For two years, a deadly strain of chicken flu known as H5N1 has been
killing birds in Asia. While slightly more than 100 people are known
to have contracted the disease, and 60 of them have died, there is
still no sign that the flu has begun to spread from person to person.
That hasn't prevented a recent outbreak of apocalyptic warnings from
health officials and experts about the specter of a worldwide
pandemic. In Hurricane Katrina's wake, health officials in the United
States are talking more and more about pandemic preparation. Some of
these ideas -- such as stockpiling vaccines -- are sensible, whether
or not bird flu turns into a human disease and begins to spread
But other ideas aren't. A few scientists have suggested "priming"
people with a dose of the new vaccine against H5N1 before we even know
whether a pandemic is coming. Vaccinating large numbers of people
against a disease that may never appear carries its own risks.
Remember the swine flu debacle of 1976? At least 25 people died from
vaccine complications and no epidemic ever erupted. That should be
Another dangerous idea for pandemic preparation has come from
President Bush. Earlier this month, he suggested using the military to
enforce a quarantine. "Who [is] best to be able to effect a
quarantine?" he asked rhetorically at a press conference. "One option
is the use of a military that's able to plan and move."
The very term quarantine can be misunderstood (not to mention the
military's role). Did the president mean gathering those exposed to
flu in a single location and forcing them to stay there? Did he mean
isolating them in their homes? Cordoning off whole communities where
cases crop up? Not all quarantines are alike; each carries its own
risks and benefits.
If this were idle presidential speculation, it wouldn't be worrisome.
But he isn't the only one talking about quarantines and calling in the
troops. In an Oct. 5 interview on "The NewsHour With Jim Lehrer,"
Julie Gerberding, director of the Centers for Disease Control and
Prevention, also wondered whether the government would need to turn to
"containment" or "quarantine the people who are exposed." She too
remarked that the military or the National Guard might be summoned "to
maintain civil order, in the context of scarce resources or an
overwhelming epidemic. . . . It would be foolish not to at least
consider it and plan for that as a possibility."
This is an example of a cure that is as frightening as the disease. It
is hard to imagine how the military would oversee a quarantined area.
If a health worker, drug addict or teenager attempted to break the
quarantine, what would soldiers do? Shoot on sight? Teenagers and
health workers were the people who most often violated quarantine
rules in Toronto during the severe acute respiratory syndrome (SARS)
scare in 2003. Moreover, the use of a quarantine to control a flu
pandemic isn't only a potential threat to life and civil liberties;
it's also a waste of money, resources and time. The reason: There
isn't any kind of quarantine that will do any good -- at least not for
a pandemic influenza.
Quarantine, from the Italian "quarantina," which means "space of 40
days," dates from 15th-century regulations devised in certain Italian
cities to control the spread of plague by sequestering those thought
to have been exposed to the disease. Along with isolation -- secluding
those who are clearly sick -- it can be an effective tool for
controlling outbreaks of certain types of disease. In 1910 and 1920,
before antibiotics, plague experts in Manchuria controlled several
deadly outbreaks of pneumonic plague using quarantine and isolation
alone. But pneumonic plague, now rare, spreads in a very different way
than flu does. Pneumonic plague germs are coughed out in large
droplets that quickly fall to the ground. If you are more than six
feet away from a plague patient, you're unlikely to catch the disease.
Also, plague patients are typically very ill before they can transmit
the germ to others. "There is no disease more susceptible to
quarantine than plague," wrote the physician Wu Lien-teh, who helped
break the Manchurian epidemics.
Influenza is entirely different. The virus spreads explosively.
Coughing, sneezing, or even speaking launches flu particles in an
aerosol cloud of tiny droplets, which can drift in the air for some
distance. Physician and flu researcher Edwin Kilbourne, who worked
with flu patients during the pandemic of 1957-58, points out that
people with flu may shed the virus even before they know they're sick
-- not much, but enough to transmit the disease. Worse, some 10 to 20
percent of flu patients have subclinical infections; they never look
sick at all. Yet they can still spread infection. Faced with a flu
pandemic, you'd hardly know where the disease was coming from.
How can you quarantine a disease like that? According to Kilbourne,
you can't. "I think it is totally unreasonable on the basis of every
pandemic we've had," says Kilbourne. "Every earlier pandemic seeded in
multiple foci at the same time. Quarantine simply will not work."
Indeed, a strictly enforced quarantine could do more harm than good.
Herding large numbers of possibly infected people together makes it
likely that any influenza strain passed among them would actually
increase in virulence. Usually, in order to spread, human flu germs
need hosts mobile enough to walk around and sneeze on other people.
Those flu strains so deadly that they kill or disable their hosts
won't get the chance to spread and will die off. This keeps human flu
virulence within bounds.
The signal exception is the 1918 flu, which acquired its extreme
lethality, according to University of Louisville evolutionary
biologist Paul W. Ewald, in the crowded and terrible conditions on the
Western Front during World War I. Troops by the train and truckload
were constantly being moved in and out of this petri dish, meaning a
severely flu-stricken soldier didn't have to move much to infect
Suppose that a government official today decided to round up exposed
people and move them to a space like the Superdome in New Orleans.
It's unlikely that even a crowded Superdome could replicate the
conditions on the Western Front. But, depending on how densely packed
people were, you could expect the flu strain trapped among them to
increase in virulence. You'd be breeding a deadlier flu.
If you let people walk around freely, only those strains mild enough
to allow people to stay on their feet would spread easily.
If quarantine won't work, what would? What about medication? Kilbourne
is not optimistic about the vaunted (and expensive) antiviral drug
Tamiflu, which can be taken to prevent or treat flu. "The problem with
antivirals is that they are untried on any mass basis," says
Kilbourne. "How long are you going to keep people on antivirals? Also,
we don't know about any side effects of the newer antivirals. Older
antivirals cause neurological problems in older people."
Kilbourne thinks that preventive vaccines are our best, and only,
strategy for combating a pandemic flu threat. The new vaccine,
developed with National Institutes of Health sponsorship, shows some
ability to protect. But Kilbourne, who in 1969 developed the first
reassortant flu vaccine (one made by combining snippets of genetic
material from different flu strains), isn't enthusiastic. First, the
new vaccine must be given in two doses, at very high concentrations.
And it's hard to grow. Kilbourne adds, "We don't have enough if a
pandemic happened tomorrow."
Still, vaccination is the gold standard for pandemic preparation --
once we know that a contagious human disease is emerging and the risk
of vaccination becomes less than the risk of disease.
That's a long way from now. Despite all the hysteria, there isn't a
shred of evidence that a pandemic is actually on the way. Developing
new flu vaccines is a useful thing to do. Pandemic or not, flu kills
thousands every year. But devising quarantine plans is useless.
orentw at mindspring.com
Wendy Orent, an Atlanta-based writer, is the author of "Plague: The
Mysterious Past and Terrifying Future of the World's Most Dangerous
Disease" (Free Press).
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