by Examined
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Monday, May 06, 2024 at 5:20:08a PDT
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In this post I’m going to provide a primary care heads up about H5N1 bird flu, speculate about where this may be headed, and finally throw some shade on all Republican and a few Democratic senators who have hamstrung us while trying to score points in the mask debate.
A long simmering issue is now rising to the level of primary care interest. Bird flu is increasingly spilling over into mammals like cows. American dairy farms are affected, and up to 20% of milk recently tested is coming up positive for the H5N1 virus. So far it looks like it is not contagious as long as it’s pasteurized.
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I have a feeling this particular H5N1 influenza virus (clade 2.3.4.4b) which has been brewing for years now and decimating wild birds, is going to be a human thing eventually. There is ample opportunity for a virus circulating in cows to test the waters in humans and pigs. Farm conditions are often cruel, and I’ve read that cows are often fed “poultry litter” – a mix of chicken excrement, spilled feed, feathers, and other waste scraped from the floors of industrial chicken and turkey plants. Makes me want to be a vegetarian for many reasons. Pigs are a stepping stone to humans, so if we hear of H5N1 spreading in pigs it will be time for even greater concern. But I am not freaking out yet. From what I’ve read and the experts I listen to, it’s probably not an imminent thing, circulating as it has been through dairy cows for the past 4-5 months without a significant spillover into humans, and having first been detected all the way back in 1996.
Understandably, people are not prepared for another pandemic. Psychologically or physically. Doctors are not either. Yet I’m cautiously optimistic as a family doc who might yet be drafted into another round of service. The purported utility of Tamiflu/oseltamivir as an antiviral against this H5N1, the candidate H5N1 flu vaccines we already have in hand, the improved infrastructure to dial up new mRNA vaccines via Pfizer/Moderna and nanoparticle vaccines via Novavax, the ubiquity of respirators and PPE compared to 2020 should we need them, the much better understanding of ventilation and infectious respiratory particle continuums versus dichotomies, old fashioned hand washing and no shortage of soap, cows sick with H5N1 having mostly non-severe diarrheal illness and not reportedly dying en masse, the “mild” human case in the Texas dairy farmer just described in the New England Journal of Medicine – all combine to keep me sane, vigilant, and patient with the science.
Here is an aside about the case report from the NEJM. It seems this dairy worker served up his diagnosis to doctors quite responsibly with full disclosure of contact with sick cows. Usually if you listen to patients, and then ask a few questions, they will lead you to their diagnosis. The dairy worker was treated with Tamiflu. He mostly had a wicked case of conjunctivitis without much respiratory tract involvement:
I also like that his household contacts were given a 10 day course of Tamiflu to prevent illness. This prophylaxis works about 90% of the time to prevent transmission of regular human influenza, though it might not have mattered here because this bird flu does not yet have the tools for sustained human to human transmission. Technically, the virus we are gaming out doesn’t exist yet. It’s a handful of future mutations away. Still, I’ll take this case report.
But I do worry about those sources citing 52% human mortality rates in the 900+ people who have sporadically contracted some version of H5N1 bird flu since it was first discovered in 1996. Yet it is highly likely that this is an overestimation and many cases have not been identified. But even a 5% mortality rate would be disastrous. I worry about how birds, poultry, and sea mammals like elephant seals and sea lions suffer incredibly high mortality rates up to 90%.
PRIMARY CARE COMMENTARY
I won’t eat unpasteurized dairy products like milk and cheese. I usually try not to anyway, except for some insanely good cheese every once in a while from DiBruno Brothers in the Italian Market of Philly where Rocky trains.
Pasteurize at will. Lawmakers should ban unpasteurized dairy for a while instead of scoring points arguing about masks. See below.
If Mr. Bluebird lands on my shoulder, I will calmly brush him away and then wash my hands. I won’t handle dead birds, or if I do it will be with major caution.
I’ll get a vaccine if this takes off (assuming I’m offered one as a front line health care worker). The CDC has been testing existing H5N1 vaccines in ferrets, and has found that vaccination appears to offer cross-protection against the virus from the man who was infected in Texas. They are also looking at people who received a previous H5N1 vaccination (not a regular flu shot that we can get) and so far encouraging results for theoretical protection.
If this takes off our regular flu shots won’t help much, so we’ll need an H5N1 specific shot. Will you be able to get one?
Here are 5 key points from an article written by rockstar Helen Branswell of STAT news:
- The world’s current capacity for producing flu vaccines (about 1.2 billion trivalent doses annually) is likely inadequate to vaccinate a large portion of the global population during the first year of an H5N1 pandemic, as two doses per person would likely be needed.
- Challenges include the relatively poor immunogenicity of H5N1 vaccines, requiring higher antigen doses or adjuvants to be effective, as well as potential bottlenecks in adjuvant production capacity. The stockpiled H5N1 vaccines may provide limited protection.
- While mRNA vaccines could help increase production speed, regulators may want more data on their efficacy and safety for H5N1 before fully embracing them for pandemic use.
- As with past pandemics, there are concerns that wealthy nations with manufacturing capacity will have early access to vaccines, while lower-income countries without domestic production may face delays, perpetuating inequities.
And last but not least it bears mentioning that our political chickens may yet come home to roost. Please consider the following not as a red/blue reader, but rather as a nonpartisan reader who genuinely cares about the societal implications of each government step into scientific and public health realms.
Recall that red senators, and a handful of blue senators, joined hands in an act of public health malpractice to ban any federal mask mandates on passenger airlines, commuter rail, rapid transit buses, and any other transportation program funded through the 2024 fiscal year (ending 10/1/2024) regardless of the situation. Such political posturing, and the conflation of a public health tool with a means of oppression, really hamstring our ability to contain what could become a more severe pandemic than the one we just experienced. Feel free to let your Senator know that they are playing with fire, not just with this bird flu possibility, but also with any future Covid variant that might evolve, and that masks do work when we need them (1, 2).
Also feel free to contact Senator Ted Cruz, who introduced an even more severe bill called the “No Mask Mandates Act of 2023.” This act would:
- Prohibit federal agencies or offices from issuing any future orders that mandate face masks or using previously appropriated federal funds to implement or enforce masking requirements to respond to COVID-19
- Prohibit the Department of Health and Human Services from requiring face masks in response to any declared public health emergency.
Senator Cruz is from Texas, the apparent epicenter of the current dairy cow problems.
TAKE AWAY
Keep an eye and ear on this bird flu.
Don’t consume unpasteurized dairy.
Don’t worry just yet.
Allow scientists and public health to keep doing their thing!
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I hope this was helpful. At the very least it provided an opportunity to craft an article title with a memorable throughline. Please add your preferred email to this list on Examined to directly receive actionable updates on flu, Covid, prevention, and other vital primary care topics from me. Have a great week 💪
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[This post originally published on Examined here.]
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