August 31, 2009
This interview with Joel Gallant, M.D., M.P.H., took place on Aug. 11, 2009; since then, parts of the transcript have been updated with more recent information.
This is our second update with Dr. Gallant this year on what the swine flu pandemic means for people with HIV. We first spoke with Dr. Gallant in spring 2009, shortly after the global swine flu outbreak had begun.
You and I last spoke at the end of April, when swine flu was still known as "swine flu" instead of "novel influenza H1N1." You felt it probably was going to end up being a pretty big deal, in terms of the sheer number of people who actually were affected by the flu, but not so much in terms of the dangerousness of the actual virus. How have things panned out in the three months since then?
That prediction turned out to be true for the epidemic we've seen so far. It has been a big epidemic, to the point that the WHO [World Health Organization] has classified it at the highest level of pandemic classification. Keep in mind that those levels don't reflect severity of the disease; they only reflect the scope of the epidemic.
It's been a big pandemic, but it has not been a big killer so far, and things have quieted down a little bit in the summer up in the northern part of the globe, as we would expect it to. The real unknown is what's going to happen in the fall, when we expect to see a resurgence of the epidemic.
As we enter the latter part of the summer here in the Northern Hemisphere, the Southern Hemisphere is going through the latter part of its winter. How have things panned out down there, as far as you know?
There is certainly plenty of flu going around, but we have not seen a huge spike, which is what we're worried about in North America and the northern part of the globe.
Do we know how much of that might be due to poor reporting in the Southern Hemisphere, as opposed to the virus actually not being that dangerous?
It's certainly possible, although we have to remember that there has been reporting of the flu from all over the world. In many parts of the world, this is perhaps the best-reported epidemic we've seen for this kind of thing. So I don't think it would be just that.
It's so well-reported that the WHO recently told everybody to stop reporting new cases, because they have gotten so many reports -- basically every corner of the world now has documented infections. The last time I checked, almost 140,000 people had been officially diagnosed around the world, about 40,000 of those in the U.S.
As of about a month ago the U.S. was at 33,000, with 170 deaths. Worldwide, I think it was around 90,000 people infected. And that was the beginning of July.
It's probably reasonable to assume that many, many more people have gotten infected, and maybe even have died from it. Officially, I think 800 have died worldwide.
Of course, we have to remember that we would expect much more death with the normal seasonal flu. A lot was made in the U.S. about the fact that we had 36,000 deaths from seasonal flu -- a typical winter flu -- versus 170 from H1N1. Yet, the 170 deaths certainly got a lot more attention than the 36,000 annual deaths from seasonal flu.
But there is a big difference, in terms of who is at risk for death, with this flu versus seasonal flu. There are a lot of very important differences.
What are those differences?
Seasonal flu typically affects people at extremes of age -- older people or very young people and infants -- or people with chronic medical conditions. What's different about H1N1 is that -- in a way, like the 1918 flu pandemic -- it tends to affect young adults more severely. In fact, people who were born before 1957, if they're healthy, are generally somewhat protected. The further out they are from 1957, the greater their risk. This is not the typical pattern you would see with seasonal flu, where it's mostly going to be older people.
Other risk factors for severe disease with this flu would be:
Do we have any numbers in terms of how many of the people who were officially infected with H1N1, or those who have officially died, had HIV?
I haven't seen numbers like that. I would imagine that it's not a huge percentage, in part because we can treat the immunodeficiency of HIV. If people are on treatment and have a decent CD4 count, they are probably not at significantly greater risk, in comparison with somebody who has a chronic immunodeficiency that is not treatable.
So you would still feel that the precautions that you gave a few months ago are accurate for people who have HIV and might be concerned about swine flu?
Yes. I think it's something we all have to be concerned about. For the average person with HIV in this country, who is on antiretroviral therapy and is doing fine, I don't think their concern should be much greater than it would be for the general population. But I don't want to downplay the potential severity of this, if we see a resurgence in the epidemic in the fall -- as we expect to see.
For me, as a journalist, this is a tough balance to strike. Because I, on one hand, want to inform people responsibly, and I want to provide the full story and explain exactly what's going on, in well-measured terms. But at the same time, the Government Accountability Office recently issued a report to Congress saying we are not ready if there is a major outbreak of swine flu this fall. There seems to be a great deal of uncertainty about what we can expect, what we should be afraid of and what we should be prepared for.
Well, that's right: This is completely unpredictable. I think there's no question that we're going to have an increase in the number of cases in the fall. Everybody knows that that's going to happen. The question is, will it be a disastrous pandemic like 1918? Or will it be a more moderate pandemic like we've seen in some other years since then?
We are absolutely not prepared for a 1918-type flu pandemic. Whether we're prepared for a more moderate epidemic is unclear. I would say that a lot of people are a little bit pessimistic about that, as well.
Wow. So where does that leave us? Should we panic?
Yeah. Panic is a good thing. [Laughs.] No, no. We shouldn't panic, in part because there's really not much the individual can do.
There are certainly flu vaccines in development. Usually a flu vaccine takes about six months to be developed, and we're hoping that we will have it in October or November. Of course, the question of supply is important: Will we have enough? If not, who will get the vaccine?
[Editor's Note: As of late August, the United Kingdom has a shipment of H1N1 vaccine in storage, where it awaits licensing approval from the European Medicines Agency before it can be distributed. That approval is expected by early October.]
Another difference between 1918 and 2009 is that, in addition to -- hopefully -- a vaccine, we also have drugs that can treat this flu. So far, the flu drugs that we use are still effective. That could change, but for now, they're quite effective.
You're speaking about Tamiflu [generic name: oseltamivir] and Relenza [generic name: zanamivir]?
Yes, Tamiflu and Relenza. Those two drugs are active against this flu virus. In 1918, we had neither a vaccine nor treatment, and we didn't have antibiotics for people who developed bacterial complications. So there really was virtually nothing we could do about the flu back then. That's no longer the case.
Those are really important points. In terms of the strains themselves, there is some rough similarity between the 1918 and 2009 viruses -- they are both forms of H1N1, right?
But the environment is so utterly different this time around that, almost regardless, we would probably be better off?
Yes. I certainly think we will be better off. Of course, there's a potential for more rapid spread, just because the world is a much smaller place than it was in 1918. But even in 1918, there wasn't much that could be done to prevent global spread, and that's certainly the case now.
So then, when it comes down to the practical nuts and bolts for people who are living with HIV, what can people do to make themselves safe? Who should be most concerned about keeping themselves safe?
I think that the people who should be most concerned are people with very low CD4 counts. People with higher CD4 counts should probably have the same level of concern that anyone else would have.
What can you do? There's not a whole lot you can do. Obviously, you would probably want to avoid traveling into a place that was in the middle of a big outbreak. But as we saw with this pandemic, things may have started out in Mexico, but they quickly spread beyond that. So, restricting travel is probably of limited benefit.
I think people who actually are sick have a bit more control over the spread of flu than people who aren't sick. People who are sick need to stay home for at least seven days, or 24 hours after they recover [whichever comes first]. They need to cover their sneezes. They need to wash their hands a lot, and try to avoid spreading it to other people.
But if you're a person who doesn't have the flu and you're out in the world, in the company of others, I'm not sure there's a whole lot you can really do to prevent infection, other than just hand washing and the usual precautions.
So you wouldn't recommend, maybe, wrapping yourself in Saran Wrap, not shaking anyone's hands and putting a face mask on? OK, that's a bit over the top. But would you consider recommending that people shouldn't shake other people's hands?
I almost feel that shaking hands is going out of fashion, in general, anyway. But, yes; in the middle of a flu epidemic, I suppose that would be one thing. Certainly, we know that hand shaking is a good way to spread flu. It doesn't have to be from a sneeze or from a cough. Washing hands is a great way to limit any damage that's done from touching.
Masks are more helpful for people who have the flu than they are for people who don't. A very simple surgical mask put on somebody who has got the flu will help to prevent spraying the flu virus into the air. But if you're wearing a mask to try to avoid the flu, the typical masks aren't quite as effective. They need to be a more expensive, well-fitting, respirator-type mask, which is not as widely available as the surgical masks.
You're one for one so far in terms of predicting how the swine flu epidemic is going to unfold. Would you care to go for two for two?
All right. I'm going to try to be an optimist, and I'm going to say that we are going to see a moderately big epidemic in the fall, but that we'll have a fairly low fatality rate, in comparison with both the 1918 flu pandemic and seasonal flu outbreaks. I'll predict that we will not see the kind of disastrous 1918-type pandemic that is so famous now, and that is so dreaded.
The nightmare scenario is a genetic reassortment between the H1N1 and H5N1 viruses, which could result in a highly lethal, highly contagious pandemic. I think that's unlikely. If I were betting money, I would bet against it. But I can't let this talk go without at least mentioning the nightmare scenario.
[Laughs.] I appreciate that. I suppose what it comes down to is that there is a limit to what we, as individuals, have control over with respect to what's going to happen. But there are some common-sense precautions that we can take -- whether we have HIV or not, whether we have low CD4 counts or not -- to keep ourselves as protected as possible, and keep other people protected.
Yes, that's absolutely right. Common-sense precautions. In the end, my motto is: Don't worry about things you can't control. Easier said than done.
If only. But this is a good start. Dr. Gallant, thank you so much.
This transcript has been lightly edited for clarity.