Doctors Consider Children Key Players in a World Without Flu
Doctors who worry about the flu know their enemy. It’s about 3 feet tall. With a cough. And a really runny nose.
In epidemiological terms, children are in the same category as ticks, rats and mosquitoes: They are vectors of disease--in this case, one of humanity’s oldest and most persistent evils, the influenza virus.
Obviously this reservoir of contagion cannot be eradicated. So researchers are doing their best to contain it. In the most important series of developments since the invention of the influenza vaccine in the 1940s, they are working on strategies that should soon help stop flu at its source, the sick kid.
One new tool is already in hand: ZstatFlu, a $40 half-hour test that doctors use in their offices to reveal whether their aching, coughing, too-sick-to-get-out-of-bed patients actually have the flu.
Soon, doctors will be able to put this information to good use. On the near horizon is a new category of flu-fighting drugs that can shorten a siege of the disease or keep folks from catching it. And perhaps most important, nearing approval is a vaccine that kids will take without a fuss.
These breakthroughs make this a noteworthy moment in humanity’s efforts to control an ancient killer. Some scientists grouse that the flu does not command the kind of respect it deserves, probably because most people alive today simply do not remember how terrible it can be.
In a bad season, flu can be worse than any other infectious disease, even the Black Death of 14th century Europe. (The word “influenza” dates to 15th century Italy, when an epidemic was blamed on the “influence of the stars.”)
“It’s a flu research utopia now,” says Dr. Gilbert Schiff of Children’s Hospital Medical Center in Cincinnati. “All of a sudden, things we have been talking about for 30 years might come true.”
Doctors are especially happy to be getting an alternative to the flu shot. The standard flu vaccine works well; it’s about 70% effective during a typical flu season. But less than one-third of the population gets one.
The main obstacle is the crybaby factor. Safe and effective as it is, this is still a shot in the arm. Doctors say squeamishness about needles makes annual vaccination just too big an ordeal for most children, and lots of adults too.
The alternative should be on the market for the 2000-2001 flu season. It is FluMist, a vaccine developed by Aviron of Mountain View, Calif., that is sprayed up the nose. Vaccination causes a cool, tingling sensation and leaves a slight aftertaste described as somewhere between strawberries and medicine. It doesn’t hurt.
“Side by side with a flu shot, you quickly learn the difference,” says Dr. Pedro Piedra, a pediatrician at Baylor University. “With the nasal spray, they may grimace a little or even smile, but there’s not a lot of concern. After a shot, they cry and cry and cry.”
For the first time, doctors say, it should be possible to vaccinate children every fall. And that could keep everyone healthier.
Kids are flu incubators. When flu is going around, they almost inevitably catch it. The virus is highly contagious and youngsters have no immunity, something that comes only from having the flu or getting vaccinated. When they get sick, children spew out higher amounts of flu virus than adults do, and for a longer time. And of course, day-care centers and classrooms are the ideal environment for coughing, sneezing, dripping children to pass viruses around.
Eventually, they bring the flu home, and soon the whole family is sick.
Testing whether wholesale childhood vaccination will break this cycle is the goal of an unusual experiment that started in August in Texas. In Temple and neighboring Belton, Piedra’s team hopes to give the spray vaccine to 15,000 children--85% of all the youngsters between 18 months and 18 years. Then they will see what happens to adults.
The question: Will Temple and Belton grown-ups go to their doctors for flu-like miseries any less often than folks 60 miles away in Austin, where there is no childhood vaccination program?
Dr. Paul Glezen, the study’s co-director, believes vaccinating kids will cut adults’ doctor visits by more than half. “We would expect that, instead of 12,000 to 14,000 visits, we will see only about 5,000 visits,” he says.
Certainly this should be good for children too. In federally sponsored nationwide tests on 1,358 children last winter, flu struck just 2% who got FluMist, compared with 13% squirted with a dummy spray. Moreover, the new vaccine appeared to work better than the standard flu shot.
Every year, the government tries to guess which strains of the virus will circulate during the winter. Last year, it missed. The vaccine armed the body to resist flu strains called A/Shenzhen, A/Wuhan and B/Harbin-like. But the real culprit turned out to be a bug called A/Sydney.
As a result, last winter’s flu shot was almost worthless. But surprisingly, the FluMist vaccine proved to be 86% protective against A/Sydney, even though it aimed at the same strains of the flu as the shot.
Why? Unlike the flu shot, which is made from dead viruses, FluMist contains a live but weakened bug. The virus causes an infection and reproduces itself, even though it produces no symptoms. As a result, it triggers a more full-fledged immune system reaction than the shot can muster. And this gives the body an edge even against strains of flu it has never encountered.
The vaccine’s price has not been set, and too high a cost could limit its use. Nevertheless, doctors have high hopes for FluMist’s impact.
“If we could vaccinate all children annually, we could go a long way toward stopping flu transmission in this country,” says Dr. Michael Marcy of Kaiser Foundation Hospital in Panorama City, Calif.
Even when children come home with the flu, a new class of drugs in large-scale testing should be useful. The medicines are called neuraminidase inhibitors for their ability to block a protein the virus needs to produce new copies of itself.
The drugs are about as effective as flu shots for warding off flu. Although not intended as substitutes for the vaccine, the drugs could protect unvaccinated folks who come into contact with flu victims, doctors say.
The drugs also speed recovery. If taken as soon as symptoms hit, they appear to shorten a bout by a day or two and make people feel considerably less miserable in the process. Two versions are racing toward approval, a Glaxo Wellcome spray called zanamivir and a pill code named GS4104 that was developed by Gilead Sciences Inc. and Hoffman-LaRoche.
Unlike two older flu medicines, Symmetrel and Flumadine, these drugs work against both influenza A and B, the two major strains of the virus, and have fewer side effects.
Some think these medicines could literally be lifesavers if--or when--flu mutates into a highly lethal form, as it does occasionally.
In a typical flu season--late December to early March--between 10% and 20% of the population catches the flu. For most, it’s a nuisance, a week or so of fever, cough and body ache. Still, it also kills about 20,000 Americans annually.
Most years, the virus evolves slightly, which means a new shot is required to stop it. But sometimes it makes a big genetic leap, acquiring a new guise that the human immune system is unprepared for. This has happened four times in this century, triggering worldwide outbreaks.
The mildest was the 1977 Russian flu, which was no more lethal than an ordinary flu. Worse were the 1957 Asian flu, which killed about 70,000 in the United States, and the 1968 Hong Kong flu, which killed about 34,000.
In a category by itself is the 1918 Spanish flu. One-third of the world’s population got sick. In the United States alone, 550,000 people died of the flu. Many now think that, worldwide, the death toll approached 40 million. Victims were often healthy people in their 20s who died in a few days of overwhelming pneumonia.
Dr. Jeffrey K. Taubenberger of the Armed Forces Institute of Pathology is deciphering the genetic makeup of the 1918 flu virus from fragments found in the preserved tissue of four victims. The goal is to figure out what made it so bad.
The work is about one-quarter done. But so far the virus looks perfectly mundane.
“All of the simple explanations for the virulence of the 1918 flu have been proven incorrect,” says Taubenberger. “We are left with the puzzle,” one that may not be easily solved, even when the entire genetic code is known.
Scientists say we are also left with the possibility that something like the Spanish flu will strike again. Some thought they saw it coming last year. In Hong Kong, a deadly strain of flu never spotted in humans suddenly leaped from chickens into people. The world’s flu experts feared the worst. But eventually, it became clear there would be no epidemic because the virus did not spread from person to person.
Nevertheless, says Dr. Robert G. Webster of St. Jude Children’s Research Hospital in Memphis, Tenn., “it alerted people to the inevitability that there will be a pandemic sooner or later.”
The flu-stopping drugs could be one important barrier against a new killer strain, assuming there are enough to go around.
“The antivirals will work beautifully in pandemics,” Dr. Arnold Monto of the University of Michigan predicts, since they stop all strains of flu. “The problem is logistics and supply.”
No one expects drug companies to stock warehouses full of these drugs awaiting a nasty outbreak when everyone in the world will want them.
Vaccine makers will certainly go to work quickly to make a protective shot if a pandemic takes off. But even if all goes well, it could take six months. By then, the flu is likely to be worldwide.
If small amounts of vaccine become available early in a pandemic, doctors doing the experiment in Temple, Texas, believe their research will offer a practical strategy for doling it out: First, vaccinate those vectors of the flu, the children.
“We are looking for an efficient way to control an epidemic,” Glezen says. “A lot of data supports vaccinating children. If you know a pandemic is coming and you will only have enough vaccine for 30% of the population, this is an option of how to use it.”
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Is It Just a Cold, or Has Flu Taken Hold?
You feel lousy. But is it a cold or is it the flu?
Both are respiratory-tract infections. Both cause drippy noses. Both are most common in the colder months, flu between December and March, colds between September and May. Beyond that, they are quite different.
Flu symptoms usually appear a day or two after infection and start suddenly. Chills are often the first sign, along with cough, headache, a runny nose and sore throat. Next come fever and muscle ache, overwhelming fatigue and no appetite. It lasts six to 10 days.
A cold is almost always a much milder illness. Although it too produces a runny nose and cough, fever is rare and is mild at worst. Most symptoms usually disappear in four to 10 days.
