Perhaps you have discovered for yourself that I am always the last to write a post on a ‘hot’ topic. I am definitely the slowest writer (and thinker?) on this blog, starting each post at least a week before it is up. So the faster writers weigh in first and I am left with clean up.

As I finish writing on Thursday, there have been 892 cases of H1N1 aka Swine flu and 2 deaths in the US. Looks like the world has avoided a disastrous pandemic like the 1919 flu that killed off 2 to 5% of the world. For now. Maybe. I hope.

However, the flood of nonsense about the flu far exceeds the infection rates from H1N1. This entry will be the limited by necessity. The quantity of quackery (9) far exceeds my ability to type. I thought that influenza virus replicated and spread fast. It pales next to the flu woo.

First off

The conspiracy loons are out again. Sorry. I can’t say theorists, as a theory does not, to the best of my understanding, apply to fantasy.

One form of conspiracy suggests that the new strain of influenza could not have happened naturally; that it has been manufactured by the government.

“The latest bioterrorism attack by the New World Order is likely a beta test. Yes, it is a bioterrorism attack. It was a hybrid strain created from human, swine, and bird flu from North America, Europe, and Asia. It was created in a laboratory. This doesn’t happen in nature.(1)”

But it does happen in nature. All the time. Making a new flu is the modus operandi of the influenza virus.

There are lots of flu’s. Human, swine, bird, cat, dog, and horse influenza. And the flu is different from most viruses in that it can jump species. So a bird flu can infected a pig. And a human flu can infect a pig. And pig flu can infect, well,  a pig. I am glad I am not a pig.

The other difference between influenza and most other viruses is that influenza DNA is in segments. Usually a virus has one long piece of DNA or RNA. Influenza has seven or eight segments of RNA.

So if a pig is simultaneously infected with pig, bird, and human strains of influenza, as it reassembles itself, it takes a few segments of pig RNA, a few segments of human RNA and a few segments of bird influenza RNA, and, much like what occurred in Frankenstein, you have a new strain of flu constructed from the parts of other flu’s. Like Frankensteins monster, it can go berserk, killing and maiming. It happened in 1919, infecting half the world and killing 2 to 5%. Or, soothed by music (can I stretch a metaphor?), it can be calmed and hurt no one, as happened in 1976 and, maybe, 2009.

When you get those new strains (what we call in the biz the genetic shift), there is no prior immunity in the population so the disease can spread rapidly and, if an aggressive strain, kill. This genetic shift has occurred regularly in history and we are somewhat overdue for a pandemic strain of influenza. You cannot predict in advance when the genetic shift will occur and, when it shifts, if the new strain has the right combination of virulence (the ability to kill) and infectivity (the ability to spread) to cause a catastrophic pandemic. Avian flu, H5N1, is virulent, but currently not infectious in humans. The H1N1 seems infectious but not virulent. Let us hope these two strains do not meet in a pig somewhere and re-assort their genes to give us the Hannah Montana flu with the best of both worlds, virulence and infectivity.

That “this doesn’t happen in nature” is completely, totally 100% wrong. The production of new strains of influenza goes back forever, or at least 1890, which is the same thing.

(from Mandel, Douglas and Bennett, the Principals and Practice of Infectious Diseases)

Why would they the evil government release such a virus into the world? Evidently some think the world is run by Ra’s al Ghul , and the purpose of releasing the flu is to decrease over population. Yes, the world is over populated, so the our secret overlords have made a new strain of flu and released it on an unsuspecting world to thin the herd. Now if it were my goal to decrease world population, influenza flu would be the last virus I would choose as a bio weapon. It ‘only’ kills, at most, 5% of those infected. Rather than starting the infection in a Mexican pig farm, I would release it in the naked mole rat warrens of Chicago O’Hare airport to insure maximal spread. And lastly, I would be competent enough to make a strain of flu that was, oh, I don’t know, lethal.

The combination of a lack of knowledge of history and biology is astounding in these web sites. As I mentioned above, flu changes. Constantly. One of these years, maybe this one, may in 25 years, there will be a perfect storm of a new strain of flu with both high infectivity and high virulence to which the world lacks immunity and a lot of people will die. It did not pan out in 1976 and it may not pan out in 2009, but, like earthquakes and volcanic eruptions, a pandemic will happen again.

The another reason this strain of influenza is alleged to have been released into the wild was by Big Pharma to sell more drugs and vaccines.

This has two variations. The first is that the swine flu is a natural phenomena that Big Pharma is taking advantage of to sell more drug. Well, duh.  But Big Pharma are pikers compared to the woo sites for pushing their antiflu nostrums, often while complaining about the avarice of the makers of Tamiflu.

The other is that the virus was deliberately released by the government to allow Big Pharma to take advantage of the pandemic to sell more Tamiflu. One web site calls Swine Flu the Big Pharma Bailout.

I can’t even begin to wrap my head around the idea that H1N1 is a joint effort of the Mexican drug cartels and al Qaeda  to accomplish some nefarious scheme or other. All conspiracy ideas are, at their core, incomprehensible when tested against reality.

So many conspiracies that the government is evolved in: bigfoot, UFO’s, Kennedy assassination cover up, suppressing the truth about alternative medicine, faked moon landings and on and on. How do they find the time to be involved in so many secret projects and still get the mail delivered, I will never understand.

You do not need a conspiracy theory to understand why one frets when a new influenza starts. Reality is far more distressing.

The other oddness in many of the flu woo sites is saying that the swine flu of 1976 is the same swine flu as 2009. The argument is since swine flu in 1976 didn’t spread or kill and the 1976 vaccine was more dangerous than the disease,  we should not worry about the swine flu of 2009 and we should avoid vaccines as the current flu will behave the same.

They are not the same. They are different strains, altered over time, and already are manifesting different pathogenicities. The flu strain from 1976 never became infectious and did not spread beyond Fort Dix New Jersey. The 2009 Swine seems to be spreading quickly around the world and has, maybe, an infectivity rate in families of about 25%. It is also apparently causing a mild to moderate disease in most people.

And it appears that rather than being a new strain, this is a direct descendent of the H1N1 from 1919. It is thought that in 1919 the influenza entered the pig population at the same time it infected humans, although pigs had a much less severe disease in 1919, and it has been circulating in the pig population ever since, evidently attenuating its virulence. Saying that this strain is the same as 1976 and we need do nothing is not rational. Equally irrational would be to say it is the equivalent to the 1919 strain and reacting accordingly. I do feel pity for those that have to make the decision as to how to react to the potential of a pandemic. If it doesn’t pan out, they look like over-reacting fools, and if it recapitulates 1919, everyone will call for their heads.

Today on the morning news program Wake Up and Panic America, or some such show my wife had on as we prepared for work, I heard the newscaster solemnly assure the American people that the flu ‘had not mutated yet” and was not yet able to kill people.

One wonders why Americans are less than knowledgeable about science when such a phrase, incorrect in general and in the specifics, appears to be the stock phase on the TV.

Of course influenza is mutating. Viruses are sloppy at reproduction. Millions of viruses are being made and there is the slow, inevitable genetic drift that ensures that the strain at the beginning of the flu season is slightly different than the stain at the beginning of the season. That happens every year in every strain of flu. What the flu does not usually do is mutate towards any goal, like increased virulence. If, as mentioned above, the Hannah Montana strain is produced in some pig somewhere, that will not be a mutation any more than the my children are a mutation of me.

An exception to this may be avian flu. The current bird flu prefers to bind to α-2,3–linked sialic acids, which are only found  deep in the lung and whereas human influenza viruses bind preferentially to α-2,6–linked sialic acids, which are in the upper airway. It is a worry with the bird flu that simple mutations (or meeting a swine flu) could change its preference from lower airway sialic acids to upper airway sialic acids with a marked increase in potential infectivity. There is not an issue for the current swine flu.

The ones to really suffer are the pigs. The disease is spread human to human. It is not spread by eating pork. Pigs are only a potential source for the disease if you are a pig farmer. Egypt killed 300,000 pigs and in the Iraq zoo (they have a functioning zoo!) they killed the Boars out of fear of influenza transmission. Bad mistake should the flu lead to a fatal pandemic a-pork-alypse (5): they have removed an important source for food.

Some web sites have blamed are the factory farms for the outbreak (6).

“To understand how this happens, you have to compare two farms. My grandparents had a pig farm in the Swiss mountains, with around twenty swine at any one time. What happened there if, in the bowels of one of their pigs, a virus mutated and took on a deadlier form? At every stage, the virus would meet stiff resistance from the pigs’ immune systems. They were living in fresh air, on the diet they evolved with, and without stress – so they had a robust ability to fight back. If the virus did take hold, it would travel only as far as the sick hog could walk. So if the virus would then have around twenty other pigs to spread and mutate in – before it would hit the end of its own evolutionary path, and die off.

If it was a really lucky, plucky virus, it might make it to market – where it would come up against more healthy pigs living in small herds. It has little opportunity to fan out across a large population of pigs or evolve a strain that could be transmitted to humans.

Now compare this to what happens when a virus evolves in a modern factory farm. In most swine farms today, six thousand pigs are crammed snout-to-snout in tiny cages where they can barely move, and are fed for life on an artificial pulp, while living on top of cess-pools of their own stale faeces.

Instead of having just twenty pigs to experiment and evolve in, the virus now has a pool of thousands, constantly infecting and re infecting each other. The virus can combine and recombine again and again. The ammonium from the waste they live above burns the pigs’ respiratory tracts, making it easier yet for viruses to enter them. Better still, the pigs’ immune systems are in free-fall. They are stressed, depressed, and permanently in panic, making them far easier to infect. There is no fresh air or sunlight to bolster their natural powers of resistance. They live in air thick with viral loads, and they are exposed every time they breathe in. “

It’s a nice story, but ignores influenza biology. Factory farms are probably the reason new strains of flu do not originate in the US. You get new strains not when influenza mutates (the aforementioned genetic drift) but when it gets new DNA from re-assortment (the shift). The shift occurs when humans, birds and pigs live in close proximity, like in small farms found in SE Asia.

Besides, the 1919 pandemic preceded the rise of factory farming and the record of pandemics stretches far into our agrarian past, when the world was full of eco-friendly, stout gentleman-farmers. We are overdue for a good pandemic. If factory farming were to blame, I suppose we should have seen more rather than fewer pandemics last century. It could also be argued that dense pig populations lead to less infectious, less virulent organisms as the crowding helps facilitate spread of virus. If the next pig is a cough away, the virus need not be particularly infectious or virulent. Highly virulent infections often become less so as they spread through a population, becoming attenuated. Rapidly killing your host is not an efficient way to spread.

Factory farms have many infectious disease issues, but helping evolve new hyper virulent flu may not be one of them.

Then there is prevention and treatment flu woo.


Wash your hands often and well. Easy enough. Infected secretions are on the phone (think Golgafrincham). You touch the phone and, by the magic of the finger, it is transferred to your mouth or nose and you get the flu. No one seems to object to hand washing.

Masks? Interesting question. Do masks prevent flu?

Well, the counterfeit masks no not. Our pharmacist informs me that counterfeit N95 masks are coming into the country. But lets say you have a real n95 mask. Will it work? Interestingly, the data to support n95 masks to prevent viral infections is not good. Most of the data is from surrogates or other, similarly sized virus. Are there clinical data to suggest that n95’s will prevent flu? Not that I can find. It should work, but should is not will.

A surgical mask, which is used to prevent the surgeon from dribbling on the wound, lets about 20% of viral particles through. The n95 lets in 5% if used correctly. If I were being exposed to an infection that was spread in part by breathing it in, I would prefer to inhale 5% of the potential infection rather than 100%. Whether that would be enough to prevent the acquisition of swine flu will depend on how infective this strain is.

There is, in the flu woo writings, perhaps a double standard. In medicine we recognize that benefits are incremental. No single prevention is 100% effective and prevention of infection is due to the summation of multiple interventions: sanitation, nutrition, vaccination, and medication. Are masks 100% effective? Nope. Are they 100% worthless? Nope. The truth lies somewhere in between. Masks are not a panacea, but then no single intervention in medicine is.

This is contrasted with woo therapies, which are often touted as the one true therapy.

Currently, every known nostrum possible is offered to combat the flu instead of the antiviral Tamiflu. As the Natural News (10) says:

“since swine flu is only a few weeks old, it is impossible for any substance to yet have “scientific evidence” of efficacy, including government-recommended anti-virals like Tamiflu. Technically speaking, there is zero credible scientific evidence that Tamiflu works to treat swine flu infections, either. Where are the studies? The scientific papers? There are none, precisely because swine flu is too new to have been carefully studied by anyone.”

That is true. Technically. At a technical level, on some days my whole practice is unproven. There is zero credible evidence, at least by Natureal News standards,  that antibiotics work for a particular infection. I know the organism (say H1N1), I know what organ  is infected (say the lung). I know whether in the lab the infection is susceptible to a given antibiotic (say Tamiflu), and I know if similar organisms are susceptible in that space, then I can alter the course of infection  with antibiotics (like occurred with prior influenza strains). Based on biologic plausibility and the Infectious Disease Law of Similars, Tamiflu should be effective. This line of reasoning is not limited to Tamiflu. For example, I have a patient with an MRSA hip infection who is allergic to Vancomycin. There are no series of MRSA in hips, with the patients similar co-morbidies, treated with any of the alternative agents for MRSA. Yet oddly enough, I expect her to respond to the antibiotic because we have a long track history of knowing that if it is sensitive in the test tube,  and has been effective in other infections, it will often work in the patient.

The natural news continues:

“I’m not against Tamiflu. It’s a very effective anti-viral drug, thanks to the fact that it’s derived from a natural anti-viral herb. If I were infected with swine flu and offered some Tamiflu, I’d take it, too.”

The naturalistic fallacy in full display. Tamilfu’s origin has nothing to do with its efficacy. It is effective because chemists have modified shikimic acid, from Chinese Star Anise, to a molecule that specifically interferes with the influenza viral neuraminidase (11):

Being the end result of 13 steps that massively alters the structure of the molecule, it is a wonder that the Natural News approves of its naturalness.

Chinese Star Anise being in short supply, chemists have developed at least three ways of bypassing the need for shikimic acid completely. Will the resultant Tamiflu be rendered ineffective because it is not longer derived from the natural product?

As an aside, as best as I can determine, there are no intrinsic antiviral effects from shikimic acid on the influenza virus.

The argument from Natural News appears to be that since plants are infected with viruses and therefore have anti-viral defenses, by consuming plants, you get the benefit of the plant anti-viral molecules.

This would be a good reason to smoke, it humans could be infected with the tobacco mosaic virus. But we aren’t. A plant has no biologic reason to have a specific anti-influenza molecule like a neuraminidase inhibitor, because plants are not infected with influenza, something about not having a lung.

Some flu woo is interesting, he writes sarcastically, like homeopathy or enemas and detox. If you are getting a respiratory virus in your colon, you have greater issues to worry about than the need for a colonic detox. There’s blood electrification, and colloidal silver and a huge list of herbal products.

What does the medical literature say about sCAMs and the treatment of influenza? There are a smattering of studies that have evaluated these products for the prevention and treatment of influenza.


Perhaps the oldest and most popular nostrum specifically suggested for influenza is oscillococcinum. Oscillococcinum (12) is a homeopathic preparation of duck liver and heart liver that has been allowed to autolyse for 40 days. Really. This preparation has an odd history, even for homeopathic remedies. Joseph Roy, a French physician during the Spanish flu of 1917, examined the blood  of influenza patients under a microscopeand saw “a bacterium that consisted of two unequal balls that performed a quick vibratory motion. Roy called them oscillococci.” Sounds like he was seeing brownian motion artifact.

There are no oscillococci. They are the N-Rays of homeopathy. He found these oscillococci in every disease he examined and concluded there were the cause of everything from flu to eczema. Since oscillococci were found in every disease, a homeopathic preparation of oscillococci would be a universal cure for all disease.

Here is how it is made (12):

“Since 1925, Oscillococcinum has been prepared as follows. Into a one litre bottle, a mixture of pancreatic juice and glucose is poured. Next a Canard de Barbarie (duck) is decapitated and 35 grams of its liver and 15 grams of its heart are put into the bottle. Why liver? Doctor Roy writes: “The Ancients considered the liver as the seat of suffering, even more important than the heart, which is a very profound insight, because it is on the level of the liver that the pathological modifications of the blood happen, and also there the quality of the energy of our heart muscle changes in a durable manner.” … After 40 days in the sterile bottle, liver and heart autolyse (disintegrate) into a kind of goo, which”

then undergoes homeopathic dilution. And is it diluted to 200 C. That’s 1 part in 1000000000000000000000000000000000000000000000000000000000








The known universe is not large enough to dilute one atom to that degree.

Now I thought that homeopathic treatments were individualized. Except when they are not, as in the case of Oscillococcinum. One wonders, since the oscillococci are non-existent, how duck liver/heart adheres to the “like cures like” manifesto, since neither the duck heart nor the duck liver, although delicious, causes flu symptoms?

Does it work? Should it? As a remedy, it violates the principals of both real medicine and magical homeopathy.

There have been clinical trials with Oscillococcinum, and, for the sake of brevity, I quote the Cochrane review (13):

“Seven studies were included in the review, three prevention trials (number of participants (n) = 2265) and four treatment trials (n = 1194). Only two studies reported sufficient information to complete data extraction fully. There was no evidence that homeopathic treatment can prevent influenza-like syndrome (relative risk (RR) 0.64, 95% confidence interval (CI) 0.28 to 1.43). Oscillococcinum treatment reduced the length of influenza illness by 0.28 days (95% CI 0.50 to 0.06).”

The Cochrane reviews are always punctilious about language. Patients who received Oscillococcinum were better 6 hours faster. There is no good reason to suggest causality, and while doubtful it is a real effect, rather than artifact of clinical trials, it is also a duration that is clinically irrelevant.

Oscillococcinum is worse than Tamiflu, which has barely clinically relevant results, decreasing the duration of illness a little over a day. Its why prevention of influenza (vaccine), if available, is always better than treatment.

Other CAM

The same lack of efficacy was found for P. quinquefolium, Sambucus nigra, Kan Jang, which failed to show benefit in the treatment of influenza (6):

“In conclusion, the effectiveness of any complementary and alternative therapy for treating or preventing seasonal influenza is not established beyond reasonable doubt. Current evidence from randomized controlled trials is sparse and limited by small sample sizes, low methodological quality, or clinically irrelevant effect sizes. For avian influenza, no data are currently available. These results strengthen conventional approaches for seasonal influenza. (6)”

Chinese herbs have also fared badly when evaluated critically:

“The present evidence is too weak to support or reject the use of Chinese medicinal herbs for preventing and treating influenza (13).

Otherwise trying to find references specific to influenza and various combinations of alternative and complementary medicine clinical trials yields so little research that I am sure those at the Natural News would never suggest them as therapeutic options for H1N1 since there is ”zero credible scientific evidence that (natural preparations) works to treat swine flu infections.”

I did find

” Treatment of fever due to exopathic wind-cold by rapid acupuncture, from J Tradit Chin Med. 1992 Dec;12(4):267-71.

57 cases of common cold, influenza, acute tonsillitis and acute bronchitis were treated by rapid needling with filiform needles at Dazhui (Du 14), Fengchi (GB 13), and Quchi (LI 11). The indices for observation were first determined, and the 19 cases that manifested an axilla temperature drop of over 1 degree C after treatment and a ratio of < 0.3 of the main symptom scores after treatment were regarded as markedly effective; the 27 cases that manifested an axilla temperature drop of 0.5-1.0 degree C and a symptom score ratio of 0.3-0.6 were regarded as effective, and the 11 cases that manifested an axilla temperature drop of < 0.5 degrees C and a symptom score ratio of > 0.7 were regarded as failures. The total effective rate was 80.7%. Analysis of the individual patients indicated that the peripheral blood leucocyte and lymphocyte counts differed insignificantly after needling, while the body temperature, rate of respiration, pulse, blood pressure and acupoint temperature all dropped, with a simultaneous increase in the percentage of T-lymphocytes. The immediate effects were especially marked in fevers due to exogenous wind and cold.”

Which did make me giggle. All fevers break making the patient feel better. I am surprised acupuncture was not 100% effective, since it is the natural history of the disease.

There is no end of nonsense touted for the prevention and treatment of the flu; there is a very short list of those that have been clinically evaluated and all have been found wanting. I will mention the one piece of advice that may indeed be reasonable, with caveats.

Vitamin D

More than important for bone and calcium metabolism, vitamin D is an important hormone for immune function.

It has been noted that influenza occurs in the winter when the least amount of vitamin D is made from sun exposure. Several studies have demonstrated that people who are low in vitamin D are at increased risk for viral respiratory infections (7). Unfortunately, the one study that looked at vitamin D supplementation for the prevention of upper respiratory infections in normal people (vitamin  D levels of 63) had no benefit despite increasing the vitamin D serum levels (8). Equally unfortunately, as an ‘immune booster’, vitamin D does not improve the response to the influenza vaccine (18).

Vitamin D deficiency is not uncommon and increasing (18). So if you are vitamin D deficient, there may be benefit in taking supplemental vitamin D. But like all vitamins, taking extra does nothing. When the gas tank is full, there is no benefit in adding more gas. Vitamin D is not a panacea and of no utility as a therapy if you are replete.

Best bet for swine flu?  Wash your hands, don’t inhale, stay away from coughers. Get the vaccine if available (given the experience of 1976, that will be a hard sell). And hope H1N1 doesn’t meet H5N1 in some lonely pig.

And finally, don’t try a ‘pox party.’ Some parents take their kids to get chickenpox when there is an outbreak in the neighborhood so they have some control over when their child is infected (I will admit to some sympathy with this position in the pre vaccine era). There is a suggestion that similar parties should be held with swine flu patients (19). I would advise against it. One, you may end up passing flu on to someone less able to contain the disease and die. And, although the current strain does not appear to be that virulent, some people may, due to the wrong gene set, be predisposed to die from the flu (19). Unless your DNA has been. decoded, why take the risk?



(2) Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006207. Interventions for the interruption or reduction of the spread of respiratory viruses.

(3) Am J Infect Control. 2006 Mar;34(2):51-7. Do N95 respirators provide 95% protection level against airborne viruses, and how adequate are surgical masks?


(5) Thanks to Rebecca Watson of SGU for this hideous pun.

(6) Complementary medicine for treating or preventing influenza or influenza-like illness. Am J Med. 2007 Nov;120(11):923-929.e3. Review.

(7) Association between serum 25-hydroxyvitamin D level and upper respiratory tract infection in the Third National Health and Nutrition Examination Survey.

Arch Intern Med. 2009 Feb 23;169(4):384-90.

(8) A randomized controlled trial of vitamin D3 supplementation for the prevention of symptomatic upper respiratory tract infections. Epidemiol Infect. 2009 Mar 19:1-9.

(9) The next James Bond movie.




(13) Cochrane Database Syst Rev. 2006 Jul 19;3:CD001957 Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes.

(14) Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004559.  Chinese medicinal herbs for influenza.

(15) Calcitriol (1,25-dihydroxy-vitamin D3) coadministered with influenza vaccine does not enhance humoral immunity in human volunteers. 1999 Apr 9;17(15-16):1883-8.

(17) Epidemiol Infect. 2006 Dec;134(6):1129-40. Epub 2006 Sep 7.   Epidemic influenza and vitamin D

(18) Arch Intern Med. 2009 Mar 23;169(6):626-32.Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004.

(19) J Infect Dis. 2008 Jan 1;197(1):18-24.   Evidence for a heritable predisposition to death due to influenza.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His multi-media empire can be found at