The Next Pandemic May Already Be Brewing

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Published 6:30, MAY 25, 2026

It began on her thirteenth birthday. The red, sore, itchy eyes. The next day, the fever. Her mother took her to emergency, at their local hospital in Surrey, British Columbia. The doctor confirmed conjunctivitis (or pink eye) but said it didn’t need treatment.

Over the next three days, symptoms escalated: vomiting, diarrhea, sore throat, coughing, difficulty breathing. Meghan Makowka rushed her daughter Joselynn Armstrong back to the ER. By now, her fever was dangerously high, her heart was racing, her oxygen level was critically low. Her lips were blue. Doctors gave her antibiotics and hooked up an oxygen mask, but when she didn’t improve, they transferred her to BC Children’s Hospital in Vancouver for specialized care. During a forty-minute ride in the ambulance, Makowka prayed the paramedics could keep her daughter breathing. They arrived around 3 a.m., November 8, 2024.

Linda Edwards was the pediatric intensive care specialist on duty that night. She saw how rapidly Joselynn was deteriorating and suspected a severe viral infection, most likely flu. She administered antiviral medication, increased the level of oxygen, and sent a swab to the lab to confirm the diagnosis. David Goldfarb, the medical microbiologist overseeing the lab, knew they were dealing with something unusual when the test came back negative for seasonal flu yet indicated a large amount of virus the test couldn’t label.

He checked the patient history and noted the conjunctivitis, a flag for the flu that had been infecting American dairy and poultry workers in recent months. Goldfarb rushed the swab to the BC Centre for Disease Control, requesting urgent analysis. Within hours, he knew they were dealing with the H5N1 bird flu, and his patient was the first person ever infected in Canada.

The result triggered alarm. Historically, the mortality rate among people stricken by H5N1 has been exceptionally high. And it is feared that H5N1 could cause the next pandemic. With every human case—seventy-one in the United States, including one death, since 2022—the question looms: Is this the beginning?

BC Children’s Hospital instituted infection control protocols, requiring Joselynn’s parents and her sister to be isolated in her room for several weeks. They were tested repeatedly until it was clear they hadn’t been infected. Public health officials searched their home to find where the virus came from, analyzed their food, inspected their dog, traced Joselynn’s movements before she got sick. They never found the source.

Meanwhile, Edwards, Goldfarb, and dozens of others focused on saving a teenager’s life. Joselynn’s condition worsened. On day two, they intubated. It wasn’t enough. Six hours later, they took the one drastic option remaining. They hooked Joselynn up to mechanical life support. Her blood was diverted through a machine, oxygenated, then recirculated, bypassing her lungs so they could rest. Edwards, who leads the Extracorporeal Life Support (ECLS) program at the hospital, explained to the parents that the chance of survival is on average 50 percent. At one point, the situation became so grim, Makowka understood the chance was only 20 percent.

Joselynn was on that machine for fourteen days. She also had kidney dialysis and multiple blood transfusions. She lay surrounded by a curtain of tubes and monitors. There was a large catheter in her neck to deliver medicines, and another in her bladder, one in her nose for nutrition, and other small tubes attached to her hands and arms. The lights were on 24/7, and at all times there were two medical staff in the room, a bedside nurse, and a specialist responsible solely for the ECLS equipment. It was six days more before the tube in her throat could be removed. The virus cleared, but a long convalescence was ahead. In the end, Joselynn spent sixty-one days fighting her way back.

Joselynn’s case offers a glimpse of the nightmare an H5N1 outbreak could become. BC Children’s has just six life-support machines—and is the only hospital in the province that can provide them for children. If the virus tore through the population, the resources needed for lifesaving care would simply not be there.

Virologists and public health specialists have warned about the pandemic threat for years. H5N1, a problem in chickens for decades, first infected humans in 1997, in an outbreak in Hong Kong. Eighteen people got sick; six died. It surfaced in humans again in 2003, and since then the World Health Organization has recorded 478 deaths among 997 cases worldwide, a case-fatality rate of around 50 percent. Just last year, out of thirty who became ill, twelve died, mostly in Cambodia.

In 2020, a new strain of H5N1 emerged in wild birds and spread rapidly from Europe to Africa, to North and South America, and even Antarctica, generating a panzootic, the animal equivalent of a pandemic. The first sign it had landed in North America was in 2021, in dead birds in Atlantic Canada that had likely migrated from Iceland. Today, bird flu is everywhere. It’s been detected in more than 200 species of mammals, including mink, dogs, cats, foxes, bears, coyotes, goats, and rodents, and has caused massive die-offs of sea lions and seals. It’s overtaken more than a thousand dairy herds across the US. It has devastated poultry farms with the loss so far of over 200 million birds in the US and 17.5 million Canada.

Fortunately, when H5N1 causes illness in humans, it’s a one-off. Humans aren’t spreading it to each other. For a pandemic to occur, there must be sustained human-to-human transmission. The worry is, with so much of the virus around, in animals near to us, a pandemic could strike at any time.

Angela Rasmussen believes a bird flu pandemic would be catastrophic, far worse than COVID-19. She’s a virologist at the University of Saskatchewan, who studies how viruses spill over from one species to another. Looking at the numbers of human cases and deaths since the current strain of H5N1 took hold, Rasmussen doubts the case fatality rate would be anywhere near 50 percent. That figure exaggerates the danger, as many mild cases likely have gone unreported. She estimates it would be closer to 2 percent—but on a global scale, it would mean 164 million deaths. Our health care systems would fall apart. The case fatality rate for COVID—which brought much of the world to a standstill and upended economies, schools, and health systems—was less than 1 percent.

An H5N1 pandemic could be economically disastrous for agriculture, threatening food security worldwide, Rasmussen suggests. Consider that between October 2024 and March 2025 in the US, 50 million sick hens were culled, causing an egg shortage that nearly doubled egg prices. If pigs got infected, there would be wide-scale swine culling. Seeing so many species of birds and mammals already affected also raises environmental concerns.

She acknowledges it’s a worst-case apocalyptic vision. “I’m not saying that would happen,” she says, “but there is a version of this that ends with the collapse of human civilization.”

What would it take for human-to-human transmission to occur? H5N1 is one of many subtypes of the influenza A virus, the only type of flu virus known to cause pandemics. It can jump from animals to humans and mutate rapidly.

Unlike seasonal flus, H5N1 has not been able to bind itself to human cells or replicate in a way that would make it infectious. It can bind to certain sugars that act as receptors on the cells of the human cornea—which explains the eye infections. It can also bind to receptors in the lower respiratory tract—which explains how it can cause infections deep in the lungs. But it can’t bind to the receptors in the nose and throat, the upper respiratory tract; therefore, we cannot spread it through coughing, sneezing, or breathing.

That is the biggest block to H5N1 becoming a pandemic. A second block is that it doesn’t interact with the proteins in human cells well enough to effectively replicate, the way it does in birds. The third is our innate immune systems, which the virus needs to get better at evading. To overcome these barriers, the virus will have to mutate. Virologists sequence the virus to look for any mutations that signal it’s getting better at adapting to humans.

One of the world’s leading flu scientists is Richard Webby, a virologist at St. Jude Children’s Research Hospital in Memphis, Tennessee, and director of a WHO Collaborating Center, which studies bird flu in the environment. No one could have been more surprised than he was to learn that bird flu was infecting cows. The first time it happened was on a farm in Texas, in late 2023. The milk was discoloured; the cows appeared to have mastitis. Oddly, barnyard cats were dying. Bird flu was so unexpected, it took several months to identify it.

Webby’s top concern was that cows were spreading the virus to each other, suggesting a mutation. Then, another shock. On April 1, 2024, the US Centers for Disease Control and Prevention confirmed that a Texas farm worker had contracted the H5N1 flu from sick cows. This was a world first. Never before had a mammal spread H5N1 to a human.

Was this the leap everyone feared? Investigations determined that the flu was attacking cows’ udders, where the receptors are similar to those in birds, rather than in the cows’ respiratory system, and workers got sick after being in contact with infected milk splashing in their eyes, or from milk particles in the air. Luckily, there has yet to be a case where a dairy worker spread flu to another person.

But Webby says the virus is just a few mutations away from enabling human-to-human transmission. “This is an incredibly nasty virus in terms of its ability to cause disease in a lot of things it infects,” he says. “It is going to be a hard task for the virus to make the change, but if it does, it is going to be potentially horrific.”

And then there’s the problem of reassortment. That’s when two different strains of the influenza virus collide in the same host and swap genetic parts to create a new version. If a person contracted seasonal flu and bird flu at the same time, a novel virus, from which we are not immune, could emerge and spread globally—fast. The more H5N1 there is around us, the greater the chance of reassortment.

It’s happened before. We’ve had four pandemics in the past century. Reassortment caused three of them: in 1957, 1968, and 2009. The 2009 outbreak resulted from a triple reassortment involving swine flu, which created a new form of H1N1, the virus behind the 1918 Spanish flu. That pandemic, still the benchmark for how catastrophic influenza can become, killed over 50 million people worldwide.

The threat is real. And the most frightening thing may be how little we can say with confidence about what comes next.

Florian Krammer, a virologist at the Icahn School of Medicine at Mount Sinai in New York, is less convinced that H5N1 would surpass COVID in severity. Typically, flu viruses are not as contagious as COVID. Therefore, he does not expect more deaths in the population overall. Also, he thinks H5N1 could be easier to stop. We already have vaccines for it, which could be manufactured on a mass scale in about three months, and we have antiviral drugs that have proven effective.

But those advantages hinge on how the situation would be managed and whether people would adhere to countermeasures—vaccines, masking, distancing. Easier to stop in principle does not necessarily mean easier to stop in practice. There is no doubt that H5N1, if not worse than COVID, will cause at least a similar scale of disruption.

Krammer thinks we need to understand bird flu better to mitigate the damage. He’s researching the possibility that we already have some immunity to it. All influenza A viruses are categorized by two proteins on their surfaces, H and N, which vary in their composition. Hence, H5N1 differs from our seasonal flu viruses, H3N2 and H1N1, the latter of which became seasonal after the 2009 pandemic.

Why we might have some immunity is that the N in H5N1 is the same as the N in H1N1, against which we’re protected by vaccination or past exposure. That overlap might mean less severe illness for some, but it cannot be said that it will prevent a pandemic. And any immunity may be too unevenly distributed across populations to significantly alter outcomes.

At the BC Centre for Disease Control in Vancouver, epidemiologist Danuta Skowronski studies disease patterns in people. She’s interested in the phenomenon of imprinting: the first flu a person is exposed to prominently influences a lifelong immune response. She tested blood samples from 575 people and found a large proportion of them had existing immunity to the N in H5N1, depending on when they were born. In another study, the BC team compared case fatality rates for several different flus and found dramatic variability in age groups, suggesting again that depending on what flu you were exposed to and when, you might have acquired some level of immunity.

Skowronski is frustrated, though, by the lack of aggregated data she could access—details such as year of birth, what happened in each individual case. It took years to scour multiple databases for such information. “It’s pretty amazing,” says Skowronski, “that after decades of dealing with this foe, we still have just a very basic understanding of influenza immunoepidemiology. And that’s really the key to risk assessment.” Further, she doesn’t believe the notion of pre-immunity means we can let down our guard. “We just don’t want this virus in our population, that’s the bottom line.”

So how to hold the virus back? Where we have some level of control is in agriculture. In Canada, there has been no case of H5N1 in dairy cattle. Any animals farmers import from the US, which still experiences sporadic infections, must test negative for flu, and we test milk for the virus. So far, so good.

The poultry story is a bigger worry. Over 650 Canadian commercial poultry farms and backyard coops have experienced outbreaks. To contain the spread, all birds and eggs must be destroyed and disposed of, along with manure and bedding, and the entire farm is cleaned, disinfected, and placed under quarantine. Canadian Food Inspection Agency (CFIA) personnel ensure that protocols are followed. There have been no reports of illness among poultry farm workers.

It would be better if chickens and turkeys did not get the flu at all. Vaccination is an option, but it has traditionally run up against trade restrictions. Countries reject vaccinated birds partly for opportunistic reasons—to shield domestic producers from competition—and partly because importers don’t want to chance bringing in infected birds. Vaccination can prevent birds from dying without necessarily stopping infection. And because vaccination masks symptoms, a flock may look healthy but isn’t. When H5N1 strikes unvaccinated flocks, birds are visibly sick, act strangely, or die en masse in as little as twenty-four hours. In the absence of these clinical signs, a vaccination program would have to be accompanied by vigorous testing to detect any lurking virus in birds with no symptoms. Who would pay for that?

Enthusiasm for vaccination, however, is growing. In December 2023, the World Organisation for Animal Health urged nations to consider it, as mass culling was no longer sufficient to control disease. China has proven it works. With over 17 billion poultry in the country, the economic losses from avian flu outbreaks weren’t sustainable. China began using vaccines in 2004, in the process virtually eliminating the illness in humans.

Egypt, Indonesia, Vietnam, and Mexico vaccinate poultry. In France, duck vaccination has been mandatory since 2023. This year, the CFIA is working with industry on two pilot vaccination programs on Manitoba farms. Rasmussen strongly supports these kinds of initiatives. If the H5N1 virus is allowed to spread unchecked through barns and herds, it will keep finding opportunities to adapt to humans. One day it will get it right.

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A pandemic can happen anywhere, but Rasmussen, a transplanted American, is deeply troubled by the potential for it starting in the US. She worries that due to cuts in health services and virology research, and reduced capacity for surveillance and testing, the current administration could lose control of bird flu.

Current US immigration policies may be a factor. Dairy and poultry farms rely largely on migrant workers, who may not report symptoms because they fear being sent to an Immigration and Customs Enforcement detention centre. She imagines a scenario where suddenly a cluster of people show up in a hospital and it is discovered, too late, that there’s been community transmission. The pandemic will have begun. Canada may face a version of the same vulnerability: 10 percent of poultry workers are temporary foreign workers. Many are precariously tied to specific farms.

Prevention is a global responsibility. As executive director of pandemic and outbreak at the vaccine manufacturer Seqirus, based in London, UK, it’s Marcus Lacey’s job to keep on top of an unending repertoire of viruses that may be a threat. He shares Rasmussen’s view that surveillance is vital. He deals with countries all over the world, and he thinks Canada and the European Union are doing a better job than the US of controlling infection, but he’s concerned about health care budgets being drained in many places. He also worries about the trust factor. He’s watching vaccination rates go down in Europe and Canada, and alarmingly so in the US, because the public has lost confidence.

Fahad Razak worries about that, too, as he considers preparation for H5N1 or any other pandemic. Razak is an internal medicine specialist at St. Michael’s Hospital in Toronto, was scientific director of the Ontario COVID-19 Science Advisory Table, and is chair of the new Public Health Agency of Canada Advisory Committee on Science. He feels COVID has made us better prepared in some ways, made us better organized, but now we need to prepare for public distrust.

“I think the way you would respond to a pandemic today would, by necessity, look very different,” he says. Because of social media and misinformation or disinformation, people won’t rally the way they did in 2020. “That is a hard problem, and I think that is the work of the next few years.”

Incorporating lessons from COVID, the federal government is currently coordinating with provinces, Indigenous leadership, and experts to update its pandemic preparedness plan, which provides guidance to the health sector. It has a contract with Seqirus to ensure 15 million doses of vaccine within three months of a pandemic onset. It has funded a new Centre for Research on Pandemic Preparedness and Health Emergencies.

But down at the nitty-gritty hospital level, Allison McGeer says bluntly, “we are a long way from being prepared.” McGeer is an infectious disease specialist at Toronto’s Sinai Health, with considerable front-line experience: SARS in 2002, the 2009 flu pandemic, and COVID. A key piece of pandemic planning, she says, is figuring out which scenarios to prep for.

What do we do when there are no beds left, when the ICU is full? How many staff will get sick? How do we share resources with other hospitals? How many patients can we realistically see in one day? It’s hard, in a beleaguered health system, to find the time or the money to worry about these details until the crisis arrives. She says philosophically, “You just have to keep working on the best you can do for the most people in the circumstances.”

Every May, Webby sends a team to Delaware Bay on the New Jersey coast, where half a million shore birds stop to gorge on horseshoe crab eggs before continuing their migration from South America. The team collects fecal matter, which his lab tests for avian flu. Each year, an average of 15 percent of the samples come back positive for various influenza viruses. That is a lot of virus.

Is it inevitable that H5N1 will be the one that successfully adapts to humans? No one can say. One thing is certain: mutations, reassortments can happen at any moment. And so can a pandemic.