Influenza Update

Reports in the national media indicate that there appears to be a decrease in the number of newly diagnosed cases of novel H1N1 influenza. While this is good news, the virus has been and is so unpredictable, that we do not know whether this decrease will be sustained or whether there will be another increase. The good news is that if cases continue to decrease, even if another wave of new cases should appear, it will give the vaccine companies time to distribute more H1N1 vaccine.

From the local perspective, there have been at least 4 cases of type B influenza identified. This means that the only known circulating viruses on the Cape are novel H1N1 and Type B influenza. Seasonal Type A influenza has yet to appear on the Cape and in Massachusetts.

Welcome to the new venue

It turns out that the old blog address did not have notification features. This new website, however, will allow you to get email notifications when I post new content.

I hope this works for everyone.

Update on the Status of the Pandemic

CDC has released the latest figures relating to the activity of influenza in the United States. The important points are:

• About 1/3 of specimens tested by various surveillance laboratories were positive for influenza
• All of the subtyped influenza A viruses were 2009 H1N1 influenza (swine flu) [That means there has not yet been circulating “seasonal” influenza A detected by these laboratories.]
• The proportion of deaths attributed to pneumonia and influenza was above the epidemic threshold for the sixth consecutive week.
• Thirty-five influenza-associated pediatric deaths were reported. Twenty-six of these deaths were associated with 2009 influenza A (H1N1) virus infection, eight were associated with an influenza A virus for which the subtype was undetermined, and one was associated with an influenza B virus infection.
• The proportion of outpatient visits for influenza-like illness (ILI) was 6.7% which is above the national baseline of 2.3%. All 10 regions reported ILI above region-specific baseline levels.
• Forty-six states reported geographically widespread influenza activity.

Even though there was continued brisk influenza activity,there was a slight decrease in the number of reported cases. It is hard to know what this means. It could indicate that we have reached the peak and the numbers of cases will continue to fall. Alternatively, the numbers could increase again, indicating that we have not seen the peak of the pandemic yet. Even if the number of cases continue to fall, there could be a second peak in the offing and we should not become complacent. We need to keep using good cough etiquette, hand washing, and get immunized when the vaccines become available.

I have continued to hear worries expressed about the thimerosal preservative in the multi-dose vials of vaccine. This concern is not supported by scientific data, whereas the real risk of getting very sick, and perhaps dying, is unquestioned if anyone is infected with H1N1 influenza virus. Therefore, if multi-dose vaccine is the only one available, have your children get it. It makes much more sense than holding on to thoroughly debunked notions that thimerosal is causing any issues in children’s health. Likewise, it is not an issue for adults either. Get the vaccine in whatever form is available.

 

Vaccine redux

The influenza vaccine shortage continues to rile the public and health care providers. As with any limited resource, there is a parallel economy ready to provide the product for the right price. In addition, declarations of need based on social status or personally created risk stratification schemes are increasingly more commonly encountered. I have to say that some of the worst human behaviors are being displayed as the pandemic continues and the press reports on every negative aspect of the infection. It is time for us all to assess what is going on, and what is not.

The pandemic continues to involve all segments of the population and the press continues to report on individual deaths even though for seasonal flu, none of this reporting goes on. An estimated 36,000 Americans die each year from seasonal flu. That is about 100 deaths per day! I have yet to see a headline in a newspaper reporting on that striking statistic.

To all of this, all I can say is that collectively, the people around the world (although the issues seem to arise more as the standard of living increases) need to focus on the total picture and what we can do to protect ourselves and our loved ones, without resorting to anger, frustration, and simply put, selfish behavior. Such antics will not increase the supply of vaccine or any other resource. This is the first real test of modern medicine and the public health infrastructure in dealing with this sort of mass infection. Earlier epidemics and pandemics have occurred as many of the pieces of the response plan were yet to be written and exercised. The pieces are in place now and we are seeing a remarkably coordinated response. That is not to say that there are not mistakes being made. There clearly are things that can be done better, and should have been done better, but everyone, from the top officials in the government on down, are learning and improving systems of communication and action plans.

Vaccine distribution continues to be sporadic and intermittent. As it becomes available, it is being administered without undue delay. Those in the designated risk groups are being offered the vaccine first and then those groups further down on the risk group list are offered the vaccine. The process seems to be moving ahead smoothly.

With respect to treatment of exposures – not everyone needs antiviral prophylaxis. I will be reviewing indications for antiviral prophylaxis and treatment in the coming days. The numbers of questions I have been fielding are increasing daily and I hope to incorporate the teaching points from these questions into future communications.

Vaccine Issues

As everyone knows, there is a shortage of influenza vaccine, especially the 2009 H1N1 (swine) influenza vaccine. In response to this, we are seeing some responses to this that are causing some problems. For example, people are being referred to the Emergency Department to receive the vaccine. This is not helping and is creating confusion. The ED is not a venue for administration of this type of vaccine and having otherwise healthy people come to the ED is not safe and degrades the mission of the ED.

The VNA is administering influenza vaccine when they have it. They can be reached at 1-800-631-3900 for additional information. Other commercial outfits (e.g., drug stores and pharmacies) are administering the vaccines when they are available. For the latest information, keep tuned to the general media as they generally alert their listeners and readers about local vaccine issues.

If someone is thought to have influenza, and there is no medical emergency, before going to the ED, calls to the primary care provider or the ED should be made. That way the best use of resources can be made with the least risk to the patient and others who may come not contact with the sick person.

Keeping confusion to a minimum will take a concerted effort. We continue to urge those with questions to call their healthcare providers and if there is still no satisfactory answer, I am available, especailly by email or through this blog, to answer questions and to try to provide up to date information concerning the status of the pandemic in our area.

Alan Sugar

How Do You Know You Have the Flu?

We have been encouraging those who think they have the flu to call the ED or their health care providers rather than just showing up for a face to face (contagious) visit. Now, the AMA is hosting a computerized algorithm to help patients and providers with making a decision as to who really needs to be seen. I am still playing with this program, but it may help reduce anxiety in those who are worried, thereby decreasing office and ED visits for those who may not need them.

The link is: https://www.amafluhelp.org

Try this out and refer patients to the site so that they may have yet another resource to help them deal with this unusual influenza season.

Effects of the Pandemic

As you have very likely heard by now, CCHC will restrict visitation of patients in both hospitals (CCH and FH) to people 18 years of age and older. This is being done, in order to minimize the risk of bringing H1N1 influenza into the hospital by school aged children, the youngest of whom, may have less than stellar hygienic manners. As we watch this pandemic unfold, school aged children are heavily represented among the ill, the class room being a perfect incubator for respiratory viruses, especially those that are as contagious as the H1N1 virus seems to be. We are cognizant of the need to be flexible and will evaluate special needs on an individual basis. In conjunction with the visitation restrictions, we are emphasizing that all visitors to the hospital assess themselves and not visit their family/friends in the hospital if they, themselves, have a febrile respiratory illness. Once again, we are stressing personal responsibility for doing the right thing.

You also are hearing a great deal of criticism of the government for promising vaccine that, unfortunately has failed to materialize as expected. While I am not sure that anyone “promised” vaccine at any given time, we were led to the expectation that there would be plenty of H1N1 and seasonal flu vaccines by now. However, the vagaries of biology have prevailed and for many perfectly innocuous and not entirely unexpected reasons, the vaccines are in short supply, with more doses coming over the next month or so. To put this in perspective, the H1N1 (swine flu) virus was identified in late April 2009 and by early to mid-October, H1N1 vaccine was shipping. That is less than 6 months from virus identification to the first people receiving their immunizations. That’s not bad and actually, is quite phenomenal when you ponder all the steps required to get to the final product and have that out the door for general use. The infrastructure is in place to administer the vaccines when they are received and the public should stay tuned to see when it comes and to which providers in order to make for an orderly path to having the highest risk groups immunized as soon as it can be done.

I have been pleased with the degree of preparedness of the various groups involved in the response to the pandemic. The level of involvement has been unprecedented. There will be mistakes, no doubt, as we proceed in dealing with the morbidity and mortality involved in responding to the pandemic. However, the level of preparedness is and degree of organizational involvement in thinking through what needs to be done and how it is going to get done is unprecedented in my medical career. We should all be reassured in that respect.

Vaccine Considerations

Here is some additional information that pertains to the current formulation of novel H1N1 (swine) and seasonal flu vaccines. The part in italics is from CDC and the blue is from me.

None of the seasonal or 2009 H1N1 influenza vaccines currently licensed and distributed by the U.S. government contains adjuvants. This means that none of these influenza vaccines contains squalene or aluminum.

 

 

This is an important consideration since there is an entire “industry” of mis-information concerning adjuvants and vaccines and their impact on human health. Nothing to worry about on this front.

The currently licensed seasonal and 2009 H1N1 influenza vaccines do not contain latex. If healthcare providers do not use the vaccine administration products provided by the vaccine manufacturers which do not contain latex, there may be a risk of latex allergy.

It is still up to the provider to monitor their patients for latex allergy and prepare accordingly. There are no latex issues, however, with the vaccines as provided by the manufacturers.

Each year, approximately 6,000 to 9,100 people in the United States get GBS [Guillain Barre Syndrome] whether or not they receive a vaccination. This means that about 140 people get GBS every week. During the 2009-2010 influenza season, CDC and FDA will be closely monitoring reports of serious problems following the 2009 H1N1 influenza vaccines and the regular seasonal influenza vaccines including GBS.

This is important given that the 1976 swine flu vaccine was associated with the development of Guillain Barre syndrome (GBS), a disease that causes ascending paralysis. Monitoring for this and other manifestations of GBS and other possible side effects has never been more rigorous.

 

Since GBS is a serious disorder that people do get every year, CDC has developed several GBS surveillance systems. These are tracking systems to identify whether some GBS cases are linked to influenza vaccinations.
These surveillance systems include some existing vaccination safety systems, such as the Vaccine Adverse Event Reporting System (VAERS), and new systems, such as the CDC Emerging Infections Program and a partnership with the American Academy of Neurology, which includes doctors (neurologists) who are most likely to see persons with GBS. None of these systems existed in 1976. Through these systems, CDC and FDA will be able to find any possible link between GBS and seasonal or 2009 H1N1 flu vaccines early in the vaccination campaign if it occurs and take appropriate action.

No one expects there to be any new or different side effects from novel H1N1 flu vaccine as they compare to our traditional seasonal flu vaccine. However, there are new and quite robust systems in place now to help with the monitoring for unusual and rare complications from these vaccines.

The bottom line is that all of the flu vaccines being used this year (when they are available, that is) are expected to present no unusual issues, but if they do, the mechanisms to detect the problems are in place. I don’t think there is much more you can ask for, expect possibly, that the vaccines actually do get here in sufficient numbers so we can get to work immunizing our population to get ahead of the virus in this pandemic season.

Alan M. Sugar

Hospital Epidemiologist

Methods to Prevent Getting Sick

Here is a list of things to do that has been making the rounds through the internet. I have seen this several times already and have commented on them each time to those who sent the email to me. I thought it appropriate to recount those comments here. The internet advice is italicized and my response is in blue.

———————–
Tamiflu does not kill but it prevents H1N1 from further proliferation until the virus limits itself in about 1-2 weeks (its natural cycle). H1N1, like other Influenza A viruses, only infects the upper respiratory tract and proliferates (only) there. The only portals of entry are the nostrils
and mouth/throat. In a global epidemic of this nature, it’s almost impossible not coming into contact with H1N1 in spite of all precautions. Contact with H1N1 is not so much of a problem as proliferation is.

This is partly true. The virus is prevented from releasing new progeny, which leads to it not being able to replicate. Whether it is killed or not is not really important. Functionally it can not infect anyone else or even other cells within an infected person’s body. If the virus gets on mucous membranes, including the eye, it can cause infection, so any hand to face activity is problematic. Novel H1N1 influenza has been shown to replicate into the lungs and that, perhaps, is one reason why it causes more severe effects in some people than does seasonal flu. In addition, this virus has been found in respiratory secretions even after 2 weeks of treatment with Tamiflu.

While you are still healthy and not showing any symptoms of H1N1 infection, in order to prevent proliferation, aggravation of symptoms and development of secondary infections, some very simple steps – not fully highlighted in most official communications – can be practiced.

Number one here needs to be get the flu shots – seasonal and swine flu.That is the best method to avoid becoming ill with influenza.

1. Frequent hand-washing (well highlighted in all official communications).

Good advice.

2. “Hands-off-the-face” approach. Resist all temptations to touch any part of face (unless you want to eat or bathe).

Good advice again, but very difficult to implement.

3. Gargle twice a day with warm salt water (use Listerine if you don’t trust salt). H1N1 takes 2-3 days after initial infection in the throat/nasal cavity to proliferate and show characteristic symptoms. Simple gargling prevents proliferation. In a way, gargling with salt water has the same effect on a healthy individual that Tamiflu has on an infected one. Don’t underestimate this simple, inexpensive and powerful preventative measure.

Off the wall, but can’t hurt.

 

4. Similar to #3 above, clean your nostrils at least once every day with warm salt water.. Blowing the nose hard once a day and swabbing both nostrils with cotton buds dipped in warm salt water is very effective in bringing down viral population.

See #3 above.

5. Boost your natural immunity with foods that are rich in Vitamin C. (citrus fruits). If you have to supplement with Vitamin C tablets, make sure that it also has Zinc/bioflavonoids to boost absorption.

No evidence that this is true, but probably can’t hurt.

6. Drink as much of warm liquids as you can.. Drinking warm liquids has the same effect as gargling, but in the reverse direction. They wash off proliferating viruses from the throat into the stomach where they cannot survive, proliferate or do any harm.

Nonsense but can’t hurt. I prefer chicken soup as a good option for all sorts of respiratory complaints. That seems to mobilize secretions making breathing somewhat easier.

All these are simple ways to prevent, within means of most households, and certainly much less painful than to wait in long lines outside hospitals.

The above suggestions certainly empower people somewhat, but how effective they are in really decreasing infection is debatable. I have no argument with staying away from hospitals for the benefit of each person and those who really need to be in the hospital for work or to receive needed medical care. Crowding the waiting rooms of emergency departments with people worried because they have swine flu is not a good use of resource and not a good way to spend one’s time if they have swine flu.

October 26, 2009

In order to reach more people and to more easily answer questions and dispel rumors, I have taken to writing this blog rather than sending out mass emails. If you choose to follow this blog (you need to actively subscribe to the blog), you will be alerted through your email address that a new posting has been made. There will be opportunities for you to comment on my thoughts and to ask questions. When asking questions, you will have the opportunity to do this anonymously or to have your screen name shown. I am also available as usual through my email to address specific concerns. However, I urge you to pose your questions and thoughts on this space so as to allow for others who undoubtedly have the same questions and concerns to have them addressed in this venue.

I will attempt to keep our community up to date concerning the latest developments as they pertain to influenza and will continue my commentary as the pandemic unfolds.

Thank you for your interest and for your questions and comments.

Alan Sugar

Hospital Epidemiologist

Cape Cod Healthcare