Flash-forward, the flu of December 09

Here are four interesting items I learned yesterday from King County’s chief epidemiologist, Jeff Duchin, MD.

  1. Lesson learned:  Closing individual schools is not effective for limiting flu transmission in a community.  Next time — if the virus appears to be more deadly — the health department will close all schools in the county, perhaps for 8 weeks or longer.
  2. Lesson learned #2: This virus spread far more rapidly than planning scenarios had predicted.  Basically, flu virus can be widespread before we know what’s hit us.
  3. Who’s first in line for a vaccine, if there’s a limited supply? Heavy-duty planning is underway for how to distribute an A-H1N1 (swine flu) vaccine next winter, assuming it’ll be available.  This will be in addition to the normal, annual flu shots.   First-responders, and most medical workers, are clearly at the top of the list.  Pregnant women, and people with compromised immune systems.  After that, it might be all children under 18, given signs that they’re being hardest hit so far.  (Normally, the elderly are considered most at risk, but not in this case.)
  4. If the virus remains less severe?  Expect simply a lot of people to be out sick, especially in schools, as everyone who didn’t get sick this spring, gets it on the second pass.   But, it wouldn’t be much different from what we’ve seen this past month.

And one note to the King County Board of Health:    Anyone watching (the meeting was recorded by King County TV) might be disappointed at the level of questioning by board members, as Dr. Duchin and other staff testified.  They asked thoughtful questions to clarify the facts.  But, nobody on the Board asked the simple questions, What parts of the “pandemic plan” did not work?  What surprises did the staff face? What needs to be improved before we face a severe pandemic?   (The lessons learned above came from a private interview, after the meeting.)

Flu reflections and questions

On Thursday afternoon, we’ll get the official “swine flu de-brief” from Public Health-Seattle & King County.  What will be the lessons learned?  Dr. David Fleming, the agency’s director, offered a possible preview back on May 4th, at a panel in Seattle hosted by the Washington Global Health Alliance (and televised by TVW).

It seems everyone involved with pandemic flu planning has been praising the response to this outbreak. Fleming said, “Boy, planning is really paying off.”  He was comparing the government reaction to anthrax and SARS outbreaks few years back, and noting that this time there was more “rational communication.”

But I don’t think the public perception is quite so triumphal.  People were confused and they see officials as being confused.  While the response may be much better than it would have been a decade ago, does it live up to the expectations of today?  After millions of dollars have been spent on pandemic flu planning, was this response good enough?

Here are a few points from the panel that struck me:

  • At the peak of concern, supplies of Tamiflu were depleted at some health care centers in King County, and Public Health had to distribute some doses from the national strategic stockpile — and this was a mild strain of flu.
  • Fleming acknowledged, “We planned for the wrong disease, a global pandemic of great severity,” or a high death rate. But it turned out to be a milder strain of flu.
  • This strain of H1N1 spread much faster than anyone anticipated.  That means the information communicated to the public has been way behind what’s actually happening in the community.  On the other hand, officials are trying not to speculate in public, and offer assurances before they’re certain about what’s happening.
  • Children and schools were a major source of transmission for this outbreak — which may have lessons for vaccinations next fall.  (A point made by Dr. Kathy Neuzil, of PATH and U.W.)
  • Agricultural workers may be a weak-link in the global surveillance system, since flu viruses can jump more easily than many realize from poultry or swine to people.  There’s now system for tracking illness among these workers. (From Ann Marie Kimball, an epidemiologist at U.W.)

Swine flu and school closures – how much longer?

Wondering if you child’s school will be next?

The top public health officials in King County — Dr David Fleming, Director, and Dr. Jeff Duchin, Chief Epidemiologist — have been hinting that school closures may not be a tactic for much longer.

As my KPLU colleague Liam Moriarty reported this morning (Friday),  “So far, none of the folks in King County with the H-1-N-1 (swine) virus have gotten any sicker than they might from any of the old familiar flu viruses. Dr. Fleming says if that trend holds in the coming days – and this bug proves to not be particularly nasty – some of the precautions such as closing schools could be relaxed ….”

On the other hand, three students at Lakes High School, south of Tacoma, were taken to Madigan Army Hospital with severe flu-like symptoms, and as of Friday morning, two of them were in intensive care units, in serious condition.  That led to closing the school, as a precaution.

Seems sensible and prudent.   If tests show that they indeed are suffering from the swine flu H1N1, then we might see school closures  as a good tactic that should continue.

I have to say, the top officials in public health agencies and school districts have seemed remarkably indifferent to the hardship the closures cause.  In particular, for single parents and parents working jobs that offer little or no sick/vacation leave, this is a whole separate crisis.

When will a leader (the Governor? a Health Director?) stand up and say to employers, “We are in an emergency situation, and I’m asking all employers in the state to give extra sick days to anyone whose child’s school has been closed for a week?”

[UPDATE, Friday afternoon: Seattle Mayor Greg Nickels deserves a prize for being the first to address the work issue.  He told a news conference today that the city is offering extra flexibility to its employees … and he called on other employers to do the same. ]

In case you missed it, in King County, four schools have been closed (as of noon Friday)(five schools as of Friday 4 pm)  because they each have a student who probably has swine flu.  (The reason for closures is to slow down the spread of the virus — to prevent a situation where lots of people are getting sick at once.  But, once the virus is confirmed to be widespread in the community, then there’s not much benefit from closing individual schools.)

If you’re like me, keep crossing your fingers that your child’s school doesn’t have a “probable” case during the next week, and maybe after that we’ll be beyond school closures.

Swine flu, without Mexico

I may be gloriously wrong on this.  But, Ill go out on a limb and suggest the possibility that this H1N1 swine flu has been in Washington state, and other states as well, for quite a while.  I won’t be surprised if it turns out that many people who suffered a flu or flu-like illness over the past month actually had this strain.

And last night’s announcement of Washington’s first six “probable” cases (see this post) added some support.  I was told by both the state Department of Health and King County’s public health officials that none of the six people who harbor the suspected virus has any connection to Mexico. They didn’t travel there, nor did they contact anyone who recently did.

In fact, in King County, the three cases only came to light because they bypassed the health department.  Why?  Because the health department was only agreeing to test samples that met the criteria of severe flu symptoms PLUS some connection to Mexico.  These three, then, were tested by independent clinical laboratories, and then forwarded to the state when they proved to be a Type-A influenza virus.

(One of those labs was at the University of Washington, and I’m still trying to learn about the other two, as well as the cases in Snohomish and Spokane.)

If they had no connection to Mexico, and they caught it locally, then this suggests that there was a good-sized reservoir of infected people in Seattle by the end of last week.  It still may have come from Mexico, but perhaps  a month ago, or longer.

Swine flu, the mystery

Everyone’s talking about swine flu. Every major news organization has done a decent job covering the basics. Here are a few extras, based on what I’ve learned so far:

  • We won’t know for a week or longer if this is indeed a serious pandemic or not. The information from Mexico is still too incomplete to tell us if the flu there is killing an unusual number of healthy young adults. It appears to be unusal, and that’s what has public health leaders around the world worried. But that appearance may prove false, once we get more data. They’re handling it with “an abundance of caution,” says King County’s chief epidemiologist Jeff Duchin. (For example, they may not be getting an accurate measure of how many people are infected with mild cases of swine flu, and that number is key to telling you what percentage are severe cases.)
  • In British Columbia, two cases of swine flu were confirmed over the weekend. Both were men who were returning from Mexico. Both cases were considered “mild” (in which case, I’m not sure how they were detected).
  • It would take six months or longer to create a vaccine. In the meantime, for those who do get sick, a drug called Tamiflu can effectively treat the disease. A stockpile is on hand, in King County and elsewhere, to deliver Tamiflu in the event this does become a major epidemic. The stockpile would be used primarily for police, fire and medical workers.
  • “What should I do?” In most cases, nothing. Public health officials say, if you are sick enough that you think you need medical attention, then call your doctor’s office. But, don’t just show up. And if you’re mildly ill and wouldn’t normally seek medical attention, then don’t seek it now. (But do take the usual precautions, such as covering your coughs, handwashing, etc.)

Vaccines and autism on trial

For anyone who still thinks vaccines are causing an epidemic of autism, please take a deep breath and open up to the possibility that such a theory might be completely wrong.

The latest verdict comes from a special tribunal.   A 3-judge panel has ruled against plaintiffs who were seeking damages, claiming their children had developed autism because of preservatives in the measles-mumps-rubella (MMR) vaccine.  We have a brief version of the story on our website.

This isn’t quite as dramatic as the Darwin trial in Dover, PA.  There was no jury, no courtroom theatrics.  Instead, it’s a court that exists only to hear complaints under the National Vaccine Injury Compensation Program.  But, the judges, who are not part of the public health infrastructure, reviewed thousands of pages of studies and other documents.  It sounds like they ruled pretty conclusively.  No link between autism and the vaccine.

This is not a surprise.  Every time an independent group has taken a look at this issue, they’ve come to the same conclusion.  And earlier this week, one of the British authors of a study that has fueled the anti-vaccine movement was revealed to have  faked some of his data (thanks to dogged reporting by The Times of London).

Opponents of vaccines have evolved their theory over the years.  Many now say, it isn’t just one vaccine, it’s the fact that so many are given at such a young age.  (Moving target?)   Still, I haven’t seen any credible evidence to suspect the vaccines.

Pot-smoking and … testicular cancer

Ouch!  That’s not a nice association.

This was a story I couldn’t exactly pass up, because it’s a such a high-interest topic.  But, the scientists involved, and every bit of training I’ve had, warn me not to make too much of it.  (Check out the story that aired on KPLU for an overview, and here’s a press release.)

Steve Schwartz of the Fred Hutchinson Cancer Research Center has been trying to understand what causes testicular cancer.  You don’t hear much about testicular cancer (unless there’s a story about cyclist Lance Armstrong) because it’s uncommon and it’s usually curable.  But, it’s also poorly understood.  At the urging of his colleague, Janet Daling, they decided to ask if there’s any association between testicular cancer and marijuana smoking.

Based on a survey of men in the Seattle area, some with cancer, some without, they found marijuana smokers had a slightly higher risk of getting testicular cancer.  It’s newsworthy because it’s the first time anyone has shown any sort of link between marijuana and an elevated cancer risk.  The study has several limitations, so it really just points to a possibility, and the need to do more careful studies.  In general, Schwartz points out, our knowledge of the long-term effects of marijuana smoking is small.

Here are some interesting tidbits from Schwartz and the study:

  • The more often you smoke pot, the more your risk goes up.  Maybe the marijuana functions as some sort of “fuel” to keep the cancer cells growing.  When you stop, their growth stops, too.  This pattern has been shown in some types of breast and lung cancer.
  • Testicular cancer is also associated with height.  Taller men, especially those over 6 ft. 2 in., have higher rates than shorter men.
  • Men of African descent don’t tend to get testicular cancer.

It’s a cancer that seems to be triggered in adolescence, and mostly hits men between the ages of 15 and 35.

Add up that profile:  Young, white, tall man who smokes pot.  Seen any of these on a college campus?

(The paper is in the journal Cancer, and it’s called “Association of Marijuana Use and the Incidence of Testicular Germ Cell Tumors.”)

Vaccine subsidies may end

My story on KPLU about a proposal to end state subsidies of childhood vaccines only brushed over the impact on pediatricians and family doctors.  It was a short story, written for a newscast.  This is not the most important budget cut pending in Olympia, or the one that will impact the most people.  But, it’s an example of a good program that probably is in trouble in this economy.

I traded messages with the president of the Washington chapter of the American Academy of Pediatricians.  Dr. Neil Kaneshiro wrote an eloquent explanation of what it might mean:

The burden on the pediatrician depends on how they respond to the change. As you have found out, it is a dramatic shift in policy. In the “old days” before Universal Purchase, pediatricians used to see kids for their checkups and then send them to the health dept for their vaccines. Not a very good system as some of those parents didn’t bother or weren’t able to take the kids in to a separate facility on a different day possibly missing work again just to get their vaccines. Now the vast majority of immunizations for kids are delivered in the pediatrician/family practitioner office because the immunization program makes it a seamless process. The benefits for kids were easy to see. No hassles and no barriers to immunizations. Immunization rates improved. (Many will say that Universal Purchase does not correlate with high immunization rates. That is true, but it definitely helps the rate by removing all financial barriers to immunizations so that any parent who wants one for their child can get it. The problem with immunization rates in Washington State is primarily with the strong anti-immunization sentiment fueled by celebrities like Jenny McCarthy. We have the highest proportion of families who opt out of school mandated vaccines in the nation.)

There are significant costs associated with provision of immunization services. Ordering, inventory, refrigeration/freezer capacity, needles, syringes, nurse/medical assistant time, physician counseling of patients.
Those are the costs with the current Universal Purchase program. When that is taken away, several other things come into play.
1. Acquisition cost. I estimate we have $150,000-200,000 worth of vaccine in our refrigerator and go through that monthly.
2. We would need vigilant monitoring of insurance reimbursement because doctors in other parts of the country have lost significant amounts of money because insurers were not reimbursing less than the actual cost of vaccine.
3. We would need to set up an entirely separate ordering and inventory system and institute failsafe measures to prevent vaccine from moving from VFC stock to Commercial stock and vice versa. Lots of potential fraud issues arise if VFC vaccine is used for someone with Blue Cross insurance. And potential bankruptcy issues arise if purchased vaccine is given to Medicaid kids.

Medicaid reimburses essentially nothing for the above services. Commercial insurance reimburses for the administration, but sometimes not the ordering, inventory refrigeration, insurance/overhead costs. The unspoken deal with the state was that physicians would move immunization services for Medicaid into the medical home since they were providing vaccines for everyone. In turn the state would be able to reduce the immunization infrastructure in the public health system as the primary care providers were taking care of it.

Depending on individual pediatricians vaccine purchasing power and negotiating position with insurers, buying and selling vaccine could be either profitable or not. Pediatricians are unfortunately not known for their business savvy and this will cause some practices to go under or stop doing immunizations.

I think that since pediatricians lose money every time they give a vaccine to a Medicaid child, it is possible that the financial strain will force some to revert back to the old system of referring kids to the health department for immunization services. Unfortunately much of that public health infrastructure has been dismantled and is unlikely to be rebuilt under the current budget situation.

The bottom line is that this will introduce barriers to immunization for kids that are not there now and our immunization rates will fall.

Mr. Gates, Rotarians, and polio

The Gates Foundation (do we still have to refer to it by its full, formal name?) is giving a whopping $255 million to help eradicate polio from Earth.  Bill made the announcement to a Rotary International conference today (1/21/09), because the Rotarians have been leading the push for polio eradication (raising money, volunteering, and using their local branches in places like India and Nigeria to push for political support).

Polio remains present in just four countries — India, Nigeria, Afghanistan, and Pakistan.   You can imagine the political/warfare challenges to delivering vaccine to remote villages in the “-stans.”  In India, the pockets of disease are also in remote areas (mostly in Uttar Pradesh).  And Nigeria has had a host of troubles, including a rumor five years ago that the vaccines were a plot against Muslim girls.  That caused a huge setback and a resurgence of the disease.

Some additional challenges today have to do with how polio behaves in the presence of other endemic diseases.  In those cases, it’s harder for the vaccine to provoke immunity, and more doses are required (sometimes 10 doses!).

There’s been a lot of debate over whether it’s worth the huge cost (billions of dollars) to wipe out the last few cases of one disease, when so many other diseases are causing more harm.  There are now fewer than 2,000 cases of polio a year.  But global health leaders say the resurgence we saw in Africa after the Nigerian troubles shows that you can’t permanently contain this highly contagious disease.  (It’s spread by a virus, either in contaminated water or by people who are carriers.)

Gates gave quite an inspirational speech to the Rotarians in San Diego.  I didn’t get a chance to hear it, but I was sent a transcript.  It turns out his wife Melinda has an aunt who was afflicted with polio, and has been in braces most of her life.

If the campaign succeeds, polio would be the second disease eradicated, after smallpox (officially gone as of 1980, according to the World Health Organization).

Malaria and the Holy Grail

Ah, the dilemma of Hope vs. Hype. I reported earlier this week that medical researchers and global health activists (including many at PATH in Seattle) are feeling a bit of success in the latest test of a malaria vaccine. It appears, so far, to be the best hope for protecting people living in malaria-infested areas. Malaria kills about a million people every year, mostly children in sub-Saharan Africa.

What I only mentioned, but didn’t have time in my radio report to explore, was the fact that the vaccine is still barely more than 50% effective. There’s no telling whether it will be better or worse than 50% once it gets into a less controlled context, in a final field trial that starts next year.  It likely will leave roughly half the population unprotected.

There are other potential malaria vaccines in the pipeline.  If any of them proves practical and at least partially effective, then you might combine two vaccines, and maybe make a big difference.  This would be like creating the “cocktail” of drugs that are helping AIDS patients survive.

Other researchers say we need a vaccine that’s at least 90% effective, ore else we’re going to allow malaria to remain the scourge of Africa.  But, there are vast challenges (scientific, technical) in creating a vaccine that good.  One candidate comes from Stefan Kappe’s lab at Seattle Biomedical Research Institute.  You can listen to my profile of him from last year, or read a recent profile by Luke Timmerman at Xconomy.com.

And, there are entire websites devoted to debunking all this as hype.

I think it’s great for science and possibly for human welfare that the Gates Foundation and others are funding this research into malaria.  But, for the next decade at least, it looks like old-fashioned remedies will have to do.