Keeping up with all the flu news

A lot of people are wondering, Just how dangerous is the swine flu virus? (More formally known as, 2009 H1N1.)

The word from epidemiologists is: Not very dangerous, for most of us.

However ….  It’s quite dangerous to people falling in certain categories.  Watch out if you are: a pregnant women, a baby, elderly, immune-compromised, morbidly obese.  Or, if you have: any lung disease or disorder, an underlying chronic health problem.  (More details on this at the federal flu website.)

H1N1 virus particles invading body tissue. (CDC)

H1N1 virus particles invading body tissue. (CDC)

The easiest way to think about swine flu is that it’s remarkably similar to regular flu, except it spreads more rapidly.  Most people get only mildly sick and are better in three days or so.  I was surprised to hear epidemiologist Jeff Duchin of Public Health Seattle & King County go so far even as to urge most of us not to call the doctor.  There’s too much over-crowding as it is.

But there is some research that indicates this virus might be a little more dangerous than seasonal flu—especially for those in the “vulnerable” list I mentioned above.  For example, one team of researchers (at Imperial College in London) found the novel H1N1 flu virus lodges deeper in the lungs than regular flu virus.  That enables it to cause more severe lung infections and may account for some of the fatalities.  But it also is less aggressive in the nose and throat – making most infections less severe.

The message from this is, if you notice complications, such as breathing problems, don’t delay seeking medical help.  The best way I’ve found to sort all the usual questions is via Children’s Hospital of Atlanta, on their website.

Other tidbits:

  • The vaccine tests are full of good news. It appears to be highly effective and can be given in a single dose.
  • The first vaccine shipments may arrive on time, or even in early October.

Other recent posts and stories:

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Schools ready for swine flu?

Soon after kids return to school, in the coming few weeks, we may see  the H1N1 swine flu come back with sudden swiftness.  That’s based on what’s happened during past pandemics, such as in 1957, and on the virus’ behavior in the southern hemisphere.  Are the schools ready?

It’s hard to tell.  They basically are continuing where they left off when the first wave of sickness passed through last spring.

My colleague, Jennifer Wing, reports on discussions between Public Health Seattle & King County and school districts.  They don’t plan to close schools this time, and sick kids won’t have to stay home for as long (it was a full week last spring).  But, from what we’ve heard so far, it doesn’t seem like anyone’s making contingency plans for absentee rates that might range in the 30-50% range.

The Virus: H1N1

The Virus: H1N1

Epidemiologists are concerned with getting timely updates on the numbers of absent students.  This is essential for monitoring when and where outbreaks are happening, and last spring some schools were better than others about reporting.

Don’t be surprised if outbreaks begin as early as September.  The evidence keeps mounting that wherever kids congregate in large numbers, that’s where you’ll see rapid transmission of flu virus.  In 1957, it took just 3-6 weeks after school started before  many cities saw a surge of illness.

What about a vaccine, to prevent illness?  The first doses may not be available until after the first wave of sickness.  But, there may be additional outbreaks long into winter, and the vaccine will protect against those.

On the other hand, swine flu infections still appears to be mild, unless you have an underlying sickness or medical condition.

Washington’s “Swine Flu Six”

I’ll offer a few posts here, shortly. First, for those of you craving detail during these anxious times, here is full text of the radio stories for KPLU:

Version one:  Six Local Cases of Swine Flu Called “Probable”

The swine flu outbreak has officially reached Washington state. Last night, the state health department announced it’s identified six people as probable cases. They’re in Seattle, Snohomish County and Spokane. More from KPLU science and health reporter Keith Seinfeld:

We have the most details about the three from Seattle. They include:

A 33-year-old female doctor, whose husband and two children are also likely infected. They’re being treated at home.

A 27-year-old single man is at home.

And an 11-year-old boy has been hospitalized but is recovering. The boy’s school is Madrona, and it is staying open because the boy did not come to school at all after he became sick over the weekend.closed for a week. UPDATE – The decision was made early Thursday morning, after public health officials determined the boy may have been contagious last Friday when he was in School.   Washington Secretary of Health Mary Selecky says this all sounds alarming:

“The reason we’re being very cautious is because this is a brand new virus, and as a result there really isn’t any immunity in the population. So, we want to prevent it from spreading.”

Public health is especially on the lookout for how easily the virus spreads, and how severe the flu is once people get it. Dozens more possible cases are in early testing stages. The best way to keep it from transferring the flu, she says, is to stay home if you’re sick, cover your cough, and wash your hands. If you don’t have enough sick days? That policy, she says, is up to each employer. Keith Seinfeld, KPLU news.

More:

  • In Snohomish County, the public health department wasn’t able to get any details, as of Wednesday night, about a 6-year-old 3-year-old boy or a 34-year-old woman who are probable cases.
  • None of Washington’s six probable cases appears to have involved travel to Mexico.
  • So far, about 95-percent of the cases labeled probable by different states have proven positive at the federal labs in Atlanta. But it may take several days to get results for Washington.

Version Two: Probable cases of Swine flu in Washington

Six people in Washington are now considered to “probably” have swine flu, according to the state Department of Health. All six are recovering. Also one woman in Victoria, B.C., has confirmed she caught the swine flu while on vacation in Mexico. More details now from KPLU science and health reporter Keith Seinfeld:

Just a few hours after saying there’s no sign of any swine flu in Washington, the state health department got results from a new batch of tests. Six people have a strain of flu that is probably the new strain of swine flu – and their samples have been flown to the federal laboratory in Atlanta for confirmation.

Of the six, three are from Seattle, two from Snohomish County and one from Spokane. An 11-year-old boy in Seattle and a six-year-old boy in Snohomish were the only children. The Seattle boy’s mother is being praised for keeping him home – so his school, Madrona, won’t have to be closed. UPDATE – But Madrona was closed Thursday, for a week, because it turns out he may have been contagious last Friday when he was in School.  Dr. Jeff Duchin, chief epidemiologist for King County, spoke at a Wednesday evening news conference televised on northwest cable news.

“You shouldn’t go to school when you are sick.  You shouldn’t go to school if you have a fever or are coughing, all around the community, because if this virus has made its way to Washington state, the way to prevent it from spreading is by keeping away from one another when we’re ill.”

The Seattle boy has been hospitalized since Tuesday, with a fever and shortness of breath, but now is in good condition. None of the others required hospitalization. One case is a 33-year-old doctor from Seattle. She and her famly are being treated, but it’s not clear yet if she may have exposed others.

Public health officials say, you should expect to see more cases in Seattle and all over Washington, as more people are tested. Results from the federal labs may take several days. Keith Seinfeld, KPLU news.

More:

  • A shipment of anti-viral medicines is en route to Washington, to add to the state’s stockpile, in case the outbreak becomes an epidemic.
  • Seattle has activated its Emergency Operations Center, at the lowest alert level, to be ready should the situation change suddenly.
  • The advice to the public remains, stay home if you’re sick, wash your hands and cover your cough.

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.

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.