Swine Flu 4.991: The Quality of Mercy

Pediatric Flu Mortality 2009

This is the picture that is worth 1000 words, and it is what informs the rest of this post.

The fall outbreak, nationally, is now officially worse than the spring outbreak. We are not seeing any cases here in Brighton yet, but we will soon — the outbreak map:

Outbreak map

now shows New York in widespread brown, along with the rest of the country.

First of all, even though the H1N1 vaccine is not available to us yet, the risk of the wild flu is now high enough for the potential vaccine risks to be acceptable. I now recommend it highly, especially for the high-risk populations: pregnant, obese, young, health care workers, parents on newborns, and those and with preexisting conditions.

Secondly, there are not very many plausible explanation for the summer vacation that the flu takes. The incidence curve and the mortality curve correlate well with seasonal variations in Vitamin D levels, due to differing sunlight-to-skin exposures:

Vitamin D seasonal variation in Australia

The science behind this connection is not conclusive, but it is a whole lot better than that purported for the so-called vaccine-autism connection, and the downside of “just-in-case” Vitamin D supplementation is negligible, which cannot be said for “just-in-case” vaccine refusal. So vaccine, Vitamin D, hygiene, avoiding crowds, “Dracula cough” –

Dracula cough/sneeze

and liberal school attendance policy remain my recommendation; taking Tamiflu prophylactically is not, except for the very high risk individuals.

The role for Tamiflu is in early, aggressive treatment of identified high-risk individuals who actually have flu, which means that rapid availability of urgent care is the key to minimizing complications. Looking at the so-called “Quality Indicators” by which practices are judged in New York, we find that the state is interested in many factors such as up-to-date immunizations, lead testing, weight and activity counseling — all laudable goals — but not availability. So the practice that dumps urgent care on emergency rooms to concentrate on crossing the T’s and dotting the I’s in preventive care will actually look like a higher-quality practice than one that actually takes care of sick children. I hope I am not the only one who finds this ironic.


Swine Flu 4.99: Sound Bites

I spoke at some length to Mr Juan Gonzalez at Daily News yesterday, with this result:


Some of the points that came up in the conversation but did not make it into the article are worth reiterating:

Mr Gonzales told me that most authorities now consider H1N1 to be more likely to produce complications such as pneumonia than seasonal flu, especially in Black and Hispanic patients. That was, on one hand, to be expected, based on the difference between the original high mortality in Mexico during the early phase of the pandemic, and the much lower mortality in the US; on the other hand, we just did not see this pattern in our practice. Some of the previous seasons, 2000/01 and 2004/05 if I remember correctly, had much higher rates of complications. I attributed the difference to our practice being much more aggressive with early detection and early treatment with Tamiflu, preventing many of the complications that could have been expected with more conservative care. On the other hand, we hardly used any Tamiflu at all for prophylaxis, expecting (correctly) that such use may produce resistant strains with more likelihood than short-course treatment of sick individuals:


I will also refer (again) to my Fox interview, back in April, in which I went over the reasons the flu may have been more severe for Mexican victims:


I would certainly concur with Mr Gonzalez’s call for more studies to determine the common risk factors that militate toward poor outcomes in Black and Latino children: not only would it help these children, but the results of such studies are always useful in protecting other populations where risk factors may be present at lower prevalences. Vitamin D deficiency and obesity are in no way limited by race or ethnicity. Diseases are not “racist”, as some commentators to Mr Gonzalez’s article suggested, but there are always genetic, cultural and socioeconomic factors that influence outcomes. The more we know about that, the better for everyone.


Swine Flu 4.98: I guess that's why they call it the news

Swine Flu is still on hiatus, and few mourn its exile (except the folks where it’s exiled to, South and Southwest, right now) — according to:


Something finally went right: it finally seems to penetrate the collective consciousness that, though swine flu is not significantly worse than seasonal flu, it is not so much a dismissal of swine flu as a threat as it is a renewed realization of seasonal flu as a significant perennial problem. This is from a CDC report from 2004:

During the 2003-04 season, CDC requested that states report deaths in children < 18 years of age who tested positive for influenza. As of May 31, 2004, 152 influenza-associated deaths in U.S. residents aged < 18 years were reported by 40 states. All patients had influenza virus infection detected by rapid antigen testing, viral culture, or other laboratory methods. The pediatric data are preliminary and subject to change as more information becomes available.

That’s 152 pediatric deaths in one season from seasonal flu alone, confirmed cases only. Cumulative total for 2008-2009 so far, including the seasonal spike and BOTH the spring and the fall H1N1 spikes, is 128. That’s not to belittle H1N1; that’s to put it in perspective — and I think the perspective is becoming clearer and clearer, and I say this because demand for seasonal flu vaccine this year is far above last year’s.

The WCBS interview with which I start this blog post is only about 5 minutes, and I hope I made my points clearly: I support the vaccine, both seasonal and swine, both injectable and nasal. I mentioned the 1976 (misspoke; said 1975 in the interview) vaccine as the worst-case scenario — even if current vaccine were as bad as that one had been, it would still be worth taking; and I think we as healthcare workers should take the vaccines both for our own sakes and for our patients and our families — and I can’t think of a better way for the state to discourage people from getting the vaccine than by making it mandatory. This is still America. You know, the land of the free and the home of the brave –

– and you have to be really brave to pass up the flu vaccine. So go get yours. In spite of it being mandatory. Save your protests for something important. I don’t think the government will keep you waiting long for some really bad initiatives worth demonstrating against.