Swine Flu 4.995: Back to the FLUture

OK, it’s not really about swine flu.  We have had a few febrile, sick children test positive for Flu A with our rapid in-office test; we don’t know if it’s H1N1 yet, but at this point it doesn’t really matter.

The CDC site is, as of now, still showing data from May 2010, including this plot which tells us that the cumulative pediatric mortality for H1N1 flu was on the order of seasonal flu mortality for the last 3 years combined.

I said this before and I’ll say this again: many of these fatalities were because of suboptimal guidelines for diagnosis and treatment of the flu — not so much because the guidelines were wrong, but because of our over-reliance on them.  There is no way a government agency can react quickly enough to new information, but individual physicians must use their best judgment at all times, and should not be discouraged from doing so by these agencies, and by our professional organizations.  Guidelines should not become straitjackets.

The initial guidelines said not to do in-office testing for flu.  Well, we did, and it took us maybe 2 days to realize that they did work well, and another 2 days to figure out that many children who were negative the first day of illness, became positive on the second. 

The initial guidelines said not to treat with Tamiflu except for high-risk and seriously sick individuals.  In two days it became clear that those we did not treat would become seriously ill in short order, and we began treating everyone, with excellent results.

The guidelines also did not allow us to suspend preventive care for the duration of the epidemic.  We partially solved the problem of exposure by offering an alternative location for well infant visits, but some patients came for checkups because HMOs sent them reminders and were exposed unnecessarily, and as for others –

The irony, of course, is that while we did a great job handling the epidemic, this very fact caused a drop in our quality indicators which are based almost entirely on preventive care measures.  Overlooking the fact that the best preventive measure for swine flu was staying away from the doctor’s office during the epidemic unless you were actually sick.

Except for suspending some preventive care visits (a sacred cow if ever there was one), all of our approaches were incorporated into guidelines, months later.

So what does this have to do with the flu that we are seeing now?  Just this: at any given time, your doctor will have the best information about the epidemics that are active in your community at that time.

If he or she is still allowed to see sick people, that is.

PS: Come get your flu vaccines!  They do work.    I did the study myself.   We’ll discuss that next time.


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Swine Flu 4.993: It Ain't Over Till It's Over

Most of the swine flu stories are about the epidemic winding down, and not being as bad as feared.  Maybe.  If you ask the numbers (or better yet, the graphs) –

Still pretty impressive.  In the rightmost pediatric mortality spike, purple is confirmed H1N1 deaths, and green is untyped.  Deaths from flu strains other than H1N1 are at 1 to 2 per week.

Several troubling developments lately.  I went to my home town, Lvov, in Ukraine, a few months ago, for the first time after 34 years,

and shortly after I left, the Polish-Ukrainian border was closed because of a then-unknown epidemic of a deadly infection in Western Ukraine.  Shortly thereafter, the epidemic was identified as a somewhat mutated H1N1 swine flu, the mutations making it somewhat less sensitive to Tamiflu, more likely to produce “cytokine storm” leading to rapidly progressive hemorrhagic pneumonia, and an antigen drift making H1N1 flu vaccine somewhat less effective for that strain.

The news isn’t all bad.  Our experience in previous years showed that (a) even a slightly mismatched injectable vaccine is better than nothing, (b) a slightly mismatched live nasal vaccine  is nearly as effective as a full-match vaccine, (c) clinically, even patients who became ill during epidemics with Tamiflu-resistant strains responded to Tamiflu reasonably well, (d) most of the cases are still caused by the “old” strain, Tamiflu-sensitive and matching the vaccine, (e) there is still plenty of vaccine available, EXCEPT for the under-2 year olds (we ran out of that, at this point), (f) there do not seem to be repeat cases of H1N1 infection in people who already had it, making it yet more likely that the vaccines will work against the mutated strain.

I did a count of H1N1 doses already given out this year.  It’s over 1400 since October 14 2009, with no serious adverse effects, and so far I know of 2 cases of confirmed flu in H1N1 vaccine recipients, neither infection causing complications.  That’s pretty good, as we are seeing between 1 and 5 confirmed cases of flu a day for the last month.   Too early for a statistical inference (odds ratio in vaccinated vs unvaccinated individuals), but looks good so far.

Way back when (late April 2009), in the Fox News interview, I mentioned that many infections are more severe in Native Americans, possibly accounting for higher flu mortality in Mexico.  This  has now been confirmed.  The CDC also now recommends more widespread use of Tamiflu in H1N1 patients, which is something we had been practicing all along.

We still recommend Vitamins A and D supplementation; elderberry extracts have been tested in test tubes and appear to slow down flu virus replication (though no human studies have confirmed this), but it’s worth a try.  And, of course, handwashing, “Dracula Cough”, and staying out of crowds.

And get your flu vaccine — H1N1 now, seasonal flu later.


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.


Swine Flu 4.97: Natural Remedies

According to the CDC, our Northeast is the least flu-affected area in the US right now.  We are administering seasonal flu vaccines now, and there is a shortage so get yours soon.  Just faxed in my order for the H1N1 vaccine; we are told that Swine Flumist will be the first available, and that leaves out the most vulnerable groups, but it is definitely better than nothing.

Of natural remedies against the flu, two have enough studies behind them to rise above the level of voodoo:

Vitamin D, which in my own experience, and in many studies, is often deficient in both children and adults, can be given safely in doses above the RDA of 400 units/day — 1000 to 2000 units a day are safe, and will raise the levels to normal quicker than 400.  Vitamin D may be the major reason behind flu’s seasonal pattern.

Black Elderberry contains substances that inhibit viral replication.  There have been studies to show that Sambucol (Black Elderberry extract) works in people; the studies weren’t the best quality, and did not address the concern of immune overreaction that may be the reason for swine flu’s (and bird flu and Spanish flu as well) increased danger to healthy young adults, but, as I said before, this is better data than what we have for most alternative medications.

Back to work.  I have a lot of smart people to vaccinate.


Swine Flu 4.96: The Count of Many Tests

I did a quick, preliminary count of positive Flu A tests in different vaccine recipients.  Of about 500 Flumist recipients, 1 had a positive test for Flu A during the “regular” season (Dec 08-Mar 09), and 39  had positive tests for Flu A during the “swine” season (Apr 09-Jun 09).  Of about 1000 Fluzone recipients, 3 were positive for seasonal Flu A, 40 were positive for “swine” flu A.  Without getting all technical about it, looks like the two vaccines are both very effective in protecting against seasonal Flu A.  Since they were never intended against Swine Flu, it is not surprising that that neither has much (if any) of a protective effect against swine flu.

Take home message: use a flathead driver for flathead screws, and Philips driver for Philips screws.  Get seasonal vaccine now, and swine vaccine when available.


Swine Flu 4.95: Famous Penultimate Words

“You can give me all the public health statistics in the world, but I believe based on all I’ve read to date that vaccinations cause a body more harm than good.”

This was posted  on a doctors-only board yesterday, presumably by a doctor.  The sentiment is one I often heard before, and yes, sometimes from physicians; but rarely have I seen a statement that so honestly examines the mindset behind voodoo medicine.

Let’s try this again, slowly:

“You can give me all the public health statistics in the world, but I believe based on all I’ve read to date that vaccinations cause a body more harm than good.”

“You can give me all the public health statistics in the world” — Public health statistics usually come in the format of, “Of 10000 people who received the vaccine, 2 died, and of the 10000 who did not,  20 died”, or similar, and thus speak for themselves.  They also come from places entirely away from any influence from pharmaceutical companies (often blamed for messing with our own statistics) such as Cuba and Iran, and are usually in line with our own.

“I believe based on all I’ve read to date” — I like fiction, too, really I do, but I do not practice medicine according to THE ANDROMEDA STRAIN, and I do not expect our foreign policy to be formulated by Tom Clancy.  A clique of quacks recycling each other’s delusions does not qualify as continuing education.

“vaccinations cause a body more harm than good” — the one thing they have harmed so far is the respect accorded a pediatrician, by taking much of the melodrama out of patient-doctor relationships.  Families look at the doctor differently when the encounter occurs in the Intensive Care Unit — I spent enough time running one at night, as Chief Resident back 20 years ago, to know this very well; and the other thing I know well is how well we vaccinated many of the diseases (that formerly put children in ICUs) into near-extinction (resulting in near-extinction for many of the ICUs, but that’s a different story).  Yes, saving a life in a close call generates more respect than saving 1000 with a shot and a bandaid — which also may be the reason why most people prefer reading fiction to statistics.

In other news:  CDC Flu tracker reports accelerating flu activity in the South but very little here in the Northeast as of yet.  Swine flu mania did at least some good, in promoting awareness that normal seasonal flu isn’t much (or any) better than the novel H1N1 2009, and seasonal flu vaccine demand is subjectively higher than it was in previous years — but, again, all too often, I hear the mantra:

“You can give me all the public health statistics in the world, but I believe based on all I’ve read to date that vaccinations cause a body more harm than good.”

Swine flu vaccines have been approved for adult use, and are being evaluated for pediatric use, with mid-October as the target date (which may be late in the season for some of the hard-hit Southern states).  The US-approved H1N1 vaccines are adjuvant-free, and contain about the same amount of antigen as seasonal vaccines, and are thus not expected  to have a significantly different side effect rate from the seasonal vaccine, but I certainly would not jump into endorsing the H1N1 vaccine for children until some of the data are in — but realizing that in the real world, and for real children, the decision point is very soon, I will continue to monitor the information.

By the way:

Ellen Kushner, SWORDSPOINT

John Scalzi, OLD MAN’S WAR

Samuel R Delany, EMPIRE STAR

These are some of the fiction books I read or re-read lately, and highly recommend — but not as sources of medical information.  I have not found nearly as much amusement and entertainment in the vaccine-related fiction found on the Internet.


Swine Flu 4.94: what if?

Still no sign of swine flu in the neighborhood, but the media are busy fanning the flames of panic.  Well, why not?  We do have a problem, might as well have it be pointed out by something as relatively mild as swine flu.

The problem has to do with the dismemberment of inpatient care in the US.  There is something called the

Milliman and Robertson Length-of-Stay Criteria

(basically a wish list from the managed health industry  about how they would like every disease treated by an outpatient or drive-through procedure).

Then there is the tendency to emphasize preventive care at the expense of curative care infrastructure: the money spent on screening and prevention is being generated by closing hospitals, and fewer physicians are doing hospital care now than ever before.  Which is fine, as long as everything you face is preventable.

As yet, swine flu is not very preventable.  Yes, they are working on the vaccine (it is not clear yet how effective it will be, I am hoping for the best, and it is promised for late October), and, yes, thinning the crowds (in schools and elsewhere), proper hygiene, vitamin supplementation and “social distancing” will be useful — but they fall short of complete prevention.  In the meantime, inpatient and intensive care facilities are pared down to bare minimum. It’s a good thing swine flu is only expected to cause a modest increase in need for intensive care — something really nasty like SARS or Spanish flu would have caused a total health care meltdown.  This is a good time for the powers-that-be (within medicine as well as government) to become unobsessed with preventive care and return to what we are really trained to do: treat the sick.  Preventive care, though important, is a fairly cookbook procedure, time consuming mainly because of the amount of advice and guidance to be dispensed, and, as I said before, having a quota of teenagers to bore today can conflict seriously with caring for the sick children in an epidemic setting — let’s think about that for a minute.