In yet another Star trek reference, words spoken by Dr McCoy to create a sense of extreme urgency — actually mean “eating too much”: “acute” = (of disease) brief and severe; “postprandial” = after a meal; “upper abdominal” relating to the area of the stomach; “distension” = the state of being stretched beyond normal dimensions.  And, yes, I am enjoying paying homage to the TV show from which I learned spoken English.  And, yes, “deadly”, “swine”, and “pandemic” are being thrown around with abandon to create a panic that need not happen.  “Deadly” may apply to anything of which anyone ever died (and, in a rather confusing email from CDC, I learned that apparently the Mexican confirmed swine flu death toll is downgraded to… 7…?

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a2.htm?s_cid=mm58d0430a2_e

Well, that’s way below what seasonal flu causes every season, but, technically still deadly.

Calling it “swine” (or “bird”) flu is also misleading, as most new strains are produced by reassortment in pigs and poultry in close contact passing the infection back and forth; and a “pandemic” means the whole world is sick with it — which applies equally well to common cold and athlete’s foot.  Reminds me of the obsessive-compulsive agnostic dyslexic insomniac — stays up all night wondering if there is a dog.

Anyway, only one positive yesterday (out of a many many anxious families) and that one not very sick either.  “Acute postprandial upper abdominal distention” also means being fed up, and it seems that the media have had their fill of hysteria, and voices of sanity are beginning to prevail:

http://www.nytimes.com/2009/05/02/health/02flu.html?ref=americas

Five days after my interview with a Miami radio station:…

http://www.youtube.com/watch?v=AU0oom3B8DM

…and the Fox News TV interview:

http://www.foxnews.com/search-results/m/22200273/swine-flu-reality.htm 

… most news and official statements are beginning to confirm what we saw.

As a training exercise, or a dress rehearsal, for handling a really severe outbreak (which this was not), the official response to this epidemic has been of great value.  I think it will be analysed for years to come to assure better preparation for a potential emergency.  So for local, state, federal and international health authorities I have nothing but praise (especially let’s give a big hand to NYC Health Department, whose actions were an incredibly short 24 hours behind the frontline view).  I am less happy about the media; this is not the time to be crying “wolf”, no matter how it improves sales, ratings, or hit counts.  Let’s save the hyperbole for when we need it.

In case anyone forgot, Star Trek V is titled “The Final Frontier”; I don’t think the flu story has a final anything in it, so I’ll stay with 4.x for the time being.

Once I post them, click “Comments” for my videos on the swine flu subject.

Our Flu A (highly likely swine flu) count is now up to 8, 2 more coming in yesterday and being diagnosed by a rapid test, and the more I think about the Mexico death toll, the more likely it seems that a perfect storm of risk factors is responsible.  The most dramatic example of a perfect storm is a cancer called Burkitt’s lymphoma, common in Equatorial Africa but rare in African Americans.  It turned out that a combination of a gene mutation, malaria and Epstein-Barr virus infection is necessary to trigger it, and only in Africa do the 3 factors (each common elsewhere) come together.  The 1976 Swine flu outbreak went nowhere outside a basic training cadre in a military base — it is theorized that a packed-in crowd of stressed-out individuals created the fertile environment not duplicated elsewhere (outside of most middle schools I know).  And, the great mathematician Srinivasan Ramanujan, deprived of vitamins A and D by his dark skin, living in sun-starved England, and vegetarian diet, succumbed to tuberculosis after being thus weakened.  I have already mentioned my thoughts on risk factors possibly prevalent in Mexico; iron deficiency, in particular, is common in my patients from Mexican families, and may contribute as well.  I am sure that is being thoroughly investigated, and more than one risk factor may be responsible, delineating areas of concern for other countries.  In the meantime, we should go about out lives, washing our hands perhaps more often and going into crowds perhaps a bit less, and as for vitamin supplements — make sure A and D are in them.

Three more Flu A cases yesterday, only one (a Mexican teenager) looking sick enough to suspect flu, but nowhere near life-threatening.  Called NYC Health Department.  Guess what?  They agree with me!  They think all new Flu A is swine flu; they agree that it is less severe than “regular” flu; they think the cases in the city are too numerous to count or confirm, and that many are so mildly ill that they will never even see a doctor; they do NOT want me to report cases or send samples for confirmation UNLESS the patient is sick enough to be hospitalized (which is perfectly reasonable, if they try to count every sniffle in New York they will have no time left for their real jobs dealing with life threatening disease).  Channel 7 News at 11 interviewed me yesterday and this is pretty much what I told them; either I was too boring or what I said was too boring, and they chose not to run my segment, opting instead for more exciting news of school closings and masks running out in pharmacies all over town.  This being the case, I will enlist professional help in bringing my message to the public: (click on the Comments link below):

(Diagnosis is made by analysis of nasopharyngeal secretions, you see.  It’s a pun.  It’s supposed to be funny.  You may laugh when ready.)

Here’s a draft of an interview I gave on Swine Flu as it impacts new mothers:

> 1)  What exactly is swine flu?

It’s a flu previously only seen in pigs.  IN fact, all flu strains arise
in pigs and poultry, and cause human epidemics when they become
transmissible between humans.
>
>
>
> 2)  New moms may have added concerns over the current swine flu threat.
> What should a new mom know about swine flu in regards to her baby?

The “additional” concern is really only for families that received the flu
vaccines as recommended by the CDC, because the seasonal flu shots do not
appear to prevent this new strain.  For people who were not immunized this
season, the garden variety, “regular” flu is probably still the greater
threat, with thousands of fatalities in US.
>
>
> 3)  How serious is the swine flu in regard to small infants? Are some
> infants more susceptible than others?

Possibly; the only place where serious cases have occurred so far is
Mexico, and the risk factors are still being analyzed there.
>
>
>
> 4)  What precautions should a mom take to keep her baby healthy?

Keep out of crowds, wash hands and everything else that touches a baby.
Vitamins A and D should be supplemented, especially in breastfeeding
babies over 2 months age and all mothers, as they are vital in maintaining
appropriate immune response, and are most often deficient.
>
>
>
> 5)  What symptoms should she keep an eye out for in her baby and when
> should she seek medical attention for her baby if she suspects swine flu
> contact?
>

The usual — fever, cough, poor appetite, cranky or lethargic, looking sick.
>
>
> 6)  If an infant does contract swine flu, what is the treatment?

Tamiflu appears to be effective; you and your doctor will decide if it is
appropriate.
>
>
>
> 7)  Is there anything I have forgotten or that you would to add to the
> topic?

The early returns suggest that this is a milder disease than regular flu,
amd is probably very widespread already, with lots of mildly sick people
running around, going about their business, and getting better without
ever being diagnosed with swine flu.  In fact, the countries reporting
cases now are those with real-time capability of analyzing virus genome to
identify it, and I doubt anyone is spending the money to test mildly ill
persons.  We will soon know why Mexican patients are more severely
affected; possibility include genetic (Native Americans appear to have
different immune response to certain infections), vitamin deficiencies, a
pool of infected individuals well into the millions leading to fatality in
a rather small percentage of cases, existence of a co-infection in Mexico,
and toxic folk remedies or counterfeit medications.
>
>

OK, here is what happened today:

3 children tested positive for Flu A.  2 of them had been immunized with Flumist, which up till now only rarely failed (maybe 5 previous positive Flu A’s out of hundreds previously immunized children tested).  The 3rd child was not immunized.  NONE of the 3 had “severe” flu — none had high fever, none looked as miserable as actors in NyQuil advertisements, none had anything resembling complications — in fact, in the middle of the epidemic 2 months ago, I probably would not have tested them because they did not look sick enough to have the “real” (garden variety) flu.  I gave Tamiflu to all three, and will follow them closely.  I do not know for sure that they had “swine” flu, but it is unlikely that “garden variety” flu would produce equally mild disease in immunized and unimmunized individuals.

So what is the most likely explanation?

I think this “new” swine flu is actually quite widespread already; I think the great majority of people who had it, never knew they had it because they did not feel sick enough to go to the doctor, and if they did, they did not look sick enough to be tested for flu.  I do not know what was different about the fatal cases in Mexico (apparently caused by the same virus), but I suspect we will find out soon.

Coming soon: Swine Flu III: The Search for Sanity…

The good news is, as of right now it does not appear to be significantly more severe, more contagious, 

or more drug-resistant than garden variety flu, and the H1N1 component of previous flu vaccines may 

actually create at least a small immunity against the swine flu, so the need to worry about this epidemic

 is most pressing for chronically ill and/or elderly individuals who are at high risk for complications from 

any strain of influenza, with the added caveat that the flu shot they received this year may not offer 

them significant protection.

We are also continuing to test for flu in the office; today we have had 3 positive

for flu A so far. (2 PM, we are open 9am to 7pm).  I have to assume these are all

swine flu, as all "regular" flu activity lately has been "B".  None are very sick;

all are getting Tamiflu, with expectations that it will work.  If you are worried, we can help.

The CDC reports mostly type A Flu nationwide and in New York, but in out office, the last 2 weeks or so, positive Flu tests have nearly all been TYpe B (unlike a month ago, when they were mostly Type A). MAkes us feel better about using Tamiflu (see earlier post) to which all Type B’s have so far been sensitive.

In other news, it seems as though people are becoming interested in what we have to say. In addition to the old NY Times, Daily News and NHK interviews, there are now articles incorporating our opinions to SIDS, obesity, “third-hand” smoke and (of all things) handling embarrassing baby situations. Our office is also mentioned by COLA (a clinical office lab accreditation organization) as a 2008 Laboratory Excellence Award Recipient, and we published a case report of an allergic reaction to a sewing needle. And, on one occassion, an interview in which I expressed an opinion was incorporated into an article that claimed the opposite. I think it is fair to say that we agreed to disagree.

We started doing more flu tests; today 5 tested positive for type A and 3 positive for type B flu.  A few comments:

(1) Flu vaccine efficacy: we had 2 positive tests so far in children who got injectable (Fluzone) flu shots; in both the disease was mild and went away quickly.  We have had NO flu at all so far in children who got the nasal Flumist vaccine.  Remember, injectable flu is shot still the only one recommended for ages under 2, over 49, and for high-risk individuals.
(2) CDC reports that most Flu A strains this season are resistant to treatment with Tamiflu, our usual drug of choice.  We tried to prescribe Relenza, to which the strains are sensitive, but ran up against the fact that none of the local insurers cover this medications.  I guess no one at the insurance companies reads  www.cdc.gov/flu/weekly…

(3) One of the children who tested positive for flu simultaneously tested positive for Group A Strep.  Both infections are running around schools and day care centers, so to have both at the same time would not be unusual; this is just a reminder not to stop looking for answers once you have one good answer: it may not be the only answer…

(4) Having Flu A does not make one immune to B, and vice versa.  It’s not too late to get you flu vaccine, even if you have been sick.

My near-classmate, Mark F. Bernstein ’83, wrote an article in the latest issue of Princeton Alumni Weekly, examining the impact of the great flu pandemic of 1918 on the Princeton campus.  The short version: the deadly epidemic that killed fifty-nine University of Michigan students and 32 Princeton town residents, killed no one on the Princeton campus.  Probable reason for this success: aggressive isolation of all persons with even mild respiratory symptoms for the duration of their illness, and restrictions on students attending public events with uncontrolled attendance.

This year’s flu is coming. We have had only 2 confirmed positive tests so far, but it is early in the season, with low (sporadic) flu activity reported by the CDC and the Google flu tracker.  This year’s decreased flu compared to previous years may be due to increasing use of Flumist, a more effective vaccine in stopping flu transmission (injectable flu still appears to be better at preventing complications in high-risk individuals), or perhaps less crowding in stores due to recession and online shopping, but this cannot be expected to remain so.  In addition to encouraging further vaccination, I would like to ask responsible education professionals to be less diligent in enforcing attendance requirements.  Staying home is still the best way to avoid transmitting the flu in schools, and people are just as contagious in the prodromal (sniffles only, no fever or aches) stage as when they are shaking with chills.

Sorry to disappoint some of the folks who will Google their way here:  It’s not about the connection, it’s about lack thereof.  Just wanted to let everyone know that, for the first time in my career, I saw an unvaccinated child with clear features of Autism Spectrum Disorder — between high-functioning Autism and significant Asperger’s syndrome.  Now, considering that I have far fewer than 150 unvaccinated children in my practice, and that 1 in 150 is the commonly accepted figure for ASD prevalence, this argues for at least as high a rate in unvaccinated as in vaccinated children.

Which brings me to, why do people think it’s the vaccines?

Sorry again; you ain’t gonna like the answer.

ASD is, for all practical purposes, a learning disability limited to interpersonal relationships.  Among other things, people with even mild  ASD cannot tell when someone is lying to them.  We responsible physicians tell them ASD is about genetics and parent age.  Translation: your children are growing up just like you but more so.

It’s as if we were saying: It’s all your fault.
From the other side, they are bombarded with another message.  Whether it’s MMR, mercury or microwaves, absence of evidence of connection is not interpreted as evidence of absence.  The more myths are debunked, the more fervently they are cherished, for at their core is this:

Someone did this to your child.

And what parent would not cling to that?

My own concerns with vaccines have nothing to do with either their safety or their efficacy.  I am concerned with the recent trend to require universal vaccination against diseases that are not significantly dangerous but rather unpleasant, which require school or work absence and medical care but are not likely to result in death or lasting damage.  I suspect that, as more children are crammed into day care for longer periods of time, other viruses will take their place — Norwalk and enteroviruses for Rotavirus,  Adenovirus for flu — negating the improvement from the vaccines.  Only if the current trend to place more and more children in day care is reversed will we see fewer sick children — and then the vaccines will really help.