Swine Flu 4.994: Guidelines

Latest Pediatric Mortality Curve

A few pieces of information are coming together now:

There was a rise in the number of severe swine flu cases during the holiday season, and

CDC recently broadened its recommendations for use of antiviral medications in suspected H1N1 influenza.

First of all, how does CDC come up with recommendations?

CDC collects data from local health departments who collect it from doctors and hospitals; it analyzes it and looks for factors that predict best outcomes. Which is excellent. But it takes a while.

Our office saw its 100th patient with H1N1 flu when the epidemic was less than a month old. We were quite aggressive with early diagnosis and early antiviral treatment from the beginning, and to us the flu appeared mild. Flu appeared more severe to physicians who followed more traditional approach — wait and treat only those who appear to be getting worse after a few days. In essence, we were reformulating our own guidelines with each piece of incoming data — with each patient we saw and with each update we read from CDC, NYC Health Department, and the media. And each update to our own, ongoing summary of experience confirmed the validity of our approach. Which is as it should be in the early stages of an epidemic that has not yet been properly analyzed by the appropriate agencies.

And, sadly, there is only one explanation for the uptick in flu severity without a corresponding uptick in its incidence during the holiday season: a significant reduction in patient access to medical care, whether patients are away from home, or because their physicians are on vacation. Which brings up to the one lamentable limitation in our services over the holidays: Yes, we were open on Christmas and New Year Day, as well as Saturdays and Sundays, in our main office; but, no, we could not follow our patients to their vacation destinations. Sigh. I am told Mexico was lovely this time of the year…


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 4.992: The Winter of our Discontent



Yes, the picture that is worth 1000 words: H1N1 mortality in children has overtaken seasonal flu mortality.  Considering how prevalent this infection has been (we were busier during late spring than during any seasonal epidemic I can recall), swine flu is clearly more contagious than seasonal, but not necessarily more virulent — an individual’s risk of contracting it is high; once contracted, the risk of complications is in the same ballpark as for regular flu, except for highest-risk groups such as pregnant women.  Our original impression of this as mild flu is based on our model of care — rapid access to care, rapid diagnosis, prompt treatment.  Children treated 24 hours after onset of fever in our office have been recovering literally overnight! 

 We have also dispensed close to 1000 doses of H1N1 vaccines (injectable and nasal), and are running out.  As always, shortages create demand, and people who were declining the vaccine a month ago are clamoring for it now.  As of last night, we were out of injectable, and down to 30 doses of nasal.  Additional doses are expected from the Department of Health, which so far has done an amazing job handling this epidemic. 

Safety of the vaccine has been reviewed elsewhere; we have seen no serious reactions to any of these vaccines.  The number of people who turn up sick after immunization with “normal” illnesses is no higher than the number of unimmunized people who get sick just from being around other sick people.  There have been too few (a couple a day) positive flu tests to say anything about how effective the vaccine is; that is the subject for another post.


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.