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

http://www.nydailynews.com/ny_local/2009/10/07/2009-10-07_unspoken_minority_toll_swine_flus_bigger_impact_on_blacks_and_hispanics_is_not_b.html

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:

http://www.who.int/csr/disease/swineflu/notes/h1n1_antiviral_use_20090925/en/index.html

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:

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

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

http://cdc.gov/flu/weekly

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.

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.

“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.

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.

It’s now about 7 weeks without a single positive flu test, which makes one wonder: where did it go?  It is certainly around in the Southern hemisphere, where it is winter now (about 1% of New Zealand’s largest cities population was seen with flu-like complaints during one week in July), and even in the Northern hemisphere, some countries are just starting seeing massive numbers of cases, and some states still have widespread flu.  So the question is, why are we not seeing any cases here in Brighton Beach?

Theory 1: Practically everyone in the neighborhood who was going to get the flu, has already done so.

–well, if that’s the case, we should be fairly safe come fall.

Theory 2: Transmission has been interrupted by “summer factors” — better ventilation, moister air, decreased crowding…

– in which case, more open windows, humidifiers, and a liberal school attendance policy should be helpful.  School un-crowding is especially important with swine flu because attack rates for this particular strain appear highest in the 5 to 24 year old cohort.

Theory 3: D-fense!  Vitamin D does appear to strengthen the immune response, especially against respiratory infections, and Vitamin D supplementation (along with A, C, zinc, and others which may be helpful) is certainly worth trying.  In my own practice I have been measuring 25-OH vitamin D levels in the serum of patients presenting for a variety of complaints, and an appalling number have come up deficient.  Although most, as expected, were either dark-skinned individuals or indoor WoW addicts, I did have a low Vitamin D level in a freckled sunburned redhead.  (Yes, I did read the riot act about hazards of sunburn).

Theory 4: An Unknown Factor.  No one knows why, in 1976, swine flu infected 100 soldiers at Fort Dix, and no one elsewhere.  If this flu strain plays a similar practical joke, that X-factor may be easier to find with modern molecular techniques.

Well, off to work…

It has been 6 weeks of relative calm: very few children with fever (and those who did, mostly had obvious hand-foot-mouth disease, pneumonia, or strep throat); not a single positive flu test in these 6 weeks, and that’s after having over 20 a day in June.  We are continuing to do flu tests, so watch this space: we’ll be among the first to know when flu returns.  It is now highly prevalent in the Middle East, the Southern Hemisphere, and other places it did not hit early.  Russia appears to have only a few cases so far, partly due to a vigorous screening and isolation program; whether it works in the long run remains to be seen.  My recommendation (Mexico is now the best and safest place to go on vacation) stands, as do all my previous advices.  I would like to re-emphasize one of them:  vitamin supplementation.  More than half of all the children I have so far tested are Vitamin D deficient (as opposed to none deficient for B12 and Folic acid), and Vitamins D and A are essential for proper immune response.