H1N1 – Stop

We’re getting some good news about the H1N1 situation, not only here in the U.S., but also around the world.  You can tell that by where it’s placed in the newspapers:  behind the entertainment tax proposal and American Idol cast-offs and ahead of The Oscars. 

The World Health Organization said that  H1N1  continues to circulate in temperate zones of the Northern Hemisphere.  However, it’s at a low level and is continuing to decline in most areas.  While Mexico and Peru have seen a slight increase in respiratory disease, activity is very low in North America (http://www.who.int/csr/don/2010_03_05/en/index.html).

Meanwhile, a closer look at the U.S. situation reveals the following (http://www.cdc.gov/flu/weekly/?date=030510):

* The nation’s pandemic flu activity was steady last week (6th week in a row);

*Doctor’s visits for flu-like illnesses are below baseline;

* Pneumonia and flu deaths are up a bit but below the epidemic levels;

* One pediatric flu death was reported, in an influenza B case from last season;

* No states reported widespread activity;

* Alabama, Georgia, Mississippi, and South Carolina had regional activity.

Meanwhile, CDC has come out with a report this past Thursday indicating that nearly 5 months after the pandemic H1N1 vaccine got off the ground, it still appears to have a safety profile similar to that of seasonal flu vaccines (http://vaers.hhs.gov/resources/2010H1N1Summary_Mar04.pdf).

For those of you who are visual learners:

Just for the moment, I want you to put aside thoughts of healthcare reform, Tiger Woods, and the Olympics.  I want you to look out beyond the horizon and concentrate on what may be happening with H1N1.  I say “may”, because no one knows for sure.  However, I see several events of which you need to be aware:

1)  WHO experts want to keep the pandemic situation at the present level and not downgrade it;

2)  There’s been a bump upward in the number of ILI illness in our colleges;

3)  Some EDs in the US are seeing another spike in patient census because of ILI illnesses.

Link:  http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/feb2410pandemic.html

Feb 24, 2010 (CIDRAP News) – “The World Health Organization’s (WHO’s) emergency committee of experts yesterday recommended holding at the current pandemic alert level based on evidence of new community spread of the virus in West Africa and the possibility of a second wave of illnesses as the Southern Hemisphere enters its winter months.

Keiji Fukuda, MD, special adviser to the WHO director-general on pandemic flu, told reporters at a press briefing today that the emergency committee, set up under International Health Regulations (IHR), met in a 2-hour teleconference yesterday and discussed whether to move from pandemic alert phase 6 (pandemic phase) to a post-peak phase…..”

So, right now, enjoy life, be alert, be prepared, maintain the hygienic necessities, get your vaccination, and watch the skies…..

Here are the latest graphs coming from CDC:

*  Visits to doctors for influenza-like illness (ILI) nationally increased slightly this week over last week, but are still low for this time of year. The national increase in ILI was driven by elevated ILI in regions 4, 7, and 9. Region 4 is comprised of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee. Region 7 is comprised of Iowa, Kansas, Missouri and Nebraska, and region 9 is comprised of Arizona, California, Hawaii and Nevada.

* No states reported widespread influenza activity. Three states reported regional influenza activity. They are: Alabama, Georgia and South Carolina.

*  Another two flu-related pediatric deaths were reported this week: both deaths were associated with laboratory-confirmed 2009 H1N1. Since April 2009, CDC has received reports of 326 laboratory-confirmed pediatric deaths: 277 due to 2009 H1N1, 47 pediatric deaths that were laboratory confirmed as influenza, but the flu virus subtype was not determined, and two pediatric deaths that were associated with seasonal influenza viruses.

http://www.cdc.gov/flu/weekly/weeklyarchives2009-2010/images/IPD06_small.gif

*  The proportion of deaths attributed to pneumonia and influenza (P&I) based on the 122 Cities Report increased slightly over the previous week but remains lower than expected for this time of year.

*  Visits to doctors for influenza-like illness (ILI) nationally increased slightly this week over last week, but are still low for this time of year. The national increase in ILI was driven by elevated ILI in regions 4, 7, and 9. Region 4 is comprised of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee. Region 7 is comprised of Iowa, Kansas, Missouri and Nebraska, and region 9 is comprised of Arizona, California, Hawaii and Nevada.

This from our colleague, Ben Batey, R,N.,who is organizing flu clinics here at UT: 

“Even though the media isn’t making as big a deal of H1N1 as it did originally, it doesn’t mean that it just disappeared. It is still as important as ever to be prepared and get vaccinated.

 The top ten reasons to still get vaccinated for H1N1:

 1. To protect yourself from the H1N1 virus.

 2. To prevent your family from getting the H1N1 virus from you.

 3. H1N1 vaccine is now readily available and this means not having to wait in long lines.

 4. The CDC estimates that between 39 million and 80 million cases of 2009 H1N1 have   occurred between April and December 12, 2009.

 5. The CDC states that though flu activity caused by either 2009 H1N1 or seasonal flu viruses may rise and fall, it is expected to continue for several more months.

 6. The CDC recommends influenza vaccination as the first and most important step in protecting against the flu.

7. H1N1 virus is very unpredictable. Unlike seasonal flu, which peaks in January and      February, H1N1 influenza will probably come in waves.

8. Millions of Americans have already been safely vaccinated.

9. Getting vaccinated is free. It is much easier and cheaper to get vaccinated then to get sick and miss a week of work or school.

10. Weekly flu clinics at the UT Main Campus Medical Center make it easy to fit getting vaccinated into your schedule.

For more information on H1N1 and seasonal flu, please go to: http://www.utoledo.edu/fluprep/index.html ”

Now with the NFL playoffs and American Idol beginning to occupy our brains, H1N1 seems to be fading into the background.  Yet….

The following is an open letter published on the CDC website from 37 well-respected organizations asking the American public to consider getting the H1N1 vaccine. 

Link:  http://www.cdc.gov/h1n1flu/open_letter_h1n1_vaccine.htm

Open Letter to the American People:

Since the 2009 H1N1 flu virus hit our shores, scientists, manufacturers, health providers, and federal, state, and local health officials have worked together to protect the health of the American people. Over 110 million doses of the H1N1 vaccine are now available, with more coming every day. Now is the time to protect yourself and those around you by getting vaccinated against the H1N1 flu.

The traditional flu season is just beginning and typically lasts until May. History tells us to prepare for another serious wave of illness. With H1N1 flu declining in many areas, we have a window of opportunity to help prevent the flu from spreading further and causing even more illness, hospitalization, and death.

The H1N1 flu vaccine is safe, effective, and the best way to protect yourself and your family from the H1N1 flu.

The H1N1 vaccine is made the same way seasonal flu vaccines are made every year. Extensive testing and monitoring have shown that the vaccine is not only safe, but also an excellent match for the H1N1 flu virus. And remember that when you get vaccinated, you don’t just help yourself; you help your community by preventing the spread of the flu virus.

We especially encourage people with underlying health conditions, pregnant women, children, young adults, caretakers of infants, and health care workers to get vaccinated against H1N1. Unlike the seasonal flu, H1N1 has hit children, young people, and adults under age 65 exceptionally hard. That is why we encourage you to get the H1N1 vaccine as soon as possible.

Fighting the flu is a shared responsibility. We ask you to join us in this fight to protect yourself and your community by getting the H1N1 flu vaccine.

Sincerely,

	Nancy H. Nielsen, M.D., PhD Immediate Past President American Medical Association		Rebecca Patton, MSN, RN, CNOR President American Nurses Association
	Judith S. Palfrey, MD, FAAP President American Academy of Pediatrics		Gerald F. Joseph, Jr., MD, FACOG President American College of Obstetricians and Gynecologists
	Welford C. Roberts, PhD, RS, REHS, DAAS President National Environmental Health Association		Susan Wysocki, WHNP-BC, FAANP President & CEO National Association of Nurse Practitioners in Women’s Health
	Geraldine “Polly” Bednash, PhD, RN, FAAN CEO & Executive Director American Association of Colleges of Nursing		Mark E. Rupp, MD President Society for Healthcare Epidemiology of America
	Larry A. Wickless, DO President American Osteopathic Association		Tom Van Coverden President & CEO National Association of Community Health Centers
	Sharon A. R. Stanley, PhD, RN, RS Chief Nurse American Red Cross		Steve H. Hanson, MPA, PAC, AAPA President American Academy of Physician Assistants
	Elena Rios, MD, MSPH President & CEO National Hispanic Medical Association		Angela Gardner, MD, ACEP President American College of Emergency Physicans
	Michael A. Barry, CAE Executive Director American College of Preventive Medicine		Richard J. Whitley, MD, FIDSA President Infectious Diseases Society of America
	Jane L. Delgado, PhD, MS President & CEO National Alliance for Hispanic Health		Harold A. Schaitberger General President International Association of Fire Fighters
	Lori Heim, MD President American Academy of Family Physicians		Denise Graham Executive Vice President Association for Professional in Infection Control & Epidemiology
	Mitchel C. Rothlolz, RPh, MBA Chief of Staff American Pharmacists Association		Michelle Beauchesne, DNSc, RN, CPNP, FNAP, FAANP President National Association of Pediatric Nurse Practitioners
	James C. Turner, MD, FACHA President American College Health Association		Joseph W. Stubbs, MD, FACP President American College of Physicians
	Clare Coleman President & CEO National Family Planning & Reproductive Health Association		Sandi Delack, RN, BSN, MEd President Amy Garcia, RN, MSN Executive Director National Association of School Nurses
	Michael R. Fraser, PhD Chief Executive Officer Affairs Association of Maternal & Child Health Programs		Lawrence A. McAndrews, FACHE President & CEO National Association of Childrens Hospitals and Related Institutions
	Bruce T. Roberts, R.Ph Executive Vice President and CEO National Community Pharmacists Association		Rich Umbdenstock President and CEO American Hospital Association
	Charles N. Kahn III President and CEO Federation of American Hospitals		Dr. Geoffrey Rutledge Chief Medical Officer Epocrates
	Robert C. Griggs, MD, FAAN President AAN		Reginald Ware CEO BlackDoctor.org
	Paul E. Jarris, MD, MBA Executive Director Association of State and Territorial Health Officials (ASTHO)		Robert M. Pestronk Executive Director National Association of County and City Health Officials (NACCHO)
	Sandra Domeraki-Prickitt Executive President Association of Occupational Health Professionals in Healthcare (AOHP)

HHS does not endorse private products, services, or enterprises.

Link:  http://www.cdc.gov/h1n1flu/open_letter_h1n1_vaccine.htm

Open Letter to the American People:

Since the 2009 H1N1 flu virus hit our shores, scientists, manufacturers, health providers, and federal, state, and local health officials have worked together to protect the health of the American people. Over 110 million doses of the H1N1 vaccine are now available, with more coming every day. Now is the time to protect yourself and those around you by getting vaccinated against the H1N1 flu.

The traditional flu season is just beginning and typically lasts until May. History tells us to prepare for another serious wave of illness. With H1N1 flu declining in many areas, we have a window of opportunity to help prevent the flu from spreading further and causing even more illness, hospitalization, and death.

The H1N1 flu vaccine is safe, effective, and the best way to protect yourself and your family from the H1N1 flu.

The H1N1 vaccine is made the same way seasonal flu vaccines are made every year. Extensive testing and monitoring have shown that the vaccine is not only safe, but also an excellent match for the H1N1 flu virus. And remember that when you get vaccinated, you don’t just help yourself; you help your community by preventing the spread of the flu virus.

We especially encourage people with underlying health conditions, pregnant women, children, young adults, caretakers of infants, and health care workers to get vaccinated against H1N1. Unlike the seasonal flu, H1N1 has hit children, young people, and adults under age 65 exceptionally hard. That is why we encourage you to get the H1N1 vaccine as soon as possible.

Fighting the flu is a shared responsibility. We ask you to join us in this fight to protect yourself and your community by getting the H1N1 flu vaccine.

Sincerely,

	Nancy H. Nielsen, M.D., PhD Immediate Past President American Medical Association		Rebecca Patton, MSN, RN, CNOR President American Nurses Association
	Judith S. Palfrey, MD, FAAP President American Academy of Pediatrics		Gerald F. Joseph, Jr., MD, FACOG President American College of Obstetricians and Gynecologists
	Welford C. Roberts, PhD, RS, REHS, DAAS President National Environmental Health Association		Susan Wysocki, WHNP-BC, FAANP President & CEO National Association of Nurse Practitioners in Women’s Health
	Geraldine “Polly” Bednash, PhD, RN, FAAN CEO & Executive Director American Association of Colleges of Nursing		Mark E. Rupp, MD President Society for Healthcare Epidemiology of America
	Larry A. Wickless, DO President American Osteopathic Association		Tom Van Coverden President & CEO National Association of Community Health Centers
	Sharon A. R. Stanley, PhD, RN, RS Chief Nurse American Red Cross		Steve H. Hanson, MPA, PAC, AAPA President American Academy of Physician Assistants
	Elena Rios, MD, MSPH President & CEO National Hispanic Medical Association		Angela Gardner, MD, ACEP President American College of Emergency Physicans
	Michael A. Barry, CAE Executive Director American College of Preventive Medicine		Richard J. Whitley, MD, FIDSA President Infectious Diseases Society of America
	Jane L. Delgado, PhD, MS President & CEO National Alliance for Hispanic Health		Harold A. Schaitberger General President International Association of Fire Fighters
	Lori Heim, MD President American Academy of Family Physicians		Denise Graham Executive Vice President Association for Professional in Infection Control & Epidemiology
	Mitchel C. Rothlolz, RPh, MBA Chief of Staff American Pharmacists Association		Michelle Beauchesne, DNSc, RN, CPNP, FNAP, FAANP President National Association of Pediatric Nurse Practitioners
	James C. Turner, MD, FACHA President American College Health Association		Joseph W. Stubbs, MD, FACP President American College of Physicians
	Clare Coleman President & CEO National Family Planning & Reproductive Health Association		Sandi Delack, RN, BSN, MEd President Amy Garcia, RN, MSN Executive Director National Association of School Nurses
	Michael R. Fraser, PhD Chief Executive Officer Affairs Association of Maternal & Child Health Programs		Lawrence A. McAndrews, FACHE President & CEO National Association of Childrens Hospitals and Related Institutions
	Bruce T. Roberts, R.Ph Executive Vice President and CEO National Community Pharmacists Association		Rich Umbdenstock President and CEO American Hospital Association
	Charles N. Kahn III President and CEO Federation of American Hospitals		Dr. Geoffrey Rutledge Chief Medical Officer Epocrates
	Robert C. Griggs, MD, FAAN President AAN		Reginald Ware CEO BlackDoctor.org
	Paul E. Jarris, MD, MBA Executive Director Association of State and Territorial Health Officials (ASTHO)		Robert M. Pestronk Executive Director National Association of County and City Health Officials (NACCHO)
	Sandra Domeraki-Prickitt Executive President Association of Occupational Health Professionals in Healthcare (AOHP)

HHS does not endorse private products, services, or enterprises.

As we come to the end of 2009, we have to feel good that H1N1 did not approach our worst fears about a pandemic.  For the past several weeks the trend continues to head in a direction that is less than ominous.  However, as you can see from the graphs, there is a slight increase in outpatient visits for flu-like illnesses.  Also, deaths due to pneumonia and flu climbed back above the epidemic threshold. As for H1N1 and kids:  There were four flu-related deaths.  That’s down from nine the previous week.  Whether these trends will continue in 2010 remains to be seen.  The following are the latest CDC graphs and maps to illustrate these somewhat mixed findings (http://www.cdc.gov/flu/weekly/?date=123109).

Let’s all hope that 2010 mirrors the best of 2009.  Meanwhile, the vaccination centers remain open.  Hint…hint.

Our deepest condolences are extended to the family and friends of the adolescent in Henry County who succumbed to H1N1 last week.  We keep reassuring the general public that this particular flu virus is generally benign for the vast majority, but we need to remember that for others, it continues to be a source of sadness and heartbreak, especially during this holiday season.

“No man is an island…” and as we mourn the loss of a treasured member of our community, we need to redouble our efforts to continue to keep this pandemic at a low simmer.  This includes reinforcing personal hygiene measures, social distancing when appropriate, and receiving the H1N1 vaccine (http://content.nejm.org/cgi/content/full/361/25/2424?query=TOC &  http://content.nejm.org/cgi/content/full/361/25/2405?query=TOC & http://content.nejm.org/cgi/content/full/361/25/2414?query=TOC).  As you know, the vaccination sites are open to all and are available at UT and venues throughout the region.  According to officials, 95 million doses are available and 10 million doses are coming out every week.

Meanwhile, there has been a recall of a number of lots of the Sanofi-H1N1 pediatric vaccine because of diminished potency.  I’ve checked with our UTMC Department of Pharmacy, with Toledo/Lucas County Board of Health and that is not an issue for us.  The lots in question have not been and are not, currently, part of our vaccination caches.  In any case, while the potency of this particular batch may not have the desired amount of immunological potency, the CDC, so far, feels that the antigenic levels are high enough that re-immunization is not indicated for the little tykes, bless their little souls.

Finally, I think there’s going to be some pulling of hair and gnashing of teeth in high-brow medical circles and at Roche Pharmaceuticals.  It has to do with a recent issue of the British Medical Journal.  There is this group, the Cochrane Collaboration, that has been trying to come to some conclusion about whether there is sound scientific data justifying the use of the anti-viral, oseltamivir (Tamiflu), to prevent or limit the complications associated with the influenza virus.  Right now, it’s “…a complex interplay between politics, public health planning, availability of trial data, publishing, and drug regulation…” (http://www.bmj.com/cgi/content/full/339/dec08_3/b5387).

The Cochrane group threw out data they could not independently verify and based their conclusions on four published studies that met their high-grade criteria.  “…Paucity of good data has undermined previous findings for oseltamivir’s prevention of complications from influenza. Independent randomized trials to resolve these uncertainties are needed,” they concluded.

Obviously, this will require further investigation and scientific oversight.  Hopefully, petty politics and financial bottom lines will not further muddy medical science and diminish public confidence.  How naïve is that?

However, I feel you, at least, need to know about this controversy and make up your own minds or raise your own questions.  Here are some of the links, including Roche’s response, to assist you:

http://www.bmj.com/cgi/content/full/339/dec08_3/b5374

http://www.bmj.com/cgi/content/full/339/dec07_2/b5106

http://www.bmj.com/cgi/content/full/339/dec08_3/b5364

http://www.bmj.com/cgi/content/full/339/dec08_3/b5351

http://www.bmj.com/cgi/content/full/339/dec10_2/b5405

http://www.bmj.com/cgi/content/full/339/dec07_2/b5164

Here is also the latest information concerning flu on America’s campuses (click to see larger):

Keep safe.

You must have heard by now that the H1N1 immunizations will now be open to everyone regardless of age and as long as you have no contraindications. 

Here is the edited announcement from the Ohio Director of Health, Dr. Alvin Jackson:

So where are we with H1N1?  Not too bad if one takes the global view.  Census in the emergency departments around the region has lessened, the vaccine distribution has improved, and now we are getting to the point where the H1N1 vaccine will be available to everyone.  I mean…everyone.   Stay tuned.  It’s going to happen this month.  Come one, come all.   That was only a matter of time as the vaccine production improved and the transportation channels got greased.

Meanwhile, there has been  new  research regarding autopsies on H1N1 patients in NY (http://www3.niaid.nih.gov/news/newsreleases/2009/FluAutopsy.htm).   The researchers discovered that the virus damages the entire respiratory tract like the 1918 and the 1957 flu viruses.  “… A microscopic examination of tissues throughout the airways revealed that the virus caused damage primarily to the upper airway—the trachea and bronchial tubes—but tissue damage in the lower airway, including deep in the lungs, was present as well. Evidence of secondary bacterial infection was seen in more than half of the victims….”

The majority of the cases studied were in the young (between 25 and 49 years of age).  That’s what makes this virus more nefarious than seasonal flu.  It targets the young.  Granted, most of these cases had chronic medical conditions, but complacency is not an option.  While we travel for the holidays, we  could be entering into a Twilight Zone of people on trains. planes, and supermarkets with communicable diseases, including H1N1.

We need to take the proper precautions that we have been extolling ad nauseam.  One way can be the H1N1 vaccine.  While there are skeptics out there (myself included), studies have indicated that the incidence of side effects and complications are  no different than with seasonal flu vaccines.  Believe me, I look at that very carefully.

Meanwhile…

Link:  http://www.cdc.gov/h1n1flu/updates/us/

So, while you’re thinking that the worst is behind us, keep in mind that H1N1 can’t read.

There’s been a major drop of flu activity on college campuses (See chart below).  This might reflect the overall drop in H1N1 activity across most of the country, but one can’t ignore the fact that these data were collected over Thanksgiving break.  Anyway, new cases were down 69% from the previous week. For Ohio, the drop was -83%.

There was one more student death bringing the total to three.  The attack rate for the week ending Nov 27 was 4.1 cases per 10,000 students. Click chart to see larger version.