WHO Pandemic Briefing # 5: Influenza In Pregnant Women

 

 

# 3569

 

 

Although some details were released this morning in a news conference, we now have the full text of the WHO’s (World Health Organization’s) 5th Pandemic Briefing document: Pandemic Influenza In Pregnant Women.

 

 

 

Pandemic influenza in pregnant women

Pandemic (H1N1) 2009 briefing note 5

31 JULY 2009 | GENEVA -- Research conducted in the USA and published 29 July in The Lancet [1] has drawn attention to an increased risk of severe or fatal illness in pregnant women when infected with the H1N1 pandemic virus.

 

Several other countries experiencing widespread transmission of the pandemic virus have similarly reported an increased risk in pregnant women, particularly during the second and third trimesters of pregnancy. An increased risk of fetal death or spontaneous abortions in infected women has also been reported.

 

Increased risk for pregnant women

 

Evidence from previous pandemics further supports the conclusion that pregnant women are at heightened risk.

 

While pregnant women are also at increased risk during epidemics of seasonal influenza, the risk takes on added importance in the current pandemic, which continues to affect a younger age group than that seen during seasonal epidemics.

 

WHO strongly recommends that, in areas where infection with the H1N1 virus is widespread, pregnant women, and the clinicians treating them, be alert to symptoms of influenza-like illness.

 

WHO recommendations for treatment

 

Treatment with the antiviral drug oseltamivir should be administered as soon as possible after symptom onset. As the benefits of oseltamivir are greatest when administered within 48 hours after symptom onset, clinicians should initiate treatment immediately and not wait for the results of laboratory tests.

 

While treatment within 48 hours of symptom onset brings the greatest benefits, later initiation of treatment may also be beneficial. Clinical benefits associated with oseltamivir treatment include a reduced risk of pneumonia (one of the most frequently reported causes of death in infected people) and a reduced need for hospitalization.

 

WHO has further recommended that, when pandemic vaccines become available, health authorities should consider making pregnant women a priority group for immunization.

 

Danger signs in all patients

 

Worldwide, the majority of patients infected with the pandemic virus continue to experience mild symptoms and recover fully within a week, even in the absence of any medical treatment. Monitoring of viruses from multiple outbreaks has detected no evidence of change in the ability of the virus to spread or to cause severe illness.

 

In addition to the enhanced risk documented in pregnant women, groups at increased risk of severe or fatal illness include people with underlying medical conditions, most notably chronic lung disease (including asthma), cardiovascular disease, diabetes, and immunosuppression. Some preliminary studies suggest that obesity, and especially extreme obesity, may be a risk factor for more severe disease.

 

Within this largely reassuring picture, a small number of otherwise healthy people, usually under the age of 50 years, experience very rapid progression to severe and often fatal illness, characterized by severe pneumonia that destroys the lung tissue, and the failure of multiple organs. No factors that can predict this pattern of severe disease have yet been identified, though studies are under way.

 

Clinicians, patients, and those providing home-based care need to be alert to danger signs that can signal progression to more severe disease. As progression can be very rapid, medical attention should be sought when any of the following danger signs appear in a person with confirmed or suspected H1N1 infection:

• shortness of breath, either during physical activity or while resting
• difficulty in breathing
• turning blue
• bloody or coloured sputum
• chest pain
• altered mental status
• high fever that persists beyond 3 days
• low blood pressure.

In children, danger signs include fast or difficult breathing, lack of alertness, difficulty in waking up, and little or no desire to play.

California: Nurse Dies From Swine Flu

 

 

# 3568

 

 

One of the lessons of SARS was that health care personnel were among the most severely affected demographic groups.  They had close, prolonged, and often intimate contact with infected patients, and many in very short order fell ill with the virus themselves.

 

Far too many died.

 

This novel H1N1 pandemic influenza is already showing signs of having a similar affect, with reports yesterday of a nurse from New Zealand dying from the virus, reports of perhaps a dozen HCWs in Argentina succumbing, and now a report today from California of a 37 year old nurse claimed by the illness.

While HCW deaths are to be expected in a pandemic, we have a responsibility as a society to extend the maximum amount of protection to those who voluntarily place themselves in harm’s way in order to care for others in a crisis.   

 

Regardless of the circumstances of how this nurse contracted the virus (whether at work, or in the community), this is a somber reminder of the seriousness of the pandemic we face.   

 

Hospitals need to take strong infection control and staff education steps now if they are to minimize tragedies such as this over the coming months.  

 

Anything less and they may find that some HCWs will be unwilling to risk working in an unsafe environment.

 

A double hat tip for this report.  First to Crof at Crofsblog and to @AIDigest on Twitter.

 

 

Swine flu fatal to local cancer nurse

By Carrie Peyton Dahlberg
cpeytondahlberg@sacbee.com

Published: Friday, Jul. 31, 2009 - 12:00 am | Page 1B

 

A cancer nurse at Mercy San Juan Medical Center in Carmichael has died of the H1N1 flu, becoming the first reported health care worker in California killed by the new variant of swine flu.

 

"We're very concerned that a nurse died," said Jill Furillo of the California Nurses Association, adding that the death underscores the need for strong infection controls to protect nurses and patients.

 

Mercy San Juan does not know whether the nurse caught the flu on the job or elsewhere, but it has notified all patients who came in contact with her when she might have been infectious, said hospital spokesman Bryan Gardner.

 

Karen Ann Hays died July 17 of a severe respiratory infection, pneumonia and H1N1, according to her death certificate. She also had methicillin-resistant Staphylococcus aureus, a staph infection that is resistant to many antibiotics.

 

(Continue . . .)

WHO Recommending Immediate Antiviral Treatment For Pregnant Flu Victims

 

 

# 3567

 

The CDC has recommended for some time that pregnant women contact their doctors regarding the possible use of antivirals if they suspect they’ve contracted the novel H1N1 virus.   

 

As in pandemics of the past, we are seeing a much greater impact on pregnant women than the general population with this virus, with a LANCET study earlier this week (see Lancet Study: Pregnancy And H1N1) suggesting a 4 fold increase in hospitalization rates for pregnant women.

 

Today, we get an even stronger recommendation from the WHO (World Health Organization) – one meant for an international audience – urging that pregnant women receive immediate antiviral treatment if hit by swine flu. 

 

They also urge that pregnant women be given priority to receive any vaccine that may become available.  ACIP earlier this week made the same recommendation for US vaccine priorities.

 

 

WHO advises swine flu drugs for pregnant women

---

Agence France-Presse | 07/31/2009 9:26 PM

GENEVA - The World Health Organization is recommending that pregnant women should have immediate access to antiviral drugs to treat swine flu because they appear to be more vulnerable, a spokeswoman said Friday.

 

"WHO is recommending that in the countries where there is a wide spread of A(H1N1) pandemic flu that pregnant women ... should be provided with adequate care and treatment immediately," said| WHO spokeswoman Aphaluck Bhatiasevi.

"Antiviral drug is recommended for treatment of pregnant women," she told journalists.

 

Bhatiasevi said the advice was based on studies among pregnant women in the United States and reports from several countries indicating that pregnant women were "more at risk of A(H1N1) infection."

 

Experts from the US Centers for Disease Control and Prevention (CDC) found in a study published on Wednesday that pregnant women could be at increased risk from swine flu compared with the general public.

 

(Continue . . . )

 

 

While there aren’t many studies out there, antivirals are believed to be reasonably safe for pregnant women.    The CDC has two sets of guidance regarding pregnancy and the novel H1N1 virus.

 

Information for Pregnant Women in Education, Child Care, and Health Care

What Pregnant Women Should Know About H1N1 (formerly called swine flu) Virus

Australia: Swine Herd Quarantined

 

# 3566

 

 

A bit of a confusing report out of Australia this morning regarding a pig farm that has been placed under quarantine after swine were found to be infected with an A/H1 influenza.

 

The article states that "It's influenza A, not the human swine flu virus 2009”,  but it isn’t entirely clear from the remainder of the article that the novel H1N1 has been ruled out as a cause.  

 

Further tests, they say, are pending.

 

The concern here is that pigs are notoriously good hosts for influenza; the are susceptible to human flu, bird flu, and of course, swine flu. 

 

When a pig is exposed to two different influenza viruses (such as the novel H1N1 and say . . . seasonal H3N2), it can become simultaneously infected with both strains.   

 

Very rarely when that happens both viruses can infect the same cell and – as the graphic below shows – end up swapping gene segments. This is called reassortment, and it is one of the ways new flu viruses come into being.

 

 

If this new reassorted virus is biologically fit (replicates well and is easily transmissible), it can then spread through the herd and sometimes even jump species back to humans.   

 

The novel H1N1 virus we are dealing with now most certainly evolved through a series of reassortments over the years, until it had obtained the right characteristics it needed to spark a pandemic.

 

Which is why there is so much concern over monitoring, and sometimes quarantining, pig herds. 

 

 

Western NSW piggery quarantined

Friday July 31, 2009, 8:24 pm

 

A piggery in central western NSW has been placed under quarantine after testing found it had been infected with a swine flu, most likely introduced by its own staff.

 

Authorities have stepped in to reassure consumers, saying pork products were still safe to eat.

 

The piggery was placed in quarantine after two tests returned positive for the influenza A H1 virus (A H1 virus), after samples were taken from some pigs on Thursday.

 

Authorities were treating it very seriously, a Department of Primary Industries spokesman said.

 

"It's influenza A, not the human swine flu virus 2009, but further testing is being conducted with the results expected next week," he said.

 

The owner and staff at the piggery had previously suffered flu-like symptoms, and are now themselves being tested for human swine flu.

 

It is the first time pigs had been infected with the A H1 virus in Australia, and follows an outbreak of swine flu H1N1 virus at a Canadian piggery in May.

 

"This is the first case of Influenza A H1 in pigs in Australia and at this stage we believe it was likely introduced by people working with the animals," NSW Primary Industry Minister Ian Macdonald said in a statement.

 

The affected 280-sow piggery which is currently housing about 2,000 pigs has been placed in quarantine and strict biosecurity measures are in place to ensure the virus does not spread."

(Continue . . .)

HCW Fatality In New Zealand

 

 

# 3565

 

 

A hat tip to Crof at Crofsblog who picked up and posted this sad story of the first front line HCW (Health Care Worker) from New Zealand to succumb to the pandemic virus.

 

 

Swine flu victim first health worker to die

The 39-year-old woman who died of swine flu in Wellington Hospital this week was a front-line health worker at Hutt Hospital, officials have confirmed.

 

The woman  understood to have been a nurse in the children's ward  is believed to be the first health worker to die from the virus in New Zealand.

 

Her death from a rare complication on Monday, after 11 days in intensive care, is the 13th to be officially recorded.

 

The coroner is investigating another 20 suspected deaths from the virus.

 

The woman had suffered a miscarriage within the previous two months. Pregnancy is a known risk factor for viral complications. However, it is not known whether she had the virus at the time she miscarried.

 

(Continue . . .)

We don’t know any of the details of how this woman contracted this virus, and whether or not it was a work related exposure.  It is certainly possible she acquired her infection in the greater community rather than at work.

 

But we do know that HCW’s are at higher risk from this virus than just about any other professional group.   Here in the United States, OSHA has created an occupational risk pyramid, and places front line HCWs at the very top.

 

Occupational Risk Pyramid for Pandemic Influenza

Very High Exposure Risk:

• Healthcare employees (for example, doctors, nurses, paramedics, or dentists) performing aerosol-generating procedures on known or suspected pandemic patients (for example, cough induction procedures, tracheal intubations, bronchoscopies, some dental procedures, or invasive specimen collection).
• Healthcare or laboratory personnel collecting respiratory tract specimens from known or suspected pandemic patients.

High Exposure Risk:

• Healthcare delivery and support staff exposed to known or suspected pandemic patients (for example, doctors, nurses, and other hospital staff that must enter patients' rooms).
• Staff transporting known or suspected pandemic patients (for example, emergency medical technicians).
• Staff performing autopsies on known or suspected pandemic patients.

 

Reports out of Argentina more than a week ago suggested that a dozen HCWs there may have died from the virus.  

 

A somber reminder that HCWs are at greater risk, and that we need to do all that we can to protect them as they work on the front lines.

UK: 150,000 Rx For Antivirals In A Week

 

 

# 3564

 

 

It’s an astonishing number, really. 

 

In the first week of operation, the NHS hotline has reportedly given out 150,000 vouchers for Tamiflu over the phone.

 

Unlike most countries, where antivirals are being reserved for those with high risk comorbid conditions – like pregnancy, diabetes, or chronic pulmonary disease – or for those with particularly severe symptoms, antivirals according to this report are being  handed out to just about anyone with flu-like symptoms.

 

 

 

Swine flu: 150,000 people take up antiviral drugs

David Rose

(AP)

An estimated 150,000 people were prescribed with antiviral drugs last week following the launch of the swine flu hotline and website.

 

The Health Protection Agency estimated that a further 110,000 new cases in England last week were diagnosed by doctors.

 

At present Tamiflu (oseltamivir) is being offered to anyone with identifiable swine flu symptoms.

 

Access to the treatments remains patchy, it has been claimed, while researchers say that some groups may benefit more than others from taking the drugs.

 

Since the launch of the National Pandemic Flu Service last week people suffering symptoms have been able to take an assessment questionnaire over the phone or on the internet.

Those who appear to have the H1N1 virus are given a unique number which can be given to a friend who can then pick up the prescription. There are over 1,100 collection points for the drug.

(Continue . . .)

This sort of liberal dispensing of antivirals is a two-edged sword.

 

It may very well reduce the number of hospitalizations, and even deaths, that a country might experience.   It may also reduce the spread of the virus, by limiting the amount of virus being shed by those infected.

 

But there are potential downsides as well.

 

There is considerable concern that overuse of antivirals could lead to resistance developing in the virus.    Already nearly all seasonal H1N1 viruses tested show resistance to Tamiflu, and the fear is that the novel H1N1 could follow suit.

 

That may not happen of course.

 

Or it could happen, whether antivirals are liberally dispensed or not.   There is a lot here, we simply don’t know.

 

Additionally,  Tamiflu is a drug.  And like all drugs, it can had adverse side effects.  Most that have been reported have been mild, but there is always a tradeoff between the risk of taking a drug and the benefits derived.

 

If a large number of people are taking Tamiflu that don’t really need to be taking it, then they are presumably incurring some small additional risk.   How small that risk might be is hard to gauge.

 

Politically, I’m sure it is very difficult for the NHS to deny hot line callers antivirals when A) they have them stockpiled  and  B) GPs are overwhelmed and cannot guarantee to see and evaluate patients during the critical first 24-48 hours of an illness.

 

All it would take to undermine public confidence in the NHS’s pandemic plans would be for someone to be denied antivirals who really needed them, and for them to come to a bad end.

 

The tabloids would have a field day with that kind of story.

 

Difficult questions, and no easy answers.

 

And issues that the US, and other countries are going to have to wrestle with over the next few months as well.

The Numbers Racket

 

 

# 3563

 

Everyone, understandably, wants to try to put a number on the two big unknowns with the pandemic of 2009.  

 

The Attack Rate, and the CFR.

In my last blog (see ECDC: Planning Assumptions For A Fall Wave) the ECDC (European Center For Disease Control) attempted to put some numbers to the type of fall wave they could expect in the EU.

 

While they are quick not to call their numbers a prediction, they come up with a likely symptomatic attack rate of 30%, and a CFR (Case Fatality Ratio) of .1% to .2%.

 

And based on what we’ve seen to date, and assuming the virus does not mutate towards greater virulence (or an older demographic) and antivirals remain effective and available, those numbers seem reasonable to me for most EU countries.

 

Of course, the virus could mutate and over time and antivirals could lose their effectiveness.   A pandemic can last for years, and the ebb and flow of the virus – and its severity - can change from year to year. 

 

As goes Europe, probably will go the United States and most other Industrialized nations, including Japan, Australia, and New Zealand. 

 

And if we accept the ECDC estimates, we can make some quick and dirty calculations regarding the number of people who might be sickened or die this fall and winter from this pandemic virus. 

 

At the .1% CFR, and a 30% attack rate, the number of deaths in the  United States would be just over 2.5 times what we normally see in a flu season.

 

Of course, normally, most of the deaths we see come from an elderly subset of our population.  With this novel H1N1 virus, we’ve seen an age shift towards much younger victims.  

 

The impact of 90,000 US deaths – assuming that a great many of those will be children and young adults – would certainly be more than 2.5 times as great as a normal flu season.

 

In other words, the numbers don’t tell the whole story.  But of course, these number may not be right, either.  

 

They are based on very preliminary observations.  And a .1% CFR may even be overstated for some industrialized countries.

What we should not expect is that this pandemic will affect all regions of the world equally; that the burden of this pandemic will be the same in Lagos, Nigeria as it is in Lincoln, Nebraska. 

 

For much of the developing world, antivirals, vaccines, or even basic hospital care are simply not going to be available.   The CFR is, therefore, likely to run higher there than in the industrialized world.

 

Additionally, countries and regions with a younger median aged population, such as is typically seen in Africa, the Middle East, and parts of Asia are likely to see a higher number of infections due to the age shift of victims.

 

 

 

Agencies like the Red Cross, Red Crescent, CARE, Save The Children, UNICEF, and others are working around the world every day to combat poverty and disease, and are going to be on the front lines during any pandemic.

 

To get an idea of what some of these agencies are dealing with, I would invite you to visit some of their websites.

• CARE
• Humanitarian Pandemic Preparedness H2P
• Save The Children

 

They could use your support.

A few months ago, I highlighted a new project called H2P, or the Humanitarian Pandemic Preparedness project.

 

 

The H2P project is geared towards promoting community & district-level pandemic flu preparedness and response in developing countries.

Many of the resources are available in multiple languages.

 

This Initiative comes through the hard work of a number of NGO’s and partner organizations, including USAID, IFRC, CORE Group (including American Red Cross, CARE, & Save the Children), AED, InterAction, & several UN agencies, including WHO, WFP, & UN OCHA:

 

H2P is a resource rich website which offers Guidance and Policy documents, Planning Tools, Training Modules, Focus Areas and Communication and Advocacy information.

 

Given the limitations of surveillance and reporting from most of the world, and our own inability to put good numbers on the number of influenza deaths each year here in the United States,  I doubt we’ll ever get a very good handle on the true impact of this (or any other) pandemic around the world.

The last moderate pandemic – in 1957 – is believed to have killed between 1 million and 4 million people globally.  That is a pretty broad range of estimates, and illustrates the difficulty in trying to quantify these things.

 

All pandemics are local, however. 

 

And while what happens in China, or India, Nigeria, or globally  may be tragic . . . what happens in your community, neighborhood, and family are likely to be of greatest importance to you.

 

While time to prepare is short, there is still much that you, your family, and your community can do to prepare for this fall’s flu season.

 

Our first line of defense is we need to practice good flu hygiene all of the time; cover our coughs and sneezes, wash our hands frequently (or use alcohol sanitizer), and stay home when we are sick.

 

But beyond that, and getting the recommended flu vaccines this fall, there are many things we should be doing.

 

Businesses that haven’t prepared, need to begin now (see Quick! Who's Your CPO?).

 

Individuals should be preparing as well (see Creating A Culture Of Preparedness  and Pandemic Solutions: Flu Buddies).

 

There has never been a better time to volunteer to help with the American Red Cross, The Medical Reserve Corps, CERT, or your Neighborhood watch.

 

We are truly only prepared as our surrounding community is.  There are roles to play for everyone, including civic organizations, schools, and church. 

 

The apparent `mildness’ (a relative term) of this first wave of H1N1 is heartening news, and we may find that the pandemic of 2009-2010 turns out to be far less serious than first feared.  But influenza viruses are unpredictable, and we’ve a long way to go before the final chapter of this pandemic play is written.  

 

The impacts, particularly in the health care delivery field, are likely to be significant even in a low fatality pandemic.   And if it is you, or a loved one that is severely hit by the virus, you won’t think of this pandemic as having been `mild or moderate’.

 

Good enough reasons to take this pandemic threat seriously, and take steps now to prepare for the fall.

 

For more information on preparedness, you can go to any of these reputable sites.

 

FEMA http://www.fema.gov/index.shtm

READY.GOV http://www.ready.gov/

AMERICAN RED CROSS http://www.redcross.org/

For Pandemic Preparedness Information: HHS Individual Planning Page

 

For more in-depth emergency preparedness information I can think of no better resource than  GetPandemicReady.Org.

ECDC: Planning Assumptions For A Fall Wave

 

 

# 3562

 

Although it may not seem like it in the UK right now - where they are already seeing about 100,000 new flu cases a week - the first major wave of this pandemic is expected to sweep across Europe this fall.

 

Understandably, officials are attempting to quantify exactly how bad this fall wave could be – in terms of the numbers sickened, and the number of deaths they might expect.  

 

Fair warning:  What follows are estimates from Norway and the UK based on incomplete, often conflicting data.

 

The ECDC warns that these should be used only for planning purposes, and are not `predictions’ of what is expected this fall.

 

The gist here is that the early expectations are for a clinical attack rate of about 30% and a CFR (Case Fatality Ratio) of between 1 and 2 per 1,000 illnesses (.1% –.2%) in EU countries.

 

These are rough estimates, based on the way the virus has acted to date, and do not take into account viral mutations that might make the virus more virulent.   There are also differences in the assumptions being made by the WHO and individual countries.

 

And to further complicate matters, we may see significant variability between different regions regarding the impact of this virus.

 

 

A hat tip to Ironorehopper from Flutrackers for posting this link.  I’ve lifted excerpts, follow the links to read the entire report. Content slightly reformatted for easier reading.

 

 

Planning Assumptions for the First Wave of Pandemic A(H1N1) 2009 in Europe

As it is summer in Europe the 2009 pandemic has yet to really accelerate in EU countries but the experience in temperate Southern Hemisphere countries suggests it is inevitable that Europe will be affected by a major first A(H1N1) 2009 pandemic wave in the autumn and winter [1].

 

The 2009 pandemic is less severe than might have been expected and ECDC has been made aware by two European Union countries (Norway and the UK) of the updating they have made of their planning assumptions specifically for a first wave of an A(H1N1) 2009 pandemic [2,3].

 

As for most planning assumptions they were developed to provide a common agreed basis for planning across public and private sector organisations in the country [4].  The UK planning assumptions were based on analyses and modelling of data from both inside and outside the UK while, because it has yet to be much affected, the Norwegian assumptions relied on international data, including UK data. The UK estimates also look at a shorter period running to the end of August 2009 [3].

 

It is important not to see these planning assumptions as predictions.  Often (but not always) they represent reasonable worst casesfor the first wave of this pandemic [4].

 

<snip>

 

UK parameters and their broader applicability

The UK paper is based on a model using parameter estimates from the UK and abroad on the 2009 strain and fitted using real data on UK cases over the period when the majority of cases were confirmed and reported daily.

Clinical attack rate

This is 30 % (The UK clinical attack rate is based on an assumption that half of the infected become symptomatic so this would imply a total infection attack rate of about 60 %). WHO assumptions are that two thirds become symptomatic [5].

 

Whether the UK or WHO is correct will be determined later when the results from serology become available.   The UK assumptions imply a basic reproductive number Ro in the interval 1.4 – 1.5 which seems to be the case at present in the UK. A Ro of value 1.4 implies a total infection attack rate of about 50 % (which would imply a clinical attack rate of 25 % in the UK planning assumptions). A higher value of Ro of 2.0 implies a total infection attack rate of about 80 % (hence a clinical attack rate of 40% in the UK planning assumptions).

 

Peak clinical attack rate

This can depend on a number of factors such as seasonality, immunity in the population and interventions that might prolong the epidemic but also reduce the peak attack rate [6]. A particularly important point to note is that local epidemics are often shorter and sharper in a pandemic than national rates and so there is a higher value for the peak clinical attack rates for local application [1,3].

 

Case fatality rate

This is one of the most eagerly sought parameters but it is also amongst the hardest to determine with any accuracy. The earliest studies of this pandemic gave a high CFR of about 0.4 % [7] compared to lower rates for the 1957 and 1968 pandemics but higher rates for 1918 [8].

 

The UK estimates are of a CFR of 0.1-0.2 though values of up 0.35% cannot be ruled out as impossible [3].  The CFR number reported in the UK are thus as stated the reasonable worst case scenario unless the virus changes its characteristics in terms of lethality while the Norwegian figure is more based on what has been directly observed, adjusted for assumed underreporting.

ECDC comment (28/07/09)

Major drivers for the pandemic at present in Europe include the value of Ro and seemingly also the effect of seasonality (influenza always spreads less efficiently in the spring and summer in temperate zones, the reasons for this remain unclear).

 

For European planning assumptions and with possible changes of the virus a broader span of Ro outside the 1.4 – 1.5 range could be considered as a highest estimate population value of 1.8 [9] has been reported. Some other studies have reported even higher values [10], but these have been from settings with more close contacts like schools or some other epidemiological background parameters like the generation time, taking these factors into account the Ro value is also between 1.4 – 1.5 in these studies.

 

Early estimates from Australia have given estimates of Ro around 2 which may reflect seasonal effects in Australia where it is winter and also by very noisy data at the beginning. Later analysis have given estimates in Australia between 1.2 – 1.5 (ECDC communication with Australian modellers). A study of the situation in New Zealand [14] have estimated R0 to around 2.3 but this is also based on very noisy data why its credibility is low.

 

When trying to estimate Ro value for the general population, most modelers agree that it is mostly 1.5, which is also what the UK is using in their plan as the most extreme reasonable value.

The UK predicted peak absenteeism rate of 12 % of the workforce is interesting and fits with the mild illness seen for most people. It suggests that the social disruption effects of the pandemic will be less than feared for other pandemics and that severe social interventions will not be necessary given good business continuity planning.

 

Case Fatality Rates (CFR) will also change as more data become available and more stable estimates will take some time to emerge. As some cases will be very mild and not reported the reported figures from official tables of cases and deaths will most often be an over-estimate of the true CFR.

 

Equally though many deaths which result from influenza (seasonal or pandemic) are not attributed to the infection in official causes of deaths and so officially reported influenza deaths are always an underestimate, sometimes grossly so [11,12]. In previous pandemics it has only been computed with any accuracy once the pandemics were over [8]. It is also important to appreciate that CFR is especially subject to social effects. In poor social settings such as Africa even seasonal influenza can result in CFR’s that are higher than seen in pandemics [13].

 

(Continue . . .)

More On The ACIP Meeting

 

 

# 3561

 

For a report on the ACIP committee recommendations read The ACIP Committee Recommendations

 

 

If you heard a collective sigh of relief today, it came from the 34% of the American population with a BMI (Body Mass Index) of greater than 30, which up until today had been cited as a possible risk factor for complications from the novel H1N1 virus.

 

Although it is a bit blurry (screen capture from the web broadcast) the slide above shows that the incidence of hospitalizations among those listed as obese by their BMI was practically the same as their prevalence in society.

 

Roughly 34% of Americans are obese, and roughly 38% of those hospitalized met that criteria.    While 6% are morbidly obese (BMI > 40), they only made up 7% of the hospitalized cases.

According to Dr. Anne Schuchat, the jury is still out on the morbidly obese, but right now there is no clear evidence that obesity – without some comorbid condition like diabetes – lends itself to a greater risk of complications from this flu.

 

Also, from the comments made during the ACIP meeting today, and those made by Dr. Anne Schuchat during the CDC conference call this afternoon, there obviously isn’t a lot of enthusiasm for using adjuvanted vaccines here in the United States.

 

The recommendations today out of the ACIP meeting were specifically for unadjuvanted vaccines.

 

Adjuvants are a somewhat controversial additive that are sometimes used to increase the immune response to a vaccine.  They are not currently licensed for inclusion in flu vaccines here in the US, and have only seen limited use in Europe for those over 65.  

 

They could be used if the HHS decided to go with an EUA (Emergency Use Authorization), but right now, there doesn’t seem to be much support for that idea.   

 

The HHS has stockpiled enough for millions of doses of vaccine, but the plans right now, according to Dr. Schuchat, are not to need them.

 

If the standard 15 µg dose should prove not to provoke an adequate immune response, or if the virus should antigenically drift away from the vaccine, an adjuvant might provoke a stronger, or broader immune response.  

 

Under those scenarios, a decision would have to be made weighing the potential (and largely unknown) risks versus the benefits.   There is scant data on the use of adjuvants for young adults and children, and the HHS obviously views adjuvants as a complication they’d rather not have to deal with.

 

Diplomatically, refusing to use adjuvants may prove a bit stickier, since using them could reduce the amount of antigen that Americans (who have large order for vaccine in place) would need.   That would, in turn, free up more antigen to make vaccine for other countries.

 

It remains to be seen how that little drama will play out.

 

So Adjuvants, at least for now, are not anticipated to be used here in the US, but they remain on the table.

 

It was pretty obvious, watching today’s telecast, that the panelists all wished they had more time, and more scientific data, with which to make their recommendations. 

 

The fall flu season is coming on like a freight train, and there simply isn’t enough time to conduct the type of studies and deliberations they would, no doubt, prefer. 

 

Clinical trials with a few hundred test subjects, however, really aren’t designed to pick up on a those rare – 1 in 100,000 – serious side effects. 

 

You generally only find those after a few million shots are given and well into the flu season.

Influenza vaccines generally have a pretty good record of safety.  Most side effects are minor, and self limiting.   A sore arm, a mild fever, maybe some body aches.   But gone in 24-48 hours.

 

But occasionally a serious side effect can occur.  Even though the incidence is very low, when you start giving hundreds of millions of shots, the number of adverse reactions will mount.

 

Some `incidents’ reported by vaccine recipients may not even be caused by the vaccine, but will evoke suspicion nonetheless.  I expect the press to be all over those, even before any causal link is established.

 

The good news here is, given that the over-65 crowd will be the last to receive the vaccine, the `noise’ that their less stable health conditions would interject shouldn’t be a factor.

 

But in the back of the minds of everyone making vaccine decisions, I’m sure, are the memories of 1976, and the worry that a new vaccine could produce a similar level of side effects. 

 

It may not be likely . . .but it is possible.  

 

The enormity of what the CDC, HHS, and public health departments around the country are about to undertake is absolutely staggering. There are a great many things that can go wrong, and undoubtedly, despite their best efforts . . . some things will go wrong.  

 

We need to accept that there are going to be bumps along the way, that not everything is going to come off as planned, and try to learn from these `challenges’ as best we can.

 

The lessons we learn now could prove invaluable if another, more severe pandemic should come down the pike in the years to come.

The ACIP Committee Recommendations

 

 

# 3560

 

 

 

It has been a long, but at times interesting, day of video  and press conferences on the pandemic H1N1 vaccination recommendations.  The bulk of today was taken up by the ACIP (Advisory Committee On Immunization Practices) conference, which ran nearly 7.5 hours.

At 4pm, Dr. Anne Schuchat held a CDC press conference which summarized some of the findings.

 

ACIP, which is a panel of 15 vaccine experts, usually meets three times a year to discuss and give advice to the CDC and HHS on routine vaccination matters.    Today was a special session to deal with the fall pandemic vaccination program, and to decide on which groups should be targeted to receive the pandemic vaccine first.

 

The morning was taken up by a series of presentations, with Q&A sessions following each, and this afternoon the panel discussed . . . and eventually voted on recommendations that now go to the CDC. 

 

The votes were not always unanimous, and there were concerns expressed by some of the panelists over the lack of data behind some of their recommendations.  

 

Nevertheless, two major recommendations came out of the ACIP meeting, which are now forwarded for approval and action by the CDC.  

These recommendations are for UNADJUVANTED Vaccines.

 

First, 5 high risk groups were selected to be targeted to receive the vaccine first.   These groups make up nearly 160 million Americans, and consist of:

Pregnant women  (4 Million)

Household contacts and caregivers of children under 6 mos (who cannot receive a vaccination themselves) (5 Million)

Health Care Workers & Medical Service Personnel (14 million)

Children and adolescents aged 6mos –24yrs (102 Million)

Persons aged 25-64 years of age with certain Medical Conditions (34 million)

 

Assuming that adequate supplies of vaccine are available in October or November, these five groups would all be targeted for vaccination first.  If 2 shots are required, then they would need roughly 300 million doses of vaccine.

While that  exceeds the amount of vaccine expected to be available in October and November, the expectation is that the uptake – or percentage of those targeted who will take the vaccine – will be far less than 100%.

 

 

As a fallback position, in the event of a major shortfall of vaccine, a smaller `subgroup’ was identified who would received prioritization for the vaccine.   It was roundly hoped, however, that this would not be needed:

 

Pregnant women  (4 million)

Household contacts of Infants < 6mos (5 Million)

Health Care Workers With Direct Patient Contact (9 Million)

Children aged 6mos – 4 yrs (18 million)

Children under 19 with chronic medical conditions (6 Million)

 

Only after these high risk groups have been offered a vaccine, and sufficient vaccine supplies are on hand, would healthy adults between the ages of 25 and 64 be offered the vaccine.

Those over the age of 64 would be among the last to receive the H1N1 vaccine, although they are still strongly urged to get the seasonal vaccination. 

 

I’ll  have a bit more on the information we got from today’s ACIP meeting in my next blog, along with some thoughts regarding the challenges that lay ahead.

Australia: A Drop In Infections?

 

# 3559

 

 

I’m always a bit slow to embrace these sorts of reports, preferring to see if the announced trend continues a week or two from now.   But, if true, this may signify that the peak of H1N1 infections in Victoria has passed.

 

This report from Jason Gale of Bloomberg News.

 

 

 

Melbourne Lab, Doctors Find Swine Flu Infections Are Abating

By Jason Gale

July 30 (Bloomberg) -- Less than two months after a surge in swine flu cases in Melbourne helped persuade the World Health Organization to declare a pandemic, infections are abating in Australia’s second-largest city.

 

The frequency of flu-like illnesses diagnosed by the city’s doctors fell by a third last week from the previous week and is the lowest since late May, according to a report yesterday by the Victorian Infectious Diseases Reference Laboratory. The pandemic H1N1 strain accounted for all flu viruses tested by the government lab last week.

 

Melbourne was one of the cities hardest hit by H1N1 outside North America when the WHO declared the first influenza pandemic in 41 years on June 11. The decline in cases is also being reflected in a drop in hospitalizations for flu and may mean that Melbourne has seen the worst of the current wave of infections, said Vincent Pellegrino, an intensive care doctor at the city’s Alfred Hospital.

 

“We do seem to have passed the worst phase,” Pellegrino said in a telephone interview yesterday. Across Victoria, 26 people are hospitalized for flu, Australia’s health department said yesterday, down from 34 a week earlier and 59 on July 9.

 

(Continue . . .)

 

Lancet Study: Pregnancy And H1N1

 

 

# 3558

 

As today’s ACIP meeting gets underway to discuss vaccines, and vaccine prioritization, we get this report from the Lancet Medical journal quantifying a bit something that we already knew.

That pregnancy is a serious complicating factor when it comes to pandemic influenza.  

 

 

 

The Lancet, Early Online Publication, 29 July 2009

doi:10.1016/S0140-6736(09)61304-0

 

H1N1 2009 influenza virus infection during pregnancy in the USA

Original Text

Denise J Jamieson MD a , Margaret A Honein PhD b, Sonja A Rasmussen MD b, Jennifer L Williams MSN b, David L Swerdlow MD c, Matthew S Biggerstaff MPH c, Stephen Lindstrom PhD c, Janice K Louie MD e, Cara M Christ MD f, Susan R Bohm MS g, Vincent P Fonseca MD h, Kathleen A Ritger MD i, Daniel J Kuhles MD j, Paula Eggers RN k, Hollianne Bruce MPH l, Heidi A Davidson MPH m, Emily Lutterloh MD d n, Meghan L Harris MPH o, Colleen Burke MSN p, Noelle Cocoros MPH q, Lyn Finelli DrPH c, Kitty F MacFarlane CNM a, Bo Shu MD c, Sonja J Olsen PhD c, the Novel Influenza A (H1N1) Pregnancy Working Group‡

Summary

(Excerpt)

Findings

From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital.

The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0·32 per 100 000 pregnant women, 95% CI 0·13—0·52 vs 0·076 per 100 000 population at risk, 95% CI 0·07—0·09).

Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation.

 

Interpretation

Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.

UK: House Of Lords Flu Report

 

 

# 3557

 

Over the past few months the UK has been harder by the Swine Flu virus than has the United States or Canada.   Estimates of the number of new cases each week are near 100,000.  

 

While most of these cases are reportedly mild, this is causing a tremendous strain on their NHS medical services.

 

Last week a `flu hotline’ was finally put online, where people could obtain antivirals without seeing their GPs.  Things, however, have not gone as smoothly as one might have hoped. 

 

Today the House of Lords Science and Technology Committee released a somewhat critical report on the government’s early response to the swine flu crisis.   

 

For those not familiar with this committee, they describe themselves thusly:

 

The Science and Technology Committee was established in 1979 and is one of the main investigative committees in the House of Lords. It represents a major forum of independent expertise, drawing on the wide experience of members of the House.

 

The Committee's broad remit is to consider science and technology. It works principally through inquiries undertaken by two Sub-Committees, constituted afresh for each inquiry.

 

Each inquiry leads to a report, published together with the evidence on which it is based, setting out the Committee's findings and making recommendations to the Government and others.

 

 

 

 

Pandemic flu report from Lords’ Committee

28 July 2009

The House of Lords Science and Technology Committee has today published its follow-up report on pandemic influenza.

• Report: Pandemic Influenza: Follow-up
• House of Lords Science and Technology Committee

While the report praises the Government’s actions in stockpiling antivirals such as Tamiflu, and entering into advance purchase agreements for pandemic specific vaccines, the Committee criticises other aspects of the Government’s preparations for the swine flu pandemic.

Some of the criticisms the Committee makes include:

• The Committee wants clarity on how intensive and critical care facilities would be expected to perform in a pandemic and where there are weaknesses in critical care provision which should be addressed.
• The Committee has ‘significant concerns’ about the delay in the operation of the National Pandemic Flu Service (NPFS) and asks the Government to explain this delay. It also seeks assurances that the service will be able to meet anticipated demand and be fully operational by autumn to meet the challenges of the anticipated ‘second wave’ of swine flu.
• The Committee is disappointed the process of ‘whole system’ testing (examining how the full range of health services could react in a pandemic) was not carried our earlier.
• The Committee asks the Government to clarify what interim services are in place until the ‘enhanced’ NPFS comes on-stream and to make clear how the service will interact with NHS Direct.
• The report calls on the Government to clarify how they will ensure NHS staff are supported in providing services that may be outside their areas of expertise and if they will be protected from legal action when they provide this treatment. The Committee also wants better guidance on ethical decisions on who could have access to limited flu treatments/vaccines.

Commenting on the Report, Lord Sutherland, Chairman of the Committee, said:

“While the Government have got some things right in preparing for a flu pandemic, such as the stockpiling of antivirals, there are other areas where we appear to be under prepared.

“We are particularly concerned that the ‘enhanced’ NPFS or ‘flu line’ is not fully operational and there seems to be a lack of clarity about how the ‘interim’ flu line will interact with NHS Direct.

“We were surprised and disappointed that the Government had not undertaken ‘whole system’ testing of health services preparations for a flu pandemic before swine flu emerged.”

Reminder: ACIP Meeting Today

 

 

#3556

 

 

ACIP is the Advisory Committee On Immunization Practices, and Today (July 29th) they will hold a special day-long meeting (which will be webcast) to discuss the vaccination program planned for this fall.

 

 

Special Meeting of the Advisory Committee on Immunization Practices

 

Centers for Disease Control and Prevention, Atlanta, GA
Wednesday July 29, 2009    8:00 a.m.-3:00 p.m. Eastern Daylight Time (U.S.)

 

1.    The links below are only to be used by participants external to CDC.

2.    The links below are available only during the day and time of the event.

3.    All participants viewing this session at CDC  must use Envision or IPTV.

 

http://intra-apps.cdc.gov/itso/iptv/iptvschedule.asp

 

 

**** URLs:

High:
http://wm-live.world.mii-streaming.net/live/cdc/5

Medium:
http://wm-live.world.mii-streaming.net/live/cdc/6

Dial-up or slower connection:
http://wm-live.world.mii-streaming.net/live/cdc/7

Referral: Effect Measure On Transmission, Pathogenicity, Virulence and Vaccines

 

#3555

 

One of the challenges to blogging about science is that it requires at least some common understanding of terms before you can progress to theories and findings.  

 

The Reveres at Effect Measure do as good of job of explaining the terms, and theories, behind epidemiology as anyone on the net. Much of what I know about the science behind influenza, I learned from their blog.

 

Yesterday and today, they have crafted a detailed look some of the important epidemiological terms, and how the efficacy of vaccines is determined.

 

While not exactly `light’ reading, the Reveres take a difficult subject and make it understandable, even to me.  

Highly recommended.

 

 

Transmission, pathogenicity, virulence and vaccines, I.

 

Transmission, pathogenicity, virulence and vaccines, part II.

ACIP Meeting Tomorrow

 

# 3554

 

 

ACIP is the Advisory Committee On Immunization Practices, and tomorrow they will hold a special day-long meeting (which will be webcast) to discuss the vaccination program planned for this fall.

Details may be downloaded from the cdc.gov website.

 

Special July 29 2009 [PDF - 65KB] Final  July 27, 2009
  or  text-only version

 

Web Access Instructions  [PDF - 31KB] New July 21, 2009
or  text-only version

 

You’ll need  Internet Explorer 5.0 or Netscape 4.7 or later, along with Windows Media player 9.0 or later to view.   Here are the urls.

 

 

Special Meeting of the Advisory Committee on Immunization Practices

Centers for Disease Control and Prevention, Atlanta, GA
Wednesday July 29, 2009    8:00 a.m.-3:00 p.m. Eastern Daylight Time (U.S.)

 

1.    The links below are only to be used by participants external to CDC.
2.    The links below are available only during the day and time of the event.
3.    All participants viewing this session at CDC  must use Envision or IPTV.

 http://intra-apps.cdc.gov/itso/iptv/iptvschedule.asp

 

**** URLs:

High:
http://wm-live.world.mii-streaming.net/live/cdc/5

 

Medium:
http://wm-live.world.mii-streaming.net/live/cdc/6

 

Dial-up or slower connection:
http://wm-live.world.mii-streaming.net/live/cdc/7

WHO Working On Antiviral Guidance

 

 

# 3553

 

 

Timing is everything.

 

While I was working on my last blog, A Tale of Two Countries, about the differences in antiviral distribution policies between the UK and Thailand, another related article has come across the newswires.

 

July 28, 2009

Anti-viral drug use examined

The World Health Organisation said on Tuesday that it will consult experts on the way anti-viral drugs such as Tamiflu are used to tackle the H1N1 flu pandemic, and possible drug resistance.

 

GENEVA - THE World Health Organisation said on Tuesday that it will consult experts on the way anti-viral drugs such as Tamiflu are used to tackle the H1N1 flu pandemic, and possible drug resistance.

 

'In the coming days we're having technical consultations by teleconference regarding antivirals,' said spokeswoman Aphaluck Bhatiasevi.

 

'But as of now WHO's recommendations for use of antivirals has not changed,' she added.

 

'They will be looking at specifics related to antiviral resistance and use of oseltamivir. WHO's recommendation for use of oseltamivir is for treatment,' she underlined.

 

(Continue . . .)

 

 

The concern is that in some countries, antivirals are being dispensed quite liberally, and that may lead to the novel H1N1 virus developing resistance.

A Tale Of Two Countries

 

 

# 3552

 

 

In the UK, if you’ve got `flu-like’ symptoms and think you may have the novel H1N1 virus, you are told NOT to go to your doctor. 

 

Instead you are directed to go to a website, or to ring up a hotline number, answer a brief questionnaire . . . and based on that, you either are issued antivirals or not.  

 

Last Thursday, on its first day of operation, the hotline dispense 5,500 courses of Tamiflu to patients who were never tested, and never saw a doctor.

 

Compare that with Thailand, where there have been more than twice the number of swine flu deaths as in the UK  (with roughly the same population). 

 

There, people with flu-like symptoms are `urged to see a doctor immediately’. 

 

Currently only hospitals have access to antivirals (the last I checked, Thai pharmacies don’t stock it).  Presumably, if you are sick enough, a doctor will refer you to a hospital.

 

 

Clinics 'not trained' to use oseltamivir

Writer: BangkokPost.com

Published: 28/07/2009 at 12:06 PM

Antiviral tablets should not be distributed to clinics across the country just yet, according to an official from the World Health Organisation.

 

"Doctors and nurses at these clinics need to be trained and know whether patients with flu-like symptoms have been infected with influenza type A (H1N1) before prescribing the antiviral oseltamivir directly to them," WHO Collaborating Centre for Research and Training on Viral Zoonoses director Thiravat Hemachudha said on Tuesday.

 

Oseltamivir should only be given at hospitals for now, because prescribing it to unconfirmed cases may lead to drug resistance, he warned.

 

He said the fatal cases may have received medication when it was too late, or maybe they only showed symptoms in the later stages.

 

"In most cases, if the patients' symptoms are clear no doctors would delay give them the medication," he said.

 

Dr Thiravat said wearing face masks and using alcohol-based hand gels may not be an effective preventative if people do not also avoid crowded places.

 

He also urged people with flu-like symptoms to see a doctor immediately.

 

The Thai Health Ministry announced last week that they had 14 million tablets of Tamiflu (1.4 million courses) and had ordered another 1 million courses of the drug. 

 

Enough for 4% of their population.

 

The UK, in contrast, reportedly has enough Tamiflu to treat nearly 50% of their population  (The US has enough for about 25%).

With 20% to 30% of the population expected to be hit by this virus over the fall and winter (admittedly a guess, since no one really knows), Thailand - with only enough antivirals to treat 4% of their population - must be more conservative in how they hand them out.

 

The concerns over breeding antiviral resistance are genuine, however.   In the past 2 years seasonal H1N1 has gone from being nearly 100% sensitive to Tamiflu to being 100% resistant.

 

Should that happen to the novel H1N1 virus, we’d be down to only one antiviral – Relenza – which is not only in much shorter supply than Tamiflu, is an inhaled powder, which makes it problematic for some patients to take.

 

The unanswered question before us is which is better?  

 

• To use antivirals aggressively now, while they remain effective, in order to reduce mortality and (hopefully) reduce the spread of the virus.
• Or to conserve antivirals for only the sickest of the sick, so as to limit the potential for resistance to develop?

 

I’m not sure I know what the right answer is here.

 

I will admit to being somewhat concerned over how readily Tamiflu is being dispensed in the UK and other countries, but I appreciate that holding onto a stockpile of antivirals until they are rendered useless by a viral mutation makes little sense.

 

I also recognize the political reality here. 

 

It would be very difficult for the any government to sit on their much vaunted stockpile of antivirals while their citizens succumbed to a pandemic virus.

 

 

Eventual Tamiflu resistance isn’t assured, by any means.  But we have seen a few scattered mutations, and the concern is these may be harbingers of things to come.  

 

All of which proves how truly difficult these policy decisions really are. There are no immediately obvious `right’ answers here. 

 

Historians, a decade from now, will probably have a better handle on it.

 

Of course, for a lot of countries, these are just theoretical problems. They have no stockpiles of antivirals, nor are they likely to see any substantial quantity of vaccine for this virus.

Canada: Vaccine For All Who Want It . . But Maybe Not Right Away

 

# 3551

 

 

Today’s news that not everyone in Canada who wants a vaccine will get one this fall should come as no surprise to anyone who has been following the vaccine story over the past few months.   

 

Since early May, we’ve heard that the novel H1N1 virus doesn’t replicate well in eggs, and that antigen yields were `disappointing’. In the past couple of weeks, we’ve learned that the yield is anywhere from 50% to 75% below that which is seen with seasonal influenza vaccines.  

 

So, while this shouldn’t affect the timetable of when vaccines will be available . . . it will affect the quantity that manufacturers can deliver.

 

Which means that in Canada (and likely in most countries that will be getting vaccine this fall), those at greatest risk will be prioritized to receive the shots first.  

 

Authorities are looking at inoculating remote and isolated communities, health-care workers, those with pre-existing chronic illnesses, and people under the age of 50 first.

 

This from the Canadian Press.

 

 

There will be enough swine flu vaccine, but maybe not at first: health official

(CP)

TORONTO — Canadian officials are finalizing the number of doses of swine flu vaccine they expect will be enough to get the country through the upcoming flu season, ahead of a July 31 deadline for ordering the country's supply.

 

There will be a sufficient amount of vaccine for all those who want or need it, Ontario's chief medical officer of health said Monday, though she cautioned there may be a shortfall at first.

 

The initial amounts of vaccine will become available about mid-November, Dr. Arlene King said as public health officials from across Ontario met in Toronto to discuss pandemic preparations.

 

"It is important that we plan for the possibility that we're not going to have the amount that we need right from the outset," King said.

(Continue . . .)

Peter Sandman: Swine Flu For Grownups

 

 

# 3550

 

 

Peter Sandman is a risk communications expert, and makes his living advising companies, agencies, and governments on how to handle media relations during a crisis.

 

Risk communications can deal with everything from a terrorist attack or a pandemic to a CEO’s indiscretion or a product recall. 

 

Depending on the circumstances, getting it right can salvage a company, resurrect a career, and even save lives.

 

The Peter M. Sandman Risk Communication Website combines the expertise of Dr. Sandman, along with his wife Jody Lanard M.D., and is is a veritable treasure trove of risk communications information.  

 

Since the Sandman website has so much information, a good place to start is the Crisis Communication (High Hazard, High Outrage) page.  Here you will find a number of articles on risk communication during events such as pandemics, hurricanes, and other disasters.

 

Today we get an editorial from Dr. Sandman that is being widely syndicated in newspapers around the world, entitled  Swine Flu For Grownups. 

Swine Flu for Grownups

Jul 27th, 2009

by Peter M Sandman
- Peter M. Sandman is a risk communication consultant based in Princeton, NJ, USA. Further advice can be found on his website, www.psandman.com.

PRINCETON – No one knows how the swine flu (H1N1) pandemic will evolve. Will it keep spreading, or will it fizzle? Will it retreat during the northern hemisphere’s summer and return in the fall? Will it stay mild or turn more severe? Flu experts just don’t know.

 

What is certain is that health officials risk mishandling how they explain this new and potentially alarming threat to the public. Although they know a lot about virology and public health, they often know next to nothing about how to talk (and listen!) to people about risks.

 

So here’s a primer on the swine flu pandemic risk communication, framed in terms of what health officials shouldn’t do when they’re telling you about this new disease.

 

 

1. Don’t feign confidence. Nobody likes uncertainty; we all wish the experts knew exactly what will happen. But we cope better with candidly acknowledged uncertainty than with false confidence. When health officials tell us confidently that X is going to happen, and then Y happens instead, we lose trust in their leadership. Smart officials are planning for various swine flu pandemic scenarios, and expecting surprises that will force them to change their plans. They should tell us so.

 

2. Don’t over-reassure. So far, this pandemic is mild. But even a mild influenza virus kills a lot of people, especially those with other medical problems. And experts worry that the novel H1N1 virus could mutate into a more severe strain. Yet officials endlessly insist that there is, as a Scottish health official put it, “absolutely no need for the public to be concerned.” This is false and it could backfire. Even before a situation deteriorates (if it does), people sense when they are being “calmed” rather than informed. Not trusting that officials will be candid about alarming information, we rely more on rumors. Not trusting official over-reassurances, we become even more alarmed.

(Continue . . . )

 

There are 7 more important points in this editorial, well worth reading in its entirety.

 

Dr. Sandman’s writings have been mentioned in this space an number of times, most recently in Experts: `Mild’ Is A Misleading Term For This Pandemic, but also here, here, here, and here.

 

If you haven’t already, you shoud make plans to visit Dr. Sandman’s website.

 

But fair warning, pack a lunch.  There is a lot to see and absorb.

Scientists To Study Vitamin D And The Flu

 

# 3549

 

 

Just yesterday, in an email to a friend, I remarked that it was sad but true: Wars and pandemics both tend to result in advances in our level of medical knowledge. 

 

Many of the techniques I used as a paramedic in the 1970s were first employed by medics during the Korean and Vietnam wars.   The whole concept of the `golden hour’ really grew out of their medevac experience.  

 

It is a tough way to do field research, though.

 

Already, with the threat of the H5N1 virus at our door we’ve made great strides in vaccine research.  Billions have been spent increasing manufacturing capacity and in developing new technologies.

 

But our ability to supply vaccine to most of the world’s 6.7 billion inhabitants remains inadequate.  Most people will have to do without a vaccine, just as many will have to go without western medicine or hospital care.

 

Hundreds of millions of people will – due to circumstance or preference – use traditional or alternative treatments for influenza in this pandemic. 

 

And like western medicine, sometimes they will help . . .and sometimes they won’t.    We should, however, come out of this pandemic with a better idea of what does . . .and what doesn’t work.

 

One of the `alternative’ treatments most often discussed on the flu forums over the past few years has been the use of Vitamin D.   You can find discussions on both the Flu Wiki and Flutrackers, plus presumably some of the other forums as well.

 

There is a good deal of anecdotal evidence supporting the idea that Vitamin D may be useful in fighting off the flu (among other benefits), but good studies supporting that theory are hard to find.  

 

That may be about to change, as we learn from this article from The Globe & Mail.  The article is lengthy, but interesting.  Follow the links to read it in its entirety.

 

 

 

Health agency to test link between flu, vitamin D

 

By screening infected blood, researchers hoping to find new ways to fight the virus

Martin Mittelstaedt

From Monday's Globe and Mail Last updated on Monday, Jul. 27, 2009 04:58AM EDT

In an effort to discover new ways to fight the swine flu, the Public Health Agency of Canada intends to test the blood of people contracting the ailment to check their vitamin D levels.

 

The agency is taking the unconventional action to try to find out whether those with mild cases of the flu have more of the sunshine vitamin circulating in their bodies than those who develop severe or even deadly reactions to the H1N1 virus.

 

If researchers determine that the vitamin protects against the swine flu, it will give health authorities another line of attack against the pandemic, besides such common-sense approaches as large-scale vaccinations and hand-washing campaigns.

 

A finding of a link to the vitamin would mean that people could reduce the odds of being harmed by the new flu bug by simply popping a low-cost supplement that is widely available at almost every drugstore.

 

Scientists have long been wondering about a possible connection between vitamin D and influenza because of the striking observations in both the northern and southern hemispheres that flu is mostly a wintertime ailment. This is the period each year when sunshine isn't intense enough to allow people to make the vitamin the natural way – in naked skin exposed to ultraviolet light – causing levels of the nutrient to plunge among those not taking supplements.

 

(Continue . . .)

 

 

 

While I don’t use my blog to actively promote alternative medicine, I do accept that the `western’ approach isn’t the only possible route to wellness.  

I’ve had a number of conversations with doctors who are very encouraged by the anecdotal reports on Vitamin D, and so have added it to my personal flu arsenal.   

 

It isn’t the only tool I have, but it is one of them. 

 

This isn’t a recommendation on my part, simply an admission.  You may wish to do some research on your own, or discuss this matter with your personal physician.   

 

In very large doses, Vitamin D can be toxic, particularly for children.  The NIH has a very conservative chart showing tolerable upper limit intake of Vitamin D.  

 

 

Many nutritionists have challenged these numbers, pointing to studies that indicate that up to 10,000 IU per day may be safe for adults. 

 

My advice, if you are interested in Vitamin D supplementation, is to read the entire factsheet, do some research, and then talk it over with your health care provider.