Global Pandemics

Here's an interesting lecture from MIT World by Hidde Ploegh, PhD, Professor of Biology, MIT; Member, Whitehead Institute.

In his role as a biochemist, Hidde Ploegh explains the "essential features of the lifestyle of the flu virus" discussing not only how viruses work to invade our systems and cause the flu, but also adding insights into the political and societal framework in which public health groups and governments deal viral disease.

Will we see a second wave of H1N1 this winter?

It may seem like the H1N1 pandemic has spread through your community. My wife had confirmed H1N1 last month. Many schools in our area closed because of the pandemic in November. Yet it's only mid-December and we know that the flu season can easily go beyond February. So, will we see a second wave of H1N1 later this winter? What about the early spring?

Experts are definitely concerned about that possibility and many are evaluating historical data, exploring computer models, and looking at other ways to predict what may happen this winter. The bottom line is that no one really knows what will happen. However, if we see a second wave, what will that look like now that many people have already been exposed and have (theoretically) developed immunity to H1N1. Will the virus mutate to the point that it will cause reinfection in those who have already been vaccinated?

There are still so many unanswered questions about H1N1. We must continue to practice proper hygiene and common sense so that we reduce the spread of viral infections this winter. That's going to be difficult since December is a busy month for stores, malls, etc. How often will you be going to a crowded place filled with potentially sick people?

Pregnancy and H1N1

This flu season is going to be a very difficult one for patients and health care providers. There's a story on CNN about how a pregnant mother and her pregnant daughter are both battling H1N1. Nancy Brizendine, 42, and her daughter Kayla Yost, 22, are both pregnant and had H1N1. It's no surprise since Brizendine works as a medical assistant. Health care professionals are getting exposed every day to the possible risk of swine flu infection. It's a scary reality, but as this virus permeates society and spreads throughout the world, a significant percentage of clinicians will get sick.

The most important point to this story is prevention. We must exercise the highest level of vigilance to protect ourselves and others from infection. If you're not in the habit of routinely washing your hands, get into the habit. If you don't have easy access to soap and water, then get some anti-microbial gel. Healthy people are dying because of H1N1 and we must do our part to protect ourselves and the public.

H1N1 and the uninsured in America

Let's face it: many uninsured patients don't have primary care providers. They are reluctant to seek medical care because they can't afford it, and more importantly - they're afraid of the potential medical bills that may result from a sick visit.

So, what's going to happen to the uninsured as H1N1 spreads across the country? We know it's going to spread because we can't stop it. Global public health agencies have admitted that H1N1 simply can't be stopped.

• We're not going to see any type of public option emerge this fall/winter. There will be no universal health coverage to help patients this winter.
  
• Unemployment is still a significant problem in this country. With unemployment comes uninsured patients and families.
• H1N1 may lead to increased hospitalization. How will individuals handle these hospital bills?

Here's a novel thought: if you're uninsured in the United States, perhaps you may wish to spend this winter in a westernized country that offers free universal health care coverage. That way, if you get sick, you'll have access to free health care. Do you have any relatives living in other countries?

This winter will be a trying period for many individuals and families living in the United States. My hope and prayer is that H1N1 infections will be mild and that they won't cause too many hospitalizations or deaths. If we all do our part to wash our hands and practice good sanitation and hygiene, then I think we'll help prevent the spread of this contagious virus.

AMAFluHelp.org

There's a new resource on the Internet to help patients deal with the flu this season. It's called: AMAFluHelp.org

As you may have guessed, the AMA (American Medical Association) has launched this website to provide educational content regarding the seasonal flu and H1N1. This educational content is available to consumers (or patients) and also to health care professionals.

Upon establishing a free account, you can subscribe to personalized, interactive Health Session Programs that have been authored by the AMA for patients and their families. These programs include:

• Child Assessment: H1N1 flu and children under 18
• Am I high risk for H1N1 and need the vaccine?
• Adult Self Assessment: Do you have H1N1 flu?
• H1N1 Post Vaccine Monitoring
• Pregnancy: Do you need the H1N1 flu vaccine?
• H1N1 Flu: Can I return to school or work?

The website is currently in "beta" stage, but it looks quite promising. The Internet has revolutionized the way that patients and professionals can learn information. It's great to see the AMA providing this resource to the public.

MIT Lecture: Reflections on the Current H1N1 Flu

MIT World has a lecture by John M. Barry about the H1N1 pandemic and it's titled, "Reflections on the Current H1N1 Flu." It's hard to believe that H1N1 has already killed several children and teenagers this fall. the winter hasn't even arrived and it's frightening to imagine what will happen since the H1N1 vaccine is being released so late in the year.

Here's a brief summary of the lecture:

John M. Barry brings unsettling news from the frontlines of H1N1 research: this novel influenza virus is very hard to pin down. In spite of international scientific scrutiny, H1N1 continues to baffle and elude, worrying health officials defending against the pandemic, and challenging some ideas about influenza in general. Says Barry, “A lot of things we thought we knew, the virus demonstrates we knew wrong.”

Barry examines the current pandemic in both historic and scientific context. Most influenza viruses share certain features: They can jump to other species by way of mutation, or by mixing genetic components with another virus that happens to be infecting the same cell at the same time. Influenza pandemics go “as far back in history as we can look,” with 10 occurring in just the last 300 years. Four of the most recent pandemics appear to have rolled out in waves of varying lethality, infecting at peak times some 30% of the human population...

To view the online MIT World lecture, click here.

Doctors discussing H1N1 vaccination

Doctors on Sermo are so many different views on the new H1N1 (swine flu) vaccine. Primary care providers, emergency medicine physicians, and hospital physicians are most likely to get exposed. If you're a subspecialist, then maybe your patients will stay at home if they have flu-like symptoms.

So, are doctors eager to get the swine flu vaccine? Are they waiting in line? Some are, but others are reluctant and hesitant. Scattered witihin the flurry of posts regarding health care reform, physicians are debating the public health implications of H1N1. Will H1N1 be like any other seasonal flu? You're going to find that some physicians don't get the seasonal flu vaccine for a variety of reasons. Will H1N1 be worse than the seasonal flu? Will we see more fatalities this flu season because of the H1N1 pandemic mixed with seasonal flu? Some people fear the unknown safety of this new flu vaccine. Will the potential risks outweigh its benefits, or will it be the other way around?

I think that every healthcare provider who has any directly patient contact should receive the H1N1 vaccine. So, if you're a radiologist and you're working out of a dark computer lab and you never interact with patients, then maybe you'll have minimal exposure. However, if you're a hospital physician or a primary care provider, then I think you'd be out of your mind to skip the H1N1 flu vaccine.

FDA Public Health Alert: Potential Medication Errors with Tamiflu for Oral Suspension

FDA Public Health Alert: Potential Medication Errors with Tamiflu for Oral Suspension

Prescribers and pharmacists should be alert for potential dosing errors with Tamiflu (oseltamivir) for Oral Suspension. U.S. health care providers usually write prescriptions for liquid medicines in milliliters (mL) or teaspoons, while Tamiflu is dosed in milligrams (mg). The dosing dispenser packaged with Tamiflu has markings only in 30, 45 and 60 mg. The Agency has received reports of errors where dosing instructions for the patient do not match the dosing dispenser.

Health care providers should write doses in mg if the dosing dispenser with the drug is in mg. Pharmacists should ensure that the units of measure on the prescription instructions match the dosing device provided with the drug.

If prescription instructions specify administration using mL, the dosing device accompanying the product should be replaced with a measuring device (e.g., a syringe) calibrated in mL.
Specific Considerations for Tamiflu Dosing for Children over 1 Year of Age:

• Dosing should be prescribed in mg according to information provided in the table below.  Caregivers for children should use the dosing dispenser packaged with the medication, unless otherwise directed by a health care provider.

• If the dosing dispenser packaged with Tamiflu oral suspension is lost or damaged, or if the prescriber wishes to use volume-based dosing, appropriate dosages in mL are also provided in the table. In these cases the prescriber and pharmacist should ensure that a dosing dispenser, such as an oral syringe calibrated in mL, is given to the patient or caregiver with instructions for use. The dosing dispenser packaged with the product should be discarded.

• Prescribers should avoid prescribing Tamiflu oral suspension in teaspoons. This can lead to inaccurate dosing. If a prescription is written in teaspoons, the pharmacist should convert the volume to mL and ensure that an appropriate measuring device, such as an oral syringe calibrated in mL, is provided. The dosing dispenser packaged with the product should be discarded.

To read the entire alert, visit the FDA site here.

Inhalable H1N1 vaccine: are you ready to inhale?

Are you ready for the H1N1 vaccine? The CDC is reporting that over 3 million doses of the inhalable (no needles!) vaccine will be available in early October. Here's a snippet from a recent CNN article:

"3.4 million doses of vaccines will be available," said Dr. Jay Butler, who heads the 2009 H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention.

So, if you hate needles, you can still get vaccinated. However, the inhalable vaccine is not indicated for pregnant women (sorry, you'll need to get the needle version). Someday, we'll see painless needles everywhere. Imagine needles so small that you don't even feel them. They already exist, but they're not commonly used (yet).

As you consider swine flu vaccination, consider a few things:

• You may not need to protect yourself, but you may need to protect others who are vulnerable. If you spend any time around young children, elderly, or immune compromised individuals, then you're a risk to them if you don't get vaccinated.
  
• Young and healthy people have been dying from H1N1. 
• Follow your doctor's advice. I realize that many people don't like the idea of vaccines, but this fall/winter is going to be very different because of the H1N1 pandemic. 

Sanofi Pasteur, Novartis and CSL Limited all have FDA-approved flu shots, and MedImmune makes the inhalable vaccine. GlaxoSmithkline is waiting for FDA approval on its flu shot.

H1N1 (swine flu) and pregnancy

I seem to see pregnant women everywhere. As the flu season approaches, it's important to consider your health this fall/winter because of the H1N1 (swine flu) pandemic. Now that an H1N1 vaccine has been approved by the FDA, it's very important for those who are at "high risk" to get vaccinated first (since we don't even know if we have enough vaccine for everyone else). This includes pregnant women.

The first place to start is the CDC's  website: "2009 H1N1 Influenza Vaccine and Pregnant Women" that can be found here: http://www.cdc.gov/H1N1flu/vaccination/pregnant_qa.htm

That page is arranged in a question/answer format, so it will probably answer most of your questions. The important thing to remember is that swine flu (H1N1) can be fatal, even to healthy people. It's very important to discuss these issues with your healthcare provider and to make an appointment so that you can get the vaccine as soon as possible.

H1N1 spreading in colleges and universities

I'm glad that I'm not a college student this year. According to this CNN report, H1N1 (swine flu) appears to have infected over 2,600 students at Washington State University. Sounds like people should stay at home and take their courses online. Distance learning is now very effective thanks to major advances in communications technologies.

The school is following guidelines from the Centers for Disease Control and Prevention (CDC) and the local health department by "treating all patients with influenza-like symptoms as if they have H1N1."

As H1N1 spreads to more colleges this fall and winter, I wonder how this will impact academic performance. Wouldn't you love to have an excuse for those lousy grades? I was sick during finals. I missed too many classes. I was quarantined.

H1N1 (swine flu) advice for parents now that students are returning to school

Now that many students are back to school, parents are very concerned about swine flu (H1N1). Dr. Sanjay Gupta on CNN offers some practical advice for parents who have concerns about this pandemic. The four points outlined by Dr. Gupta include: keep your sick kids at home, call your pediatrician before taking your child to the doctor, and make sure you know when you must call your doctor.

We know that many students (and parents) are going to get sick this fall/winter with H1N1. Let's hope that parents and teachers don't over-react to this situation but that they use common sense as they deal with swine flu and that they consult their healthcare providers appropriately. Emergency rooms and primary care offices will be extremely busy this fall/winter. What's going to happen as healthcare providers get sick? We're probably going to see some significant shortages of healthcare providers this fall/winter.

Here's my tip for parents:
Have a backup plan so that you can go somewhere else in case your healthcare provider is unavailable. If your pediatrician is a solo practitioner and he/she gets sick, then you'll have to find a different office.

Disturbing reality about swine flu (H1N1)

The disturbing truth about swine flu is that it may kill hundreds of thousands of people in the U.S. this fall/winter. According to a recent story on CNN, the estimated number of deaths is 90,000. That's not an insignificant number when you consider that the seasonal flu kills roughly 40,000 each year. Although several vaccines against H1N1 are currently in development, they probably won't get released to be very helpful. As a result, many patients may choose to refuse the vaccine because they may think that the vaccine won't have any beneficial effect to protect them. The reality is that they should probably still get the vaccine because you never know if you'll get infected early or late in the flu season.

There's no doubt that this fall/winter will be very busy for hospitals, emergency rooms, and primary care offices. Avoid the hospital unless you really need to be there. Wash your hands at every opportunity and carry and use hand sanitizers. Let's see how schools get affected as students get ready to return to the classroom later this month and early next month.

Is your workplace prepared to handle the swine flu pandemic? Read the CNN story here.

Swine flu deaths around the world exceeding 1,100

According to this CNN story, the World Health Organization is reporting that global swine flu deaths are exceeding 1,100. We know that H1N1 is an unstoppable pandemic. This virus has spread in six weeks like how the common flu virus spreads in six months! We're waiting for effective vaccines and I'm sure we'll see them. The question in my mind is: will we have enough vaccines?

So who should get the vaccine?

The priority groups include pregnant women, health care and emergency services personnel, children, adolescents and young adults from six months to 24 years of age, household and caregiver contacts of children younger than six months and healthy adults with certain medical conditions.

Even though there are strong public health campaigns to get people vaccinated, we know that some simply won't receive the vaccine. Either they will refuse it, or they won't have access to medical care. Some won't make it a priority and they won't get the swine flu vaccine in time. Will we have enough anti-viral therapies for all those who don't receive a vaccine?

100,000 new cases of swine flu in the UK last week

According to the Department of Health, swine flu has been spreading rapidly in the UK. Last week, 100,000 new cases were reported and children 14 or younger were predominantly affected according to CNN. There are currently over 800 patients hospitalized in the UK with swine flu and that number is only going to increase by the fall/winter. How will hospitals deal with the overflow situation? Let's hope that the National Pandemic Flu Service will help alleviate the significant public health burden that we're about to experience this coming winter.

FDA authorizes emergency H1N1 test

In the primary care setting, it can be very challenging to accurately diagnose influenza. Now, we have to worry about a specific type of flu, H1N1 (also known as swine flu). Fortunately, the FDA has authorized the use of a diagnostic test for emergency use. Here are a few snippets from the FDA press release:

FDA Authorizes Emergency Use of Another Test for 2009 H1N1 Influenza Virus

The EUA for the Focus Diagnostics Influenza H1N1 (2009) Real-Time Reverse Transcription Polymerase Chain Reaction (RT-PCR) diagnostic test is the third diagnostic test authorized under an EUA by the FDA since the public health emergency involving the 2009 H1N1 influenza virus was declared on April 26, 2009. The Focus Diagnostics test amplifies the viral genetic material obtained from swabs of the nose or throat, or from nasal discharges. A positive result indicates that the patient is infected with the 2009 H1N1 influenza virus. However, the test does not indicate the stage of infection. A negative result does not preclude influenza virus infection.

The EUA authority allows the FDA, based on the evaluation of available data and other things, to authorize the use of unapproved medical products or unapproved uses of approved medical products following a determination and declaration of emergency. The Focus Diagnostics test is an unapproved device whose use is authorized by the EUA. The authorization ends when the declaration of emergency is terminated or when the FDA revokes the authorization.

Emergency Use Authorization is part of Project BioShield, which became law in July 2004.
Focus Diagnostics is based in Cypress, Calif.

Swine flu continues to spread

I read a sad story on CNN about a premature baby who died in Florida. The mother had swine flu (H1N1) and then developed significant respiratory symptoms. The baby was born 14 weeks early, but did not survive. The mom is currently in critical condition.

"We have seen, with this virus, worse complications and severe infections in pregnant women," said Dr. Anne Schuchat, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. "We're urging women who are pregnant who develop fever or respiratory symptoms to seek care promptly." The CDC is recommending that pregnant women receive the swine flu vaccine in addition to the standard flu vaccine.

Meanwhile, we're hearing reports of countries (such as China) quarantining students while other nations are extending summer vacations for their students. What will this fall and winter look like? What will travel be like? According to MSNBC, "The World Health Organization said Tuesday that deaths from the new H1N1 virus have doubled in the past three weeks, rising to over 700 from about 330 at the start of July." We can't stop the swine flu pandemic, but we can control how quickly it spreads. Let's hope that we see some safe and effective vaccines soon.

Inovio Biomedical H1N1 DNA Vaccines

Here's an interesting heading: "Inovio Biomedical H1N1 Influenza DNA Vaccines Demonstrate 100% Responses Against Swine Flu in Vaccinated Pigs." I realize that we're not pigs, but this vaccine may be quite effective in humans too. Here are some interesting bits from a recent press release:

Dr. Niranjan Sardesai, Senior VP, Research & Development, presented the data at the Annual Conference of DNA Vaccines in Asia 2009 held in Beijing, China, July 9-10, 2009, in a presentation entitled, “Pandemic and Seasonal Influenza DNA Vaccines Delivered Via Electroporation.”

Dr. J. Joseph Kim, Inovio’s CEO, said, “Our innovative SynCon™ technology has the potential to protect people from influenza strains not exactly like the ones that make up the existing vaccines. This is a clear advantage for our universal flu program over conventional influenza vaccines. We are pleased to report our H1N1 preclinical results using pigs, a more natural model for the current influenza pandemic. We look forward to advancing our SynCon™ universal flu vaccine program toward clinical investigation.”

In this study, scientists immunized pigs with consensus H1N1 influenza DNA vaccine candidates on day 0, day 14, and day 28. Sera collected on day 28 and day 42, after two or three doses of vaccine, respectively, showed hemagglutination inhibition (HI) titers above the protection threshold in 100% of the vaccinated animals against a swine H1N1 virus previously isolated from pigs. On-going additional animal studies are testing the ability of Inovio’s SynCon™ human H1N1 and swine H1N1 based vaccines to cross-protect from currently circulating human and swine H1N1 viruses as well as the new influenza A/H1N1 of swine origin.

In a similar collaborative study with scientists from the National Microbiology Laboratory of the Public Health Agency of Canada and the University of Pennsylvania, Inovio previously demonstrated that mice immunized with Inovio’s SynCon™ H1N1 DNA vaccine provided 100% protection in a lethal challenge study against an unmatched H1N1 virus that caused the 1918 Spanish flu, which killed over 40 million people worldwide.

Inovio’s novel SynCon™ technology enables the company to design DNA-based vaccines with the potential to protect against unmatched sub-types and strains of pathogens. Inovio has created SynCon™ DNA vaccines based on influenza HA, NA, and NP proteins that are common to strains H1N1, H2N2, H3N2, and H5N1, which make up the majority of seasonal and pandemic influenza. Using a designer approach, Inovio can formulate these DNA plasmids together to rapidly develop a universal influenza vaccine potentially targeting all these strains. The resulting vaccine could target seasonal as well as pandemic-potential influenza strains such as avian influenza and swine flu, which has already been designated pandemic status. Significantly, being based on a common set of antigens derived from a broad range of flu strains, such a universal vaccine would have the potential to provide greater protection against evolving, unmatched flu strains.

The fall is quickly approaching. Let's hope that we have enough H1N1 vaccine to go around the world so that we don't suffer mass fatalities from this swine flu pandemic.

How much swine flu vaccine will we need?

How much is enough? That's the question of the year as we prepare for the worst part of the swine flu pandemic. We know that swine flu (influenza H1N1) has spread throughout the U.S. and healthy people are dying from this common illness.

CNN has a story titled, "CDC: U.S. may need 600 million swine flu vaccine doses." Is 600 million doses going to be enough? What if we need more? Each adult will probably need two separate doses of vaccine (two shots, ouch!). According to CNN, "Congress passed a supplemental appropriation for $7.5 billion, which President Obama recently signed, to cover the costs of preparing for the virus, which includes a vaccination campaign." New and old pharmaceutical companies around the world are racing to prepare a safe and effective swine flu vaccine. Will they be prepared before it's too late? What if they're not safe? These are some of the questions that health officials are facing. To read the CNN story, click here.

U.S. swine flu - 1 million?

According to Time.com, the U.S. may have hit 1 million swine flu cases. Lyn Finelli, a flu surveillance official with the Centers for Disease Control and Prevention (CDC), made the 1 million estimate in a presentation to a vaccine panel in Atlanta. The number is based on mathematical modeling that uses data from surveys by health officials.

The United States has roughly half the world's swine flu cases, with nearly 28,000 reported to the CDC so far. The U.S. count includes 3,065 hospitalizations and 127 deaths. Here are some interesting stats: The average age of swine flu patients is 12, the average age for hospitalized patients is 20, and for people who died, it was 37. It seems to be deadliest to people 65 and older, with deaths in more than 2 percent of elderly people infected.

So, do you think more people will be getting the flu vaccine this year? I'm willing to bet that people who normally don't get the flu vaccine will definitely want to get it this year. It's possible that the swine flu vaccine may be given in two separate doses, 21 days apart. To read the full story at Time.com, click here.