H1N1: Here for the Duration

As the flu season heats up and the weather cools down, the media are beginning to more frequently report deaths from H1N1 influenza. Although overall influenza-related deaths are still within the expected range for this time of year, there have been 60 pediatric deaths from H1N1 reported to the CDC since April, including 11 this week, and hospitalization rates are indeed higher than normal.

In the public health arena, many of us are wondering just how the public will react to these reports and the growing numbers of children who are ill or dead. While it's true that an average of 36,000 Americans die every year from the flu, the majority of these individuals are usually elderly or otherwise compromised, and if the number of children who die continues to climb, anxiety and fear will rise proportionately.

The government claims that the H1N1 vaccine is safe, and they are urging every pregnant woman and individual between the ages of 6 months and 24 years to be immunized, among others. I have heard projections that only 20% of eligible Americans may actually elect to receive the new vaccine, but I am not certain how accurate that estimate is. When the vaccine begins rolling out to local health departments, schools, medical providers and municipalities next week, it remains to be seen how the public will respond to well-publicized offers of mass vaccination against a novel disease.

Of course, at times like these, the public can react in many ways. A small percentage feel that the government has overreacted, blowing the risks of H1N1 out of proportion. While this could potentially be the case when the book is finally closed on H1N1, there would be even greater consternation if the government underreacted and millions needlessly died. Hurricane Katrina taught a mean lesson when it comes to government negligence, and it appears that the Obama Administration does not want to repeat such a disastrous mistake at a time when the stakes are so high.

Meanwhile, other segments of the population worry and fret over every sneeze and cough, while others simply wait to be told what to do. Most, I feel, are simply watching the headlines, testing the winds with a tentative finger, and biding their time as the situation develops and changes.

So, the reports of deaths continue to roll in, cases are diagnosed daily, and the entire infrastructure of the global community itself is potentially at risk. You can wager any amount of money that massive contingency plans have been made by most every government on earth, contingency plans that focus on how crucial infrastructures can continue to function in the face of widespread illness.

Plans for continuity of operations are now being drafted by hospitals, newspapers, factories, schools, and many companies and organizations that realize the potential for massive disruption if widespread illness should visit their particular organization. Just imagine if you run a high school. What would you do if 50% of your teachers were ill, or 75% of food workers, custodians or bus drivers called in sick? Woe to those who leave their plans undrafted.

The wave of H1N1 is indeed beginning to swell, and just how powerful and far-reaching that swell will become remains to be seen. To be sure, it will be a historic flu season in many ways. Whole economies may be impacted greatly by the disease, schools may be closed, factories may lay idle, and governmental and non-governmental organizations may be crippled by absenteeism and illness. And when it comes to the children, we can only hope that the number of deaths is kept to a bare minimum in the larger scheme of things.

H1N1, Fear, and the Need for Calm Vigilance

As the public health infrastructure gears up for the coming flu season and the potential resurgence of H1N1 from its summer lassitude, those of us on the front lines of that infrastructure are left with many questions.

First, as we await the first shipments of seasonal flu vaccine (which should begin arriving soon), we are faced with questions from the public about whether they are eligible for the seasonal flu vaccine, whether or not they will be able to receive the H1N1 vaccine, and how they might protect themselves against these strains of flu that threaten to sicken and perhaps kill thousands of people. We are also faced with the public relations nightmare of explaining the different criteria for the two vaccines, based on the fact that younger people are more susceptible to H1N1 infection, whereas the elderly more often succumb to seasonal flu. While there is some overlap between groups susceptible to both illnesses, a great deal of education will need to be done in order to allay fears and identify who will receive vaccinations.

Next, there are fears that schools, municipal offices, police and fire departments, hospitals and other critical services may be seriously curtailed or shut down if large numbers of employees become sickened with a virulent form of the flu. Just the other day, I attended a meeting with a number of local school officials, and weighty issues of great import were discussed at length as the group wrestled with contingency plans that may or may not come to fruition.

It is the fear of the unknown that drives the anxiety surrounding H1N1, and the potential for widespread illness and death does indeed stoke the fires of the media machine and the conspiracy theorists alike. For me, on the front lines of local public health, my job is to allay citizens' fears, prepare for a double-pronged mass vaccination campaign (for seasonal flu and H1N1), and meet with local officials and others in order to answer questions and suggest ways for citizens to be healthy and maintain a calm but alert vigilance.

This will be an interesting flu season, without a doubt, and it will only be hindsight that will inform us whether our preparations were thoughtful, wasteful, alarmist, or simply prudent.

Influenza Marches On

Even as March begins and February is left in the dust, flu season shows no signs of abating. In the last week, two otherwise healthy teenage boys died from the complications of influenza infection in Maryland. It is unclear whether or not they had been vaccinated against the flu, but even the most optimistic prognosis tells us that this year's vaccination does not confer complete protection against some of the strains making their way around the country.

According to the Washington Post, 83 Americans under the age of 18 died from complications related to influenza last year. This year, 17 young Americans have died, not including the two Maryland teens.

Checking in on the CDC website devoted specifically to influenza, 24.6% of all specimens submitted to the CDC for testing have been positive for influenza, and the proportion of deaths is well below the "pandemic threshold".

In terms of the flu vaccine, it appears that several circulating B strains are indeed not covered by this year's vaccine, and several strains are also showing resistance to common antiviral drugs. Still, public health officials and the CDC recommend vaccination in order for susceptible members of the public to be afforded the most protection possible.

When checking on Google Flu Trends, one notes that high levels of flu activity can be seen in most regions of the country, although overall flu activity for the United States is still deemed as "moderate". This information mostly concurs with that of the CDC surveillance site, where widespread activity is seen throughout the northeastern, southeastern and southwestern US.

In terms of pandemic flu, resources have been mobilized by the federal government to prepare for such an eventuality, and public health officials like myself are regularly updated on how national preparations are developing. Unbeknownst to most Americans, enormous stockpiles of antiviral medications are currently stored in massive warehouses in every region of the country, and this Strategic National Stockpile (SNS) can be mobilized and delivered to local municipalities within 24-48 hours of its activation. Many of us public health officials have surveyed local schools and buildings as SNS sites for emergency dispensing of such medication, and plans have been submitted to the CDC so that we can quickly receive these deliveries from regional SNS sites.

The 1918 flu pandemic that killed anywhere from 20 to 100 million people worldwide does indeed seem like a long time ago, and protections against such an eventuality were at that time completely nonexistent. These days, the flu vaccine (which we realize can be woefully inadequate at times) and antiviral medications (to which some strains of the flu are resistant) do offer us some modicum of protection. Adding insult to injury, we are now seeing many secondary bacterial infections in patients with the flu, realizing that some of those infections are themselves antibiotic resistant organisms like MRSA (methycillin-resistant staph aureus), adding yet another layer of complication to the prevention and treatment of acute influenza.

Not to paint a picture of doom and gloom, I am simply pointing out that the surveillance, treatment and epidemiology of influenza has become increasingly complicated in the 21st century, and the likelihood of further resistant strains developing is rather high. Since most epidemiologists feel that a worldwide pandemic is indeed likely in the coming century, it seems that the judicious use of government resources to prepare for such an event is indeed quite prudent.

While I have not personally been touched by an influenza-related death, I feel deeply for the parents of children who have died during this flu season, and I hope that our collective efforts to thwart further unnecessary and tragic losses are widely successful. We've seen that influenza is no laughing matter, and being prepared for the worst often seems to be our best defense.

If the Flu Fits.....

Well folks, on the eve of Thanksgiving here in New England, I was (figuratively speaking) hit by a truck that most likely was a case of influenza. Vaccinated against the flu more than a month prior, I was hoping---like so many other people around the world---that I would be spared serious illness this winter season, but those hopes were apparently in vain.

That early assault sent me once to the emergency room with the worst chest pain of my life (on the very night that all of the symptoms began), and three times to the nurse practitioner to beg for a bronchodilator and codeine cough syrup. Eighteen days later, I'm struggling with asthmatic bronchitis and am now using inhaled steroids to keep the coughing at bay. As the sun goes down, my lungs seem to naturally fill with congestion, and my level of fatigue is enormous. While I indeed miss exercising and working out, the mere thought of doing twenty laps at the local pool makes me swoon with delirium.

According to the Centers for Disease Control and Prevention website, there have been only 507 positive influenza tests in all of the United States so far this season. This means that only 1.6% of the more than 30,000 specimens submitted for testing so far have actually been positive for influenza. Concurrently, Google's Flu Trends website states quite firmly that, at least in the U.S., influenza activity is quite low, essentially agreeing with the CDC's current data.

No matter the numbers, and no matter how little flu activity is truly being seen out there in the world, those of us who are sure we've already been stricken feel that our Personal Statistic of Significant Suffering (PSSS) is certainly worthy of notice. For myself, I have suffered enough for several winters' worth of illness, and this lingering bronchitis must, on some level, earn me a flu season medal of honor.

For other flu sufferers out there---if you're reading this---one of your own feels your pain, and my wishes to you for a speedy recovery and a subsequently healthy and prosperous winter. And for those of you who have as yet escaped illness, may you continue to be well, and enjoy the holidays and New Year in well-deserved good health.

Stay tuned for more updates on nationwide flu activity as this new Public Health Nurse recovers from his own personal bout of wintry illness and doldrums.

Flu Flurry

The flu vaccines have arrived, and the flurry of vaccination has begun. Sore shoulders and fears of needles are the notions of the day. Hospitals and health centers practice "force protection", vaccinating employees against illness and lost productivity, unless, of course, the vaccine itself lands said employee in bed for a few days, a small price to pay for the ultimate avoidance of full-blown flu.

In the media and beyond, warnings and predictions of a pandemic loom large, some epidemiologists predicting an eventual worldwide scourge that will dwarf the death and destruction of 1918. Although this may eventually occur, it seems best as a healthcare provider to focus on the here and now, teaching self-care, hygeine and handwashing, protection of family and friends, and avoidance of those who are acutely ill. My immune-compromised patients are the ones for whom I am most concerned, as well as my patients with severe respiratory disease.

There is a certain panic that overtakes a segment of the population as the shipment of vaccine is inevitably postponed by the Feds. Even this year, despite previous experience, we received a small shipment which quickly disappeared, followed by utter silence from the Department of Public Health, leaving us in complete ignorance of the arrival of subsequent shipments.

In a recent post, I prayed aloud that the season's supplies of flu vaccine would flow like "champagne at a wedding". While the supply is not yet intoxicatingly large, some 400 doses arrived to the clinic this week, fifty of those routed to our office for vaccination of our "most vulnerable" patients. Who, then is "most vulnerable" among our caseloads? The 35-year-old with completely suppressed AIDS who has a fully reconstituted immune system or the elder with diabetes and COPD? Is it the schizophrenic with hypertension and daily contact with 100 others at a day program, or the morbidly obese homebound woman with asthma? These are rhetorical questions, obviously enough. They're all "vulnerable" and should all be protected to whatever extent we can do so. Hopefully, the supply will be abundant, and everyone who wants a vaccine will receive one forthwith.

In terms of planning for a pandemic, workshops and municipal plans abound, and I belong to a local group of trained volunteers who can set up a mass distribution site and vaccinate thousands in the span of a few days. Still, if people are going to get sick, there's just no stopping it no matter how many workshops we attend.

So, we do our best, jab as many people in the arm as we can, cross our fingers, and hope to survive this flu season unscathed.

The Phlegm and the Fury

As a nurse, I absolutely dread the advent of flu season. Obviously, I personally dread getting the flu myself. It's debilitating, demoralizing, and seems to take forever to recuperate from. It necessitates lost days at work, eats up my earned time for future vacations, and can set me back physically for weeks.

Aside from my own selfish reflections vis-a-vis the flu, I loathe the inevitable confusion and rancor over flu vaccine stocks. First, we usually hear that last year's problems with inventory and distribution have been solved and that "this year will be different". Not long after that pronouncement, we generally learn that the clinic has not received the number of doses ordered from DPH, and that our affiliate hospital system is having problems obtaining its full allotment. Aside from that, tainted vaccine and factories failing inspection always seem to make the evening news.

As the patients' panic calls begin to pour in, I do my best to quell fears, subdue the masses, and fight to get my hot little hands on enough vaccine to inoculate the thirty or forty most vulnerable of my caseload. Failing my ability to adequately meet my patients' needs, I punt, sending them to any and every flu clinic that I can locate in the city.

For people with AIDS, cancer, hepatitis and COPD, a year without a flu shot seems unthinkable, although I try to also educate them that a vaccine will not protect them completely. It's also hard for them to understand that a bunch of scientists basically takes what amounts to an educated guess as to which strain will snake its way across the US this year. They've been wrong before, and sometimes you just have to get sick.

Aside from the struggles over the vaccine and its relative lack or abundance, the sick calls then begin. Patients with the flu---even though it's definitively a virus---inevitably want antibiotics. While some protracted viral illnesses will indeed manifest secondary bacterial infections in some part of the respiratory system, we try to assist our patients to "tough it out", weather the storm, soothe the symptoms with NSAIDS and fluids and rest, and call us in the morning. This tactic is the most difficult to finesse, especially when our patients are used to using medicines to eradicate symptoms. Sometimes, I tell them, you just have to slog through the phlegm and the fury to get to the other side. They're generally not amused.

So, as October winds up into the middle of the month, Flu Vaccine Fever will soon spread like TB on a hermetically sealed city bus. The symptoms: frequent calls as to when the shipment of vaccine will arrive; requests for prophylactic antibiotics; requests for prophylactic Percocet (why not?); and panicked calls with fears that the dreaded illness has finally struck pay-dirt in the patient's home. My mantra: fluids, Tylenol (Ibuprofen if any liver disease is present), more fluids, sleep, more fluids, more sleep, and still more fluids. And don't forget to sleep. And, oh, did I mention the fluids?

The Flu Vaccine Fever will soon be upon us. May compassion fill my heart, may patience be my guide, and may vaccine supplies flow like champagne at a wedding.