H1N1 (Swine Flu): True or False? Flu Viruses Live Longer on Surfaces Than Cold Viruses

Most people know that cold and flu viruses can contaminate doorknobs, handrails, elevator buttons and other surfaces.

Studies have found that the survival time for both kinds of viruses varies greatly, from a few seconds to 48+ hours. The reasons have to do with a number of factors, including the type of surface, humidity and temperature.

• For example, cold and flu viruses survive longer on inanimate surfaces that are nonporous, like metal, plastic and wood, and less on porous surfaces, like clothing, paper and tissue.
• Most flu viruses can live one to two days on nonporous surfaces, and 8 to 12 hours on porous surfaces.
• A rather unnerving 2006 study found that avian influenza seemed particularly hardy, surviving as long as six days on some surfaces. (The study noted how long the virus was viable in avian feces. http://www.who.int/mediacentre/factsheets/avian_influenza/en/)

Cold viruses, it turns out, deteriorate quickly. A study in 2007 found that when objects in a hotel room — light switches, telephones — were contaminated with a cold virus, 60 percent of healthy volunteers picked up the virus when they touched one of the objects an hour later. Eighteen hours later, the transmission rate was cut in half.

On human skin, cold and flu viruses generally last less than a few minutes, but that’s plenty of time for people to infect themselves.  Studies show that most people touch their hands to their face, eyes or mouth many times — enough to cause infection.

So the answer is…flu viruses tend to survive longer than cold viruses.

http://www.nytimes.com/2009/12/15/health/15real.html?sq=flu%20viruses%20live%20longer&st=cse&scp=1&pagewanted=print

www.nurse.org/wa/arnpcare/0609care.pdf

H1N1 (Swine Flu): Hand Sanitizers’ – Claims Don’t Always Correspond to Real-World Practices

Nothing like a few diseases to give rise to a whole new class of products proclaiming that “they” will kill 99.9% of common bacteria, viruses and fungi. This includes everything from hand-sanitizing liquids to products like computer keyboard and shopping cart tissues. However, they often are based on laboratory tests that don’t represent the imperfections of real-world use. Human subjects, or countertops, in labs are usually cleaned first, then covered on the surface with a target bug. That is of course a far cry from a typical kitchen counter or a pair of human hands.

Jason Tetro, a microbiologist at the University of Ottawa showed the difference by testing three hand-sanitizer products for CBC News last month among eighth graders in Hamilton, Ontario. Three popular sanitizers killed between 46% and 60% of microbes on the students’ hands, far short of 99.99%. Bugs that aren’t killed by sanitizers aren’t necessarily more dangerous than those that are. But the more that remain, the greater the chance of infection, doctors say.

The companies whose products were evaluated responded that those lab tests are what health regulators require. “Real-world application is completely subject to interpretation,” says Jay Beckman, head of sales for MGS Soapopular Inc., the U.S. distributor of Soapopular, one of the products tested. “Nothing is guaranteed.”

Soap can be effective, but human nature can stand in the way. In a now famous study Navy recruits (1996 – 1998) were directed by their commanding officers to wash their hands at least five times a day. That and other measures helped reduce outpatient doctor visits for respiratory illness by an impressive 45%. (http://linkinghub.elsevier.com/retrieve/pii/S0749379701003233)

Civilians, lacking a commanding officer to direct them, can be a bit more problematic hand washers. Most, left to their own devices, don’t scrub the required time to achieve clean hands (20 seconds).

CDC recommends singing Twinkle, Twinkle Little Star or "Happy Birthday" twice to achieve that 20-second goal.

To cite a 99.9% fatality rate, manufacturers don’t have to kill 99.9% of all known bugs. Regulations don’t require them to disclose which bugs they exterminate, just that the products are effective against a representative sample of microbes. For instance, many products can’t kill clostridium difficile, a gastrointestinal scourge, or the hepatitis A virus, which inflames the liver. Yet by killing other, more common bugs, they can claim 99.9% effectiveness.

Rules governing claims of efficacy vary by agency. In the U.S., the EPA oversees claims about products intended for inanimate objects, while the FDA regulates skin products, including hand sanitizers. To claim that other microbe-unfriendly products such as household cleaners kill 99.99% of germs, companies are permitted to show such deadliness less than 99.99% of the time, according to the EPA’s rules. The standard test is run on 60 slides inoculated with a specific bug, and 59 of them treated with the product must exhibit the claimed rate of germ death. The 60th can fail to allow for a mistake on the part of testers, according to Jean Schoeni, director of research at TRAC Microbiology, which conducts EPA testing. “It’s a very fussy, particular test,” Dr. Schoeni says. Furthermore, if fewer than 59 slides show the high kill rate, manufacturers get a do-over.

If trained lab testers sometimes need a redo, aren't consumers wielding a spray bottle likely to fall short of optimal sanitizing technique? "It's highly likely," Dr. Schoeni says. She notes that some products need to sit on surfaces for 10 minutes to attain desired kill rates, yet many home cleaners are likely to wipe them off long before that.

Some companies would like to say their products kill the swine-flu virus — a claim that some can reasonably make. However, the FDA bars companies from making claims for over-the-counter products about killing viruses, and has recently issued five warning letters to companies “for false/misleading H1N1 claims,” according to an FDA spokesman. H1N1 is, manufacturers say, rather fragile and easy to kill. But because of the FDA rule, many don’t test the efficacy of their products on the virus, says Doug Anderson, president of ATS Labs, which studies germ-killing products.

http://online.wsj.com/article/SB126092257189692937.html?mod=WSJ_hpp_RIGHTTopCarousel

H1N1 (Swine Flu): Mild Pandemic? It All Depends On How You Define It…Don’t Lull Yourself To Sleep!

Mike Osterholm, CIDRAP Director and author of the subsription series CIDRAP Business Source brought up an important issue in this weeks writing…We should banish the word “mild” from the influenza lexicon. There’s no such thing as a mild case of influenza, any more than there are “mild” auto accidents or “slightly” pregnant. There are cases that for reasons we don’t understand don’t make you very sick, and there are cases that can lay you lower than you ever want to be, including the ultimate….death. What Osterholm does with great clarity is to revisit the idea this is a mild pandemic.

Both Osterholm and CDC’s most recent disclosure of about 10,000 deaths, 47 million infections and over 200,000 hospitalizations are thought-provoking once you really study the numbers. (http://www.cdc.gov/media/transcripts/2009/t091210.htm)

To compare the often quoted number of 36,000 excess deaths from seasonal flu to this 10,000 number is an "apples and oranges" affair. The 36,000 number is an excess mortality figure derived by different and non-comparable methods.

Here is Dr. Osterholm’s reasoning:

• In that CDC study, only 9,000 of those estimated annual seasonal deaths are due directly to influenza or secondary bacterial pneumonia.
• The other deaths are among persons who have influenza and who die of events like heart attacks or strokes.
  • If you want a comparison, think of the guy who has a heart attack while snow blowing his driveway after a large snowstorm and whose death is labeled “storm-related.”
• More important, though it’s not just the number of deaths but the pattern of illness in the population, flu’s descriptive epidemiology:
  • More than 90% of the estimated seasonal influenza deaths occur in the elderly, who in many instances have existing serious health conditions that mean their deaths may not be far off, regardless of their influenza illness.

We all realize that death is inevitable and that “early deaths”—or those that occur well before our elderly years — ideally just shouldn’t happen. The way we count influenza mortality, an influenza-related death in an 87-year-old person with advanced Alzheimer disease is the same as the death of a 22-year-old otherwise perfectly healthy pregnant woman. Both deaths are equally tragic, but any reasonable person would agree they are not equivalent public health outcomes.

Of the estimated 9,820 deaths:

• 1,090 (11%) have occurred in children 0-17 years of age
• 7,450 (76%) in people 18-64 years of age
• 1,280 (13%) in people over 65 years of age

This age distribution differs considerably from what we see with seasonal influenza.

While this pandemic is not 1918 (for which we can be most thankful - keep in mind no one knows what prevents this or any other pandemic from repeating that catastrophe), it is still pretty bad, already producing more estimated hospitalizations than seasonal flu and we aren't even into the heart of flu season yet.

• It’s challenging our healthcare system unlike any previous seasonal influenza season over the past 30 years. That makes it hard for me to call this a “mild” pandemic.
• Yes, there are mild, moderate, or severe influenza illnesses on an individual basis. But how do we describe a pandemic that hits a limited group of people really hard and causes only “routine influenza” for most others?

Most flu infections don’t have dire consequences (thankfully!), but a significant number do. And we never know who is going to win (or loose) the flu lottery. The convergence in our views extends to the same analogy: automobile accidents. As we’ve noted several times, it doesn’t make much sense to call any encounter with several tons of moving steel “mild.” It may be an encounter that produces little or no damage, but that’s luck. Anyone who’s gotten the repair bill for what can happen when hit by another car going only 5 miles per hour won’t consider the encounter “mild.” Any such encounter has the potential to be a catastrophe and the really bad ones are often just plain dumb luck.  And while the number of people killed each year in motor vehicle accidents is roughly the same as seasonal flu, we don’t usually think of our nation’s annual highway death toll of 40,000 as “mild” either. Its age distribution isn’t too different than pandemic flu’s either, the source of much anxiety to any parent whose child has just gotten their driver’s license.

It’s not just that “mild” is an inapt word. It is an inapt and dangerous idea. It is based on comparing total deaths in flu seasons with each another, not with the public health toll they exact. It is worse than a word not conveying the proper seriousness. It sends a message that itself has consequences, promoting a lack of urgency about taking rational public health measures like vaccination.

That’s especially pertinent this year when we don’t yet know what the usual flu season (January to March) will bring, either with seasonal flu or a recrudescence (“wave three”) of swine flu. As Osterholm points out, even with available vaccine now certain in the next few months, we are likely to find ourselves in January with a very large proportion of the population still without immune protection.

Are you feeling better that this is just a “mild pandemic?”

http://scienceblogs.com/effectmeasure/2009/12/mild_pandemic_bite_your_tongue.php

http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/index.html

H1N1 (Swine Flu): interleukin 17 – Molecule Linked to Severe H1N1

One of the scariest aspects of the H1N1 pandemic is the apparent randomness of the virus: Why do many people have a mild illness and a fairly quick recovery and then others are hit with extremely severe, and sometimes deadly, illness. Now, it appears scientists are one step closer to understanding why some people may be at greater risk of developing virulent forms of H1N1, as well as other respiratory illnesses.

Toronto scientists, in collaboration with colleagues from Spain, have identified a molecule they believe is linked to severe forms of illness. The results, published in the December issue of the online intensive care journal, Critical Care, (http://ccforum.com) could eventually help health officials target populations that may be most vulnerable.

“It’s probably not an isolated example that is specific for H1N1, and it probably spills over to other types of respiratory illness,” said David Kelvin, senior scientist and head of the experimental therapeutics division at the Toronto General Research Institute and one of the study’s authors. The researchers looked at blood samples from 10 H1N1-infected individuals in intensive-care units, 10 patients in non-ICU parts of the hospital, 15 outpatients with the illness and 15 people without H1N1. They focused on analyzing 29 cytokines, or molecules that regulate immune function, to determine if there were any patterns among those with severe forms of the disease.

They discovered that those patients with the most virulent forms had elevated levels of one particular molecule called interleukin 17. High levels of the molecule have previously been associated with inflammation and autoimmune diseases however it is too early to draw a link between high levels of that molecule and the risk of pneumonia or death related to H1N1.

It is still not known if elevated levels of the molecule can predict severe illness, or whether it applies to large groups of people. But the finding does give scientists a solid basis to work with as they continue in their quest to identify what makes certain people more vulnerable to virulent respiratory illness.

Dr. Kelvin said he and his colleagues have been searching for this kind of discovery for years, and they believe it has implications for targeting preventive therapy in future pandemics, as well as seasonal influenza. While they have looked in the past at patients with other respiratory illnesses, they never found a meaningful connection between severe illness and elevated molecule levels.

“This is the first time we've come across something in 10 years, and we've looked pretty rigorously,” Dr. Kelvin said. “It's almost like a smoking gun. If you don't know where to look you'll never get the job done.”

Dr. Kelvin said researchers are expanding their study to look for similar patterns in people living in other countries, such as China. They hope to find links between molecule levels and severe illness, and will look for genetic differences that may make some more susceptible to severe illness. Eventually, health officials may be able to develop a simple blood test that can identify who is at greatest risk of severe illness in future pandemics or flu outbreaks.

http://ccforum.com/content/13/6/R201/abstract

http://www.theglobeandmail.com/life/health/h1n1-swine-flu/molecule-linked-to-severe-h1n1/article1401612/

H1N1 (Swine Flu): Japanese Experience – Aggressive Treatment & Social Etiquette Yields Better Results

Eight hours after Tokyo office worker Shungo Yamamoto started feeling feverish and faint, he got a diagnosis of H1N1, received antiviral drugs and embarked on three days of self-imposed isolation last month.  “I knew it was influenza immediately” because of the fever and joint pain, Yamamoto, 25, said. His doctor confirmed the diagnosis with a nose swab test and prescribed five days of the antiviral drug Tamiflu. When he left the doctor’s office, Yamamoto put on a mask, bought a three-day supply of food, rented DVDs and headed home, where he stayed for the duration of his illness.

Japan’s aggressive treatment against H1N1 influenza, the result of hygiene standards, social etiquette and a willingness to test and medicate immediately, means the country has fared better than the U.S. or the U.K. in battling the first pandemic in 41 years. A WHO report shows:

• Japan’s mortality rate is 2 deaths for every 100,000 people.
• The rate is higher by 11 times in the U.K.
• 16 times higher in the U.S.
• 43 times higher in Australia

“No doctor in Japan would tell a flu patient just to go home and sleep it off,” said Norio Sugaya, a pediatric specialist at Keiyu Hospital in Yokohama, a port city south of Tokyo. Sugaya sits on a committee that advises WHO, a Geneva- based arm of the United Nations, on managing swine flu patients.

In the U.K., a study this month found patients typically waited three days to start taking Tamiflu, one of two medicines available to fight the new virus as well as seasonal influenza.  CDC recommends that antiflu drugs be given to hospitalized patients, pregnant women and others with increased risk of complications. In Japan, doctors are advised to administer the medicines to anyone suspected of having flu, even if a rapid diagnostic test is negative, according to the Japanese Association for Infectious Diseases, a Tokyo-based organization of specialist doctors that provides treatment recommendations.

Japan accounted for an amazing 3/4's of the Tamiflu dispensed globally in the drug’s first 5 years of sale, according to Roche in a November 2005 filing to the U.S. FDA. Three years later, Japan’s government announced plans to stockpile enough antiflu medicines for 45 percent of its 128 million people. That may be triple the amount required to treat every swine flu patient. WHO estimates the proportion of people sickened by the pandemic virus ranges from 7 percent to 15 percent, depending on the country.

Japan’s status as one of the biggest users of antiviral medicines and its approach to treating seasonal and pandemic flu should be compared with practices elsewhere and the data should be published in English, said Lance Jennings, a clinical virologist with Canterbury Health Laboratories in Christchurch, New Zealand, who has studied flu for more than 30 years.

“If you have better capacity to diagnose cases earlier and are treating appropriately and early, you’re more likely to reduce the number of patients who will go on to develop more- severe influenza,” Jennings said in an interview. While the majority of pandemic flu sufferers got over their illness within days without treatment, 1 percent to 10 percent needed hospitalization and as many as a quarter of those patients required intensive care, WHO said on Dec. 4.

Tamiflu and Relenza (an inhaled medicine) appear beneficial in fighting the H1N1 virus, especially if treatment begins within 48 hours of the onset of symptoms, researchers said in a study in the New England Journal of Medicine in November. A paper in the same journal in December reported reduced complications, including deaths, among hospitalized patients treated with the medications.

A survey of Japanese patients in 2005 found 85 percent sought medical treatment for flu and 90 percent of consultations took place within 48 hours after the first symptoms appeared, according to David Reddy, who heads Roche’s influenza task force in Basel.

“These people do not wait until it’s too late,” Reddy said in a telephone interview. “Japan has to be the gold standard of management of influenza. It’s almost a societal response in terms of the way people modify their behavior.”  Japanese have become accustomed during the past decade to wearing masks in public to ward off allergic reactions to pollen from cedar trees throughout the country, said Masataka Yoshikawa, a researcher who tracks consumer behavior at Hakuhodo Institute of Life and Living, the research arm of a Tokyo-based advertising company. Japanese expect someone with a cold or flu to wear a mask to limit the spread of the virus, he said.

“Hand-washing, gargling and wearing masks are three hygiene measures that are very well accepted in the community in Japan,” said Nikki Shindo, the Japanese doctor who is leading WHO’s investigation of H1N1 patients. “People don’t really hesitate to wear masks in public places. Even the 24/7 convenience stores sell high-particulate respirators at a reasonable price.”

Some researchers say they are skeptical that Tamiflu is effective and concerned that the virus will develop resistance to the drug because of misuse. An analysis of 20 studies published in the British Medical Journal on Dec. 8 showed Tamiflu offered mild benefits for healthy adults and found no proof it prevented lower respiratory tract infections or complications of flu. There is little evidence to show that otherwise healthy people should be given Tamiflu routinely, the researchers said.

“Based on our analysis and other subsequent work, there is no doubt that the drug can reduce complications,” said Frederick Hayden, a professor of clinical virology at the University of Virginia School of Medicine in Charlottesville, who was one of the first doctors to study Tamiflu in patients.  Missing doses or failing to complete a course of medicine increases the risk that a drug-evading strain will emerge, said William Aldis, an assistant professor of global health at Thammasat University in Bangkok and a former WHO representative to Thailand. In societies such as Japan, where treatment compliance is high, patients are less likely to contribute to drug resistance, he said.  “So this is one more reason to think carefully before applying Japan’s approach elsewhere,” Aldis said.

Japan, whose flu season typically peaks between January and March, may face more deaths from H1N1 if the infection trend follows that of seasonal flu, said Hitoshi Oshitani, a virology professor at Tohoku University in Sendai, in northern Japan.  “Japan will enter its regular peak flu season from now, and we have to observe whether the pattern continues or not,” he said. Oshitani, who advises WHO on pandemic strategies for developing nations, also credits the country’s school-closure program for helping battle swine flu.

http://www.bloomberg.com/apps/news?pid=20601202&sid=auxGTNXRwuAI

H1N1 (Swine Flu): Death Toll Revised to 10,000 Since April 2009 in U.S.

CDC has revised the death toll for the H1N1 pandemic to almost 10,000 people since April, a significant jump from mortality numbers released last month. A month ago, the CDC estimated that only about 4,000 had died. CDC also noted that:

• 50 million Americans, one sixth of the country, had caught the disease
• 213,000 people had been sick enough to be hospitalized

Several flu experts said they were not shocked by the sudden jump because the new figures were as of Nov. 14, when this fall’s wave of swine flu cases was reaching its peak. The previous estimate of 4,000 deaths, issued last month, was only through mid-October. By next month, deaths should not have risen quite as abruptly because the fall wave is tapering off and hospitals have fewer people in intensive care, experts said. “I’m not surprised,” said Lone Simonsen, an epidemiologist at George Washington University’s School of Public Health. “This includes most of the fall wave.”

How many will ultimately die of the H1N1 flu depends heavily on whether there is a third wave in January, as happened in the 1918 and 1957 pandemics, and on whether the virus changes to be more lethal or drug-resistant. Predicting that requires a crystal ball.

Dr. Thomas R. Frieden, Director of the CDC said about 85 million doses of the H1N1 vaccine were now available. Some states have so much that they are asking that everyone over six months old get vaccinated, not just high-risk individuals. There is “still a good window of opportunity” to get vaccinated, Dr. Frieden said, adding that he plans to get the nasal spray vaccine himself “in a few days.”

Mutations making the flu more lethal and drug-resistant have been spotted in many countries, but thus far only in small numbers of isolated cases.

Michael T. Osterholm, director of the CIDRAPat the University of Minnesota, agreed that trying to guess how many would die by spring was “calling the score at halftime.” Mr. Osterholm was troubled by recent predictions that the pandemic would be the mildest on record.

“So the C.D.C. says 50 million have been infected so far,” he said. “Another 50 million have been vaccinated. And maybe 20 million have got innate immunity because of their age. You do the math — that’s 120 million who are immune out of 320 million, so two-thirds of the population is still not immune. It’s amazing how many people are acting as if this is all wrapped up. The numbers could still go up dramatically.”

Dr. Arnold S. Monto, a flu expert at the University of Michigan School of Public Health, said the flu might reach the lower end of a widely publicized forecast made in August by the President’s Council of Advisers on Science and Technology, which predicted 30,000 to 90,000 deaths.

Deaths appear to be lower than expected, Dr. Monto said, partly because young victims are better able to tolerate the aggressive drug and oxygen therapy used in hospitals to save those with overwhelming pneumonia. Flu deaths are hard to count because tests are inaccurate and some people die without being tested. In addition, some die of heart attacks, emphysema or organ failure, though flu triggered their illness. About 36,000 die in a typical flu season, according to a well-known 2003 study, but epidemiologists used different methods to calculate the 10,000 swine flu deaths, said Dr. Beth P. Bell, of the CDC.

In 2003, they counted winter deaths over a decade; this season’s model is based on lab-confirmed flu hospitalizations. The old method would probably conclude that more than 10,000 had died thus far, but it is impossible to know how many, Dr. Bell said. Dr. Frieden said Thursday that all the experts he consulted were divided over whether the country would have a January wave. “Half think we will,” he said, “and half think we won’t.

Also, Dr. Frieden noted that American Indians and Eskimos had died at four times the rate of other Americans. That is probably not because of genetic differences, he said, but because of poverty and childhood malnutrition, among other factors. (Canadian Indians have also had high death rates. But so did Australian aborigines, who have similar rates of poverty, isolation and underlying disease but are genetically distant from North American Indians.)

http://www.cdc.gov/media/transcripts/2009/t091210.htm

http://www.nytimes.com/2009/12/11/health/11flu.html?em

H1N1 (Swine Flu): So Far? “Mildest Pandemic On Record” – Forecast? Stay Tuned!

With the second wave of H1N1 infections having crested and now trending down in the U.S., leading epidemiologists are predicting that the pandemic could end up being ranked as the mildest in modern times. However, experts warn that the flu is notoriously unpredictable so don’t let your guard down…yet.  This study indicates that the death toll is likely to be far lower than the number of fatalities caused by past pandemics.   The predictions are being met with a mix of skepticism, relief and trepidation.

Harvard researcher Marc Lipsitch, DPhil, and colleagues from the U.K. Medical Research Council and the CDC, released a study “The Severity of Pandemic H1N1 Influenza in the United States, from April to July 2009: A Bayesian Analysis” on PLOS Medicine detailing that the current statistics are revealing that it has been no more severe than an average flu season.

There are some pretty big caveats next to that prediction:

• Most of the deaths and hospitalizations in a typical flu season are elderly people. Most of those killed or hospitalized in the H1N1 swine flu pandemic are children and young adults.
• Deaths attributed to seasonal flu include heart attacks, strokes, and other fatal conditions triggered by the flu. Nearly all deaths attributed to H1N1 flu are due to flu or to bacterial complications of flu.
• The new predictions would be four or five times higher in populations without access to mechanical ventilation or intensive care.
• All bets are off if the H1N1 swine flu shifts to older populations.

Even so, the new numbers are cause for relief if not for celebration. Before the 2009 H1N1 swine flu came along, planners were preparing for a pandemic with a case/fatality ratio of 0.1% — that is, for one death in every 1,000 symptomatic infections. The Lipsitch team now calculates that the H1N1 swine flu has a case/fatality ratio no higher than 0.048% — and maybe seven to nine times lower, depending on the methods used for calculation. “I think it is very likely to be the mildest pandemic on record,” said Marc Lipsitch. “This is a serious disease (however),” Lipsitch said, He noted that between one in 70 and one in 600 people who fall ill with H1N1 swine flu will be hospitalized.

The CDC has been careful not to characterize the severity of the 2009 H1N1 pandemic. The new predictions are very much in line with CDC's working estimates, says Beth Bell, MD, MPH, associate director for science at the CDC's immunization and respiratory disease center.

“This study sends the message that this is primarily a young person’s disease and highlights the importance of taking advantage of this window of opportunity to get the vaccine and take preventive measures,” says Bell. “While most people who get this illness do OK, it can be very severe — and the severity is concentrated in younger people.”

Public health officials worry that people may become complacent about getting vaccinated, which could prove disastrous if a third wave of infections swells later this winter or the virus mutates into a more dangerous form. Lipsitch and others stressed that the multibillion-dollar vaccination campaign and other intense responses were appropriate, given the uncertainty of what the nation and world was facing.  ”We got lucky,” Lipsitch said. “But if we didn’t have a plan in place and we had 60,000 or 70,000 deaths, people would have been justifiably outraged.”

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000207

http://www.washingtonpost.com/wp-dyn/content/article/2009/12/07/AR2009120703162.html?hpid=topnews

H1N1 Swine Flu: Autopsies Show Same Lung Damage as 1918 Flu

Highlighting the H1N1 flu’s ability to turn deadly is a new study from James R. Gill, MD, from the New York City Medical Examiner’s office, and Jeffrey Taubenberger, MD, PhD, of the National Institutes of Health.  The scientists reviewed autopsy reports, hospital records and other clinical data from 34 people who died of 2009 H1N1 influenza infection between May 15 and July 9, 2009. All but two of the deaths occurred in New York City.

A microscopic examination of tissues throughout the airways revealed that the virus caused damage primarily to the upper airway—the trachea and bronchial tubes—but tissue damage in the lower airway, including deep in the lungs, was present as well. Evidence of secondary bacterial infection was seen in more than half of the victims.

The scientists reviewed autopsy reports, hospital records and other clinical data from 34 people who died of 2009 H1N1 influenza infection between May 15 and July 9, 2009. All but two of the deaths occurred in New York City.

The researchers also examined 33 of the 34 cases for evidence of pulmonary bacterial infections. Of these cases, 18 (55 percent) were positive for such infections. Not all of those individuals who had bacterial pneumonia along with 2009 H1N1 virus infection had been hospitalized, however, indicating that some had acquired their bacterial infections outside of a health-care setting.  This raises the possibility, say the authors, that community-acquired bacterial pneumonia is playing a role in the current pandemic. “Even in an era of widespread and early antibiotic use,” write the authors, “bacterial pneumonia remains an important factor for severe or fatal influenza.”

Computerized tomography (CT) lung images were available in four cases of pulmonary bacterial infection. In all four cases, the CT scans showed an abnormality known as ground-glass opacity, which are patches of rounded haze not seen in normal lung images.

It is not known, say the researchers, whether the abnormalities detected by CT in the four cases also occur in people who have milder H1N1 infections. They call for additional investigation into the utility of CT scans as a tool to help clinicians identify and better treat severe H1N1 infections.

http://www3.niaid.nih.gov/news/newsreleases/2009/FluAutopsy.htm

H1N1 (Swine Flu): Vaccine Safety – Report of Adverse Reactions in the U.S. October 1–November 24, 2009

There has been lots of discussion about the pandemic H1N1 vaccine amongst the protagonists and the antagonists alike.  The protagonists believe the vaccine is safe and we must have it in order to stop the spread of the disease and the antagonist believe it is unsafe and will cause wide spread death and suffering and is part of the Big Pharma response.  Wow – not much middle ground there!

MMWR Report

CDC has just issued the MMWR that details the first reports on vaccine safety in the U.S.  The FDA licensed the first 2009 pandemic vaccine (H1N1 monovalent vaccine or “H1N1 vaccines” on September 15, 2009.

• None of these vaccines contains an adjuvant.
• The licensure and manufacturing processes for the vaccine were the same as those used for seasonal flu.

The H1N1 vaccines are available as a:

• Live, attenuated monovalent vaccine (LAMV) for intranasal administration
• Monovalent, inactivated, split-virus or subunit vaccines for injection (MIV)

Vaccine Adverse Event Reporting System (VAERS)

To assess the safety profile of H1N1 vaccines in the United States, CDC reviewed vaccine safety results for the H1N1 vaccines from

• 3,783 reports received through the U.S. Vaccine Adverse Event Reporting System (VAERS)
• Electronic data from 438,376 persons vaccinated in managed-care organizations in the Vaccine Safety Datalink (VSD), a large, population-based database with administrative and diagnostic data, in the first 2 months of reporting (as of November 24).

VAERS data indicated 82 adverse event reports per 1 million H1N1 vaccine doses distributed, compared with 47 reports per 1 million seasonal influenza vaccine doses distributed.

• No substantial differences between H1N1 and seasonal influenza vaccines were noted in the proportion or types of serious adverse events reported.
• No increase in any adverse events under surveillance has been seen in VSD data.

Many agencies are using multiple systems to monitor H1N1 vaccine safety. Health-care providers and the public are encouraged to report adverse health events that occur after vaccination.

Reports to VAERS

VAERS enables early detection of potential new, rare, or unusual patterns of adverse events, which then can be investigated using other methods and systems to determine whether an actual association with vaccination exists. What are the reporting requirements?

• Health-care providers and manufacturers are required to report to VAERS certain adverse events in vaccinees brought to their attention after vaccination with licensed U.S. vaccines.
• Health-care providers and members of the public may also report other adverse events voluntarily.

There were several changes made to VAERS to enhance reporting with the initiation of the H1N1 vaccination program.  This included providing VAERS contact information on influenza vaccination record cards, advertising in medical journals, utilizing state vaccine safety coordinators, and increasing the number of staff members who code reports and obtain and review medical records,

CDC and FDA staff members review all VAERS data. Reporting rates were calculated per 1 million doses distributed as of November 20.  Through November 24, VAERS received:

• 3,783 reports of adverse events after receipt of H1N1 vaccine 204 were categorized as serious
• 4,672 reports after receipt of seasonal influenza vaccines, of which 283 were serious

Vaccine data from October 5 – November 20 revealed the following:

• H1N1 Vaccine a total of 46.2 million doses (11.3 million LAMV and 34.9 million MIV doses)
  • Overall VAERS adverse event reporting rates were 82 per 1 million H1N1 vaccine doses distributed
  • The serious adverse event reporting rates were 4.4 serious adverse events per 1 million doses distributed.
• Seasonal Flu: 98.9 million doses
  • Overall VAERS adverse event reporting rates were 47 per 1 million seasonal influenza vaccine doses distributed.
  • The serious adverse event reporting rates were 2.9 serious adverse events per 1 million doses distributed.

However, the percentage of serious adverse events among all adverse events reported after receipt of seasonal influenza vaccines was slightly higher (6.1%), compared with the percentage of serious adverse events after receipt of H1N1 vaccines (5.4%), and this finding was consistent for inactivated (5.8% versus 5.5%) and live attenuated (7.3% versus 4.7%) vaccines.

Vaccine Deaths

• VAERS received 13 reports of deaths occurring after receipt of H1N1 vaccine
  • Three deaths occurred after receipt of LAMV
  • 10 after receipt of MIV.
  • In nine of these deaths, significant underlying illness (including illness that might be indication for vaccination) was present
  • One death resulted from a motor vehicle crash
  • The remaining three deaths await review of final autopsy results or death certificates by CDC

Guillain-Barré Syndrome

• VAERS had received 10 reports of Guillain-Barré syndrome
• Two additional reports of possible Guillain-Barré syndrome were identified by medical officers reviewing other reports to VAERS describing neurologic events.
• After chart review, four of these 12 reports (all after receipt of MIV) met Brighton Collaboration criteria^¶ for Guillain-Barré syndrome, four did not meet the criteria, and four are under review.

Anaphylaxis

• VAERS also received 11 reports of anaphylaxis
• Additional eight reports of possible anaphylaxis were identified by medical officers reviewing reports to VAERS of serious allergic events.
• Of these 19 cases, 13 met Brighton Collaboration criteria, five had an anaphylaxis diagnosis on medical record review, and one has not been confirmed.
• Three of the Guillain-Barré syndrome cases and 15 of the anaphylaxis cases were coded as serious adverse events, in accordance with federal regulation.

The remaining 173 nonfatal serious adverse events after vaccination with H1N1 vaccines are under chart review. These reports fall into the following diagnostic categories: neurologic or muscular condition other than Guillain-Barré syndrome (49 [28%]); pneumonia or influenza-like illness (27 [16%]); other noninfectious conditions, including multiple medical symptoms (19 [11%]); respiratory or ear, nose, and throat condition (17 [10%]); allergic conditions other than anaphylaxis (16 [9%]); pregnancy complications** (15 [9%]); other infectious symptoms (10 [6%]); gastrointestinal (eight [5%]); cardiovascular (six [3%]); and psychiatric (six [3%]). Each category includes a variety of diagnoses; no patterns were identified.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e1204a1.htm#tab2

H1N1 (Swine Flu): Flying & Sick?? Do Us All A Favor – Don’t! CDC Issues New Guidelines on Illness & Travel

It was no surprise to anyone who travels by plane – that air travel was a culprit in the fast spread of H1N1 globally.

The research study published in the June 29, 2009 New England Journal of Medicine clearly demonstrated that countries that received the most airline passengers from Mexico in the spring were the most likely to see H1N1 swine flu infection.

To that end, CDC has revised its guidance regarding air travel and disease transmission.

Background

Commercial air travel is often characterized by the movement of large numbers of people in closed and semi-closed settings. As with other close contact environments, these settings can facilitate the transmission of influenza from person to person or through contact with contaminated environmental surfaces. CDC recommends that efforts to reduce the spread of influenza on commercial aircraft focus on encouraging air carrier employees and passengers who have an influenza-like illness (ILI) not to travel.

The new guidance provides guidance for the management of ILI during and after a flight, including personal protective measures for the crew, and is meant to supplement CDC’s recent guidance for employers on ways to decrease the spread of seasonal and 2009 H1N1 influenza in the workplace. See CDC’s Guidance for Businesses and Employers to Plan and Respond to the 2009-10 Influenza Season, which is available at http://www.cdc.gov/h1n1flu/business/guidance/.

Management of Passengers and Crew Members with ILI Influenza-Like Illness (ILI)

Symptoms of influenza can include some or all of these symptoms: fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, tiredness, diarrhea, or vomiting. Not everyone with influenza will have a fever (a temperature of 100° F [37.8° C] or greater). Flight crew should consider someone to have a fever if the ill person feels warm to the touch, gives a history of feeling feverish, or has an actual measured temperature of 100°F (37.8°C) or greater. Because the symptoms of influenza are not specific and most persons who have a respiratory illness are not tested for influenza, an ILI has been defined as an illness with fever or feverishness plus either cough or sore throat.

Passengers or Crew with ILI before a Flight

If a cabin or flight deck crew member or a passenger has an ILI prior to a flight, CDC recommends that he or she not board the aircraft until at least 24 hours after fever has resolved without the use of fever-reducing medications. Airline crew should also follow individual company policy if ILI develops prior to a flight. More information for travelers is available at http://www.flu.gov/individualfamily/travelers/index.html.

Development of ILI in Passengers or Crew during a Flight

Crew members should take the following actions if a person develops ILI during a flight:

• Minimize the number of persons directly exposed to the ill person and if possible separate the ill person from others by 6 feet without compromising flight safety
• Keep interactions with the ill person as brief as possible

Ask the ill traveler to wear a face mask if it can be tolerated and one is available.

• If a face mask cannot be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing
  • Provide a plastic bag for proper disposal of used tissues
• Practice good hand hygiene and encourage others, including the ill person, to do the same
  • Hands should be washed with soap and water especially after coughing or sneezing, after using the restroom, or after touching potentially contaminated surfaces or items. If soap and water are not available, an alcohol-based hand rub can be used
• Dispose of soiled material, such as items contaminated with body fluids and used personal protective equipment, in a sturdy plastic bag that is tied shut and not reopened, according to state solid waste regulations
• Report to CDC, on a voluntary basis, persons with ILI on international flights bound for the United States who require medical assistance. The need for medical assistance can be based on consultation with the airline in-flight medical consultant or per the ill person’s request
  • Notify the CDC Quarantine Station (http://www.cdc.gov/ncidod/dq/quarantine_stations.htm) at or closest to the airport where you are arriving of the ill person prior to arrival or as soon as illness is noted. If unable to reach the Quarantine Station, call 866-694-4867 to speak with the Quarantine Duty Officer covering that airport
• If possible, continue operating the aircraft air conditioning or ventilation system until all passengers and crew have disembarked to maximize air circulation in the cabin and thus the filtering of virus particles. Safety concerns may preclude this step on some aircrafts.

If the ill person is a crew member, CDC recommends, in addition to the actions listed above, that the ill crew member

• Follow individual company policy for onset of illness or incapacitation during flight operations
• Discontinue work as soon as possible without impacting flight safety, and
• Return to work after fever has resolved for at least 24 hours without the use of fever-reducing medications.

Quarantine officials will work with the airline and airport partners to assist with arrangements for medical transportation of the ill person, if indicated, and will implement any necessary infection control measures and surveillance activities.

Personal Protective Measures

Hand Hygiene

Routine hand hygiene is an important line of defense against the influenza virus, as well as other viruses and bacteria. Wash hands with soap and water for 15-20 seconds. If soap and water are not available, use an alcohol-based hand rub. Hands should always be washed before donning and after removing gloves and other personal protective items.

Gloves

Crew members should wear impermeable, disposable gloves if they are physically tending to the ill passenger or have contact with potentially contaminated surfaces or lavatories. Crew members should avoid touching their faces with gloved or unwashed hands. Hands should be washed with soap and water or with a hand rub after removing gloves. Improper use or disposal of gloves may actually increase transmission.

Face Masks and Respirators

Routine use of face masks and N95 respirators is not recommended for airline crew members (see CDC’s Interim Recommendations for Face Mask and Respirator Use to Reduce 2009 Influenza A (H1N1) Virus Transmission at http://www.cdc.gov/h1n1flu/masks.htm). Crew members should consult company policies for the voluntary use of a face mask or N95 respirator.

Employers that allow workers to voluntarily use an N95 respirator should review the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard (29 CFR 1910.134). Information for the voluntary use of respirators in the workplace may be found in Appendix D, Information for Employees Using Respirators When Not Required Under the Standard, available at:
http://www.osha.gov/SLTC/etools/respiratory/voluntaryuses.html

Post-Flight Management of Crew Exposure

Flight deck and cabin crew members and ground personnel who may have been exposed to a passenger or worker with ILI should monitor their health for 7 days after the exposure. Any of the following signs or symptoms should be reported per employer guidance: fever, cough, sore throat, runny or stuffy nose, body aches, tiredness, nausea, vomiting, or diarrhea. CDC recommends that flight deck and cabin crew members who develop ILI should remain isolated at home or in a hotel and should not travel until at least 24 hours after they are free of fever (a temperature of 100° F [37.8° C] or greater) without the use of fever-reducing medications. Flight deck and cabin crew members who develop symptoms while outside the United States should follow their airline’s policy to obtain medical care overseas, if required.
Personnel at increased risk for severe complications of influenza, such as persons who are pregnant or have chronic health conditions like asthma or heart disease, should consult their primary-care or occupational health providers. Guidance for people at high risk of developing flu-related complications may be found at http://www.cdc.gov/h1n1flu/highrisk.htm.

http://www.cdc.gov/h1n1flu/guidance/air-crew-dom-intl.htm

http://www.forbes.com/feeds/hscout/2009/06/29/hscout628514.html