H1N1 - vaccine, lessons learned

Reuters has posted an article saying there are 71 million doses of H1N1 vaccine left in the U.S. That's right, readers, million. Holy cow! (Or should I say chicken... get it?)

And here is a USA Today editorial on 5 lessons to be learned from the pandemic. Some points are well-taken; for example, the feds can't do it all. State and local health departments and other responders are vital to the fabric of our public health infrastructure and are critical to maintain in order to bolster preparedness.

Here are lessons learned from Jeffrey Levi, of Trust for America's Health, as posted on The Huffington Post. He, again, mentions public health department resources and the need to increase resources to be able to adequately respond to a situation such as the H1N1 pandemic.

Overall, the county is significantly more prepared to respond to a pandemic now than we were a few short years ago, but there are still major gaps in our core public health capabilities that must be addressed if we're going to be able to protect the American public from future threats.

Here are lessons learned from CIDRAP, the University of Minnesota's Center for Infectious Disease Research and Policy. This article also highlights infrastructure and capacity but touches on risk factors for pregnant women and obese populations as well.

And here is a previously-posted Op-Ed by Richard Wenzel in the NY Times about what has been learned from the H1N1 pandemic.

Happy reading, and feel free to post your own lessons learned!

What We Learned From H1N1's First Year

This article by Richard Wenzel of the Virginia Commonwealth University discusses what we learned in the past year about H1N1. It brings up some interesting points, like the discrepancy in recommendations about masks, reducing risk of transmission, and community mitigation strategies.

It is not an easy task, but our public health authorities need to become clearer about the lexicon of uncertainty.

And Wenzel ends the article with a reality and a call to action:

But the struggle between people and pathogens is a part of life itself. We cannot continue to be surprised every time a new virus emerges. Instead, we must use the lessons we’ve learned during the year since H1N1 arrived to develop more effective public health responses.

National Public Health Week!

It's been awhile since I did a posting of interesting links. Enjoy!

1. National Public Health Week is this week! Go public health!
   
   
   
2. Norovirus: Tara Parker-Pope has an article in the NYT about noro and how difficult it is to get rid of it. Take a look, and see CDC's page about noro for more information.
3. Superbugs: This has been awhile, but it's an interesting Nick Kristof piece about antibiotics and the rise of superbugs and the implications of those superbugs.
4. HIV prevalence in DC: Some promising news about the HIV epidemic in Washington, D.C. is explained in this article.
5. Travel's impact on pandemics: An interesting Canadian study will analyze the impact of travel and travel restrictions on the H1N1 pandemic.

How the CDC counts H1N1 cases

Thought you (you one person reading this, you) might be interested in this Wall Street Journal blog post about how CDC counts H1N1 cases.

The accompanying print article discusses how H1N1 information is based on flawed data. Carl Bialik writes that CDC relies on "the nation's patchy surveillance system" for its data - Well, Carl, if the U.S. were to fully fund states to perform adequate surveillance, maybe we'd be able to provide better data for you! (Are you listening, Congress?)

Lonely office links

It's 2 days before Christmas. All the CSTE-ers are off celebrating, leaving the lonely Jewish girl here. To work? Nah, to blog! So here are some links for you to peruse while you're getting away from your visiting families:

1. A New York dog is confirmed to have H1N1. The American Veterinary Medicine Association (and surely the National Association for State Public Health Veterinarians as well) wants to ensure the public that while the virus can be passed from human to animal, there is no evidence the virus can be passed from animal to human. No need to stop petting Fido.
2. Associated Content's health news section has come out with the Top 10 health stories of the decade. H1N1 is #1, while health care reform comes in at #9. Hm. Other stories that made the cut include food safety, screening tests, and the HPV vaccine (all stories I've blogged about here!).
3. The Washington Post reports that fewer people are getting tested for H1N1, which "proves" that the second peak has subsided. Has it? Could this just mean that fewer people are being tested because physicians are assuming flu-like symptoms to be H1N1? Fewer tested could just mean that.... fewer are tested, not that the incidence of H1N1 is declining.
4. This op-ed piece discusses One Health, the initiative/idea that animal and human health intersect in increasingly important ways. It is, indeed, a concept that is gaining ground, and so I encourage you to take a look.
5. This editorial in the NY Times discusses the end to abstinence-only funding for sex education programs. It includes an important quote:
   

   Ideology, censorship and bad science have no place in public health policy.

   
   

A couple links for the day

1. This article discusses a newly-developed pandemic planning tool that will help health officials "quickly analyze pandemics and craft better response strategies." The author also says, "these results could be valuable in developing an aggressive preventive strategy and deciding how best to use limited resources."
2. Second, the health world today is discussing a new study that shows the overuse of CT scans can lead to cancer deaths, says this article. "Widespread overuse of CT scans and variations in radiation doses caused by different machines... are subjecting patients to high radiation doses that will ultimately lead to tens of thousands of new cancer cases and deaths," says the study. The article emphasizes that the risk for any one individual is relatively small, but the overall risk for the population is much larger.
3. Finally, in breaking news from the NYT, a million doses of infant H1N1 vaccine have been recalled, apparently because they are slightly less potent than recommended. Unfortunately, this slip-up will probably mean even more negative publicity for the vaccine and for public health. Oh, boy.
   

Some recent links

1. This interesting article discuses evidence-based medicine and the recent mammogram recommendations (I know, they're still talking about it.) Take a look and see what you think.
2. As I've discussed before, climate change is expected to have a major impact on health and public health. This article is about its impact on mental health specifically. The point that makes the most sense is that climate change is expected to bring more natural disasters, bringing more life upheaval and therefore more stress and mental health issues.
3. Cancer death rates are declining, according to this article. Researchers who found this statistic examined colorectal cancer as an example, and found that the decline was mostly due to better screening. Here is the study from which the article draws, which is worth a read - interesting.
4. The CDC has reported that the death toll from H1N1 is at 10,000, but also suggests that the number of new cases could be trickling off. It says one in five Americans have had H1N1. Mike Osterholm says, in my opinion accurately, that this pandemic is not over:
   

   “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.”

5. This article describes the dismal state of public health and its critical understaffed numbers. It's a great article.
   

   "If swine flu is a test of public health, we've already flunked. And we have only ourselves -- and the political leaders who have been disinvesting in public health since 1980 -- to blame."

6. Finally, a new report from the Institute of Medicine about the National Vaccine Plan seeks to elevate vaccines to a higher public health priority, increase funding, and other recommendations. This article explains the highlights of the report. The updated plan is expected to take effect in 2010. However, the development of this plan does not ensure its implementation:
   

   "Siegel has doubts that the proposed policy can be implemented and enforced. 'There are extremely difficult obstacles -- fear, noncompliance, media hype and poor government choices,' he said."

   
   

Some links for you

1. Massachusetts public health officials explain the dissemination of their H1N1 vaccine allotment. Patience, all you patients out there!
2. The WHO has discovered new data that show that 1.2 million people over the age of 5 die of foodborne illness each year in Southeast Asia and Africa. That number is significantly higher than previously estimated, providing new reason to address this issue in the developing world.
3. In case you're one who needs everything, check out these iPhone apps about H1N1.
4. There is a new tool to show where AIDS treatment and care in San Francisco is lacking. Click here for the map itself.
5. Obesity is an alarming public health issue, and this latest article has alarming numbers. If trends stay as they are now, 43% of adults will be obese in 2018. Wow.
6. This article highlights that many public health professionals around the country are being reassigned from their normal job duties to work on H1N1 assignments. This is disrupting usual public health activities that address ongoing problems that are not going away simply because this pesky flu virus has shown up. It's a problem, but it doesn't appear it will be solved.
7. Representative David Camp says in this article about the breast cancer screening recommendations: "I mean, let the rationing begin. This is what happens when bureaucrats make your health care decisions." Right, the U.S. Preventive Services Task Force is bureaucrats. They're not experienced physicians and trained professionals. Sure.
8. Lots of money is being poured into fighting healthcare-associated infections. This article details the stimulus funding being given to the issue.
   

Weekend links

1. There have been several teen suicides in California, prompting public outcry against suicide, which is the 3rd leading cause of death among teens, according to CDC. Actions are being taken to curb suicide in California, including counseling, suicide hotlines, and other measures. "These poor kids died from an untreated psychiatric illness, or undertreated. It's not as if it's a mysterious thing and it's not as if it's not preventable," says Madeline Gould, a psychiatrist. Once again, and I reference another suicide posting I've done, suicide is preventable, and it's important to treat mental illness and reach out to people.
   
   
2. Not surprisingly, H1N1 is hindering health departments' ability to conduct other activities. Dr. David Fleming, health officer in Seattle, says, "we're being held hostage by a national shortage of the vaccine."
   
   
3. The Infectious Diseases Society of America conference brought a lot of discussion of various infectious diseases this weekend. Antibiotic resistance is still a concern, according to this article in the Atlanta Journal-Constitution. There is also a virulent strain of MRSA going around, posing another infection-related problem in hospitals.
   
   
4. At the IDSA conference, Dr. Paul Offit, a frequent vaccine spokesperson, spoke out for the H1N1 vaccine. Another article about the speech can be found here.
   

   "... Now the seasonal flu vaccine and H1N1 flu vaccine are being skipped by millions of people who somehow distrust the science that went into making them, even though the illnesses they cause can be fatal.

   But hey, it’s a free country. Paul Offit just throws up his hands: “Is it your right to catch and transmit a potentially fatal infection? The answer is ‘yes,’” he says."

   The article continues:
   

   "So despite vaccines’ overwhelming safety profile when compared to the risks run by exposure to the diseases they prevent, and despite the exhortations of the CDC and World Health Organization, some people just gravitate toward other sources of information they deem more reliable."

5. In food safety news, the Produce Safety Project put out results of a survey showing that there are significant gaps in foodborne illness response. The survey asked about types of questionnaires administered, the time frame in which they were completed, types of questions asked, and how the data collected were used. They found that state health departments don't ask about fresh produce initially, use a mixed questionnaire with open- and closed-ended questions, and are more likely to interview an individual linked with an outbreak. This survey did not assess staffing or funding levels, which will be discussed in a forthcoming assessment by CSTE about foodborne illness epidemiology capacity. They did report, however, that "the decisions of the responding states appear to be driven by available resources." Very true.
   

Can Saudi Arabia prevent an H1N1 outbreak at the hajj?

A very interesting story in yesterday's New York Times. (I know, another NYT article, but that's my newspaper of choice and I'm sticking to it.)

"Saudis Try to Head Off Swine Flu Fears Before Hajj"

So: will they be able to? They are recommending that those who are young, pregnant or elderly, and even those with certain chronic conditions, stay home this year. The hajj is a central ritual of Islam, and I am very skeptical that Saudi Arabia will be able to convince countries to not let or strongly discourage people from participating in this important tenet. In 2008, 3 million participated in this annual pilgrimage, this year taking place November 25-29.

Saudi Arabia, the host country of the hajj, has contacted public health experts from America medical schools and the U.S. Navy's medical laboratory in Cairo for help with any assistance they may need. (And they will need assistance!) In 2008, a flu outbreak occurred at the Catholic World Youth Day in Sydney, at which a Tamiflu-resistant strain emerged.

Officials recognize that it will be impossible to keep H1N1 away from the event and even to slow its spread. So they are encouraging those most vulnerable to stay home. Will this work, though? It is such an important part of Islam - the fifth of the five pillars of Islam. Will those who are coming be able to access the H1N1 vaccine? That is doubtful too, although China says it will vaccinate all of its pilgrims attending the hajj.

It will be very interesting to monitor this story in the next few weeks and see what happens - we'll keep you updated at the Epi Cafe!

Mr. T - and more!

Who can resist all of the H1N1 public service announcements going around? First was the video featuring Elmo, then the Atlanta Falcons, and now... you guessed it... Mr. T. He was quoted as saying “I’m the baddest in the world, and the flu gonna be all washed up when I’m through with it,” Mr. T said. “No, I don’t hate the virus. I pity the flu.” Perhaps not hard-hitting news, but still newsworthy, I'd argue!
(And by the way, this is from The Rebel Yell. Not a real news story!)


CDC has published new guidelines about infection control for H1N1 in hospitals. Because of the shortage of recommended N95 respirators, other measures must be taken to reduce risk of infection. Click here to view the guidance and here to read the RWJF Public Health Digest article about this issue.

This article also discusses infection control, in a larger sense. It mentions 10 ways hospitals can reduce infections, from hand washing to reporting laws to computer surveillance.

By now, of course, you've heard about Obama declaring H1N1 a national emergency. If not, read it here! This doesn't have anything to do with prevalence or severity. Rather, it opens up resources and allows hospitals and health departments to do more to cope with the pandemic.

This article has nothing to do with anything, but I didn't know the field of psychiatric epidemiology existed. So that was interesting to learn.

According to a recently published study, Holocaust survivors are more likely to get cancer later in life, perhaps due to the extraordinary physical and mental stress they underwent in the 1930s and 40s. This AJC article explains more.

Finally, CBS News reported that H1N1 is not as prevalent as thought, according to a 'study' they conducted. Effect Measure, a great epidemiology/public health blog (besides this one of course), examined this article and took issue with it.

2 H1N1 Links

First, the Obama girls have gotten their H1N1 vaccinations. Good for you, girls, and good for you, parents, for setting the example that the vaccine is acceptable. And, in case you were wondering, the vaccine is readily available in the DC area, and the White House doctor applied to receive 2 doses of vaccine just like every other site would apply.

Second, an article sure to spark controversy. This article asks the question, "Who should get a chance to survive when the number of severely ill people far exceeds the resources needed to treat them all?" It is an interesting issue, one that will surely bring debate to your dinner table.

The coolest video

This video is so neat! It explains how a virus, specifically influenza, invades one's body. This is from NPR. Click here for the web link.

H1N1 self-assessment tool

There is a new self-assessment tools for H1N1 that seem quite interesting.

Emory University and Microsoft have come out with one self-evaluation tool. This tool assesses whether the user has H1N1 or another virus. The user is asked, at the end of the assessment, if he or she would like to submit the data to Emory for research purposes. It will be interesting to follow-up and see how the data are used. Here is the privacy statement that talks about how the data are used if submitted. Once symptom and basic demographic info is entered, the assessment is given.

When I entered my fake data, the tool told me "you probably don't have the flu, but you may be sick from something else" and told me to go to my physician if I am worried about my health. It then gave me resources to find more information.

Flu.gov also houses this self-evaluation tool.

Today's links

First, the EPA set out new standards that airlines have to test and disinfect water on planes. Ew, you mean they weren't doing this before? Read here for the article, and read here for more from the EPA.

Second, and a biggie. The first doses of H1N1 vaccine are just now becoming available, and there is much excitement over it. According to this article, several states were offering the nasal spray to children, with shots beginning next week. Public health officials are battling myths and opposition to the vaccine, posing public relations troubles for CDC and state health departments.

Here is an article about immunizations and opposition to them.

Finally, a tongue-in-cheek article from the Huffington Post about Big Pharma and H1N1.

Enjoy!

H1N1 vaccine: "Don't blame flu shots for all ills"

The NYTimes published a great article about the forthcoming H1N1 vaccine. The article states that when the public starts receiving the H1N1 vaccine, there will be deaths and other health issues such as heart attacks, strokes, and miscarriages. However, these illnesses are not necessarily caused by the vaccine. Basically, federal officials are in a public relations nightmare. How can they explain to the public (and in a tiny sound clip, no less) this non-causal relationship?

There are thousands of people who have, say, seizures every day. If the proportion of those who have recently received the vaccine and have a seizure is statistically significantly higher than those who have not received the vaccine, there may be a causal relationship. If, however, the rate of seizures among vaccinated and unvaccinated people is similar, a relationship is unlikely.

The article says:

"To defend itself, Dr. Butler [chief of the swine flu vaccine task force at CDC] said, the C.D.C, has compiled data on how many problems like heart attacks, strokes, miscarriages, seizures and sudden infant deaths normally occur. And it has broken those figures down for various high-priority vaccine groups, like pregnant women or children with asthma. When vaccinations begin, it plans to gather reports from vaccine providers, hospitals and doctors, looking for signs of adverse events, so it can detect problems before rumors grow."

The emphasis on this point stems from several sources. First, the 1976 vaccination program against swine flu had horrendous problems with Guillain-Barré syndrome as well as deaths that were attributed to the vaccine. Second, anti-vaccine groups are much more prominent and vocal now than they have ever been, and these groups may pose threats to the credible information being put out from sources such as CDC. Third, it's just plain confusing. It's hard to understand, especially for a public getting information from multiple and possibly conflicting sources.

So all those who are reading this (which isn't many), spread the word! There will be illnesses and health events that happen after people get the H1N1 vaccine. But most of these events are likely to have occurred anyway. CDC will be closely monitoring health events to determine whether they are caused by the vaccine or not, rest assured.

Here's another article in the Washington Post about the same issue.

Links

I know, you're saying "More links? Write a real article!" Well, there are just so many interesting links, I can't help myself.

• The Wall Street Journal reports that H1N1 (we are not calling it swine flu anymore, people!) may affect businesses and the workplace with people out sick. CSTE is heavily involved in putting together a Continuity of Operations plan so that we can carry on our work tasks while at home if needed. Talk to your employer about it!
  
• The 2009 Flu Vaccination Challenge - the beginning of flu season means the beginning of the flu challenge, a campaign to raise vaccination rates among health care workers. The podcast linked to on this page features Dr. William Schaffner, a great speaker!
• There is a new vaccine being developed for norovirus, very interesting. This vaccine stems from the tobacco plant; plant-based vaccines can be developed more quickly and therefore get to the public more quickly.
• A new study in Science (as reported here in the Atlanta Journal-Constitution) indicates that students and parents should get the H1N1 vaccine first, so that those most likely to get the virus are protected. The current guidance is for those who are most likely to be hit hard by the virus to be vaccinated first. An interesting debate.
• This article reports on a new finding that individuals enrolled in the food stamp program are more likely to gain weight. One of the recommendations of the study is that there be economic incentives for food stamp recipients to buy healthier foods.

H1N1 Vaccine News

CDC has released the latest H1N1 vaccine news and the priority populations for receiving the vaccine. The Advisory Committee on Immunization Practices (ACIP) met yesterday and determined recommendations. Priority populations include:

• pregnant women,
• infant caregivers,
  
• health care and emergency workers,
  
• those 6 months - 4 years old, and
  
• those 5 - 18 years old who have a complicating health condition such as a compromised immune system or chronic health disorder.

Before the vaccine is widely released, it will go through a series of clinical trials to test for safety. Officials are hoping the vaccine, made by 5 companies, will be available in October. It is important to note that there will be two influenza vaccines this fall: one for the H1N1 virus and one for the 'normal' seasonal virus. Each protects against a separate strain, and you will need to be vaccinated against both for full influenza protection.

Atlanta Journal-Constitution article
MMWR article about seasonal influenza vaccine

WHO General-Director increases influenza pandemic alert to Phase 5

So what does that mean exactly? The phases are mapped out by the World Health Organization and sketch out the face of a possible influenza pandemic. Currently, we're still at pandemic-alert.

Interpandemic period

Phase 1 : No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low.

Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.
Pandemic alert period

Phase 3: Human infection(s) with a new subtype but no human-to-human spread, or at most rare instances of spread to a close contact.

Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.

Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

Pandemic period

Phase 6: Pandemic: increased and sustained transmission in general population.
Notes: The distinction between phases 1 and 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, and other scientific parameters.


If you have a lot of time on your hands, or are interested -- check out the WHO global Influenza preparedness plan here. It might be interesting to see how well the US and the world as a whole is following the plans set prior to the reality of an actual pandemic. There are so many different variables that could never be accounted for when a group of people are writing a plan. And as we all know -- rarely do things happen according to a plan. Unfortunately when this whole pandemic is over, the US and the world's actions will be scrutinized and judged. It's important to keep in mind that the folks at the ground level are working as hard as ever to keep the public safe.