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Early Flu Season Highlights Planning Shortfalls

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Early Flu Season Highlights Planning Shortfalls

Despite years of planning, we really weren't ready for pandemic flu

Judging by my email inbox, swine flu (aka H1N1(A) or A/California/H1N1) has people fairly confused. I get notices that swine flu is just media hype, designed to encourage profits for drug companies. Then the same people send emails warning that you can’t get the swine flu vaccine because the government wants to kill you off. First the Obama girls aren’t getting the vaccine (so you shouldn’t, either), then they got it and that’s not fair, because there’s others who can’t.

Seems like Public Health just can’t win for losing, and that’s not just on the Internet.

Despite 90-plus years of preparing for the next big influenza pandemic, our current national bout of swine flu demonstrates that we’re not as prepared as we thought we were.

On the plus side, Public Health and the government can point to several things they did right. They recognized the threat in this new form of H1N1 flu; they promptly ordered vaccinations to be prepared; they issued anti-viral medications and masks to health districts nation-wide; they established websites and hotlines to provide accurate information; they encouraged hospitals, schools and other entities to develop preparedness plans.

But as swine flu makes its premiere early throughout the U.S., it is, unsurprisingly, the shortfalls in pandemic preparedness that stand out.

Vaccine shortages

Vaccine shortage is only the first. Delays in the time it takes to create and package the vaccine have left many areas coping with limited vaccine distribution at a time when flu is already widespread. And while it’s hard to see how things could have been done differently, the harsh truth is there just won’t be enough vaccine to protect everyone. The U.S. ordered 195 million doses for its population of 304 million; elsewhere, it’s estimated there will only be enough vaccine to protect approximately half of the world population. The latest numbers suggest the U.S. may only get 150 million doses before this flu season comes to an end. Yet there are approximately 159 million people just in the “high risk” groups identified by the CDC as priority recipients for a vaccine. Nonetheless, Health and Human Services Secretary Kathleen Sebelius continues to assure that, eventually, there will be enough vaccine for everyone.

The culprit in this is a vaccine program that relies on growing virus in eggs for production—a time consuming process. But because there is little profit in flu vaccines (despite the hype that swine flu is a “plot” to make money for pharmaceutical companies), there has also been little interest in developing a new, and faster, method of growing the virus needed.

An added glitch to the system was that much of the first vaccine available was the FluMist form, a nasal spray that uses live, attenuated virus and is not recommended for use in people with a hypersensitivity to egg proteins, those with a history of Guillain-barre syndrome after vaccination, anyone with asthma or under the age of 24 months, people with a compromised immune system, or anyone who might be considered high risk for complications from influenza infection. In addition, federal science officials in the U.S. say pregnant women should stay away from the nasal spray, though experts at the World Health Organization say it’s safe for pregnant women to use.

In practice, many who thought they would be vaccinated in the first run found out they would not be, either due to the contraindications or due to concerns with the nasal form of vaccination. That left, for example, almost 2,000 vaccine doses in Spokane begging for a nose to infiltrate on the first day of vaccination.

That same problem also plagued area elementary schools, causing additional delays in vaccination for those needing or wanting the shot.

Medical response

With the vaccine lagging behind the outbreak, the pressure on medical centers to respond to ill patients is also highlighting some strains in the system. Just in this area, intensive care units in all area hospitals have at times been almost full: Kootenai Medical Center, Sacred Heart, Deaconess and Holy Family have had critical care units operating at peak capacity. These are the hospitals where critically ill patients are sent from our area, as they have more specialty resources available to desperately ill patients.

Luckily, hospitals have been planning for months on how to handle a surge in pandemic flu cases; other medical offices seem to be less prepared for what to do when flu is moving through a community.

A large pediatric practice in Coeur d’Alene, for example, has made no preparations to protect infants under the age of six months or, indeed, any other children coming to the office for “well-baby” checkups from a waiting room full of potentially flu-infected children. This situation can be seen at medical offices throughout the region.

And while many hospitals across the nation are limiting visits from children, among whom the virus is spreading rapidly, not all do, though truthfully, there’s been little to show that a ban on visitors will even work.

In these cases, it’s up to the individual to be informed and proactive regarding their own health. If you’re scheduled for a non-emergency visit to the doctor, especially if you are pregnant, have an infant, are in a high-risk group or your immune system is otherwise compromised (for example, chemotherapy patients), and that doctor does not have well-patient waiting rooms, tell the office you’ll wait in your car until the doctor can see you.

If you’re in a hospital and meet any of those risk criteria, don’t hesitate to inform medical personnel if you believe you’re being exposed to someone who’s ill.

H1N1 testing

Testing is also an area where the resources of Public Health are lagging behind the need. Studies of two “rapid tests” for swine flu showed that one could only detect about 10 percent of actual swine flu infections, while the other could detect only 40 percent. This is part of the reason why, back in July, WHO and the CDC quit requiring testing for suspected cases of swine flu and instead recommended a diagnosis based on symptoms. The best test for determining the presence for swine flu at this time is real-time reverse transcription polymerase chain reaction (rtRT-PCR); it is not, however, a “rapid” test that can be performed in your local doctor’s office.

This identification shortfall will further complicate responses to an epidemic now that seasonal flu is also making an appearance. There is no way to tell by symptoms which flu a person might be infected with; and with the risks inherent to swine flu, smart policy will require that all flu cases be treated as if swine flu were the diagnosis. This will undoubtedly create concern in those infected but more importantly, may drive their response when vaccinations become more widely available; many may believe they don’t need a vaccination because they were already sick, a decision that potentially could cause some to become infected who might otherwise have een protected.

Staying home

As might be expected, economic concerns can get in the way of individual health. Current recommendations say that those who contract swine flu can return to work 24 hours after fever subsides naturally. The science, however, is showing that people can be infectious for a much longer period of time—potentially, for as long as they have symptoms. Isolating yourself for that long a period, however, can have serious repercussions on both the national economy and your family’s personal finances.

Yet even staying home until 24 hours after fever breaks naturally can be difficult for those living in a stressed economy where every penny counts. Some businesses are being pro-active about this: Bonner General Hospital, for example, is not only encouraging workers to stay home if they’re ill, they’re modifying their policies regarding sick days to make it possible for those workers to do just that. Many businesses, however, can’t afford to provide paid sick days at all, much less afford to increase those to accommodate swine flu. And many employees simply cannot afford to miss work.

This situation is even more complicated for parents of school-age children, who must not only come up with a plan to deal with their own potential illness, but for that of their children as well. The schools don’t want your child if he’s sick, and neither do the day cares. So who’s going to stay home to watch him when he’s ill?

More serious is the recommendation that those with symptoms stay home and not head immediately to their doctor or emergency room; it is not recommended that you seek medical attention unless symptoms are serious. Yet if symptoms are mild at first, growing serious later, that recommendation may have drastic consequences on your individual health, as the benefits of antiviral drugs in fighting serious symptoms are decreased if that drug regime is undertaken more than 48 hours after symptom onset. In some of the studies undertaken of those who have died from H1N1 infection, anti-viral medication was not started within 48 hours (or not taken at all) in every patient who died.

Vaccine responses

Another question to be answered by scientists in the future is the efficacy of providing FluMist® vaccines to school age children. Because they were more readily available, much of the earlier vaccination was undertaken with the nasal mist form which contains live, but attenuated, viruses. All studies to date have shown this is a safe way to vaccinate, and that the attenuated viruses have little ability to cause infection in others beyond the person vaccinated. In addition, in the 0.6 percent to 2.4 percent chance that the virus does spread, it appears to be so weak as to be crippled in its ability to make a person sick.

Yet never before have we attempted to vaccinate entire schools full of students against influenza; what risks might not appear in a small-scale study might seem more obvious in retrospect from a nationwide undertaking. Though the risk of vaccination is vastly smaller to an individual than the risk from the flu itself, Public Health might have to deal with the repercussions of a widespread vaccination program that’s little understood by the public at large.

Public response

Most of these shortfalls could have been avoided with proper funding of a Public Health system that would provide better educational outreach to the public, support for the science necessary to understand and respond to various strains of flu, funding for better methods of vaccine production and testing, and financial support to ensure that people are able to respond in a way that not only protects their own health, but the health of their community at large. Just the cost of Tamiflu alone is $60 to $80 for those who need it—a stiff price to meet for families struggling in the current economic times.

Pandemic illness is not a plus, and every person lost to death from this virus diminishes us all. But the debut this year of A/California/H1N1 can be to our benefit in the long run if it helps us to better understand the role that Public Health plays in our lives, and increases our willingness to support it when pandemic doesn’t threaten.

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Landon Otis

Tagged as:

health, public health, flu, vaccination, pandemic, H1N1, swine flu, rapid flu test

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