November 2009

Swine-flu furor

As people scramble for vaccines, others wonder if fears are overblown

By Gail Binkly

Related story

Alternative views on combating flu

Lori Cooper, head of the Montezuma County Health Department, likes to say that her job has become “all swine, all the time” in recent months.

Interest in and fears about the H1N1 swine-flu virus are escalating both locally and around the country — even as health officials say that, for most people, H1N1 is no greater a threat than the seasonal flu that sweeps the population each year.

“It’s still generally a mild disease and people recover at home,” Cooper said, “but sometimes it goes deep in the lungs. They’re not sure why it hits some people so hard and not others.”

BOBBI LOCK, A NURSE WITH THE MONTEZUMA COUNTY HEALTH DEPARTMENT, GIVES A NASAL-SPRAY VACCINATION AGAINST H1N1 FLU.Nationwide, more than 1,000 deaths have been attributed to H1N1; nearly 100 of those were children. In October, two Montezuma County men died as a result of H1N1, becoming the first swine-flu deaths in Southwest Colorado.

The numbers seem alarming, but by comparison, about 36,000 people die every year across the United States from the seasonal flu and its complications.

“It has to be put into perspective,” said Lyn Patrick, a doctor of naturopathy in Durango. “What’s different about the swine flu is that there are different high-risk populations.”

And that’s the key. While the seasonal flu normally preys on the very young and the very elderly, the swine flu has struck hard at some unusual populations.

According to the Colorado Department of Public Health and Environment, through Oct. 24 there had been 25 deaths from H1N1 in the state. The majority of those, eight, were in the age group from 25 to 49. Seven victims were under 18, and just four were over 65.

The two men who died in Montezuma County were 51 and 29.

In addition, pregnant women seem to be especially vulnerable to the swine flu. Public health officials reported that, nationwide, 100 pregnant women had to be hospitalized in intensive- care units during the first four months of the H1N1 outbreak, and of those, 28 died from the virus.

“People under 24 years of age seem to be reacting the most,” Cooper said. “For the over-65 age group the threat is much less. Actually, percentage- wise, infants under 6 months are at the highest risk, and pregnant women.”

Researchers theorize that flu can be more dangerous for pregnant women because the pregnancy puts pressure on their lungs, making them more vulnerable to respiratory illnesses. This is true for the seasonal flu as well as H1N1.

“There also seem to be some connection with obesity,” Cooper said, probably for the same reason — reduced lung space.

The highest-risk groups for H1N1 are considered to be children under 5, pregnant women and people from 5 to 25 with an underlying conditions such as cancer, blood disorders (including sickle cell disease), chronic lung disease such as asthma or COPD, diabetes, heart disease, kidney or liver disorders, neurological disorders, neuromuscular disorders (including muscular dystrophy and multiple sclerosis), and weakened immune systems (including people with AIDS).

It’s impossible to say how many people are contracting H1N1 because most will not need to see a doctor. However, public health reports indicate that flu activity has been unusually high so far this season, and officials say flu that occurred before November was most likely H1N1.

Sue Ciccia, director of health services for School District Re-1 in Montezuma County, said in early October the district had many children with flu, but that the number has been decreasing. “We have no way of knowing whether it’s H1N1 or seasonal flu,” she said.

Because there aren’t enough doses of swine-flu vaccine to go around yet, Ciccia said the district is emphasizing the need for good hygiene and prevention. She thinks the message is getting out.

The district’s nurses started back at the end of August with a “cover your coughs, wash your hands” campaign, providing school principals with information to give to parents and teachers. “I think being a bit proactive helped.”

The district has actually been promoting good hygiene for the past three years, after the district developed a pandemic-flu plan. “We’ve been teaching them about washing their hands, counting to 20 or singing Happy Birthday twice,” Ciccia said. “I hear from parents that the kids come home and they remind their parents if they haven’t counted to 20 while washing their hands.”

Ciccia said it’s important for parents to keep recovering children home from school until they have been fever-free for at least 24 hours, to avoid spreading the illness to other kids. “The children will cough for a while after the flu, and they should cough into the crook of their arms so they don’t share it with everyone else.”

Ciccia said school officials have talked about when and if school closings might be necessary. “If there weren’t enough teachers to teach and monitor the students safely, that’s when we’d probably do it,” she said. “We do talk about it. Absenteeism, homework, activities would all have to be considered. We’re not there yet, but we have had that conversation.”

The worst flu

“The sickness preyed on the young and healthy. One day you are fine, strong, invulnerable. . . You might notice a dull headache. Your eyes might start to burn. You start to shiver and you will take to your bed, curling up in a ball. . . It may take a few days, it may take a few hours, but there is nothing that can stop the disease’s progress. . . You die — by drowning, actually — as your lungs fill with a reddish fluid. . . .

“Children were orphaned, families destroyed. Some who lived through it said it was so horrible that they would not even talk about it. . . It went away as mysteriously as it appeared. And when it was over, humanity had been struck by a disease that killed more people in a few months’ time than any other illness in the history of the world.” — Gina Kolata, “Flu: The Story of the Great Influenza Pandemic

Since the influenza outbreak of 1918- 19, nothing like it has been seen again – and public health officials would like to keep it that way.

That flu pandemic killed half a million Americans and an estimated 20 million to 100 million people worldwide.

One in every four people fell ill, many of them young and healthy. The virus is believed to have killed by a cytokine reaction that ignited the immune system against itself, so that those with the strongest immune systems became the sickest. More people died than were killed by the Black Death in the Middle Ages, or in the world war that was ending then.

But after that winter, that particular pandemic went away, never to return.

People have wondered ever since: Could such an apocalyptic plague occur again? Or do modern medical techniques and knowledge about prevention make a recurrence unlikely?

Guy Walton, infection-control specialist and employee-health nurse at Mercy Regional Medical Center in Durango, said many things are different today from the conditions in 1918, but that doesn’t mean another deadly pandemic can’t happen.

“A lot of things have changed that make it more scary and less scary,” Walton said. “The fact that traveling around the world takes much less time than it did 93 years ago is a huge difference. It means that the spread of disease can be much more universal, more likely.

“On the other hand, a lot of people who have serious problems with influenza actually develop and die of secondary infections like pneumonia, and in 1918 they didn’t have the antibiotics to treat those.”

The flu of 1918 was a strain that was both easily contagious and highly deadly. There were many reports of young, healthy people dying within hours of falling ill.

So far, no other flu strain has emerged that has had both characteristics, Walton said. The H5N1 avian (bird) flu that developed in the Orient in recent years is a much deadlier disease than the typical seasonal flu, killing up to two-thirds of its victims, but is not very contagious. H1N1 is very contagious but does not have nearly such a high mortality rate, except for people in the high-risk categories.

“The 1918 flu was deadly, and many people were susceptible to it,” he said.

Still, H1N1 has some things in common with the 1918 flu — in particular, the fact that it can be deadlier in the young than in the elderly, who mostly seem to carry some immunity to H1N1, evidently having been exposed to a similar virus in the past.

Walton said it’s important to take the flu seriously and not to assume that it can be “cured” if someone does get seriously ill.

“A lot of people just assume Tamiflu [an antiviral medication] is a good treatment for the flu,” he said. Tamiflu can help ward off the flu in some situations, but it is not a cure in the way that antibiotics are for bacterial infections, he said.

“And we’re worried about overusing antivirals,” Walton added. If it’s prescribed too often, the viruses will develop Tamiflu resistance.

Public health officials don’t want to take chances. They urge people, particularly those in high-risk groups, to be vaccinated annually against the seasonal flu and against the new strains, such as this year’s H1N1, that may emerge.

Walton said the H1N1 vaccine is very effective. “One thing that’s really good about the H1N1 vaccine that’s different from the seasonal flu vaccines we’ve done before is they developed it so soon,” before the virus could mutate, he said. H1N1 emerged as a threat last spring, and researchers were able to isolate the virus and develop a vaccine for it quickly. In contrast, seasonal flu vaccines have to be developed long before the flu emerges in the winter, and researchers essentially are guessing as to which strains will be circulating. Flu viruses like to mutate into new forms, so that developing a vaccine against them is like shooting at a moving target.

“The H1N1 vaccine is a very good match” for the virus, Walton said. “With H1N1 they knew specifically what they were looking at. So it’s not likely we’ll have something much more effective until there’s another leap in science.”

Walton said he does think there may be excessive concern about H1N1 vs. the seasonal flu. “I think people are very excited about it,” he said, “because they’re very worried. I think some of their worries aren’t realistic, and some of them are.”

Part of the concern is the fact that so much of the population carries no immunity against the virus and will thus get sick, even though most cases will not be life-threatening. The other thing that scares people is “the fact that the people who are getting seriously ill don’t fit into the regular flu patterns,” he said.

The vaccination debate

As flu cases soar, demand for swine-flu vaccine has been high across the country, even as production of the vaccine has lagged.

According to CNN, some 100 million doses were supposed to have been ready by the end of October, but instead the manufacturer had only released about 40 million, with 10 million more expected per week after that.

But even as more people seek to be vaccinated against both swine flu and seasonal flu, there is a vocal minority that balks at flu vaccines and even vaccinations in general, believing them to riskier than the diseases they are intended to prevent. Some theorize that the push toward vaccination is a government or pharmaceutical-company conspiracy.

“If you have some idiot government official demanding, telling me I must take this vaccine, I’ll never take it,” talk-show host Rush Limbaugh has vowed, and on the other side of the political spectrum, liberal commentator Bill Maher has also said he fears the vaccine.

This leaves many citizens in the middle, wondering whether it’s worthwhile to get the shot. Is the vaccine dangerous? Is the virus a real threat? Or is the whole matter overblown?

Public health officials say the vaccines are safe and effective and that the benefits outweigh the risks, particularly in high-risk populations.

“Normally I would like to see five years of safety data on anything, especially something I’m going to give to my kids,” said CNN’s chief medical correspon dent, Dr. Sanjay Gupta, on one program late in October. However, he said, there has been a much higher rate of pediatric deaths from H1N1 than is normally seen at this time of year from the seasonal flu, and a third of those deaths were in children with no underlying medical conditions, so he had his children vaccinated.

Some people are concerned about flu shots in particular and vaccinations as a whole. However, public health officials say those fears are groundless.

Concern has been expressed that flu vaccines carry dangerous amounts of mercury, aluminum and formaldehyde. Health officials say that’s untrue. They say the mercury present in the vaccines (as part of the preservative thimerosal), is a tiny amount, used to kill the vaccine and keep it free from contamination. The mercury is not methylmercury, the form that is present in some fish and is easily absorbed by the body, but is another form that is simply excreted.

There is no aluminum in the U.S. flu vaccines, according to the Denver Post, and any formaldehyde used in vaccines is not the type of smelly chemical used to preserve animal cadavers, but is a type of formaldehyde that naturally occurs in the body.

Still, there is growing doubt about the effectiveness of seasonal flu vaccines in the elderly, the high-risk group that is usually urged to get them. An article in the November 2009 Atlantic magazine maintains there is no scientific evidence to show that seasonal flu shots reduce deaths in the elderly, but concluded, “There is little immediate danger from getting a seasonal flu shot, aside from a sore arm and mild flu-like symptoms. The safety of the swine flu vaccine remains to be seen. In the absence of better evidence, vaccines and antivirals must be viewed as only partial and uncertain defenses against the flu.”

[For another look at doubters’ concerns, see “Alternative views"]

Still, local officials generally agree that the flu shots are effective and worthwhile — and they’re all that’s available to stave off the flu, other than the standard measures of good hygiene and avoiding sick people.

Vaccination against pneumonia may also be a good idea, especially for the elderly. “We do recommend the pneumonia vaccine,” said Cooper. “You can get that at all ages.” The shot protects against a number of different strains of bacterial pneumonia — the type that might develop following the flu — and is good for several years.

Jane Looney, a spokesperson for the San Juan Basin Health Department in Durango, said that every year when seasonal flu clinics are conducted, health workers promote the pneumonia vaccine. “For the seasonal flu clinics, the majority of folks are seniors over 65, and we make sure they’re upto- date on the pneumonia vaccine,” she said. “Now it’s also recommended for people under 65.”

Concerns about H1N1 may be exaggerated, at least for the majority of people, but officials say the publicity has also raised awareness of the dangers of the annual flu.

And for those debating whether to be vaccinated, many will ultimately decide based not so much on whether they are at risk of death from influenza, but on whether they are willing to risk a week of fever dreams, bonedeep chills, a fiercely sore throat, and a hacking cough.

“I always get the seasonal flu shot,” said Re-1’s Ciccia. “I’ve had the flu enough times that I just don’t want to do that any more.”