Looking Into a Murky Crystal Ball

The CDC has just published the status of flu in the USA, as of Sept 12, 2009. The horizontal axis is weeks (1 - 52) and the vertical is national case load (% of visits for flu reported by US surveillance network of doctors).


As you can see from the color coded chart above (Red, this season. Green, last season. Blue, the season before last) this year was no different from the last two up until about week 15-16. It followed the usual pattern until then, a little blip over Christmas and then the surge in cases over the peak months of January through March. In normal years the case load for influenza goes away after April, as you can see from the tame blue and green lines, until it raises its ugly head again over the next winter.

Not so this year. There was a little spike towards the end of April,  just about when most of us first heard of H1N1 Swine Flu for the first time. This initial small wave quickly dissipated and along with it our interest in learning more about a possible pandemic. I got emails from members irritated with me for continuing to write about a “non-event”.

Well, history teaches us that pandemics come in waves. That little spike towards the end of April was just a preamble. Look at the red line now. At a time of the year when there should be next to zero flu cases, we are already well over the levels expected during normal peak influenza season of January – March. I have little reason to expect this ominous trend will die down any time soon. We are in for a rough ride folks. This particular version of influenza may not kill as many people as the 1918 Spanish flu did (we hope), but it will surely make a lot of people quite ill. For immune compromised people like us that presents a big challenge.

How are things in your neck of the woods? The CDC updates the map of USA each week with the status. Here is how the map looked by September 12. Twenty one states are already at the highest level (“Widespread”, dark brown color), at a time when there should be none at this stage. Many communities registered a surge in flu cases as their local school systems opened for business after the summer holidays – not a coincidence. Schools are a very good way of spreading germs throughout the community, as most of us can imagine.


The good news about H1N1 swine flu

There is good news, and I want to be sure you hear it.

For starters, while this particular virus seems to be very good at spreading itself around (highly infectious), the number of people dying from it is still relatively low (low mortality) – at this stage. Of course, no one has a crystal ball to predict how that may or may not change over time. Most people who are infected with the virus get sick for a few days (but continue to infect others for a lot longer! Cover those coughs!); a small percentage get really sick and need hospitalization and special care; a further small percentage of the hospitalized cases deteriorate alarmingly fast and die, usually from pneumonia and multi organ failure.  In many instances, death is due to opportunistic bacterial infections that kill the patient already weakened by H1N1.  Bacterial pneumonia is a frequent cause of death in hospitalized H1N1 patients.

No one has any solid statistics on how immune compromised cancer patients fare in this scenario. There is ample evidence that people with pre-existing conditions such as late term pregnancy, asthma, lung disease, cardiac disease, diabetes etc fare a lot worse and have substantially higher death rates. I am guessing that CLL is not a good thing to have either in this context, not an unreasonable extrapolation you will agree.  You party animals you, try not to get pregnant in the near future, OK? 

The other bit of good news is that while there have been scattered reports of one or two patients who were refractory to Tamiflu (Oseltamivir), so far this virus has remained sensitive to Tamiflu. Let us hope it stays that way. The next line of defense is Relanza (Zanamivir), generally administered as a mist. (There have been one or two very interesting reports of Relenza given intravenously in extremely ill patients who then got better very quickly).  Both Tamiflu and Relenza are anti-viral drugs.  Please do not confuse them with a vaccine, a totally different thing altogether.

Physicians strongly discourage use of either of these anti-viral drugs as a prophylactic measure to prevent catching the flu. Makes sense, we are in this for the long haul and it is not possible to take Tamiflu for weeks and months.  That is a good way to develop drug resistance and in any case it will add to the already big headache of drug shortages. It has become clear that taking Tamiflu soon after onset of symptoms is a whole lot more effective than taking it several days after.

H1N1 Swine flu vaccine

There is a lot of confusion swirling around the H1N1 swine flu vaccine. I will attempt to clarify some of the points.

The good news is that a single shot of swine flu vaccine protected healthy adults within eight to 10 days, according to a U.S. study. That doubles anticipated stockpiles and may help people get immunized faster. The concern earlier this summer was that the flu shot would have to be given twice to get a decent level of protection.  Not so, it seems.

The bad news is that the rate at which vaccine can be manufactured has turned out to be a lot slower than we hoped.  Most vaccine manufacturers use the old fashioned chicken egg approach to make vaccines and this is a slow process.  There is no way we can make enough vaccine to protect everyone before the next big wave, even in wealthy countries. There will be prioritization, with different risk groups getting access to the vaccine at different times. Epidemiologists expect the peak to come as early as next month, long before enough vaccine to protect all 159 million Americans considered “at risk”. Pregnant women, children, young adults and people with chronic lung or heart disease or diabetes, health care workers and emergency medical personnel are among the priority groups.

For a change, grandma and grandpa are not top of the list for influenza this season. That does not mean they get out of jail free, it just means there are others who are more at risk this year and need to be protected first. Remember this “W” shaped graph from the 1918 Spanish flu pandemic? we discussed it in an earlier article titled “Lessons from History“. Older people died, as they always do during the flu season. The news is that a disproportionately high percentage of young people died too.

Should you get the H1N1 flu vaccine?

As always, chances are that CLL patients will not mount much of an immune response to this or the garden variety annual flu shot. In other words, even if you get high priority and are among the first people to get vaccinated, chances are not very good that you will be protected against infection. Strategies such as getting double shots of the same vaccine may not be possible this year, what with the shortage of available vaccine. Let me emphasize the “Jab & Dab” protocol we sponsored as a clinical trial is only an experimental approach, unproven as of now.

What to do? Get the vaccine shots, both for garden variety annual flu and the special H1N1 Swine flu vaccine, for whatever small benefit it may have for you, even with the CLL.  But be even more sure to get each member of your family vaccinated as well. Your best protection lies in herd immunity.If you are surrounded by people who are not infected, you wills stay uninfected as well. Please use commonsense and prudence in your social interactions. Your grand kids are likely to be the biggest chink in your armor. Please consider expressing your love for the cute little germ factories this year by getting them a few more coveted toys and gifts, a few less hugs and sloppy kisses.

What about fears of the safety of the vaccine? These have been blown out of proportion by a mile in the lay press and on the gossip circuit. Getting vaccinated is a thousand times safer than getting sick with the flu. all Please do your families and yourselves a favor, encourage everyone to get vaccinated as soon as possible, both with the annual flu shot as well as the H1N1 vaccine shot.

Vaccine availability

The Food and Drug Administration has approved four H1N1 flu vaccines for national distribution. The vaccines are made by CSL Ltd., Diagnostics Ltd., Novartis Vaccines and MedImmune LLC. Three are injectable vaccines and one is a nasal spray. The FDA expects initial lots to be available in the next four weeks, with 40-45 million doses available by mid to late October. Based on preliminary data from clinical studies, a single dose of the vaccines induces a robust immune response within 8-10 days in most healthy adults. Studies are still underway to determine optimal dosing for children. The H1N1 vaccines will not protect against seasonal flu, which needs a separate vaccine, FDA noted. You need to get the regular flu shot for annual flu as well as another shot to protect against this H1N1 swine flu.

Health officials expect more than 3 million doses of H1N1 flu vaccine to be available in the first week of October. “3.4 million doses of vaccines will be available,” said Dr. Jay Butler, who heads the 2009 H1N1 Vaccine Task Force at the Centers for Disease Control and Prevention. “All of that vaccine is the inhalable vaccine.”   This form of vaccine is marketed in the United States as FluMist and is approved only for healthy individuals between the ages of 2 and 49. Pregnant women are not allowed to get this type of vaccine because it contains a live virus. While they did not specifically mention CLL patients, I expect “FluMist” is not appropriate for us chickens either – because it contains a live virus. You need to wait a couple of weeks more until the regular injectable vaccine shots become available (targeted for end of October). Is it safe to be around people who have had FluMist? Good question, I do not know the answer to that. If any of you had guidance on that question from your doctors, do speak up and let us know.

View from a crowded country

As some of you know, I have extended my visit to India for several months more.  It gives me a chance to see how things work during a health crisis in a crowded and poor country.  Some of what I observe here will happen in the USA too, it is just a matter of time.  Human nature is pretty much the same the world over.

A recent report in one of the local newspapers was about an enterprising young man collecting discarded (infected?) face masks from the waste bins in and around hospitals and recycling them.  He was doing brisk business and raking in the rupees as panicked citizens were only too happy to buy what they thought was  “protection”.  It will never happen in the USA or Europe, you say?  I beg to differ.  Over the last seven years I have heard some pretty hard to believe stories about snake oil salesmen making lots of money, exploiting the fear and insecurity of people facing deadly diseases.  Have you heard of  the “coral calcium” story a few years ago? Huge swaths of precious coral reefs were destroyed feeding this craze in USA.  Calcium from coral reefs is no better for you than the simple calcium tablets you can buy at the nearest drug store for just a few pennies.  Often it can be significantly worse for you since it may have high levels of heavy metal contamination due to pollution of coastal seas.

Another local report underlined a huge problem all of us will face, sooner or later.  The capital city of the state where I now live is called Hyderabad.  Even at this early stage the hospitals and other health-care resources are stretched to breaking capacity.  Extremely ill patients are being shunted from one hospital to the next as they run out of capacity.  Several patients died because they could not be admitted anywhere soon enough to be of help. ICU beds are in very short supply, as are ventilators to help patients struggling with pneumonia.  Hospital staff (doctors and nurses) are falling sick themselves, further limiting health-care.  This is in the state capital.  You can imagine the status in more remote areas and poorer neighborhoods.

How long before we run into the same problem in the developed countries?  Sooner than you think.  We have perfected the art of cutting costs and maximizing short term profits, with the result there is little surge capacity in any of our hospitals.  I am willing to bet dollars to donuts we too will run into capacity problems before long.  What happens to the heart attack victim when ambulances have to travel hundreds of miles before they can find an ER room able to accept them or an ICU bed that is vacant? Non-emergency care will be bumped down the queue as our system tries to cope with a huge surge of demand from H1N1 patients.  Where does that leave chronically ill people like CLL patients who need to depend on medical intervention on a regular basis? Sobering thoughts worth discussing, you think?