It's still mild right?

indigo girl · May 1, 2009

Spreading everywhere, but still mild. They are unsure if it will stay mild. The first cases in Mexico were probably mild as well, and they thought it was only seasonal flu so they went unnoticed.

They actually cannot stop the spread. Mitigation strategies are designed only to delay it, and give communities time to muster resources if it becomes more virulent. If everyone is sick at once, there is no one to take care of the sick...If you spread things out, it's easier to handle.Tracking cases is almost impossible now. Many will go unnoticed again because this is still mild.

Building up immunity is a good thing, but remember these viruses mutate very rapidly. There may be only limited immunity, and even none at all if there truly is a second wave is next winter.

It's kind of eerie really. We will grow used to this mild sickness, and it will fade away. Everyone will breath a sigh of relief, and wonder what all the hoopla was about. We will forget this, and move on. Then next winter, bam!

Let us hope it does not play out that way anyway, but it feels very strange to me right now and, so very different from watching bird flu cases which are still continuing despite this new flu virus. In fact we will probably not even know if this virus is in bird flu endemic areas like Cairo or Jakarta though it likely will be given the pattern of spread. It is all very disorienting, at least to me.

Hopefully we will not need to use our stockpile of Tamiflu this time around. We may really need it later though Secretary Sebelius said very reassuringly in the press conference today that they could make more. I am sure that they could, but how quickly if even the manufacturers were getting sick in a 2d wave? That is why, incidentally, those people are in a priority group for receiving the antivirals first. We need them to be able to function.

Just my 2 cents...

indigo girl · May 7, 2009

Between a virus and a hard place

We are watching an historical event unfold before us. No one knows what the outcome is going to be. Cautious concern is still advised even if the virus disappears from the northern hemisphere during the warmer weather.

http://www.nature.com/nature/journal/v459/n7243/full/459009a.html

Damned if you do, damned if you don't. The emergence of a new, swine-flu-related H1N1 strain of influenza in people in North America, with sporadic cases elsewhere in the world, has left the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and the World Health Organization (WHO) in Geneva in an unenviable position.
For more than a week now, these two agencies have been holding daily media briefings to keep the world informed about the rapidly unfolding story. There is ample reason for concern: a new flu virus has emerged to which humans have no immunity, and it is spreading from person to person. That has happened only three times in the past century. The pandemics of 1957 and 1968 were mild in most people but still killed many, and that of 1918-which also seemed mild in its early phases-killed at least 70 million people worldwide. As Nature went to press, the WHO had already upped its pandemic threat level from 3 to 5, and a final step to its highest level of 6-a global pandemic-seemed only a matter of time.
Yet at this early stage, the consequences of the pandemic are so uncertain that communicating the risks is a delicate matter. Influenza viruses evolve rapidly, making it extremely difficult to predict what this strain might look like a few months from now. If the agencies alert people and the pandemic fizzles out, they will be accused of hyping the threat and causing unnecessary disruption and angst. Indeed, just such a media backlash is already beginning, because most cases so far have been mild. But if the agencies downplay the threat and an unprepared world is hit by a catastrophe on the scale of 1918, the recriminations will come as fast as you can say 'Hurricane Katrina'.
The risk is not hyping the pandemic threat, but underplaying it
Also encouraging is that many governments now have at least some kind of pandemic plan in place, thanks to the scare over the H5N1 avian flu virus earlier this decade. Five years ago very few of them did. But many of those plans contain an important element that has been conspicuously absent in the current communication by governments and public-health authorities: during a severe pandemic, there is only so much they can do. Much of the response will depend on local communities taking action for themselves.
Scientists can help, by serving as credible voices to inform their communities of the risks and uncertainties, and by pointing people to the pandemic-planning resources on the CDC and WHO websites, the PandemicFlu.gov site, and many others. For the moment, the risk is not hyping the pandemic threat, but underplaying it. We know a tsunami is coming. No one can say whether it will be just a large wave, or a monstrous one, but it is time to start thinking about at least being ready to move to higher ground.

Commentary from Effect Measure on the editorial from Nature

The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

http://scienceblogs.com/effectmeasure/2009/05/swine_flu_what_does_so_far_so.php

Breathing easier, may be an apt phrase for an almost audible collective sigh of relief. So far, the incipient swine flu pandemic is not extremely nasty. Is this perhaps premature? The world's premier scientific journal, Nature, and many flu scientists, suggest it is:
No one on the public health side has over reacted. When an outbreak or pandemic is unfolding, you get only one chance. The window is a narrow one. CDC (and WHO) have acquitted themselves well, so far. CDC's daily briefings have been straightforward and informative. The public, understandably, has bounced back and forth from fear to relief and back again. I don't think either pole is avoidable. If the scientists are baffled and uncertain, the public has a right to be, too. But CDC has been steady and consistent in their approach (more so than HHS or Homeland Security, in my view) and they clearly understand the most important thing: this outbreak is still evolving and it is premature to write it off.
The idea this is "mild" flu virus is so far true, but mild is a relative term, as we have pointed out here. And "so far" is another important qualifier. This virus is spreading relatively quickly, but it isn't everywhere and not much time has passed. With exceedingly virulent strains like the 1918 virus many people died relatively quickly but with flu death usually comes weeks after the onset of infection. Not that many people have been infected as yet. If the pace of new cases accelerates, we will likely seem many more hospitalizations (currently there are only 35 in the US) and more deaths (currently there are two):
"My own personal view is that it is too early to say what the severity is," says [Marc Lipsitch of the Harvard School of Public Health], who works with the CDC...
...with influenza one cannot be sure of anything. In the coming months we will be watching the southern hemisphere closely to see what happens as they enter their flu season. That may give us a clue as to what to expect in the fall.
. . . or it may not.

I agree with the Reveres that CDC and WHO are doing a fine job, and that HHS and Homeland Security are giving mixed messages. I know Sebelius is new to the job, but the constant hand waving is distracting from her message of everything being just fine. I cringed for her sake during that first webcast when she said Tamoxifen instead of Tamiflu, and could not pronounce zanamivir. Ouch! No doubt she will grow into the job. I sure do miss the former Secretary Leavitt though. He inspired confidence. He knew the score. I don't think Sebelius does yet. I hope for everyone's sake that she is able to catch up quickly.

lamazeteacher · May 8, 2009

Well so far the case I have right now, isn't terrible. I'm in my 3rd day, started Tamiflu and Doxycyclin yesterday. Today my throat became more sore again, and my nasal congestion is worse. Not too much coughing.

I'm staying at home!

When I taught IC to nurses at orientation and yearly skills review, I'd repeat something I'd been told by another ICN: When you have a cold, you don't know whether you'll make it to work in the morning. When you have the flu, upon awaking you KNOW you won't go to work.

If I was working, and there was no swine flu pandemic, I might have gone in to work, but by the early afternoon, it would have been very hard to finish, as my fever returned......

indigo girl · May 8, 2009

Well so far the case I have right now, isn't terrible. I'm in my 3rd day, started Tamiflu and Doxycyclin yesterday. Today my throat became more sore again, and my nasal congestion is worse. Not too much coughing.
I'm staying at home!
When I taught IC to nurses at orientation and yearly skills review, I'd repeat something I'd been told by another ICN: When you have a cold, you don't know whether you'll make it to work in the morning. When you have the flu, upon awaking you KNOW you won't go to work.
If I was working, and there was no swine flu pandemic, I might have gone in to work, but by the early afternoon, it would have been very hard to finish, as my fever returned......

I just read your other post about getting tested just now and responded over there, but I think I missed what you were saying until now. I have not heard that it takes that long to get a positive result. These are not rapid field tests? That is very interesting. I may have to ask someone about that.

I think that it was wise to start the Tamiflu though as early as you have done. I do hope that you feel better soon.

lamazeteacher · May 9, 2009

It's hard to know what to post where, as there are so many threads about this. I'll stick to this one regarding the course of my illness.

It's day 5 of my flu, day 3 of Tamiflu and Doxy, and no improvement in most symptoms so far. Fever continues, when tylenol wears off, sore throat isn't as bad (no more fire there). My rhinitis and HA are the chief mischief makers, sinuses kicking in, now.

My energy level is the same, medium (I'm usually quite high energy), so this morning I called my favorite breakfast place (Panera Bakery, a great chain throughout the USA)to ask for my breakfast sandwich and a decaf mocha without whipped cream, and told them that I couldn't go inside to pick it up. They said to call when I got there.

I wore gloves to handle the money, giving a twenty to a girl entering the place as I called it to say I was there. (I have great faith in selected strangers' honesty). Then I felt like collapsing (not actually, I was sitting in the car) as fatigue hit hard.

So I ordered some chicken noodle soup for later.

I had felt some nausea, possibly from the doxycycline, and eating helped it go away. I can always eat! I did enjoy the sandwich..... and mocha.

oramar · May 13, 2009

It's hard to know what to post where, as there are so many threads about this. I'll stick to this one regarding the course of my illness.
It's day 5 of my flu, day 3 of Tamiflu and Doxy, and no improvement in most symptoms so far. Fever continues, when tylenol wears off, sore throat isn't as bad (no more fire there). My rhinitis and HA are the chief mischief makers, sinuses kicking in, now.
My energy level is the same, medium (I'm usually quite high energy), so this morning I called my favorite breakfast place (Panera Bakery, a great chain throughout the USA)to ask for my breakfast sandwich and a decaf mocha without whipped cream, and told them that I couldn't go inside to pick it up. They said to call when I got there.
I wore gloves to handle the money, giving a twenty to a girl entering the place as I called it to say I was there. (I have great faith in selected strangers' honesty). Then I felt like collapsing (not actually, I was sitting in the car) as fatigue hit hard.
So I ordered some chicken noodle soup for later.
I had felt some nausea, possibly from the doxycycline, and eating helped it go away. I can always eat! I did enjoy the sandwich..... and mocha.

Yes, your post points up something I meant to bring up. What is considered mild? Is it any case that does not require medication, that the patient recovers from without seeking medical aid? Or is it any case that does not hospitalize you or kill you? Plenty of people will get it and get better without every going to a doctor but they will be very sick just the same. When my son and I had Hong Kong flu in 1971 we were extremely ill. We both recovered without ever seeking medical help. First of all there was nothing they could do for you back then, no anti viral medications, no vaccines were avaliable back then. Being a young nurse, I observed us both for signs of dehydration, kept us as hydrated as I could. I also watched for signs of secondary bacterial infection. Neither of us ever had any of those. There was no use trying to contact a doctor or go to a hospital in 1971 as there was nothing they could do and as they were overwhelmed already. We both recovered completely with our own immune systems as our only means to fight it off, that was all you had back then. However, if someone would have told me I had a mild flu I would have smacked them. Sever, moderate, mild are all very subjective terms.

indigo girl · May 13, 2009

What is considered mild? Is it any case that does not require medication, that the patient recovers from without seeking medical aid? Or is it any case that does not hospitalize you or kill you? Plenty of people will get it and get better without every going to a doctor but they will be very sick just the same.

Good question. Looks like they do not want us to use the Tamiflu unless the case is severe. I think that they are worrying about the development of Tamiflu resistance. Also, we might be needing that Tamiflu later for the return of the virus during our regular flu season. Our supplies are finite.

The suggestion to build up stockpiles of antibiotics, antipyretics, O2 is rather concerning.

You might get the feeling that they are worried, wouldn't you? Think about it. Have you ever heard of any organization with any status suggest this kind of advice before?

This link is to the notes a poster over at flutrackers took from yesterday's WHO briefing.

http://www.flutrackers.com/forum/showpost.php?p=232221&postcount=1

Most cases are mild but, of the severe cases/deaths, they fall into two groups those that have other medical conditions and a group of young healthy adults. The high risk factors include pregnancy, the immunocompromised & and those that would be regarded as high risk for seasonal flu. They are looking hard at the young healthy group for a common factor but numbers are small and no pattern yet.
-Current guidance for treatment of general population: Do not use antivirals and do not hospitalise. Do use antipyretics, analgesics, analgesics (but not aspirin), antibiotics & oxygen as required - also build up stockpiles of these.
-Pneumonia: Primary in severe cases, little secondary (but expect this to change), some ventilator associated case.
-They are urgently seeking data from physicians regarding treatment results with antivirals, especially zanamivir. While resistance is confirmed in vitro little is known about clinical efficacy.
-Due to the complex developing system of strains and resistance they are building a matrix – along with rapid regional strain prevalence detection – more clinicians to use in choosing treatment options.

Listen to Dr. Nikki Shindo, Medical Officer, WHO Global Influenza Programme

http://whoterrance.vo.msecnd.net/mediacentre/audio/press_briefings/VPC_12MAY2009_Influenza_A_H1N1.mp3

indigo girl · May 13, 2009

Transcript of WHO briefing for 5/11/09

The definition of disease severity is explained by Dr. Keiji Fukuda, Assistant Director General of WHO:

http://www.who.int/mediacentre/influenzaAH1N1_prbriefing_20090511.pdf

Severity is a different characteristic, it is a different feature. When we talk about severity, there is a couple of different ways that it can be discussed and thought about, but I think this is a useful way to think about it: one of them of course is that there is disease severity, at the level of people. You know, regular, ordinary individuals, and the question for them is that: “If I get infected, will I develop mild illness, will I develop medium illness, or will I develop a severe illness?” So this is one aspect of severity: if a person gets infected, how many people are going to have mild illness, how many people are going to have severe illnesses. It is not really just a matter of how many people are dying, but it really is a matter of how many people develop different effects of illness, which can be considered severe. For example, it can be that people develop severe respiratory disease, severe complications and do not die. There are many ways that we look at clinical severity.
Now a different kind of severity, a different way to look at it is that we know that these outbreaks and these epidemics have an effect on countries. When they get affected, they can have their economies affected significantly, either through decreases in travel, decreases in trade, because people are concerned and they do not want to go out. There are a number of effects like that on countries, which again are a different kind of severity, but really have an impact.
When we take both of those things together, what is the disease impact on people, what is the impact on societies and countries, it is clear that the effect of pandemics can be different on different countries. If you come from a developed country, you may have one level of impact, if you come from a developing country, in which you have fewer resources, you can have a different kind of impact. In these different countries we have different groups of people, some of whom are more susceptible to disease, because they are vulnerable in a variety of ways, either because of things such as not having enoughfood, or perhaps having infections such as HIV be common in the population. There are a number of different reasons for why different populations can be more vulnerable than other populations. And it also has to do with the fact that some countries are able to respond to outbreaks and to epidemics better than other countries, because they have more resources, they have more things that they can put into place. We are really again aware that severity is not just a simple issue, it is not how many people are dying and that answers the question. It is really looking at all of these things and that is an important point to understand about what is severity.

Katnip, RN · May 13, 2009

Didn't the CDC say that from this point on we should be hanging on to out stores of Tamiflu and Relenza and only giving it to pregnant women and those at high risk with chronic illnesses, etc?

It sure is different from a report I read last week that said they were expecting to see only 1700 cases total in the US.

And I agree with the assessment of the potential this coming winter. I was telling my family a couple of weeks ago that this may not be such a bad time to catch the thing. But Hopefully they'll have a vaccine ready for if and when it hits again.

indigo girl · May 13, 2009

Didn't the CDC say that from this point on we should be hanging on to out stores of Tamiflu and Relenza and only giving it to pregnant women and those at high risk with chronic illnesses, etc?

This is from yesterdays's CDC briefing. The use of Tamiflu in Europe and other countries where there only few cases of S-OIV have occurred is different from the suggestion of its use in the US.

http://www.cdc.gov/media/transcripts/2009/t090512.htm

The circumstances in the U.S. are very different from the circumstances in a number of European countries. We have this virus in every -- pretty much, almost every state in the country, and suspected it's likely already to the states that haven't confirmed it yet. We don't have a situation where we can contain the virus's geographic distribution, and our focus is on reducing illness and death and mitigating the impact that this virus has as well as focusing our efforts on areas where they can have the most impact. So, the priority here is for antiviral drugs for treatment of influenza, where we think the treatment will make a difference, and that's for people with severe illness presentation or for people who have underlying medical conditions or pregnancy, where the complications of an influenza infection might be worse than in other people. So, our focus for antiviral drugs is primarily on treatment. And we are aware that there are some other countries where there's a lot of preventive use of antiviral drugs around the traveler, around the first case that they've seen. That circumstance is not likely to have a benefit here in the United States based on the transmission patterns we're seeing and the stage of the outbreak that was present by the time we recognized this virus...

indigo girl · May 13, 2009

And I agree with the assessment of the potential this coming winter. I was telling my family a couple of weeks ago that this may not be such a bad time to catch the thing. But Hopefully they'll have a vaccine ready for if and when it hits again.

http://www.cdc.gov/media/transcripts/2009/t090512.htm

Emma Hitt: Yes, hi, thank you for taking my question. You talk about the novel H1N1 virus coming back during the fall. Is that a certainty? And will it definitely pick up back in the fall? And also, do you expect the H1N1 virus to be more robust during the summer months than the seasonal flu strain?
Anne Schuchat: We wish that we knew what was going to happen in the fall. Influenza is usually seasonal, and usually, there is very limited circulation in the northern hemisphere during our summer months. But there is increased circulation in the southern hemisphere during that same time period. We don't know whether the novel H1N1 virus will circulate in the U.S. next fall, and if it circulates, whether it will be more severe, of similar severity or less severe than now. We think that if we have good information coming from the southern hemisphere and we see a lot of disease or severe disease associated with this virus, that that would increase the likelihood that we would continue to see problems in the fall. But we, unfortunately, cannot predict. The other thing is that these viruses continue to change. Because we have seasonal influenza strains, including an H1N1 strain that is resistant to oseltamivir and zinamivir. But because we have an H1N1 strain that's circulating that's resistant and we have this novel H1N1 strain, we also don't know whether there might be a reassortment between the human seasonal flu strain and the novel strain. So, there's a lot of unknowns, a lot of uncertainties and a real priority to have good laboratory surveillance and monitoring of the circumstances in the southern hemisphere and the ongoing occurrence here in the U.S. Next question?