Flu Emergency. How prepared are we?

NYS, Boston declare public health emergency as widespread flu remains "intense"

New York State joined Boston, MA by declaring a public health emergency as a result of seasonal influenza. Boston Mayor Thomas Menino made the emergency declaration on January 9, 2013, New York followed with its own emergency declaration at the direction Governor Cuomo on January 12.

The NYS declaration includes an Executive Order that allows pharmacists to administer flu vaccination to people six-months and older. Governor Cuomo strongly urged all New Yorkers to get a flu shot and directed the NYS Health Department to "to marshal all needed resources to address this public health emergency and remove all barriers to ensure that all New Yorkers - children and adults alike - have access to critically needed flu vaccines." Mayor Menino included statements urging people to remain home when sick in addition to getting a flu vaccine. Mayor Menino further stated that "This is not only a health concern, but also an economic concern for families..."

Could we see flu coming?
The public health emergencies in Boston and New York State were issued during week 2 (January) 2013 while influenza had been identified as "high" or "widespread" in some states since week 46 (November) 2012. According to the Centers for Disease Control and Prevention,  Mississippi was experiencing high or widespread flu activity in November (week 46) and by week 47, flu was identified as high or widespread in Tennessee, Alabama, Louisiana, and Texas. By week 52 there were 30 states, including New York and Boston, that made the list of states experiencing high or widespread flu.

By comparison, Google Flu Trends identified NY and Massachusetts as having "high" flu activity on December 12, 2012. Flu activity was identified as "intense" in  NY and in Boston on December 23, 2012.

Both the NY and Boston public health officials encourage vaccination and have opened flu vaccine clinics and since the declarations of emergencies, mainstream media attention has expanded. Looking back, we haven't seen the flu awareness campaign as we did in response to the 2009 Swine flu situation.

Are public health and local health care systems prepared to deal with unexpected biologic situations? The answer is not reassuring.  According to Trust for Americas Health 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness. See also States Lagging in Emergency Preparedness by Healthday News.

While the 2012/2013 Flu Season continues, the question on the minds of many is: why is flu so bad this year?  While this question will be studied and debated, an easy answer may be that people simply did not get vaccinated and were unprepared for an early start to the flu season. The CDC states that its too early to define peak of flu season. However, the Washington Post is reporting that over 60% of Americans have not been vaccinated as of November 2012. Meanwhile, an interesting side story is developing...despite low vaccination rates, retail and healthcare systems are reporting dwindling vaccine supply. If vaccine supply is drying up when 60% of the population didn't get the shot, how ready were we in the first place?

3 things to know about seasonal flu

In this post will explore several areas of seasonal influenza. We'll take a look at what influenza is and is not, what causes it, and the various types. We'll also discuss the normal impact of influenza and the potential extraordinary impact of influenza.

1. Terminology.
The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

2. Types of Influenza.

There are several types of influenza viruses… so more concerned about, others, not so much. Influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

3. Impact.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.



Further Consideration.
Prevention of transmission of flu sometimes takes on a life of its own. We need to remember that the flu virus is one of the most infectious pathogens we know of and that type a influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza.  The flu virus can remain active on a contaminated surface or item for up to 48 hours.

We'll discuss prevention strategies, P. P. E., and pharmacology versus non-pharmacology strategies in our Medical/Biological posting next week.

Commonn Sense Influenza

Prevention of transmission of flu sometimes takes on a life of its own. The media hype and hysteria can easily overwhelm the facts. We need to remember that the flu virus is one of the most infectious pathogens we know of and that Type A influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza. Knowledge and common sense can keep us safe.

The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

There are several types of influenza viruses and  influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.

Forward Thinking for Flu

 It's that time of year again. Time to be forward thinking for flu.

As we approach another flu season it remains unclear what, if any, role H1N1 Swine Flu will play. Will there be another Type A influenza strain that will impact us? Will we see Swine Flu back as a seasonal visitor? Or, will we simply continue to have the various seasonal flu wax and wain throughout the season? I'm safe to say I don't know, nor will predict. Equally safe is the bet that nobody knows for sure.

Despite the less-than-glamorous remarks I get from some planners and responders, I continue to hold the position that flu; seasonal or novel strain, is a naturally occurring biological event. Look at the situation in that frame for just a second or two...If you knew there was going to be a biological event occurring in your community in the next few months, would you begin preparing for it now? I certainly hope so.

We know that seasonal influenza kills 30-35 thousand people in the United States every year. And we also know (now) that vaccine production and distribution in the event of a novel (or, perhaps intentional) biological event will be slow and sparse. So why wait until flu season (with or with a novel strain or variant) to begin preparing to meet the demands this naturally occurring event will place on your public and your service? I'd like to offer my list of things to consider when reviewing/planning for the 2010 flu season:

First, start or renew your infection control practices now. Get in (or back in) the habit of disinfecting your apparatus at the beginning of each tour, after each patient, and at the end of each tour. This includes wiping down all surfaces in the patient care compartment of ambulances, equipment that comes in contact with patients, and the cab of the vehicle. Don't neglect the place were you ride! Wipe down or disinfect the cab...with special attention to door handles, radio microphones, and the steering wheel.

 Second, although vaccination is still a great way to protect yourself from getting the flu, non pharmacutical interventions go a long way in stopping the spread of any disease. Remember to follow good hand hygiene practices by washing your hands as often as possible and using waterless sanitizers when soap and water are not available. Practice respiratory ettiquette - cover your cough and sneeze. Do so by coughing or sneezing into your elbow reduces the spray of material that comes out of you and into society. Also, wear a mask and don't be afraid to put a mask on your patient. The Centers for Disease Prevention and Control has recently dropped their requierment for N95 masks in the setting of flu in favor of surgical masks (See my previous Mitigation Journal post CDC Drops N95 Requirement) Also, consider appropriate social distancing...that is, stay home if you're sick. Many employers don't like to hear about this one. It is irresponsible to go to work (especially if you have contact with the public) if you are ill. Those involved in planning must account for the possibility that the workforce will be decreased, perhaps significantly, by members not reporting due to illness. You must also consider the absentee rate to increase due to employees remaining home to care for significant others who are ill or children when schools/daycare centers are closed. 

I encourage everyone to review the Mitigation Journal posting Bio-Event Ready or Die! 3 Thing to do, Today. originally posted August, 2009, for more on this topic.


For a summary of Mitigation Journal blog postings and podcast episodes on flu and flu-related topics, click here

Mandate the shot or not?

Debate over mandated vaccination continues

Voice your opinion, take our informal poll located in the right sidebar. 

What rights do I forfeit to work in health care?

Do health care workers have a "duty" to be vaccinated against seasonal flu? 
The answer to that question is "yes" ccording to the New York Times  who published an article suggesting that health care workers "should know better and anyone". The article cites a recent survey conducted by the CDC and claims that while doctors and nurses are "getting the message" about flu vaccination, mid-level providers and other health staff are not. They goe on to state that "Vaccinations of health care personnel should be required, either by state laws or by employers" and further notes that compliance is 95% when flu vaccination is mandated by an employer.

Should health care employers "mandate" workers to be vaccinated?
According to an opinion published in Medscape, Why Hospital Workers Should Be Forced To Get Flu Shots, by Arthur L. Caplan, PhD, the answer to the question of mandated flu vaccine is clearly affirmative. Correctly noting that seasonal influenza impacts high risk groups such as extremes of age, immune-compromised, and those living in long term care facilities, he states -

"Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot."

He goes on to say -

"...every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot."

Can a seasonal influenza vaccine be mandated as a "condition of employment" be enforced?
New York State attempted to mandate vaccine during the 2009 H1N1pandemic for all health care workers. The vaccine mandate was made by then Governor David Patterson despite a lack of vaccine, a sustainable mass vaccination program or a declaration of public health emergency. There was also considerable debate as to who, exactly, was considered health care workers. Most studies overlook non staff health care professionals such as EMS providers, firefigters and other public safety responders who contact the public in and out of the hospital setting.

Should we include environmental/support service staff or provide for blanket inclusion of anyone who would walk into a hospital?

Not everyone agrees with vaccine mandates.
New York State Nurses Association vigorously opposed the vaccine mandate in 2009. (See NYS Nurses Opposes Mandates for Vaccine) In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers for that year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The full text of the CDC's statement can be found here.

Can vaccination be mandated without a formal declaration of a public health emergency?
You may recall that the United States Army (2003) had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine in preparation for deployment to a area with a credible Anthrax threat. The Army Anthrax vaccination program was eventually halted by federal court in 2006.  

If the Army cannot mandate vaccine soldiers in the presence of a credible threat, can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency?

If health care providers are mandated to be vaccinated today, what will be mandated tomorrow? 
What do the experts say? The opinion of the CDC is echoed by other infectious disease. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

More than one controversy in this situation.
There is no doubt that flu vaccination will prevent the spread of flu, seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination?

JAMA Busts Flu Vaccine Myths

Worthy of Myth Busters, JAMA debunks common influenza vaccine myths

The 2012/2013 influenza season may be winding down, but the excuses for not being vaccinated against seasonal flu continue. Vaccination rates seem to be low despite an early and ferocious flu season and healthcare workers seem to be on the lower end of the vaccine numbers. In response to the reluctance of many to get the flu shot, JAMA recently published a paper outlining (and debunking) common arguments against flu vaccination.




MYTH: The Vaccine does not work.
JAMA Response: Busted! Notes the flue vaccine is not as effective as common vaccines, but "not as effective" does not mean "not effective". They go on to state that this years influenza vaccine was estimated at 62% effective by mid-season. According to the article:

"A prevention measure that reduced the risk of a serious outcome by 60% in most in- stances would be a noted achievement; yet for influenza vaccine, it is seen as a “failure.” JAMA.

Myth: The vaccine causes the flu.
JAMA Response: Busted!

"...people may develop an influenza-like illness or even laboratory-confirmed influenza after vaccination. This does not mean the illness was vaccine induced but rather was likely due to a noninfluenza viral infection" and "exposure to influenza before immunity from the vaccine had time to develop, or the fact that the vaccine is not 100% effective."

Myth: I have an allergy to eggs.
JAMA Response: Busted! The article states that those with severe allergic reactions or anyphylaxis after exposure to eggs should avoid flu vaccine. Those with such a reaction should consult an allergist for detailed assessment. They further state:

"...recent evidence-based guidance advises that all other egg-allergic patients should receive influenza vaccination based on the rationale that the risks of not vaccinating outweigh the risks of vaccinating these individuals as long as basic precautions are followed."

Myth: I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immunocompromised person.
JAMA Response: Busted! This may be the most important flu vaccine myth to bust as it directly impacts those who need the vaccine (or protection from flu) the most. Those with comorbid conditions or underlying medical problems are at most risk of complications from seasonal influenza. According to JAMA -

"...these groups have been specifically recommended for influenza vaccination because the vaccine is safe in these persons and can prevent serious morbidity and mortality." and "it is important for clinicians to recognize the individual’s desire to prevent harm in close contacts but to redirect this good intention by emphasizing the morbidity due to transmitted influenza."

Myth: I never get the flu/I am healthy.
JAMA Response: Busted! This excuse sounds a lot like Optimism Bias from the It Wont Happen to Me crowd. According to the JAMA article:

"Refusing vaccination because of a perceived low risk ignores the potential risk to close contacts, especially those who cannot get vaccinated or who will not mount a strong immune response to the vaccine and rely on herd immunity for protection."

References:
Influenza Prevention Update, JAMA. 2013;309(9):881-882. doi:10.1001/jama.2013.453. Examining Common Arguments Against Influenza Vaccination

Related:
NYS Nurses Association Opposes Mandates for Vaccine 
No Vaccine? No Mask? No Job. 
Influenza Vaccine Overrated? 
Best Disease Prevention is Action

Selected Reading on the Flu Situation

Here are a few of the many articles I've read in the last few days on the topic of Swine Flu and flu in general.

Avian Flu Research Sheds Light on Swine Flu
"...A new study by University of Maryland researchers suggests that the potential for an avian influenza virus to cause a human flu pandemic is greater than previously thought. Results also illustrate how the current swine flu outbreak likely came about..."

Is Swine Flu A Worldwide Threat?

Pandemic Flu Vaccine 6-Month Lag Time
"...the first wave of pandemic flu may be over before people are vaccinated..."

Influenza: The H’s and N’s

A tremendous amount of media attention has been placed on avian flu and pandemic situations. Hyped media attention and public confusion on the topic underscores the need for emergency responders to have the basic information and understanding of key concepts regarding types of influenza, terminology, and other details. Responders not armed with a basic understanding may lack the ability to gain situational awareness placing themselves, the public, and potentially their families at risk.

The term influenza is not synonymous with Avian Flu or pandemic. Influenza can be categorized in a variety of ways, but in general, influenza or flu is caused by a family of viruses known as Orthomyxoviridae and can be broken out into three types; type A, B, and C. There are numerous illnesses that can be responsible for the classic flu symptoms like body aches, chills and fever. Symptoms can range from mild to severe and include serious complications such as bacterial infections and pneumonia. Type A influenza crosses species and is the most hearty, or virulent, of the three strains. Highly Pathogenic Avian Influenza, or HPAI, is a type A flu virus. Type B flu virus targets only humans, is common and less severe than type A while type C, which impacts humans and swine, is rare and my have only mild symptoms or none at all.

Type A flu viruses receive much of our attention and is home to H5N1 or avian flu. The H’s and N’s represent designation of proteins of the virus and are important to the classification of Type A flu. Understanding the role of the H’s and N’s will also aid in understanding why vaccine development can be difficult. Designations such as H5N1 are used to further classify one type A virus from another. The “H” stands for hemagglutinin antigen (sometimes HA is used rather than just H). There are fifteen different hemagglutinin antigen (H/HA) proteins. The H proteins give the virus the ability to attach to the host cell. The “N” represents neuraminidase antigen (again, sometimes documented as NA rather than N). The neuraminidase protein allows the virus to be released from the cell and spread infection. There are nine neuraminidase antigen (N/NA) proteins. The numerous combinations of H’s and N’s allow the type A virus to infect such a large number of species. Remember, there are 15 different H proteins and 9 N proteins...that means there are 135 combinations of protein variations for type A influenza virus. Here’s the catch; a vaccine designed to work for one combination of proteins will not work for another and since type A (and B) influenza changes slightly from one flu season to another, creation of a vaccine for that particular season is tricky business. Keep in mind that the virus wants to survive and to do so will have to change; either slightly or drastically. A slight change in the virus is known as antigenic drift while drastic changes are called antigenic shifts. It is the antigenic shift that can cause a virus to change enough to cause severe disease or pandemic.

References:

www.pandemicflu.gov
www.dhs.gov Pandemic Planning and Preparedness

Vaccine. Mandate or Not?

Vaccine. Mandate or Not? CDC says no. Other infectious disease experts say yes.

As you may recall, New York State attempted to mandate H1N1vaccine for all health care workers despite a lack of vaccine or a declared public health emergency. Yes, there was a pandemic declared, but no public health emergency. There was considerable debate as to who, exactly, was considered health care workers...did it include EMS? Firefighters? Or simply, anyone who would walk into a hospital? The New York State Nurses Association came out swinging hard against the vaccine mandate. We posted on this way back on July 31, 2009. See NYS Nurses Opposes Mandates for Vaccine in Mitigation Journal.

In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers this year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The details of this CDC decision were posed in the Mitigation Journal Blog (CDC: Vaccine Not a Requirement. 12 Aug 2010) The full text of the CDC's June 22 statement can be found here.

What will it be for the 2010-2011 flu season? Mandated vaccine or not? Well, the CDC has their opinion and other infectious disease experts have another view. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

There is more than one controversy in this situation.

Should flu vaccine be mandated? I think a better question is: "what rights do I forfeit to work in health care?" We already require health care workers to undergo TB testing. Hepatitis vaccine is offered, but can be declined. The SHEA position paper states "a condition of employment" in regards to flu vaccination...but who will enforce it? You may recall that the United States Army had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine. That 2003 mandate for Anthrax vaccine was in preparation for soldiers who were deploying to a area with a credible Anthrax threat and was eventually halted by federal court in 2006 (note: the Army is planning to restart the program 2010-2011). If the Army cannot mandate vaccine soldiers in the presence of a credible threat, how can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency or credible threat?

Are we following the CDC, WHO or other groups such as SHEA? What are policy makers to do when these expert groups disagree? Last years NY mandate covered anyone who had patient contact in a health care facility. That included some EMS personnel...and here is the lunacy...only commercial (private) ambulances were included in the mandate. The rationale was that commercial or private ambulance services had a higher call volume and, therefore, higher risk. There was no consideration for the numerous EMS providers who work/volunteer for multiple agencies (and hence, have a higher exposure). Also, the 2009-2010 H1N1 vaccination plan had EMS near the bottom of the list to receive vaccine. The point is, if health care workers are going to be mandated to receive vaccine, EMS should fall under that...if EMS responders refuse, if hospital health care workers refuse...what will the system impacts be? I would predict a near-crippling effect on our ability to manage daily volumes.

There is no doubt in my mind that flu vaccination will prevent the spread of flu...seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated from nature by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination? That answer is no. I'm also concerned about the "what's next" factor. If we mandated to be vaccinated for flu or loose jobs today, what will be mandated (under pain of unemployment) tomorrow? 

More to follow. Feel free to comment (constructively) or email for discussion.

Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.

No vaccine, no mask? No job

Healthcare providers fired over flu vaccine mandate

ABC is reporting the firing of eight hospital Indiana hospital employees, three of them nurses, for failure to comply with influenza vaccination program. USA Today is running a story about a registered nurse who has been fired for not wearing a mask after declining flu vaccine. These reports indicate a growing trend in healthcare: comply with flu vaccine mandates or risk loosing your job.

Mandate the shot or not? We may have an answer to that question.
There are indications that mandated participation in flu vaccine programs have become normal. Notice the term flu vaccination program, meaning that there is more than just vaccine involved. Flu programs typically give the healthcare employee a choice to be vaccinated or, decline the vaccine and wear a mask while at work. Having reviewed a number of policies, we've noticed a growing number of healthcare agencies (including non-hospital facilities) have begun to require "participation" in a flu program. The meaning of the word "participation" changes frequently between facilities and can indicate a vaccine requirement, receipt of vaccine or signed declination, or vaccine/decline and wear a mask.

As noted in the USA Today piece, some healthcare providers feel stigmatized by being requiered to wear a mask. Some may consider their privacy has been eroded as they feel compelled to explain why they have to wear a mask.

What NOT to do for Flu

Here is some good info in the setting of flu from TIME/CNN: The top five things NOT to do in a pandemic situation -

1. DONT go to the hospital
2. DONT be afraid to eat pork (and yes, I think we should continue to call this SWINE FLU)
   
3. DONT hoard anti-viral medications (lets add to this one...DONT take antibiotics...they wont work on flu - antibiotics are for bacterial infections, flu is viral. Taking any medication...antibiotic or antiviral...when you're not sick can lead to the development of resistance, too)
   
4. DONT leave your home if you feel sick (lets add to that if you have fever and respiratory symptoms...or symptoms suggesting cold/flu of any kind)
5. DONT panic (its Swine Flu...not an IRS audit)

And now for a few of my own...

• Call 9-1-1 only if you need to...remember, ambulance crews are limited and calling an ambulance will NOT guarantee you get a hospital bed any faster (if at all)
• Wash your hands...all the time
• cover you cough/sneeze
• practice appropriate social distancing
  

London Olympics: A Biological Ground Zero?

The 2012 Olympics in London are at risk of becoming the next pandemic ground zero according to research conducted by Maplecroft.

The bad news is that London is only part of the story.
Singapore, North and South Korea, Italy, Germany, Netherlands, Belgium, France, and Spain make the extreme risk of pandemic list, too. None of them are hosting an Olympics, yet are on the same list with the same extreme risk ranking. Confusing? No so much.

Many of the countries noted by Maplesoft are at risk of flu spread as a result of environmental and living conditions. South East Asia is noted in the report as being "a particular risk of emerging strains of influenza" and China is noted as a particular concern. This should not be a surprise. We've been following the development of widely publicized diseases like Avian Flu from these areas for several years. What's different is our level of awareness today. We recognize that global events that bring so many people together from diverse locations brings with it increased disease spread potential.

What makes the 2012 Olympics in London different?
Nothing. In fact, the risk of disease transmission is not unique to  the London Olympic Games in any way. We would be having this same conversation if the Games were being held in Lake Placid, NY or Beijing, China. Mass gatherings have the potential to spread disease, influenza or otherwise. We discuss influenza most often because of the attention drawn to influenza A - H1N1/Swine Flu and H5N1/Highly Pathological Avian Influenza. Although they top the list of notable flu viruses, it's important to remember there are many other diseases of concern. These diseases hold threat potential regardless of the location of the event. The fact is simply highlighted because of the diverse population and environments the athletes and spectators will be coming from. Immune system status, comorbid conditions, and overall state of health of attendees will also be factors in the spread of disease. People will bring diseases as diverse as the culture and health environment they come from...and they'll take other diseases home with them, too. We should also consider the fact that the Olympic Games will be a high-profile event that may be an attractive target for a variety of threats including the biological bomber. Read more: YOU, the biological bomber

What may be different today is our awareness and sensitivity to the biological threat. 
Naturally occurring or intentionally released, a biological agent can be an extraordinarily deadly situation. Perhaps worse than a nuclear detonation, without the big bang, if you will. The good news is that, when compared to other threats, the biological event may be able to be contained and person-to-person transmission limited by simply washing your hands and wearing a mask. The non-pharmacological interventions go a long way to slow the spread of disease and support vaccination efforts. Read more on non-pharmacological interventions.

Technology is a new ally in disease tracking. As described in this video clip from Reuters, public health officials from all over the world are working to improve disease tracking before, during, and after the London Games.

How will the media respond to athletes and attendees at the London Games wearing masks?
This would not be the first time the issue has come up. The United States Cylcling team came under scrutiny for wearing face masks during the 2008 Olympic Games in Beijing. Pollution and air quality prompted the athletes to don the masks and subsequently sparked political issues between China and the U.S. Masks for pollution is one issue. Donning masks to prevent the spread of disease is quite another. Consider the global impact if we were to hear of a "flu-like" illness spreading through London and, at the same time, see athletes wearing N95 masks. It wouldn't take long for the speculation of an outbreak to be spun into the next pandemic.

Preparedness, of course.
There is another side to the threat...preparedness. The widely cited Maplecroft report clearly describes the 10 nations most at risk for pandemic influenza. What is less often noted is that this same report ranks an areas ability to contain a disease. This same research concluded that the U.K. is one of the countries most likely to be able to contain an outbreak:

"...the UK’s strong governance, highly developed infrastructure, well educated population and advanced health system also places it among the 10 countries with the highest capacity to contain a potentially lethal outbreak of a strain of flu." - quoted from Maplecroft.com

What's less clear is the preparedness in other countries. Attendees and athletes will return home with whatever (if anything at all) they've been exposed to. While strong infrastructure adds to resiliency, the lack of that infrastructure will add to disease complication and management. Read more on flu and biological preparedness.

MJ 219: Understanding Flu and Biological Events

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 If I told you that there was a biological event coming this winter that would kill 36,000 to 40,000 people, would you be concerned? What if I told you that this biological event would target the old, the young, and those with chronic medical conditions; what would you say?

If I told you that flu season is around the corner, how concerned would you be?

This post is an introduction to our popular classroom session Understanding Flu and Biological Events. In this program we tackle these issues and compare seasonal flu (a predicable, natural event) and intentional events involving biological material.

This weeks posting is a primer as we enter flu season.

Click the player below to view the movie:




Click the player below for the podcast audio only version:

FDA: 2013-2014 Influenza Vaccine Composition

Quadrivalent Vaccines for Add Influenza B Protection Recommended

The strains of influenza virus to be included in next years seasonal flu vaccine have been determined. the 2013-2014 vaccine will provide options for both trivalent and quadrivalent  vaccines and include flu strains from the 2012-2013 vaccine plus addition strains. The typical flu vaccine contains three flu strains (trivalent) two Influenza A and one Influenza B. For the first time, a vaccine containing protection against four strains of influenza, a quadrivalent vaccine, will be an option.

According to the Centers for Disease Control and Preventions weekly surveillance update:

The World Health Organization (WHO) has recommended vaccine viruses for the 2013-2014 Northern Hemisphere vaccines, and the Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) has made recommendations for the composition of the 2013-2014 influenza vaccines to be used in the United States. Both agencies recommend that trivalent vaccines contain an A/California/7/2009-like (2009 H1N1) virus, an A(H3N2) virus antigenically like the cell-propagated, or cell-grown, virus A/Victoria/361/2011 (A/Texas/50/2012), and a B/Massachusetts/2/2012-like (B/Yamagata lineage) virus. It is recommended that quadrivalent vaccines containing an additional influenza B virus contain a B/Brisbane/60/2008-like (B/Victoria lineage) virus in addition to the viruses recommended for the trivalent vaccines. These recommendations were based on global influenza virus surveillance data related to epidemiology and antigenic characteristics, serological responses to 2012-2013 seasonal vaccines, and the availability of candidate strains and reagents.

Additional Commons Sense Influenza

 The inclusion of an additional influenza B virus ("It is recommended that quadrivalent vaccines containing an additional influenza B virus...in addition to the viruses recommended for the trivalent vaccines") appears to be a result of the 2012-2013 flu season. As the CDC notes they have characterized 1,340  influenza viruses since October, 2012. Of those influenza viruses, 105 have been H1N1 2009, 827 N3N2 influenza A and 408 influenza B. Also, according to the CDC:

"Since the start of the season, influenza A (H3N2) viruses have predominated nationally, however in recent weeks, the proportion of influenza B viruses has been increasing. During week 8, 53% of all influenza positive specimens reported were influenza B viruses."

The Food and Drug Administration Vaccines and Related Biological Products Advisory Committee

made the final recomendation at their meeting in February, 2013. According to the FDA website, the Vaccicnes and Related Biological Products Advisory Committee "reviews and evaluates data concerning the safety, effectiveness, and appropriate use of vaccines and related biological products..."

The FDA committee recommended next years influenza vaccine should retain the current influenza A H1N1 strain and replace the influenza A H3N2 component with an A H3N2 virus. They also recommend replacement of the current influenza B strain, the B/Victoria lineage strain. 

YOU: the Biological Bomber

Suicide bomber attacks are a fact of life in other nations. Suicide bombers are notorious for strapping on an explosive-laden vest, walking into a soft target location, and...detonating. Corpses, walking wounded bloodied and maimed walk in the midst of collapsed buildings and broken glass. (more on soft targets: Mall shootings here, MD shot in hospital here, 2011 planning problems here

Envision the carnage and hysteria caused by a suicide bomber.

Now envision a bombing scenario that's exponentially more deadly. More lethal than conventional explosives with an impact far greater than a nuclear weapon. In this attack there will be no detonation, no big bang to call us to action. Chances are we wont even know this bombing has taken place until our hospitals are overflowing.

The biological bomber is one such scenario. A Typhoid Mary of our time, rather than strapping on explosives, the biological bomber infects themselves with a disease and goes into society with the intention of infecting as many people as possible.

Like their suicide bomber counterparts, the biological bomber may actually be bombers working in a coordinated simultaneous attacks on several locations. Unlike suicide bombers who can only blow themselves up once,  multiple biological bombers in a coordinated attack could infect hundreds in multiple locations. Would you be able to recognize a biological attack?

The biological bomber will want to spread a disease that is transmitted easily from person to person. A disease that has a lingering incubation period, a disease that will present with commons signs and symptoms of flu. Diseases of interest may come from the Centers for Disease Control and Preventions category A list. Something exotic like Smallpox, plague, or the Nipah virus may be the choice. Even seasonal flu would make an effective agent of attack. The strains of Type A influenza included in seasonal flu vaccine are know to anyone who can search the internet. A would-be biological bomber would only need to infect themselves with a flu strain not included in the vaccine or some novel stain of virus to bypass our first line of biological defense. Of course, our ability to obtain vaccine and other medications will be an issue.

Soft targets and locations of critical infrastructure would be prime locations for the biological bomber attack. Shopping malls, sporting events, and public gatherings make the list of potential targets. Of all the soft target/critical infrastructure locations, your local hospital takes the prime spot on the list. Hospitals hold special value for the biological bomber:

1. Many patients have compromised immune systems making them more susceptible to infection and a greater mortality.
2. Hospitals have a large transient visitor population in the form of visitors and suppliers. These people will move in and out the hospital and into the community and will help spread any disease. 
3. Medical providers in the hospital will also be at risk for infection...a biological attack on a hospital may cripple the ability to respond to the medical needs of a community. Forget about surge capacity...there will be no capacity when physicians, nurses, and non-clinical staff become too ill to work or refuse to report to work. (not to mention a lack of preparedness on the part of many health care systems)

YOU: The Biological Bomber. 
Much of what you've read about the biologic bomber is theory; apocalyptic, cataclysmic theory. But there is a biologic scenario that puts you in the staring role and can be every bit as dangerous as the terrorist biological bomber.

Failing to practice the personal responsibility of hand hygiene, respiratory etiquette, and appropriate social distancing when ill puts  you in a position to spread disease including seasonal flu or other diseases. These simple practices along with getting the appropriate vaccines can help prevent YOU from becoming an unwitting biological bomber.

Vaccine and non-pharmacological interventions (hand hygiene, respiratory etiquette, appropriate social distancing) are also effective methods used to prevent the spread of disease, naturally occurring or otherwise. Proper use of these interventions along with personal protective equipment will boost protection for health care and traditional responders adding to our resiliency.

September 11, 2010

September 11, 2010...

There will be hundreds, perhaps thousands, of blog postings and podcast discussions today. Many will have titles like "Always Remember" or "Never Forget". While even more will talk about the details of time and events from 9-11-01. There will also be ceremonies and services featuring memorials and testimonials. Where were you when...will be a popular conversation.

I, however, will take a slightly different path behind the keyboard and mic of Mitigation Journal on September 11, 2010.

With the greatest of reverence and everlasting memory of those who died in the attacks of 9-11-01, I will ask those responders who remain to reflect on where we are now and what we'll be doing tomorrow.

Are we better prepared in 2010 than 2001? Prepared to do what, you ask...as well you should.

Can you remember the public enthusiasm that greeted the responders who flooded into New York City in the days following 9-11-01? Can you picture the signs that read "Thank You"? The ones the read "Our Heroes" as lines of ambulances and fire apparatus drove by? Can you still picture the crowds welcoming responders of every color uniform and vehicle?

Can you remember the stream of funding in the months that followed as we suddenly realized that weapons of mass destruction training was needed? And the awakening that one spore could kill?

The American Fire Service could seemingly have anything needed as our nation realized the need for its First Responders. And we got it. There was money for training classes and protective clothing. There were funds for apparatus and buildings.

Is the fire service better prepared in 2010? Prepared to do what, you ask...as well you should.

How much as been spent and squandered on dysfunctional apparatus and worthless "WMD" and terrorism training?  How much of that training and apparatus was never put to use because it did not fill any real firefighting function outside of terrorism? Nearly everyday we're reading about firefighter line of duty deaths from cardiac disease or from entrapment, collapse, or apparatus crash.  How much "preparedness" have these topics gotten? What can the fire service point to as a measure of preparedness in the wake of all this terrorism and WMD training? Protection of infrastructure in our communities? No. In a level of audacity never before heard, the American Fire Service told hospitals that, in case of chemical or biological attack, your local fire department is going to be too busy...better get ready to deal with those contaminated self-referrals on your own. For the first time in our history, the fire service is telling someone "we're not coming".

Recently, legislation aimed at aiding those responders and rescuers who worked at Ground Zero and are now dying from pulmonary diseases...failed. Almost without a whimper. No crowds, no signs, no aid. Cities in every state are faced with demands to cut fire department budgets, reduce staffing, cleave benefits. On September 12, 2001, the American Firefighter was still a hero. In 2010 the fire service is another taxation anchor wincing under the public scrutiny and shouts for tax cuts.

Is our emergency medical services system better prepared in 2010? Prepared to do what, you ask...as well you should.

EMS as a whole received a scant amount of preparedness dollars in the wake of 9-11-01. When asked why, one legislator remarked "aren't the ambulance drivers part of the fire department"? Despite changes to the National Response Plan, now the National Response Framework, EMS remains on the fringes, fragmented and without any nationally recognized leadership. Despite increases in training and education paramedics, who are allowed to give injections to a variety of sick people in the back of an ambulance, have been barred from assisting a flu vaccination clinics during the Swine Flu pandemic of 2009...adding to the nauseatingly slow vaccine distribution at some public vaccine clinics. EMS is the service that should be best able to identify an unfolding biological event. In 2010 we still ask "aren't the ambulance drivers part of the fire department"?

Is our public health system better prepared in 2010? Prepared to do what, you ask...as well you should.

Hospital preparedness, surge capacity, resource triage, and sufficiency of care were all buzzwords after 9-11-01. The buzz has faded into annoying tinnitus as many hospitals and public health organizations go through the motions of checking the boxes on the Joint Commission list...functionality optional...check mark required.  Decontamination precautions remain unworkable at many health care facilities. Issues of surge capacity continue to dog hospitals as over crowding forces patients into the halls waiting hours to be seen by a doctor. Discussions on the triage of limited medical therapy (ventilators, for instance) is hotly debated and unsettled. Oh, and that pesky flu...even after 9-11-01, SARS and the Avian Flu threat; we fall short of vaccine production and distribution capability...even when given months warning as in the case of Swine Flu.

As I've written and said many times before...It is time to stop training for WMD terrorism events. It is also time to stop living in the "post 9/11 era" and start living in the pre (insert next event here) era.We must recognize the need for all-hazards training. This training must be delivered in a way that puts the material into context, so the skills and knowledge can be used every day. Our readiness for natural disasters must also improve.

Never forget. Always remember. Are we better prepared in 2010? Prepared to do what, you ask...as well you should.

MJ Podcast #182: The Problem with PODs, Flu Season Preparation, and Prescription Medication Abuse.

This week on Mitigation Journal Podcast edition #182

I received a number of emails this week about a comment made on edition 181 of Mitigation Journal podcast...I was talking about my support for the United States Postal Service pharmaceutical delivery program the lack of functionality and failure potential of points of distribution. Leading off edition 182 is a discussion A few listeners/readers wanted to know why...nobody disagreed with me...just wanted more information on my opinion. One podcast listener actually wants me to write an opinion for their superiors and deliver some training on the topic of comprehensive biological event planning.

Matt and I also discuss the need to revisit flu season planning. Who knows what we're in for this flu season, but this is a good time to develop (or encourage) those good non-pharm infection control practices; respiratory etiquette, hand hygiene, and appropriate social distancing. Its also a good time to revisit your services infection control plan...review, update, train on it.  This segment of the podcast expands on several recent blog postings. For more on these topics check out these postings in Mitigation Journal blog CDC: Vaccine not a requirement, Forward Thinking for Flu  , and CDC Drops N95 Requirement

And finally this week, we talk about the importance of a medication profile and history in the pre-hospital environment. Medications and medication history are important but never so important as they are today. Prescription medication abuse is increasing faster than meth use and the rate of emergency calls due to abuse is rising. EMS responders must add medications and medication history to the list of things-to-do. I also encourage everyone to have a field guide that lists medications, indications, and side effects. I recommend the EMS Field Guide and Field Guide app for iPod/iPhoneTouch from Informed Publishing.

NYS Nurses Association Opposes Mandates for Vaccine

Representing over 37,000 nurses, the NYS Nurses Association (NYSNA) has spoken out against a new regulation making flu vaccine mandatory for all people who care for patients in health care...including nurses. Under the new regulations, nurses would be mandated to get a seasonal flu shot as a condition of employment. No shot, no work.

My first thought was: how could anyone be against this?! But, after reading the testimony, I can understand it...moreover, there are a number of Ripple Effect points to consider. After reading all the material, I think NYSNA has a number of valid points.

The first point is: Can this be mandated when no current public health emergency exists? The NYSNA is clear that they fully support and encourage nurses to get flu vaccine. Most would agree that getting a flu shot is good preventative action. When working in health care, what rights do you give up? Consider all the issues the military had mandating Anthrax vaccine not too long ago. Keep in mind you can still decline to get a HBV series and work...

I'll be talking about this in detail on the next Mitigation Journal Podcast (Edition 118 expected release 8/3/09). In the meantime - I've talked about the three best things you can do - now - to prepare for biologic events now, without vaccine...you can hear my recommendations on Mitigation Journal Podcast Edition 117.

Below are the links to the NYS Nurses Association press release and testimony.
Medical News Today story: http://www.blogger.com/post-create.g?blogID=18608016
NYS Nurses Association Press Release: http://www.nysna.org/news/press/072309.htm
NYS Nurses Association full text of testimony delivered by Eileen Avery, MS, RN, Associate Director, NYSNA Education, Practice and Research Program to the State Hospital Review and Planning Council, July 23, 2009, New York, NY.

MJ#244: Are we prepared for Flu?, Act to prevent disease, and Great Flu Apps

Please visit www.mitigationjournal.org for compete show notes and features

Edition 244 Recorded on February 25, 2013

This week on Mitigation Journal:

Flu Emergency. How prepared are we?

Personal Action for Disease Prevention

Flu Informed with 3 Great Apps

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!