Tuesday, April 28, 2009

School Closure and Swine Flu

One of the big lessons learned often cited from historians of the 1918 influenza pandemic is that communities who practiced social distancing had significantly less mortality than those who did not. A problematic lesson to emulate in places like New York City. But here in the land of desert and suburban sprawl it is a possibility. The media is reporting that school districts in Texas have closed schools due to this flu (which the pork industry is lobbying to change from swine flu to North American flu as they are already taking a financial hit from lowered pork sales).

School closure is a double edged sword. On the one hand, you have the potential (although there is little evidence based research to back this up) to quell flu activity in your community. On the other hand, with kids out of school you run the risk of losing a significant proportion of your workforce as they go home to care for the kids. Not a problem in some industries, but it is a problem when we talk about healthcare workers. Especially if the case count continues to creep up. So should we close the schools? The advice from CDC is yes when you have one confirmed case or one epi linked case. I have heard some health authorities who say that is too conservative -- the time to act is now, get ahead of the thing -- and others who think it is too liberal, a gross over reaction.

I caught a CNN reporter yesterday (it is now a permanent fixture in our emergency ops center) discussing the "scary, deadly virus." Um, CNN guy, that is not helpful. Fear mongering only makes this worse. A commentator from Mexico City on NPR stated that 20 million of his neighbors were infected -- with fear. Fear is what prompted the literally hundreds of calls my staff fielded today. A bit of fear is a good thing. Too much is paralyzing.

Should we panic? No. We should be cautious. We should all have enough food and supplies in our homes to minimize trips out in public. We should avoid crowds. And wash our hands a lot. And certainly if we are sick, we should take some personal responsibility and stay home.
The cases in the US reported so far have been relatively mild. I am hopeful that trend will continue. I would like nothing more than for this to fizzle out in a y2k bust and let us have egg on our faces for over reacting. I would much prefer that to the nightmare scenarios in our disaster drills. However it goes, to all the workers battling this disaster, take care of yourselves too. God bless, and God speed.

Monday, April 27, 2009

Swine Flu Day

This has been my day. The phone rang constantly, to the point that I had to set it to go immediately to voicemail. As I checked my voicemail, more messages rolled in. Most of the calls were from physicians. Guidance from the state health department told them to contact their local health department for additional information. Unfortunately, we do not have the answers yet either. My health department has very limited lab capacity, yet all these providers want testing for swine flu.

Many of them are seeing positive influenza A in their offices. I have been trying to get their specimens to the LRN for additional testing. So far we have no confirmed cases, but I suspect it is only a matter of time.

I am also getting calls from the schools -- should they close or not? And city leaders -- what should they do? I advised EMS to mask up when on runs with febrile patients.

Are we all going to die???

The problem here is lack of information. Please be patient with us -- we are doing our best to give good advice, but the known is so limited at the moment. And it changes literally minute to minute.

Swine Flu Continues

There has been much activity surrounding swine flu. Since I got to work at 6:30 this morning it has been constant phone calls and emails. It is a bit overwhelming. At least 10 doctors have called me saying they have positive flu A cases and they want further testing for swine flu. I am trying to get that arranged. Normal flu A season had come to an end, so all these cropping up are not good news. That being said there is not a flurry of activity with the hospitals, good news there. Hopefully this bug will continue to be a mild illness. I will try to post more this evening.

In the meantime, while I do not recommend anyone freak out, this is a good time to ensure that you have a 2 week supply of food for your family -- just in case it is advised that you stay home. It would also be prudent to stay away from crowds of people. And please, wash your hands.

Friday, April 24, 2009

Swine Flu Concern

There is a large swine flu outbreak in Mexico. I copied the text of a news article for you:

Mexico shuts schools over deadly influenza epidemic
Article from: Agence France-Presse

April 24, 2009 07:46pm
MEXICAN authorities have closed all schools in the capital and central Mexico as the WHO announced hundreds of human cases of swine flu in the country, including 57 suspected deaths.The outbreak has killed at least 20 people in the past month, Health Minister Jose Angel Cordova said in announcing the school closures. "This afternoon the epidemic was confirmed by Canadian and US labs to be a new influenza virus," Mr Cordova said in a televised statement in which he urged people to avoid large crowds, shaking hands, kissing people as a greeting, or using the subway. The Government has gathered 600,000 vacines to help protect health care workers dealing with the outbreaks, the health minister said. The World Health Organisation said there are 800 suspected swine flu cases in Mexico and seven cases reported in the southwestern United States. It was not immediately clear whether Mexican authorities had identified the outbreak as that of swine flu, as labelled by the WHO. Since March 18, 13 people have died in Mexico City, four in the central state of San Luis Potosi, two in Baja California in the northwest and one in the southern state of Oaxaca, Mr Cordova said.

Wednesday, April 22, 2009

Swine Flu

In an MMWR Dispatch this week, CDC reported cases of Swine Influenza A in a couple of children in Southern California. It doesn’t seem like the two kids had interaction with each other, nor did they have contact with pigs. The question then is, where did these kids get swine flu? It suggests there is some person-to-person transmission occurring. The report asks for surveillance from this California healthcare providers along with surveillance of people who work with swine or who were in contact with the sick kids. The report notes that one of the sick kids travelled to Texas earlier this month, so there are some investigations and enhanced surveillance happening there too. One wonders how the kid got to Texas – Vehicle? Airplane? -- and if there were other exposures en route.

Swine flu is an issue because most of the population probably does not have any antibodies. There has been a lot of concern among public health officials in the last couple of years about influenza pandemics. Of specific concern is the influenza A H5N1 virus. However, there is just as much chance of a pandemic from another strain, such as this one. According to the report, “This particular genetic combination of swine influenze segments has not been recognized previously among swine or human isolates in the United States, or elsewhere based on analyses of influenza genomic sequences available on GenBank.”

Pandemic is a scary sounding word. It doesn’t necessarily mean death, destruction, and the end of life on earth as we know it (despite often being portrayed that way). From the report it appears that the kids had mild illness, and both have recovered. The fact that it was swine flu was picked up through enhanced influenza surveillance and might not have been caught otherwise.

Monday, April 13, 2009

Dead Cows

I got a call this morning from a woman concerned about some dead cattle. She lives out in the country, and at her fence line, several cattle on her neighbor’s property are dead. She said that she called the Sherriff’s office and an animal control guy came out and took pictures. She called them today to find out what they were going to do about it and animal control told her they couldn’t do anything because the cattle are on private property.

Now I know there is more to this story than she knows, because I have worked with those guys and they wouldn’t just take pictures and be done with it. That being said, there is something funny about living in the West. It has to do with jurisdiction. Out here in the West, people guard their freedom and independence with a vengeance. Government authority is pretty limited – especially in the unincorporated areas. If you live in an unincorporated area, jurisdiction falls to the County. But the County has much, much less authority than City government. So when the animal control folks say they can’t do anything about the dead cattle, it may be true. If they have contacted the owner and the owner refuses to let them on the property, they will need to get a search warrant. Which means they have to establish probable cause. That is likely the reason for the photographs – to get a sense of how the animals died. Did they starve to death? Then they could argue for animal cruelty and get a warrant that way. Was it a natural cause? They will need to convince a judge to write the warrant though, which is another tricky step.

Meanwhile, this woman is terrified it is anthrax.

Thursday, April 9, 2009

Sixth Graders are Goofy. And They Are Having Sex.

A group of researchers out of the University of Texas School of Public Health recently published results of a recent study on the sexual behavior of middle school students. They looked at the rates of kids engaging in various sorts of intercourse (vaginal, anal, oral), and here's what they found: By age 12, 12% of students have had vaginal sex, 7.9% have had oral sex, 6.5 have had anal sex, and 4% have engaged in all three.

By age 12???

Meanwhile, schools are supposed to teach abstinence only, and not allowed to discuss safe sex.

If you start having sex at 12, how many partners have you had by the time you're in your mid-20s? How many opportunities to contract an STD? If you are having sex at 12, how likely is it that you really understand the implications of catching an STD? I'm thinking you don't.

The study goes on to note that a third of these kids aren't using condoms, and -- seriously -- a quarter of them have had 4 or more partners.

I understand reluctance around the issue of providing sex education to kids. I don't want to give anyone tacit approval either. But, come on. Isn't part of our responsibility as parents, as educators, as adults, to make sure that our children are safe?? Clearly these children are engaging in unsafe activities. And the adults are preaching Just Say No and withholding life-saving information.

My department gives a HIV/AIDS prevention program targeted at IV drug users in the county jail. On a recent visit over there, I had a 19 year old girl ask me questions about her recent chlamydia diagnosis. "I just don't understand how I caught this," she told me. "I've only been with 17 guys."

I kid you not.

Ok, it is easy to poke fun at that, but she was serious, she truly did not understand STD transmission. The thing is, a lot of other young people don't know either. I've had high school kids tell me that you can do it anally and still be a virgin. They didn't know anal sex was riskier than vaginal.

It's time to rethink this whole abstinence only stance and provide real sexual education to our children.

Monday, April 6, 2009


How about another measles outbreak? This one took place in Washington state. Eight kids in one household all got sick. They did not visit the pediatrician because of the rash, but rather due to complications of measles infection. Two developed pneumonia and one thrombocytopenia.

Nineteen cases altogether were associated with the outbreak. Of these, 16 were school-aged. All of these were unvaccinated due to philosophical exemption. Eleven of the children were homeschooled and 5 attended a faith-based private school.

The cases were linked to a large religious event held in a neighboring city. Four of the cases attended this event. Unfortunately, a month past before public health learned of the first cases which left lots of room for transmission. They believe the outbreak was stated by a Japanese national who also attended the event. She developed a rash while at the conference, and her brother had been clinically diagnosed with measles prior to her arrival to the US. She had received an MMR due to the exposure to her brother. There is not definitive evidence of this connection, however.

I feel compelled to out my stance on philosophical vaccine objections. As a public health worker and infectious disease epidemiologist, I should be hard core pro-vaccine. I am not. I understand parental concern over vaccines and I disagree with my colleagues who seek to demonize vaccine objectors. The scientists say one thing, the parents whose children have been inured by vaccines say another. How do you decide what is best for your child?

Vaccine preventable diseases can be devastating. In his autobiography, Benjamin Franklin wrote: “In 1736 I lost one of my sons, a fine boy of 4 years old, by the smallpox… I long regretted bitterly and I still regret that I had not given it to him by inoculation; this I mention for the sake of parents, who omit that operation on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that therefore the safer should be chosen.” The dilemma for parents today is that we are much more likely to be confronted with examples of vaccine injury than illness and/or death from vaccine preventable diseases. As such it is rational for parents to avoid the injury.

Nonetheless, at present, science does not validate the levels of anxiety about vaccines.

This is Public Health

Happy National Public Health Week! Check out a great video on public health here. And give a big shout out to all the public health professionals who work to keep all of us safe.

Friday, April 3, 2009

Measles Outbreak in a Hosptial

The National Immunization Conference was well worth the trip to Dallas, despite the hellacious downtown traffic and exorbitant parking fees. One of the more interesting sessions was on the recent US measles outbreaks. Preeta Kutty gave a talk on the outbreak in Arizona.

A little measles background. Prior to the introduction of measles vaccine in the US, between three and four million people were infected annually. Of these, about 48,000 required hospitalization, and 450ish died. Now we see less than 100 cases per year, and almost all of those are epidemiologically linked to imported cases. Looking at the genetic sequencing of the measles isolates, we can further discern that the virus was imported by linking it back to known endemic strains. Presently, measles is not endemic in the US – thanks to the vaccine. Despite all this, MMR uptake has been declining recently due to the concerns over a hypothesized MMR-autism link, leaving pockets of vulnerable populations. When an imported case is introduced into one of these pockets, we have seen several generations of transmission. I have lots to write about MMR and autism (another hot topic at the conference), but that will be in a different post.

Worldwide, measles continues to be a significant cause of morbidity and mortality. The World Health Organization reports that in 2007, there were 197,000 deaths from the disease. There continues to be a global initiative to eliminate measles from the earth; however, one wonders how much progress will be lost due to safety concerns over the vaccine.

At any rate. Last year, a traveler from Switzerland brought measles to Arizona. The patient made multiple visits to an emergency room before proper diagnosis – she was at first sent home with a “viral syndrome.” During those visits, she was never masked (measles spreads most commonly through coughing). Because measles was not recognized at first, the patient was not placed under isolation. Fourteen people altogether were infected. Six of them caught measles nosocomially – that is, from being in the hospital with the index case. Another case caught it in a pediatrician’s office. Interestingly, the hospital did not have record of immunity among the health care workers. They ended up requiring proof of vaccine or positive titer checks. This resulted in a delay in vaccination of susceptible health care workers. Four hundred people were vaccinated at the hospital. In total, estimates are that 4269 patients, 1872 healthcare workers, and 410 others were exposed to measles.

Lessons learned here? First off, if you are in charge at a healthcare facility – any healthcare facility – make sure you know the immune status of your employees (all of them). They should either provide proof of vaccination or positive titers. Some facilities forgo the proof option altogether any have them show positive titers. A tedious and expensive process to be sure, but better than ended up in a blog as the hospital with the nosocomial measles outbreak. Ok, that was mean. I really feel for their infection control and occupational health folks. I know they had to have had a rough time with all this.

Next, we need to continue educating our healthcare workers about the signs and symptoms of measles. In their defense, measles is hard to detect in the prodromal period, especially in the absence of Koplik’s spots. All the worse when you would have no reason whatsoever to suspect measles. Still, lots and lots of healthcare workers have never seen an actual case of measles (frankly, I haven’t), or a lot of other vaccine-preventable diseases.

The final lesson here is to ensure that cases are isolated and that public health is contacted upon suspicion, not conformation. Time between suspicion and conformation can be several days depending on your lab resources. If you wait for conformation to start implementing control measures, you have the potential to end up with a lot of cases.