OK Everybody, Back In The Pool.

Coffee Brown, MD, University of New Mexico, Talk Radio News


Atypical Flu Update 05/06/09
Today’s numbers: 642 cases in 41 states. There are now 2 deaths
reported with one being wholly American. Whereas the first was a
Mexican child who contracted the disease in Mexico, the second, per
WebMD, had no reported connection with Mexico other than living near
the border in Texas. She was young, but had other conditions’
“co-morbidities,” including recent childbirth, obesity, and recent
pneumonia. Counting her as the as the only native fatality so far, the
mortality rate in the U.S. is 0.1 percent.
Worldwide, there 1516 confirmed cases in 22 countries, with 29 deaths
in Mexico out of 822 confirmed cases (3.5 percent mortality), and no
deaths so far reported outside of Mexico and the U.S.
The World Health Organization is still not recommending travel
restrictions, except to advise people who feel ill to stay home.
WHO alert status remains at stage 5. Clusters of cases do not seem to
be occurring yet, which may mean that the virus weakens with time.
Nevertheless, the Centers for Disease Control and Prevention remind us
that we have weeks of this contagion to go yet.
The overall severity of this flu outside of Mexico is “mild to
moderate” per the CDC.
Per Secretary of Health and Human Services Kathleen Sebelius, “School
closing has gotten a lot of attention. There's a balance with the
importance of making sure our children go to school every day. The
virus transmits very quickly child to child, the end result has been a
more mild version of the disease than was originally feared and the
lethality seems at a much less significant level”
The current guidelines are to keep schools open, even if some students
get the flu, as would be done during any normal flu season, she says,
though that makes it even more important to keep symptomatic children
home.
“So we're urging parents to take steps if your child is sick, please
do not send your child to school. If a teacher is sick, please don't
come to school,” sebelius said.
And home means home. “And parents, don't turn around and keep your
child home from school and send him or her to the mall. This is really
about staying home,” Sebelius added.
The recommended period of “grounding” is seven days, even if symptoms
resolve, because that is how long sufferers may remain contagious.
So, did the CDC, WHO and media over-react? This flu is looking less
scary by the day, but it started with a significant number of
fatalities, and it was clearly a very different strain than had been
seen before. While we may start to feel some relief at this point,
these things can change quickly. Washing our hands, avoiding others
when we have symptoms, and insisting on common courtesy (Hey, cover
your mouth when you cough), may help reduce the 35,000 deaths per
year, and billions of dollars in lost productivity we have come to
think of as “normal.”

First Things First

Coffee Brown, MD, University of New Mexico, Talk Radio News

There are many blocks in the arch of medical reform, but Health Information Technology is the keystone, according to a panel of policy makers who spoke and answered questions at the Brookings Institution. Everything from electronic medical records, to electronic ordering, to integrated billing, to error reduction and decision support, won’t fix medicine by itself, the experts concluded.

Presenters at the event included: U.S. Sen. Sheldon Whitehouse (D-RI); former Rep. Nancy Johnson (R-Conn.) and Chairman of Health IT Now! Coalition; and Charles P. Friedman, Ph.D., Deputy National Coordinator for HIT Department of Health and Human Services. to discuss the current administration’s plans to upgrade the use of information technology in medicine.

“We are at a preposterous level of health information primitiveness,” White said.

According to moderator Darrell M. West, Vice President and Director, Governance Studies, Brookings Institution,, only one major business in the U.S. is less computerized than medicine; mining.


West co-wrote Digital Medicine: Healthcare in the Internet Era, published by Briikings. He said only one major business in the U.S. is less computerized than medicine; mining.

"Amazon can tell me what I’ve bought before, what I looked at today, and what I might like to buy tomorrow,” he said, adding that the majority of U.S. hospitals still keep manually-written, and, potentially life-saving, patient records in paper form.

According to the Institute of Medicine, only one in five clinicians in the U.S. are using electronic medical records.

West said the most optimistic projections are for savings of about $120 billion per year, but he believes the figure will be less.

Whitehouse quoted estimated healthcare savings as high as $320 billion per year , and he thinks that number could be a trillion.

The panelists agreed that interoperability is the first hurdle for the technology. Many, or most, of the computerized systems that exist now in hospitals can not share data with other computers.

This is intentional, Johnson said, because the competitive private business model favors a proprietary approach to information.

West said his doctor was using EMR now, but would never integrate the last 26 years of notes, “because that would cost too much.”

"Having HIT on a doctor’s desk is like having a car in the garage. you can enjoy the radio, air-conditioning and cigarette lighter but without a good road, you’re not going anywhere,” Whitehouse said.

The infrastructure, lines, connectivity and hardware all have to support the data flow, he said.

He pointed out that just moving data is not enough, “We need information aggregation, cross-checking, error reduction, decision support” and portability. The patient must be able to take data from system to system when traveling.

“Medicaid alone is approaching a $37 trillion obligation, not counting Medicare, VA benefits, S-CHIP, and similar entitlements. HIT is a necessary first step toward avoiding a healthcare cost tsunami,” he said.

Johnson discussed the tension between making the new healthcare more individuated and patient centered and avoiding the sort of consumerism that lets patients cow doctors into ordering expensive but unneeded tests and procedures.

She also pointed out the enormous proportion of healthcare costs that go to hopeless or marginal care, such as end-of-life care, or the prolongation of the lives of non-viable newborns. “No other country counts one breath as ‘live birth,’” she said. Many require hours, days, up to one year of life before being considered “live births”, she finished.

Friedman said the outlines of healthcare reform are clear and unlikely to change, but many details are still being worked out, not least a carrot and stick program to encourage and/or coerce stakeholders to adopt and “meaningfully use” HIT. “Meaningfully” is still being defined, but refers to applying this technology to actually improve clinical outcomes.

Whitehouse said that Republican opposition to Clinical Effectiveness Research surprised him. “No company would attempt a transformation one one-hundredth this complex” without Quality Assurance and accountability. “Someone has to be in charge."

The Coughing, Aching, I-Can't-Get-To-Sleep Report

Coffee Brown, MD, University of New Mexico, Talk Radio News

A-H1N1 flu Update #4, 05/04/09

What’s new today?
Dr. Richard Besser, Centers for Disease Control and Prevention, says this flu appears to be about as contagious as the more usual varieties.

Jose Angel Cordova, Mexico’s Secretary of Health, believes the epidemic there is beginning to wane. 

According to the World Health Organization, there are a total of 1005 cases in 21 countries: In the U.S. 286 cases in 36 states. In Mexico, 590 cases with 25 deaths for a 4.2 percent mortality, which is half again the rate of the 1918 flu pandemic. The total mortality, if Mexico is not separated would be 2.5 percent, the same as in 1918. However, the mortality rate for those contracting this flu outside of Mexico remains zero.

What about medicines?
The CDC has issued a reminder that aspirin is dangerous for children under 18 years old, especially if flu is suspected, because of the risk of Reye’s Syndrome. Tylenol/acetaminophen, taken as directed, is safe for fever and body aches. It does not shorten the infection, nor does it treat any respiratory symptoms.

The atypical flu is sensitive to the readily available antivirals Zanamivir and Oseltamivir, but resistant to Amantadine and Rimantidine. Patterns of sensitivity to antivirals vary from season to season.

And Travel?
The WHO has no travel advisory in place presently, but the CDC recommends curtailing non-essential travel to Mexico. The University of New Mexico, which maintains strong ties with Mexico, has issued its own travel advisory for staff and students.

While there have been reports that the WHO has elevated its alert status to Phase 6, as of 09:00 EDT their website still lists phase 5. Phase 6 will represent confirmation of local outbreaks in more than one country i.e., person to person transmission will be occurring within the separate countries. It is an expected stage. Note that phases 7 and 8 will describe the tapering off of the contagion.

Can we go back to calling it swine flu?
For the first time, in Canada, a herd of pigs has been shown to be infected, according to Reuters. Neither the CDC nor the WHO has issued any warnings about pork. (But you shouldn’t kiss a pig.)

So ... is it over?
In the U.S., the cycle has not yet begun to decline. Because of the possibility of this variant flu returning in fall and winter, Besser says, the CDC is proceeding with the first steps in the manufacture of a vaccine.

If There's No Pork, Where's The Beef?

Coffee Brown, MD, University of New Mexico, Talk Radio News


A typical flu season kill 37,000 Americans. The swine flu, officially known as "2009 H1N1", may be responsible for up to 160 deaths in Mexico and one infant death in the U.S.

Of those who have contracted the disease outside of Mexico, the illness has been relatively mild. So, what's the big deal?

"This is a whole new kind of flu," said Dr. Anthony Fauci, Director of the National Institute for Allergy and Infectious Diseases. Flu viruses mutate slightly every year, but not like this, Fauci said. Genes from four separate viruses - avian, human, and two kinds of swine flus, have combined into this strain.

Our vaccines and immune systems have "never seen anything like it," Fauci said. That's what makes it potentially more dangerous. While this means that we have little or no natural immunity, it does not necessarily mean that this flu must be any more infectious or virulent than the average flu.

So, why is it called "swine flu"? Actually, Sen. Pat Roberts (R-Kan.) really wishes we wouldn't call it that, as it's hurting the pork industry. Fauci agrees, "The name that is now being used is 'the 2009 H1N1 flu.'"

Despite Egypt's decision to eliminate all swine from the country, people can still eat pork without contracting the swine flu. The American Heart Association may advise moderation, but this flu is entirely unrelated to pigs. Still, the pork industry and health officials are going to have to come up with a catchier name than "2009 H1N1 flu" if they want us to stop calling it "swine flu."

Epidemic or Pandemic? An epidemic means that more cases are occurring than predicted. With seasonal flu, epidemiologists have so much experience that they can usually predict the number of cases fairly accurately. The number they are seeing right now wouldn't even be noticeable in the middle of flu season, but this one was winding down for the year. Since this is really a new type of flu, the CDC don't yet have the experience to predict a "normal" season or number of cases.

A pandemic occurs when a disease covers a large geographic area, such as a continent, or multiple continents, as this one has. The common cold is a type of pandemic, though we usually don't bother to call it that. Neither word actually refers to the severity of the disease, the likelihood that a sufferer will end up in the hospital or even die.

So what about the rising number of cases? If that makes you nervous, stop watching them, because the numbers will rise steeply with every re-count for the foreseeable future, whether this is a killer flu or of ordinary severity.

On April 29, 2009, the WHO raised the level of alert to "phase 5. "What does that mean? Phase 4 meant human to human transmission, phase 5 means the same thing, but in more than one country, phase 6 will mean clusters of cases, outbreaks, in more than one country. Phases 7 and 8 describe the trailing off of the disease.

So, is it going to get worse, or go away? It may do either. The behavior of flus is variable, and epidemiologists don't have enough information yet to predict this one's course. Almost any scenario imaginable could occur.

At a Senate hearing Wednesday, convened on short notice in response to this flu, John McCain (R-Ariz) asked, "Should we close the borders?"

"No," Richard E Besser, MD, Acting Director, Centers for Disease Control and Prevention, HHS,responded. That was tried during the SARS outbreak, and it appears to have been unsuccessful. Simulations suggest that closing the borders would have little, if any, effect on limiting spread, and it would tie up massive resources that could be put to much better use elsewhere. If we had been one of the later countries to be hit, we might have tried closing the borders to buy a few more weeks to get ready, but even then the gain would be slight, Besser said. The World Health Organization concurs.

That led Sen. Richard Burr (R-N.C.) to ask about resources. Besser told him that stockpiles of antivirals , masks, and respirators are sufficient, because they had been bought when funding was better. Recent cutbacks have cost public health thousands of jobs, lost or threatened, and have made it harder for states to exercise their pandemic control plans.

The Office of the Biomedical Advance Research and Development Authority , which prepares contingency plans and caches supplies, has never had its own funding, but has receives sporadic money from NIH, according to Fauci.

In his 100 day address last night, President Obama re-iterated many of these points, saying "We are continuing to closely monitor the emergency ... (This is) obviously a very serious situation," adding that schools with confirmed or suspected cases should close temporarily.

Obama is requesting $1.5 billion for the further stockpiling of medicines and equipment, and for logistical support. He echoed the CDC and WHO by reminding people, "I've asked every American to take the same steps you would take to prevent any other flu: Keep your hands washed; cover your mouth when you cough; stay home from work if you're sick; and keep your children home from school if they're sick."

Readers: Please send questions, tell us what you need to know.

A Swine Flu Primer

Coffee Brown, MD, University of New Mexico, Talk Radio News Service

Is swine flu the pandemic we know is coming? According to federal agencies and a blue-ribbon panel of experts: maybe. The situation is early enough and changing fast enough that we can reasonably hope for the best even as we plan for the worst. This primer is designed to help you do just that. We will continue to post updates. The short answer is that basic hygiene is the most important thing to concentrate on.

The swine flu is a virus, not a bacteria, therefore, antibiotics are not useful against it.
The virus is Influenza A (H1N1), meaning that not all flu is this particular swine flu, and not all respiratory viruses are this virus. This virus has elements of human, avian, and swine flu virus genetics (i.e., not human genes, or bird or pig). There is little or no current human resistance to this strain. Pork is not in any way associated with this virus at this time. raising pigs or eating pork are not thought to carry any risk whatsoever for this infection.

Well then, what can you do? For now, treat this as good practice, not just for the WHO and the CDC, but for each individual: Wash your hands frequently, cover your face when you sneeze or cough, wash your hands after doing so, and demand the same courtesy from those around. Clean doorknobs, faucet handles and similar items that are touched by many other people. Avoid unnecessary travel to Mexico, Avoid work, school, or gatherings if cases have been reported in the immediate area, or if you have any infectious symptoms. Working while ill is not the heroic thing to do.

Should you go to work or school? Yes, with these exceptions: If you have any respiratory symptoms or if swine flu has been identified in your immediate community. These are also the circumstances which would support wearing a mask or avoiding gatherings.

What symptoms should you look for? If your are worried about a contact, symptoms should begin within 7 days. Symptoms should include some combination of the following:
Respiratory symptoms, like sniffles, congestion, cough (typically not productive), or sore throat, are almost always present. Fever, muscle aches, chills, fatigue and malaise are frequent, Occasionally nausea, vomiting, and diarrhea. If you believe you may have the flu, your doctor can test for it.

Currently available antivirals are effective against this strain, and a quarter of government stockpiles, totaling about 11 million doses, have been released from government stockpiles to communities for treatment and prevention. Protection lasts about 10 days. Your has physician has specific guidelines for the use of these medicines, They should NOT be used “just to be sure.”

The current flu vaccine is not effective against this strain. A new vaccine is under consideration, but will not be available over the short term. First steps, distributing a “seed virus” to pharmaceutical companies to create pilot batches of vaccine, have begun. The pilot batches need to be tested for safety and effectiveness before full-scale production is requested. By the time that decision can be made, the pattern of this disease will be much more clear. The whole process takes several months before vaccines are available to consumers, which means it will not be available during this season. The vaccine may still be important, though, because history shows that a second or even third wave may present during fall and/or winter.

Sen. Arlan Specter (D-Penn.) attended today’s hearing briefly to emphasize the need to balance fully informing the public with the need to keep the problem in perspective.

What is the government doing about this? Plans have been long since prepared for just this situation, supplies, like antivirals, masks, and respirators have been distributed by the CDC and FEMA. Daily updates are being distributed to healthcare workers all over the country. The CDC advises a regional containment strategy, varying the level of response to the local pattern of illness. Increased screening of arrivals from out of the country, or travel restrictions within the country, would not be expected to reduce the spread.

We are on Stage 4 alert, per the WHO, how bad is that?
It simply means that there definite cases of human-to-human transmission, Stage 4 does not mean that the disease has become more severe.

All the really sick people are in Mexico. It is not known why the most severe cases appear to be confined to Mexico so far, but the CDC expects some severe cases to occur here as well. How worried should you be? Think of this as similar to an orange level terrorist alert. The emergency designations allow government resources and authorities to be positioned before a disaster occurs.There is a real possibility that the outbreak will worsen, but for now, it’s a matter of being ready. Of the 40 American cases as of last night (04/27/09), one has been hospitalized, none has died, the rest have been mild.

As of 04/28/09, 64 cases had been confirmed, and five Americans hospitalized. These numbers will be outdated by the time you read them. What does that signify? This is an expected event: more cases will be discovered each day for a while, and therefore more hospitalizations. The percent who become severely ill may go up, if this turns out to be highly contagious and virulent, or may go down, as screening picks up more of the milder cases that would normally go un-noticed. The ultimate pattern is not clear this early, but all government agencies are taking the possibility of a true pandemic seriously, and individuals should do the same. States and municipalities should review their infectious disaster plans.

Because of increased attention and the need to report new developments rapidly, expect conflicting information and ongoing reappraisal.

Harkin asked the panel whether funding is adequate for their response. they responded collectively that past funding has made it possible to begin work on a vaccine, and also enabled surveillance that Schuchat said lead to the virus beginning analysis in the U.S. before Mexico sent specimens to Canada for identification. Harkin said that he was disappointed that Mexico considered American bureaucracy a stumbling block, and that he would follow up on that. The panel also told him that reduced funding undermined the states’ ability to operate existing epidemic plans, had cost PHS 12,000 employees.

This Information is from The Centers for Disease Control http://www.cdc.gov/swineflu/ ,the World Health Organization’s http://www.who.int/csr/don/en/ Dr. Richard Besser and the Senate Appropriations Committee Chaired by Sen Tom Harkin (D-Iowa).
Witnesses included: Rear Adm. Anne Schuchat, interim deputy director for Science and Public Health Program at the Centers for Disease Control and Prevention; Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases; and Paul Jarris, executive director of the Assn. of State and Territorial Health Officials.