We’ve JUST TODAY added a new feature to the Guilford County Department of Public Health website (www.guilfordhealth.org).  If you look at the top right corner under “Event Calendar” and “County Main”, you will see a Halloween orange button.  The button is labelled “H1N1 & Seasonal Flu Vaccine Availability – Click Here”.

Go ahead…click there and I’ll wait….

Okay back now.

Well, as of today, the pickin’s are kind of slim.  BUT we are expecting to receive a shipment of H1N1 vaccine next week and a larger one the week after.  So when we get vaccine, we will put the information out to you here (as well as other ways).  But if you want to know if and when we are holding clinics…that’s the best place to look first.

There seems to be a routine forming by which we (the Guilford County Department of Public Health) are finding out about flu vaccine availability. Each Friday afternoon we are receiving reports from the state immunization branch telling us how much flu vaccine will be coming our way the next week.

The first week we received 2100 doses of FluMist (the nasal form). The second week we got 1600 doses of injectable vaccine in multidose vials. The third week (which was last week) we didn’t get any. (But other clinical services in our community received some.)

Last Friday we learned that we will be getting 400 doses of injectable in multidose vials sometime this week. We’ll know when we will get the vaccine, when we see it on the truck.

And that process seems to be how it will be for the next few months. Although there are national projections of vaccine supply running out into early December, and we can estimate how much the county will get over that time, we don’t know how much we at the health department will see beyond next week. We’re learning how much we will get one week at a time.  That makes planning large clinics impossible.

What vaccine we have been given so far is either up some little one’s nose, in some little one’s arm, or is promised to someone who has made an appointment with us. We dearly would love to have an open walk-in clinic or four to get the vaccine out as fast as we can to as many as we can…but we don’t have enough vaccine to do so. I’ll let you know as soon as that is possible…hopefully next week….or the next.

And remember we are not the only folks in the county getting vaccine this week. With 6400 doses in various forms (multidose injectable, single dose prefilled injectable, and nasal doses) coming to our county, we’re still chipping away at the epidemic.

I remain focused on getting vaccines into school-age or college-age children and pregnant women. The schools are where the tipping point of this epidemic resides.  The health department will continue to survey the community for providers needing vaccine and we have and will continue to share what we get with others.

I thank you for your patience.

It has been bothering me over the last several days that the language we use to describe influenza vaccinations is really negative. When we give someone an influenza immunization we tell them we just gave them a flu “shot”. The British call it a flu “jab”. Both terms are subtly violent. I shot someone or I jabbed someone. It just sounds bad.

Now I’ve been trying to come up with a substitute word that embodies the intent of the action. We really are expressing concern and our desire is to prevent harm for the person. But giving someone an influenza “kiss” or “hug” just sounds silly.

Of course if we change things now, we may see the same problem with language that happened early in the spring when swine flu first started. People, like me, labeled the virus “swine flu”. Because there was great concern within the farming communities that the pork industry was going to see sales decline, CDC began struggling to find a substitute term. Unfortunately, they came up with “H1N1 novel influenza virus”. So in every conversation and publication since that decision the comments go like this: “The H1N1 novel influenza virus”….”huh”….”You know, swine flu”…”oh, yeah”. That’s why in most of this blog I continue to call it swine flu because that’s how most people remember and differentiate influenza viruses.

But I think it would help a great deal if we came up with a new name for the flu shot or the flu jab. I’m not even happy with calling it a “vaccine”. You see the origin for “vaccine” is a Latin term, “vacca”, which means cow. The first real vaccination was cowpox; used to eliminate smallpox. So since other immunizations don’t come from cows, they really aren’t technically vaccinations. They are immunizations. But in reality there isn’t anything to be gained by taking on that battle, so we’ll use the term vaccination a lot in this blog.

So, help me think of a new positive word to describe this truly life-saving miraculous act, that of giving a vaccination.

I don’t remember where I read this story.

A man owns a ranch. He has a wife and a son. One day his horse runs away. The wife and son are distraught. Without the horse there is no way to ride to town to get supplies. The wife says to her husband, “we are done for”. The rancher says, “Maybe yes, Maybe no, Time will tell”.

The next day the horse returns leading twelve other horses. The son is elated. “We’re rich now with thirteen horses.” The rancher smiles and says, “Maybe yes, Maybe no, Time will tell”.

So the son starts to tame the wild horses. He falls off the horse, breaking his leg. His wife says, “we are done for”. The rancher says, “Maybe yes, Maybe no, Time will tell”.

So the next day an army comes through the region, conscripting all able bodied young men. They find the son with a broken leg and pass on. The boy is left at home. The wife celebrates, “Our son is safe and all is well”. The rancher says….well you can guess.

I was reading the Scientific American that arrived today. An article by Christine Soares entitled “Pandemic Payoff” (Scientific American November 2009 page 19-20) explains that the current H1N1 novel influenza virus is the progeny of the 1918 virus. More pertinent to our story is her discussion of how the current virus has not caused the same level of devastation as that of the 1918 one. Clearly the virus does not have the virulence of the 1918 strain, but there is also measured immunity in people older than 60 (see MMWR 2009;58:521-24). Although it is not clear where the immunity arose, some might well be associated with receipt of the swine flu vaccine. At the time the 1976 swine flu vaccine campaign was halted as a failure (see the IOM report).

Perhaps now we should say, “Maybe yes, Maybe no, Time will tell”.

There seems to be no topic that is more polarizing than mandatory vaccination of healthcare workers.

Truth be known the conversation has been ongoing for years. Dr. Gregory Poland has been a pioneer in leading the discussion about the appropriateness of mandating vaccines. (see Gregory Poland and others. “Requiring influenza vaccination for health care workers: seven truths we must accept” Vaccine 2005;23:2251-5. Much of my own understanding of the issue and the discourse that follows are derived from his convincing arguments.)

In 2006, I attended a meeting at the annual SHEA conference (Chicago) in which Dr. Poland had reviewed his article. Another speaker at the same meeting told a story I will not forget. A man at her hospital had undergone a liver transplant and was wheeled from the OR into the recovery room. The nurse receiving the man was wrapped in a blanket and told the patient and his family that she felt she should really be home. She was having chills from fever and aching all over. But because the postop area was understaffed, she felt she had to be there to struggle on in the shortage.

Well the man contracted influenza and died during that hospitalization.

So the true story illustrates what happens too many times in hospitals across our country every flu season.

Although health care workers have professed that their unwillingness to get the influenza immunization is an individual rights issue, the requirement of medical personnel to get the seasonal (and H1N1) vaccine is actually a patient safety issue.

We are all welcome to our own opinion. Indeed, this blog exists as a vehicle for me to tell you my opinion about things and for you to express your opinion back. But let’s start with a the seven truths according to Dr. Poland (with which I heartedly agree):

1. Influenza infection is a serious illness causing significant illness and death every year.

2. Influenza infected healthcare workers can and do transmit influenza to patients.

3. Influenza vaccination of health-care workers assures that in the midst of an influenza epidemic that there are health care workers available to care for the sick.

4. Influenza vaccination of health-care workers is already recommended by multiple authorities including the Centers for Disease Control and Prevention, the Infectious Diseases Society of America, and the Society for Healthcare Epidemiology of America. Despite these authorities, voluntary healthcare worker immunization rates have been poor uniformly.

5. Mandating vaccines in order to work obviously does provide the needed herd immunity for a hospital. (It is estimated that you have to have at least 90% of your healthcare workers vaccinated in a hospital to provide protection for patients.)

6. It’s really not an issue about individual rights. It’s an issue about protecting the most vulnerable among us. Healthcare workers have an ethical responsibility to do no harm. Transmitting influenza is doing harm even if it is unintentional. Vaccination markedly diminishes the probability that transmission will occur.

7. In the few hospitals that have already mandated vaccinations, there is a huge outcry of resentment and opposition to the requirement. But after the first year or so, tempers calm and healthcare workers realize it’s not such a big deal after all.

From my standpoint I understand. I hate being told what to do even when it’s in my best interest. However I’ve been getting influenza vaccines for as long as I can remember. Every time I get a vaccine for influenza admittedly there’s that little twinge of doubt. But when I remember that I’m not really doing it for myself and I’m doing it for others, there is no question that I’m doing the right thing.

Let’s hear what you have to say.

Influenza is now widespread in North Carolina. We are seeing continued activity in the schools, our hospitals, emergency rooms and private practice clinics. Although I hear rare reports of influenza viruses other than swine flu in Guilford County, the vast majority of flu that is circulating is swine flu. So the story in October 2009 is the same as it’s been all summer. “If you have the flu… meaning if you have fever, cough, sore throat, headache, muscle aches… then you have swine flu.”

At this point in time the only cultures that are being done for swine flu are being done on patients who are so sick that they’re admitted to the intensive care unit. When I met with infection control folks from the hospitals last week I found out that many people are on ventilators and had either tested positive for influenza or are waiting for influenza tests to confirm the suspicion that they have the flu. Influenza is not a big deal. Influenza is an ordeal.

Now the CDC has been monitoring this virus very closely. They have been looking for changes in the makeup of the antigens. Fortunately there have been no reports of significant changes in the virus. This is good news so far. It means that the virus is not becoming more deadly nor is it drifting away from the swine flu vaccine. We do know though that this summer one of the camps in or around Asheville had an outbreak of swine flu. They put the campers and counselors on tamiflu to prevent them from getting sick. Two of the campers got sick anyway. They were able to culture influenza from those two and found to no surprise that the virus had developed resistance to the antibiotic. Doctors were given a word of caution from the state health department to reserve Tamiflu for those people who were sick. Since the summer I haven’t seen other reports of resistant virus.

We shouldn’t be surprised when in the coming months seasonal influenza start circulating in our community as well. Historically seasonal influenza usually starts happening in midwinter. Indeed on average it usually peaks some time in February or March. But then history has told us that flu doesn’t circulate in the summer. From a public health standpoint this is a teachable moment. Influenza is lived in the present and understood in the past.

In the past, shift viruses like swine flu tend to come in waves and hit children the hardest. Those tendencies seem to be playing out again with the swine flu virus. We’re seeing the second wave of the epidemic happening right now. We had the virus enter North Carolina in April, smolder during the summer and then reach a conflagration when the schools reconvened. There may be other waves; there’s no way to predict with flu. But it’s clear that we are seeing our children suffering the brunt of the infections. Almost all of our schools have seen absentee students with the occasional teacher sick as well.

Back in the spring the CDC took blood samples from people 65 years and older. They checked the blood for antibodies to the current swine flu and found them in the majority. Whether these people have antibodies from seeing other influenza infections, other influenza vaccines or the 1978 vaccine campaign is unknown. But it is reassuring that we probably don’t have to vaccinate everyone in the community, at least not everyone over 65.

Years ago Japanese doctors had the idea of taking the seasonal influenza vaccine and giving it to schoolchildren. They gave it to almost all their schoolchildren. They then found that influenza rates in grandparents and parents plummeted. Since children live in a unique world and have contact with each other in ways more intimate than adults, they are the prime movers of influenza in a community. If they are adequately protected from influenza, the adults are as well.

So we just got the projections of influenza vaccine coming to Guilford County over the next several months. I had anticipated that we would get a couple of small deliveries and in one big massive bolus of flu shots; enough for everyone in the entire county. But the projections tell a different tale. It looks like we’re going to be getting several thousand doses each week through December. Although there may well be more coming after the first of the year, we definitely must prioritize who gets the vaccines first. I’m putting school children and college kids and pregnant women first. The children are the ones getting the brunt of the illnesses, they are likely the epicenters of transmission and they have suffered most of the casualties. Pregnant women, if sick, have four times the probability of ending up in the hospital. So those are my choices of who should be first in line.

What do you think?

I just received an e-mail from the state Department of Health and Human Services, North Carolina. After thinking about it for months the CDC decided to stick by their policy requiring N95 masks when healthcare workers attend to patients with or suspected to have influenza.

Let me explain. There are two kinds of masks used when a doctor or nurse go into the room of a patient with infection. Surgical masks are the most common. Generally you’ve seen pictures all along of operating rooms where doctors are wearing these masks while working. Surgical masks are comfortable and work exceedingly well to prevent breathing in most infections, and keeping surgeon’s spit out of the operating field.

But if the infectious agent is carried in really tiny droplets (like TB or chickenpox), then you need a mask with really tiny filters. These masks are called N 95 masks. These special masks have to be fitted and tested for each health care worker. They fit tightly around the face and, although not impossible to wear, are generally more uncomfortable. They are also more expensive. And they are in really short supply across the nature.

Since April the state Department of Health and Human Services has been heroically reasonable and rational. They have countered the standing CDC policy requiring N95 masks for influenza and they have given permission for hospitals including ours to use surgical masks for influenza care. That was a sensible thing to do.

But as the CDC repeated their policy this last week and double dog dared the use of surgical masks, our state department of Health and Human Services has backed down. It’s tough to go it alone against the CDC. In fact, it’s illegal in North Carolina for them to do so. Since it is truly difficult for our state to have laws governing the treatment and prevention of every infectious diseases, our law says that whatever is good for the CDC is good for us. State legislation requires that the Department of Health and Human Services follow CDC guidelines. So DHHS really didn’t have a choice in the matter.

So what this means locally is that all our county hospitals must now struggle to find enough N95 masks to allow every healthcare worker caring for influenza patients to have one. That’s not going to be easy because most distributors are out. If the North Carolina Department of labor occupational safety and health gets sticky about it they can fine hospitals if they find them not using N95 masks.

One more challenge to the influenza epidemic.

What do you think?

You may have heard about the report from Harvard University. Researchers there did a telephone survey where they asked people whether they would take the swine flu vaccine when it arrived. A depressingly large number said “No”. The prevailing reasons given were that people don’t believe swine flu is a big deal. And they are concerned that the vaccine isn’t safe.

Along these lines, I had an e-mail forwarded to me that reported that the federal government was covering up an epidemic of Guillain-Barre Syndrome due to the vaccine. The e-mail only took three or four sentences to write and one button to send to every email box on the planet. The truth and rebuttal took me three or four pages. I give you the shortened version of what I wrote back to my friend.

Swine flu isn’t a big deal; it’s an ordeal.

Now flu vaccines have been given for decades. No one has an absolutely accurate tally but you can estimate that it’s been given hundreds of millions of times. So we know a lot about what to expect when you give a flu shot. There really aren’t that many surprises left with flu vaccines. You can expect that you may have a sore arm. A minority of us will run a low grade fever that will go away with a nap and Tylenol. And that’s what nearly all of us can anticipate following an injection with an influenza vaccine.

But then there are rare events that occur in and around the vaccine season. That’s where the confusion arises.

Many years ago I found a library book called something like the Physics of Music. Now before I went to school for Masters degree in public health I played in a jazz band called the Larry Tate Quartet. Being both a saxophone musician and scientist I thought this would be a great book to read. In reality I found it incomprehensible. Although Richard Feynman is one of my heroes, I don’t understand what he did. It was a lot of equations about waves, harmonics and stuff that really wasn’t very jazz like. But I do remember the introduction to the book. The author told the story that aborigines in Australia used to think that solar eclipses were due to gods eating the sun. And the way to get the sun back was to beat drums and shout. For thousands of years their observations indicated… that they were correct. You do get the sun back by scaring away the demons.

What this points out is the problem people have about temporal causality. We have as humans the tendency to attribute anything that happens to us to what just happened. And for the most part, this works well. If you go out in the forest picking berries and leaves for dinner… and after dinner you get sick… you’re not likely to want to eat those very same berries and leaves again. Or so it might seem reasonable. But what may have happened and you didn’t realize was that there was a norovirus circulating in your village at the same time. Rather than being sick from what you ate you were sick from an invisible virus.

People don’t carry flight recorders, much less microscopic flight recorders. When we blame leaves and berries for our norovirus illness, we abandon a good food source and have to spend time looking for something else to eat. Of course, I’m using this just as an example.

So let’s look at vaccines and Guillian-Barre Syndrome.

GBS is an illness where the body’s immune system attacks its own nerves. GBS manifests by weakness and paralysis that starts in the feet and works upward. It’s rare and sporadic. What I mean by “sporadic” is that it happens unpredictably in scattered time and locations. So if you take any time period or place, you might by chance alone see one case of GBS. GBS tends to occur during the months when there are respiratory viruses circulating in the community. So when do we give flu shots? We give flu shots during the time when there are respiratory viruses circulating in the community and when there might be GBS on its own.

So if you give 100,000 doses of vaccine and you see a case of Guillain-Barre syndrome, you can’t tell what caused the GBS. The vaccine was given a few days, a few weeks or even a month before the first signs of weakness developed. But just like the gathering of leaves and berries, just like shouting at the demons eating the Sun, we humans think that something that happens to us must be due to what just happened. So we’ll blame the flu shot for the GBS, when it wasn’t the shot’s fault.

Now there are some bacteria that have proteins that look a lot like proteins in the spinal column. So it might make some sense that when a human gets infected with the bacteria they would make antibodies to the spine proteins and get into trouble. But there aren’t any proteins in the influenza virus that looked like us. It doesn’t make biologic sense to point to the influenza vaccine as a cause of GBS.

So I was intrigued to read the e-mail saying that the government was covering up an epidemic of GBS due to the swine flu vaccine. First the government doesn’t track GBS. They don’t have any numbers to hide. Second the CDC and the FDA are populated by people whose sole intent is to help people. They prevent disease. They monitor drugs for safety. They may not always reach their goal. But they are not evil. I have friends who do and have worked for the CDC and FDA. Anyone who works for the government, including myself, seems to be fair game for any made-up rumor. But it’s not true and it’s not fair to declare something is a “governmental coverup” as if that’s just common knowledge.

We gave our first H1N1 vaccines last week. The lag time between antigen exposure and GBS even if it were to be a cause is several days or weeks. So the email claimed that the government was covering up an epidemic of a disease that takes days or weeks to develop caused by a vaccine that hadn’t been given yet.

What do you think?

Let’s start a conversation together, you and me.

I’ve had the rare privilege of being a doctor for thirty years. I became a “bugdoc” twenty five years ago.

There was a textbook of infectious diseases that I remember reading in my internship. It said that infectious diseases were unique among illnesses in that most were curable. I liked that idea. I liked the idea of studying diseases that came to us out of the mist of antiquity and others that were just found out yesterday.

In just the last few years, I’ve cared for a person who had leprosy. I’ve cared for people with Lyme’s disease and hundreds of people with HIV. I also directed the Infection Control program at Moses Cone Health System for a decade.

I left Moses Cone almost two years ago to follow a different path. I’m in the midst of obtaining a master’s degree in the School of Public Health Education at UNCG.

In April 2009, I became the Medical Director of the Guilford County Department of Public Health. A few weeks after starting my job, swine flu (H1N1 novel influenza virus) came to Guilford. It’s been a busy first few months as your medical director.

We’ve got a lot to talk about. Since, I don’t have a house big enough to have you all over to dinner, we can use this web log (blog) to chat about what interests you about your health, what you’ve heard about that might be bothering you. I’ll do my best to answer your questions. Chances are I’ll have to tell you, “I don’t know”….a lot. But I’ll do my best to find out the answers…because part of the fun of Infectious Diseases and public health is finding out what you don’t know and then looking for the answers.

But let’s agree first on some boundaries.

The most important rule is let’s be kind to each other. I’ll do my best to respect your opinion. If you disagree with what I say that’s fine; indeed I’d rather read a comment that disagrees with what I say and tells me why than one that just says “fine”. Let’s find out why we disagree and maybe we both can learn something new.

Askguilfordhealth.com is a moderated blog. That means that I want your comments and I will read your comments… but I need to approve them before they are posted. I will not censor something just because I don’t agree with it. To quote Arianna Huffington’s advice, I will delete comments that:

• are abusive, off topic or use excessive foul language.
• use ad hominem attacks, including comments that celebrate the death or illness of any person, pubic figure or otherwise. (”Ad hominem” means “against the man”. For example, I prefer that you say “Ward, I don’t agree with your statement about holding off on vaccinating health care workers until children receive the swine flu vaccine, because….”. I will delete the comment that says, “Ward, I think you are an idiot” for saying that”. See the difference?)
• contain racist, sexist, homophobic or any other slurs.
• are solicitations and/or advertising for personal blogs and websites.
• use thread spamming
• are posting with the explicit intention of just being provocative

I’ve lived in Guilford County for twenty one years and intend to retire and die here. You are my family and my neighbors. Let’ find out together how we can make this a better place.

I’ve already written a few posts to get us started. Let me know what you think.

Ward