CR Poll: Americans unsure about getting swine flu vaccine

September 30, 2009

News about the swine flu and the H1N1 vaccine permeates airwaves and news headlines all over the world, but Americans aren’t so sure about whether they’ll get the vaccine when it becomes available this fall. According to a new poll conducted by the Consumer Reports Health Ratings Center, the majority of U.S. adults say they are either reluctant or unsure about whether they or their children will get vaccinated for the swine flu.

Just 34 percent of Americans said they definitely planned to get the swine flu vaccine, while 21 percent said they would not. Forty-three percent said their decision would depend on how things go. And though children are among the groups given priority for swine flu immunization, many parents said they were unsure about what they would do when the vaccine becomes available.

And all the uncertainty about whether or not to get the swine flu vaccine appears to be linked to the confusion over risk. Of the adults we polled, more than half of the people at high risk for flu complications don't realize they are. Among people who classified themselves as high risk for swine flu complications, 60 percent in our survey said they would definitely get vaccinated, and 29 percent said it would depend on circumstances. But more than half (55 percent) of those who reported that they had medical problems such as diabetes, asthma, or heart disease didn't realize that their medical conditions put them at higher risk. Meanwhile, the Centers for Disease Control and Prevention specifically recommends it for about 160 million Americans, including health-care and emergency workers, pregnant women, people who live with or care for children under 6 months of age, young people from 6 months through 24 years old, and adults ages 25 to 65 who have an underlying health condition or compromised immune system.

Take a look at the results of our swine flu poll, and tell us if you’ll be getting the swine flu shot when it becomes available this fall. Why or why not?

CIDRAP: First H1N1 vaccine doses headed to states, cities

Robert Roos News Editor

Oct 1, 2009 (CIDRAP News) – The first 600,000 doses of pandemic H1N1 vaccine—all of them the nasal-spray formulation—are on their way to 25 states and major cities and should arrive by Tuesday, Oct 6, matching earlier predictions, federal health officials said today.

"We are transitioning from the planning to the implementation phase" of the H1N1 vaccination effort, Dr. Anne Schuchat of the Centers for Disease Control and Prevention (CDC) said at a news briefing.

States and large cities began placing orders for vaccine yesterday, said Schuchat, who is director of the CDC's National Center for Immunization and Respiratory Diseases. She didn't name the states or cities, but urban areas that work directly with the CDC program are Washington, New York, Chicago, and Los Angeles County.

"Vaccine ordered yesterday should be arriving out to the sites by Tuesday," she said. "We're really pleased that this is starting, and it's earlier than we were planning."

In response to a question about when the doses will become available, Schuchat said, "There's a good chance they'll be available later next week in a lot of the sites."

CDC officials have been predicting that the earliest doses would reach providers in early October. CDC Director Thomas Frieden said last week that the first doses could reach providers as early as Oct 6.

Schuchat said that—as predicted previously—all of the earliest doses will be the live-virus nasal-spray vaccine, which is made by MedImmune. Like the company's seasonal vaccine, FluMist, it is approved for healthy people aged 2 through 49 years, but not for pregnant women or people with chronic conditions that raise their risk for flu complications.

"We believe a lot of the states will be directing those early doses to healthcare workers," Schuchat said. "There's a bit of a myth out there that the workers shouldn't get the live vaccine, but that's a myth. Most healthcare workers who are under 50 and don't have those chronic conditions can receive the nasal spray."

She said the CDC plans to release information each Friday on how much vaccine was available for ordering and how much was shipped to each of the states and large cities, as of the preceding Wednesday.

The CDC has contracted with McKesson Corp. to distribute the vaccine doses to vaccination sites designated by state health departments. McKesson also distributes vaccines in the CDC's Vaccines for Children program.

Schuchat cautioned that the vaccination drive will face some bumps in the road. "At the beginning we'll have a bit of a slow start. But we've ordered enough [vaccine] so everyone who wants to be vaccinated can be."

HHS releases children's Tamiflu to states
In other comments, Schuchat said Health and Human Services Secretary Kathleen Sebelius has released 300,000 pediatric doses of the antiviral drug Tamiflu (oseltamivir) from the national stockpile for distribution to states that may need it.

"Basically each state that needs their proportion of that supply will receive this Tamiflu over the next week," she said.

The CDC said earlier this week that Tamiflu for children could run short as the flu spreads and advised that pharmacists may need to formulate the medication, sold as a liquid, on site by mixing the adult formulation with other ingredients.

"Some of the liquid formulation will have an expiration date that may have passed, but the FDA [Food and Drug Administration] has extended the expiration date of those courses after careful testing," Schuchat said today.

She reported that Texas and Colorado have already requested and received allocations of the liquid antiviral, getting 22,000 and 4,600 doses, respectively.

Death toll in pregnant women rises
On another topic, Schuchat updated the CDC's numbers on H1N1 complications in pregnant women. As of late August, 100 pregnant women in the United States had required intensive hospital care for H1N1 and 28 had died, she said.

On a conference call with clinicians earlier this week, CDC officials said that about 5% of H1N1 deaths have been in pregnant women, though they make up only about 1% of the population. As of Aug 20, 24 of the 484 deaths in the country involved pregnant women, officials said.

"The H1N1 influenza in pregnant women has really been striking," Schuchat said today. CDC obstetricians have been talking to "doctors around the country who have never seen this kind of thing before."

She added that the CDC has not previously tracked seasonal flu complications in pregnant women, so it's not entirely clear if complications are actually much more common with the new virus or if it just seems that way because of increased surveillance.

CIDRAP: Preparedness report spells out H1N1 challenges

Lisa Schnirring Staff Writer

Oct 1, 2009 (CIDRAP News) – Though the nation is going into its second wave of the H1N1 pandemic armed with crucial improvements such as better vaccine capacity, remaining challenges in medical surge and vaccine distribution could hamper response now and into a third wave, preparedness experts said today.

Hospitals across the nation vary in their ability to bear the burden of mounting H1N1 cases, the experts said at a press conference during which they unveiled a 38-page report from Trust for America's Health (TFAH), a nonprofit, health advocacy group based in Washington, DC.

Fifteen states, including Arizona, Connecticut, and Oregon, could run out of hospital beds by the fifth week of the second wave if 35% of the population gets sick with pandemic flu. Twelve states—among them New Mexico and North Carolina—could reach or exceed 80% of their capacity.

Jeff Levi, PhD, TFAH executive director, said some health facilities in big cities were overwhelmed during the early stages of the pandemic. "Our point is that how readily even a mild pandemic can overwhelm the system," he said. "We need a better system for addressing these issues, and some states are beginning."

TFAH authors based their projections on a 35% attack rate, which is a planning projection at the low end of the range of scenarios included in an Aug 24 report by the President's Council of Advisors on Science and Technology (PCAST). The TFAH authors used the Centers for Disease Control and Prevention's (CDC's) FluSurge modeling program to estimate the number of hospitalizations in each state.

However, they said erosion of the public health funding and workforce that has accelerated over the past few years will make it difficult to meet the challenges, unless steady federal funding streams, such as those that support police and fire services, are established for public health departments.

Robert M. Pestronk, MPH, executive director of the National Association of County and City Health Officials (NACCHO) said periodic funding infusions are important, but the approach isn't helping build a strong public health system. "There isn't any end point in preparedness. It requires sustained funding," he said.

According to a recent survey from NACCHO, budget cuts forced public health departments to eliminate 8,000 positions between January and June of this year, which reflects a larger loss than all of 2008.

Levi said a strong pandemic vaccine delivery performance from states might help blunt some of the impact on hospitals. However, a 2008 federal report on state pandemic plans revealed that 21 states had gaps in their preparations to handle mass vaccinations. "It's a complicated task, even in the best of circumstances," he said.

Adding to the vaccination challenge, public health officials may have a hard time reaching risk groups with vaccine messages, because some in the priority scheme, especially children, young adults, and members of minority groups, haven't routinely been targeted for seasonal flu immunization, Levi said.

He added that public health systems can also help reduce the burden on hospitals by getting higher-profile messages out about when to seek medical care for pandemic H1N1 infections,

• Some of the other pandemic challenges addressed in the TFAH report include:
• Antivirals: some states have limited stockpiles because of budget constraints and other obstacles
• Surveillance: current systems are outdated, don't track flu in real time, and aren't ideal for identifying clusters or monitoring severity
• Medical equipment: 25 million N-95 respirators were released from the federal stockpile at the beginning of the outbreak, with no action to replace the supply, which could be difficult because of limited availability.

Today's TFAH report included recommendations to improve response to the current and future pandemic waves. For example, the authors recommended that states and localities refine their plans for rapid vaccine distribution and that the federal government allocate more resources for vaccine delivery, especially if insurers don't provide adequate coverage.

The experts urged public health department to extend their vaccine campaigns beyond the flu season to help prepare for a potential third wave of the pandemic.

States should at least purchase enough antiviral supplies to cover their at-risk populations, and the federal government should consider making antiviral stockpiling solely its responsibility, the report advised.

Though federal officials have been working hard to improve surveillance to monitor the spread of the pandemic H1N1 virus, the TFAH authors said officials should consider funding and implementing detailed surveillance improvements outlined in the PCAST report.

Longer-term improvements should include the establishment of regional consortiums to organize and plan for health emergencies, as well as redoubled efforts, such as overtime incentives, to develop a medical surge workforce.

The most important improvement, though, would be a steady funding stream to support public health preparedness, Levi said. "We're trying to surge a public health system that has been critically hampered," he said.

Seasonal Vaccine "FluMist" and Swine Flu "FluMist" Do Not take together

Excerpt:

Can seasonal vaccine and novel H1N1 vaccine be administered at the same time?

Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine

http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm



Key Facts About Seasonal Flu Vaccine
excerpt:

There are two types of vaccines:

* The "flu shot" — an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions.
* The nasal-spray flu vaccine — a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine" or FluMist®). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant.

http://www.cdc.gov/flu/protect/keyfacts.htm


And this:

Influenza A (H1N1) 2009 Monovalent Vaccine (MedImmune LLC)

INDICATIONS AND USAGE---------------------------
Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal is indicated for the active immunization of individuals 2-49 years of age against influenza disease caused by pandemic (H1N1) 2009 virus. (1)

http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm181970.htm

CDC: 2009 H1N1 Influenza Vaccine

September 29, 2009, 11:30 AM ET

What are the plans for developing 2009 H1N1 vaccine?

Vaccines are the most powerful public health tool for control of influenza, and the U.S. government is working closely with manufacturers to take steps in the process to manufacture a 2009 H1N1 vaccine. Working together with scientists in the public and private sector, CDC has isolated the new H1N1 virus and modified the virus so that it can be used to make hundreds of millions of doses of vaccine. Vaccine manufacturers are now using these materials to begin vaccine production. Making vaccine is a multi-step process which takes several months to complete. Candidate vaccines will be tested in clinical trials over the few months.

When is it expected that the 2009 H1N1 vaccine will be available?

The 2009 H1N1 vaccine is expected to be available in the fall. More specific dates cannot be provided at this time as vaccine availability depends on several factors including manufacturing time and time needed to conduct clinical trials

Will the seasonal flu vaccine also protect against the 2009 H1N1 flu?

The seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu.

Can the seasonal vaccine and the 2009 H1N1 vaccine be given at the same time?

It is anticipated that seasonal flu and 2009 H1N1 vaccines may be administered on the same day. However, we expect the seasonal vaccine to be available earlier than the H1N1 vaccine. The usual seasonal influenza viruses are still expected to cause illness this fall and winter. Individuals are encouraged to get their seasonal flu vaccine as soon as it is available.

Who will be recommended to receive the 2009 H1N1 vaccine?

CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that certain groups of the population receive the 2009 H1N1 vaccine when it first becomes available. These target groups include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years old, and people ages of 25 through 64 years of age who are at higher risk for 2009 H1N1 because of chronic health disorders or compromised immune systems.

We do not expect that there will be a shortage of 2009 H1N1 vaccine, but availability and demand can be unpredictable. There is some possibility that initially the vaccine will be available in limited quantities. In this setting, the committee recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions.

The committee recognized the need to assess supply and demand issues at the local level. The committee further recommended that once the demand for vaccine for these target groups has been met at the local level, programs and providers should begin vaccinating everyone from ages 25 through 64 years. Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over the age of 65.

Do those that have been previously vaccinated against the 1976 swine influenza need to get vaccinated against the 2009 H1N1 influenza?

The 1976 swine flu virus and the 2009 H1N1 virus are different enough that its unlikely a person vaccinated in 1976 will have full protection from the 2009 H1N1. People vaccinated in 1976 should still be given the 2009 H1N1 vaccine.

Where will the vaccine be available?

Every state is developing a vaccine delivery plan. Vaccine will be available in a combination of settings such as vaccination clinics organized by local health departments, healthcare provider offices, schools, and other private settings, such as pharmacies and workplaces. For more information, see State/Jurisdiction Contact Information for Health Care Providers Interested in Providing H1N1 Vaccine.

Will this vaccine be made differently than the seasonal influenza vaccine?

No. This vaccine will be made using the same processes and facilities that are used to make the currently licensed seasonal influenza vaccines.

Are there other ways to prevent the spread of illness?

Take everyday actions to stay healthy.

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. If soap and water are not available, use an alcohol-based hand rub.*
• Avoid touching your eyes, nose or mouth. Germs spread that way.
• Stay home if you get sick. CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
  

Follow public health advice regarding school closures, avoiding crowds and other social distancing measures. These measures will continue to be important after a 2009 H1N1 vaccine is available because they can prevent the spread of other viruses that cause respiratory infections.

What about the use of antivirals to treat 2009 H1N1 infection?

CDC has issued interim guidance for the use of antiviral drugs for this season. CDC also has published Questions & Answers related to the use of antiviral drugs for this season.

Will two doses of vaccine be required?

The U.S. Food and Drug Administration (FDA) has approved the use of one dose of 2009 H1N1 flu vaccine for persons 10 years of age and older. This is slightly different from CDC’s recommendations for seasonal influenza vaccination which states that children younger than 9 who are being vaccinated against influenza for the first time need to receive two doses. Infants younger than 6 months of age are too young to get the 2009 H1N1 and seasonal flu vaccines.

What will be the recommended interval between the first and second dose for children 9 years of age and under?

CDC recommends that the two doses of 2009 H1N1 vaccine be separated by 4 weeks. However, if the second dose is separated from the first dose by at least 21 days, the second dose can be considered valid.

Can seasonal vaccine and novel H1N1 vaccine be administered at the same time?

Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine

2009 H1N1 Influenza Vaccine and Seniors

September 30, 2009, 2:30 PM ET

Why aren't people 65 and older recommended to get early doses of 2009 H1N1 vaccine?

There are two main reasons why people age 65 and older are not included in the groups recommended to get the initial doses of 2009 H1N1 vaccine:

1. People age 65 and older are least likely to get sick with this virus, and,
2. There will be limited amounts of vaccine available at first, so the first doses are recommended to go to those who are most likely to get infected and become very ill.

There has been very little 2009 H1N1 illness in people 65 and older since the 2009 H1N1 virus emerged. This has been true both in the United States and in the Southern Hemisphere during their flu season. Studies of who is most likely to be infected with 2009 H1N1 show that people 65 and older are the least likely to get sick with this virus. (One analysis showed that only 1.3 people for every 100,000 people 65 and older are had been infected with 2009 H1N1. This is compared to 26.7 per 100,000 of those 5 years to 24 years of age and 22.9 per 100,000 in those younger than 5 years old. Rates among younger persons were 15 to 20 times higher. This has been true both in the United States and in the Southern Hemisphere during their flu season.) Laboratory tests on blood samples indicate that older people likely have some pre-existing immunity to the 2009 H1N1 flu virus.

Because there has been so little 2009 H1N1 illness in people 65 and older, the Advisory Committee on Immunization Practices (ACIP) recommended that CDC and immunization programs focus on getting the first doses of 2009 H1N1 vaccine to those people who are more likely to get infected with the 2009 H1N1 flu virus. This includes all children and young adults 6 months through 24 years old, pregnant women, and adults 25 through 64 years of age who have health conditions associated with higher risk of medical complications from flu. In addition, the 2009 H1N1 vaccine is prioritized for people who live with or care for children younger than 6 months of age, and health care and emergency medical services personnel with direct patient contact. Persons 65 and older are a high priority for seasonal vaccine, just as they have been in past years. Please visit http://www.cdc.gov/h1n1flu/vaccination/acip.htm to see a summary of ACIP’s 2009 H1N1 vaccine recommendations.

Will people age 65 years and older be able to get the 2009 H1N1 vaccine this season?

Yes. The U.S. government has purchased 250 million doses of 2009 H1N1 vaccine, so anyone who wants to get the vaccine will have the opportunity to do so. While people 65 and older are not included in the groups recommended to get the earliest doses of vaccine, they can get the 2009 H1N1 influenza vaccine as soon as the high risk groups have had the opportunity to be vaccinated. Some communities and providers will offer the 2009 H1N1 vaccine to people 65 and over sooner than others, depending on how quickly they meet the needs of the initial prioritized populations. While the early doses of 2009 H1N1 vaccine are being given to those in high risk groups, CDC's priority for people 65 and older is to have them get their seasonal flu vaccine first, and to seek medical advice quickly if they develop flu-like symptoms this season. This will determine whether they need medical evaluation and possible treatment with antiviral medications.

Should people age 65 and older get the regular flu vaccine this year?

Yes. CDC's priority for people 65 and older is to have them get their regular, or “seasonal,” flu vaccine as soon as possible while we are waiting for more doses of the 2009 H1N1 vaccine. Seasonal flu viruses are expected to circulate along with 2009 H1N1 viruses this season. People age 65 and older are at increased risk for complications from seasonal influenza compared to younger people and are recommended for annual seasonal flu vaccines. This year is no exception.

What should people age 65 and older do if they feel like they have the flu?

People age 65 and older should seek medical advice quickly if they develop flu symptoms this season to see whether they might need medical evaluation and possible treatment with antiviral medications. People 65 and older are prioritized to get antiviral drugs if they become sick with the flu according to CDC’s antiviral guidance this season.

Why are people 65 and older prioritized for antiviral treatment if they get sick with the flu, but they are not in one of the early groups prioritized to get 2009 H1N1 vaccine?

People 65 and older are the least likely to be infected with 2009 H1N1 flu, but, if they become infected, they are more likely than people in some other groups to develop serious complications from their illness. That is why people 65 years and older are prioritized for treatment with antiviral drugs this season if they do become sick.

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season

September 29, 2009, 6:00 PM ET

Excerpt:

Summary Points

• Most patients with clinical illness consistent with uncomplicated influenza who reside in an area where influenza viruses are circulating do not require diagnostic influenza testing for clinical management.
• Patients who should be considered for influenza diagnostic testing include:
• Hospitalized patients with suspected influenza
• Patients for whom a diagnosis of influenza will inform decisions regarding clinical care, infection control, or management of close contacts.
• Patients who died of an acute illness in which influenza was suspected.
• When a decision is made to use antiviral treatment for influenza, treatment should be initiated as soon as possible without waiting for influenza test results. Antiviral treatment is most effective when administered as early as possible in the course of illness. (http://www.cdc.gov/h1n1flu/recommendations.htm)
• Clinicians should be aware that the sensitivities of rapid influenza diagnostic tests (RIDTs) and direct immunofluorescence assays (DFAs) are lower than real-time reverse transcriptase polymerase chain reaction (rRT-PCR) tests and viral culture. A negative RIDT or DFA result does not rule out influenza virus infection. (http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm). Further, these tests cannot distinguish between 2009 H1N1 and seasonal H1N1 or H3N2 influenza A viruses.
• If most circulating influenza viruses have similar antiviral susceptibilities (as is the case currently in the United States), information on the influenza A subtype may not be needed to inform clinical care.
• If identification of 2009 H1N1 influenza virus infection is required, testing with a rRT-PCR assay specific for 2009 H1N1 influenza or viral culture should be performed.
• Laboratory tests to diagnose 2009 H1N1 influenza, such as rRT-PCR, should be prioritized for hospitalized patients and immunocompromised persons with suspected influenza where RIDT or DFA testing is negative or to determine influenza A virus subtype in patients who have died from suspected or confirmed influenza A virus infection.
• Information on testing of pathology specimens for suspected 2009 H1N1 influenza virus infection can be found at (http://cdc.gov/h1n1flu/tissuesubmission.htm).

H1N1 FluMist will not be for everyone

04:53 PM CDT on Wednesday, September 30, 2009
By JANET ST. JAMES / WFAA-TV

The first H1N1 vaccines to arrive in North Texas will be the FluMist - that's the one that doctors spray up your nose.

The FluMist looks like a syringe but it's filled with liquid vaccine.

Half is squirted in one nostril, the other half in the other side, just like an ordinary nasal spray.

Many pediatricians prefer it for children who fear needles.

But it is not for everyone.

Unlike the flu shot, which is a dead virus, FluMist is a weakened, live virus - which means it cannot be given to everyone.

FluMist is recommended for healthy people, from two to 50 years old, which means most school aged children are eligible.

Those at highest risk from seasonal and swine flu cannot take it. That group includes patients who have underlying medical conditions, including asthma; those with a weak immune system; children over five with a history of wheezing; pregnant women; people with a history of Guillain-Barre syndrome, which has been linked to the previous swine flu vaccine; and anyone with an allergy to eggs.

If you are not eligible for or don't want the FluMist, the shots should arrive by mid-to-late October.
hat-tip Shiloh

Many swine flu deaths linked with second infection

Wed Sep 30, 2009 3:32pm EDT

WASHINGTON (Reuters) - Many people who have died of H1N1 swine flu in the United States have also had bacterial infections, health officials reported on Wednesday.

A study of 77 patients who died of the new pandemic H1N1 virus showed 29 percent of them had so called bacterial co-infections, the U.S. Centers for Disease Control and Prevention reported.

About half of these had Streptococcus pneumoniae, which can be prevented with a vaccine, the CDC said. It said doctors may be missing these infections in people severely ill with flu.

The CDC has already reported that H1N1, declared a pandemic in June, has become more active as weather cools and schools reopened after summer breaks. Cases are reported in all 50 states and it is still circulating globally.

H1N1 is not any more deadly than seasonal influenza so far but it attacks a younger age group than seasonal flu does and because virtually the entire population lacks immunity, it can infect far more people at once than seasonal flu usually does.

"The findings in this report indicate that, as during previous influenza pandemics, bacterial pneumonia is contributing to deaths associated with pandemic H1N1," the team of experts at the CDC and state health departments reported.

"Our influenza season is off to a fast start and unfortunately there will be more cases of bacterial infections in people suffering from influenza," CDC epidemiologist Dr. Matthew Moore, who helped organize the study, added in a statement.

The report noted in previous pandemics -- in 1968, 1957 and 1918 -- many of the patients who died were also infected with S. pneumoniae, Haemophilus influenzae, Staphylococcus aureus and group A Streptococcus, which causes rheumatic fever and "strep throat".

The CDC team noted that at first it did not appear that people who were seriously ill with swine flu or who died of it had secondary infections but doctors may have missed them.

"Routine clinical tests used to identify bacterial infections among patients with pneumonia do not detect many of these infections," the CDC team reported.

Five of the patients who died, including a 9-year-old and an 11-year-old, had infections with the so-called superbug methicillin-resistant S. aureus or MRSA. None of the seven children who died had reported medical conditions that should put them at special risk of flu complications, although one was obese and one had Down syndrome.

The researchers cautioned that the patients whose cases were studied may not represent the nation as a whole. But like most of the victims of swine flu, they were young, with a median age of 31 and ranging from 2 months to 56 years.

Moore said people getting flu vaccinations should also ask about getting a pneumococcal vaccine.

Wyeth's Prevnar is part of the routine series of immunizations that children should get, and Merck and Co. makes a vaccine against so-called pneumococcal bacteria that is available for adults, mostly those over 65. Merck also makes an Hib vaccine, although there is no vaccine to prevent group A streptococcal infections or MRSA.

(Editing by Bill Trott)
hat-tip hawkeye

Dutch researchers find mutation linked to greater virulence in swine flu virus

Published Wednesday September 30th, 2009

TORONTO - Dutch scientists have reported they have found what was thought to be a key mutation in some swine flu viruses from the Netherlands, a change many virologists feared would give the viruses the ability to cause more severe disease.

But so far the evidence seems to suggest this mutation does not make the new H1N1 virus more virulent, the researchers said Tuesday.

The change, at position 627 on the PB2 gene of the virus, is known to increase the ability of flu viruses to replicate; prolonged viral replication can lead to more serious illness. The mutation has been found in all known human flu viruses, including the three that caused the pandemics of the last century.

"Everybody predicted that this mutation is going to have a big impact on virus replication of the new H1N1," said Dr. Ron Fouchier, one of the authors of the report and a molecular virologist at Erasmus Medical Centre in Rotterdam.

"If you would have asked me three months ago, I would have bet my car on it. But nobody placed that bet because everybody was sure that it would increase (virulence)."

If they had, it seems they might have been able to claim the keys to Fouchier's SUV.

Three people either known or suspected of having been infected with the mutated H1N1 viruses suffered only mild disease. And ferrets infected with a laboratory synthesized H1N1 virus with this change also did not suffer more severe disease. Ferrets are the standard animal model for human flu.

"Given the information that we have at present, we have no indication for increased virulence," said Dr. Marion Koopmans, chief of virology in the infectious diseases laboratory of the National Institute of Public Health, The Netherlands.

"This is a mutation that is in the textbooks as something to look out for, but whether it really confers something to these (H1N1) viruses remains to be seen."

Koopmans, Fouchier and a number of colleagues disclosed the surprising findings through ProMed, a website and mailing list that serves as an early warning system for infectious diseases developments. It is closely scrutinized by scientists and public health officials in the infectious diseases sphere.

The Dutch scientists reported finding two viruses with this change that appear to have been transmitted between mid-July and mid-August in the West Frisian Islands in the north of The Netherlands. The area is a popular destination for Dutch and German campers.

One of the mutated viruses was recovered from a male who had been there and who started developing symptoms on Aug. 9. The second was found in a girl who hadn't been to the area, but whose sister had been camping there at the time. The sister was also sick, but there was no specimen from her to test. Koopmans said the working assumption is that the sister who went camping was also infected with this virus.

The first virus was only discovered in mid-September, when it made its way to Koopmans' lab. An investigation at that point showed the male and the sister had been part of a group of 24 who shared two tents on the island. Most of the members of the camping party reported having been ill.

Koopmans said officials have looked at specimens from the area and from the regions from whence the campers came, but haven't found more viruses with this change.

"There's no evidence yet that this virus has spread any further in Holland," Fouchier said. "Of course we're currently still looking for it. Every virus we get our hands on we check (position) 627. But we haven't found any more."

Labs have been looking for this mutation from the moment the new H1N1 virus was fully analyzed and it was seen it didn't have the same amino acid at position 627 as other human viruses have.

Some scientists even suggested the virus might not be fully adapted to spread among humans because it didn't have this change, but instead had an amino acid at position 627 that is normally seen in avian flu viruses. The pandemic virus, which is a never-before-seen hybrid of swine, avian and human genes, has an avian PB2 gene.

Dr. Richard Webby, head of the World Health Organization's influenza collaborating centre at St. Jude Children's Research Hospital in Memphis, Tenn., said there is good evidence this mutation is associated with adaptation of avian influenza viruses to humans, but the proof that it is linked to severity of disease is less clear.

Viruses with this change show increased virulence in mice and sometimes in ferrets, but not always, he said, suggesting the ferret data probably are more reliable. "I think this is one instance where mice are probably lying a little bit," Webby said.

In some flu viruses this change is known to allow the virus to replicate at cooler temperatures, meaning they can infect the upper airways, rather than the warmer deep lung area preferred by avian flu viruses.

That might actually be a good thing with this H1N1, Webby said, noting autopsies have shown that in severe cases the pandemic virus wreaks havoc deep in the lungs.

Dr. Nancy Cox, who heads the influenza division at the U.S. Centers for Disease Control, warns people should not take too much comfort from the fact this change doesn't seem to make the virus more virulent at this point.

"We just know that influenza can change in unpredictable ways through mutation and reassortment," she said, referring to the process by which flu viruses swap genes with each other.

"The unexpected can arise, and arise very quickly. So we shouldn't write this off. It is causing hospitalization. It is causing fatalities. And in every single case that you hear about, it's a tragedy."
hat-tip Dutchy

WHO Lowers Expectation Of H1N1 Vaccine Output, Appeals For Donations To Fight Pandemic

Article Date: 28 Sep 2009

International drug makers are expected to produce three billion doses of the H1N1 (swine flu) vaccine, "enough for just under half the world's population," a WHO official said Thursday, Canwest News Service/Ottawa Citizen reports. "The agency was hoping pharmaceutical companies would be able to make about five billion doses a year, but data collected over the summer led to the revised estimate," the news service writes (Fitzpatrick, 9/24).

"These supplies will still be inadequate to cover a world population of 6.8 billion people in which virtually everyone is susceptible to infection by a new and readily contagious virus," the WHO said in a written statement. "Global manufacturing capacity for influenza vaccines is limited, inadequate and not readily augmented" (9/24).

The organization hopes to acquire a total of 300 million doses of the H1N1 (swine flu) vaccine - 100 million doses more than total pledged donations - for countries having difficulty accessing the vaccine, a WHO official said Thursday, the Washington Post reports. The WHO's goal is to distribute a supply of H1N1 vaccines to 90 countries, who combined make up "about 3 billion of the world's 6.8 billion people," the newspaper writes. "They either can't afford vaccine or have been unable to find a manufacturer able to supply it to them over the next few months, when the swine flu pandemic is expected to peak."

"We hope that the whole world will have some access to the vaccine," said Marie-Paule Kieny, director of WHO's Initiative for Vaccine Research. "In some countries it will be possible to vaccinate the whole population and in some countries only 10 percent." So far, the vaccine makers Sanofi Aventis and GlaxoSmithKline have agreed to donate a total of 150 million doses of H1N1 vaccine, and, last week, nine developed countries pledged to give 10 percent of their stockpiles - which Kieny estimated at "about 50 million doses in all," the first of which will become available in late October.

"In the meantime, WHO officials are seeking to fill the projected 100 million-dose gap with donations from other countries and manufacturers, of which there are 36 worldwide," the newspaper writes (Brown, 9/24). Kyodo News/Japanese Times reports the Foreign Ministry of Japan on Thursday announced the country would offer about $12.2 million in emergency aid to the WHO to help purchase H1N1 vaccines for developing countries (9/25).

Kieny also said the H1N1 vaccine continues to appear safe, Bloomberg reports. "Side effects from the swine flu vaccine given to 44,000 people in China have so far been mild, with just 14 cases of adverse events reported," Kieny reported Thursday, according to the news service (Serafino, 9/24).

Critics Question U.N.'s $1.5 billion H1N1 Appeal

In a related story, the Associated Press examines a recent report by the U.N. that the organization needs nearly $1.5 billion to fight the H1N1 virus. According to the news service, WHO Director-General Margaret Chan on Thursday met with top health officials to discuss the report and the appeal on the sidelines of the U.N. General Assembly meeting.

Because "most people recover [from H1N1] without ever being treated, not all experts are convinced swine flu merits such attention - and some critics even suspect the U.N. is using the pandemic as a convenient way to raise money," the news service writes. The WHO has rejected this claim, arguing even if the H1N1 virus fails to mutate into a more deadly form it could devastate already weak health systems in developing countries.

"Globally, WHO estimates more than 3,500 people have died of swine flu - far fewer than those killed by diarrhea, pneumonia, or road accidents," leading some experts, in turn, "to contend that WHO's prediction the virus could lead to 'civil disruption' in poor countries may be overblown." The article includes comments by health experts who question the WHO's recent funding appeal and the organization's handling of the H1N1 pandemic (Cheng, 9/24).

U.S. Health Officials Anticipate 6M H1N1 Vaccine Doses By Early October

Also on Thursday, U.S. health officials announced "[m]ore than six million doses of swine flu vaccine will be available by the first week in October, more that twice as many as had been recently expected, federal health officials said," the New York Times reports. Most of that vaccine "will be the FluMist nasal spray, which is recommended only for people ages 2 to 49 and not for pregnant women or people with health problems" (McNeil, 9/25). HHS Secretary Kathleen Sebelius emphasized there would be "plenty of vaccine for everyone who wants it," CNN reports (9/24).

This information was reprinted from globalhealth.kff.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Global Health Policy Report, search the archives and sign up for email delivery at globalhealth.kff.org.