Novel Influenza: Global Agenda, Many Unknowns

There are young adults on ventilators with a diagnosis of novel H1N1 influenza. There are discussions about how to ration hospital beds and ventilators. The first doses of vaccine are available, and people are lining up–in crowds–to receive it. At the same time, there is growing resistance to vaccine mandates. People ask, what should they do?

Power. The questions are tainted with politics. The World Health Organization (WHO) wants more power–not just to advise on international travel and quarantines, but over legal and economic systems. Director General Margaret Chan can boast: “The world can now reap the benefits of investments over the last five years in pandemic preparedness”–which were based on predictions by the WHO flu czar (Michael Fumento, Forbes 10/16/09).

At a September speech in Copenhagen, Chan said that “the present economic system does not distribute wealth on the basis of values of solidarity and equity, thus hindering improvements in health outcomes.” We need a “fundamental re-engineering of the international systems to incorporate a moral dimension.” She called for “health care reform,” sounding the same themes as its U.S. proponents: “fairness” and reducing “disparities.”

The pandemic is a “watershed event.” It could be a needed wedge to achieve global governance: “Public health had no say in the policies that seeded the financial crisis or set the stage for climate change. But public health has much to say about the influenza pandemic.” It makes the need for “health in all policies” apparent, Chan stated.

In the U.S., emergency health powers acts give state public health departments expansive powers over the allocation of economic resources as well as control of human activities. Their first power exercise is vaccine mandates. In New York, the Department of Health handed down a directive (since revoked) to private health facilities to require workers to receive seasonal flu vaccine by Nov 30–or be fired.

Opposition is building. The Public Employees Union, a group of nurses, and a teachers’ union filed suit, and a N.Y. Supreme Court justice granted a temporary restraining order. “These people are not government property,” stated Roy Russell, R.N. “We are professionals and we know the risks.” Although there is not yet a mandate in Arizona, signs are appearing, asking the public to support first responders who decline mandatory vaccines; three-fourths of Chandler firefighters refused an early batch of H1N1 vaccine.

Safety. Public health authorities assure the public that the vaccine is safe–since it’s made the same way as other flu vaccines. But people are skeptical. Some doctors in Mississippi, having heard of “several” cases of Guillain-Barré in H1N1 vaccine recipients, are advising patients and staff not to receive it. About 75% of persons answering an online survey by the Association of American Physicians and Surgeons (www.aapsonline.org) say they intend to decline the vaccine (also see News of the Day on that site).

China is the first to vaccinate against H1N1, and launched a clinical trial in 13,000 adults and children. Experts concluded that one dose is probably enough, at least in adults. While one official said that vaccinating 30% of schoolchildren would greatly mitigate a severe epidemic, another said a 70% rate was required (Science 2009;325:1482-1483).

A report from China of a placebo-controlled study in 2,200 subjects was published on NEJM.org on Oct 21. A better antibody response and fewer adverse effects were seen for vaccine without an alum adjuvant. Subjects were followed for 35 days after the first dose and 14 days after a second dose. Most reactions were mild and involved the injection site.

Efficacy. There is astonishingly little evidence that influenza vaccine, although it does stimulate an antibody response, actually prevents death from influenza. In the November issue of The Atlantic, Shannon Brownlee and Jeanne Lenzer observe that many studies claim a 50% reduction in all-cause mortality during the winter in persons who receive flu vaccine in the fall. Yet influenza accounts for only 10% of deaths, even if all illnesses that influenza might aggravate are included. Vaccine skeptics argue: “For a vaccine to reduce mortality by 50 percent means it has to prevent deaths from falls, fires, heart disease, strokes, and car accidents. That’s not a vaccine, that’s a miracle.”

The “healthy user effect” could largely account for reduced mortality, argue Brownlee and Lenzer, but authorities say it would be unethical to do double-blind, placebo-controlled studies–since we “know” that the vaccines work.

Canadian seasonal influenza vaccination campaigns are being thrown into disarray by a study linking seasonal flu shots to a higher rate of H1N1 influenza. Though the study has been called an “international anomaly,” some provinces are suspending seasonal flu shots for persons under the age of 65. They will concentrate on vaccinating against H1N1, currently the cause of most confirmed influenza cases, and possibly resume the seasonal flu shots once the H1N1 wave passes (Globe and Mail 9/29/09).

How Bad Is the Outbreak? According to an Oct. 21 CBS News report, the CDC abruptly advised states to stop testing for H1N1 in late July, although many continued to test anyway. It was considered a waste of resources to test since we already knew we were having a pandemic. In some states, more than 90% of patients with influenza-like illness tested negative for influenza. Between Aug 30 and Oct 10, only 29.4% of reported tests were positive for influenza A, and all subtyped influenza A viruses were H1N1 (www.cdc.gov). Only 2% of some 400 viruses tested were resistant to oseltamivir (Tamiflu).

Death rates may be difficult to interpret because pneumonia and influenza (“P&I”) are lumped together. For 2006, National Vital Statistics Reports list 55,477 U.S. deaths from pneumonia, but only 849 from influenza. The pneumonia may have followed influenza.

Transmission. People may shed virus before they feel ill. However, “the contribution of asymptomatic influenza virus infection to transmission among household members, institutional residents, or communities is unknown during seasonal epidemics or pandemics” (Khazeni N, et al. Ann Intern Med 2009;151:464-473). Additionally, to the best of our knowledge, there are no studies of the relative rates of virus shedding in asymptomatic persons who are vaccinated versus those who are not.

Medical workers have long relied on surgical masks to protect against influenza and other infections, although there is no convincing proof of efficacy. They allow from 4% to 90% penetration of aerosol particles, and are open on all sides. N-95 masks, even if not individually fitted, are better (N Engl J Med 10/4/09, doi:10.1056/NEJMpo908437).

Other Possibly Helpful Measures. In a double-blind, placebo-controlled study of 326 children, daily dietary probiotic supplementation for 6 months decreased incidence of cough, fever, and rhinorrhea; antibiotic prescriptions; and missed school days from illness (Pediatrics 2009;124:e172-9).

Frederick Klenner, M.D., successfully used intravenous vitamin C in a number of viral illnesses, including polio and encephalitis. Although he did not specifically detail his experience with influenza, he did mention treating a number of cases successfully, noting that the dose and the number of injections were related to the fever response to therapy and duration of illness. Dogs and cats with distemper, caused by a virus “somewhat akin” to influenza, have been cured, even in cases considered hopeless by some veterinarians. Belford gave larger dogs 2,000 mg vitamin C IV daily for 3 days, and cats and smaller dogs 1,000 mg daily for 3 days (Thomas E. Levy, M.D., Curing the Incurable).