Affiliated Physicians November 07 Newsletter

CDC, HHS, OSHA DISCUSS GUIDANCE FOR STOCKPILING AND USE OF FLU PANDEMIC ANTIVIRAL DRUGS AND PPE'S

Thursday afternoon, an important step was taken by the CDC, HHS, and OSHA to introduce new guidance on the stockpiling and dispensing of antiviral drugs and personal protective equipment in preparation for a flu pandemic.

Over 100 key business and governmental leaders participated in the conference call. Here are some of the key points included in the presenters’ reconsideration of their antiviral and PPE strategies.

What this means to you: Consider, well in advance of a flu pandemic, the pros and cons of stockpiling versus dispensing antivirals to employees pre-pandemic.

What this means to you: An in-person physician assessment is required to prescribe and dispense antiviral drugs. How will this factor into program implementation lead-time?

What this means to you: Who among your employees should be included in a corporate antiviral distribution program (eg. critical employees, all employees, family members)

What this means to you: Investigate various types of equipment available and calculate quantities based on OSHA guidance estimates.

This long-awaited proposed interim guidance discussion, currently in the “stakeholder engagement phase,” offers reassurance for the multitude of companies that were proactive in implementing full antiviral/PPE stockpiling and distribution programs to date. Ongoing reporting by the CDC and others, regarding guidance during the policy proposal process, will certainly help shape pandemic preparedness programs for businesses currently considering full program implementation or a staged approach to pandemic flu preparedness.

For the first time, scientists have solid evidence suggesting exactly why the flu is so common in winter.

A new animal study suggests that the influenza virus' success hinges on low relative humidity and cold temperatures. Such conditions keep the virus more stable and in the air longer than warm, humid conditions, scientists said. And apparently, the frosty weather's role is more important than that of the human body in helping the virus thrive.

"We've always thought the immune system wasn't as active during the winter, but that doesn't really seem to be the case," said study coauthor Peter Palese, a virologist at the Mount Sinai School of Medicine in New York City.

When we cough or sneeze, tiny droplets of water enter the air and hang around until they drop to the ground-or an unsuspecting passerby breathes them in. Once inside our airways, any flu viruses that have hitched a ride on the droplets can launch an attack.

He thinks that the conditions not only suck away the droplet's water weight, allowing them to float in the air longer, but also dry out virus-blocking mucous and cells in our airways. Bigger viral doses combined with the body's disabled means to flush them out, Palese said, gives the flu a better fighting chance to infect a person, regardless of their immune system's strength.

This correlation has been obvious, Palese acknowledged, but solid explanations for wintertime viral success have eluded scientists because modeling human-like disease transmission in animals is difficult. Many animals, such as mice, fail to transmit the viruses that make humans sick.

"The only animals that can model virus transmission are ferrets, but they're very expensive, big and hard to work with," he said. "They also like to bite a lot." By reading an 88-year-old medical study, however, Palese's team discovered that guinea pigs simulate human coughing and sneezing extremely well.

"I never believed what my grandmother told me about getting sick when it's cold, but it turns out she was right," Palese said. "Guinea pigs aren't humans, but this is some of the best evidence yet to explain the seasonality of the flu."

Although the flu spreads primarily through the air, the viruses can survive on doorknobs, handrails, telephones, computer keyboards and other surfaces. Medical experts report that frequent hand washing, especially before meals, can lower the risk of picking up as well as transmitting diseases such as the flu.

From September 24th to October 12th of this year, The Financial Banking Information Infrastructure Committee (FBIIC) and the Financial Services Coordinating Council (FSSCC), with the support of the US Department of the Treasury and other federal agencies, conducted a nationwide pandemic influenza exercise. A total of 2775 financial services companies, including banks, credit unions, and securities firms, participated as part of an effort to test existing pandemic plans and to examine the possible impacts of a global crisis on the US financial markets. This exercise was the largest of its kind ever in the United States.

Prior to the exercise, 63.9% of the participating companies reported having pandemic-specific business continuity plans while only 42% report having pandemic-specific Human Resources policies. After the exercise was completed, only 12% felt their firm's pandemic plans were 'very effective'.

Some issues coming out of the exercise which participating firms found challenging included school closings, difficulties restocking ATMs, rolling black and brownouts, and increased network demands from employees trying to work from home. Positive findings included the projected rise of the US dollar as investors searched for safe investment havens.

Children would likely be both prime spreaders and targets of a flu pandemic, but they're being overlooked in the nation's preparations for the next super-flu, pediatricians and public health advocates reported Wednesday.

The report urges the government to improve planned child protections, including how to care for youngsters if a pandemic closes schools.

...said Dr. John Bradley of the American Academy of Pediatrics, which co-authored the report with the Trust for America's Health.

Concern is rising that the Asian bird flu known as H5N1 could trigger the next worldwide influenza epidemic if it mutates to become more easily spread person-to-person.

Children have long seemed particularly vulnerable to H5N1, possibly because they are more likely to touch or play with the diseased birds who spread it. Wednesday's report says nearly 46 percent of bird flu deaths since 2003 were among people 19 or younger.

Bird flu aside, germ-ridden youngsters already spur regular flu's spread through communities every winter, and experts have long called for better pediatric pandemic preparations.

· A stockpile of anti-flu medications contains only enough pediatric doses for 100,000 children; child vaccine doses are still under study.

· No protective face masks come in child sizes, although it's also not clear that children would tolerate wearing one.

· There are no plans for how to feed the 30 million children who rely on the school lunch program, if schools close.

TROOPS, PREGNANT WOMEN, AND HEALTH CARE WORKERS GIVEN PRIORITY STATUS FOR PANDEMIC VACCINE

n the early weeks of a flu pandemic, the first to receive scarce supplies of vaccine will include the military, medical and emergency workers, pregnant women and babies - nearly 23 million people - under a draft federal plan outlined October 23rd in Washington, DC.

The plan was developed by a government working group that met with scientists and business and community representatives over several months. It provides guidelines for pandemic planners and offers a glimpse into some agonizing decisions that could be necessary in the context of a swift-moving infectious disease and a shortage of protective vaccine.

"Once a pandemic starts, vaccine will come rolling off the line in lots, so there has to be a priority scheme on who would receive it first," says William Raub, science adviser to Health and Human Services Secretary Michael Leavitt.

"The committee tried to identify those who would be critical to national and homeland security, critical to fighting the flu itself, and critical to maintaining a functioning society."

In meetings, the working group and other participants highlighted pregnant women and children as a priority, the report says. This also is an efficient use of vaccine, it says, because immunizing pregnant women protects their newborns, too, and children need lower doses, stretching limited supplies.

Jeffrey Levi of Trust for America's Health, an advocacy group, says the report, being presented at a meeting of the National Vaccine Advisory Committee, is "logical," but more discussion is needed to refine how vaccine will be distributed and used in different populations.

The plan provides for changes based on local needs and severity. In mild pandemics, which cause fewer deaths among the young and healthy, it makes sense to move those at risk of serious illness, such as the elderly and people with chronic illnesses, higher on the list, Raub says.

For instance, the plan doesn't target such groups as banking, food and agriculture, postal or chemical workers in a mild or moderate pandemic. But in a severe pandemic, those groups are in the third tier for vaccination, just behind electricity, natural gas, communications and water personnel and essential government workers.

"The more severe the pandemic, the more aggressive people would be in trying to protect critical workers," Raub says. "But if it's at the milder end, critical workers would be a smaller group, so there would be more emphasis on getting everyone vaccinated. The disruption of society wouldn't be the same."

A pandemic occurs when a new flu virus emerges that can spread as easily as the seasonal flu, which causes 200,000 hospitalizations and 36,000 deaths each year. Because it's different from known flu viruses, people have no built-in immunity, so everyone is at risk.

Beginning this month, AP Flu Watch will feature a column by Affiliated Physicians' Medical Director, Dr. Avram Nemetz. Dr. Nemetz is an experienced speaker on influenza and pandemic issues as well as corporate medicine and occupational health. In this new feature column, Dr. Nemetz will discuss a wide variety of medical issues emerging out of the news and latest medical trends.

ANTIVIRAL MEDICATION VS. SEASONAL INFLUENZA: WONDER DRUG?

By: Avram Nemetz, MD
Medical Director,
Affiliated Physicians

Back in the Stone Age of influenza treatment-about 1997 or 1998-new antiviral medications were developed and came onto the market. Representatives from the pharmaceutical companies making Tamiflu and Relenza trooped into my medical office bearing explanations and free pens, and offered free samples of their latest wonder drugs to make it easy for me to try them out for my patients.

"Back before good antiviral medications were available, there had been very little that doctors could do for someone who was diagnosed with influenza"

Influenza is different from a less-serious, non-influenza common cold virus. Real influenza is caused by the influenza virus, which is contracted mostly by inhaling the same air as an infected individual who has exhaled the virus particles into the surrounding atmosphere. After a two-day incubation period, influenza presents with the sudden onset of high fevers, shaking chills, terrible body aches, and a cough that hurts your chest from the beginning of the illness.

If before 1997 someone came into my office with those symptoms, all I could say to them was, "Look, you're going to have a miserable week. You have influenza--the real flu--and you're going to be acutely ill for 3-5 days. You need to go home, rest, drink plenty of fluids, take Tylenol for the fevers and body aches, and just wait it out. You can't possibly be in the office when you have something like this-you're going to have to miss a week of work. If all goes well, in a week, the fevers should be gone and the cough will fade away-but it will be two weeks before you have your stamina back. If next week, your fever is gone but the cough is persisting, call me back. Bronchitis or pneumonia can develop after the flu, and we'll get you on an antibiotic sooner rather than later if the cough persists."

Now, with the new antiviral medications, the scenario could be different. The manufactures claimed that when taken within 24-48 hours after the onset of flu symptoms, Tamiflu or Relenza could block the influenza virus from penetrating the cells lining the respiratory tract, prevent them from replicating, and allow your immune system to overwhelm the invading virus. This was the theory, but how would it work in practice?

Flu season arrived, and this time I would have a new tool at my disposal-if a patient could get to me in time. A healthy young man came into work feeling fine, but by 10AM he didn't feel right, and by 3PM he had shaking chills, a temperature of 103, and a new rattling cough in his chest. He walked into my office to see a doctor, since he knew right away he was very sick. Now, since I had Tamiflu and Relenza samples in my cabinet, I could give him the first dose of the medication right away, tell him to take the second dose at bedtime, and then continue the medicine twice per day for a full five-day treatment course.

"Repeatedly, I had the experience of patients calling me back the next day... and telling me "Doc, it's gone! I'm fine. I'm at work."

Repeatedly, I had the experience of patients calling me back the next day-24 hours after the onset of illness, with two or three doses of the antiviral medicine in their system, and telling me "Doc, it's gone! I'm fine. I'm at work." It was very impressive what the medications could do.

It doesn't always work this perfectly. But statistics in the medical literature have subsequently confirmed that if you use antiviral medications quickly enough, within 24-48 hours of the beginning of noticeable illness-both for seasonal and potentially for pandemic flu-their effectiveness against the flu and its complications can be amazing.