Critique of the WHO pandemic response is now out

We blogged early and often about the H1N1 pandemic, including posts about the controversy surrounding the WHO response and whether there was any industry influence at play. An independent expert panel has now released a draft report on the 2009 H1N1 response. Here are the media summaries from the NY Times, Science Magazine, and the Nature blog The Great Beyond.

Regarding the industry conflict-of-interest (COI) issue, the report takes WHO to task for poor handling of COI and lack of transparency, but concludes that there is "no evidence of attempted or actual influence by commercial interests on advice given to or decisions made by WHO." I’m not sure what such evidence would be required…direct cash payments to members of the WHO advisory committee? Anyway, given that the panel felt that WHO waited too long to call the pandemic, it is unlikely they’d conclude that this decision was driven by industry COI.

Read the report yourself—now that Iowa has thawed out and the sun has appeared, I have no time to detail all 15 of the recommendations the panel made.

H1N1 Flu Deaths in the UK on the rise

Per a government report in the BBC and other UK papers, there have been 39 deaths from the flu this winter with 36 confirmed as H1N1-related while the other three were caused by influenza B.  Unlike here in the US, the UK vaccination committee does not recommend a flu "jab" for healthy children less than 5 and other children ages 5 to 15.  All but one of the deaths occurred in people <65yo. Around 20% of all ICU beds in England are now filled with confirmed or suspected influenza patients.

Health Secretary Andrew Lansley said "the people we would wish to vaccinate are people in at-risk groups and over 65s who can be contacted via their GP." Which makes some sense since 23/38 deaths (one patients data wasn't available yet) were from high-risk groups. However, that still leaves 40% of patients without any risk factors. Since there is no vaccine shortage, I wonder why they aren't broadening their vaccine strategy to include younger children. As it is, only 23% of currently eligible children <5 get vaccinated.

The H1N1 virus continues to attack younger children and not older adults. In English children <4yo, the influenza incidence is 184 cases/100,000 while it is only 36 cases/100,000 in those >65yo. An epidemic is defined as an incidence >200 cases/100,000.  Seems like rapid vaccination of children might be a good idea, particularly when you look at the graph below showing 2010-2011 as an active year, similar to the spring of 2008-2009 season when H1N1 began.  If H1N1 vaccine was available in spring 2009, I bet they would have promoted it more than they are promoting the vaccine now.

Oh, Happy New Year!

BBC report (12/30/2010)
Guardian report (1/1/2011)

UK Health Protection Agency Epidemiological Report 30 December 2010

ILI Activity with 2010-11 in red  - taken from UK HPA report (link above)

2009 H1N1 Pandemic Response: Looking backward and forward

Recently in PLoS Medicine, Gabriel M. Leung from the Food and Health Bureau, Hong Kong and Angus Nicoll from the European Centre for Disease Prevention and Control reflected on the public health response to pandemic H1N1. They discuss what went right and what should be done now to augment our future responses.

I really liked that their primary points highlighted that "public health messages...should not confuse what could happen (and should be prepared for) with what is most likely to happen" and that "decisions regarding pandemic response during the exigencies of a public health emergency must be judged according to the best evidence available at the time."  I've pasted below the list of pandemic "Firsts" which included a special shout out to the challenging "blogosphere," of which this here ye olde blogge was a member.

Box 1. A Series of “Firsts” about Pandemic (H1N1) 2009

• The first pandemic to emerge in the twenty-first century. It has been more widespread and remains ongoing, compared to SARS.
  
• The first pandemic to occur after major global investments in pandemic preparedness had been initiated.
  
• The first pandemic for which effective vaccines and antivirals were widely available in many countries, thus requiring public health authorities to earn and retain the confidence of health care providers through whom such are usually distributed.
  
• The first influenza pandemic to coincide with the ongoing HIV/AIDS pandemic and for which preliminary data do not suggest a substantial, disproportionate impact on HIV-infected patients.
  
• The first pandemic that took place within the context of a set of International Health Regulations and global governance, which had not been widely tested until the present.
  
• The first pandemic with early diagnostic tests that led to rapid diagnosis but also an early obsession in the media and of policymakers with having reports of the numbers of those infected.
  
• The first pandemic with antivirals available in many countries that led to a hopeful expectation that the pandemic might be containable, leading to the preparation for and implementation of a “containment phase” in some places.
  
• The first pandemic in which intensive care was available in many countries to treat critically ill patients, fostering an expectation that everyone could be treated and cured.
  
• The first pandemic with instant communication so that early impressions (such as the experience and response in Mexico and the Ukraine) could be shared ahead of proper scientific analysis.
  
• The first pandemic in which web-based platforms of traditional journals expedited dissemination, complemented by other innovative online resources (e.g. PLoS Currents: Influenza, http://knol.google.com/k/plos-currents-i​nfluenza#, based on Google's knol technology).
• The first pandemic with a “blogosphere” and other rapid social media messaging tools that challenged conventional public health communication.

Source: G. Leung and A. Nicoll. Reflections on Pandemic (H1N1) 2009 and the International Response. PLoS Med 2010

Prior seasonal influenza infections protective against 2009 Pandemic flu (if you're a ferret)

Looking back at the 2009 flu season, I realize how calm it is now compared to then.  I hope it stays that way!  In that pandemic, the attack rate was 50% in young populations compared to perhaps 10% in adults.  Why would this be the case? Serologic analysis showed little cross-reactivity between recent seasonal influenza A(H1N1) viruses and pandemic A(H1N1). The authors of a recent JID paper postulated that the lower attack rate in adults could result from multiple past exposures to viruses with similar B epitopes or since there is conservation of T cell epitopes between pandemic H1N1 and seasonal influenza A, then cellular immunity may also reduce disease severity. There's also the fact that adults responded to a single dose of pandemic H1N1 vaccine, while children did not, suggesting that past exposure to seasonal strains is important.

To examine the role of prior immune reponses in seasonal influenza on exposure to pandemic H1N1, Laurie et al. in the Oct 1 JID, studied the impact of one or two prior infections in a ferret model.  The found that a single prior infection with a seasonal influenza A virus, A/Fukushima/141/2006 (H1N1) or A/Panama/2007/1999 (H3N2), reduced the duration of shedding following challenge with 2009 pandemic H1N1, but not reduce the infection rate nor did it reduce the transmission to other ferrets.

The authors then tested whether two prior infections with seasonal influenza was protective against pandemic H1N1.  They determined that infection with seasonal A(H1N1) followed by A(H3N2) reduced the infection rate along with the amount and duration of shedding in ferrets challenged with pandemic A(H1N1). Interestingly, no virus was transmitted to other ferrets, nor did the exposed naïve ferrets experience seroconversion to pandemic flu.

Good news, if you're a ferret.

Laurie KL, et al JID, October 1, 2010.

WHO exaggerated H1N1 Threat, Potential COI issues

Two separate European reports criticized the WHO for exaggerating the H1N1 threat and failing to disclose pharmaceutical conflicts of interest. The first report was from the Health and Family Affairs Committee of the Parliamentary Assembly of the Council of Europe (say that three times) and looked at the pandemic response and the second was from BMJ and the Bureau of Investigative Journalism and looked at the 2004 guidelines which were written by three experts with financial ties to Roche and GlaxoSmithKline. Washington Post article (here), BMJ+BIJ (here), Council of Europe article (here) and pdf of Council of Europe report (here). I wonder if N95 manufacturers are getting nervous?

Why your friends spread influenza and you don't

There was a really interesting study by Nicholas Christakis and James Fowler in the May 15th Economist (here) and posted online (full manuscript here). The general thought behind the study was that people in the center of social networks, the ones with more friends or connections, would be more likely to be infected with influenza sooner. Thus, if you could identify people in the center they could serve as an early warning system for flu. The problem is, this would take a significant amount of effort. The insight into this problem comes in the form of what is called the friendship paradox. This 'paradox' suggests that your friends have more friends than you do.

To test this theory, Christakis and Fowler identified 319 students and then 425 of their friends. If friendship paradox would work in identifying influenza then the 425 should get flu earlier. So they followed the 744 students from September to December 2009 during the H1N1 epidemic and found that the friends, the 425 more likely to be in the center of the network, developed influenza (self-diagnosed and confirmed) around 2 weeks earlier. In fact, self-reported symptoms peaked 83 days earlier and visits to healthcare facilities peaked 46 days earlier in the connected group. Maybe this is a new method that could be added to other monitoring systems. Either way, come influenza season, stay away from your friends, especially the ones who are really friendly.

Hurry up, CDC

It has been a while since we blogged about the ridiculously stupid mask fiasco, mainly because the 2009 H1N1 virus is off the radar in most parts of the country and world.

This hasn’t stopped California OSHA from citing UCSF for not requiring N95 masks for the care of patients with suspected or confirmed 2009 H1N1. A post from the EIN this morning details the citation, which includes a fine and a requirement to rectify the situation by June 6, 2010. Here is a short excerpt from that EIN post:

I am…concerned about the short time window which we have been given to rectify the situation. Given the availability of 2009 H1N1 vaccine and increasing evidence in the literature that N95 masks are not superior to surgical masks, we plan to appeal before making a change in our practice; however, it is unlikely that OSHA will be willing to consider such an appeal without a formal change in the CDC guidance. I have heard that the CDC will soon be providing updated guidance on infection control practices for 2009 H1N1 - does anyone know the status of these guidelines and when they will be available?

Given that the “2009 H1N1” is going to be with us as a seasonal strain now, the CDC has only two options that make any logical sense: either back off the mistaken N95 recommendation, or begin requiring N95 use for all suspected or confirmed seasonal flu.

It would be nice if CDC acted quickly, and if OSHA held its fire until new guidance is issued.

Addendum: Rather than spending its time and resources doing post-hoc punishment of hospitals that responded appropriately to 2009 H1N1, California OSHA should be doing more to reduce the real threat of HIV transmission in the porn industry. So far, Cal OSHA has taken the bold step of “setting up an advisory committee to study the issue”.

H1N1: One year later

This morning's New York Times has an OpEd piece by Dick Wenzel in which he reflects on the H1N1 influenza pandemic over the past year. Click here to read it.