Louisville Medicine Volume 62, Issue 8 - Page 34

SPEAK YOUR MIND If you would like to respond to an article in this issue, please submit an article or letter to the editor. Contributions may be sent to editor@glms.org or may be submitted online at www.glms.org. The GLMS Editorial Board reserves the right to choose what will be published. Please note that the views expressed in Doctors’ Lounge or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine. JANUARY NINJAS Mary G. Barry, MD Louisville Medicine Editor editor@glms.org I t’s cold, and it’s dark, and the new bridges are not open. Traffic is tore up, as we say in Kentucky. Our patients drive in, dodging the orange barrels and nursing their colds and aches and wondering why they feel like hell, and we can tell them: once again the flu shot did not work right. Once again, for the seventh year in a row, the powers that be who select the flu shot ingredients have been wide of the mark. In the winter of 2008, they had missed so badly - of the Influenza B type, 98 percent of viruses were not included in the vaccine, and 77 percent of the A type were not - that all of us in the office fell like dominoes. We had fevers of 103 for a week, deathly aches, and burning chests. I have no idea who actually worked in the office for one of those weeks. I spent my time making morning rounds for me and my quarantined partners. I dressed in haz-mat clothes, dragged at a snail’s pace from room to room, wrenched small thoughts out of my fevered brain, and triaged my puny efforts to the patients’ dire needs only. Then I went home to bed, and stayed there, till morning came again. I lost four elderly women to that flu. Their chests filled up and whited out and they died of bacterial pneumonia inside of 48 hours. In fact, they were felled by the same flu that had orphaned them in 1918. January of 2009 was a typical flu season – we all took the shot, and only some of us got a little sick; it sort of worked. Then spring came and in April, up from the Southern Hemisphere came the Swine flu, a brand new virus not possible to foresee. 32 LOUISVILLE MEDICINE Only age and antibodies saved us. Young people died. The CDC responded in force, released some of the national stockpile of supplies, and mobilized emergency teams for vaccine development and production. They declared a pandemic, held summits, mandated distribution to the most at risk, and managed to get new flu shot versions out to 75 percent of the high-priority front line troops by December. The pandemic was so bad that they were recommending empiric antibiotics and antivirals for “typical presentations” in the young, even before confirmatory positive tests. This was something very new for them, designed to lower the death rate from pneumonia. They did great against a new enemy. Overall, the World Health Organization estimated a death toll from Swine flu that was 15 times higher than the laboratory-confirmed death rate. Estimates vary wildly: for instance, the Lancet in 2012 gave a range of 175,000 to 550,000 deaths from the Swine flu. But all authorities agreed that unlike typical seasonal flu, 80-90 percent of deaths were in people younger than 65 – the exact opposite of a normal year. Hardest hit were pregnant women and those under 15. The Swine flu came from the Axis of Evil that is the influenza genome, and was a novel re-assortment of genes from four different sources. Our younger partners got sick, everybody’s kids got sick, half the office was gone all fall; the rest of us soldiered on. According to the CDC, the flu of 20102011 was a mixture of Influenzas A and B and the vaccine was tested out to a 99 percent match. Yes the Axis had other ideas: something called antigenic drift happens when viruses attack humans. They change then, the little bastards, and most of us got sick that winter too, but far less so than in the previous two years. “Partial protection” we called it, and with the memory of 2008 still fresh, we were grateful. Our gratitude is waning, though, since that scenario keeps recurring. The 20112012 version was estimated at 52 percent effectiveness, and the next year at 46 percent (only 9 percent for the AH3N2 strain in those older than 65). We got flu, but not horribly. Last winter the ’09 H1N1 came back, and the shot’s effectiveness was estimated at about 62 percent with the measure being “kept you from going to the doctor for flu symptoms.” That is not quite the measure the average human being uses. We got flu, but not badly. We continued to twist our patients’ arms to get flu shots, to help the herd immunity, to avoid pneumonia, to avoid the misery. But this year something different, something scary, was announced. The CDC issued a warning that the vaccine/virus match is only about 40 percent for the shot and “is investigating” reports that the flu-mist, for little ones, is a much more severe mismatch. The estimate is that Influenza H3N2 will predominate, and this is the flu that tends the hit the oldest and the very youngest the worst. Dr. Frieden of the CDC warns all to treat for flu at the early stages, to use anti-