Pandemic Flu Preparedness for Dialyzors

Discussions for Patients, Family, and Friends HD For Patients
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Here’s information from CDC for dialysis clinics on treating patients who have or may have H1N1 flu. The same instructions could prevent transmission from patient to helper in the home setting. Make sure your clinic has seen this document.

CDC H1N1 Flu | Interim Additional Guidance for Infection Control for Care of Patients with Confirmed, Probable, or Suspected Novel Influenza A (H1N1) Virus Infection in Outpatient Hemodialysis Settings
http://www.cdc.gov/h1n1flu/guidance/hemodialysis_centers.htm

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[quote=Beth Witten MSW ACSW;17705]Here’s information from CDC for dialysis clinics on treating patients who have or may have H1N1 flu. The same instructions could prevent transmission from patient to helper in the home setting. Make sure your clinic has seen this document.

CDC H1N1 Flu | Interim Additional Guidance for Infection Control for Care of Patients with Confirmed, Probable, or Suspected Novel Influenza A (H1N1) Virus Infection in Outpatient Hemodialysis Settings
http://www.cdc.gov/h1n1flu/guidance/hemodialysis_centers.htm[/quote]

Of course the Guidance assumes the unit has N95 masks stockpiled. All US providers have scores of masks per employee stockpiled right? Right? We’re going to want them this fall so they’re on hand right?

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Here’s an update that includes case fatality clues for the swine flu (highlighted). The “regular” flu is far more dangerous.

1 Million Americans Likely Stricken by Swine Flu: CDC
06.25.09, 05:00 PM EDT
The virus shows no signs of mutating as it continues global trek, officials say

THURSDAY, June 25 (HealthDay News) – An estimated 1 million Americans have been infected with the H1N1 swine flu, which continues to produce mild illness and a fairly quick recovery in patients, U.S. health officials said Thursday.

The estimate is based on mathematical modeling, Lyn Finelli, a flu surveillance official with the U.S. Centers for Disease Control and Prevention, said at a vaccine advisory meeting in Atlanta, the Associated Press reported.

Nearly 28,000 cases – about half the cases in the world – have been reported to the CDC, including 3,065 hospitalizations and 127 deaths, the news service said. By comparison, an estimated 15 million to 60 million Americans are infected with the seasonal flu each year, leading to roughly 36,000 deaths.

Meanwhile, the head of the World Health Organization said Thursday that the previously undiscovered virus, which first surfaced in mid-April in Mexico, has yet to show any signs of mutating.

Health officials are closely monitoring the H1N1 swine flu virus as it migrates from the Northern Hemisphere to the Southern Hemisphere, where the flu season is now under way. Scientists are concerned the virus could mutate as it circulates around the world, becoming more virulent and posing a greater health threat.

“The virus is not mutating for the moment, it is stable,” Margaret Chan, director general of the World Health Organization, said in Moscow, according to Agence France Press, citing Russian news agency reports.

Still, Chan underscored the need to closely monitor the virus’ spread around the globe, adding that it was highly “unpredictable.”

The WHO last week formally declared a pandemic, triggered by the rapid spread of the H1N1 virus across North America, Australia, South America, Europe and regions beyond.

What makes the H1N1 strain different from the typical seasonal flu is that about half of the people killed worldwide were young and previously healthy. In contrast, regular forms of the seasonal flu typically prove most lethal to the very young and the elderly.

Late last week, U.S. health officials said that the new H1N1 swine flu continued to spread in some parts of the country, especially in the Northeast, even though flu season is usually over by now.

“The U.S. will likely see [swine] flu activity continue throughout the summer,” Dr. Daniel Jernigan, a medical epidemiologist with the CDC’s Influenza Division, said during a press conference.

Even though H1N1 swine flu infections continue to be mild, for the most part, health-care workers need to do more to protect themselves from infection by the virus. A small sample of 26 health-care workers found that half became infected while at work, according to a report in the June 19 issue of the CDC’s Morbidity and Mortality Weekly Report.

“This includes one case where the exposure was to another ill health-care person,” Dr. Michael Bell, the CDC’s associate director for infection control, said during a June 18 press conference.

Bell said infection-control procedures need to be taken seriously.

Bell reiterated that the H1N1 swine flu continues to produce relatively mild symptoms in patients, and much has been learned about the precautions that health-care workers need to take since the virus first surfaced in April. “These lessons need to be applied so if something worse comes around we will be prepared to deal with it safely,” he said.

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Dori shouldn’t we ask ourselves where these numbers are coming from? That million number is extrapolated from phone surveys - “Do you, or anyone in your household have symptoms of respiratory disease” … Yes? then you’re counted as having H1N1. Do you suppose this being allergy season would impact people’s answers? Here is the transcript from today’s CDC press briefing - some good questions. The CDC has a seroprevalence test, and has had one for some time - let’s see those results.

The 36,000 number is not relevant to what is happening right now. This Slate article gives a good overview. Have you ever known someone who died of the flu? Have you ever known someone who died in a car accident? Both supposedly claim about the same number of lives a year. Right now H1N1 - in our summer - has over 3,000 people hospitalized with over 80% of those under 50. Avg hospitalized age 19. Avg death age 37 (see CDC transcript). That is NOTHING LIKE seasonal flu which typically impacts the very old or the very young. H1N1 is far more dangerous than seasonal flu.

What exactly do people expect to happen during the actual flu season? There is no, and there is no plan to, test people for H1N1 in a timely manner. Without testing you are not going to get anti-virals in the two day window of effectiveness after onset of symptoms.

It’s all about the economy. It should be called the World Commerce Organization.

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All excellent points, Bill! It would be nice if the CDC had a head-to-head comparison of flu surveillance, hospitalization, and death rates by age group…

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Normally flu all but stops after April. In June we’ve had over 100 confirmed flu deaths, a number that is surly going to grow as pathology reports come back. (the last New York City update on deaths and hospitalizations was June 19, 2009. The next update is due July 1, 2009. link)

The CDC does archive their flu surveillance reports - here is access to historical data for comparison and here is the most recent report. In previous years the reports stop in May.

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The messaging around H1N1 has not been at all clear. The CDC director is required to declare the Pandemic Severity Index as soon as the WHO declares that the world is at phase 6 of a pandemic.

And sure enough the day after the WHO went to stage 6 it was reported but not repeated, that the CDC had said this pandemic has a category 2 severity. It looks to me like the CDC followed their rules, and at least told the American Academy of Family Physicians - how does this square with the whole it’s not even as bad a seasonal flu meme?

The math is the math. The case fatality rate implied by 36,000 deaths a year is about .05% (i.e. 5 people dying out of 10,000 people getting sick; based on typically about 20% of the population gets the flu).

A stage 2 severity pandemic has a case fatality rate of between .1% and .5% meaning 10 to 50 people die for every 1,000 who get sick.

On the 11th the CDC said H1N1 was up to a magnitude deadlier than seasonal flu (not to mention the age shift among those impacted), yet this “not even as bad as seasonal flu” meme persists. Actually not just persists, it is fully embedded in the public consciousness.

Think about the about the fatalities implied by the “one million are infected” talking point. Was that number meant to prepare us for news that is coming? Question: if one million people in the US are infected right now how many deaths will result? At the seasonal CFR it would be 500 at the stage 2 CFR it would be between 1,000 and 5,000. And it is June.

But um carry on … nothing to see here … just enjoy the summer … I’m sure the CDC, DHHS and DHS has everything under control …

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I appreciate your analysis of this, Bill–it’s definitely a step beyond what the news sources are picking up. Since most of the stories of people who died refer to other health problems, that suggests that–like any other flu–folks with other health problems are more vulnerable. Since there IS an effective treatment for H1N1, it would seem that recognizing the symptoms and seeking medical help early would be the best strategy for those who are vulnerable, which would likely include people with kidney failure.

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The information on underlying medical conditions has not been very clear - in the media reports of deaths that mention underlying medical conditions I’ve seen gout listed, obesity (usually extra weight is an advantage when you get sick and the term seems to be being used in a subjective way in media reports), asthma, diabetes and pregnancy.

In the CDC messaging they have said that over 50% of deaths have had an underlying medical condition (could be as high as 80%) and they include people with “asthma, people with diabetes, heart disease, people with chronic lung disease and, of course, people who are pregnant”. I think you would have to include people with stage 5 CKD in the category of people at increased risk of severe illness due to H1N1.

I don’t know what the thinking or motivation of the messaging has been but the results are clear - people believe H1N1 is not a serious health problem right now. I think H1N1 is a serious health problem right now and the messaging should include preparedness for a severe winter flu season.

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Here is some solid information on underlying conditions that has been made available through wikileaks. Checkout this chart from page 15 of the (PDF link)
“Director’s Update Brief Tuesday 09 JUN 2009 1100 EDT Day 52”.
wow day 52 … of the panflu year?

Out of 201 H1N1 hospitalizations 16 had “Chronic Renal Disease”.

We need to understand what they consider “Chronic Renal Disease” - if they mean stage 5 CKD then this is a giant flashing red light, if they mean stage 3-5 CKD it’s less worrisome.

Any ideas on how we could find out what “Chronic Renal Disease” means exactly in CDCspeak?

>

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Hi Bill, why would it be less worrisome if they mean stages 3-5 CKD than just stage 5? I have a couple of CDC contacts. Not sure either would be placed to know about this, but it can’t hurt to ask.

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Well one in seven adults are thought to have some stage of CKD … that’d be 14% just stage 3 through 5 might be around 8%. The question is are they disproportionately represented?

CKD5 is a much smaller group - 550,000 or so people. In a sample of 200 you would expect few if any dialyzors. If they are disproportionately represented that should be communicated.

It’s a small n but this is the sort of data that should be available each week. This is three weeks old … what are the numbers today?

There are some questions. Look at the number for smoking there is a benefit, they’re under represented. I think 20% smoke.

What percentage of people have diabetes? How over represented are they?

ETA: I just saw immunocompromised has it’s own category so if Chronic Renal Disease means CKD5 then were talking 375,000 or so dialyzors and they’d be greatly over represented

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Well, this AP story is troubling…

Drug-resistant swine flu seen in Danish patient

By MIKE STOBBE, AP Medical Writer – Mon Jun 29, 4:05 pm ET

ATLANTA – For the first time, a case of swine flu has proven resistant to Tamiflu — the leading pharmaceutical weapon against the new virus, international health officials said Monday.
The resistance was seen in a patient in Denmark, who has recovered.

“The goods news is they just found one,” said Dr. Carolyn Bridges of the U.S. Centers for Disease control and Prevention.

It appears the strain developed in a patient who was taking the drug to prevent illness, and it has not spread to others. That’s a much better scenario than if the patient had not been taking Tamiflu and picked up a drug-resistant strain already spreading through the public, said Bridges, associate director for science in the CDC’s influenza division.

Also, it is not a mutation that includes pieces of both seasonal flu and the new pandemic form of the virus, according to Roche, the Switzerland-based pharmaceutical company that makes Tamiflu. Scientists have been worried about the new swine flu swapping genes with seasonal or other types of flu and perhaps mutating into a more dangerous or more infectious form.

Until an effective vaccine is developed, the drugs Tamiflu and Relenza have been considered the best available defense against the swine flu virus, which has caused nearly 28,000 reported illness in the United States, including more than 3,000 hospitalizations and 127 deaths.

Tamiflu resistance has not been seen in nearly 200 swine flu samples tested in the United States, Bridges said. But the resistance has been seen in other types of flu. Late last year, CDC officials reported that the most common flu bug circulating at the time was overwhelmingly resistant to Tamiflu. Health officials have believed it was probably a matter of time before a swine flu sample tested resistant, too.

The Danish case was isolated, however, and guidelines from the CDC and the World Health Organization continue to recommend Tamiflu as a treatment. No details were released on the patient’s age or gender, or on when the patient was sick.

“It is possible to see occasional reports of resistance while a drug remains largely effective,” said Terry Hurley, a Roche spokesman.
Related Searches:

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On the heels of Japan announcing a case of Tamiflu resistant H1 N1 there is this:

Swine Flu Monitor: CDC Will Report Only Relenza Effective Against H1N1 Virus
Cheree Cleghorn | July 2, 2009

More than 99 percent of the seasonal H1N1 viruses have shown resistance to Tamiflu, which has been considered one of the first-line drugs for this strain in prior years.

A Centers for Disease Control and Prevention advisory committee has found drug resistance in all but one of the anti-viral drugs used for influenza-like illness, “whether the infection is caused by a seasonal virus or the pandemic H1N1 virus.” (Emphasis added)

Since spring, SmithGlaxoKline, manufacturer of Relenza, has reported “ample” supplies of the drug through company statements and news stories.

What Can You Do?

[ul]
[li]Report flu-like symptoms to your doctor right away to determine what is appropriate for you.[/li]
[li]If your doctor tells you to take antiviral medication, you should start it right away.[/li][li]According to the CDC advisory panel, only one medication is effective with this year’s influenza-like illnesses. The drug brand name is Relenza.[/li]
[li]Consult the CDC Swine Flu section on its Home Page, which has advice for patients and those who care for them at home.[/li]
[/ul]
Medpage Today
“Zanamivir (Relenza), a neuraminidase inhibitor, should be the preferred treatment for patients with influenza-like illness, whether infection is caused by a seasonal virus or the pandemic H1N1 virus, an advisory committee to the CDC said. (Emphasis added)

“Even if laboratory tests are negative but flu is still suspected, zanamivir should be used when antiviral treatment is considered, the Advisory Committee on Immunization Practices agreed here.

“Oseltamivir (Tamiflu), another neuraminidase inhibitor, could be used in case of a test that’s positive for seasonal influenza A H3N2 or B, or for pandemic influenza A H1N1, although more than 99% of the seasonal H1N1 viruses were resistant to the drug, the committee noted.

“The recommendations were based on testing for antiviral resistance, which found that all strains recently isolated, including the new H1N1, were susceptible to zanamivir. “Researchers found varying levels of resistance to the adamantanes, rimantadine and amantadine.”

“The recommendations, which will be published in an upcoming issue of Morbidity and Mortality Weekly Report, stressed that treatment should start as soon as possible for patients needing treatment.” ( Emphasis added)

Source: Medpage Today, June 29, 2009
Citation: CDC Morbidity and Mortality Weekly Report, Publication Pending.

Me: But ah you know don’t worry … no need to prepare for the Northern hemisphere’s flu season … I’m sure it will be fine

>

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Here’s a new article I found on Salon.com. I put some things in bold. Beth emailed our CDC contact, but hasn’t heard back yet…

Jul 2nd, 2009 | WASHINGTON – With swine flu continuing to spread around the world, researchers say they have found the reason it is – so far – more a series of local blazes than a wide-raging wildfire.

The new virus, H1N1, has a protein on its surface that is not very efficient at binding with receptors in people’s respiratory tracts, researchers at the Harvard-MIT Division of Health Sciences and Technology report in Friday’s edition of the journal Science.

“While the virus is able to bind human receptors, it clearly appears to be restricted,” Ram Sasisekharan, lead author of the report, said in a statement.

But flu viruses are known to mutate rapidly, the research team noted, so this one must be watched closely in case it changes to become easier to spread.

On June 11, the World Health Organization declared a level 6 pandemic alert for H1N1. More than 300 people have died and more than 70,000 people have been infected, according to the WHO.

It’s currently flu season in the Southern Hemisphere and the spread of the virus in Argentina has prompted schools there to give students an early vacation and one province to declare a public health emergency.

On Thursday, Health and Human Services Secretary Kathleen Sebelius said the United States will provide 420,000 treatment courses of the anti-viral medicine Tamiflu to the Pan-American Health Organization to help fight the flu in Latin America and the Caribbean.

“Viruses know no borders. The U.S. recognizes that a novel virus such as the H1N1 is a burden borne by all nations, and all of us have a responsibility to help support one another in the face of this challenge,” Sebelius said at a meeting of health ministers in Mexico.

Sasisekharan’s paper, meanwhile, warned that the H1N1 strain might just need a single change or mutation to make it resistant to Tamiflu.

And the illness is not limited to the south.

England’s health minister said Thursday that his country faces a projected 100,000 new swine flu cases a day by the end of August and must revamp its flu strategy. Britain has officially reported 7,447 swine flu cases and three deaths, but officials acknowledge the real number of cases is far higher, since many with the virus have not been tested.

Vaccine makers, meanwhile, are working to develop shots for use in the fall and winter if the flu continues to spread.

The discovery that the new virus can spread between people, but inefficiently, is consistent with the pattern of illness seen so far, says Sasisekharan. Most outbreaks have occurred in limited clusters, sometimes within a family or a school, but have not spread much further.

They also noted that the new virus is more active in the gastrointestinal tract than the seasonal flu, leading to intestinal distress and vomiting in about 40 percent of those infected.

The research by scientists from MIT and the federal Centers for Disease Control and Prevention was funded by the Singapore-MIT Alliance for Research and Technology and the National Institutes of General Medical Sciences.

On the Net:

Science: http://www.sciencemag.org

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um but this is spreading outside of the conventional flu season, so are they saying that H1N1 spread less efficiently in the summer than seasonal flu spreads in the winter?

And they’re basing this on ferret studies instead of releasing the seroprevalence studies that they must have that makes no sense unless they are trying to steer the message.

Do you detect any dissonance in the recent messaging?
There have been a million cases in the US, but it doesn’t spread easily.

It’s the same as seasonal flu yet there have been over 80 pediatric deaths since April - which matches the total maximum in the previous four seasonal flu seasons.

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I think it’s always wise to be a bit suspicious of official messaging, especially when the facts don’t seem to add up…

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I just called the CDC’s info line 1-800 number. I asked what exactly is meant by Chronic Kidney Disease (or Chronic Renal Disease). The person on the phone said that it does not refer to “kidney stones or urinary infections. It would have to be disease severe enough to effect your immune system.”

So that suggests they’re talking about CKD5 or at least under a doctor’s care for CKD. That can’t be very many people … I don’t know a million? Three million? even if it was three million then it increases your risk of hospitalizations by a factor of eight.

There is one explanation that does not mean H1N1 is more severe in people on dialysis. If people are being barred from dialysis when they are known or suspected of having the H1N1 flu. On the KCER pandemic calls it was clear that some providers - at least one of the LDOs - had a policy to send dialyzors with flu symptoms to the ER. If that is happening it could explain dialyzors disproportionate representation on the underlying conditions list.

It’s frustrating to not have access to the information the CDC is collecting. If a dialyzor does end up in the hospital with H1N1 there is no official communication back to the unit or network. And if it isn’t reported it hasn’t happened. I think that explains the lack of official cases among dialyzors.

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First Tamiflu-resistant swine flu case found in teenager (Hong Kong)
http://www.thestandard.com.hk/breaking_news_detail.asp?id=15461

A 16-year-old girl was found to be infected with a mutation of the swine flu virus that is resistant to the antiviral Tamiflu soon after arriving from San Francisco, the Department of Health said today. …

double plus ungood

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NOT liking the sound of this one…

New flu resembles feared 1918 virus: study

By Maggie Fox, Health and Science Editor - Mon Jul 13, 7:37 AM PDT
WASHINGTON (Reuters) - The new H1N1 influenza virus bears a disturbing resemblance to the virus strain that caused the 1918 flu pandemic, with a greater ability to infect the lungs than common seasonal flu viruses, researchers reported on Monday.

Tests in several animals confirmed other studies that have shown the new swine flu strain can spread beyond the upper respiratory tract to go deep into the lungs – making it more likely to cause pneumonia, the international team said.

In addition, they found that people who survived the 1918 pandemic seem to have extra immune protection against the virus, again confirming the work of other researchers.

“When we conducted the experiments in ferrets and monkeys, the seasonal virus did not replicate in the lungs,” said Yoshihiro Kawaoka of the University of Wisconsin, who led the study.

The H1N1 virus replicates significantly better in the lungs."

The new swine flu virus has caused the first pandemic of the 21st century, infecting more than a million people, according to estimates, and killing at least 500. The World Health Organization says it is causing mostly moderate disease but Kawaoka said that does not mean it is like seasonal flu.

“There is a misunderstanding about this virus,” he said in a statement. “There is clear evidence the virus is different than seasonal influenza.”

Writing in the journal Nature, Kawaoka and colleagues noted that the ability to infect the lungs is a characteristic of other pandemic viruses, especially the 1918 virus, which is estimated to have killed between 40 million and 100 million people.

OLD PROTECTION

They tested the virus in blood samples taken from nursing home residents and workers in 1999 in California, Wisconsin, the Netherlands and Japan.

People born before 1920 had a strong antibody response to the new H1N1 virus, meaning their body “remembered” it from infection early in life. This finding supports a study published in Nature in August that also found people who survived the 1918 pandemic still had immune protection against that virus.

Flu viruses change constantly, which is why people can be re-infected and why the vaccine must be changed regularly. Current seasonal strains of H1N1 are distant cousins of both the 1918 pandemic strain and the new H1N1 strain.

“Our findings are a reminder that swine-origin influenza viruses have not yet garnered a place in history, but may still do so, as the pandemic caused by these viruses has the potential to produce a significant impact on human health and the global economy,” the researchers wrote.

Other tests showed the virus could be controlled by the antiviral drugs Relenza, made by GlaxoSmithKline, and Tamiflu, made by Roche AG, the researchers said.

The World Health Organization said on Monday that vaccine makers should start making immunizations against H1N1 and that healthcare workers should be first in line to get them.

Companies working on an H1N1 vaccine include Sanofi-Aventis, Novartis AG, Baxter International Inc, GlaxoSmithKline, Solvay and nasal spray maker MedImmune, now part of AstraZeneca.

(Editing by Doina Chiacu)