H1N1 Update: Prevalence, Severity, Tamiflu, Current Recommendations

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H1N1 Update: 
Prevalence, Severity, Tamiflu, 
Current Recommendations

Recent information from the CDC has brought a few facts about how
today's H1N1 epidemic is behaving. It is time to take a look at the
new information.

Prevalence
In keeping with prior posts on this ongoing epidemic, it is clear that
the H1N1 epidemic became quite widespread this October.

All but 2 states in the US reported that H1N1 is widespread.
We know that in our region that very large numbers of people
have had H1N1 infections.

Keep in mind, however, that this H1N1 virus is hard to prove
present using commonly used lab and office testing. The usual
tests for influenza do not accurately work when testing for H1N1.

Advanced Pediatrics follows the lead of infectious disease experts
in only believing the results of H1N1 specific testing, available only
via national laboratories at the CDC, or worldwide at the WHO.

Severity
National reports from the CDC have documented 114 deaths
from H1N1 in children ages 0-21. They estimate that the real
number is closer to 300. Roughly two-thirds of these fatalities
were in children with serious underlying medical conditions, such
as muscular dystrophy and cerebral palsy.

As with nearly any infection, there are rare but reported cases
of death from this infection in otherwise healthy children.

These numbers are technically higher than in previous flu years,
but my read of them is that they are similar. The highest number of
fatalities previously was 88. Now 114 is higher than 88, but the two
numbers are actually quite similar. That is, the number of fatalities
this year has not jumped to 1000 or 10,000. Such a jump would indeed
be evidence that this H1N1 flu virus is particularly dangerous.

But the numbers have not jumped to 1000 or 10,000, they are pretty
much staying around 100 or so. This makes H1N1 very much as little
a risk as the seasonal flu, so far.

On a very local level, Advanced Pediatrics, like all practices,
has seen a huge jump in the number of people with viral
infections in October. But for this month, not a single child
or adolescent got ill enough to be admitted to a hospital
from Advanced Pediatrics.

Our read at Advanced Pediatrics is that this H1N1 virus, at least
this October, was not much more severe than the usual annual flu bug.

Most importantly, it does not matter for your child what the stats are.
The key point for each person who gets ill is to determine if that person,
at any point in time, has mild or serious illness.  

If your illness is mild (cough, fever up to 105.8, runny nose, achy,
poor appetite, poor sleep, sore throat), you are not in danger.
Keep comfy, stay alert for changes to more severity, do not panic.

If your illness is severe (stiff [not just sore], it's hard to get air in
and out of your chest, altered consciousness, severe pain, or a
sense that something terrible is happening), seek medical care
immediately and urgently- call us, get to an ER, call 9-1-1.

Tamiflu
Much will be made of the recent news that the US is releasing the last of
its stockpile of liquid Tamiflu in response to the reported numbers of
childhood fatalities.

Keep in mind, Tamiflu is much weaker than antibiotics for ear infections.
By this we mean that the usual experience of stunning cure seen
with antibiotics for ear infections is simply not seen with Tamiflu and H1N1.

It is estimated that use of Tamiflu may make a 7 day illness perhaps a 6 day
illness. It is not the case that if you take Tamiflu all of a sudden your H1N1 illness
goes away.

For the vast majority of patients with mild (see above) illness, it may not be
apparent that Tamiflu made them any better.

If you have severe illness (see above), then the small degree of help Tamiflu
can offer suddenly becomes relevant. Just a bit of help from a medicine
in a potentially lethal illness could save a life.

And so we continue to propose we all follow the advice of the top
experts: do not use Tamiflu for mild illness since it will not help.
Do use Tamiflu for severe illness, since it may help.


Bottom Line, or Current Recommendations

1. Don't panic. The H1N1 epidemic is widespread but so far mild for nearly all children
2. Stay tuned. The H1N1 virus can change.  
3. We will post any changes in severity, so keep checking these posts.
4. Tamiflu does not work well for mild illness and should not be used if mildly ill.
5. Tamiflu may help with severe illness and should be used if severely ill.
6. H1N1 immunizations will be very widely available as production rolls it out.
7. The first shipment had limited numbers, but plenty more is on the way.
8. Stay posted, we will post when we receive H1N1 immunizations.
9. We recommend all receive H1N1 immunization.
10. At this time, this is a reasonable, not urgent recommendation.
11. Don't panic. It does not help you or your family.
12. Advanced Pediatrics remains committed to being informed, objective, and available.

Dr. Arthur Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

H1N1 Shots AVAILABLE AT SHAKER HEIGHTS TONIGHT

H1N1 SHOTS AVAILABLE AT SHAKER 
HEIGHTS TONIGHT

6-9PM TONIGHT THURSDAY, OCTOBER 29

No appointments

You can live anywhere and go

Only the following will be immunized tonight:

• Pregnant women
• All children 6months up to 5 years old
• Children 5-18 years old with chronic conditions
• Emergency responders
• People who live babies less than 6 months old

Call

216-491-1480

or go to

www.shakeronline.com/calendar/eventdetails/event2531.asp

for details.

Dr. Arthur Lavin

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*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Working Together to Manage a Shortage

Working Together to Manage a Shortage

It seems prudent to post a note during this stressful, transient time
between our first and subsequent deliveries of H1N1 vaccine about
how we need to manage this challenge.

First of all, this is not a dangerous crisis. The H1N1 illness so far
is incredibly mild. Further, we anticipate having lots and lots of H1N1
vaccine. The US is making 190 million doses, only 13 million have
been finished and shipped, so almost all the vaccine is yet to be
shipped, and will be shipped and available.

Secondly, Advanced Pediatrics has given a great deal of thought
on how best to distribute the limited doses of flu vaccine, H1N1 and
seasonal, as it becomes available.

This is how we do it:

1. We only make appointments for flu vaccines that we actually have on hand.
2. We do not make appointments for flu vaccines that we do not have.
3. When we receive a shipment, we put a carefully determined number of doses in reserve for critically ill children.
4. We then set up appointments for all the doses available be alerting the practice by posting on our web page and/or e-mail alerts.
5. Appointments for H1N1 and seasonal flu vaccine are then made on a first-come, first-serve basis for all but the most critically ill children.
6. Advanced Pediatrics makes these vaccines available only on this basis.
7. Every family has the same opportunity to obtain a flu vaccine appointment.
8. Only shortages of manufacture have caused families to have to wait for flu shot appts.

Another option would be to not provide flu vaccines at the office. That would lead to fully equal 

treatment, but would be a very poor choice. Why not make the vaccine available to 

everybody we can?

Of course, even the most fair approach to making a limited item available will create 
frustration and disappointment. Please believe us when we say that we wish American
pharmaceutical manufacturers could make enough H1N1 and seasonal flu vaccine for use
well before any flu season.

But the reality is that they cannot, and so we are all, practice and family, thrust into
managing a situation of temporary shortage.

As such, we remain most grateful for your understanding and patience as we work together
to make H1N1 and seasonal flu immunization available to your children.

Thank You,

Dr. Arthur Lavin and the Advanced Pediatrics Team

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Update on SEASONAL flu immunization

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Update on SEASONAL flu immunization


We are still prioritizing H1N1 flu immunization and so at this time
we are not opening appointments for new seasonal flu shot appointments.


We will be opening appointments for seasonal flu appointments soon, so
stay posted.




Dr. Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

All Firsts before Seconds

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All Firsts before Seconds


With the demands of two flu epidemics straining our nation and community, we
thought it would be wise to make a simple point:


The top priority must be given to the first doses of H1N1 and seasonal flu
immunization.


That means we will not be giving booster doses to anyone who needs them
until everyone who needs it gets their first dose.


So first doses first, and only after that, seconds.


Thanks for all your understanding.


We will keep you posted,


Dr. Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

October Update on H1N1

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October Update on H1N1
As October draws to a close here is where we stand on the
H1N1 epidemic of 2009 and our immunization program 
for H1N1 and seasonal flu:

The Illness

1. Right now the H1N1 epidemic is quite widespread in our area.
2. Cleveland is experiencing very high incidence of H1N1 infections.
3. The illnesses in children in our practice remain quite safe.
4. Illness is notable for high fever and typical cold symptoms.
5. No one from Advanced Pediatrics has been admitted to the hospital for this illness.

The Immunizations

1. Advanced Pediatrics was one of the first practices in our region to receive a shipment of H1N1 vaccine. It was all in the nasal spray form
2. Within 12 hours of receiving the vaccine, the practice was notified it was available and all doses were administered within one week.
3. We anticipate receiving many, many more doses of the nasal spray as well as abundant ininjections for infants and older children and adolescents in the coming weeks.
4. Announcements on H1N1 immunization availability will be posted in real time, as it happens on this web page.
5. When decisions are made about days for new vaccine administration, emails will be sent out to announce that step.

Don't forget Seasonal Flu

H1N1 is here and now.

H1N1 immunization is of the moment as well.

But starting in a few weeks, a new flu epidemic will be hitting, seasonal flu.

We are still focusing our efforts on H1N1 prevention, but should have
some new appointments available for seasonal flu immunization soon.
When those appointments are opened, we will post a notice on this web
posting.

Bottom Line:

• The H1N1 epidemic of 2009 is here and now
• So far, to date, the illness is quite mild
• No serious outcomes have occurred from H1N1 in the practice, so far
• We have received and administered only our first shipment of H1N1 vaccine
• Much more H1N1 is expected to be delivered, we check every day
• We will notify by web post and email when we receive our H1N1 vaccines
• Make sure you are immunized against seasonal flu, we will post when appointments for seasonal flu immunization open again.

Dr. Arthur Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Advanced Pediatrics' Recommendation to Immunize for H1N1 is a reasonable, not urgent recommendation

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H1N1: So Far Very Mild, 
Vaccine is on the Way

H1N1 influenza infection has increased emotionally, but not medically.

As noted earlier in the series of posts on the subject of H1N1 (swine)
influenza infections, this has become an epidemic.

Certainly in the Greater Cleveland area, this virus has become
quite common, if not nearly universal across all our families and
households.

The chance of getting an H1N1 infection has jumped to such a
high level, that recently President Obama declared the H1N1 epidemic
of 2009 a national emergency.

One could easily be forgiven for panic.

But the point of this post is to offer an equally compelling
perspective: so far this epidemic has been strikingly mild.

Not only the vast majority, but in the case of Advanced Pediatrics,
every case has been very mild, causing no lasting harm, at all.

And so the recommendation from Advanced Pediatrics to seek
H1N1 immunization is more a reasonable than urgent
recommendation.

We say reasonable, since it makes sense to seek protection
from an infection that might get more severe over time.

Not urgent, because so far the infection has been so mild.

And so now we come to the unavoidable challenge of logistics.

The production of H1N1 is going to take a few weeks. Within a month or so,
we expect that all medical facilities, including Advanced Pediatrics, will
have lots more H1N1 vaccine material than you could possibly demand.

But right now, shipments are dribbling in. That means right now, many
of the families at Advanced Pediatrics are frustrated, perhaps frightened,
maybe even angry. The H1N1 epidemic is raging, and we do not have
all the doses we have ordered. A recipe for strong feeling.

That is where the reality of our current situation comes into such strong play.

Yes, it is frustrating for all of us not to have all the H1N1 vaccine we need.

But, it must be kept in mind that if you get H1N1 infection today, you will simply
get a cold. That's it.

So for now, when everyone is getting infected with H1N1, it is critical that we
all keep in mind that you will most likely just have a cold.

We are working hard to make sure that as soon as the United States ships
H1N1 vaccine to Advanced Pediatrics (no one can buy it, it can only be
delivered via the government), to set up times to have the vaccine
administered.

So stay posted, we will alert you by posts to this blog whenever a new
shipment arrives and new immunization dates can be set.

In the meantime, your family, as always, depends on your guidance.
Stay informed. Be aware that as of right now, there is little if any
danger from H1N1, so panic has no justified place in your family.

BOTTOM LINE
H1N1 infection is very, very widespread in our area, now.

So far, these infections have been quite mild, basically giving
people colds, aches, and such. No one has even been admitted
from our practice to the hospital during this epidemic.

H1N1 vaccine is being delivered slowly, but will be
delivered. I am confident we will have ample supplies
to protect the entire practice, and in good time.

Our current situation is, therefore, actually quite good:

• The disease is mild.
• A vaccine has been created that works to protect us from H1N1
• The vaccine is as safe as the flu vaccines in use for decades
• We will have plenty of H1N1 vaccine in plenty of time, just not right now.

We look forward to working together with your family to get through these

rather tumultuous times, just keep in mind that right now most of the tumult

is in our minds, and not reflected by the actual facts on the ground.

Dr. Lavin

\
*Disclaimer*

The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The Limits of a Rush

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The Limits of a Rush
It turns out the US government, and our CDC has made a
decision to make the H1N1 vaccine as safely as possible.

This sounds like a good idea, and it is.

But the safest choice turns out to take the longest to make.
The safest choice involves slowly growing the H1N1 vaccine
virus on eggs, requiring about 6 months to make the vaccine.

Another option is a more modern and far faster technique, but
that is not yet tested for safety.

We welcome the CDC's decision and are pleased that the
H1N1 vaccines we offer are very, very safe to take.

BUT, This choice has led to a very slow
roll-out of the H1N1 vaccine in the US.

190 million doses are being made, but only
13 million doses are actually made so far.


NO WAY AROUND IT, WE WILL NOT HAVE
ENOUGH H1N1 VACCINE ON ANY DAY
TO VACCINATE ALL MEMBERS OF OUR
PRACTICE ON A GIVEN DAY.

What we have done is reserve enough 
doses of our first shipment to have 
enough for high-risk children.

What we have also done is try to alert 
everyone when we have a shipment of 
H1N1 arrive.

What we cannot do is provide doses that 
we do not physically possess, no one can.

We will work with everyone to maximize 
the ease of getting H1N1 immunization,
we do ask that all families recognize that 
limits of supply are not something we like,and to work together with our staff to find the best way in for H1N1 immunization.


Within hours of receiving our first
shipment of H1N1 vaccine, our team
established 4 special flu vaccine
clinics and will have administered the
entire first shipment of hundreds of doses
in less than a week. It is not clear how
we could possibly get the material out any
faster.


This is a frustrating time, an epidemic
is raging, vaccine is in short supply.
Please know that we share your
frustration and look forward to working
together to protect your children as
quickly as possible.




Dr. Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

New Cause of Chronic Fatigue Syndrome Perhaps Found

New Cause of Chronic Fatigue 
Syndrome Perhaps Found

Scientists near the epicenter of one of the largest known outbreaks or epidemics of chronic fatigue syndrome (CFS) have published an astounding finding:  about two-thirds of people with CFS have traces of a novel virus, XMRV.  Only about 3% of those without CFS have traces of XMRV in their tissue.  The investigators suspect about 100% of people with CFS actually have this virus in them.

If the findings hold up, chronic fatigue syndrome will suddenly cease to be a problem of the mind, but will be known as an infection, a retroviral infection.  The only proven retroviral infection in humans is HIV.  But it seems very likely that reflects our ignorance and that retroviruses play a much larger role in human life than we know.

What follows is my current understanding of retroviruses, a group of germs it looks like we better learn much more about.

The Basics About Viruses

Viruses are a very ancient and peculiar part of all life.  In essence, they are just traveling bits of information.  The information is contained in their tiny bits of DNA or RNA whose only purpose is to make more viral DNA or RNA.

A typical virus is just a strand of a few genes of DNA packaged in a protein that contains the right combination to enter its target cell.  The viral DNA finds its way into the cell's DNA and takes over.  Soon the poor infected cell stops what it was supposed to do and starts making an astounding number of copies of viral DNA and its coating proteins.  The cell explodes, releasing vast numbers of new viruses to repeat the cycle.  This is how nearly all the usual viral infections we experience, like colds, flus, measles, mumps, chickenpox work.

The nice part of the usual DNA virus is that a dead cell cannot dysfunction, so the body can replace it, you heal, all is well.

Some Basics About Retroviruses

The retroviruses are far more insidious.  They have RNA in their centers. The RNA enters the cell and directs the cell to make DNA that inserts itself very gently into the cell's DNA.  Usually this does not kill the cell.  It continues to go about its business, but additionally starts making viral RNA, and the retrovirus reproduces.   The viral reproduction, however, does not kill the cell, and the viral DNA remains in the cell's DNA.  If you are lucky, the cell really is not harmed or changed, and life goes on unharmed or changed.

But, often, the retrovirus leaves the cell a bit altered in its usual function.  That bit of alteration often leads to serious dysfunction of critical cellular systems, such as growing.  As a result, many known retroviral infections in animals cause cancers to sprout.

If important immune system cells are infected and their function messed up, the immune system function can be jammed.  This is the problem seen in the most famous retrovirus of them all, HIV.  Infected cells include very important immune system cells, devastating normal immune function.

If XMRV is the cause of chronic fatigue syndrome, then we will have an example of the retroviral process interfering with neurological function.  

Clearly, the retroviruses can cause havoc in important functions of the body, including how cells grow, how the immune system works, and perhaps how the brain functions.

Retroviruses in Evolution

But the impact of retroviruses is clearly not limited to just causing disease.

Remember that retroviruses leave their traces in the cell's DNA?  That leads to one of their most striking properties.  Over the course of the last 3 or so billion years, retroviruses have left their DNA traces on essentially all living cells.  It turns out viruses have been around nearly as long as life.  Back when life on Earth was only single-celled organisms, essentially bacteria, viruses were already infecting cells.  Retroviruses were there all along as well, and their viral DNA has been passed along the generations of life.

As a result our human DNA is estimated to be about 10-15% ancient retroviral DNA.  When scientists sequenced the human genome, they found that vast stretches of human DNA did not encode for any known product, most of the human genome is not genes!  Not all, but about 15% of those stretches are from retroviral infections that took place over somewhere around 200 million years ago.  It is not known if these ancient retroviral sequences in our DNA do anything, but one striking possibility is that they are responsible for the development of placentas in mammals.  Soon after the egg is fertilized, the sequences of DNA that lead to the placenta forming and invading the mother's uterus appear to be retroviral in origin.

A Summary of Properties of Retroviruses

And so retroviruses are indeed a highly unusual set of infecting agents.  Their properties that we understand so far, are striking:

• They have to create and then insert viral DNA into the cell's DNA without killing it.
• This leads to persistence of their DNA sequences if the changes enter into reproducing cells.
• Retroviral infections tend to be permanent changes in our DNA.
• They do not kill cells, only change their function enough to reproduce.
• The changes in function lead to a wide variety of sometimes very interesting, sometimes very upsetting changes in the organism's functions.  So far we know that retroviruses can:
• Create placentas
• Cause cancer (many, many examples in animals, perhaps prostate in humans)
• Cause failure of the immune system
• Cause alterations in neurologic function, e.g., chronic fatigue syndrome

The Seven Families of Retroviruses
As you might guess, we know very, very little about retroviruses.  So far about 7 families of retrovirus have been identified in humans and animals.

In the sixth family resides the most famous retrovirus, AIDS.

The proposed viral cause of chronic fatigue syndrome is in the third grouping, hence the reference to gamma retroviruses.

The fourth or delta retrovirus family contains the only other known human retrovirus, HTLV, which is closely related to HIV, but not identical.

For alpha, beta, and epsilon retroviruses, the only known examples are animal viruses that cause a variety of cell growth problems, or cancers.

Treating Retroviral Infection

The only treatment known for any retroviral infection is to stop the retrovirus from converting its own RNA into our DNA.  And that approach has only been shown to work on AIDS.

But, if HIV retroviruses can be stopped in their tracks, their is much hope others can as well.

BOTTOM LINE:


It is not yet proven that XMRV causes chronic fatigue syndrome.  The initial evidence is compelling, but compelling evidence has proven not to be proof in other situations.


Most upsetting, we cannot offer new, novel therapies for chronic fatigue syndrome just yet.  We first have to find out if XMRV is an actual cause, and then find out how to stop or reverse its effect. 

But, the discovery that a gamma retrovirus, XMRV (Xeno Murine Retro Virus, i.e., unusual rat retrovirus) may cause chronic fatigue syndrome opens a new door of understanding, and for the first time, hope for prevention and cure for this serious malady.

I suspect, that as we learn more about retroviruses, we will find that there are alot more of them in humans than we thought, and that their impact may include not just dread diseases, but some fairly vital side impacts (like forming placentas) as well.


I will keep this web site updated as we learn more about the cause of chronic fatigue syndrome, and retroviruses.

Dr. Lavin

*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.