The reason advice is needed is two-fold. First, although I’ve raised a child before, I’ve not had charge of an infant during a pandemic. Second, few other people have either, and the nature of advice, common knowledge and practice about things in general and health related issues in particular is not usually rational, in my opinion.

We’ve already decided to skip the usual Huge Thanksgiving Get Together for the simple reason that there will be thirty or forty people there, and it simply does not make sense to wander into a crowded house full of people with a new baby during a flu pandemic.

An alternative has been suggested. This is a smaller, more limited Thanksgiving dinner with just a few family members, and that’s all. But there are three problems with this emerging, at least in my mind: 1) At least two people who will be there have rather proudly declared (and I love you guys, but you are way off on this one …) that they don’t do vaccines. They are not denialists, they just think the vaccines will make them sick. And of the other people who might visit I’m not sure who or who else might have the vaccine; 2) There will be at least one, possibly two, other vulnerable individuals who will also be at the get-together, so this may not be a good idea for them either. (Though they are older than what seems to be a high-risk cutoff for Novel A/H1N1 Swine Flu, and by that time will have been vaccinated.); and 3) I’m not sure that spending five hours in a house with one person who is sending out flu infectoids is much different than spending five hours in a larger house, more densely crowded, with, maybe, a dozen people sending out the infectoids. In fact, the way social events like this work, it is quite possible that the expected number of people woud grow rather than shrink. Will it be eight people? Ten? Fourteen? All these numbers are less than 30 (the best guess for the main Thanksgiving event) but I’m not sure if I care about that difference. Yes, I understand that exposure for longer periods and to more infectious sources should be more highly correlated with actual infection across many instances, statistically, so the probabilities are different. But …

We are talking about my baby. If I had a hundred babies, I might not mind so much if two or three of them died of the flu. But with just one …. I’m not so sure that aggregate values and probabilities are of any great interest to me. My baby does not get to be several thousand dots on a graph only a few of which will get sick. He is allowed to be only one dot.

My current plan is to monitor the situation, and consider a visit that falls short of staying around for hours and having dinner, but would allow the people to see the child and visa versa. Although the unvaccinated will be wearing those scary masks and everyone will be washing their hands every few minutes.

As I suggested above, there is likely to be a certain amount of irrationality in a decision making process like this one. I’m not sure what will emerge in this particular case, but for the more general circumstance of family meeting baby vs. limiting exposure to baby, here’s a few items that come to mind:

First, if you read the “how to not screw up your baby” literature, you’ll see a common question addressed: When is it “safe” or advisable to “take your baby out” after it is born? The answer in this literature strongly implies that new parents are often too shy about going out with baby. It is perfectly OK to cart around a properly swaddled new-born. Just don’t let sick people touch it, and be smart about what you are doing. In fact, you will see comments in this expert advice literature such as “It is probably healthier to get your baby … and yourself! … out of the house early and reasonably often! Don’t be a hermit.” and so on.

And of course, that is all true. But, this advice addresses a question other than: “When is it safe to bring my baby into contact with other people who may have the Pandemic Flu?”

And, the advice does not specifically mention my baby. Here, we are talking about my baby. If I had a hundred babies, I might not mind so much if two or three of them died of the flu because I took them out because some FAQ on taking care of new borns told me to. But with just one …. I’m not so sure….

A second feature of this sort of discussion is the necessity and importance of the family visit, of the “coming out” of the new born for all to meet and stuff. Obviously, this is a very important thing to do, but it is possible that the importance of everyone getting to meet and greet the new baby is not quite as great as the baby surviving his first several weeks of life, despite one’s desire to avoid social awkwardness of any kind.

Let me be quite stark about this: Cousin Jeeter may feel great about meeting the new baby now, but how is Jeeter going to feel if the next day he suddenly comes down with the flu, and two weeks later finds out that he probably gave the flu to his infant cousin, who has died, and no, Jeeter is not invited to the funeral. I understand that dead baby comments are in bad taste and there will be people mad at me for making the stark link between this decision and that outcome.

Tough. We are talking about my baby. If I had a hundred babies, I might not mind so much if two or three of them died of the flu. But with just one …. I’m not so sure that someone’s sensitivity to facing the stark reality that this flu … this pandemic flu we are having now … appears to be potentially deadly to anyone under 18 years of age is of any great interest to me. Yes, the chances that an infant will die from the flu are low. A week or two in the NICU should take care of him, and organ damage caused by such a major infection early in life won’t matter for … decades, if at all. But we are talking about my baby, so I might be a little picky about this.

A third fallacy that is of great importance is that if everyone washes their hands, there won’t be any problem. While it is good to wash hands a lot to reduce flu transmission, this only reduces transmission to some extent. The flu is transmitted very nicely by flying through the air. Even if an infected person coughs into his or her sleeve, the air that comes out of the person’s mouth has a zillion tiny saliva spaceships each occupied by thousands of eager flu viruses, which blow around the sleeve and into the air. Those tiny, microscopic droplets float around in the air for many minutes, possibly hours. They are then breathed in by other people in the room. They can also land on surfaces such as … candy in a candy dish, the rims of drinking glasses, the nipple of a baby’s bottle, the cat, or on someone’s hair.

Yes, a really good way to get the flu is if an infected person coughs slimy stuff into his hand, and shakes your hand thus putting the slimy stuff on your palm, then you wipe your nose with the palm of your hand or maybe you lick your palm or something. But for the most part, the way flu actually gets from one person to another is when there are two people in a room, one is infected and the other not, and they both breath for a while, with the infected person coughing or sneezing now and then.

Am I exaggerating the air borne infectious nature of this flu? Maybe, maybe not. Conditions vary, the flu varies, it is all a game of complex interconnected probabilities, so there is certainly a calculable probability of infection via direct hand to hand (to mouth) contact vs. airborne only.

But we are talking about my baby. If I had a hundred babies, I might not mind so much if two or three of them died of the flu transmitted via the air. But with just one …. I’m not so sure that aggregate values and probabilities are of any great interest to me.

I feel very lucky that all the close and more distant family members in our case will be totally understanding and supportive of whatever decisions we make (though everyone really should get vaccinated). The problem is, what exactly should that decision be?

So, what are you doing for Thanksgiving? What do you think we should we do?

Athens, Ga. – Each year, the influenza virus evolves. And each year, public health officials try to predict what the new strain will be and how it will affect the population in order to best combat it.

A new study by an international team of researchers, led by assistant professor Andrew W. Park, who holds a joint appointment in the University of Georgia Odum School of Ecology and in the College of Veterinary Medicine, may make their task a little easier. The study breaks ground by working across scales and linking sub-molecular changes in the influenza virus to the likelihood of influenza outbreaks. The paper, published in the Oct. 30 edition of the journal Science, shows the relationship between the evolution of the virus and immunization rates needed to prevent an outbreak in the population.

Park explained that these findings can help inform efforts to prevent future outbreaks. “Public health officials will be able to assess the usefulness of a vaccine based upon its relationship to the current influenza strain and the population’s immunity level,” he said.

New model may help scientists better predict and prevent influenza outbreaks
Writer: Beth Gavrilles, 706/542-7247, bethgav@uga.edu
Contact: Andrew W. Park, 706/542-5373, awpark@uga.edu
Oct 29, 2009, 14:00

Athens, Ga. – Each year, the influenza virus evolves. And each year, public health officials try to predict what the new strain will be and how it will affect the population in order to best combat it.

A new study by an international team of researchers, led by assistant professor Andrew W. Park, who holds a joint appointment in the University of Georgia Odum School of Ecology and in the College of Veterinary Medicine, may make their task a little easier. The study breaks ground by working across scales and linking sub-molecular changes in the influenza virus to the likelihood of influenza outbreaks. The paper, published in the Oct. 30 edition of the journal Science, shows the relationship between the evolution of the virus and immunization rates needed to prevent an outbreak in the population.

Park explained that these findings can help inform efforts to prevent future outbreaks. “Public health officials will be able to assess the usefulness of a vaccine based upon its relationship to the current influenza strain and the population’s immunity level,” he said.

Through previous vaccinations or infections with earlier strains of the influenza virus, many individuals already have some level of immunity, Park noted. The influenza virus is continually evolving, however. By substituting different amino acids at key molecular points, the virus increases its chances of evading the immune system’s defenses, allowing it to reproduce and spread.

As the number of amino acid differences between a new strain and the strain an individual was vaccinated against increases, the likelihood of becoming infected increases, Park said, as does the likelihood of becoming infectious and the length of time they will remain infectious. These factors combine to increase the chance of an outbreak in a population.

Working with equine influenza, the research team looked at the likelihood of an influenza outbreak in a population that had all been vaccinated with the same strain of the virus. They found that outbreaks began occurring when there were two or more amino acid differences and that the size of the outbreak increased with the number of amino acid differences. They also found that large outbreaks were more likely to occur if the virus and the vaccine were from different antigenic clusters – meaning that a host’s immune system perceives the two strains as different. Comparing these results with an earlier human influenza study revealed similar trends.

Another key factor in determining the risk of an outbreak in real populations, however, is the individual variation of immunity in the population. Because the virus keeps changing, so do the vaccines used against it. This causes the immunity of the population to be heterogeneous – some individuals have been infected with or vaccinated against last year’s influenza strain, some against strains from previous years, and some have no immunity at all. Park and his colleagues found that the degree of variability of immunity in the population plays a crucial role in determining the risk of an outbreak.

Park added that in measuring for the first time how the difference between the population’s immunity status and a new virus strain influences the risk of an epidemic, the team has taken a critical step toward linking these relationships with the dynamics of epidemics, not just for influenza but for a wide range of infectious diseases.

I have no idea if the flu, whatever kind it was, was really the reason for the lack of a bed, and I’m not sure if the lack of space was the issue or if this was a mater of a lack of other resources. She did not wait long and was in the ICU pretty quickly, so it was not much of an issue.

But it did cause me to wonder if we are starting to see an over taxing of health care resources due to Swine Flu, or if the flu was merely being added to the list of reasons given when something expected (like an ICU bed) is not available.

And just as I was wondering that, I saw this: Swine flu and ICU bed use in Canada and Mexico, which reviews recent literature on this question and concludes:

…too many hospitals have prepared by paying lip service to pandemic planning. It’s time to take it seriously. Very, very seriously. Lives hang in the balance.

Read the blog post at Effect Measure to get the detailed analysis.
___________________-
* We have a little confusion here in Minnesota. Our Republican governor made a speech a while back asking people to not use the term “swine flu” (he was pandering to the swine industry) so a lot of people, especially Republicans, I noticed, use the term “H1N1” instead. It would be nice if the process for settling on terminology used to describe these viral phenomena was somehow formalized by epidemiological experts or officials.

The GLM is a very strange site which has, as Revere points out, declared itself to be an important go-to place to find out about language trends across the world. I have not decided what I think about this site except when I browse around it it I feel my guard going up, and up and up. In a recent post, the GLM lists cases of inappropriate political correctness. The GLM says “Once again, we are seeing that the attempt to remove all bias from language is itself creating biases of their own” and they point out as the number one example of this … Swine Flu:

Though hundreds of millions know of the current pandemic as Swine Flu, various governments and agencies for political motives ranging from protecting pork producers to religious sensitivity have chosen to address the virus by its formal name, influenza A(H1N1).

… which I take as a statement by GLM that insisting that this not be called the Swine Flu is dumb.

Effect Measure agrees with GLM. (Be careful reading Revere’s post, because although s/he clearly gets what GLM is saying and characterizes it properly, s/he fails to stick with the GLM approved nomenclature; GLM is not saying that “swine flu” is “politically incorrect” … GLM is saying that the identification of Swine Flu as a politically incorrect term is the top Politically un(Correct) lexicographical events of the year. The distinction is important.)

You will remember that the Swine Flu was the Mexican Flu for a while (in the media) but my understanding is that epidemiologists have a rule, though it appears to be unwritten, to not name diseases after places, having done that before and people getting mad at them. For exeample, we no longer call the Spanish Flu that …. we call it the 1918 flu.

The fact that we call “ebola” ebola might be because of our racist western Caucasoidoheteronormative shit-ass attitude (Ebola is a town in Zaiare/Congo) but we also still call “marbug” marburg, and that’s a town in the dead center of Caucasoidoheteronormativeville. So on this one I’m keeping my race card close to the chest.

However, something comes out of this discussion by Revere that I find utterly astonishing. According to Revere, who is always right so I’m not questioning it: The Swine Flu does not have a formal name.

The Swine (nee Mexican) H1N1 novel 2009 flu strain does not have a formal name? Holy crap! Epidemiology or fluology or whatever the appropriate science is does not have a system of naming novel diseases so we can talk about them? One of the fundamentals of science is description, and one of the fundamentals of description is knowing what to call stuff. Hey, there are reasons to wait to name something, to make sure that what you are naming really exists, for instance. But this does exist and has for some time …. and it doesn’t have a name?

Were this a new protein it would have a name. Were this a new gene or allele it would have a name. Were this a new species of matazoan it would have a name. Were this some category of artifact in archaeology, it would have …. six or seven names!!!

So what’s up with that? Can we get a system please? Thanks.

Person 1: “So, how effective is the seasonal flu shot?”

Person 2: “I heard about 1%. If you get the flu shot, you’ll have a 1% difference in if you get the flu.”

Person 3: “That’s crazy. I don’t know where you are getting your data from. It can’t be 1%, but I admit I don’t know what the actual answer is, but it can’t be that.”

Persons 4 through 6: “Well, if YOU don’t know, and HE says 1%, I’m going with the 1%. Too much trouble to get a flu shot anyway.”

Person 3: “Wait, wait! That’s crazy! That makes no sense!” as persons 1, 2, 4, 5 and 6 are filing out of the break room to go back to work. “You can’t leave thinking that 1% is correct! It can’t be correct!!!”

Person 5: [Over her shoulder on the way out the door.] “Hey, why don’t you go ask your husband. He’s a Scienceblogger, right?”

Another answer is found by checking with the CDC web site. They say that in persons under 65 who are otherwise not at risk, the flu vaccine reduces the chance of getting influenza by about 70 to 90%

But, if you go to one of the authoritative science blog sites like Effect Measure, you get a somewhat different story:

CDC wants us to get vaccinated for flu every year. … They want us to get vaccinated because they think the vaccine works … citing figures that the vaccine is 58% effective or 91% or effective or some other number, depending on what group is being talked about … This post is not about contradicting CDC, since I mostly agree that flu vaccination programs are sound public health. It is about clarifying some things that are glossed over when CDC talks … bla bla bla bla bla

and so on and so forth and I’m pretty sure I know less than when I started after reading that post. (… in a good way … it is an excellent post.)

It turns out that the issue is quite complicated, but I think I can explain it. But you have to be ready to change how you think about a couple of things.

First, you have to understand that at some level, a vaccine only works on people who get the flu. The vaccine does not shield you like a force field on Star Trek so the virus does not get at you. No. The virus gets at you, gets in you, and is inside your body …. so in a sense, you’ve “got” the flu, and then your immune system fights it off hopefully before you become symptomatic. Or maybe it fights it off enough that you get sick but not too sick. Or maybe it fights it off enough that you end up not spreading it to someone else. The vaccine sets things up so that your immune system is prepared to do this much more effectively than if you had not had the vaccine. (Oh, and by the way, does that person who did not get the flu from you, because you had the vaccine and thus did not pass it on, count when counting percentage of effectiveness of the vaccine?)

So you can see that it is fairly complicated. How to count the flu as an infection or the vaccine as an anti-flu agent is a matter of infection, symptom, virulence, reinfection, and so on.

There is another level of complication: There is not one flu. The so called “seasonal flu” is, in a given year, several different strains of influenza virus. The so called “flu vaccine” is a mixture of vaccines for each of several strains that are believed to be the most likely to circulate. Some of these vaccines may actually give cross immunity to other strains, or they may not. Generally not much, it would seem. Usually, the strains that are addressed by the vaccine are the very ones that are circulating, but some years, a strain or two circulates above minimal levels that was not included in the mix. A very high number for infection rates for a non-vaccine strain might be 20 or 30%, but that is rare.

Here’s the question one really wants to know the answer to: Imagine two alternative universes. In one there is seasonal flu but no vaccine, in the other there is a vaccine. Within both of those universes we pick out a large number of people matched up in both … the dopplegangers if you will … and vaccinate all of them in the second universe. Then we ask, Of these paired-up people, how many got the flu in the first, no-vaccine universe, vs. how many got the flu in the second, vaccine-capable universe?

If we picked 10,000 people to vaccinate, and in the non-vaccine universe, 1,000 of them got the flu badly enough to be as sick as a dog or worse (like, they died) and in the vaccine-capable universe, of the 1,000 dopplegangers only 200 got the flu to this level, we could say that the flu vaccine is 80% effective. I’m pretty comfortable saying that this 80% is a useful, meaningful number.

But the reality is more complex. In truth, the vaccine might be 100% effective for one strain, 50% for another, and there might be a rare strain circulating that is not addressed in the vaccine, but the prevalence of each strain vs. differential effectiveness resulted in the observed apparent overall effectiveness of the strategy of vaccination of 80%. In truth, 78 of those people who did not get the flu didn’t get it not because the vaccine worked but because they were never exposed to the flu in the vaccine capable universe because the person who was going to give them the flu did not get it themselves. In truth of those 800 people who “didn’t get” the flu, 123 of them did get it, and did get sick, but not too sick and they didn’t think it was the flu even though it was. In truth, 18 people in the first universe were counted as having the flu but it was a false positive. And so on.

In conclusion, no, it is not 1%. It is closer to 70 to 90% just like the CDC says, on average, for people not otherwise at risk who are under 65.

If you don’t get vaccinated because you think vaccines are dangerous or you think you can avoid the flu by taking vitamins then you are a moron. If you do’t get vaccinated because you think the flu vaccine is only 1% effective then you are … an entirely different kind of moron. Either way, get a shot and don’t be a moron. The person you give the flu to because you didn’t get the shot may be one of those that dies. Wouldn’t that be smart. Not.

Here’s the story: There is a study coming out of Canada, done in Canada, that seems to show that in Canada people who get the seasonal flu shot have an increased, perhaps doubled, chance of getting H1N1

The way this would work is like this: If your immune system gets trained to handle a certain infection, it focuses a bit too much on that specific version of the infection and ignores other similar infections. All the soldiers are at the wrong side of the castle, as it were.

There is a story in the Globe and Mail about this, Here is David Dobb’s original post on this, and if ERV has not written about it yet, tell her to.

The H1N1 Rap was written, composed, produced, and performed by John D. Clarke, MD, FAAFP. This music video is a fun, highly educational, and entertaining way to learn about prevention of the H1N1 virus.

In this paper, the researchers report an interesting method of assessing the severity and distribution of the novel “swine flu” H1N1. The look specifically at travellers from the US, the UK, Spain and Canada to Mexico. These people are more likely to be checked and properly assessed for flu, and I suspect they may overstate their likelihood of having the flu for various reasons. So, one can assume that a much closer to 100% rate of observation would occur with these travelers than with people sitting at home in any given population.

The researchers, looking specifically at April 2009, conclude:

We find that the number of cases in Mexican residents may exceed the number of confirmed cases by two to three orders of magnitude. While the extent of disease spread is greater than previously appreciated, our estimate suggests that severe disease is uncommon since the total number of cases is likely to be much larger than those of confirmed cases.

The methods used in this paper are beyond what I’m prepared to discuss and evaluate. But you can evaluate them directly by reading the paper, which you can access by clicking here. PLoS is an OpenAccess journal.

Lipsitch, M., Lajous, M., O’Hagan, J., Cohen, T., Miller, J., Goldstein, E., Danon, L., Wallinga, J., Riley, S., Dowell, S., Reed, C., & McCarron, M. (2009). Use of Cumulative Incidence of Novel Influenza A/H1N1 in Foreign Travelers to Estimate Lower Bounds on Cumulative Incidence in Mexico PLoS ONE, 4 (9) DOI: 10.1371/journal.pone.0006895

In the US, according to MSNBC,

The government estimates that about 120 million swine flu vaccine doses will be available to the public by late October. Nearly 160 million people are in the priority groups considered most vulnerable to infection or most at risk for severe disease, Schuchat said.

Since it is expected that two doses will be needed per person, it will be necessary to subdivide the target population and use a finer priority scale. Here is the order of priority:

1. Pregnant women
2. Household contacts of children younger than 6 months
3. Subset of health workers who have direct contact with ill people
4. Children 6 months through 4 years of age
5. Children 5 to 18 who have greater risk factors for the flu

I’m a little uhappy that our health care system has not figured out how to produce sufficient supplies of effective vaccines against novel flus. It is almost like the whole medical, pharmaceutical, and scientific world has been hampered by eight years of … oh, never mind..

Probably the latter, but health officials seem interested in the developing data.

From CTV:

… in a report released Friday, health officials detailed the cases of 10 Michigan patients who were very sick from swine flu in late May and early June and ended up at a specialized hospital in Ann Arbor. Three of them died.

Nine of the 10 were either obese or extremely obese. Only three of the 10 had other health problems. Two of the three that died had no other health conditions.

This hardly settles the question of whether obesity is its own risk factor for swine flu. It’s possible the patients had undiagnosed heart problems or other unidentified conditions.

The report is called Intensive-Care Patients With Severe Novel Influenza A (H1N1) Virus Infection — Michigan, June 2009 and is published in MMWR, the CDC’s rapid turnaround publication for disease. The report warns:

This report describes the clinical findings of a limited series of patients with novel influenza A (H1N1) virus infection and refractory ARDS …. This patient group represents the most severely ill subset of persons with novel influenza A (H1N1) virus infection and is notable for the predominance of males, the high prevalence of obesity (especially extreme obesity), and the frequency of clinically significant pulmonary emboli and MODS. All required advanced mechanical ventilator support, reflecting severe pulmonary damage. The pulmonary compromise described in this report suggests that severe pulmonary damage occurred as a result of primary viral pneumonia. Although data are not available, this damage also might be attributable to secondary host immune responses (e.g., through cytokine dysregulation triggered by high viral replication). However, bacterial coinfection in the lung not identified by blood culture or bronchoalveolar lavage cannot be excluded.

…

The high prevalence of obesity in this case series is striking. Whether obesity is an independent risk factor for severe complications of novel influenza A (H1N1) virus infection is unknown. Obesity has not been identified previously as a risk factor for severe complications of seasonal influenza. ….

Further characterization of severe cases of novel influenza A (H1N1) virus infection in the United States and worldwide is needed to determine the frequency of the findings from this limited case-series.

You can read the report here.

Clearly this is very preliminary and I suspect that this will not develop. In other words, I suspect that existing poor health related to the cardiopulmonary system is a serious risk factor with any flu. But we shall see.