Another two children have died from influenza-related illnesses according to information released by the Centers for Disease Control on Jan. 11 in a draft press release which will be formally issued on Jan. 14. Adult deaths from influenza are not counted specifically, as they are more likely to be from pneumonia and there would be a lag of some weeks between a person contracting flu, it developing into pneumonia and then resulting in their death. Pediatric deaths from flu are of a more acute nature, due to the undeveloped nature of a child's immune system.
The director of the CDC, Dr. Tom Frieden, as well as a Medical Epidemiologist from the Influenza Division, Dr. Joe Bresee hosted a press-briefing conference call Friday morning.
The bottom line - it's flu season. Most of the country is seeing or has seen a lot of flu and this may continue for a number of weeks.
stated Dr Frieden in beginning his address.
There are two more influenza associated pediatric deaths reported in the past week. That brings the total to 20 deaths this season.
47 states this week reported widespread geographic influenza activity, which is up from 41 last week.
24 states and New York City are reporting high levels of influenza-like illnesses (ILI) presenting for treatment, down from 29 states and New York City last week, with a further 16 states reporting moderate levels of ILI, which is up from nine last week.
Dr Bresee later said:
"At this time of the year we also see lots of other respiratory viruses like respiratory syncytial virus, metapneumovirus, parainfluenza virus and those are circulating now too. We are seeing a norovirus, which causes vomiting and diarrhea."
This year's flu season is, so far, the worst influenza outbreak in 10 years. Data released by the Centers for Disease Control lists a total of 18 deaths of children so far this season from flu-related complications. Since October 1, 2012 there have been 2,257 people hospitalized with the flu, though no adults have yet died in relation to it. Adult deaths related to flu, which generally means pneumonia, take several weeks to develop and be reported, so we may not yet be seeing an accurate picture in relation to adult mortality from this year's flu season.
The flu season this year is staging a three-pronged attack on us. The influenza season has begun early with a particularly aggressive strain of virus; there is a new type of norovirus or 'stomach flu' doing the rounds, known as the Sydney 2012 variant and we are in the midst of the worst outbreak of whooping cough that we have seen for 60 years.
The predominant flu strain circulating is an H3N2 variety, which typically kills more people than the H1N1 strains that usually predominate.
Noroviruses are particularly contagious, as patients suffer from explosive diarrhoea and projectile vomiting, which can distribute material containing the virus for yards. Dehydration can occur very quickly with these symptoms, so it is important to seek medical care if you are experiencing them, particularly for fluid-replacement therapy via an intravenous line.
The C.D.C. said the United States was having its biggest outbreak of pertussis in 60 years this month. There have been about 42,000 confirmed cases, a number which has not been seen since 1955. Whooping cough is caused by the Bordetella pertussis bacteria and the symptoms include an intractable dry, hacking cough which can cause breathlessness. It is generally an unpleasant but not fatal disease in adults and older children lasting around six weeks, but it is occasionally fatal in infants. There were 18 deaths from whooping cough reported in 2012, with 15 of those being in infants under the age of one year.
The CDC further says that the proportion of people seeing their health care provider for influenza-like illnesses or ILI has been elevated for four consecutive weeks climbing sharply from 2.8% to 5.6% over that time. Last flu season, that rate peaked at just 2.2%. During the 2009 H1N1 flu pandemic, ILI peaked at 7.7%, with the states reporting a total of 43,771 cases of probable and confirmed influenza cases to the CDC between April 15, 2009 to July 24, 2009. Of these cases 5,011 people were hospitalized and 302 people died equating to a death rate of 7%, which is just under the epidemic threshold of 7.1%, a distinction without a difference for many who were affected by it.
During the 2007-08 season the rate of ILI peaked at 6% and during the 1998-99 and 2003-04 seasons ILI peaked at 7.6%.
“While we can’t say for certain how severe this season will be, we can say that a lot of people are getting sick with influenza and we are getting reports of severe illness and hospitalizations,”
says Dr. Joe Bresee, who is Chief of the Epidemiology and Prevention Branch in CDC’s Influenza Division.
Flu season has begun with a bang and hospitals are being overwhelmed by the influx of patients seeking treatment. In some areas, supplies of Tamiflu, an antiviral drug which can be given to those at high risk of complications from the flu, are running low.
Some, like Lehigh Valley (Pa.) Hospital-Cedar Crest, have erected temporary tents in front of their emergency departments to deal with the hordes of sniffling, sneezing, fever-ridden patients and try to separate the contagious from the remainder of the hospital. At Lehigh Valley Hospital, an infant has died from flu-related complications over the weekend, LVH spokesman Brian Downs confirmed on Wednesday.
Some hospitals have restricted visitors in an effort to minimise cross-infection and others are encouraging the use of face masks and handwashing before visitors enter the hospital to visit loved ones.
The city of Boston declared a public health emergency earlier in the week after treating 700 cases of influenza, a number ten times greater than the total for last year's flu season. A quarter of those seen for influenza required admission to hospital and influenza patients accounted for 4% of the patients seen by the emergency department.
Massachusetts General Hospital in Boston has treated 532 confirmed influenza patients this season and admitted 167, even more than it did by this date during the 2009-10 swine flu pandemic according to the NY Times.
Flu season typically doesn't peak until late January or February though some years it can occur as late as April or May, lasting an average of 12 weeks, though it can last as long as 16 weeks or four months, so the nation is set to see even greater numbers of influenza in the coming weeks, putting pressure on hospitals around the nation to meet the greatly increased demand for their services, while maintaining stringent infection control practices in an effort to limit transmission of the virus to staff and patients.
Eight Chicago hospitals were forced to redirect ambulances to other facilities on Monday and Tuesday of this week as they reached capacity. The University of Chicago Medical Center, Swedish Covenant Hospital and Northwestern Memorial Hospital were amongst those facilities.
The vaccination debate
The Centers for Disease Control is, as always, recommending immunisation for the population in an attempt to curb the spread of the disease, however, many people are concerned about the side effects of the vaccine and its ineffectiveness. It is well known that vaccines are less effective in the very young, the very old and those with underlying illnesses who don't have enough of an immune response to the vaccine to build up an adequate response to them. Unfortunately these are exactly the demographic of people who would benefit most from being effectively immunised against influenza and they then become reliant upon 'herd immunity' or the reduced occurrence of the disease in a population of people who are mostly vaccinated.
As at Jan. 4, the last date for which data has been tallied, 128 million doses of influenza vaccine have already been administered this season, vaccinating around 37% of the American population.
Donte Stallworth, the New England Patriots' wide receiver, tweeted to his 128,000 odd followers last weekend saying:
"When I first heard H1N1 came from Mexico, I started to do my own research because the influenza virus almost always comes from Asia....
"Man oh man, the things I found out about H1N1 that #they weren't telling us...
"I advised family & close friends against taking the H1N1 vaccine. Mainly because there was no trial period. No research on long term effects"
If you are considering being vaccinated against the flu, do so early a the vaccine takes at least two weeks to work.
When talking about vaccines, efficacy and effectiveness are two different concepts.
Efficacy relates to the ability of the vaccine to stimulate the body to produce antibodies against a particular disease.
The effectiveness of a vaccine relates to the percentage of people it will actually prevent the disease occurring in, in real life.
Flu vaccines, have an average efficacy rate of 59% across all age groups and an effectiveness of 35%, according to a recent meta-analysis from researchers at the Center for Infectious Disease Research and Policy, University of Minnesota.
This year, Frieden said the 2012-2013 influenza vaccine has been shown to have an overall vaccine effectiveness of 62 percent, meaning that a vaccinated person has a 62% lessened chance of developing a full-blown flu, which requires medical treatment.
About 90 percent of all of the strains circulating are included in the vaccine. The other 10 percent are a second influenza B. This means that the current year's vaccine is a pretty good match for the strains which are circulating in the population. The current vaccine is about 55 percent effective against influenza A stains and 75 percent effective against influenza B strains.
Dr. Joe Bresee, Medical Epidemiologist with the Influenza branch of the CDC said of the flu vaccine efficacy and effectiveness rates:
“So what we have known for a long time is that the flu vaccine is far from perfect. But it's still by far the best tool we have to prevent the flu.”
For many people, however, this is simply not a good enough reason for them to get the jab. Others have philosophical or religious reasons for refusing the vaccine.
Eight employees in an Indiana university hospital were fired last month for refusing the flu vaccine.
In September, Indiana University Health Goshen Hospital announced to its employees that flu shots were now mandatory for all hospital employees. There was considerable pushback against the mandate, with 1,300 employees, mostly nurses, refusing to be vaccinated and a great deal of media coverage surrounding the core issues of public responsibility and healthcare rights. In the end, eight employees who had refused vaccination were fired.
The influenza virus
Influenza, more commonly known as "the flu", is a contagious respiratory illness caused by viruses which infect the nose, throat, airways and lungs, causing symptoms such as fever, muscle pain, headache, malaise or general tiredness, cough, runny nose and watery eyes. In children symptoms can also include ear infection, nausea and vomiting.
The virus is transmitted between people via aerosolised droplets infected by the virus, which are created and spread up to one metre or three feet, when people with the virus sneeze, cough or even talk. Many people are infected by touching surfaces which are covered in the bacteria and then touching their mouth, eyes, nose or food without first washing their hands.
The typical incubation period for influenza is 1—4 days, with an average of 2 days, meaning that it will take this long for symptoms to appear from the time a person becomes infected. Adults become infectious themselves, shedding influenza virus particles from the day before symptoms begin through 5—10 days after illness onset. However, the amount of virus shed, and presumably infectivity, decreases rapidly after the 5th day after the development of clinical symptoms.
The acute phase of the illness typically lasts for between three and seven days, however, the cough and malaise can persist for up to two weeks.
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Osterholm MT et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012 Jan;12(1):36-44. Epub 2011 Oct 25.
American Public Health Association. CDC Announces Early Start to 2012-2013 Flu Season. (2012). Accessed January 10, 2013.
Centers for Disease Control and Prevention. 2012-2013 Influenza Season Week 52 Ending December 29, 2012. (2013). Accessed January 10, 2013.
Centers for Disease Control and Prevention. 2009 H1N1 Early Outbreak and Disease Characteristics.(2009). Accessed January 10, 2013.