More thoughts on pandemic H1N1 influenza

As this is written in late January, the H1N1 pandemic in the United States has subsided to very low levels and there is no sign yet of a winter/spring next wave. Locally, in our own emergency room, we are experiencing a slight uptick in influenza-like illness, but whether that portends anything at all remains to be seen.

Influenza H3N2 viruses are remarkable for their near total absence, suggesting that Don Kaye’s argument (in the January 2010 issue of Infectious Disease News) that H3N2 viruses will disappear for the next 40 to 60 years may indeed be correct, though I’m not willing to concede that point just yet. An interesting issue looming for a decision next month is what to put into next season’s vaccine; more of that next month.

‘Apt and lucky’

“Apt and Lucky.” So wrote Donald McNeil, Jr., in The New York Times on Jan. 2, 2010, in characterizing the U.S. response to the global challenge of pandemic H1N1 influenza, quoting the opinions of a number of medical experts.

I will generally concur. There was a great deal of uncertainty last spring about the severity of this new pandemic virus and early reports from Mexico were quite alarming. In retrospect, the decisions to prepare a vaccine and to stockpile neuraminidase inhibitors were entirely appropriate.

This country, as well as the rest of the world, was lucky that the virus did not prove to be nearly as lethal as early reports suggested. William Schaffner, MD, an occasional guest editorialist in Infectious Disease News, was quoted as giving the federal government’s response at least a B+. Overlooking for the moment the flail about N-95 respirators, CDC acted responsibly, walking a fine line between being unduly alarmist on the one hand, while yet attempting to prepare the public for a pandemic that could possibly be quite disruptive and quite threatening. Anne Schuchat, MD, in particular, deserves commendation for proving to be an articulate and careful spokesperson in her virtually daily television news updates during the height of the pandemic.

The feds did overpromise on when vaccine would become available and were never able to fully overcome the widespread public belief that the vaccine was not adequately safety-tested. Anthony Fauci, MD, also called upon frequently by the television media, made numerous attempts to convince the public that the vaccine was prepared and tested in the same way as seasonal flu vaccine, but he was only partially successful.

H1N1 vaccine

Today we are awash in H1N1 vaccine, and while some is still being administered to people, it is clear that there will be a great deal of vaccine left over. A late winter/spring wave of H1N1 influenza would surely result in more immunizations, but such a “third wave” is nowhere in sight.

Interesting insight into the public’s behavioral psychology was provided in the perspective in The New England Journal of Medicine by Danielle Ofri, MD, published on December 31, 2009, and titled, “The Emotional Epidemiology of H1N1 Influenza Vaccination.” One might argue about whether there is such a thing as “emotional epidemiology.” I prefer to think of it simply as behavioral psychology at a population level.

Disease risk

Several other interesting issues emerged as the fall wave subsided. It emerged that indigenous populations have a 3- to 8-fold higher rate of severe disease, hospitalization and death from H1N1 than the rest of the population. This was observed in Australia, New Zealand, Canada and the United States. In the United States, this phenomenon was observed in several states that are home to significant populations of American Indians – including New Mexico and South Dakota – as well as in Alaska. In Anchorage, for example, American Indians, Alaska natives and some native populations of the Pacific region all shared this increased risk.

The reasons for this are not at all clear. The rate of underlying disease such as asthma, diabetes, heart disease and perhaps obesity may be contributing factors, but are not likely to be the whole explanation. Access to care may be a major factor, but that again is likely not the whole story. Alcohol abuse may contribute as well. It is clear that this increased risk, if we are to understand it fully, requires substantial further study. Of interest, much the same increased risk was observed and documented by public health investigators among American Indian/Alaskan Native populations during the 1918-1919 pandemic.

Controversy

Finally, and most recently, the conspiracy theorists have emerged - and emerged in force. Wolfgang Wodarg, a German politician and physician, who happens to chair the health committee of the Council of Europe, has charged that the H1N1 threat was “a false pandemic” and that the WHO was unduly influenced by vaccine manufacturers to declare a pandemic, thus allowing the manufacturers to reap a substantial profit while assuming little or no risk. Thus, even as this column is being written, a debate is taking place within the Council of Europe on the theme “False Pandemics: a threat to health.”

Dr. Wodarg’s posture on this issue has been described – both in Europe and in the United States – in terms varying from “historically inaccurate” to “preposterous” to “implying a basic lack of understanding of public health planning.”

WHO is well represented in this debate by Margaret Chan, MD, director-general of WHO, and Keiji Fukuda, MD, her special assistant for pandemic influenza, and their own council of scientific advisors. Public health authorities in European countries (except Poland) as well as European vaccine manufacturers appear to support WHO’s actions completely and I suspect the conspiracy theorists will ultimately be silenced. To the extent that this might turn in to a thorough and constructive review of WHO’s actions and recommendations, this debate might prove to be very positive. We shall shortly see.

Poland, incidentally, was the only country in the world that rejected the vaccine altogether over safety fears, fears that the vaccine had not been adequately tested and a gesture of defiance against the pharmaceutical industry. This decision was quite dramatic and was supported by most of the government and evidently most of the population. The Polish medical profession was said to be deeply divided over this issue.

It’s interesting that the conspiracy theorists emerged in Europe and not in the United States. Perhaps the U.S. government kept its citizens better informed about their pandemic planning or perhaps the European populations have been more exposed to sensationalized media reports on now disproven theories about the hazards of MMR vaccine, thimerosal and autism. In the U.S., there has been general acceptance of the need for vaccine, but there have been lingering concerns about vaccine safety. In our zero-risk tolerance society, a “safe” vaccine is evidently not safe enough.