Monday, November 23, 2009

The Second Wave

Note to all Malaysians. While the first wave of swine flu origin Influenza A (H1N1) appears to be tapering off, it is too early to relax.

Time to put that face mask on.

It has been made official that the second wave of the swine flu pandemic has hit Montreal and public health authorities are responding by opening the floodgates of vaccination centres to all 5- to 19-year-olds, a group hit particularly hard by the potentially fatal H1N1 virus1. The number of cases in the nothern hemisphere, especially in the US and Britain is also increasing.

"If the second wave occurs, the virus could spread fast like the Spanish flu in 1918. That was also a H1N1 virus and killed millions in the second wave. But the current one is not a pure H1N1 as in 1918 but a mixed one that is mild and we need to study it further," Health Minister Datuk Seri Liow Tiong Lai said2.

"The US has declared a national emergency over the H1N1. It shows the second wave is hitting the northern region, so we have to be prepared to face this second wave.” In Malaysia, 77 people have died since the H1N1 outbreak in May this year.

Judging by the speedy spread of the first wave, Malaysian experts suggest that the second wave will hit hard coming December. Some anticipate that the waves might arrive sometime mid next year or in two to three years time. Irregardless of when the unpredictable second wave strikes, the government remains optimistic they will have the situation under control. Currently, the government has increased surveillance on the number of cold and cough cases as well as H1N1 at the Kuala Lumpur International Airport. On another matter, Liow said the 1Malaysia community clinics will be launched early next year, run by hospital attendants and nurses to provide direct outpatient treatment.

Having attended one of the briefings organized by Hospital Tengku Ampuan Rahimah, Klang, it dawned upon me on the level of danger that we are exposed to once the second wave of H1N1 englufs our nation. We have underestimated the potential malignancy of the pandemic and should strap up all efforts to minimize transmission and reduce mortality that is expected to rise three folds.

The wards may end up looking like this if the spread of H1N1 is not under control. Hospital admissions rise.

Vaccines to protect against the 2009 H1N1 flu virus is now available. Both the flu shot (in the arm) and the nasal spray form of 2009 H1N1 vaccines have been produced and licensed by the Food and Drug Administration. Administration of the 2009 H1N1 flu shot began in the early weeks of October in the United States.

Since the initial stockpile in Malaysia is low, the Advisory Committee on Immunization Practices (ACIP) has recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children, especially those younger than 5 years of age and those who have high risk medical conditions are at increased risk of influenza-related complications. Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over the age of 65.

HTAR (and i’m sure many government hospitals across the nation) place much importance of having their healthcare and emergency medical services personnels vaccinated because front-line healthcare workers (i.e. doctors, pharmacists and nurses) are prone to being infected due to the nature of their profession and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity. Vaccination is free.

Yeap, vaccination is free. Great. So are the other shots that i am supposed to take as well such the seasonal influenza vaccine and Hepatitis B vaccine. My questions are

  1. Does the seasonal flu vaccine also protect against the 2009 H1N1 flu
  2. Can i take the seasonal vaccne and Pandemrix® at the same time
  3. How many doses of Pandemrix® are required
  4. Are there any reported side effects from GSK’s Pandemrix because there’s the recent scare of what is being called dystonia following the seasonal flu vaccine.

So, let’s address these questions separately with reference to CDC’s H1N1 recommendations dated 13 November 2009. If you wish to read more or have unanswered questions swirling in that head of yours, you can visit their official website. Good stuff.

Does the seasonal flu vaccine also protect against the 2009 H1N1 flu?

Straight to the point, the seasonal flu vaccine will not protect you against 2009 H1N1 flu.

Can the seasonal vaccine and the 2009 H1N1 vaccine be given at the same time?

Inactivated 2009 H1N1 vaccine (i.e. Pandemrix®) can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine (this means i can take it with the seasonal flu vaccine and the Hepatitis B vaccine offered by the hospital). Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine.

How many doses of vaccine are required?

The vaccine is supplied in separate vials, one containing the adjuvant, and the other the inactivated virus, which require mixing before intramuscular injection. Originally it was thought that two doses given 21 days apart would be required for full effiency. Subsequent testing has allowed the UK programme to consist of just a single dose for most people, with a two-dose schedule for children under the age of 10 years and immunocompromised adults. So i guess i’ll just be taking a single dose. Thank god! I hate those prickly needles.

Are there any reported side effects from the 2009 H1N1 vaccine?

Since Pandemrix® is new in the market, its side effects has not made its way in an official report. However, GlaxoSmithKline stated in their patient information leaflet that the common side effects are headache, tiredness, pain, redness, swelling, fever and aching muscles and joint pain3. These side effects doesn’t sound so menacing right? My friend who works in the bureau said that it has been reported that one doctor collapsed right after taking the injection. This happened in two different hospitals in West Malaysia.

I mean this is all quite a scare following the story of Desiree Jennings4, a 28 year old cheerleader who was apparently healthy until August when she received the seasonal flu vaccine. She developed an apparent neurological reaction in which she has difficulty speaking and walking, with involuntary muscle contractions and contortions. Her symptoms (including speech) are relieved, however, by walking backwards or by running. She also seems to have attacks of muscle contortions. This lady who is a victim of a rare vaccine reaction is now the latest poster child in the war against vaccines.

I am not hinting to you that you shouldn’t take the vaccine. It is a matter of choice. Pandemrix has been authorized under ‘Exceptional Circumstances’ which mean that it has not been possible to obtain full information about the pandemic vaccine but one should be noted that the benefits of Pandemrix are greater than its risks for the prophylaxis of influenza in the officially declared H1N1 pandemic situation. Since no post marketing surveillance data is available, the company that makes Pandemrix® promises to collect information on the safety of the vaccine while it is being used. Plus, the European Medicine Agency will review any new information that may become available and update the public on a regular basis.

Just a word of caution to those planning to receive Pandemrix®. People who are allergic to eggs might be at risk for allergic reactions. So, be careful!

To all healthcare personnels out there, do take everyday actions to stay healthy.

  1. Wear a mask most of the time. The WHO and CDC recommend the use of NIOSH N95 respirators as a measure of protection against the H1N1 swine flu virus
  2. Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue properly in the trash after you use it.
  3. Wash your hands often with soap and water before and after contact with patients. If soap and water are not available, use an alcohol-based hand rub.
  4. Avoid touching your eyes, nose or mouth.
  5. Get an MC if you’re sick! CDC recommends that you stay home from work limit contact with others to keep from infecting them.

These measures will continue to be important even after the vaccine is available for everyone because they can prevent the spread of other viruses that cause respiratory infections.5

All countries should immediately now activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia. After all it really is all of humanity that is under threat during a pandemic.

Dr. Margaret Chan

  1. Montreal Gazette. Canada: Second wave of H1N1 hitting Montreal. November 14, 2009.
  2. Rajoo, D. A. for Malaysian worries with second wave of H1N1. May 8, 2009.
  3. European Public Assessment Report. Pandemrix. Dated October 2009.
  4. Novella, S. Neurologica blog. The dystonia flu-shot case. October 30, 2009
  5. Centers for Disease Control and Prevention: 2009 H1N1 Recommendations. November 13, 2009.

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