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JANUARY NINJAS
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
I
t’s cold, and it’s dark, and the new bridges
are not open. Traffic is tore up, as we say in
Kentucky. Our patients drive in, dodging
the orange barrels and nursing their colds
and aches and wondering why they feel like
hell, and we can tell them: once again the
flu shot did not work right. Once again, for
the seventh year in a row, the powers that
be who select the flu shot ingredients have
been wide of the mark. In the winter of 2008,
they had missed so badly - of the Influenza B
type, 98 percent of viruses were not included
in the vaccine, and 77 percent of the A type
were not - that all of us in the office fell like
dominoes. We had fevers of 103 for a week,
deathly aches, and burning chests. I have
no idea who actually worked in the office
for one of those weeks. I spent my time
making morning rounds for me and my
quarantined partners. I dressed in haz-mat
clothes, dragged at a snail’s pace from room
to room, wrenched small thoughts out of my
fevered brain, and triaged my puny efforts
to the patients’ dire needs only. Then I went
home to bed, and stayed there, till morning
came again. I lost four elderly women to that
flu. Their chests filled up and whited out and
they died of bacterial pneumonia inside of
48 hours. In fact, they were felled by the
same flu that had orphaned them in 1918.
January of 2009 was a typical flu season
– we all took the shot, and only some of
us got a little sick; it sort of worked. Then
spring came and in April, up from the
Southern Hemisphere came the Swine flu,
a brand new virus not possible to foresee.
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Only age and antibodies saved us. Young
people died. The CDC responded in force,
released some of the national stockpile of
supplies, and mobilized emergency teams
for vaccine development and production.
They declared a pandemic, held summits,
mandated distribution to the most at risk,
and managed to get new flu shot versions
out to 75 percent of the high-priority front
line troops by December. The pandemic
was so bad that they were recommending
empiric antibiotics and antivirals for “typical presentations” in the young, even before
confirmatory positive tests. This was something very new for them, designed to lower
the death rate from pneumonia. They did
great against a new enemy.
Overall, the World Health Organization
estimated a death toll from Swine flu that
was 15 times higher than the laboratory-confirmed death rate. Estimates vary
wildly: for instance, the Lancet in 2012 gave
a range of 175,000 to 550,000 deaths from
the Swine flu. But all authorities agreed that
unlike typical seasonal flu, 80-90 percent of
deaths were in people younger than 65 – the
exact opposite of a normal year. Hardest
hit were pregnant women and those under
15. The Swine flu came from the Axis of
Evil that is the influenza genome, and was
a novel re-assortment of genes from four
different sources. Our younger partners got
sick, everybody’s kids got sick, half the office
was gone all fall; the rest of us soldiered on.
According to the CDC, the flu of 20102011 was a mixture of Influenzas A and
B and the vaccine was tested out to a 99
percent match. Yes the Axis had other ideas:
something called antigenic drift happens
when viruses attack humans. They change
then, the little bastards, and most of us got
sick that winter too, but far less so than in
the previous two years. “Partial protection”
we called it, and with the memory of 2008
still fresh, we were grateful.
Our gratitude is waning, though, since
that scenario keeps recurring. The 20112012 version was estimated at 52 percent
effectiveness, and the next year at 46 percent
(only 9 percent for the AH3N2 strain in
those older than 65). We got flu, but not horribly. Last winter the ’09 H1N1 came back,
and the shot’s effectiveness was estimated
at about 62 percent with the measure being
“kept you from going to the doctor for flu
symptoms.” That is not quite the measure
the average human being uses. We got flu,
but not badly. We continued to twist our
patients’ arms to get flu shots, to help the
herd immunity, to avoid pneumonia, to
avoid the misery.
But this year something different, something scary, was announced. The CDC issued a warning that the vaccine/virus match
is only about 40 percent for the shot and “is
investigating” reports that the flu-mist, for
little ones, is a much more severe mismatch.
The estimate is that Influenza H3N2 will
predominate, and this is the flu that tends
the hit the oldest and the very youngest the
worst. Dr. Frieden of the CDC warns all to
treat for flu at the early stages, to use anti-