Bird Flu Blues

I've been doing some reading and a lot of thinking about the bird flu these last couple of weeks. Here's the list of points that I find particularly pertinent:

• The current bird flu strain, which started in domestic fowl, has retained its virulence in domestic birds, but has evolved into a survivable infection in wild, migratory birds.
• Bird flu has not yet mutated to a form that will spread to humans and through humans, but the flu virus mutates easily and is currently present and being transmitted in a large number of birds, leading to increased replication and increased risk for mutation with each replication.
• Presence in migratory birds means bird flu will extend across Asia and head to Europe, safely nestled inside birds.
• Newly reconstituted Spanish flu virus was clearly a bird flu. And it's still really, really virulent.
• We suck at administering flu shots.

The last one is really distressing. Think about it--there's not really much we can do to change whether or not the bird flu mutates into something that will spread to humans. Sure, people are trying to prevent it by slaughtering entire flocks of chickens and ducks, but it's slipped that leash. Trying not to live with our chickens is probably a good step in the right direction, but there are parts of the world where people don't really have that choice. If it happens, it happens, and we'll just have to deal.

It's the dealing I take issue with. Last year was the start of the salutary lesson we have received in just how good our ability to deliver vaccine is. There were 2 manufacturers of vaccine for 2004/2005. One of them repeatedly failed quality inspections and none of their vaccine was usable. Pasteur Aventis came through, but distribution was a nightmare. In our clinic, we didn't have enough vaccine during the recommended vaccine season of October through November, but by January, we were drowning in it. We ended up having to throw a lot of it out.

This year, we ordered our vaccine from a different source, and ordered a different variety. So, you'd think, in a year when the CDC is claiming no problem with supply, we'd be busily vaccinating away, making sure everyone in our practice is fully protected. But then you'd be wrong. No, we just got the first 25 of the 160 vials that we ordered today, when we originally ordered them for early October. The local hospitals had so little supply, they have already run out. We have no idea when more will be available. The state of NH has insufficient supply to support local flu clinics and tells us that California and points west of us get the first supply, since flu usually starts there. That was news for us, since we've already documented a case in our clinic this past week, not that it's been posted at the CDC yet.

We've been given to understand that the bulk of our supply has been diverted to the Katrina vicitms by the same CDC that is now announcing no supply problems. I have no real issues with distributing vaccine to refugees, though I personally feel any refugee camps are likely to be cleared out by the time flu season hits. What really frosts my cookies is having the CDC announce that there's no shortage, when they single-handedly created one!

And here's the real concern: if we can screw up so much in a regular flu shot season with no underlying supply problem, what the hell is going to happen if a bird flu hits? It may be very difficult to get vaccine made and distributed in time, and the panic that will without a doubt accompany it will make it all worse. So what do we do to prevent the spread or limit the effect?

One thing I've noticed we do a pretty poor job at in this country is make any kind of accomodation for prevention of illness. We seem to feel that we have a prerogative to do exactly as we wish, whether or not it increases our risk of disease. We make no attempts to isolate the ill. In fact, we expect them to soldier on as much as possible, especially if we're their managers or family members. I have an elderly patient with asthma who shares a room with her teenaged granddaughter. I have another patient with dreadful lung disease who goes from well to near-dead in less than 24 hours, and who still welcomes her young, snotty nosed grandchildren and cuddles them on her lap. It's miserable to separate yourself from loved ones when they're sick, but that's the likeliest source of your next respiratory illness.

Last year, despite the inadequate immunizations, the flu season was mild. The year before wasn't bad, either, at least in New Hampshire. That year was distinguished by a snowstorm on Christmas day and a lot less visiting over the holidays. Ever wonder why the flu gets so severe in January? Last year, people were very jumpy because of the SARS scare. For the first time ever, we instituted the wearing of masks in our clinic, for those people with respiratory infections, including staff. We weren't alone in this. I think this may have had an impact. The CDC apparently doesn't feel that masks are all that effective, but I think it limits the amount of respiratory droplets that get dispersed through coughing, keep people's hands away from their mouths and noses, and just decreases the volume of stuff that's out there in the environment.

I can personally attest to the importance of individual attempts to avoid infection. For many years I have practiced near-religious hand washing, both before and after seeing patients For most of that time, I have had relatively few colds. Then suddenly, several years ago, I started having cold after cold after cold. It seemed one no sooner cleared, than another one started. I couldn't figure out what was going on. My family seemed to be getting the illnesses from me, not the other way around. Eventually, it dawned on me. I had recently started looking up noses as a routine part of examining people. It was impossible to keep track of how many times people breathed in my mouth or coughed on me when I did this. I could look at throats from a distance, and ears and eyes were off to the side, but for noses I had to get right in there.

I immediately turned over a new leaf. First, I vowed to stop looking up noses unless it was really, really necessary. Second, when I had to look up a nose, I ALWAYS wore a mask. Presto change-o! No more colds.

I've also changed from wearing clothes that need dry-cleaning (including suit jackets that would get worn multiple times before being cleaned) to wash and wear clothing so that my personal germ load is reduced. After all, I see patients with some really nasty germs. I don't need to wear them in to see other patients. I don't look as elegant as before, but I suspect I'm a lot healthier to be around. A study actually showed that male doctors' ties in hospitals were covered with nasty bacteria. It strikes me that polo shirts left casually open would actually be a better choice for them.

So here's some community based advice for people wanting to avoid colds and flu:

• Avoid sick people. This sounds easy, but it includes family members. Don't get too huggy or kissy-faced with friends and loved ones who aren't sick. Content yourself with patting their hand and then washing afterwards.
• Wash your hands a lot.
• Don't touch your mouth or nose except after washing your hands to prevent transmission of germs here.
• Stay home if you're sick. Don't take those germs to work. If you must go out, wear a mask that you change frequently, or use kleenexes that you dispose of in a sanitary fashion and wash your hands a lot.
• Refrain from coughing on people.
• Try to avoid going to the doctor's office for unnecessary visits in the winter. That's were sick people go. If you're really paranoid about it, see if your doctor provides masks for people with symptoms and snag one on the way in.
• At home, don't share glasses and wipe off the phone if someone else has to use it.
• A recent study suggested that people who drink tea every day have a reduced risk of getting the flu. Not sure how that works, but it's probably the most pleasant preventive I can think of!
  

If you do get sick with a high fever and something that feels like a cold otherwise, call your doctor right away. There are some medications that can shorten the flu for you, and may reduce your risk of complications, but you have to start them within 72 hours to get any benefit. Otherwise, pamper yourself with plenty of rest, and take in some chicken soup with chicken in it. Tylenol helps with the fever. The arthritis strength version lasts a whole 8 hours and provides smoother relief of fever. For those in the United States, a cool product called Mucinex DM is now over the counter and has high levels of dextromethorphan (a cough suppressant) and an expectorant in it, to keep your cough loose, and less frequent. My husband and I swear by Tessalon perles for those nasty dry coughs, but that's available by prescription only.

Try to avoid nasal decongestants. They only get you in trouble.

Finally, I heard a recent report on the health benefits of sinus irrigation, especially in prevention of colds. I'm not sure if I can support that, but I did buy a Sinu-cleanse neti pot from Walgreens and am using it to see if it provides any benefit for chronic stuffy nose. If it goes well, I'll give it the husband test, and then see if it's ready for prime time. To be honest, after using it for 3 days I'm fairly certain that you have to have a lot of determination and a strong constitution to want to pour water up your nose every day.

Bush goes crony again

Bush nominated his next Supreme Court justice today, and revealed to the world his complete and utter commitment to the concept of cronyism. The news said, prior to the announcement, that there were stories Laura Bush was pushing for a woman to replace Sandra Day O’Connor. Surely there are other women somewhere out there in the judiciary that have even a drop more experience that Miers? Even a week on the bench would give them an edge. This is slightly more legitimate than making Brown the head of FEMA, since at least this woman is a lawyer and presumably understands law, but you think there’d be a little more care taken after the recent Hurricane Katrina debacle. After all, even the Economist has run an op-ed piece about the obvious and dangerous Bush tendency to elevate incompetent people to high posts, just because he knows them.

I suspect there were two forces at work that led to this woman’s nomination. The first was that Bush knows her. He is presumably aware to a great degree of where she stands on issues that are near and dear to his heart, though if I were him, I wouldn’t rely on her views being precisely his, even if she has appeared to support him wholeheartedly. My experience with lawyers has suggested that they are a somewhat flexible lot, fitting themselves into the proper mode to give their clients exactly what they need. Like hired gunfighters in all those Old West movies, they defend their clients the best they know how and generally don’t let absolute truth and a rigid set of morals confine them in their activities. There is legal truth, after all, and a truth of the greater world. Legal truth is what has been decided in a court of law and depends on previous judgements and only what is presented in the court at the time of the trial. If an attorney can get something barred from testimony, no matter how true it is, then it doesn’t exist.

No, I’m not saying all lawyers are like this. In fact, I have a fairly balanced view of lawyers for your average doctor. I have found in my dealings with them, that they tend to have supple minds, and are often found of argumentation. Trial lawyers in particular are far more tolerant of confrontation than ordinary people. They seem to relish it, and even get a charge from a good battle in court. It’s not clear they need to be crusading for any particular cause to get that adrenaline hit. Yes, some lawyers will go on a crusade, and there are plenty of people with a law degree who never appear in court. There are other things in law they enjoy. I think Perry Mason has done the general population a disservice, though, by making us expect such principled behavior from all trial lawyers.

To the point, Mier’s compliance and agreement with all things GW may not run quite as deep as he would like to think. I’m sure she’s not a flaming liberal, because such a person wouldn’t have been able to survive being so closely associated with him for so long. She may, however, harbor a somewhat more moderate soul. Of course, she could be the Genghis Khan of frothing-at-the-mouth conservatives, too. We can’t be sure. What we can be sure of, is that if she’s nominated, we will find out. Once she’s on the Supreme Court, she will have to answer to no one except her own conscience, whichever deity she follows, and her own understanding of the law.

This leads directly to the second force at work. Bush managed to neatly nominate someone who had such good credentials and was so unshakeable, he slid through Congress sleeker than a greased pig in shit. There aren’t really that many candidates like Roberts out there. What better way to go than to nominate someone who has almost no public record for anyone to object to? I’m sure Bush has learned the lesson taught by his conservative buddies when running against Kerry—if you have many years of public service, which includes some of the compromises you need to make to get things done, you’re vulnerable to anyone who wants to reinterpret what happened and spin it in the direction they want it to go. Pretty soon they’ll be wanted to nominate someone just out of law school, and eventually, why not get them when they’re pre-law? Or wait—that may not work. What if they’re like me and publish a blog that is available to the public, even if no one bothers to read it?

I expect Bush will get this nomination confirmed. At this point, he owns the Congress, more or less. Perhaps some of the more ideologically driven Congressmen on the far right will be as uncomfortable as the Democrats are bound to be, but I suspect they won’t oppose their president on this. And the Democrats may decide they just can’t stand it and commence a filibuster, but they’re too far in the minority for that to be ultimately effective.

In the best of all possible worlds, Mier would be nominated and prove herself to be a capable, moderate and thoughtful justice. Too bad things don’t usually happen like that.