Please send items of interest for the E-News -- and other feedback -- to E-News editor Dave Cundiff, MD, MPH <cundiff@reachone.com>. Thanks!
CONTENTS:
1) AAPHP, APHA Meetings Set for Philadelphia in December
2) New Resources on Influenza Epidemiology, Pathogenesis
3) On-Line AMA Publication Features Ethics of STD Treatment
4) Detecting Tularemia on the National Mall
5) AMA Resolution on Affordable COBRA Insurance
6) Member Update
7) Call for Articles - AAPHP Bulletin
8) Acknowledgements and Erratum (misspelled name)
1) AAPHP, APHA Meetings Set for Philadelphia in December:
The American Public Health Association (APHA) has rescheduled its annual meeting, originally scheduled for next month in New Orleans. The rescheduled meeting will be held in Philadelphia, PA on December 10-14, 2005 . APHA's updated meeting information is at http://www.apha.org/meetings/ .
AAPHP's fall business meeting, also in Philadelphia, is tentatively scheduled for Sunday, December 11, 2005 -- with educational sessions that Sunday, Monday, or both. Please plan to attend if you can.
We are working to confirm AAPHP's meeting date, place, and speakers as quickly as possible. We'll keep E-News readers informed.
2) New Resources on Influenza Epidemiology, Pathogenesis:
Last week's New England Journal of Medicine (NEJM, 2005-09-29) includes an article on "Avian Influenza (H5N1) Infection in Humans" (p. 1374-1385). Incidence, transmission, pathogenesis, diagnosis, treatment, and public health measures are all discussed concisely and fairly clearly. NEJM subscribers are eligible for up to an hour of Category 1 CME for study of this article.
Highlights of the NEJM article for me were these:
H5N1 influenza has been detected in birds primarily in and around Southeast Asia since its detection in Hong Kong in 1997. H5N1 influenza appears to be easily acquired by ingestion (especially of an infected animal's blood). H5N1 influenza does not appear to be efficiently transmitted by respiratory droplets. Tissue invasion is more common with H5N1 influenza than with the usual human influenza strains. Diarrhea is commonly seen and it may represent gastrointestinal replication. It isn't clear whether waterborne transmission will play a role in H5N1 influenza outbreaks. The very high mortality rate among hospitalized patients may or may not represent the "tip of the iceberg" clinically. Milder illnesses, including subclinical infections, have been reported. The ratio of mild illness to severe illness is unclear. H5N1 appears to have a longer incubation period than other influenzas. The range of incubation periods appears to be two to eight days and possibly up to 17 days, although some scientists speculate the longest incubation periods may reflect exposure to infected animals or environmental sources. Clinically severe illnesses are seen; dyspnea is often a prominent early symptom. Readily available tests are unreliable, so reference lab testing is required. Neuraminidase inhibitors should be given presumptively, based on clinical and epidemiologic suspicion. Oseltamivir-resistant H1N1 variants have been isolated from some patients with H5N1 disease. Oseltamivir-resistant H1N1 viruses tend to be less infectious (and, other sources say, less pathogenic) than the oseltamivir-susceptible parent viruses. Some scientists speculate that when oseltamivir resistance develops in H5N1, the resistant virus may be less dangerous than the one we're seeing now.
Prevention of H5N1 transmission may be more complex than prevention of other influenza transmission. In addition to the usual respiratory measures, secretion precautions and fecal-oral precautions may be appropriate. H5N1 influenza should be suspected with clinically compatible presentations anywhere the virus has been found in the environment. It should also be suspected whenever a clinically compatible case is seen in an individual exposed to ducks (sick or healthy); or to domestic fowl or wild birds showing signs of illness; or to poultry confinement areas. Currently available influenza vaccines aren't very helpful against H5N1 influenza, but they may be of some help and they may help to prevent co-infection and the much-feared development of an H5N1/human influenza hybrid with true pandemic potential.
On-line access to this article is available free at http://content.nejm.org/cgi/content/full/353/13/1374 . CME credit requires a subscription to the journal.
Last week, CDC scientists published their report on the reconstitution of the 1918-1919 swine flu virus. There has been a lot of discussion about the wisdom of publishing the genetic sequence, because a credible threat of swine flu release would provoke worldwide fear.
CDC says the genetic evidence suggests that swine flu jumped directly from birds to humans, probably gaining transmissibility by mutation and not by recombination.
CDC's public communications imply that by studying the mutations that made swine flu highly transmissible and pathogenic, we can better evaluate whether wild influenza viruses are mutating in a more lethal direction or not.
Most news media reports of H5N1 avian flu have reported lab reports of H5N1, even when very preliminary, as if they were all confirmed cases of the highly pathogenic H5N1 circulating in Southeast Asia. Some are, some aren't. A high proportion of preliminary lab results aren't confirmed. Not all H5N1 strains are highly pathogenic for humans. A recent report of oseltamivir resistance appears to have been based on extrapolation from H1N1 observations, rather than direct observation of any H5N1 strain.
Web sites that are updated cautiously, so that their information is reliable, include the World Health Organization English-language avian flu site at http://www.who.int/csr/disease/avian_influenza/en/ and the CDC avian flu site at http://www.cdc.gov/flu/avian/index.htm . For real-time updates with perspective, consider subscribing to the ProMed-Mail service of the International Society for Infectious Diseases ( http://www.promedmail.org or http://www.isid.org ). This service, which is still free (donations requested), averages seven or more E-mails daily on a variety of infectious disease topics, with commentary by expert moderators. If you have time for it, you'll learn a lot!
U.S. DHHS Secretary Mike Leavitt has been sounding the preparedness alarm, apparently trying to get the world ready without inspiring panic. One recent news story on this is at http://www.cnn.com/2005/WORLD/asiapcf/10/06/birdflu.wrap/index.html . He was also quoted on National Public Radio this morning, to the effect that if this virus develops significant human-to-human transmission ANYWHERE, it is an imminent danger EVERYWHERE. ( http://www.npr.org )
Others point out that the "if" in Secretary Leavitt's statement is the key thing. We don't know whether highly pathogenic avian influenza H5N1(HPAI H5N1) will mutate into the next pandemic strain, and expert opinion doesn't agree on the statistical probabilities involved. However, according to Dr. Michael Osterholm at the University of Minnesota, we have had 10 influenza pandemics in the last 300 years; the last pandemic was in 1968. It isn't clear whether HPAI H5N1 will become a pandemic strain, but it is clear that a pandemic will come along sometime. Using current vaccine technology and medications, we cannot react to new strains as quickly as the new strains can spread. We will rely on surveillance for early detection; separation of humans to slow the spread; and judicious, targeted use of vaccines and drugs to minimize the damage from pandemic influenza.
Meantime, reports suggest that the next draft plan for pandemic influenza will emphasize "local" decision-making, with military support at the discretion of local health officials. (Editor's note: What a compelling argument to have public health physicians as key decision-makers in local health departments!)
CDC's next Clinician Outreach teleconference will be held tomorrow, 2005-10-11, from 1:00 to 2:00 pm EDT. Dr. Ray Strikas and Kari Sapsis, from the National Immunization Program, will present information on "The Upcoming Flu Season", with particular emphasis on vaccine supply, priority groups, CDC's planned educational campaign, and public education resources. The toll-free number is (888) 566-6584, and the Passcode is the word "Influenza". All clinicians are welcome to attend.
(Editor's Note: I don't expect more than a passing reference to HPAI in this teleconference. The best references on HPAI may still be the electronic ones.)
3) On-Line AMA Publication Features Ethics of STD Treatment:
The October, 2005 issue of Virtual Mentor , AMA's on-line journal of ethics in medicine for students and residents, features the theme, "Ethical Decision Making in the Diagnosis and Management of STDs". Articles by public health physicians and others discuss a variety of issues in STD and HIV prevention, diagnosis, and treatment. One of the case commentaries was authored by AAPHP's E-News editor.
The current issue is on the Web at http://www.ama-assn.org/ama/pub/category/3040.html . Past issues can be searched by issue or by theme at http://www.ama-assn.org/ama/pub/category/3523.html .
4) Detecting Tularemia on the National Mall:
U.S. Government BioWatch sensors detected the presence of Francisella tularensis on the National Mall on the weekend of a national antiwar demonstration 2005-09-24 and 2005-09-25. Follow-up testing confirmed this was tularemia. No human cases were suspected, even after precautionary announcements. District of Columbia health officials believe the bacteria were of natural origin (though tularemia is rare in the District) and not at dangerous levels.
The initial posting in the ProMED-Mail thread is at http://www.promedmail.org/pls/promed/f?p=2400:1001:1895649173871876667::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,30577 . Paging forward through the recent archives will reveal an interesting discussion about environmental survival of F. tularensis variants.
(Editor's Note: This report, and the reports of avian influenza's apparent geographic spread, emphasize the need for wise choice of lab screening in the environment. The environment is always more complex than we suspect. When we look harder for something, we often find it. But then what does it mean? Authorities at all levels appear to have handled this situation well. In a politically charged environment, the possibilities for manipulation -- by anyone you can imagine, for a wide variety of motives -- multiply greatly.)
5) AMA Resolution on Affordable COBRA Insurance:
AAPHP's President and AMA Delegate Arvind K. Goyal, MD, MPH, who sees many airline workers in his practice, has noted that insurers are beginning to price COBRA coverage so high that the intent of the COBRA law is not met. He has submitted the following resolution on our behalf, to the AMA's Advocacy Interim Meeting scheduled for December 2005:
*** Resolution introduced by AAPHP for I-05 ***
WHEREAS, The COBRA Insurance law was written to enable continuing Health Insurance coverage for up to 18 month period for workers who lost their jobs or were between their jobs; and
WHEREAS, Many Health Insurance Companies have continually raised premiums so that many unemployed workers are forced to decline COBRA coverage in spite of their potentially increased physical and mental health needs during unemployment; and
WHEREAS, The premiums for COBRA coverage are sometimes set at 3 and 4 times of what the affected individuals or their employers would pay for similar continuing Health Insurance coverage if still employed; BE IT THEREFORE
RESOLVED, That our AMA publically call upon the Health Insurers Association/s and the Congress of the United States to review and propose fixes which would make COBRA Insurance available and affordable for workers without or between their jobs.
Comments received by the end of November will be taken into account as AAPHP's delegates represent us at the AMA.
(Editor's Note: AAPHP members interested in comprehensive health system reform, please contact president Goyal through http://www.aaphp.org or through the E-News editor at cundiff@reachone.com . While the AMA has historically been unsympathetic to comprehensive system-reform proposals, there are other avenues for policy expression. Even organized medicine may be changing its attitude, however slowly -- at least here in the Northwest.)
6) Member Update:
Thanks to Clarence L. Brumback, MD, MPH; Anand Chabra, MD, MPH; Don MacCorquodale, MD, MSPH; and Leah Z. Ziskin, MD, MS. These public health physicians joined and/or renewed AAPHP membership since our last member update.
New memberships and renewals are being accepted for 2006. Members joining or renewing now can pay 2006 dues at the 2005 rates ($85 Active, $30 retired). Go to the Web site at http://www.aaphp.org or call AAPHP's Membership Officer Rob Rader at (202) 207-0709.
Watch for further membership announcements in future issues of E-News.
7) Call for Articles - AAPHP Bulletin:
A printed AAPHP Bulletin is planned for November 2005. Please submit articles for consideration to Dr. Goyal, by the AAPHP Web site or through the E-News editor, during October. Thanks!
8) Acknowledgements and Erratum (misspelled name):
Thanks to the sponsors and moderators of ProMED-Mail at the International Society for Infectious Diseases and Elsevier Medical Publishers, for original distribution of much of the material summarized in this issue.
In the 2005-10-02 E-News, we gave the name of one of CDC's "Mental Health and Disasters" presenters as "Leila McKnight, PhD". We spelled Dr. McKnight's first name wrong. The correct name is "Lela McKnight, PhD". We regret the error.
AAPHP offers free E-News subscriptions on request to all public health physicians. We are still offering free E-News subscriptions to anyone who is involved in public health emergency response. Please refer your colleagues to us. Thanks!
Dave Cundiff, MD, MPH
AAPHP Secretary and E-News Editor