Category: Health and Health Care

H1N1 Update

November 13th, 2009 — 11:16am

A large number of my patients have been asking questions about H1N1 and I thought it would be helpful to provide information on my blog.

The most frequent inquiry regards my position on the issue of H1N1 vaccination. While I agree that this is a very important consideration, it is critical that any opinion of mine be understood in the context of what we know and don’t know about this virus and its behavior so far.

First, some history about the disease to this point. Swine flu is not a new illness. There is lab evidence that generations of many humans working in close contact with pigs have antibodies to the virus, which indicate prior exposure to H1N1 in those individuals.  What is new (since last spring) is the ability for the virus to spread from humans infected by contact with pigs to other humans. It’s worth noting that many epidimiologists have been predicting for some time that this modification of the virus to be able to spread through the human population would occur; not “if” but “when”. And “when” appears to be now. The main reason swine flu has been such a concern over the years is because it has always had specific characteristics which make it more capable of “jumping species”. 

There is a larger issue of how viruses jump from animals to humans in the first place and while there is some debate on the matter, it is generally thought to be tied to increasing human population and mobilization, coupled with stressful environments for animals that we breed and grow for food. There is still much we don’t know about this complex process, but there are probably some practical things we could be doing which would reduce the chance for future events like H1N1. Needless to say, as a health care practitioner focused on prevention and pro-active health I believe this to be an extremely important matter, but not really relevant to what we can and should be doing regarding H1N1 now.

The H1N1 virus made the clear jump to human-to-human transmission back in the spring. Since then it has been rapidly spreading throughout the globe and the CDC estimates that one half of the world’s population (2.5-3 billion people) will be exposed to the virus over the next 2-3 years. Since the onset, the virus’s virulence (the measure of complication and death per number of cases) has been similar to that of the seasonal flu. However, this flu is different in two significant ways; the total number of suspected cases and the age group it most affects. The large number of cases is the result of the high communicability of this virus coupled with the fact that it is new in the human population and thus there is no “herd immunity” from previous exposure. The affected age group is primarily 0-50 years old, with few cases 0-2 years old, steadily increasing and peaking number of cases 8-15 years old and gradually decreasing and then becoming steady, 25-50 years old. The over  50 set seem to largely get a free pass with this virus; ironic, as the seasonal flu kills on average 36,000 people in this country annually and the significant majority of them are over 60. It is strongly suspected that the primary reason for this is that there were several seasonal flu strains from the 1930’s through the 1950’s which were similar enough in profile to H1N1 that many people alive during that time have antibodies close enough of a match that they avoid significant illness when exposed to H1N1. What is less clear is why children are so disproportionally affected. Remember, “affected” refers to cases resulting in complications and/or death, not the total number of cases of exposure; it is expected that all age groups are exposed, just unequally affected. As is the case with elderly and the seasonal flu, the majority of complicating cases of H1N1 are younger people with identified, pre-existing health conditions. It is not clear to me from any statistical data to this point that H1N1 is causing complications in a higher percentage of “healthy” people per total number of cases than the seasonal flu does on average each year.

This raises a critical question and concern for me about the description of people as “healthy” in these situations. Dorland’s Medical Dictionary defines Health as…”an optimal state of mind and being, not merely the absence of disease or infirmity”. To describe a child with no pre-existing health condition who gets sick and/or dies of the flu as having been “healthy” prior to the illness would assume, as a parallel that a 45 year old man running for the bus, who’s never had chest pain in his life and suddenly has a massive, life-threatening heart attack, was “healthy” up to the moment of his catastrophic MI. This misrepresentation is, in my opinion very dangerous and at the end of this report I will come back to the issue in a more practical and useful way.

So, having described the virus and its behavior to this point in time, I’d like to look at the way we, as a culture and particularly our governing institutions have responded. Until about five weeks ago, my examination of the data provided by the CDC closely mirrored what was being substantively reported in the media as a public service outlet. Then, in early October there was a run of news stories regarding high profile individual’s concerns and negative attitudes toward the swine flu vaccine. This mostly centered on the fact that it is a new vaccine being rushed into production and the question of whether or not there are safety issues (has it been “vetted” well enough). There is some concern within the medical community itself (see Dr. Mercola’s website for specifics) though certainly not “mainstream”. Immediately on the heels of this, there was a distinct shift of tone and divergence from the context of the data being generated by the CDC as far as news about H1N1 in mainstream media was concerned. The script changed very clearly to the goal of generating fear and anxiety in people in order to get them to take this virus and the need for the vaccine seriously. Now, news stories primarily talk about numbers out of context; “ 44 children have died in the US since August, 119 children have died in the US since the virus started last spring, 11 last week alone…”. These are the headlines, but they mean little without the broader data to interpret them in. I could just as easily say that 44 kids will die in car accidents in the next two weeks and I would be technically correct, but without data about total number of kids in cars per miles driven during that time its rather abstract (remember, there are 300,000,000 people in this country; being a child and dying in a car accident this week is statistically equal to winning mega-millions). I am very angry that media as a public service outlet for information has abandoned merely informing us and is now attempting to persuade us to think and behave a certain way through fear and intimidation as a means to an end. If people cannot trust the process, there is great risk in them not trusting the motive.

Health officials are no longer confirming suspected cases of swine flu through blood analysis; only those resulting in complications and/or death. This means that statistics about the virus’s virulence (again, the rate of problem cases as a percentage of the total number of cases) are estimated. I feel confident in the science used to generate these estimates that it is likely accurate. As I indicated earlier, I have seen no data which suggests that, so far the virulence of H1N1 is different than that of the average seasonal flu. Because it is a new virus in humans and because of certain characteristics in its make-up there is some concern that it may become more virulent over time as it spreads through the population. This is not a prediction, just an acknowledgement of the potential for it to occur. Given the large number of people expected to be exposed to H1N1 over the next few years, any meaningful increase in its virulence will be very significant in terms of the total number of injuries and death and in assessing individual risk.

This brings us to the issue of the H1N1 vaccine. Availability problems aside, public health officials are aggressively promoting the vaccine for children, pregnant women, people working with children and health care providers. The vaccine is created using the same model and technique as for the seasonal flu vaccine and I do not believe there is any evidence to suggest that it is less reliable or safe.  Many of you know that I have broader concerns about vaccinations overall as an intervention, but I am choosing not to bring them into this discussion. Parents of individual children and young to middle-age adults need to make individual decisions about whether to vaccinate or not. Again, the critical criteria are the ongoing assessment of the virulence of the virus and the health status of the individual in question.

Now, back to the matter of interpreting one’s health status. I am appalled that virtually all the public health information about how to protect yourself from H1N1 revolves around exposure to the virus itself; washing your hands regularly, avoiding people who are sick, removing yourself from others if you are sick, etc. These are all meaningful recommendations for how to avoid the illness, but I haven’t heard word one about how to reduce one’s chance of a bad outcome if you do become exposed. If the statistics overwhelmingly show that it is sick people who make up the majority of bad H1N1 cases, then logic would dictate that being healthy substantially reduces your risk of a bad outcome. And since being healthy is not merely the absence of symptoms, but an optimal state of physical and mental well-being, then how about some promotion of behavior which inherently supports a good baseline for health. This would include: sufficient amount and quality of sleep, fresh air and reasonable amount of physical activity, consistent and proper amount of hydration (water), good nutrition (both what you put in and what you don’t), effective stress management (maybe the most important of all) and support therapies which help the body from the inside out to be more resilient and adaptive. As a chiropractor I have a particular focus on the role a properly functioning nervous system, free of interference from the spine has on baseline health and certainly encourage people to get adjusted for constitutional support and not just for problem-solving. But I have a great appreciation and regard for many other disciplines as well; massage, shiatsu, acupuncture, reiki to name a few. Being healthy is not a roll of the die; it is substantially about the choices we make.

To review; H1N1 is a significant event that should be taken seriously and monitored carefully, but not over-hyped and taken out of context.  Individual decisions regarding vaccination should be informed and not fear-driven. And we should all be supporting ourselves and those we’re responsible for in being healthy and adaptable.

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