December 16, 2003 Denver, Colorado – Greg Gahm, M. D., is an internist geriatrician at Presbyterian St. Luke’s Medical Center in Denver, Colorado. After graduating from the University of Colorado Medical School in 1982, he did a fellowship in Health Administration at Harvard University in 1986 and a sabbatical in clinical preventative medicine at Stanford University in 1991. Recently, Dr. Gahm has been caring for seventy-five elderly patients and two, who tested positive for Influenza A, died. That’s 3% of his patients. Dr. Gahm points out that if the 80 some nursing homes in Colorado each had 75 patients, that’s about 6000 sick people in nursing homes. Three percent of those is 180 likely deaths from influenza A. But influenza deaths in the elderly are not required to be reported. It’s pediatric deaths which must be reported. Currently in Colorado, there are eleven confirmed pediatric deaths with two more suspected. Dr. Gahm thinks it is important to understand how many elderly deaths are under-reported which emphasizes why it is as important for those over sixty with weaker immune systems to get vaccinated each flu season as it is for young children whose immune systems are not developed.
As of this date, Colorado’s public health offices are reporting 9,300 confirmed cases of Influenza A since October. “That’s five weeks of hard hitting flu which is very unusual and it’s not over yet. Usually flu peaks for a couple of weeks and tapers off. No one was prepared for such a dangerous flu so early in the season – that’s why most people had not even had flu vaccines in October and that’s why the Fujian was able to spread so fast,” Dr. Gahm explained.
I asked him today about the headlines he generated last week when he said he suspects hundreds of elderly people in Colorado have died of the Fujian flu strain.
Gregory Gahm, M. D., Internist Geriatrician, Department of Geriatrics, University of Colorado, Presbyterian St. Luke’s Medical Center, Denver, Colorado: “I stand by my earlier statement last week that many elderly people in Colorado’s 80 nursing homes have died from Fujian-related illness. If we’ve got a close facility, there are very few more common viral diseases that spread as quickly as influenza does and come on all at once. So, if we have a facility with seven or eight people that all within a couple hours start coughing with a high fever and we test two or three and get one or two positives, we immediately jump to the conclusion that they are all influenza which is a reasonable jump to make. But because we didn’t actually go test the other ten or twelve people, we don’t report them.
So, even in nursing homes probably when we’re testing, we’re only reporting about 20% of the number of people who actually have it. I think last night we were at about 9,300 positive influenza tests in Colorado and I think that is only 10% to 20% of the actual number of people who have actually had clinical influenza.
HOW MANY HAVE DIED FROM INFANTS TO THE ELDERLY SO FAR?
That gets tough because the Health Dept. only tracks pediatric deaths, and I think we are at 11 and two questionable. So we might be at 13 young children right now. In a normal year in this state, we have two to three. So we’re at about five times the normal in pediatric deaths.
One of the misleading things that has come out in the media is, ‘No elderly deaths have been reported, so maybe it’s just hitting kids.’ No, elderly have been reported because even in my patients, when I knew they died from influenza and I fill out their death certificate and list cause of death, influenza, that ends up on a death certificate. It goes to a county recorder’s office. It gets filed away and three to five months from now, somebody might pull those and enter them and try to track and see. I’m trying to be specific about listing the death as influenza if I think that’s the cause. But more often death certificates for the elderly will say emphysema, heart attack, cardio-pulmonary arrest they are not going to say influenza. But if you track it back the fact that you had ten times as many myocardial infarctions over a two week period and influenza happened to be terribly prevalent here is a good indication there is a link.
But legally, I don’t have to report those deaths as influenza. There is nobody to report them to and nobody has the time to do that. So it ends up real misleading to say that all the deaths are pediatric because that’s the only thing we track.
COMING BACK TO YOUR OWN SAMPLING OF 3% OF THE 75 PATIENTS THAT YOU ARE TRACKING DYING WITHIN 48 HOURS. IF YOU TAKE THAT 3% OF THE 9,300 COLORADO CASES THAT HAVE BEEN IDENTIFIED SO FAR, YOU ARE HAVING MANY MORE DEATHS THAN HAVE BEEN REPORTED LINKED TO FUJIAN.
Pandemic Threat in the Future?
ARE WE MOVING INTO A TIME IN WHICH INFLUENZA A VIRUSES SUCH AS FUJIAN COULD BE CHANGING IN SUCH RADICAL FASHION THAT WE REALLY COULD BE HEADED TOWARD THE POSSIBILITY OF A PANDEMIC THAT COULD BE MORE DANGEROUS?
I agree. I know there is a gentleman at Mayo and Paul Glezen, M. D., at Baylor who have been trying to tell people, ‘Don’t be surprised if we get hit with a pandemic.’ But it probably won’t be an A Fujian strain, something with different proteins on the surface of the virus the H3N2 letters and numbers we talk about.
If those are normal numbers if the H is a 1, 2 or 3 and the N is a 1 or 1 2, that’s just not going to lead to a pandemic because there is a lot of natural immunity in the human population against those kinds of viruses.
I think the real scare is when there is a change to an H5N2, sort of like the chicken flu, and it happens to be a variant that people have not seen at all. If there is a major change like that like with the chicken flu (that caused Hong Kong to kill over a million chickens to control the virus), it fortunately was not very virulent. So, it didn’t spread far and fast as SARS did later. I think if we see something like an H5N1 or H5N2 and it also spreads pretty quickly, then I think we’ll be in for a pandemic.
AND WHAT DO WE DO THEN WHEN WE’VE HAD EVEN A PROBLEM NOW OF HAVING THE HEALTH INFRASTRUCTURE DEAL WITH AN INFLUENZA IN THE FALL OF 2003?
I think what we do then is hope that the World Health Organization (W.H.O.) keeps doing a good job of surveillance and can find it quickly and we can develop vaccines quickly because that clearly is the best option. Still for this year, that’s the best option. For people who haven’t been vaccinated, get vaccinated. If you can’t find normal vaccines, get FluMist. It’s a little more expensive, but it’s a lot cheaper and easier than putting up with the symptoms of the disease.
2004 Flu Vaccine
WILL THE PHARMACEUTICAL COMPANIES SUCH AS CHIRON, WYETH AND AVENTIS HAVE MANUFACTURED A FLU VACCINE THAT WILL DEFINITELY COUNTER THE FUJIAN H3N2 NEXT FALL 2004? I UNDERSTAND IT IS HARD TO GROW AND I’M CURIOUS IF THAT MEANS THAT THE AUSTRALIAN AND NEW ZEALAND DOCTORS WHO HAVE BEEN WORKING WITH IT SINCE E THE SUMMER WHEN FUJIAN ERUPTED THERE HAVE THEY BEEN ABLE TO COME UP WITH A SUCCESSFUL VACCINE TO FUJIAN IN THE SOUTHERN HEMISPHERE?
Yes and no. There are a number of people, even here in the U. S., who have. But it requires a little bit different technique. Whenever you do something new or different, if you are Chiron, Aventis or Wyeth or anyone else, the first thing is litigation fears. I think they can grow this Fujian virus I think in dog kidney cells (and not in egg which is standard). But even if they do that to create Fujian vaccine that will protect 100,000 people, there are going to be 6 people in those 100,000 that have a bad reaction to the dog-kidney-produced vaccine and who will sue the manufacturer because the dog kidney was used.
THE MEDICAL RESEARCHERS CANNOT GROW FUJIAN IN EGG THE WAY THEY USUALLY DO WITH INFLUENZA?
Right, not the normal techniques. They have to use other techniques and the pharmaceuticals have to get those approved and have some sort of assurance because it is a little different that they are not going to be held liable if this does not work or causes problems they cannot foresee because they have not done it before.
I think the other thing that makes the A Fujian this is sort of a mixed message: part of the good for 2004 about A Fujian is because so many people will be exposed this year, they will carry that immunogenicity over to next year. So, the chances that A Fujian will do the same thing a year from now are pretty minimal. But here is one A strain that could do this and means there could be others. So, in general, we need to have a better national policy to figure out how to do this, how to make enough vaccine.
One of the nice things about all this is that people are scared enough that they are a little less worried about the shot than getting the flu from the shot, an old wives tales and myth, that keep people from getting vaccinated every year. Maybe people will develop a better public policy and people will be more willing to be vaccinated year to year.
WHAT I’VE LEARNED FROM YOU TODAY IS THAT WE CAN’T ASSUME A GUARANTEE THAT INFLUENZA CAN EVEN BE MADE EASILY IN A VACCINE.
Right. And difficult to make them cost-effective to produce on a massive scale. In a good public policy, we need to have at least half or two-thirds of the population vaccinated every year. We need to expand to healthy, school-age kids and healthy young adults. They are the ones that spread the flu so quickly. If we had such a national policy, then the pharmaceuticals would have the time and ability to figure out how to make 160 million doses of vaccine of A Fujian that does not grow well in eggs.
WHAT DO WE DO ABOUT THE PEOPLE WHO ARE AFRAID OF GETTING ANY VACCINES BECAUSE OF THE CONSPIRACY THEORIES THAT VACCINES ARE BEING USED AGAINST US?
I run into that all the time and wish them the best if a bad strain comes along and they get very sick. Those fears usually last clear up until you have something like this and then there is a fear of death for your kids and vaccination looks like it’s protective. Again, once you stop and understand a little more about the vaccination process, it’s a lot harder to justify that you get flu from the vaccine. That’s a myth.”
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