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temsmedic
05-01-2009, 18:15
I'd like to post the following for discussion:

I have considered the following actions, if a very dangerous pandemic presented [not the current one, but more like H5N1, with a very high mortality rate]. The underlying premise is that it will be just about impossible to avoid being infected during the entire course of the pandemic, with it's multiple waves, as we provide health care with increasingly limited resources. We have all seen the graphs of the 1918-19 pandemic's death rate, and read about the lack of medical resources for those that are infected at the peak of the pandemic.

So, I have considered:

a) start Lipitor when I know the virus is heading our way.
b) when the first patient presents, start double dose antivirals [already stockpiled]
c) [I'd now consider adding vitamin D after reading some of the articles posted in the "Pandemic" thread]
d) Go into an influenza patient's room, and get infected.

This plan would optimize my chance of survival, and if I was gravely ill, there would likely still be nurses, ICU beds, ventilators, etc to take care of me.

The added benefit would be that IF I recovered, I'd be able to see patients without any mask/respirator, and would be more efficient for the mountains of work that will flooding the ER.

The wildcard would be the timeline on vaccine availability, although if the country is paralyzed, I wouldn't put it past them to send us placebo vaccine, to get the health professionals to show up to work.

I'd appreciate your thoughts.

swatsurgeon
05-01-2009, 19:06
the reality is....find a safe quiet place without other people. Transmission vector is not 100% known as well as you don't know your immediate immune status and different scenerios could play out very differently depending on your "general" state of health.
Would not advocate being purposely infected...anti-virals are a shot in the dark, vitamin D ?????

We deal with viruses every day.........

ss

doctom54
05-01-2009, 19:51
I'd like to post the following for discussion:

I have considered the following actions, if a very dangerous pandemic presented [not the current one, but more like H5N1, with a very high mortality rate]. The underlying premise is that it will be just about impossible to avoid being infected during the entire course of the pandemic, with it's multiple waves, as we provide health care with increasingly limited resources. We have all seen the graphs of the 1918-19 pandemic's death rate, and read about the lack of medical resources for those that are infected at the peak of the pandemic.

So, I have considered:

a) start Lipitor when I know the virus is heading our way.
b) when the first patient presents, start double dose antivirals [already stockpiled]
c) [I'd now consider adding vitamin D after reading some of the articles posted in the "Pandemic" thread]
d) Go into an influenza patient's room, and get infected.

This plan would optimize my chance of survival, and if I was gravely ill, there would likely still be nurses, ICU beds, ventilators, etc to take care of me.

The added benefit would be that IF I recovered, I'd be able to see patients without any mask/respirator, and would be more efficient for the mountains of work that will flooding the ER.

The wildcard would be the timeline on vaccine availability, although if the country is paralyzed, I wouldn't put it past them to send us placebo vaccine, to get the health professionals to show up to work.

I'd appreciate your thoughts.

a) The data on statins (such as lipitor) is not very convincing and to me there are a lot of problems with the study http://www.chestjournal.org/content/132/4/1407.full.pdf
b) You can use Tamiflu 75 mg ONCE DAILY as a prophylactic agent. Studies are for use up to 6 weeks. I have used it in the nursing home for that with good success
c) If you are low on vitamin D, which a lot of geriatric patents are, then it MIGHT be helpful
d) just plain silly

Physicians, nurses and other health care workers use PPEs and do their jobs. There is a risk but it is accepted as part of the profession.
The analogy to a soldier is appropriate. He wears his body armor etc and does his job. He may get wounded or killed but that is accepted. He doesn't deliberately get wounded early so he can get better care.
You stay in the battle until they carry you out.

temsmedic
05-01-2009, 21:00
a) The data on statins (such as lipitor) is not very convincing and to me there are a lot of problems with the study http://www.chestjournal.org/content/132/4/1407.full.pdf
b) You can use Tamiflu 75 mg ONCE DAILY as a prophylactic agent. Studies are for use up to 6 weeks. I have used it in the nursing home for that with good success
c) If you are low on vitamin D, which a lot of geriatric patents are, then it MIGHT be helpful
d) just plain silly

Physicians, nurses and other health care workers use PPEs and do their jobs. There is a risk but it is accepted as part of the profession.
The analogy to a soldier is appropriate. He wears his body armor etc and does his job. He may get wounded or killed but that is accepted. He doesn't deliberately get wounded early so he can get better care.
You stay in the battle until they carry you out.




I know that the Lipitor data isn't strong, but there is a lot of evidence that it works by decreasing inflammation. I must admit, that I am approaching an age where I guess that I don't need to worry about my "immune storm". There is a thread in the "General Discussion" section on pandemic influenza that posted a couple good papers on Vitamin D which led me to add that to my list. It would be ideal to take prophylactic Tamiflu... if you can get it. The Puget Sound area of the NW is already sold out, and they have a waiting list, until the stockpile meds are released. They haven't announced how they are going to differentiate those that are trying to stockpile meds from those that need it for real disease. There is about zero chance that you will be able to take it for the entire course of even one wave of a pandemic.

I work in a ER with a 65k volume/yr, but we only have a couple reverse flow rooms. If a big pandemic hits, I think that the chance of me avoiding the disease is about zero. The question isn't "if", it's "when".

I like your tactical analogy. If someone told you that you were going to take a high velocity round, but had a choice to take it whenever it arrived, or outside an Emerg Dept, with an IV in, and trauma team ready and available, which would you pick?

I appreciate your comments.

Blitzzz (RIP)
05-05-2009, 09:13
I'll be in chemo for the next 4 days. See you all when I get back.
Blitzzz

temsmedic
05-05-2009, 14:07
I saw my first pt that meets the CDC def'n of a "probable H1N1", 2 y/o male w/fever to 39.5. Sat out in the waiting room for two hours with his cough, then put in a shared room. Infl A positive, sent to hlth dept for confirmation of H1N1.

Like the chemo comment. Does SA also stand for smart ***? Don't jump me, I expected pithy, critical responses, which is exactly the reason I posted the item for discussion. Doesn't hurt my feelings if you think that I am FOS.

FYI, I didn't wear a mask today with the probable H1N1. There is some thought that the next wave in the fall could be worse, I'll take this strain, since it's pretty weak. H1N1 seems more like media hype. I suspect that the CDC knows this, but is letting it run so that they get a good test of their pandemic response plan.

The Reaper
05-05-2009, 14:29
Like the chemo comment. Does SA also stand for smart ***?

Do you find his cancer treatment humorous?

TR

shr7
05-05-2009, 14:58
I expected pithy, critical responses, which is exactly the reason I posted the item for discussion.

In an attempt to move this towards a more productive discussion, I'll provide a critical response.

Before I do, I want to differentiate actions that I disagree with (would not recommend / would not do myself) with actions that I have a problem with (could potentially have a negative influence on pandemic outcome). Yes, I know it is unlikely that one person could create a negative outcome, but I am speaking of behaviors that if widespread, would create such a result.

Points in your posts that I disagree with:

Use of Lipitor. I feel your time and money could be better spent elsewhere. Will it hurt? Probably not. Besides drug side effects / medication interactions, if it was a behavior that caught on, it probably would not have a negative effect (or positive for that matter, if we can critically evaluate literature; that was not a pretty study, and I can draw multiple alternate conclusions just off the top of my head from that same data.)

From the case you mentioned. Is that a probable case? A probable case of S-OIV infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza RT-PCR. Maybe, but you didn't mention if any RT-PCR testing was done.

I have a problem with:

To continue our analogy, a soldier jumping in front of a bullet early in the war to make sure he gets the best care before the medic is too busy, MEDEVAC takes too long, and the hospital is too crowded. Providing more work and less resources for those who were WIA unintentionally. Now, his squad is down a man, leading to more casualties and possibly a mission failure.

Just like I have a problem with a Dr. taking advantage of his/her position to get the best medical care at the expense of others and to the detriment his/her patients because this particular ER now only has 2 docs instead of 3.

And, especially as a pharmacist, I have a HUGE problem with "double-dosing" antivirals as prophylaxis (ignoring CDC recommendations) effectively halving your supply for no good reason. Now only 20% of patients will receive doses instead of 40%. And I have a SUPER MEGA HUGE problem with you "stockpiling" these medications. You mention in your first post that they are "already stockpiled". I hope I am misinterpreting this when I take it to mean that you are stockpiling them...

My $0.02, hope this can be a productive discussion.

SR

doctom54
05-05-2009, 16:09
I'll be in chemo for the next 4 days. See you all when I get back.
Blitzzz

From a professional view point, stay out of crowds (that includes church) after the chemo.
Hope things go well. Our prayers are with you.

Tom

doctom54
05-05-2009, 16:13
I saw my first pt that meets the CDC def'n of a "probable H1N1", 2 y/o male w/fever to 39.5. Sat out in the waiting room for two hours with his cough, then put in a shared room. Infl A positive, sent to hlth dept for confirmation of H1N1.

Like the chemo comment. Does SA also stand for smart ***? Don't jump me, I expected pithy, critical responses, which is exactly the reason I posted the item for discussion. Doesn't hurt my feelings if you think that I am FOS.

FYI, I didn't wear a mask today with the probable H1N1. There is some thought that the next wave in the fall could be worse, I'll take this strain, since it's pretty weak. H1N1 seems more like media hype. I suspect that the CDC knows this, but is letting it run so that they get a good test of their pandemic response plan.

Your ED sounds like it isn't up to speed on this issue.
In my office we are taking temps at the entry door and if febrile they are sent to a separate waiting area and given a mask to wear. It may be overkill but I think it is good training and will get people in the correct mindset for when the next wave hits.
SA = "situational awareness" USAF term or "keep your head out of your a$$" US Army term ;)

mugwump
05-05-2009, 17:35
Use of Lipitor. I feel your time and money could be better spent elsewhere. Will it hurt? Probably not. Besides drug side effects / medication interactions, if it was a behavior that caught on, it probably would not have a negative effect (or positive for that matter, if we can critically evaluate literature; that was not a pretty study, and I can draw multiple alternate conclusions just off the top of my head from that same data.)

Agreed, retrospective studies lack power and there are no placebo controlled trials that say statins will work. But smart folk I deal with - guys who make judgements about giving experimental cytokine-moderators to healthy volunteers - think statins may help. Their judgement is based upon potential mode of action (NF-kappaB antagonist) and anecdotal reports (not just Chest). But you very well may be right; I've heard other folk argue that statins don't/won't work. I would get a course of beta-lactam + EES for each family member before statins. But that having been accomplished and as statins are over-the-counter in the EU and will be here soon, I think the average PS'er can read the package insert and use them intelligently.


And, especially as a pharmacist, I have a HUGE problem with "double-dosing" antivirals as prophylaxis (ignoring CDC recommendations) effectively halving your supply for no good reason. Now only 20% of patients will receive doses instead of 40%. And I have a SUPER MEGA HUGE problem with you "stockpiling" these medications. You mention in your first post that they are "already stockpiled". I hope I am misinterpreting this when I take it to mean that you are stockpiling them...

My $0.02, hope this can be a productive discussion.

SR

I took this thread as being for the medical professional. Prophylactic use of anti-virals by practicing medical professionals during an ongoing, virulent pandemic is different from the average Joe poppin' Tamiflu. It has been discussed by serious people. For instance, the WHO ground teams were on prophylactic Tamiflu regimens. (And you'll be shocked to hear that I don't have total faith in CDC recommendations, although they've done a good job lately, IMO.)

My guess is it won't matter anyway...flu rapidly acquires resistance to neuraminidase inhibitors. The current H3 and H1 strains, with the exception of this spankin' new swine variant, are nearly 100% resistant to Tamiflu. My guess is this swine virus will acquire it too.

You'll go apoplectic to hear I've been stockpiling Tamiflu (and Relenza, too!) for years :( and that I have double doses (the currently recommended dosage for H5N1) of each drug for each member of my immediate family. And two local businesses have stockpiled tens of thousands of doses between them. And one is actively adding to its stockpile right now. :eek:

mugwump
05-05-2009, 17:38
Best of luck Blitzzz.

The Reaper
05-05-2009, 18:04
If there is no shortage, people are acquiring a single course or so per family member or less, and supplies are presently adequate, how is it "hoarding"?

It would seem to me that additional purchases of widely available antibiotics would merely spur the pharm companies to make more.

TR

mugwump
05-06-2009, 09:52
If there is no shortage, people are acquiring a single course or so per family member or less, and supplies are presently adequate, how is it "hoarding"?

It would seem to me that additional purchases of widely available antibiotics would merely spur the pharm companies to make more.

TR

Spot on. Roche and Glaxo both cut back production of their anti-virals early in 2008 due to lack of demand. Won't stop the current trend of retroactive demonization, though. I heard this second hand, so who knows: the county health officials mentioned in passing that they had the right to confiscate from local businesses the anti-viral stockpiles that the government has been urging them to "hoard" since 2005. These are Fortune 100 companies with security and lawyers out the wazoo and a direct stake in any pandemic so I doubt it could really happen, but we can all see where personal property rights are headed in this country.

mugwump
05-06-2009, 09:54
Probenicid? Grapefruit juice? Utility, dangers? I'm thinking young healthies, not old farts taking multiple concurrent meds.

greenberetTFS
05-06-2009, 10:35
I'll be in chemo for the next 4 days. See you all when I get back.
Blitzzz

Good luck Blitzzz, My wife is starting her Rituxan(chemo) treatment in 2 days, it's for her RA. She gets it every 6 months on a two week interval. Hope they can keep it in remission for you also.................

GB TFS

frostfire
05-06-2009, 13:49
Physicians, nurses and other health care workers use PPEs and do their jobs. There is a risk but it is accepted as part of the profession.

Doing ER/ED assignment this summer. I've pretty much made peace with the fact that ER staff serves additional purpose as canaries in the mine. I'm not just referring to pandemic flu, but bioterrorism as well. My strategy would simply be maintaining my immune system at max via healthy diet, exercise, and vitamins/supplements, carrying OH-based hand sanitizer and moisturizer, using proper PPE and following SOP to the letter, and turning off the faucet and opening the restroom door with paper towel or elbow. I'm sure you all have heard/read about more germs on faucet than toilet seat.

Still, I very much like the idea of screening febrile patients right off the bat. I'm formulating ways right now to suggest this to the power-that-be without coming across the wrong way.

Best wishes with chemo, Blitzzz. I echo the advise of avoiding group of people especially in an enclosed environment. I myself got kicked out of my summer lodging arrangement after the house manager found out about my ER assignment. His wife is also under treatment for cancer.

olhamada
05-06-2009, 15:23
If there is no shortage, people are acquiring a single course or so per family member or less, and supplies are presently adequate, how is it "hoarding"?

It would seem to me that additional purchases of widely available antibiotics would merely spur the pharm companies to make more.

TR

Last week, in the middle of the front page, the WSJ had a world map showing the percentage of Tamiflu/Relenza that was available in each country for its given population. According to their data, we've got enough to cover 16% of our population.

Something to think about.

From a Public Health perspective, hoarding should be strongly discouraged. But when I'm thinking about my family, well that's a different story.

This bug's evidently quite mild. However, the CDC is now starting to worry about this Fall's influenza. They think it will be quite a bit more virulent.

I agree with you TR, I bet supplies of Tamiflu and Relenze multiply between now and this fall. Problem is many of these viruses are resistant. Two months ago JAMA reported last year's flu showed a 70% resistance.

olhamada
05-06-2009, 15:41
I'll be in chemo for the next 4 days. See you all when I get back.
Blitzzz

Good luck Blitzzz. Saying a prayer for you. PM/email me with your room# if you get a minute.

Red Flag 1
05-06-2009, 17:06
Last week, in the middle of the front page, the WSJ had a world map showing the percentage of Tamiflu/Relenza that was available in each country for its given population. According to their data, we've got enough to cover 16% of our population.

Something to think about.

From a Public Health perspective, hoarding should be strongly discouraged. But when I'm thinking about my family, well that's a different story.

This bug's evidently quite mild. However, the CDC is now starting to worry about this Fall's influenza. They think it will be quite a bit more virulent.

I agree with you TR, I bet supplies of Tamiflu and Relenze multiply between now and this fall. Problem is many of these viruses are resistant. Two months ago JAMA reported last year's flu showed a 70% resistance.

Sufficent supply for family works for me, hoarding does not..IMHO. This could be quite a money maker for a few drug companies; maybe.

The current administration now has the lever and time it needs to elbow it's way into national health care. Ford tried it in 1976 in terms of flu shots only, not a very good outcome. There is potential here for this to become a solid political path to government run health care, a brick in the wall at least. I can see this administration dictating who makes what drug available for which patients.......I pray I am wrong! I am worried about the fall season.

My $.02.

Blitzz, I wish you the best with you're chemo! Prayers out!!!!

RF 1

temsmedic
05-06-2009, 20:24
A large number of the 1918 Pandemic fatalities died of bacterial pneumonia, after their lungs were damaged by influenza and the cytokine storm. It would be reasonable to consider the PPV23 [pneumococcal] vaccine as part of our pre-pandemic preparation.



http://ecdc.europa.eu/documents/pdf/PPV23_18_Jan.pdf

7. FUTURE PERSPECTIVES
Use of pneumococcal vaccines to reduce morbidity and mortality
from bacterial pneumonia in an influenza pandemic
Bacterial pneumonia is an important complication of seasonal and pandemic influenza and
during previous pandemics, secondary bacterial pneumonia has been an important cause of
morbidity and mortality. S. pneumoniae superinfection complicates many cases of influenza
and some bacterial pneumonia caused by S. pneumoniae can be prevented by immunisation47.
Issues related to the role of pneumococcal vaccines in pandemic influenza preparedness
activities may include: logistics of mass vaccination with PPV23 during a pandemic; vaccine
supply; shelf life; and need for cold storage. Nevertheless, increasing the current use of
pneumococcal vaccines among the age groups for which it is universally recommended (i.e.
persons aged under two years (PCV7) and those aged 65 and older (PPV23)) could reduce
the burden of pneumococcal disease and can also be expected to benefit persons susceptible
to influenza.

shr7
05-07-2009, 14:57
Mugwump -

I think we are in agreement over the statins. Those much smarter than me will say that they may help, and those much smarter than me that say they do not. I have been reading with interest the ongoing argument in Chest regarding this issue. I do believe that starting a statin would not be my first step if pandemic flu broke out, however, but I will keep my eye peeled for more data on this as time goes on.

I also completely agree with your "Prophylactic use of anti-virals by practicing medical professionals during an ongoing, virulent pandemic." Regardless of what the CDC says (and even they include certain health care professionals in their recommendations), I completely agree with you about it being a different situation than average Joe poppin' pills.

I also agree it probably won't matter soon. Articles from years ago all spoke how Tamiflu resistance was very uncommon and unlikely to be a problem, now look what we have, nearly 100% resistance in Type A influenza (up from 12% last year).

Also, I was under the impression doses for antivirals of all origins were the same. For Tamiflu, 75mg daily for prophylaxis and 75mg twice daily for treatment. Unless you are speaking about "double-doses" for treatment, I am not aware of any other reason to give one person twice daily for prophylaxis instead of two people once daily, doubling your coverage.

As for the probenecid, I agree that could be a way to extend our supply of Tamiflu. It was used successfully in the past as a way to extend penicillin supplies. Or course, not a benign drug, but worthwhile to look at. Studies are starting to come out looking at the kinetics of Tamiflu when used in combination with probenecid. One is linked below:

http://aac.asm.org/cgi/reprint/AAC.00047-08v1

I would say we do not know enough about the kinetics at this time to know an optimal dosing strategy for these medications when used in combination, so I would not feel comfortable if a pandemic were to hit tomorrow taking 1/2 doses of Tamiflu with probenecid, until I knew what regimen would be effective.

As for grapefruit juice or any other hepatic oxidase (CYP450) inhibitors, they would unlikely have any effect on Tamiflu (oseltamivir) concentrations. Tamiflu is a prodrug, oseltamivir phosphate, which is converted by hepatic esterases to its active metabolite, oseltamivir carboxylate, which is then excreted out through the kidney. It is not a CYP450 metabolite and would not react to any medications given that inhibit CYP450 enzymes. Probenecid works through inhibition of the renal excretion of oseltamivir carboxylate, so through a different mechanism.


TR -
You bring up a good point about increasing demand for these medications. I don't want to answer prematurely without getting all my facts correct, so I will get back to you with my personal thoughts on the subject.

SR

greenberetTFS
05-12-2009, 10:04
IRONY AT IT’S BEST.......

2,500 people get the Swine Flu and everybody wants to wear a mask.
Six million people have AIDS and no one wants to wear a condom....................:rolleyes:

GB TFS :munchin