Pandemic Flu

[Pete]

I think as mugwump had REed this before.

I realy hate to try and find stories in the on line edition of the Fayetteville Observer. Anyway on page 3A of the Tuesday October 31, 2006 edition is a Randolph E. Schmid story, The Associated Press, on "Resistant strain of bird flu found."

Reports on a new strain that sidesteps the current vaccines. Infecting people as well as poultry. The new variant has become the primary version in several provinces of China and has spread to Hing Kong, Laos, Malaysia and Thailand.

Dr Perdue, WHO, says the new variant doesn't indicate any increased risk to people "other than the fact it seems to be pretty widespread."

[mugwump]

Originally Posted by Pete

I think as mugwump had REed this before.

I realy hate to try and find stories in the on line edition of the Fayetteville Observer. Anyway on page 3A of the Tuesday October 31, 2006 edition is a Randolph E. Schmid story, The Associated Press, on "Resistant strain of bird flu found."

Reports on a new strain that sidesteps the current vaccines. Infecting people as well as poultry. The new variant has become the primary version in several provinces of China and has spread to Hing Kong, Laos, Malaysia and Thailand.

Dr Perdue, WHO, says the new variant doesn't indicate any increased risk to people "other than the fact it seems to be pretty widespread."

I don't know what to make of this report -- to me it's old news. This Fujian strain has been around for quite a while; it's the one that infected some people in Thailand late this summer. When the Thai gov't said at that time (correctly) that the source of the virus was Southern China, Beijing went ballistic and demanded a retraction, which they got.

All sorts of weirdness going on, with legitimate press sources drying up in Indonesia and the iron grip on the Chinese media being tightened. And now this, with official Chinese media publishing stories about the Fujian strain coming out of China and how the Chinese poultry vaccination program apparently applied the selective pressure which brought this strain to the fore. Weird, not China's style at all.

It doesn't really change anything, there's still a fairly significant risk of a breakout this winter (4:1 against a pandemic, which is still pretty scary in my book). It could be this strain, or one of the other 3 -- or none of them (I hope).

[mugwump]

I asked the Smart People about this "new strain" and here's the assessment:

I was wrong (well, only partially right) about Thailand and this "new" strain. The original Fujian strain infected the folks in Thailand this summer. This "new" strain the MSM have jumped all over is the original Fujian strain (which originated in Fujian Province in Southern China) that has mutated just enough so that the poultry vaccines which the Chinese developed against it are now useless. It's the same old story with flu viruses: they mutate all the time, which is why you have to get a new flu shot each year.

This means: 1) the Chinese have pissed away great wads of money vaccinating 2 billion fowl -- don't gloat, we want them to be successful 2) new waves of mass poultry die-offs and culls are likely 3) new pockets of poultry-human infections are possible 4) it's a bad omen for the human H5-based vaccines under development (like the one I worked on).

All that aside, this virus is no more dangerous than the original strain it evolved from, and it shows no more adaptations toward easy transmission among humans.

[mugwump]

I've gotten a couple of PMs asking for prescription drug recommendations in case of panflu. The two folks who asked have access to a sympathetic physician. [BTW - If you've been rebuffed by your doc in the past, it might not hurt to try again. I had to get a blood test for my Zocor renewal and something (probably independent research) has turned my doc around.]

I'M NOT A DOCTOR. If you get and use this stuff without careful consideration, you are fishing for a Darwin Award. FOR EXAMPLE, PROMETHAZINE CAN KILL YOUNG CHILDREN. You must get some instruction on how and when to use this stuff, and how to modify the dosage strength for children.

The best book I've found that pulls the influenza treatment information together is The Bird Flu Manual by Grattan Woodson, MD. The book details best practices for home care of a flu patient, including the use of both non-prescription and prescription meds. He also details how to calculate doses for children, make up suppositories for those who can't take meds by mouth, etc. I recommend it highly. You can find it here. Woodson is a good guy and is big on fluwikie.com. Get his free pamphlet on home care here. (It's also excellent, but limited by the removal of the prescription drug section). Get the book.

The following are for ONE PERSON. The number of pills is after the '#'. Ramp it up by however many people you are planning for. The stuff with the stars is the most critical.

Prescription items:

--**Tamiflu 75mg #20 (oseltamivir, a neuraminidase inhibitor): doesn't prevent or stop the flu, but limits viral release from cells and thereby slows the infection. The current H5N1 strains are showing some Tamiflu resistance already, but it's still worth getting and using (the resistance pattern could change at any point). Comes in packs of 10 x 75 mg, which is 10 days at the daily dose. The current protocol is to double that dose, so for each person you'll need 2 packs -- note that this dosage level is twice what the packaging says. This must be taken at the first sign of infection to work effectively.

--Promethazine 25 mg # 60 tablets (Phenergan) -- for nausea, vomiting, cramping

--Hydrocodone 5 mg #60 tablets: for pain and coughing -- you'll be splitting these as 2.5 mg doses -- you need a pill splitter

--diazepam 5mg #60: for anxiety, muscle aches, insomnia

--**azithromycin 250mg 20# (twice daily for 10 days) OR **moxifloxacin 400 mg x 10# tablets (400 mgs once daily for 10 days) for community-acquired bacterial pneumonia
AND
--**augmentin 500mg #20 tablets for community-acquired bacterial pneumonia

--**Zocor 40mg #20 tablets for prevention of ARDS (acute respiratory distress syndrome AKA "cytokine storm") Your doc probably hasn't heard of this unless s/he's following things very closely. Search on "ZOCOR" in this thread -- I cite some journal articles (Ben Gurion hosp and U of Chi, I believe). Get a pill splitter from the drugstore and split your 40 in half - take half in the morning and half in the evening. If you are taking care of a sick loved one, you should also start taking the Zocor on the same schedule.

Non-Prescription items: (no stars here, get it all)

--ibuprofen 200 mg #100 tablets

--diphenhydramine 25mg #100 (Benadryl)

--Robitussin DM 12oz or generic equiv.

--acetaminophen 500mg #100 tablets

Oral Rehydration Solution (ORS)

Most who pass as a consequence of flu die from: 1) primary effects (ARDS, cytokine storm); 2) dehydration; 3) post flu bacterial pneumonia. The antibiotics may help w/ the pneumonia. Much of your nursing efforts will center on keeping the patient hydrated. I assume everyone has had the experience of having the flu, staggering to the pot after a bout of the bone-shaking chills and peeing dark, dark yellow. Well, that level of non-care will kill you if you catch this flu. Keep your patient hydrated. This is the solution you should use:

Expedient Oral Rehydration Solution (based upon WHO formula, revised 2004)

This formula is based upon the readily available "Morton Lite Salt Mixture" found in blue 11 oz. containers. The container should say "Half the Sodium of Table Salt" and the first two ingredients should be salt and potassium chloride.

Morton Lite Salt 1 tsp.
Baking Soda 1/3 tsp.
Table Sugar 2 tablespoons
Potable Water 1 Liter (= 1 Qt. + 2 tablespoons)

Chill if possible. This tastes quite salty to someone who isn't dehydrated. You can mix it with sugar-free Kool-Aid or Crystal Lite or whatever as long as it is sugar-free. Add the minimum flavoring to make it palatable. Avoid products with sugar or the artificial sweetener Splenda (sucralose) which will change the osmolality of the solution and possible worsen diarrhea. If the patient will drink it plain so much the better.

Have small children start with 1 tsp. every 5 - 10 minutes, which is usually quite well tolerated. The amount can be increased every 30 - 60 minutes (2 tsp, 3 tsp, 2 tablespoons, etc. every 5 - 10 minutes).

Adults can go on the same increasing schedule but start with a tablespoon.

If the patient is moderately to severely dehydrated (skin "tenting" is present - when pinched skin does not return to the original flat shape; compare with your own skin) and unresponsive you can still use an eye dropper to introduce small amounts of solution into the mouth - I'm talking drop-by-drop over time, not pumping whole droppers full repeatedly into the mouth. Over several hours you can administer a significant amount of solution - tedious but potentially life-saving.

[x SF med]

Mug-
The only issue I have with the pharma list is in the OTCs - both Ibuprofen and Acetominophen? I thought it was contraindicated to take both within a 48 hr period due to the renal implications ( the compounding effect of the renal activators in both) - am I mistaken?

I have to admit that the Pt will be pretty 'comfortable' with the phenergan, valium and hydrocodone ...

[Cincinnatus]

Don't know if there is something specific to flu so that taking acetaminephine and ibuprofen is contraindicated, but in both my EMT course (SOLO) and a class by Dr. Keith Brown (RESQDOC) taking them together was encouraged as they have a synergistic effect. Naproxin sodium in the place of acetaminephine was also recommended. HTH.

[InTheBlack]

Some people get nauseous from codeine. What about Hydrocodone?

My pharmacist said I could indeed take both Acetaminophen and Ibuprofin at the same time, and that I should since they work on different pain pathways. Along with Darvocet, for a root canal.

It puzzles me that the "standard" narcotic pain pill is combined with Acetaminophen, since the acetaminophen does not reduce inflammation.

[mugwump]

Originally Posted by InTheBlack

It puzzles me that the "standard" narcotic pain pill is combined with Acetaminophen, since the acetaminophen does not reduce inflammation.

It's an abuse disincentive; the thinking is that you can't get high without blowing out your liver from a tylenol overdose. In reality, the solubility of acetaminophen and oxycodone are so different that all the junkies use "cold water separation" to get the codeine out while leaving the Tylenol behind.

[mugwump]

Originally Posted by x_sf_med

Mug-
The only issue I have with the pharma list is in the OTCs - both Ibuprofen and Acetominophen? I thought it was contraindicated to take both within a 48 hr period due to the renal implications ( the compounding effect of the renal activators in both) - am I mistaken?

That was the message when ibuprofen went OTC in the mid-80s -- they've changed the recommendations with further research. Now it's recommended to combine the two to lower temperature and relieve aches and pains:

* ibuprofen 2-4 tablets (400-800mg) every 4 hours
plus
* acetaminophen 2 tablets (500mg) every 6 hours

The combination increases the benefits but not risk of side effects.

I can't say enough how important it is for all of us untrained folk to get the book, or at least look into home care further. For instance record keeping during care is critical. You'll be tired, scared, and maybe sick yourself. With every pill on a different administration schedule you'll screw it up without records. Make sure you have a battery powered clock.

Originally Posted by x_sf_med

I have to admit that the Pt will be pretty 'comfortable' with the phenergan, valium and hydrocodone ...

Gratten is very conservative with the meds in the book, and has specific circumstances/trigger points when they should be administered or avoided.

[mugwump]

And BTW the list is mostly Grattan's. I amended the antibiotics (now that I do know something about), added the Zocor, and swapped in a better ORS formula (Grattan's has no potassium, this one is better).

[Cincinnatus]

FWIW, I've found that when I've taken oxycodone w/ acetaminephine it both takes effect more quickly and seems to be just a little more effective against pain than pure oxycodone.

I've found hydrocodone and codeine to be about equally effective against pain, but hydrocodone to feel "cleaner" (i.e., I feel less sluggish, don't get as constipated, don't have a hungover feeling when the effect wears off.) YMMV

My understanding of the logic in taking acetaminephine (or naproxin sodium [Aleve]) is that the former is primarily an antiimflammatory with some analgesic effect and the latter are analgesics with some antiimflammatory effects, hence the synergistic benefit.

Ooops, cross posted with mugwump.

[x SF med]

Mug-
With the recent (last 18 mos) findings on the more extensive renal implications of either high or extended dose acetominophen, esp. in cases of extreme fever and dehydration (already reduced renal function) - do you see the protocol changing? Ibuprofen does have renal implications, although less severe than acetominophen, without the puritic catalysation. With the multiple levels of nephrotic compromise (puritic, dehydration, and chemical) could this protocol be ammended to a single OTC - probably ibuprofen, for the anti inflamatory, antipuritic, and analgesic properties. Yes, I know that ibuprofen has a much lower efficacy as an antipuritic, but isn't that offset by the increased anti-inflamatory properties and slightly lower renal implications? I do tend to be a little more conservative in pharma therapy - start at a lower level and work up.

Would short term low dose steroid therapy be indicated (in addition to, or in place of the NSAIDs), if access to doctors was available - or would the initial (switch-over) natural immunodeficiencies in steroid contraindicate this approach?


Slap me if I'm going too far with this, or if my assumptions are way off base.

[mugwump]

x_sf_med --

Sheesh, you know more about this than I do. All I know is that the panflu protocols I've seen recommend the acetaminophen/ibuprofen therapy (US, New Zealand, UK, and Woodson et al.)

Your observations may be partly behind the urgent recommendations for keeping the patient well hydrated. That, plus the elevated fluid loss from high body temperature and the fact that this flu is causing serious inflammation, with associated "leaky" capillaries.

If H5N1 breaks out and the pattern seen in Indonesia is repeated, we'll see very high body temperatures (over 105 F) with the risk of brain damage. Following the 1918 pandemic there were 1 million people who came down with a disabling Parkinson’s-like disease labeled “encephalitis lethargica.” (This was the subject of the book and Robin Williams movie Awakenings.) There is broad speculation that this disease was caused by direct viral effects from the flu or the sustained high temperatures caused by the disease. Keeping temperature below 101F is judged to be very important.

High dose prednisolone (steroid) therapy is indeed being discussed. I don't know enough about it to make a recommendation. Statins are over-the-counter in the EU and will be here as well, fairly soon. Those I have no problem recommending. Steroids are a different kettle of fish. Search on "cytokine dysregulation" and "steroids" in Google -- you'll get a lot to chew on.

[The Reaper]

Every physician we have had, to include pediatricians have recommended that Acetominophen and Ibuprofen be taken concurrently for maximum effect.

If you read the referenced work, Dr. Woodson recommends that approach as well and explains the logic.

TR

[x SF med]

Thanks TR - Woodson reccomends in peds cases starting with acetominophen, then trying ibuprofen, then the combo; and seems to suggest the same for adults, saying both taken together are well tolerated.

It seems it's a six of one, half dozen of the other approach - as long as hydration is kept up - that's his biggest point throughout.