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August 29, 2007

'Ordinary' Influenza: A Public Health Failure

This post by ScienceBlogling revere about the horrendous human cost of influenza is getting some serious exposure.  This gives me an excuse to mention something I haven't in a long time:

Stop worrying about avian influenza.  Get serious about 'ordinary' influenza.

Why?  Last year, 'ordinary' influenza killed roughly 36,000 U.S. residents.  That's about equal to breast cancer which kills 40,000 annually.  Before the polio vaccine, the polio virus killed 3,000 people annually, and, even if you adjust for population increases, that number would be roughly 9,000 in today's terms. HIV/AIDS kills about 18,000 U.S. residents annually. That means, in the U.S., for every person who died from AIDS, two people died from influenza. With AIDS and breast cancer, people run, walk, jump, skip, and pogo stick for The Cure. Lots of bleeping ribbons. But influenza is a silent killer.

And most of those deaths could be prevented.

I've described elsewhere how a sane vaccination strategy could lower influenza deaths by eighty percent--that's over 28,000 lives.  And we don't need to piously invoke Hope for a Cure.  We just have to vaccinate more people--and the right ones.  It's that simple.

Could you even imagine the kind of pandimensional shitstorm that would ensue if we could reduce AIDS or breast cancer by eighty percent, and we didn't, simply because we couldn't get it together?

For a long time, I was willing to support the concern about avian influenza because I figured that the steps needed to prepare for avian influenza could be 'repurposed' for ordinary influenza. All of the things we'll need to stop a pandemic are the same things we can use every year to treat the annual influenza outbreak: the ability to rapidly produce hundreds of millions of doses of vaccine, a serious distribution system (actually, having a system would be helpful), and educating people about proper public hygiene.

None of that has happened. We don't produce enough vaccine to adequately vaccinate the U.S. population against the annual epidemic (we would need roughly 200 million doses), and that's a reflection of our 'surge' capability, so good luck if an avian pandemic happens.

But what's truly scandalous is our vaccination strategy--or lack thereof. Let's leave aside the fact that people actually have to pay money to receive a vaccine against a disease that kills 36,000 people annually.

Actually, rattle that last sentence around in your noggin.  For that not to be utterly insane, you have to have Ayn Rand's Atlas Shrugged shoved so far up your ass that it's sticking out of your mouth.

And the people who are vaccinated are the wrong people. Yes, elderly people should receive the influenza vaccine because it reduces their likelihood of death by about thirty percent. The focus on the elderly, however, ignores a basic, albeit Yogi Berra-esque, rule of viral transmission: the best way to avoid getting influenza is to not come in contact with people who have it. In other words, we have to vaccinate those who spread the disease: medical workers, nursing home patients and staff, and children aged 5-18. Studies indicate that vaccinating seventy percent of children aged 5-18 could reduce influenza deaths by up to eighty percent.  In other words, the grandchildren are killing their grandparents.

All that requires is enough vaccine and a system to get it to the people who need to take it (for children, it's called schools).  Since we can't even do this right, even though we know that we will have an ordinary influenza 'epidemic' every year, I don't think we stand a chance against a real pandemic. 

The reason we haven't implemented these simple steps, I think, is because we've been far too focused on avian influenza. Quite simply, people don't really care about avian influenza. They're too focused on trying to get by, not losing their jobs, and, to use El Jefe Maximo's phrase, "putting food on their family." Worrying about something that might happen isn't even on their radar screens in any serious sense*.

We need to stop focusing on a possible pandemic, and start focusing on the annual epidemic. Because right now, we're not prepared for either.

*Of course, if you ask people, they'll state they're worried, but not enough to do anything about it, which is what matters.

Crossposted at Mike the Mad Biologist


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Great point; great post. A much-needed wakeup call.

Sadly, the argument can be adapted to any number of other easy opportunities to prevent tragedies that are staring us right in the face. We panic over scary, exotic-seeming problems, but we aren't even bothering to pick the low-hanging fruit.

(One point: The flu/AIDS comparison is a bit strained. The current AIDS death rate of "only" about 18,000 per year in the US is due to the widespread availability of anti-retroviral therapy. Recorded deaths from AIDS in the US climbed steadily every year from 1981 - 1995, peaking at over 50,000 deaths in both 1994 and 1995. Highly-active anti-retrovirals were introduced in 1996 and the death rate immediately plummeted; it reached 19,000 in only 3 years, and has remained below that ever since. So we are currently in, if not a "best-case", at least a "pretty-good-case" equilibrium with AIDS - absent a true cure - but in more or less a worst-case situation with influenza, where we're doing almost nothing at all. Arguably, the intense focus on AIDS is the reason why it's less deadly than the flu; if we ignored AIDS to the same degree we do the flu - or, to the same degree the Reagan Administration did consistently - it would still be much more deadly. So the comparison between death rates from flu and AIDS may not be an illustration of misplaced priorities, but rather of the impact possible when appropriate attention is paid.)

There's one thing you are missing, Mike.

We care more about some deaths than others.

More controversially, we SHOULD care more about some deaths than others.

Most influenza deaths are in the "we don't, and shouldn't, care as much" population--in contrast to AIDS and polio.

In graphic terms, I have a friend who is dying of lung cancer. Catching the flu, and dying of that, would be merciful.

Great post, and I agree with everything you are saying about keeping a greater eye on what is happening rather then what may happen, but I also have a concern about the Avian Flu. I have been watching the studies on this for some time now, and I just posted today an artical about how they now belive that the Avian Flu has found a way to transfer from human to human.

While I agree that a greater part of our reasearch, resources and time should be spent on things that are currently happening I also feel it would be a very bad idea to just ignor the potential of things that could occure.

If we spent 60-70% of our time on what is happening now and 40-30% of our time prepareing for thisngs to come I would be happy.

In a pandemic, the caregivers on the front lines of treatment for the sickest people are themselves most vulnerable to contracting the nasty disease... and they are the ones who treat the sick.

When your nurse dies, you probably die too. You and a bunch of other people.

I work in a hospital, and every year, I get my flu shot through my employer. I also work in a private health setting, and every year, I am offered a flu shot there. It's starting to become a condition of employment. Doesn't that happen in the US? In our city, vaccinating the elderly and nursing home residents has made a large difference; for one thing, nursing homes are harder to get into, as the previous death spikes in the winter have ended.
Which population is larger? Children or elderly? Which population is most at risk? It may make sense to vaccinate the elderly first, if the cost per life saved is better. However, if the cost per life saved by vaccinating children is also reasonable, that may be a next priority.

I work in a hospital, and every year, I get my flu shot through my employer.

I don't work in a hospital, but each year I am offered (and have) a flu shot, on grounds that I'm a healthy young person but share a household with 'at-risk' people. If there could be more of that sort of thing as a matter of course in the workplace, or through some other everyday provider, it'd be no bad idea.

Flu virus may be a more complex problem than Mike may make out, but the underlying message is potent: if we can't handle ordinary viruses competently, what hope have we against the yet to be evolved out-of-the-ordinary ones (still less any bioterror attack)? It's a challenge for everyone involved in public health, from greatest to least, expert to civilian.

It works the same way in the war system. Weapons of Regular Destruction kill way more people than Weapons of Mass Destruction. WMD = Useful for scaring the sheeple. WRD = Land Mines, AK-47s, guided missles = Business as Usual.

Peace & Love,


Why is that when I was a child, vaccines lasted a lifetime? Why is it now that they are vaccinating everyone for everything annually, even pets? When we know darn well that the reason for a vaccine is for the immune system to build up anti-bodies and handle a cold or flu all on is own?
Why? I guess its all about money.

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