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How Contagious Is That Dinner Party? And How Best To Evade Friends’ Bugs?

(Faruk Ateş/Flickr)

(Faruk Ateş/Flickr)

“This is not a question for an expert on etiquette!” I expostulated. “It’s a question for an Infectious Disease specialist!”

The trigger for that objection: A query to Social Qs, the New York Times etiquette column on “awkward situations.” The writer describes a group of 10 close friends who meet regularly for dinner; one, who is immuno-suppressed, asks that another member who is getting over the flu and still on antibiotics keep 12 feet away and avoid touching anything she may eat. The reader asks: “Shouldn’t one of them have declined the invitation? But which?”

The columnist responds that no, no one needed to bow out, and that this distance-setting arrangement seems a good compromise, adding, “I hope the person with the flu called her doctor to make sure she was no longer contagious — for everyone’s sake.”

Surely you can understand my frustration. Fine, the flu patient could call her doctor, but what about the rest of us, hungry for more general knowledge on contagion for our own social gatherings? Why not answer the obvious questions? Like: Is 12 feet really far enough to avoid flu germs? Are you still contagious when you’re finishing a course of antibiotics?

Oddly, the day after I read that column, a similar situation played out at my house: One friend was getting over a respiratory infection, still coughing, and another friend regretfully said she could not stay and chat at the dining table, for fear of carrying a germ to an immuno-compromised loved one.

That did it. I called CommonHealth’s go-to guy on infectious disease questions of public interest, Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates, and shared my annoyance. Actually, he gently corrected me, this is an issue of both medical science and etiquette. Our conversation, lightly edited:

Dr. Kruskal: You need to have the facts and then you can figure out the etiquette in light of them.

First, when it come to infectious disease transmission, we know a fair amount, but there’s a lot that is still argued over. So let’s take flu as a good example. We know that there are multiple mechanisms by which flu is transmitted, or by which you could postulate reasonably that it might be transmitted:

Dr. Ben Kruskal (Courtesy)

Dr. Ben Kruskal (Courtesy)

• Physical contact: You’ve got germs on your hands, you touch somebody else’s hands or face. Or indirect contact — you touch your face, and then touch the doorknob. A few minutes later, someone else touches the doorknob and then their face.

And there are two different mechanisms of airborne transmission:

• Respiratory droplets, which fall to the ground pretty quickly after they leave your mouth and nose. People argue about the distance they can travel — some people say three feet, some say six feet. Six is a very conservative estimate.

• And then there’s what’s called true airborne transmission (technically, droplet nuclei), which is the mechanism by which TB, measles and chicken pox are all transmitted. And that’s the kind that can go much longer distances and can linger in the air for a long time afterward.

So which is flu?

Flu looks like it’s probably mostly droplets, with some contact, and then there’s a lot of debate in the medical literature about whether there’s some component of airborne transmission or not. If it’s there, it’s probably not huge — we’re arguing whether it’s .1 percent or 1 percent or 5 percent, but it’s probably not more than that.

What else should we know? Continue reading

5 Reasons You Should Worry Way More About Flu Than Ebola

(CDC)

(CDC)

By Veronica Thomas
Guest Contributor

A deadly virus is sweeping America, putting nearly 10,000 people in the hospital so far. No, it’s not Ebola. We’re talking about the common seasonal flu that shows up every fall and lingers on until spring.

Every year, 5 to 20 percent of Americans get the flu and, depending on the strain, anywhere from 4,000 to 49,000 people die from the virus or its complications, like pneumonia. And this season’s flu virus is shaping up to be pretty nasty — so nasty that the CDC declared a national flu epidemic at the end of December.

As a graduate student at the Harvard School of Public Health, I’m baffled by this: A couple months ago, I couldn’t step on a subway car or flip through Facebook without being bombarded by panicked comments about Ebola spreading to the U.S. But when it comes to the real and immediate threat of the flu: radio silence.

“Ebola is exotic. It has a very high mortality rate that people are very much aware of. It seems like you can be exposed to it without your control,” says Dr. Alfred DeMaria, medical director for the Bureau of Infectious Disease at the Massachusetts Department of Public Health. “All of those [factors] contribute to a higher perception of risk than the flu.”

In reality, far, far more people die from flu-related complications than from Ebola, but it’s a very small proportion of the millions who get sick each year. That’s one reason we should be more concerned about the flu than Ebola, Dr. DeMaria says. Here’s why else:

1) The flu is next door, not across the Atlantic.

Ebola has tragically claimed over 8,600 lives in West Africa, largely because many countries don’t have the capacity to contain the outbreak or treat infected patients. And though the news cycles have moved on, Ebola hasn’t. As the virus continues to spread, Ebola remains a real threat for some West African countries.

But for ordinary Americans: “The risk of getting Ebola is somewhere in the order of magnitude of getting personally hit by a meteorite,” Dr. DeMaria says. Just four people have been treated for Ebola in the U.S., and only one has died. No new cases have been reported since October. Continue reading

Quick, Take Tamiflu? Maybe Not A Slamdunk If You’re Young And Healthy

(Photo via Compfight.com)

(Photo via Compfight.com)

As I listened to CDC director Dr. Tom Frieden issue a ringing endorsement of the prescription antiviral drug Tamiflu last week, I was also hearing a confused “But…but….but…” in my own head.

The crux of my confusion: I had the decided impression that the data on Tamiflu as a flu-fighter were underwhelming. That it just isn’t all that effective. That doctors prescribe it because they have nothing better, but without a lot of hope that it will do a lot of good.

Among the factors that formed that impression:

• A MedPage Today post last month headlined “Why Is Tamiflu Still Around?” with the subhead, “Tamiflu doesn’t help, so why are docs still prescribing it?”

• The data-driven doctors who run the Slow Medicine series had written last week that they accepted the updated CDC guidelines recommending quick antiviral therapy for high-risk patients. But….

“…as for patients who were previously healthy with less severe disease, we are more skeptical. The CDC recommends consideration of antivirals among such patients if the medications can be started within 48 hours of symptom onset. However, we suspect the side effects of antiviral medications are greater than the pharmaceutical companies have let on (identification of adverse effects for short term medications is particularly difficult). In most cases, good supportive care with close follow up will be more helpful than a marginally effective medication with uncertain side effects with attendant risks of future resistance.”

• And Dr. Ben Kruskal, chief of infectious diseases at Harvard Vanguard Medical Associates, had recently responded to my email query about Tamiflu with this:

“My enthusiasm about antivirals for flu is mixed. They’re the best tool we have, but the evidence for the most hoped-for benefits is scanty indeed.”

Bottom line? Dr. Frieden’s bottom line was simply that antivirals are under-used and if a member of his family got the flu, he’d want them treated with Tamiflu. But the chief of the CDC has to think at the level of a whole population; what about those of us who think at the level of an individual?

You may prefer a more nuanced take from the likes of the Slow Medicine analysts and Dr. Kruskal, to wit:

Maybe the real Tamiflu bottom line here is that there’s no simple bottom line.

Yes, if the patient is elderly or a baby or severely ill or otherwise at high risk of flu complications for any number of underlying health conditions — asthma, diabetes, cancer — quick prescription of antivirals (Tamiflu, Relenza and a new intravenous form, peramavir) makes sense. The potential dangers of flu complications in such high-risk patients are especially scary, so the potential benefits from the antivirals loom larger.

But if the patient is otherwise healthy, Dr. Kruskal says, while it’s a reasonable decision to take Tamiflu, “I wouldn’t call it entirely a slam-dunk.” Continue reading

In Tough Flu Year, CDC Touts Prompt Tamiflu Prescriptions

(Photo via Compfight.com)

(Photo via Compfight.com)

Note: We’ve also posted a follow-up to this news story: Quick, Take Tamiflu? Maybe Not A Slamdunk If You’re Young and Healthy.

Flu seasons are never good, but this year’s is shaping up as a notably nasty one. It’s dominated by a strain of virus — known as H3N2 — that tends to cause more severe symptoms and is a poor match for this year’s vaccine. And we’re still right in the middle of it.

So today, CDC director Dr. Tom Frieden issued this new, Tamiflu-touting message to reporters and the public: “Anti-viral flu medications are greatly under-utilized. But if you get the flu, and if you get medicines early, they could keep you out of the hospital; they could keep you from having to go into the intensive care unit; and they might even save your life.”

If I or one of the members of my family got flu or a flu-like illness, I would get them or me treated with Tamiflu as quickly as possible.

– CDC director Dr. Tom Frieden

That message is especially important, he says, for people at high risk for complications of flu, including elders over 65, pregnant women, very young children and people with underlying health issues such as asthma or diabetes. The anti-virals work best if taken within the first 48 hours of flu onset.

In case you’re now feeling an urge to run out and stock up on Tamiflu, well, first of all, you can’t. Tamiflu and its ilk are available only by prescription.

And second, you shouldn’t. It would make you a bad citizen. Frieden reports that though manufacturers have a big enough supply overall, there are spot shortages of Tamiflu around the country, and it may already take some calling around to find a pharmacy with a supply. Stockpiling could deprive patients who need the drug more than you do.

Dr. Alfred DeMaria, medical director for the Bureau of Infectious Disease at the Massachusetts Department of Public Health, says a local pediatrician recently told him about prescribing an antiviral drug for a Cystic Fibrosis patient at high risk for flu complications. The family had to go to several pharmacies before they could fill the prescription.

“Why was that? The pharmacies have just-in-time inventory for expected sales,” Dr. DeMaria says, “and if those expected sales go up because people say, ‘Oh, it’s going to be a bad flu season; they’re recommending Tamiflu; I’m going to get some and keep it just in case,'” then supplies run short.

The new CDC recommendations encouraging health care staffers to write more antiviral prescriptions may surprise those familiar with less-than-exciting reports on how effective the drugs can be. In general, if taken early, they appear to cut the flu’s duration by 20 percent, from an average of five days to four. Continue reading

Why You Really Need A Flu Shot (Even Though The Vaccine Isn’t Great)

(WFIU Public Radio/Flickr)

(WFIU Public Radio/Flickr)

By Richard Knox

This flu season is shaping up to be a bad one. And this year’s vaccine doesn’t work very well against the most common flu virus going around. So should you even bother getting a flu shot?

Yes. Putting it a different way: My wife, my daughters and I will. And the evidence says you’d be somewhere between slightly foolish and dangerously blasé if you don’t — depending on your personal risk factors.

I know there are naysayers — the Internet is full of them. “I recommend that my patients of all ages not take these incessantly promoted immunizations, primarily because of their lack of effectiveness,” writes blogger Dr. John McDougall. He says he’s not one of those across-the-board vaccine deniers but just doesn’t think flu vaccines (of any given year) are worth taking.

To understand why I think he’s wrong — even this year, when vaccine effectiveness is expected to be even lower than usual — you need to know something about the situation we’re all in.

Several viruses circulate during any given flu season. And flu viruses are always changing — sometimes not so much from year to year; sometimes in a bunch of little ways (a phenomenon called genetic “drift”); and sometimes in a big, sudden way, called a “shift,” which touches off pandemics.

Drifts Or Shifts?

Public health researchers constantly monitor flu virus mutations. But even the smartest flu dudes can’t know in advance when they’ll happen, or whether mutations will be drifts or shifts.

This year, one of the flu viruses outwitted them. Or, since viruses can’t have intentions, it’s better to say that random genetic drift in that viral strain, called H3N2, happened in late March. That’s a bad time in the annual cycle of vaccine production.

Just a few weeks earlier, leading flu specialists gathered at the World Health Organization in Geneva and decided that this season’s vaccine (for the Northern Hemisphere) should contain the same viruses as last year’s — two type-A viruses (an H1N1 that caused the pandemic of 2009 and has stuck around since, and an H3N2 that first appeared in Texas two years ago) and two type-B flu viruses.

Late-Breaking Mutant

Making each year’s flu vaccine is a complicated business that waits on no virus. The recipe has to be decided in February to get the chosen viruses growing in hundreds of millions of special chicken eggs, the first step in vaccine production. Continue reading

Mass. Reports First Case Of Cold Virus, E68

Massachusetts has its first confirmed case of a cold virus that has sent hundreds of children to hospitals across the the country.

The case of an 8-year-old girl who was treated at Boston Children’s Hospital and released means Enterovirus 68 is here and spreading, says state epidemiologist Al DeMaria. It is not typically as dangerous as the flu, he says, except in children with asthma.

“Compared to influenza virus, this virus does not cause a lot of serious complications,” DeMaria said. “In fact, the vast majority of children who have asthma attacks get better.”

DeMaria urges children with asthma to take their management medications. He asks everyone to wash their hands often.

– Here’s the full press release from the state Health Department:

The Massachusetts Department of Public Health (DPH) today announced a confirmed case of Enterovirus D68. The patient is a school aged child with a history of asthma who became ill in early September and has since been treated and released from an area hospital. Due to privacy considerations, DPH will not be releasing additional patient information.

“With enterovirus D68 now widespread across the country, this news comes as no surprise,” said DPH Commissioner Cheryl Bartlett, RN. “We have been working closely with pediatric providers and area hospitals to ensure the proper testing was done to identify the virus. For most children, this virus is relatively mild – but for children with asthma or other respiratory illnesses, it can be serious. Parents should contact their pediatrician if their child is experiencing respiratory issues.”DPH State Epidemiologist Dr. Alfred DeMaria underscored the importance of simple, common-sense steps such as hand-washing to reduce the spread of illness. “As with any other respiratory virus, hand washing is the key to reduce spread, use soap and warm water for 20 seconds” said Dr. DeMaria.

Other tips for parents and patients include:
Avoid touching eyes, nose and mouth with unwashed hands
Avoid kissing, hugging, and sharing cups or eating utensils with people who are sick
Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone in the home is sick

Continue reading

Big Data Hubris? Where Google Flu Trends Went Wrong

flu graph

(Keith Winstein, MIT)

Last January, MIT computer science graduate student (and former Wall Street Journal reporter) Keith Winstein reported on the dramatic divergence between Google’s flu data and the official CDC flu numbers: Is Google Flu Trends Prescient Or Wrong?

“This could be a cautionary tale about the perils of relying on these ‘Big Data’ predictive models in situations where accuracy is important,” Winstein said in an interview with CommonHealth.

Bingo. A paper by Northeastern University researchers and others, just out in the journal Science, looks at where Google Flu Trends went wrong — and presents the errors as exactly that sort of cautionary tale. And one of the morals of the “The Parable of Google Flu: Traps in Big Data Analysis” is that Google needs to share its workings better with other research outfits. From news@Northeastern:

By incor­po­rating lagged data from the Cen­ters for Dis­ease Con­trol and Pre­ven­tion as well as making a few simple sta­tis­tical tweaks to the model, Lazer said, the GFT [Google Flu Trends] engi­neers could have sig­nif­i­cantly improved their results. But in a com­panion report also released Thursday on the Social Sci­ence Research Network—an online repos­i­tory of schol­arly research and related materials—Lazer and his col­leagues show that an updated ver­sion of GFT, which came about in response to a 2013 Nature article revealing GFT’s lim­i­ta­tions, does little better than its predecessor.

While Big Data cer­tainly holds great promise for research, Lazer said, it will only be suc­cessful if the methods and data are made—at least partially—accessible to the com­mu­nity. But that so far has not been the case with Google.

“Google wants to con­tribute to sci­ence but at the same time does not follow sci­en­tific praxis and the prin­ci­ples of repro­ducibility and data avail­ability that are cru­cial for progress,” Vespig­nani said. “In other words they want to con­tribute to sci­ence with a black box, which we cannot fully scru­ti­nize and understand.”

If sci­en­tists are to “stand on the shoul­ders of giants,” as the old adage requires for moving knowl­edge for­ward, they will need some help from the giants, Lazer said. Oth­er­wise fail­ures like that with Google Flu Trends will be ram­pant, with the poten­tial to tar­nish our under­standing of any­thing from stock market trends to the spread of disease. – See more at: http://www.northeastern.edu/news/2014/03/does-big-data-have-the-flu/#sthash.XqZV5IJD.dpuf

Read the full Northeastern story here.

Flu Or Just Crud? Latest Wrinkle In Flu Tracking: Home Tests

The rapid home flu test distributed by GoViral (Courtesy GoViral)"

The rapid home flu test distributed by GoViral (Courtesy GoViral)

You’re aching, you’re shivering, you’re coughing. You’re definitely, miserably sick, but is this real, potentially serious flu or just some garden-variety winter crud?

Better find out. You pull your handy-dandy virus test kit from the shelf, insert the nasal swab gently into your nostril and twist it around three times to coat it with your (copious) mucus. You swish the swab in liquid and deposit drops of your germy mix on the four wells of the instant test. Ten minutes later — voila. Sure enough, you test positive for an influenza type A. You call your doctor to ask about anti-viral meds, and — as a good citizen of your disease-tracking community — you go online to report your diagnosis to Flu Near You. On its map, you see that you’re not alone: a dozen of your neighbors have the same bug.

Futuristic? Not if you live in the Boston area and are part of a new flu-tracking experiment funded by the National Science Foundation, called GoViral. Run by researchers at Boston Children’s Hospital, the three-year project is just getting under way now, as this year’s flu season takes on steam.

Flu is more than a nuisance. It’s a serious threat — infecting tens of millions of Americans a year and killing an average of 24,000 — and public health types try hard to track and understand it. The CDC monitors reports from doctors’ offices, including lab test results. Google Flu Trends watches online searches for telltale symptoms. Flu Near You, where GoViral is based, already brings together thousands of volunteer sentinels who report online when they have symptoms. Now, GoViral will take testing into the home, where many flu patients hole up rather than seeing the doctor.

“It’s never been done before, to give a lot of people in their homes these tests,” said Dr. Rumi Chunara, GoViral’s lead researcher. “This is the first time that we’re actually crowdsourcing diagnostic samples from people.”

The project breaks new ground in flu tracking, said Dr. Lyn Finelli, who leads flu surveillance and response at the National Center for Immunization and Respiratory Diseases at the CDC: “This is the first time that I know of that anybody has used what we call participatory surveillance,” she said, “where people indicate whether they’re well or ill, and participate in home testing and send the tests in. This is a very novel look at a surveillance system and home testing.”

Dr. Chunara plans to distribute several hundred free flu test kits to Boston-area members of the public who sign up (here) this winter, and expand to encompass more areas next year. The kits include the rapid test, which can only check for four common viruses but gives an instant answer, and also a saliva test that must be sent in to a laboratory and can reliably detect 20 common viruses (though you may be better by the time you get the result.) Continue reading

CDC Hit By Shutdown But Others Track Flu

Screen shot 2013-10-04 at 10.35.42 AM

Not exactly reassuring, that tweet above from Dr. Tom Frieden, director of the Centers for Disease Control and Prevention. “Frightening!” tweeted ABC News chief medical editor Richard Besser in response.

NPR reports that the government shutdown has left only about 4,000 of 13,000 CDC staffers at work. Though a skeleton emergency operation center remains active and can be ramped up if there’s a major disease outbreak, the agency will not be monitoring flu activity across the country as it usually does.

That’s the bad news, and flu is no mere nuisance: it hits tens of millions of Americans a year, killing an average of 24,000. And it’s harder to be prepared if you don’t have up-to-date intelligence on the virus and its many strains.

Now the good news: It’s not flu season yet — it tends to peak in mid-winter. Flu vaccines are already available, and in more flavors than ever. And though CDC flu-tracking is considered the gold standard, there are other trackers at work:

• Athenahealth, Inc., a medical software company, has just announced that it will step in to track the flu by using its ability to monitor data on about 300,000 patients visiting primary care doctors around the country each week. It will issue weekly reports on flu patterns to help us watch for spikes.

In a blog post, Athenahealth core analytics director Iyue Sung writes that “Fortunately, we currently see no evidence of an early influenza outbreak.” But adds that “recent history shows that the flu can begin spreading at any time, and once it does begin, it spreads very quickly.” To follow the Athenahealth flu reports, keep an eye on this Athenahealth blog here.

(Keith Winstein, MIT)

(Keith Winstein, MIT)

Google Flu Trends took some flak last year (including here on CommonHealth) for erring on the high side and contributing to some January hype about the “possibly worst flu season ever.” But it is committed to refining its methods and though it may be prone to overestimates, its technique of aggregating search results about flu symptoms is surely still useful in a canary-in-the-coal-mine way.

• Flu Near You is a crowdsourcing effort run by our HealthMap friends at Boston Children’s Hospital in partnership with the American Public Health Association and the Skoll Global Threats Fund. You can contribute your own reports; browse its map to see how your region is looking, flu-wise; and you can also use it to see where vaccines are available near you. Continue reading

New Push To Mandate Flu Vaccine For Health Workers — But Some Push Back

As Massachusetts prepares for flu season, there’s a growing push to make flu vaccinations mandatory for health care workers, WBUR’s Martha Bebinger reports:

Numbers released by the state Department of Public Health show that 84% of hospital staff were vaccinated last year. But there is a range, with some hospitals at 47% and others at 99%. The consumer advocacy group Health Care for All’s director, Amy Whitcomb Slemmer, says various vaccination options should address most people’s objections.

vaccinearm“We’re trying to make sure folks are healthy,” Whitcomb Slemmer said. “We want hospital workers to continue to do their job. The time has come to require hospital employees and health care personnel to be vaccinated against the flu.”

The Massachusetts Hospital Association has filed legislation that would mandate flu vaccination for hospitals workers. But some health care workers — like the nurses union — object to forced preventive care. Continue reading