Swine flu seems to be trailing off -- for now, at least

The current wave of pandemic H1N1 influenza infections is trailing off a little, the Centers for Disease Control and Prevention said this morning, and other indicators seem to confirm that diagnosis. In particular, the numbers of prescriptions written for antiviral agents are declining, and so are diagnostic tests for the virus.

According to the CDC, swine flu activity is widespread in 43 states now, down from 46 last week, but health officials fear a resurgence as people travel around the country for the holidays, carrying their germs with them.

During the week ending Nov. 6, prescriptions for the four antiviral drugs used in combating swine flu fell by nearly 15% to 472,415, the lowest number in several weeks, according to Wolters Kluwer Pharma Solutions of Bridgewater, N.J. The company provides data about prescriptions for the drug to the Food and Drug Administration and independently prepared an analysis for The Times, using a tool called Pharmaceutical Audit Suite.

During the same week in California, however, prescriptions for the four drugs -- more than 90% of them for Tamiflu -- climbed 17.4% to 17,672. The California Department of Public Health reported Thursday that hospitalizations and deaths in the state were declining, but that information is from a week later than the drug data.

During the first week of November, prescriptions for the antiviral drugs rose nearly 26% to 7,394 in the Los Angeles/Long Beach/Santa Ana area; rose 26.5% to 1,436 in the Riverside/San Bernardino/Ontario area; and rose 33.5% to 2,635 in the San Diego/Carlsbad/San Marcos area. Most other areas of the state showed similar increases.

Quest Diagnostics of Madison, N.J., which manufactures a genetic test for swine flu and also uses the test in its commercial testing laboratories, said demand for the test has fallen since Oct. 27 after several weeks of strong demand. In specimens it tested in its own facilities up to Nov. 10, the number that tested positive for swine flu virus has been dropping in all age groups except for people over 65. The decline suggests that many of the patients seeking tests had other respiratory infections. In the over-65 group, the percentage of positive tests has tripled since late August and is now at 14%, the company said. The proportion of positive tests for swine flu has dropped across the country except for the Northeast, where it has doubled in the two weeks ending Nov. 10.

In other swine flu news:

-- Health authorities around the world have been on the lookout for cases of Tamiflu-resistant swine flu virus, fearing that a wide spread of resistant strains would make treating infections much more difficult. So far, about 50 cases have been identified, including two clusters observed this week -- a group of four cases in North Carolina and a group of five in Wales. All four of the North Carolina patients were hospitalized and were very ill with underlying severely compromised immune systems and multiple other complex medical conditions, according to researchers from the Duke University Medical Center. Three of the four died. No details have been released about how the patients caught the resistant virus or whether there was any contact among them.

Five patients at University Hospital of Wales in Cardiff were identified with Tamiflu-resistant swine flu infections, and three of them appear to have caught it in the hospital. The only previous case in which transmission of a resistant virus is thought to have occurred involved two youths at a North Carolina camp this summer. In other patients, the virus developed resistance while they were being treated and they did not pass it on to anyone. Two of the five patients have recovered, one is in critical care, and two are receiving normal care.

-- A batch of about 170,000 doses of swine flu vaccine manufactured by GlaxoSmithKline has been recalled in Canada after health officials noticed an unusually high number of allergic reactions to the vaccine. Most of the cases involved immediate anaphylactic reactions to the vaccine, and recipients were treated on site by medical personnel at the immunization clinics. No lasting effects of the allergic reaction have been observed. Glaxo said it is investigating the batch to see if there is anything unusual about it.

-- Thomas H. Maugh II

Swine flu declined slightly last week, but watch out for Thanksgiving, CDC says

Pandemic H1N1 influenza activity declined slightly last week, with only 43 states reporting widespread activity, compared with 46 states the week before, officials at the Centers for Disease Control and Prevention said this morning.

Even though levels have declined, however, they are still "higher than peak activity in many years," said Dr. Anne Schuchat, director of  the CDC's National Center for Immunization and Respiratory Diseases.

Officials fear, moreover, that flu activity will pick up as people travel around the country for Thanksgiving and Christmas. Unfortunately, she said, there are little data from seasonal flu on which to base predictions because such data are usually not prevalent so early in the year. Respiratory disease in general, however, does tend to increase early in the year after travel for the Christmas holidays. "We don't really know what is going to happen," she said.

There were an additional 21 laboratory-confirmed pediatric deaths last week, bringing the total for the year to 171 -- compared with 40 to 50 in a normal flu season. Fifteen of the deaths were confirmed to be caused by swine flu and the other six were confirmed to be caused by influenza A and are assumed to be swine flu. Overall, about two-thirds of the children who have died suffered from underlying conditions, such as asthma, cerebral palsy and muscular dystrophy.

As for the swine flu vaccine, "we are not where we want to be, but it is quickly being ordered and shipped," Schuchat said. As of this morning, 54.1 million doses have become available, 11 million more than were available last Friday, she said. About half of the doses shipped so far have been given to children, she said, and "the vast majority have gone to people who self-identified as being in a priority group." She said CDC will report data next week about potentially adverse events, "but so far we haven't seen any signals of unusual occurrences with swine flu vaccine or seasonal vaccine that would prompt us to feel urgent interventions are needed."

Schuchat also said that the agency is closely monitoring reports of an unusual strain of the swine flu virus that has been observed in some patients in Norway. The unusual strain has been seen sporadically in locations around the world, including the United States, she said, but so far there is no evidence that the mutation involved will make the virus more lethal or increase its resistance to the antiviral drug Tamiflu.

-- Thomas H. Maugh II

Deaths following swine flu immunization not linked to vaccine, the WHO says

There have been about 40 deaths worldwide among people who have recently been vaccinated against pandemic H1N1 influenza, but there is no evidence the deaths are related to the vaccine, officials from the World Health Organization said today. At least 65 million people have been vaccinated, and it is inevitable that there will be some deaths among such a large group, said Dr. Marie-Paule Kieny, director for the Initiative for Vaccine Research at the WHO. Although some investigations are still ongoing, she said at a news conference in Geneva, "results of the completed investigations reported to WHO have ruled out that the pandemic vaccine is the cause of death."

She said fewer than a dozen suspected cases of Guillain-Barre Syndrome have been reported following vaccination. "Only a few of these Guillain-Barre cases may be linked to the pandemic vaccine," she said. "Illness has been transient and patients have recovered." Guillain-Barre has been a particular concern because many cases occurred during the 1976 swine flu vaccination campaign, although none were definitively linked to the vaccine. That has led to the belief in some quarters that the vaccine is worse than the illness.

Kieny said that at least 80 million doses of the vaccine have been distributed to 16 countries, and at least 65 million have been administered so far. Those figures may be conservative, however, "because immunization campaigns are underway now in 40 countries. Overall, she said, the WHO has received reports of one adverse event for every 10,000 doses of vaccine. Among those reports, five out of 100 have been for serious events, for an overall rate of five serious events for every 1 million vaccinations. Many of those events were allergic reactions among people with unsuspected allergies to eggs.

-- Thomas H. Maugh II

Swine flu cases drop on college campuses for first time

For the first time this academic year, college campuses have reported a significant drop in cases of influenza-like illness, generally assumed to be pandemic H1N1 influenza, according to the American College Health Assn. Unfortunately, the association also recorded the first two deaths from the pandemic among college students at participating campuses.

There were 6,373 cases of illness reported on the campuses enrolling more than 3 million students in the week ending Nov. 13, a 27% drop from the week before, and 12 hospitalizations. Only 95% of the campuses reported cases, down from 98% the prior week. All but five states reported significant declines in disease activity during the week. The five states and regions with increases were New Jersey, Louisiana, Missouri, Idaho and the District of Columbia. South Dakota and Utah reported a 100% drop, with no new cases during the week.

Only limited data have been collected yet about the availability of the swine flu vaccine on campuses, but the figures show that only about 3% of students have been vaccinated to date.

In other swine flu news:

-- Canada has reported a spike in swine flu-related deaths, with more people dying of the virus during the week ending Nov. 17 than in any other week this year. Thirty-seven people died during the week, bringing the total number of laboratory-confirmed deaths in the country to 198, out of a population of 34 million. About 10% of the population has so far received the swine flu vaccine, according to health authorities.

-- The California Department of Public Health said today that 5.19 million doses of swine flu vaccine had been distributed within the state, enough for about 13.4% of the population. All counties have received at least some doses. A chart at the agency's website compares the doses filled to population.

— Thomas H. Maugh II

Prescriptions for Tamiflu and other swine flu antivirals up 6%

U.S. prescriptions for Tamiflu, Relenza and two other antiviral drugs used in the fight against pandemic H1N1 influenza totaled 587,960 in the week ending Oct. 30, a 5.9% increase from the week before, according to Wolters Kluwer Pharma Solutions of Bridgewater, N.J. The number of prescriptions for the drugs filled in California during the week rose 2.2% to 15,048, according to the company. Nearly 98% of the prescriptions were for Tamiflu.

Wolters Kluwer provides information on prescriptions for the antivirals to the Food and Drug Administration to help that agency track progress of the flu. The company independently generated data about the prescriptions for The Times using a tool called Pharmaceutical Audit Suite.

There were 5,880 prescriptions filled in Los Angeles/Long Beach/Santa Ana during the week, an 8.5% increase from the week before; 1,873 filled in San Diego/Carlsbad/San Marcos, a 28.5% increase; and 1,135 in Riverside/San Bernardino/Ontario, a 2% decline. The rest of the state had much smaller numbers of prescriptions filled, and declines were common.

In other swine flu news:

-- Asia will get its own stockpile of 500,000 courses of Tamiflu and Relenza by next April to help with shortages, a Japanese donor agency said today. The Japan Trust Fund will underwrite the $18-million stockpile, which will be held in Singapore and funneled to other countries as needed. That stockpile seems likely to be too late for the current flu season, however.

-- Researchers at Ohio State University have put together another way to monitor how swine flu has been moving around the world. It can be seen here. The map uses genetic data from the swine flu virus to track how infections have moved from country to country.

-- The debate continues over whether exposure to previous seasonal flu viruses or vaccination against them provides some protection against swine flu. Two papers last week reached diametrically opposite conclusions. A new report Monday from the La Jolla Institute for Allergy and Immunology comes down on the side of protection, although the amount of protection is not clear. In a study that was based in part on theory and in part on laboratory work, vaccine expert Alessandro Sette and his colleagues looked at the markers on the surface of seasonal flu viruses for the best 20 years and compared them to swine flu. They reported in the Proceedings of the National Academy of Sciences that there are enough similarities that T cells produced by the body against those markers should also recognize swine flu markers. Recognition of the swine flu virus by T cells would not prevent an infection, but it "may make the infection less severe," said co-author Bjoern Peters.

"This may explain why the pandemic has not been as severe as expected," said Alison Deckhut-Augustine of the National Institute of Allergy and Infectious Diseases, which funded the research.

-- Thomas H. Maugh II

Swine flu continues slow climb on college campuses

Influenza-like illnesses on college campuses, generally assumed to be primarily pandemic H1N1 influenza, grew slightly during the week ending Nov. 6, with 8,951 new cases reported -- an increase of 1% from the previous week. There were 15 hospitalizations on the 295 colleges and universities reporting to the American College Health Assn. and still  no deaths. Ninety-eight percent of the campuses reported activity, compared to 97% the week before.

In other swine flu news:

-- The World Health Organization on Thursday changed its guidelines for administering antiviral drugs such as Tamiflu, urging that the drug be given to severely ill patients even before the presence of the swine flu virus is confirmed. "Seeking early medical attention can save lives," said Dr. Nikki Shindo of the WHO's global influenza program. "The window of opportunity is very narrow to reverse the progression of the disease. The medicine needs to be administered before the virus destroys the lungs." She said the guidelines, which are similar to those in place in the United States, had not been adopted earlier because agency officials were not yet confident about the safety of the drugs and they feared shortages.

Shindo said the agency is sending emergency supplies of Tamiflu to six countries in eastern Europe where the outbreak is becoming severe: Afghanistan, Mongolia, Belarus, Ukraine, Azerbaijan and Kyrgyzstan. The agency is also sending ventilators to Ukraine, where there have been more than 100 deaths in the last month. The WHO says more than 6,000 deaths linked to swine flu have occurred worldwide, but that figure includes only about 1,000 deaths in the United States. On Thursday, the Centers for Disease Control and Prevention said that its best estimate is that about 3,900 swine flu deaths have occurred in the United States, which would bring the world total to more than 9,000 deaths. Even that is most likely an underestimate, experts said.

-- In the United States, for the week ending Oct. 23, the most recent for which data is available, 587,960 prescriptions for Tamiflu and other antiviral drugs were filled in the United States, according to Wolters Kluwer Pharma Solutions of Bridgewater, N.J., which also tracks prescription data for the Food and Drug Administration. That total includes 14,673 prescriptions filled in California.

-- Apparently garlic is good for more than Italian cooking and fending off vampires. Many people believe it can also fend off swine flu. Sales of garlic in Serbia have surged and prices have risen sharply as residents have sought out the pungent cloves to protect themselves from the current outbreak there. Serbia has so far had 270 laboratory-confirmed cases of swine flu and eight deaths, up from 130 cases and two deaths at the beginning of the month. Health authorities there have been taking a more rational approach, however, today ordering  3 million doses of swine flu vaccine from Novartis.

-- An Italian inventor has attacked swine flu in his own way, creating an automatic holy water dispenser similar to the automated water faucets in public bathrooms. Some Catholic churches in Italy had suspended the use of holy water fonts, where parishioners dipped their hands in water and crossed themselves for a blessing, because of fears of spreading the swine flu virus. Luciano Marabese devised a terra cotta urn that allows churchgoers to wave their hand under it to trigger the release of a small amount of the water. He said he has received orders from all over the world.

-- Thomas H. Maugh II

4,000 have died from swine flu, CDC will say

Researchers at the centers for Disease Control and Prevention are recalculating the number of people who have died from pandemic H1N1 influenza and its complications and are expected to announce next week that the total is more than 4,000, not the 1,200 figure that is currently used, according to the New York Times.

The new estimate, which actually will be a range of deaths, will be calculated to reflect the number of deaths that are actually triggered by swine flu, even though the ultimate cause of death may be bacterial pneumonia, other infections or organ failure. The calculation method is the same that is used to produce the 35,000 figure that is associated with deaths in a typical flu season, and the recalculation is meant to give a more direct comparability to that number.

The new figure does not mean that swine flu is more severe than researchers previously thought -- simply that they are producing a more realistic total for the number of deaths caused by it.

-- Thomas H. Maugh II

FDA commissioner reassures doctors about swine flu vaccine safety

Dr. Margaret A. Hamburg, commissioner of the Food and Drug Administration, sent a letter to all U.S. physicians today thanking them for their help in combating the pandemic H1N1 influenza virus and reassuring them about the safety of the vaccine against the virus. The letter reiterates what public health officials have been saying for months -- that the vaccine is made exactly the same way as the seasonal flu vaccine and that there is absolutely no reason to believe that it is any less safe. The seasonal flu vaccine has been given to hundreds of millions of people with no significant adverse effects. Hamburg said 41 million doses of the swine flu vaccine are available as of today.

The letter also said that federal agencies are making extraordinary efforts to monitor the vaccination program for potential adverse events and asked doctors to report any events they think might be linked to the vaccine to the Vaccine Adverse Event Reporting System. She concludes, "The benefits of preventing serious consequences from infection with the 2009 H1N1 influenza virus far outweigh the risks associated with vaccination."

In other swine flu news:

--The swine flu pandemic is affecting U.S. blood supplies, according to the Wall Street Journal.  Because the flu is widespread, the number of available donors is down by 27%, according to America's Blood Centers, a coalition of independent blood collection agencies that is responsible for about half of the U.S. blood supply. Moreover, many people who have donated are calling a day or two later and saying that they have come down with the flu. Their blood donations are destroyed, even though there is no evidence that influenza can be transmitted through blood.

--U.S. officials took considerable heat last week when it was announced that detainees at the Guantanamo Bay detention facility would receive the swine flu vaccine ahead of most Americans, even though the number of people involved was fewer than 250. The vaccination plans were called off. Now, a similar brouhaha has arisen in Canada, where military authorities say that Afghan detainees in Kandahar in southern Afghanistan will get the vaccine before the public. The officials say the vaccination is required by the Geneva convention, which mandates that prisoners receive the same treatment as soldiers, who are a high priority for vaccination.

The Canadian government said that it will have delivered 8.5 million doses of the vaccine to provincial governments by the end of the week. The country has ordered 59 million doses of the vaccine for its population of 30 million.

--Beginning next week, the National Geographic Channel will begin airing a daily two-hour block of programs designed especially for kids stuck at home with the flu. The programming will be culled from the channel's regular programming to provide supplemental education and will be accompanied by additional material at the channel's website.

--As ridiculous as it may sound, people who did not earn a high school diploma may be more likely to contract swine flu and the vaccine may not be as effective in them, according to researchers at the University of Michigan. And no, it is not because they are more likely to believe the tripe they read on vaccine denialists' websites. Instead, it has to do with infection by a common virus known as cytomegalovirus, or CMV. CMV infections tend to persist for very long times and worsen as a person ages, and they make it more difficult for those who are infected to fight off infections like swine flu. They also reduce the immunity stimulated by vaccination.

Epidemiologist Jennifer Dowd of the university and her colleagues had previously shown that the elderly who have limited education have a more difficult time controlling CMV infections, rendering them more susceptible to other infections. Their new study, to be published in the journal Epidemiology, found a similar situation with younger people. They concluded that a person with less than a high school education had the same level of immune control as someone 15 to 20 years older with more than a high school education. So, apparently the moral is: If you can't get the swine flu vaccine, go back and finish high school.

--The CDC has initiated a text alert program to provide information about swine flu to cellphone users. To enroll, text "health" to 87000 or sign up online.

--GlaxoSmithKline said today that it will donate 50 million doses of swine flu vaccine to the World Health Organization for distribution to the world's poorest countries. The donations are expected to arrive through December. Glaxo, Sanofi-Aventis, MedImmune and CSL have jointly agreed to donate 156 million doses to the agency, which said it has a list of 95 countries where it hopes to vaccinate at least 10% of the population.

-- Thomas H. Maugh II

Tracking antiviral prescriptions for swine flu [Updated]

While the Centers for Disease Control and Prevention tracks the progress of pandemic H1N1 influenza infections by monitoring deaths and hospitalizations, the Food and Drug Administration monitors its progress by tracking prescriptions for the antivrial drugs that are used to treat severe cases: Tamiflu, Relenza and, to a much lesser extent, rimantidine and amantadine. Such prescriptions give an indication of the number of severe cases of influenza. While the FDA doesn't release the data, the company that compiles it, Wolters Kluwer Pharma Solutions of Bridgewater, N.J., has agreed to provide some of the data to The Times.

During the week ending Oct. 23, the most recent week for which data is available, 14,673 prescriptions for the drugs were filled in California, an increase of 18.27% from the week before. The vast majority of those prescriptions were for Tamiflu, which is the drug most physicians use to treat severe influenza. The total included 5,403 prescriptions in the Los Angeles/Long Beach/Santa Ana region, a 33% increase from the week before; 1,150 in Riverside/San Bernardino/Ontario, a modest 1.4% increase; and 1,531 in San Diego/Carlsbad/San Marcos, a 38% increase. San Francisco/Oakland/Fremont had a 65% increase to 690 prescriptions, while Modesto had a 105% increase to 39. Bakersfield had an 11% decline to 554 prescriptions, while Yuba City, Merced, Susanville and Stockton all showed modest declines.

Nationwide, prescriptions were up 25%, according to Wolters Kluwer Pharma Solutions chief executive Mark Spiers. Most notable were a 168% increase in the  New England states and a 120% increase in the mid-Atlantic, which tracks well with data from the CDC. Prescriptions were also up 85% in the upper Midwest. Prescriptions were down nearly 8% in the Mountain West and 21% in the South Central region.

[Updated at 2:57 p.m.: Wolters Kluwer said 75,742,192 prescriptions for the antiviral drugs were filled during the week ending Oct. 23.]

[Updated Nov. 12 at 8 p.m.: The 75,742,192 prescriptions was the total number of all prescriptions filled in the United States during the week ending Oct. 23. The number of prescriptions for the four antivirals filled during the same week was 587,960.  And the company did not supply the FDA data to the Times, but calculated it independently for us.]

-- Thomas H. Maugh II

Swine flu news from around the world

Pandemic H1N1 influenza is now worldwide, with more than 199 countries and territories reporting laboratory-confirmed cases, according to the World Health Organization. The official toll is now more than 6,000 deaths, but WHO authorities think that is an underestimate, since laboratory testing has been reduced and most countries have stopped counting individual cases. Influenza-like illnesses accounted for 8% of visits to physicians' offices in North America during the most recent week for which data were reported to the WHO -- although more current figures from the Centers for Disease Control and Prevention said it had declined slightly to 7.7% -- and 40% of respiratory samples tested were positive for influenza. Virtually 100% of those influenza samples were swine flu.

Activity has been increasing in Europe and Central and Western Asia, signaling an unusually early start to the winter flu season. Early reports from China had indicated that the H3N2 strain of seasonal flu was circulating along with swine flu, but more recent reports indicate that swine flu now predominates. That does not mean, however, that the seasonal flu will not come back after this wave of pandemic influenza passes.

-- What appears to be an outbreak of swine flu is sweeping an isolated whaling village on a remote Alaska island. The Alaska Army National Guard has been called in to transport an emergency medical team from Nome, 135 miles away, because so many of the 130 residents of Diomede have been stricken. Most of the residents of the town are Ingalikmiut Inuit, who depend on subsistence fishing to survive. Anecdotal reports have previously suggested that indigenous peoples may be more susceptible to influenza, but there has so far been no firm evidence of such an association.

-- Ukraine has been suffering an outbreak of swine flu, and officials now say that a January presidential election may have to be postponed until May if it is not brought under control.  The WHO and European health authorities have sent in emergency teams to help with the situation, but the outbreak has become a political football, with recriminations being traded by the two main presidential candidates. Some authorities have estimated that as many as 750,000 Ukrainians have been infected with the virus, but only 30 cases have been laboratory-confirmed so far. At least 86 people have died of what appears to be swine flu.

-- Officials from the European Center for Disease Control and Prevention are predicting that, in a worst case,  as many as 40,000 Europeans could be killed by the swine-flu virus and a similar number by a succeeding wave of seasonal flu. The ECDC said 389 deaths had so far been linked to the virus in Europe, including 154 in Britain, 73 in Spain, 25 in Italy and 22 in France.

-- The U.S. military said it had begun receiving swine-flu vaccine and will begin immunizations soon. Vaccination is mandatory for all military personnel and highly recommended for civilian employees and family members of service people. The Department of Defense has so far ordered 3.7 million doses of the vaccine.

-- Thomas H. Maugh II