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September 28, 2009

RE: Pandemic (H1N1) Influenza Issues Update

At the request of B.C.’s physicians, a web resource has been established to provide a centralised and ongoing source of current information about the emerging issues surrounding the novel 2009 pandemic H1N1 (pH1N1) influenza virus (see http://www.hls.gov.bc.ca/pho/physh1n1.html - please bookmark this site). You are encouraged to visit the website and sign up to receive notifications when significant updates or additions are available.

In B.C. we work closely with many partners to provide accurate and timely information for providers and the public. The Office of the Provincial Health Officer has developed an ongoing process, including the establishment of formalized working groups, for expert review of the materials that will be posted to this site.

Throughout the evolving influenza season we will update and revise this information as necessary and also provide access to provincial- and health-authority specific information.

In particular, we draw your attention to the following points below. Please see the website for more details and regular updates.

SEASONAL INFLUENZA VACCINATION

As a result of national level discussions about the complexities of concurrently running 2 or even 3 influenza vaccine programs, the possibility of novel 2009 pandemic H1N1 (pH1N1) influenza infections replacing the usual predominance of H3N2 infections, and the potential interaction between seasonal vaccine receipt and pH1N1, we have made the following decisions:

Vaccination against seasonal influenza using the trivalent product (contains the three strains of influenza virus – A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Brisbane/60/2008) will:

• Be targeted in October for those aged 65 years and older and residents of long term care facilities beginning mid-October;
• For others at higher risk of influenza complications the seasonal vaccine will be offered following the November-December delivery and administration of the pH1N1 vaccine (i.e. seasonal trivalent influenza vaccine will be offered to eligible persons in early 2010). More details on this latter offering will be forthcoming.

In addition, we recommend that workplace-based seasonal influenza immunization programs be delayed until after the pH1N1 vaccination programs have been implemented (i.e. pH1N1 vaccination programs are expected to be completed by end of 2009).

Note these are subject to change if the regular seasonal H3N2 virus makes an unexpected recurrence.

Given patterns of activity over recent years in the northern hemisphere, and more recently in the southern hemisphere this past season, it is considered unlikely that seasonal influenza H3N2 strains will play a major role in influenza illness early in the 2009/2010 season. Thus, delay represents the best balance of benefits, risks and logistics while the focus is on preventing pH1N1 illness.

B.C. has thus made a decision to delay the usual broader offering of seasonal influenza vaccination. We are also aware of preliminary research findings suggesting that prior receipt of seasonal vaccine was associated with moderately increased likelihood of pH1N1 illness (odds ratio approximately 2) during the spring/summer 2009 in Canada. Although this association has not been linked to more severe disease or found in other countries and study methods are still undergoing scientific peer review, expert opinion has been to take the results into consideration pending more definitive knowledge and this has also informed decisions. Should patients under the age of 65 request seasonal influenza vaccine prior to receipt of pH1N1 vaccine, they should also be informed of this so they can make an informed decision.

TESTING FOR pH1N1 FLU VIRUS

Most adults and children with pH1N1 will have typical influenza-like illness. Nearly all children are infected with a number of different viruses during winter and pH1N1 is another with similar signs and symptoms. It is at the clinical discretion of the physician whether the patient needs testing for pH1N1 and/or treatment with antivirals.

Test ONLY to support appropriate treatment as follows:

• Patients NOT at high risk for complications, with typical influenza-like illness who request testing, should be advised that it is NOT NECESSARY.
• Testing by nasopharyngeal swab is recommended only for cases of influenza requiring hospitalization or if the test result will affect management (such as discontinuing antivirals based on a negative test in a pregnant woman).
• As antiviral medications are most effective when started early, treatment decisions in the community should not wait for the results of laboratory testing if performed, but should be made based on the severity of symptoms, the presence of risk factors and the influenza viruses circulating in your community.

ANTIVIRAL TREATMENT FOR pH1N1 FLU VIRUS

If influenza is strongly suspected based on clinical presentation and the presence of pH1N1 is in the community, antiviral use should be considered for the following patients:

· All patients (including children) with moderate to severe clinical influenza-like illness regardless of whether they are admitted to hospital;

· Patients with milder illness who may be at higher risk for subsequent complications, including:

o Pregnant women

o Adults and children with chronic health conditions including cardiac or pulmonary disorders (including bronchopulmonary dysplasia, COPD, cystic fibrosis and asthma), diabetes mellitus, other metabolic diseases,  cancer, immunodeficiency or immunosuppression, renal disease, anemia or hemoglobinopathies as well as conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration

You may wish to consider giving higher risk patients a prescription in advance, seeing patients quickly if they develop influenza-like symptoms and planning for calling in a prescription if the person becomes ill. To help guard against the development of resistance, please familiarize yourself with the proper antiviral dosing regimen and duration and reinforce clinically-indicated use with patients. Currently, dosing regimens are unchanged from that of regular seasonal influenza, and are dependent upon weight and require adjustments for people with renal failure. Check package inserts. The WHO also advises that risk of antiviral resistance is higher in severely immuno-compromised people with prolonged illness and persistent viral replication given extended treatment and in patients given post-exposure prophylaxis.

REPORTING CASES OF pH1N1 FLU VIRUS INFECTION

Physician reporting of serious outcomes dues to pH1N1 influenza is important to monitor the impact of the pandemic. Physicians are required to report to their Medical Health Officers any cases of lab-confirmed pH1N1 respiratory infection:

• Whose illnesses are severe enough to require admission to hospital; or
• Who die, regardless of whether admitted to hospital.

pH1N1 INFLUENZA VACCINATION

pH1N1 vaccine is anticipated to be available in both adjuvanted and non-adjuvanted formulations by mid-November with the possibility of earlier emergency release. Non-adjuvanted vaccine will be available for pregnant women and children under three years of age and has been selected because there will not have been adequate testing of adjuvanted product on these groups.

Enough vaccine is anticipated to be available to immunize all British Columbians and those visiting B.C. who need and want to be vaccinated.

The immediate priority will be to target those who are anticipated to need and benefit most from immunization, as well as those who care for them, including:

· persons with chronic medical conditions under the age of 65

· pregnant women

· children 6 months to less than 5 years of age

· persons residing in remote and isolated settings or communities

· health care workers involved in pandemic response or who deliver essential health services

· household contacts and care providers of infants < 6 months of age and persons who are immunocompromised

· populations otherwise identified as high risk

Early indications are that a single dose might be adequate for older children and adults.  Younger children (age to be determined) may need two doses given three weeks apart.

Vaccine will be available through health authorities, special clinics organized by public health nurses, physicians’ offices, community health nurses who work in First Nations communities, and through health care facilities for health care workers and residents of long-term care. Details of clinic dates and locations will be available through the regional health authorities or local health unit.

We commit to keeping the medical community updated on any further changes.

Sincerely,

P.R.W. Kendall Eric R. Young, MD
OBC, MBBS, MHSc, FRCPC BSc, MHSc, CCFP, FRCPC
Provincial Health Officer       Deputy Provincial Health Officer

Message from the College of Physicians and Surgeons of British Columbia

The College of Physicians and Surgeons of British Columbia appreciates the work of provincial experts and the collaboration of many stakeholders in compiling a single provincial source of reliable information regarding the diagnosis and management of novel pH1N1 influenza. Successful management of pandemic influenza is dependent upon timely dissemination of relevant information to those who need to know. We strongly encourage your participation in subscribing to the updated features of this website to ensure that the physicians who manage influenza-like illness (ILI) are conversant with the management and treatments listed.

Dr. Heidi Oetter, Registrar

Dr. W. Robbert Vroom, Deputy Registrar , CPSBC liaison to pH1N1 Clinical Advisory Committee

Message from the BCMA

The BCMA is pleased that there will be one source of reliable information for physicians about H1N1. We believe this approach will greatly reduce possible confusion about emerging information and minimize the time physicians and their MOAs will need to spend on keeping up-to-date about the issue. The BCMA has agreed to assist in sending notices of important updates to members.

Brian Brodie, MD
President, BC Medical Association

2. My relaxed diet plan is failing and I am going back to starving, starting this morning.  I am sorry to bore you with these details but I find it motivating to put it in writing, so there you go.

3. I went hiking yesterday and it was awesome.  Except for the part where my shoes, which are not hiking shoes, rubbed all the skin off my right heel leading to bleeding and general grossness.  It didn’t hurt but when your hiking companions are giving you regular updates on the status of your pulped flesh you feel like you ought to do something about it, for aesthetic reasons if nothing else.  I applied a bandage and only then did I realize that actually it had been sort of painful, because all of a sudden it felt much better.  So hooray for aesthetics!  Or something.

4. I totally cheated on being a vegan yesterday.  I had a small ice cream cone at the base of the mountain, my first in nearly two years.  It was truly, deeply delicious and I enjoyed it thoroughly.  Until I got a stomach ache, at which point I swore off dairy again.  Until dinner, when I had pizza with cheese on it.  Also delicious, but unpleasantly greasy and I don’t know if that’s because the pizza was unusually greasy of if that’s just the way cheese is.  In either case I am back to not eating dairy and glad to do so.  It was a nice holiday but… yeah.  All done now.

!

And this is why I don’t have sunglasses.  Never mind the squinting and headaches, I wouldn’t be able to read for days!  And it’s not just books, it’s the computer monitor too.  I’m not exactly blind without them but I couldn’t exactly see anything without them either,  if you see what I mean.  Which I wouldn’t, if I didn’t have my glasses.

But it’s awfully bright out so I might bite the bullet and go for it after I get back from holiday next week.

And you know what the worst part will be?  The whole time they are gone I will poke myself in the eyes over and over as I try to push my (absent) glasses up my nose to get better focus.  Habit: it’s what’s for dinner.

1. HOLY FLAPJACK JOY my favourite band in the entire world Clutch is coming to Vancouver next month (Commodore Ballroom) and you better believe I already bought my ticket.  I squee with fantabulous delight!  So far I’m going alone so if you’re going, let me know and assuming you are not a creepy internet stalker (eg, I know you) we can go together.  I will try not to pee on your shoes with excitement, but no promises.

2. I survived another trip to the dentist today.  I have bizarrely sensitive teeth and some of the tools just make me want to kill myself when they’re applied to the delicate nerve-ending-rich surface of my pearly whites.  I always dread my cleanings.

3. Oh!  This reminds me of when I got my wisdom teeth pulled – all four had to go because I have an abnormally small mouth (I swear!) and they were all pointing due west, impacted, etc.  I ended up with all four sockets infected after surgery, which was the worst pain of my life.  I couldn’t sleep much through it despite the pain meds, and when I would doze, I would dream of a cement mixer grinding up my teeth.  And wake up crying.  Finally the infection got treated and cleared up, and then I got dry socket in two places.  And I am here to tell you that dry socket is fucking child’s play compared to an infection.  Having had both in rapid succession I can say with authority that I would take fifty dry sockets over a single infected one.

Just in case you wanted to know my opinion of dry socket vs. infection at the site of a former molar.

4.  I baked raspberry oatmeal squares tonight and they turned out beautifully.  Tender, moist, with a hint of crispness in the crust, sweet but not too sweet, flaky… I could go on but it’s getting obscene.  Next time I make them I’ll take pictures and post the method here because they are so simple and so good!

Anyway, hunger is reinforcing in a way – it’s proof I’m cutting out enough excess caloric matter.  So I try to embrace it.  I am downing shocking amounts of diet pop as a distraction.

But speaking of food, one thing vegans do well is cool dinners on hot nights.  Tonight we’re having grilled pita bread (brushed with a little olive oil then sprinkled with big crunchy salt) with hummus, olives, a salad of cucumber, avocado, tomatoes and greek style dressing, and some smeat soy skewers grilled as accompaniment.  Nearly no cooking and very hearty.   Last night we had french bread with hummus and bruschetta.  I figure as long as I’m starving I might as well not waste precious calories on food that is anything less than great.

Anyway, now that I am dieting and sleep deprived I spend all day long fighting two very strong biological urges.  No snacking for obvious reasons.  And napping utterly devastates my night’s sleep so it is strictly verboten… but sometimes I just want to cry with frustration over the bizarre logic of disallowing myself to sleep when I know I could get an hour or so in with no trouble at all in the afternoon.

And my oral defense is coming up in a week and a half.  Which now that I think about it might be part of the sleeplessness.

So I am not the happiest person these days.

JESUSA: My faith, my loyalty.

That… kind of freaks me out.  I didn’t notice where the plates were from but wouldn’t it be weird if they were Canadian?

And two, I have consulted with my family doctor and I think I am going to get an IUD.  There’s a variant with progesterone which – I shit you not! – is more effective than a tubal ligation.  Srsly!  I am blown away.  But apparently this is because in addition to preventing implantation is actually prevents ovulation in the first place, so you are super secure from a babies perspective, yet it is totally reversible,  AND!  This is the best part: for most women, after three to six months, you stop menstruating all together.  (Should that be “altogether”?)

I have had this experience before.  Many years ago I was on an injectible birth control called depo-provera which was handy because you get the shot once every three months, but not handy in that I ballooned in weight and lost my interest in sex and would cry at the drop of a hat.  For example, the Royale toilet paper commercials?  With the fluffy white kittens?  Serious waterworks.  And long distance phone plan commercials… oh man.  I cried like a baby.  But no period.  Which was soooo awesome.  Turns out it wasn’t worth it.

Aside: at the time I had a number of women tell me they wouldn’t want to forgo their periods because it was an intrinsic part of being a woman, something distinctly female and a part of the woman-experience.  I… do not get this.  I can’t speak for anyone else but I really dislike the experience.  It’s uncomfortable ranging to painful, it’s gross, it requires expensive outlay for, um, management products… why on earth would I want to keep it?  Or, why would I be sad that a side effect of a treatment I want is cessation?  Frankly it’s the sort of thing you should throw a party over, not be sad about.  IMO.

So I have a referral to a gynecologist.  I am worried it will be painful to place.  Does anyone have experience with this?

Protest, despair, detachment.

Brief aside: I noticed when I was off the pill that my appetite fell away.  For the months I was off it I ate way less and experienced less hunger than I had in years.  I lost weight without even noticing.  And I felt pretty mad about all the times I’d gotten down on myself for being a greedy pig because I always seemed hungry… when the whole time it was the fucking medication!  So I am looking into other options because this hungry all the time stuff?  It’s fucking bullshit.

Anyway then I went back on the pill – and my appetite returned.  It brought its friends the fats too.  So I am on a diet.  And I think I have passed through protest and despair and am solidly into detachment.  I am not very interested in food, don’t have trouble resisting it, and am losing weight, hooray.

But you know this is indicitave of a sad, painful inner state of affairs.

So naturally it becomes very important to figure out how to get to sleep at night.  For me, this combines with fear of the consequences of insomnia to produce anxiety and frustration on a scale guaranteed to preclude sleep.  The cure becomes the problem, as whatever it is that was keeping me up in the first place is eclipsed spectacularly by my anxiety around trying to overcome the difficulty achieving sleep.  I try many things: meditation, thought stopping, story telling… But it always comes back to, Why can I not get this method to work?  Why is this happening to me?

Another strange part of insomnia: exhaustion and sleepiness are not the same thing.  I can feel utterly exhausted, just totally wiped out, yet experience not a hint of sleepiness.  This is incredibly frustrating.  Sometimes I feel my body crying out for rest and my brain just doesn’t go along.  The attendant frustration makes it that much harder to fall asleep (can you fall asleep furious?), and so in effect the more I need to sleep the harder it is to get any.  Therefore, there is no connection between getting really tired and sleep therefore coming easier.  In fact, in my experience the opposite is true.  If I get overtired, I am guaranteed worse sleep or sleeplessness.   Breaking the cycle is the key and despite a lifetime of this problem I have never hit on a reliable method.  I describe this phenomenon as “being too tired to sleep.”  It is an expression that makes instant sense to other insomniacs and no sense whatsoever to regular people.

Often, when I am in a poor sleep phase, I go days without ever experiencing the sensation of dropping off to sleep slowly, of “falling asleep.”  I transition seemingly instantly from exhausted alertness to sound asleep – and only notice I fell asleep upon waking, when I can tell time has passed.  This is a very disconcerting experience.

Going to bed is also not a permanent thing either.  I often get up and read or do quiet housework in the night, to break up the boredom and also to create a new instance of going to bed – I have found sleep comes within an hour of lying down or not at all.  Better to get up and try again later.  But this makes for some odd night time activities and bad sleep schedules.

Insomnia can also create some bizarre superstitions.  Like Skinner’s pigeons, I can become irrationally attached to rituals that coincide with good sleep.  I need to wear certain garments, or lie in certain positions, or brush my teeth in a certain spot in the bathroom.  Violating the ritual is anxiety provoking and therefore sleep interrupting – in this way my rituals are “real.”  I know this is foolish but that’s hardly relevant.

Insomnia is indeed suffering.  And it makes me rather impatient with people who complain about a bad night’s sleep as one characterized by waking up two or three times – on my very best nights, I wake up four or five times.  That is an achievement and I’m grateful for it – I never sleep through the night.  And yes, my standards aren’t relevant to your experience of suffering, but nonetheless, I can’t bring myself to feel bad for people who have trifling interludes of broken sleep.  On the other hand, that probably tells you something about how terrible sleeplessness is, that people will moan loudly about one or two poor nights’ sleep.

At my very worst, I have daytime hallucinations that preclude me from driving or working or, basically, functioning.  At my best I can get 7 hours of sleep over 8-9 hours in bed.  Most of the time I’m somewhere in between, fluctuating.  This is a major part of my life.  I would give a lot to fix it.

So.  I have a complaint to register.  After a full lifetime of really innocuous periods, mine have started going insane.  I was that woman who had no PMS symptoms other than mild cramps which could easily be ignored.  The event itself was, what, a few days at most and really light.  In fact, I was frankly suspicious of women who complained of moods and things, assuming it was just an excuse to be a bitch for a few days a month and get away with it.  Now?  Holy christ on a sidecar, this is horrible!  It’s like my guts are ripping themselves apart and bolting for the exit.  I am in a lot of pain all the time and you would be horrified at the, um, product.  I am.  It’s been a couple months of this and I have decided to go back on the birth control I was on before which clearly was keeping my Rampaging Guts in check.  Lesson learned: Don’t mess with your hormones, they hold all the trump cards.

Also, I went on to one of those “how to find the right bra size” websites today on the recommendation of a blogger I read (What?  Don’t you get all your advice from your internet friends that you’ve never met?).  It is actually quite a long and informative article.  I decided to follow along with the measuring advice because I am in need of some new bras, having  basically worn the elastic out of my current crop so that I am getting into discomfort-when-walking territory.  Why not get an accurate sizing before heading to the store, right?  Anyway, do you want to know what bra size it says I’m supposed to wear?  30-DDD, also known as the 30-F!  Ha!  I think the reason “they” say most women are wearing the wrong sized bra is because the “real” sizing is so clearly wrong.  I mean, I got boobs, but not that kind of boobs!

Seriously, do you know of an online sizing source that you trust?  This just seems wrong.  And I am too shy to let those stern older women in Sears help me.

Finally, my scar from the mole removal is still a really bold dark red and I believe it is shaped like Alberta:

Okay, so the southern border is at a slight angle.  But other than that, the resemblance is uncanny!

Apologies for the crappy mole picture, I was trying to keep my enormous boobs out of the shot.

Today the bee is in fine form.  I think he’s got a table saw going.

In other news, I finally removed the exo-blister super bandaid from my former-mole site.  It’s been six weeks (I’m a slow healer).  I’ve got a rather angry looking scar.  I’d show you but I can’t take a picture of it without also getting parts of the body covered by the bathing suit in there, but just imagine a big red/purple raised blotch.  Sort of gross.  But cancer free!  A bit hurty though.