The Flu & ‘Negligent Homicide’

Dr. Robert Webster and I both joined St. Jude Children's Research Hospital right out of training at about the same time over 35 years ago. Rob is a PhD virologist who is internationally recognized for his laboratory and field work in influenza and SARS, serving as an advisor to governments around the world, particularly in Asia. But I know Rob best as a good friend and colleague. He had the most exotic career of any of us at St. Jude, traveling the world to obtain fecal and blood samples from ducks, chickens, and pigs, and culturing and typing the viruses, particularly influenza-type viruses. He studies the evolution of the viral immune phenotypes in an attempt to understand (and predict) the leap of such viruses from animals to humans. He would return from these excursions and give engrossing lectures that were scientific detective stories about the genetic shifts in the viruses and which of them might be dangerous. He would remind us of the history of influenza epidemics and pandemics, like the deadly one of 1918 that killed far more American soldiers than the World War. I had dinner with Rob recently and we talked about our families and what we were doing. When I told him I wrote a column he said he hoped I would write about a terrible problem that results in the unnecessary deaths of cancer and transplant patients and the elderly. The problem is the transmission of influenza virus from health care workers to patients, particularly those who are immunosuppressed; they are most unable to fight the infection and, even worse, when infected, continue to shed the virus and infect others until they die. Real-Life Examples He related several vignettes to make his point: ▪ The province of Ontario, Canada, had such a bad outbreak in geriatric facilities of influenza passed from health care workers that resulted in fatalities that they made a strict new policy: Any health care worker who fails to be immunized for influenza and contracts the disease is suspended from work without pay until he or she is no longer infectious. As a result, the rate of infection of patients plummeted. ▪ The SARS epidemic in Hong Kong was widely promulgated largely by health care workers from the index case, an ill physician from the mainland. ▪ SARS is easier to contain than influenza. It is not as contagious and the patient does not begin to shed infectious virus until about the eighth day of illness, so quarantine is an effective means of control. Influenza is highly contagious and the virus is shed by the second or third day of illness, so quarantine is not usually an effective way to control spread. Influenza, as we all know, may present as an apparently simple upper respiratory infection. I can recall Rob swabbing the throats of anyone at St. Jude who complained of a cold to look for the virus. We were a small place then, and the basic scientists, physicians, nurses, and other staff ate together and crossed paths often during the day. We were often surprised when he told one of us we had influenza because we didn't feel very sick. (He also had a scientific reason for accosting us in the hallway, too; he wanted to know the phenotype of the viruses that appeared in Memphis as an epidemiological tool when connected with information from his worldwide network of colleagues.) This was a very important lesson to all of us: our apparent “winter cold” could kill our patients. Get Immunized! So what is Rob's advice to us who care for patients? First, get immunized. He feels strongly that all health care workers should be vaccinated because of the risk of passing the virus to so many vulnerable patients.Figure: Joseph V. Simone, MD, is Clinical Director Emeritus of Huntsman Cancer Institute, Professor Emeritus of Pediatrics and Medicine at the University of Utah, President of his own consulting company (www.SimoneConsulting.com), and Chairman of the Institute of Medicine's National Cancer Policy Board. He was previously Physician-in-Chief of Memorial Sloan-Kettering Cancer Center and Director of St. Jude Children's Research Hospital, and has served as Medical Director and Chairman of the National Comprehensive Cancer Network and as a member of the NCI's Board of Scientific Advisors. Dr. Simone welcomes comments about this column, as well as suggestions for future topics. E-mail him at [email protected]A few days before writing this, we heard the news that a major supplier of influenza vaccine had contaminated a large portion of its supply so there would be a significant shortage of vaccine this year. Rob believes that health care workers, particularly those who care for the elderly or the immunosuppressed, should be given the vaccine preferentially in the face of the shortage. What to do if one contracts influenza? Rob says there are two antivirals that can be effective: ▪ Rimantadine, preferentially used in Canada, is relatively inexpensive, though resistance tends to develop rapidly, which makes it less successful for infected families. ▪ Tamiflu is one of the neuraminidase inhibitors. (Hemagglutinin and neuraminidase provide the two principal antigens of the viruses that provide their identities—for example, H5N1 is the strain of avian influenza now threatening Southeast Asia.) Tamiflu is more expensive than rimantadine but is very effective, creates less resistance, and if given early enough can stop the spread of the virus. So as a favor to my old friend, Rob Webster, and much more important, as a favor to our cancer and transplant patients, get immunized and wash your hands often. And be especially alert to the possibility that your upper respiratory infection this fall and winter could be due to influenza virus. Don't be guilty of negligent homicide.

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