The Third Wave
There is little doubt that the number of reported infections and even more importantly the number of reported deaths due to H1N1 have decreased greatly over the past few weeks. The trend is clear and to be expected, and it influenced my decision to use the window of opportunity and risk the long flight from India to the USA at this time.
But influenza pandemics come in waves. We had the first wave early summer of 2009, the second wave in early Fall. Both of these waves are out of the ordinary, un-seasonal. In normal years the flu season gets underway in real earnest sometime after Christmas. Pediatric deaths due to H1N1 have already outstripped the usual numbers for the whole season and I fear the worst is still ahead, in the cold months of deep winter.
“How We Treat Influenza in Patients With Hematological Malignancies”
The latest edition of “Blood” yet to hit the bookstands has a very important paper that should be mandatory reading for all hematologists taking care of immune compromised patients. The abstract is below, for your convenience. If you wish to read the full text article, send me a personal email and I will try to point you in the right direction.
Blood.. [Epub ahead of print]
How we treat influenza in patients with hematologic malignancies.
Casper C, Englund J, Boeckh M.
Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States;
The 2009 H1N1 influenza pandemic has heightened the interest of clinicians for options in the prevention and management of influenza virus infection in immunocompromised patients. Even before the emergence of the novel 2009 H1N1 strain, influenza disease was a serious complication in patients with hematologic malignancies receiving chemotherapy or undergoing hematopoietic cell transplantation. Here we review the clinical manifestations of seasonal and 2009 H1N1 influenza and discuss current diagnosis, antiviral treatment, and prophylaxis options. We also summarize infection control and vaccination strategies for patients, family members, and caregivers.
PMID: 20009037
We kind of knew our guys were at more risk. This article gives us chapter and verse, expert guidance on what to expect, what to do and how best to protect not jus the patients with blood cancer but also their families and care givers. I have tried to summarize the major points below:
Early Stage:
- Patients with blood cancers are more likely to get infected. Like we did not know that already.
- Initial upper respiratory infection in blood cancer patients may lack the usual symptoms – fever, fatigue, body ache. The theory is that in immune-compromised patients immune responses are just too weak. These symptoms are signs that a fight is going on. Our guys do not put up much of a fight, especially if they are on corticosteroid therapy. The most you may notice is a case of sore throat, sniffles, mild headache – easily dismissed as trivial.
- They may not look or feel sick, but they are shedding virus particles liberally, increasing risk to their caregivers. This article and others point out that immunocompromised patients shed virus copiously for longer periods of time, compared to healthy people.
Disease Progression Deeper into the Lungs
- The most serious consequence of influenza infection is pneumonia, leading to lung injury and death. I must have emphasized this point a dozen times by now: the single biggest cause of death in CLL patients is pneumonia.
- This paper reports that progression from upper to lower respiratory tract happens in about a week in patients with blood cancers. That is a short fuse!
- This viral pneumonia is frequently complicated by additional bacterial and fungal infections.
- The single biggest risk factor is lymphopenia – decreased white blood count. This may sound confusing. Most of our guys have sky high WBC! True, but the high WBC is almost entirely made up of useless cancerous CLL cells. T-cell counts are not separately measured, but if you have been through fludarabine, pentostatin or Campath therapy, very likely you have low T-cell counts. If on top of that you also have neutropenia (low neutrophil counts), you are at risk. The high WBC and ALC in a CLL patient just means the tumor load is high, but it does NOT mean you have healthy fighting troops.
- Use of high dose corticosteroids increases the length of time that the patient is shedding live virus.
- Influenza infection is one of the most serious causes of death in recently transplanted patients.
- The authors suggest that more vigilance is required in monitoring immune compromised patients precisely because they may not show many of the common symptoms of fever, fatigue and body-ache. It pays to be more suspicious than otherwise.
- If you are a CLL patient and you have influenza, the authors suggest you should get a chest scan to rule out lower tract infection and pneumonia.
- Not everyone is in the same boat:
“A wide spectrum of immunosuppression exists among patients with hematologic malignancies, ranging from chemotherapy to allogeneic transplantation following myeloablative conditioning with vivo or ex vivo T cell depletion or refractory graft versus host disease. Underlying conditions that complicate influenza disease in otherwise immunocompetent persons may be present, including diabetes, obesity, and pulmonary or cardiac disease.”
The “Hutch” Experience
The Seattle Hutchinson Cancer Center is one of our preeminent expert centers. They have probably done more stem cell transplants than just about any other center in the world. As you can imagine, they would be particularly concerned about protecting their patients, since transplant patients soon after the procedure are among the most immune compromised folks you can find.
Hutch instituted a policy of aggressive monitoring, assuming the worst sooner rather than later, aggressive anti-viral therapy (including high dose and intravenous administration of multiple antivirals and antibiotics) as well as IVIG therapy as appropriate. You will have to read the full text of the paper to get all the details.
So, did all the extra work and sometimes over the top vigilance make a difference? I am very relieved to report it did, otherwise I would be just bringing you bad news without giving you any hope for prevention. Below is the chart of H1N1 detection in the community at large (Puget Sound, Seattle area) compared to the patients treated at the Hutch.
As you can see, the green line representing the incidence of H1N1 in the Seattle WA community was about the same as the rest of the country. There was the first wave peaking in early summer, followed by the more recent second wave peaking towards the end of May, 2009, dribbling down to present low levels.
Comparing the green community incidence to the blue (seasonal flu) and red (H1N1 flu) incidence rates at the Hutch is truly impressive. Hutch was able to stop this infection in its tracks! The blue and red lines are just about hugging the zero count! Way to go guys. I take my hat off to the hard work and perseverance of the Hutch staff in protecting their patients. This is remarkable success.
What contributed to the effectiveness of the Hutch program? What are some of the take home messages for us? Below is a chart of the various components of the Hutch program. Some of the things they found very effective are quite simple, things that you can do yourself at home.
Take home points
- It is not yet time to call this sucker a thing of the past. If I am not mistaken, there will be a third wave soon, it is gathering speed as I write.
- Our guys are more at risk of getting infected and dying from it.
- Simple things like hand washing, social distancing, getting the vaccination when it is available – all of these will help.
- CLL patients are not typical in how they show symptoms. They may not have the usual high fever, fatigue, body ache. You are smart not to ignore more “trivial” symptoms such as sniffles, sore throat and mild headache.
- Take the Hutch paper and the link below from the CDC to your oncologist and GP if they are still complacent about your high risk profile.
- http://www.cdc.gov/h1n1flu/immunosuppression/index.htm
- No one can be a better advocate for you than you yourself. Take care, stay healthy this up-coming flu season!
29 comments on "“How We Treat Influenza in Patients With Hematological Malignancies”"
I am a watch and wait (WBC 40K for the last 5 years and generally in great health) and caught swine flu 6 weeks ago. Four days into it my vigilant nurse wife noticed fluid in my lungs with her stethescope. I quickly went on antibiotics and that probably saved my life. I did develop a bad case of pleurisy (wet at first then dry) that is still just now resolving itself. I got the seasonal flu shot but could not get the innactivated H1N1 vaccine in time. I would warn all CLL patients to be vigilant…this flu goes to the lungs fast! Make sure you are being monitored closely and if you can get the vaccine do it.
Once again, Thank You for the warning.
I received a script from my Hematologist that i should have two H-1 vaccines one month apart & then wait two weeks prior to having a chance at being protected. I do not believe that I will be protected even then because I am immune compromised; therefore I do social distance-I do not hug, kiss or shake hands with anyone other than family & even then it is a rarity. I wash my hands continually & I do not go any place that is crowded including movies, malls, large restaurants. it is hard, but I want to be safe.
May all of you heed Chaya & the Blood article’s information so that you have a safe & healthy New year! Welcome back, Chaya
Chaya,
Thanks so much for this timely article review and reminder. I got my H1N1 vaccine last week in San Francisco and have been thinking I might break my social distancing retreat in several weeks. I think I’ll hold off until we see about this third wave and until my husband is able to find vaccination. In California, the availability of vaccinations for those over 64 is extremely spotty. While some counties have opened up to all groups, many have not and many docs didn’t order it. Thanks again for always being ahead of the curve and for watching out for us.
Lynn
Chaya, Thanks for the info. Both my kids got “presumed” swine flu. It was going around their school. The real problem is that even though there’s a lot of hype about HINI, the authorities are not following up to find out who has it versus some other virus. Some pediatricians were doing tests for Flu A versus Flu B and then deciding that Flu A must be H1N1. Our pediatrician didn’t think the test was useful because it gives a lot of false negatives and if Flu A came back positive it wouldn’t necessarily mean swine. So we were sent away with Tamiflu and told to use it that night if the fever went high. I took Tamiflu preventatively and it worked very well. Ten tablets over ten days. I didn’t get sick even though my kids sneezed on me for well over a week. My primary care physician also put me at the top of her list for the vaccine, above the older generation. She only had 20 doses. I felt quite guilty taking away from people 20 or 30 years my senior but she said she didn’t have enough for all her older patients and that experience indicated that many would have immunity. I have not had any side-effects that I’m aware of.
I also read a useful Dr’s article about avoiding flu generally, the gist of which was to wash hands, avoid sick people but also to gargle with salt water and use a netti pot to clean nasal cavities and sinuses. The reasoning behind these last two is that a virus can sit in your upper respiratory tract for a few days before it takes hold and flushing out on a regular basis will wash infections out before they become active.
evansjenny:
These days there is little point in testing flu to see if it is H1N1 or garden variety annual flu. Almost all of the flu circulating in communities is the H1N1 variety and it is better to assume that any flu is the H1N1 flu.
As for nasal irrigation, there has been a warning that doing it too often (with the netti pot or other such gizmos) can strip the nasal passages of their protective mucus layers. Once more the lesson is not to do anything to excess.
Chaya, Chaya, how could we make it through our periods of sickness and treatment without you! You are so often ahead of the curve with your research, analysis and common sense prescriptions (suggestions). Thank you, again and again.
Having been through a number of therapies over the last seven years (PCR, CVR, Treanda) my immune system is a bit wobbly. Am at the end of the standard Non-Hodgkins lymphoma treatment (my CLL seems to have given way to NHL after the Treada treatment). Just got the H1N1 vaccine from my oncologist at NY Presbyterian (he just received his small stock). But in early August, with the flu season imminent, my doctor insisted that I take prophylactically Bactrim and Levaquin every other day, and continue the anti-viral and anti-biotic until the end of January 2010, a month after my last of twelve NHL infusions. I wash my hands many times a day, keep fingers out of the orifices, and have hardly been out of the house in the last six months. No parties, movies, theatre or subways and I keep up with my friends by telephone and email. I feel like a conservationist! But it feels right.
Chip
Thank you once again Chaya for continuing to look us out for all. Could I ask you what is the present advice regarding whether we need two shots of the H1N1 vaccine or is one sufficient.
My own situation is that I am approximately nine months post SCT with a DLI eleven weeks ago. However following the appearance of GVHD six weeks ago I was put on very heavy dose of Prednisolone(200mg daily) which sorted it out. I am now down to 45mg but will take sometime to stop completely (in addition to 15mg Tacrolimus, 450mg Valganciclovir and 15mg Posanconazol daily). I had both the seasonal flu shot and the H1N1 vaccine two weeks ago, but at the moment a second shot is not scheduled.
Clum
Clum:
There is no formal guidance from the authorities about a second H1N1 shot for immune compromised patients.
However, the precedent exists on two shots for small kids who do not mount much of a response to a single shot and who are much more vulnerable. I think it boils down to you sweet-talking your doctor into giving you a second shot. Most communities now have plenty of shots left over and willing to vaccinate even low risk cases like me.
On the flip side of it, I doubt even a second shot will get you sufficient safety margin in terms of immune protection. Your best bet might be getting and filling a prescription for anti-viral Tamiflu and starting the treatment at the very first sign of something not quite right.
Please talk it over with your oncologist and your transplant team. In view of the heavy duty immune suppression to protect against GVHD you are definitely an “at risk” patient.
I appreciate this very thorough update. I copied the article from the web site you suggested for Clinicians about the H1N1 special conditions for Immunosuppressed patients.I am also calling my Oncologist’s office tomorrow to see if can get the flu shot. I got the regular flu shot in November. I was previously told the H1N1 vaccination probably wouldn’t be very effective. I am going to try and get it if possible.
Thank you again so much for this very timely report.
Enjoy your holidays. A Merry Christmas to you and your daughter.
Anita
I too got the H1N1 flu and within 4 days had pneumonia (also W&W, WBC around 30K but otherwise in good health). I developed a small pleural effusion from coughing and did some damage to the muscles in my chest. It was no fun. Now I keep antivirals at hand and head for the hills if anyone coughs nearby. I get a PTSD reaction if the flu enters the hospital where I work!
Chaya and anyone who might read,
Just wanted to wish you a very Happy and HEALTHY Christmas and New Year.
Self has discovered something new; through having had the misfortune of being dragged into CLL, long before I neede to know about it; (Not ill, would not have been “found out” normally,no treatment neede or intended or offered, would be stupid to do anything)I have realised that far from making me run to the Doctor, it makes me stay away completely. I have no wish to be subjected to any testing or monitoring; nor do I visit the local Cancer centre with its supporting services (dietician, councellor, pseuchiatric whatever, cancer nurse and so on, as well as: an opportunity to meet other “cancer-sufferers”!. I did see thoughts about “hand-holding” done by other than doctor; fine, just don’t let it develop into an idustry….and…it needs to be voluntary, from the patients side, most of whom are after all, normally functioning human beings, in spite of being diagnosed. Do not see any possible benefit in lumping all cancer-people together, like some sort of separate species of creatures.
My take; I stay away, and keep quiet. It has given me more than ehough to try to cope with, without having strangers tying to tell me what to think or how to react. It is after all my misfortune and MY life; not just someones tick on a flow-chart. Sorry chaps.
Anyway, thanks for your very lucid and “straight” site Chaya! You manage to keep things in the “sane” sphere.
Mette
Where is Vitamin D in all this? A rhetorical question, to be sure.
Bruce
Chaya,
I too fear a much more devastating third wave of flu this winter.
I am in the process of deciding about chemotherapy to control my ITP (PRC or FCR) as a prelude to a 2nd transplant, and the increased risk of flu when on these meds is yet another factor to weight into the equation. Waiting to March or April may make sense if it is possible.
Be well
Brian
Chaya,
The fact that some of the vaccines have ingredients, such as mercury in them; Is it wise to still have the vaccine, or just risk getting the swine flu?
Chris
As always, a big thank you Chaya for keeping us so well informed.
My best wishes to you and your family this holiday season. Kay
ChrisW;
Please have the vaccine. The risk of getting swine flu is too large and the consequences of swine flu in an immune compromised host too extreme to take the chance. You get a lot more mercury by eating different varieties of fish. This issue has become an urban legand that needs to be put into context. You can DIE of swine flu, and that risk goes up significantly if you have CLL. The mercury content in vaccinations of various sorts is far below the amounts we get from other sources.
Chaya,
As usual, you are the one who provides us with the timeliest & most informative updates on important topics. We all owe you so much for your time and efforts in fighting this dragon. My question is what, if anything, those of us who are in W&W and have never received any treatment should be doing? I was diagnosed because on a swollen node in my throat. My counts are all just barely above normal with my only real symptons being some swollen nodes. I developed a sore throat, sniffles and achy body about a week ago. I went to gp and he diagnosed as an upper respiratory infection but definitely not flu. Since I had just completed a regime of antibiotics for an infection caused by minor oral surgery, he did not want to prescribe any additional antibiotics and told me to just drink plenty of liquids, get rest and take vitamin C.
Thanks for all that you do and Happy Holidays,
Steve
Thanks Chaya for all the info.
I had my second shot of the Swine flu vaccine last Friday; Like Clum I am also almost 9 months post SCT and we both followed the same SCT protocol, The instructions from the Transplant team in London was to take the second shot 3 weeks after the first one and everybody in the household to have the vaccine as well.
This time my arm was a bit tender for a couple of days, but today it feels fine. just a bit itchy.
I feel safer having had the vaccines, but I also have avoided crowds.
Thank you so much for your updates!
I’m W&W, and have had both my seasonal flu and H1N1 vaccines. I work at one of the largest universities in the country, so it’s impossible for me to avoid crowds. I’m around hundreds of different people every day. So far, so good.
Above in your graph, did you mean to say that the green line represents influenza A?
doggeedoc:
Influenza A covers the spectrum of H1N1 and most of the common strains of annual flu out there. There is almost zero influenza B this year. So the green line in the chart represents H1N1 + most of the seasonal influenza in the community.
Thank you for keeping us informed.
Wishing you all the best in the coming year.
Monique
be sure you have the pneumonia vaccine regardless of age…i am 3 1/2 years into diagnosis with a poor FISH prognosis, yet have not quite doubled WBC in those years…feel good with no flu shots or prophylaxis. I do not restrict my activities or associations…fear is a self-fulfilling prophesy.
Bobarmstrong,
Glad you are doing so well !! However, from the posts we see here of CLL-ers who have developed pneumonia from H1N1, it does seem like a no-brainer to get the vaccine. I and my husband have finally been able to get the vaccine and we are both relieved and feeling less stress. And, I’m not sure I agree with your “fear is a self-fulfilling prophesy”. Sometimes fear gives one that moment of pause and reflection before doing something unwise.
Thanks Chaya. Just wondering if you know if having had swine flu offers protection from getting it again.
My daughter was told by an asthmatic friend that her doctor recommended she gets the immunization shots even though she had the flu. The reason seemed far fetched to me – that asthma somehow lessens the effect of immunity from the flu if you’ve had it – but the friend may have misunderstood what the doctor said.
I’ve had the flu, am on permanent medication for asthma and sinus polyps, Stage 0 W&W and am now wondering if I should have the jabs. Plus, my family had a flu following mine, but they weren’t tested. Should we assume they had swine flu and are now immune from catching it again, or should they be immunised too?
Is there a test to determine immunity to swine flu?
anaturallearner
You ask very good questions, I regret I do not have simple or clear cut answers.
It is generally accepted that once a person has had a particular variety of the flu bug, they get immunity and therefore protected from catching the same infection a second time. However, there have been several reports that suggest there may be exceptions to this rule as far as H1N1 is concerned. Some patients caught the H1N1 infection more than once. We do not quite know why. It could be because they had only very mild infection the first time and therefore did not get sufficient immunity; or the virus has mutated sufficiently between the first and second infections that the immunity they did get after the first time was not tailor made for the second infection with a slightly altered version of the virus; last but not least, it could be that the two different infections reported in the same patient were actually a long drawn out single infection because the patient had not been able to fight it off.
A couple of these possibilities are interesting in the context of CLL patients. Chances are that with the out of whack immune systems of CLL patients any immunity generated because of a first infection is going to be mediocre at best – for all the same reasons why CLL patients get so little joy from vaccinations. I would not rule out the possibility of second infection with H1N1, even though you have had a prior exposure to the same virus. I think your best protection is going to be in herd immunity and prudent social distancing.
Bobarmstrong:
I disagree strongly with the sentiments in your recent comment. Being prudent, pragmatic and taking precautions in the face of real danger is not giving way to fear. Doing otherwise is foolish. CLL patients are immune compromised: they are at increased risk of getting the infection, increased risk of it becoming more dangerous viral pneumonia once they are infected. Since their bodies cannot deal with the virus effectively they will be carriers and shedding the virus for much longer periods, endangering everyone else around them. Like LynnS I hope you continue to be healthy. But I strongly urge the rest of you guys out there not to adopt this policy of bravado. “Fear is a self-fulfilling prophesy” is a trite saying that is no more than a cheap shot in this case.
Just a note on symptoms: I had a very, very high temperature ONLY – no cough, no sore throat, no cold, not even a sniffle, no aching bones. I was extremely ill. Currently in treatment and assumption was made that I had a bacterial infection (in my central line), so was given two types of antibiotics. Four days later someone decided to do a nasal swab and swine flu was confirmed. Tamiflu was excellent with my temperature dropping 3degrees (C) in 12 hours.
As always with CLL, nothing is as it seems.
Try and enjoy the holiday season.
Thank you Chaya very much for this timely advice. I have only been given my yearly regular flu shot, but will head back to my oncologist for the swine flu jab. Sloan Kettering didnt have it back in November. I believe they may have it now.
On another note, what is your position on the pneumonia shot? I know it doesn’t really give us the immunity we need, but is the 5 year waiting period between shots acceptable ?
I agree that the symptoms can be sneaky and do not reflect the onset on any flu. Where I live, we are in swampy and dank conditions in the winter and everyone has some type of sniffles our cough. I have had the flu in the past prior to CLL diagnosis, and it was miserable for a few days. This time, and I am not even sure it was the flu, I felt a bit yucky for a few days – and then awakened one morning barely able to move. My wife got me to the urgent care center virtually immediately and I was put on a short course of Azithromax. Helped quite a bit but did not completely resolve the issue as of this point (3 days in). By the way, I had a pneumonia and normal flu shots just a month ago and also had a pneumonia shot about 5 years ago. My physical reaction was quite a surprise but this has taught me to get on top of things quickly.
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