WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

27 September 2018

It is recommended that egg based quadrivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus;
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage); and
  • a B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage).

It is recommended that egg based trivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus; and
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage).

It is recommended that the A(H3N2) component of non-egg based vaccines for use in the 2019 southern hemisphere influenza season be an A/Singapore/INFIMH-16-0019/2016-like virus together with the other vaccine components as indicated above.

Source: WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

Flu View Phase 6

Source: Flu View Phase 6

CDC Interactive Map – Weekly Influenza

A Weekly Influenza Surveillance Report Prepared by the Influenza Division

Source: FluView Phase 8

Some Rural Americans Forced to Travel 100 Miles to a Hospital – Rural Hospitals Close

https://www.esquire.com/news-politics/politics/amp22335922/rural-america-hospitals-close/

NewsOK.com: Opioid prescribing laws to change Nov. 1

NewsOK.com: Opioid prescribing laws to change Nov. 1.
https://newsok.com/article/5612140/opioid-prescribing-laws-to-change-nov-1

As opioid crisis raged Insys pushed higher doses of addictive drug and pushed salespeople to own doctors – MarketWatch

https://www.marketwatch.com/story/as-opioid-crisis-raged-insys-pushed-higher-doses-of-addictive-drug-and-pushed-salespeople-to-own-doctors-2018-10-17

New Jersey- The flu is here, and it’s going to get worse

Source: The flu is here, and it’s going to get worse. Why you should get your flu shot now | NJ.com

Washington DE- Doctors issue warnings after reports of flu-related deaths | WJLA

Doctors are issuing warnings to people after several reports of flu-related deaths.

In North Carolina, two flu-related deaths were reported. A 29-year-old lawyer died from a heart attack after complications from the flu, and an older person also died.

Flu season typically starts in October and ends in May. During the last week of September, the state of Virginia reported less than two percent of emergency room and Urgent Care visits were for flu-like symptoms.

In D.C., four cases of the flu were reported by hospitals, and Maryland has not started monitoring flu cases.

The Center for Disease Control (CDC) estimates in 2017 that the flu killed 80,000 people including 180 children in the United States. It’s considered the highest death toll in nearly 40 years.

Source: 7OYS: Doctors issue warnings after reports of flu-related deaths | WJLA

Doctors Urge CDC to Clarify Rx Opioid Guideline 

Dr. Kertesz believes many chronic pain patients have suffered under the guideline, because it has led to widespread tapering and discontinuation of opioids. He invited other healthcare professionals to co-sign the letter. To date, well over 200 have.

To see a list of signatories, click here. If you are a healthcare professional and also wish to sign the letter, click here.)  

CDC.jpg

Authors: Health Professionals for Patients in Pain

Any professional who cares for patients, including physicians, pharmacists, nurses, psychologists and social workers, is invited to sign on to this letter, as are any professional organizations that wish to endorse formally. 

I. In 2016, the Centers for Disease Control and Prevention, CDC, issued a Guideline for Prescribing Opioids for Chronic Pain for primary care physicians. Its laudable goals were to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy. The Guideline reflected the work of appointed experts who achieved consensus on the matter of opioid use in chronic pain.

Among its recommendations are that opioids should rarely be a first option for chronic pain, that clinicians must carefully weigh the risks and benefits of maintaining opioids in patients already on them, and that established or transferring patients should be offered the opportunity to re-evaluate their continued use at high dosages (i.e., > 90 MME, morphine milligram equivalents).

In light of evidence that prescribed dose may pose risks for adverse patient events, clinicians and patients may choose to consider dose reductions, when they can be accomplished without adverse effect, and with possible benefit, according to some trial data.

Nonetheless, it is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation, as data to support the efficacy and safety of this practice are lacking.

II. Within a year of Guideline publication, there was evidence of widespread misapplication of some of the Guideline recommendations. Notably, many doctors and regulators incorrectly believed that the CDC established a threshold of 90 MME as a de facto daily dose limit. Soon, clinicians prescribing higher doses, pharmacists dispensing them, and patients taking them came under suspicion.

Actions that followed included payerimposed payment barriers, pharmacy chain demands for the medical chart, or explicit taper plans as a precondition for filling prescriptions, high-stakes metrics imposed by quality agencies, and legal or professional risks for physicians, often based on invocation of the CDC’s authority. Taken in combination, these actions have led many health care providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care.

III. Adverse experiences for these patients are documented predominantly in anecdotal form, but they are concerning. Patients with chronic pain, who are stable and, arguably, benefiting from long-term opioids, face draconian and often rapid involuntary dose reductions. Often, alternative pain care options are not offered, not covered by insurers, or not accessible. Others are pushed to undergo addiction treatment or invasive procedures (such as spinal injections), regardless of whether clinically appropriate.

Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use. Others have experienced preventable hospitalizations or medical deterioration in part because insurers, regulators and other parties have deployed the 90 MME threshold as a both a professional standard and a threshold for professional suspicion. Under such pressure, care decisions are not always based on the best interests of the patient.

lV. Action is Required: The 2016 Guideline specifically states, “the CDC is committed to evaluating the guideline to identify the impact of the recommendations on clinician and patient outcomes, both intended and unintended, and revising the recommendations in future updates when warranted”. The CDC has a moral imperative to uphold its avowed goals and to protect patients.

Therefore, we call upon the CDC to take action:

1. We urge the CDC to follow through with its commitment to evaluate impact by consulting directly with a wide range of patients and caregivers, and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation.

2. We urge the CDC to issue a bold clarification about the 2016 Guideline – what it says and what it does not say, particularly on the matters of opioid taper and discontinuation.

Signatories here represent their own views, and do not purport to reflect formal positions of their employing agencies, governmental or otherwise.

Source: Doctors Urge CDC to Clarify Rx Opioid Guideline — Pain News Network

Texas Influenza Surveillance Summer Report

Current Extended Flu Activity Report (PDF)
(September 23, 2018 – September 29, 2018)
Report produced on 10/05/2018

Summary:
Influenza activity remains low across the state of Texas. It appears that influenza activity peaked in late January. Compared to the previous week, the percentage of patient visits due to influenza-like illness (ILI) and the percentage of specimens testing positive for influenza reported by public health laboratories slightly increased. The percentage of specimens testing positive for influenza reported by hospital laboratories marginally decreased. No influenza-associated pediatric deaths were reported. One influenza-associated outbreak was reported. In addition to flu, other respiratory viruses—especially rhinovirus/enterovirus—were detected in Texas during week 39.

Hospital laboratories across Texas voluntarily report influenza tests (antigen, culture, and PCR) to the National Respiratory and Enteric Virus Surveillance System (NREVSS). Providers throughout Texas also submit specimens for influenza testing (PCR) to Texas public health laboratories, including the Texas Department of State Health Services (DSHS) state laboratory in Austin and the nine Texas Laboratory Response Network (LRN) laboratories. The results reported by Texas NREVSS participants and public health laboratories for the current week are summarized in the two tables below. Additional influenza test results (rapid tests, culture, PCR) and ILI activity were reported from providers and public health departments throughout the state.

2017-2018 Texas Influenza Surveillance Activity Reports:

10/05/1809/28/1809/21/1809/14/1809/07/1808/31/1808/24/18,  08/17/18,
08/10/1808/03/1807/27/1807/20/1807/13/1807/06/1806/29/1806/22/18,
06/15/1806/07/1806/01/1805/28/1805/18/1805/11/1805/04/1804/26/18,
04/20/1804/13/18, 04/06/1803/29/1803/23/1803/16/1803/09/1803/02/18,
02/23/18, 02/16/1802/09/18, 02/02/1801/27/1801/20/18, 01/12/18, 01/05/18,
12/29/1712/22/1712/15/1712/08/1712/01/1711/29/1711/17/1711/10/17,
11/03/1710/26/1710/20/1710/12/17

Source: IDCU Influenza | Activity Report

Opioid prescribers in Georgia get letters from U.S. Attorney

Federal prosecutors in Atlanta have put about 30 doctors on notice that they’ve been identified for prescribing opioids in significantly greater quantities or doses than their peers.

The doctors, who were not publicly identified but work in the metro and North Georgia area, were notified by letter. Some also were found to have prescribed opioids to patients who may have a high risk of abuse, the U.S. Attorney’s Office said Friday.

“Medical professionals have an obligation to the safety and well-being of their patients,” U.S. Attorney BJay Pak said in a statement. “Many opioid prescribers may not realize that they are over-prescribing opioids. We aim to make these medical prescribers — who are outliers — aware of their atypical practices, so that they can make informed decisions about whether their opioid prescriptions are for a legitimate medical purpose.”

The letters are part of an initiative by the U.S. Department of Justice to reduce opioid prescriptions by one-third over the next three years. The Department of Justice has not determined if the 30 doctors who were put on notice have broken the law, but federal authorities will continue to monitor prescribing habits, Pak said.

In the letters, prosecutors provided the doctors with specific information about their prescription patterns. The doctors were also given guidelines by the Centers for Disease Control and Prevention for prescribing opioids for chronic pain.

Neil Campbell, executive director of the Georgia Council on Substance Abuse, applauded the move.

“This is a really good thing,” she said. “There’s been such an abuse of prescriptions and it’s hurt a lot of people. Most doctors don’t want to give more painkillers than they need to, but unfortunately that’s not the case with everyone.”

Source: Opioid prescribers in Georgia get letters from U.S. Attorney

15 Years with My Pain Dr. and My Last Appointment Became My Final Appointment – National Pain Report

Editor’s Note: John Sandherr is a 58-year old man who lives near Pittsburgh, Pa. He has suffered from chronic pain for thirty years and has undergone 10 surgeries. . He is an arachnoiditis survivor and is an outspoken chronic pain advocate. He credits his wife Deb for helping him survive the past thirty years. We’re glad he has added his voice to the National Pain Report.

On August 8th just over 2 months ago I went to my monthly visit to see my Pain doctor. It was like any other appointment that I’ve had for over 15 years. Every 28 days I would go in to get my pain medication and get a short but thorough exam from the Dr. or by his Physician Assistant. Each month was routine for me because of all the documentation that supports the severe pain I suffer with.

There was nothing routine about my visit on that day – as soon as I walked in I was told by the receptionist, “Today is your last visit, I need you to sign this paper and you will be given your medical records. As of August 12th Dr. Frank will no longer treat pain patients, you need to find a doctor and fast.” I must have looked like I was hit by a truck and then a train because the girl said, “are you OK?” and I said, “NO, will you be giving me the name of a doctor that I can follow up with?” “NO” was all she said.

I took a seat and completed the forms I was given and returned them to the girl, she then handed me a large yellow envelope that had 186 pages of office notes that went back 6 years. I didn’t ask but I assumed that 6 years is the required amount of time to conform to the guidelines.

After I went back to my chair I was lost and broken and as I sit and write this all of those feelings come rushing back, my mind is blank but racing, my breathing is slow and then fast, my heart is pounding so fast I can actually hear it. I remember – three cleansing breaths – i can quiet my racing heart but for just a few minutes.

After a 10 to 15 minute wait Dr. Shani called my name, she could hardly look me in the eyes. I sat across from her in the same chair I always have but there must have been a look of desperation mixed with fear etched into my face as Dr. Shani said to me, “John you look terrible” and I came right back with, “I can’t believe this is happening.” She didn’t know what to say while I sat there with tears that started rolling off my lower jaw. “I’m scared to death” I said, “and I don’t know what I’m going to do, no doctor is going to prescribe what I’ve been taking for the last 10 years. I’m done.” She couldn’t disagree and I knew it.

Dr. Shani spent the next 10 minutes giving me a pep talk – I gave her credit for trying and for caring. I had regained what composure I had left and asked Dr. Shani “why is Dr. Frank closing the pain clinic”? The answer came with no hesitation as Dr. Shani looked me right in the eye and uttered “he wants to spend more time in the Operating Room and more time at the Addiction Clinic he opened last year”. That statement left me thinking, I know Dr. Frank is a workaholic, he has fewer pain patients but that was due to those that got booted for failing a drug test or requesting more medication much too early. I was Dr. Frank’s oldest or longest patient, no one else had 15 years of treatment at the clinic, just me.

Glued to the chair, I knew getting up meant never coming back. This wasn’t easy, just 6 months prior I had asked Dr. Shani if the anti-opiate campaign was something I should worry about, was Dr. Frank going to close his doors someday soon. Shani told me not to worry and that Dr. Frank was a well established Dr. in the field of pain management and the patients had nothing to worry about, I needed to hear that. It seems that no one could foresee all that would happen over those next 6 months and I felt like I should have been ready for it, I read about this situation while on The National Pain Report and I never thought it would happen to me.

With nothing left to do and thinking about what was next, I had but one last thing to ask Shani, “can you please give me the name of a Dr. I can call, a Dr. that might be able to prescribe anywhere near the dose I’m on and have been on for over 10 years,” Shani said, “I can’t do that John” so I said, ”Okay, how about off the record?” She wrote down three names on a small piece of paper she had ripped off her calendar and slid it across the table to me. I asked if these Dr’s would be comfortable keeping me on my current dose and I already knew the answer to that question (I’m on over 350 mg of OxyContin & OxyCodone, daily) – “No, you will need to wean yourself down over the next 60 to 70 days, as much as you can – you can do it John”, that was her reply.

Shani slid the prescriptions across the table and said – Good luck. I looked over the medication, everything was there. Fifteen years of what I believed to be good successful years had come down to 12 sheets of paper and little hope.

Medication, I now had enough to get me through the rest of the year, if I cut back starting the next day, plus it gave me more time to look for and find a Dr. to treat me.

I just couldn’t walk out of that office without making some kind of a statement. I walked over to Shani and first gave her a big hug for taking such good care of me for so many years and then with my hands on her shoulders I looked at her and said “I can reduce the medication and I will do my best, but no matter what, I’m still going to end up in the Hospital and it won’t be for a short stay. It’s not the reduction of the medicine that worries me, it’s all that pain that will only get worse  and that’s what worries me the most, I’m afraid I won’t be able to take the pain.” Shani, a short thin woman from India looked up at me with sad eyes and said, “I know John and I’m sure you will.” That reply left me feeling extremely helpless and fearful but it’s that kind of attitude that won’t do me a lick of good.

Out the door I went and as I got into my car I kept thinking – my pain is real, I’m not a drug addict, there is little hope of finding a Dr. to treat me, my condition is progressive, I’ve tried nearly every pain modality medicine has to offer and the one thing that allows me to be a productive member of society and ease my suffering is Opiate Pain Medication. Every day I read a news article that says a vast number of Americans believe that there is no place for opiates to treat any kind of pain. Now I hear that many are calling for a complete ban on opiates and I wonder if those people have ever had the need for a pain medication. If opiates are banned, what will people use in their place? I’m not sure if they have given that any thought and they won’t until they are in severe pain.

Fifteen years is a long time, so, Dr. Frank became very familiar with my medical issues and my personal issues, he once asked me, “how can you even walk when according to these test results you should be in unbearable pain and I can see that on your face and when you squirm in that chair yet you always seem to have a smile on your face.” I would say, well I can smile or I can cry but I know I’m better off than the patient I just saw in the waiting room, sitting in a wheel chair with no feeling from the waist down and still in pain. There will always be a person that is worse off than me and that keeps me going.

Less than a week later I was at my surgeon’s office for a follow up visit with Dr. K an Orthopedic specialist I’ve been seeing for over 12 years. I’d developed drop foot in my right foot; the left foot went about 4 year prior. After only a few minutes Dr. K came walking through the door. He said, “John Sandherr, man are you screwed.” He said, “I spoke to Dr. Frank the other day and he told me he was closing his pain clinic.” He told me the DEA was making it almost impossible to treat pain patients with Opiates so he’s going to stick with his addiction clinic. “What are you going to do,” he asked me. “I know what you’re taking and it’s a big dose, but you need it John.” He said, “I could operate on you and you might feel better for a few months, but after that you will be worse off because of all that scar tissue you have from the other 10 operations you’ve had…or is it eleven. I feel for you brother, If ever there was a patient that needs to use pain medicine it’s you.” Dr. K went on to tell me about a good friend of his that had a run in with the DEA over a single prescription he had written for a patient, the standard 7 day supply of Percocet following knee surgery. He was told that some of the pills wound up in the hands of someone other than the patient and for that reason he is now under investigation.

I hold no grudge against Dr. Frank for closing the Pain Clinic and I know it was not a choice he made purely for money. What angers me is we now have a government telling Dr’s what they can or cannot prescribe for a patient that has not demonstrated any sign of drug addiction. People that are in pain and depend on opiates for relief deserve to be treated with what helps them the most. Just a week after my last visit the Governor of Pennsylvania signed a new bill that will almost force Dr’s to comply with when prescribing opiates. With that and the new “Monitoring System” the state just put in place, Dr’s now have a difficult and time consuming job and what they really want to do is help those in pain.

When I found out that – Bain Capital a Hedge Fund company – are investing in substance abuse for profit it all made sense. I was working in the Mortgage Industry when the housing market collapsed; there were Hedge Funds for investing in housing failure. Many became multi-millionaires overnight.

It was Dr. Isben that said “follow the money” and I’ve started to do that. The money is invested heavily on addiction, not helping people in pain. Can we convince enough of the right people that the real facts have not been revealed?

Source: 15 Years with My Pain Dr. and My Last Appointment Became My Final Appointment – National Pain Report

WHO | Influenza update – 325

Information in this report is categorized by influenza transmission zones, which are geographical groups of countries, areas or territories with similar influenza transmission patterns. For more information on influenza transmission zones, see the link below:

Summary

In the temperate zones of the southern hemisphere, influenza activity appeared to decrease in South America and Southern Africa. Influenza activity remained at low seasonal levels in Australia and New Zealand and at inter-seasonal levels in most of temperate zone of the northern hemisphere. Increased influenza detections were reported in some countries of Southern and South-East Asia. Worldwide, seasonal influenza subtype A viruses accounted for the majority of detections.

National Influenza Centres (NICs) and other national influenza laboratories from 85 countries, areas or territories reported data to FluNet for the time period from 03 September 2018 to 16 September 2018 (data as of 2018-09-28 04:54:34 UTC). The WHO GISRS laboratories tested more than 68731 specimens during that time period. 2512 were positive for influenza viruses, of which 2120 (84.4%) were typed as influenza A and 392 (15.6%) as influenza B. Of the sub-typed influenza A viruses, 1104 (65.3%) were influenza A(H1N1)pdm09 and 586 (34.7%) were influenza A(H3N2). Of the characterized B viruses, 54 (55.1%) belonged to the B-Yamagata lineage and 44 (44.9%) to the B-Victoria lineage.

The WHO Consultation and Information Meeting on the Composition of Influenza Virus Vaccines for Use in the 2019 Southern Hemisphere Influenza Season was held on 24-26 September 2018 in Atlanta, United States of America. It was recommended that trivalent vaccines contain the following: an A/Michigan/45/2015 (H1N1)pdm09-like virus; an A/Switzerland/8060/2017 (H3N2)-like virus; and a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage). It was also recommended that quadrivalent vaccines containing two influenza B viruses contain the above three viruses and a B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage).
The vaccine recommendation for the 2019 Southern Hemisphere Influenza Season can be consulted at this link below:

Source: WHO | Influenza update – 325

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