There are several really good flu pieces in the NY Times from the last few days. One set of stories is on the issue of vaccine distribution, including this one:

Citigroup has received 1,200 doses, more than half of what it requested, health officials said, and in late October, Goldman received 200 of the 5,400 doses it asked for. By contrast, Memorial Sloan-Kettering Cancer Center received 200 of the 27,400 doses that it requested for its workers, according to the New York City Department of Health and Mental Hygiene.

Jessica Scaperotti, a health department spokeswoman, said the priority was to get the vaccine to pediatricians, obstetricians, gynecologists, community health centers and public and private hospitals. Private companies that have asked for the vaccine are also eligible to receive it, as long as it is distributed to people who are considered at risk.

A follow-up story was based on the press conference at CDC Friday:

The federal health official in charge of immunization and respiratory diseases said Friday that swine flu vaccine should be distributed through many outlets, including workplace clinics, to get it to high-risk people as quickly and efficiently as possible.

The official, Dr. Anne Schuchat of the Centers for Disease Control and Prevention, was responding to a furor caused by the revelation that the employee health departments of some big Wall Street banks, including Goldman Sachs and Citigroup, had received small shipments of vaccine — while pediatricians, clinics and major hospitals waited for their full allotments.

"There’s nothing wrong with an employer-based clinic," Dr. Schuchat said. "When you look at adults and where they get vaccinated, it’s a common place. It’s convenient."

Workplaces often have employees who are pregnant, have newborns at home, or have asthma or diabetes, she said, adding, "Our goal is put vaccine in the path of people who are in those priority groups to make it as easy as possible for them to be vaccinated."

As noted when we discussed this on Friday, however it gets to high risk patients, it gets to high risk patients. This very-foreseeable furor is based on the idea that Wall Street isn't very popular right now (arrogance is out, humble is in) and that somehow, they were line jumping ahead of others. But here's what the experts say:  

Local health departments decide who gets each vaccine lot, and the centers sent a letter to all state, county and city health officers on Thursday reminding them to make sure it was going only to people at risk.

The agency itself had "no evidence that providers were giving vaccine outside the recommended priority populations," Dr. Schuchat said.

Independent flu experts noted that workplace clinics could control who got vaccine, while public vaccination campaigns have been plagued by reports of people begging vaccinators for shots or admitting having lied about being pregnant or asthmatic.

Just assume there is no public trust, and document everything. Give them vaccine and make the companies accountable. Vaccinate the high risk group however you can. Do it transparently. Don't have the companies defend it (no one trusts them, and recognize that no one trusts them), have the health department defend it. And at the end of the day, recognize that our public health infrastructure is cobbled together with bailing wire and duct tape. Fix it at the state and local level before it breaks down altogether (and yes, the stimulus would have been a perfect place to get the money...)

Susan Collins: "Everybody in the room is concerned about a pandemic flu, but does it belong in this bill? Should we have 870 million dollars in this bill? No, we should not."  

Actually, yes, we should.

...

Now, while Wall Street actually gives out vaccine, these outlier docs don't.

Public health leaders are at a loss to explain the skeptical minority, except to say that it mirrors the chronically low percentage of health-care workers who get the seasonal flu vaccine every year. Officials worry that these doubters could have a disproportionate influence in an already frustrating and confusing situation, and stress that the studies conducted so far and the intensive monitoring underway indicate that the vaccine is as safe as any flu vaccine.

"I am very disappointed, deeply puzzled and very disturbed by this," said William Schaffner, president-elect of the National Foundation for Infectious Diseases. "The people for whom these doctors are not recommending this vaccine are clearly high-priority patients who could have very adverse outcomes if they get infected with the virus."

I am completely with Schaffner. Patient questions about vaccine are one thing, medical profession harm from denying patients vaccine is another thing altogether. As a doc who treats high risk children, I am ashamed of my (occasionally) under-informed colleagues, but not surprised. Some people including docs put their finger in their ears and hum loudly whenever facts that distract them present themselves. To break through that, the professional societies need to do a better job educating the health profession (you can see it in the usually poor 50% compliance with seasonal flu shots, which is much better this year than most.) But you have to actively ignore the data sent out by AAP, AAFP, CDC and others to stay this ignorant. Just goes to show doing something of this magnitude (flu vax education) is of the herding cats variety of difficult.

Also, while Wall Street gives vax, swine flu clinics in NYC are not well attended.

Seven of the city's weekend swine flu vaccination clinics for middle and high school students opened Saturday - but turnout was so low that the Health Department invited more people in.

The presence of available vaccine, more than anything else, will defuse the Wall Street story.

...

Meanwhile, on vaccine, here's new polling data:

Only about a third of adults who have tried to get a swine flu vaccine have been able to get it, according to a new national poll released Friday.

That's true even for people who are at extra risk for severe complications and should be at the front of the line. The numbers are about the same for parents who tried to get the vaccine for their children, the Harvard School of Public Health poll found.

And here are the numbers:

Only 5% of those polled said they already had been inoculated. Of the rest, 52% said they did not plan to get vaccinated. Of the 40% who said they wanted the vaccine, 12% said they already had attempted to find it but failed.

   Of those polled, 70% said they think the H1N1 vaccine is safe for most people, while only 17% said there was a strong chance the vaccine is unsafe.

As I noted yesterday, since 20-30% of Americans get a voluntary flu vax every year, we are doing better than the norm. And we are certainly doing pretty well on the vaccine safety issue, despite the occasional nutter who claims otherwise. The CDC vaccine safety page is here.

...

Finally, the big clinical issue is to treat or not to treat.

According to the Centers for Disease Control and Prevention, antivirals should be given in the most severe cases of the flu, or when a patient is in a high-risk group, which includes pregnant women and children under 2.

But that leaves a large gray area for mild or moderate cases or people who have simply been exposed to the virus and want to prevent its taking hold. For the moderately ill, the drug may shorten the duration of symptoms by about a day. But it is expensive, costing about $100 for a 10-pill adult course, and it can have side effects like stomach aches, nausea and, more rarely, confusion and nightmares.

There's some good advice within from flu experts Andy Pavia (I interviewed Dr. Pavia on Daily Kos here) and Anne Moscona (Cornell.)

It comes down to a judgment call for doctors and parents, said Dr. Andrew T. Pavia, chief of the division of pediatric infectious diseases at the University of Utah and chairman of the pandemic influenza task force of the Infectious Diseases Society of America.

"There is no group for whom treatment is inappropriate if they are ill with influenza," Dr. Pavia said. But, he cautioned, "in mild to moderate illness, treatment has to be begun within 48 hours to have substantial benefit."...

The guidance "leaves room for clinical judgment," said Dr. Anne Moscona, a professor of pediatrics and microbiology at the Weill Cornell Medical Center. "And it leaves room to decide on a case-by-case basis, thank God, but humans want to be told exactly what to do. If the C.D.C. gave more specific guidance than that, they would be making it up."

Still, best advice is check with your own doc. At this point in time, tamiflu shortage is not an issue. pediatric meds are in short supply, but pharmacies (you may need to call around) can make a suspension from adult capsules.

...

A joint Q&A interview (myself and CDC) is here on momlogic.