Effect Measure

Pregnancy and influenza planning

Posted by revere on October 27, 2006
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A letter from Philip Mortimer of the UK’s Health Protection Agency to the CDC journal, Emerging Infectious Diseases, calls attention to an apparent increased risk for death from influenza among a subpopulation, pregnant women. Mortimer alerts us to the fact that most (all?) national contingency plans for pandemics do not take this into account.

Mortimer cites literature from the 1918 pandemic that contains ominous figures:

Bland reported on pregnant influenza patients in Philadelphia and elsewhere in the fall of 1918; of 337, 155 died [Bland PB. Influenza in its relation to pregnancy and labour. Am J Obstet Dis Women Child. 1919;79:184-97]. Harris obtained by questionnaire from obstetricians medical histories of 1,350 pregnant patients in Maryland and in 4 large US cities [Harris JW. Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases. JAMA. 1919;2:978-80]. Pneumonia developed in half (678) of these patients and 365 died. Death rates from pneumonia were >40% for every month of pregnancy; fetal loss was >40% in all months but the fifth (37%).

According to a contemporaneous report from England, the influenza death rate for pregnant women was 25.4% [Bland PB. Influenza in its relation to pregnancy and labour. Am J Obstet Dis Women Child. 1919;79:184-97]. These inquiries into pregnancy must have been biased toward severe cases, but the influenza pandemic in 1918-19 may nevertheless have decreased live births in England and Wales, which reached new lows in the first half of 1919 [Registrar General's Report 1918/19. London: Her Majesty's Stationery Office; 1919. p. xxviii]. A controlled American study during 1975-1979 has since confirmed that pregnant women are at risk for influenza even in interpandemic years [Mullooly JP, Barker WH, Nolan TF. Risk of acute respiratory disease among pregnant women during influenza A epidemic. Public Health Rep. 1986;101:205-11]. (P. Mortimer, letter in Emerging Infectious Diseases, Open Access)

A characteristic of pandemic years compared to interpandemic years is a marked shift of the age distribution of cases to younger age groups, particularly young adults. We also know that pregnant women have altered immune systems.

So Mortimer makes a good point. Will it be lost on policy makers?

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  1. #1 william
    October 27, 2006

    In 1918 1 in 5 US Army recruits had either TB or veneral disease. And yes, pregnant women were a prime target of Spanish Flu. But many people in 1918 had weak immune systems due to TB and venereal disease also. That may be why so many soldiers died in 1918 from Spanish Flu.
    Coughing up blood also happens in advanced stages of TB, and pneumonia is common in TB patients. How many of those who died, including pregnant women, actually died of TB rather than Spanish Flu. These victims were not tested. It was all the medical staff could do to try to treat the sick. There was no time for testing. Will the same thing happen now?
    There were recently emergency WHO and UN meetings, in South Africa, regarding XDR-TB(extreme drug resistant TB) and MDR-TB (multi-drug resistant TB). The minister of health of South Africa said, “Without special efforts to test multi-drug resistant (MDR) patients for rsistance to other drugs, government will be unaware of the presence of XDR-TB among TB patients. This means a lack of investment in new diagnostic tests and new TB drugs could allow XDR-TB to explode, out of control, and cause a pandemic.
    What happens if at the same time H5N1 becomes a pandemic,XDR-TB also becomes a pandemic? Which medication does a doctor give the patient? If 2 pandemics hit at the same time, will the hospital laboratory systems collapse from excessive demand for test results. Of course they will. And what does the doctor do then? If he has a patient bleeding from the mouth, does he or she give the patient Tamiflu, or one of the first or second line drugs for TB. If it is regular TB, he can give a first line drug, if it is MDR-TB, second line drugs will need to be given.
    If it is XDR-TB, constant testing will be required to determine which second line drug to give.
    And if the hospital lab is shut down, what does the doctor do? Should the doctor give Tamiflu, first line TB drugs, and second line TB drugs at the same time. I hope he does not, since second line TB drugs are very toxic.
    XDR-TB is epidemic in Eastern Europe now. An article in Nature magazine says it may be impossible to stop XDR-TB.
    Houston, we have a problem.

  2. #2 neal
    October 27, 2006

    William, you need to get a life.

  3. #3 william
    October 27, 2006

    One further comment and I will stop.
    For some XDR-TB patients there are only 2 second line drugs that still work. The cure rate is about 50%. What happens if XDR-TB develops a resistance to these 2 remaining second line drugs? It means there will be no way to stop it, period. It was announced there will be no new TB drugs until 2015.
    It is still not clear to me how many of those in Indonesia who supposedly died of H5N1, but tested negative for H5N1, may have actually had TB. Where they tested for TB? I doubt it.
    Myth: XDR-TB only kills people infected with AIDS. This is false. Of 60 patients who recently died in South Africa from XDR-TB, 44 had AIDS, and the rest were healthy adults.
    So don’t think XDR-TB cannot kill you because you do not have AIDS.
    So we have a situation where we may have 2 simultaneous pandemics, one with H5N1, and one with XDR-TB. And very few countries in Africa have tests for XDR-TB, so it is impossible to know how many patients are infected. What is known is that every province in South Africa now has XDR-TB patients, and more deaths are being reported daily, with medical staff and patients in South African hospitals being infected all the time. Patients in those hospitals go into a panic when they learn XDR-TB patients have been admitted.
    Now combine all this with the fact that more and more people in Indonesia are being infected with H5N1, and about 50% of those die.

  4. #4 william
    October 27, 2006

    Neal,
    Why don’t you make an intelligent comment, buddy?

  5. #5 neal
    October 27, 2006

    William,
    when the subject line says: Bird Flu – Pandemic Preparedness why don’t you stick to the subject matter? Your incessant off-topic blathering is wearing me out. I come here to learn about the latest developments in preparing for the possible pandemic. I don’t read all the Revere posts, just the ones that interest me. So, then I start to read one on that subject…along with all the comments, as I believe many folks here have valuable information to contribute as well. But, I guess I need to re-think my premise on that…

  6. #6 Red Crayon
    October 27, 2006

    Two observations. Readers will be interested also in Doug Almond’s article in JPE (no access to JPE? try this PDF file).

    Almond is interested not in the pregnant mothers, but in their kids in utero, and he postulates that the negative effects extend to the birth cohorts that were exposed to 1918 while in the womb. He looks at economic outcomes etc.

    Second, just something to ponder. Pregnant women have downregulated immune systems so why would this not have been protective against the “cytokine storm”? Women, overall, had lower death rates than men in 1918, but that statistic, of course, refers to all women.

  7. #7 mary in hawaii
    October 27, 2006

    I just emailed this entry to my pregnant daughter-in-law: maybe it will finally prove to be the impetus that will make my son decide to follow my advice and prepare. I hope so. Thanks for the article, in any case: that’s what it’s all about.

    Off topic, I would like revere(s) or anyone else to give their learned opinions on something. Yesterday CIDRAP had an article about a recent study in which a number of migratory birds were purposely infected with High Path H5N1, but only wood ducks and laughing gulls became symptomatic, even though all the test birds sampled had the virus in their blood. It occured to me that if these other birds could be asymptomatic with high path H5N1 infections, then maybe some errors have been and are continuing to be made when USDA and other inspectors find H5N1 in migratory birds in the US and Canada, and then decide it is low Path H5N1 based on the fact that the birds are not sick. My question: what is the possiblity of this being the case, and if it is, what are the epidemiologic implications for the secret spread of high path H5N1 through North America.

  8. #8 revere
    October 27, 2006

    Mary and everyone else: I am in Europe and my computer won’t post to the blog. I don’t know why and I am going crazy with frustration. With any luck some of the other Reveres will fill in, but there will be gaps.

    Meanwhile, I got this link that may be useful for answering your question. It looks quite good:

    http://birdflubook.org/index_new.php

  9. #9 william
    October 27, 2006

    Neal,
    This is a public health site, not a bird flu site. If you are looking for only information on bird flu, I suggest you look somewhere else. Next, the word blathering is hostile and unacceptable. If you come to this Blog site to insult people, please do not post here. I am not insulting you, why do you insult me?
    Next, as Revere informed me on one of his responses to one of my posts in the past, these issues are a question of life and death. They are serious issues. Revere created this blogsite to assist in the protection of human health, period.
    Rather than attack me, why do you not just ignore what I say, and make intelligent statements in regard to human health. You obviously have an interest in these subjects, and I am sure you are intelligent; but this is no place to release your hostility, so please ignore what I say. Is that so difficult?
    Do you realize what may happen if XDR-TB becomes a pandemic? If you become desperately ill, bleeding from the mouth, and drowing in your own body fluids, you will not be worrying about what a stupid psychotic clown I am. You will fear for your life.
    All that I ask is that you have the courtesy to allow me to express my views. Revere is always here to control me and keep me in my place; which he often does. But he still allows me to express my views. So please do not worry about whatever stupid statements I make. Revere will take care of it for you. Completely ignore whatever I say.
    But if you become infected with XDR-TB, you will be thinking only about whether or not you will live or die, not about some stupid statement I made.
    Revere is very special, and he knows better than any of us just what a human tragedy a pandemic will be.
    Please have a nice day, and forgive me if you feel I have insulted you.
    But I insist on my right to express my views, just as you are free to say whatever you want.

  10. #10 crfullmoon
    October 27, 2006

    (Wonder what percentage of US population -or any country’s population- currently has a STD or is HIV+? Or has MRSA, TB, cancer, ect…)

    Pregnant women after a certain point also have physically reduced lung capacity, crowded by the baby, which I don’t imagine helps.

    Protecting pregnant women (and productive young people and current essential workers) would have benefits for their families, and ultimately for the economy and national resiliance when post-pandemic recovery becomes possible. Sounds like a “national security issue” to me.

    (And an ethical issue to those currently not warning the public and not preparing for the worst-case.)

  11. #11 crfullmoon
    October 27, 2006

    Red Crayon, the pdf was interesting. Thanks.

    My grandmother was in a state where it looks like she arrived just about the same time the 1918 pandemic did, so probably prenatal exposure wasn’t much of a factor. (Not that she had many years of education, but, girls “on the farm” sometimes missed out that way – maybe more so post-pandemic; guess I can still ask her, about how long the other girls her age stayed in school, and find out.

  12. #12 william
    October 27, 2006

    http://www.aidsmap.com/en/news/FD903A8B-11CA-46BE-A8DE-5DA47746D7B6.asp
    In an article entitled XDR-TB: Now More Cases Than Bird Flu
    it says South Africa has detected 284 cases of XDR-TB in the province of Kwazulu Natal alone, exceeding the 256 cumulative cases of avina flu worldwide.
    I know, you will say what has this to do with pregnant women in 1918 that died of Spanish Flu?
    There were many women in 1918 that were infected with TB. Probably some of them also contacted Spanish Flu, due to their weak immune systems. There is a need to look at H5N1, XDR-TB, and AIDS, to see if there is a relationship between these diseases.
    AIDS is causing XDR-TB to spread 6 times faster than it would alone. In Eastern Cape Province of South Africa, there are 20 patients waiting for confirmation they have XDR-TB, and the disease has caused 14 deaths there recently.
    XDR-TB is exploding before our eyes. What happens if XDR-TB arrives in Indonesia, where there are many H5N1 patients? What happens if both diseases arrive in the US at the same time?
    Someone in public health had better wake up fast, because this XDR-TB freight train is coming down the tracks at expotential speed. There are only about 2 toxic second line drugs between it and disaster. If it becomes resistant to those 2 drugs, we have a slight problem.

  13. #13 lugon
    October 29, 2006

    I wonder if pregnant women can take statins.

    Apparently they shouldn’t? http://www.usatoday.com/news/health/2005-01-12-statins-risk_x.htm