A Light Sneeze

“Caught a light breeze, caught a light sneeze

caught a lightweight lightning seed.

Boys on my left side, boys on my right side

Boys in the middle and you’re not here.”

Tori Amos, Caught a Lite Sneeze

                 

Now, you might think of flu as just a really bad cold, but it can be a death sentence. Every year, 36,000 people in the United States die of seasonal flu. In the developing world, the data is much sketchier, but the death toll is almost certainly higher.

Seth Berkley

I recently read an article that postulated that non-immunized taxi cab drivers in New York City are major culprits in the annual spread of influenza infections, (“Taxi Flu Epidemic:  Most Cabbies Are Not Vaccinated,” The New York Post, April 19, 2015).  The article wondered if a program that mandated the immunization against influenza of all licensed cab drivers in New York… would cut down on the transmission of disease.  

The question is a good one because it directs focus toward some larger and more important questions:  How do the flu do those things that flu do?  What role might Public Health better play in protecting public health?  Do workers who largely serve the public have a social obligation to protect the public against preventable communicable disease?

 

If the answer is yes for cabbies… then for whom else does it equally apply?  How about bus drivers, (et tu Ralph Kramden)?  How about any public servant who unknowingly places young infants and elderly unimmunized customers at increased risk of hospitalization and death... with something so simple as a cough, a light sneeze, or a friendly handshake?

People over the age of sixty five immunize against influenza and pneumonia at dismally low rates.  The herd immunity rate for the elderly is traditionally less than twenty percent.  They are at very high risk of catching influenza from others.  This same group is disproportionately sickened and killed by influenza and the pneumonias that are spawned by it.

Influenza related pneumonias cause six to eight percent of all deaths in persons aged over sixty five years.  Ten percent of all costly emergency room visits for pneumonia by this crowd end in death.  Fifteen percent of these same emergency room visits result in multiple costly Medicare-readmissions-within-thirty-days.

The mortality graph for influenza related pneumonias has a vertical axis that tracks numbers of deaths, and a horizontal axis that tracks victims ages.  The curve typically creates a letter U.  The base of the U curve anchors over the age of thirty five; and the two stem tips peak at the age of one year, and again at the age of seventy years.  The majority of deaths plotted are shared equally by infants and by the very old, over fifteen thousand of each annually… lending height and uniformity to the U curve.

The deadly influenza pandemic of the early nineteen hundreds created an atypical graph curve that looked like the letter W.  The middle peak of the W curve centered over the age of 35 years.  The majority of deaths were caused by secondary pneumonias… and mortality was shared across a spectrum of all ages of victims.  It is folly to assume that such an influenza pandemic could never again occur.

To illustrate the health risks posed, consider a day in the life of one favorite patient living in Monroe County, Michigan.  Her name has been changed for reasons of confidentiality.

Ann is seventy years old.  She foolishly does not immunize against influenza or pneumonia.  Ann was hospitalized with mild bronchitis ten years ago.  Ann lives alone in her own home and is economically home-bound.  She has Medicare insurance coverage, and receives a monthly social Security check, but does not qualify for additional economic assistance.  She uses the local transit system to complete all weekly errands.  One recent weekly itinerary with potential exposure to flu risk ran as follows:

• Ann scheduled a series of errand stops with the local public bus transit system.  The transit system drivers are not required to get an influenza vaccine.

• The first stop was at a local bank.  The bank tellers are not required to get an influenza vaccine.

• The second stop was at the post office to check the post office box, and to mail some bills.  The postal employees are not required to get an influenza vaccine.

• The third stop was at the local library to return some books and to pick up some new books.  Library employees are not required to get an influenza vaccine.

• The final stop before returning home was at the local supermarket to do some light shopping.  The cashiers are not required to get an influenza vaccine.

There are several thousand home-bound seniors like Ann living in Monroe County.  If Ann dies of influenza related pneumonia at the local hospital later this flu season… to whom do we look? Who dealt the hand?

Some questions answer themselves.  People over the age of sixty five need to immunize against influenza and against pneumonias at much larger numbers.  A twenty percent herd immunization rate is unacceptable.  Medicare provides the vaccines cost free.  Immunizers need to get better at beating the bushes to get the elderly immunized.  Primary caregivers are simply not doing enough.

People who work directly in service of the public are morally and ethically obligated to immunize against influenza.  Workers who have health insurance are currently entitled to cost free immunizations as a benefit.

Employers with uninsured employees have a social obligation to provide workers with cost free vaccinations.  Cost free influenza vaccinations are available at any subsidized Public Health Department clinic.  Employers are obligated to require that all employees be properly immunized against influenza.

A single preventable death will always be too dear a price to pay.  Whose death is replaceable?  A senior who refuses to immunize, a service worker who refuses to immunize, an employer who refuses to demand immunization of all public service employees… could each directly contribute to a single preventable death this very year.  How many of the forty thousand deaths from influenza that happen this season will have been single preventable deaths?

Let the cab driver, the bank teller, the librarian, the cashier, the transit bus driver, and all others who work to serve the public take heed:  the senseless demise of someone that somebody else loves is at hand this year for the sake of a lightweight lightning seed… or of a light sneeze.

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