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H1N1 (Swine Flu) and HIV: How U.S. HIV Health Care Settings Are Gearing Up for the 2009 Flu Season
A Webinar From AIDS.gov
Miguel Gomez: This is Miguel Gomez with AIDS.gov, [www.aids.gov] and I want to welcome everyone to our webinar and conference call on H1N1 preparedness and HIV/AIDS.
And during the course of our time together I really hope that we'll be able to share some information; one about the basic facts about H1N1, two the important facts about H1N1 as it relates to HIV/AIDS, and three, what we can all do to support H1N1 preparedness in our communities.
Miguel Gomez
And as we move through this time together, just really reinforcing that we do not want to scare individuals, but we want those we reach and serve, and our staff, well informed. And that we all have an obligation to keep ourselves well informed. And we need to take opportunities to help others in our -- or be prepared to help others in the community, if they need help responding to H1N1.
And I'm real excited that we have speakers from the CDC, NIH, and we'll have representatives from grantee community helping us today, from DC, Chicago, New York. And I'll introduce them through the course of the call. And we're also going to take questions after our grantees speak. And our operator will reinforce how you can ask those questions.
And I have a special message for those who are not watching on the Webinar but are just following us on the phone, that the slides that you're unable to see are really just all web pages that are available on flu.gov and cdc.gov, and we'll make those, actually the entire format of what we're presenting today, available to everyone in about a week.
And I really want to start the call with our colleague from the CDC, Dr. John Brooks. And Dr. Brooks is in his office is responsible for research on how to improve the quality of care for people living with HIV to better understand the consequences of better treatment and longer survival, and has been a lead voice on HIV and H1N1 for the department and really grateful to have you with us sir.
And I want to start with our first question, a more general question, about what we all need to know. Sir?
John Brooks: Well, thanks Dr. Gomez very much. And good afternoon everyone who's on East Coast. I suppose a good late morning to those of you on the West Coast.
I really appreciate the opportunity, Miguel, to speak and share space with friends and colleagues and interested persons -- what we know and have learned about novel H1N1 flu that's relevant for persons living with HIV infection.
As Dr. Gomez mentioned, my name is John Brooks and I work at the CDC. And just to give you a sense of the background about what's been going on with regard to preparation for H1N1, I'm sure that most of you are well aware that in the Federal level, agencies throughout Health and Human Services as well as in coordination with many other departments throughout the government, have been responding very aggressively to H1N1 since we first learned about it earlier this year in the spring.
And since that time, we've been expecting and planning for a resurgence of H1N1 influenza. We continue to see percolating activity of H1N1 more so than we would have normally expected during the summertime, and we are anticipating that there may be resurgence.
An important part of planning for a possible resurgence is to let people like yourselves know what they should expect, and to start planning ahead of time for the event that we see a lot of flu cases, a lot more than we may have seen in past years. Our planning efforts are ongoing, but let me emphasize that influenza is unpredictable. And we are -- we know that we may well be surprised.
Now my goal over the next couple of minutes is to go over with you what we know and have learned about novel H1N1 flu that's relevant for persons living with HIV infection.
I'll be addressing most of my comments to persons living with HIV and persons and organizations who care for or provide services for persons living with HIV infection. However let me say that much of what I'm going over is also applicable to adults and adolescents living with other immune-compromising conditions.
So to get started, I think if I had to summarize two key themes of what I'm going to talk about on today's call, the headlines would be -- first, be informed, and then secondly, stay informed. So be informed and be prepared and stay informed.
I'll review what we need to know to get prepared and stay informed, again for persons with HIV and their providers, and go into a lot more detail on these issues in just a minute.
But I first wanted to review for you some basic resources that you can access to learn more about H1N1. The first is shown here on this slide I believe, which is the CDC's main web page [http://cdc.gov/h1n1flu/] for the H1N1 flu.
Now this is a large Web site. It's regularly updated. It's full of information. Many, many questions that people have can be answered here, and, is the first place I would refer folks to go if they have very specific questions.
If you see on the top right of this picture here [http://cdc.gov/h1n1flu/], there's a place where it says that you can get email updates, and folks are -- it's a little lower down. I'm watching the cursor move. In the box a little higher up, just a little higher up. There you go. Just above that. One more there. Get an email updates.
If you'd like to receive email updates anytime, this Web site is updated -- and that will include updates for everything, including issues that are related to HIV infection. This is a place to sign up and you'll receive those. Now as -- sorry go ahead.
Miguel Gomez: Well, and actually John on this page, one of the things that's also just really wonderful is there's other tools like you can also follow and get updates directly on Twitter. [http://twitter.com/flugov] And also, another good resource which we'll link to this Web page is of course flu.gov. [http://www.flu.gov/]
John Brooks: Exactly.
Miguel Gomez: And sir, you know, you -- a second ago as you saw on the next slide the next question that you alluded to that did want to talk to is really speaking to what people living with HIV and their providers need to know. Could you share that information, sir?
John Brooks: Yes, absolutely. Thanks very much. I think the first thing that I want to say -- and this is really to echo what Mr. Gomez said earlier -- is we have abundant reason to be cautious, but there's no reason to panic right now.
The information that we've got available so far this year doesn't seem to indicate that people living with HIV infection are at any greater risk of getting the novel H1N1 influenza. But we'll be monitoring the situation throughout the winter season to see if that changes. But right now there's no obvious extraordinarily increased risk. And this is consistent with our prior experience with seasonal influenza, mainly that persons living with HIV are generally at about the same risk of catching influenza as everyone else. However, there are relatively good data that suggest that persons living with HIV infection, and especially persons with low CD4 cell counts that would be a CD4 count less than 200 or you have AIDS, can experience more severe complications of flu if they get it.
So for that reason, persons living with HIV infections should really do as much as they can to prevent getting infected with influenza. And if they think they've gotten infected or it if they do get infected, to get proper treatment.
There are a number of important things that you can do to reduce your risk of acquiring influenza, including both seasonal and H1N1 influenza, if you're living with HIV infection.
The first is, is to reduce your likelihood of exposure to that virus. You know, you're going to hear this over and over, it's becoming a mantra that I see everywhere but it's so true. Washing your hands works.
Wash your hands often. With soap and water or an alcohol-based sanitizer. And, you know, you, any time you pass through a bathroom or in your kitchen washing dishes, that's an opportunity to wash your hands.
I just wanted to point out that on the Web right now, the site -- the Web site that's showing is the CDC's web site [http://cdc.gov/h1n1flu/hiv_flu.htm] for information specifically for persons who have HIV infection. If you want it -- much of what I'm saying now, is also accessible here on this Web site [http://cdc.gov/h1n1flu/guidance/ ].
In addition to washing your hands, another important thing to do is to avoid touching your eyes, your nose, or your mouth. This is the way the germs can get spread and get into you. It's also important to the extent possible to avoid close contact with sick people. And in general we think of close contact as contact that's within about 6 feet.
Another really important aspect for persons living with HIV infection is to do things to keep your immune system strong. And a good way to do that is to maintain a healthy lifestyle. You know, sort of a basic eating right, getting enough sleep, and reducing your stress as much as possible are very important things to keep in mind during a period when there may be a lot of stress on us from what we're hearing in the news and what's going on during the flu season.
It's also really important that if you're taking medicines for HIV infection -- and I'm speaking here specifically about anti-retroviral medication or also some antibiotics that persons are occasionally prescribed to prevent what we call opportunistic infections -- any medications that your doctor is prescribing you presently for HIV infection, take these. Don't miss any doses. These medicines keep your immune system strong. And it helps -- it can help it fight off the flu and fight the flu if you get it.
Next, when the vaccine becomes available for H1N1, get vaccinated. But also get vaccinated for the seasonal flu. I should let you know if you don't know already that persons living with HIV infection in the United States are a priority group for vaccinations against the H1N1 when this vaccine becomes available.
This vaccine will probably consist of two shots. A first shot, and then one a few weeks later, a second shot. You also however still need to get the shot for seasonal influenza which is available now, and should be coming into clinics over the next couple of weeks.
Its -- the strains of flu that are -- that that to which the vaccine will offer protection are also circulating out there. And so you need this second -- this regular seasonal influenza vaccination to protect against those.
Important though to know that just that seasonal influenza vaccination we don't have -- we don't believe that it confers any protection or provides any protection against the novel H1N1 flu.
It's important to also talk to your doctor and make sure that in addition to your seasonal influenza vaccination that all of your other immunizations are up to date.
And I'm also thinking about a vaccination that is recommended for all persons living with HIV infection against the bacteria called Pneumococcus. The trade name of the vaccine is Pneumovax®.
This is a bacteria that persons with HIV infections are more prone to getting sick with, and that can also make people who've had the flu or are having the flu ill. It can predispose a person with flu to getting the second infection. So if you aren't sure you've had it already, check with your doctor to make sure that you've gotten it.
Lastly if you're -- if you've had a really close contact with someone who you think might have influenza, contact your provider. That person will help you be able to determine whether you need drugs called chemoprophylaxis or medication to prevent you from developing influenza in the event you were exposed to it.
So what are the symptoms of influenza? Well symptoms are those of sort of typical influenza. We know that there's cough, fever running nose, aches and pains. With this strain of the novel H1N1, some people seem to have been reporting more nausea and vomiting than we've seen with other strains.
In terms of what you can do if you think you have the flu, the first thing is to contact your doctor and if possible seek his or her advice by phone, or by email or, not necessarily by immediately going into the office.
And why am I saying this? Well, in the event that you feel sick but it turns out to be something else, you don't want to enter an office space where there may be a lot of other people that could have the flu that they'd pass to you. And in the event that you do have influenza, you don't want to go into a space unprepared and possibly expose people in the waiting room to that influenza.
These are all countermeasures to try and reduce spread of the virus. If you need to seek healthcare, consider wearing a face mask or covering your nose with a tissue. And when you arrive at the office ask -- let them know that you're there because you think you might have the flu, and that you need to have a mask.
If you're diagnosed with influenza H1N1, you need to stay at home for at least 24 hours after your fever is gone except to get medical care and for other necessities. And your fever should be gone without the use of fever reducing medication. So, that's without taking acetaminophen or aspirin or ibuprofen.
So, there is definitely treatment right now for H1N1 influenza. There are a couple of drugs that we know can treat the flu. Two of those are drugs to which this virus are susceptible. These drugs are called antiviral drugs. And, now those are different than antiretroviral drugs. And the two antiviral drugs to which H1N1 is susceptible are called zanamivir and oseltamivir. Following...
Miguel Gomez: Go ahead Dr. Brooks. Go ahead.
John Brooks: Sorry. I was going to say follow your doctor's recommendations, and take these antiviral drugs if your doctor recommends them, and keep taking your antiretroviral medication for HIV while you're sick unless you're instructed otherwise to do so by your doctor.
Importantly stay informed. As I mentioned earlier things can change. So find out where you can get information relevant to you, where it's located such as the CDC Web site [http://cdc.gov/h1n1flu/] and flu.gov [http://www.flu.gov/] and other places.
Pay attention to what's in the news and other media. We communicate regularly with POZ Magazine, Project Informed, The Body, NAM, other organizations that you could maybe see some things showing up for. And as I mentioned earlier, sign up for emails if you're interested.
And then lastly, before I go on to talk about what we -- what providers can do. Now, you might want to make a point of the next time you see your doctor for routine HIV related healthcare to, talk to him and/or her and make sure that you've got adequate supplies of antiretrovirals, and other prescription medications on hand. We usually recommend at least two weeks.
And in preparation for the possibility that you might get sick, have enough medication, over the counter medication for colds and flu available at home as well as perhaps tissues and canned soup, or other comfort measures that you might want to have with you.
And then lastly, now's the time to think about making sure that you've got a friend or a family member or someone else that if you get sick you can contact to help you out.
So let me stop there and ask Mr. Gomez if he had a -- wanted to move...
Miguel Gomez: Well I think the best thing is you alluded to it. Let's actually talk about what advice you do have for the providers, please sir?
John Brooks: Yes, that's a really important point. You know, providers, both providers provide medical care and those persons of the community who provide public health support and support the programs for people with HIV infection are really critical to this the whole effort.
And, I wanted to point out we have a web site that has information. I think it's on the next slide, ten action steps that you can take if you are a medical office, but this would be applicable to other situations where people are seeing persons with H1N1.
And let me just summarize basically what this and some of our other guidance says. The first thing is to prepare your clinic or office setting for the arrival of patients with H1N1. You want to assess what supplies and quantities of such supplies you might need. Consider how you would handle a surge of patients. What if 10% or 20% of your clinic's population showed up on one day?
Begin now of trying to find out where seasonal flu vaccine and the H1N1 flu vaccine will be made available in your community. That's -- it's -- that's a decision that's made at the state health department level, and you should work through them to find out where you'll be able to get access to those vaccines in your own community.
And then, I think on the next slide there's a picture of a nice brochure [http://www.cdc.gov/flu/professionals/flugallery/2009-10/pdf/certain_medical.pdf ] that our Influenza Division put here together that's got a little bit a title -- awkward title, information for flu about persons with certain medical conditions. And that includes HIV infection and other immune-compromising condition.
This is a great brochure to print out. It's four pages, double sided. It'll be two pages of paper only that you can keep in the office and give to people or circulate to people on the line.
It's also important to prepare your staff. Make sure that any staff members you have who might have contact HIV-infected persons are vaccinated against both the seasonal flu and the H1N1 flu when that vaccine becomes available.
Review with your staff the steps that they need to take to protect themselves during an outbreak of flu and how to institute effective infection control measures. And I won't go into a lot of detail about what those measures are. But there's a very detailed guide on the CDC Web site about that that should be able to answer most people's questions.
It's important to consider how you might -- how you plan to deliver services from your organization if staff members become sick. What if 10% or 20% of your staff were sick and out? You know, how -- what are you going to do in terms of providing services to your patients or others? And what might -- what would you do if you had to close your office temporarily?
And then lastly, consider developing a plan for sharing information about the patients in your clinic with other healthcare providers. Imagine that your patient's been admitted to the hospital and you know all the information about their HIV related care, but perhaps the person in the hospital doesn't have access to that. Have you got a way for them to reach you or to access that information and get it together quickly for them?
And then, it's important to also prepare yourself. You know, review our guidance [http://cdc.gov/h1n1flu/guidance/] for clinicians and public health providers on the CDC web site. And prepare your patients and the clients that you see.
Alert your patients for instance to this brochure [http://www.cdc.gov/flu/professionals/flugallery/2009-10/pdf/certain_medical.pdf]. Tell your patients what you want them to do if they think they have influenza. How would they reach you? Do you prefer telephone, email? Do you have other ways of having them reach you?
And have a message that you're going to give to patients about what they need to do if they need to come in to see you. Ensure all the patients' vaccinations are up to date including the pneumococcal vaccination that I mentioned earlier. Encourage folks to take good care of themselves.
And then lastly, if you haven't done so already, consider having patients make out a card showing all of their medications they can keep in their wallet. Make sure they know their latest CD4 cell count and their latest viral load data, at least those two numbers which are very important when -- if they're seen by someone else, and that they think, that you remind them to think, of the name of a person who they can reach out to help them if they get sick.
Miguel Gomez: Dr. Brooks, thank you. And what's so interesting about the federal advice that you're providing, we'll shortly after hearing from our colleague Eda Knight [sic], actually hear from community providers, and what their actions are already taking.
So sir, thank you very much. And I know there'll be some questions for you.
I'd like to leave Atlanta and actually jump to Rockville, Maryland for a moment. Dr. Libby Higgs who's the Deputy Branch Chief at the National Institute of Allergy and Infectious Diseases in the Collaborative Clinical Research Branch.
And, Dr. Higgs thank you so much for joining us today. And could you really share with us what is happening at NIH when it comes to H1N1 and HIV. Ma'am?
Libby Higgs: Well, Miguel, thank you so much for inviting me to join you today. And John that was a really fantastic overview of where we are with the virus at this time.
As I'm sure everyone's aware, the job of NIH is to help provide the data that comes from research to support pandemic preparedness. And here at NIAID -- the National Institute of Allergy and Infectious Diseases [http://www3.niaid.nih.gov/] -- we've been partnering with colleagues in HHS and focusing on three broad areas -- vaccines, better understanding of pathogenesis of the illness, and trying to think through research for novel antiviral approaches.
So just starting with the vaccine, to give you a big picture overview, the NIAID has designed as -- and is in the process of implementing vaccine trials with the novel H1N1 '09 influenza vaccine through a network of sites across the nation. I'm sure some of you have read about that in the papers.
And the focus of these initial trials in addition to developing safety information is to try to understand what the appropriate dose is, what the amount is, the number of doses that might be required. And we're looking at these studies in the broad patient population in which they might be utilized. So that includes adults and children and HIV positive individuals.
Those trials are now underway and they been enrolling rapidly specifically to HIV. There are 12 that are going to be targeted towards HIV positive adults, HIV positive pregnant women and perinatally infected HIV positive children.
We are also interested in learning a lot more about this novel virus in pathogenesis studies, epidemiologic studies. And we have planned and are implementing a number of studies both in the US and in the southern hemisphere to better understand the illness, the complications of illness, the length of viral shedding, where the virus is replicating -- these types of questions so we can better understand and treat the illness.
With colleagues in the NHHS across HHS and in industry we've been exploring trials that might use novel approaches to antiviral therapies.
As Dr. Brooks articulated we have two antivirals zanamivir and oseltamivir to which the virus H1N1 virus is sensitive. But we are trying to look ahead and think about what we might -- both of those, one of those is oral and the other one is inhaled.
We're looking ahead to studies that might be using antivirals prophylactically or in an intravenous formulation and thinking through combination therapies in the case of development of resistance. So, Miguel, that's a quick overview.
Miguel Gomez: Appreciate it. And if people want to learn more about NIH activities related to H1N1, where would they go?
Libby Higgs: We have a lot of information on our NIAID Web [site] [http://www3.niaid.nih.gov/]. If you go to our homepage you can -- you'll be redirected to H1N1 '09 http://www3.niaid.nih.gov/topics/Flu/understandingFlu/2009h1n1.htm. You can also get there through the -- if you go to NIH, that will redirect you to the NIAID's web page as well. And I can send you those web sites if it's helpful.
Miguel Gomez: Great. And I know for all of our listeners we've mentioned multiple web sites and on AIDS.gov we have an H1N1 page. And we will list all of those for folks.
Doctor, thank you very much. And I'm most excited because I'm going to turn to our folks in the community. And I'm going to start with our colleagues both in New York and in Chicago.
We have Ms. Iliana Gilliland. Ma'am, did I pronounce your last name correctly?
Iliana Gilliland: That's fine, Iliana Gilliland.
Miguel Gomez: Great. You're a training manager at the AIDS Foundation of Chicago which is wonderful. And we also have Paul Stabile who is the Director of Clinical Care at the William Ryan Community Health Center in New York City.
And I'm really glad to have both of you joining us and being able to share your experience. And I'd like you both to answer the question, what are some of the concerns you expect to hear from your clients and staff about H1N1?
Iliana Gilliland: Well thank you for....
Miguel Gomez: Go ahead and start in Chicago. Great.
Iliana Gilliland: Thanks. And also thank you to the speakers for a great presentation. And I believe they all -- just through the presentation we just hear from them, we are going to be able to answer too many questions we are going to receive from both the clients, the patients and the case managers.
As you probably know, we here at the AIDS Foundation don't provide direct services. But we coordinate a case management program in all Chicagoland area. We have over 200 case managers in 57 agencies around the community providing direct services to people living with HIV and AIDS.
We're pretty sure that we're going to receive questions from both lines, the case managers and the consumers. And from the case managers it's going to basically what's, what to do, if the client calls asking for services, or how to get the vaccine, where to go if they feel sick, if they can take the medication or not, questions like that and pretty much were answered by the two speakers and presenters already.
And from the -- of course our responsibility here, the AIDS Foundation is to be sure that our case manager will inform, and they have access to all the services available in the community, so they can pass that information to the consumers.
Miguel Gomez: Really appreciate that. And Paul in New York, could you answer the same question?
Paul Stabile, director of clinical care at the William Ryan Community Health Center in New York City
Paul Stabile: Sure. Again thank you for having us participate. We really appreciate that.
Just some brief information on my facility. We are a community health center network or a multi-centric facility located in Manhattan, Federally qualified and JCAHO accredited. We have about 41,000 registered patients, and of those about 1100 are HIV positive.
And actually in the past week I've been hearing pretty much from all of my HIV positive patients concerns about the H1N1 flu. They want to know what they need to worry about. And certainly everything that Dr. Brooks discussed are the education that we're trying to provide them as well regarding the vaccine.
There are some concerns that actually two patients brought up regarding concerns about taking the virus. And after talking to them a bit about it, they were thinking about other viruses that are contraindicated that are weak and live viruses such as the varicella. So we certainly do have some education to provide for some patients regarding the safety of the H1N1 vaccine when it becomes available.
They all want to know when it will be available. In this location we are hoping to receive vaccine in mid to late October. And we were talking with patients regarding the need for two flu shots for H1N1 plus the seasonal flu. So that doesn't go over too well. But, they are aware that it is necessary. And then again they want to know what to do if they do get the flu. And again we're providing education on that. But really, the questions with patients mirror the increased media attention in the past week or two regarding H1N1.
Miguel Gomez: Sure and you have both actually started to address how you're preparing to respond to H1N1. Is there any additional comments that either one of you would like to add?
Iliana Gilliland: Sure. I want to add that we had invited all our agencies to participate in this national educational call to get informed.
We are making sure that providers have the Federal guidelines and other fact sheets. And we scheduled presentations about the H1N1 in our upcoming coalition in our next case management meeting which is September 8 where we expected to have over 100 people getting all this information.
We are educating the staff and encouraging them also to get vaccinated for both the H1N1 and the seasonal flu, and are preparing our human resources staff also to have a contingency planning event, large number of the staff are out sick. And we are passing that information also to agencies.
All the staff here will also be making sure that we have the supplies we might need like tissue and hand disinfectant and information about washing your hands on a regular basis.
We are inviting all the health department officials to our coalition meetings to brief us on their vaccination programs and how to access them. And we will post the information online, and let the media know where to access the HIV information and the H1N1 information.
Of course I want to echo what you said at the beginning that we are not trying to scare people. But we just want to be sure that our case manager well informed. And we want to be sure that they know how to do in case they have people, consumers sick or if they are sick themselves. So that's basically what we're doing here in Chicago.
Miguel Gomez: Iliana, thank you very much. Paul and did you have anything to add, sir?
Paul Stabile: Yes, absolutely. As a community health center we did develop an in-depth protocol that we will implement assuming that we get an influx of potential influenza patients. And that will be activated by our chief medical officer and our senior administrative staff. So that having that in place certainly helps us to prepare up front. We will be developing triage stations and isolation rooms. We plan to use rooms that are being used for classrooms will be -- then be turned into isolation rooms so that patients who exhibit signs of influenza are not in our main waiting areas. And we're also changing our process flow so that those -- all same patients don't go to intake and discharge areas but are treated in one location to also minimize risk to other patients.
We are, in terms of our HIV specific patients, we've already started the education process for our medical staff as well as our support staff including case managers and social workers. And we're putting together a memo to go to staff that details a lot of the information that Dr. Brooks described as well as putting together a patient information sheet on both in English and in Spanish to inform our patients of those -- just those issues.
We are making good use of our support groups for our HIV patients as a way to get a number of patients together to impart information, and our medical staff are available and scheduled to talk to patients during those support groups as well.
We are targeting certain populations of our HIV patients. We want to make sure that our patients who are using asthma medications are being diligent in the use of their inhalers so as not to compromise them if they do get...
Miguel Gomez: Sure.
Paul Stabile: ...flu. And also we have a subpopulation of patients, female patients, who are mothers or caregivers who are actually have a more difficult time maintaining adherence to medications and to appointments are also at greater risk because they may get exposed to children who are exposed to flu at school. So are doing a special outreach to them to make sure they're aware of the importance of keeping, taking their medications and informing their providers if they have any symptoms of flu or if any of their children have symptoms of flu.
Miguel Gomez: Thank you both. And as you prepare those materials, if you could share them with us we'll also put them up on the AIDS.gov web site. I'm sure others would benefit from seeing what their colleagues have done.
Paul Stabile: We'd be happy to do that.
Miguel Gomez: Well, thank you both. And I'm not sure if Dr. Shannon Hader was able to join our call. Dr. Hader, are you on the line?
Then what I am -- I apologize for that. What I'm going to do is I'm actually going to ask the operator to let the listeners know how they can ask questions again. Andrea?
Coordinator: Thank you. If you would like to ask a question, please press star 1. That is star 1 if you'd like to ask a question.
Miguel Gomez: And for our panelists, I did get one email question which was, what special precautions for people living with HIV/AIDS who share living environments designed to make their special needs?
John Brooks: This is John Brooks. And on -- there is a guidance [http://cdc.gov/h1n1flu/guidance/] on the CDC Web site about what to do if you're the caregiver for someone who has HIV/AIDS or other problems, what you need to do to prepare yourself, and the space in which you're living with that person to try and reduce the risk of transmitting H1N1 and taking care of that person.
Miguel Gomez: Thank you. And, operator, is there a question?
Coordinator: We do not -- oh we do have some questions finally. And Shannon Hader, she is with you now.
Miguel Gomez: Okay, why don't we take some questions and then I'll turn to Dr. Hader.
Coordinator: Okay. Our first question comes from Christiana Cares. Your line is open.
Christiana Cares: Hi. Thank you. I have a question about vaccination. I know that all people with HIV are going to be recommended to get the H1N1 vaccine.
But as the vaccine first becomes available and supplies may be limited, do -- is there -- are there going to be any recommendations or guidelines about how to prioritize vaccine within the HIV population, for example deferring vaccine among those who have high CD4 counts or conversely those who have extremely low CD4 counts who may not respond to vaccine very well?
Miguel Gomez: Thank you for your question. Dr. Brooks, if you...
John Brooks: Yes.
Miguel Gomez: ...would start. And also, if you'd also explain the five groups that...
John Brooks: Yes.
Miguel Gomez: Great.
John Brooks: Let me go through that, sure. That's a great question. Thanks so much for answering it.
Just to highlight what Miguel just mentioned, the five target groups that are initially targeted for vaccination comprise approximately 160 million Americans.
And those persons are first pregnant women, secondly, persons who live with or provide care for infants less than six months of age. That would include parents, siblings of the child or daycare providers. Third are healthcare and emergency services personnel. Fourth are persons ages 6 months to 24 years. And then the fifth, persons aged 25 to 64 who have medical conditions that put them at higher risk for influenza related complications, including of course HIV infection.
It's a good point that you raised that the vaccine won't be all immediately available, and the Advisory Council on Immunization Practices, about ten days ago considered what they would do if they had to prioritize among these top groups who would be the first to get the vaccination. And in the event that the supply does seem to be limited, they targeted five groups which comprised about 42 million Americans or about 25% of that first group that I talked about.
Now adults and adolescents aged 25 to 64 with medical conditions such as HIV are not included in that highest of high-profile groups, although children and adolescents aged 15 to 18 years who have medical conditions that put them at higher risks for influenza are.
There was a -- the reasoning behind this was that the other groups seem to be even greater risk than persons living with HIV for complications related to H1N1 or have occupational reasons why they need to be protected against this. But the anticipation is that there will ultimately be adequate vaccine available to cover all five, all the persons included in the top five priority groups.
I don't know if Libby had anything she wanted to add or...
Libby Higgs: No.
John Brooks: Okay.
Miguel Gomez: Thank you doctors. And I'm most pleased that I've learned that Dr. Hader, thank you from the operator, has been able to join us. She is our lead voice in the District of Columbia for HIV/AIDS.
She's the Senior Deputy Director of the HIV/AIDS Administration. And Dr. Hader, could you actually share what you're doing to prepare to respond to H1N1?
Shannon Hader: Sure. We are I think really focusing on two fronts. One is recognizing the specific context for HIV here in the District.
And then two is integrating with the systemic response to Pan flu for the District overall.
So on the first front I want to, you know, we're really focusing on part of what Dr. Brooks mentioned, which is ensuring that people with HIV not only maintain but potentially improve their immune system. So I'll meet what he said in terms of making sure folks that are in care and treatment and on ARVs stay in care and treatment and take their medication.
But we're actually trying to raise the bar on that as well. Our local data suggests that there's a good number of people with HIV in the District who haven't been in care for quite a long time. And we think this is a really important time to be able to say if you're not in care for ARV or for HIV or if you're in care but maybe have deferred ARVs, even though they're medically indicated, now's a good time to get reconnected to appropriate care and treatment for a condition. So that's one major opportunity and message there we're emphasizing.
Then two is as a medically vulnerable population then, making sure that our response to Pan flu for the HIV population is fully integrated and a core part of our overall emergency preparedness response to flu in the district.
We're lucky because for our HIV population from our surveillance database, from our care and treatment services and from our ADAP services, we actually have very good reach to the providers of services to our affected population.
And so it's our job within the Department of Health as the HIV/AIDS Administration to be able to provide access to those connections, communications, service providers to our sister agency within the Department of Health which is our Health Emergency Preparedness and Response Administration headed up by Ms. Beverly Pritchett, who's here with me today. And so I'm going to defer to her for further descriptions of what we're doing for the systemic response and how our medically vulnerable populations including those with HIV fit in.
Miguel Gomez: Actually that's wonderful. And demonstrating that partner[ship] is terrific. And we hope to see that across the United States. Dr. Pritchett?
Beverly Pritchett: It's Ms. Pritchett.
Miguel Gomez: Oh sorry.
Beverly Pritchett: That's okay. Well, thank you, Dr. Hader and Miguel.
First of all, our message here in DC is to learn about the pandemic flu and take action now. We'd like to remind everyone from individuals to institutions not to panic, but to remember the basics. Cover your cough, wash your hands, cough or sneeze into your elbow.
If you're sick, please stay home. And then the new guidance, following the new guidance from CDC, stay home until at least 24 hours after the last designation of fever and try to avoid close contact with sick people whenever possible.
Most importantly for those people who are immune-compromised, they need to follow the advice of their medical doctor and if they have further questions, to call us here at the Department of Health.
As Dr. Brooks mentioned earlier, immune-compromised individuals are part of our first priority for the H1N1 vaccination. And that's a very significant message that we're trying to get out across our population also.
The -- here in the District of Columbia, we also have some very special needs programs that address a significant portion of our population. And so we're advising individuals infected with HIV/AIDS to obtain their prescription antiviral medication through the alliance pharmacies which is our DC specific insurance program and ADAP pharmacies which cater to this particular population.
Because we have issued our antiviral distribution from the strategic national stockpile to these pharmacies so that they will be readily available to this population.
We're getting ready to launch our vaccination program. And we have already issued 3366 regimens of antiviral medications to our particular pharmacies that service this population.
Miguel Gomez: Ms. Pritchett, thank you. And I'm going to have more questions for you. But I know that there's a lot of people lined up in the queue to ask some questions so I'm going to jump back to you, ma'am.
Beverly Pritchett: Okay.
Miguel Gomez: I'll turn to the operator.
Coordinator: All right. Our next question comes from Beth Robinson. Your line is open.
Beth Robinson: Yes, thank you very much. I had a question kind of following-up on her comment. Are all the ADAP programs throughout the United States, are they planning to gear up for provision of antiviral medications through the ADAP program?
And you mentioned that nausea and vomiting is going to be one of the -- is one of the symptoms as well with this particular flu. And so is -- are going to be needing to have a anti-nausea medications available as well?
Miguel Gomez: And Ms. Pritchett and Dr. Hader, I'll let you start answering the question and I can do some follow-up.
Beverly Pritchett: So I can I think comment a little bit on the ADAP program. You know, each ADAP program is under state regulation both in terms of how they supply drugs, how they distribute drugs, how they authorize drugs. But everybody does have a mechanism for making those decisions.
Here in the District we are what's called a direct purchase jurisdiction. So all of our regular ADAP drugs like antiretrovirals, we actually buy through our central pharmacy and send to pharmacy distribution sites. And so for us using that exact same distribution system for the national stockpile of antivirals was a really easy and natural thing to do.
But there's no national ADAP how-to policy on this. This is something that has to be dealt with state by state.
Miguel Gomez: And actually Paul, do you know the answer what's happening in your community, sir?
Paul Stabile: Yes. In New York State ADAP covers not just antiretrovirals, but other mediations as well. And in the spring when we had some H1N1 flu, the antivirals were covered through ADAP in New York.
Miguel Gomez: Okay. Well I want to thank you for the question. And we'll also on our Web page post how HRSA [http://hab.hrsa.gov/] responsible for the ADAP program answers that question too. I'd like to actually see if there's another question please?
Coordinator: That question comes from Kellie Norcott. Your line is open.
Miguel Gomez: Hi Kellie.
Kellie Norcott: Hi. Hi, thank you. My question is about an MMWR dispatch that came out a couple of weeks ago regarding two severely immune-suppressed people who became resistant to Tamiflu [oseltamivir phosphate]. I believe they were severely immune-suppressed. But I wonder if this has any implications for monitoring clients for resistant to Tamiflu [oseltamivir] with their -- with HIV?
John Brooks: Hi, Kellie. This is John Brooks. That's a great question. And this is important MMWR. Just to let folks on the line know what that MMWR was about, it described two patients. I believe they were from the -- from a cancer center in Seattle who had -- were very, very immune-compromised, not related to HIV infection, but related to treatment to cancer.
And they had -- I believe they had been exposed to oseltamivir as a form of chemoprophylaxis to prevent getting infected in that -- eventually developed H1N1. And it turns out that their strain of virus was resistant to the drug oseltamivir.
Add that's a cautionary story insofar as, you know, we have with all drugs we use to treat any infectious disease we have to be -- we're always balancing the risk of inducing resistance to using it in a therapeutic way to treat disease and to prevent disease.
It's to the best of my knowledge at the present time, there's not a way for a provider it's a -- at a local level to know that if they've got a patient who's testing positive for H1N1 to know if that virus is, that individual virus is resistant or not resistant to either zanamivir or oseltamivir.
But at the national level, CDC in coordination with the World Health Organization, the local state and health departments throughout the country will be monitoring this through an influenza monitoring network. It will be providing guidance on what to do both in terms of Chemoprophylaxis and treatment and which drugs to use as the flu season evolves.
And I think, as Libby Higgs had mentioned earlier, they're working with industry to look into other possible agents as well.
Libby Higgs: Yes, this is Libby Higgs. That's a really excellent question and observation. And those, just the issue of oseltamivir resistance is being tracked on a global basis as John said, the most cases have occurred in the setting of cases patients who've been prophylaxis or individuals who've been exposed and gone on prophylaxis. There's one or two cases where of primary resistance where the person had not been on medication. And those two reports, I think perhaps one or both of them may have been -- I think it was actually treatment at least in one of the cases.
John Brooks: I know one -- there were also two children at a summer camp who've got prophylaxis but then...
Libby Higgs: Right. So we had cases of prophylaxis oseltamivir resistance in prophylaxis...
John Brooks: Yes.
Libby Higgs: ...from around, we've had cases from Japan, Hong Kong. I mean there's several of them globally.
But I think it is important to remember that zanamivir remains active to the oseltamivir resistant viruses, that common mutation. We call it the 275 mutation. And, as John indicated, we are going to be monitoring those across the country and globally. Influenza does mutate fairly frequently and shifts and drifts as we all know. But I think zanamivir remains active against that mutation. And it is difficult at the provider level without sequencing the virus to determine if resistance has developed.
So it is good that we have inhaled zanamivir available. And we are working with industry to look at other antiviral possibilities.
Miguel Gomez: Thank you doctors. Is there another question?
Coordinator: There is. And that comes from Simone Edwards. Your line is open.
Simone Edwards: Hi. How are you doing? I'm working for an agency where we provide services to HIV positive clients. But they live out in the community. They're in a supported housing program. So our case managers only see them on a weekly basis. Should we come up with some kind of like action plan to deal with that? Because a lot of times what happens is the clients don't report much to us. They might feel -- they might not feel well and they just kind of stay home and kind of deal with it and not report it to us. So it's difficult for us to kind of like come up with some kind of plan of action if we're not told. Like how would you deal with that sort of situation?
Miguel Gomez: Great. And since Iliana talked about training case managers in Chicago, ma'am, would you like to start answering that question?
Iliana Gilliland: Sure. Well, I think that the first thing it's important for that case managers to have a conversation with the clients even if they don't ask, even if they don't request that information.
It would be important for the case managers to go to the clients and talk to them about these, yes, informing them again, not scaring, not creating panic, but just informing them as to general information what to do if you get sick or just general information about the vaccination, important information about keep taking your medication and keep informing the case managers on a regular basis about any changes in your health. I think that will be the first line will be for just for the case managers to keep an open conversation with all the consumers they have in their caseload.
Simone Edwards: Okay. And I have a lot of clients that are for some reason or another they're not on HIV medication sometimes because the doctor feels that their CD counts are really, you know, high, they don't need to be on medication. Are those people at an increased risk?
Iliana Gilliland: That is a question, I think, for one of the physicians.
John Brooks: Yes, this is John Brooks. You know, that's a -- it's a great question. And we really don't have a lot of good data to know if how much more HIV may put you at risk for acquiring H1N1 as well as seasonal influenza.
The best data that's available now suggests that if there is some increase it's pretty small. It's not a very large increase that we can track very easily and that the risk of a person with HIV which is probably about the same as that of a person without HIV infection.
But nonetheless I think the important message here is regardless of their risk of acquiring it or not, having a low threshold to seek care is very important particularly if they have a low CD4 cell count which may put them at greater risk of complication with influenza in case they got it.
Simone Edwards: Okay, thank you very much.
Miguel Gomez: Operator, another question?
Coordinator: We do. And that comes from Claire Hicks. Your line is open.
Claire Hicks: Thanks. The question's already been answered.
Miguel Gomez: Terrific. Thanks, Claire. Next question, ma'am.
Coordinator: Next question comes from Lindsey. Your line is open.
Lindsey: Hi. Could you talk about any special considerations for people who are HIV-positive and also have tuberculosis?
Libby Higgs: That's a good question.
John Brooks: That's a great question, Lindsey.
Libby Higgs: This is Libby Higgs again. I don't think we have a lot of data but right now in the southern hemisphere, Southern -- many countries are experiencing quite a bit of the illness and surge that we anticipate because it's their normal flu season. And I don't know of any data at this point to indicate that those individuals are at greater risk for more severe disease.
And in terms of thinking through the medications, there shouldn't be any contraindications to influenza the medication. There certainly isn't to the vaccination. John, do you have anything to add to that?
John Brooks: Yes, you know, it's funny; we've been working on a review paper just recently looking at viral hepatitis and also tuberculosis and influenza and kind of the intersection of the two [diseases with influenza]. And it's a great question because it has not just implications in this country, but I think as you pointed out Libby, elsewhere in the world where tuberculosis is an even more prevalent disease.
I think the first point you made, the point you made about interaction of drugs is important. There doesn't seem to be any drug, drug -- important drug interactions between anti-tuberculosis medications and antiviral medications or so that you could, you know, you would withhold treatment or alter treatment for influenza in a person who's receiving treatment for tuberculosis.
But tuberculosis does cause lung damage, pulmonary damage. And it can increase the susceptibility of getting influenza if you are exposed.
So for that reason persons who have tuberculosis who are, again, a very small number of persons in this country, but should probably be given good guidance and advice of what they can do to protect themselves and prevent exposure to influenza. And again, if they think they have been infected or sick, to seek care and consultation as soon as they can.
It's interesting that in influenza, large influenza pandemic, persons with tuberculosis, that the fatalities among persons with tuberculosis have been greater than expected which is not entirely beyond what we might expect because they're at greater risk as a result of their tuberculosis.
But the point is that they may -- they like persons with HIV infection and certainly the combination of HIV and TB is -- makes it even more complicated. Those persons are particularly increased risk for complications of the influenza. So they would want to seek care.
Miguel Gomez: Thank you, Dr. Brooks. And I'm noticing that it's close to the top of the hour but -- and so I want to thank everyone. But because this is so important I want to take one or two more questions. Operator?
Lindsey: Now my concern is...
Coordinator: Are we taking anyone?
Miguel Gomez: Oh, did you have a follow-up, ma'am? Go ahead. I think we just lost her.
Coordinator: Okay. Our next question comes from Medea Gaitan. Your line is open.
Miguel Gomez: Medea, please.
Maria Gaitan: Oh, hi. Can you hear me?
Miguel Gomez: Yes.
Maria Gaitan: It's Maria, actually.
Miguel Gomez: Oh, Maria.
Maria Gaitan: I'm not that mythical. Anyway, I work in Hoyt County Department of Health Services and we serve over 1 million LEP patients every year. And my concern is about accessibility of the information. I know that you mentioned that there was some Spanish language information available. And that's extremely important. That is are by far our largest language. But we serve almost over 100 languages in our county. And the big ones are Korean, Chinese, Tagalog, Armenian and Vietnamese.
I'm just wondering if there were -- there might be any efforts in the direction of providing a couple of other languages?
Miguel Gomez: Dr. Brooks, can you speak from the CDC perspective?
John Brooks: Yes, I sure can. If you go to the CDC's main Web site for flu you can view everything in Spanish. And there's a button you would click to do that.
I know that most of the information that's available or a great deal of the information that's available on the CDC web site is made available in many of the languages that you've described. I'm not sure yet how much of that has been translated or been made available in those languages -- that information specific about flu.
But if you watch the Web site regularly they'll -- you'll be able to find out. And I would sign up for that email update and contact someone. And I'm going to make a note here after this call to contact someone to see if I can find out more about what they're doing.
Miguel Gomez: And we'll put an update to answer that question because we also got an email on that same question by email.
Maria Gaitan: Thank you very much. Please know that Korean, Chinese, Tagalog, Armenian and Vietnamese are huge...
Miguel Gomez: Yes.
Maria Gaitan: ...also in our system. And thank you.
Miguel Gomez: Sure. Thanks for letting us know.
Maria Gaitan: Sure.
Miguel Gomez: Thank you. Let's take one more question please.
Coordinator: Our next question comes from BJ Cavnor. Your line is open.
Miguel Gomez: BJ?
BJ Cavnor: Hi. Thank you very much. I'm calling from Cascade AIDS Project in Portland, Oregon. And my question regards the cost of the vaccine. First of all, what if any will there be?
Miguel Gomez: Dr. Brooks?
John Brooks: I'm not aware of what the cost -- I don't know what the cost structure's going to be.
Beverly Pritchett: This is Beverly Pritchett. I can answer that question. If you're talking about the H1N1 vaccine?
BJ Cavnor: That's correct.
Beverly Pritchett: There will be no cost for the vaccine itself since it is being provided by the government. The vaccine will come with sharps containers, the syringes, alcohol wipes, a wallet sized card that allows you to record the shot that you're on or the dose that you're on, you know, one or two since we expect it to be a two dose administration. But if you're a private provider then you can in fact charge for the vaccine administration according to the insurance rates of your area.
BJ Cavnor: But for those of us who work in the community there will be no charge to our clients?
Beverly Pritchett: There -- well you can charge for the administration of the vaccine, but there will be no -- you cannot charge for the vaccine itself.
BJ Cavnor: That's fine.
Beverly Pritchett: That the only people who cannot charge are public health. Like when I hold a mass vaccination clinic then I cannot charge for the administration of a vaccine.
BJ Cavnor: Okay. The second question to that is a follow-up, is there, will it, looks like be two doses. How often or what's the range of time between those doses?
Beverly Pritchett: I don't believe it's been finalized yet, but they're expecting between 21 and 28 days.
BJ Cavnor: Okay. And finally is there any idea as to when we can expect to see the vaccine?
Beverly Pritchett: We are being told mid-October to be the timeframe. But it may be as early as the end of September or as late as the end of October.
BJ Cavnor: Okay. How will the vaccine be administered? Is it going to be in injection or...
Beverly Pritchett: There are different methods that are available. There is a nasal spray which is live attenuated vaccine. And there is a single dose syringe. Both of those do not contain the thiomersal. And then there's also a 10 dose vial which does in fact have the thiomersal -- well some of them may and some of them may not have thiomersal included in those.
Libby Higgs: Libby Higgs here. It's the live attenuated vaccine would not be the vaccine for HIV positive patients. It would be the shot, the injection.
BJ Cavnor: Right.
John Brooks: Yes, and Libby, this is John Brooks. The H1N1 vaccine that's being developed now is a dead strain.
BJ Cavnor: So the nasal vaccine remedy would not be the one that patients with HIV would choose?
Beverly Pritchett: It would not be advisable.
BJ Cavnor: Okay, thank you.
Miguel Gomez: Thank you both. And I'm just noting that there are additional questions and trying to respect it, we're slightly over the top of the hour. I'm actually going to really encourage people to fill out their evaluations, to continue to stay in touch and stay informed, be at a place that you're constantly getting updates on H1N1 information, and also important to realize that we all may be called upon to help our other colleagues in the public health community respond.
I'm torn between still wanting to see that there's still more questions so I'll take one more before closing and then we'll end the call. Operator?
Coordinator: Our next question comes from the Metro Health Department. Your line is open.
Woman: Hi. Thank you for taking my question. Can you hear me?
Miguel Gomez: Yes ma'am.
Woman: Good. I understand that the H1N1 vaccine will be a series of two. When one is administered and we have the incubation period of 21 to 28 days or so -- I understand that's not been confirmed yet for sure -- should a patient come down with the H1N1 within that length of time will you forgo the second one till the next season or will you give it upon recovery?
Beverly Pritchett: That's a very good question, and I have not seen that addressed in the literature yet on the vaccine.
Woman: Thank you.
Libby Higgs: I did -- Libby Higgs from NIH, would like to say that we don't -- those in the trials, in the safety trials and the trials to answer the questions about the dosing and the amount of vaccine are underway now and we don't have those results yet.
Miguel Gomez: Well, again I really want to thank all of our speakers, all of our participants for joining us today on this call sponsored by AIDS.gov, and again, encourage folks to go to flu.gov [http://www.flu.gov/] which can link you to the multiple sources that we talked about today.
And again, on AIDS.gov [www.aids.gov] we'll have a web site or we have a web page [http://www.aids.gov/h1n1/] which we'll make available proceedings from this call and others can listen to this call in the future. And again, thanking all of you and on behalf of HHS thanking everyone for their participation, their time and hope everyone has a good afternoon. Thank you very, very much. Goodbye.
Libby Higgs: Goodbye.
John Brooks: Bye-bye.
Coordinator: Thank you. This concludes today's conference. You may disconnect at this time.


text:
Thursday, December 17, 2009
Flatulence and Cream of Wheat
47 comments:
- Amber said...
Glad to hear she is doing well - and it's easy to forget those small joys and blessings - thanks for the reminder!
- December 17, 2009 at 12:21 PM
- Quilt or Dye said...
So glad your mom is doing better. I hope the progress continues for her!
- December 17, 2009 at 12:34 PM
- Andi said...
Glad your mum is feeling better.
We have coined a new term in this house: flatulante (rhymes with vigilante).
Seems appropriate here.
Andi x
- December 17, 2009 at 12:38 PM
- True Blue Nana said...
I will never think of farts in the same way again. I would have to say my husband must be exceedingly healthy if farts are a sign! Glad your mother is doing well. I know this has been a difficult time. I am glad to see you are getting to the other side. We all should concentrate on the little things in life. Those are what are important day to day.
- December 17, 2009 at 12:41 PM
- Meg said...
Jacquie, so glad your mom is mending--keeping you guys in my thoughts. Hope you have a bit of time for some happy sewing!
- December 17, 2009 at 12:41 PM
- Jackie Russell said...
I'm so glad to hear that your mom is doing better. Does she read your blog?
- December 17, 2009 at 12:42 PM
- connie said...
I am glad things are looking up for your Mom. I am dreading the day when I have to deal with one of my parents being sick. I love the title of your post it made me giggle......
Have a wonderful Christmas and sending many good thoughts!
- December 17, 2009 at 12:46 PM
- Di~ said...
Hi Jacquie! I hope your mom is better soon! You are not only a superb quilter, but a superb writer!, even tho' your title has me red faced!:)
- December 17, 2009 at 12:48 PM
- Poppyprint said...
Wonderful news that your mom has turned the corner to wellness Jacquie. Cream of Wheat is okay, but for full symphonic effect, I recommend Red River Cereal. Hope you are back at your machine soon.
- December 17, 2009 at 1:04 PM
- BaileyGirl5 said...
Yay!! I'm so glad your Mom is doing better. It is so stressful to see your mother sick and in pain.
I have your deer quilt saved as one of my favorites and I would love to do a similar one for one of my sons. Thanks for all your inspiration!
- December 17, 2009 at 1:04 PM
- Rose said...
I just never know what the topic is going to be when I stop by! Glad to hear she's doing ok.
- December 17, 2009 at 1:25 PM
- Needled Mom said...
Oh yeah....so glad to hear your mom is doing better.
- December 17, 2009 at 1:34 PM
- Victoria said...
This is a joyous post, and a wonderful, humorous, and touching reminder to be grateful for every blessing. Good to hear your Mom is doing a bit better, hope her health continues to improve!
- December 17, 2009 at 1:38 PM
- Dee said...
...so we bowed our heads and gave thanks.
Merry Christmas!
- December 17, 2009 at 1:40 PM
- debra lynn said...
I agree, cream of wheat is the best when your sick. Glad she is doing better.
- December 17, 2009 at 1:43 PM
- Jane's Fabrics and Quilts said...
aaa, the body works in wonderful ways, I am so happy your mom's is waking up!
- December 17, 2009 at 2:08 PM
- Cheryl Arkison said...
Sometimes the pleasures in life are just so basic. A good reminder for all of us!
Great news for you.
- December 17, 2009 at 2:12 PM
- Anina said...
Oh yay! I'm SO glad your mom is feeling better. A wonderful Christmas gift.
- December 17, 2009 at 2:30 PM
- Karen said...
My life is all about farts with my 4y.o son at the moment. Boys and all things tiolet...
Glad to hear your Mum is on the mend.
- December 17, 2009 at 2:35 PM
- the Campfollower said...
Jacquie, I am so happy your mom is recovering. And right on with the happy sound of a good toot. As a nurse I can't even remember all the times I have had to encourage my lady patients to just relax and cut one loose. It is hard to do when you have been instructed all your life that farting is rude. My proyers are still with you and your mother.
- December 17, 2009 at 3:07 PM
- Sharon said...
Glad to hear your mom is on the mend. I know the joy of hearing the fart, my dad was in the hospital and couldn't eat until this happened. My mom and I walked in and saw his name on a food tray and we yelled, "Dad farted! whoohoo!" Simple things make us smile!
- December 17, 2009 at 3:23 PM
- 2ndAvenueStudio-Rachel said...
in our house we play the "Butt Trumpet" to celebrate broccoli (or any non stinky greens/fiber processing) or if my hubby eats dairy he becomes a "Sulfuritic Bastard".
Stay strong, elder care can be really exhausting. Be sure and take some time just for you.
- December 17, 2009 at 3:35 PM
Thanks for sharing....life is fragile. Praying for continued progress, strength, peace and courage.
- December 17, 2009 at 4:10 PM
- shellysquilts said...
Hey Jacquie, While I'm very happy your mom is doing better, I'm not sharing your fart dancing joy with my 10 year old son. It would just be putting gasoline on his already gassy fire.
- December 17, 2009 at 4:10 PM
- Beth said...
Perhaps a cream of wheat inspired quilt is called for??
- December 17, 2009 at 4:19 PM
- em's scrapbag said...
Over joyed to hear the good news of your mom and that you will soon be back doing the things you enjoy and do so well.
- December 17, 2009 at 4:33 PM
- Stephanie D. said...
Well, consider yourself an honorary member of the health profession now! We can get positively giddy over body functions. lol
- December 17, 2009 at 6:06 PM
- fabricartist21 said...
Prayers for your MOM!! Calling all bloggers I am having a huge giveaway on my blog and will be adding a new item everyday until 12/24. Check it out.
- December 17, 2009 at 9:30 PM
- paulette said...
You made me chuckle....I hope your Mom doesn't read this...:o) You'll be in trouble! Sent to your room! Thanks for making my day and I'm so glad your mother is feeling better and passing wind! ha ha ha ha ha ha...reminds me of being in the classroom when someone uses the fart work and everyone laughs...we are all children at heart!
Take care!
- December 17, 2009 at 9:49 PM
- Melanie said...
I'm happy to hear your mom is doing better. Hope the holidays bring more good news and progress.
- December 17, 2009 at 10:11 PM
- Dorrie said...
Never take for granted those small blessings. It really is a lifetime of small achievements that make us truly rich. I hope your mom feels better soon. And I hope you take some time and really rest.
- December 17, 2009 at 10:13 PM
imagine my surprise after having a couple of glasses of wine, I find Jacquie talking about flatulence. I am a GI nurse. That means, my specialty is gastrointestinal nursing. My specialty is all about farting. I had to reread your post twice. I am all about farting in my job and I love cream of wheat. I thought I might be dreaming, but I am not. Farting is a good thing, as I tell my patients, it is their ticket out of here. Yes, I celebrate farting everyday. Sometimes I tell my patients that they, indeed, have won the blue ribbon for the best fart of the day.
- December 17, 2009 at 10:15 PM
- MightyMom said...
you think that's good, just wait till her first post-op poop!!
I usually do a happy dance for my patients on that day. let me know and I'll dance for your mom. :-)
- December 17, 2009 at 11:06 PM
- Kritta22 said...
Oh such wonderful news! Thanks for sharing...seriously!
I'll never think of a simple fart the same way again!
- December 17, 2009 at 11:33 PM
- Theresa said...
My first baby was born 8 weeks prem via emergency ceasarean. I wasn't allowed up until I passed wind. I waited...and waited...then worried I'd missed it. I was so sick and all I wanted to do was fart. I told every specialist and nurse that came to see me. Oh the pain. Yup...it's not working unless you do it. Thanks for the memories! Merry Christmas.
- December 18, 2009 at 4:25 AM
- Cynthia said...
Happy to hear that your Mom is doing well. It gives me hope for my father. He had his open heart last Thursday. He's doing great but still not eating. Why does it bother us when someone isn't eating? I guess it truly means their not feeling well. He's also kind of blue. I guess the cold weather doesn't help.
Merry Christmas
- December 18, 2009 at 6:46 AM
- Marie said...
yep!! the more farting the better!! it's a gas powered world we live in .... hugs and prayers to your family -- one day at a time (or one fart at a time!) happy christmas!
- December 18, 2009 at 7:21 AM
- B&G Foods said...
Glad to hear your mom is feeling better and that she enjoyed her Cream of Wheat!
- December 18, 2009 at 8:17 AM
- KateKwiltz said...
Oh, Jacquie, I'm so happy she's doing better! And what I can only interpret as a gesture of support, Archie just settled into my lap -- and farted. And I will try to be grateful. :)
Get well, Mom!
- December 18, 2009 at 9:26 AM
- sara said...
My dad had intestinal surgery a year ago last thanksgiving - and we, too, learned the true meaning of passing gas...a real blessing! Glad she is on the mend and you are almost back in the studio - i've missed your daily blogs!
- December 18, 2009 at 11:37 AM
So glad to hear that your mother is doing better. I can't wait to see what you create with all that energy!
- December 18, 2009 at 8:23 PM
- bellsjo said...
Your blog post title made me giggle! Hurrah for farts (or pumps as they are also known - but I think that might just be an expression from the north of England!) so glad news is good and your mum is on the up. Christmas blessings to you all.
- December 19, 2009 at 3:29 AM
- Randi said...
Glad your mom is better. Hope you have a very Merry Christmas!
- December 19, 2009 at 9:48 AM
Happy to hear things are turning around for your mom. I wish you the very best for the coming days ahead. Neat insight and a good reminder for us all to appreciate the dailies in our daily living.
- December 19, 2009 at 10:29 AM
Savor it all right? Even Cream of Wheat!
- December 19, 2009 at 4:16 PM
- nicolette said...
Glad to hear you're mum is doing better! I smiled reading your post, it's so true!
I experienced the same joy after having heavy stomach (belly?) surgery.
- December 21, 2009 at 7:48 AM
- prashant said...
I hope the progress continues for her!
How to make a website
- December 28, 2009 at 8:46 PM

subset: commoncrawl


text:
iOS Vulnerability: Please Update
Apple has released a software patch for a serious SSL bug in iOS 6 and 7. This update is available for all compatible iOS devices, please backup your phone and update immediately.
The version of iOS on a device can be checked by launching the Settings app, selecting General, and then selecting About. To update, launch the Settings app, select General, select Software Update, and update to iOS 7.0.6 (or 6.1.6 on the iPhone 3GS and 4th Gen iPod Touch).
The vulnerability is an apparently errant line in Apple's "Secure Transport" API that causes signature verification to never fail. This allows unchecked attackers to impersonate "trusted" servers and intercept and decrypt communications at will.
The same SSL bug also exists in OS X 10.9 Mavericks, and Apple has promised that a patch is "coming soon"; the patch is expected to be released sometime later this week. OS X 10.8 Mountain Lion and earlier versions of OS X do not seem to have the vulnerability. If you use OS X 10.9 Mavericks, please use an alternative browser such as Firefox or Chrome for the meantime.
For more information, please see this article from Apple Support: http://support.apple.com/kb/HT6147 or email email@example.com


text:
The Sports Xchange
By Dave Del Grande, The Sports Xchange
SAN FRANCISCO -- Nate Schierholtz blasted a Sergio Romo fastball into the first row of the right field pavilion at AT&T; Park for a ninth-inning home run that broke a scoreless tie and delivered the Chicago Cubs a 1-0 victory over the San Francisco Giants on Saturday night.
Romo (3-6), the losing pitcher on Friday night after a two-out error by Brandon Belt in the ninth inning, was facing just his second batter in relief of Madison Bumgarner, who shut out the Cubs for eight innings.
The All-Star was matched pitch for pitch by fellow left-hander Chris Rusin, who was making just his third start of the season for the Cubs. Rusin, who had never finished the sixth inning in any of his nine previous career starts, turned the ball over to reliever Pedro Strop (1-0) after seven shutout innings.
After the Giants blew a golden opportunity to score in the eighth, Schierholtz stunned the fans of his former team by towering his 14th home run barely over the 20-foot-high brick wall just to the left of the 365-foot mark. It was his third home run in eight games on the Cubs' current road trip.
As they had an inning earlier, the Giants loaded the bases in the ninth, this time against Cubs closer Kevin Gregg. But pinch-hitter Tony Abreu grounded into a double play to end it for his second save in two nights and 21st in 24 opportunities this season.
Coupled with Friday's dramatic win, the Cubs clinched the three-game series in San Francisco. They have now won or split six of their last seven road series and, at 5-3, assured themselves of a winning record on a nine-game trip that ends Sunday against the Giants.
The loss was the Giants' sixth in their last seven games and 18th in 25 games against National League Central competition this season.
One night after the Cubs' Edwin Jackson and Giants' Matt Cain took dueling shutouts into the sixth inning, Rusin and Bumgarner were even better. They carried a 0-0 game into the eighth, with Rusin leaving first, replaced to start the bottom of the inning by Strop.
Rusin, who was coming off a win at Arizona in which he pitched five innings, struck out three in his seven shutout innings. He allowed three hits and two walks.
Thanks to two mental mistakes by Strop consecutive bunts, the Giants nearly broke through against the reliever in the eighth.
But after loading the bases on a walk to pinch-hitter Gregor Blanco and bunts by Andres Torres and Marco Scutaro on which the Cubs failed to get anyone out, Strop ran his string of consecutive scoreless innings for Chicago to 9 2/3 by getting outs at the plate on ground balls by Buster Posey and Pablo Sandoval and then striking out Hunter Pence.
Blanco was pinch-hitting for Bumgarner, ending the left-hander's night after eight scoreless innings. Bumgarner, like Rusin, did not factor in the decision.
Bumgarner gave up four hits and two walks in his eight innings. He struck out seven in his eighth consecutive start allowing two or fewer earned runs.
Two defensive gems -- one by each team - kept the game scoreless entering the ninth.
The Cubs threatened to score in the top of the sixth when, with runners on first and second, Schierholtz smoked a line drive to center field. But Torres, the Giants' center fielder, raced in and made a diving catch to end the inning.
Pence led off the Giants' seventh with a double and advanced to third on Jeff Francoeur's grounder to second. After Joaquin Arias grounded out with Pence holding third, Brandon Belt's bid for a shutout-ending single was nabbed by leaping Cubs first baseman Anthony Rizzo.
Rusin carried a perfect game into the fifth inning. That ended with a one-out walk to Pence, and his no-hitter was gone two batters later when Joaquin Arias spanked a single up the middle, just out of the reach of diving second baseman Darwin Barney.
The left-hander got out of his first jam of the night when Belt hit the first pitch he saw on the ground right to Barney, standing two base runners.
Rusin needed just 27 pitches to go one time through the Giants' lineup. Among the nine batters, only one pulled the ball on him -- Bumgarner, who grounded out to third baseman Cody Ransom.
The Cubs had four base runners in the first five innings against Bumgarner, but none reached scoring position. Two of the four Cubs who reached base during that stretch did so via Giants errors.
NOTES: Rusin's only other two starts for the Cubs this season had come as a last-minute replacement for a traded pitcher -- RHP Scott Feldman, dealt July 2 to Baltimore, and RHP Matt Garza, traded Monday to Texas. Both times, Rusin started the day with the Cubs' Triple-A affiliate in Iowa and had to travel to Oakland and Arizona. ... The Cubs' starting lineup included Giants castoffs Ransom, Schierholtz and LF Cole Gillespie. ... Giants RHP Ryan Vogelsong gave up a two-run homer -- the only hit he allowed -- in a 45-pitch, 2 2/3-inning stint for Class A San Jose on Friday night. The former All-Star's next injury-rehab start will come for Double-A Richmond (Va.) after he joins the Giants for their White House visit on Monday. ... With Friday's trade that sent LF Alfonso Soriano to the New York Yankees, the Cubs do not employ a player who was on the 2007 National League Central champion team. Only RHP Jeff Samardzija remains from the 97-win Cubs team of 2008.


text:
Moorea Sights
Moorea is an easy island to explore by car. The one coastal road is just 61 km (37 mi) long, and the best part of a day is needed to travel the road and stop off at the villages, bays, little churches, and cafés along the way and to travel into the interior to the Belvedere lookout and the marae (ancient temples).
The lagoon and bays can be discovered on organized excursions that may
include a picnic lunch on one of the motu at the island's northwest corner. There are also small motorboats for hire for a half or full day, with no license required. You won't find too many tracks of endless white sands on Moorea; however, the top resorts have lovely man-made beaches and the lagoon-side pensions and lodges always have at least a little patch of sand.
Half-day and full-day 4WD tours take in all the sights and some areas inaccessible to motorists, while hiking is a great way to see the pineapple and fruit plantations and lush valleys.
Browse Sights
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North Coast 10
West Coast 9
East Coast 6
The Interior 3
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Archaeological Site/ Ruins 1
Beach–Sight 5
Educational Institution 1
Industrial Site/ Mill/ Factory 1
Museum Village 1
Neighborhood/ Street 2
Religious Building/ Site/ Shrine 1
Town/ Village 11
Viewpoint/ Scenic Overlook 2
Zoo/ Aquarium 2
Moorea Sights
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text:
- Gaia Tree Center
- Iquitos, Peru
- Nov 25 - Dec 2, 2019 (8 days)
- $1,088.00 - Program Price
About This Event
Dear friend
You are invited to join us for a week of deep healing and cleansing at Gaia Tree Center in the Amazon rainforest of Peru. Our intensive week-long retreats provide an opportunity for you to connect with the spirit of ayahuasca for the purposes of healing and spiritual growth.
The sacred medicine of Ayahuasca is the world's most holistic natural medicine. It works on all aspects of your being – the physical, mental, emotional and spiritual and allows you to experience expanded awareness and connect with your inner soul and higher self.
During the retreat you'll take part in 5 Ayahausca ceremonies led by the Maestro Segundo Chani
Our Ayahuasca retreats are for those who seek a responsible and safe way of expanding their self awareness and consciousness.
What we offer:
5 Ayahuasca Ceremonies over 8 days & 7 nights
Optional kambo ceremony with Matses trained bushman
Shamanic Plant Dieta
Shamanic Consultations 1 to 1
Private transportation from Iquitos, accommodation and meals
Orientation meeting about Ayahuasca, ceremonies and the retreat process
Integration discussions in the mornings after ceremonies
Jungle excursion, night walk and boat trips on the reserve
Preparation and integration support
Meditations and body-mind practices to help you go deeper in your process
Visit to a remote jungle community and artisan market to support villagers
Artisan crafts from our shamans community
A maximum of 12 guests
Venue Highlights
Thank you!
We're glad you've joined our retreat community. See you around :)Return to my event ×


text:
Walkin Interview for "Fresher Candidates" held this weekend by top most companies in your city and from reputed MNC's across all major cities. Just wakin for an interview as per scheduled and walk out with an offer of your choice. Jobs & Interviews are available in all specializations for fresh graduates as well as experienced professionals.
Disclaimer: Walk-ins Info team team is not responsible for any changes in the schedules and venue details after being posted from the relevant references. Please confirm the same, before walking for any Interview. You can also apply to the mentioned e-mails address, if unable to appear for the interview..


text:
Jack-o'-Lantern Pops
- 1 package (10-1/2 ounces) miniature marshmallows
- 3 tablespoons butter
- 1/8 teaspoon salt
- Red and yellow gel food coloring
- 6 cups Rice Krispies
- Wooden pop sticks
- Miniature chocolate, green and yellow Tootsie Roll Midgees, as desired
- Miniature green apple AirHeads bars
- Black decorating gel or chocolate frosting, optional
- 1. In a large saucepan, combine marshmallows, butter and salt. Cook and stir over medium-low heat until melted. Remove from heat; tint orange with red and yellow food coloring. Stir in cereal.
- 2. With buttered hands, shape mixture into six pumpkins. Insert a wooden pop stick into each pumpkin.
- 3. Cut chocolate Tootsie Rolls crosswise in half; press one half into the top of each for stems. Cut AirHeads into thin strips; roll between hands to form vines. Press vines into pumpkins near stem. For leaves, roll out green Tootsie Rolls on waxed paper to 1/8-in. thickness. With kitchen scissors, cut out leaves and attach to vines.
- 4. Add Jack-o'-lantern faces using decorating gel or additional Tootsie Roll cutouts made with yellow and chocolate Tootsie Rolls.
Nutrition Facts
1 serving: 310 calories, 6g fat (4g saturated fat), 15mg cholesterol, 385mg sodium, 64g carbohydrate (30g sugars, 0 fiber), 3g protein.
Dec 31, 1969
Very cute and yummy! My niece made these for a family dinner. She did not use the Popsicle sticks and made 8 pumpkins. She also used green Laffy Taffy instead of the Air Heads.
Nov 11, 2010
My grandchildren don't think it's Halloween unless I make these. I make them smaller so it is easier for little ones to eat.
Oct 12, 2010
I have made this recipe twice for school parties and the kids love it!! They are so cute and taste very good. Make sure to butter your hands well before handling and squeeze the mix together tightly to form the balls. I never use a stick.
Oct 31, 2009
This recipe was HORRIBLE. I was so excited to make this cuz it was cute and looked easy. But it was SO hard to get them to stay together. As soon as you put the popsicle stick and tootsie roll in, they fall apart. And they keep falling apart no matter how many times you shape it together again. This might have worked if someone tweaked the rice crispy recipe...I would NOT make this again.


text:
Sold out.
We will notify you when this product becomes available.
WEIGHT18" – 3.7 lbs – 1.73 kg
DIMENSIONS 18" x 11" x 9" – 45.7cm x 28cm x 23cm
MATERIALABS / Polycarbonate composite
WHEELS Specially designed Protruding Inline wheels with Metal Bearings
HANDLE Internal Reversed-Curve Handle System designed especially for Children
TSA LOCKNo
If you do not see rotation, and are using IE 7 , then goto Tools > Internet Options > Advanced... Scroll Down to Multimedia and make sure "Play animations in webpages" is selected.


text:
To work together in Word Online, you edit a document as you normally would. If others are also editing it, Word Online alerts you to their presence, and shows you the paragraph they're working on. There's no special co-authoring mode and no command to begin co-authoring.
As authors come and go, Word Online notifies you briefly.
You can always see who is currently working in the document by clicking near the top of the window.
A colored indicator shows you where others are editing the document.
Opening the document in your desktop application
If you want to make changes that require features of the Word desktop application, click Open in Word and continue editing. For example, you might want to add a table of contents or a bibliography whose entries update automatically.
Note: Co-authoring in the Word desktop application requires Word 2010, Word 2013, or Microsoft Word for Mac 2011.
In the Word desktop application, be careful not to introduce content or functionality to the document that will prevent other authors from editing the document in Word Online. For example, don't use permission features such as editing restrictions or marking the document as final. If you want to restrict access to the document, use the permission features where the document is stored (OneDrive, Office 365, or SharePoint).
If someone does save the document with features that aren't supported by Word Online, you can still co-author, just not in Word Online anymore. If everyone in the group has Word 2010, Word 2013, or Word for Mac 2011, continue working together in Word (click Open in Word and continue editing).
If someone in the group doesn't have one of those versions of Word, you need to remove the unsupported features from the document so that everyone can continue to work together in Word Online. Do the following:
In Word Online, click Open in Word (requires Word 2003, or later, or Word for Mac 2008 12.2.9 or later).
In the Word desktop application, remove the unsupported features. For details about what's supported, see Differences between using a document in the browser and in Word.
Save the document (press Ctrl+S in Windows, or ⌘+S on the Mac).
If you used Word 2003, Word 2007, or Word for Mac 2008 12.2.9, close Word so that others can continue co-authoring the document in Word Online.
If another author saves the document with unsupported features before you have saved the document in Word Online, you might not be able to save your work in Word Online. If you have Word 2010, Word 2013, or Word for Mac 2011 you can prevent losing your changes by opening the document in the Word desktop application. Click Open in Word, copy your changes from Word Online, and then paste them in the document in Word. When you save the document in Word, your changes are saved on the server.
If co-authoring in Word Online isn't working
If co-authoring isn't working in Word Online, it might be because someone has the document open in a version of Word that doesn't support co-authoring. The document might contain features that are not supported for editing in Word Online, or some other problem. For help, see Troubleshoot co-authoring Word documents.
Note: In SharePoint 2010, Word Online does not support co-authoring, but you can work together in Word 2010, Word 2013, and Microsoft Word for Mac 2011.


text:
Crazy Snowboard — Free App of the Day
Winter may be winding down, but that doesn't mean you still can't head out and hit the slopes! All you have to do is boot up Crazy Snowboard and you may as well be in Aspen ... where the beer flows like wine. That right there is reason enough to make Crazy Snowboard today's Free App of the Day!
Combining tilt controls with a tap and release mechanism to grab some serious air, Crazy Snowboard will have you tearing up the mountain side in no time. Like the old Tony Hawk games, you will be able to link your tricks together to increase your multiplier and score big.
Speaking of skating, there are also plenty of things on which to grind your snowboard, such as rails, boxes, logs, and even candycanes! See how many you can link together to ramp up your bonus multiplier and boost your score. You can also go head-to-head against your friends to see who is the Crazy Snowboard champion!
It's time for some shredding, man. Download a copy of Crazy Snowboard today for your iPhone and iPad!