Effect Measure

Swine flu: not a walk in the park

A kind reader directed my attention late yesterday to an article on the Boston Globe’s web site about three schools closing in Boston because of absenteeism from flu-like illnesses. I was struck by a comment made by a freshman at Boston Latin that seemed to get it exactly right:

The closing surprised freshman Wilhelmina Moen, who noted it was nice that authorities were concerned about the student’s health.

“I’m not that worried,” said Moen, who lives in Brighton. “It’s the same thing as the other kind of flu. That flu kills too.” (Stephen Smith, Andrew Ryan, Elizabeth Cooneym Boston.com)

So far illness caused by this virus seems similar to the illness caused by seasonal flu. The word “mild” is sometimes applied to flu that doesn’t kill you or send you to the hospital. If you’ve had flu — this one or the more usual seasonal kind — that won’t be much comfort to the wracking muscle and joint pains, fever and miserable respiratory symptoms. But at least you didn’t wind up in the hospital, although you could have. Influenza can be very nasty, and as the young highschool student, it can kill you.

What if you do wind up in the hospital from swine flu? We now know something about hospitalized cases in California, thanks to a report in CDC Morbidity and Mortality Weekly Reports (MMWR). As of May 17, California had 553 probable or confirmed cases of novel H1N1 (swine flu), of whom 30 wound up in the hospital for 24 hours or longer. Mainly longer. The median length of stay of the 23 for whom it is known because they have been discharged is 4 days; but for the 7 still hospitalized it is already 15 days.

Age range was older than other reported (non-hospitalized) cases, with a median age of 27.5. Two thirds had underlying medical conditions. A good example of how flu might contribute to death or serious illness is given by one of the detailed case histories in the MMWR:

Patient 29. A woman aged 87 years with multiple medical problems, including recently diagnosed breast cancer with possible abdominal metastasis, hypertension, diabetes mellitus, coronary artery disease, cerebrovascular disease, chronic renal insufficiency, and obesity, was brought for care at an emergency department on April 21 after being found unconscious by her daughter. The patient had reported onset of fever, cough, and weakness 2 days before admission and also new onset of orthopnea and bilateral leg swelling. She was wheelchair bound and had no recent history of travel or known contact with ill persons. In the emergency room the patient was afebrile, with a blood pressure of 57/39 mmHg, pulse 57, respiratory rate of 14 breaths per minute, and oxygen saturation of 87% on room air. Electrocardiogram was suggestive of non Q-wave myocardial infarction. Chest radiograph showed bilateral pneumonia and congestive heart failure with marked cardiomegaly. . . . The patient went into respiratory arrest and was subsequently intubated and started on low dose dopamine, and admitted to the ICU with a diagnosis of myocardial infarction, congestive heart failure, pneumonia and presumed sepsis. A chest computed tomography (CT) scan showed complete atelectasis of the right middle lobe, bilateral ground glass opacities of the upper lobes, and bilateral pleural effusions. A subsequent bronchoscopy identified a large cauliflower-shaped mass in the right lower lobe airway. Multiple blood, urine, and sputum cultures were unrevealing; rapid antigen test was positive for influenza A, with subsequent confirmation of novel influenza A (H1N1) at the CDPH VRDL. The patient remains hospitalized in critical condition under intensive care.

Without the intensive surveillance I doubt this woman’s concurrent infection with influenza would ever have been diagnosed. It is certainly the case that the contribution of flu to other causes of death is underestimated when using the death certificate coding for influenza.

For the hospitalized patients the most common admitting diagnosis was pneumonia and dehydration, accompanied by fever, cough, vomiting (but not diarrhea) and shortness of breath. 60% had chest x-ray signs of pneumonia. Six (20%) wound up in intensive care and 4 on ventilators. Here’s another case history from MMWR:

Patient 18. A man aged 32 years with a history of obstructive sleep apnea sought care at an emergency department on May 5 with a 3-day history of fever, chills, and productive cough. The patient reported he had been taking amoxicillin for a diagnosis of sinusitis, following complaints of vertigo and dizziness, for the past 2 weeks. His vital signs showed a temperature of 99.1°F (37.3°C), blood pressure of 89/58 mmHg, and heart rate of 84 beats per minute. Physical exam of the chest showed good air movement bilaterally, although chest radiograph revealed bilateral infiltrates. His complete blood count and chemistries were normal except for an elevated white blood cell count of 13.8 cells/mm3 with a differential of 94% segmented neutrophils and 4% lymphocytes. An arterial blood gas showed respiratory acidosis and hypoxemia with pO2 of 80 mm Hg on room air. The patient was admitted to the ICU on empiric broad spectrum antibiotics and required intubation on the second hospital day for worsening hypoxemia. Initial microbiologic workup and influenza rapid antigen tests were negative; the patient was started on oseltamivir on hospital day 2. A repeat rapid antigen test and bronchoalveolar lavage viral culture were positive for influenza A, with subsequent confirmation of novel influenza A (H1N1). The patient improved, was extubated on hospital day 5, and was discharged on hospital day 10.

This was a relatively healthy young adult who went rapidly downhill with respiratory distress and also wound up on a ventilator. His body temperature was below the threshold used to define influenza-like illness (100 degrees F.) and originally a rapid flu test was negative for influenza. False negatives occurred in 5 out of 30 of the hospitalized cases reported on here. This patient did have swine flu and became critically ill and had a stay in the intensive care unit. His influenza was certainly not “mild” in any sense of the word.

As far as we know at the moment, these patients are not unusual in the sense that their experience is unlike “the usual” seasonal influenza. On the contrary, one reason for concern about a flu virus that can spread faster and to more people (and younger people) is not that its illness is unlike seasonal influenza but that the illness it causes is (so far) very much like seasonal influenza.

Any influenza is not a walk in the park. Unless it’s the kind of park a prudent person wouldn’t walk through late at night. Then, maybe, it is a walk in the park.

Comments

  1. #1 george
    May 20, 2009

    As the parent of young adults, I find it disconcerting that they have an increased risk of becoming seriously ill, even dying, if they catch this flu. Normally, I’d be thinking about elderly relatives in this way as flu season approached.

    And let’s not forget, the twenty-somethings are among those least likely to have adequate health insurance.

  2. #2 ravyn
    May 20, 2009

    I’m a little concerned about the use of rapid antigen testing in the context of swine H1N1 for several reasons.

    First, I wonder if clinicians fully appreciate that the test must be interpreted in according to the local prevalence. Negative results from these tests should not be relied on when the prevalence is very high (such as in the height of the flu season).

    Second, do we really know the prevalence of H1N1 well enough to correctly interpret these results?

    Third, what is described in the hospitalization cases seems inconsistent with experience. For a test with reasonable sensitivity, when prevalence is low, false negatives occur infrequently. For example, using a test with about 73% sensitivity when the prevalence is less than 5%, false negatives occur in about 1% of all negative results. H1N1 does not appear to be that prevalent. Yet, 5 of 30 hospitalized patients had false negatives. That concerns me, and seems to be yet another unusual characteristic of swine flu.

    A rapid point-of-care test can be useful, but there is already confusion about appropriate use with “typical” seasonal flu. I’d like to see some expert guidance from the CDC on the appropriate role of rapid testing for swine flu.

  3. #3 Snowy Owl
    May 20, 2009

    What University of Michigan flu studies can tell us about how to deal with swine flu.

    What conclusions draw U-M from the study that would be relevant to the current outbreak of swine flu—or future outbreaks of other strains?

    The study suggests that masks plus handwashing are most effective when their use is started at the first sign of outbreak—before the flu spreads.

    Up to date information on U-M flu preparations at
    http://www.umich.edu/flu-swine.php

    Snowy

  4. #4 revere
    May 20, 2009

    ravyn: rapid flu tests have a sensitivity of only about 50%, so if the prevalence is high there are a lot of false negatives. Their main use has been as a crude indicator of whether there is influenza in the community, not as a diagnostic tests for individuals. Unfortunately there is a tendency to use it this way by clinicians, and the initial use in this outbreak as a signal for confirmatory testing also used it this way. Now CDC is not saying there should be a positive rapid test before considering swine flu as a diagnosis.

  5. #5 Rod
    May 20, 2009

    As a reporter for a smallish daily paper,who must cover many topics, I’ve found this site extraordinarily helpful. I’ve a question: The Indiana State Department of Health’s May 20 update on novel H1N1 flu reports 70 of the 105 confirmed cases are persons between 5 and 24. There are no confirmed cases among the 65-and-old population.

    Is this significent data? How should it be assessed? Is there, perhaps, a connection to the

    I know enough about influenza to know I know very little about influenza. Other than the obvious sources (CDC, this site, Aetiology blog) any suggestions on who to call?

  6. #6 Rod
    May 20, 2009

    Whups … second paragraph should have concluded “absence of fever in some victims”

    Darn sensitive mouse…

  7. #7 Snowy Owl
    May 20, 2009

    I just have access to comments made by the Head of Epidemiology of Japan, sorry no links,

    He said, even Japan Tiny GP offices have up-to-date kit test, that is why numbers of confirmed cases are skyrocking.

    His concern is Tokyo, 38 millions people in a 60km range.

    He expect it in the next few days.

    Nikkei Market is very nervous for their capacity for Exportations due to massive absenteism. (In Japan Culture, most of the time even when sick and financially strain you DO NOT go out and spread viruses, it is part of their cultures, they put mask on for years not to protect themselves but to protect Society).

    Snowy

  8. #8 PanFluWatch
    May 20, 2009

    Revere,

    Have you heard anything about obesity as a risk factor for severe disease with H1N1?

    The Washington Post ran a disappointingly bogus story claiming that the MMWR article found obesity was a major risk factor, and while I was able to demonstrate that that makes no sense (and that the authors of the paper make no such claim), the Post’s story also included this:

    Excerpt:
    “We were surprised by the frequency of obesity among the severe cases that we’ve been tracking,” said Anne Schuchat, one of the CDC epidemiologists managing the outbreak. She said scientists are “looking into” the possibility that obese people should be at the head of the line along with other high-risk groups if a swine flu vaccine becomes available.
    End.

    Now, I’m a bit behind the times at the moment, but I haven’t seen anything to support this elsewhere. On the other hand, I’m inclined to assume that an epidemiologist who DOES have a lot of the data at her fingertips would know what she’s talking about. Any thoughts?

    For more on this, see:
    http://panfluwatch.blogspot.com/2009/05/obesity-and-h1n1.html

  9. #9 PanFluWatch
    May 20, 2009

    Rod:

    Off the top of my head, I’d also recommend http://www.cidrap.org, and promedmail.org, though they can both be a little technical at times.

  10. #10 PanFluWatch
    May 20, 2009

    Sorry, Rod, that’s http://www.cidrap.umn.edu, NOT cidrap.org. I think it’s time for another cup of coffee…

  11. #11 passerby
    May 20, 2009

    I wonder your opinion about the practice in Asia (e.g. Hong Kong) to isolate all those people who have close contact with the confirmed cases. Is it effective? Does its benefit cover its costs?

    The new flu is now spreading fast within the US. It’s also spreading fast out to other countries. Should the US gov’t do more? I notice that it’s already off the front page of most news agencies.

  12. #12 revere
    May 20, 2009

    Rod: The relative “sparing” of the older age group is uncertain but most likely quite real. There is no firm explanation, but most people think it may indicate some immunity from experience with pre-1957 H1N1 (the pandemic in 1957 replaced H1N1 seasonal flu with H2N2 and the 1968 pandemic replaced H2N2 seasonal flu with H3N2; in 1977 H1N1 “came back” and started co-circulating with H3N2). As for people to read, any reporting by Canadian Press’s Helen Branswell will add information (her rolodex and reliability are legendary), and the CDC media office has a lot of resource information. CDC’s daily press briefings are a way to keep up and get CDC thinking.

    PanFluWatch: Helen Branswell has a piece on it. It sounds like this is a product of the analysis of hospitalized cases reported on in MMWR (although the obesity data are not given there). I didn’t comment on it since no data were given, but Schuchat elaborated slightly at the press briefing as a comment. My impression was that it is something they have noticed in the scant data but haven’t really analyzed to see if there is confounding or some other explanation. I expect the data will generate a lot of hypotheses for follow-up, some of which will grab the imagination of the press. Nothing can be done about it. As a scientist interested in the topic I am glad to hear about things like this, but of course I’ll interpret differently than the public. Like everything, it’s a trade-off. We’ll just have to wait for more data.

  13. #13 Snowy Owl
    May 20, 2009

    Off the top of my head, I remember a higher sysceptibility of Obese to develop Lung infections.

    As for a reference fo the above journalist may I suggest
    the Scientific Library at Flutrackers.com

    Snowy

  14. #14 phytosleuth
    May 20, 2009

    The obesity connection might be an artifact of the number of obese people on the North American continent.

    There might be a connection with high insulin or high glucose tied to inflammation. Also some research on adipocyte cells infected with influenza increasing production of interleukin 6 which may create inflammation (low grade). In vitro though.

    “…maintenance of normoglycemia…protects against mitochondrial and organ damage…”(Crit Care Med 2009; 37:1355-1364)

    It could be immune function in obese folks is not as good. Or all of these.

    Still too early to make any assumptions. Maybe you shouldn’t “feed a fever” after all.

  15. #15 neil
    May 20, 2009

    Look up pickwickian syndrome on wikipedia.

    That will explain a lot relative to obesity being a factor.

    Dr. Schuchat mentioned this in yesterday’s conference. Her citation tweaked my memeory, and I had heard of this before, odly enough.

    Obese people have a very difficult time breathing when lying on their backs. They even develop hypoventilation, and sometimes stop breathing.

    Add this to lung congestion and other symptoms of flu and you’ve got an “exacerbating underlying medical condition.”

  16. #16 revere
    May 20, 2009

    The first step is to confirm that the association is real. That hasn’t been done yet. Then we can worry about why.

  17. #17 neil
    May 20, 2009

    I forgot to make one point very clear:

    flu = infiltrates
    infiltrates = less O2 sub 1

    FAT = difficulty breathing = less O2 sub 2

    (Less O2 Sub 1) + (Less O2 sub 2) = much greater risk of worse flu outcome.

  18. #18 The Doctor
    May 20, 2009

    Obese patients are much harder to care for technically when critically ill. For instance, it is harder to start IVs without causing tissue trauma, it is harder to keep them clean and it is more difficult to move them around. They are also at higher risk for complications due to obesity. For instance, when sedentary an obese patient is at much higher risk for phlebitis and pulmonary embolism. The immune system of the obese is “sluggish” compared to that of the non-obese which puts them at higher risk for infections complicating use of IVs or urinary catheters.

    So, I can not say for sure that obese patients are at higher risk for complications due to influenza but what I can say is that in general they are at higher risk for a variety of serious complications when critically ill irrespective of the cause.

    Grattan Woodson, MD

  19. #19 PanFluWatch
    May 20, 2009

    Actually, though, the MMWR paper does give a breakdown by obesity; only 4 of the 30 hospitalized patients(13.33%) were obese (lower than the prevalence of obesity in California’s general population), only one of whom ended up in the ICU/required mechanical ventilation.

    6 out of the 30 cases described (20%) were admitted to the ICU, and 4 out of 30 (13.33%) required mechanical ventilation.

    With only 4 obese patients represented -and a whopping total of 30 patients of any sort to look at- it’s hard to say anything definitive, but I certainly don’t see anything in this data to indicate a higher risk associated with obesity. Apparently the authors didn’t see a relationship, either, because they make no mention of one.

    Maybe it’s a language precision issue: perhaps the people who are saying there appears to be a relationship really mean “overweight,” versus “obesity.” That’s a broader category, and it wasn’t reported in the MMWR paper.

  20. #20 M. Randolph Kruger
    May 20, 2009

    Revere and you know I like the numbers, do you have any on what it cost to get a good outcome? As previously and repeatedly stated, UHC would bankrupt us. Take a UHC situation and add in a pandemic and then we could see cost exponentiation beyond the entire GDP.

    The Chinese truck driver cost 50,000 USD two years ago at Chinese costs to bring him out after two months. Extraordinary costs and efforts were used. So, we get to the cheap seats of H1N1 and well, if we were in or out of a UHC scenario it doesnt matter… Both would and will go broke in a high numbers pandemic.

    Did a little research on the 1968 flu in the US. For those hospitalized it was 23,000 USD on average (big bucks back then). Did the conversion from that to todays money…140,000 bucks and it wasnt high path as a rule, just nasty like this one.

    I cant see UHC with the limited availability of care under that, or the more available under insurance working either in a high number pandemic. That takes it back to the government which reeling as it is already from the deficits would lose the capability to pay… The old people make it mostly so far. No productivity as a rule beyond about 65… So in my opinion, this will bankrupt the US under all scenarios even if it continues now to the “2/3rds” of the US population getting it if even 25% require hospitalization.

    You have any numbers for what it cost for any of those cases so I can average them?

  21. #21 revere
    May 20, 2009

    Randy: I don’t understand your reasoning. Everyone knows that to finance exactly the same amount of care via private insurance is more expensive. So you are suggesting that we just let people go without care, right? I don’t have any estimates. I don’t think it’s relevant to the discussion except that without UHC more people will die.

  22. #22 melbren
    May 20, 2009

    I understand that seasonal flu vaccine does not protect against this current swine flu–but weren’t there some studies about seasonal flu vaccine being associated with a lowered risk for developing the secondary bacterial infections that often follow a primary influenza virus infection? (A pediatrician told me this specifically regarding otitis media–that, apparently, certain bacterium tend to hang out with certain viruses?) Is there any truth to this?

    I am interested to know if those who suffered more severely from swine flu were less likely to have had the seasonal flu vaccine. (Along those same lines–of those who suffered the most severely, were they more likely to have been suffering from dual infection–primary viral and secondary bacterial?) I have always wondered if there was convincing research on the subject–if it turned out to be true, it would be another very compelling argument for routine seasonal flu vaccines. Especially for us mommy-types.

    And just to “weigh in” on the whole obesity issue (sorry, couldn’t resist)–I hope we factor in the established socioeconomic link between poverty and obesity. Socioeconomically disadvantaged people have a greater incidence of obesity and less access to health care; it is plausible that swine flu is more likely fatal to obese people because swine flu is more likely to be fatal to poor people. Which brings me full circle–wouldn’t the poor have been less likely to have received a seasonal flu vaccine?

    Just wondering. But it would be interesting to look at Mexico’s statistics.

  23. #23 M. Randolph Kruger
    May 20, 2009

    Revere, what I am saying is that either or system is going to collapse if this gets to high numbers of MILD cases. Ability to tax for those who have no HEALTH INSURANCE is a big cost right now. In other words your supposition is only based upon the idea that it costs less. Well if you only provide limited care I guess that would be true. Everyone gets the same shitty care under UHC… right? Wheres my flower pot?

    But my point is that to tax to cover a pandemic for those who have no health insurance and then have to pay for your own is a bit much for any economic system to bear. Both go under. I totally disagree that to provide the same care for everyone would cost less, especially if its government run. It just means someone gets to piggy on someone elses dime is all. Hell, it will collapse it in a year or so anyway without help from a pandemic.

    It goes back to whether health care is in the Constitution.. a right. Bill of Rights? .. Haven t seen it in either. And yes you are right many will get no care at all, both those that pay for health insurance and for the people who have no health insurance. They can get health care and we pay for that too.

    Count on one thing that if the cases get beyond 50,000 in the US that have to be hospitalized then the tents are going to go up like they are already in Japan.

    Indeed I am saying that if we are Obamanized into UHC that this will collapse the entire system and that means that the system will crowd out private insurance and turn it into yet another cash cow to steal from like Social Security. But that is ignored in the argument. Shouted down. Same in the UK for just a short time longer.

    It will collapse both private and UHC but the difference is that if you paid for it to the government and you dont get it, then you can sue the government. You can sue the insurance companies but like Katrina, you wont get a thing. But thats the known. You can sue the government post of it and get a nice big settlement because you did pay for it and the government will be around afterwards. They wont be able to plead they didnt know, surge, capacity etc. So that “It costs less” doesnt even work in their normal flu season over there and the health minister said that they have to start rationing it. Now what happens then?

    The UK system is in tatters and about to fall apart and they are now paying 51% of their income to the government if you make more than 38,000 equivalent in dollars a year. So its a spread the misery to everyone rather than the wealth. They have all of their people who have never held a job too. Those people here will riot post of the pandemic of high numbers. No money except to pay healthcare, inflation runaway and we can only print so much money.

    So, cost for 200 million (2/3rds of the US) and lets say about 25% are hospitalized or cost the 50,000 Chinese costs in dollars in some manner (military intervention, actually seeing a doctor, hospitalization etc), and live or die for whatever reason then we are looking at 50 million people. Thats 250,000,000,000 plus the lawsuits for those who got no care and paid for it and thats a taking under the law. Not going to be able to say, “We did our best” under UHC. Litigation will kill UHC in its own right even if this continues to climb in numbers. I saw a model today in a briefing that said about 1 to 2 million cases in the US in the next 2 months.

    What is ones life worth under UHC or health insurance? That, a jury WILL decide.

    My point is simple and that is that I am reading the above and well sorry I just dont get the vibes that the powers that be have a clue what to do. GDP is gone, and into the negative column. The Administration has borrowed and IS spending more than all of the previous administrations combined and we have this bug we can see in the distance coming our way. Add in the costs of all the future liabilities to the taxpayers and I see no way out.

    You will of course say wars in Iraq and everything and I understand those costs. They ARE in the Constitution and Obama doesnt seem to quick to be cutting that out either. So, you tell me how in heck anyone is going to pay for this if this comes? I can see that MILLIONS who need to be in the hospital will never make it in there having paid for both UHC for the “poor” and healthcare. The poor will be the first to run for the hospital… Its free to them remember. Even if the above number is right by even 1.5 trillion dollars, there will be no recovery at all and the US will be doomed. No one to tax.

    I read about these cases and I wondered aloud how much its costing for them to be in the hospital at UHC/Private insurance expense is all. I bet their costs for the 15 days is well over 200,000 for 23 people and two weeks or pushing it.

    Look it up. I have read that it costs at least 1700 bucks a day per bed overall to be in the hospital and thats basically if they do nothing to or for you. I am not beating up UHC, I am just saying both UHC and private are going to be dead permanently after a pandemic of any size in the US.

    Going to find out if its a right or a privilege at about 50,000 cause thats about all the beds we got.

    Should have closed the borders and the airports…. but thats just me.

  24. #24 revere
    May 20, 2009

    melbren: Secondary bacterial infections are just that: secondary to infection with flu. So if the seasonal vaccine doesn’t prevent the original flu infection (at the moment it appears dobtful it protects against swine flu) then it will have no effect on secondary infections either.

  25. #25 revere
    May 20, 2009

    Randy: Just look at a North American model and feel free to ask Canadians what they think. It has nothing to do with the Constitution. The Constitution says Congress can make laws and that’s how we will get UHC if we get it. You just make assertions, most of which are untestable, opinion or false.

    I get that you are scared shitless of UHC. I’m not. Let’s just leave it at that.

  26. #26 Lisa the GP
    May 20, 2009

    If you ‘read between the lines’ when looking at my little ‘home alone’ post on the fluwiki, you can guess at how nasty my personal experience of ‘ordinary flu’ was.

    I keep ‘reassuring’ people that this is no worse than ‘regular’ flu, but although true it feels a little disingenuous because I think a lot of people have forgotten how bad a true flu feels.

    I think most people mistake bad colds for flu, at least when they remember how they think they felt.

    How many times can I put something in single-quotes in a single post?

    On an unrelated topic–Revere if you’re still reading replies on this thread–Murray Valley Encephalitis on today’s ‘promed’ news–cause of death:’brain failure’?

    Is that an Australian term, do you know, or bad reporting? Somehow I think that wouldn’t fly as a diagnosis on a US death certificate…(I laughed, as I’m pretty sure all death involves ‘brain failure’.)

  27. #27 M. Randolph Kruger
    May 21, 2009

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1838950

    http://www.springerlink.com/content/q01lx2477w465243/

    Brain failure by a Aussie doc as he interprets that. He does go into a bit of detail when it happens though with an addendum page. These were the two that he directed me to.

    Lots of encephalitis in the river areas where he works. Horses, cows, birds… all carry the bugs.

  28. #28 Lisa, San Jose CA
    May 21, 2009

    Randolph, the cause of death on that kid’s certificate wouldn’t be ‘brain failure’, but something like ‘EBV encephalitis’.

    I just haven’t run across that term used in that way before. It’s like saying someone died of ‘respiratory failure’ instead of ‘mixed bacterial pneumonia’ with contributing causes of ‘influenza’ and ‘COPD’.

    Anyway we’re getting off topic.

  29. #29 pft
    May 21, 2009

    While any flu is not a walk in the park, if this flu is not anymore severe on average than seasonal flu, I do not understand why it should be treated differently.

    Not saying there should not be more testing or that preparations for a worsening should not be made, but panic and cancelling trips, forced quarantines in some countries (occupants of 1 hotel in Hong Kong were quarantined for 7 days because of one sick occupant), travel restrictions in some countries (have a temperature and you are refused boarding) seem a bit over the top.

    I don’t necessarily disagree with school closings, this is done sometimes when there is a severe seasonal flu outbreak, and the end of the school year is coming, and the weather is improving. Trying to infect yourself to get some immunity while it is mild is stupid, so I am not in that camp either.

    There there is no guarantee that efforts to limit the spread by draconian measures will pay off, or even not make matters worse by limiting the amount of community immunity during the next flu season.

  30. #30 Lisa the GP
    May 21, 2009

    pft, the reason to treat it differently on a *social system* level is that far more people may have it at the same time than usual. Even if the % of people needing hospitals is small, the absolute number could still out-strip available beds.

    This absence of availability could then translate into a higher death rate than would be seen from seasonal flu because some folk who should be in the hospital will be at a lower level of care.

    So it is a concern for politicians and people involved in healthcare delivery and resource allocation.

    For individuals who actually *catch* the virus, their personal experience of the illness itself sounds as though it will be similar to familiar versions of the flu.

    Which is why, even amidst the authorities own ‘panic’, they’re telling people not to worry. The vast majority of individuals who catch this flu will need no more than rest, fluids, and supportive care as for typical flu. But *in aggregate*, the number of more severely ill individuals is still enough to cause headaches on a macro scale.

    Would you want to be the politician who didn’t do anything, and then have the hospital overflow so that a campaign donor’s granny dies after no bed was available for her?

    Would you want to be the public health officer who didn’t provide guidelines for closing schools, so that 6 schools got hit at once and swamped the medical system, where if you’d closed a few maybe the same number of cases would have been spread out over a few more weeks and the system would have had the capacity to handle them?

    As individuals we only need to worry as much as we do for other strains of flu. But as a *society* we need to take steps to prepare.

  31. #31 BECKY
    May 21, 2009

    All have very good points, but as a 27.5 year old considered to be obese with heart problems, I am very scared. Low income and not the best insurance(causing me to be put on waiting lists rather than immediate treatment or flu shots for that matter)all due to my disability. Not sure what to do and at this point with all the hype about obesity and flu I feel like I’m just waiting to die. Will there be treatment? Will they put me last in a treatment line-up because of insurance? Will they send me home because of my frequent medical visits and age assuming I’m fine? And my kids too? So much worrying, I think I am more scared of what the U.S. regulations etc. will do with me if infected rather than actually cathing the flu!

  32. #32 Tom DVM
    May 21, 2009

    Becky

    We are pretty early in this pandemic, so I would take any conclusions regulators have reached with ‘a grain of salt’.

    It seems that they may be pushing underlying health conditions a little too much because they think it may ‘calm’ the general population.

    Having said that…you have every right to be worried. Pandemics do not come along every day. That last one was forty-one years ago.

    If you google ‘Crofsblog H5N1′, you will see a variety of resources. There is a list of flu forums. Visit them and sign up to one that you feel comfortable with and ask your question there.

    They are all very helpful and very informative…just what you need at the moment.

    Hope that helps!!

    /:0)

  33. #33 Kristin
    May 21, 2009

    Revere, I would like to comment about the UHC thread here – as someone who has worked in US healthcare for over 12 years and now lives in England, working for the NHS, I’ve seen both sides of this.

    First the US: On the financial side, because of EMTALA all patients presenting to the ED must be seen and treated, regardless of ability to pay, citizenship, etc. Therefore, even without UHC, the serious inpatient cases you mention would still cost the same – legally(if not ethically), these patients must still be cared for, as they will likely come in through the ED. In addition, if current ED usage patterns were to hold during an outbreak, the patients without healthcare insurance would present to the ER for even very mild cases more so than those with insurance, as those without insurance won’t have cheaper alternatives. Not only is this a much more expensive way to treat the cases that are not truely emergent – but it is (obviously) less ideal than a situation where patients can present to their local physician for more mild cases.

    On the other side, here in the UK – right now every household is being given a small pamphlet that outlines the basics of the current outbreak, steps to preventing infection (includ

  34. #34 Kristin
    May 21, 2009

    Revere, I would like to comment about the UHC thread here – as a US citizen who has worked in US healthcare for over 12 years and now lives in England, working for the NHS, I’ve seen both sides of this.

    First the US: On the financial side, because of EMTALA all patients presenting to the ED must be seen and treated, regardless of ability to pay, citizenship, etc. Therefore, even without UHC, the serious inpatient cases you mention would still cost the same – legally(if not ethically), these patients must still be cared for, as they will likely come in through the ED. In addition, if current ED usage patterns were to hold during an outbreak, the patients without healthcare insurance would present to the ER for even very mild cases more so than those with insurance, as those without insurance won’t have cheaper alternatives. Not only is this a much more expensive way to treat the cases that are not truly emergent – but it is (obviously) less ideal than a situation where patients can present to their local physician for more mild cases.

    On the other side, here in the UK – right now every household is being given a small pamphlet that outlines the basics of the current outbreak, steps to preventing infection (including the ‘Catch it, bin it, kill it’ campaign designed to encourage sanitary coughs and sneezes), and information about what to do if a person is ill. A system is set up whereby everyone should (now, ahead of time)prepare a network of ‘flu friends’. Then, in the case of illness, the patient should call the hotline for screening. If phone triage indicates, the patient will be told to present to the A&E for treatment – and which one to go to. However, for milder cases, the patient will be instructed to have a flu friend pick up antiviral medication(free of charge) on their behalf and take it to the patient. The patient should not go out, and this message is being given now, ahead of any potential outbreak. Every UK citizen is being told that if they suspect they are ill, they need to stay home – from work, from the doctor, from everywhere. Just simple, stay-at-home advice. While there is no direct evidence of how this system will work, the aspect of universal triage suggests the burden on the healthcare system could be reduced through utilizing appropriate levels of care: keeping miler cases away from the acute care centers allows the acute care centers to care for those who will be acutely ill.

    I’m not saying the UK system as-is would work across the US (because I don’t think it would, except maybe in some small communities). But what I am saying that the US system is flawed in two ways when it comes to dealing with an outbreak of influenza: 1) The current healthcare system uses the ED as defacto Universal Health Care, and as we all know (that in addition to being a very expensive and resource-dense method of healthcare), the EDs are terribly overly burdened with the uninsured as it is, and will likely be more so in the case of influenza outbreak; and 2)a planned system that provides treatment for everyone, in the case of an outbreak, would seem to be a key first step to preventing panic – and panic/fear can create terrible burdend during an outbreak, including increased economic cost. I’m arguing that when the population knows there is a plan, when people are confident they (and their loved ones) will be covered within this plan, people are likely to remain calmer. Perhaps not calm, per se, but less nervous or panic-stricken than if they feel they have no health care coverage, or even that they might be left out altogether in a crisis. General rule: Uncertainty leads to fear. True universal coverage takes out one piece of uncertainty.

    In short, if the argument is about cost, I argue that the uncovered population is a more expensive group to care for in the case of an outbreak. In addition, true public health (population health, preventative health) is cheaper and more efficient to administer and from what I’ve seen, the US is very far behind in this regard.

  35. #35 Rod
    May 21, 2009

    Snowy, PanFluWatch, Revere, thank you for the help.

  36. #36 Lisa the GP
    May 21, 2009

    kristin, thanks for the insider view on universal health care.