Severe cases in swine flu: lack of clinical details

Two elite flu reporters, Helen Branswell (Canadian Press) and Declan Butler (Nature), both noted yesterday the dearth of clinic information on the serious and fatal swine flu cases. First Butler:

Clinical researchers have been slow to respond to the 2009 flu pandemic, lament researchers writing in today's Lancet. "Public health officials, virologists, epidemiologists, and policy makers have done well in responding to a rapidly emerging and complex problem. By contrast, the clinical research community's response has been delayed and modest, " writes Jeremy Farrar, a researcher in Ho Chi Minh City, Vietnam and colleagues from Vietnam, the US and Mexico.

They deplore the "lack of information" on the pathogenesis and clinical aspects of those with severe illness, and argue that trials and other clinical research are urgently needed to better understand the disease, and learn of necessary tweaks to treatment regimes. What research is being done isn't being published fast enough, add Farrar et al., contrasting this with the speedy publication by researchers in other disciplines who have published in fast-tracked journal articles, or shared on public wikis - eg here - in advance of formal publication. Clinical researchers need to "catch up," they conclude, "To do otherwise would be unethical." (Declan Butler, The Great Beyond [Nature blog])

I don't know the slowness is "unethical." Clinicians in the midst of an outbreak have their hands full managing critically ill patients. Papers don't write themselves. They require time, effort and spare energy, three things not so abundant in such circumstances.

Branswell offers a view what those circumstances look like and a few hospitals:

In a typical flu season, the Winnipeg hospitals where Dr. Anand Kumar works might see one, maybe two life-threatening cases of viral pneumonia caused by influenza.

So seeing 10, 15 and more flu patients in those same hospitals' intensive care beds in June is still a shock, suggests Kumar, a critical care specialist who works at three different hospitals in the city.

"You just don't see this many of them," Anand says of the patients, struggling to survive swine flu infections.

"You don't see rows and rows of patients on ventilators because they have respiratory failure, a viral pneumonia kind of thing. It's unusual." (Helen Branswell, Canadian Press)

We have no idea how representative this is of ICUs in areas with a lot of circulating swine flu, but this is without dobut an unsettling description. The data aren't available to calculate hospitalization rates or case fatality rates with any confidence, but the contrast with a regular flu season in this description certainly gives one pause.

At any rate, the clinical spectrum of underlying pathology has not yet been described. It sounds much like the patients that go sour fast are taken down by a rapidly progressive primary viral pneumonia (where the influenza virus infects the cells of the lower respiratory tract). What role, if any, a dysregulated innate immune response ("cytokine storm") or secondary bacterial infections play we don't yet know.

I expect we'll see some published case series relatively soon. Branswell reports the doctors she interviewed have some in preparation. They will almost certainly receive expedited review and publication, as would be appropriate. We're just two months from initial cases, so it's not surprising there's a lot we don't know about what is happening. But in the same time the virus has spread around the world, continues to circulate during summer months in the northern hemisphere and has established a foothold in the southern hemisphere, at the start of its flu season.

The world of public health is fastening its seat belts. It could be a rough ride. But flu is unpredictable, so you never know. Maybe it will surprise us pleasantly, this time. But I doubt it.

More like this

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The online publication of three papers and a commentary yesterday in the Journal of the American Medical Association (JAMA; free access, links at bottom of post) provides some further data on what demand for critical care resources might be from the current swine flu pandemic. One paper reports on…
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Helen Branswell has a story about a battle being waged among virologists and occupational health specialists regarding how influenza is spread from person to person: Later this week virologists, infection control specialists and occupational health experts from Canada, the U.S. and Britain will…

Thank you Reveres to bring this sollicitated point up.

I have received 4 times more requests on this issue this week than the week before from my International contacts.

I received;
4 requests from India, North West, North East, Center and South East.
Few intense request from surrounding Lybia (Virulent plague outbreak), a request from Francophone African Country.
Request from North and South America.

Can you, please, in a NutShell as you know how to do it, describe the whole infection process, symptoms and probable outcome.

There is definitely a surge of worrying and frustration, Professionals on the ground wants a source of information out of their usual networks.

Thank you for your experience sense of Timing Reveres.


Hello !

I found this article on the bbc:

But I can't seem to find out much more, other than that a company (virabiotech) has been created to fund the research for this universal-vaccine against the flu (that they discovered allready in 2006)

How come we don't offer this a chance now that we apparently have a pandemic underway...? Somebody knows more about this research, is the science-community not convinced of it's efficiency ?

By luther blissett (not verified) on 20 Jun 2009 #permalink

luther: If you go to the sidebar under categories: vaccines you will find many posts on the "universal vaccine" effort. It is underway in many labs and a number of trials. There is intense activity in this area, but so far no one has put such a vaccine through development. Lots of activity in many places. It is not being ignored.but it is also a difficult technical challenge that has not been "solved."

I can't stand the vague references to 'underlying conditions' that seem to accompany so many swine flu death reports. Were those conditions especially acute when the person got sick? Did they actually contribute to the cause of death? Or do the officials keep stressing underlying conditions just to hide the awful truth that usually flu deaths are a result strictly of the virus itself provoking a cytokine storm and multiple organ failure, that even the healthy (or even especially the healthy) are not protected from?

In any case, patient confidentiality or no, I think the authorities owe us a little more information about how and why these people are dying.

JD: There have been several accounts of what underlying conditions mean. The modal condition is asthma, but flu always picks on those with comorbidities. As for more details of individual cases, there are state laws that prohibit release by authorities in many states, and in some cases the underlying conditions may carry stigma (e.g., HIV). There is also the problem of the effect on the living, e.g., family members who might be (wrongly) shunned. As to what we in the public are "owed," I'm not sure I am owed anything. We need case series so we can see what the patterns are, but knowing that Mr. X had diabetes doesn't help me as an individual except to draw the possibly false conclusion that if I don't have diabetes I am safe. Most deaths from flu -- even in 1918 -- weren't cytokine storm (which is not a good name for possibly many different kinds of immune dysregulation, although it has a nice graphic name). Most deaths in the first few days are probably primary viral pneumonia, which isn't treatable either, so there is nothing to hide here. If you are young and healthy you are at risk, but so far the risk is small. Nothing hidden. But it's like bird flu. We don't know why this person rather than that person. A lottery, and that's scary enough.

Well its spreading nicely in 98 degrees here Revere. 12 suspected, 5 confirmed. ILI in every practice out there and doctors are posting it on the door-"If you think you have swine flu please call xxx-xxxx and do not enter the facility"

My pair of GP's...hubby and wife are coming out to treat them on a table and a tent they have set up out back. If they are fairly toasty, they call to see if they have a bed at the hospital. Right now thats a big no. Memphis has almost as many hospital beds as it does whiplash willie attorneys. Right now they are full up with pneumonia, dehydration cases and ventilator patients. Waiting list now for the ventilators.

Now here's the rub. Clinical details would likely be more available if they were testing... they arent. Initially the labs were swamped with H1N1 testing and about 1/3rd were positive as this is the collation point for the mid-south.

Now its a hit and miss sampling. They are only putting "influenza" down on the charts. My neighbor who is a cop's wife is director of nursing at BMH and is the trainer for all the EMT's in the county and she said that she goes in, she suits up, she puts on the gloves and mask with a full face shield. 14 nurses in the same hospital with suspected H1N1... still no testing and the docs apparently aint asking for it either.

I buy into Helen and Declans assertions without a doubt. But for my money and its not UHC, they ought to be testing everyone if for no other reason to determine if there are mutations that are turning high path. I dont want to find it out by seeing people go first and using them as the mutation dummies.

But thats just me. My virologist drinking buddy says that if it crosses 102, trouble breathing or you think you have trouble breathing, aches, limited pee output or stopped output you should be calling the doctor. If it crosses 103 he said call 911. I guess that any medico would buy that, especially if its a kid or a toddler.

By M. Randolph Kruger (not verified) on 20 Jun 2009 #permalink

I am generally disgusted with what passes for healthcare in this "advanced society". I am afraid that if some real scientific studies were done that the flu would be found to be unprofitable. The main remedies (vaccines and Tamiflu) which the profiteers wish to sell may be found to be almost completely worthless. The underlying condition which leads to a total failure of the immune system to defeat the flu may be malnutrition. How can anybody make money out of that?

JD #4

I can't stand the vague references to 'underlying conditions' that seem to accompany so many swine flu death reports.

I do not know the exact numbers, but I understand that a large portion of the seriously ill patients in WInnipeg are from St Theresa Point. When I taught a basic statistics course to adult learners there, we collected some data on the numbers of smokers (it was to demonstrate the t-test, not sampling, and was not a proper survey). The proportion of smokers was about 2/3 and may be an underestimate for the community as a whole. There is also a high incidence of diabetes (my guess would be about 30% but it is just a guess). I imagine both of these would contribute to the 'underlying conditions'. Some similar communities are also experiencing increasing rates of TB infection.

By Richard Simons (not verified) on 21 Jun 2009 #permalink

I am absolutely at odds over the downplaying of this pandemic. Here in NYC, television news has been reduced to a 15 second blurb to report any count of local deaths, with no further details. Just weeks into the outbreak, hospitals stopped testing; it soon became apparent that H1N1 could not be tracked fully. Finally, the CDC and WHO had less frequent updates. As Revere reported weeks ago, the actual number of cases is most likely far higher.

Although I really do understand the logistics involved, I kind of feel shortchanged not having pertinent up-to-the-minute data. AM I GOING THROUGH WITHDRAWAL? Am I alone? I'm just not at all happy to realize I must sit back for a few years to find out more, when some definitive report is finally published, and the current pandemic simply becomes known as the '2009 Flu.'

I want meat! This is not like H5N1 and SARS, whose news updates became scant due to their periodic nature. It's more like waiting to see if an undetected asteroid is on it's way by 2012, as some people seem to believe. Just a potential crisis that is getting quite a bit of press, because there 'may' be reason for concern.

Maybe I AM in withdrawal, nothing else; just a slight form of PTSD, from something that appeared more ominous than it really is. If that be the case, I apologize to all of Revere's readers for needing to sound-off. A bit of therapy? I think I may feel somewhat better.

But, I did have my own scare.

Thanks for mentioning asthma as an underlying condition. As a lifelong 'sufferer' who got tired of having to go to the hospital during crisis, I've learned how to control flares pretty well. The elimination of processed foods and those that cause acid reflux is easier than avoiding enviornmental triggers such as a stranger's perfume, industrial pollutants and their smells, among many others. Yet, when I feel it's getting out of control, I start a descending prednisone regimen of about 5 days duration, which always nips it in the bud.

Otherwise, I really haven't been ill for quite a number of years...until last month.

About two days after going to a small function by NYC subway, I developed a headache--which is unusual for me. Soon I was wiped out. Chills (no fever, even though it felt like I had one), horrible nausea, pain throughout my body/bones, an unusal cough, then, the gasping for air--so, I reached for the prednisone. The first day I took a higher than usual dose of 50mg, but was concerned when it didn't have it's usual 'immediate' effect. Although I was well aware of H1N1, between my debility and the fact that my local ER has serious issues, I felt safer at home with elderberry tea and an organic cough syrup. By the next week I felt much better. Both of my asthma-free boys developed much milder symptoms--even the one with antiphospholipid antibody syndrome, an autoimmune disease.

Maybe it was just a cold; I'll never know. I really doubted my local hospital would have tested me for this flu. Now I have no idea if I have immunity.

BUT, if it IS true that this flu compromises asthmatics, they should know how important it is to GET TO AN ER IMMEDIATELY. I did not suspect flu. Asthma has this way of creeping up on you dangerously, since we are used to labored breath. Perhaps asthmatics need more information about their risk factor, and, given a regimen of steroids to have on hand--just in case.

As far as those other individuals are concerned--those who also suffer from the same undisclosed underlying illnesses as the unfortunate souls who have died after contracting H1N1--a media black-out is a dangerous option.

Those who NEED this info probably have no clue that they could be in jeopardy.

Marsha: While there are some for whom H1N1 is a top news priority, there are many claims for the public's attention (e.g., Iran, the economy, etc.). Moreover the logistical problem is something "the public" created by voting consistently for lower taxes. We can't have it both ways. For an individual, the current situation isn't any different than a regular flu season, where widespread infection with the virus usually doesn't bear any mention. The issue is what is going to happen, and for that planners and policy makers, more than individuals, need information. Sadly, they will be hampered by the lack of infrastructure as well, but the disappearance from the news is less of an issue.

This is a timely post for me: my daughter and her boyfriend have come down with fevers, sore throats, chills, vomiting and etc. He was sick a week or so ago, then felt better for a few days, and is now sick again. My girl texted us on Fathers Day to say she was not feeling well and wouldn't be over. Today she called to tell me more. It doesn't sound grave (poor choice of wording,) but I am concerned.

Fortunately, I am taking my son to the doc today for a different reason. I'll ask how they are responding to such symptoms. The b/f's dad is a dermatologist, and he checked his son's throat, but said the red popsicle obscured any information. Both kids say it is very painful to try to swallow.

Okay, I am getting nervouser by the minute. I'm thankful to everyone here for info over the past few years. I did insist a couple years back that the Ped give my daughter the adult pneumo vaccine. At least she has that going for her.

Reveres: how long did your illnesses last? It's harder taking care of children once they move out on their own.

By wenchacha (not verified) on 22 Jun 2009 #permalink

So you don't think, Revere, that the government should be making it clear to the public that this flu may well turn into a 1918-level pandemic, and that people who can afford to would be wise to stock up on food, drugs, and other supplies in the event of severe supply-chain disruptions?

And if so the question then becomes, of course, for how long a period of time?

By Jon Schultz (not verified) on 22 Jun 2009 #permalink

wenchacha: Flu can last from a day or two to a couple of weeks. Usually 3 - 4 days acute phase and run down feeling for varying periods of time afterwards. The thing to watch for is feeling better and then suddenly worse, since that's a sign of secondary bacterial infection.

Jon: Lots of places you can find out about personal prepping, but not here. We do community level stuff. I don't think it is productive to benchmark everything to 1918. That's like benchmarking your city's homicide rate to the Wild West. It is not impossible for this to be1918 but not very likely IMO. It doesn't have to get anywhere near that for us to be in a world of hurt given the brittleness of our health care system. But collapse of critical infrastructure? I don't think so.

Revere: I'm not sure the "wild west" analogy is applicable, because the homicide rate existed at that time under circumstances which no longer apply. I think a better analogy is hurricanes, and the fact that we had a "flu hurricane" in 1918 at a level of severity which, many people believe, could in fact happen again despite current medical advances. And even that is not a "worst case scenario," which is another important benchmark in the equation, considering the possibilities of a pandemic with H5N1 lethality.

The question then becomes the likelihood of various levels of storm severity, and the likelihood of critical infrastructure being affected in different cases. In any event I think the government should be making the dire possibilities, which I think are very real, more clear to the public, and that at least one of the reasons they are not is an undue concern for the protection of industries as opposed to the public welfare.

By Jon Schultz (not verified) on 22 Jun 2009 #permalink

P.S. Although, upon further reflection, perhaps the primary reason is simple fear of criticism if they talk about dire possibilities and then nothing terrible happens. In either case I think the public is woefully underinformed about the possible dangers, and that is a failure of both our public health agencies and the major news outlets.

By Jon Schultz (not verified) on 22 Jun 2009 #permalink

Leah: The connection of pediatric mortality and MRSA is now well known. See this post for more details.

i am from India and i visited U.S.A during the peak period
of swine flu epidemic (from May 2009 TO JULY 2009).ON MAY 17th I visited the zoo at ST.Louis. The climate was very chilly for indian standards even during summer.after a day or two i developed severe cold, and cough and runny nose. i did not go to a doctor and took Tylonol tablets for a few days and it became alright and i continued with my tour going to florida and new york and innumerable malls and shops in betweeen. the cold cough persisted through out my stay in usa and back again in india. after coming back to india i consulted a doctor and he gave me some antibiotics which cured me for about a week. again the same old cough and cold and sore throat persists. my doubt is, can it be swine flu acting slowly on my body with my underlying conditons ( i take anti hypertensive/cardiac medicines). Kindly answer my question.( It is almst three months since i had that bout of cold in USA.)

By K..C..Mukund (not verified) on 05 Aug 2009 #permalink