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Seeking Lessons in Swine Flu Fight
By LAWRENCE K. ALTMAN, M.D.
Published: August 10, 2009
As the three-month-old outbreak of swine flu raises havoc during the winter season in the Southern Hemisphere, officials in the United States are carefully seeking clues from there to deal with its likely return in this country in the fall, before a vaccine can protect large numbers of people.
Although much about the swine flu pandemic and the virus remains unknown, experts say this outbreak has exposed several weaknesses in the world’s ability to respond to the sudden emergence of a widespread illness.

Over all, the pandemic’s severity has been “moderate” compared with past influenza pandemics, the World Health Organization says, although it has spread with “unprecedented speed” to at least 168 countries. And although influenza typically strikes in colder months, the swine flu virus, A(H1N1), has swept through summer camps in the United States and Canada. That pattern has led to the prevailing belief that many more people will get swine flu than seasonal influenza this fall and winter, but that the country could face outbreaks of both strains, perhaps at different times.

One of the weaknesses that officials and experts point to is that despite years of planning it is evident that the infrastructure of the health departments in many countries, including the United States, is inadequate (in varying degrees) to deal with the sudden appearance of a new strain of influenza. Also, the number of beds in hospital intensive-care units and emergency rooms is limited, as is equipment like mechanical respirators to help patients breathe when the virus attacks the lungs.

Another problem is communication.

Officials and experts say they have learned a lot about human swine influenza. But relatively little of that information, including periodic summaries of what has been learned since the beginning of the pandemic, has been reported and published. Some experts said researchers were waiting to publish in journals, which can take months or longer. Journals impose severe penalties for disclosing information before publication, although they say they exempt matters of public health importance. Whatever the reason, delays in reporting such information can hamper plans for public health responses.

Few experts can match the personal overview that Dr. Richard P. Wenzel, chairman of the department of internal medicine at Virginia Commonwealth University in Richmond, has had of the swine flu virus’s activity in the United States, Mexico and four South American countries. At the invitation of former trainees in those countries and aided by some travel support from industry, he has visited them to observe cases, advise on control measures and critique their data.

Dr. Wenzel, a former president of the International Society for Infectious Diseases, said he had observed a broad spectrum of illness from human swine influenza: people who experienced few or no symptoms to those who rapidly developed complications and died.

The standard definition of influenza includes a fever. But an odd feature of the new virus is the lack of fever in a significant proportion of documented cases, even after some patients become seriously ill. In Chile, it was about half, in Mexico City about a third and elsewhere, less, Dr. Wenzel said. Lack of fever has been noted by other observers in several Canadian cases.

Analysis of data from specimens yet to be tested may shed light on how often infected individuals who have no fever spread the virus.

Epidemiologists stress the need for rigorous methodology to produce the solid data that is crucial for planning. For example, a need exists to account for the several-week delay that can occur between the onset of symptoms and death in influenza and other illnesses. Failure to take that time lag into account can seriously underestimate the death rate, depending on when in the course of the pandemic the information is obtained.

So absence of fever among substantial proportions of patients, when fever is specified in the definition, can cause serious underestimation of case totals.

Also, absence of fever limits the usefulness of thermal scans to identify people who have the virus and thus control the pandemic.

Diarrhea is a symptom that appears to be occurring in a larger percentage of cases than in seasonal influenza, giving clear reason to reinforce the importance of frequent hand washing.

Dr. Wenzel said he had urged his doctor hosts to test patients’ stools to determine how often the virus is present and the extent to which it is responsible for transmission.

Few such studies have been done, and there are reports that laboratories have received samples inadequate for testing.

Little specific information is available about when infected people stop shedding the virus, and thus stop spreading the illness. That information is particularly needed for those with impaired immune systems from H.I.V. infection, chemotherapy and anti-rejection drugs used in organ transplants.

Mexican doctors found the swine influenza virus on the hands of workers, on tables next to patients’ beds, on other hard surfaces and on a computer mouse, Dr. Wenzel said. So, he added, “infection control in hospitals must be assiduous to prevent spread, particularly those with impaired immune systems.”

The course of illness can become life-threatening in just a few hours among patients who had shown only mild symptoms, Dr. Wenzel said, but his visits showed that “doctors know little about what treatment works in severe cases.”

Mexican and Argentinian doctors have noted that cases peak over a four-week period, drop substantially over succeeding weeks to very low numbers, and then pop up elsewhere in the countries, Dr. Wenzel said.

Two more unusual features of the new virus are that pregnancy, particularly in the third trimester, and obesity seem to increase the risk for complications of the infection.

Dr. Anthony E. Fiore, an influenza epidemiologist at the Centers for Disease Control and Prevention in Atlanta, said that “we were unable to find” published articles that looked at obesity as a risk factor.

Studies are under way, he said, to clarify whether obesity is an independent risk factor for complications of influenza or whether obese people have conditions like heart disease, asthma and other chronic lung ailments that put them at such risk.

Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University in Nashville, said many people were reluctant to acknowledge that they or family members are obese. The 10 centers in a C.D.C.-sponsored program to track influenza hospitalizations, he said, have started collecting information on height, weight and body index to better determine obesity’s predisposition to complications.

Doctors actively involved in patient care are hampered by the lack of a standard, reliable rapid test to determine if a patient has swine influenza or some other respiratory illness. The diagnosis of swine influenza A(H1N1) has to be made through special tests known as P.C.R., for polymerase chain reaction. The tests are used in research laboratories but otherwise are generally available only through local and state health departments.

The P.C.R. tests, even if offered by a commercial laboratory, generally cannot be done in time to help a doctor determine whether a patient in an office, a clinic or a hospital has seasonal or swine influenza — a factor in determining what treatment to offer.

That situation has imposed new demands for local and state health departments that are working under severe budget restraints. Health departments doing the tests may be able to tell medical practitioners about swine influenza activity in geographical regions, but not in individual cases.

“We are stuck diagnostically,” Dr. Schaffner said. He added, “While we have increased expectations of what public health departments can do, and the science behind it, we do not have the infrastructure to do it.”

For example, last spring, Dr. Schaffner’s team at Vanderbilt conducted drills to retest their pandemic plans and learned that while some things worked very well, others had problems.

The area assigned for setting up an expanded outpatient clinic no longer existed because a new building had been constructed. “So we had to quickly find a new place,” Dr. Schaffner said. In addition, some elements of the pandemic plan had not been completed because the staff had been busy with other things.

The drills also showed the need to better plan for replacing absent hospital administrators “who are critical in determining which phase of your pandemic plan you are going to move into.”

Dr. Schaffner is trying to alert other institutions to the kinds of gaps identified by Vanderbilt, which has strived to be well prepared.

Health professionals and the public, Dr. Schaffner said, should be receiving more information in a timelier way about what has been learned about the swine influenza pandemic. Some such information is often reported at scientific meetings, but the summer is the doldrums for such gatherings.

Speaking about some of the gaps in clinical and epidemiological details, Dr. Schaffner said that “it is worth being tough and saying how come we do not know more.”

http://www.nytimes.com/2009/08/11/healt ... wanted=all

This will be a MAJOR problem in the schools this fall.

Thank you. Very informative article from a credible source. Excellent reading material regarding insight into the virus and what's been learned so far.

The onset of symptomless swine flu really worries me. I'm already concerned about people not being tested for swine flu as the primary diagnosis when hospitalized for secondary infection. The symptomless version only adds to the anxiety.

Mind me saying this - but never before have we had this huge amount of obese people among us. In 1918 there were very few obese people. So I wouldn't expect too much data on that.

The inability to contain or control a serious outbreak is the understatement of the century. Even now they display their ignorance in the guidance they have put out. I would put to those who read these blogs and by chance some bumbling idiot from the CDC were to actually come here to read this some other weak points that were left out of the article.

First off risk management vs monetary cost should be last on the list of criteria during any kind of pandemic. This attitude not only tied the hands of the CDC but also tied the hands of the WHO. Any person with two cents worth of a brain would realize that the primary goal of any kind of health service should be to contain and delay the spread of any kind of pandemic by all means necessary. The reason for this is simple. Although containment may fail, the delay process would allow enough time for researchers to develop and distribute a vaccine during a pandemic situation. Examples of failure of this are across the board with every country to delay the spread as much as possible on international, national and local levels.

Containment and delay policies should have been put immediately in place the moment the problem in Mexico was first discovered. Air traffic to infected regions should have been heavily restricted. Public venues should have been closed sooner and international aid should have been offered to the first infected country to motivate this process. When you look at the cost of the failure to implement this policy you can see what the effects are immediately globally. You allowed the spread of a potentially dangerous virus to spread across the world in what can only be deemed in record breaking time. Where once remote regions may have had years to deal with a wide spread pandemic it happened in a matter of weeks due to the failure of governments to act because of financial consideration. New Zealand and Australia are prime examples of that. I would further put to you that financially speaking you will pay the toll. For in the short term you may have allowed business and commerce to continue but in the long run you will pay the same price if not a heavier one through heavy infection of work force, business closures for weeks if not months on end and yes even the dreaded but eventual school closures the must occur despite your best effort.

Financial peer pressure has led to countries condemning mask, which according to research has been proven time and time again to reduce infection.
It has led to misinformation by governments to their populations to the point of putting the general public at such ease as this virus is no longer considered a threat by the average person on the street.
It has led to a certain amount of complacency in the education system to slow or stop the spread of the virus in the community. Many educators still have not a clue how to handle this outbreak.
It has even led to a certain amount of complacency in the medical profession here in the states. Who repeat the government line so many times they to have begun to believe it.

I could go on there are so many examples of mistakes made due to the worry about the economic impact. But , I would conclude by saying that the initial financial impact of a heavy move to delay and contain would have been a drop in the bucket to the impact of allowing a spread that will be so fast that hospitals and businesses will be over whelmed and closures which may have once been regional now will be globally. What would have been billions will now be trillions. Hopefully you will learn before something really deadly appears.

The lack of fever will cause many problems with the spread in schools. So many parents send their children to school while ill if there is no fever due to work obligations.

I have a question based on the observed absence of fever in many positive cases. Would Mkey or Wotan care to speculate on this.

I have always understood fever and runny nose to be the cardinal signs of flu. About 3 weeks ago we had an outbreak of H1N1 in the staff hostel which we contained, however, this week we have had a major outbreak of viral conjunctivits among staff in the same hostel. They have no fever and no other symptoms as yet.Could there be a link? Could this be H1N1 presenting in a manner that is atypical of seasonal flu. The conjunctivitis is severe and widespread.

Flu, including pandemic H1N1 swine flu, causes conjunctivitis and pink eye.

I recall reading about H1N1 going through a school district earlier this year. Parents were not concerned about the absenteeism, because they said that many illnesses were circualting at the time (late spring / early summer), including steph throat, gastro intestinal problems, and pink eye, in addition to those with flu-like symptoms. However, H1N1 causes sore throat, gastro-intestinal problems, pink eye, and flu-like conditions.

Thanks, It just seems too co-incidental, same building, same time frame, viral in nature rather than bacterial. Is it worthwhile having them swabbed?