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Man with severe swine flu defies the odds
ELISSA DOHERTY
November 15, 2009 12:00am

ROBERT Pridham was about to die: in the grips of swine flu, his lungs were so inflamed he couldn't breathe.

With not even a ventilator able to help, family members and his fiancee were given the devastating news they should say goodbye to the 30-year-old.

Doctors had seen few cases of swine flu this bad and believed he had just hours to live.

But in a South Australian first, doctors at the Royal Adelaide Hospital miraculously brought him back from the brink of death with a new machine likened to an "artificial lung".

The blood was drained out of his body, oxygenated in the machine, then pumped back via large drips in his neck and legs. The Extra Corporeal Membrane Oxygenation machine had never before been used in SA, and was a last resort to arrest the pneumonia stemming from swine flu.

"I wouldn't be here otherwise," Mr Pridham, of Strathalbyn, said this week.

"I've been told I was very lucky to get through it."

In SA, 29 people have died after contracting swine flu this year, with 9107 confirmed cases.

The Strathalbyn Racecourse groundskeeper was unconscious through much of the two-month ordeal that struck without warning.

One day, he was healthy and fit, working, playing golf and dreaming of his upcoming wedding.

The next he was struck down with fever, which within a week sent him into intensive care, and a 3 1/2-week coma.

It started after a game of paintball on September 6, when he began experiencing the shakes and a burning 42C temperature.

His GP initially dismissed it as a normal flu, advising painkillers and rest.

But his condition worsened during the week, until he was struggling to breathe, wheezing and desperately dehydrated.

Rushed to the Mt Barker Hospital, he was quickly sent to the emergency department of the RAH where he was diagnosed with swine flu.

"I can't remember much, I was sent to ICU and put on a drip," he said.

"I was put in a coma and about three weeks later, re-awoken.

"They saved my life, I'm very glad they used the machine."

Filling in the gaps, his fiancee Lauren Hollitt, 24, said it had been their worst nightmare.

The family was told three times to say goodbye to him, because the pneumonia filling his lungs with infected fluid was so serious. "One night we all stayed at the hospital overnight and slept on the floor, we weren't sure what was going to happen," she recalled.

"But we never said goodbye - none of us wanted to give up hope.

"I just kept talking to him and saying 'I love you'." Weak but breathing on his own, Mr Pridham was finally discharged on Monday, and will return to work in the new year.

Ms Hollitt said it was like a "dream" to have him home after more than two months in hospital.

Associate Professor Rob Young, the RAH's director of intensive care, said the machine had been a last resort for Mr Pridham.

After swine flu began gripping the country, the ECMOs were fast-tracked to three Adelaide hospitals, at a cost of $210,000. Prof Young said Mr Pridham's case had been unusual because he had such a severe strain of swine flu with no underlying medical conditions.

"He had only hours to live, he would have died if that machine had failed," he said.

"The first time we used it was going to be a challenge, but it was our last, only option.

"The ICU can be a pretty horrible place, so to see someone so sick who has survived has been a real boost to the staff."

The grateful Pridham family has arranged a race day at Strathalbyn next month to raise money for the ICU.

The ECMO machines are saving swine flu victims around the world and others with life-threatening heart and lung problems.

New wave of swine flu expected early 2010
By Charmaine Kane
Dec 4, 2009

Queensland's Chief Health Officer Dr Jeanette Young says she expects the second wave of the swine flu pandemic to hit the state in February or March next year.

She told a medical conference on the Gold Coast today the disease caused a thousand deaths in the northern hemisphere last week but Australia's risk is lower because the population is much smaller.

She says a new vaccine offers safe, effective protection but only 10 per cent of Queenslanders have been immunised so far.

"We know through a lot of extensive modelling that has been done that if we can get 40 per cent of the population immunised then we will significantly reduce the impact," Dr Young said.

"Otherwise we will see a very similar flu season to what we saw last year with about the same morbidity, the same mortality and the same admissions to hospitals and ICU."

H1N1 still a danger for school kids: AMA
[...]

Second wave of swine flu to hit
[...]
EXPERTS predict a second wave of swine flu will hit Australia as early as the end of this month.
[...]
Robert Booy, an infectious disease expert at The Children’s Hospital at Westmead, said there was evidence a second wave was coming and it was possible that it could be worse than the first round last year.
[...]

CASE FILE OF THE KILLER VIRUS

- 37,584 confirmed cases of H1N1 in Australia.

- 191 Australians have died from swine flu.

- Median age for casualties is 53, compared with 83 for seasonal flu.

- 4912 hospital admissions; 14 per cent admitted to intensive care.

- Indigenous Australians are 10 times more likely to be admitted to hospital; 13 per cent of people who died were indigenous.

- 7700 children under 10 had confirmed cases, with 15 per cent admitted to hospital.

- 21 million doses of pandemic (H1N1) 2009 vaccine were bought by the federal government.

- 6.6 million doses of the vaccine have been distributed across jurisdictions.

Source: Federal Department of Health and Ageing, NSW Health

Two new swine flu cases spark warnings in Tasmania
February 9, 2010

There have been two new cases of swine flu in Tasmania as authorities prepare to vaccinate 350,000 people before a predicted second wave of the virus hits.

Primary school-aged siblings from the south of the state were infected with the H1N1 virus by a relative visiting from the UK last month.

Health Authorities say the outbreak has not spread but the Deputy Director of Public Health Chrissie Pickin says it is a warning for parents to vaccinate their children.

"Children are really the super spreaders of this disease, not necessarily the ones who get it most severely, but perhaps the ones who can pass it on to others who are more vulnerable," she said.

Dr Pickin says vaccinating children will reduce the severity of a second wave.

"We had seven people die, including a 12-year-old girl and we really don't want to see any more deaths from swine flu next season," she said.

The Health Service is offering free vaccines at festivals and pharmacies around the state.

Flu season on its way, warns Yass doctors
17 Feb, 2010

Local doctors are renewing their call for community members to vaccinate themselves against the Pandemic H1N1 influenza in preparation for the fast approaching influenza season.

The Northern Hemisphere experienced an early start to their influenza season with the Pandemic H1N1 2009 virus being the predominant strain of circulating influenza, according to Greater Southern Area Health Service Vaccination Coordinator, Alison Nikitas.

"An early start to Australia's influenza season is likely, which is why being prepared and getting your family vaccinated against pandemic influenza before the influenza season starts, makes sense,” Ms Nikitas said.

Local doctors have been running regular H1N1 influenza clinics since the vaccine became available last year. They continue to urge members of the community to vaccinate themselves against the Pandemic strain.

Dr Ray Burn said “swine flu won’t go away” in his Towards Health column last week.

“Maybe the next European winter will not have a major outbreak of swine flu and maybe it won’t spread to Australia even if this happens. A lot of people died from swine flu last year. What level of risk are we prepared to take for our children and ourselves?” Dr Burn asked.
[...]

The swine flu pandemic in Australia has been equated to a bad year for seasonal flu, and about as deadly but across a broader age group. University of WA Professor in Microbiology David Smith said the influenza A(H1N1) virus had not prompted a significant increase in flu deaths in 2009 over what would have occurred in a typical flu season...

Prof Smith said Australians should expect a milder flu season this year, and while swine flu could continue as the dominant strain more people had immunity to it through the federal government's free vaccination program or prior exposure.

Swine flu jabs may be wasted
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Dr Peter Eizenberg, a GP and former member of the federal government's immunisation committee, said a significant proportion of the government's 21 million doses could go to waste now that the new seasonal flu vaccine had arrived.
[...]
Dr Eizenberg said he expected people would be attracted to the seasonal flu vaccine from now on because it was impossible to tell which one of the three strains would dominate in Australia until the season was under way. The swine flu strain had predominated in the northern hemisphere, he said.

This post wraps the latest debate about the impact of pandemic influenza in Australia, and includes an article from public health physician, Dr Craig Dalton (how bad was the pandemic really, he asks), PLUS a stack of links to recent international publications (these are at the very bottom).

In the letters pages of the latest Medical Journal of Australia, intensive care doctors from four hospitals have raised concerns about a previous MJA article, which concluded that “the clinical course and outcomes of pandemic (H1N1) 2009 influenza virus are comparable to those of the current circulating seasonal influenza”, and that “the high number of hospital admissions reflects a high incidence of disease in the community rather than an enhanced virulence of the novel pandemic influenza virus”.


The intensive care doctors are “concerned that these assertions underemphasise the true severity of the influenza pandemic, and have led to inappropriate reporting in the media”.

The authors of the original article responded, saying that the large numbers of intensive care admissions for pandemic flu are “not a function of enhanced virulence of the pandemic strain, but rather a function of vast numbers of infected individuals in a naïve population”. They also cite an article by the Australian and New Zealand Intensive Care Study investigators in support of their conclusions, noting that this group also found no difference in outcome between pandemic (H1N1) 2009 and seasonal influenza.

Meanwhile, Craig Dalton and other NSW colleagues reported the results of their investigations into whether patients with pandemic flu were more likely to end up in intensive care than those with seasonal influenza A infection. Based on state-wide data, they calculate a relative risk of 4.9 (95% CI, 3.5–7.0) for admission to ICU with pandemic (H1N1) 2009 influenza compared with seasonal influenza A infection.

Also in the journal, Dr Peter Collignon, Director of the Infectious Diseases Unit and Microbiology Department at Canberra Hospital, suggests that most of the mortality predictions for this epidemic have been consistently wrong and exaggerated. Together with predictions of second and third killer waves, these have generated needless fear and inappropriate responses, he says.

Craig Dalton has provided this overview below for Croakey readers. He writes:

“Was it a beat up or a near miss? Controversy continues but we now have most of the pieces of the puzzle to answer this question.

It was, as health authority sound bites so clearly stated: “mild in most, severe in some”. There were concerns in Mexico in early March about a nasty respiratory outbreak that was thought to be due to seasonal influenza, but it wasn’t until two children in California were identified with a new flu strain by a molecular fingerprinting study that pandemic alarm bells were rung.

The pandemic virus hit Australia before the usual influenza season. Many general practitioners and emergency departments were swamped with pandemic influenza patients or those that feared they had pandemic influenza. This gave an initial impression of high influenza attack rates in affected communities.

However, our own Flutracking.net influenza surveillance, Google Flu Trends and work absenteeism surveillance suggested influenza-like illness rates were no higher than previous years and the rates were lower than in 2007. Importantly influenza related mortality was no different in the general community and from an anecdotal perspective – just looking at the low rates of illness among work colleagues, family and friends – it just didn’t feel like a “bad flu year”. However, it was a different story in hospital wards and intensive care units.

Because most of the pandemic related disease was mild it took some 4 to 6 weeks before we saw severe cases of pandemic influenza began to mount. Between June and August Intensive care units steadily admitted more and more patients with severe lung disease due to pandemic influenza. The Australian New Zealand Intensive Care (ANZIC) study found that obesity, pregnancy, asthma and other chronic lung conditions, diabetes, and Indigenous status were associated with increased risk of admission to ICU and the age of admissions were younger than patients typically admitted to ICU with seasonal influenza. The study also found that 32% of the patients had no underlying risk factor to explain the severity of their influenza infection. While pandemic patients were young, the median age of all cases was the twenties, for hospitalisation it was the thirties, for ICU admission the forties and for deaths the fifties – each decade seemed to move patients to a need for higher care or towards a fatal outcome.

Controversy rages in this week’s edition of the Medical Journal of Australia where three letters debate the seriousness of the pandemic and the appropriateness of the pandemic response. Some Australian research suggests that pandemic influenza cases in hospitals and ICU had similar illness severity and death rates to those with seasonal influenza. While seasonal and pandemic influenza (who are mostly younger) patients might have the same outcome once they are admitted to hospital or ICU, what the hospital and ICU focused studies couldn’t measure was whether infection with pandemic influenza increased their chance of admission to hospital or ICU in the first place.

In research published in the same issue of the Medical Journal of Australia, we compared the risk of ICU admission among people in NSW infected with the usual seasonal influenza that was circulating at the same time as the pandemic strain was circulating. We found that people infected with the pandemic strain were five times more likely to be admitted to an ICU than those infected with routine seasonal strains.

Studies of antibodies against pandemic influenza in the community in Australia and overseas is suggesting that perhaps one third of people were infected with pandemic influenza with higher rates in children and lower rates in adults. These infection rates are much higher than the influenza illness rates we saw in the community and since most of the people with antibodies did not complain of an influenza-like illness it appears that most of the pandemic influenza infections had no symptoms.

So we have weathered the first wave of the pandemic with around 200 deaths, nowhere near the worst case scenarios of 44,000 deaths estimated based on the 1918 influenza pandemic.

While the 2009 pandemic influenza virus appears much milder than the 1918 strain, it is difficult to compare the two because of the advances in society and medicine over the last 90 years. While we have many people living longer with immune compromising diseases today, the immunity of the general population is higher due to good nutrition and better living conditions.

Many Australians will have been saved from a fatal post-flu bacterial pneumonia by a simple course of antibiotics prescribed by general practitioners, many will have been saved by expert mechanical ventilation in intensive care units and many of the patients who received ECMO, or heart lung bypass treatment, would almost certainly have succumbed to the virus without this treatment. There is emerging controversy over how effective the antiviral agent Tamiflu is in preventing fatal outcomes, but it likely also played a part in moderating this pandemic.

It is tempting to describe the initial pandemic responses as an over reaction, however, the initial reports from Mexico cited devastatingly high death rates and in public health emergencies it is important to surge the response and then wind it back as necessary. Fortunately, health authorities were able to recognise that this was a “mild in most, severe in some” pandemic and set aside the old pandemic game plan to focus on protecting those most at risk.

Given that there was probably widespread transmission of the pandemic virus in Australia before it was first detected it is still unclear what contribution public health interventions such as contact tracing, antiviral treatment, isolation and quarantine made to moderating the pandemic. If public health interventions did slow transmission of the pandemic virus, their greatest benefit may have been to smooth the pandemic peak and ease the number of cases admitted to hospitals and ICUs to help them cope. We can always learn from our pandemic response but it is clear that the pandemic virus was more likely to put young people in hospital and five times more likely to put a patient in ICU compared to seasonal influenza.

Now as we await the second wave to hit Australia in 2010 we are fortunate to have an effective pandemic vaccine. It can provide protection for both those with known risk factors for severe disease and for the perhaps 30% of us who have no known risk factors who may still be among the unlucky minority who will require the services of an ICU this winter if infected with pandemic influenza.”

• Dr Craig Dalton is a conjoint senior lecturer in the School of Medical Practice and Population Health at the University of Newcastle, and chief investigator on the national Flutracking.net influenza surveillance program. The opinions expressed are his own.

A wrap of other recent news in pandemic flu:

• Millions of doses of the Commonwealth’s swine flu vaccine could expire as people opt for the new seasonal flu vaccine, which provides broader protection for the year ahead, according to this report in The Age. Dr Peter Eizenberg, a GP and former member of the federal government’s immunisation committee, said a significant proportion of the government’s 21 million doses could go to waste now that the new seasonal flu vaccine had arrived.

• Meanwhile, CSL is doing very nicely, thank you.

• And this survey suggests that those most likely to have had the pandemic flu vaccination may have been those in least in need of it – given the evidence of prior immunity in elderly people. This study, released by the Australian Institute of Health and Welfare and funded by DOHA, found the uptake of the H1N1 vaccine was three times as high in those aged 65 years and over (42%) than in those aged 18–64 years (14%).
• A recent Canadian study whose authors concluded: “Our findings offer experimental proof to support selective influenza immunization of school aged children with inactivated influenza vaccine to interrupt influenza transmission. Particularly, if there are constraints in quantity and delivery of vaccine, it may be advantageous to selectively immunize children in order to reduce community transmission of influenza.” This is one public health blog’s take on the findings, as well as how it was reported in the New York Times.

• A British news report on recent Cochrane Collaboration review raising questions about effectiveness of influenza vaccination in elderly.

• Meanwhile, the latest WHO Update doesn’t suggest there is much evidence of the “second wave of infection” that we’ve been warned about in recent times. It says: “In the temperate zone of the southern hemisphere, overall influenza activity remained low, with sporadic detections of pandemic and seasonal influenza viruses”.

• And the latest European data, comparing activity between week 40/2009 and week 07/2010 with historical data where available, shows:

•In most countries that reported data, levels of influenza activity are well below recent pandemic peak levels and across most of the European Region, the first wave of pandemic influenza activity is considered to be at an end.
•In 19 of 22 countries reporting five or more years of data, the peak clinical consultation rates that were observed during the 2009/2010 pandemic season did not exceed peak clinical consultation rates observed during the previous years. However in several countries, clinical consultation rates did exceed recent historical peaks within some younger age groups.
•4 572 laboratory-confirmed deaths associated with pandemic (H1N1) 2009 had been reported to WHO/Europe. Although these are underestimates of the actual number of deaths associated with pandemic H1N1 (2009) virus infections, these crude estimates of mortality suggest similar rates to those observed in countries during the winter season in the southern hemisphere.
• A Wall Street Journal report on the “flu season that fizzled”

• Meanwhile, the US plans to roll out mass seasonal vaccination

• And in Ireland, children have reportedly missed their vaccinations against measles, mumps and rubella because the programme fell behind as healthcare staff tried to cope with the demand for the swine flu jab.