My newest podcast is up on iTunes (go here for the web-based version).  It’s the first of a two (maybe more) part series on influenza – covering flu in general.  We have been seeing a significant number of cases of the flu over the past week, which is extremely unusual for this time of year.  Epidemic flu goes around between November and Late April, with sporadic cases appearing at other times.  What we have seen so far is not sporadic, so it probably represents pandemic flu (H1N1).

I did a poll on Facebook, asking what people thought of the H1N1 situation.  The overwhelming majority responded that they felt the press and the government were hyping it way too much.  This really surprised me – not that people would think that, but that a majority of people felt this was the case.  It may have related to how the question was phrased or what the other choices were, but still this number betrays a lack of worry about the H1N1 virus.

This worries me.

I don’t think the fear of the H1N1 is misplaced.  The normal flu kills over 30,000 people per year, and the H1N1 is expected to infect 3 times more people than the usual flu (for reasons I will go into in the next podcast).  The implication of this is that even if this flu is “nothing special” it will kill over 90,000.  Put in perspective, prostate cancer killed 27,000 men and breast cancer killed 41,000 women in 2008.  A “normal” potency H1N1 virus could then kill more than both of these combined.

Thankfully, the cases we’ve seen so far have not been severe, but still there have been 522 deaths already from the H1N1 in the US.  But in 1918, the virus mutated around this time of year and became significantly more deadly.  I think those who get it now are actually probably fortunate.

The warnings about pandemic influenza are not hype.  But the cynicism about the government and the press are widespread.  Some of the more “unconventional” thought (read into that word generously) espouse conspiracies by the government.  Here’s one example of this:

It’s man-made. It can be used as a biological weapon. It was developed as an AIDS vaccine-related organism. It was extracted from AIDS patients. It is responsible for virtually all of the symptoms which AIDS patients suffer from. The AIDS virus is at best a co-factor, and not even such a strong co-factor as to bring on all of the symptoms of AIDS. This particular organism, the micoplasma, is associated with this upper respiratory flu-like illness. And it’s also associated in its pathogenic process with a whole variety of other symptoms that mimic AIDS.

This guy is totally nuts extreme, but the theories on the Internet of this flavor abound.

Unfortunately, the religious right Obama-haters have seized on this as anything from a means to push universal health to a weapon to sterilize the US populace.  I can assure you that this has nothing to do with Biblical thought and everything to do with the vulnerability of some people to fear-mongering.  I even had one patient ask me what I thought about the sterilization theory.  I reassured her that I had just gotten mine – although sterilization is no longer an issue for me as it has already been done with my consent.  She laughed and went ahead with the vaccine.

But less extreme people still feel this is far too much hype for the severity of the disease.  This scrutiny puts the CDC in a bad situation.  The only thing that would vindicate their dire warnings is the exact thing they are trying to prevent: a deadly pandemic.  Conversely, the more they succeed in preventing this problem, the more people will cast aspersions on them.

Take it seriously, folks.  It’s like a massive storm forming in the tropics – it could be deadly and it could be a dud.  Either way, we need to do whatever it takes to minimize the damage.

“I need to talk to you” was the greeting I was met with this morning as I walked into the office.  There were “a large number of flu cases in a local school” and we need to prepare for it.  These are supposedly “documented” H1N1 influenza.

My nurse and I sat down and we batted around scenarios that would possibly come up.  Our expectation is that the phones will be ringing constantly today, as word of this alleged outbreak spreads through the community.  Prepare for the worst and hope for the best.

• When do we make people come in?
• When do we call in medication?
• When do we call in prophylactic medication?
• What do we do about our staff who is seeing patients?

Here are the decisions we have made thus far (based on CDC recommendations):

• Any child under 5 and high-risk people with symptoms must come in.
• Symptoms of “flu-like illness” are defined as fever (over 100.5) with sore throat and/or cough.
• For our lower-risk patients with symptoms who has had direct contact with a confirmed case of flu, we will call in antiviral medications as long as symptoms have been there less than 48 hours.
• For high-risk people without symptoms who have direct contact with a confirmed case of flu, we will call in prophylactic antiviral medication.
• We will refuse medication outside of these guidelines.
• Patients with fever and cough in the office will be asked to wear a mask we provide

Even if today’s initial news turns out to be negative, we have been seeing a good amount of confirmed influenza cases.  This is far outside the norm for this time of year, so it is likely the H1N1 variety.  The good news is that it has been relatively mild.  The bad news is that very few people have antibodies against this and nobody has been immunized.

Panic?  No, but we do need to prepare for whatever onslaught of phone calls we face.  Our nurses bear the brunt of community fears, and we need to cover most every contingency.

We haven’t seen any sick pigs yet.

Before you get too “conspiracy theory” on me, let me assure you that I am not going to talk about how the influenza virus pandemic is the work of terrorists (unless the Napoleon and Snowball are trying to take over our farm).   I am also not suggesting that children are terrorists (although some do raise my suspicion).

The virus that brought such worry and even panic seems now to be “fizzling out” and people are now questioning if the authorities and the press overreacted to the threat.  Will this be a replay of the “boy who cried wolf” and have us complacent when a real threat comes?  One writer questioned if the flu “overreaction” was “more costly as the virus itself.”  Another article cites an Austrailian professor (of what, the article did not say) who stated that “the country would be better off declaring a pandemic of some the real health problems it has, like diabetes and obesity.”

The real din, however is in the countless letters to the editor and calls to radio talk-show hosts mocking the “alarmism” put forth by the WHO and others about this flu.  This does appear to be in the minority, as one poll said that 83% of Americans were satisfied with the management of the outbreak by public authorities.  Still, I suspect the volume of the dissent and sniping at the non-serious nature of the pandemic so far will only increase over time.  The number of people who know better than public health officials will multiply.

This pandemic is a catch-22 for public health officials, as an excellent article on the subject states:

The irony is that the overreaction backlash will be more severe the more successful the public health measures are. If, for example, the virus peters out this spring because transmission was interrupted long enough for environmental conditions (whatever they are) to tip the balance against viral spread, CDC and local health officials will be accused of over reacting.

Which brings me to the connection to terrorism.  If public authorities somehow thought there was a 10% chance that New York City would be hit with another major terrorist attack, how big should their reaction be?  If they suspected that there was a reasonable probablity, say 5%, that the subways would be flooded with sarin gas, should they shut them down?  I would certainly hope they wouldn’t leave that many people open to the chance of death.

And what is the best outcome?  The best outcome is that this is an overreaction.  The best outcome is that the terrorists, in fact, have reformed and are instead joining the Professional Bowling tour.  I would welcome this outcome (not to mention the exciting infusion of young talent to the tour).  The problem is, the officials have no idea how it will play itself out.  Truth be told, since 9/11, there have not been any major terrorist attacks in the US.  Does this mean that the money spent on the department of homeland security has been wasted?

As a pediatrician, I am very accustomed to overreaction.  If you bring in your 20 day-old child to my office with a fever of 102, I will do the following:

1. Admit them immediately to the hospital
2. Draw blood tests looking for serious infection
3. Check a urinalysis to make sure there isn’t an infection (using a catheter to get the sample)
4. Start IV antibiotics as soon as possible
5. Perform a spinal tap to rule out meningitis.

This seems a little over-the-top, doesn’t it?  The child just has a fever!  The problem is that children this age with a fever caused by a virus look identical to those who have meningitis.  By the time their appearance differentiates, it is too late.  This forces me to do the full work-up on every infant with fever and treat each one as if they have meningitis or some other serious infection.  I do this despite the fact that the cases of meningitis are far outnumbered by that of less serious problems.

If this is your child, don’t you want me to do that?

Knowing what we know about pandemics, the same caution was, in my opinion, absolutely the right thing to do.  If the virus turns out to be nothing serious, hallelujah.  I don’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused.  I want this to be a lot of worry for “nothing.”  Please let it be so.

But I still don’t think it is time to relax.  As one commenter on an earlier post I wrote about this pandemic stated:

It’s still a bit early to relax. The 1918 flu went around first in the spring and was very mild – kinda like this. Then it came back in the fall after incubating and mutating and was a killer.

I think the CDC and WHO probably will be concerned about this until next year, at least. Just to be on the safe side.

Remember that that flu, which was mild in the spring, went on to kill 20-100 million people.

For this reason, I hope the voices of reason win out over the armchair quarterbacks that don’t have to make these decisions that could mean the life or death of millions.  Will you tell me that evacuating the NY subways wouldn’t be a good thing on the threat of Sarin gas?  Would you criticize me for “overreacting” if your infant with a fever turned out to just have an upper respiratory infection?  I hope not.

If you would, then that gives us ample reason to ignore your opinions on how this flu was handled.

Quiet and Questions

Today was the quietest day of the week.  People were still asking questions, but the worry in their eyes was a little bit less.  A little.

The box of masks promised me yesterday was on my desk today.  My nurse got back from a trip to Arizona; she said everyone was nervously looking at someone on the plane who was coughing.  Nobody was wearing a mask, though.

I did a couple of flu tests – both negative.  I did bot more to quell fears than anything.  Patients wanted their coworkers and/or parents to know it was OK.  There were a bunch of visits after which I stated, “This isn’t Swine Flu.”  This was usually met with a grin, not a sigh, but some people looked relieved.

I met up with some skeptics – both in the office and online.  Is this worth getting panicked about?  Is it worth all the press coverage?

I have to say, I find myself wondering this myself.  But my experience as a doctor teaches me that it is far better to overreact to something than to not take it seriously enough.  I have this with patients coming into the office all the time.  They have pain in their chest that they think is nothing, but they come in to be on the safe side.  When I tell them I don’t think it is their heart, they get all embarassed and apologize for “wasting my time.”  I immediately reassure them that they shouldn’t be embarrassed.  The best-case is that they came in and it was nothing serious.  The worst-case is that they sat at home while they were having a heart attack.

The same thing is true with the flu.  If we get all worked-up about the flu and it ends up being something that is not serious, I will be very happy.  The world will be spared a big tragedy.  But if we take this threat lightly and it ends up being a virus as deadly as some previous pandemic viruses, a lot of life will be lost because of our fear of overreaction.

But is the flu worth worrying about?  There haven’t been many deaths due to it so far – at least in the US.  So why should we get worked up about it?  Here is the rationalle for a strong reaction:

• This is a virus against which nobody is immunized.
• The fact that it was a pig virus that mutated means that it is significantly different from other flu viruses our bodies have been exposed to in the past.  This is the reason pandemics are so deadly – the body takes longer to build up defenses and fight off the virus because it is basically new to the person.
• The type of influenza – Influenza A, is a more virulent strain in general than Influenza B.
• Even if this virus is an “average” or a “mild” influenza virus, the death tolls could still be quite high without aggressive action.  Each year there are over 40,000 deaths in the US attributable to influenza (1) – and this is in a population that has a significant percentage of immunized people.
• The H1N1 strain of this virus is the same strain found in the 1918 Spanish flu virus that cause the worst pandemic on record.  20 to 100 million people died of that pandemic – a large proportion of which were younger, more healthy individuals, not the people who typically succumb to flu each year. (2)

No, it doesn’t seem that this virus is as virulant as the 1918 strain, but early indications in Mexico was that the death rate was quite high.  The decision to exercise caution and act as if this would be similar to the Spanish flu virus is wise.  Delay could result in the unnecessary deaths of thousands, even millions of people.

I am not being sarcastic at all when I react to this with caution (I know my readers are used to a bit of that).  Statements by authorities of an “immenent pandemic” (3) sure as heck make me nervous.  Maybe this is an overstatement.  I sure hope it is.  If so, I don’t think it would be correct to call it a “mistake.”

The best case scenario is that the threat is over-blown.  Prepare for the worst and pray for the best.

4/29

Yesterday was the day when things really changed around here.  Nearly every visit seemed to have discussions about flu, and many of the phone calls revolved around it as well.

I got a note from my nurse saying that a patient was having diarrhea and so was worried he had the “swan flu.”  Not sure who was at fault (nurse or patient), so I responded asking if she meant “swan flew.”  Really, she was probably just writing it like it sounds with the Georgia southern drawl.  I reassured the patient that this didn’t sound like influenza.

“Did you hear that they have a case of swine flu at the medical college?” a patient asked me.  My nurses had heard the rumor that our local teaching hospital was housing a new case of the dreaded virus.  Things were quieter for a while after this sunk in.  Later in the day we found out that it was a positive flu test that was being tested for swine flu – not yet confirmed.

“What are we going to do about this for the doctors and the staff?” I asked my office manager and partner.  “How are we going to keep ourselves from getting sick?  Should we get Tamiflu to use prophylactically?  Do we have masks?”

My office manager showed me recommendations from the CDC website.  They were a bit vague, but suggested wearing protective masks and possibly taking medication.  How long would we have to take the medication?  Could we even get it?  Nobody knew.  My partner did say that our medical supply salesman told him that we cannot get masks at all.  They are totally sold out.

A while later, my partner showed me recommendations by the AAFP regarding the treatment of swine flu.  It recommended that Tamiflu be combined with Flumadine.  The recommendation, however, didn’t agree with what I got directly from the CDC which said to just use Tamiflu.  He seemed miffed that I would not trust the AAFP, but their document sited the CDC document that said to use monotherapy.

The nurses fended off a number of requests to call in Tamiflu to people who weren’t sick.  Our policy will be that people have to come in to be treated.  It’s always been our policy, but the fear seemed to make our patients forget.

“Do you think it’s coming here?” a patient asked me during a routine recheck.

I paused to find the best words, “Yes I do.  I don’t think there is much question that it is coming here; it’s just a question of what it will do when it does.”  He was quiet for the rest of the visit.

The pandemic warning level was raised to 5.  I had to look up what that meant.  I didn’t talk with my patients about it.

4/30

This morning started with a discussion about plans.  What will we do when the flu hits?  I am pretty sure that most routine visits will be canceled – and a lot of them should be.  I really don’t want healthy babies coming to an office with a virus that could really cause them harm.  We’ve already had a couple of cancellations for that reason, but not a whole lot.

Here’s what we decided:

• Once flu is in the area, we will go into “sick mode.”  We will cancel all routine appointments and only see scheduled and walk-in visits for acute illnesses.
• We will somehow secure masks and/or medication to give to anyone with direct patient contact.  We’ll also minimize the number of people with close contact.
• We will consider reducing staff numbers to decrease their risk of exposure.
• If we don’t have any protection for the providers, we will consider shutting down.  I don’t want to take flu home to my own family.  I don’t want my staff and colleagues to be infected.  It’s OK to take risk, but we shouldn’t be foolishly standing in the faces of hundreds of influenza patients without any protection.

One of my morning patients, a nurse from the local hospital, told me she could get me a box of the anti-viral masks.  Another patient is part of the Georgia National Guard, and told me that his task is to guard the stockpile of medication at the CDC, should the pandemic become acute.  It’s hard to think that it would come to people storming the CDC for Tamiflu.  I don’t know if he’s right, but it isn’t beyond belief.

I did my first flu test of this outbreak this morning on a patient with fever of 102, body aches, and a stiff neck.  It wasn’t classic flu, but I certainly felt like the test was needed.  I didn’t have a mask as I did my exam and wondered how much risk I was taking.  The test was negative, and I sent the person on to the ER so that labs and a possible spinal tap could be done.  That was good news for me, but I am not sure how good it was for the patient.  Maybe just a little good.

I saw my first person in a mask today.  It was the parent of a kid I was seeing (who wasn’t wearing a mask).  I was tempted to make a comment, but thought better of it.  Could I really blame her for wearing a mask?  I am at much greater risk than they are, but I take that risk every day.  When do I start wearing a mask?

We got news today that we could give Tamiflu to children under 1 year of age.  I was relieved, as I had a hard time dealing with questions from parents of happy little infants.  The parents would do anything to prevent the child from getting sick, but without treatment, the only way to prevent potentially serious illness is for the parents to avoid getting sick.  At least now I can give them a little more to hold on to.  I still wonder how much medication will be available.

At the end of the day today we heard that Georgia had its first confirmed case in Atlanta.  Atlanta gets everyting before we do.

Credit

The news we all are seeing is certainly scary.  It looks like we are going headlong into a pandemic – something that very few of us have experienced.  There is an edge of panic among the public, and I find myself looked to for reassurance.  Given what I know about a pandemic, I can’t be too emphatic in my reassurance.

Since this is an unprecedented happening in our lives I feel compelled to share things from the front-lines of the pandemic.  What are patients saying?  What are their fears and what sicknesses am I seeing?  What does my staff think?  What do the docs think, how are we preparing, and how do we react when it hits?

So take me as your “war correspondent.”  I am the guy with the helmet on reporting back to the masses about what is happening to the troops.  The CDC and their generals will fill us in on the big picture of things, but none of us live our lives in the big picture.

This post is a kick-off of my flu “coverage.”

Stay well.