We have been inundated with so much information about the 2009 H1N1 that it’s hard to keep it all straight. Here’s my top ten list of what’s most important to know, much of it coming from the website of the Centers for Disease Control and Prevention, which has done a spectacular job of providing timely and useful information:
1) What is the 2009 H1N1 Flu (Swine Flu)?
Different from the typical seasonal influenza virus, this is a new type of flu virus that appeared in Mexico in April, 2009 and soon spread to the United States and around the world. It contains a combination of genetic material found in influenza viruses that infect humans, birds, and pigs.
2) Why are people concerned about the 2009 H1N1 pandemic?
Over the past century, three major pandemics have swept through the world and caused severe illness and death. The most devastating by far was the influenza pandemic of 1918, which killed 40-100 million people worldwide and 500-750,000 Americans at a time when the U.S. population was only about 100 million. The 1957 “Asian flu” caused about 70,000 deaths when the U.S. population was about 170 million. The last pandemic, in 1968, killed about 34,000 out of 200 million Americans.
3) How does the 2009 H1N1 influenza compare to the typical seasonal flu?
Because the 2009 H1N1 virus is new, most people – especially children and young adults – have little or no immunity against it. It is spreading more quickly than the usual seasonal flu but seems to be somewhat milder – though still capable of causing severe illness and death. The typical seasonal flu affects 15-60 million Americans, leading to more than 200,000 hospitalizations. Annual deaths range from 17,000 to 52,000 annually, averaging about 36,000.
The elderly are especially at high risk of seasonal flu, with over 90% of deaths occurring in patients over 65. In contrast, 2009 H1N1 has preferentially affected young adults and children while older patients appear to have some immunity. Only 18% of deaths from H1N1 have been in patients over 65.
For both the regular flu and the 2009 H1N1, certain groups are at increased risk for complications once infected – children under 5, pregnant women, and patients with underlying medical conditions such as suppressed immune systems, asthma, diabetes, neurological disorders, kidney problems, and heart disease as well as adults over age 65.
4) What Can We Expect This Fall?
Flu virus tends to die down over the summer because it survives better when the weather is cold and dry than warm and humid. That’s why during our summer the H1N1 virus spreads to the Southern Hemisphere, where it’s winter. But the virus never really went away in America and is now surging much earlier than with the regular seasonal flu.
In August, a panel of experts prepared an extensive report for President Obama about the virus. While warning that the exact impact of H1N1 was impossible to predict, the panel outlines a “plausible scenario” that included 60-120 million infected Americans, as many as 1.8 million hospital admissions, and 30-90,000 deaths. Others, including the CDC, have suggested that these estimates are a “worst case scenario.”
Unfortunately, the influenza virus is famously unpredictable and the above “plausible scenario” could be way off in either direction. Although the virus is relatively mild now, it can quickly change on its own through mutation and become more deadly. Another way of changing is if two different viruses happen to infect the same cell at the same time. The two different strains could then trade genetic material. Hypothetically, the 2009 H1N1 that is currently sensitive to the antiviral medication Tamiflu could become resistant to Tamiflu if it combines with last year’s seasonal flu strain which was 99 percent resistant to the drug. Fortunately, until now the virus has been stable genetically and it remains sensitive to Tamiflu and Relenza.
5)What are the symptoms of the 2009 H1N1?
The symptoms are very similar to those seen with the regular seasonal flu: fever, headache, fatigue, cough, sore throat, runny nose, and aches and pains. In addition, there may be gastrointestinal symptoms such as nausea, vomiting, and diarrhea.
6) How can you catch H1N1?
Just as with the regular seasonal flu, the virus enters your body through your nose, mouth, or eyes. People infected with H1N1 shed virus starting a day before symptoms begin and lasting up to a week or longer in some patients. An uncovered cough or sneeze in a patient with influenza can send infectious virus-filled droplets into the air. If you touch a surface that’s infected with flu virus and then touch your mouth, nose, or eyes, the virus can enter your body and cause infection.
7) How do you prevent the seasonal flu and 2009 H1N1?
The most effective way is through vaccination – assuming you are in a group for which immunization is appropriate. The CDC recommends vaccination with both the regular seasonal flu vaccine, which is already being given, and the 2009 H1N1 vaccine once it becomes available around mid-October. So far, the 2009 H1N1 vaccine has been shown to be safe in adults; the CDC told me this week that studies in children and pregnant women should be done within about 2-3 weeks. Health officials want to vaccinate at least 159 million Americans. Experts predict there will eventually be enough vaccine for all Americans who want it. But only about 45 million doses are expected to be available with the first batch in mid-October.
Those on the priority list to get the 2009 H1N1 vaccine include pregnant women, people in close contact with infants 6 months and younger, health care workers, those ages 6 months to 24 years, and people ages 25 to 64 with serious conditions that put them at high risk for complications from flu.
Experts stress the importance of covering your mouth with a tissue when you cough or sneeze. Wash your hands often with soap and water or an alcohol-based hand cleaner. Remember: you don’t get flu from virus that’s only on your hands; you get it when you touch your face and give the virus a way to enter your body. Avoid close contact with sick people. And if you are sick with the flu, the current CDC recommendation is to stay home for at least 24 hours after your fever is gone without the use of fever-reducing medication. In some situations, the use of a face mask may be indicated, especially to try to prevent flu in patients at increased risk for complications; click here for the CDC’s recommendations.
8.) Who should receive treatment with anti-viral medication such as Tamiflu and Relenza?
Last week the CDC said that most people who come down with the 2009 H1N1 flu should just ride it out and not take antiviral medications such as Tamiflu and Relenza. Dr. Anne Schuchat of the CDC said the majority of adolescents, adults and children “can be cared for with mom’s chicken soup at home, rest, and lots of fluids.” But she stressed the importance of early treatment with antiviral medications – within 48 hours if possible – for certain patients at increased risk of complications, especially those hospitalized, under age 5, over age 65, or with chronic medical conditions.
A key change in advice from the CDC involves patients at high risk who may have been exposed to the H1N1 virus. Before last week, doctors were advised to give them medication to prevent infection; now doctors are being given the option of “watchful waiting” – observing the patient closely and only starting antiviral treatment if evidence of flu develops.
9) What warning signs should prompt immediate medical evaluation and treatment?
In adults, warning signs include: trouble breathing, pain or discomfort in the chest or abdomen, dizziness, confusion, severe or persistent vomiting, and symptoms that improve but then return with fever and worse cough. In children, warning signs include: trouble breathing, bluish or gray skin color, inability to drink enough fluids, severe or persistent vomiting, change in mental status (e.g., not waking up, not interacting, or being unusually irritable), and symptoms that improve but then return with fever and worse cough.
10) Should I get the 2009 H1N1 vaccine if I think I’ve already had the H1N1 flu?
The CDC told me “yes” – because the vast majority of patients diagnosed with 2009 H1N1 were not specifically tested for the virus. It may have been some other virus that made you ill. And even patients who had positive “quick tests” in the office for influenza A cannot be absolutely certain they had the 2009 H1N1 virus because the kits are sometimes wrong and because there’s a small chance that the strain of influenza A detected was NOT the 2009 H1N1. So the CDC recommends playing it safe and getting the both the regular seasonal vaccine and the 2009 H1N1 vaccine if you are in a group for which immunization is suggested.
For this week’s CBS Doc Dot Com, I discuss very practical advice – especially for parents – about H1N1 with Dr. Thomas Farley, who was appointed New York City Health Commissioner in May 2009 and immediately found himself smack in the middle of the 2009 H1N1 outbreak.
Click
here to watch the interview.
It is quite popular among certain medical bloggers, who count themselves as scientifically sophisticated, to disparage so-called “alternative medicine.”
Indeed, there are entire websites devoted to demonstrating (in homage to Penn and Teller) that various forms of alternative medicine – such as homeopathy, therapeutic touch, the medical application of crystals, Reiki, naturopathy, water therapy, bio-photons, mindfulness training, energy healing and a host of others – are completely devoid of any scientific merit whatsoever; are pablum for the uneducated masses; are, in short, irreducibly and unredeemably woo.
These same medical authors are scandalized into virtual apoplexy by the fact that the NIH has funded an entire section to “study” alternative medicine, and worse, that most respected university medical centers in the land now seem to have embraced alternative medicine, and have established well-funded and heavily-marketed “Centers for Integrative Medicine” (or other similarly-named op-centers for pushing medically suspect alternative “services”).*
Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.
Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat legitimate (and plenty respectable) will further the cause of covert rationing. That is, the more people who can be enticed to seek their diagnoses and their cures from the alternative medicine universe, where they are often spending their own money, the less money these people will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.
So, for several years alternative medicine was seen by DrRich pretty much as it is seen by all of the anti-woo crowd – as an unvarnished evil.
But in recent days the scales have fallen from DrRich’s eyes. He now realizes he was sadly mistaken. Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.
What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. Even more remarkably, a goodly chunk of this money was paid by Americans themselves, out of their own pockets.
The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.
This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.
One reason so few primary care doctors have taken this route (choosing instead to retire, to change careers and become deep-sea fishermen, or simply to give up and become abject minions of the forces of evil) is that they do not believe patients will actually pay them out of their own pockets.
Well, ladies and gentlemen, this new report from the CDCP demonstrates once and for all that Americans will, indeed, pay billions of dollars from their own pockets for their own healthcare – even the varieties of healthcare whose only possible benefits are mediated by the placebo effect. DrRich believes that many of the people buying homeopathic remedies are doing so less because they believe homeopathy works, and more because they feel abandoned by the healthcare system and by their own doctors, and realize they have to do SOMETHING. The CDCP report, in DrRich’s estimation, reflects the magnitude of the American public’s pent-up demand for doctors whose chief concern is for them, and not for the demands of third party payers.
Perhaps more importantly, this new report implies that it will be somewhat more difficult than DrRich previously believed for the government to outlaw private-sector healthcare activities. Creating a monolithic government-controlled healthcare system would naturally require the authorities to make it illegal for Americans to spend their own money on their own healthcare, thus rendering direct-pay medical practices illegal, and putting the final stake into the heart of the doctor-patient relationship. But the rousing success of the alternative medicine universe will make such laws difficult to enact.
To see why, consider just how encouraging this new CDCP report must be to the third-party payers. Thanks in no small part to the efforts of the government (and the academy) to legitimize alternative medicine, Americans are spending $34 billion a year on woo. This amount indicates tremendous savings for the traditional healthcare system. The actual amount saved, of course, is impossible to measure, but has to be far greater than just $34 billion. Some substantial proportion of patients spending money on alternative medicine, had they chosen traditional medical care instead, might have consumed expensive diagnostic tests, surgery, expensive prescription drugs, and other legitimate medical services. Furthermore, those legitimate medical services (as legitimate medical services are wont to do) often would have generated even more expenditures – by extending the survival of patients with chronic diseases, by identifying the need for even more diagnostic and therapeutic services, and by causing side effects requiring expensive remedies. (While alternative medicine is famous for being useless, it is also most often pretty harmless, and tends to produce relatively few serious side effects – except, of course, for causing a delay in making actual diagnoses and administering useful therapy, but that’s a good thing if you’re a payer.) So the amount of money the payers actually save thanks to alternative medicine must be some multiplier of the amount spent on the alternative medicine itself.
What this means is payers (which under a government system means the government) will be loathe to do anything that might discourage the success and growth of alternative medicine, and this fact alone may stop them from making it illegal for Americans to pay for their own healthcare.
Still, we musn’t be too sanguine about these prospects. Under a government-controlled system, the imperative to control every aspect of healthcare (in the name of fairness) will be very, very strong. It is easy to envision the feds declaring several varieties of alternative medicine to be covered services, so people wouldn’t have to buy alternative medicine themselves.
But alternative medicine (bless it) will be impervious to government control. Practitioners of alternative medicine aren’t doing what they are doing in order to be subject to federal regulation and bureaucratic meddling. If the feds declare, say, homeopathy and therapeutic touch to be legitimate, covered services under the universal health plan, why, the alternative medicine gurus will simply come up with entirely new forms of alternative medicine specifically to remain outside the universal plan. (New varieties of alternative medicine already appear with dizzying speed, and can be invented at will. No bureaucracy could ever hope to keep up.)
Therefore, as long as the central authorities depend on alternative medicine as a robust avenue for covertly rationing healthcare, the purveyors of woo will always be able to flourish outside the real healthcare system. And this, DrRich believes, represents the ultimate value of woo, and establishes why we should all be encouraging and nurturing woo instead of disparaging it.
DrRich has speculated before on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. Some of these were: medical speakeasies; floating off-shore medical centers on old aircraft carriers; medical centers just south of the border (the establishment of which, at last, would stimulate the feds to seal the borders against illegal passage once and for all); and combination medical center/casinos on the sovereign land of Native American reservations.
But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to practice a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open. Simply declare this kind of practice to be a new variety of alternative medicine. Likely, you will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what you’re doing. But what you’re actually doing will be so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.
Alternative medicine, in other words, will provide American doctors who want to practice the kind of medicine they should be and want to be practicing with the cover they need to do so. And this is why we must support medical woo, and celebrate its continued growth and success.
* A list of these academic medical institutions now sporting Centers of Woo is maintained by Orac, and can be found here. The length of Orac’s cavalcade of woo, and the famous names appearing on it, is truly stunning. The sinking feeling one gets from looking at Orac’s list can only be surpassed by actually clicking on a few of the links he provides, and sampling some of the actual woo-sites offered by these prestigious academic centers, which read like excerpts of some of the more unguarded moments from Oprah, or even the Huffington post.
Friends visiting New York City this summer keep asking if it’s safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.
I like to think my friends are pretty sharp, discerning folks (after all, they’re choosing my company) so I have to attribute these inappropriate questions to a wider problem.
For reference, here’s the latest and thought probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.
So why were ED’s swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:
…with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.
The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.
…The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.
All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process…
Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They’ve decided it’s just not in their interest.
I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.
There are many factors driving the public appetite for health risk information — and that’s understandable. I think it’s even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.
But what happened in NYC this spring was media malpractice — night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasion in which a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority — by the next day the lead story was ED’s are overcrowded and schools are closing.
EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.
But I’m more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.
It wasn’t enough to help ED’s this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It’s really the first good viral news I’ve heard in a while.
*This blog post was originally published at Blogborygmi*
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 than the virus itself.“ Another article cites an Australian professor (of what, the article did not say) who stated that “the country would be better off declaring a pandemic of some of 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 probability, 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:
Admit them immediately to the hospital
Draw blood tests looking for serious infection
Check a urinalysis to make sure there isn’t an infection (using a catheter to get the sample)
Start IV antibiotics as soon as possible
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.
Last year the Centers for Disease Control and Prevention (CDC) announced that there were 40 percent more new HIV infections each year than was previously believed. And yet, a new (2009) survey by the Kaiser Family Foundation has found that Americans, even those in the high risk groups for HIV, are worrying less about HIV/AIDS. How can this be?
The survey suggests that:
Fewer Americans consider HIV an urgent health problem.
Only 17 percent of people aged 18-29 (those traditionally the most sexually active) reported that they were personally very concerned about becoming infected with HIV.
In spite of HIV rates being seven times higher among African Americans, personal concern about HIV has decreased in this population.
More than half of people aged 18-29 have not been tested for HIV, in spite of the fact that the CDC now recommends HIV testing for all adults.
The survey also found that misinformation and stigma about people living with HIV still exist.
Although 44 percent of the 2,554 adults surveyed reported that they would be comfortable with a coworker who had HIV, 51 percent would be uncomfortable having their food prepared by someone who was HIV positive.
One-third of the people surveyed incorrectly believed that HIV could be transmitted by sharing a glass of water; touching a toilet seat; or swimming in a pool with an HIV positive person.
18 percent believed there was a cure for HIV and 24 percent believed there was a vaccine available to prevent HIV.
This is scary stuff and suggests that families, parents, schools, and medical professionals have their work cut out for them – more HIV education, please!
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