What We Don't Yet Know About Swine Flu That's Scary

HealthLeaders Media Staff, April 29, 2009

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That is, the news you just read about the world-wide outbreak of swine flu is already out of date. More cases have occurred, and in many other states and countries. This morning (April 29) it was even renamed: H1N1 Flu, and termed "pre-pandemic."

Public health officials from the Centers for Disease Control and Prevention in Atlanta to the California Department of Public Health are using terms like "fluid," "evolving," and "rapidly" to describe the pace and path of this virus while at the same time trying to reassure health providers everywhere to stay calm, that things are under control.

These experts believe that enough supplies, antiviral drugs and support are securely stockpiled and quickly deliverable because of thoughtful and long-standing disaster planning. They express confidence that practitioners from counselors to surgeons and hospital executives across the country are well-braced for whatever might come from this hybridized virus.

But there is considerable nervousness in their voices.

"We are wary that it could get worse, in the severity of illness, as time goes on," said Bonnie Sorensen, MD, chief deputy director of the Department of Public Health in California, where case counts are increasing.

Richard Besser, MD, CDC acting director said at a news conference yesterday, "People are concerned. And we're concerned. Concern is a good thing if it drives planning and action." However, he cautioned, "As we continue to investigate cases here, I expect that we will see deaths in this country."

There's an awful lot about the current outbreak that just isn't yet known, he and other health officials acknowledge. Just how far will H1N1 flu spread? Why did so many Mexicans die from what appears to be a nearly identical strain, while only one death has been attributed to the virus so far in the U.S.? Perhaps those cases now recognized among Mexicans were just the worst, and there are many more patients in that country with milder ailments who didn't seek care, or who did but were not diagnosed.

Why are so many younger people getting sick rather than older people, the traditional victims of seasonal flu which kills an average of 36,000 people in the U.S. each year?

CDC officials yesterday said they would rename the virus because the calling it "swine" implies it is transmitted by eating pork products or touching pigs, when it is not.

"Predominantly, it's the fact that young healthy people are getting sick that scares people," says Nancy Pratt, senior vice president of clinical effectiveness for Sharp HealthCare, a five-hospital system along the California-Mexico border, where so far 10 of the state's 11 confirmed and four unconfirmed patients reside.

Pratt also says that providers need guidance from the CDC on when to give antiviral medication. Do you hold off, because the patient is not that sick and you know there's a limited supply? We know most patients will recover without it. Or do you pull the trigger because the patient may have co-morbidities (and be a higher risk of complications)? That's a big question for us right now."

Chris Van Gorder, CEO of Scripps Health, a San Diego regional healthcare network where some of the first H1N1 patients were seen, advised hospitals and physicians to be proactive in getting information and distributing it.

Van Gorder also advises hospitals to check supplies and order more. "Contact vendors to make sure they are prepared to increase supply delivery if necessary. Most hospitals use 'just-in-time' inventories now so they don't maintain excess stock." Having extra lab test kits and N95 masks are critical, he adds.

Think ahead with other community hospitals to maximize healthcare resources. Most of the time, county public health officials coordinate this activity, but if they can't or don't, hospitals will have to step in, he says. "Monitor patient capacity, isolation capacity, and equipment respiratory disease capacity," he says.

Also, he says, review plans for how to manage employees as well as their families. Providers may have family members who are ill at home and may have to stay at home to help them. "Pandemic plans must incorporate consideration of family members," he says.

Timothy Uyeki, MD, medical epidemiologist with the CDC's influenza division, said today. The virus "can be assumed to be transmitted similarly to influenza A and B viruses, but research is needed. There are many unanswered questions about this virus that CDC scientists and others are working to address."

For example, he says, "It is too early to determine the most affected age groups."

Officials at other state health organizations and providers are worried too.

Ernie Schmid, director of policy analysis for the Texas Hospital Association, the state which yesterday had six confirmed cases of H1N1, calls the infection "the number one public health problem of interest right now."

The media's "24/7 coverage has leant an air of seriousness. Hospitals know how to deal with these issues, but it's the fear of a pandemic that's got everyone's attention," he says.

Will public officials be able to forge an effective vaccine in time? The rapid influenza test commonly used is reliably accurate, but is it also accurate to determine if a patient has H1N1? Now, most states must send their saliva samples to the CDC for confirmation, which may take as long as a week.

In the first days of the outbreak, it was unclear whether H1N virus particles could be transmitted through aerosolized mists, which must survive an indefinite period of time while hovering in the air. At some point CDC officials changed the information to suggest the virus is carried through droplets from coughing or sneezing, or through contact such as touching something recently touched an elevator button recently touched by an infected finger.

Besser and Sorenson say that over the next several weeks, health officials should look for many adjustments in various guidelines as more is learned.

For health providers in hospitals and other clinical settings, knowing which patients to worry about, and what to advise them, remains unclear. In many affected regions of the country, patients seeking routine care in their physician's offices appeared wearing simple paper masks. They were there for routine care, but feared others might be coughing or sneezing infectious viral particles.

CDC and other experts want health providers to tell their patients not to come into healthcare settings if they have respiratory symptoms. Instead, they advise, call a physician first to discuss symptoms, rather than risk infecting others. Health providers too should not come to work if they are sick. Infection control experts also advise those working in hospitals and other healthcare settings to separate those with respiratory symptoms away from other patients.

"You don't want to put patients with respiratory infections in the same area as patients with chest pain or broken bones," says Pratt.

In San Diego County, which saw some of the first confirmed cases, some schools have been closed and border officials are looking carefully at those crossing the border for signs of illness. Physicians' offices are filled with routine patients wearing masks as a precaution.

On the good news front, Uyeki said, "Efforts are underway utilizing multiple strategies to develop candidate vaccines against this new virus." Other advisories are listed at CDC's Web site.

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