The Flu Pandemic

[docB]

I have been reading some histories of the 1918 flu pandemic which killed as many as 60 million people according to some sources. There are some very worrisome parallels to what’s going on now.

The 1918 flu began in the spring and while it was widespread it was very mild. It was so mild in fact that some questioned if it was influenza at all. It smoldered throughout the summer and then in late August and September it suddenly became much more virulent and began quickly killing massive numbers of young, healthy people. It is eerie how similar the current pandemic has been up to this point.

Fortunately we have additional weapons against the flu that they didn’t have in 1918 the most effective of which is vaccination. However influenza is notorious for mutating quickly. Just as the regular annual flu shots have trouble hitting the moving target that flu presents the swine flu is likely to be as difficult.

I’m not trying to be alarmist but the more I notice how similar these pandemics are behaving the more I feel like I’m in a disaster movie during the calm before the storm.

I am concerned.

---

Members don't see this ad.

 

[pseudoknot]

I'm surprised to hear this from you.

The parallels are indeed close. Apparently the sequence of the current strain has been compared with the one from 1918, and they think it's missing whatever made that so virulent. I haven't had time to really read the literature on this due to board study, so I'm not sure exactly what this means.

The details aside, as you point out influenza is capable of rapid mutation and so whatever we know about the current strain could change. However, there have been other strains that started out similarly and didn't amount to much. I think there's no way of predicting it.

I believe that in our lifetimes we will see a pandemic of similar scale to the one in 1918. Hopefully this isn't it.

Have you been reading The Great Influenza?

 

[docB]

Yes, I am currently reading The Great Influenza. I also read Flu by Gina Kolata which was pretty good.

 

[Jeff698]

Geez, y'all make me feel bad, reading all that medical stuff.

I'm just reading some photography books. And watching movies. Lots of movies.

I like being out of residency. I do like the Cliff notes version of what you're reading, though. Keep it up. I'll call it vicarious studying.

Take care,
Jeff

 

[docB]

I really like medical history. I read a book called Stiff that was about cadavers and the eveloution of dissection that was pretty good.

I read a fascinating book that I found in my grandmother's house called Behind the Doctor by Logan Glendening that was written in 1933. It's a history of medicine up to that time. In his assessment the greatest breakthrough in medicine was insulin. "Diabetes is cured. No one ever need die of this malady again." Really interesting. No mention of antibiotics of course.

I really like all of Malcolm Gladwell's books too. I was given Blink at an EmCare medical conference because it talks about how EPs make snap judgements and are right most of the time.

 

[dchristismi]

The parallels are scary. I have seen several influenza cases, all but one pretty mild... I presume they are the H1N1flyingpigwhateveryoucallitflu. The patients are so freaked out - especially the parents. I've taken to hinting that it might just be a good thing that their kid got this version, just in case it gets worse.

And I really loved Blink.

 

[deleted65604]

Don't get me wrong, I loved the book Blink, but I had a hard time buying all of the premises. It started out good, but didn't entirely back up all of its claims, or teach you HOW to make good judgements.

In the end, it said, "You should trust your gut instict...unless it's wrong."

But, it was a good read nonetheless, and presented in a novel way, that made you look at things a little differently.

The reaction to that book, was another book called Think, whose philosophies I agreed with a lot more.

The author hated Blink and is staunchely conservative. It wasn't as fun of a read, but I think it contained important ideas that our society should adopt.

 

[RxnMan]

...The 1918 flu began in the spring and while it was widespread it was very mild. It was so mild in fact that some questioned if it was influenza at all. It smoldered throughout the summer and then in late August and September it suddenly became much more virulent and began quickly killing massive numbers of young, healthy people. It is eerie how similar the current pandemic has been up to this point...

There is no reason to believe that this strain will randomly mutate into one of similar virulence to the 1918 strain. Previous random events cannot predict future random events. The fact that the media caught wind of a new buzzword "pandemic" does not mean that "the swine" will suddenly become worse. I remember avian flu being trumped up the same way.

H1N1 is being incorporated into this next season's flu shot. I would expect it will be targeted to the cellular component that makes it unique compared to previous strains, which should provide partial protection even in the event of a mutation.

 

[pseudoknot]

Here is an article on the current A/H1N1 pandemic by John Barry (author of The Great Influenza). He seems to take the current situation fairly seriously.
http://www.washingtonpost.com/wp-dyn/content/article/2009/06/22/AR2009062202386.html

 

[Grace34]

I agree with docB...I thought the current pandemic was taken waaaay out of proportion, until I started reading John Barry's book. I don't think I fully appreciated the concept of increasing virulence, and that's what scares me. Also, there were actually 3 waves of that flu virus, and some people caught all 3.

 

[KidDr]

I agree with docB...I thought the current pandemic was taken waaaay out of proportion, until I started reading John Barry's book. I don't think I fully appreciated the concept of increasing virulence, and that's what scares me. Also, there were actually 3 waves of that flu virus, and some people caught all 3.

It will be interesting to see what happens if/when we have a pandemic with a severe strain of flu (it remains to be see whether or not that ends up being a mutated form of H1N1). The ED I work in (peds) has been intermittently overwhelmed almost to a breaking point with this pandemic (mostly worried well, but also a fair number of kids who were pretty sick, both with H1N1 and all the regular stuff we typically see in the summer). It seems to have gotten better over the past week, so perhaps this current wave is dying down.

If H1N1 mutates (or a new, more virulent strain shows up) and a much higher percentage of these kids start showing up in the ED really sick, we will have to start doing triage outside of the ED waiting room, and restricting who actually gets in (including turning away some of the chronically ill kids, like the chronically trached/vented kids). And that will get ugly. We talked about it at a staff meeting awhile back, and someone brought up the issue of whether or not we (as physicians) will be protected from lawsuits in that kind of a situation. Theoretically I guess the answer is yes (the hospital lawyers could write up something that would protect us), but I have a hard time believing that we'd actually be protected. Any other thoughts on this? Anyone else work for a hospital/group that's addressed the issues of triage and liability in the setting of severe pandemic flu?

 

[docB]

Anyone else work for a hospital/group that's addressed the issues of triage and liability in the setting of severe pandemic flu?

Good question. I haven't head of anyone looking at issues involved with quarrentine of EDs, staffing, liability issues, etc. and I work for a big EM corporation (EmCare) and a big hosptial chain (UHS). If neither of those entities have said anything about it to the troops on the ground then I imagine few have.

 

[WilcoWorld]

1- There is no reason to believe that this strain will randomly mutate into one of similar virulence to the 1918 strain. It may not be predictable, but it's possible.

2- Previous random events cannot predict future random events.
2b - I remember avian flu being trumped up the same way.

3 - H1N1 is being incorporated into this next season's flu shot. I would expect it will be targeted to the cellular component that makes it unique compared to previous strains, which should provide partial protection even in the event of a mutation.

1 - Surely there is, "random mutation" is exactly how this sort of thing happens...well, that plus recombination.

2 - No, they can't, but doesn't that render 2b irrelevant?

3 - I hope you're right, and sorry about 1&2 - I'm feeling feisty after a couple post-shift beers.

 

[RxnMan]

No worries, here's my response.

1 - Surely there is, "random mutation" is exactly how this sort of thing happens...well, that plus recombination...

1) Of course, but there's no proof to say that this virus has to mutate this fall, or when it does, that it will become more virulent. It could just as easily become less virulent.

2 - No, they can't, but doesn't that render 2b irrelevant?

2) My point was that the threat of mutation is always there, but nothing about this virus (to my knowledge) identifies it as likely becoming worse.

I say this while on Tamiflu.

 

[RxnMan]

Good question. I haven't head of anyone looking at issues involved with quarrentine of EDs, staffing, liability issues, etc. and I work for a big EM corporation (EmCare) and a big hosptial chain (UHS). If neither of those entities have said anything about it to the troops on the ground then I imagine few have.

During my peds outpt rotation, they were discussing triage plans. For them, a multi-clinic group, they would designate certain clinics as recieving flu cases and all suspected pts would be diverted there, and well kids would be diverted to the other clinics.

Sick people at the flu clinics would then be transferred as needed to the hospital or told to go home. This is in a middle-class suburban pop. (may not work for urban communities).

 

[DrJosephKim]

There are some great articles on the swine flu pandemic in the New England Journal of Medicine this week. Check it out.

 

[futureapppsy2]

Tamiflu-resistant H1N1 has been found in Denmark, Japan, and Hong Kong--this can't be good!

 

[GeneralVeers]

Tamiflu-resistant H1N1 has been found in Denmark, Japan, and Hong Kong--this can't be good!

We are overusing Tamiflu IMO.

Flu symptoms less than 48 hours? Great here's some Tamiflu, you MIGHT feel better 24-48 hours sooner, or maybe not.

 

[AmoryBlaine]

Probably the thing that annoyed me most during this latest flu scare were the number of residents, attendings, nurses, EMTs scornfully saying "it's just the flu."

They are hopefully right but not familiar with the history of the 1918 pandemic. Barry's book actually uses this dismissive tone as a sort of rhetorical device. "This was influenza, 'only influenza' " he says over and over while he describes corpses stacking up in the streets.

I think there should be a mini campaign among physicians to discourage the use of the term "the flu" for any minor viral illness in much the same way we are supposed to be saying "stroke" instead of "CVA."

 

[Aznfarmerboi]

I have been reading some histories of the 1918 flu pandemic which killed as many as 60 million people according to some sources. There are some very worrisome parallels to what's going on now.

The 1918 flu began in the spring and while it was widespread it was very mild. It was so mild in fact that some questioned if it was influenza at all. It smoldered throughout the summer and then in late August and September it suddenly became much more virulent and began quickly killing massive numbers of young, healthy people. It is eerie how similar the current pandemic has been up to this point.

Fortunately we have additional weapons against the flu that they didn't have in 1918 the most effective of which is vaccination. However influenza is notorious for mutating quickly. Just as the regular annual flu shots have trouble hitting the moving target that flu presents the swine flu is likely to be as difficult.

I'm not trying to be alarmist but the more I notice how similar these pandemics are behaving the more I feel like I'm in a disaster movie during the calm before the storm.

I am concerned.

Thank you!!! I have been trying to preach in pharmacy forums since the outset of flu breakout that it is not now, but future strains that we should be worried about.

I too find it annoying on how many healthcare people use the term casually and how lay people are now taking this event as a joke.

 

[AmoryBlaine]

Thank you!!! I have been trying to preach in pharmacy forums since the outset of this flu breakout that it is not now we should be worried about but future strains!

I too find it annoying on how many healthcare people use the term casually and how lay people are now taking this event as a joke.

That is mostly the fault of newsmedia (and the people that patronize it) for making everything into a crisis. You get burnt out after the 10th end of the world story in a year...

 

[dhb]

I agree with you docB this could become nasty very quick.
In my view the problem is not so much H1N1 mutating but recombining with H5N1 which i think is still active in Asia where it killed a high percentage of young healthy people.
Since it wasn't capable of transmission between humans it wasn't to much of a problem but H1N1 does have this capability...

 

[WilcoWorld]

Some good news:

The federal government expects to mount an H1N1 vaccination campaign this fall, initially targeting schoolchildren, adults with health problems, pregnant women, and healthcare and emergency workers, according to Health and Human Services (HHS) Secretary Kathleen Sebelius. Sebelius said the current estimate is that some vaccine will be ready for distribution in mid-October. HHS is working with its advisory committees to decide which groups will be offered vaccine and in what order, but added, "We know that young people have been disproportionately impacted by this virus, and we anticipate that school-aged children, non-elderly adults with underlying health conditions, pregnant women, and healthcare and emergency workers who are likely to come in contact with the virus will be priority groups to whom vaccine will be offered."

 

[cls4n6]

As a frequent lurker here I really find this topic fascinating- thank you all. I read The Great Influenza a few years ago and thought it was really well-written- great medical history, wonderful description of viral (esp. flu) behavior- for the layman, and scary reflection of Wilson's behavior.

Two other good books of this ilk are; The Coming Plague (Laurie Garret) and Six Modern Plagues and How We are Causing Them (Walters- a veterinarian).

And just for gins and giggles- try Roach's "BonK"- as good, if not better than her "Stiff".

 

[GeneralVeers]

For the record I don't tell anyone they have "The Flu" unless they are documented Influenza A or B positive. Everyone else I tell them that they probably have a virus, but I have no testing to confirm that hypothesis.

 

[gramcracker]

Tamiflu's never been shown to change outcomes, just symptom reduction for 24 hours. I tell people "Oh, you have flu-like symptoms and it's summer time? Yup, probably swine flu. Rest and fluids."

 

[deleted109597]

We used to argue with our lab about being able to test people, but they flat out refuse. "It's not flu season" is the number one answer. The only people we really test are the old people being admitted for respiratory distress anyway. I just don't like another part of the hospital telling me what I can and can't do. It would be like the radiologist refusing a CT because the mechanism doesn't warrant, without, you know, examining the patient.

 

[RxnMan]

We used to argue with our lab about being able to test people, but they flat out refuse. "It's not flu season" is the number one answer. The only people we really test are the old people being admitted for respiratory distress anyway. I just don't like another part of the hospital telling me what I can and can't do. It would be like the radiologist refusing a CT because the mechanism doesn't warrant, without, you know, examining the patient.

Huh. My institution is the opposite. They test and quarantine anyone with a sniffle or a cough, regardless.

 

[12R34Y]

Check out the announcements by WHO today AND CDC.

WHO: swine flu vaccine not coming along as planned now many not till the end of the year!

CDC: Swine flu remarkably similar to 1918 flu and has enhanced ability to infect lung tissue (ie kill you).

Foxnews front page and yahoo news.

more bad news.

later

 

[Kubed]

The first punch came today when we lost a girl in the ICU today who had been lingering for a few weeks after getting hit hard with h1n1. The next one came when they announced we've had a spike in the number of lab confirmed cases. The bell ringer was when they said a few of those were residents.

 

[diphenyl]

The virus has already mutated and is becoming tamiflu resistant now. We have two confirmed cases of tamiflu resistant strains in my county. Why is that? Cus some docs are crazy handing it out to every one. I see ton's of flu like sx's in the ED and the nurses for some reason feel the nedd to test everyone. Given the limited resources this is foolish. If a person has a flu right now it is probaly swine flu. They don't need a 40% sensitive test to confirm that.

 

[Jeff698]

The virus has already mutated and is becoming tamiflu resistant now. We have two confirmed cases of tamiflu resistant strains in my county. Why is that? Cus some docs are crazy handing it out to every one. I see ton's of flu like sx's in the ED and the nurses for some reason feel the nedd to test everyone. Given the limited resources this is foolish. If a person has a flu right now it is probaly swine flu. They don't need a 40% sensitive test to confirm that.

The only real reasons I can see for testing are for surveillance/public health and for clinical purposes. Clinically, I only think they give me helpful information in my sick admitted patients.

We get lots of information from our ID folks about this. During the initial media frenzy we were told to horde tamiflu and use it only for sick, admitted folks. Something happened about two weeks ago and now it seems they're telling us to treat everyone who sniffles or is around sniffles.

Shrug.

Take care,
Jeff

 

[docB]

So we're 7 months down the line from the original post in this thread and halfway through the flu season. Thankfully H1N1 has thus far not mutated into the virulent threat to life we had feared. Are we in the clear?

 

[deleted65604]

I haven't seen a news headline about H1n1, or a positive influenza test for weeks if not months.

 

[Stitch]

I think we're in a lull but that it will pick up in the next few months. That's historically what the Spanish flu did. But who knows. I hope it's done with.

 

[Jeff698]

At the risk of saying the "Q" word, I haven't been seeing much flu-like stuff in awhile. Lots of allergic rhinitis but then I live in the Cedar capital of the world.

I have been waiting for the other shoe to drop on this for some time. I'm still a bit apprehensive after our H1N1 butt-kicking last year.

Take care,
Jeff

 

[deleted65604]

So, has anyone seen any seasonal flu? Is Tamiflu going to be effective for seasonal influenza as well?

 

[Stitch]

So, has anyone seen any seasonal flu? Is Tamiflu going to be effective for seasonal influenza as well?

I question whether Tamiflu is effective for anything at all. The CDC claims it 'reduces morbidity and mortality' but there's absolutely NO data supporting that statement.

According to our state lab (Virginia) 99% of identified strains continue to be novel H1N1. It will be interesting to see if that changes in the oncoming months.

Sine I rarely send for flu testing, I wonder how much isn't being reported.

 

[GeneralVeers]

Sine I rarely send for flu testing, I wonder how much isn't being reported.

The answer is most of it. My group (except for a few ultra-conservative docs) has pretty much stopped testing for it (both the flu and H1N1 tests).

When patients request it to be done, I explain to them the reasons why a positive or negative test will not change management. Most are satisfied with this explanation and don't continue to demand testing.

 

[WilcoWorld]

As Stitch alluded to, we're not out of the woods yet, as H1N1 could come back worse next year. In my opinion, while it wasn't as bad as it could've been, it was still a pretty bad year. At one point half of our ICU was filled with young, previously healthy patients with H1N1-related respiratory failure, and not all of them made it.

Whether you think it was bad or not, I think this is a damned if you do, damned if you don't situation. If we had we not "pulled the fire alarm" on H1N1 and there was a pandemic that would obviously be bad. Now that we did pull the alarm, we'll never know if the less-than-disastrous flu season was a result of public health measures or an indication that we were a bunch of Chicken Littles.

I know I'm largely preaching to the choir here, but I've been having this conversation with some non-med friends lately who have accused "us" of crying wolf, so I've got my soap box at the ready.

 

[Stitch]

As Stitch alluded to, we're not out of the woods yet, as H1N1 could come back worse next year. In my opinion, while it wasn't as bad as it could've been, it was still a pretty bad year. At one point half of our ICU was filled with young, previously healthy patients with H1N1-related respiratory failure, and not all of them made it.

My sister died of confirmed (PCR) H1N1 this December. Right next to her were two other young previously healthy adults in the same situation: severe ARDS and out of ventilatory options. So even if overall the numbers weren't horrible, this thing killed people and the spread was rapid. I think that makes it right to make people aware of it and follow it. I just wish the vaccine had been more widely available and that people would take vaccination seriously.

Whether you think it was bad or not, I think this is a damned if you do, damned if you don't situation. If we had we not "pulled the fire alarm" on H1N1 and there was a pandemic that would obviously be bad. Now that we did pull the alarm, we'll never know if the less-than-disastrous flu season was a result of public health measures or an indication that we were a bunch of Chicken Littles.

That's exactly it. You can't win, and people want a black and white, right and wrong answer when there isn't one.

 

[EM2BE]

My sister died of confirmed (PCR) H1N1 this December. Right next to her were two other young previously healthy adults in the same situation: severe ARDS and out of ventilatory options. So even if overall the numbers weren't horrible, this thing killed people and the spread was rapid. I think that makes it right to make people aware of it and follow it. I just wish the vaccine had been more widely available and that people would take vaccination seriously.



That's exactly it. You can't win, and people want a black and white, right and wrong answer when there isn't one.

Sorry to hear. I have seen some bad cases as well. Not a huge number, but it does seem to affect even those that were previously healthy.