Thursday, 17 December 2009

Is Swine Flu really mild?

Despite the not coming of my prediction of severe deaths in November,
the 2nd wave actually hit.

The number of deaths had been minimised but still very tragic, but why
the 2nd wave? People dropped their guard allowing the 2nd wave. Once
they realise how bad it was, people and doctors start taking

The good news is that in Malaysia, from the worst death incidences,
due mostly to non-usage of Tamilflu, despite their availability, it is
now zero. Doctors in Malaysia are now well trained. For instance, my 2-
year old nephew got mild flu, but chest sound and later X-ray
confirmed the start of a pneumonia at a specialist hospital. He was
quickly prescribed Tamilflu and antibiotics. He was quickly cured.
Just imagine what will happen if he were treated mildly as had
happened in the early days in Malaysia. Despite having high fever and
chest pains, doctors still do not consider it as swine flu. Let alone
have an X-ray. My nephew didn't see a specialist first, he was seen by
a general practitioner at SMC but probably they are more experienced
and caring than new government doctors.

The 2nd wave was stopped because vaccinations were started and people
in US start taking precautions. Prior to the 2nd wave in November, 20%
doctors didn't prescribe Tamilflu immediately, and yet it had strained
the US health care.

By December only 1 in 7 US citizens got the Swine flu and yet, some
healthcare already strained. Vaccination is ongoing but slow moving.
The usual peak flu season is January to March when school resumes.
December is vacation time.

Let us hope that more citizens opt for the vaccination because even if
only 2 out of 7 remained unvaccinated, it will likely overburden their
health care.

Why should Malaysia care? We never have any peak flu season but many
of us visit US and they may return to Malaysia bringing this flu
Mild pandemic? Bite your tongue.

Category: Pandemic preparedness • Swine flu
Posted on: December 16, 2009 6:44 AM, by revere

A spot-on column in CIDRAP Business Source [subscription] by Center
for Infectious Disease Research and Policy's (CIDRAP) Director, Mike
Osterholm, reminded me to say something I've wanted to say for a long
time. We should banish the word "mild" from the influenza lexicon.
There's no such thing as a mild case of influenza, any more than there
are "mild" auto accidents. There are cases that for reasons we don't
understand don't make you very sick (or sick at all), and there are
cases that can lay you lower than you ever want to be, including six
feet under. What Osterholm does with great cogency is put paid to the
idea this is a mild pandemic. His reasons will be familiar to readers
here, but he says them extremely well.

Both Osterholm and we find CDC's most recent estimates (November 14)
of about 10,000 deaths, 47 million infections and over 200,000
hospitalizations "credible and thoughtful." To compare the oft quoted
number of 36,000 excess deaths from seasonal flu to this 10,000 number
is an "apples and oranges" affair. The 36,000 number is an excess
mortality figure derived by different and non-comparable methods (see
our post here for more details). Here is some of Osterholm's version:

In that CDC study, only 9,000 of those estimated annual seasonal
deaths are due directly to influenza or secondary bacterial pneumonia.
The other deaths are among persons who have influenza and who die of
events like heart attacks or strokes. If you want a comparison, think
of the guy who has a heart attack while snow blowing his driveway
after a large snowstorm and whose death is labeled "storm-related."

More important, though, is what we pointed out early on. It's not just
the number of deaths but the pattern of illness in the population,
flu's descriptive epidemiology:

More than 90% of the estimated seasonal influenza deaths occur in
the elderly, who in many instances have existing serious health
conditions that mean their deaths may not be far off, regardless of
their influenza illness. We all realize that death is inevitable, and,
as a public health practitioner, I find that this mad race to
eliminate the top 10 causes of death is not always well thought
through. If we were to accomplish such a goal, there would be 10 new
leading causes of death, and I'm not so sure some of those would be
better than the current ones. But I think we can all agree that "early
deaths"—or those that occur well before our elderly years —just
shouldn't happen. The way we count influenza mortality, an influenza-
related death in an 87-year-old person with advanced Alzheimer disease
is the same as the death of a 22-year-old otherwise perfectly healthy
pregnant woman. Both deaths are equally tragic, but any reasonable
person would agree they are not equivalent public health outcomes.


Of the estimated 9,820 deaths:

* 1,090 (11%) have occurred in children 0-17 years of age
* 7,450 (76%) in people 18-64 years of age
* 1,280 (13%) in people over 65 years of age

This age distribution differs considerably from what we see with
seasonal influenza. (Dr. Michael Osterholm, Featured article CIDRAP
BUsiness Source; subscription required)

Which brings me back to the issue of "mild" flu and mild pandemics.
While this pandemic is not 1918 (for which we can be grateful,
although no one knows what prevents this or any other pandemic from
repeating that catastrophe), it is still pretty bad, already producing
more estimated hospitalizations than seasonal flu and we aren't even
into the heart of flu season yet:

It's challenging our healthcare system unlike any previous
seasonal influenza season over the past 30 years. That makes it hard
for me to call this a "mild" pandemic. I just don't believe the term

Yes, there are mild, moderate, or severe influenza illnesses on an
individual basis. But how do we describe a pandemic that hits a
limited group of people really hard and causes only "routine
influenza" for most others?

Whatever you describe it, I'm with Osterholm. Don't call anything
connected with flu, mild. Most flu infections don't have dire
consequences, but a significant number do. And we never know who is
going to win the lottery. The convergence in our views extends to the
same analogy: automobile accidents. As we've noted several times, it
doesn't make much sense to call any encounter with several tons of
moving steel "mild." It may be an encounter that produces little or no
damage, but that's luck. Anyone who's gotten the repair bill for what
can happen when hit by another car going only 5 miles per hour won't
consider the encounter "mild." More importantly, any such encounter
has the potential to be a catastrophe and the really bad ones are
often just plain dumb luck. Mostly we don't have such terrible luck.
Yet even a fender bender can be expensive or result in minor injuries
and be emotionally traumatic as well as result in lost work. Whatever
you might be tempted to call an auto accident (minor or a scratch or a
fender bender), very few people would be prone to call it "mild." And
whle the number of people killed each year in motor vehicle accidents
is roughly the same as seasonal flu, we don't usually think of our
nation's annual highway death toll of 40,000 as "mild" either. Its age
distribution isn't too different than pandemic flu's either, the
source of much anxiety to any parent whose child has just gotten their
driver's license.

It's not just that "mild" is an inapt word. It is an inapt and
dangerous idea. It is based on comparing total deaths in flu seasons
with each another, not with the public health toll they exact. It is
worse than a word not conveying the proper seriousness. It sends a
message that itself has consequences, promoting a lack of urgency
about taking rational public health measures like vaccination.

That's especially pertinent this year when we don't yet know what the
usual flu season (January to March) will bring, either with seasonal
flu or a recrudescence ("wave 3") of swine flu. As Osterholm points
out, even with available vaccine now certain in the next few months,
we are likely to find ourselves in January with a very large
proportion of the population still without immune protection.

After all, what's the hurry? It's a mild pandemic.

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