Sunday, November 29, 2009

Keeping pandemic danger in context

Pandemic flu hit close to home last week, when a graduate student of mine died of complications related to H1N1. News reports have since mentioned that he suffered from another chronic health condition that likely contributed greatly to his demise. Meanwhile a new study from Toronto reports a much greater percentage of children hospitalized with H1N1 have asthma, compared to typical flu-related hospitalizations on any other given year. Roughly 22% of pediatric H1N1 admissions had asthma, compared to only 6% in seasonal flu admissions over the previous 5 years. Finally we are hearing of more cases of anti-viral-resistant strains of H1N1, especially oselatmivir (Tamiflu) resistant strains.

Should you be arming yourself against this invisible threat? We still don’t have a very good profile of H1N1. It is certainly a new viral subtype (though it did make its rounds previously in the 1970’s). Since there is intense scrutiny, we are naturally detecting lots of it. Many folks, myself included, appear to have suffered suspected bouts that were surprisingly mild. Assessing outbreaks is all about comparing what you are experiencing with what you expect. The viral subtype is different than we expect, which is interesting to scientists and laboratories, but not necessarily to clinicians. Laboratory confirmation occurs in some, but not all cases. So many reported cases are best guesses. We still don’t have a good sense of the number of exposed persons that have not developed symptoms, and without that number as a denominator, its hard to calculate the rate at which people are being sickened with any reasonable accuracy. On the one hand, if infection is as wide spread as is feared, then the death rate probably isn’t as bad as one would expect, even if certain populations such as young people are dying in greater numbers than expected.

Having other health risk factors certainly increases your risk, as evidenced by the Toronto study and my personal anecdote. This is generally the case with all disease. And with the rise of drug-resistant disease we should all reconsider our own personal need for flu treatment. As with many conditions, personal choice among the majority-healthy has implications for the minority-unhealthy. If you are a person with no underlying risk factors, and are otherwise healthy, the responsible thing to do is probably to forgo antiviral treatment. Those drugs should be left for those at greater risk, since casual use by healthy people may be convenient, but also increases the risks and rates of drug-resistant disease.

Despite the relatively high level of confusion around vaccine shortages in the general public, and poor communication by public health officials, stressing a little less and taking simple precautions like washing hands and covering mouths when coughing are probably our best protection. With so many unknowns, worrying just doesn’t seem like a worthy strategy.

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