“Let’s not mess around, this virus is nasty”: Dr Chris Smith

12 06 2009

Fran Kelly has a great interview with Dr Chris Smith, here, on ABC Radio National Breakfast. Smith is a virologist in Cambridge.

He politely disagrees with Laurie Garrett’s assessment yesterday: “Let’s not mess around, this virus is nasty…”. It still has a “mortality rate” associated with it – about 0.5%, which, according to Chris Smith, puts it on a par with Spanish Flu in 1918. It’s not, therefore, “completely wimpy”.

Fran Kelly then asks him about the danger of mutations. Smith agrees it’s a risk: “the thing about flu is that it’s a moving target…” . The virus uses RNA as its “genetic material”, which is just a single strand of material. This is unlike DNA, which has two strands – one a mirror image of the other. These strands act as an error checking system. In other words, flu, because it is RNA based, not DNA based, more easily makes mistakes as it passes on. So we will see new variants that are “potentially more virulent”.

At the moment Australia is is the “virological canary in the cage” – everyone’s watching our flu season here to see how things go.

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15 responses

13 06 2009
GSE

“virological canary in the cage” Shouldn’t it be a canary in a coal mine?
Thanks for the bog. I assume your information is correct.
It’s an absolute shame that our government does not provide us with basic information.
The gov’t website has last been updated on the 8th!
You’ll find more info on the situation in OZ in New York Time than local media – shame.
Anyways, the tally of cases goes up, but is it safe to assume that people get over the symptoms in a few days? If that’s the case, why doesn’t anyone actually tell us how many people are sick on any particular day?
I hear people say: “1300 are sick with SF”, but that’s obviously not correct, 1300 HAVE BEEN sick up to date, which means that today it may only be 50 or 100 people across the country – correct?
And if that’s correct, how come at about 600 cases our health system was “stretched” – a world class (some say it is – I don’t believe it) system stretched after dealing with 600 patients? Something’s not right with that picture…

14 06 2009
aussieflublogger

Hi. Yes I agree. These stats are not showing how many people are sick right now. They are simply showing how many have been diagnosed with this since the first case was reported. Most of these will be better by now, since most people get over the flu in a few days to a week (I assume!). Cheers. Nick.

14 06 2009
Dr Attila Danko

The recent change in Victoria to treatment of case definitions and limited testing
http://humanswineflu.health.vic.gov.au/downloads/hp/h1n1_swineflu_hp_1006.pdf
is deeply troubling to me. I am a busy GP in a walk-in clinic in Ballarat, so I have a high proportion of my patients presenting with acute illness. What I have found is that there is a lot of “flu-like illness” around that meets the case definition; but despite testing dozens of people I have yet to pick up even one case of true influenza, swine or otherwise. In other words, they all have colds. But a severe cold can look like influenza. Yes, they have had fevers too, often measured in my surgery. My feeling is that they have jumped the gun. This influenza is not widespread in my community yet. If I followed the guidelines strictly I will be prescribing Tamiflu in large numbers to people with a cold where it is useless.

Lets say that some of these people then catch swine flu at the end of their Tamiflu course. They will then have low levels of Tamiflu in their blood which will encourage the development of Tamiflu resistance. Let’s say that in a couple of weeks time we start to really get thousands of H1N1 infections. How much Tamiflu or Relenza will we have left then if it has been used up for colds? How much Tamiflu resistance will we then have because of our indiscriminate use?

I believe we need to encourage and trust GP’s judgement on this. As a GP, I get to know an epidemic by seeing it. As time goes on and I get some positive test results back I will learn by seeing many influenza patients the clinical intuition that will give me a sense of who only has a cold and who has this influenza. Then I can prescribe antivirals with much more confidence and specificity.

An even better way would be for every GP to have rapid office influenza testing in their clinic. Even though there are some problems with sensitivity, it is far better than the present situation where it takes about a week to get a simple Influenza A test result back from the lab.

Tamiflu is a scarce resource. We are wasting it and we may not have enough when we really need it.

14 06 2009
aussieflublogger

Hi Attila. Thanks so much for this fascinating comment! The picture you’re painting does sound like a recipe for promoting Tamiflu resistance. I’m off to have a look at the link you’ve posted on the change in recommended treatment. I’d be interested in your further thoughts and to hear from others. I’ll try to post on this a bit later today and get a thread running on it. Cheers. Nick.

14 06 2009
GSE

Great reading guys – thank you. It’s good to see some first-hand professional opinions. I visited my great GP last week with an unrelated issue and we had a chat about SF. My GP suggested “no panic” – that’s why I love her.
Anyway, I do have a question related to something I read during the first couple of weeks of SF spread.
In Victoria we were told that the Tamiflu have been all sold out in the pharmacies. That bit of news made my blood boil. At the time there were about 50 – 60 cases in OZ, and Tamiflu was already gone.
As far as I understand, Tamiflu is a prescription-only medication, so the fact that it was sold out would mean that hundreds of GP prescribed it willy-nilly to patients who weren’t presenting with the flu.
Is it “legal”? Shouldn’t GP follow some sort of a code or at least common sense and tell people to go home, and come back when they are actually sick?
There were “concerned mothers” on the radio crying that they gave Tamiflu to their children as a preventative measure and the kids ended up with severe stomach problems…
I can understand uneducated, panicked people chewing on Tamiflu like it was lollies, but the GPs who prescribed it should be flogged naked in a public square for the enjoyment of the masses (well, maybe not flogged).
Is that not a gross professional misjudgement on the part of those GPs?

14 06 2009
GSE

“…Victoria has abandoned its daily caseload updates…”

http://www.theaustralian.news.com.au/story/0,25197,25628852-2702,00.html

14 06 2009
Dr Attila Danko

GSE: It is difficult as a GP to resist pressure from patients that are scared, also it was recommended for a while to prescribe it to patients that were about to travel. (Ironic now that Victoria has the most cases per capita! although that is probably just because our health systems are more accessible than in most of the world). I agree that too many GP’s gave in to patient’s demands; but since that time many more deliveries have been made to pharmacists, they often only stock a few packets each before influenza season starts. Of course, with the most recent guidelines we will expect to see Tamiflu fly off the shelves as soon as more deliveries are made. The terrible thing now is that this waste is not only encouraged, it is mandated!

My local pharmacist said they had none left on Friday, however they said they did have Relenza. We actually make Relenza here in Australia in the GSK plant in Boronia and I have heard they are cranking up production. I am loathe to suggest that the guidelines should be changed to include Relenza however, as at least we may have some of that available for when we need it, that is, in perhaps another 2 weeks.

An article in the local paper said they were all panicking about cases in a nursing home, and had thrown Tamiflu about the place, but they said they are not testing them!! My bet is that they have this cold that’s going around, especially as we know that almost NOBODY over 65 is getting this novel H1N1.

(probably because they got the swine flu of 1957)

14 06 2009
GSE

Thanks for the reply Attila.
You said: “It is difficult as a GP to resist pressure from patients…” resisting panic should be an integral part of a GP’s job in my opinion.
Releasing retorvirals to the public, as you mentioned before, can only cause the virus’ resistance to the drug – how will the GPs feel then… will: “Oh shit, I shouldn’t have…” cross their minds? I think that giving in to patient’s pressure is just unprofessional.
How is it that in an apparently world-class system the control over the drugs, coordination, testing etc. are all falling apart?
Mexico (a third world country) managed to stop the spread by closing all schools, restaurants and public gatherings for two weeks and yet their economy survived.
We “cannot afford” not to have an AFL match or close schools – when will anyone actually act?
End or rant 😉

14 06 2009
Dr Attila Danko

“…Victoria has abandoned its daily caseload updates…”

It’s really quite bizarre. We are very much at the beginning of this yet they are behaving as if we are at the end. Reminds me of the aphorism: if you don’t measure a temperature you can’t find a fever. It does not seem to be spreading exponentially in the US but they are not in flu season, whilst we are. We cannot predict how this will be on the basis of what has happened in the northern hemisphere.

Now, it may be true that they cannot do all the specific typing novel H1N1 tests; however given we have no other influenza spreading at the moment non specific influenza testing will do, and we should be doing it everywhere, so we can track this accurately in real time. This will give us data to make better judgement calls on the use of antivirals.

From the Australian article:

quote
“The patient was initially refused priority testing because he fell outside Victoria’s risk criteria, and could not be fast-tracked even after classmates tested positive to swine flu.

“They said they couldn’t do it – it was on the slow train to nowhere and had been sent interstate,” Dr Charlesworth said. “I asked if I could at least have Tamiflu for the patient, for his household, and for myself – and they said, ‘No, because he doesn’t have swine flu at this stage’.”
end quote

We need to validate the clinical judgement of experienced doctors because that is what we’re trained for; we can make an individual judgement call that can be much more appropriate for the situation. Chief Medical Officer, give us data, not guidelines!

14 06 2009
GSE

Stop reporting, stop testing, stick fingers in your ears, close your eyes and it will all go away…

14 06 2009
Dr Attila Danko

GSE: I know you’d like to whip those bad doctors but as a society we have created this situation to some extent. We all expect to get what we want and to sue if we don’t. Patients become clients and the customer comes first. I would say that almost every doctor at some stage under multiple pressures and a full waiting room with sick kids has given in to a patients demands if they are not too big a deal, like a request from a naturopath for a certain blood test or an antibiotic or antiviral when it was not neccesarily the first choice of the doctor. That’s not to say it’s right, just that we are human, and sometimes it’s expedient to get that patient dealt with so you can see that child with a raging fever and desperate crying in the waiting room.

Who knows if someone was refused Tamiflu and got sick they might very well sue the doctor.

14 06 2009
GSE

I do understand the rationale, but with all due respect I still disagree with prescribing unnecessary drugs. Where does one stop? Codeine, morphine…
The “new way” where the patients, students etc. are customers is an absolute disaster. I just happen to be a tertiary teacher and we are also told that our students are customers. As a logical extension GPs will prescribe whatever the customer wants, teachers will teach what the customers want to know… Fast forward 30 years ahead, what do you see? Imagine GPs who were the customers of a university and learned only what they wanted to and are prescribing drugs that their customers want to take – sounds like fun.

14 06 2009
Dr Attila Danko

GSE, we decide which battles to fight and generally we fight against addictive drugs and hold a hard line against those and also ridiculous requests. Not that there isn’t room for improvement. But you are absolutely right, it is the undermining of respect that is the problem and this would be more rife in teaching than in medicine I imagine. Probably high school teachers have the worst of it.

14 06 2009
Does the Victorian Government’s response risk creating Tamiflu resistance? « Swine Flu in Australia

[…] comment is under this post. I’ve reproduced the relevant parts below: The recent change in Victoria to treatment of case […]

16 06 2009
Kellene

It is the risk of mutation that concerns me. The Swine Flu certainly does bear similarities to the 1918 Spanish Flu Pandemic — the initial break out in the spring proved mild, but in the fall it came back with a vengeance, killing millions. Indeed, the world is watching what will happen with the flu in the southern hemisphere. http://tinyurl.com/lhxb6b

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