Australia to go to “sustain” shortly

15 06 2009

Michael over at Avian Flu diary has a fascinating post here.

He quotes an AFP report saying Australia is expected to raise the alert level to “sustain” shortly.

He also has a great discussion about the Southern and Northern hemispheres’ current experiences.

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13 responses

15 06 2009
Dr Attila Danko

Another update. After getting my first Influenza A positive result today (almost 1 week after testing!) I rang the lab to find out if this would be further tested for specific typing (ie. novel H1N1) I ended up having a very lovely and informative chat to one of the microbiologists there. She reckons that about 2/3 of all influenza currently circulating in Victoria is actually non-swine seasonal flu. However samples from around the Austin and northern suburbs are now almost all novel H1N1. She also said that much of last years seasonal influenza in Australia was resistant to Tamiflu. She also agreed with my conclusion, based on seeing hundreds of patients with colds, and getting negative results bar one from the dozens I have tested (because they had severe symptoms) that there is not really that much true influenza around yet, swine or otherwise.

There are confusing statements going around, with some recommendations that (more sensibly) we should now only be treating high risk people with Tamiflu. (ie. people with respiratory disease etc). The recommendations on the link I posted to earlier though still stands. (treat everyone who meets the case definition).

By the way, the definition of “mild illness” is a slippery definition. My patient who tested positive had what most people would describe as severe symptoms, practically bedridden with aches and pains and feeling unwell, nauseous, cough, hot sweats and chills. My patient is at no risk of death, so this probably makes it classified as mild. However most lay people would assume “mild” means a bit of a sniffle and cough where you can go about your business. Ordinary influenza has got quite severe symptoms that put you in bed for a week, and if the one I tested is swine, it has these severe symptoms too, but nothing different to the influenza we usually see.

Totally irresponsible reporting from the Age today
http://www.theage.com.au/national/onethird-of-victorians-may-have-flu-20090614-c7eq.html
One third have swine flu?? Bollocks! One of those academics who hasn’t been near a patient in decades, most likely.

15 06 2009
Dr Attila Danko

Another update: talked to the reporter for the above story and told her of my experience and on my discussion with the microbiologist from Dorevitch Pathology. She was very interested in following this up. Hope we get some more accuracy in reporting.

btw, anyone out there or am I posting to the ether?

15 06 2009
aussieflublogger

Hi Attila

No – you’re not posting to the ether (although it can feel that way)!

In fact H5N1 has picked up your first comment and blogged on it already – you can see that here:

http://crofsblogs.typepad.com/h5n1/2009/06/australia-to-go-to-sustain-shortly.html

So – please keep it up – it’s fascinating – and it’s being read.

I’ll get your comment up on a separate post later in the afternoon – it deserves more visibility.

Cheers

Nick

15 06 2009
Dr Attila Danko

Ha, yes I noticed that not long after I posted; I suppose many posts may be very well read but active commenters are a very small proportion. Thanks for the encouragement.

15 06 2009
Grace RN

Doc,

The world is listening to you; please, blog away!

15 06 2009
aussieflublogger

Hi Attila – and I’ve managed to put your comment up as a post now – have a look if you’ve missed it:
https://ozswineflu.wordpress.com/2009/06/15/259/

15 06 2009
Dr Attila Danko

Well, another positive test for influenza A this afternoon. Results coming in quicker, only 5 days since the swab. Again a much more severe illness clinically. I’m starting to get more of a feel of this influenza. I feel good that I started both of them on Tamiflu immediately on a stronger than usual suspicion.

16 06 2009
Grace RN

Good gut instincts; how long have you been in medicine? Watching Australia’s course with panflu from USA; I really dread our fall and winter but it is still circulating up here.

What’s the temp/humidity like where you live?

16 06 2009
Claudia

You may be surprised to learn that many people are paying very close attention to what you write – observations from people with their feet on the ground (in more ways than one, apparently) are invaluable.

Some of us have long realized that “mild” translates into “didn’t need a bed in ICU or ventilator support” and doesn’t reflect the true clinical course of the disease. Anyone who has ever suffered through a bout of influenza knows that “mild” and “influenza” are pretty much oxymorons and have no connection at all to one another.

We in the US are quite aware that we need to follow very closely what happens in your part of the world during our summer in order to be better prepared for what our fall and winter may be like this year. From what I see so far, we are very likely to be in for a far worse situation than our government would like us to believe.

I commend you for your decisions to treat your patients with antiviral drugs when you think necessary. I wish I thought my doctor would do the same if I presented with significant symptoms, but right now I don’t believe he would.

16 06 2009
The Doctor

Dear Doctor,

In the US, our doctors have been given very poor guidelines to follow by the CDC. It sounds like your national heath authorities are providing their doctors with the same type of poor advice. The hapless docs in the US who have followed the CDC guidelines have seen the patients they turned away from their clinics and ERs die like dogs within a week or so of first contact. While there has been only one death in AU so far, since you are following the North American pattern, this will change soon. Beware.

What doctors everywhere need to do is what doctors have always done; take care of the patient before you as best you can. Do not listen to the government or pay attention to the health department guidelines. The only thing to listen to is the patient. The only thing to do is what is best for the patient and only doctors like you can decide that no one else.

In the US, it is not the government so much as the insurance companies that run the show. To take care of patients properly here, doctors often have had to resort to guerrilla tactics. We do what we must to get the patient what they need.

This is what I suggest you do too. As physicians, we have a high ethical standard to adhere to. It is this standard that differentiates our profession from many others. One that is older and much more revered than whatever standard, if it can be called a standard that is followed by our elected and appointed government officials.

There is no confusion here. Doctors must do what is right for their patient first. That sums our ethic up in a nutshell.

The ethics of our politicians are not at all so clear. They place the interests of their contributors ahead of their constituents. They think their beliefs and prejudices should influence their polices.

Compared to the ethic doctors must hew to, the “moral” positions and actions of our elected officials can only be described as infantile by comparison.

Don’t forget this. Do the right thing for the patient first and foremost and disregard what those with challenged ethical standards demand of you unless it corresponds with what is best for the patient. That is our standard. This is our sacred duty to the patient and it is the patient to whom our entire duty lies and to no one else.

Good luck and best regards,

Grattan Woodson, MD
Atlanta, GA USA

19 06 2009
Dr Attila Danko

Thanks for the kind comments! Grace, I graduated 11 years ago and have worked in general practice (family physician) for 7 years. It’s perfect influenza weather here, frosts on the clear mornings and drizzly cold showers otherwise. It occasionally snows here too, which I like a lot. I certainly expect increasing influenza, both novel H1N1 and the seasonal one, over the next few weeks, my guess is that probably novel H1N1 will come to dominate in time given the lack of immunity to it. Grattan, you are absolutely right that our ethical duty is to the patient’s well being and this overrides guidelines, especially ham-fisted ones. We also owe a duty to unseen patients too, I believe, in terms of trying to ensure access and to avoid contributing to wasteful use of medication and drug resistance in the community. We have no duty at all to innapropriate guidelines that fly in the face of the best interests of our patients, both seen and unseen.

19 06 2009
Grace RN

Oh, it sounds cold and damp there!! Course, it’s ‘spring’ here in New Jersey and as cold and rainy as our March.

A/H1N1 is hitting our area (around Philadelphia/Philadelphia county population ~1,500,000 within an area of 142.6 square miles/369.3 km,, Pennsylvania USA) pretty hard. The metropolitan area has ~ 5,116,830 people within an area of 3,855 square miles. That’s a pretty densely packed population here. I live within the metropolitan area.

Check out this update from the county Dept of Health:

Health Update
Increase in Local Transmission of H1N1 Influenza A (Swine Origin) and
Updated Recommendations for Patient Testing and Reporting
June 12, 2009
In the last week, cases of influenza A have increased dramatically across Philadelphia and one death was
confirmed in a 26-year-old woman. At present, over 90% of influenza circulating in Pennsylvania is the novel
H1N1 strain; there is very little seasonal influenza still circulating at this point. Emergency Department visits for
influenza-like illness have also risen to levels normally seen in Philadelphia during the peak of seasonal flu
transmission, particularly among children < 13 years of age, who now account for 70% of cases reported to
PDPH (see figure).
0
10
20
30
40
50
60
70
80
90
100
1/4 – 1/10
1/11 – 1/17
1/18 – 1/24
1/25 – 1/31
2/1 – 2/7
2/8 – 2/14
2/15 – 2/21
2/22 – 2/28
3/1 – 3/7
3/8 – 3/14
3/15 – 3/21
3/22 – 3/28
3/29 – 4/4
4/5 – 4/11
4/12 – 4/18
4/19 – 4/25
4/26 – 5/2
5/3 – 5/9
5/10 – 5
/16
5/17 – 5/23
5/24 – 5/30
5/31 – 6/6
6/7 – 6/13
No. of Lab. Confirmed Influenza A Reports
0
2
4
6
8
10
12
% of Total ED Visits
Influenza A ED Influenza-Like Illness
PDPH Laboratory Surveillance of Influenza A and Emergency
Department Surveillance of Influenza-Like Illness, 2009 Season
Recommendations for Identification and Clinical Management of Influenza
In light of this recent increase in community transmission of novel H1N1 influenza A, influenza-like illness is
more likely to be due to influenza A, in the absence of another explanation for symptoms. The increase in
cases among children 5-15 years of age has resulted in many school-based clusters or outbreaks of influenza.
Secondary spread to household contacts is also common. PDPH recommends the following for the diagnosis
and management of cases during this period of high-level transmission in the community:
• The diagnosis of influenza can be made clinically in children with symptoms of influenza-like illness (in
the absence of another likely diagnosis) if they attend school or childcare programs with recognized
outbreaks, or have siblings with influenza. Testing to confirm infection is not necessary in
Philadelphia in these situations.

Testing is recommended for the following persons with influenza symptoms:
o Hospitalized or fatal cases
o Pregnant women
o Persons who reside or work in facilities or institutional settings with high potential for outbreaks,
(e.g., group homes, shelters, correctional facilities, long term care facilities), to assure
appropriate clinical and public health management. Testing of patients once there is recognized
transmission in a facility is not necessary.
o Persons in age groups that have had a low incidence of disease (infants 65 years);
o Persons in whom the diagnosis may be uncertain because of atypical symptoms.
• Empiric usage of antiviral medication should be considered for appropriate persons
(http://www.cdc.gov/h1n1flu/recommendations.htm). Persons with chronic medical conditions who are
close contacts to persons with influenza are also candidates for antiviral prophylaxis. Patients who are
hospitalized with presumed or confirmed influenza should also be treated with antiviral medications.
Pharmacists who have difficulty locating Tamiflu® suspension can find directions for emergency
compounding of suspension using capsules, at http://www.tamiflu.com/hcp/dosing/extprep.aspx.
• All persons with influenza-like illness, even in the absence of a laboratory confirmation, should be
advised to remain home, staying out of work, school or childcare programs for one week after the
onset of symptoms. This exclusion recommendation is particularly critical to limit transmission
in school and childcare settings, and PDPH is advising school officials to enforce this
exclusion period for all students with flu symptoms, unless their physician provides a note
indicating an alternate diagnosis. PDPH has developed guidance specifically for the control of
influenza in schools. This document can be located at https://hip.phila.gov.
• Healthcare workers and others who are employed in healthcare facilities and have direct patient
contact may transmit this infection to vulnerable individuals. During this period of high transmission in
the community, facilities and agencies should implement active surveillance for influenza symptoms
and exclude those who are ill for one week. Healthcare workers are at risk for both community and
occupational exposures.
Surveillance for Influenza at PDPH
At this point in the epidemic, reports of individual cases of influenza who are neither hospitalized nor
pregnant are no longer requested; cases of influenza in other persons are no longer being
investigated. PDPH Division of Disease Control is now tracking aggregated laboratory data from viral
diagnostic laboratories, and monitoring city-wide trends in influenza morbidity as demonstrated by visits for
influenza-like illness in Emergency Departments and in sentinel practices. Isolates from hospitalized or fatal
cases are priorities for sub-typing by the Pennsylvania Department of Health.

PDPH requests that clinicians report the following:
• All hospitalized persons with influenza, or others with severe disease
• Pregnant women with suspected or confirmed influenza
• Outbreaks of influenza in a facility, school, program, or other setting that require special containment
measures
These recommendations are likely to change as the epidemiology and transmission characteristics of this
strain evolve. Screening and reporting recommendations will likely be revisited during the winter influenza
season.

Sorry it’s so long, but the link doesn’t open.

Grace RN

Please keep blogging!

20 06 2009
ElmPedsDMGDonS

Many of us in the North are looking to your experiences to get some early sense of what this may be for us when our winter hits, so we appreciate your updates mightily.

Does your equivalent of our CDC similarly post fairly current rates of influenza (by type and of percent of outpatient visits for influenza-like illness in sentinel clinics) compared to seasonal baselines?

My optimistic expectation is that by peak season we’ll merely be seeing 2 to 3 or so times more influenza cases than typical – so long as A/H1N1 neither mutates nor reassorts with an Asian Avian, swapping out its North American Avian bit for an Asian Avian bit like Mr. Potato Head swaps noses while on its world tour. If your experience turns out to be less of an incidence than that 2 to 3 times increase over baseline then some of us in the North may begin to breathe a bit easier.

Thanks and please keep posting!

Don Seidman MD

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