Flu Pandemic Update 04/30/09

Yesterday, we reported that the World Health Organization (WHO) raised the worldwide pandemic alert level to Phase 5. A Phase 5 alert is a "strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short."

Today, the Centers for Disease Control have added two new recommendations for prevention of swine flu spread:

- Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.

- Develop a family emergency plan as a precaution. This should include storing a supply of food, medicines, facemasks, alcohol-based hand rubs and other essential supplies.

We agree with these recommendations and continue to advise our patients to avoid travel to Mexico for any reason. The CDC recommendation to avoid travel to Mexico is available at: http://wwwn.cdc.gov/travel/contentSwineFluMexico.aspx.

We also recommend avoidance of any commercial air travel unless absolutely necessary and to consider wearing a mask when on airplanes or in crowds.

And of course, kissing pigs is absolutely inappropriate.

Meanwhile, there has been another confirmed human infection in Egypt with Avian influenza (H5N1). Investigations into the source of his infection indicate a history of close contact with dead and sick poultry prior to becoming ill. Of the 67 cases confirmed to date in Egypt, 23 have been fatal. There has not been evidence in Egypt of human to human transmission of H5N1.

The number of confirmed cases in the US is now 109 (with one death).
Several school districts in Texas are closed (including Fort Worth ISD).
A complete list of closures is available at:
http://ritter.tea.state.tx.us/swineflu/schclosings.html

We will continue to update this blog as new information becomes
available.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Flu Pandemic Update

The Public Health Conundrum: hope for the best, prepare for the worse and still avoid panic. The problem is that it is not yet known how dangerous this virus is. Not all flu pandemics are serious.

The 1918 Spanish Flu (an H1N1 virus) pandemic saw infection of between
20 and 40% of the world's population and killed 20 million worldwide,
including 500,000 in the US. The 1957 Asian Flu pandemic killed almost
70,000 in the US and 2 million worldwide. The 1968 Hong Kong flu (H3N2)
killed a million worldwide and almost 34,000 in the US.

To keep these numbers in perspective, the "regular" seasonal influenza
virus kills about 36,000 people a year in the U.S.

Upgrade to Phase 5

The World Health Organization on Wednesday raised its alert level for
swine flu to phase 5, one step short of a full pandemic, as the disease
continues to spread to around the globe.

Raising the alert indicates that the virus is causing multiple
outbreaks, or widespread human infection. It also signals that efforts
to produce a vaccine will be ramped up. The WHO said all countries
should activate pandemic preparedness plans.

WHO Director-General Margaret Chan made the decision Wednesday to raise
the alert level from phase 4 -- signifying transmission in only one
country -- after reviewing the latest scientific evidence on the
outbreak.

Texas Responds

Texas Gov. Rick Perry on Wednesday issued a disaster proclamation. State
Health Commissioner David L. Lakey said there were 16 confirmed cases in
Texas, including a 23-month old child in critical condition (who later
died). Another hospitalized patient -- a pregnant woman -- also was in
critical condition, with a swine flu diagnosis considered a "high
likelihood," Dr. Lakey said, cautioning that pregnant women may be more
susceptible to complications from the infection.

More information:

Explanation of the World Health Organization (WHO) pandemic "Phase" system

Perspective: Pandemics and Scares in the 20th Century

Prevention Recommendations from the Center for Executive Medicine

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Prevention / Treatment: Recommendations For Our Patients

I have reviewed the CDC, World Health Organization (WHO) and Texas Department of Health (TDH) recommendations. Of course, they are all different. However, based on their recommendations and with an abundance of caution given the lack of knowledge about this virus, I would recommend the following:

1. Avoid all non-essential travel by commercial air. Air in commercial airliners is partially recirculated and disease transmission between passengers is a known risk.

2. Do not travel to Mexico for any reason until further notice. Though not yet definite, there is some discussion of closing the border with Mexico. (Though this is not an effective strategy, politicians often appear to not be constrained by logic or evidence.)

3. Avoid crowds when possible. For example, shopping should be done at non-peak hours when stores are less crowded. I would not recommend large gatherings such as movie theaters, etc. in areas where cases have been confirmed or suspected.

4. Very frequent hand washing with soap and hot water or the use of alcohol-based antibacterial hand gel sanitizer.

5. Any individual with fever (> 100° F) and cough and/or sore throat should be isolated and should be tested for influenza. We have obtained sufficient rapid flu tests to perform testing on each patient in our practice and will order additional tests as needed to maintain this capability.

6. Any individual with confirmed or suspected influenza should follow additional precautions:

a. Separation from others in single room if available until asymptomatic;

b. If the ill person needs to move to another part of the house, he/she should wear a mask;

d. Cover the nose/mouth when coughing or sneezing;

e. Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use;

f. Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Update: First Death in US

U.S. health officials said swine flu has killed a 23-month-old child in
Texas, the first U.S. death in the current outbreak and the first
reported outside Mexico.

The flu death was confirmed Wednesday by Dr. Richard Besser, acting
director of the Centers for Disease Control and Prevention, in an
interview with CNN. Kathy Barton, a spokeswoman for the Houston Health
and Human Services Department, said Wednesday that the child had
traveled with family from Mexico to Brownsville in south Texas. She said
the child became ill in Brownsville and was taken to a Houston hospital
and died Monday night.

In the U.S., the number of confirmed cases rose to 66 Tuesday, including
five people in California and Texas being treated at hospitals,
according to the CDC and state health departments. The new data
indicated the strain was causing more severe illness in the U.S. than
originally seen; only one of the first 40 confirmed cases had to be
hospitalized.

Many Americans with swine flu probably contracted the virus during
travel to Mexico. However, there is also clear evidence of spread of
the virus from person to person in the U.S. In New York City, students
who returned from a trip to Mexico have become ill. But the 45
confirmed cases also include several students, staff and relatives who
didn't go to Mexico but who appear to have caught the virus from those
who did.

Confirmed Cases

United States - 91
Mexico - 26
Canada - 6
New Zealand - 3
United Kingdom - 2
Israel - 2
Spain - 2

Deaths

Mexico - 7
United States - 1

It is not known why cases in Mexico have been severe, while cases
elsewhere have been mild.

There is also no risk of infection from this virus from consumption of
well-cooked pork and pork products.

Vaccine Availability

Any effort to develop and distribute a vaccine is likely to be met with
a delay of approximately 4 months. Sanofi aventis, one of the world's
largest vaccine makers, is waiting for the WHO and the U.S. Centers for
Disease Control to pick the strain of the swine-flu virus that would
best work in a vaccine. Their CEO was interviewed recently and
indicated that after that decision was made, vaccine production would
take approximately 15 weeks.

Our updated recommendations for preventing the spread of illness will be posted shortly.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

Perspective: Pandemics and Scares in the 20th Century

History suggests that influenza pandemics have probably happened during at least the last four centuries. During the 20th century, three pandemics and several "pandemic scares" occurred. These are described in more detail below.

1918: Spanish Flu

The Spanish Influenza pandemic is the catastrophe against which all modern pandemics are measured. It is estimated that approximately 20 to 40 percent of the worldwide population became ill and that over 20 million people died. Between September 1918 and April 1919, approximately 500,000 deaths from the flu occurred in the U.S. alone. Many people died from this very quickly. Some people who felt well in the morning became sick by noon, and were dead by nightfall. Those who did not succumb to the disease within the first few days often died of complications from the flu (such as pneumonia) caused by bacteria.

One of the most unusual aspects of the Spanish flu was its ability to kill young adults. The reasons for this remain uncertain. With the Spanish flu, mortality rates were high among healthy adults as well as the usual high-risk groups. The attack rate and mortality was highest among adults 20 to 50 years old. The severity of that virus has not been seen again.

1957: Asian Flu

In February 1957, the Asian influenza pandemic was first identified in the Far East. Immunity to this strain was rare in people less than 65 years of age, and a pandemic was predicted. In preparation, vaccine production began in late May 1957, and health officials increased surveillance for flu outbreaks.

Unlike the virus that caused the 1918 pandemic, the 1957 pandemic virus was quickly identified, due to advances in scientific technology. Vaccine was available in limited supply by August 1957. The virus came to the U.S. quietly, with a series of small outbreaks over the summer of 1957. When U.S. children went back to school in the fall, they spread the disease in classrooms and brought it home to their families. Infection rates were highest among school children, young adults, and pregnant women in October 1957. Most influenza-and pneumonia-related deaths occurred between September 1957 and March 1958. The elderly had the highest rates of death.

By December 1957, the worst seemed to be over. However, during January and February 1958, there was another wave of illness among the elderly. This is an example of the potential "second wave" of infections that can develop during a pandemic. The disease infects one group of people first, infections appear to decrease and then infections increase in a different part of the population. Although the Asian flu pandemic was not as devastating as the Spanish flu, about 69,800 people in the U.S. died.

1968: Hong Kong Flu

In early 1968, the Hong Kong influenza pandemic was first detected in Hong Kong. The first cases in the U.S. were detected as early as September of that year, but illness did not become widespread in the U.S. until December. Deaths from this virus peaked in December 1968 and January 1969. Those over the age of 65 were most likely to die. The same virus returned in 1970 and 1972. The number of deaths between September 1968 and March 1969 for this pandemic was 33,800, making it the mildest pandemic in the 20th century.

There could be several reasons why fewer people in the U.S. died due to this virus. First, the Hong Kong flu virus was similar in some ways to the Asian flu virus that circulated between 1957 and 1968. Earlier infections by the Asian flu virus might have provided some immunity against the Hong Kong flu virus that may have helped to reduce the severity of illness during the Hong Kong pandemic. Second, instead of peaking in September or October, like pandemic influenza had in the previous two pandemics, this pandemic did not gain momentum until near the school holidays in December. Since children were at home and did not infect one another at school, the rate of influenza illness among schoolchildren and their families declined. Third, improved medical care and antibiotics that are more effective for secondary bacterial infections were available for those who became ill.

1976: Swine Flu Scare

When a novel virus was first identified at Fort Dix, it was labeled the "killer flu." Experts were extremely concerned because the virus was thought to be related to the Spanish flu virus of 1918. The concern that a major pandemic could sweep across the world led to a mass vaccination campaign in the United States. In fact, the virus--later named "swine flu"--never moved outside the Fort Dix area. Research on the virus later showed that if it had spread, it would probably have been much less deadly than the Spanish flu.

1977: Russian Flu Scare

In May 1977, influenza A/H1N1 viruses isolated in northern China, spread rapidly, and caused epidemic disease in children and young adults (< 23 years) worldwide. The 1977 virus was similar to other A/H1N1 viruses that had circulated prior to 1957. (In 1957, the A/H1N1 virus was replaced by the new A/H2N2 viruses). Because of the timing of the appearance of these viruses, persons born before 1957 were likely to have been exposed to A/H1N1 viruses and to have developed immunity against A/H1N1 viruses. Therefore, when the A/H1N1 reappeared in 1977, many people over the age of 23 had some protection against the virus and it was primarily younger people who became ill from A/H1N1 infections. By January 1978, the virus had spread around the world, including the United States. Because illness occurred primarily in children, this event was not considered a true pandemic. Vaccine containing this virus was not produced in time for the 1977-78 season, but the virus was included in the 1978-79 vaccine.

1997: Avian Flu Scare

The most recent pandemic "scares" occurred in 1997 and 1999. In 1997, at least a few hundred people became infected with the avian A/H5N1 flu virus in Hong Kong and 18 people were hospitalized. Six of the hospitalized persons died. This virus was different because it moved directly from chickens to people, rather than having been altered by infecting pigs as an intermediate host. In addition, many of the most severe illnesses occurred in young adults similar to illnesses caused by the 1918 Spanish flu virus. To prevent the spread of this virus, all chickens (approximately 1.5 million) in Hong Kong were slaughtered. The avian flu did not easily spread from one person to another, and after the poultry slaughter, no new human infections were found.

In 1999, another novel avian flu virus (A/H9N2) was found that caused illnesses in two children in Hong Kong. Although both of these viruses have not gone on to start pandemics, their continued presence in birds, their ability to infect humans, and the ability of influenza viruses to change and become more transmissible among people is an ongoing concern.

From Department of Health and Human Services

Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Crossing Oceans

The World Health Organization (WHO) reported today that the swine flu epidemic has crossed oceans - the first cases have been confirmed in the Middle East and Asia (in addition to Israel, Canada, Mexico, the US, Spain and France). All of the reported deaths have occurred in Mexico.

Deaths: 152, all in Mexico, 20 confirmed as swine flu and rest suspected.

Sickened: 1,995 people in Mexico got pneumonia but swine flu not yet confirmed. 64 confirmed in U.S. (details below), including 28 at one New York City school. Elsewhere, six confirmed in Canada; two confirmed in Scotland and seven suspected; 11 confirmed and 43 suspected in New Zealand; two confirmed and 25 suspected in Spain; two confirmed in Israel; one suspected in South Korea; one suspected in France; 13 being tested in Sweden; 12 being tested in Denmark; five awaiting test results in Norway.

U.S. cases: The Centers for Disease Control and Prevention (CDC) reports a total of 64 confirmed cases in the U.S. as of 10 AM CST today. (California 10 cases, Kansas 2 cases, New York City 45 cases, Ohio 1 case, Texas 6 cases.)

Also from the CDC: Today, CDC reports additional cases of confirmed swine influenza and a number of hospitalizations of swine flu patients. Internationally, the situation is more serious too, with additional countries reporting confirmed cases of swine flu. In response to the intensifying outbreak, the World Health Organization raised the worldwide pandemic alert level to Phase 4. A Phase 4 alert is characterized by confirmed person-to-person spread of a new influenza virus able to cause “community-level” outbreaks.” The increase in the pandemic alert phase indicates that the likelihood of a pandemic has increased.

The WHO will host a scientific review on the current outbreaks of swine flu tomorrow (April 29) and we will post an update when information from that review is available.

Comments / Posted by Scott W. Yates, MD, MBA, MS, FACP

World Health Organization (WHO) pandemic Phases Explained

Explanation of the World Health Organization (WHO) pandemic "Phase" system:

In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans.

In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat.

In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a foregone conclusion.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.

Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.

In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Goodbye Pontiac

GM is pulling the plug on its Pontiac Division.

That's like amputating the foot of a patient who is having a heart attack.

-- Jim Barach

Posted by Scott W. Yates, MD, MBA, MS, FACP

New Prostate Cancer Screening News

An influental doctors group is backing off its call for annual prostate cancer screening tests after age 50.

"Many men do not need yearly screening," but each man's risk should be individually assessed, said Dr. Peter Carroll, who helped write new American Urological Association guidelines that will be released today.

The new stance from the AUA brings it more in line with advice from other experts, who say annual screenings lead to unnecessary biopsies and treatment with little proof that they save lives. Screening involves a physical exam and a blood test for the level of prostate-specific antigen.

The urology group's new advice says men should get a baseline PSA test at age 40, and followups at intervals based on each man's situation. A high PSA at age 40 can indicate a higher risk of prostate cancer, said Carroll, a urologist at the University of California at San Francisco.

Doing a baseline test "makes a lot of sense to me," said Dr. Eric Klein, prostate cancer chief at the Cleveland Clinic.

Others disagreed.

There is no proof that a baseline test will save lives, said Dr. Barnett Kramer, a National Institutes of Health scientist.

"The same issue of harm comes up - overdiagnosis. A baseline PSA, just like regular PSA screening, can lead to the diagnosis of cancers that would not have harmed a man had they not been detected," Kramer said.

Prostate cancer is the most common nonskin cancer in American men. There were an estimated 186,000 new cases and 28,660 deaths from it last year.

Despite its name, PSA isn't very specific. It can rise for many reasons besides cancer, such as the use of certain medicines, the normal enlargement of the gland as men age - even things like a hard bike ride or recent sex.

THE ASSOCIATED PRESS / Monday, April 27th 2009, 4:00 AM

Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Update 04/27/09

Mexico:

The most recent World Health Organization statistics include 20 confirmed cases of swine influenza from Mexico (the vast majority of the thousand or so total cases reported are unconfirmed). While the media attention has focused on Mexico City, the disease is not limited to that region. Suspect clinical cases have been reported in 19 of the country's 32 states.

United States:

As of noon central time today (updated after map image produced), the CDC reports 40 laboratory confirmed cases in the US: (California 7 cases, Kansas 2 cases, New York City 28 cases, Ohio 1 case, Texas 2 cases.)

Recommendations:

The CDC recommends the following to prevent spread:

Avoid close contact. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.

Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.

Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.

Clean your hands. Washing your hands often will help protect you from germs.

Avoid touching your eyes, nose or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Practice other good health habits. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Not Time to Panic:

To keep this all in perspective, there has also been an outbreak of Pertussis in Australia this spring, with more than 7,000 cases reported. Also this year, the Yellow Fever virus exposure zone in Brazil has expanded to include Sao Paolo. Since February 2009, twenty-two cases have been reported; Yellow Fever has a mortality rate approaching 50%. Yellow Fever, Pertussis and Influenza (probably including Swine Flu) are preventable with appropriate vaccination.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Update: U.S. Declares Public Health Emergency

What to do:

1. If you are not ill, avoid crowds in public places until the scope of this illness is more clear.

2. If you have not had a flu vaccine for the 2008 - 2009 season, consider being vaccinated. There is no current data about the effectiveness of this strategy, but there is also little or no downside. Quoted in a Bloomberg news report, one virologist has suggested that there may be benefit:

"The dominant form of flu circulating in the U.S. in the most recent flu season was an H1N1, said Frederick Hayden, professor of clinical virology at the University of Virginia Health Sciences Center in Charlottesville. That suggests that people who got this year’s flu vaccine, which gave protection against the H1N1 virus, might also have some protection against the swine flu, he said."

3. If you have a flu-like illness and are concerned about whether you've contracted the Swine Flu, first, do not panic. There have been no deaths in the United States to date and only one patient has reportedly been hospitalized briefly. If you have had recent symptom onset, particularly if you've recently traveled to Mexico, call your physician to discuss possible tests to determine whether you have an influenza virus infection and if so, how best to proceed.

The most recent WebMD report discusses today's public health emergency declaration:

CDC Has Reports of at Least 20 People in the U.S. Sickened by Swine Flu

April 26, 2009 -- The U.S. government today declared the swine flu outbreak a public health emergency. Swine flu has sickened at least 20 people in the U.S., by the CDC's latest count.

"We are declaring today a public health emergency," Secretary of Homeland Security Janet Napolitano said today at a White House news briefing. That declaration is "standard operating procedure," Napolitano said. "It is similar to what we do when we see a hurricane approaching a site. The hurricane might not actually hit but allows you to take a number of preparatory steps. We really don't know ultimately what the size or seriousness of this outbreak is going to be."

As part of the emergency, the Department of Homeland Security is releasing 25% of stockpiled antivirals -- Tamiflu and Relenza -- to the states.

Here's what officials want you to do: Stay home if you're sick, avoid close contact with people who are sick, wash your hands often, avoid touching your eyes, nose, and mouth, and cover your mouth or nose with a tissue when coughing or sneezing.

The CDC has gotten reports of lab-confirmed swine flu cases in eight people in New York City, seven people in California, two in Texas, two in Kansas, and one in Ohio.

All of those swine flu cases have been relatively mild, although one person was briefly hospitalized, according to Keiji Fukuda, MD, assistant director-general for health security and environment at the World Health Organization.

The eight swine flu cases in New York City involved students at Saint Francis Preparatory School in Queens. All have recovered fully, according to a news release from the New York City Department of Health and Mental Hygiene.

So far, U.S. cases of swine flu have been milder than those seen in Mexico, where the World Health Organization has confirmed that at least 20 people have died from swine flu; health officials are investigating dozens more deaths in Mexico.

CDC officials yesterday said they expected more swine flu cases to be reported as public health officials heighten their hunt for the new strain of swine flu virus, which is a mix of swine, human, and bird flu viruses.

Countries around the world are watching for the virus, and scientists are scrambling to learn more about the virus and stop it before it becomes a pandemic.

Fukuda says the global health community is taking the swine flu threat "very seriously" but wants more information before deciding whether to raise the WHO's pandemic alert level from phase 3 to phase 4.

An influenza pandemic occurs when a new influenza type A virus emerges for which there is little or no immunity in the human population, begins to cause serious illness, and then spreads easily from person to person worldwide, according to background information from the U.S. Department of Health and Human Services.

The WHO has a scale ranging from phase 1 (low risk of a flu pandemic) to phase 6 (a full-blown pandemic is under way).

Symptoms of swine flu seen in U.S. patients so far have been "relatively nonspecific -- high fever, cough sore throat, muscle aches, possibly vomiting and diarrhea in some numbers," says Schuchat.

The problem is, those symptoms aren't unique to swine flu.

They "can be caused by so many different things," Schuchat says, which makes it "impossible" for a patient to tell if they have swine flu, as opposed to another flu virus or a different illness.

"This is a dilemma, a challenge, we're wrestling with," says Schuchat. She encourages patients to use their judgment about whether they're sick enough to see a doctor, and to definitely do so if they've recently been to a high-risk area, such as Mexico.

Schuchat also notes that there have been cases of the virus spreading from person to person in the U.S. The two confirmed cases in Kansas are a husband and wife, one of whom traveled to Mexico. Two days after returning home, the spouse became ill, says Schuchat.

By Miranda Hitti, WebMD Health News. WebMD Senior Writer Daniel J. DeNoon contributed to this report.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Update: Two Human Cases of Swine Flu Confirmed in Texas

From Texas Department of State Health Services News Release / April 23, 2009:

The Texas Department of State Health Services today announced that swine flu has been confirmed in two 16-year-old boys from Guadalupe County near San Antonio.

One became ill on April 10, the other on April 14. Their illnesses were relatively mild. Neither was hospitalized. Both have recovered. Though the boys are friends, it has not been determined how either became infected.

Laboratory test results received today from the U.S. Centers for Disease Control and Prevention indicate that the illnesses were caused by a swine influenza A (H1N1) virus. Preliminary lab data suggests that the virus closely matches the viruses from recent swine flu infections in human cases from Southern California.

State public health officials are investigating to determine if any close contacts of the boys have become ill and are asking hospitals, doctors and others in the area to be especially alert for other possible cases.

DSHS and local public health agencies in Texas were already involved in a CDC-led swine flu investigation because one of the two original cases from Southern California, a 10-year-old boy, traveled to Dallas for an extended visit with relatives. No additional cases connected to the boy have been confirmed.

Initial information from the investigation of the two teenagers' illnesses indicates no recent travel and no connection to the boy who traveled to Dallas from Southern California.

Symptoms of swine flu in people are similar to those of regular or seasonal flu and include fever, lethargy, lack of appetite and coughing. Some with swine flu also have reported runny nose, sore throat, nausea, vomiting and diarrhea.

Health officials say the public should follow standard precautions to reduce the spread of any respiratory illness.

- Stay home when you are sick to avoid spreading illness to others.

- Cough or sneeze into the crook of your elbow or a tissue and properly dispose of used tissues.

- Wash hands frequently and thoroughly with soap and warm water or use an alcohol-based hand sanitizer.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Measles Cases in D.C. Area Prompt Awareness Campaign

WASHINGTON -- An unusual series of five measles cases in the Washington area prompted public-health officials from Maryland, Virginia and the District of Columbia Monday to start an awareness campaign to urge people to protect themselves from the potentially deadly disease.

Officials also planned to announce details of recent measles activity in the area, including places, dates and times when people may have been exposed to the illness as part of the recent cases.

Measles, best known for a red skin rash, is a potentially fatal, highly infectious virus that spreads through contact with an infected person sneezing or coughing. Health officials say because measles has been nearly eradicated in the U.S., having multiple cases in a short time frame is cause for concern.

World health authorities have said measles deaths have dropped significantly world-wide. But federal health officials say the disease has been resurgent in the U.S., with nearly half of those involving children whose parents refuse vaccination.

Recent cases in California, Pennsylvania, Iowa and now the Washington region show that as long as measles exists somewhere in the world, it's still a threat, said Athalia Christie, senior technical adviser with the American Red Cross and member of the Measles Initiative, a global group.

The regional awareness effort will include urging parents to make sure their children are vaccinated and information on what symptoms to look out for.

Earlier this month, health officials announced that four cases -- affecting three adults and a child -- had been reported since February in Montgomery County, Md. Officials believe the cases may have originated with an unvaccinated adult returning from abroad.

In D.C., Department of Health spokeswoman Dena Iverson said doctors confirmed Friday that a city resident also had measles. That person was treated and released from a local hospital and is no longer considered contagious, Ms. Iverson said. Officials didn't provide the person's age.

She said health officials were working to contact people who may have been exposed to that case. The last confirmed measles case in Washington was April 2008.

The D.C. case isn't related to the four cases reported in Montgomery County, said Mary Anderson of the county's health department.

"It's becoming a regional issue," Ms. Anderson said. "We want to…talk about specific exposure sites so people who've been at those places can be aware, and talk about the value of being protected against measles."

The disease is no longer endemic to the U.S., thanks to high childhood-vaccination rates, but every year cases enter the country through foreign visitors or Americans returning from abroad.
(Associated Press)

Posted by Scott W. Yates, MD, MBA, MS, FACP

Esteem

"All men seek esteem; the best by lifting themselves, which is hard to do, the rest by shoving others down, which is much easier."

-- Mary Renault

Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Spreads - 16 Dead in Mexico CIty

The UK Based Guardian has reported that 16 people have now died in Mexico City as a result of the Swine Flu. A prior blog post here (see April 21 posting below) included the first report of this illness in humans. Two children were affected in Los Angeles earlier this week (and one of these children was reportedly in Dallas after having recovered). The cases in Mexico City are believed to be the first deaths from the Swine Flu - the seven known patients in the US have all recovered.

The full story from the Guardian follows:

Swine flu epidemic kills 16 in Mexico City

Fears of a pandemic rise as authorities close schools and universities in an attempt to control the spread of the virus

An epidemic of a swine flu never identified before has broken out in Mexico City killing at least 16 people so far and raising fears of a pandemic.

All kindergartens, schools and universities in the metropolitan area were closed today in an attempt to control the spread of the virus that authorities say may be linked to a further 45 deaths.

"This is a new virus that we haven't seen before," health minister Jose Angel Cordova said in an interview with MVS radio. "We have taken these measures because this is a virus that has the potential to become a pandemic."

The minister said close to 1,000 cases of infection had been registered so far, mostly in the metropolitan area of 20 million people, although three other Mexican states have also been affected to a lesser degree.

There have also been seven reported cases of the same virus reported in the United States, five in Southern California and two in Texas. All those patients have recovered.

The Mexican minister said the authorities were considering extending the precautions to include shutting down workplaces as well as schools, but for the moment urged employers to be tolerant of absences.

He said that while the situation was "very worrying" he believed the epidemic "is controllable".

The impact of the preventative measures on city life was felt immediately as the population woke up to news of the epidemic that was announced in a late night statement. Radio and TV stations repeated official advice to stay away from crowded places "unless urgently necessary," and to seek medical help at the first sign of the very high fevers and acute respiratory symptoms associated with the illness.

At Mexico City's biggest airport, airlines began requiring passengers checking in for domestic and international flights to fill out forms to help decide who could be at risk of carrying the virus. Anybody deemed to be so was reportedly asked not to fly.

Meanwhile, the media was flooded with questions from city dwellers concerned about everything from the dangers of eating pork to travel on the metro.

Many people heading to work in the morning wore blue surgical face masks, and chemists said their supplies were running out.

The partial shutting down of the metropolis was a dramatic reversal from the government's previous position that minimised the unusual number of flu deaths picked up by the media, saying it was due to an extension of winter.

Cordova said the sudden change of tack happened when samples analysed in highly specialised laboratories in Canada and the US revealed that the virus causing the deaths was a completely different strain.

The Geneva-based World Health Organisation said today that it was concerned about the epidemic and had activated its strategic health operations centre. The agency added that it was in daily contact with US, Canadian, and Mexican authorities

Jo Tuckman in Mexico City
guardian.co.uk
Friday 24 April 2009 17.02 BST

Posted by Scott W. Yates, MD, MBA, MS, FACP

Patients Need Time

"Fifty to 75 percent of known preventive measures don't get done. This boils down to one thing -- time."

-- Dr. David DeAtkine Jr., internist and endocrinologist in Birmingham, Ala.

Posted by Scott W. Yates, MD, MBA, MS, FACP

How to Make Primary Care Better

By Benjamin Brewer, MD

I wasn't invited to any inauguration parties for President Obama. If I had been, I would have tried to bend his ear with some ideas on how to revive primary care in this country.

It's high time to build a modern primary care system that meets the needs of all Americans. It won't be easy and will require an uncomfortable discussion about medical costs and benefits. But judging from Mr. Obama's inaugural address, he may be the man to get change started.

I would have told him to fund primary care adequately. We also need to change how we pay for it, starting with an overhaul of Medicare, so our medical system gets the results we deserve for the money we're spending.

I agree with his call for better use of technology to improve care and lower costs, and I would have told him that the country needs to put in place standards for health information technology and infrastructure.

The need for change is clear. We spend twice as much as many other developed countries on health care, yet we have worse quality. The countries that do better all have systems that are based on effective primary care.

My patients intuitively understand where we need to go. The hallmarks of an effective system are ready access, a provider who can be the main source of care for most needs, comprehensive care and coordinated care.

Decades of research have shown that good primary care reduces costs and improves outcomes, yet we have ignored these fundamental facts to our detriment. I see this blind spot as the biggest flaw in our current system.

Medicare, Medicaid and private insurers all contribute to poor quality by providing incentives for primary care doctors to churn patients through their offices as quickly as possible.

A lot of the great care I give is viewed as worthless by the folks who control payments. If the care didn't happen during an office visit, then Medicare, Medicaid and most commercial insurers pretend it doesn't exist.

Services that earn me the least are often the ones patients value most, such as email messaging, phone advice, and calling in prescriptions to avoid an ER visit.

Why doesn't Medicare pay me to hold a family meeting for a patient suffering from Alzheimer's or to coordinate care among multiple consultants? How about the uncompensated work I do researching cases, reviewing charts and completing disability reports.

I think every small town and urban neighborhood should have a family doctor, just like my community of Forrest, Ill. Sadly, few medical students want to take the modest pay or put up with the hassle to practice primary care practice where it's most needed. We have a problem with an inadequate primary care work force because we have a problem in funding.

Over the long haul, flooding the country with foreign trained M.D.s won't cure the primary care shortage. Even these doctors will find soon enough that they won't be able to cover their operating expenses with what the government is paying.

To get real reform we're going to need to put more money into primary care. I have a few suggestions about where to start looking for it.

The first dollars can come from the Medicare Advantage program. We can lower payments to hospitals for surgical care, radiology and other high-margin services and move the money to primary care.

We can revoke the tax exemptions of supposedly nonprofit hospitals that don't fulfill their mission of community service. We can cut down on costs for office visits to doctors by paying a lesser amount for phone and email contact instead.

We can lower the Medicare pay scale for specialty care, lab tests and procedures. Let's expand the use of non-physician personnel to deliver repetitive procedural care like colonoscopies, not just simple checkups or minor illnesses. We already use advanced practice nurses in specialized and technical fields like anesthesia and neonatology.

There will be tough challenges. An expensive, national health information project won't solve the bulk of our health-care problems, despite the hype.

One reason is that slapping software on top of screwy systems for documenting care only goes so far. It's essential that we simplify the delivery of care and ease the administrative burden on those providing it.

In the end, an adequately funded system of primary care is the key to the health-care reform our country really needs. The community of primary care physicians, nurses and physician assistants stand willing and able to do this work, if the tools and resources are made available.

Posted by Scott W. Yates, MD, MBA, MS, FACP

Change the World and Have Fun Doing it!

"I get up every morning determined to both change the world and to have one hell of a good time. Sometimes, this makes planning the day difficult."

-- E. B. White

Posted by Scott W. Yates, MD, MBA, MS, FACP

Swine Flu Sickens 2 California Kids

CDC Believes Flu Was Contracted in Person-to-Person Spread

April 21, 2009 -- Two California children got sick with a mysterious new strain of swine flu -- and the CDC thinks they got the pig virus via person-to-person contact.

Both kids, a 10-year-old boy from San Diego County and a 9-year-old girl from Imperial County, are now well. However, the girl had a 104.3-degree fever before she recovered. And the boy traveled by airplane from San Diego to Dallas while he still had flu symptoms.

Is this the first sign of a flu pandemic? That's possible, but not likely, says Lyn Finelli, DrPH, chief of flu surveillance at the CDC. "While we have a low index of suspicion this is a pandemic, we are being careful to rule out any possibility," Finelli says. "We don't know yet." "We have here detection of two cases of swine flu virus in children. We are trying to figure out where they came from and how serious they are," says Dan Jernigan, MD, MPH, deputy director of the CDC's influenza division. The CDC has dozens of people tracing the children's contacts, beginning with close family members. Each of the children had two family members come down with the flu -- in both cases, one family member had the flu before the child had the flu, and one after. All recovered, but flu virus was not obtained from any of these family members while they still had symptoms. Over the weekend, the CDC developed a specific test for the new swine flu virus; testing of the children's contacts is now under way. It's likely that the tests will reveal other people who recovered from the infection.

CDC has not activated its Atlanta-based command center. But California has, Finelli says, and is putting all available health care workers on the job of tracking down the children's contacts.

Both children attended school, and California authorities are planning to trace the children's school contacts. Meanwhile, the 10-year-old boy remains in the Dallas area and has made a full recovery from his one-week symptoms of fever, cough, and vomiting. So far, the CDC says, Texas health authorities have not found any new infections. The boy traveled to Texas with three other children unaccompanied by adults; crew members who assisted the children are now being tested.

The CDC is withholding the name of the airline that flew the boy and his three companions from San Diego to Dallas on April 3.

Swine flu viruses don't normally infect humans. When they do, it's almost always because of contact with an infected pig. But neither child had any direct contact with pigs. Moreover, the viruses recovered from the children are not like the swine flu viruses common among pigs. That raises the specter of human-to-human spread of the virus, Finelli says. "This virus is different, very different from that circulating in pigs. That was a red flag," Finelli told WebMD and several other news organizations. "The other red flag is both cases appeared almost simultaneously, 100 miles apart. When we see two cases [of swine flu] without animal contact that occur simultaneously and they have a different virus [than in pigs], we are concerned."

What worries the CDC is that the two cases might signal the beginning of a flu pandemic with a virus new to humans. But CDC spokesman Tom Skinner notes that it's the CDC's job to be worried. Several things about the cases are reassuring:

Both cases were detected by routine flu surveillance.

Southern California has unusually excellent flu surveillance -- and there has not been a large number of flu cases from unusual flu strains. The virus is the H1N1 strain of swine flu. There are human strains of H1N1, raising at least the possibility of cross-protection -- especially in adults. Not reassuring is the finding that the new swine flu strain carries three genes from Eurasian swine flu bugs not known to be circulating in the U.S. The new strain apparently is a reassortant virus that assembled itself from the genes of at least two different swine flu viruses. It carries no human flu genes. Swine flu last spurred headlines in 1976 when an outbreak of swine flu at Fort Dix, N.J., killed one healthy recruit, caused four cases of serious pneumonia, and spread to some 230 soldiers before it vanished.

It's still not clear where the 1976 virus came from or why it went away -- but it spurred widespread public alarm and a vaccination program that badly misfired before being terminated.

The CDC, the California Department of Public Health, and the health departments of Imperial and San Diego counties urge all of those counties' residents and visitors who develop flu-like symptoms to seek medical attention. Doctors who see these patients are advised to send swab samples to state or local health authorities. They are also asked to get full interviews to ask about other family members or contacts who may be ill.

Here's the CDC's advice for all people who get flu-like symptoms, whether it's normal seasonal flu or swine flu:

Stay home when you are sick to avoid spreading illness to co-workers and friends.
Children with flu-like symptoms should stay home to avoid spreading illness to classmates and staff.
Cough or sneeze into your elbow or a tissue and properly dispose of used tissues.
Wash your hands thoroughly with soap and warm water or use an alcohol-based hand sanitizer to get rid of most germs, and avoid touching your eyes, nose, and mouth.
Stay healthy by eating a balanced diet, drinking plenty of water, and getting adequate rest and exercise.

The new swine flu bug is resistant to the older flu drugs amantadine and rimantadine. Tests are under way to see if it remains sensitive to the newer flu drugs Tamiflu and Relenza.

The CDC announced the swine flu cases in a special MMWR Dispatch published today.

By Daniel J. DeNoon, WebMD.

Posted by Scott W. Yates, MD, MBA, MS, FACP

The 21st Century Physician

"The defining characteristic of the 21st century physician will be a physician who is still wise, has great interpersonal skills, but uses information technology to deliver safe and effective health care."

-- Joseph Scherger, MD, member, Institute of Medicine Quality of Care Committee

Posted by Scott W. Yates, MD, MBA, MS, FACP

New Debate on Prostate Cancer Screening

U.S. Study Shows PSA Test Doesn't Save Lives; European Study Shows Modest Benefit

Interim findings from an eagerly awaited ongoing government study show no evidence of a survival benefit associated with aggressive screening for prostate cancer using the prostate specific antigen (PSA) test.

More prostate cancers were detected over an average of seven years of follow-up among men who had regular PSA testing in addition to digital rectal exams compared to usual care, which could have included screening. But the increase in prostate cancers did not translate into fewer deaths from the disease.

The findings are certain to add to the controversy surrounding the value of PSA testing for prostate cancer screening, and the debate about whether current screening practices have led to overdiagnosis and overtreatment of prostate cancer.

The study, funded by the National Cancer Institute was published online ahead of publication in the March 26 issue of the New England Journal of Medicine.

"What this report tells us is that there may be some men who are diagnosed with prostate cancer and have the side effects of treatment, such as impotence and incontinence, with little chance of benefit," NCI director John E. Niederhuber, MD, says in a news release.

"Clearly, we need a better way of detecting prostate cancer at its earliest stages and as importantly, [we need] a method of determining which tumors will progress."

Screening Beneficial in European Study

To add to the confusion, findings from a major European trial appearing in the same issue of the New England Journal of Medicine did show a modest, 20% survival benefit associated with PSA screening in men followed for an average of nine years.

Both the U.S. and the European studies will be presented this week at the European Association of Urology annual meeting in Stockholm, Sweden.

For every 10,000 men screened with PSA over a nine-year period in the European trial, seven fewer deaths from prostate cancer were reported.

But the European researchers estimated that 48 additional men whose cancers were detected as a result of screening would need to be treated to avoid one prostate cancer death.

That compares with about 10 additional treatments among women screened with mammography needed to prevent one death from breast cancer, prostate cancer screening researcher Michael J. Barry, MD, of Harvard Medical School tells WebMD.

Barry, who wrote an editorial that appeared with the studies, adds that the new research helps to quantify the benefits and risks associated with PSA screening.

"When you look at the two trials together it becomes clear that the benefits, in terms of survival, are fairly modest," he says. "They are similar to what we see with mammography, but in my opinion it comes at a much higher price in terms of overdiagnosis and overtreatment."

Longer Follow-up May Be Needed

NCI researcher Christine D. Berg, MD, tells WebMD the failure of the U.S. trial to show a survival advantage associated with PSA testing could be due to the relatively short follow-up.

The researchers plan to follow the almost 77,000 men participating in the trial for a total of 17 years, and the men in the PSA arm of the trial will continue to have annual screenings.

Berg points out that in the European study the survival advantage was not seen until after seven years of follow-up.

But she echoed Barry's concerns that costs of PSA screening in terms of increased treatment may not be justified by the benefits.

"Personally, I think we should do some screening, but we really can't say what the optimal screening protocol should be at this time," she says. "The best we can do is counsel men to talk to their physicians."

Current Screening Recommendations

The U.S. Preventive Services Task Force, which makes recommendations about health care screenings, recently concluded that there is insufficient evidence to determine if the benefits of prostate cancer screening outweigh the risks in men younger than 75.

Prostate cancer screening is not recommended for older men.

The American Cancer Society does not support routine prostate cancer screening, but the group does urge men who have an average risk for the cancer, beginning at age 50, to talk with their physician about the pros and cons of screening. These discussions should take place at age 45 for men at higher risk.

"I think you will have a lot more men having this discussion with their health care providers as a result of these studies, and from our point of view that is a good thing," American Cancer Society Deputy Chief Medical Officer Len Lichtenfeld, MD, tells WebMD.

Lichtenfeld says the studies are likely to lead to vigorous debate within the medical community about the value of PSA screening.

"For years we've been saying wait for the trials, but so far the trials have not given us a definitive answer about whether prostate cancer screening is beneficial or harmful," he says.

"I suspect there will be a substantial amount of discussion over the next few weeks and months among the experts to try and put these findings into perspective and try and tease out what the message should be."

By Salynn Boyles, WebMD Health News

Posted by Scott W. Yates, MD, MBA, MS, FACP

The Constitution

They keep talking about drafting a Constitution for Iraq .... why don't we just give them ours? It was written by a lot of really smart guys, it has worked for over 200 years, and we're not using it anymore.

-- Anonymous

Posted by Scott W. Yates, MD, MBA, MS, FACP

Pharmacology - The Abuse of the Tablet

From the Journal of the American Medical Association (100 years ago):

The convenience of the tablet form of medication has doubtless developed in the medicine-taking public a dangerous contempt for potent drugs that has been bred of familiarity. This was recently exemplified by the case reported in our British contemporaries of a woman who took thirteen aspirin tablets between 3 pm one day and 10 am the next. She died of heart failure and, in accordance with the medical testimony, a verdict was returned of death accelerated by an overdose of aspirin.

The very advantages that a tablet has in case of administration, convenience and portability, are in themselves elements of danger, when drugs in this form are indiscriminately used by the public.

JAMA, 1908;51:2220,2228

Posted by Scott W. Yates, MD, MBA, MS, FACP