Tuesday, November 24, 2009

Practice Pandemic: What we have learned to date

Two weeks after my last post, and although the days are still busy, we are actually seeing patients in the Emergency Department who don’t have flu-like illness  (yay!).  Flu assessment clinics are starting to come down, and maybe the peak for this phase of the pandemic at least has past.  Time to reflect on what we did right and wrong, and maybe how to do better next time.

I can hear some of you sigh from here.  Next time?  Will the fear mongering never stop??

It isn’t fear mongering, though, to plan wisely for events like this in the future.  The story of new illness in the last half century has largely been that of infectious or infectious-like disease; Ebola, AIDS, Kawasaki’s, Lyme disease, West Nile, SARS, now new forms of pandemic influenza and many others.  The apocalyptic view of these is almost certainly an over-interpretation.  Nonetheless, we will probably see striking surges in patient flow in the future related to new emerging illness.  Not planning would be foolish.

There are lots of issues, and no doubt we will be hearing more about this in the months to come. For now, though, here are three of mine:

1)      Should we have done anything at all?

The cost isn’t in, but it will be high.  We purchased enough vaccine to immunize an entire nation, we spent money on pandemic planning at every level from individual businesses right up to the federal government.  We hired all those folks to staff the flu assessment centres and poured money into public service messages, communications and doctor “tool kits”.  All that for a virus that, for most, was only minimally worse than the usual seasonal flu.  Did we over-react?

The retrospectoscope, they say, has 20:20 vision.  There are two ways to look at this process.  Canada spends roughly $180 billion per year on health care;  in those terms pandemic costs will likely not be a high percentage of the overall budget.  Also from everyone’s perspective, politicians to nervous parents, it is far better to be safe than sorry.  This was a new virus, and in the spring, when decisions had to be made, the hazard associated with it was just not known.  We have a model, only a century ago, of a similar event that had substantial impact. 

Wise leaders don’t roll the dice with population health.  No, I don’t think we over reacted.

2)      Was the immunization campaign appropriate?

During the week that peak patient flow (to date) was recorded at the emergency department I work in, we had immunized only 20% of the population.  Six year olds with cystic fibrosis were still not on the list to be immunized, while healthy four year olds were lining up for hours.  Did this make sense?

There were certainly problems.  In the pandemic planning process, the assumption was that anti-vaccine hysteria would be a stronger force, that the population needed to be informed about the benefits of vaccination.  With the unfortunate deaths in Ontario of three children due to H1N1, that was just no longer true.  Parents wanted their kids protected, and right now.  Public health practitioners were left making decisions on the fly about whether it was best to try to nip the pandemic in the bud, by immunizing the pre-schoolers who are probably a big reservoir, versus focusing on those who had high risk characteristics. 

What could we have done better?  A clear strategy regarding the rationing of immunization and treatment, laid out not just for the health care workers but also for the public in the weeks leading up to the flu’s arrival would have been very helpful.  Most healthy adults were happy to step back and let others get to the front of the line first, I think.  Individuals who were at high risk for bad outcomes, not just for catching the flu, should have had their needs met, at the same time as front line providers and, say, hockey players.

3)      Were medical professionals prepared?

I think we were as ready as we could be.  The nitty gritty details over who to treat with Tamiflu, who to admit for observation, who to worry about were to some extent issues that we needed experience with the virus in order to assess.  Once it became clear that most children were not going to suddenly deteriorate, our emergency times improved and so did the confidence in our treatment decisions.

What would have helped?  We should have all been logged into one big chat room at the end of each shift, with less worry about privacy and confidentiality and more about sharing knowledge and experience.  I know that our group initiated an email discussion within a few days of the onslaught, and, I think, established a reasonably uniform approach for each practitioner.  But others, particularly those in isolated clinical settings, were not so lucky.  We had  a lot of phone calls from excellent family physicians asking just how we interpreted the various guidelines.  We live in a world of highly linked social networks; something like this for the H1N1 surge would have been very useful.

There are probably many other areas of potential improvement, these are just my thoughts.  Any comments?  What was your experience of H1N1 like?  Let us all know by clicking the comments bar below.

Friday, November 6, 2009

An excellent article ...............

One of the big problems with the internet is that ignorance and fear are given a platform that is just as large as knowledge and wisdom.  One of the big problems with celebrities is that they are tempted to speak without knowing what they are talking about.  Combine the two, and children and families can be injured.

Worth a look.


Wednesday, November 4, 2009

H1N1: Two weeks in, and what to expect now ...

It has been two tiring weeks for anyone involved in the public or acute care health systems, whether as workers, patients or family members.

Tonight on the radio, I heard an announcer discussing the possibility that the immunization program in Nova Scotia might start to slow down the rate of new cases.  I noticed that the spokesperson for public health was careful not to support this notion ... she correctly pointed out that, although the immune system starts to react almost immediately on contact by the vaccine, it generally takes two weeks for the shot to generate maximum benefit.  We have just begun the immunization campaign in Nova Scotia; according to the CBC, about 9% of the population has been immunized to date.

From a viral perspective, in other words, there is still a lot of food to eat on the table.

Australia has it's peak flu season in our summer, so they have already been through one H1N1 season.  According to their surveillance data,  the peak of the epidemic occurred 9 weeks after onset, and the incidence of new cases only fell to below the level seen at two weeks (where we are now) after 15 weeks.  That's nearly four months, for those of you with plans to hold off on that immunization.  A long, long time to hold your breath in public.

Canada will probably do better.  The H1N1 vaccine was not available in July, when Australia was facing its outbreak.  Australia has a high quality medical system; nonetheless, their intensive care units were stressed by the load of patients requiring ventilators.  While this is a very rare thing in children with this disease, and very uncommon even in adults, if 1/3 or 1/2 of your entire nation is sick with the flu, the numbers of "rare" things start to become significant.  There is every reason to believe that the vaccine will reduce the overall rate of disease, and therefore the stress on critical areas like ICU's and Emergency Departments.

All this depends, of course, on us getting enough individuals immunized in time.  The Harper government was on record last week that Canada will be amongst the first to offer full immunization to its citizens, and that the current timeline to complete that process is .... Christmas.  I don't want to criticize public health officials, who have been working flat out on this problem since the spring.  But we do have to recognize that Christmas is 9 weeks into our national pandemic ... or at about the same time the Australians experienced their peak.

Finally, H1N1 isn't the only kid on the block.  Beginning every year in late December and peaking in February, a bug called RSV comes to town.  If during those months you have a nasty, snotty nose and a bad cough, or your baby / toddler is wheezy and hot, odds are good that you have RSV.  As a westerner I have always thought of RSV as the cash crop of emergency pediatricians ... February is certainly the month you find us toiling in the fields.  It is usually the busiest month of the year, with the greatest number of hot, coughing  children.  Sound familiar?

So ... my forecast is for a pediatric heat wave, with associated hack, wheeze and a whole lot of snot right through until April.  Get out your wellies, folks...

Tuesday, November 3, 2009

Whoops ........ you ARE writing to me .....

Just finally realized that some of you were writing me back (sorry ... new to blogger ...).  So I have published all the comments and have started writing my responses.  Check below!