Agree or disagree, but our show on the gap between the real and the hypothesized threat of H1N1 swine flu sure prompted you to react. Rather than spreading your postings over several blog entries, might as well stick with our previous blog posting Second Wave of Swine Flu? We Aren't Worried as the focal point for your comments.
I did want to answer a number of points raised so far.
CB, a Canadian-born physician working in Australia writes:
"The Department of Health and Ageing (i.e. the Australian) figures do not show the number of additional presentations to ER's and GP clinics across the country (estimated to be around 20-40% increase from base levels in most urban jusridictions), nor the increased demand for pathology sevices during the period. Australia's ERs struggled but coped during the outbreak - are Canada's emergency departments prepared to withstand this impending extra load?
As for pathology, apparently the pathology services in Quebec and Ontario are unable to cope with the sheer numbers of H1N109 swabs they are getting now... what will it be like in 2-4 months time with the flu season in full swing? How can they hope to contain the spread if they can't provide timely diagnosis of the illness?
2) A small but significant number of those in ICUs across the county were fit and healthy individuals in their 20s or 30s and have required ECMO(cardiopulmonary bypass) up to 2 weeks to survive. In addition, of those on mechanical ventilation, H1N109 patients have tended to required longer time on ventilators and longer times in ICU than the typical severe pneumonia patient. At one point during the outbreak, around 1/5th of all ICU patients in Australia were H1N109 positive.
3) Australian winters are rather mild in comparison, and people don't tend to hunker down as in the northern hemisphere. Simply, while the virus may turn out to be not be all that lethal in the final analysis, it is nonetheless dangerous and presents a massive challenge in terms of resources to any health system."
CB, the valid points you raise can also be used to support the arguments raised on WCBA. What's driving the big increase in clinic and ER visits, as well as testing? If it's a real need, then the expense is worth it. But if it's people being driven to the ER after implied warnings from public health officials that it's better to be safe than sorry, well, then, maybe not. Justified or not, we can certainly agree on one thing: H1N1 sure is putting a strain on health care resources.
Ken posted this entry that we feel is worth highlighting too:
"The show on H1N1 down playing the risks of this flu may be accurate in describing the number of infections but does not adequately speak to the potential seriousness for some of those who do get infected. I'm a healthy 46 year old husband and father of two and like my doctor didn't really worry much about this flu. So when I got sock in late June I figured it would just pass. A few days In It was worse so I went to my doctor who gave me antibiotics and sent me home. I end up going for a different script the next day when the first set didn’t agree with me. The doctor did chest x-ray and noted I had some pneumonia starting. Two more days at home were uneventful but by the third night my cough had gotten much worse and by morning I was having trouble breathing and having chest pains. My wife drove to the local rural hospital emergency and they repeated the x-ray and found both lungs now full of pneumonia and my O2 stats dangerously low. I remained in the induced coma for 2 weeks on respirator and at one point had 13 iv’s running. In the first few days I suffered a heart attack and major organ failure and kidney shutdown requiring dialysis 3 times. For the first few days they could not tell my wife if I would live. Once stable it took another week before I started to improve, two weeks before they were able to bring me out of the coma.
In all I spent 5 week in hospital and another month recovering at home. I had caught H1N1 and developed a secondary pneumonia in both lungs. I also went from being very healthy to nearly dying in just over 7 days!!
While it may only be some people who get this sick it is critical that patients and doctors very carefully and closely monitor anyone who does get sick with this flue because it can go from a benign infection to life threatening illness very quickly, as it did in my case. I nearly died and would have left behind two teenage children and a wife. Most of the story I only learned later after they woke me in ICU in the third week.
So the message should be don’t panic but if you have the flu be very careful and you need to be proactive with your doctor if things get worse. You should also let people know what are the signs and symptoms indicating that your condition may be getting serious or life threatening. I didn’t know, and it nearly cost me my life."
Thanks for writing in, Ken, We're very glad you're feeling better. Couldn't have said it better myself. To an individual who gets a life-threatening case of swine flu, it's an unmitigated disaster. But to a population at risk, it may be a different story. Some of us are very susceptible to the effects of this virus; most others are not. The challenge is to try and figure out who is at risk and to pour Canada's best efforts in trying to protect them.
By that logic, while we may be wasting vast sums of money trying to blanket all of Canada with swine flu protection. That said, I think we should pour resources into at risk remote First Nations communities.
Finally, Tania wrote in to ask when she can download the podcast of "Swinefeld". The answer is, you can download load podcasts of each new show beginning the midnight prior to the show's original airdate. "Swinefeld" is listed under Podcasts with an airdate of September 19, 2009.
Dr. Brian Goldman takes listeners through the swinging doors of hospitals and doctors' offices, behind the curtain where the gurney lies. 
Comments
No where in the public debate on H1N1 have I heard a mention of the role that vitamin D could play.
Information from the Vitamin D Council suggests that people taking vitamin D could have higher levels of immunity than those who don't.
Suggest a good lood at evidence being aduced by the Vitamin D Council.
Thank you
Peter Junger, Vancouver, BC
Posted by: Peter Junger | September 21, 2009 02:42 PM
Thanks for your comments and entirely agree with your questions. Before I attempt to respond, if the Australian experience is going to be used as a sort of guide for the Canadian response, then it helps to understand the phases of the Australian efforts to combat swine flu.
A few things to consider:
1) Once Australia shifted from the "contain" to "protect" posture in late May/ early June 09, all Australian medical services ceased testing patients who did not possess risk factors for severe H1N109 illness (Diabetes, cardiopulmonary diseases, alcoholism, member of a high risk group within the population, etc, etc). Pathology services were stretched even with this narrowed focus. The DOHA figures do not include the ??100 000+ Australians who are believed to have suffered a mild form of the disease and were never tested or treated.
2) In H1N109, the key difference between now and earlier this year - and a major driver of the Australia response - was that the high risk populations were entirely unvaccinated against the virus initially. Around 1000-1500 Australians die annually from 'regular' influenza - a virus (or more correctly, a collection of virus strains) for which the at-risk populations are specifically protected against with annual vaccination campaigns. Without this annual effort, the number of victims are theorized to be 10 000+ annually. Thus, an early goal of the whole effort was preventing the virus from wreaking havoc in nursing homes, aboriginal reservations, cancer wards, etc, etc.
Now that a vaccine is available, it would seem that the logical, most economical thing to do in Canada is to mass vaccinate all high-risk individuals as soon as possible, which would perhaps allow for less intrusive and/or less extreme public health announcements to the general population. In doing so, it would likely have the knock on benefit of limiting undue anxiety among the 'worried well' who innundated Australian EDs during the winter months. Australia did not have this option as there was no vaccine available, hence the need for a rather strong (and rather effective) public health campaign. The unfortunate and unavoidable side effect of this effort was increased public anxiety which almost certainly contributed to increased presentations to GPs and EDs over the time period.
As for those with no known risk factors who become severely ill, from the Australian experience, it wasn't the actual H1N109 virus, but instead bacterial superinfections which followed the development of H1N109 which led to the majority of otherwise healthy individuals being admitted to ICU on a ventillator/ECMO. This is also believed by some to be the reason why the spanish flu of 1919 killed so many. These numbers are believed to be extremely low for the current virus (rough estimate of 1 in 10 000 to 1 in 100 000 of otherwise healthy H1N109 victims).
Anyway, to answer the question posed by WCBA. First, I would argue that there is an innate tendency of a population to worry with any new disease, and with this in mind, there will inevitably be an increase in presentations regardless of any public health measure or lack thereof. That said, the question then becomes is the public health mob justified in raising the alarm (and hence anxiety levels) with the 'implied warnings,' which has the effect of amplifying the public's anxiety levels and therefore contribute to even more (sometimes utterly absurb) presentations of the worried - well than would otherwise be expected. To this question I answer: ABSOLUTELY if the vulnerable population remains at risk, and ABSOLUTELY NOT if the authorities can get their act together and mass vaccinate all aboriginal reservations, homeless shelters, nursing homes, elderly and others who, for whatever reason are otherwise clinically immunodeficient, within the near future.
Thanks for the show and good luck up there!
Posted by: CB | September 27, 2009 03:45 AM
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