Influenza Sudden Death Syndrome

[link to www.ctv.ca]

Critics say 'mild' a misleading term for H1N1

Updated Sun. Jun. 28 2009 12:37 PM ET

The Canadian Press

TORONTO -- Officialdom's mantra about H1N1 -- "it is overwhelmingly mild" -- might seem incongruous if we knew the number of children, teens and young adults in ICU beds right now alive only because a breathing machine has taken over for their ravaged lungs.

The heavy reliance on the word "mild " could be creating a false impression of what is actually going on and what the world may face in coming months, some experts worry.

Peter Sandman, a risk communications guru from Princeton, N.J., suggests if authorities are trying to ensure people don't panic about the new H1N1 outbreak, they are concerned about the wrong thing.

"In North America, swine flu panic is much rarer than swine flu deaths," Sandman says.

"The problem isn't panic or even excessive anxiety. The problem is complacency, both about what's going to happen and about what might happen."

When the new H1N1 virus burst onto the world's radar, it was, for awhile, the hottest story of the 24-7 news cycle. The long threatened pandemic, it seemed, was finally underway.

But instead of the 60-plus per cent death rate of H5N1 avian flu -- seen for years as the pandemic frontrunner -- the wire was tripped by a seemingly wimpy virus that is causing a lot of flu, but is no viral monster.

In many places, public health officials have bent over backwards to tamp down anticipated panic. The results? Within a few weeks, most people appeared to be convinced the pandemic was (past tense) a non-event, a blip of flu activity over-hyped by the sensationalist media hoard.

"When we're told that swine flu is mild, we don't think, `It will infect a half to a third of the world population and kill a few million people, mostly young people, before it's over,"' says Sandman. "We think, `It's like having a bad cold."'

Well, H1N1 isn't over. And it's not like a bad cold sweeping the globe.

But officials and experts are having a hard time striking the balance in messages to the public, unclear what they are dealing with now and what it might become.

"I think the problem is we don't know how to paint this picture properly," says Dr. Allison McGeer, a flu expert at Toronto's Mount Sinai Hospital.

"Because it's perfectly true that most cases are mild. But it doesn't mean that you shouldn't worry about it."

Regular flu, as anyone who has had it know, is no walk in the park.

And with this new flu, a small subset of people gets very, very sick. Their lungs are overwhelmed by an aggressive viral pneumonia one doctor described as looking like a "white out" on an X-ray. A number of hospitals are struggling to keep these people alive.

Generally much younger than the typical hospitalized flu patient, many of these people have been on ventilators for weeks. And every day, officials in some part of the globe announce that a 15-year-old boy, a 24-year-old woman or an otherwise healthy pregnant woman in her third trimester has lost the battle.

"When you look at those things then you begin to say `Well, is it really accurate, is it really fair to say that this is a mild phenomenon?"' says Dr. Keiji Fukuda, the World Health Organization's top flu expert.

Fukuda and his team have been warning for some time that the unusual age pattern of severe cases, the odd out-of-season spread and the fact that the virus is killing some previously healthy young adults makes the term moderate a more appropriate severity assessment.

That pattern, seen in previous pandemics, makes flu watchers sit up and take notice. "What it really leads you to conclude is that boy, we'd better watch this pretty carefully," Fukuda says.

There still isn't a good estimate of the percentage of total swine flu cases that becomes gravely ill, or the percentage that succumbs to the virus's onslaught. Currently the numbers may seem small; 23 deaths in Canada, 127 in the U.S., 263 worldwide. (Swine flu has already beat bird flu in terms of death tolls.)

But as a human pathogen this virus is still a baby, despite its rapid global spread. No one knows what it is going to be when it grows up.

Some things are clear though. Since most people seem to have no immunity to the virus -- some people over 60 may have some -- huge numbers will probably catch this flu over the next couple of years. In a relatively tight time frame, lots of people will come down with the flu -- far more than would be seen during a regular flu year.

To understand that impact, think back to elementary school arithmetic and fractions. If the denominator (the total number of cases) gets substantially bigger, the number of people falling gravely ill will rise sharply, even if the proportion of severe cases (the numerator) doesn't change.

And sheer numbers could make the outbreak get nasty, fast.

Several centres in North America are already struggling under the load of critically ill patients -- and this is summer, the season when flu viruses don't transmit as efficiently as they do during the cold winter months.

"If this is as bad as it's going to get, this is still not going to be a cakewalk," says Dr. Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota.

"We still have relatively few people in the population getting sick. We don't know -- 10 per cent? Five per cent? We don't know yet."

"But if in fact we're stretching medical resources, particularly in the pediatric community now in many communities, people will start to die with higher frequency with the same disease spectrum if care is compromised and we can't get every kid on a pediatric vent(ilator)," Osterholm warns.

"Even if the disease severity doesn't change but this fall we see more people get sick at the same time, we're in trouble. Now, add in the potential for this virus to obviously change and cause more severe illness -- I mean none of this is good. I don't know how we can sit here and say `Oh, this is mild."'

Some people worry the constant refrain that swine flu is mild may be keeping people who are becoming severely ill from seeking care as soon as they should. They also worry young people -- the demographic least likely to get a shot for seasonal flu -- may decide they don't need to bother when H1N1 vaccine is ready.

McGeer thinks by that time the virus will have issued its own assessment.

"Unfortunately I think the number of deaths in the end is going to be high enough that people will get the message and generally will get their vaccine."

bumpity bump ...

H1N1: Heart needs to be checked too

Scientists analysing the earliest deaths due to swine flu in Mexico, believed to be the country of origin of the H1N1 virus, had made a vital finding this week , almost 62% of the fatal cases had an increased level of Creatine Kinase (CK).

Present in skeletal and heart muscles, this enzyme if secreted in higher quantities is an indication of heart or muscle damage. In cases of H1N1 infection, scientists found that patients who died of Myocarditis or inflammation of the heart muscle had increased CK levels.

The finding is crucial for India which has also reported deaths due to Myocarditis following H1N1 infection. Samrat Pandya, the 31-year-old resident of Gurgaon, who died on Thursday following two cardiac arrests, was diagnosed with myocarditis after an ECG was conducted. A central team that returned from Pune also reported deaths there due to Myocarditis.

Experts now are saying that doctors in charge of screening patients with H1N1 symptoms, besides looking at lungs for pneumonia or other respiratory diseases caused by H1N1, should also look for the condition of the heart. Professor of medicine at AIIMS Dr Randeep Guleria said an eco cardiograph must be done to rule out heart complications of a suspected H1N1 patient.

"If muscles and the heart gets damaged, they start secreting CK. Rise in CK means there is muscle or heart damage. In some people virus stays in the throat while in serious cases, it goes into the lungs causing pneumonia and enters the blood circulation to go to various organs, later causing multi organ failure. Therefore it is vital that doctors don't just look at the lungs but also the heart. If found affected, the treatment has to be then modified accordingly,"

[link to timesofindia.indiatimes.com]