Friday, May 1, 2009

Learning From History: 1918 Flu Pandemic, Hong Kong SARS, Swine Flu & Influenza A(H1N1)

As politics move into public health we have to perhaps look for solutions from history in order to pick out relevant bits that may yet save some lives.

WHO: Swine Flu is now officially Influenza A (H1N1) WHO H1N1 UPDATES

1918 Pandemic:
Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness
The Journal of Infectious Diseases DOI: 10.1086/591708 (2008).
David M. Morens, Jeffery K. Taubenberger, and Anthony S. Fauci
National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Oct 1,2008
Background. Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics.
Conclusions. The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs). Prevention, diagnosis, prophylaxis, and treatment of secondary bacterial pneumonia, as well as stockpiling of antibiotics and bacterial vaccines, should also be high priorities for pandemic planning.

Bacteria that normally inhabit us do not bother us until we are weakened. Other mechanisms such as quorum sensing, might indeed be involved. Use of antibiotics is generally not recommended in colds but for Influenza the approach might have to be different given the conclusion of this paper. It may be timely for family doctors to have another look at this article.

Given MRSA and the like are rife in hospitals it is generally not a good idea to stay in any hospital unless there is a need to isolate someone with a virulent mutant virus as was the case with the SARS outbreak.

Tamiflu is the modern answer but it has to be used early and is not without problems. See
FDA site for details.

Hong Kong SARS: It is well known that nearly the whole population of Hong Kong were wearing masks during the SARS outbreak of 2003.

Many doubted the virtue of the mask. Some had gone on record to say that covering your mouth and nose when you sneeze and washing your hands frequently is more effective.

From the
CDC website:
“Human influenza is transmitted from person to person primarily via virus-laden large droplets (particles >5 µm in diameter) that are generated when infected persons cough or sneeze; these large droplets can then be directly deposited onto the mucosal surfaces of the upper respiratory tract of susceptible persons who are near (i.e., within 3 feet) the droplet source. Transmission also may occur through direct and indirect contact with infectious respiratory secretions.”

All very well. As transmission is most likely due to good size droplets and not truly airborne, tight fitting mask is not really essential. A mask will allow a likely sufferer to sneeze into the mask and not his hands though. Your hands may be needed to hold on to rails and handles. Where can you wash your hands anyway on a bus or in the subway?

Mask wearing in Hong Kong AFP

In any case, wearing of masks raises public awareness and is a much lower risk preventative measure then mass intake of Tamiflu or vaccination.

Most homes in Hong Kong have a stockpile of proper masks (not supplied by government) and many hospitals and clinics require the wearing of masks by visitors and patients since SARS. Ib March 2008 the masks were again out in force in a
flu scare. Hong Kong is a crowded place and we have to rely on public transport and risk exposure to others. It never became an epidemic. The masks could have saved the day. We might never know. But it may not be such good news for vaccine manufacturers.

A policeman guards a Hong Kong hotel where 300 people are under quarantine.

SARS, Freedom & Knowledge

Learning from History: Swine Flu & Antibiotics

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