Cover Story - July 2009
Tex Med. 2009;105(7):16-21.
By Crystal Conde
In late spring, images of scared Mexico City residents wearing masks brought home the reality that an outbreak of H1N1 swine flu was taking a deadly toll south of the U.S. border. The virus rapidly spread north to Texas, where public health officials quickly began working to prevent the disease from devastating Texas and the rest of the country.
Six people have died from the disease in Texas, schools were closed, and Gov. Rick Perry asked the Centers for Disease Control and Prevention (CDC) for 850,000 courses of antiviral medications from the Strategic National Stockpile to prevent swine flu from spreading in the state.
The swine flu outbreak is a reminder of how quickly an infectious disease can spread and threaten the health of people across the world.
To make sure physicians were up to date on the latest news and recommended treatments for swine flu, the Texas Medical Association promptly prepared a special educational session on the disease for TexMed 2009 in May. Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, addressed a packed room of physicians and reporters. He stressed that his department was in constant contact with local public health officials and the CDC to stay abreast of the impact of the H1N1 strain of the virus.
Edward J. Sherwood, MD, Central Texas Veterans Health Care System chief of staff and chair of TMA's Committee on Infectious Diseases, also was on hand to provide information about the disease. He says medicine's response to swine flu and the public's thirst for knowledge about the virus are impressive.
"It's a wonderful thing that people pay attention. A new infectious disease threat could be serious, so it's good that people become alarmed enough to pay attention and want to learn more," said Dr. Sherwood, the Williamson County health authority. "In 2009, as evidenced by the swine flu episode, our ability as a nation to recognize emerging infectious disease threats early, to evaluate them, and to determine the magnitude of the threat is truly remarkable."
The emergence of the potentially deadly novel virus not only grabbed the public's attention, but it also gave physicians an opportunity to educate patients about the severity of swine flu and the impact seasonal influenza has on the United States each year.
Because public health officials predict swine flu could become worse in the fall, just in time for seasonal flu, physicians need to prepare to deal with both viruses. Experts recommend physicians ramp up vaccination efforts in their offices (including having themselves and staff vaccinated), work closely with local public health departments to monitor the diseases, stay up to date on their severity, and assess their patients' risk for the diseases.
Information about pandemic influenza is available in the October 2007 issue of Texas Medicine . The articles inform physicians about pre-hospital pandemic influenza triage, the role of nonpharmaceutical interventions during a pandemic, pandemic planning for physicians' offices, DSHS pandemic preparedness plans, and other valuable topics.
Swine Flu, the Sequel
History teaches us that new strains of flu come in waves. The flu pandemics of 1889, 1918, 1957, and 1968 began with relatively mild illnesses in the spring, followed by more severe eruptions a few months later.
Dr. Lakey says physicians should prepare for H1N1 flu to behave similarly and to potentially intensify in the fall.
"The CDC is predicting that what we'll see next with the virus is a circulation in the Southern Hemisphere, as that part of the world enters the winter flu season. We'll be watching the spread and severity of the disease to help us prepare for the potential that this strain will come back during the Northern Hemisphere's seasonal flu," he said.
James W. LeDuc, PhD, deputy director of the Galveston National Laboratory at The University of Texas Medical Branch (UTMB), says that because swine flu is a novel disease, everyone, especially those with underlying health conditions, is susceptible to it.
"I think we're most concerned now about this new strain of flu because it has the potential to be a true pandemic. That occurs when there's no preexisting antibody or protection in the population," he said.
The CDC is working to develop an H1N1 vaccine, which could be available by October.
Dr. LeDuc, who was the director of CDC's Division of Viral and Rickettsial Diseases before joining UTMB, says the vaccine industry faces a challenge in attempting to create a novel vaccine at the same time it is producing seasonal flu vaccines. He says it's possible that even if a swine flu vaccine is available in the fall, the supply would be limited early on.
Pedro Piedra, MD, professor of molecular virology, microbiology, and pediatrics at Baylor College of Medicine in Houston, says the CDC will issue prioritization guidelines if that happens. Vaccine usually goes to high-risk individuals first - the elderly, children younger than 5, pregnant women, and patients with chronic metabolic or neuromuscular diseases.
Dr. Lakey says DSHS will work with TMA and other health care organizations and public health entities to distribute the vaccine.
In the meantime, Dr. Lakey says DSHS is working closely with the CDC to give Texas physicians information that would enable them to implement immunization policies and procedures to protect patients and themselves.
"Physicians should keep H1N1 flu on their radar and watch over the summer and early fall as we get more information about what this virus is going to do and its potential severity," he said.
Prepare and Respond
The swine flu outbreak means physicians need to be more focused and prepared than ever to respond to a public health emergency.
Dr. Sherwood advises physicians to use this opportunity to establish or fine-tune a routine that includes effective infection control practices and efficient methods for recognizing those individuals who need immunizations.
"By having an effective routine in place all the time, when the unusual occurs, we're not putting something new in place; we're just doing what we do all the time, making us better prepared to respond to emerging health threats," he said.
He says effective infection management measures include using masks, hand hygiene, and cough control to reduce transmission of all respiratory diseases.
Having an office response plan for any kind of pandemic situation, especially for influenza, is a good idea, says Andrew Eisenberg, MD, MHA, a family physician and member of TMA's Council on Public Health and the Be Wise - Immunize ™ Physician Advisory Panel.
He also advises physicians to develop a good relationship with their local public health departments and local hospitals.
"Doctors will need to know the disease patterns in the community, not just in their offices," he said.
Physicians also have a role in advising and educating their patients, Dr. Lakey says.
"Many people are scared during times of an emerging infectious disease threat, and they look to their physicians for guidance and perspective. Frontline physicians are leaders locally, and communities look to those physicians for advice on how to respond," Dr. Lakey said.
During infectious disease outbreaks, physicians also play a surveillance role by reporting increases in flu-like illnesses to their local and regional health departments and by sending suspected swine flu specimens to designated laboratories for testing.
Dr. LeDuc calls this year's swine flu epidemic an experiment of nature and says the public health community has learned a lot from it.
"The planning that has been done in advance of this outbreak positions us well to be prepared for it," he said. "The same thing goes for investments in lab infrastructure to monitor what viruses are in circulation so they can be rapidly identified."
The Galveston National Laboratory worked with the CDC to diagnose isolates from Texas and Mexico and to develop reagents the CDC and the World Health Organization could use to validate rapid diagnostic tests.
On the local level, John Carlo, MD, MSE, Dallas County Health and Human Services (DCHHS) medical director and a member of TMA's Council on Public Health, says responding to the spring swine flu wave was a learning opportunity for the department. Suddenly, DCHHS began receiving about 400 specimens a day, when it typically gets only 40. He said the lab received more than 1,100 specimens from outpatient offices.
"Our local lab was the reference lab for diagnostic capability," he said. "That's challenging because we don't do that on a day-to-day basis at that level."
Dr. Carlo says dealing with the surge in lab specimens made it apparent the department needs a more formalized process for recording and reporting test results.
"We weren't as ready as we could have been for managing a large database all of a sudden," he said.
Dallas County also witnessed a large increase in outpatient and emergency department visits during the week of April 20. Area emergency departments recorded a 200-percent increase in visits for flu-like illness.
Flu Shots Needed
Regardless of what happens with swine flu, physicians shouldn't forget about vaccinating themselves and their patients against seasonal flu this fall. In fact, Dr. Piedra says physicians need to be better about reminding those in their care of the seriousness of seasonal influenza.
According to the CDC, an average of 36,000 people die from flu-related causes, and another 200,000 are hospitalized each year in the United States.
Dr. Sherwood compares flu-related mortality to an airplane with 100 passengers crashing every day and killing everyone on board.
"Most people would stop flying if that really happened. But it happens every year with flu, and people still go to work sick, don't get vaccinated, and don't practice hand hygiene consistently," he said.
To help track cases of influenza-like illnesses in Texas, physicians can participate in the CDC's U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet). According to Dr. Lakey, DSHS needs more physicians to assist with weekly monitoring of seasonal flu. (See " Program Tracks Flu Statewide .")
Physicians hope seasonal flu's disturbing annual death count, combined with a possible swine flu recurrence, will bring more focus to vaccination and other effective measures to prevent illness.
"I wish it would remind people that seasonal flu is a major pathogen and continues to be the leading cause of morbidity and mortality in the United States, and it's vaccine preventable," Dr. Piedra said.
Dr. Sherwood adds that health care professionals need to be more conscientious when it comes to preventing the disease.
"Physicians have an ethical duty to take those reasonable steps we can to protect our patients from threats such as flu," Dr. Sherwood said. "Most hospital workers are healthy enough that they're unlikely to die from flu, but we can't say that about the patients we care for, especially those in the ICU."
Dr. Piedra says that physicians can be vaccine advocates by being immunized themselves and that patients are more likely to get a flu shot when their doctors recommend they do so. Vaccination recommendations for health care personnel and information on infection control in health care settings are available on the CDC Web site .
TMA has resources physicians can consult for seasonal influenza vaccination guidance. The association's Be Wise - Immunize initiative is responsible for administering more than 127,000 shots to Texas children since 2004. The Be Wise - Immunize Physician Toolkit for Children and the Physician Toolkit for Adolescents are available online . You also can request toolkits from Tammy Wishard, TMA's outreach coordinator, by calling (800) 880-1300, ext. 1470, or (512) 370-1470, or by e-mailing Tammy Wishard .
Both toolkits are comprehensive reference guides on childhood vaccinations for physicians and their staff members. Plus, they offer new educational materials for physicians' offices and patients.
TMA backed some key immunization-related bills in the recent legislative session that marked a victory for vaccines. (See " Vaccine Laws Benefit Texans .")
To stay on top of the potential severity of a swine flu reemergence and to be prepared for influenza season, Dr. Sherwood recommends physicians pay attention to reliable sources of information.
The CDC has a seasonal influenza Web site for health professionals and a site dedicated to novel H1N1 influenza resources for clinicians .
TMA also has set up an online Swine Flu Resource Center with the latest news, relevant articles, information for physicians, lab testing protocol, reports from the governor, and resources.
DSHS has a Web site health professionals can visit, as well, for Texas-specific flu information .
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Program Tracks Flu Statewide
The Texas Department of State Health Services (DSHS) implements the Centers for Disease Control and Prevention's (CDC's) U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet). Participants provide data on influenza-like illnesses each week to help the CDC monitor the impact of influenza.
During the 2007-08 influenza season, 130 Texas health care professionals participated by reporting influenza-like illness data to the CDC each week. The CDC compares the percentage of patient visits for influenza-like illness reported to sentinel providers with the national baseline of 2.2 percent. This allows the center to survey influenza activity around the nation.
Participation in the program involves reporting the total number of patient visits for influenza-like illness by age group (0-4, 5-24, 25-64, 65 and older), along with the total number of patient visits for any reason. Physicians submit the data once a week to the CDC via the Internet or fax.
DSHS says a majority of participants report that the entire process takes less than 20 minutes each week. In addition, sentinel providers can submit specimens from a subset of patients for virus isolation, free of charge. And they receive feedback on the data submitted, summaries of regional and national influenza data, and free subscriptions to CDC's Morbidity and Mortality Weekly Report and Emerging Infectious Diseases journal.
Physicians interested in enrolling in the program can request a form from Irene Brown, sentinel influenza coordinator in the DSHS Infectious Disease Control Unit, by calling (512) 458-7111, ext. 6878, or e-mailing firstname.lastname@example.org .
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Vaccine Laws Benefit Texans
In May, Gov. Rick Perry signed into law Senate Bill 346 by Sen. Jane Nelson (R-Lewisville). It provides for an adult immunization registry and directs the Health and Human Services Commission to develop guidelines for informing the public that once individuals turn 18, they or their parents may consent in writing to have their immunization information remain in ImmTrac , the state immunization registry. TMA and the Texas Public Health Coalition supported the bill.
Children who turn 18 will have one year to consent to allowing the Texas Department of State Health Services (DSHS) to maintain their immunization histories in the registry. DSHS will no longer maintain the data if consent is not given after that year has expired.
DSHS and the Texas Education Agency will collaborate to inform local school districts of the immunization registry consent requirements. SB 346 also allows health care payment plans and physicians to submit to ImmTrac immunization data for adults.
Governor Perry also signed Senator Nelson's SB 347 into law. It authorizes DSHS to share data in the ImmTrac registry across state lines during a disaster or emergency declared by the president or a governor of a state.
Immunization information could be released to a health authority in another state if Texas residents have to be evacuated due to a disaster. Likewise, DSHS may receive immunization information from the health authority of another state if its residents relocate to Texas because of a disaster.
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This review of available literature by two Dallas public health officials shows that authorities should not expect school closings alone to contain an influenza epidemic in a community. By John T. Carlo, MD, MSE, and Wendy Chung, MD, MSPH
July 2009 Texas Medicine Contents
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