In My Opinion
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Influenza came late this year, but quickly made up for lost time. With a name that sounded more like a Michael Crichton novel than an upper respiratory infection, ‘The Swine Flu’ instantly caused a media frenzy. Despite the strain’s uncommon safety profile (mortality and critical illness rates far below that of even a typical seasonal outbreak) the press stoked fears of a cataclysmic plague. The virus had hatched on a farm in Mexico, spread into Mexico City, and then stowed away to more than 60 nation around the globe. For reasons that remain unclear the swine flu then settled in the United States, where more confirmed infections have occurred than anywhere else in the world, including Mexico.

Ultimately, the American swine flu’s human toll, though frightening and tragic, was shockingly small, including ten deaths as of early June. Common seasonal flu typically takes more than ten thousand lives each year in the U.S., and affects hundreds of thousands more people. Because of this fortunate low acuity, rather than a test of the country’s ability to manage a virulent infectious outbreak the episode soon became a test of managing information. Since 9-11 the U.S. has spent more time, effort, and money on ‘preparedness’ than any nation in history, and dissemination of information is the linchpin of any preparedness infrastructure. So how did we do?

Though day-to-day medical handling of the swine flu outbreak included clinics and primary care providers, ultimately the burden fell to the nation’s safety net, emergency medical providers. It is emergency providers who may therefore be best able to judge the nation’s performance during the crisis. For emergency physicians the need for accurate, current information was profound and immediate. In my ED daily updates arrived via email, with algorithms for care and detailed patient recommendations, all of which originated at city and state levels of government. In addition, less formal, internet-based clearinghouses blossomed (EPM among them) where reliable medical information and reproductions of state-produced information on the breadth, impact, and recommended strategies for influenza and influenza-like illnesses were consistently available.

As for public information, headlines and updates were ubiquitous. Laypersons were inundated with competing news sources, most touting the outbreak’s few lethal cases. In spite of the disparity in both the source and content of the messages they received, health care providers and the lay public were both exposed to hefty flows of information. This was the success story of Swine Flu 2009: information was diligently produced, and constantly available. But was the information accurate?

Despite the fact that the spring 2009 swine flu was among the safest outbreaks ever tracked, and despite a primary medical recommendation for those with symptoms to stay home, Americans flooded their local ED’s. Lay people believed, from media reports, that swine flu was extremely dangerous, and presumed that emergency care was mandatory for anyone experiencing an influenza-like illness. Our preparedness infrastructure therefore conspicuously failed the test of public information. Rather than collaborating with media to refine the message, or openly challenging contrived and provocative media reports, state-level offices and personnel allowed false public information to go unchecked and uncorrected. Emergency departments and the patients in them paid the price.

As for the information directed to physicians, in New York City, where the outbreak peaked, the Department of Health crafted algorithms to guide the recommended care and prevention of influenza and influenza-like illness. In consultation with the state more than 20 updates to the algorithms were released during the eight-week outbreak. The most puzzling, and most consistent, point of information in these algorithms was a recommendation to treat virtually everyone with antiviral medicines. The departments of health recommended that patients with even mild URI symptoms and virtually any history of any medical problem, or common contact with anyone who has a medical problem, be prescribed anti-influenza drugs.

On what evidence did the NYC DOH recommend prescription-only antiviral medications for all? Cochrane and other large-scale reviews show that oseltamivir and zanamivir reduce influenza symptoms by roughly one half day to a day compared to placebo, though only when given <48 hours after the illness begins. Unfortunately, the medicines frequently seem to add nausea, vomiting, or diarrhea, and cost roughly $100 per prescription. They also only work for those with test-confirmed influenza. The simple use of NSAIDs, it would seem, could rival these agents for symptom control, and without the side effects or cost.

With such a tepid, selective, symptom-only impact, and at such considerable expense, why use them? I asked my local infectious disease specialists this question. Treatment, they said, may reduce complications such as death, pneumonia, or hospitalization.

I looked further. Interestingly, despite the fact that 10,000-20,000 people typically die each year in the U.S. from influenza, antivirals have never been shown to decrease either mortality or critical illness. As for other complications, one meta-analysis of ten trials suggested small reductions in pneumonia and a 1% reduction in hospitalization. But the meta-analysis was retrospective, it used only cherry-picked secondary outcomes, and the studies were hand-selected from a Roche database. And yet this remains the only combined data ever to report any significant benefit on complications. Two much larger reviews have since concluded that the drugs have no appreciable effect on the use of relief medications or subsequent need for antibiotics.

With prescription drugs recommended for anyone experiencing even a mild URI (and their family members), and with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

With no evidence of benefit, clear data of the dangers of crowding, and at significant cost, the city DOH implemented algorithms that encouraged the masses to flood ED’s for testing and treatment—all to reduce ‘complications’ (with zero supporting evidence) for an influenza strain that appears to be the least likely in history to cause complications. What gives? I asked this question to an infectious disease expert in my hospital, a man with great influence and knowledge, even in the rarefied air of state- and institution-level guidelines. The answer, he felt, was simple: we have to do something.

The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process, and there is no reason that therapeutic guidelines should fly in the face of published evidence. The crush and crisis of the spring swine flu of 2009 was felt most powerfully in EDs. Emergency physicians and healthcare workers once again became the system’s whipping boys, and it is important that we make ourselves known. Future preparedness plans should focus on rebuilding trust, respecting evidence, and avoiding fear-based tactics that result in medical panic, as well as the use of inappropriate drugs that line the pockets of the few with deadly consequences for the many.

David Newman, MD, is the author of Hippocrates’ Shadow: Secrets from the House of Medicine
 

Comments   

# Swine Flu Frenzy or Foresight?Chris Carpenter 2009-08-03 13:03
Interesting commentary on the spring 2009 swine flu response in the northern hemisphere. This weekend the NY Times ran a series of op-eds on the emerging H1N1 swine flu pandemic in the southern hemisphere (http://www.nytimes.com/2009/08/02/opinion/02toner.html?_r=1&ref=todayspaper) including a commentary by EP Eric Toner.

I completely agree with Dr. Newman that the media's primary motivator is revenue-generat ing headlines rather than fact-based substance. One solution to this problem, which is not unique to the 21st Century, is to involve more physicians in reporting health-related news. Increasingly, EPs are involved in the news business so hopefully the accuracy and evidence-basis for future medical reports will improve.

As far as the spring 2009 swine flu reporting, I would not pass judgment on over-responsive ness until the 2010 flu season has passed, if not the 2011 flu season since the 1918 flu disaster really began ~1915 and did not officially end until 1920.

Keep up the thoughtful commentary, David!
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