Without high-tech care, H1N1 death toll could soar, studies suggest (Link)

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Without high-tech care, H1N1 death toll could soar, studies suggest

By Helen Branswell Medical Reporter (CP) –

TORONTO — Developing countries with limited access to advanced health-care

facilities may be in for a rough ride with swine flu and even countries with

high-tech ICUs may find themselves pushed to the limit as their hospitals

struggle to save gravely ill H1N1 patients, new studies suggest.

The studies, which compare outcomes among H1N1 patients admitted to intensive

care units in Canada and Mexico, showed the death rate in the latter was more

than double that seen among Canadian patients. Just over 40 per cent of

critically ill Mexican patients succumbed to their illness by day 60, compared

to 17.3 per cent of Canadian patients by day 90.

" I think this H1N1 (virus), it's not going to be the one that people would say

'Oh, my God, that killed off X per cent of our population', " said Dr. Rob

Fowler, a critical care specialist and senior author of both studies.

" But we're going to see large numbers of patients that have illness, a subset

that are critically ill and in different parts of the world it's actually going

to translate into lots of people dying that wouldn't have otherwise died -

especially so if you can't support them (medically). "

The studies were published online Monday by the Journal of the American Medical

Association. Their publication was timed to coincide with Fowler's presentation

of the data at a conference staged by the European Society of Critical Care

Medicine.

Dr. Osterholm, an infectious diseases expert at the University of

Minnesota, said the findings should serve as an eye-opener for the large segment

of the public that has dismissed swine flu as a mild form of influenza.

For many it is, but " for a very small number of patients, this illness is hell, "

said Osterholm, director of the Center for Infectious Diseases Research and

Policy.

An editorial that accompanied the package said saving that group of patients

depends on the ability of medical teams to employ sophisticated mechanical

ventilatory support. There may not be enough of these beds available or the

trained staff needed to deliver this kind of care, the authors warned.

" Clinicians and hospitals should take note that the rescue therapies used in

these studies have the potential to cause harm if not implemented in a

co-ordinated manner, " noted Dr. White and Dr. Angus, critical care

physicians at the University of Pittsburgh.

They suggested hospitals need to make plans for how they will handle an influx

of severely ill cases, noting that while the number of such cases during the

spring wave was modest, the burden they place on hospitals in both Canada and

Mexico was " sobering. "

" Any deaths from 2009 influenza A (H1N1) will be regrettable, but those that

result from insufficient planning and inadequate preparation will be especially

tragic, " Angus and White said.

As they and many others have noted, this pandemic is not triggering the volume

of severe disease experts feared the world might see with the first pandemic of

the century.

While it's not currently possible to estimate what percentage of people who

catch the virus need to be hospitalized, it is clear that for most people, H1N1

is indistinguishable from regular influenza.

But a small proportion of patients became profoundly ill and did so quickly.

Fowler said those who went into this sharp decline generally ended up in the ICU

within about 24 hours of entering hospital.

There medical teams battled to save their lives, hooking these patients up to

ventilators that breathed for them or even the types of bypass machines - called

extracorporeal membrane oxygenation, or ECMO - used in cardiac surgery.

These patients are far younger than those hospitals generally see dying from flu

or the complications of flu, said Dr. Anand Kumar, an intensivist who treated

many of these patients in Winnipeg hospitals this spring and the lead author on

the Canadian study.

He said any loss of life in an ICU is difficult, but it is especially hard when

the cases are like those this virus often kills - younger adults and middle-aged

people who were relatively healthy before they contracted the virus.

" To lose somebody 24, 25, 30, 40 years old - it's just not their time, " Kumar

said.

He said he's gotten emails from intensivists all over asking why public health

authorities are calling this flu mild, " because it's certainly not mild from an

ICU context. " The World Health Organization also objects to the use of the term

mild to describe this pandemic, calling it moderate.

Where resource-intensive therapies are available, chances are decent that H1N1

patients will pull through, these and other recently published studies have

found.

But where they are not, the death toll will be higher, said Fowler, a critical

care specialist at Toronto's Sunnybrook Health Sciences Centre.

" This is a young, relatively healthy group of patients that has their lungs

fail. And if you can throw the book at them to get their lungs through this,

then you have a pretty good shot at keeping them alive, " Fowler said.

" And I think in places that aren't able to do that, well ... you have a much

lesser likelihood of making it. "

The comparison of the outcomes between the two patient groups - 168 confirmed or

probable cases in Canada, 58 in Mexico - provided some other important

information.

Fewer of the patients from Mexico were treated with antiviral drugs like

Tamiflu, allowing the authors to compare the outcomes of the patients who

received the drugs and those who did not.

Antiviral treatment is recommended for all patients sick enough to require

hospitalization, even if treatment is commenced later than the 48-hour window in

which therapy is supposed to start for best results. In Canada most of the

patients would have received the drugs, so there would be no way to assess

whether they were helping or not.

But by comparing the data from the two countries, the authors showed that people

who received the drugs were seven times more likely to survive than those who

did not.

" People should get these drugs, " Fowler said.

The Canadian study also found a disproportionately high percentage of the

severely ill cases were women - 67.3 per cent. The virus is especially tough on

pregnant women, but the pregnancy doesn't account for all of the excess in

women, Fowler said.

He admitted the gender imbalance among severe cases is puzzling.

" I have no idea why that could be the case, " Fowler said. " But that does seem to

be something that has been consistently reported ... that critically ill women

are over-represented relative to critically ill men. "

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[Guest guest]

Thanks very much for this post, which I am archiving.

I hope that this does open people's eyes, especially those of the conservatives

who had wanted to cancel the development and production of a Swine Flu Vaccine.

....Dr. Osterholm, an infectious diseases expert at the University of

Minnesota, said the findings should serve as an eye-opener for the large segment

of the public that has dismissed swine flu as a mild form of influenza...

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