The new influenza, what I know as of this week

What I do not know is what to call it. Is it “swine flu,” "Mexican flu" or what?

Never in my experience has there been more confusion and finger pointing.

As there has been some boycotting of swine products, there is some objection to calling it swine flu. Mexico, which is reeling economically as a result of the violence associated with drug dealing, does not also want to be tarred with the responsibility for this epidemic. If, as some claim, the first cases were identified in the United States, should we close the border to protect Mexico? Political points were made when it was noted that the appointments of critical individuals were being held up by Republicans in Congress, specifically, the appointment of Governor Sebelius as the head of Department of Health and Human Services because of her support of choice for women.

Philip A. Brunell

A number of things seem clear. People who are visible publicly, whether in show business or as vice president, should not pontificate on subjects about which they have limited expertise. We have spent a lot of money and expended a lot of effort on preparing for a disaster. Whether the current situation qualifies is uncertain, but it certainly gave us a chance to test the system, which seems to be working quite well. Money still is the bottom line.

The news seems to be filled with the effect on the airlines, the drug companies and dollars spent. Unfortunately, many of these news reports fail to provide important information on influenza. In all fairness, some information still seems to be lacking or at least confusing.

Although I cannot claim to be more than an amateur epidemiologist having had basically a several weeks course at CDC taught by a master teacher, Alex Langmuir, I still try to practice some of the fundamentals.

The first is ascertaining the cases in any epidemic investigation. Admittedly, we cannot be responsible for what happened in Mexico but we would like to have had some basic information before charging ahead. It now appears that only a few of the roughly 150 deaths have been proven to be caused by this new influenza virus.

The latest information from Mexico is that the number of cases seems to be falling, which if sustained, is good news. I was somewhat surprised by the absence of information about the contacts of the initial U.S. cases in California and Texas. It would have been good to know how much human spread there was of this putatively animal virus.

In a New York high school, where some of the patients traveled to Mexico prior to their illness, there seems to be considerable spread.

One of the other things we need to know in evaluating this spread is what efforts were made to prevent it, eg, isolation, prophylaxis, etc. If there is significant person-to-person spread, it will obviously increase the number of cases but it also enhances the chances for a mutation, which might result in a more virulent strain.

It also must be appreciated that we now are looking for cases, which was not the case a few weeks ago, so it is not surprising that there will be an increase in the number found. I am certain that the number of cases in the United States will increase, but how much of this is because we are out there looking for cases is difficult to assess.

Another rather disturbing facet is the nature of the virus itself. Initially we were told that the virus, which had been so devastating in Mexico, was identical with the virus recovered here in the United States. It has variously been reported as a swine-swine strain by laboratories at Columbia and/or Scotland or a swine, swine, human, avian strain. The latter seems rather remarkable as for a strain to be derived from more than one species, it requires two different infections of the same individual to occur during the time the virus is actively replicating so that there can be reassortment of the eight RNA segments. For this to happen multiple times in a single victim seems remote.

Where do we go from here? At this time, the illness caused by this virus, whatever it is, does not seem to be any worse than seasonal flu, which is pretty bad.

One may reasonably question whether restriction at this time should be any greater than during the flu seasons of the past.

Closing schools not only affects kids’ education, but also the parents who must make provisions for these children at home.

Using the precautions for any influenza illness is prudent and perhaps will remind us of what these are. Hand washing is always good. Restriction of those with febrile respiratory illness is prudent. The use of masks is problematic. The neuraminidase inhibitors also have a role in treatment and prevention. The FDA has authorized use of oseltamivir in children younger than 1 year even though they had not been approved for use in this age group previously. They have also approved the use of an RT-PCR, which had not previously been approved using the same authority. The details and doses can be found at the FDA web site.

How important is it to develop a vaccine? This epidemic occurred at the end of the influenza season in the Northern Hemisphere. It would be naive to think that it will not be spread to the Southern Hemisphere whose flu season should be starting shortly. Some cases have already been confirmed in New Zealand. If it then comes back to us after circulating for several generations and having a chance to mutate further, we might be in for a very bad flu year in 2009-10. To use President Obama’s “out,” this is above my pay grade.