Time (5/29, Szalavitz) reported on “anti-overdose kits,” which are “part of a growing nationwide effort to stem the increasing rate of accidental drug-related fatalities.” These kits often include “include vials of the drug naloxone,” which is “commonly used in hospitals and ambulances to reverse opiate overdose.” Currently, “at least 17 states, along with” several “city health departments,” have “programs” that distribute these types of kits to drug users. One “study published in the journal Addiction found that after naloxone training, addicts did just as well as medical professionals at recognizing the symptoms of overdose and determining when to use the medication.” Meanwhile, “addiction experts say the experience of coming back from an overdose is frightening enough…that few addicts would consider using naloxone as an insurance policy to justify taking more drugs.”

The Washington Post (5/31, Aratani) reported that “hospitals in the District [of Columbia] and Maryland must frequently divert ambulances carrying all but the most critically ill and injured patients because of emergency [department] overcrowding, forcing many less-critical patients to travel farther for care, increasing costs and potentially causing dangerous delays.”

Some “healthcare analysts say ambulance diversions in the Washington region illustrate a national problem that has led some states to ban the practice.” However, “detailing the extent of concern is difficult because of the limited information available in many states…about how often those redirections occur and a lack of national standards.” According to an analysis by the Post, “some DC hospitals diverted ambulances the equivalent of one out of five days in 2008, and some Maryland hospitals’ emergency [departments] diverted ambulances at least 15 percent of the time last year.”

Link: http://www.nytimes.com/2009/06/01/us/politics/01health.html?_r=1

June 1, 2009
Hospitals Mobilizing to Fight Proposed Charity Care Rules
By ROBERT PEAR
WASHINGTON — Hospitals plan to begin a lobbying campaign this week to prevent Congress from including charity care requirements in legislation to overhaul the health care system.

The Senate Finance Committee is considering a bipartisan proposal that would require hospitals to provide “a minimum annual level of charitable care” as a condition for getting or keeping the tax-exempt status available to charitable organizations.

In a bulletin on Thursday, the American Hospital Association urged hospital leaders around the country to contact Congress by telephone or e-mail.

“Ask your senators to oppose charity care proposal,” the bulletin said in big bold type.

“A formulaic, one-size-fits-all charity care standard will hamstring hospitals’ efforts to respond to the unique needs of their communities,” the bulletin said. “It would penalize children’s, teaching and research hospitals and those in rural areas because they provide community benefit in a variety of forms other than just charity care.”

The debate is one of many battles raging behind the scenes as Congress returns this week for a push on health care legislation, among other issues.

New, more stringent standards for tax-exempt hospitals were among the policy options set forth two weeks ago by the Finance Committee chairman, Max Baucus, Democrat of Montana, and the senior Republican on the panel, Charles E. Grassley of Iowa.

Mr. Grassley said that many hospitals got “a tremendous advantage” from their tax-exempt status, but did not provide enough charity care to justify it. “If, as a result of health care reform, everyone has health insurance, presumably hospitals should see a steep decline or the elimination of uncompensated care,” Mr. Grassley said.

In a study last year, the Massachusetts Hospital Association said that coverage of the uninsured, under a 2006 state law, had reduced the demand for free care.

But Gail R. Wilensky, a former administrator of the federal Medicare and Medicaid agency, said, “No matter what expansions in coverage we have, there will be some people who will slip through the cracks and remain uninsured.”

Consumer groups say it is often difficult to tell the difference between for-profit and nonprofit hospitals. Nonprofit hospitals have denied care to some uninsured patients and used aggressive tactics to collect bills owed by low-income people, they say.

Under the proposal described by the Finance Committee, tax-exempt hospitals could not refuse service because of a patient’s inability to pay, and they would have to follow certain procedures before taking collection actions against patients.

If a hospital violated these standards, the government could revoke its tax-exempt status or impose excise taxes as a penalty.

Tax-exempt hospitals do not have to pay federal income taxes, may have access to tax-exempt bonds issued by state and local governments, and are eligible to receive tax-deductible contributions.

The Congressional Joint Committee on Taxation estimates the value of these tax breaks at more than $6 billion a year.

Before 1969, the Internal Revenue Service required hospitals to provide charity care to qualify for tax-exempt status. Since then, the agency has not specifically required such care, as long as hospitals provide benefits to the community in other ways — for example, by offering health fairs, screening for cancer and cholesterol, providing emergency care, training doctors and conducting medical research.

The hospital association is one of six groups that went to the White House on May 11 to announce their commitment to cut $2 trillion from the growth of health spending over 10 years. President Obama hailed the announcement as “a watershed event.”

In a letter to the groups a day later, Mr. Obama said, “I will hold you to your pledge.”

On Monday, the six groups plan to report back to the White House with a list of cost-cutting proposals. They include a standardized insurance claim form, greater use of health information technology and increased efforts to coordinate care, manage chronic diseases, prevent medical errors and reduce hospital infections and readmissions.

The six groups represent doctors, hospitals, insurance companies, health care workers and makers of drugs and medical devices.

Influenza A(H1N1) – update 42 Source: WHO

1 June 2009 — As of 06:00 GMT, 1 June 2009, 62 countries have officially reported 17 410 cases of influenza A(H1N1) infection, including 115 deaths.

Table. U.S. Human Cases of H1N1 Flu Infection
Web page updated June 1, 2009,
11:00 AM ET
Data reported to CDC by May 28, 2009, 12:00 AM (midnight) ET
(Updated Mon, Wed, and Fri) States* Confirmed and Probable Cases Deaths
Alabama 84 cases 0 deaths
Alaska 1 case 0 deaths
Arkansas 7cases 0 deaths
Arizona 547 cases 4 deaths
California 804 cases 0 deaths
Colorado 61 cases 0 deaths
Connecticut 196 cases 0 deaths
Delaware 121 cases 0 deaths
Florida 166 cases 0 deaths
Georgia 29 cases 0 deaths
Hawaii 73 cases 0 deaths
Idaho 13 cases 0 deaths
Illinois 1103 cases 3 deaths
Indiana 146 cases 0 deaths
Iowa 71 cases 0 deaths
Kansas 79 cases 0 deaths
Kentucky** 77 cases 0 deaths
Louisiana 122 cases 0 deaths
Maine 11 cases 0 deaths
Maryland 48 cases 0 deaths
Massachusetts 470 cases 0 deaths
Michigan 234 cases 0 deaths
Minnesota 60 0 deaths
Mississippi 16 cases 0 deaths
Missouri 36 cases 1 death
Montana 14 cases 0 deaths
Nebraska 43 cases 0 deaths
Nevada 102 cases 0 deaths
New Hampshire 40 cases 0 deaths
New Jersey 74 cases 0 deaths
New Mexico 108 cases 0 deaths
New York 605 cases 4 deaths
North Carolina 14 cases 0 deaths
North Dakota 6 cases 0 deaths
Ohio 23 cases 0 deaths
Oklahoma 82 cases 0 deaths
Oregon 148 cases 0 deaths
Pennsylvania 123 cases 0 deaths
Rhode Island 14 cases 0 deaths
South Carolina 46 cases 0 deaths
South Dakota 7 cases 0 deaths
Tennessee 104 cases 0 deaths
Texas 1403 cases 3 deaths
Utah 247 cases 1 death
Vermont 3 cases 0 deaths
Virginia 31 cases 0 deaths
Washington 575 cases 1 death
Washington, D.C. 20 cases 0 deaths
West Virginia 3 cases 0 deaths
Wisconsin 1641 cases 0 deaths
Wyoming 2 cases 0 deaths
TOTAL*(51) 10,053 cases 17 deaths
*includes the District of Columbia

**one case is resident of KY but currently hospitalized in GA.

This table will be updated Monday, Wednesday and Friday at around 11 AM ET

International Human Cases of Swine Flu Infection
See: World Health Organization.

NOTE: Because of daily reporting deadlines, the state totals reported by CDC may not always be consistent with those reported by state health departments. If there is a discrepancy between these two counts, data from the state health departments should be used as the most accurate number.

Emergency Medicine Journal 2009;26:461-462; doi:10.1136/emj.2008.066258
© 2009 BMJ Publishing Group Ltd and the College of Emergency Medicine.
EMERGENCY CASEBOOKS
Boerhaave’s syndrome: a pain in the neck
J D Craik1, C H Laffer2 and A Newton3

1 Weston General Hospital, Grange Road, Uphill, Weston-Super-Mare, UK
2 North Bristol NHS Trust, Frenchay Hospital, Frenchay, Bristol, UK
3 Department of Emergency Medicine, Weston General Hospital, Uphill, Weston-Super-Mare, UK

Correspondence to:
Dr J D Craik, 3 Thorndale, Clifton, Bristol BS8 2HU, UK; johnathancraik@hotmail.com
ABSTRACT

Boerhaave’s syndrome, or post-emetic rupture of the oesophagus, classically presents with vomiting, chest pain and subcutaneous emphysema. Mortality in this condition is very high and increases dramatically with delayed diagnosis and intervention. The vast majority of patients have a tear in the left posterior-lateral wall of the lower third of the oesophagus and require urgent surgical intervention. Spontaneous rupture of the cervical oesophagus is very rare and may present differently to oesophageal perforations elsewhere. A case is presented following vomiting in a 70-year-old woman, which was diagnosed by computed tomography scan and treated conservatively. The attending physician must be alert to the diagnosis of post-emetic cervical oesophageal perforation as prompt diagnosis and treatment is essential to reduce morbidity and mortality.

Emergency Medicine Journal 2009;26:459; doi:10.1136/emj.2008.062968
© 2009 BMJ Publishing Group Ltd and the College of Emergency Medicine.
EMERGENCY CASEBOOKS
Carotid sinus massage: is it a safe way to terminate supraventricular tachycardia?
H Adlington and G Cumberbatch

Department of Emergency Medicine, Poole Hospital, Poole, UK

ABSTRACT

A 63-year-old women with a history of palpitations presented to the emergency department with a supraventricular tachycardia; the patient was cardiovascularly stable. Carotid sinus massage (CSM) was performed to help identify the underlying rhythm. During massage the patient had an immediate cerebrovascular accident, resulting in a left hemiplegia. Given the prevalence of atherosclerotic vascular disease in the general population and the safe alternatives available, it is recommended that CSM not be used for the termination of narrow complex tachycardia in the elderly population.

Emergency nurse practitioners and doctors consulting with patients in an emergency department: a comparison of communication skills and satisfaction
H Sandhu, J Dale, N Stallard, R Crouch, and E Glucksman
Emerg Med J 2009; 26: 400-404

Background: Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was undertaken to compare the content of, and satisfaction with, consultations made with patients presenting with problems of low acuity to an ED.

Methods: Patients presenting with “primary care” problems were allocated to senior house officers (SHOs, n = 10), specialist registrars/staff grades (n = 7), sessionally-employed general practitioners (GPs, n = 12) or ENPs (n = 6) randomly rostered to work in a consulting room that had a wall-mounted video camera. At the end of each consultation the doctor/ENP and the patient were asked to complete the Physician/Patient Satisfaction Questionnaire. A stratified sample of videotaped consultations (n = 296) was analysed in depth using the Roter Interaction Analysis System. The main outcome measures were length of consultation; numbers of utterances of doctor/ENP and patient talk related to building a relationship, data gathering, activating/partnering, and patient education/counselling; doctor/ENP and patient consultation satisfaction scores.

Results: ENPs and GPs focused more on patient education and counselling about the medical condition or therapeutic regimen than did ED doctors. There were no significant differences in consultation length. ENPs had higher levels of overall self-satisfaction with their consultations than ED doctors. Patient satisfaction with how actively they participated in the consultation was significantly associated with the amount of talk relating to building a relationship and activating and partnering, and patient satisfaction with information giving in the consultation was significantly associated with the amount of talk relating to building a relationship.

Conclusion: These findings suggest differences between ENP and ED doctor consultations which are associated with some aspects of patient satisfaction. In contrast to previous reports, consultation length was not greater for ENPs than for doctors. There is a need for further research to test the generalisability of these findings and their impact on clinical outcome.

Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility
Marc A. Bellazzini, Peter M. Rankin, Ronald E. Gangnon, Lars Petter Bjoernsen
American Journal of Emergency Medicine – May 2009 (Vol. 27, Issue 4, Pages 454-459

Abstract
Objectives
The aim of this study is to determine which maneuvers result in greatest cross-sectional area (CSA) of the internal jugular vein (IJV) and reduce collapsibility as measured by ultrasound during simulated venipuncture.

Methods
A total of 52 healthy adult volunteers were prospectively studied in an academic emergency department. Cross-sectional area of the IJV was recorded at baseline, with Valsalva, hepatic pressure, and a combination of hepatic pressure plus Valsalva. Subjects were studied in supine and Trendelenburg. Measurements were repeated using pressure applied to the ultrasound transducer to simulate venipuncture and evaluate degree of IJV collapse.

Repeated measures analysis of variance models were used to assess the effects of the maneuvers on the diameter equivalent of the cross-sectional area (CRADE).

Results
With simulated venipuncture, both Valsalva and Trendelenburg position were significantly (P < .0001) associated with increased CSA of the IJV. Valsalva in either Trendelenburg or supine position was associated with the largest CRADE (1.20 and 1.13 cm, respectively). Without simulated venipuncture, CSA of the IJV were increased in all settings (P < .0001), but the relative impacts of Valsalva and Trendelenburg position were similar. Hepatic pressure had no impact on CSA of the IJV (P = .94).

Conclusions
All maneuvers with the exception of hepatic pressure led to a statistically significant increase in IJV CSA as compared with baseline with and without simulated venipuncture. Valsalva was the only maneuver, when used alone or in combination, to increase the CSA by greater than 50% and prevent collapse by 50% or more under simulated venipuncture.

Survey of Radiologists’ Knowledge Regarding the Management of Severe Contrast Material–induced Allergic Reactions
No radiologist provided the ideal dose and administration route of epinephrine (defined as a 0.5-mg intramuscular injection [1:1000]) for the management of the severe contrast material–induced adult allergic reaction scenario.
Radiology 2009 251: 691-696

Purpose: To evaluate radiologists’ knowledge of the appropriate management of severe contrast material–induced allergic reactions by means of a telephone survey.

Materials and Methods: Institutional research ethics board approval was obtained. Following verbal consent, a telephone survey of radiologists working in Canada’s 13 English-speaking and 13 U.S. university–affiliated radiology departments was performed. Participants were selected by using a multistage sampling scheme and simple random sampling within departments. Given a severe contrast material–induced allergic reaction case scenario, radiologists were first asked their initial medication of choice, then questioned specifically on the use of epinephrine. The Canadian and U.S. cohorts were compared by using the 2 and Fisher exact tests, as appropriate, and proportions and 95% confidence intervals (CIs) were computed.

Results: A total of 253 (81%) of 311 radiologists from a 30% target population were surveyed. Ninety-one percent (231 of 253; 95% CI: 88%, 94%) of radiologists chose epinephrine as the most important initial medication. No radiologist gave the ideal response, but 41% (94 of 231; 95% CI: 35%, 47%) provided an acceptable administration route, concentration, and dose; 17% (n = 39; 95% CI: 12%, 22%) of radiologists provided an overdose. Only 11% (27 of 253; 95% CI: 7%, 15%) of radiologists knew what concentration of epinephrine was available in their drug kit and/or crash cart and what equipment would be required to administer it to a patient.

Conclusion: Radiologists’ knowledge of epinephrine for the management of severe contrast material–induced allergic reactions is deficient.

© RSNA

TEACHER: George Washington not only chopped down his father’s cherry tree, but also admitted it. Now, Louie, do you know why his father didn’t punish him?
LOUIS: Because George still had the axe in his hand.

But I digress…

1) Now with the vaccines, kids with bacterial meningitis are rarer than a Republican in Washington D.C. This study tried to see whether the presence and frequency of bands can help to distinguish bacterial meningitis from aseptic meningitis in kids. While the numbers are higher with proven bacterial meningitis, there is too much cross-fertilization to be of much help. That means that if the CSF of a kid has little to no bands don’t use that information to diagnose aseptic meningitis.
http://omniphysicians.com/2009/05/31/do-bands-distinguish-between-bacterial-vs-aseptic-meningitis/

2) Why are patients noncompliant with their meds? They studied this with over 450 patients (hypertension, DM, seizures) in the ED. The researchers developed a 60-item survey that assessed demographic and socioeconomic information, as well as a variety of psychological factors potentially relevant to adherence (health attitudes, health beliefs, depression, anxiety, and social support. So why aren’t they taking their meds? They’re psychologically screwed up. I bet you knew that already.
http://omniphysicians.com/2009/06/01/its-all-in-the-head/

3) How did all these people get swine flu? In over 1/2 of the cases, the source is unknown. Of the rest, 25% of patients contracted the virus from a family member, 12% had traveled to Mexico, 12% had contact with a known or suspected case, and 5% were healthcare workers who were exposed on the job. It’s not true that 15% got it because they looked like pigs!
http://omniphysicians.com/2009/06/01/finding-the-source-of-h1n1/

4) This was an epidemiological study examining how kids get hurt playing baseball. Between 1994 & 2006, the annual number of injuries declined by 24.9%, and the annual injury rate for children younger than 18 years decreased significantly (P < .000). The most commonly injured body parts were the face (33.5%) and the upper extremity (32.4%). The most common injury diagnoses were soft tissue injury (34.3%) and fracture (18.4%). The most common mechanism of injury was being hit by the baseball (46.0%). Children in the 9- to 12-year age group had the highest injury rate (2.4 per 1000 population). When injury rates were calculated by using baseball-participation data (2003), children in the 12- to 17-year age group had a higher injury rate (19.8 per 1000 participants) than those in the 6- to 11-year age group (12.1 per 1000 participants). Despite the fact that this is a safe sport and kids get hurt even in safe sports, the researchers living in an Obama world propose solutions to a virtually non-existent problem: all youth baseball players wear properly fitted mouth guards, that all leagues, schools, and parks install safety bases, that all batters use helmets with face shields, and that all players use safety baseballs. Why don’t we just pitch imaginary baseballs and swing at them with imaginary bats?
http://omniphysicians.com/2009/05/31/baseball-injuries/

Paul R.

PERSPECTIVE
Lessons From Outbreaks of H1N1 Influenza
Richard A. Stein, MD, PhD

Ann Intern Med 7 July 2009 | Volume 151 Issue 1

A new H1N1 triple-reassortant “swine” influenza virus was recently described in individuals from the United States and Mexico who presented respiratory symptoms, and the same virus was subsequently confirmed in patients from several countries around the world. The circumstances surrounding the emergence of this pathogen, and the factors that facilitated the initial cross-species transmission, are still incompletely understood. It became apparent in the early days of the outbreak that the virus can be directly transmitted between humans. Pathogens that originate in animal reservoirs and subsequently acquire the potential for human-to-human transmission have caused outbreaks throughout human history. Although each outbreak is marked by its own particularities, it is important to remember the teachings that emerge from previous epidemics and pandemics. Integrating the important lessons of the past will provide the best opportunity to understand host–pathogen interaction and the most powerful approach to implement effective prophylactic and therapeutic measures.

——————————————————————————–
On 17 April 2009, the CDC reported that a girl, age 9 years, and a boy, age 10 years, who had flu-like symptoms and lived in adjacent counties in California had tested positive for an H1N1 “swine” influenza virus (1). The Federal District of Mexico had reported influenza-like illnesses on 18 March. By 13 May 2009, the strain—which seems to be a reassortant (Figure) with nucleotide sequences derived from swine, avian, and human viruses (2)—was confirmed in patients from Mexico, the United States, Canada, Spain, the United Kingdom, and at least 28 other countries. The virus derives the name “swine” from the animal reservoir thought to be responsible for initiating the outbreak in humans. An animal source was not required for subsequent infection because direct human-to-human transmission had become possible. An estimated 58% of the 1407 known human pathogens are zoonotic, which means that they normally occur in animals but also infect humans (3). After a microorganism crosses the species barrier, a major concern is whether it can be directly transmitted between humans, who tend to be in closer contact with other humans than with animal reservoirs. Microorganisms that gain this ability have historically caused the most devastation. The notorious 1918 influenza pandemic—deservedly known as the “mother of all pandemics”—infected more than one quarter of the world’s population and claimed an estimated 50 to 100 million human lives (4). Its origins have always been debated. Some have proposed that the virus resided in an avian reservoir and entered the human population either directly from birds or indirectly through an intermediate host, facilitated by overcrowding and by the proximity of pigs, chickens, ducks, and geese (5). The reconstructed 1918 influenza virus is able to replicate and cause respiratory disease in swine, and scientists believe that it continued to circulate in swine after its introduction into the pig population during the pandemic (6). Whereas human influenza viruses do not easily infect birds and avian viruses do not replicate efficiently in humans, swine have repeatedly been shown to serve as “mixing vessels” that allow genetic reassortment between different influenza virus strains (5, 7).

Two features of the influenza virus, compounded by current globalization trends, explain its ability to become a particularly worrisome zoonotic threat. One feature is the high error rate during genomic replication, which is typical of RNA viruses. The other is the segmented influenza virus genome, which facilitates reassortment between different viral strains that infect the same cell (Figure). At a time when air travel makes it possible to reach the most remote corners of the planet in a matter of hours, any emerging or re-emerging infectious disease stops being a local issue and instead becomes a global medical and public health priority. These considerations explain why, for a long time, the question about the next influenza pandemic has been not if, but when (8).

Details of how the current influenza virus emerged, although still scarce, will enhance our knowledge about factors that enable viruses to cross the species barrier and cause disease in humans. The importance of human–animal contact in occupational settings will probably be a key take-home lesson. Farmers, meat processing workers, and veterinarians have had markedly higher antibody levels against swine influenza viruses—sometimes concomitantly against 2 isolates—than control participants (7), and a pregnant woman who visited a Wisconsin country fair that displayed pigs developed a fatal infection in 1998 (9). This echoes a lesson from the severe acute respiratory syndrome (SARS) outbreak: In the winter of 2003 to 2004, after the World Health Organization declared an end to the SARS epidemic, 4 new cases were reported in the Guangdong Province in China. Epidemiologic investigation revealed that 2 of the patients were a 20-year-old waitress who worked in close proximity to civet cages and a 40-year-old physician whose dining table in the same restaurant was within 5 meters of the cages (10). All palm civets from the restaurant tested positive for the SARS coronavirus, and sequencing of the S gene that encoded its attachment protein implicated this virus, rather than the one circulating from the previous epidemic, as the source of the outbreak.

After a pathogen crosses a species barrier, epidemic spread requires efficient direct transmission within the population. Despite several studies that have focused on the mechanistic details of airborne virus dissemination, our understanding of human-to-human influenza transmission is, as recently characterized, “woefully inadequate” (11). Air travel clearly plays an important role in establishing infectious foci in new countries. Although human-to-human transmission during air travel has been thought to require flights as long as 8 hours and to affect only passengers seated within 2 rows of the index patient (12), this view is changing because of reports of in-flight spread occurring over considerable distances within the cabin and during shorter flights. In 1977, 72% of the passengers on an Alaska Airlines flight, which was delayed for 3 hours while the aircraft sat on the tarmac, developed influenza within 72 hours (13). On a 3-hour flight between Hong Kong and Beijing on 15 March 2003, passengers sitting as far as 7 rows from an index patient developed SARS (14). Epidemiologic details from the current H1N1 outbreak should significantly complement our understanding of in-flight airborne pathogen transmission, an important facet of global preparedness planning.

With ever-expanding air traffic volumes, the global spread of pathogens is changing. When researchers modeled the 1968 to 1969 Hong Kong influenza pandemic (15), on the basis of data regarding air travel in 53 cities in the year 2000, they found that the virus spread almost simultaneously in the Northern and Southern hemispheres—which underscores the narrowness of the period during which intervention could halt the epidemic. Of note, the study also predicted that Sydney and Johannesburg, which were the 48th and 45th cities to be affected in 1968, would be among the first cities to report cases in 2000. New Zealand was one of the first countries outside Mexico to report patients in the current H1N1 outbreak, which confirmed the prediction of very rapid spread to distant countries.

Strong international collaborative efforts, such as those that occurred during the SARS outbreak, can have a dramatic effect on an epidemic. The delayed reporting from China, where the first case of SARS was diagnosed on 16 November 2002 but not investigated by WHO officials until 12 April 2003, contrasts with the quick communication from Vietnam about the index cases (16, 17). This prompt response is credited with effectively controlling the outbreak in Vietnam and making it the first country to be declared SARS-free and removed, on 28 April 2003, from the World Health Organization list of travel advisories (18). During the current pandemic, the proactive reporting of new infections and the decision by Mexican officials to close schools and businesses in the wake of the outbreak, along with the prompt implementation of screening checkpoints and quarantines in many countries, may have substantially slowed the global spread of the infection.

Social isolation measures save lives. In the fall of 1918, Philadelphia, Pennsylvania, had much higher flu mortality rates than did St. Louis, Missouri. In Philadelphia, city officials allowed a 28 September citywide parade to continue despite having identified the first cases on 17 September. They banned public gatherings and closed schools only on 3 October. In comparison, St. Louis, where the first cases occurred on 5 October, adopted social distancing measures on 7 October. As a result, the peak weekly excess pneumonia and influenza death rate between 8 September and 28 December was 8.3 times higher in Philadelphia than in St. Louis (19). A survey that examined the responses of 17 U.S. cities during the 1918 pandemic concluded that early implementation of nonpharmaceutical interventions, including social isolation measures, lowered excess mortality rates by 50% (19).

Although initial studies in infectious disease epidemiology assumed that individuals within a population transmit the microorganism at similar rates, transmission from individuals known as super-spreaders is much more efficient. In what is known as the 20/80 rule, 20% of infectious persons are thought to contribute at least 80% of the net transmission potential of a microorganism (20). During the SARS outbreak, a 44-year-old man in China infected 35 cases by direct contact (21). In the Hong Kong SARS outbreak, a super-spreader had a runny nose, an uncommon manifestation in SARS, in addition to the cough, fever, and malaise present in other patients. Some investigators have proposed that co-infection with other viruses might make a patient particularly infectious (22, 23). Investigative efforts during the current and future outbreaks should therefore focus on identifying patients who exhibit atypical or uncommon manifestations of influenza.

Insight into the influenza virus genome has provided valuable information with potential medical and public health benefits. Unlike the 1957 and 1968 pandemics, which were caused by reassortment between avian and human strains, the pandemic in 1918 was most likely caused by an avian virus that accumulated mutations and, subsequently, evolved and adapted to humans (24). Thus, at least 2 mechanisms could explain zoonotic outbreaks (25). In addition, analysis of amino acid substitution rates in the 1918 virus suggest that genes of avian origin could have been circulating in human influenza viruses as early as 1900, which points toward the possibility of detecting sequence modifications years before zoonotic pathogens cause human epidemics (24, 25). The sequence of the current H1N1 strain will probably provide clues about how this virus emerged and what factors enabled animal-to-human and then human-to-human transmission. We must learn, from all the zoonotic pathogens that have afflicted humankind, the particular circumstances that facilitated each outbreak. If we can integrate this information successfully, we will understand what makes us vulnerable to pathogens that cross species barriers.

As an important lesson with immediate applicability, it is essential to appreciate the value of nonpharmacological interventions during outbreaks. We can save many lives if we maintain a high index of clinical suspicion in persons with occupational or casual exposure to animals that present zoonotic potential and quickly implement social distancing measures. These 2 actions are highly beneficial, particularly during the initial stages of an outbreak, when limited information is available on the biology of the pathogen. It is then that an alert clinician can make a big difference.

Author and Article Information

From Princeton University, Princeton, New Jersey.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Richard A. Stein, MD, PhD, Department of Molecular Biology, Princeton University, Princeton, NJ 08544; e-mail, ras2@princeton.edu.

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The source of exposure is unknown in about 45% of US H1N1 flu cases so far, according to findings presented yesterday by Michael W. Shaw, PhD, of the CDC’s Influenza Division. Speaking at a webinar sponsored by the New York Academy of Sciences (NYAS), Shaw said that 25% of patients contracted the virus from a family member, 12% had traveled to Mexico, 12% had contact with a known or suspected case, and 5% were healthcare workers who were exposed on the job.

As of Friday, there
had been 15,510 confirmed cases and 99 deaths in 53 countries.

Source: Washigton Post, 5/31/09

New Virus Spurs Experts to Rethink Definition of Pandemic

By David Brown
Washington Post Staff Writer
Sunday, May 31, 2009

Influenza experts are acknowledging that they were almost completely
surprised by the way the current swine flu outbreak unfolded, so much so it
is forcing the world to rethink what a pandemic is and what pandemic
preparedness means.

Virtually every assumption made since planning for a pandemic began in
earnest after the deadly “bird flu” outbreak of 2004 in Southeast Asia has
been contradicted by the six-week history of swine-origin influenza A
(H1N1).

Although they acknowledged there might be alternative scenarios, nearly
every expert assumed that the next pandemic strain would jump from birds to
human beings someplace in Asia. They also assumed that, like the H5N1 bird
flu virus, which is lethal in 60 percent of people who catch it, the new
strain would be recognized immediately and would have to be fought with
drastic measures.

Instead, the virus emerged in North America, appears to have come from pigs,
had spread widely by the time it was noticed, and kills less than 1 percent
of the people it infects.

The world expected a fastball pitcher throwing smoke. Instead, it got a
junk-baller who is throwing everyone off balance.

“Everyone was thinking about H5N1 and the possibility that we would be in
for partial global population collapse,” said David S. Fedson, a physician,
influenza expert and former drug company executive who has written
extensively on pandemic planning. “We never addressed severity, because we
knew it would be severe. And now we have this funny virus coming out of
pigs.”

The consequence is that, despite five years and hundreds of millions of
dollars spent on getting ready, the world is oddly unprepared for the
incipient pandemic of H1N1 swine flu it now confronts. As of Friday, there
had been 15,510 confirmed cases and 99 deaths in 53 countries.

In the United States, plans to “limit non-essential passenger travel in
affected areas” were never invoked, and an aggressive school-closing policy
was quickly revised when it became clear that the virus did not travel like
wildfire, and in all but a few cases caused only mild illness.

In Europe, many countries are using a public health strategy that is likely
to miss many of the new flu cases rather than find as many as possible –
exactly opposite the strategy typically invoked in the early stage of a
pandemic.

Some experts think there has been a reluctance to document “community
spread” of the swine flu virus in countries such as Britain and Spain
because it would force the World Health Organization to declare Phase 6 — a
global pandemic — and tag those nations with triggering what seems like an
unnecessarily loud alarm.

The most obvious manifestation of the world’s second thoughts was the WHO’s
announcement last Tuesday that it will convene a conference of experts by
e-mail and videophone over the next two weeks to consider changing the very
definition of pandemic.

The purpose is to add measurement of the disease’s severity to the criteria
for moving to Phase 6, which declares “that a global pandemic is under way.”

The current rules say that if a wholly new strain of flu is spreading easily
from person to person in at least two different regions of the world, then
it is a pandemic. With that happening in North America and almost certainly
in Europe, too, Phase 6 has already been reached in all but name. While
acknowledging that Phase 6 is defined unambiguously, WHO officials say quite
clearly they do not want to go there anytime soon.

“If you go and declare Phase 6 without very clear evidence that there is a
sort of change in the global situation, it can lead to extra work for
countries without much gain,” Keiji Fukuda, the WHO’s assistant
director-general, said last week.

Equally important, he said, it could lead to panic and “cynicism that
something is being declared which is not usefully producing something in
terms of public health benefit.”

Sandra Mounier-Jack, a health policy expert at the London School of Hygiene
and Tropical Medicine who has written extensively about pandemic planning,
agrees.

“If you announce Phase 6, many governments would be puzzled what to do,” she
said.

The puzzlement would not end there.

“To a lot of people, that would mean the risk has increased and the danger
is greater — even though the virus is no different than a few weeks ago,”
she added.

In many developing countries, plans are still being written. A survey of
Africa’s pandemic preparedness that Mounier-Jack and her colleagues did in
June 2007 found that although 35 of 53 countries had plans, they scored on
average 36 percent on a measure of “aggregate completeness.”

Hitoshi Oshitani, a virologist at Tohoku University Graduate School of
Medicine in Sendai, Japan, has reviewed pandemic plans of Asian countries.

“Most of them do not have a concrete plan for Phase 6,” he said Friday from
Geneva, where he is helping the WHO develop guidance for low-income
countries.

Most plans focus on ways to contain or delay the arrival of a highly lethal
virus such as the H5N1 strain, which since 2004 has infected 427 people and
killed 258, nearly all of them in Asia. The strategies include isolating
patients, quarantining contacts, “social distancing” rules for the general
population, and messages about personal hygiene.

Oshitani said very few plans address the situation that exists in the United
States, Mexico and probably many other countries: namely, wide dissemination
of a virus that is truly dangerous to only a small fraction of the
population.

“We are not assuming such a kind of pandemic,” he said. “A mild pandemic but
very severe for certain people — this kind of scenario was not included in
most of the pandemic plans.”

In that situation, the priority is to identify the people at highest risk –
pregnant women, AIDS patients and people with underlying medical conditions
– and try to protect them, ideally with a vaccine or antiviral medications.

That nearly all the swine flu vaccine and supplies of Tamiflu to be made in
the next year will be bought by rich countries (or nationalized by the
countries where they are made if the situation becomes dire) may also
explain some of the reluctance to declare Phase 6 now, Fedson thinks.

“If you do that, it may increase the pressure on WHO to deliver on supplies
of vaccines and antivirals, which it already knows will be very difficult to
do,” he said.

But perhaps the biggest reason is that the WHO wants to have one louder
alarm at the ready should swine flu turn into a more dangerous virus over
the next year. Even if that does not happen, the H1N1 strain may turn out to
be more dangerous in certain places and populations than it appears to be
now.

The WHO wants to be sure the world is listening — and will hear something
it cannot easily dismiss — if it needs to sound that siren.

Demographic, Socioeconomic, and Psychological Factors Related to Medication Non-adherence among Emergency Department Patients
Presented at the American College of Emergency Physicians National Meeting 2005, Washington DC.

Daniel P. Davis, MD, Matthew D. Jandrisevits, PHD†, Stacy Iles, BS‡, Tory R. Weber, MA‡, Linda C. Gallo, PHD‡

Demographic, Socioeconomic, and Psychological Factors Related to Medication Non-adherence among Emergency Department Patients
Daniel P. Davis, Matthew D. Jandrisevits, Stacy Iles, Tory R. Weber, Linda C. Gallo
The Journal of Emergency Medicine
Received 27 March 2009; accepted 8 April 2009. published online 25 May 2009.
Corrected Proof

Abstract
Background: Many Emergency Department (ED) visits are related to medication non-adherence; however, the contributing factors are poorly understood.

Objectives: To explore the relative contributions of demographic, socioeconomic, and psychological factors to medication non-adherence in an ED population.

Methods: This was a cross-sectional analysis enrolling patients with one of three illnesses requiring chronic medication usage (hypertension, diabetes, or seizures). Trained research associates administered a 60-item survey that assessed demographic and socioeconomic information, as well as a variety of psychological factors potentially relevant to adherence (health attitudes, health beliefs, depression, anxiety, social support, and locus of control). Patients rated their overall prescription medication adherence and estimated the number of days in the preceding month on which doses were missed. In addition, treating physicians estimated the degree to which the ED visit was related to medication non-adherence; clinical data were abstracted to help validate patient and physician assessments. The relationships between non-adherence and demographic, socioeconomic, and psychological variables were explored using multivariate statistics and logistic regression. Covariance analysis was performed to validate subscales, and receiver-operator curves were used to define optimal threshold values.

Results: A total of 472 patients consented to participate, with good representation for various demographic and socioeconomic groups. Each psychological factor related significantly to both patient and physician ratings of non-adherence (p < 0.05). Of all demographic and socioeconomic factors examined, only current or historical drug use predicted non-adherence.

Conclusions: Psychological factors seem to be important determinants of medication non-adherence among ED patients. These data may help define future research directions and interventions.