Triage by Mirage
First, the mirage. This excerpt is from our CDC.
Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season
September 8, 2009 2:00 PM ET
Objective
To provide updated guidance on the use of antiviral agents for treatment and chemoprophylaxis of influenza including 2009 H1N1 influenza infection and seasonal influenza, and assist clinicians in prioritizing use of antiviral medications for treatment or chemoprophylaxis for patients at higher risk for influenza-related complications. Additional revisions to these recommendations should be expected as the epidemiology and clinical presentation of 2009 H1N1 influenza is better understood. This guidance can be adapted according to local epidemiologic data, antiviral susceptibility patterns, and antiviral supply considerations. Clinical judgment is always an important part of treatment decisions.
I’ll paraphrase the summary.
- Treatment with Tamiflu or Relenza is recommended for all persons with suspected or confirmed influenza requiring hospitalization.
- Or for persons with suspected or confirmed influenza who are at higher risk for complications (children younger than 5 years old, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and persons younger than 19 years of age who are receiving long-term aspirin therapy.
- Other people do not require antiviral medications for treatment or prophylaxis, unless they are short of breath or have rapid shallow breaths or have other signs of lower respiratory tract illness.
- Treatment should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit.
- Treatment should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid tests can range from 10 % to 70%.
- Groups at higher risk for 2009 H1N1 influenza complications are similar to those at higher risk for seasonal influenza complications.
One would gather, from the above, that only certain people, in predictable groups, need worry themselves about swine flu.
Now the triage. Apply the CDC guidance to the following cases.
Garland swine flu victim ‘did not have underlying health problems’
Monday. September 14, 2009
By JANET ST. JAMES / WFAA-TV
GARLAND — Dallas health officials say the first child in North Texas to die of swine flu did not have underlying medical conditions
<snip>
School officials say Cynthia went home sick from school with a fever Thursday. She saw a doctor that day and then went home.
The popular student was taken to the hospital Saturday in respiratory distress. Her mother, Maria Bidillo, said Cynthia’s symptoms appeared very much like ordinary flu until that day.
“She was really weak,” Bidillo said. “In the evening, [she told me] ‘I don’t feel good, I need to go to the doctor.’”
Cynthia died later that same day.
State suspects swine flu in death of Scottboro boy
Posted by David Brewer August 31, 2009 5:57 PM
SCOTTSBORO, AL – State health officials said an 11-year-old Scottsboro boy who died Monday morning was apparently the state’s third fatality from swine flu.
<snip>
Jackson County Coroner John David Jordan declined to name the child, but said the boy was taken to a local doctor’s office Sunday and again Monday. He said the child was transferred to Highlands Medical Center in Scottsboro after he collapsed at the doctor’s office.
Later reports stated that this little guy felt symptoms on Friday night and felt well enough to play soccer on Saturday.
Davidson County Child Dies From H1N1 Influenza (Tennessee)
September 2, 2009
ASHVILLE, Tenn. – A 5-year-old boy has died from H1N1 influenza in Davidson County.
Officials with the Metro Public Health Department said the boy became ill Friday night and died Monday night at an area hospital.
None of these cases qualified for Tamiflu treatment under the CDC’s guidelines, though the 5 yr. old arguably might have. Consider now that from one-third to one-half of all deaths would not fit the guidelines for Tamiflu treatment and that the CDC itself acknowledges that Tamiflu treatment should be given within 48 hours of symptom onset.
What’s going on here? The CDC knows that these cases have occurred and will continue to occur; this guidance was issued after the deaths of two of these three. Unfortunately, the three children that I’ve referred to here are not the only people to have this rapid onset of serious and fatal illness.
Well then, what about people that don’t have rapid onset? The next excerpt is a bit long, I know, but please read it all, or, even better, follow the link to the entire story. All text emphasis is mine.
Widow urges others to take swine flu seriously
By CARRI GEER THEVENOT
LAS VEGAS REVIEW-JOURNAL
Sep. 12, 2009
Copyright © Las Vegas Review-Journal
Richard and Elizabeth MacDowell didn’t live under a rock.
They had heard news reports about the swine flu pandemic. They had even discussed the topic.
“It was one of those nebulous things that happened to someone else,” Elizabeth MacDowell said Friday. “Maybe that’s why I’m so determined to come public with it.”
On Aug. 31, the swine flu claimed her husband’s life and changed hers forever. She is telling their story because she wants others to take the disease seriously.
<snip>
At 51, Richard MacDowell didn’t fall into a high-risk group. When the health district reported his death, along with the death of a 41-year-woman, a spokeswoman did not identify them by name but said both had underlying medical conditions.
Elizabeth MacDowell insists that her husband of 10 years suffered from nothing more serious than arthritis before he began feeling sick on Aug. 14. That day, a Friday, Richard MacDowell said he felt a little tired and had a sore throat.
“Nothing alarming,” Elizabeth MacDowell said.
He felt a little worse on Saturday but went to work on Sunday. His job as a shuttle bus driver involved transporting tourists between McCarran International Airport and the hotels.
After work that day, he went to an urgent care center and received a prescription for an antibiotic. “He told me it was pneumonia,” Elizabeth MacDowell said.
By Thursday, he was feeling worse. He returned to the urgent care center and was sent home with a prescription for cough syrup.
“His cough at this point was outrageous,” Elizabeth MacDowell said.
The coughing kept both of the MacDowells awake at night. On Saturday, Aug. 22, Richard MacDowell returned to the urgent care center with a 102-degree fever.
This time, he was sent home with oxygen tanks and a prescription for a different antibiotic.
Richard MacDowell still couldn’t sleep, and he made his fourth trip to the urgent care center the following morning. He still had a 102-degree fever.
“He’s walking like a little old man,” Elizabeth MacDowell recalled. “He could barely move.”
This time he returned home with a nebulizer, a device used in treating respiratory diseases.
“By Monday night, he was gasping for air and choking,” Elizabeth MacDowell said.
That’s when she decided to take her husband to Valley Hospital Medical Center.
At the hospital, Richard MacDowell told his wife to go home and get some rest. He knew he had kept her awake the previous four nights.
Elizabeth MacDowell remembers how her husband’s skin felt — sweaty and clammy — as she kissed him on the forehead before leaving. When she returned the next morning, she found him attached to a ventilator.
“I never spoke to him again after Monday night,” she said.
A doctor told Elizabeth MacDowell that her husband might not recover. He also told her a swine flu test had come back negative. A few days later, she learned that a different type of swine flu test had a positive result.
Elizabeth MacDowell’s phone rang early on the morning of Aug. 31. Medical professionals were trying to resuscitate her husband. She made it to the hospital within 10 minutes, but Richard MacDowell was already dead.
“It just wore him out,” his widow said.
Some folks in Texas have caught on. Again, emphasis is mine.
Many Who Get Flu Won’t Get Prescribed Antivirals
Daniel Novick-KFOX News Weekend Anchor/Reporter
Posted: 6:16 pm MDT September 12, 2009
Updated: 9:07 pm MDT September 12, 2009
EL PASO, Texas — As fall and winter is just around the corner, doctors are gearing up for a long year dealing with the flu — particularly the swine flu. And in their preparations, doctors are getting guidance from the federal government to not prescribe antiviral medication like Tamiflu and Relenza to patients who are not considered high-risk.
Are you angry? You ought to be. Young, otherwise healthy people, going to the doctor without initially showing any signs of serious illness, make up a substantial portion of the deaths from swine flu, and are excluded by the CDC guidance from receiving Tamiflu until it’s too late to do them any good. That could be me, or you, or our kids.
Who is getting triaged here? And why?
