Postcard from Latin America #5

Dr. Richard Wenzel writes from Argentina:

Schools are closed, and will be for 4 weeks, and all high risk, young adults (e.g., pregnant women) are not allowed to work. Only young adults screened at hospitals can get oseltamivir. Met with the Minister of Health of Buenos Aires, and he told me yesterday that of 85 deaths in the region - half of the total deaths in Argentina- one fourth were in pregnant women. In Sao Paulo, Sergio Wey told me that there pregnancy was the leading risk factor for severity. In Argentina obesity is a close second risk factor for dying with H1N1. Also in Argentina I was told that diarrhea occurred in 10-20 percent, in the 12 percent range I heard about in Mexico. So far no one has tested stool for virus. I also heard about severe cases in Chile and Argentina in solid organ and bone marrow transplant patients. Not sure how many were nosocomial.

Postcard from Latin America #4

Dr. Richard Wenzel writes from Chile:

Made rounds in the adult and peds ICU of one of the university hospitals- hospital clinico UC. They nodded concurrence that about one-third of non-icu admissions have no fever. More interesting they volunteered that half of the outpatients with H1N1 confirmed had no fever. Each had anecdotes that they have screened patients with rhinorrhea only and confirmed H1N1. The point is that the clinical expression of H1N1 is extremely broad. Obviously screening patients with fever will miss many. Lastly, for counting patients, if fever is part of the case definition, the denominator will be greatly underestimated.

The adult in the ICU was an obese 34 year old man whose weight was 150 Kg and BMI was 40. Obesity was recognized informally in Mexico City when I was there earlier. The recent MMWR notes obesity as well. Obviously the question is whether the weight per se is an issue, and maybe these patients have no reserve when they get viral pneumonia. However, I suspect that insulin resistance is a factor: many have underlying hypertension and diabetes (i.e., metabolic syndrome).

Of interest is how H1N1 is managed in Chile vs Brazil. Here clinicians make a clinical diagnosis- confirmation is not essential - and order oseltamivir. The drug is given to patients free of charge.

Postcard from Latin America #3

Another email from Dr. Wenzel as he travels through Latin America:

Arrived earlier in Chile and will be at the Ministry of Health tomorrow. H1N1 spreading here in their winter but I'll know more tomorrow. Chile prepared well after Mexico. I'll get first hand information in Argentina about their preparations later in the week.

Postcard from Latin America #2

More from Dr. Wenzel as he visits several countries in Latin America:

Had dinner with former fellows- Claudio Pannuti and Sergio Wey- and their colleagues in Brazil. There is an upsurge in influenza thought to correlate with vacationers returning from Argentina and Chile. Pregnancy is the risk factor for severity of illness in cases that they have seen. What is unusual is how the government is managing the outbreak. Ill patients with ILI can be screened in this megacity of approximately 15 million by law only at 7 hospital ERs. The screen is with an immunoblot with a sensitivity of 70 percent. If and only if a patient with a positive screen also has some defined high risk elements will oseltamivir be given. A confirmatory PCR test is then done and sent to a single lab. The results of the PCR are available only after 10 or more days. The important point is that ID specialists cannot write a prescription for oseltamivir or screen for flu; this is controlled by law by the physicians at the 7 EDs.

Postcards from Latin America

Our mentor, Dr. Richard Wenzel, is back in Mexico and from there will be heading to Argentina, where an H1N1 outbreak is in full swing and for which a travel alert was just issued. Here is an excerpt from his e-mail yesterday:

Mexico has a new spike of H1N1 cases and the focus is especially high in Chiapas in the south. They have many on respirators with approximately 50 percent mortality - reminiscent of the severe cases in April in Mexico City. Just as in the cases earlier in Mexico City, the Chiapas cases have underlying conditions in only half. Also cases now appearing in Cancun and Merida. Very odd for flu to be here in summer. The big question is how Mexico might distribute the 20 million doses only that they will have by December--to young adults vs high risk young adults vs children who may be efficient transmitters. Even when they target a group, there will be too few doses, and how do you announce the program?

The WHO has quietly announced that it will no longer be tracking H1N1 cases and deaths. The numbers they report have always been grossly inaccurate estimates, given that only a fraction of actual cases are tested. Nations are now asked to report their first few cases only, and to be vigilant for clusters of deaths attributable to H1N1.

I’ve also noticed that, despite all the hullabaloo about the name of this virus when it first swept across the U.S., “swine flu” is now back in vogue. Even the NY Times is back to using “swine flu”.