H1N1 Death Rate Surges

By Peter Laird, MD

While health officials talk about the expected H1N1 surge this fall when children return to school, the H1N1 virus has not taken any time off - H1N1 has been quite active through July. In a dramatic surge of death before the school year has even started, the CDC this week reports an 18% increase in hospitalizations for H1N1 related illness (5,515 to 6,506) and a staggering 24% increased death toll (353 to 436) in only one week.  

The World Health Organization (WHO) likewise revised the projected impact on the world’s population to over 2 billion people who will develop H1N1 infection in the next two years.  The continued media reports of mild H1N1 illness in the majority of people infected belies the true magnitude of death that this virus will reap, as it rampages around the world at a record pace. Although the majority of people infected will recover quickly, millions will succumb.

The CDC's report of the 24% increased death toll in America in the middle of summer is not good news. There seems to be mounting data that planning on an H1N1 case fatality rate of 0.4% is too optimistic; there is data is pointing to a higher rate:

H1N1 Mortality Rate Increases
As of July 31st, the World Health Organization reports 1154 deaths due to the H1N1 virus among a global total of 162,380 cases, for an overall mortality rate of 0.71%. Consequently the H1N1 death rate has increased more than 60% after holding steady at about 0.44% since mid-June. The current H1N1 death rate also surpasses the death rate from early June (0.66%). Among the tabulated deaths, 87% (1008) have occurred in North and South America.

The trends are not good.

The facts are emerging that H1N1 will soon explode in ever increasing numbers as the summer months give into the cooler and less humid fall.  The experiences in our summer camps captures the true nature that this pandemic is a real threat especially to renal patients and we should all take special precautions as Bill has advised for several years to first avoid and if needed, treat the coming flu.

Comments

[Bill Peckham]

I wish we could have confidence in the numbers. This flu is reported to spread very easily - the WHO's estimate that 30% of the world's population may get sick over the next two years would be a best case scenario.

Either it spreads very easily and millions of people have already caught it - therefor the case fatality rate is a low .4% - OR is does not spread very easily and it'll take two years, two flu seasons, for 30% of the world to catch this novel pandemic strain of flu.

You would think the United States would have a federal agency that would be testing and reporting how many people have been exposed to a pandemic disease. You would think that this agency, this Center if you will, would have the job of informing the public with detailed data so that the Disease could be Controlled.

Dialysis patients have blood tests every month - what percentage of them have H1N1 antibodies indicating exposure to the virus? 1%? .001%? 10%?
Knowing the current prevalence and severity of these early sentinel cases would help the dialysis community to prepare. We should really think about creating an agency that would collect and pass along detailed data when the country faces a pandemic disease.

[roberta mikles]

What, if anything, is being implemented in facilities to protect patients and staff?

My suggestions to the dialysis community, after speaking with many, many patients, and staff, throughout the US, are the following:

(1) Re-educate staff in effective infection control practices to prevent the spread of infectious agents.
(2) Remind staff that they are not excluded from this flu and that they, too, can bring home infectious agents, to their families including children
(3) Increase unit surveillance e.g. increase observations of staff to ensure implementation of effective infection control practices, esp. hand hygiene. Of course, staff who are observing MUST be well-educated in effective practices.
(keeping in mind, many surveys support the fact that there is lack of supervision, staff education, and unit-level oversight in regards to ensuring implementation of effective infection control practices.)
(4) Encourage staff to staff communication if observations indicate lack of effective infection controls
(5)Increase unit-level oversight of disinfection of equipment. (Often patients cough and sneeze on such items as televisions, chair arms, arm rests, blood pressure cuffs, etc.) Without thorough disinfection, transmission of infectious agents will be transferred from patient to patient. Ex: A patient coughs or sneezes on a television, that is used by all patients who sit in that chair. If there is not effective disinfection of the tv, e.g. wiping down w/ disinfecant, the next patient will touch the tv set and then those nasty germs, from the previous patient, are now on the hands of the next patient.
(6) Teaching patients correct way to cough, sneeze and teaching proper hand hygiene.
(7) Place alcohol dispensers close to entrances and exits, that patients and staff use, so that hand hygience can be user-friendly
(8) Educate patients on infection control practices that staff will be implementing in order to prevent the transmission of infection.
(9) Encourage patients to ask staff if they have washed their hands, e.g. prior to donning gloves, before taking supplies off of treatment carts,
(10) Encourage patients to speak up if they observe staff not implementing effective infection controls,
Patients should be able to speak up if they observe incorrect procedures without the fear of any covert or overt retaliation from staff. Many patients will not speak up due to fear of retaliation.
It must be a team effort of staff and patients in the prevention of transmission of infection.
Hand Hygiene is nothing new. Agencies and task forces, etc. are all attempting to re-invent the wheel. All is takes is a higher-level of awareness and understanding by those providing care that infection kills. However, infection control, including hand hygiene is the most basic of basic practices, and truly shame on those health care professionals who knowingly take short cuts or are lax in implementing such, for they are cognizant of the fact that they are contributing to the potential negative outcome of a patient(s) Health Care professionals should think 'this could be me or my relative - what type of care would I want'. Providers must stress more attention to ensure effective infection controls are being implemented. This is about life and death
Roberta Mikles, RN
Patient Advocate

[Peter Laird, MD]

Thank you Roberta on your suggestions for dialysis units. The retaliation that you speak of is quite real even with an MD after your name. Perhaps the most distasteful aspect of dialyzing in unit was the interaction with staff that didn't want to adhere to basic hygiene standards. The two times that I made it a big issue, I had immediate retaliation and was branded a difficult patient.

The worst incident was when one of the staff saw my wife at a store and approached her. Thinking it would be a cordial exchange, my wife was shocked when instead the staff member asked her how she could stand to live with that man (me)? Apparantly I had also been branded as a controlling and possibly abusive husband as well.

Roberta, the retaliation is real and everyone that I know stood up for different issues was either mocked behind their back or other forms of retaliation. I have seen this in every unit I have gone. It is a pervasive problem that is not being addressed adequately.

Thank you for your strong stand as an advocate for dialysis patients like me and Bill.

[Bill Peckham]

The worry I have is that without proper activities right now staff may be reluctant to come to work OR patients will be bared from dialysis if they show any symptoms of influenza like illness.

Staff will want N95 masks. If right now units were busy fit testing the staff and giving inservices on their proper use, the staff would have confidence to face the challenges that are coming our way.

If all staff took Roberta's message to heart they would have the confidence to continue working during a wide spread flu outbreak. Without strict adherence by staff AND patients people will not trust that the dialysis unit is safe - for them or their families.

The current incenter dynamic that Peter so eloquently relates is the dynamic that will undermine the provision of dialysis during the inevitable spikes in flu cases and fear that will happen in the next four months. If patients and staff can not have confidence in each other the provision of dialysis will be disrupted.

There is a third issue: transportation. Most dialyzors rely on funded transportation to get to and from dialysis. Right now patients and drivers should be preparing to protect each other so that transportation service can be maintained. If patients were given surgical masks and told that the point of the masks is to protect the drivers and then patients started to wear masks ahead of widespread community outbreak that would build trust and help drivers to feel safe going to work.

Patients have to accept their responsibility to protect the people we rely on for dialysis - units should provide patients with the tools they will need.

[Bill Peckham]

Before this pandemic there was a lot of pandemic planning that focused on preventing illness and death. Now that we are in the midst of a pandemic many of the tactics developed in prepandemic planning has been pushed aside. It's worth remembering what was recommended we should do in this period before a vaccine is available and antivirals have limited availability (this was put together by crfullmoon):

http://www.flu.gov/faq/planningresponse/pr-0018.html
"What are non-pharmaceutical interventions as part of a community mitigation?
Some community mitigation strategies during a pandemic involve the use of medications (pharmaceutical interventions) and other actions do not involve the use of drugs or vaccines, so they are often referred to as non-pharmaceutical interventions or NPIs by health professionals.

The non-pharmaceutical interventions will be our first line of defense in a pandemic.

Examples of non-pharmaceutical interventions include:
•keeping sick people and well people apart,
•limiting contact between people by closing places where large groups of people gather,
•promoting hand washing,
•covering coughs and sneezes, and
•wearing face masks and respirators."

http://www.pandemicflu.gov/faq/planningresponse/pr-0017.html
""Community mitigation" refers to the actions that communities and Federal, State, and local governments will take to reduce the effects of a flu pandemic.

A pandemic cannot be prevented, but certain actions can be taken to help slow its spread. These actions may include:
•asking sick people to stay home and away from others,
•asking household members of a sick person also to stay home,
•dismissing children from school and
•closing child care facilities to protect children, and
•limiting direct contact between people.

Other protective measures include:
•hand washing,
•covering coughs and sneezes,
•wearing face masks (i.e., loose-fitting disposable masks that cover the nose and mouth) and respirators, and
•using antiviral drugs (drugs that fight viruses) and vaccines"

2008: http://www.pandemicflu.gov/faq/planningresponse/pr-0019.html

"What community mitigation actions would health officials recommend to help limit the spread of pandemic flu?

Health officials recommend various community mitigation actions depending on the severity of the pandemic. One or more actions may be needed.

In all pandemics, health officials will recommend that:

•People sick with influenza should stay home and away from work and the community. They may be given antiviral drugs as treatment for the illness.
•Everyone practice good health habits:
◦Washing hands with soap and water before eating, drinking, or touching the face (or using an alcohol-based hand gel if soap and water are not available).
◦Covering coughs and sneezes with a tissue or sleeve, not with hands.
◦Washing hands or using alcohol-based hand gel after coughing or sneezing.
◦Throwing used tissues away in a trash can.
◦Wearing facemasks when in crowded settings (See the recommendations for the use of face masks and respirators at www.pandemicflu.gov/plan/community/maskguidancecommunity.html)
◦Avoid crowded situations as much as possible.

In addition to the above community mitigation actions, in a severe pandemic, health officials may recommend that:
•Household members stay home if anyone in the household is sick with pandemic flu. Some household members who are well may be given antiviral drugs or vaccine to prevent illness. They may be asked to wear an N95 respirator (a type of mask that fits snugly on the face and covers the mouth and nose to minimize breathing in small particles floating in the air) while caring for someone who is sick.
•Students stay home from school. Childcare and after-school programs close. Parents protect their children and teenagers by reducing out-of-school social contacts.
•Businesses allow some people to work from home, change their work hours, or take other actions to limit contact between people at work.
•People avoid public gathering places, such as theaters and shopping malls. Places of worship, may be closed. Events such as sporting events and concerts may be delayed or canceled.
•Individuals who are feeling well may wear a facemask if they need to be in a crowded place."

>>>>>>>>>>---------<<<<<<<<<<

That was a lot of planning but now all that is being promoted for us to do is cough in our sleave and wash our hands. That's not good enough for people on dialysis or living with a transplant.

The flaw in all this planning has always been that the various degrees of response relied on an accurate reading of the pandemic's severity. The problem is that questions of pandemic severity can be answered only in retrospect.

How many people get sick, the percentage of the population (the Attack Rate), and how many of those who get sick are hospitalized and/or die, all are used to trigger the levels of response according to the plan.

Right now since there is no testing there is no way to know the pandemic's severity. NY City has not reported their hospitalizations or fatalities for over a month.

People on dialysis and living with a transplant should know that for them this is a severe pandemic and they should follow ALL non pharmaceutical interventions.

[Roberta Mikles]

Peter, and Bill:

Thank you for validating my thinking on the culture of the dialysis units, and, in fact, the reality that retaliation is alive and well, but not well for the patient . I am just shaking my head, back and forth, even knowing that a physician has experienced retaliation. This shows retaliation is not selective, but perhaps wider spread then one might believe. It is unfortunate that providers do not admit that this retaliation exists. The Networks did their 'conflict resolution for difficult patients', however, were staff truly educated on what the patient experiences, or perhaps that staff, might just be the reason for the conflict? It is not always the patient's fault. Patients have a right to protect themselves, and with more, and more, media attention to health care and preventable errors (and, flu), patients and their loved ones are becoming more educated. I have always been an ""unapologetic outspoken advocate for safe delivery of care"". I have been criticized, labeled and talked about behind my back, but the reality is that providers, be it dialysis, hospital, physician offices, etc., need to keep in mind that patients and their loved ones, have a right to be as educated as they want, as well as to ask questions and question what is being done. We have had some wonderful experiences when bringing to staff's attention the lack of effective infection control practices being implemented (a thank you from staff for telling them), however, we have also experienced the opposite. Unfortunately, in any health care setting, when one speaks up they are often labeled as 'difficult', 'problem', etc.. And, as I stated, staff should think 'what if this was my loved one, or myself?' (that is what I taught nurses in my teaching days). I am involved in an Advisory Council, at a hospital, and,.. we are focused on patients asking staff if they have washed their hands, including physicians, as well as to ask questions about their delivery of care, etc.and staff are educated as to the patient being their own advocate, or their loved ones advocating for them.
This is not to say that we have also received wonderful thoughtful delivery of care with education provided.
Roberta Mikles, RN
Patient Advocate
World Patient Safety Day
www.patientsafetyday.com
"every day is patient safety day"