John C Kim and International Adoption Video

Tuesday, May 12, 2009

Many Swine Flu Cases Have No Fever - NYT ; makes it much more complicated to curtail an epidemic. The other point here is that they have to allay fears of hospital staff ,and how we reacted to spring outbreak is not heartening.

Many Swine Flu Cases Have No Fever

Published: May 12, 2009

Many people suffering from swine influenza, even those who are severely ill, do not have fever, an odd feature of the new virus that could increase the difficulty of controlling the epidemic, said a leading American infectious-disease expert who examined cases in Mexico last week.

Fever is a hallmark of influenza, often rising abruptly to 104 degrees at the onset of illness. Because many infectious-disease experts consider fever the most important sign of the disease, the presence of fever is a critical part of screening patients.

But about a third of the patients at two hospitals in Mexico City where the American expert, Dr. Richard P. Wenzel, consulted for four days last week had no fever when screened, he said.

“It surprised me and my Mexican colleagues, because the textbooks say that in an influenza outbreak the predictive value of fever and cough is 90 percent,” Dr. Wenzel said by telephone from Virginia Commonwealth University in Richmond, where he is chairman of the department of internal medicine.

While many people with severe cases went on to develop fever after they were admitted, about half of the milder cases did not; nearly all patients had coughing and malaise, Dr. Wenzel said.

Also, about 12 percent of patients at the two Mexican hospitals had severe diarrhea in addition to respiratory symptoms like coughing and breathing difficulty, said Dr. Wenzel, who is also a former president of the International Society for Infectious Diseases. He said many such patients had six bowel movements a day for three days.

Dr. Wenzel said he had urged his Mexican colleagues to test the stools for the presence of the swine virus, named A(H1N1). “If the A(H1N1) virus goes from person to person and there is virus in the stool, infection control will be much more difficult,” particularly if it spreads in poor countries, he said.

The doctor said he had also urged his Mexican colleagues to perform tests to determine whether some people without symptoms still carried the virus.

He also said he had examined patients and data at the invitation of Dr. Samuel Ponce de León, who directs Mexico’s national vaccination program.

Dr. Wenzel said that an unusual feature of the Mexican epidemic, which complicates the understanding of it, was that “in recent months five different influenza viruses have been circulating in Mexico simultaneously.”

Pneumonia rates at one of the hospitals Dr. Wenzel visited, the National Institute for Respiratory Diseases, reached 120 per week recently compared with 20 per week during the past two years, suggesting a possible relation to the swine flu.

The pneumonias that the flu patients developed did not resemble the staphylococcal lung infections that were believed to be a common complication in the 1918-1919 influenza pandemic, Dr. Wenzel said.

He said the two Mexican hospitals were well prepared for an outbreak of respiratory disease. “We have a lot to learn from the Mexican experience,” he said.

For example, when the first cases were detected and the virus seemed particularly severe, Mexican doctors activated a program to allay anxiety among staff members.

Hospital officials made it clear that they would care for staff members, offering them information, a hot line, psychological support and medical examinations.

“This aspect of epidemic response is not well appreciated in the United States in my estimation, yet is critical for success,” Dr. Wenzel said. “We haven’t put nearly enough into managing fear among health workers.”

Hospital officials had good measures to screen workers and arriving patients, including supplies of alcohol sponges for people to clean their hands. Healthy nonessential workers were told to go home. Hospital officials also made sure there were enough breathing machines and oxygen canisters for patients with respiratory distress.

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Personal Web site for John C Kim: KIDDOC.ORG

I am a pediatrician specializing in General Pediatrics, International Adoption Medicine, and in the diagnosis and coaching of families pursuing joy.