Canadian Medicine

As of Friday afternoon the Public Health Agency of Canada's listed 51 confirmed cases of the H1N1 flu (more on the nomenclature later).


All the cases have so far been mild and everyone who's been infected in Canada has recovered. The number of confirmed cases, however, has been rising every day.

Update: As of May 5, there were across the country, with most in BC, Alberta, Nova Scotia and Ontario.

WHAT YOU SHOULD KNOW
Physicians trying to stay abreast of all the information about the virus may have read Canadian Medicine's summary earlier this week, "What Canadian doctors need to know about swine flu".

Last night, the Public Health Agency of Canada released several sets of interim guidelines, including a document to help direct . The guidelines include advice for doctors on screening, triage, infection control precautions, and safety guidelines for doctors on how to protect themselves while examining patients.

More information for physicians and other healthcare professionals -- including infection control measures for hospitals and acute-care facilities, case reports, public health response guidance, and more -- is available on .

VACCINE NEWS
Dr Marie-Paule Kieny, the director of the WHO's Initiative for Vaccine Research, estimates that it will be four to six months before an effective vaccine can be developed and delivered, . She said the seasonal flu vaccine does not appear to protect against the H1N1 virus.

THE POLITICAL FLU
Just as physicians and nurses have kept busy of late examining and assuaging sniffling patients, so too have our representatives in the provinces and in Ottawa busied themselves with monitoring the disease, preparing an appropriate response, and politicking.

Federal Health Minister Leona Aglukkaq, who was seen as an inexperienced selection for the cabinet seat because her previous experience was as health minister of a territory with just one hospital, has largely escaped criticism and has even earned some praise. She consulted opposition health critics Dr Carolyn Bennett, of the Liberals, and Judy Wasylycia-Leis, of the NDP, about her decisions, and she's deftly deferred to her in-house medical experts like chief public health officer Dr David Butler-Jones on technical questions. The Globe and Mail that she "gracefully survive[d] her first day in the eye of the storm" earlier this week and Jan Kasperski, CEO of the Ontario College of Family Physicians, lauding Ms Aglukkaq. "Her calm vigilance now strikes us as exactly the right approach," a Montreal Gazette editorial . Ms Aglukkaq criticisms of her as being inexperienced. "I was at the territorial-provincial-federal table when we put the pandemic plan together for the country... That plan that we developed in partnership with the provinces and the territories is now in effect and working quite well in my opinion."

Ms Aglukkaq told The Globe and Mail, "In situations like this, it's very important to put aside party politics and be talking with my opposition critics, updating and briefing them on matters of this nature." That sentiment reminded me of the comments Dr Aaron Johnston, a BC family doctor who worked in Nunavut, emailed me when Ms Aglukkaq was first appointed health minister last October. "[A]lthough Leona is a Conservative MP her background is as an MLA in a consensus parliament rather than a partisan parliament," he wrote, "and perhaps that will be of some use to her in this minority government situation."

Not everyone was quite so impressed, however. Maclean's reporter Aaron Wherry Ms Aglukkaq's performance this week "a minor revelation" but tempered that by adding "[i]f only, it seems, because she would seem for now to understand how poorly prepared to manage a worldwide health crisis she —- or anyone —- may be." Mostly, Mr Wherry was struck by her openness to working with the opposition and willingness to admit a mistake given how infrequent it is to "see someone behaving like something other than a self-aggrandizing outlet for utter nonsense, let alone freely admitting one’s own limitations." Her answer to one question seemed lacking to him. "But if it lacked in substance, it lacked equally in ill intent."

Meanwhile, Rick Mercer irreverently , "The real tragedy? If the swine flu becomes a pandemic Canadians may have no choice but to find out who Canada's Health Minister is."

THE VIRUS'S NAME
A closing note on terminology, for those of you who were wondering about my "don't-call-it-swine-flu flu" coinage in the headline. Swine flu is out, thanks to lobbying efforts by Big Pork and thanks to trade and business worries from government officials.

The World Health Organization is the disease influenza A(H1NI), which, though it doesn't have quite the same visceral ring to it as did swine, is certainly more accurate considering no pigs are sick with the virus and it cannot be spread by eating pork. (The name change may also help save some pigs from being exterminated, as has happened in Egypt.)

The virus has been described in some journalists' shorthand and elsewhere as the Mexican flu. Even Prime Minister Stephen Harper was using the phrasing. The Mexican flu usage, however, has been assailed on multiple fronts. One free-trade critic that Mexico is not alone in the blame for the hazardous conditions at pig farms that are suspected by some of spreading the virus. "You might call this the 'NAFTA flu,'" said Common Frontiers coordinator Rick Arnold, alleging that multinational corporations took advantage of lax regulatory conditions in Mexico. Others -- with a rationale less political than realistic -- have similarly suggested calling it the North American flu.

Craig MacFarlane, a lecturer in the Carleton University department of law and sociology PhD candidate, made a different argument for not calling it the Mexican flu. "Those of us who study animals know that there is a strong connection between the treatment and representation of animals and other forms of human discrimination," he . Calling the disease the Mexican flu amounts to a slur on Mexicans, he argued. "Carol Adams (The Sexual Politics of Meat) has profitably explored the relationship between sexism and animal use; Charles Patterson (Eternal Treblinka) and Boria Sax (Animals in the Third Reich) have pointed out the connection between industrial agriculture and the Holocaust; and Marjorie Spiegel (The Dreaded Comparison: Human and Animal Slavery) has looked at the connection between racism and animal use. And, of course, Upton Sinclair’s The Jungle should not be forgotten."

Of course, plenty of people haven't been able to resist making light of the serious situation, suggesting names like "", "", or, along the same lines as Mr MacFarlane's analysis, "".

National and international health officials have ratcheted up the warning levels about the A/H1N1 swine influenza. The World Health Organization raised its influenza pandemic alert from phase 3 ("Predominantly animal infections; few human infections") to phase 4 ("Sustained human to human transmission"). "The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable," said WHO director-general Dr Margaret Chan in .

Update, Wednesday, April 29: The WHO announced today that the swine flu is expected to become a pandemic and raised its alert level to phase 5 on the , which indicates the early stages of a pandemic with "widespread human infection." "All countries should immediately activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia," said Dr Chan in . "At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities."

On Tuesday alone the number of laboratory-confirmed cases of swine flu in Canada rose from six to 13, with more under investigation. Cases have now been confirmed in BC, Nova Scotia, Ontario and Alberta. The chief public health officer warned that the disease is likely to kill some Canadians. "We will likely see more cases, we will likely see more severe illnesses and we will likely, unfortunately, see some deaths as well," Dr David Butler-Jones in Ottawa. "We hope not, but it is a normal part of an influenza outbreak."

To prevent the spread of the disease, people who suspect they might be infected have been warned to see a doctor immediately. Are physicians prepared to deal with suspected cases of swine flu? Several provinces have already published instructions online to guide physicians in dealing with a patient suspected of carrying the swine flu virus.

Ontario has produced the most comprehensive set of guidelines for physicians. After an initial notice to doctors last Thursday, the province's Ministry of Health and Long Term Care published on Sunday. "" (PDF) emphasizes the importance of following good infection control and hand hygiene practices, and encourages doctors to post (PDF) to remind patients to be aware that they could spread respiratory illnesses if they have the flu. Patients who present with flu-like symptoms should be given masks, asked to use alcohol hand cleansers and separated from other patients and staff if possible.

If patients with flu-like symptoms have travelled to Mexico recently, they should be examined by clinicians wearing fitted N95 respirators, eye protection, and gloves and a gown "when there is a risk of contamination with respiratory secretions."

The Ontario guidelines recommend following the BC Centre for Disease Control's (PDF) for treatment of this year's influenza strains. First-line treatment should be zanamivir, not oseltamivir, despite the fact that swine flu has been shown to be sensitive to oseltamivir. (That recommendation may change if more cases appear in Canada.) Treatment must be started within 48 hours of the time symptoms appeared, the guidelines say.

A huge part of any infectious diseases response is reporting and surveillance. To that end, the Ontario guidelines ask doctors to report suspected cases to public health officials: "Clinicians are advised to report individual cases of ILI with a travel history to an affected area to their local public health unit." (The only affected area so far is Mexico.)

Quebec also strongly advises that all patients who have flu-like symptoms wear a mask and be particularly vigilant about maintaining good hand hygiene practices, particularly in healthcare facilities. The Ministry of Health and Social Services recommendations also agree with Ontario's suggestion to doctors to wear eye protection, a mask and gloves when examining patients with flu-like symptoms. The patient should be quarantined. These precautions should last for a minimum of seven days since the symptoms first appeared, the Quebec guidelines say, though that time period may have to be extended for children and immunocompromised patients.

Quebec's Ministry of Health and Social Services also released a copy of its guidelines on how to operate a hospital during an influenza pandemic, as a precauation. The document is available (PDF), in French only.

Nova Scotia published a very basic set of questions and answers for health professionals, available (PDF). The document estimates the virus's incubation period at two to nine days and encourages travellers to Mexico to get this year's flu vaccine before they leave (though it's not yet known whether there is cross-protection against the swine flu).

Canadian doctors may find it useful to keep handy a copy of the . Annex G, "Clinical Care Guidelines and Tools," provides an extensive, thorough explanation of many of the practical things you may need to know.

The full document is available (PDF).

Educated in Nova Scotia before she moved to the United States to do degrees in biblical studies and medicine, Dr Val Jones is now one of the most popular physician bloggers. Her work has appeared in MedPage Today, Revolution Health, a now-defunct blog called Dr. Val and The Voice of Reason and, most recently, her own internet company .

Last year, Dr Jones was accredited as a member of the National Press Club in Washington, DC, and has focused much of her recent reporting on health policy reform efforts. She still practises medicine part-time as a rehab specialist at Walter Reed Army Medical Center. Dr Jones is also a talented cartoonist and ' take on medicine displays a sharp, wry sense of humour.

This week, Dr Val agreed to answer some questions for Canadian Medicine:

Canadian Medicine: Did you know as an undergrad at Dalhousie University, in Halifax, Nova Scotia, that you wanted to be a physician?

Dr Val Jones: Dr. John Schullinger, a pediatric surgeon at Columbia University College of Physicians and Surgeons, saved my life as a baby, and he kept in touch with my mom via Christmas cards every year. I grew up admiring him greatly and wanting to "give back" and maybe save other babies as a way to thank him. I got side tracked here and there, but eventually ended up in medical school at Columbia with him as my mentor. It was very touching for me, though I feel a little guilty that I didn't become a pediatric surgeon.

What inspired you to move from Nova Scotia to Texas?

I had a spiritual awakening in college, and became a Christian. I went to Texas to get a Masters' degree in Biblical Studies in an effort to learn more about the history of my newfound faith. I worked as a youth minister in Texas for a short time, and then went on to do research at the Mayo Clinic before medical school. I'm a bit unusual in that I'm fully committed to science-based medicine and also maintain moderate religious views.

You’ve been among the most popular medical bloggers for the past few years. What do you attribute that to?

Endurance. I'd like to say it's because I've got "mad skills" but honestly, it's probably more related to the fact that I have the stamina to write something original every day for years on end. I'm also a social creature, so I enjoy leaving comments on other peoples' blogs and participating in social media on a regular basis.

Do you still practise medicine? Do your patients ever mention things you’ve written?

I volunteer as a rehab physician at Walter Reed Army Medical Center about once a week. Unfortunately, I haven't yet met a soldier who's read my blog. However, the Deputy Director of Communications for the National Museum of Health and Medicine (on the Walter Reed campus) found me on Twitter and gave me a guided tour of the museum. That was a real treat. I blogged about it .

Any advice for doctors who are interested in getting into writing and/or blogging?

Just try it and see if you like it. Blogger is free, or you can create your own website at very little cost. And if you find that you enjoy it and want to do it regularly, you can join a network like Better Health to enhance your traffic and amplify your voice.

In addition to your writing career, you’re also draw medicine-themed cartoons. How did you get into that?

When I was working at Medscape one of the editors complained about the lack of good medical cartoons. I'm a problem-solving kind of person so I figured I'd try my hand at cartooning (I always liked to draw). I came up with the cartoon series idea and it became a big hit -- I've even had my work featured at medical conferences and at the National Press Club. I wish I had time to do more of it.

You started a company and blogging website called Better Health last year, which has seen you following healthcare reform political events in Washington quite closely. What’s your best guess on where the healthcare in the US is headed?

It's headed towards rationing. There's just no way around it. Everyone is going to have to tighten their belts, and figure out how to do more with less. That doesn't sit well with the American psyche.

Would you like to see the US adopt a Canadian-style single-payer system?

Actually, I wouldn't. I think we're going to have to find a "uniquely American" solution. I'd be happy to have primary care delivered by low cost, cash-based medical practices (like Doctokr Family Medicine), make sure everyone has at least a high deductible sickness insurance plan, and have the government subsidize care for the very ill or very poor. Employers can also incentivize healthy lifestyle choices -- this has been working well for Safeway and Caterpillar for example. The trick is to make sure that no one stakeholder has too much power - so the system doesn't exist to serve their priorities, but the needs of patients.

Is healthcare in Canada still demonized in the US to the extent it was in the 1990s? There was a touch of that just recently when opponents of universal healthcare shoehorned the death of actress Natasha Richardson into the public-vs.-private paradigm.

I haven't noticed any demonization. I think the perception is that the Canadian system isn't a great model - that there are long lines for care, that people are crossing the border when time is of the essence, and that the provincial governments (rather than physicians and patients) are determining how and when care is provided. I don't know if most Canadians would agree with that description. But one thing I can tell you -- the US should definitely look to Canada for legal reform. In a recent , I learned that frivolous lawsuits are charged to the plaintiff's account, that judges set awards (not juries) and there are caps on payouts. If the US adopted that approach to legal matters, I'm sure we'd save billions a year... which, if we were smart, we could invest in getting more people access to affordable, quality healthcare.