FeedRSS Feed
October 19, 2009 13:44  by Dr. Neil Rau

Recent media attention has focused on the findings of a Canadian study published in the Journal of the American Medical Association, which profiled the ugly face of H1N1. This study, which reported on otherwise healthy women having died from this disease in Canadian intensive care units (some pregnant, many others not), made headlines last week.

It’s important to reflect on a key limitation of this study: it was not intended to look at the population as a whole. Instead, it described the most severe cases observed and treated in a referral centre with a huge catchment area (most of Manitoba, and some of Northwestern Ontario). Many “otherwise healthy” patients had underlying risk factors for a bad outcome, such as obesity or asthma. So to extrapolate from this study that otherwise healthy women are at high risk of severe disease, or that women are at greater risk than men, is nothing more than misleading.

While the virus is making a comeback in British Columbia, flu activity is remarkably cool in Canada overall -– so far, the second wave has no semblance of 1918, 1957, or even the mild pandemic of 1968. (I often wonder if the WHO will ultimately downgrade the current pandemic from “moderate” to “mild”, as it continues to underperform these previous pandemics, some of which have been called “mild”). No mass absenteeism has been observed with the current second wave, and despite dire predictions to the contrary, no one has been left to languish in hospital hallways for want of intensive unit care. Fewer than a dozen Canadians have died during the second wave, but these are early days still.

The Australians just finished facing H1N1 “full blast” without a vaccine in hand. While a few unfortunate expectant Australian women did succumb to H1N1, the actual numbers were not staggering, even if slightly worse than seasonal flu. Yes, a vaccine, had it been available to Australians during their first wave, may have averted some of these deaths. For the same reason, it follows that the vaccine should be available sooner rather than later for Canadians to address the current wave. It takes two weeks for the vaccine to protect, so the vaccine needs to get off the shelves and into peoples arms as soon as possible.

All the same, there’s more good news out there: the virus has not changed! It has not acquired new genes to make it more virulent or deadly. It has not “drifted” from its original form to render current vaccine production ineffectual. Despite sporadic reports of resistance to antivirals (specifically Tamiflu®), resistance has not become widespread. Good stewardship and the limited use of antivirals keeps it as a viable option to be deployed for severely afflicted individuals at this time.

So what should pregnant women do? It’s still not clear. We also don’t know if expectant mothers will have access to the non-adjuvant form of the vaccine at the same time that the adjuvant form becomes available.

Option A:  Do nothing. Although pregnant women are at four times the risk of severe H1N1 disease as compared with the general population, the decision to receive the vaccine still depends on the perception of this nonetheless small risk. The same relative increased risk of severe disease in pregnant women has long applied to seasonal flu, yet only 1 in 7 pregnant American women routinely obtained the seasonal flu vaccine until now. Given that H1N1 compares similarly to seasonal flu, the otherwise healthy might reasonably choose to take a pass on the vaccine altogether, and visit their doctor for an antiviral prescription if a typical flu-like illness develops and does not improve within 48 hours.

Option B (cautious approach): Pending availability of non-adjuvant vaccine, obtain an advance prescription or supply of an antiviral drug (e.g. Tamiflu®), to be taken in future in consultation with the treating physician (The Canadian Society of Obstetricians and Gynecologists has made this recommendation). Self-prescription certainly has its flaws, and is the antithesis of good drug stewardship. 

Option C (even more cautious): Option B plus get whatever form of vaccine becomes available - sooner rather than later, especially if flu activity is picking up.

While Canadian expectant women waiting longer than their American counterparts for a vaccine makes for bad optics -- giving the vaccine to the most vulnerable sooner rather than later will make good on a huge investment and effort.  Bad optics aside, the disease has not changed and mass casualty will not ensue -– vaccine or not.

Please Add Comments (6)    E-mail this    Permalink

Comments

Add comment


 
  Country flag

Click to change captcha
biuquote
  • Comment
  • Preview
Loading




Dr. Marla Shapiroclose [x]

Dr. Marla Shapiro, MDCM CCFP MHSc FRCP(C) FCFP, is a family physician and the Health and Medical Contributor for CTV's Canada AM as well as the editor of Parents Canada magazine, launched in March 2007.

She completed medical school at McGill University and trained at the University of Toronto for her Masters of Health Science in Community Health and Epidemiology. She holds a Fellowship in Family Medicine and is a NAMS credentialed menopause specialist. She is an associate professor in the Department of Family and Community Medicine at the University of Toronto, where she recently won an award for Creative Professional Activity.

Dr. Shapiro won the Society of Obstetricians and Gynaecologists of Canada/Canadian Foundation for Women's Health Award for Excellence in Women's Health Journalism in 2006 for her documentary "Run Your Own Race." Her book, "Life in the Balance: My Journey with Breast Cancer" was released in the fall of 2006 and is a national bestseller.

For her lifelong commitment to family medicine, Shapiro was awarded the College of Family Physicians of Canada's Award of Excellence for 2008.

Angela Mulhollandclose [x]

Angela Mulholland is the editor of CTV News' semi-weekly health newsletter MedNews Express as well as the MedNews Express Blog.

She has been a journalist for CTV News since 2000, covering current affairs, health and entertainment for CTV.ca. Before CTV, she worked for CBC.ca for two years.

She has a degree from St. Jerome's University in Waterloo, ON, and studied journalism at Sheridan College in Oakville. She lives in Toronto with her husband and two children.

Monica Matysclose [x]

Monica Matys has been the health and wellness reporter for CTV News Toronto since 2001. Her feature health report, Lifetime, can be seen on CTV Toronto's News at Noon and at 6 p.m.

Her interest in the medical field began while working for a medical publishing company as the editor of a monthly magazine. One of Monica's favourite days on the job was the time she got to spend a day in Credit Valley Hospital's Emergency unit. "It really opened my eyes to the strains on our system," Monica explains.

Matys grew up in Scarborough, and has an honours degree in Journalism from Carleton University in Ottawa. She lives in Toronto with her husband and two children.

Avis Favaroclose [x]

Avis Favaro has been with CTV News since 1992, producing stories for CTV National and CTV News Channel - Newsnet- as well as for CTV affiliate stations across the country.

Avis and producer Elizabeth St. Philip won the 2008 Media Awards for Excellence in Health Reporting handed out by the Canadian Nurses Association and the Canadian Medical association for a story on BPA found in food cans.

She has been nominated for an impressive 12 Geminis, winning once for a unique story on an experimental cancer treatment developed in Winnipeg in the 1940's.

Avis has a masters in journalism from UWO and a Bachelor's degree in History, and launched her journalism career as a writer/reporter at Global in 1982.

Dr. Yoni Freedhoffclose [x]

Dr. Yoni Freedhoff, MD CCFP Dip ABBM, is the founder and Medical Director of the Bariatric Medical Institute in Ottawa, a multi-disciplinary behavioural weight management program. Formally trained in family medicine, since 2004 his practice has been exclusively dedicated to the treatment of overweight and obesity.

Dr. Freedhoff has been referred to as a "nutritional watchdog" by the Canadian Medical Association Journal and a national "obesity expert" by the Canadian Obesity Network. His advocacy efforts for improved public policies regarding nutrition and obesity have found him testifying in front of the Canadian House of Commons, giving press conferences with the Ontario Medical Association, commenting regularly in the national media, and as a sought after lecturer.

Dr. Freedhoff explores issues pertinent to nutrition, obesity, public policy and advocacy in his daily blog Weighty Matters which is ranked among the world's top health blogs and was voted the top Canadian health blog of 2008 by the Canadian Blog Awards.

Dr. Grant Lumclose [x]

Dr. Lum is a sports medicine physician. He is the medical director and founder of Athletic Edge Sports Medicine, a multidisciplinary sports medicine organization offering services to the athletic and active public.

He is involved in the care of recreational, elite amateur and professional athletes, including players in the NHL, NFL and NBA. He is also involved in the performing arts medical community, taking care of musicians, vocalists, dancers and other performing artists.

Dr. Lum studied medicine at the University of Toronto, where he graduated in 1992. He completed a two-year residency in Family Medicine, and then specialty training in Sports Medicine.

He is a lecturer at the University of Toronto's Faculty of Medicine, an adjunct professor at York University's Faculty of Fine Arts, and medical director of George Brown College's Fitness and Lifestyle Management Program.

Dr. Lorne Brandesclose [x]

A senior oncologist at CancerCare Manitoba, Dr. Brandes received his MD from the University of Western Ontario in 1968.

Following post-graduate training at the Royal Marsden Hospital (London) and the University of Manitoba, he joined the faculty at U. Of M. in 1975, where he is a professor in the Departments of Medicine and Pharmacology.

He is also affiliated with the Manitoba Institute of Cell Biology.

Dr. Katy Kamkar, Ph.D., C. Psych.close [x]

Dr. Katy Kamkar, Ph.D., C. Psych., is a Clinical Psychologist at the Work, Stress and Health Program/Psychological Trauma Program, at the Centre for Addiction and Mental Health (CAMH). She also provides private practice at the CBT Associates of Toronto and is a lecturer in the Department of Psychiatry, University of Toronto.

She completed her Honours Degree in Psychology and Mathematics at York University and her Masters and Ph.D. in Clinical Psychology at Concordia University. She also completed a Clinical/Research Postdoctoral Fellowship at CAMH. She has received numerous academic awards and distinctions.

Kamkar provides consultation, comprehensive assessments, and evidence-based Cognitive-Behavioural treatment for Mood and Anxiety Disorders, including psychological distress related to stress and anxiety in the workplace. She also provides training, education, and supervision as well as various educational seminars and workshops. She adheres to a scientist-practitioner model of practice and integrates research and science with practice.

One of Dr. Kamkar's greatest interests has been to provide education to enhance public awareness of mental health/illness in general and of psychological distress in the workplace. She has written articles for comprehensive public resources and provided numerous public relations - media work.

Dr. Neil Rauclose [x]

Dr. Neil Rau grew up in Ottawa. He initially studied mathematics at the University of Waterloo before completing his MD at the University of Toronto in 1991. He completed training in Internal Medicine and Infectious Diseases at McGill University in 1996, before establishing a busy private practice in Oakville. He is currently the medical director of Infection Prevention and Control at Halton Healthcare Services.

In 2008, he completed his training in medical microbiology at the University of Toronto and he now serves as the medical microbiologist and chair of the patient safety steering committee at his hospital.

He is a lecturer at the University of Toronto. Since 2008, he has also been Infectious Diseases section head at the Association for Medical Microbiology and Infectious Disease Canada. He is also a frequent contributor to CTV News.

He lives in Toronto with his wife and two children, and is an avid amateur concert pianist.

Cara Rosenbloom, RD close [x]

Registered dietitian Cara Rosenbloom believes that nutrition can make a difference in overall health and wellness and enjoys translating complex nutrition information into usable and helpful advice.

Rosenbloom holds a literature degree from the University of Western Ontario and a Bachelor of Applied Science in Food & Nutrition from Ryerson University. She completed a dietetic internship at North York General Hospital to become a registered dietitian.

Prior to becoming a nutrition columnist, Rosenbloom worked as a dietitian at The Hospital for Sick Children for three years. She is a member of Dietitians of Canada and the College of Dietitians of Ontario and the president of Words to Eat By, a nutrition communications company.