Editorial
We must not underestimate an enemy like pandemic
(H1N1) 2009, especially now. This
influenza pandemic has already created havoc in
communities worldwide, including some in Canada. The
virus’s place of origin, the speed of its spread and the severity
of the illness in otherwise healthy people could not be
foreseen before the initial outbreaks, even by experts. In
addition, containment, a first step in the control of an outbreak,
has failed.
The pandemic (H1N1) 2009 virus is life-threatening for
some patients and mild for most who are infected. If the
disease continues to evolve in the northern hemisphere as it
is has in the southern hemisphere, especially in Chile and
Australia, we will probably experience a more severe resurgence
this coming influenza season. Most industrialized
countries have already put their pandemic plans into action,
to good effect. However, based on round one, we should
plan for important increases in pandemic (H1N1) 2009
cases that manifest at the two ends of the spectrum of disease
severity.
Obviously, prevention through immunization should
remain our top priority. However, we must identify vulnerable
or at-risk groups as a first step. Then, we must decide how
best to vaccinate these groups.
Canada and much of the Western world have limited experience
in conducting time-sensitive mass vaccination campaigns.
We already have problems delivering routine
influenza vaccination to vulnerable groups. For instance, in
some years only 15% of individuals in Nunavut communities
received the vaccine.1 During the most recent outbreak of
mumps among young adults among Nova Scotia, only 15%
of targeted individuals were vaccinated.2 This is the same age
group likely to be severely affected in the upcoming second
wave of pandemic (H1N1) 2009. We need to act now to overcome
these access and delivery problems.
No immunization program is 100% effective. If a sufficient
number of cases are not prevented, we can expect a
large number of young critically ill patients filling all tertiary
level intensive care beds. Unlike most seasonal influenza
strains, this pandemic (H1N1) 2009 strain seems to invade the
lower airway and alveoli, not just the upper airways, resulting
in more severe illness.3,4 The world’s experience so far tells us
that serious illness associated with this virus often manifests
as acute lung injury resulting in overwhelming hypoxemia.
Advanced life-support technologies, including high-frequency
oscillation, extracorporeal membrane oxygenation
and nitric oxide for prolonged periods are often required to
save these young lives.
All of these technologies require highly specialized care in
tertiary centres. These resources are limited and can easily be
overwhelmed. If they are, major health care institutions could
grind to a halt.
In most jurisdictions, surge planning has not yet included
how to secure experienced health care personnel and triage
specialized equipment. We will also need to make hard decisions
about who gets access to these limited resources. Now
is the time for leaders to communicate a sense of urgency in
getting modified plans finalized based on recent experiences
and rapid feedback from stakeholders.
To start, national leadership is needed in all countries. A
visible independent health care czar, with executive powers
across all jurisdictions and who is ultimately accountable to
the highest office in the country, must be in place. Then, local
leaders must be identified. All stakeholders should have clear
communication with and rapid access to experts. We need
leaders at all levels who will work together quickly and collaboratively
to solve problems such as moving equipment and
personnel from one area of a country to another as required
without barriers imposed by licensing, hospital privileges and
malpractice insurances concerns.
In countries such as Canada that have shared responsibilities
between many levels of government, collaboration and
clear communication are essential as a first line of defence.
To see that this happens, governments need to have or enact
laws to provide the necessary power to ensure rapid action on
complex issues.
A health czar should also make sure that researchers have
the money needed now to answer the urgent outstanding
questions about this emerging health threat, such as why are
specific groups are more susceptible, and to identify treatments
that work best.
The health czar needs to communicate to all sectors of
society that everyone has the responsibility to make an individual
pandemic action plan: governments at all levels
(including the municipal level), schools, daycares, businesses,
families and individuals. For instance, we should adopt the
UK approach of creating a “flu buddy” system, where individuals
partner with one another to take responsibility for
checking on each other’s health status.
This is not a time for complacency. The health czar and
other national leaders should immediately convene a summit
to link public health officials, the critical care community,
first responders, other health care providers, decision-makers,
community planners and the public, to communicate next
steps and to ensure that actions taken by leaders will work at
the ground level. While we still hope for the best, we need to
act now to deal with the worst that pandemic (H1N1) 2009
may deliver. Doing so will save lives.
Paul C. Hébert MD MHSc
Editor-in-Chief
Noni MacDonald MD MSc
Section Editor, Public Health
CMAJ
With the Editorial-Writing Team (Matthew B. Stanbrook
MD PhD, Ken Flegel MDCM MSc, Amir Attaran LLB
DPhil, Laura Eggertson BA)
Competing interests: See www.cmaj.ca/misc/edboard.shtml
Cite as: CMAJ 2009. DOI:10.1503/cmaj.091426
REFERENCES
1. Steenbeek A, MacDonald NE, Sobel I. Influenza vaccine use in Nunavut: A brief
overview of the uptake rates across the regions. Can J Public Health. In press.
2. Hatchette TF. Students, saliva and swelling: a perfect storm for the sharing of
mumps. Presented at the annual conference of the Association of Medical Microbiology
and Infectious Disease Canada, Vancouver, Canada; 2008 Mar. 1. Available:
www.ammi.ca/pdf/2008_ToddHatchette.pdf (accessed 2009 Aug. 5)
3. Munster VJ, de Wit E, van den Brand JM, et al. Pathogenesis and transmission of
swine-origin 2009 A(H1N1) influenza virus in ferrets. Science 2009;325:481-3.
4. Maines TR, Jayaraman A, Belser JA, et al. Transmission and pathogenesis of swineorigin
2009 A(H1N1) influenza viruses in ferrets and mice. Science 2009;325:484-7.
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