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Dr. Flu: Interview with influenza expert Greg Dworkin
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Dr. Greg Dworkin is Chief of Pediatric Pulmonology and Medical Director of the Pediatric Inpatient Unit at Danbury Hospital in Danbury CT, where he has been in clinical practice for twenty years. Dr. Dworkin serves on the Danbury city and school Pandemic Flu Task Forces and is a founding editor of Flu Wiki and its sister site, the Flu Wiki Forum. As an expert on influenza, he graciously took time out of his hectic day for this Examiner exclusive.
Steven Andrew: H1N1 better known as swine flu, has caused fewer deaths than the common cold over the last couple of months here in the US. In that light, what is it about this strain that has so many health officials worried? 
Dr. Greg Dworkin: First of all, the pandemic is just beginning, not ending. The last three had second waves and sometimes third waves, over 9-12 months or longer, so it’s too early to judge how mild it is. Second of all, the novel H1N1 virus is hitting younger people than is typical. Normally most hospitalized flu patients are over 65, but 41% of the hospitalized pandemic virus patients are older children and young adults, according to CDC. The highest hospitalization rates are in the youngest kids. Finally, although it is extraordinary enough to see flu cases in June, we don’t know yet what will happen this summer and this fall.
So break that down, what does that mean in layman's terms?
Well, flu pandemics often come in spiky waves and it's usually the second or third wave that's the worst. The second wave of the great flu pandemic of 1918 had a 30% infection rate (IR) and 2.5% case fatality rate (CFR). The 1968 pandemic was milder, but still would be classified as moderate, like the current one. So far it's way too early to say what the IR and CFR on this latest strain will be, although there's some reason for cautious optimism that it will, at worst, resemble the '68 pandemic. But if it's only a little more virulent than the 1968 outbreak, 90 million Americans would get real sick -- commerce and essential services would grind to a halt. 45 million might require medical care straining health services to the limit. And 200,000 people would never recover. So this is serious business all the way around and that's why those of us in the public healthcare community are so concerned about a second or third wave.
Is it really necessary to close schools and offices when one single case of possible swine flu is suspected?
That’s a great question, and a complicated one, because it depends where in the outbreak you are, and how severe the disease is. Early on, before it was clear the virus was milder than feared, and when it was not established in the community, school closure was a useful tool to slow community spread. But once it’s already established in a community, school closure doesn’t do as much for the community.
Is Tamiflu our best treatment, are their other, equally effective alternatives, and is there enough to go around? If there is a shortage, who decides who receives the medication and what criteria are those decisions based on?
The best treatment is not to get it, so prevention and vaccines (which are not yet available) are always the power tools in the toolbox. Tamiflu and Relenza both work, though neither is a panacea. Most patients don’t need either, though some will, especially those with underlying conditions like asthma, or conditions like pregnancy, which are prone to complications. Hospitalized patients and those with underlying conditions will get the meds, and at the moment we have enough to treat those who need it. CDC has given us guidance about who needs treatment, but the decision is made between a health care provider and their patient. We certainly may face shortages of medication, especially if people who don’t really need it use up what we have.
It seems like the World Health Organization waited an awful long time before springing into action. Is that correct, and if so, why the delay?
It does seem like that, although there was a lot going on behind the scenes. If you mean by ‘action’ the declaration of a pandemic, that did take a long time, partly because governments did not want to cause a drop in tourism during a recession. That declaration could have been made sooner. But guidance, consultation and advice to governments from WHO was ongoing. And don’t forget, they really don’t talk to the general public, they advise governments.
As a physician, what is your biggest worry going forward and where can readers keep abreast of the latest news?
My biggest worry is complacency, people assuming that this pandemic is just a bunch of media hype, that it's over, that the danger is past. Look at the table below, let those numbers sink in for a moment: even in the milder pandemic scenario, hospitals and clinics would have to stack bed-ridden patients like cords of wood, up and down the hallways, over flowing through the waiting rooms, and out into the parking garage.
We don’t know what the virus will look like in the fall, and medical facilities are swamped as it is (every day is a crisis day in your local ER.) If this strain turns out to be less virulent than those scenarios, and we all hope that that will be the case, then most people can care for themselves at home without prescription medicine, or get by with a visit to their primary care doctor. But those instructions and that information has not been widely disseminated. The best way to stay abreast of information is to check with reliable sources like CDC's flu page and your local health department. But that's information you have to go get.
Note -- Dr. Dworkin's comments are offered here for general information purposes only and are not to be taken as specific medical advice. If you or someone you know is experiencing flu like symptoms, make an appointment with a licensed physician immediately. Or, if the symptoms are severe, seek immediate emergency care.
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