Dr. Bonnie Henry, the BC Centre for Disease Control’s director of Public Health Emergency Management, couldn’t have chosen a better time to release her new book Soap and Water & Common Sense: The Definitive Guide to Viruses, Bacteria, Parasites, and Disease (Anansi). In the midst of this year’s confusion and concern among patients about the H1N1 pandemic flu and growing panic among physicians fearing a stampede to their office doors, Dr. Henry’s book issues an important reminder: wash your hands! Dr. Henry, who helped run Toronto’s response to SARS and is now on the Public Health Agency of Canada’s advisory group on H1N1 flu prevention and control, spoke to Parkhurst Exchange about what doctors need to know to be ready for the H1N1 flu.

EXPERT OPINION

PE Based on the research that's been done and your experience and intuition as someone who's seen lots of outbreaks, how serious will this one be?
DR BONNIE HENRY I think it’s going to be a bit of a paradox. Normally with influenza the see extremes of age -- the very young and the very old people -- being most severely affected. And with this pandemic, with this virus, it’s been different. From what we’ve see in the southern hemisphere particularly and the early part of what we saw here in Canada, we are seeing that mostly young people are being affected -- people under the age of 50. Usually we’re the people that don’t get so sick with influenza. For most people -- the vast majority of people -- who get sick with this disease, they seem to feel terrible for a couple of days but they get better without needing medical care. It’s a small proportion -- but because so many people are getting sick it’s a large number -- of people that end up in hospital. It’s mostly young people and a good proportion of those people end up needing ventilator care or ICU care. So that’s the dilemma we’re in. For most people it’s going to be, you know, feeling terrible for a few days but being able to recover quickly. But for a small proportion of people -- and it’s hard to predict who those people are -- they will get really sick and end up in hospital.

PE Are you among the people who think the virus will actually infect something like 40% of Canadians?
BH No, I don’t anymore. Those were the planning assumptions we used, that we’d probably see as many as 30-40% of the population getting infected -- that’s not sick with the disease but infected. What we’re seeing from the southern hemisphere and some of the outbreaks that we saw here in the spring is that it’s probably less than that, maybe around 20% of people being infected, and as many as half of them getting sick enough to need to stay home or seek medical care. I think -- can I use the word? --we are lucky in a sense that this is not a severe pandemic. Certainly there’s a small proportion of people that are getting really sick with it and we need to care for them.

PE And are we prepared to do that in Canada?
BH We can’t underestimate how important the vaccine is because it’s going to prevent people from getting sick in the first place. Because we can’t predict who those young, otherwise healthy people are who will get really sick from this disease. We can predict about half of the people with underlying illnesses will be more at risk but the other half? We just don’t know why some people get really sick so preventing the disease in the first place is the best thing we can do.

PE Besides the vaccine, what about our readiness with regard to ventilators, hospital capacity, the number of healthcare workers available even just to give the vaccine, and the anticipated burden on family physicians this fall?
BH Having been in practice I know that concern. We’ve learned a lot in the last few months and there’s a lot of work being done behind the scenes trying to help that side of things. We’ve done a lot of work in the provinces looking at what is the best way to manage this. How do we help clinicians determine who needs to be seen and who doesn’t? There are a couple of things we’ve put in place. Many of the provinces have telephone nurse lines, so we’ve developed protocols for the nurse lines that are specific to this pandemic so we can help people understand how to care for themselves at home and when they do need to seek medical care. The other thing we’ve been working on with family doctors across the country is mitigation methods. For people we know might have more severe disease, let’s talk to them now and make a plan for if they get sick with influenza. So we are working a lot with family doctors in the community and some of the clinics and hospitals that look after people with underlying illnesses like diabetes clinics or cancer care, working with the patients in those clinics, saying, “There’s a medication called Tamiflu, an antiviral medication that can help prevent you from getting severe disease.” We’ve been focusing on using our antiviral stockpile for people who have underlying illnesses in hopes we can prevent some of the more severe illness. And we’ve been across the country working on making sure we know where the ventilators are. This may be surprising but nobody’s ever tallied it up before. We’ve thought about this part of our pandemic planning, that we need to know things, you know, how many ventilators we have, how many ICU beds, and more importantly how many staff, nurses and respiratory technicians and physicians available to work. There is a much more coordinated plan in each province now. We learned a lot from what happened in Manitoba and from what happened in the southern hemisphere, particularly in New Zealand. But, you know, nothing will be perfect, but we’ve come a long way in at least making the connections and knowing how things are going to roll out.

PE What do physicians need to know about preparing their offices to prevent the spread of the flu this season?
BH We’ve been working on those. Certainly in BC we have a website on our provincial health officer’s site -- and other provinces are doing similar things -- where we’ve put up guidance for family physicians’ offices, things like talking to your staff about influenza, about what it means, about the signs and symptoms, and asking them to triage people by phone. When [patients] call in to confirm an appointment or to make an appointment, ask them if they have a fever or a cough and if they do, try and organize the schedule so people come in when there are few people in the waiting room. And if it’s a routine visit and the person is sick, can it be postponed until the person is better? Not all routine visits really can. Things like setting up your waiting area so you can separate people by around two meters since influenza is mostly transmitted by large droplets. Having the ability for people to wash their hands or clean their hands when they come into your waiting area, so having alcohol-based hand-rub or access to soap and water, having masks so that you can ask people who have a fever and cough to cover their mouth and nose while they’re waiting and while you’re assessing them.

PE Those sound like good ideas we should be using all the time, to tell you the truth.
BH [Laughs] Yes, absolutely. I’ve been through this before. This is the very same advice we told people for SARS. We do this all the time, although in a busy family practice most of the people you see are not people who have infectious diseases, so we get out of practice with it. So we need to be thinking again about it. You know, we see outbreaks of measles and we always say to people that if people are coming in with measles or chicken pox in a pediatric practice that they come in at a time of day when there are fewer people in the waiting area or you designate a time of day for assessing people with infectious diseases so that you’re not exposing others to it, especially people who may be vulnerable to severe illness. I hate to say it but it is a little bit of common sense, but it’s something we’ve got out of practice on because we’ve been so lucky for many years in not having many serious infectious diseases and a great vaccination program.

PE Do you think it’s appropriate that some of the provincial medical associations have been asking for new fee codes for doctors treating patients with the H1N1 flu?
BH I do. I think it’s very appropriate. Our province [BC] has a new fee code that’s time-limited for this pandemic because we don’t want, necessarily, people to be running to their doctors’ offices. We want them to be able to be assessed by the clinician that knows them best and determine whether they need to take antiviral medication or determine whether they do need to be seen. So the clinician can assess them over the phone and say, “No, stay home and get somebody to get the antiviral for you and start taking it.” Or can say, “I’m a bit worried about this. You need to come in so I can see you.” Or, “You need to go to the emergency room.” So I think it’s very reasonable to have a fee code for that.

PE Logic would say that if having a billing code for phone consults works during a pandemic to deal with people coming in with infectious diseases, wouldn’t it also work not during a pandemic?
BH Maybe. [Laughs] I don’t know about that. We would have to look at it how it would be used. But I do think for getting through this it’s a very important piece to help us manage this without putting clinicians at risk.

PE I ask because I think many physicians would like to have the option to bill for phone calls occasionally.
BH Yeah, and we do so much by phone we don’t get paid for. Look at lawyers, for example. Talk to your lawyer for ten minutes on the phone and you get billed for it. [Laughs] But, you know, part of it is built into other fee codes. I think there’s a lot of potential for abuse, but clinicians are professionals and should be trusted to use things appropriately. I’m a little on the fence. I do know that this time I was one of the people that advocated for this because we know there are going to be a lot more people infected than usual with influenza this year, and this is one really important strategy to help clinicians be able to cope with that and to help protect our communities.

PE Have you treated any patients yet for the H1N1 strain of the flu?
BH No, I haven’t, actually, except for my nephew. I did give advice to my sister.

PE And not to get into family relations here, but can you impart any advice based on what you saw?
BH People feel terrible with this. Influenza is not a nice disease. People who have really experienced influenza understand -- they describe it as being hit by a truck. It’s not the sniffles and a cold that are usually circulating at this time of year for most people, especially for kids. They feel terrible for a couple of days but kids bounce back quickly. It can be quite frightening for a day or two if they have a fever and are feeling very, very tired with muscle aches and headaches, which for my nephew, for example, is very unusual. Parents need to be reassured. And what are the worrisome signs? If they’re not breathing very well or having difficulty breathing or if they’re turning blue or being very lethargic -- they need to know the worrisome signs but they need to be reassured that rest is really important, keeping well-hydrated, lots of fluids. Most kids, in my experience with influenza, don’t feel like eating much, so finding something that will keep their fluids up. A lot of children who ended up in hospital in Manitoba, for example, from discussions with my colleagues, have been there because they were dehydrated. So keeping hydrated with lots of fluids that they like -- fruit juices or soups, stuff like that, can really help. Usually they bounce back pretty quickly, after a couple of days.

PE Is there any chance of doctors’ vaccination rates being dramatically higher this year than usual? I think some years it’s only around 50%.
BH If we could get to 50% I’d be really happy. [Laughs] I hope so. We do really well in long-term care homes. I think we’ve all recognized the importance of healthcare workers getting immunized to protect not only ourselves but to protect patients in long-term care homes. But we don’t do too well in other healthcare settings. We tend to be in that demographic, as clinicians, that think we are invincible to it all. This pandemic strain preferentially affects people our age -- the median age of people who end up in the ICU is 40. So this year more than ever the best way to protect ourselves and be able to look after our patients is to get the vaccine.

PE Are you going to get it?
BH Yes, I’ll be first in line.

PE Well, that’s because you guys get priority.
BH Ha ha. Well, healthcare workers are first in line. I know there has been lots of confusion -- seasonal versus pandemic, when to get it. The bottom line, to me, is we need to focus -- and most provinces in Canada have come to this decision -- that we want to focus on what is causing the most illness, and what is causing most illness right now is pandemic influenza, the H1N1 strain. Having said that, we do still see a little bit of the other circulating strains, particularly the H3N2 that’s been circulating for the last few years. It causes more severe disease in elderly people, and we’ve seen some really bad outbreaks in long-term care homes. So we need to protect from those seasonal strains too. Anybody who has risk factors from severe influenza should be getting both [the H1N1 flu vaccine and the seasonal flu vaccine]. Other than that, young people should be focusing on getting pandemic flu vaccine.

PE Your new book is about the frequently ignored importance of basic hygiene in preventing disease transmission. Doctors have been lectured about this for years and hospital systems have even tried incentives like giving away gift certificates to get doctors to wash their hands.
BH Does it make it difference? It does.

PE But is this as good as it gets? We’re far from perfect.
BH There are programs around the world that have shown you can do better. It is a little frustrating. What we have on our side in hospitals now are the alcohol-based hand-rubs. They’re really making a huge difference in prevention of transmission of infection between patients and between healthcare workers moving between patients. That is making a difference, but it’s a slow but steady increase. One of the interesting things I saw recently was a study in the States where the only difference in a hospital was an increase in hand hygiene, quite dramatically from around 30% to somewhere around 70-80%, and they saw a dramatic decrease in absenteeism from respiratory infection. So it does work in hospitals as well as in other places. And in the community we forget the basics really do make a difference, so this book is really focusing on what we can do at home and around the house and with our family. And one of the most basic things is to wash hands regularly. And if you don’t have soap and water to use the alcohol-based hand-rubs. I think we forget sometimes -- when we want something to be fixed quickly, we want the instant cure -- that the most important things we can do are prevention things, and some of them are very simple.

PE The journalist Michael Specter wrote recently in The New Yorker that it was a huge mistake to initially label this pandemic “swine flu” because of the comparison to the 1976 swine flu scare and that year’s vaccine’s side effects.
BH The 1976 fears were what actually triggered Canada to develop our on-shore capacity to make vaccines because we were reliant on a plant in the United States for vaccine development and they said, “We’re keeping it all for ourselves” in 1976 because they wouldn’t share any vaccine with any other country until they’d immunized their entire population.

PE Although in that case, when the disease never arrived and the vaccine had some rare but serious side effects, that protectionism actually turned out to be beneficial for Canadians.
BH That’s right. But it was an eye-opener that the protectionism issue would come up between the two countries, and of course it’s come up many times since, and it’s the reason we have our own vaccine manufacturing. But I agree it is a misnomer. This has not only got swine in it but also some avian genes and human genes. It’s a triple reassortment, we call it. So swine is a misnomer, and people do remember that [the 1976 vaccine problems], especially older clinicians, and the concerns that happened with that. But we’ve come a long way in vaccine development and we shouldn’t be concerned about it as much. On the other hand we do need to be very careful, and in Canada we have been very prudent, about making sure the vaccine works and is safe before we use it. I’m just hoping it will be here soon.