The good news is that the vast majority of the pandemic H1N1 flu cases in Canada have been mild and the number of fatalities has been held to fewer than 70 as of late summer. The bad news is that we probably haven't seen the worst of it yet.

Dr. David Butler-Jones, the nation's first Chief Public Health Officer, is leading the Public Health Agency of Canada's preparations for the anticipated second wave of pandemic H1N1 flu, expected to arrive this fall with the potential to cause far greater damage than the virus has caused so far. He spoke with Parkhurst Exchange about what physicians need to know.

EXPERT OPINION

PE What should we expect this fall with regard to the number of pandemic H1N1 flu cases in Canada?
DAVID BUTLER-JONES It’s a bit of anyone’s guess. The flu is unpredictable, but given what we’re seeing in the south and what we’ve seen here, it’s almost certain that it will be back and it will, if not dominate, be a big part of this coming flu season. But almost certainly it will dominate. Look at Chile, where it’s displaced all other types of influenza viruses.

PE How should doctors prepare to deal with that kind of prevalence?
DBJ Well, in general, the severity is similar to annual flu, but then there is a small percentage that attacks young, previously healthy adults who go very quickly from being well to severely ill with sort of overwhelming pneumonia. So part of it is being able to discern between those who need a routine kind of care and those that are obviously unusual and getting sick quickly and need to be hospitalized and have more intensive attention. The other thing is that with any pandemic part of the issue is sheer numbers. It’s not so much that the disease itself is more severe than a bad annual flu, but rather than 10-15% of the population you have 25-40% of the population affected. So, much larger numbers. So being able to, both in terms of the work that we do in public health and government in terms of advising the public on what to do, being able to deal efficiently with what we see, is just like in any flu season, but it’ll be magnified in terms of the numbers.

PE Are you concerned that it’s going to be a struggle for Canadian doctors to keep up with the flu this fall? It’s been a struggle for a lot of doctors to keep up with their patient loads over the past few years, even without a pandemic.
DBJ It’ll be a challenge, but that’s part of why we are working together across the public health system and the healthcare system to make sure we can minimize the impacts and the disruption. Hopefully -- well, I guess there are two things. One is having the antivirals in place, which does two things, one of which is it reduces severity and the consequences of it, and also reduces the amount of spread potentially in terms of how long someone is infectious to other people. That will help. Ultimately having a vaccine is the only thing that will actually stop a pandemic. Or time. [Laughs] At least for Canada we are in a better position than just about any other jurisdiction. It’s going to be a challenge for everybody. You can’t underestimate it, whether it’s like a nasty regular flu year or it’s more than that -- at this point it’s hard to predict.

PE And from your perspective, you have to prepare for the worst.
DBJ You have to prepare for everything and adjust accordingly. The plans were all based on sort of moderate to severe and what we saw was sort of mild to moderate, other than the less common but very important severe disease in healthy people. You have to adjust to that. In the spring we didn’t want to -- other than for those at high risk of severe complications -- we didn’t want to use lot of antivirals because we didn’t want to risk resistance, particularly at the end of the flu season. The fall will be different and I expect we’ll be much more liberal with antivirals. So we’ll see. We’re sort of working through all that at the moment.

PE I want to return to the topic of the severe class of flu cases that you mentioned. In a conference call with reporters in June you mentioned there were then about 500 severe cases in the country. Do you think the proportion of very severe cases will rise this fall or will physicians continue to see predominantly young people whose flu cases are relatively mild?
DBJ I expect it will probably be a similar percentage in terms of a small proportion of the total.

PE But that absolute number will be much higher...
DBJ That ought to really create a challenge for ICUs, et cetera, right? Like, most ICUs in hospitals have however many ICU beds and ventilators, et cetera, and you get double the usual [number of cases requiring intensive care] and they’re going to be hard-pressed, so that’s one of the reasons that hospitals, health regions and others are really planning for how they actually deal with an increased number. Though hopefully, again -- and back to what we were saying earlier about the use of antivirals in early treatment and ultimately a vaccine, hopefully before we get into the worst of the flu season, will certainly mitigate that -- anyways, it’s something they need to be able to -- well, you can’t plan for everything but you need to actually be able to plan for the possibilities of what we’re seeing. And hopefully we’ll see a lot less but you don’t want to be caught on the other side.

PE There is obviously some concern that the H1N1 flu vaccine isn’t supposed to be ready for distribution until November. Will Canada’s stocks of Tamiflu and Relenza be sufficient to keep the spread of the flu under control until then?
DBJ Firstly, it’s hard to say exactly when it will return. We’re still seeing some virus circulating, though much less than we were seeing, say, a month or two ago. So when it will resurge is unpredictable. Normally we don’t see a lot of influenza activity until just sort of starting in November and then picking up particularly after Christmas, sort of peaking in January, February. Whether we’ll see a great increase early or not -- it’s hard to predict at this point. But in terms of your question around Tamiflu and Relenza, we do have in stockpiles, we think, sufficient to treat those who need and want to be treated, assuming that the antivirals are, in fact, effective, and so far they are. There have been a few cases of resistance around the world, but certainly not widespread yet. There’s one in Canada so far. On the other hand, the seasonal H1 is pretty universally resistant to Tamiflu, so how long we will actually have that as an effective treatment is hard to say, but we do also have stockpiles -- not as much, but we do also have stockpiles -- of Relenza that could be used in the most severe cases.

PE Is there any support available to physicians who work outside of hospitals, in private practice? Public Health Agency guidelines have suggested increased use of masks, gloves, alcohol-based disinfectant gels, and those sorts of things. Are those being distributed to doctors?
DBJ Well, there is certainly lots of information out there, and newspapers will be stepping up again in the next month in preparation for fall. Docs can go to the web for guidelines. For physicians, I mean, it’s their own practice, right? It’s private practice. So in terms of what they have -- there are several things that are quite prudent in a basic office. Making sure you have handwashing facilities and you wash your hands regularly through the day, Having a gel dispenser or whatever is not expensive and it’s simple as a supplement for patients, staff, et cetera -- it doesn’t replace handwashing but it’s a very useful supplement. Having masks -- just regular surgical masks, which, again, are inexpensive and in this situation where it’s droplets as opposed to airborne spread of the virus, work just as well as the N95 respirators for this kind of setting, and so having those ready to hand out so if a patient does happen to come in with a cough that reduces the risk to others. But handwashing and keeping your hands away from your eyes and nose and mouth is the best way [to prevent transmission].

PE What I’m hearing is that doctors shouldn’t be expecting to spend a lot of money on respirator masks or other fancy equipment.
DBJ No, no. Generally, you need to have some. You don’t need a lot, but if you are doing an aerosol-generating procedure, which is unlikely in the general practitioner’s office -- if you are intubating or on positive pressure or those kinds of things -- or if you have uncontrolled cough in a patient, then it’s a different thing, and the guidelines are on the web. But in general for most physicians’ practice, that is not going to be a big issue. People need to remember that the mask alone is not enough. If you come in contact with the virus and then you rub your eyes or put your fingers in your mouth or whatever -- I mean, that’s a lot of the way we actually spread this virus. So keeping hands washed and keeping them away from your face is pretty critical with or without a mask. And then even how you put the mask on or take the mask off, if you are handling the mask and then you rub your nose or your eyes, then, again, you’ve just transferred the virus from the mask to yourself.

PE There’s been a very worrying amount of H1N1 flu spread through some First Nations communities on the Prairies, particularly in Manitoba. What do doctors in those communities need to know about treating First Nations patients
DBJ Well, it’s actually not something that seems to have been duplicated elsewhere, so whether it’s an issue because of early spread of the virus or just exactly what all the factors are, so far is not clear. It’s not that First Nations people are more likely to get the virus, but in Manitoba certainly they were a higher proportion of those who were severely ill. What we don’t know at this point is if there is a genetic factor that may contribute, or is it obesity, diabetes, underlying chronic disease, smoking, which all clearly increase the risk of severe disease? And unfortunately those factors are also higher in some communities. You’d see one community hard-hit and then the neighbouring community less so, which is actually quite typical of influenza, from 1918 on from there where you’d have quite a spectrum, one community hard-hit and in the neighbouring community, with every factor similar as far as we can tell, not as hard-hit. So those things we don’t understand. The main thing: clearly, underlying social conditions have an impact on all infectious diseases. So, living in crowded conditions -- whether it’s in downtown Toronto, Winnipeg or northern Manitoba or Ontario -- crowded conditions increase the likelihood of spread, just by close contact, et cetera. And underlying social factors, either because of chronic disease conditions or other factors or just by poor health generally, can increase the risk of severe disease, and -- whether it’s infectious disease, chronic disease, whatever -- the impact on the poor and the marginalized is harder than it is on others, and influenza is no exception to that.

PE That being said, do you think it would be prudent for doctors in those communities to devote special attention to those people -- who, like you said, could very well be in downtown Toronto as well as elsewhere -- when it comes to considering prevention and prophylaxis?
DBJ It’s not an issue of race, but any person who is for whatever reason marginalized or disadvantaged will have bigger challenges and they deserve more attention.

PE Do you think it might be worthwhile for doctors whose practices have electronic records, for instance, to search for and try to identify the population that need more attention, and to call people in?
DBJ I’m not sure how practical that would be. Anyone with underlying factors -- lung disease, heart disease, diabetes, obesity, like a BMI over 30, or pregnant women -- have been shown to be at greater risk of severe disease. And so if you have influenza-like illness, like fever and cough and muscle aches and that kind of thing, then early treatment is certainly worth considering -- now or in the fall. So if you have patients like that, when they present -- you can’t really do much to call them in, but hopefully people are getting the message that if have you have underlying chronic conditions, then, at the very least, considering treatment with Tamiflu or Relenza is definitely something that’s worth doing. Now, it may not be warranted in all cases -- that’s an individual clinical decision -- but they are at high-risk and so that [early treatment] is something that you can do. The other thing is that anybody who has worked extensively with populations that have more challenges, whether it’s in the inner city or remote areas, knows that you have to adapt your procedures to that community and knows that they face challenges that, yes, someone in suburban Toronto who is more affluent is less likely to face. But, again, it’s about likelihood -- it’s not about one or the other. So having your antennae up is certainly worth it, but clearly there’s no reason to discriminate. There’s never a good reason to discriminate, but be conscious of your patient and circumstances. I remember when I trained in the ’70s -- and I’m sure it was true back in Osler’s day -- recognizing that not only the patients and what they present with, but the circumstances in which they live, how they live, where they live, is an important part of our understanding as physicians and our ability to provide either effective treatment or prevention. So I’d keep it in that kind of focus. The other is that, as we’ve been doing for remote communities, et cetera, your threshold in this case, for influenza, for early treatment will be lower than when you are close to a hospital. Because if you miss it then they’re being flown out, and many of these communities have high rates of underlying chronic diseases, and so spending a lot of time who doesn’t have that? You might as well just treat them.

PE How will the Public Health Agency’s consideration of those kinds of underlying social conditions that you mentioned, for instance in the remote communities that seem to be more prone to a fast spread, influence the decision-making process on vaccine priority?
DBJ It’s part of risk assessment. We haven’t finalized it. At least in terms of vaccine priority, we already know we don’t have to actually have that decided until we have the vaccine to give to people, so we are watching very closely what is happening elsewhere in world so that we can take advantage of that experience in guiding the priorities. We’re fortunate in Canada in that those other countries have to prioritize and signal their priorities now because most of their population will not have access to the vaccine because they won’t have enough vaccine. In Canada we should have enough vaccine to provide for everybody who needs it and those who want it, so that’s not an issue for us. We will be prioritizing as information comes along and we’ll adjust accordingly. But clearly certain groups, logically, we know there’s a high risk in certain chronic diseases, severe obesity, pregnant women, and the impact in northern remote communities particularly, is going to be greater. And the north will tend to get flu a bit earlier because the winter comes earlier. So all of that will be factored in. But in terms of treatment, obviously anybody with moderate to severe disease, we know many of the risk factors now, not just for seasonal influenza but in addition for this one [pandemic H1N1 flu]. Obesity, for example. Over 30 BMI, early treatment is certainly worth considering.

PE It’s our understanding that the provinces and professional associations will not -- and, indeed, cannot -- mandate vaccinations for medical professionals, despite the WHO’s declaration of a pandemic. Two questions: Do you think a mandate would help, hypothetically speaking? And do you think a mandate is ethically defensible?
DBJ We’ve kind of gone around that a few times and generally courts have not supported compulsory immunization for healthcare workers. It is, at the end of the day, an issue of choice. It’s prevention, not treatment. That being said, I think every professional body encourages its members to be immunized. The reality is if I am not immunized and I get the flu, I kill my patients. I mean, that’s the reality. We’re the ones -- doctors and nurses -- who take it, by and large, into the nursing home, and spread it around. The fact that we are lucky to get 50% of our colleagues to actually take the vaccine -- it’s just amazing, when you think of it. I mean, it’s different if you have a contraindication or whatever, but in so many other realms if you basically give a noxious agent to a patient and kill them, that’s malpractice. And yet a totally or largely preventable disease that we then carry and share with our patients, somehow that’s okay? I don’t think that’s okay. At the end of the day, it’s a matter of choice but my hope is that unless there’s a reason not to, basically why would we not, as physicians or nurses or healthcare workers, why would we not protect not only ourselves but our patients and families and friends?

PE Legal questions aside, do you think a mandate is ethically defensible?
DBJ It’s a hypothetical. The ethics of how do we justify not being immunized as an individual physician who cares for patients, or a nurse or whatever, how do we rationalize not being immunized? That, I don’t understand. Given that we have an average of 4,000 premature deaths every year in Canada from influenza, the vaccine is available for healthcare workers, it’s exceedingly low-risk, and it could save a lot of lives. So why do we agonize about all kinds of other decisions that have far less impact than the simple action of being immunized to protect ourselves and others?

PE So do you think it’s ethically defensible?
DBJ Well, the courts have ruled otherwise. I mean, the ethical position would be: Why would I not do anything reasonable? I don’t go drunk into surgery, so why would I not be immunized against a disease that could kill my patients? So the ethics of care and reason -- it’s not an extraordinary kind of a thing. It’s a very simple thing and extremely low-risk. I’ve chosen to be in a profession that is intended to improve the health of the people I work with.

PE I seem to recall that when I worked in childcare in Massachusetts when I was younger, I had to get the flu vaccine as a requirement for my job.
DBJ And some U.S. universities wont accept you unless you’ve had immunization against measles. Certainly, it’s ethically defensible to require that as a condition of employment, because, again, it’s an issue of protection of patients. So that’s defensible. So far, the courts have tended to rule differently, at least in the cases that I am aware of. But whatever the courts rule, being immunized in order to reduce the risk to those I’m charged with protecting -- I really don’t think there’s a choice there.

PE Not to belabour the point, but I’m not sure it’s been tested under federal law?
DBJ Generally this is provincial, and sort of labour standards stuff. It may be that if it’s not a condition of employment... I don’t really know, so it’s probably best to leave it at that, and leave the legal stuff to the lawyers... But ethically, the bottom line is that immunization against diseases that we would share or could share with our patients is important not just for our own protection, but for the protection of those that we care for.

PE Will medical professionals and other vital service providers have access to the vaccine before the general population does?
DBJ It’s a matter of, basically, week one versus week four. I’ve never seen any guidelines that did not encourage making sure that healthcare workers, who are going to be both more heavily exposed and necessary for treating the disease, that they would not be high-priority. I’m certainly expecting that healthcare workers would be early on the list.

PE Will government officials, such as yourself, also be early on the list, since we need you in Ottawa formulating policies and such?
DBJ Well, it’s not just policies and talking to you guys. [Laughs] This one is a bit different in terms of what we are planning for, so we’ll see what the recommendations say, but generally, healthcare workers, those who are at greater risk of severe disease, essential services are more likely to be earlier rather than later, but given that we’re talking a matter of weeks it’s probably less critical here than for countries that don’t have enough vaccine.

PE Do you have anything you’d like to convey to doctors, either about preparations for this fall or about what to do once things get going?
DBJ Well, I think the key thing is that good basic infection control saves lives every day, not just during a pandemic. Influenza vaccine saves lives every year, not just during a pandemic. So the basics of washing hands in the clinic, the use of alcohol gels as a supplement, avoiding other people when we’re sick, coughing into our sleeves and not our hands, keeping our hands away from the mouth and eyes even if we’ve washed our hands -- those things make a huge difference every day. You know, I sometimes say in speeches that during SARS, other than in the affected hospitals, Toronto was probably one of the safest places to be on the planet from an infectious disease standpoint, because people were washing their hands like crazy and staying home when they were sick, so those regular, mundane infections that kill a small percentage of us on a regular basis were less. Soap is a marvelous invention. We take it for granted. Antibiotics and antivirals can’t treat everything. Good technique and good hygiene are key all the time. If people get better at that as a result of the pandemic then that will serve us well long-term. It’s amazing -- I trained in the ’70s and I remember people joking about the washing of hands to amuse the nurses. No! There is no substitute. A lot of these bugs don’t jump through screens and don’t jump through curtains -- I mean, a few diseases do spread in a room quite easily, but the vast majority are person-to-person contact -- so good, basic infection control practice has a huge impact every day, whether in the clinic or the hospital or wherever it is. Like in the last couple of years of focus on C difficile or MRSA or any number of things. This all pretty basic and pretty important stuff and I can’t stress it enough.