Gert van der Hoek
In Memoriam - Editor, Senior Moderator
Re: Tracking World Wide Virulence of Swine Flu
.....
[Google Translation]
14/08/2009 - 19:59 - Updated 14/08/2009 - 22:20
The progress of the pandemic press hospitals and health system
While the swine influenza vaccine is not enough, the number of patients increases and threatens to exceed capacity of the Brazilian health system. What to do?
PETER MOON AND RODRIGO TURRA
"In recent weeks, the hospital began to see some cases many weird, strange cases like never seen in my life," says Paulo Olzon infectologist of 62 years. The observation is not junk. Olzon is a professor of the Paulista School of Medicine and infectologist since 1971. He had the opportunity to care for patients with symptoms that almost all infectious diseases may occur - or almost all.
In four decades of occupation, Olzon never seen cases of pneumonia with developments such as rapid and severe in those four patients, three men and a woman aged 25 to 45 years, hospitalized in the second week of August in the Intensive Care Unit (ICU ) of the Hospital S?o Paulo, in S?o Paulo. The four are at risk of life. Only survived thanks to the fact that they were hospitalized in ICU in a timely fashion with the best resources of medicine.
"One of the patients had returned at night from work to home is complaining of pain in the body and was sleeping," says Olzon. "At two in the morning, he did not stop coughing or more could be on foot. His family had to carry him at dawn to the hospital where he was hospitalized. At two o'clock in the afternoon, the functioning of the lungs was compromised. We intubated so, to use the mechanical respirator. At the same time, we had to drain 800 ml of liquid only the left lung. "
One patient had viral pneumonia, and that the more dangerous bacterial pneumonia. The bacterial pneumonia is the most common form of pneumonia, being responsible for the vast majority of cases (which includes the other three patients treated for Olzon).
The bacterial pneumonia, as its name suggests, is caused by several types of bacteria that attack the bronchi and lungs. She is responsible for the most serious cases of swine flu, when the virus A (H1N1) invades the respiratory system and begins to reproduce itself in cells of the lungs, killing them. The dead cells form a breeding ground for the bacteria that cause bacterial pneumonia.
Many patients develop milder forms of bacterial pneumonia, requiring hospitalization in common beds for treatment with antibiotics, rest and observation. A minority of patients may develop more severe forms that require hospitalization in the ICU, where he remained for several days or weeks. Not always save everyone.
With viral pneumonia is different. The damage caused by the virus A (H1N1) is fulminant and devastating. No spare time for opportunistic bacteria to take its place. Without the possibility of immediate hospitalization in the ICU, the viral pneumonia and mortality in 100%. It was thus in the Spanish Flu of 1918. Thus even today, 91 years later.
But the hospital in time in an ICU of patients with viral pneumonia does not provide any form of a passport to survival. The American historian John Barry, author of The Great Influenza - The history of the most deadly pandemic in history (The Great Influenza, 2004), the best medical arsenal the beginning of XXI century can only save 6 in 10 patients. One patient with viral pneumonia treated by Paulo Olzon was lucky to get a bed in ICU.
The month of July came to an end with a balance of 85 dead by the swine flu since the beginning of the first cases in May. Enough two weeks of August for the total of deaths quadruple. On Friday (14), the balance of state secretariats of Health reported 339 deaths, which made Brazil the second highest number of victims, ahead of Mexico (163) and Argentina (337) and behind the United States (477).
The increase in the number of deaths does not mean that the virus A (H1N1) swine influenza is becoming more dangerous, just that it is very contagious and is spreading rapidly across the country. Thus, even with a very low mortality, the virus affects hundreds of thousands of Brazilians. In their vast majority, they do not develop symptoms or have symptoms of a common flu. A minority may develop complications (such as non-severe pneumonia) and require hospitalization.
The lowest proportion of cases may progress to severe pneumonia, which end up in ICU. "Because of the influenza pandemic, the hospital beds are under enormous pressure. The biggest problem is in the ICU," says Furtado Juv?ncio, the president of the Brazilian Society of Infectious Diseases, and infectologist of Hospital Heliopolis, S?o Paulo.
Jorge Curi, president of the Paulista Association of Medicine, says that the major hospitals of the clinical state of S?o Paulo, as the Hospital de Clinicas da Unicamp, in Campinas, are already being forced to suspend or postpone the elective surgeries, those who did not are emergency, to free beds for patients with common cold.
In the Hospital Israelita Albert Einstein, Sao Paulo, the swine flu was responsible, in July, for a 20% increase in attendances in the emergency room with the same month of 2008. "The average annual increase in hospital visits is 5%. An increase of 20% from one year to another is a huge percentage, consistent with a pandemic," said Luis Fernando Aranha, the superintendent of Einstein.
The most recent statistics point to the Paran? and the Brazilian state where the total number of patients grows faster. The number of hospitalizations caused by swine influenza in the state tripled in 10 days. Increased from 255 admissions to the day August 1, 1007 to the 12th, says the State Secretary of Health, Gilberto Martin.
The use of beds in ICU doubled from 84 to 169. Although the Paran? have 24 thousand beds in common and 1364 ICU beds, the increase in occupancy caused by swine flu forced the health system to suspend all elective surgery, non-emergency. "This jump is worrying but not alarming," says Martin. "If the upward curve will continue must reassess our procedures for no overload in the health system."
The situation in S?o Paulo is not very different. "The end of last week was a crazy, but the level of attendance this week fell from 250 to 180 per day," says David UIP, director of Instituto Em?lio Ribas, S?o Paulo. IPU says that with the end of winter and increased temperatures, the swine influenza will not disappear, but the number of cases should stabilize. "A pandemic may increase as both may decrease," said IPU. "But we know that with the heat the number of admissions will be stabilized within the capacity of care."
Some hospital administrators are preparing for another scenario. About 80 patients with swine flu passed by beds of the Hospital Santa Catarina, S?o Paulo. Currently, there are 27 inpatients in a total of 320 beds. "Cases of swine influenza account for 10% of the occupation," says Luciano PATAH the technical director of Santa Catarina.
PATAH says that the pandemic has not yet reached its peak in the city of S?o Paulo. He says the peak should occur in the next 15 days, when the return to school can make the number of patients with avian double. "We are preparing to reserve up to 20% of beds for cases of influenza. I believe that the use will maintain the level of 20% by the end of the semester in December. With the start of the summer holidays, the demand must fall. "
If the total number of patients actually double in the coming weeks, as PATAH, many hospitals, especially the public, will have to gain agility and create solutions to build beds and absorb the new patients, regardless of severity. One example is Osasco, in Greater S?o Paulo. Its health system is operating at maximum capacity in the service.
According Gelsi Aparecido de Lima, the Municipal Secretary of Health, Osasco has 188 beds and 12 beds of common ICU, of which 9 are occupied. "The number of admissions increased by almost 15% with respect to 2008. It is too much for our network, "says Lima. "If demand continues to increase, we will reach the threshold of our ability, and we will have overcrowding."
This is the great fear of specialists. What if the numbers do not stabilize the epidemic and continue increasing? This hypothesis can not be discarded, given the unpredictability of the influenza virus. The potential capacity of the virus A (H1N1) infect millions of people is the worst nightmare of epidemiologists, and the reason for the international race led by the World Health Organization to develop a vaccine. The vaccine is the only protection against the pandemic. But it should only start to be available in late November, so even in limited quantities. Where to put seriously ill patients are, by then, all the ICU beds are occupied?
"This is the scenario for which we are apparently moving," says Furtado Juv?ncio. "I doubt that the epidemic ends here 15 or 20 days. The virus is still circulating. From here one month, the health system may be overloaded. " Given this possibility, Brown is creating a new Heli?polis in hospital intensive care unit for patients with breathing difficulties. "We also set up a charge of infectious disease that run 24 hours a day just to meet cases of flu in a special wing, separated from the rest of the care."
Although the initiative of Heli?polis is replicated across the health system of the country, yet, depending on the behavior of the virus A (H1N1), the expansion of the network may not be sufficient to meet demand. "In Brazil, the health system works well within the limits of their capacity," says Jorge Curi, the Associa??o Paulista de Medicina. If the total of patients exceeds the supply of beds and common, especially in ICU, doctors can reach the point of being forced to choose who treat. "It's a tragedy that I do not wish for anyone. But we are already having to choose, "said Curi. "We doctors unfortunately are subject to such situations and choices."
.....
