Why it broke and whether it’s fixed
By David Himmel
It begins with an ache. Then a chill. And before you can reach Walgreens, you find yourself in the grip of an influenza outbreak.
The final days of last December brought holiday cheer and the third biggest flu season since 2002. After New Year’s Day, so many infected patients flocked for help that eight Chicago hospitals simultaneously instituted bypasses. It seemed something terrible was among us. But a large outbreak doesn’t necessarily mean we’re dealing with a deadly virus. A large outbreak is simply bad timing.
So says Dr. David Zich (pronounced zeek), an emergency and internal medicine physician at Northwestern Memorial Hospital. “This year, it came right with the holidays,” he says. “And it corresponded with people who have high stress during that time. [There were many] not getting enough sleep, and they weren’t taking care of themselves. Then they got with friends and family and spread [the virus] to a lot of people in a short amount of time. It was the perfect storm.”
When news of the multihospital bypass broke, things became hysterical. But that was human error, not the fault of the virus. Hospital bypass is a common and systemic back-up plan that all hospitals may enact in order to keep patients safe. Zich says NMH goes on bypass 15 or 20 times a year, mostly during summer, NMH’s busy season. Often a bypass occurs when the hospital is far beyond capacity, meaning that inpatient beds are full. And in a busy metropolitan city like Chicago, being near capacity is routine. Hospital bypass may also occur because of an electrical or plumbing problem in the building or any number of factors, Zich says. The bypass hysteria was mostly media induced because eight hospitals on bypass all at once sounds frightening if it’s not clear what a bypass is.
During a bypass, patients are not turned away at the door. It simply means that stable patients in Advanced Life Support (ALS) ambulances are told to go to the next closest hospital no more than five minutes away. “We never turn away walk-ins. No hospital does,” says Zich. “If someone were critically ill; a shock or trauma patient, we would accept them regardless of a bypass status.”
NMH was one of the eight hospitals that went on bypass that day. At the time, there were 27 people in the NMH emergency room (ER) who had been treated and were stable and waiting until they could be admitted as an inpatient. Also, the ER waiting room was completely filled with people waiting to be seen, with the sickest patients prioritized to be seen first.
“Once any of those factors let up, we [go] off bypass,” says Zich.
That might have happened sooner if not for the panic. Nurse stations were bombarded with phone calls; people were concerned that they couldn’t come in and be seen. Nurses tried to reassure frantic callers while treating patients.
The perfect storm. Still, this year’s particular strain of flu is not a superbug, Zich says, and the majority of strains are covered by the vaccine.
“Each year, influenza strains tend to mutate,” says Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “They change enough year to year [so] that, if you want to be optimally protected, you then have to get vaccinated with a vaccine that closely matches the predicted strain.”
It so happens that this year’s strain of H3N2 is quite a close match to the current vaccine, Fauci says. Coming up with an effective vaccine isn’t easy because, as Fauci said, the vaccine is created based on a prediction of a strain determined by looking at the type of strain present in other regions of the world during the previous flu season. Even with a good match, the vaccine is not completely protective.
“It’s a constant game of playing catch up,” he says.
There has been talk of a universal vaccine—a single shot that prevents illness against all strains of flu year after year, similar to vaccines we have for measles, mumps and rubella. But unlike flu, those viruses don’t change as dramatically or as quickly. Fauci calls this miracle shot “aspirational.”
“Even if we get one, it might be something that you have to take every five years or so.”
With flu, the virus has certain proteins called hemagglutinin. The body’s response against hemagglutinin tends to protect us. But it’s that part of the virus that does all the changing. And sowe have to update the vaccine every year. What scientists have recently discovered, however, is that there is a part of the hemagglutinin that does not change. But our bodies don’t recognize that part and, therefore, won’t keep us from feeling sick.
Under a microscope, hemmaglutinin resembles a mushroom. It has a head and a stem.
“The head changes, the stem does not change much at all,” Fauci says. “The vaccines we have today don’t elicit a response against the stem. We have to find a way to [make that happen].”
Development to that end is progressive. “The concept has been proven in animals,” he continues. “We have already moved into phase 1 of clinical trials with humans to test its safety.” When phase 1 is completed, a larger sample of volunteer humans is given the vaccine to further test its safety and the nature of the immune response it induces. The third and final phase will prove or disprove [whether] the vaccine actually works, but it will take years to reach that conclusion because scientists will have to keep track of the same people year after year, flu strain after flu strain.
Meanwhile, the annual prick in the arm will have to do. It’s not 100 percent guaranteed protection, but it’s better than nothing. The Center for Disease Control and Prevention says that on average, the flu season lasts between mid-November to mid-March. Last year, however, the season’s peak hit in April. And in 2009, the year of the dreaded H1N1 strain, it peaked in mid-October.
How long the peak of the season lasts has to do with when it’s introduced to the population and the virulence of the strain, meaning how much of the virus you need to be exposed to before it makes you sick. It is also dependent on how well it can survive on surfaces and how easily it’s transferred.
“Past outbreaks had fairly broad peaks,” Zich says. “This year was very sharp. That goes back to the notion that the peak was at the holiday season. But the bug isn’t that strong. Once the [holidays] left us, so did the virus. In fact, this is pretty much the sharpest peak we’ve had in 12 years.
“Maybe it’ll have a resurgence, but I think it’s going to continue to get better. All indicators show us that the worst is behind us.”[email_link]