As the influenza A(H1N1) virus continues to spread in several countries, we find ourselves faced with a pandemic. The increasing number of severe cases and deaths, particularly evident in countries with advanced disease surveillance systems, are harbingers of community-wide infections. We therefore surmise that the epidemic has progressed from the initial to middle stage.
During the initial stage, disease prevention in Asia focused on border quarantine to contain and isolate H1N1 patients entering the country. Countries that were successful at managing the prevention of viral spread at this stage were able to delay the onset of the middle stage, allowing for more preparation time and resources.
However, once the virus begins to spread domestically, the prevention strategy must adjust its focal point from single incidences to the epidemic at large. Public health advocates and officials must push for comprehensive nationwide disease prevention and mitigation. In addition, public health policies should focus on reducing fatal and severe cases and mitigating their impact on the healthcare system. In other words, protecting hospitals and healthcare workers from nosocomial, or hospital-acquired, infection should be the first priority.
It deserves mentioning that Taiwanese have the habit of “hospital shopping” — often visiting different hospitals. In addition, many part-time medical staff work and study in a number of different locations or settings. Once hospital infections occur, the low immunity of hospitalized patients could add a complicated and unpredictably dangerous element to epidemic spread.
When death rates associated with this novel virus were still relatively low, disease prevention measures became lax.
We must become much more vigilant, however, as in the current conditions more severe cases and novel H1N1 clusters are occurring than two weeks ago.
As the number of indigenous novel H1N1 patients continues to grow, thorough epidemiological examination is urgently needed for every severe case. Medical professionals must make every effort to identify risk factors immediately after hospital admission.
To achieve this, the US Centers for Disease Control and Prevention regularly release the results of H1N1 epidemiological findings in its “Morbidity & Mortality Weekly Report.”
At present, we have learned that the most severe cases of novel H1N1 in the US and several other countries belong to certain high-risk groups. However, the risk factors are still unknown for between 20 percent and 40 percent of severe cases who had no other known chronic disease. This implies that some prevention measures and risk assessment are carried out blindly and require further study. Such epidemiological investigations will require the close cooperation of patients, their families, medical workers and public health workers.
As of last Tuesday, 44 severe cases had been reported in Taiwan, five of which were fatal. Apart from the first death, involving a patient who suffered from chronic hepatoma, none of the other fatal cases had any other chronic disease. Epidemiological investigation of these cases is critical for maintaining public health. We must identify the key factors, particularly for the deaths of the six-year-old child and the 24-year-old college student, and adjust precautions accordingly to maximize prevention efforts.
In response to several outbreaks involving novel H1N1 clusters in Taiwan, we provide three recommendations:
First, before schools open this month, all schools, nursing homes, military bases, hospitals, large public places and buildings with high population density should actively carry out daily reporting of self-measured body temperature, syndromic surveillance and follow standard operating procedures for influenza prevention to avoid severe outbreaks such as those that have occurred in Southeast Asian countries as a result of undetected cluster cases and insensitive surveillance.
Second, we should emphasize health education, reduce campus transmission and install hand-washing facilities at public places.
Third, the recent identification of novel H1N1 cases among the military in flood disaster areas and the closure of several schools in northern and central Taiwan because of H1N1-infected students show the potential epidemiological changes in future weeks if precautions are missed.
The large influx of rescue and medical workers entering Typhoon Morakot disaster areas accelerated H1N1 infection rates in a region already lacking resources.
Rescue workers and other personnel that would like to help flooded residents must first receive public health and disease prevention training.
In the large influenza battle ahead, we must face the epidemic cautiously and head-on, using scientific approaches to disease prevention.
King Chwan-chuen is a professor in the Institute of Epidemiology at National Taiwan University. Yen Muh-yong is deputy superintendent at Taipei City Hospital.
TRANSLATED BY EDDY CHANG
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