Second Wave Of Swine Flu Could Overwhelm Resources In Europe And North America Say Canadian Expert

A panel of experts in Canada has written an article in a leading medical journal suggesting that if the H1N1 pandemic swine flu follows the same disease pattern in the northern hemisphere this fall as it has in the southern hemisphere, then resources in North America and Europe could be overwhelmed. The experts say strong leadership will be needed to mobilize effective immunization and other campaigns and they also call for the appointment of national and local leaders and champions.

The editorial article was written by Dr Paul Hébert, Editor-in-Chief of the Canadian Medical Association Journal (CMAJ), and colleagues, and appears in the 17 August issue of the journal.

Hébert and colleagues wrote that vaccination must be the top priority against H1N1 flu this fall if the anticipated second wave of the pandemic virus follows the same pattern of spread in the northern hemisphere as it has in the southern hemisphere.

Canada and much of the Western world does not have much experience in implemeting time-sensitive mass vaccination campaigns, wrote the panel. We already struggle to get vulnerable groups vaccinated for seasonal flu, they added.

For example, in some years, only 15 per cent of people living in Nunavut (a major portion of northern Canada) are vaccinated, and last year, during the most recent outbreak of mumps in Nova Scotia's young adult population, only 15 per cent of targeted individuals were vaccinated (note this is the population segment most likely to be severely affected by the 2009 H1N1 swine flu).

"We need to act now to overcome these access and delivery problems," wrote Hébert and colleagues.

"No immunization program is 100 per cent effective. If a sufficient number of cases are not prevented, we can expect a large number of young critically ill patients filling all tertiary level intensive care beds," they warned, adding that although most infections have been mild so far, unlike most seasonal flu strains, in more serious cases the new 2009 pandemic H1N1 virus seems to invade the lower respiratory system more aggressively, causing more severe illness.

"The world's experience so far tells us that serious illness associated with this virus often manifests as acute lung injury resulting in overwhelming hypoxemia," they wrote.

Hébert and colleagues suggest Canada needs national leadership to make sure vaccines, expertise and equipment reaches everyone that needs them. New laws may be needed to give people power to act quickly.

Each country should have a "visible independent health care czar, with executive powers across all jurisdictions and who is ultimately accountable to the highest office," they added.

After that, the priority is local leadership, including "champions" to coordinate rapid response.

"In countries such as Canada that have shared responsibilities between many levels of government, collaboration and clear communication are essential as a first line of defence," they wrote.

"To see that this happens, governments need to have or enact laws to provide the necessary power to ensure rapid action on complex issues."

They also pointed out that a second wave is likely to hit the northern hemisphere this fall if the H1N1 virus follows the same pattern as it has in the southern hemisphere. This would overwhelm our resources; for example in most areas there are still no plans on how to get the correctly trained health professionals in place to "deliver technologies to help patients survive".

Hébert and colleagues wrote "this is not a time for complacency", and urged that health czars and other national leaders call an immediate summit and bring together officials from public health, critical care, first response, and other health care areas, as well as decision makers, community planners and members of the public to:

"Communicate next steps and to ensure that actions taken by leaders will work at the ground level".

One of the ideas that health czars need to get across to the public is that everyone has a responsibility in tackling the pandemic, it is not just a top down approach, but also a bottom up approach that is needed.

An example of the bottom up approach that Hébert and colleagues referred was one being promoted in the UK called the "flu buddy" system, where individuals partner with one another and take responsibility to check each other's health status regularly.

Improved Colorectal Cancer Survival Linked To Postdiagnosis Use Of Aspirin

US researchers found that patients who regularly took aspirin after being diagnosed with colorectal cancer had a reduced risk of dying from the disease, and the benefit was greater for patients with a type of colon cancer where the tumors overexpress the COX-2 enzyme, which happens in around two thirds of cases. However, more work needs to be done to confirm the result before applying it to patient care, said the researchers.

The study was the work of investigators from Massachusetts General Hospital (MGH), Dana-Farber Cancer Institute and Brigham and Women's Hospital and is published online in the 12 August issue of the Journal of the American Medical Association (JAMA).

Lead author Dr Andrew Chan, of the MGH Gastrointestinal Unit told the press that:

"While previous studies by our group and others showed that aspirin and other non-steroidal anti-inflammatory drugs reduce the risk of developing colorectal cancer, this study is the among the first to show that aspirin can also improve survival in patients who have already been diagnosed with colorectal cancers."

"Moreover, the benefit appeared to be especially strong among patients with cancers that express COX-2," he added, stating that:

"This is an important first step toward developing targeted approaches to improving patient outcomes."

Chan and colleagues brought together data from two ongoing prospective studies, the Nurses Health Study (NHS) and the Health Professionals Follow-Up Study (HPFS), which capture detailed health information on their participants every two years. Researchers use the comprehensive data from these studies to look for links between various factors such as use of drugs and incidence of several diseases.

For this study, Chan and colleagues focused on the data from 1,279 study participants who were diagnosed with stage 1, 2 or 3 colorectal cancer during the period of the studies and for whom data on their use of aspirin before and diagnosis was available.

The results showed that:

* After a median follow up of 11.8 years, 193 (35 per cent) of the 549 participants who regularly used aspirin after being diagnosed with colorectal cancer had died, and of these deaths 81 (15 per cent) were from colorectal cancer.

* This compared with 287 total deaths (39 per cent) and 141 colorectal cancer-specific deaths (19 per cent) among 730 participants who did not use aspirin.

* Compared with those who did not use aspirin, participants who regularly used aspirin after diagnosis had a 29 per cent lower risk of dying from the disease and a 21 per cent lower risk of dying from any cause.

* Among 719 participants who did not use aspirin before diagnosis, those that started using aspirin after diagnosis had a 47 per cent lower rate of death from colorectal cancer compared with those who did not.

* Tumor samples from 459 participants were tested for COX-2 expression.

* Among these, regular aspirin use after diagnosis was linked to a 71 per cent lower risk of dying from colorectal cancer for those participants whose tumors overexpressed COX-2, whereas aspirin use was not linked to lower risk among those whose primary tumors had weak or no expression of COX-2.

The authors concluded that:

"Regular aspirin use after the diagnosis of colorectal cancer is associated with lower risk of colorectal cancer-specific and overall mortality, especially among individuals with tumors that overexpress COX-2."

Senior author Dr Charles Fuchs of of Dana-Farber said:

"We believe our results could lead to improvements in the therapy of patients with colon cancer."

"We're now following up this observational study with a randomized trial to evaluate adding the COX-2 inhibitor celecoxib -- which is less likely to have the gastrointestinal side effects of aspirin -- to standard chemotherapy."