A new study, Clinical Aspects of Pandemic 2009 Influenza A (H1N1) Virus Infection, published in The New England Journal of Medicine (NEJM) that concluded that “the number of laboratory-confirmed cases [of pandemic A H1N1 influenza] significantly underestimates the pandemic's impact” buttresses what many authorities have been saying: that had there not been a concerted global effort to vaccinate persons with the highest risk from contracting the virus, in combination with aggressive use of antivirals, both the death toll and the number of hospitalizations would have been much higher.

The new study in the NEJM stated that “in the United States, an estimated 59 million illnesses, 265,000 hospitalizations, and 12,000 deaths had been caused by the 2009 H1N1 virus as of mid-February 2010.”

The study found that “deaths have occurred despite early therapy” with specific antivirals, “but the administration of oseltamivir even after an interval of more than 48 hours since the onset of illness has been associated with reduced rates of death among hospitalized patients infected with the 2009 H1N1 virus, seasonal influenza virus, or H5N1 virus. Decisions regarding antiviral treatment should not await laboratory confirmation, and patients presenting with progressive illness more than 48 hours after the onset of illness should be treated empirically with oseltamivir as soon as possible. Patients with progressive or severe illness who have a negative initial test result for 2009 H1N1 virus should continue to receive therapy unless an alternative diagnosis is established.”

Continuing, the study stated that “available findings highlight the importance of early use of antiviral drugs and antibiotics in the treatment of serious cases and of the potential value of influenza-specific and pneumococcal vaccines for prevention.”

The study further noted that “the burden and character of disease in low-resource settings are still incompletely understood, especially with respect to disadvantaged populations, including marginalized, refugee, and aboriginal populations. Poverty, homelessness, illiteracy, recent immigration, language barriers, and cultural factors may impede access to care, with the potential for more serious outcomes of influenza. Thus, public health efforts reduce risk factors and to identify at-risk populations for the purpose of providing immunization and early care, including the use of antiviral drugs, should focus on social as well as clinical factors. Both experience with previous pandemics and recent modeling efforts indicate that the age bias observed for outbreaks of 2009 H1N1 virus infection may shift in coming months toward older persons, with implications for the allocation of public health resources.”

The also pointed out that “major gaps exist in our understanding of viral transmission, pathogenesis of disease, genetic and other host factors related to susceptibility or disease severity, and optimal management of severe illness.”

Meanwhile, a presentation this month to the Pediatric Academic Societies annual meeting in Vancouver, British Columbia, “Should We Fear Flu Fear Itself? Lessons from the Spring 2009 H1N1 Influenza Outbreak,” warned that “episodic surges in patient volumes may compromise emergency departments’ [EDs] ability to deliver adequate care, as shown by recent experience with H1N1 influenza.”

“At a time of heightened public concern regarding flu, but little disease prevalence, [the studied] EDs experienced a significant increase in patient volumes due to an influx of pediatric patients. Parental anxiety regarding flu increased ED visits by pediatric patients to a greater extent than the epidemic of actual disease that followed,” the presentation noted.

As the H1N1 pandemic swept across the United States, EDs and hospitals across the country reported surges of not only the sick, but also people seeking medical care because they thought they might have contracted the pandemic flu virus.

In Utah, where EDs were surged during the pandemic, new triage guidelines for dealing with mass casualties from a catastrophic disaster at a time when resources will be stretched thin have been developed by the Utah Hospitals and Health Systems Association for the Utah Department of Health.

In such a situation, the guidelines for overwhelmed hospitals and EDs calls for denying care to the sickest adults and children.

The guidelines were required as part of then-Gov. Jon Huntsman’s Taskforce for Pandemic Influenza Preparedness.

"The choice is: When you don't have enough, who do you do it for?" state epidemiologist Robert Rolfs told the Salt Lake Tribune, which reported that he’d “joined hospital medical officers, nurses, emergency doctors and an ethicist who wrote the recommendations.”

Emergency preparedness officials and authorities have long warned that in the event of a large-scale, mass casualty disaster, triage will necessarily have to prioritize people who have the highest odds of survival, which isn’t necessarily the way triage is performed under normal circumstances.

[Editor’s note: How to best triage victims of a large-scale mass casualty disaster will be the subject of an upcoming HSToday.us Kimery Report]