ARTICLE IN BRIEF
Neurologists in South and Central America describe efforts to contain and treat H1N1.
Influenza A (H1N1) virus, which first surfaced in Mexico in late March, has been linked to over 4,100 deaths worldwide, according to the World Health Organization (WHO). And countries in Central and South America have been at the epicenter of the outbreaks, classified by the WHO in June as a pandemic.
In an effort to learn firsthand about how some of the countries in that region were faring with efforts to treat and contain the virus, Neurology Today spoke to AAN member neurologists — in Mexico, Panama, and Ecuador — some of whom have played lead roles in public health outreach efforts.
Overall, few neurologic events have been reported, some efforts are under way (in Mexico) to detect possible neurological reactions to the vaccine, when available, and younger people, particularly those with underlying conditions, seem to be more at risk for death.
In Mexico, where there were 22,363 confirmed cases and 248 deaths related to H1N1 as of Oct. 9, 71 percent of the patients who died were 20-50 years old, and 56 percent the confirmed cases were younger than 18.
The main neurological complication in Mexican patients (24 percent) was headache, said Alejandra Gonzalez Duarte, MD, research investigator and assistant professor of neurology at the National Institute of Medical Sciences and Nutrition (Instituto Nacional de Ciencias Médicas y Nutrición) in Mexico City. There were three cases of delirium among those who died, but she added that could have been related to other contributing factors, such as obesity, diabetes mellitus, and hypertension.
Some patients have reported lightheadedness and dizziness after starting treatment with oseltamivir (Tamiflu), but there have not been any complaints of delirium or psychiatric abnormalities associated with oseltamivir, Dr. Duarte said.
From April 16 to May 14, all non-essential activities — including schools, businesses, and other commercial and professional activities — were stopped. Since then, several schools have remained closed according to the number of cases seen. Currently there is a station in every school and many public places like the airport where people are examined for symptoms before being granted permission to enter.
At most institutions, Dr. Duarte noted, consultation for symptoms, diagnostic procedures, and treatment are free.
Because it is estimated that individuals who receive vaccination against swine flu could be at a four- to eight-fold risk for developing Guillain-Barré syndrome (GBS), she said an epidemiologic census will be established to evaluate the emergence of this condition.
The Ministry of Health is working on several forms for general physicians in order to increase awareness about GBS symptoms. One report, for example, is being developed that will gather all possible information about suspicious cases, including the clinical and paraclinical information (pertaining to abnormalities underlying clinical manifestations) and the time of adverse effects. A consent form with an explanation of the low but present risk to develop GBS will be provided to each person.
As of Oct. 1, Panama had reported 776 confirmed cases and 11 deaths from H1N1. But said neurologist Fernando Gracia, MD: “I think that we have under-registered some deaths because H1N1 is more fatal than normal flu.” Dr. Gracia, director of the Faculty of Health Sciences at the Latin American University of Science and Technology School of Medicine and head of neurology at the Hospital Santo Tomas in Panama City, was Minister of Health of Panama from 2001 to 2004.
Swine flu has spread most rampantly among younger people, he said, with more cases in children younger than 15 years old and in people between 20 and 39 years old. The deaths of H1N1-infected people in Panama have occurred among pregnant women and have been associated with other co-morbidities, including malnutrition, diabetes, heart disease, pneumonia, and asthma.
The Ministry of Health “reacted very well” initially, said Dr. Gracia. They used TV and radio to educate the public about the virus; established guidelines for the prevention and management of the infected; and purchased oseltamivir. While training for physicians was initially poor, now physicians are becoming more knowledgeable about the disease. The Ministry also launched a vaccination campaign so that people will be ready once the vaccines — which will be free of charge — become available, most likely in October, Dr. Gracia said.
But he said the public outreach efforts waned this summer as officials focused more on national elections for president and congress. The public information campaigns against swine flu are beginning to build again, he noted, now that cases are mounting. Understandably, the public is very worried about the epidemic, Dr. Gracia said. While there is currently enough oseltamivir for existing cases in Panama, if there is a second wave with of cases, the amount of available medication could dwindle to zero, he said.
At Hospital Santo Tomás (Saint Thomas Hospital), a level 1 trauma center and the largest public and teaching hospital run by the Panamanian Health Ministry, no neurologic adverse events from H1N1 have been reported, said Dr. Gracia.
Panama was the first country in Central America to have the test to confirm H1N1. This is why at the beginning of the global epidemic, Panama had more reported cases than neighboring countries, he said.
Currently, Costa Rica has reported more cases and deaths from H1N1 than Panama, “maybe because the initial prevention of the population was not as strong as the measures taken in Panama at the beginning of the epidemic,” said Dr. Gracia. “Other countries such as Honduras and Nicaragua had no reports because they don't have the test to confirm H1N1.”
As of Sept. 29, there have been 1,175 cases and 60 associated deaths from H1N1 in Ecuador.
However, the vast majority of patients had a short course of illness and recovered completely, said Marcelo Cruz, MD, professor of neurology at the Neurosciences Institute at the Central University of Ecuador in Quito. Dr. Cruz, an expert on parasitic diseases and neuroepidemiology, is the former Minister of Public Health of Ecuador and a World Bank consultant for health reform.
Usually the patients have had “predisposing illnesses such as asthma, chronic obstructive pulmonary disease, and malnutrition,” said Dr. Cruz, “but in other cases no obvious risk factor was detected.”
“In Ecuador we have seen H1N1 cases in younger populations, probably because they are most active, travel more, and are exposed in their homes and abroad,” Dr. Cruz said. In one week alone, there was a 42 percent increase in the number of cases and 50 percent increase in deaths, “so the belief is that this epidemic is here to stay,” he said.
In response, the Ministers of Health of the Union of the South American Nations convened in Quito on Aug. 8, and “advised that we should start making plans to acquire doses of the future vaccine,” Dr. Cruz said. On Sept. 10, Ecuador requested 900,000 vaccines from the Pan American Health Organization.
“In our case, the people are very eager to be vaccinated,” said Dr. Cruz. “Fear of getting swine flu is higher than fear of complications. We'll have to wait and see if there are side effects, particularly Guillain-Barré syndrome.”
Dr. Cruz noted that patients who recovered have not complained of neurologic symptoms, and there is not any information released on neurologic symptoms of those who died.
As was the case in Panama, the Ministry of Public Health of Ecuador reacted quickly “to this epidemic, adhering strictly to WHO and Pan American Health Organization directives, and the results are very good,” said Dr. Cruz. From the outset of the epidemic there was a strong campaign to disseminate guidelines for prevention and treatment in Ecuador. He noted that this was not the case in Argentina, the South American country with the highest number of cases and deaths. As of Sept. 7, there had been 512 deaths and 8,384 confirmed cases there. Argentina did not immediately declare a national public health emergency when the flu appeared, he explained, and only started to take measures once the epidemic had advanced.
The public health ministry in Ecuador instituted an electronic surveillance system on all passengers coming from abroad at the two international airports (in Quito and Guayaquil) — cameras were placed to detect the temperature of travelers within seconds. All travelers with fever were isolated and examined for H1N1. “Several cases were picked up this way,” Dr. Cruz said.
The Ecuadorian government has earmarked $50 million to buy sufficient doses of oseltamivir, which is now available free of charge.