‘Virus hunter’ Bonnie Henry on H1N1

The risk of running out of infection meds, and the perils of pedicures and dirty organic produce

090914_interviewDr. Bonnie Henry is a physician, preventative medicine specialist, and epidemiologist—or “virus hunter.” Before becoming the director of public health emergency management at the B.C. Centre for Disease Control, she fought outbreaks of SARS in Toronto and the Ebola virus in Uganda. Dr. Henry is leading emergency preparedness for the Vancouver 2010 Olympics. Her new book, Soap and Water & Common Sense, documents our constant battle against viruses, bacteria and other bugs, including the new pandemic strain of H1N1.

Q: What’s your message to parents who are worried about their kids getting swine flu, especially as school starts?

A: Most people recover at home without any need for health care. But parents need to be really careful for two things. One is if their children have underlying illnesses that make them have less ability to fight off the virus—bad asthma, diabetes—they should think now about making a plan, talking to their doctor. Because these kids would most likely benefit from antiviral treatment [such as Tamiflu]. If your child doesn’t have underlying illnesses, you still should be careful. So if they’re having a hard time breathing, turning bluish, a baby who is very lethargic, irritable, not drinking—those are indications that they should be assessed by a physician.

Q: I saw an online poll asking if people thought Canada is prepared for an H1N1 pandemic. Seventy-five per cent said no. Are we?

A: I think we’re as prepared as you can be, but there’s always more to do. One of the things that we learn every time there’s a crisis is that getting consistent and up-to-date information to everybody is always difficult. It’s important that we get messages to people that are relevant to them in a way that they can understand. We’re not always good at that.

Q: I get the impression that for years we’ve been bracing for the next big influenza pandemic. How much of our concern about swine flu is actually due to the virus’s unique profile, and how much is anticipatory anxiety, however justifiable?

A: In my world we’ve been planning for an influenza pandemic for a long time. And you’re right, we’ve been planning for a really bad one. And this wasn’t a really bad one. We didn’t know that at first. I think the reaction that we all had at first was a lot of concern and that probably engendered a fair amount of fear that’s now, we realize, unwarranted. We talk about H5N1, the avian influenza—it’s a very frightening disease. It has a case fatality rate of up to a third of people who get this—or more—die from it. We were very concerned about seeing something like that. But most people do not get very sick with this strain of H1N1. It’s a mild to moderate illness. Now that we understand a bit more of it we’ve been backing off.

Q: The Canadian Medical Association Journal recently reported that Canada is lagging in getting the vaccine to people who need it most—that waiting until mid-November is too late. The health minister and chief officer of public health replied that if we need it sooner, it will be available in October. Who’s right?

A: I think there are some factual errors in the CMAJ article. One is that they say that because we’re using—or Glaxosmith Kline is producing—a vaccine that’s an adjuvant [a chemical substance that assists another], that that’s taking longer. That’s not true. My understanding is that the vaccine development is progressing at the same rate as for [every other country]. Health Canada has a branch that licenses vaccines. They have an expedited process for influenza vaccines, including this one. So it can be done very quickly. But there need to be studies done to show that it actually works to protect people and we need to make sure that it’s safe. That’s what takes time. There is some leeway. If we start seeing a lot of people getting really sick and we need it without those studies being finished, then the public health officer has the ability to work with regulators to get it approved more quickly.

Q: You were at the H1N1 medical conference in Winnipeg last week. Since then, the federal government has said it plans to unveil “pan-Canadian” recommendations to help hospitals handle a potential surge in swine flu cases this fall. What might those include?

A: The issue that took us by surprise around the world is a higher proportion of young people are ending up needing intensive care because of this virus. That can really stretch our ICU system. So this meeting was to make sure we know what resources we have, looking at measures that can reduce the need for ICU beds, and that may be temporary suspension of some surgeries, and making sure that areas that don’t have a lot of ICU support can transport people rapidly to another facility. That’s what we saw a couple of months ago in northern Manitoba. We’re trying to pull together in a much more co-operative way than we have in the past.

Q: Every year many of us debate getting the flu shot or not. Who needs it this year?

A: We have two shots this year, the seasonal influenza vaccination, and the pandemic H1N1 one. We’re still recommending that the same risk groups get the seasonal influenza vaccine. And for the pandemic vaccine it may be offered to everybody because we know that most people in the population in Canada don’t have immunity. There are people with underlying health conditions that make them more at risk for H1N1. So we encourage them to get the vaccine first.

Q: Tell me about the title of your book.

A: It comes from Dr. William Osler, who was a Canadian, although he made his name in the U.S. in the late 1800s as the father of modern medicine. For many bacteria and viruses the last common pathway to us getting sick is us putting our hands in our mouth. So if we’re careful washing our hands, that goes a long way to protecting us from getting ill.

Q: You write that “health officials are concerned that we may run out of medications altogether that can treat infections.” How imminent is that threat?

A: I don’t know how imminent, it’s hard to predict that. But we have seen cases, thankfully rare cases, of individuals who are infected with certain strains of bacteria that are resistant to every antibiotic we have available. The other side of it is that we haven’t put a lot of time and effort into developing new antibiotics. We went through this period where we felt that infectious diseases were no longer a threat. Pharmaceutical companies aren’t developing new antibiotics because they don’t make as much money off them. So that combination of an increasing level of resistance in the bacteria, plus not a lot of new antibiotics, could put us in a place where we have infections that can’t be treated.

Q: Superbugs are drug-resistant bacteria; H1N1 is a virus, but could it become a superbug?

A: We don’t have drugs that actually kill viruses very well, so viruses can develop resistance to these few medications available to treat viral infections. There are two classes of drugs that can treat influenza viruses specifically. H1N1 is resistant to one of those, and it’s susceptible to the other. But we worry that it can develop a mutation that will make it resistant to this drug, which is called oseltamivir, or Tamiflu. If that happens then there will be nothing that will actually treat that virus.

Q: You’re leading the emergency preparedness measures for the Vancouver Olympics. What are the risks ahead?

A: We’ve always made plans for making sure that we could detect if there was influenza circulating in the athletes’ village, for example, or among spectators, and that we would provide immunization for the volunteers, and staff. We’ve also put in measures to make sure that there are lots of handwashing sinks and hand hygiene products. We’ve been working on messages for what to do if people get signs of influenza. The athletes and their medical teams know the effect influenza can have on their ability to participate, so there’s a very high rate of immunization. We expect it to be the same this year.

Q: There really is no escaping bacteria or bugs. Is there any truth to the old notion that eating a few germs—say unwashed fruit—is good to build up your immune system?

A: I don’t think it’s good to eat dirt.

Q: You say organic doesn’t mean bug-free, that it may be riskier than non-organic?

A: Most of the pesticide agents and fertilizers that are used in organic farming are natural, which in most cases means manure. It is really imporant, even with organic—or especially with organic produce—to make sure that you wash it carefully.

Q: How can sports turf spread infection?

A: This is about an antibiotic-resistant infection called methicillan-resistant Staph aureus. There is a community-associated strain of this bug that can cause skin infections. There was a professional football team where a number of the players had scrapes on their skin from the Astroturf and were infected with this strain of CA-MRSA, and they had passed it between each other by sharing whirlpool baths and towels. So it’s important to cover up wounds and not to share equipment.

Q: And the produce-misting machine at the grocery store?

A: Legionella causes a type of severe pneumonia called legionnaire’s disease. It is a bug that has adapted to our urban water systems and can grow in warm water. Legionella has gotten into some of the misting systems in grocery stores. For most of us, we breath in a bit of the bug and our immune systems are able to fight this off. But for some people, if they get a high dose or their immune systems are compromised, they can get very sick.

Q: You recommend not shaving or waxing 24 hours before a pedicure. Or if you’re having both services, get the pedicure first. Why?

A: The thing about pedicures is you tend to soak your feet in a water bath first and there have been occasions where that water has been contaminated with unusual bacteria that usually don’t cause us a problem. But if you just shaved or waxed your legs you have tiny little cuts around the hair follicles and these can get infected.

Q: You’ve battled SARS in Toronto, Ebola in Uganda. What impact did that have on you?

A: Probably the first is that there’s an element of fear around infectious diseases, particularly with an outbreak. Battling that fear is just as important as curing the infection. The second thing is that every time there is an outbreak there are incredibly heroic people involved in stopping it. I’ve always been amazed by other health care professionals who put their lives on the line.

Q: Have you had any nasty infections?

A: The sickest I ever got was when I was doing some work in Pakistan, and got infected with, I think, E. coli 15787, so I was wiped out for a number of days. I ate something that I shouldn’t have, and became infected. I learned my lesson, that’s for sure.

Q: What was it you ate?

A: It was probably sugar cane from a market that had been kept fresh by being splashed with local water. Just a small amount can make a huge difference. It can make you ill.