Dr. Ben Kruskal, Director of Infection Control at Harvard Medical Associates: Conversation with David Harlow about Swine Flu / H1N1

My conversation with Ben Kruskal, MD, PhD, HVMA Director of Infection Control, about swine flu / H1N1 continues.

In today’s installment we discussed incidence of new cases, their concentration among children, chances for emergence of a more virulent strain of flu, and closer coordination between large ambulatory practices such as Harvard Vanguard Medical Associates (which has 400,000 patients) and the state Department of Public Health.

The audio file of our conversation runs about 10 minutes and is available for download/podcast.

Update 5/15/09: Read the linked transcript or the copy below.

Our earlier conversation is available here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control,
Harvard Vanguard Medical Associates, May 14, 2009

David Harlow:  Hi, this is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal from Harvard Vanguard Medical Associates where he is Director of Infection Control.  We spoke a week or so ago about swine flu or the H1N1 virus, and I am eager to learn whether this week you see any change in the progression of this pandemic or epidemic and what sort of changes you see in its progression?  I looked at the numbers today, here in Massachusetts we’re up to about 133 confirmed cases as of this morning.  So, I’m curious to see if you see a progression or a trend in the past week or so?

Dr. Ben Kruskal:  Well it’s pretty clear that the virus has, as predicted, started to spread pretty widely in the community and the number of confirmed cases being reported is clearly a pretty big underrepresentation of the real number of cases because we’re not even attempting to test all cases.

David Harlow:  Okay, so these are just lab confirmed cases, is what you’re saying?

Dr. Ben Kruskal:  Exactly.

David Harlow:  Okay and what was interesting to me in looking at the Department of Public Health’s figures is that the majority of these cases are among school-aged children, and CDC said last week that it felt it was no longer necessary to close schools in the event of children being sick.  I am wondering if these numbers might cause us to reconsider that approach.

Dr. Ben Kruskal:  Well, I think what CDC said was not to not close the school at all, but rather not to close the school for a single case which is what the original advice was.  What they are now saying is that the school should only be closed if there is a significant cluster within the school, so I think they’re still acting responsibly in the sense that if the school is clearly a focus of spread, that is the time to close things down.  If there are one or two cases that are well-contained, then the inconvenience to the large number of people would occur from closing the school isn’t worth it.

David Harlow:  Okay, fair enough.  And so I think it was in New York today or yesterday where a number of schools were closed.  There is a cluster of 50 cases in one of the schools, so that’s consistent with what you are saying, and the CDC policy.

Dr. Ben Kruskal:  It is also very interesting to see that cases do seem to be concentrated among younger people and the explanation for that isn’t clear.  I think the predominant speculation is that older people may have encountered strains that were related enough to afford them some immunity, whereas younger people have never seen a strain like this before.

David Harlow:  Interesting.  So you’re referring to the swine flu that we had in the mid-70s?

Dr. Ben Kruskal:  Not necessarily that strain, but some other related strain at some point far enough back — at least 20 years back — so the young people who are the predominant population affected so far wouldn’t have had any exposure.

David Harlow:  And are those numbers in terms of age distribution consistent across other areas as far as you know, beyond Massachusetts?

Dr. Ben Kruskal:  It’s a little hard to make good sense out of the numbers and areas that don’t have a lot of cases because the people who are being tested are very a skewed population, and probably not representative of all cases.  I think in the areas where many fewer cases are reported the predominance of adults is largely because they’re looking at people with travel histories.

David Harlow:  Okay.  So how do you see this playing out over the next weeks and months as we get into the warmer weather, and how do you see this playing out next fall or next winter?

Dr. Ben Kruskal:  Well it’s still very much up in the air.  The fact that there is as much transmission as there is, even in the relatively warm weather that we’ve been having in the last couple of weeks, is a little bit of a concerning sign to me that transmission may continue at a really, really high rate even through the summer.  So in terms of spread, it’s surprising that it’s still going on at the rate its going.  There is a concern based on some previous examples of novel strains that as the virus is transmitted from person to person, there may be selection for more virulent sub-strains and that the severity of disease may increase over time.  In some prior outbreaks, the virus has gone underground for the warm season and then re-emerged in a more virulent form in the fall, but I am somewhat concerned, seeing the level of the transmission we’re still sustaining now, that we may be possibly headed for more severe cases even sooner than the fall.

David Harlow:  So it likely will continue even through the warmer weather which will be unusual as I understand it.

Dr. Ben Kruskal:  Absolutely, but again the degree of spread that we’re seeing now is pretty unusual as well.

David Harlow:  Bu

t thus far at least, it doesn’t seem to be that virulent an illness?

Dr. Ben Kruskal:  No, thank goodness, it has been quite mild in the vast majority of cases.

David Harlow:  So, I’m interested to hear how you are dealing with this on behalf of your medical group in dealing with the large population [of 400,000 patients] that you are responsible for?  What are you and your team doing on a daily or weekly basis in order to help manage this?

Dr. Ben Kruskal:  Well, we started from the very beginning and we’re fortunate enough to have a plan in place which we were able to adapt quickly to the current situation.  We focus on providing information for our patients that’s been crafted centrally but we’re not relying every on every individual doctor and nurse to create the message themselves.  We had the help of specialists in communications and we have also been working hard to get timely, consistent and accurate information out to our staff in order to equip them to deal with patients’ questions and concerns.  The patient anxiety clearly has been much, much bigger than the actual number of cases, so I think done a reasonably good job of giving people these tools and giving our patients information directly as well.  In addition, we focus very heavily on protecting our staff, knowing that it’s hard to come to work if you think you’re going to be infected with something nasty and we’re taking precautions that may be excessive given the relatively mild nature of the illness, but again being conservative and making sure that our staff feel safe coming to work.

David Harlow:  I also understand there’s has been a national stockpile of antiviral medication being distributed, has that been distributed to your group as well or is that going just to pharmacies?

Dr. Ben Kruskal:  It actually was initially meant to be distributed only to hospitals and we were active in lobbying the Department of Public Health to include the ambulatory health care organizations as well and succeeded in getting a significant chunk of the distribution for large practices such as Harvard Vanguard.

David Harlow:  So have you been coordinating with the State Department of Public Health along other lines as well?

Dr. Ben Kruskal:  Yes.  We’ve been talking to them for quite some time about the role of ambulatory care providers in provision of care in pandemics and other disasters and I think we’ve really pushed their attention in the direction of what ambulatory care can provide in a disaster like that, and we have extensive discussions which I think have helped to inform the way they are working with other ambulatory groups as well.

David Harlow:  That’s encouraging and it makes a lot of sense, since so much care that was in the hospitals traditionally has really been pushed to the ambulatory setting.

Dr. Ben Kruskal:  Right, and enabling the primary care providers to continue to function during an outbreak has several advantages.  One is that by virtue of the existing relationship that we have with our patients we may be able to convince them of things that they might otherwise feel too nervous to hear from a provider they never met before,  so we can help them comply with public health directives in a way that’s much harder for an unknown person to do.  In addition, we can take the load of the worried well and the mildly ill off of the hospital, so they can focus their attention on the things that only they can do, which is caring for the most severely ill.

David Harlow:  That makes a lot of sense.  Thank you for your time.  This is David Harlow on HealthBlawg.  I’ve been speaking with Dr. Ben Kruskal, the Director of Infection Control of Harvard Vanguard Medical Associates here in Boston, Massachusetts.  Thank you again.

Dr. Ben Kruskal:  Thanks David.