‘Underlying Conditions’ May Add to Flu Worries

‘Underlying Conditions’ May Add to Flu Worries

http://www.nytimes.com/2009/05/28/health/policy/28flu.html?_r=1&ref=health

By ANEMONA HARTOCOLLIS
Published: May 27, 2009

In announcing this week that swine flu had been implicated in the deaths of two more New Yorkers, the city’s health commissioner, Dr. Thomas R. Frieden, added a by-now familiar caveat: Both of them, he said, had “underlying conditions.”

He went on to enumerate a list of conditions that could aggravate the effects of swine flu and that characterize a large portion of New York’s population: diabetes, asthma, heart disease, lung disease, a weakened immune system and, possibly, obesity.

He did not even mention three other risk factors that alone apply to more than 1.2 million New Yorkers and 50 million Americans: pregnancy, being younger than 2, or being older than 65.

Since the beginning of the swine flu outbreak, the phrase “underlying medical condition” has been transformed from a snippet of medical jargon into a household phrase. Mayor Michael R. Bloomberg had fully absorbed the new vocabulary lesson by the city’s second swine flu death on Sunday, that of a woman in her 50s. In an expression of empathy, he said his father had also died in his 50s, “because of an underlying health condition.” (In his autobiography, the mayor wrote, his father had heart damage from childhood rheumatic fever.)

Dr. Frieden intended his warning, which he has applied to all four New York deaths so far linked to the H1N1 virus, to be at once helpful to those who might be more at risk for the disease and reassuring to those who are not.

But it may apply to so many households that efforts to control public fears by using the term may be having something of an adverse effect. Even accounting for people who have more than one condition, statistics suggest that the city’s long list of red flags may encompass as many as one in three people.

“Many, many people share the same underlying causes that my husband had, and if he’s at risk, many people are at risk,” said Bonnie Wiener, the widow of Mitchell Wiener, 55, the first New Yorker to die of swine flu, on May 17.

She disputed the city’s assertion that underlying conditions were a factor in his death. “He was overweight and he was taking medicine for high blood pressure,” she said. “How many people 50 and above don’t?”

About 50 percent of swine flu hospitalizations globally and about 70 percent of those in the United States seem to involve underlying conditions. Besides Dr. Frieden’s list, they include anything that makes it difficult for patients to clear their lungs, which can include some severe mental problems, seizure disorders or neuromuscular disease.

They include chronic heart, liver and kidney disease; suppressed immunity, whether caused by H.I.V. or drugs taken by cancer or transplant patients; and blood diseases like sickle-cell anemia, which lowers the blood’s ability to carry oxygen.

A similar list of conditions applies to any strain of flu.

About 400,000 New Yorkers have asthma, the city’s most common chronic childhood illness; about 700,000, or 12.5 percent of adults, have diabetes; about 100,000 have H.I.V.; about 17,000 women are pregnant at any time, a conservative estimate, and about 900 people have tuberculosis, another risk factor, according to 2008 city statistics.

There are about 1 million New Yorkers older than 65 (although there is some evidence that people born before 1957 may have antibodies to H1N1) and 228,000 younger than 2. Obesity — which the federal Centers for Disease Control and Prevention suspect may play a role because it can impede lung functioning and immune responses — is practically epidemic. One-third of adult Americans and more than 1 million adults and teenagers in New York City are considered obese, but those with severe obesity are considered more at risk.

“We were surprised by the frequency of obesity among the severe cases that we’ve been tracking,” Dr. Anne Shuchat, the centers’ director of immunization and respiratory disease, said at a May 19 press conference.

The centers’ officials have said that pregnancy is a risk factor because it suppresses the immune system to protect the fetus and can decrease lung capacity.

Compounding the anxiety is that public health officials, citing medical confidentiality, have refused to disclose not just the identities of those who have died but even the most basic information about their health conditions. (Mr. Wiener’s case was widely known because of his long career in the school system.)

Judy Trunnell, 33, a teacher from South Texas, was the first American citizen to die of swine flu, in early May, after delivering a healthy baby girl by Caesarean section. A Texas Health Department spokeswoman said she had “chronic underlying health conditions,” which her husband, Steven, later denied on CNN.

More details came to light a week later through a routine scientific study, a weekly “Morbidity and Mortality” report by the federal disease centers. Without using her name, it said she had a history of psoriasis (not considered an underlying condition) and mild asthma, in addition to her pregnancy.

Warnings about underlying conditions appeared to be propelling people toward bursting emergency rooms. At Maimonides Medical Center in Brooklyn, Sally Maugeri, an unemployed kitchen worker who had a cough, had brought in her nephew, Salvatore Soria, 10, who had been sick with coughing, vomiting and diarrhea, and his mother, Joanne Maugeri, 50, on Tuesday.

They had a trifecta of underlying conditions: Salvatore had a history of asthma, while Sally Maugeri was nine months pregnant and said that diabetes ran in her family. “The fact that he’s sick and I’m pregnant, I wanted to come in to see if he has the swine flu,” she said. “Because I have underlying symptoms, it makes me more scared.”

Doctors diagnosed pneumonia in Salvatore and sent him home with amoxicillin, an antibiotic.

On Wednesday, Shanaz Hossain brought in her son, Abir, 12, and daughter, Zarin, 10. Abir had a fever of 103.6 at home, Mrs. Hossain said, but her worries were aggravated by his asthma, the dreaded underlying condition that she had heard about on the television news. Abir’s private doctor had diagnosed strep throat, but his mother took him to the emergency room for a chest X-ray. “Of course I am still worried,” she said.

Such anxiety has been a headache for doctors. They say that people with underlying conditions who have flu symptoms should consult their doctors, but that visiting an emergency room full of sick people may actually put them in more danger.

“Like the asthmatics, we’d really prefer that pregnant women would stay away from the emergency departments,” said Dr. Steven J. Davidson, the chairman of the hospital’s emergency medicine department.

But City Councilman John C. Liu, who represents Flushing, Queens, where the outbreak is widespread, said the Bloomberg administration had failed to disclose enough information to a jittery public. “The cloak of secrecy is not alleviating anyone’s fears, whether they’re real or perceived,” he said.

But Dr. Scott Harper, a city epidemiologist, said that looking at the conditions behind just a handful of deaths could give people a false sense of security.

“This isn’t an issue of secrecy, it’s an issue of privacy,” Dr. Harper said. “If you’re talking about two deaths in this size population, to be able to make decisions about your personal health knowing about medical details on those two deaths doesn’t seem realistic. What does seem realistic is to look at things that are published widely.”

Reporting was contributed by Jack Begg, David W. Chen, Ann Farmer, Donald G. McNeil Jr. and Mathew R. Warren.