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H1N1 in Mexico - Lessons Learned

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The Mexicans have taught the world that transparency and full disclosure was brave and admirable and saved countless lives but came at the price of severe economic consequences. The argument made by me and others after SARS that the World Bank should provide incentives to countries for rapid reporting of novel pathogens causing epidemics seems to still be valid today.

A week or so after the outbreak, a flight to Mexico from Atlanta was only 15% occupied, and on arrival the airport was nearly deserted. I had been asked to Mexico City by my colleagues at the National Institutes of Respiratory Infection and planned to make rounds with them in the wards and ICUs.

The city was awakening from the infection control measure called social distancing. The traffic on this mega city of 20 million was only half of its usual density compared to my experiences in 25 prior trips. Cabbies still wore masks, as did the staff in all restaurants, most of the police officers, and perhaps 10-20% of the citizens walking around. On that day the swimming pools and restaurants were opening for business; football (soccer) was about to resume, and schools were opening on Monday, May 11th.

Almost two weeks earlier Mexican health authorities announced to the world the increasing number of cases and deaths from the new strain of influenza virus fully cognizant of the economic consequences. In a brief 10-day interval they made a critical decision for transparency, in bold contrast to the 110-day interval before the world learned about SARS in China. Because there was no vaccine and no certainty that the available drugs to treat influenza would be effective, the only option left was social distancing.

On Friday and Saturday I made rounds on the wards and ICUs of the National Institute of Respiratory Infection and National Institute of Nutrition. Outpatient visits had fallen in the last week by almost two thirds, but as referral centers the ICUs were still full, and three new admissions per day were occurring. Patients in their 20s, 30s, and 40s were on respirators, and so the inhuman statistics now had meaning. In the last few weeks, those in ICUs intubated and on mechanical ventilators included a bus driver, a housekeeper from one of the hospitals, an anesthesiologist and a mechanic. H1N1 appears to be an equal opportunity virus.

Outside the hospital, medical residents in training and wearing masks were screening all people entering the hospital. At another table nurses and physicians had set up a center for health care workers and their families to answer any questions, to give the 24/7 hotline and instructions. They were essentially managing fear and offering psychological support. One infectious diseases specialist told me he cried at the outset of the epidemic, worried about his young son and wife. Another said his wife forbade him to sleep on the same floor as her and their two-year-old child. A third physician thought she would lose her 16-year-old daughter when fever, diarrhea and respiratory distress arrived. Fortunately, the teenager is recovering. The management of fear among health care workers in the face of death and uncertainty is an essential element of response to an epidemic. Their creative implementation of triage outside of the hospital entrances is wise.

On Saturday rounds in the ICU at the Nutrition Institute, a young man had just died and a second had relapsed and returned from the ward to be intubated. Influenza has the ability to cause severe illness and kill healthy young people. We have been fortunate in the U.S. with mild cases, but complacency would be a foolish path ahead.

Influenza H1N1 may rear its dark side yet in the U.S. It may soon advance to South America where the winter is approaching, and may resurface with a new face in the Northern Hemisphere in the fall and winter 2009-2010. We have time to prepare for a vaccine if needed, and we certainly can applaud the Mexican health authorities and learn from their remarkable encounters with H1N1.