H1N1 Pandemic and Ophthalmology

Letters to the Editor H1N1 Pandemic and Ophthalmology Dear Editor: In all situations, but critically important during an emergency such as the current novel influenza A (H1N1) virus pandemic, health care is a limited resource. Turnover time in emergency departments must improve in order to handle large numbers of acutely ill patients,1 and this task may require the resources (physicians, nurses, technicians, beds, equipment) of other departments. We describe the diversion of resources from an ophthalmology department and a precipitous decrease in non-acute ophthalmic clinical and surgical care at a large academic, tertiary care hospital during the height of the H1N1 pandemic in Cordoba, the second largest city in Argentina. In 2008, the population of Argentina was 39,745,613, of whom 3,221,001 lived in Cordoba province.2,3 The population of Cordoba city (where the hospital is located) was 1,309,536 the same year.2 The hospital is one of the main public hospitals in Cordoba province to which many patients with H1N1 were triaged after the start of the pandemic. In July 2009, at which time the highest incidence of new H1N1 cases was recorded in Cordoba (according to data compiled from the Ministerio Salud de la Provincia de Cordoba, the health center database in Cordoba), 2024 patients entering the emergency departments in the province were suspected of having H1N1 and were tested for H1N1. Of these patients, 893 tested positive for H1N1 using a real-time reverse transcription-polymerase chain reaction (rRT-PCR) detection system (Bio-Rad Life Science Research, Hercules, CA); 54 of these patients died in July or August 2009. Another 850 patients tested negative for H1N1; 17 of these patients died. Thirty-five patients were positive for seasonal influenza, of whom 2 patients died. Another 166 patients had clinical signs and symptoms of H1N1, but were under investigation by rRT-PCR as of August 2009; 8 of these patients died. At Transito Caceres de Allende hospital, 3125 patients with suspected H1N1 entered the emergency department between June and August 2009. Of these patients, 257 patients were hospitalized with severe respiratory illness and were treated with intravenous ceftriaxone 1.5 g/12 hours, clarithromicin 500 mg/12 hours, and oseltamivir 75 mg/12 hours. All patients tested positive for H1N1; none of these patients died. The remaining patients were not tested for H1N1 due to high demand for the rRT-PCR test. During July 2009, much of Argentina was closed except for emergency services (fire and police), supermarkets, and public libraries. Schools (including universities) and public centers were closed because of a government-imposed curfew and because of community fear. Other than the emergency department, most departments at the hospital offered curtailed services as doctors were diverted to caring for patients with H1N1. Nurses, technicians, other ancillary staff, and administrators remained at home. Most appointments in the ophthalmology department were cancelled; few ophthalmologists were available in clinic, and many patients did not show up for their appointments. The number of completed, non-emergent ophthal-

mology clinic appointments decreased from 1300 in July 2008 to 60 in July 2009, a drop of over 95%. Only one ophthalmic operating room was open in July 2009. No cataract surgery was performed; only emergency surgical procedures (retinal detachment repair and ruptured globe repair) were performed. The number of ophthalmic surgical procedures decreased from 105 in July 2008 to 6 in July 2009, representing a drop of over 94%. All inpatient beds, including those from ophthalmology, were dedicated to patients with H1N1. In conclusion, these results from a large hospital in Cordoba demonstrate that the H1N1 pandemic can be expected to have a major effect on allocation of health care resources. Although H1N1 has few ophthalmic manifestations (conjunctivitis4,5 and keratoconjunctivitis5 have been reported and were seen in a very small number of patients in Cordoba), the outbreak had a short, but highly disruptive impact on the functioning of the ophthalmology department and in general, on non-acute care at a major hospital. The precipitous curtailment of ophthalmic services occurred at the peak of the H1N1 incident cases in Cordoba province, which is similar in size to Chicago (the city of Cordoba has a population similar to that of Dallas). Although the disease has slowed in much of the Southern Hemisphere, it has continued to spread in parts of the Northern Hemisphere. During the week of October 18-24, 2009, a review of the key indicators found that influenza activity continued to increase in the United States from the previous week; 48 states were reporting widespread influenza activity (http:// www.cdc.gov). Unless prevention of H1N1 (through means including education, identification, hygiene, isolation, and vaccination) increases, disruptions in ophthalmology departments in the Northern Hemisphere where the H1N1 pandemic has yet to peak could occur if similar policies and procedures are employed. IRENE C. KUO, MD Baltimore, Maryland FERNANDO PELLEGRINO, MD Buenos Aires, Argentina PABLO FORNERO, MD LILIANA BRITOS, MD, PHD GABRIEL PEDETTA, MD VICTOR E. REVIGLIO, MD, PHD Cordoba, Argentina References 1. Lurie N. H1N1 influenza, public health preparedness, and health care reform. N Engl J Med 2009;361:843–35. 2. INDEC, Instituto Nacional de Estadística y Censos (2001). Censo Nacional de Población y Vivienda 2001. INDEC, Cordoba, Argentina. 3. Estadísticas Vitales 2007. Ministerio de Salud y Ambiente, Argentina. Año 2008, serie 5, numero 51. 4. Sebastian MR, Lodha R, Kabra SK. Swine origin influenza (swine flu). Indian J Pediatr 2009;76:833– 41. 5. Athanasiu P, Anghelescu S, Predescu E, et al. Rapid detection by immunofluorescence of multiple viral infections in patients with keratitis. Virologie 1984;35:83– 8.

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