Iowa Cat Contracts H1N1 Influenza

A Discussion of Zoonoses

First it was ringworm; now this. According to the Washington Post, a cat in Iowa (name withheld) is believed to be the first case of H1N1 in a domestic animal. It is thought that the cat caught it from a human, although it has not been labeled Human Flu by concerned veterinarians. The 13-year old cat, now recovered, did not comment. At the present time, people in Iowa should continue to feed and pet their cats.

Maybe it's Iowa? The 1918 Influenza Pandemic that killed millions worldwide actually started in Iowa, too. People in Iowa blamed Spain. Recommendations to evacuate the State of Iowa have not been issued. People should not panic.

The H1N1 flu has also been confirmed in two ferrets, which both died. It was not clear if the ferrets lived in, or recently visited Iowa. H1N1 has been found in turkeys. That's nice to hear with the upcoming holiday. My property is overrun by turkeys, so maybe I should consider thinning the population as a public health project?

I guess it is only fair -- pigs and/or birds are the primary reservoirs for influenza that transmits to humans. I sure hope that dogs aren't next. I am not sure I could live in a world where dogs can't kiss you or lick your hand. I sort of like cats, but they rarely are the "lick you in the face" species. I definitely would not be allowing a ferret near my face.

Animal to human transmission of disease is called zoonoses. Probably the most common zoonotic disease that I see in my clinic (other than ringworm - tinea corporis) would be giardia, an intestinal parasite that can live in water sources. Those water sources, like streams or rivers, are typically contaminated upstream by animals that poop in or near them. Of course, fish always poop in the water, but no one seems concerned about this obvious fact. Giardia causes annoying bouts of diarrhea and impressive, both in volume and smell, intestinal gas - two symptoms that would seem to be incompatible, let alone socially problematic. Kids, not known for their high levels of bathroom hygiene, can easily spread Giardia in day-care facilities and schools, and eventually to their parents. I coined my own team for kid-borne diseases called "Pedianosis".

There are hundreds of zoonotic diseases. Perhaps the most famous of zoonotic diseases would be AIDS. HIV infections were thought to be a mutation of a monkey or chimpanzee virus, contracted by humans in Africa that decided it would be a good idea to eat them, or more disturbingly, have carnal relationships with them (an unlikely rumor). One minute, you are having a little monkey tartar; and then you become unusually ill.

Lyme disease, contracted primary from deer ticks is becoming more common as growing populations of deer exist closer to humans. A different tick carries Rocky Mountain Spotted Fever. The son of a medical provider in our clinic came down with Lyme disease a few years ago, thought to be transmitted by a tick found on lizards! My home of course is also a lizard sanctuary. I tend to leave them alone, although the do periodically scare the crap out of me when they peak out from rocks. My initial fear is that his head represents a SNAKE! Wild turkeys apparently cannot catch or desired to eat lizards.

Fleas living on rats caused the Bubonic Plague that killed half the population of Europe in the Middle Ages. Cats have fleas, but fortunately not Bubonic Plague-carrying ones. Bats, skunks, and feral dogs can carry deadly rabies. Pet turtles (as well as eggs and poultry) can carry salmonella. E.coli can be found in meats, especially improperly cooked ground meats sold at certain, unnamed fast-food restaurants. Even snails (not escargot, one of my favorites) cause some serious diseases. Perhaps, the world's most dangerous creature, the one that causes most of the deaths worldwide is the lowly mosquito which carries malaria, yellow fever, and a few other killers.

A few minutes ago, I saw a young man who was bitten on the hand by a feral cat that was living in a car (convertible, if you should inquire) at the auto repair shop where he works. His well-meaning boss offered a cash bonus to anyone who successful caught the cat. The cat was not pleased when he was incarcerated in a plastic milk crate, so he decided he would bite the hand that caught him. It was an impressive infection. At least he didn't get H1N1.

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Masks and Dark Glasses

As a seasoned medical provider, I can't tell you the importance of actually "seeing" the patient. I have always had issues when people come in wearing dark glasses. Since the eyes are the window to the soul, I find it very difficult to have an effective medical encounter with someone wearing dark glasses. When you address a particular medical question, you instinctually look at the eyes for response. Is the person making direct eye contact? If your patient is a teenager, are they "rolling their eyes" at you? Are they gazing downward? Before I start any medical encounter, I ask the person to please remove their dark glasses so I can see them, and not my own reflection.

Morgan / CC BY 2.0

H1N1 flu pandemic has hit our area big time. We set up a "flu station" in the lobby where people can use hand-sanitizers and pick up a surgical mask to wear. When I enter the examining room now, it is not uncommon for everyone to be wearing masks - except me.

Just like the eyes, I also like to see a person's entire face. I want to see if they are smiling, grimacing in pain, or frowning at me. If a person had both a mask and dark glasses, I would just assume they had a big paper bag on their heads. Just like the dark glasses, I ask them to remove their masks once they are in the examination room. I don't know how Westerners can practice medicine in the Middle East. If I saw a person wearing an Islamic burqa, I am not sure how I would react. But at least, could see her eyes.

The Lone Ranger wore a mask, like no one would really recognize a well-spoken man in clean white clothes, riding a white horse along with this companion, an Indian that speaks like Tarzan. Bank robbers and train bandits wear a scarf or bandana over their mouth and nose. Spiderman wears a full face mask apparently so you won't recognize him as Peter Parker. Superman doesn't wear a mask, but uses a pair of dark-rimmed glasses when he changes into Clark Kent - another clever disguise designed to fool idiots. A guy in a ski mask coming to my front door would definitely get a rise out of me.

Josh Westbrook / CC BY-ND 2.0

If someone walked into a bank today, wearing a surgical mask and dark glasses, they would definitely get the attention of the security guards. Halloween is just around the corner, so our pediatric practice allows the staff to dress up, without masks, of course. Masks typically scare kids, even surgical masks. We don't get the Trick or Treat crowd in our rural neighborhood anymore. I sort of miss them.

The first time that I saw people in public wearing surgical masks was in Japan many years ago. Japan is a crowded, but highly-organized and respectful society. When I inquired about the masks, I assumed that people were protecting themselves from the germs of others. To my surprise, it was the people in the masks who were trying to keep their germs to themselves. They had colds or influenza and did not want to infect others. This is a very respectful hygienic practice that we rarely see in the U.S. People on the subways in the U.S. will just about sneeze in your face; or sneeze in their hands just before the grab the hand rails.

I have been exposed to so many cases of H1N1, that I expect that I have some residual immunity. I have been endured numerous sneezes and coughing in my direction. I have held contaminated hands. I have wiped noses of children. If and when the H1N1 vaccine arrives, I am not really sure I need it. I will take it for my patients, of course, but I suspect that I am either immune from prior infections, or darn lucky.

One provider was complaining this week that he had to wear to complete biohazard suit, complete with a battery-powered air filtration system and full spaceman helmet when he was examining a baby in the ICU. The baby was in protective isolation. He said it was impossible to listen to heart or lung sounds using a stethoscope while wearing a space helmet and noisy respirator.

Until this pandemic is over, we must all learn to tolerate people in surgical masks - even when they are surgeons. It could be worse. We could all be wearing those space suits.

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Doing Your Part

Your Responsibilities as Member of a Community and of the Human Race

In the last two weeks, we are starting to administer the seasonal flu vaccine. You would be surprised how many people are refusing it because they do not think they need it. But, what about the rest of us?

We all share this small planet; a planet with limited natural resources, and a planet that is progressively becoming more polluted and damaged. Globally, steps are being made to limit greenhouse gases, preserving the protective ozone layer, finding cleaner fuel sources, and replacing some what has been exploited and raped over the centuries.

I grew up in a strip coal mining area, where beautiful topsoil was moved aside in order to get at a narrow layer of soft coal. Thanks to the efforts of environmentalists, much of that land has been restored. The air and our streams are no longer stinky and yellow. It was commonplace to run sewer lines directly into a pristine creek. A generation ago, people mindlessly dumped their trash along the side of rural roads, or simply threw out their fast-food bags from a moving car. Thanks to Lady Bird Johnson's efforts, our roadsides are no longer piles of discarded junk and rubbish. Little by little, America became more beautiful when people started caring.

A week ago, we were given evacuation orders when a wild fire threatened our neighborhood. Over eighty homes were burned to the ground. Had the wind changed directions, our home would have been lost, too. The cause of this fire is yet undetermined, but arson is a possibility. A few minutes ago, the Department of Forestry spotter plane buzzed and circled my house. There was another fire; this time only a mile away and the wind was blowing in our direction. The quick efforts of our local fire department quickly got this fire under control. According the Highway Patrol, a motorist threw a cigarette out of the window, starting a roadside brush fire. Throwing a burning cigarette out of a moving car deserves jail time, in my opinion. Of course, they will never catch the culprit.

Are we all doing our share? Do you turn out the lights in rooms that are unoccupied? Do you use energy-efficient bulbs? During the summer months, do you set that thermostat a little higher? Do you drive the speed limit and wear your seat belts? Do you recycle your aluminum cans, glass, and plastic? Are you immunized against vaccine-preventable illnesses? Do you wash your hands? Do you smoke? All of these seemingly little things help our planet and your community. As members of the human race, these are your responsibilities.

As a child, we did not have seat belts in our vehicles. Children were not restrained in infant car seats; they could freely jump from the back seat to the front if they chose. Motorcyclists were not required to wear helmets. So, how does wearing seat belts impact our role in the community or the human race? A non-seat-belted person is more likely to sustain serious head and neck injuries, assuming they are not killed. If they have health insurance, the bills could be astronomical for their care. This will raise rates for all of the other insured people who do wear seat belts. If the person does not have health insurance, the state and federal government will end up footing the bills, and of course, guess who pays the state and federal government through taxes?

Smokers feel that they have a right to smoke. Apparently, "Freedom to Smoke" is protected by our Constitution somewhere. Smokers pay the same insurance premiums as you and I, but of course, smokers tend to get more respiratory illness, such as pneumonia, asthma, or emphysema, use the emergency room more often, and have a higher rate of cancer, requiring expensive surgeries and cancer treatments. Smokers have higher absenteeism at work and lower productivity. Again, the insurance companies (and we non-smokers) foot the bill, as well as the government. When smokers flick their cigarettes out of a moving car and start a fire, someone else still has to pay for those damages. When a person chooses to smoke, they impact more than just their own lungs. They seriously impact ALL of us, directly and indirectly, in so many ways.

If people defend their right to smoke, do they also defend their right not to wash their hands? Is personal hygiene (or the lack of) protected by the Bill of Rights? Someone comes out of a public restroom and doesn't wash their hands. They put their contaminated (poopy) hands on the door handles. A little child touches that handle and becomes seriously ill. The simple act of washing your hands can have a major impact on the community.

There was a major public health effort in the 1950's. If people had the right to refuse vaccinations, no one really exercised those rights. Everyone felt that it was our community responsibility - our duty - to be vaccinated, so that people would not get polio, or measles, or whooping cough. In less than a decade, the incidence of these vaccine-preventable diseases plummeted. Everyone, by getting vaccinated, did their part. These public health efforts have saved millions of lives and billions of dollars, yet now, people feel they have the right to refuse vaccinations for personal reasons...stupid reasons. They don't care if they, or their children get the diseases, and they certainly don't care if they spread it to others in the community. You cannot achieve "herd immunity" unless all or most of the herd has been inoculated. Just like one bad apple making the others rotten, if there is an unimmunized person in a community, the disease will survive. An epidemic starts with one.

There are people in the community that count on "herd immunity". Our efforts to vaccinate ourselves and our children is their only protection. They want others to take any risks, but then expect the insurance companies and society to take care of them if they get one of these serious, preventable diseases. Medical care is God-awful expensive, not just in dollars but in emotional toll. Are their calculable risks to taking vaccines? Sure, very small ones. The risks of serious vaccine reactions are considerably less risky than the chance of getting struck by lightening, but yet people are afraid. Some of these fears are created and nurtured by the Internet, backed up by pseudo-science and charlatans.

Perhaps the real barrier is trust. Since the 1950's, Americans seem to have lost faith in their government, perhaps for good reasons. Remembering thalidomide and other recalled drugs, they do not trust the pharmaceutical companies. They do not trust the FDA that approved these drugs. Often, they do not even trust their medical providers - the people that they chose to participate in their health care. People do not trust banks, the post office, the military leaders, or our President. What happened? Right now, President Obama is trying to make a complacent and mistrusting population aware of the serious health threat that influenza can cause. Millions of Americans died in 1918 and it can happen again. Why don't people listen?

In order for people to share responsibility, we have to have trust. We have to trust that everyone will do their part and not opt out or make excuses. We have to trust our elected leaders and our scientists, and we need to come down hard on those who betray basic, human trust. It has been said that we can trust, but verify. It is perfectly normal to question recommendations, but at some point, it will come down to trust. Do you trust your government? Do you trust your medical providers? Do you trust your own judgments?

As a medical provider, I am on the front line. I had to take four nasal swabs for a pertussis test this week on a 15-month old. The mother does not "believe" in vaccines, so none of her children are immune. I can take care of her because I am immune to pertussis. I took my vaccine. Otherwise, I would be putting my own life at risk. I can take care of people with influenza and other life-threatening illness because I am vaccinated, and this is my job. Vaccines are not perfect; few things in life are perfect, but vaccines are and will remain one of our best defenses. It is much easier to prevent an illness than treat one, I can assure you.

Please do your part. Don't throw trash out of the window. Turn off unnecessary lights and use energy-efficient bulbs. Wear your seat belts or helmets, and secure your children in car seats. Don't smoke, and if you do, stop. Wash your hands. Unless you have a true contraindication, take the recommended vaccines. Be honest and learn to develop trust (again). We live in the same community; on the same planet. We are all in this together.

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The 2009 Flu Season: Ready or Not; Here it Comes!

In a medical office that cares primarily for children and adolescents, the summer months are very manageable. We even have open appointments on the same day. However, when school starts, the flood gate of illnesses will start to come in.

High on the list of fall season illnesses has got to be influenza. The H1N1 strain of influenza (formerly called the swine flu) still has health officials worried. Now that H1N1 has been officially declared a worldwide pandemic, no one is really sure what will happen when the real flu season begins. Are we going to have thousands or even millions of victims? Should we expect massive school closings and work absenteeism? In this fragile economy, will this pandemic push us over the edge? No one really knows, but planning for the worst-case scenario is probably prudent.

There was a time when I could give away flu shots, even with all of my persuasive arguments. At the opening of a new urgent care facility several years ago, the owner's decided to give free flu vaccines to everyone on our first Saturday. The clinic opened at nine AM. The crowd began forming hours before. By the time we arrived at the clinic, the line of people, mostly an impatient mob of assertive and highly-vocal senior citizens, stretched down the street. Expecting a smaller turn-out, we only had one medical assistant assigned to the flu shot clinic. Even at full pace, the most she could administer was about one injection every five minutes or so (including registration and medical history). That is only about twelve an hour if everything went smoothly. There were at least 200 people in line! You do the math. As the hours progressed and tempers flared with the waiting crowd, someone announced that we were running out of vaccine. Lord, help us if that happened. I was sure that I would be caned to death during the inevitable riot. Some quick thinking resulted in "rain checks" for the ones at the back of the line. They weren't happy about it, but when you run out, you run out.

Because of this past experience, I often fear for my own personal safety when we run out of vaccine in our office. For the last two years, we were frequently required to ration our rapidly-depleting stores of vaccine to the most critical patients. I sure hope that the supply this year will be plentiful. I would hate to see those angry mobs again. The federal government, known for their efficient way of handling public health issues, promises there will be plenty of vaccine to administer. We will see.

Each person may need THREE flu vaccines: one for the regular seasonal flu and two for the new swine flu strain (one now, and then a second booster in a month). Multiply that by the number of patients we see in our clinic every day (over three hundred), and we may have a shortage of medical assistants just to administer them.

A few days ago, I had three patients come in to evening clinic. All had been to an orientation and band camp at the local high school, and all three were very ill with flu-like illnesses. I saw two of them; one was positive for Type A flu (H1N1 is a type A flu) and started on Tamiflu, and the other was negative. My partner saw the third patient and clinically diagnosed him with influenza and started him on Tamiflu. The next day, the news service had picked this up - "Three Confirmed Swine Flu Cases in Local High School." I suspect that one of the parents called the media. First, it takes about two weeks to confirm the one type A case was H1N1 or not, so there are no confirmed cases at the moment. Of course, this would not a newsworthy. As you might imagine, the school system went into panic and sent out phone announcements to all of the parents. This resulted in dozens of people streaming into our office to be tested for H1N1, none of which even had classic symptoms or known exposure.

All three of those students, including the one that may have had H1NI, wanted to go to school anyway, where they would have freely shared their illness with umpteen others. This is exactly how local epidemics begin.

One of the parents worried because a neighbor, three houses down, supposedly died from H1N1, so she was worried if the flu could be airborne this far, or if fleas on rats could have carried it to her home! Apparently, she is confusing influenza with the Bubonic Plague. So much misinformation...

We have not received any flu vaccines in our office, not even the seasonal flu, but I suspect the demand will be high. If the new H1N1 vaccine is approved, and I suspect it will be, then I can only hope that we get our share of vaccine to distribute.

All medical providers hate to ration vaccine, but high on the list of people to get the vaccines first would be the medical providers. It is not that we are looking out for ourselves first, it is just that we are on the front line to get an infection. Since influenza is contagious a day BEFORE, we could be infecting hundreds of people without knowing it.

Ready or not, the 2009 Influenza Season has really begun (or perhaps, never ended from last year). Medical providers are on high alert. Health departments are gearing-up. Are we really ready? That is the big question.

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• Swine Flu Guide
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Interesting Tidbits from the Medical Literature

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

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Bird Flu? Swine Flu? Mexican Flu?

Last year, it was the bird flu panic. People stopped eating chicken (you can't get it that way), feeding pigeons, and worried about living along migratory bird routes. Many stockpiled is oseltamivir or zanamivir - antiviral flu medications - and waited anxiously for cases to appear in their neighborhood. The bird flu is still out there (somewhere) and a few cases are still popping up from time to time, but it was not the worldwide pandemic that it promised to be.

Now, we have the swine flu panic and public health departments are gearing up for what could be another potential disaster. Since a particularly-virulent flu bug was the cause of the last worldwide pandemic in 1918 and resulted in several million (yes, million) deaths, we tend to take notice.

This pandemic occurred during the height of the First World War and was erroneously dubbed the Spanish Flu, apparently to take the heat off of the good people in Kansas where it actually started. Other flu pandemics and epidemics have been called the Hong Kong flu since many of these strains were identified first in China, where people, birds, and pigs live in much closer proximity. Since the swine flu appears to have originated in Mexico, I suspect someone will start calling it the Mexican Flu. Influenza by any name is just as concerning.

The swine flu virus tends to live quite contently in pigs, hence its namesake. However, flu viruses have an annoying tendency to mutate and adapt, sometimes making the jump from pigs to humans (or birds to humans). When it jumps species, the next step is the worst of all - human to human transmission. The Type A strain of swine flu (H1N1) is transmitted from human to human. So far, nearly 1300 cases have been reported including over a 100 deaths in Mexico. There are at least seven cases in the U.S. now. Incidentally, you cannot get swine flu from eating pork or pork products. Don't throw away your stockpile of Spam or Honey-baked Ham.

Today, one case was reported in our local neighborhood at a Catholic school. The school is now closed until further notice and several frightened parents have brought children in to be tested. We have one parent coming in today (in a mask) because her child owns a pig. Although their pig has not traveled to Mexico to visit relatives, they want the child tested. Our local health department has gone into high gear and heightened surveillance to prepare for the worst, should it happen; although when we tried to send in a specimen today, the Health Department was closed! Within the first hours of work today, we have received numerous instructions on the proper way to collect specimens from any person that has vague "flu-like" symptoms such as fever, cough, or sore throat (just about ALL of my ill patients have those).

Several years ago, there were three cases of meningitis at one local high school. For months, people would not even shop in that town, or allow their children to play in the McDonald's playground. I am surprised there weren't guard towers and razor wire surrounding the town.

Right now in Mexico City, large gatherings of people such as sporting events or church services have been canceled and millions of surgical masks have been handed out. I haven't seen this many surgical masks since I went to Japan. In Japan, people often voluntarily wear surgical masks on subways when they are ill to protect their fellow travelers. You don't really see that level of courtesy in the U.S., where someone is likely to sneeze or cough directly in your face. During the 1918 flu pandemic, movie houses and taverns in the U.S. were closed in large cities and yes, people were wearing cloth masks or handkerchiefs over their mouths and washing their hands.

People tend to panic when these things public health issues happen. Misinformation and fear often trumps common sense. We had a person today, who was exposed to a neighbor, and this neighbor was exposed to a parent who had a child in kindergarten who goes to the school where there was one case of confirmed swine flu. Whew!

A year ago today, my wife and I were driving through Mexico to deliver children's clothing to an impoverished area in Baja. At that time, we were not worried about influenza, just the drug wars along the border that so far, has taken the lives of over eight thousand people. Medical care in Mexico can be sparse and many of those deaths may have been because people did not have access to medical services soon enough. As of today, there were no confirmed swine flu deaths in the U.S. and I pray that the Mexican health officials can contain this virus before there are any more deaths in this country.

Until the breadth and extent of this potential pandemic is confirmed, people should just relax, get the facts, follow the news, wash their hands, avoid getting downwind of a sneeze, and wait until the public health department offers specific instructions for your particular area.

It is still okay to still eat a BLT.

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• WebMD Swine Flu Center
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