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Jul/Aug 2009
Volume 30, Issue 6

Geography of Pandemics: A Coin Toss

Enrique Acosta-Gio, DDS, PhD

As of 7 AM GMT, June 19, there are 44287 officially reported cases of influenza A (H1H1) infection, including 180 deaths. Mexico had 7642 laboratory-confirmed human cases of infection, including 113 deaths. The US reported 17855 laboratory-confirmed human cases, including 44 deaths. In Canada, 4905 laboratory-confirmed human cases and 12 deaths were reported. Australia, Chile, and the United Kingdom have reported 2199, 3125, and 1752 cases respectively.1

Moctezuma’s Paradox

In 2006, the Mexican government presented Dr. Julio Frenk, the founding director-general of the National Institute of Public Health in Mexico, as a candidate for the vacant position of director general of the World Health Organization. Ultimately, the job was awarded to Severe Acute Respiratory Syndrome (SARS) and influenza veteran Dr. Margaret Chan from Hong Kong. Perhaps then almost everyone believed the next outbreak would be influenza, probably of avian origin, and it would come from Asia—but H1N1 showed up first in North America.

Plan, Prepare, Practice...Then Consider Other Scenarios

In 2007, the National University of Mexico held a meeting on pandemic influenza where the pandemic case study involved a virus originating in a faraway land. At that time, we thought that the university would remain open, giving us the time for a stepwise response as the outbreak evolved. The Mexican authorities’ swift response to slow and contain the dissemination of H1N1 was to provide the population with face masks and a crash course on cough etiquette, as well as recommendations for “social distancing” from April 24 to May 6. This included closing all educational facilities from preschools to universities.

We the People...and Infection Control

“Social distancing” was followed voluntarily by most of the population and enforced in most commercial venues. To some, however, these measures were reminiscent of a stage of siege and cause for much anxiety. Indeed, a significant part of the population felt uninformed, “forcibly” secluded, vulnerable, powerless, and subject to a dictatorial state.

Dentists, adequately trained in infection control, could help disseminate influenza information to their patients. In the course of responding to people’s concerns, oral healthcare providers can bring to the public’s attention the true nature of infection prevention and control measures. Infection control empowers each of us to reduce the possibilities for transmissible diseases to jump from an infected person to a new susceptible host. When everyone acts responsibly, society accomplishes the common objective of containment. Contrary to what people perceive as an intervention of “Big Brother” government in their lives, the recommended “social distancing” enables authorities to facilitate the individual’s compliance. Each of us is in control.

Dentists, Patients, and H1N1
During an outbreak of influenza and in the absence of state and local regulations, dentists and their staff who present with symptoms consistent with viral respiratory infection should refrain from seeing patients. The Centers for Disease Control and Prevention (CDC) recommends that persons with febrile respiratory symptoms should defer elective dental treatment until 7 days after onset or symptoms subside, whichever is longest.

For symptomatic patients with confirmed or suspected H1N1 who need urgent dental treatment, the CDC recommends that such care be provided in a facility that has airborne-infection isolation. For aerosol-generating procedures, personnel who directly care for patients with suspected or confirmed H1N1 cases should wear a fit-tested disposable N95 respirator. However, in Mexico, this author could not readily identify a procedure room with negative pressure.

Lessons Learned in Mexico
At the height of the outbreak during social distancing, two frequently asked questions were: Sould dentists continue to treat patients; and could patients use this break from work to seek dental treatment. One would think that, during social distancing, all elective dental treatment should be deferred regardless of whether the patient were symptomatic. This scenario concerned Mexican dentists because when the authorities strongly recommended everybody stay home, we didn’t know when the emergency measures would be lifted and for how long patients would be unable to come to our private practices. Also, at that time, we had little or no information on transmission modes, transmissibility, and at-risk groups.

Most H1N1 cases have been mild, and the infection is thought to spread much like a common seasonal flu. Basic infection control measures such as hand washing, not touching one’s face, and avoiding close contact with people who are ill can substantially reduce the risk of transmission.

The world over, oral healthcare providers must know and apply infection procedures to protect themselves and their patients. In some countries, high standards are part of dental education and enforced by law. In others, the challenge remains to develop specialized faculty and educational programs about infection control, as well as occupational and patient safety.

Get all necessary vaccinations and supplies in advance. During the scare, I phoned to order seasonal flu shots for my family. A few minutes later, I attempted to order extra doses but the stock had been depleted. The same problem happened with alcohol-containing hand rubs and face masks. In Mexico, people can walk into a “farmacia” and buy over-the-counter practically every medicine; however, oseltamivir phosphate (Tamiflu,® Roche Laboratories Inc, Nutley, NJ) is now a controlled medication with the same prescription requirements enforced for psychotropics.

This outbreak should make dentists aware of the profession’s capabilities to contribute to global health. Dentists should be vigilant as outbreaks occur and some emerging infectious diseases persist. We must keep updated as new information becomes available.

Looking Forward to the Look Back
During the next few months, the retrospective investigation will help us understand the where, when, how, who, what, and why. Emerging infectious diseases is one of my preferred topics at the Organization for Safety and Asepsis Procedures’ annual symposium, and I constantly update my slides to teach my students about pandemic preparedness. However, when dental students hear their professors talk about the risks of a biologic event of global significance, they seem to wonder about their educators’ sanity. In the aftermath of this close encounter, I will ask them: What else did we learn?


1. World Health Organization Web site. Geneva, Switzerland. Accessed June 22, 2009


Novel Influenza A (H1N1) Virus Resources for Dental Professionals. Organization for Safety and Asepsis Procedures Web site.

About the Author

Enrique Acosta-Gio, DDS, PhD
School of Dentistry,
National University of Mexico,
Mexico City, Mexico

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