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Fit and healthy, and dead of swine flu

PHILADELPHIA -- Laura Brewster, healthy and fit at 56, ran, swam and played tennis. Three weeks ago, she returned to her suburban home from a dream vacation in China. Less than a week later, she was dead of swine flu.

PHILADELPHIA -- Laura Brewster, healthy and fit at 56, ran, swam and played tennis. Three weeks ago, she returned to her suburban home from a dream vacation in China. Less than a week later, she was dead of swine flu.

Kevin Hirsch, 26, almost never missed a day of work at a McDonald's restaurant in Northeast Philadelphia. "He didn't have a runny nose, a cold, or a fever in 15 years," said his father, Mickey, who disconnected his son's life support on Nov. 18 after nearly 15 agonizing days in the ICU.

For months, public health authorities have emphasized the dangers of swine flu for people with specific medical conditions. Such patients account for between 60 percent and 80 percent of hospitalizations and deaths.

But 20 percent to 40 percent do not fit that profile. Some may have gotten medical care too late. Some may have had underlying conditions not known to them or their doctors or factors, such as a genetic predisposition, that science has yet to discover. Others may simply have lost out in the roll of the dice, like the nonsmoker who dies of lung cancer.

As a society, we tend to think everything has a clear cause, said epidemiologist Laurie Kamimoto, who leads the U.S. Centers for Disease Control and Prevention's surveillance of influenza hospitalization.

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"I don't think people cozy up to the idea that it (may be) just bad luck," she said.

Most at risk?

Scientists worldwide are trying to determine who is most at risk from novel H1N1 influenza. Children were identified early on. The biggest risk factors for seasonal flu -- pulmonary, heart and metabolic diseases (such as diabetes), and immune systems that are suppressed (by drugs for cancer and diseases such as HIV) -- do raise the risk of complications from swine flu.

Pregnancy, another known risk, appears to be an even greater factor in this pandemic. Hypertension, a history of smoking and obesity also may make people more vulnerable.

Morbidly obese people (body mass index of 40 and above), currently 5 percent of the U.S. population, were hospitalized at five times the expected rate, Kamimoto and colleagues reported in the New England Journal of Medicine last month. Most had other chronic conditions, however, so the reasons are unclear.

Brewster, the middle-aged suburban woman, and Hirsch, the young man from the city, each had a slight brush with possible new risk factors: She smoked one or two cigarettes a day before quitting last year. He, at 5 foot 4 and 180 pounds, qualified as obese (defined as BMI of 30 and over; his was 30.9).

In interviews, however, their doctors and families described them as unusually healthy and at no particular risk of complications. They were not members of any group currently given priority for immunization, and they did not get vaccinated.

With vaccine supplies slowly increasing, the federal government is expected to soon expand the number of groups recommended to receive the vaccine.

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Lethal threat remains

Meanwhile, new swine flu cases have plummeted nationwide. Experts fear that demand will also drop, leaving people vulnerable to a return wave in winter or spring.

Mickey Hirsch is worried, too. And in the weeks since Kevin's death, he has turned grief into action.

The single father of three had a powerful bond with his preternaturally happy eldest son, who had a constellation of cognitive deficits, from severe learning disabilities to an inability to think abstractly, since infancy. "He didn't understand history, didn't understand God, but he understood sports," Hirsch said, "and he had a Ph.D. in public transportation."

Now the independent contractor is on a whirlwind campaign for vaccination, tacking more than 100 homemade posters around his Northeast Philadelphia neighborhood, and corresponding with thousands of people on the "Prayers for Kevin Hirsch" Facebook page set up during his son's illness.

For those who are uncertain, he offers support, personally escorting dozens to get vaccinated at a nearby city health clinic.

And for those who loudly question the worth or safety of vaccines, he is blunt: "They should be thankful that their parents didn't feel the same way when it came time to get the polio vaccine. Otherwise you would be on crutches or in wheelchairs."

Stanton Segal, medical director of Aria Health and an attending physician at its Torresdale Campus, the hospital where Kevin Hirsch died, is less strident. "It is a good illustration of how important it is to get vaccinated," he said. "This was a pretty healthy young guy."

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In fact, researchers have noticed a paradox with this flu and others. "Some of the people in the most robust health," said Andrew T. Pavia, chief of pediatric infectious diseases at the University of Utah School of Medicine, "have the most severe disease."

One possibility is that their immune systems are so aggressive that they fail to shut down, overwhelming the body.

Genetic link?

The trait may turn out to be genetic. A paper that Pavia coauthored last year in the Journal of Infectious Diseases found that the siblings, children and grandchildren of people who died in the 1918 influenza pandemic were more likely than others to die of flu-related complications decades later.

Inherited or not, an immune system so strong that it can kill when provoked might be strong enough to confer unusually good health otherwise, Pavia said.

Such a scenario could help explain, in theory, cases like Laura Brewster's.

"She entered your life with the gusto of a Nike ad and challenged you to just do it," said Fran Duffy, rapidly tapping the words on a small laptop for a visitor at her home just outside the city.

The women's friendship began at a swimming pool more than 10 years ago; when Duffy later lost the ability to speak after a stroke, Brewster became a part-time caregiver. It was Brewster who suggested a 12-day adventure, Shanghai to Beijing, including the Great Wall, the terra cotta army of Xi'an, and a Yangtze River cruise.

On the last day, she developed a cough and figured it was a mild flu. It had worsened by the time she arrived home on Thanksgiving Day, her family said. Two days later, her doctor said her lungs seemed clear but he wrote prescriptions for medicine to ease her breathing, and for a chest X-ray.

"Oftentimes early on there can be no indication that things are going to get much worse," said Jaclyn Rosenzweig, an infectious-disease doctor at Abington Memorial Hospital who later consulted on the case. "On the other hand, if they sent everybody into the hospital who had influenza, the hospitals would be overwhelmed," she said, and all the mildly sick patients would spread disease.

On the Sunday after Thanksgiving, one day after seeing her doctor, Brewster went to Abington. By the next day, she was on life support. Two days later, she died.

"She was the picture of health," Duffy wrote on her keyboard, "the most unlikely person" to die from swine flu.

"I would have thought I'd be more vulnerable."

Related Topics: HEALTH
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