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H1N1 Flu Vaccine: The Bottom Line

If you’re a bit confused about the H1N1 vaccine recommendations, you are in good company! They are a bit confusing because this year’s flu season is a bit confusing. To add insult to injury, the recommendations for H1N1 are just similar and dissimilar enough from “seasonal flu”, Influenza A&B, that sorting it out can make your head spin and your tongue get tied.

Kim Carrigan and I attempted to clear the air about this challenging topic recently on Fox News Boston…as you’ll see, I even got tripped up once, so don’t feel badly if you’re a bit confused!

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*This blog post was originally published at DrGwenn Is In*

Top 10 Things To Know About The H1N1 Flu

We have been inundated with so much information about the 2009 H1N1 that it’s hard to keep it all straight. Here’s my top ten list of what’s most important to know, much of it coming from the website of the Centers for Disease Control and Prevention, which has done a spectacular job of providing timely and useful information:

1) What is the 2009 H1N1 Flu (Swine Flu)?

Different from the typical seasonal influenza virus, this is a new type of flu virus that appeared in Mexico in April, 2009 and soon spread to the United States and around the world. It contains a combination of genetic material found in influenza viruses that infect humans, birds, and pigs.

On June 11th the World Health Organization (WHO) declared a phase 6 pandemic – its highest alert level. On July 16th the WHO called the pandemic the fastest moving pandemic ever.

2) Why are people concerned about the 2009 H1N1 pandemic?

Over the past century, three major pandemics have swept through the world and caused severe illness and death. The most devastating by far was the influenza pandemic of 1918, which killed 40-100 million people worldwide and 500-750,000 Americans at a time when the U.S. population was only about 100 million. The 1957 “Asian flu” caused about 70,000 deaths when the U.S. population was about 170 million. The last pandemic, in 1968, killed about 34,000 out of 200 million Americans.

3) How does the 2009 H1N1 influenza compare to the typical seasonal flu?

Because the 2009 H1N1 virus is new, most people – especially children and young adults – have little or no immunity against it. It is spreading more quickly than the usual seasonal flu but seems to be somewhat milder – though still capable of causing severe illness and death. The typical seasonal flu affects 15-60 million Americans, leading to more than 200,000 hospitalizations. Annual deaths range from 17,000 to 52,000 annually, averaging about 36,000.

The elderly are especially at high risk of seasonal flu, with over 90% of deaths occurring in patients over 65. In contrast, 2009 H1N1 has preferentially affected young adults and children while older patients appear to have some immunity. Only 18% of deaths from H1N1 have been in patients over 65.

It’s estimated that between April and June, more than a million Americans became ill from 2009 H1N1; the CDC stopped reporting individual cases on July 24th, 2009. While the vast majority of cases have been relatively mild, as of September 3rd there were 593 deaths and 9,079 hospitalizations in the United States and territories.

For both the regular flu and the 2009 H1N1, certain groups are at increased risk for complications once infected – children under 5, pregnant women, and patients with underlying medical conditions such as suppressed immune systems, asthma, diabetes, neurological disorders, kidney problems, and heart disease as well as adults over age 65.

4) What Can We Expect This Fall?

Flu virus tends to die down over the summer because it survives better when the weather is cold and dry than warm and humid. That’s why during our summer the H1N1 virus spreads to the Southern Hemisphere, where it’s winter. But the virus never really went away in America and is now surging much earlier than with the regular seasonal flu.

In August, a panel of experts prepared an extensive report for President Obama about the virus. While warning that the exact impact of H1N1 was impossible to predict, the panel outlines a “plausible scenario” that included 60-120 million infected Americans, as many as 1.8 million hospital admissions, and 30-90,000 deaths. Others, including the CDC, have suggested that these estimates are a “worst case scenario.”

Unfortunately, the influenza virus is famously unpredictable and the above “plausible scenario” could be way off in either direction. Although the virus is relatively mild now, it can quickly change on its own through mutation and become more deadly. Another way of changing is if two different viruses happen to infect the same cell at the same time. The two different strains could then trade genetic material. Hypothetically, the 2009 H1N1 that is currently sensitive to the antiviral medication Tamiflu could become resistant to Tamiflu if it combines with last year’s seasonal flu strain which was 99 percent resistant to the drug. Fortunately, until now the virus has been stable genetically and it remains sensitive to Tamiflu and Relenza.

5)What are the symptoms of the 2009 H1N1?

The symptoms are very similar to those seen with the regular seasonal flu: fever, headache, fatigue, cough, sore throat, runny nose, and aches and pains. In addition, there may be gastrointestinal symptoms such as nausea, vomiting, and diarrhea.

6) How can you catch H1N1?

Just as with the regular seasonal flu, the virus enters your body through your nose, mouth, or eyes. People infected with H1N1 shed virus starting a day before symptoms begin and lasting up to a week or longer in some patients. An uncovered cough or sneeze in a patient with influenza can send infectious virus-filled droplets into the air. If you touch a surface that’s infected with flu virus and then touch your mouth, nose, or eyes, the virus can enter your body and cause infection.

7) How do you prevent the seasonal flu and 2009 H1N1?

The most effective way is through vaccination – assuming you are in a group for which immunization is appropriate. The CDC recommends vaccination with both the regular seasonal flu vaccine, which is already being given, and the 2009 H1N1 vaccine once it becomes available around mid-October. So far, the 2009 H1N1 vaccine has been shown to be safe in adults; the CDC told me this week that studies in children and pregnant women should be done within about 2-3 weeks. Health officials want to vaccinate at least 159 million Americans. Experts predict there will eventually be enough vaccine for all Americans who want it. But only about 45 million doses are expected to be available with the first batch in mid-October.

Those on the priority list to get the 2009 H1N1 vaccine include pregnant women, people in close contact with infants 6 months and younger, health care workers, those ages 6 months to 24 years, and people ages 25 to 64 with serious conditions that put them at high risk for complications from flu.

Experts stress the importance of covering your mouth with a tissue when you cough or sneeze. Wash your hands often with soap and water or an alcohol-based hand cleaner. Remember: you don’t get flu from virus that’s only on your hands; you get it when you touch your face and give the virus a way to enter your body. Avoid close contact with sick people. And if you are sick with the flu, the current CDC recommendation is to stay home for at least 24 hours after your fever is gone without the use of fever-reducing medication. In some situations, the use of a face mask may be indicated, especially to try to prevent flu in patients at increased risk for complications;
click here for the CDC’s recommendations.

8.) Who should receive treatment with anti-viral medication such as Tamiflu and Relenza?

Last week the CDC said that most people who come down with the 2009 H1N1 flu should just ride it out and not take antiviral medications such as Tamiflu and Relenza. Dr. Anne Schuchat of the CDC said the majority of adolescents, adults and children “can be cared for with mom’s chicken soup at home, rest, and lots of fluids.” But she stressed the importance of early treatment with antiviral medications – within 48 hours if possible – for certain patients at increased risk of complications, especially those hospitalized, under age 5, over age 65, or with chronic medical conditions.

A key change in advice from the CDC involves patients at high risk who may have been exposed to the H1N1 virus. Before last week, doctors were advised to give them medication to prevent infection; now doctors are being given the option of “watchful waiting” – observing the patient closely and only starting antiviral treatment if evidence of flu develops.

9) What warning signs should prompt immediate medical evaluation and treatment?

In adults, warning signs include: trouble breathing, pain or discomfort in the chest or abdomen, dizziness, confusion, severe or persistent vomiting, and symptoms that improve but then return with fever and worse cough. In children, warning signs include: trouble breathing, bluish or gray skin color, inability to drink enough fluids, severe or persistent vomiting, change in mental status (e.g., not waking up, not interacting, or being unusually irritable), and symptoms that improve but then return with fever and worse cough.

10) Should I get the 2009 H1N1 vaccine if I think I’ve already had the H1N1 flu?

The CDC told me “yes” – because the vast majority of patients diagnosed with 2009 H1N1 were not specifically tested for the virus. It may have been some other virus that made you ill. And even patients who had positive “quick tests” in the office for influenza A cannot be absolutely certain they had the 2009 H1N1 virus because the kits are sometimes wrong and because there’s a small chance that the strain of influenza A detected was NOT the 2009 H1N1. So the CDC recommends playing it safe and getting the both the regular seasonal vaccine and the 2009 H1N1 vaccine if you are in a group for which immunization is suggested.

For this week’s CBS Doc Dot Com, I discuss very practical advice – especially for parents – about H1N1 with Dr. Thomas Farley, who was appointed New York City Health Commissioner in May 2009 and immediately found himself smack in the middle of the 2009 H1N1 outbreak.
Click
here to watch the interview.


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H1N1 Flu and Back to School: Focus on Prevention

It used to be that we’d get all our kids settled back to school and then enjoy a bit of a pause before the other shoe fell with the inevitable concern over another flu season. With Swine Flu, Influenza H1N1 not taking a summer vacation and showing no signs of letting up, we didn’t have that luxury this year.

I went onto My Fox Boston this morning and talked with Keba Arnold about this very unique flu season with 2 influenza strains traveling among us and offered some practical tips to not only prevent the flu but be ready should it impact your town’s schools:

Don’t try and absorb everything at once. Focus on prevention today and I’ll help keep you informed as we learn more about the flu shots your family will need, when they will be available, and any breaking CDC alerts that are important for your family’s well being during the flu season.

*This blog post was originally published at Dr. Gwenn Is In*

Are H1N1 Influenza Fears Pure Hype?

PlanetHype

My newest podcast is up on iTunes (go here for the web-based version).  It’s the first of a two (maybe more) part series on influenza – covering flu in general.  We have been seeing a significant number of cases of the flu over the past week, which is extremely unusual for this time of year.  Epidemic flu goes around between November and Late April, with sporadic cases appearing at other times.  What we have seen so far is not sporadic, so it probably represents pandemic flu (H1N1).

I did a poll on Facebook, asking what people thought of the H1N1 situation.  The overwhelming majority responded that they felt the press and the government were hyping it way too much.  This really surprised me – not that people would think that, but that a majority of people felt this was the case.  It may have related to how the question was phrased or what the other choices were, but still this number betrays a lack of worry about the H1N1 virus.

This worries me.

I don’t think the fear of the H1N1 is misplaced.  The normal flu kills over 30,000 people per year, and the H1N1 is expected to infect 3 times more people than the usual flu (for reasons I will go into in the next podcast).  The implication of this is that even if this flu is “nothing special” it will kill over 90,000.  Put in perspective, prostate cancer killed 27,000 men and breast cancer killed 41,000 women in 2008.  A “normal” potency H1N1 virus could then kill more than both of these combined.

Thankfully, the cases we’ve seen so far have not been severe, but still there have been 522 deaths already from the H1N1 in the US.  But in 1918, the virus mutated around this time of year and became significantly more deadly.  I think those who get it now are actually probably fortunate.

The warnings about pandemic influenza are not hype.  But the cynicism about the government and the press are widespread.  Some of the more “unconventional” thought (read into that word generously) espouse conspiracies by the government.  Here’s one example of this:

It’s man-made. It can be used as a biological weapon. It was developed as an AIDS vaccine-related organism. It was extracted from AIDS patients. It is responsible for virtually all of the symptoms which AIDS patients suffer from. The AIDS virus is at best a co-factor, and not even such a strong co-factor as to bring on all of the symptoms of AIDS. This particular organism, the micoplasma, is associated with this upper respiratory flu-like illness. And it’s also associated in its pathogenic process with a whole variety of other symptoms that mimic AIDS.

This guy is totally nuts extreme, but the theories on the Internet of this flavor abound.

Unfortunately, the religious right Obama-haters have seized on this as anything from a means to push universal health to a weapon to sterilize the US populace.  I can assure you that this has nothing to do with Biblical thought and everything to do with the vulnerability of some people to fear-mongering.  I even had one patient ask me what I thought about the sterilization theory.  I reassured her that I had just gotten mine – although sterilization is no longer an issue for me as it has already been done with my consent.  She laughed and went ahead with the vaccine.

But less extreme people still feel this is far too much hype for the severity of the disease.  This scrutiny puts the CDC in a bad situation.  The only thing that would vindicate their dire warnings is the exact thing they are trying to prevent: a deadly pandemic.  Conversely, the more they succeed in preventing this problem, the more people will cast aspersions on them.

Take it seriously, folks.  It’s like a massive storm forming in the tropics – it could be deadly and it could be a dud.  Either way, we need to do whatever it takes to minimize the damage.

*This blog post was originally published at Musings of a Distractible Mind*

The Many Faces Of Code Blue

Just over a month ago, our unit had several H1N1 flu patients.  And they were sick.  Really really sick.  They were also fairly young – 30’s to 50’s.  I wondered at the time why the media hullabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.

Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator.  I was really glad to see the decrease in this particular patient population.  I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease.  Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.

And what of the times that we admit patients and don’t know they have a communicable disease?  At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.

I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.

The most harrowing patient we had was a woman in her 30’s who was pregnant.   Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80’s and would take a long time to come back up.  Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.

I’m somewhat jaded about coding people at this stage in my career.  I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse.  She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore.  At that time, I couldn’t imagine being in that frame of mind.  Being new, I was expected to go to every code blue that was called so as to get experience.  My heart started going into SVT at simply hearing the word “code.”  If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.

I eventually got to a place where I could fairly confidently go run a code without freaking out.  I’ve been an ICU RN for 11 years.  In those 11 years, there have been some awful codes.  Two stand out in my mind, and the absolute worst was on the pediatric floor.  When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???”  My second thought was to wonder if it was really an adult overflow patient.  Sometimes the gyn surgeries went to the pediatric floor if there was no more room on the surgical floors.  You know, maybe one of them got a little too much morphine and the nurse called a code.  A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.

No such luck.  After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed.  I thought I was going to be sick.  PICU nurses – bless you all.  I could not do that for any length of time.

She didn’t make it.  Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it.  But on that day a huge chunk fell out.

Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career.  Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.

However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it?  That took me back to the days when I was new and inexperienced.  I’ve never seen anything like that happen.  Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.

Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.

If it had, it surely would have made my top 3.

*This blog post was originally published at code blog - tales of a nurse*

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