Prevention is key for what experts think will be the flu season of all flu seasons
When it comes to the flu, communicable disease experts over the years have learned one cardinal rule: expect the unexpected.
Influenza is one of nature's great quick-change artists, mutating and combining with different strains, foiling both the body's defenses and medical efforts to stop its spread. The genetic gymnastics of the virus often leave public health experts struggling to keep up, to say nothing of trying to stay a step ahead.
“The H1N1 influenza and influenza generally is unpredictable, and that means two things,” Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention, said in a press conference earlier this month. “First, we have to vigorously monitor to see whether it's changing, who it's affecting and what's happening with it. And second, we have to be ready and prepared to change our approach depending on what the virus does.”
The presence of the highly contagious H1N1 strain of influenza, also known as swine flu, means this year's flu season promises to be like none other in the past 30 years. So public health authorities are urging the public to heed two primary messages: Get your annual flu shot early this year, and be prepared to ride out the flu on your own.
A new strain
The H1N1 influenza first appeared in the U.S. in April, and although media attention to new cases and deaths has quieted down, the virus continued to spread through the summer. But typically, flu viruses tend to survive longer outside the body during winter months, coinciding with kids being in school and individuals spending more time indoors, which facilitates its spread. So doctors are bracing for a new wave of cases this fall.
“(H1N1) is no more serious than the regular seasonal influenza we see every single year, which usually starts in the third week in January, peaks in February and burns out the first week of March.
That has been a regular pattern that has been absolutely consistent for the last 20 years, with one exception three or four years ago,” said Dr. John Chunn, a pediatrician with Central Oregon Pediatric Associates in Bend. “I think we're going to see October look like February.”
Chunn said the presence of the H1N1 strain makes this year significantly different. By all accounts, the symptoms it causes seem to be no worse, and possibly milder, than the seasonal flu in past years. But the virus has turned out to be more contagious than other strains of flu and has shown it will probably stick around for a while, at least until more people build up antibodies to it either by getting sick or through a vaccine. Clinical studies have shown that H1N1 tends to crowd out other strains of the flu, meaning most people who come down with the flu this year will likely have the H1N1 strain.
“I compare this to a pot of water that's been left on simmer. We're just waiting for somebody to turn it up to a boil,” he said. “And the person that's going to turn it up to a boil is the schools. And it's going to happen.”
Back to school
Local health officials are keeping a close eye on schools because they act as germ incubators once kids return. In Georgia, for example, where school started in August, there has already been a rise in regional flu activity. And Washington State University in Pullman, Wash., saw a spike in flu cases when students returned for the fall semester. Over a 10-day period, the school's health clinics saw or fielded calls from more than 2,000 students with flu symptoms. The school's health clinic has confirmed several cases of H1N1 but is not testing all the students to determine whether they have H1N1 or another strain of flu.
“The symptoms of this flu have been quite mild in most of the people on our campus who have contracted it; by most accounts, it has been milder than the usual cases of seasonal flu,” university President Elson Floyd said in an update on the outbreak last week. “Most cases have been relatively short in duration — three to five days — so students who have contracted it toward the end of one week might very well be better by early in the next.”
The campus example, however, might not be the best reflection of what might happen if H1N1 begins to spread through local schools. The tight quarters of dormitories and fraternity or sorority houses may increase the likelihood of students passing on the virus. And because students don't generally go home after class each day, the surge in flu cases may not spread to the broader community as easily.
The concern for local school districts is that healthy kids, who face few risks from the disease, may bring the virus home to more vulnerable people at home, such as pregnant women or people with chronic illnesses.
Health officials are also hoping to learn how the virus will act this winter by looking at countries in the southern hemisphere, which have experienced their traditional flu season during the North American summer. “Large numbers of people, particularly school kids, became ill,” CDC's Frieden said. “In some locations, hospitals had challenges to keep up with the number of people coming in, but overall, no increase in the level of severity, no increase in the death rate.”
Experience with H1N1 suggests that otherwise-healthy people may get a miserable illness this year but won't face any serious risks. Evidence suggests that the H1N1 strain has more dire consequences mainly for people with other underlying health conditions.
A CDC report on 36 deaths among children with H1N1 in the U.S. found that two-thirds had some sort of serious underlying illness or disability, such as cerebral palsy, muscular dystrophy, or long-term breathing or heart problems. Most of the other children who died had a bacterial infection in addition to the flu.
Adults with chronic conditions, pregnant women and young children all appear to be at greater risk for complications. As a result, public health response to the virus has focused on protecting those groups from getting sick. Primarily that means vaccinating those groups first once the H1N1 vaccine becomes available. Officials expect the first doses of the vaccine to be available in October and to filter in over the coming months.
Seniors, who typically face greater risks from seasonal flu, appear to have some resistance to the strain, possibly because their bodies have seen similar strains in the past and have created antibodies.
Community response
The Deschutes County Health Department has created a priority list for H1N1 vaccination, starting with pregnant women, those with chronic illnesses, and critical medical personnel and those caring for the sick and infants younger than 6 months. As more vaccine supply becomes available, the county will vaccinate children ages 6 months to 4 years, and then children in schools. The county will be working with school nurses to hold H1N1 flu shot clinics, which will require parental consent before a shot is administered.
“It will be available (to the general public) if we have some left after the target population,” said Shannon Dames, communicable disease manager for Deschutes County. “I hear there's plenty.”
Until the community is widely vaccinated, county officials are urging people to take other steps to prevent the spread. Those include frequent hand-washing or use of hand sanitizer, good coughing and sneezing etiquette, and staying home if you come down with flu symptoms (See flu symptoms chart on Page F1).
Dames said local doctors and clinics have struggled about how to send the right message to patients about when to seek care and when to stay home. On the one hand, they don't want patients waiting at home when they are seriously ill and need treatment. But on the other hand, there may be little they can do for the garden-variety flu, whether caused by H1N1 or another strain.
“What we want people to think about is our most vulnerable populations are in that provider office and the ER,” Dames said. “What you're doing is you're going into that clinic, you're exposing other people and you're coming out with ‘Drink plenty of fluids and get plenty of rest.'”
Officials at Cascade Healthcare Community, which owns or operates hospitals in Bend, Redmond and Prineville, had considered posting signs at the entry to the emergency rooms, asking patients who don't meet the high-risk criteria to consider staying away to avoid infecting vulnerable patients. They backed off that plan to ensure they wouldn't violate laws preventing emergency rooms from turning people away.
CHC Medical Director Dr. Alan Ertle said that for those who simply have the flu with no other complications or risk factors, doctors won't be routinely prescribing antiviral drugs .
The hospital has on hand 150 courses of antiviral drugs, but will be very judicious in how those are used, to avoid the risk of creating drug-resistant strains of the flu virus. Those medications will be released only if the medical director confirms a patient meets the criteria for antiviral use outlined by the CDC.
Pediatricians at COPA, the local pediatrics group, may take a different approach.
“I think there is a lot of pressure this year to not prescribe medications for this because of the potential for it to become resistant,” Chunn said. “I think that is absolutely an unknown at this point. And I am leaning toward treating kids if they present with symptoms.”
Symptoms of the flu include sore throat, a cough that's usually dry, fever and, in particular, body aches from head to toe.
If parents can bring in a child in the first 48 hours of having the flu, Chunn said antivirals can cut in half the duration of illness, the severity of the fever and the risk of a secondary infection.
“It would be very difficult for me if a child comes in with a fever of 104 degrees, very uncomfortable, coughing their brains out, and I do have medicine that will make him feel better, that I'm not going to give because it can potentially become resistant,” he said. “Being asked to do so, by authorities who aren't taking care of patients but are just making recommendations, is a bit cavalier on their part.”
Ertle said the hospital system is running through a variety of contingency plans about how to deal with a surge in flu cases, how to protect its own employees and how to limit the spread of the flu through the community. He believes it's a matter of when, not if, flu cases will spike. “I think every place is going to get hit by this,” he said.
It's also why health officials are urging Central Oregonians not to delay in getting their regular flu shot this year.
“We want everybody to get seasonal vaccine, as soon as possible, bottom line, no exception,” Dames said.
While the regular flu shot probably won't confer any protection against the H1N1 virus, it will minimize the number of people who get the flu, keeping them out of doctor's waiting rooms and emergency rooms. Earlier vaccination with the seasonal flu shot will also limit the chances that H1N1 will interact with other flu strains and mutate to something more life-threatening.
“We don't want people getting two viruses at one time, the seasonal virus and H1N1 virus,” Dames said. “If people don't get vaccinated, there's a higher risk that they're going to get both viruses at the same time. If you get both viruses, you have a higher rate of mortality risk, and we have a higher risk of the two viruses intermingling and mutating.”
Previous media reports in the region erroneously claimed that getting both vaccines at the same time could lead to the vaccines mutating. Dames says that was simply a misinterpretation, and the health department will still give individuals both vaccines at the same time if the opportunity presents itself.
Dames also stresses that the H1N1 vaccine, now in clinical trials, is being developed in exactly the same way as the seasonal flu vaccine, which typically includes three different strains of flu virus.
“It's not like there's a new process that we're testing out on some new vaccine,” she said. “It's just a different strain.”
