Posted tagged ‘swine flu’

H1N1 update: Can we relax now?

December 22, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

While no one is ready to call it over, H1N1 season seems to winding down in most parts of The United States. In my practice, we’ve seen only a handful of cases in the last few weeks. We’re also getting far fewer panicked phone calls for Tamiflu (the wonder-drug, as in “I wonder why so many people think this stuff works so well?”) The vast majority of children and adults who had H1N1 (or “Swine”) flu recovered after four or so days of fever and misery.


There are definitely some sobering statistics. About 1 in 6 Americans probably came down with this flu by mid-November, an astonishing number that reflects just how rapidly and thoroughly a new virus can spread. There have been far too many deaths among children: about 212 at last count, a number that is certain to rise as further reports are processed. Obese adults and pregnant women also turned out to be particularly vulnerable.

The vaccine turned out to be both safe and effective, but probably didn’t reach a “critical mass” of widespread availability until a little too late for most people. Cases of H1N1 are waning just as the vaccine is becoming easy-to-find, and it’s difficult to know for certain just how big an impact the vaccine has had on the epidemic. The Swine Flu of 2009 illustrated some important lessons for dealing with an epidemic: it takes too long to make influenza vaccines using current technology, and it’s difficult to distribute millions of doses of vaccines through 50 states and thousands of health departments. Hopefully lessons from this pandemic can spur development of improved vaccine technologies and public health infrastructure to support a massive delivery of vaccines, medicines, and  other stuff needed to keep a country healthy.

Some dosing issues for the H1N1 vaccine were confusing. Early studies showed that a single dose was effective in adults, but that two doses were needed in children. Because of poor availability and quirks in the FDA licensing, getting two doses into children proved quite challenging, and I’m doubtful that even now most families have gotten both doses for their kids. A more recent study from Australia trumpeted in the headlines just this week announced that a single dose is effective for most children—but that formulation used twice as much influenza antigen in each dose, so the results really don’t apply to the H1N1 vaccines available in the United States.

At this point, I still recommend that children who haven’t yet reached their ninth birthday get two doses of the H1N1 flu vaccine. Though the epidemic is winding down, in some years flu comes back when the coldest part of winter hits, after children return to school in January. Also, H1N1 is not going to disappear after this year—you can bet it will be part of next year’s flu season. Getting two doses this year means that your child is primed for good immunity next year (when presumably H1N1 will be included in the ordinary seasonal flu vaccine.)

There was also a recent recall of some lots of children’s H1N1 vaccine, about 800,000 doses in total. These lots were found to be a little less potent than they were supposed to be, by about 10-12%. The affected lots were only designed for children less than three, who all are supposed to get a second dose. Even if your child got one of these sub-par doses, as long as you get that second dose of vaccine your child will be well-protected.

So: yes, H1N1 was pretty bad—many people got sick, and some died. But it wasn’t a huge catastrophe. Hopefully, the worst is behind us. Keep washing your hands and using that hand sanitizer, and if you haven’t been immunized yet, it’s still a good idea. Children less than 9 still ought to get two doses of H1N1 vaccine, which has been remarkably free of serious side effects.

Not that anyone wants to hear about this, but there’s the “regular” flu season, still to come! Just because H1N1 has overshadowed other causes of flu so far, don’t expect that we’ll get to skip the ordinary flu season. That’ll be here, probably in January. Did I mention you ought to keep washing your hands?

I know the kids are delighted to have to get two kinds of flu vaccines this year, for both H1N1 and for ordinary seasonal flu—so plan to stop by QuikTrip for a tasty chocolate-mint milkshake on the way home. Or pick up a box (or three*) of Trader Joe’s Candy Cane Joe-Joes. Either one will put a smile back on a child who had to get a shot. Heck, they’re probably more effective than Tamiflu for a child who ends up getting the flu.

*One for child, one for you, one to mail to me!

Flu: To shot, or not

September 15, 2009

The Pediatric Insider © 2009 Roy Benaroch, MD

Good news: today, the FDA announced the approval of vaccines to prevent novel H1N1 influenza. It sounds like these immunizations will be available in the coming weeks, and studies in adults performed so far show excellent and rapid immune responses with minimal side effects. Studies looking at children are currently underway, and confirmation of the safety and effectiveness of these vaccines for all ages should be available by the time they’re distributed.


My state has one of the highest rates of H1N1 influenza, probably thanks to our twisted, evil preoccupation with starting school too early (oddly, the school boards have not sought my opinion on this matter.) So we’ve been seeing dozens, maybe hundreds, of H1N1 cases in my office. The good news is that no one has been super-super-sick; the bad news is that many kids have been pretty-super-sick, and their parents and siblings are getting it too. Tamiflu can help some, if started early, but really hasn’t proven to be particularly effective. Probably better for most victims to just head to bed, and have chicken soup, tea with honey, and maybe a popsicle or two. Best case scenario: a 4 or 5 day illness, and hopefully no trips to the hospital for children or the parents when they get it.

Other parts of the country have barely started experiencing a spike in H1N1 cases, so the vaccine may indeed be able to avert a huge epidemic—if it’s distributed and used quickly. If a community can get a big chunk of its citizens vaccinated, especially the children, the spread of the virus can be halted.

That’s still a big if. It’s going to be logistically difficult to distribute enough doses of the vaccine quickly enough. Furthermore, some people seem reluctant to accept the vaccine.

Myth: This H1N1 vaccine is new, so it might not be safe.

Fact: Every year’s flu vaccine is “new,” in the sense that they’re made from different flu strains. But the technology and method to make them is identical from year to year, and has been identical for decades. Rates of adverse reactions, serious and non-serious, do not vary from year-to-year, and don’t seem to depend on the strains involved. Nonetheless, safety testing is an essential part of vaccine development, and the H1N1 vaccine has been tested both here and abroad in thousands of patients. Side effects are uncommon, and almost all of them have been very minor.

Myth: Some people “get the flu” from the vaccine.

Fact: The commonly used injected vaccine is not live, and cannot transmit influenza. A small percentage of people run a brief fever or feel a little achey after the flu shot, but that’s not nearly a full-blown case of the flu. The newer, nasal mist flu vaccine is a live vaccine, but the virus used has been adapted so it cannot survive at normal human body temperatures. It cannot transmit the flu.

Myth: Only people who are infirm or elderly get the flu; or only weak people die from the flu.

Fact: Though you’re more likely to die of flu if you have pre-existing illnesses like heart or lung disease, many healthy young adults get very seriously ill with influenza, especially in pandemic years like the one we’re having now.

The best ways to protect yourself and your children against the flu are to practice good hand washing and hygiene, to avoid sick people, and to get flu vaccinations. The flu vaccine not only protects the recipient, but also the whole family, and the community. Where uptake of flu vaccines has been good, there’s a dramatic drop in influenza cases for everyone—including very young babies, who can’t get vaccinated, yet are at very high risk of complications, and including the elderly, in whom vaccinations are ineffective.

It’s not clear now how much H1N1 vaccine can be distributed, or what risk groups will be targeted. It is clear that from a public health point of view, the most important vaccine recipients are school-aged children, because they serve as the reservoir and source of spread of infection for communities.

Right now, immunizations against other flu strains are available—though the injectable kind is running in short supply, as many manufacturers have focused their efforts on H1N1 vaccine. Please, if you have children, get a winter flu vaccine administered as soon as you can, and keep in touch with your pediatrician’s office to find out when H1N1 vaccine will be available in your community. We’re all in this together. Go get your shots.

A Pandemic Primer for Parents

August 29, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

It’s here.

The “new flu”, officially known as “Novel-H1N1 influenza,” and often referred to as “swine flu,” is now widespread throughout the United States and the rest of the world. We’ve seen dozens of cases in my office, and will probably see hundreds more in the next few months. The World Health Organization has officially declared it an epidemic, and I’m officially declaring it a great big pain in the arse. For parents, kids, and pediatricians, it’s going to be a long, long winter.

The new flu first appeared in Mexico in the spring of 2009, and cases very started appearing in the United States soon after. Although early media reports focused on a very high mortality rate, hundreds of those early cases were later re-classified  by United Nations health officials as unrelated to, or at least not-definitely-caused-by, the new flu strain. Still, media reports have seemed to give the impression ever since then that this new flu was far deadlier than influenza infections we have seen before. While there is some fear that the new flu could become more virulent, right now the strain circulating here is not worse than any other flu. It’s more common, and it’s spreading faster, but in terms of how sick your child is likely to get the new flu is no worse than ordinary winter flu. Which is still pretty bad, don’t get me wrong, but the media is really pushing an unwarranted “killer flu” story that’s causing a lot of unnecessary anxiety.

Let’s set the record straight.

Why is the new flu special? Why are they making such a big deal about it?

This influenza strain, called “Novel H1N1,” truly is a new flu virus. No one has ever been exposed to it before, so almost none of us have any protective antibodies (about a third of elderly people have some antibody protection, presumably from flu strains that circulated long ago, but it’s unclear if that will help prevent them from getting sick.) It has quickly spread throughout the globe, and we’re seeing many cases of flu right now caused by this new strain well before the start of the usual winter flu season.

It is worse than regular flu?

Because no one is immune, the new flu will probably infect far more people this year than typically get the winter flu. Some health authorities estimate that ten percent of the American population will get it. With so many sick people, there could be a major impact on businesses and the economy, and on the ability of hospitals and clinics to help take care of sick people.

But at least so far, individuals who catch this new flu are no sicker than individuals who catch the ordinary winter flu. It makes people sick, sure, but the vast majority of us will recover fully with no medication needed.

Why is it called the swine flu, anyway?

The new H1N1 flu is genetically similar to an influenza virus that occurs in pigs, and may it is probably a mutated version. But you can’t catch swine flu from being around pigs or eating pork.

Good, I like bacon. If I can’t get it from pigs, where can I catch it?

People, especially sick people, and especially sick people who don’t wash their hands.

How can my family avoid it?

There are many strategies that can help. As a community, we need to encourage sick people to stay home from work, and sick children to stay home from school. People with flu need to avoid crowds for about a week, or at least 1 day past the time all symptoms improve. This creates difficulties with people feeling they need to get back to work—but we’re all in this together. Employers need to encourage people to stay home, and schools need to STOP penalizing children for missing days when they’re sick.

One of the most important strategies for avoiding the flu is to keep your hands clean. Flu virus must get into your body through the lining of your nose, or your mouth, or your eyes. It can’t get through your skin. Even if you just shook hands with The Captain of the Influenza Snot team, you won’t catch the flu until you touch your own face. Wash your hands frequently, or use hand sanitizer. Use a tissue if you’ve got an itchy nose rather than your bare hand, and throw that tissue away afterwards. And stop fiddling with your contact lenses, will ya?

Isn’t there a vaccine for the swine flu?

Yes, there is a vaccine in development—but the CDC is now saying they think it will be available in mid-October, and that’s probably optimistic. It’s not clear how it will be distributed, how many doses will be necessary, how many doses will be available, or for whom the vaccine will be recommended. You can follow the latest news about the vaccine and availability at the CDC’s novel H1N1 flu site.

Will the ordinary winter flu vaccine help?

You should definitely get the ordinary winter flu vaccine, which is available now. While it won’t specifically protect you against the new flu, soon the regular winter flu will also be circulating, and getting them both will be a miserable double-whammy. If fewer people catch the ordinary winter flu, may help prevent the new flu from becoming more virulent.

What are the symptoms of the flu?

Fever, body aches, headaches, runny or congested nose, and cough are the most frequent symptoms. Some people also have nausea, vomiting, or diarrhea. The symptoms last about five days. While some people use the word flu to describe any sort of bad cold, the symptoms really are quite different from and more severe than an ordinary upper respiratory infection.

If I think I have the flu, or my child has the flu, should I go to the doctor?

People are having severe symptoms should certainly see their doctor. This includes difficulty breathing or pain that isn’t relieved by over-the-counter medicine. People whose illness lasts longer than five days without improvement, or people who are at high risk for complications of the flu (babies, elderly people, or those with chronic health problems) should also strongly consider a doctor visit.

On the other hand, most people with influenza have relatively mild symptoms that are at least temporarily relieved by rest and over-the-counter medicine. These people really ought to stay home so they don’t unnecessarily expose more people to illness, and so they don’t overwhelm clinics and emergency rooms that will be needed for sicker patients.

What are the warning signs of severe flu—the signs that we need to see the doctor right away, or go to the emergency room?

  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Severe or persistent vomiting
  • Not waking up or not interacting
  • Being so irritable that a child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough


What can relieve symptoms of the flu?

Rest and fluids are very important. Over the counter medicines like ibuprofen (Motrin or Advil) and acetaminophen (Tylenol) will help relieve the aches and fevers. Honey helps cough, nasal saline spray helps congestion, and a nice pot of chicken soup helps everything. I like ice cream and popsicles, too (I am a pediatrician, after all.) There are shelves full of “cold and flu” medications available at the local CV-Rite-greens, but by and large they don’t actually work.

There are a few medications that can be prescribed to fight the flu virus, but they’re not especially effective and shouldn’t commonly be used. The one that’s most widely known is Tamiflu. Ordinary winter flu has already become nearly 100% resistant to this drug, and the new flu is quickly becoming more resistant as well. To work, Tamiflu and other flu medications need to be started as soon as possible after infections; even then, they don’t confer a tremendous benefit. Currently, anti-flu medicines are recommended only for cases of severe flu and for people at high risk for complications from flu.

What’s the incubation period for flu? How long is a patient contagious?

The incubation period for ordinary flu is 1-4 days, usually 2. A person becomes contagious 1 day prior to the fever, and can continue to spread the virus at least until the fever is gone (5 more days), and probably for one further day. Although these characteristics aren’t as well studied for the new flu virus, they’re probably about the same.

What’s with the masks, anyway?

Media reports on the new flu from Mexico, and the Bird Flu of East Asia, invariably showed people wearing masks. Though flu virus can spread in coughs and sneezes, the main way that masks probably help is by preventing healthy people from reaching up to scratch their noses, or reaching into their own mouths. Likewise, eye protection will not only keep sneezed flu-laden mucus from reaching you, it’ll also keep your hands away from your own eyes. That’s a very good habit for this winter.

Wow, thanks unpaid physician author, I’ll sleep much better tonight! But what if I have more questions?

Stay away from the “It bleeds, it leads” local news, and instead check out these reliable resources: