H1N1 Influenza: One New York City Pediatrician's View

H1N1 Influenza (Swine Flu) & Kids

Medical Author: David Perlstein, MD, FAAP
Medical Author: Melissa Conrad Stöppler, MD

Six months have passed since my last posting about swine flu, now known globally as the novel H1N1 virus. We in New York City experienced a very significant increase in the number of patients evaluated in our Emergency Departments and offices last spring. Interesting, though, we did not see a huge increase in the number of "sick" patients requiring admission to our hospitals. Overall, my own hospital experienced a 95% increase in pediatric visits to our Emergency Department, and a 35% increase in adult visits. We admitted 17 patients who tested positive for H1N1. We did see some critically ill individuals, all with known risk factors for complications of H1N1 infection (pregnant women, obese individuals, and very young children), but no elderly patients.

Between April and June 2009, New York City reported 990 flu-related admissions to hospitals and 54 deaths. Since August, the rest of the nation has experienced increases in novel H1N1 cases similar to the increases NYC experienced between April and May. Looking at the CDC US Surveillance Map, there is widespread illness in the USA; however a closer look at the current numbers reveals that since August, in Region 2, (which includes New York), there is next to no activity when compared to the rest of the country. In the NY Region there have been only 91 cases of H1N1 and 72 seasonal flu cases. That compares to an average of 2000 cases of H1N1 in all other regions.

We are still preparing for huge surges in volume. Most New York City hospitals have Pandemic Influenza Working Groups. In my own hospital we have developed a multi-phased response to our expected increase in visits which to date have not materialized.

• We meet weekly to discuss both how to respond to influenza and how to prevent it in our staff and patients.
  
  
• We are currently limiting visitation to our labor and delivery units as well as our neonatal ICU.
  
  
• We have educational and informational posters up all over our facilities, recommending hand hygiene and flu-prevention measures.
  
  
• We are vaccinating both our patients and our staff with both seasonal flu vaccine and H1N1 vaccine (when available).
  
  
• We are routinely isolating and testing patients for influenza in the hospital (52 suspected, but 0 positive for influenza using PCR, which is a highly sensitive and specific test).
  
  
• We are prepared.

I personally have also been very impressed by the fact that despite the publicity regarding the flu right now, including President Obama's declaration of an influenza emergency, it has not resulted in mass hysteria in New York City. Children are getting colds, and other viruses such as respiratory syncytial virus (RSV) are circulating, but our clinics and Emergency Departments are not inundated with unnecessary visits. Cool heads are prevailing, and that is good. Last May New Yorkers were panicking. Now that we have experience, we are not.

The rest of the country can learn from New York's experience with the H1N1 virus. Continue to use available and inexpensive preventive measures, such as hand washing, covering your cough, and staying at home if you're sick. Getting the flu stinks. Most have had it and, and most get better. It also has great potential to cause severe illness in high-risk individuals as we have seen year after year, and as I wrote last April.

That is why I still believe that the number one way to prevent influenza is to get vaccinated annually. I do. My children do. My patients do. We are now in the middle of a pandemic influenza outbreak throughout the United States. "Flu season" doesn't start until January or so. So do something about it and get vaccinated.

On Friday, April 24, 2009 I received a message from the New York City Department of Health advising me of a conference call to discuss the recent outbreak of swine flu in the United States, and possibly at a school in Queens, New York. That seems like a long time ago.

Since then, there have been an increasing number of suspected and confirmed cases reported in several states including Arizona, California, Indiana, Kansas, Massachusetts, Michigan, Nevada, New York, Ohio, and Texas as well as other countries, including Mexico, Canada, New Zealand, the UK, Israel, and Spain.

Most of the disease outside of Mexico has been described as mild illness with few hospitalizations, though on Wednesday, April 29, 2009 it was reported that a 23 month old child in Texas died from complications of the virus. This is sad, but this is not surprising or unique to swine flu. It is what influenza does. It is why Pediatricians and public health officials press so hard for universal vaccination.

The last Influenza season (2007-2008) alone, almost 100 children died from complications of laboratory confirmed influenza, and according to the U.S. Centers for Disease Control and Prevention (CDC) estimates, on average, influenza is believed to contribute to 226,000 hospitalizations and 36,000 deaths per year in the United States. Annual vaccination continues to remain the best method for preventing influenza and its potentially severe complications. Unfortunately, there is no vaccine to protect humans against swine flu, at least not currently; therefore good infection control practice is recommended to try to prevent the spread of the virus. These are the CDC guidelines; they are not innovative guidelines, and most children are already familiar with them:

1. Cover your nose and mouth with a tissue when you cough or sneeze.
   
   
2. If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands.
   
   
3. Put used tissues in the trash.
   
   
4. Clean your hands after coughing or sneezing. Wash with soap and water or with alcohol-based hand cleanser.
   
   
5. Avoid touching your eyes, nose, and mouth.
   
   
6. Caregivers should avoid face-to-face contact with infected individuals and clean their hands with soap and water or an alcohol-based hand rub after contact.

If you haven't been fortunate enough to avoid an infection with influenza (swine or other) there are some additional recommendations I can offer you.

1. First, call your pediatrician if your child develops flu symptoms, such as fever, cough, sore throat, headache, chills, muscle aches, and fatigue.
   
   
2. Most mild cases of influenza, especially in children over 2 years of age, can and should be managed at home to prevent the spread of the virus to others.
   
   
3. As with much other flu-like illness, treatment is basically supportive, including comfort measures, such as the use of antipyretics (acetaminophen, ibuprofen, Tylenol, Motrin, and Advil). Remember that children 18 years of age and younger should never be treated with aspirin or aspirin-containing medications, such as bismuth subsalicylate (Pepto-Bismol), unless prescribed by a physician. This is due to the increased risk of Reye Syndrome.
   
   
4. In some cases treatment with an anti-viral medication such as oseltamivir (Tamiflu) or for children over 7 years old, zanamivir (Relenza) is a possibility. You should talk to your physician about the indications.
   
   
5. For children less than 2 years of age and for older children with known risk factors for severe disease, such as immune deficiencies, kidney disease, congenital heart disease, hematologic disease, and severe lung disease, treatment with an antiviral drug is recommended to prevent serious illness.
   
   
6. You should always talk to your physician to determine whether testing or admission to a hospital is warranted.

Testing for swine flu is not very accurate, which is why the CDC generally refers to the symptoms as influenza-like-illness (ILI). The rapid flu tests which are currently available on the market are believed to identify positive cases less than 70% of the time, which means almost a third of the time a patient who actually has swine flu will not have a positive test. This limits the effectiveness of the test as a diagnostic tool, and in some states and cities, such as New York City, testing is not even being recommended.

Lastly, this situation is evolving, and there are daily updates by local, state, and federal health agencies.

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