Everyone should be back in school now. In one of my recent blogs, I discussed a "teacher cheat sheet" that is helpful for teachers on the front lines. One of my patient families suggested that I discuss the potential H1N1 influenza epidemic. The Maryland Department of Health and Mental Hygiene continually updates Maryland healthcare professionals on influenza and infectious diseases. My latest update is as follows.
H1N1 Influenza Update: August 28, 2009
Throughout the summer, Maryland DHMH has continued to monitor H1N1 influenza virus. Outbreaks, especially in summer camps, have been reported, and Maryland's sentinel surveillance systems have documented ongoing H1N1 influenza activity. As of August 24, there have been 164 hospitalizations (approximately 40% among children) and 7 deaths identified in the state. At this time, no resistance to antivirals has been found in Maryland, although there are scattered instances of Oseltamavir (Tamiflu) resistance noted, including in NC, WA and CA. There is no data yet to indicate any change in severity or character of the H1N1 influenza virus, but this remains a legitimate concern. The outbreak continues to affect those in younger age groups, including pregnant women, and those with underlying medical conditions. Click here to view Maryland's flu data.
In light of documented Oseltamavir (Tamiflu) resistance, and since most otherwise healthy H1N1-infected children and adults have had uncomplicated illnesses, federal and state authorities warn healthcare providers to limit use of influenza antivirals, when possible, to decrease selective pressure and subsequent development of antiviral resistance. Post-exposure antiviral chemoprophylaxis is recommended for those at high risk of influenza complications (age < 5 years, pregnant females, those with underlying chronic medical conditions or immunosuppression). Treatment is recommended for those with elevated risk of influenza complications and those severely ill or hospitalized with influenza-like symptoms.
What is the reality for both H1N1 and the seasonal flu epidemics? The biggest concern in regard to H1N1 is that it is a new strain of influenza virus with the only epidemiologic history recorded in the spring of the Northern Hemisphere and winter in the Southern hemisphere. By most accounts, it is a relatively mild illness with most people recovering without complications. The biggest difference between H1N1 and seasonal influenza is the target population. In seasonal influenza, the high-risk populations are the very young and the elderly. Because of possible exposure to some of the swine components of the flu many years ago, adults older than 64 may be less susceptible to the disease. Thus, high-risk groups include ages 6 mos to 24 years, the medically vulnerable (chronic medical conditions between 25 and 64 years of age), and pregnant women. Decisions on who has priority to receive the vaccination are based on these guidelines. Healthcare workers and first responders are included in the first wave of vaccinations. Currently, H1N1 influenza vaccination is expected to begin some time in mid-October. Your pediatric and internal medicine offices are fully informed and will be expected to stock the vaccine. It appears that only one dose of vaccine will be required based on the latest information from The New England Journal of Medicine.
Anyone with Diabetes is high risk and will need to be immunized with the H1N1 vaccine, as well as the seasonal flu vaccine (shot or "flu mist" depending on age). In the interim, it is important to use simple precautions to protect yourself and family members. This includes covering your mouth when you cough (coughing into your elbow), washing hands frequently with soap and water or using portable hand washing dispensers etc., disposing used tissues, and staying home if you are ill.
Many of my patients and families are concerned about side effects of the new vaccine. As health professionals, we share the same concerns. Perhaps the biggest issue with the new H1N1 vaccine is based on the experience of the flu vaccine during the 1976-1977 season. Due to a swine flu epidemic (not the same genetic profile as the current swine flu) at Fort Dix, the government increased swine flu vaccine production and millions were immunized. Unfortunately, Guillain-Barre Syndrome (a rare neurological disorder) was identified in approximately 500 of the 40,000,000 people who received the vaccine (Washington Post op-ed section: 09.07.09), resulting in 25 deaths. As a result of this debacle where no pandemic of Swine flu occurred, the vaccine production methods have radically changed and the risks that had been previously associated with 1976-77 flu vaccine are extremely small. The new H1N1 vaccine will be manufactured in the same way as the seasonal flu vaccines, which is reassuring. In addition, the Center for Disease Control has established a post H1N1 vaccination surveillance program to monitor side effects and significant reactions in a timely fashion.
A word about using antivirals, such as Tamiflu: the official guidelines suggest use of these medications for those with chronic illnesses as post-exposure prophylaxis. These medications may prevent the flu or ease the course once contracted. Keep in mind that should your child or teen contract either the H1N1 or seasonal flu, the same recommendations for care should be followed. Drink fluids, maintain blood sugar, do not omit insulin (contact your diabetes team for guidance in insulin dosing) and use Acetaminophen or Ibuprofen to control fever. DO NOT USE ASPIRIN as there is an association with a severe neurologic disease (REYE'S syndrome) that is associated with influenza and aspirin administration. Watch for ketones and be prepared to increase fluids and provide extra insulin should they develop. If vomiting occurs, and your child or teen is unable to keep fluids down, it is time to call the diabetes team for further instructions. Intravenous fluids may become necessary. If your child is low and unable to keep fluids down or eat, low dose glucagon may be an option to avoid continued hypoglycemia and to raise blood sugar. Discuss this treatment option and dosing with your diabetes team. Above all, trust your judgment. If you are worried that your child or teen is not looking good, call your diabetes team and/or visit a hospital that is knowledgeable about caring for children and teens with diabetes.
Published On: September 16, 2009