The horse is out of the barn on this one, but luckily it's not very severe... (recent changes in green)

The Big Picture:

Swine flu, like the regular seasonal flu, is highly contagious.  As of June 18th, Massachusetts has had 1273 confirmed H1N1 cases.  This number likely reflects just a small portion (less than ¹/10^th) of the actual cases, since the CDC and other public health authorities do NOT recommend, and most doctors and hospitals are not performing, routine testing of all (or even most) possible cases.  This means that the “horse is already out of the barn” on this epidemic.  The reality is that no matter what anybody does at this point Swine Flu will continue spreading through the U.S. population until most individuals have had it and become immune.

Fortunately, the last month has shown us that this Influenza strain causes a relatively mild disease, with few complications (comparable to regular seasonal flu).  Just like with regular flu, there can occasionally be complications and even deaths, usually among people with health risks (severe chronic illness, pregnancy, very young infants, the elderly) – but most people at all ages feel sick for for 3-7 days and then recover spontaneously with no treatment.  Essentially everything we have written about regular seasonal flu on our website in the past also applies to Swine flu – except that there is no vaccine. 

There remains a possibility that the H1N1 virus could “mutate” over the summer and return in a more dangerous form next fall or winter.  Because of this possibility, one could argue that it might be better to catch it sooner than later, since catching the current mild version will likely confer immunity.

Diagnosis of H1N1 Influenza and School/Camp Exclusion:

The idea that the spread of this disease might be controlled through measures like isolating individual cases or even closing schools is looking less realistic and more futile with each passing week.   The public health authorities (CDC, state DPH’s) have coined the term “IFI” (influenza-like-illness) to refer to individuals with fever (>100.5°F) and either cough or sore throat.  Most people with Swine flu actually have both, along with several other symptoms that may include any combination of the following:  chills, headache, muscle/joint/body aches, runny nose, breathing problems, fatigue, vomiting, or diarrhea.

Recently the CDC and the Mass DPH revised their recommendations for schools.  Previously, any child with an IFI was to be excluded from school or camp for 7 days after the start of symptoms.  This policy was based on the assumption that most IFI was indeed Swine flu, but seemed a bit like closing the barn door after the horse has gotten away to many of us.  Now the officials have relented and adopted a more reasonable policy which states that children should be kept home until they have been fever-free (without the help of fever control medicines) for 24 hours. 

We understand that a parent might want to know for sure whether their child has H1N1 or not.  As mentioned above, however, even though the public health authorities recommend keeping them home, they do NOT recommend testing every patient with an IFI.  The diagnostic test for influenza is expensive and not 100% accurate, so a negative test does not rule out the flu.  The process of collecting the specimen is quite unpleasant for the child, and can spread the virus to others.  Therefore the current recommendations are to only test patients who are so sick they need to be hospitalized, or who because of underlying illness are at extremely high-risk for complications.  In most cases symptoms, not test results, should determine which children need to stay at home.

Prevention:

Because there is no vaccine for H1N1 yet, public health officials recommend taking simple steps to keep your family healthy.

• Wash your hands frequently with soap and warm water or use an alcohol-based hand sanitizer.
• Cover your cough with a tissue or cough into your inner elbow and not into your hands.
• If you are sick stay home from work and if your child is sick keep them home from school or camp until 24 hours after their fever has gone away.
• Stay informed about the latest developments on the H1N1 flu.

An H1N1 vaccine is now being tested.  News media have speculated that it may be available by mid-October and in plentiful quantities.  This is optimistic and assumes that no problems crop up during the testing or the manufacturers ramp-up to full scale production.  The truth is that no one yet knows for sure when the H1N1 vaccine will be made available or, when it is, whether supplies will be limited or not.  Until we have that information, it is difficult (and premature) to formulate an office policy regarding such a vaccine.  What we can say is this:

• IF the H1N1 vaccine becomes available relatively early in the season, before most children have caught swine flu already, AND it is available in unlimited quantities, then we would certainly recommend that all our patients get it and would mobilize our office resources to make that happen.
• If supplies are limited, however, we would have to pick our sickest and highest risk patients to give it to, and…
• If it doesn’t materialize until late in the season, after most people have already gotten sick, there may be no point.

Antiviral Treatment:

Tylenol for fever (or pain), rest, and plenty of fluids are the most important treatments for Swine flu.  Topical anesthetics for sore throat (sprays, lozenges) may also help.  As always, we do NOT recommend cough suppressants.

Since (at least so far) H1N1 is such a mild disease, we are not routinely prescribing Tamiflu.  We do consider prescribing it for certain high-risk patients, however, including:

• Ex-preemies less than 2 years old
• Children with serious chronic illnesses like heart disease, cerebral palsy, asthma or diabetes
• Children on long-term aspirin therapy
• Children who have compromised immune systems (either immune deficient or on medical treatments that suppress immunity)
• Family contacts of adults or children in high risk categories

Tamiflu works best if they are taken within 2 days of when symptoms start, so even people with mild illness should call us right away if they are in one of the above categories.

Who Should Be Seen in the Office:

Most children with an influenza-like illness (IFI) may be safely managed at home.  Children with mild symptoms who have been sent home from school but have no high risk conditions should remain home.  They do NOT need to be evaluated in the office, but may not return to school until they have been fever-free for 24 hours (without Tylenol or Motrin).

Our main concern when we see a child with IFI in the office is not whether they have H1N1, not do they need to be tested, not even should we prescribe a medication.  Our main concern is are they OK, or do they need to be hospitalized?  Any child who has severe symptoms or is ill-appearing (difficulty breathing, lethargic, not urinating, in great pain) should be brought in for a visit.  In addition, any child with chronic illness or special health care needs should also be seen.  For more details on when not to be concerned vs. when to call for a sick visit, please look here. 

Internet Resources:

To learn more, click on any of the following links.

     Centers for Disease Control and Prevention (CDC)
     Massachusetts Department of Public Health (Mass DPH) 
     Boston Public Health Commission
     U.S. Department of Homeland Security

We Are Here For You:

Swine flu is a medically and epidemiologically complicated issue - one that is changing with new updates all the time.  As always, if you have any questions or concerns (especially if we have not addressed something in this update or on our website), please do not hesitate to contact us.