FYI

Aspirin

Let us remind everyone that people under the age of 17 may not take aspirin at any time, but especially,if they have the flu. We never recommend aspirin. If it is given to people in this age group with the flu, it may cause Reye syndrome which can cause liver and brain problems and can be fatal.

However, several patients have been given Pepto-Bismol. The bismol is bismuth-subsalicylate.  This is related to aspirin and should never be given to children. We never recommend Pepto-Bismol and it can never be used when kids have the flu. Some cases of the flu have been associated with nausea or intestinal problems. 

Please don't give either. 

MV

What to do if you have the flu....

The NYC Department of Health has posted the following information on home isolation. It is good advice.

http://www.nyc.gov/html/doh/downloads/pdf/cd/cd-h1n1flu-homeisolation-new.pdf

The CDC has recommended the following information for K-12 Schools. It is just plain good advice.

Interim Recommendations: K-12 Schools

• K-12 SchoolsSchool dismissal is not advised for a suspected or confirmed case of novel influenza A (H1N1) and, in general, is not advised unless there is a magnitude of faculty or student absenteeism that interferes with the school’s ability to function.
• Students, faculty or staff with influenza-like illness (fever with a cough or sore throat) should stay home and not attend school or go into the community except to seek medical care for at least 7 days even if symptoms resolve sooner.
• Students, faculty and staff who are still sick 7 days after they become ill should continue to stay home from school until at least 24 hours after symptoms have resolved.
• Students, faculty and staff who appear to have an influenza-like illness at arrival or become ill during the day should be isolated promptly in a room separate from other students and sent home.
• Aspirin or aspirin-containing products should not be administered to any confirmed or suspected ill case of novel H1N1 influenza virus infection aged 18 years old and younger due to the risk of Reye syndrome. Refer to pediatric medical management for guidance regarding use of any medications, especially those containing aspirin.  (http://www.cdc.gov/h1n1flu/clinicians/)
• Parents and guardians should monitor their school-aged children, and faculty and staff should self-monitor every morning for symptoms of influenza-like illness.
• Ill students should not attend alternative child care or congregate in other neighborhood and community settings outside of school.
• School administrator’s should communicate regularly with local public health officials to obtain guidance about reporting of influenza-like illnesses in the school
• Schools can help serve as a focus for educational activities aimed at promoting ways to reduce the spread of influenza, including hand hygiene and cough etiquette.

Students, faculty and staff should stringently follow sanitary measures to reduce the spread of influenza, including covering their nose and mouth with a tissue when coughing or sneezing (or coughing or sneezing into their sleeve if a tissue isn’t available), frequently washing hands with soap and water, or using hand sanitizer if hand washing with soap and water is not possible.

MV

Our experience with H1N1 Flu

We now have some experience with H1N1 flu. We do not have the ability to test for H1N1 flu. Those tests are reserved for hospitalized patients. We do have a rapid flu test which will test for Influenza A, which is the family H1N1 belongs to. Because there is very little influenza A circulating at this time, it is presumed that all positive tests are H1N1. That's a reasonable assumption. Here is our data so far:

• We have tested 59 patients since 5/19/09. Of those, 17 tested positive, 16 for influenza A and 1 for influenza B. (This proves that there is some regular influenza around.) 
• The average temperature reported at home was 101.7. (99.3-103).
• The average temperature in our office was 99.5. 
• 4 patients reported cold symptoms and 2 reported a sore throat 
• 71% reported a cough 
• 18% had a positive chest exam-2 with pneumonia and 1 with wheezing. 1 asthmatic had no chest symptoms. The two with pneumonia were given antibiotics without further complications.
• 6 % (1 patient) had GI symptoms.  
• All but one patient was treated with Tamiflu.  
• The average age was 9 with a range of 3-16. 

OK, what does that mean?  

• The assessment that H1N1 flu is a "regular" flu is probably correct.
• Kids who get it are mostly school-age kids 
• We should probably focus on the kids who are at high risk (Asthma, chronic respiratory or health conditions, immunological and cardiac problems.) 
• We should stay calm. If you get the flu this year, you won't get it next year. So, you don't need to get an extra series of flu shots next fall. 

What has been NYC's experience? As of 5/28 we have had 201 hospitalizations:

• 43 0-4 years with 0 deaths
• 92 5-24 years with 0 deaths
• 60 25-64 years with 4 deaths
• 6   65+ years with 0 deaths

It appears that the disease strikes the young and middle-aged and is lethal primarily for the middle-aged patients, most of whom have other health problems. 

It appears that people born before the early 1970s may have some underlying protection. The normal risk groups, those under 2 and over 65 have not had any deaths. 

While the age mix is different than the normal seasonal flu, the lethality of the flu is not any different than the normal flu. This is supported by the analysis of the genetic makeup of this flu. It may change; but for now, it is just the flu. Take some ibuprofen and stay home. Do we need to get excited? That's an unanswered question, but the data seems to say, "Not very much." 

We don't usually treat the flu or do prophylaxis unless a child is at specific high risk. We vaccinate.

If we have a flu vaccine next year, we may just do the same as always. That's not a bad thing.

Stay tuned.............

  

Further Experience

As the week has progressed we have had several patients with positive rapid tests for Influenza A daily. We presume they are H1N1 cases. Several of the milder cases have not been treated with Tamiflu by mutual agreement. We continue to offer the medication to anyone who tests positive.

Most of the schools which have been closed or have had high absences have been outside Manhattan, primarily Queens. However,  there are several schools on the list that are located in Manhattan 

We are hoping that the warmer weather and the long Memorial Day weekend will help curtail this outbreak. 

MV

Change of Plans

We have had 6 patients test positive for Influenza A in the last 2 days. These patients mostly had been vaccinated against influenza. We presume these are H1N1 flu cases. 

We have changed our protocols and will be treating all patients who test positive for Influenza A with Tamiflu. 

We will monitor our clinical experience, take advice from the public health authorities and keep you informed. 

The information from the public health authorities is limited and the Department of Health appears to be conflicted as to what to do. People are acting irrationally. In one family, one of 3 children tested positive. The others are well. One of the siblings was sent home from school when the school found out her sister was sick. She was told not to come back until instructed to. Her mother, a hospital employee who is also well, was told not to come in to work. 

People are panicking and acting irrationally. We should use the information available to us and act responsibly.

MV

Changing Scene

It was not a good weekend. There were a lot of calls from parents of high school students with high fevers and muscle aches and pains. While we had only one student, a middle school student in Manhattan, with a positive flu test for influenza, there was a lot of concern and an awful lot of worried parents with sick children. 

As we know from the studies, this virus is a new but typical flu virus. We normally expect 30,000 deaths in a routine winter. We have had less than a dozen so far. 

However, it appears that the virus has broken through and we are having an outbreak in NYC. The letter from the Department of Education and the Department of health summarizes the situation and the way we should approach the outbreak. 

"As you may already know, there are three different strains of influenza currently circulating in New York City: two seasonal viruses that arrived last fall and the new swine origin H1N1 virus, which this year’s vaccine does not prevent. So far, the symptoms of the new H1N1 flu have closely resembled those of seasonal flu, but any influenza virus can cause severe illness, so we are taking aggressive precautions. 

Besides suspending classes at schools experiencing unusual clusters of illness, the Health Department advises students, staff and their family members to seek medical advice if they belong to any of the higher-risk groups listed below and think they have had close contact with someone who has the flu during the past week: 

People over 65 or under 2 years of age 

People with chronic lung, heart, kidney, liver or blood disorders 

People with immune systems that are compromised (either due to illness or medicines) 

Pregnant women 

People on long-term aspirin therapy 

Individuals in these categories may be advised by their doctors to take preventive medications such as Tamiflu or Relenza. However, most people who get the flu do not need to seek medical care and do not need to be tested for H1N1 flu. The Health Department recommends testing only for people who are in the hospital. Most people who get the flu should stay home. 

The best way to prevent additional cases of flu in our schools is to ensure that people with symptoms stay home. If your child has a fever, accompanied by cough or sore throat, please do not send the child back to school until 24 hours after the symptoms resolve. "

Our current approach to sick children is to assess the child. We will be testing children who have high fevers and severe aches and pains. We cannot get enough materials to test anyone. If a patient tests positive but is not severely ill  but does not have cardiac, respiratory or immunological risk factors, we will treat symptoms but not treat with Tamiflu.  There is a significant concern that the routine use of Tamiflu will produce resistant organisms. The routine flu this year was completely resistant to Tamiflu. Overuse of Tamiflu is most likely the reason. 

It is not clear how this will progress. Stay tuned. 

Some resources

First, we would like you to set up a RSS feed for this blog so we can reach you quickly when something hits the news or when we have things we want you to know. We want to be able to reach you quickly. 

The concern with the H1N1 flu appears to be decreasing as we learn more. Here are some resources you can link to:

The first, CDC H1N1 Flu | H1N1 Flu and You, is a constantly updated flu summary for H1N1. It is excellent and comprehensive. 

The second, New England Journal of Medicine HealthMap, allows you to have "fun" tracking the flu.

The third, HealthMap | Global disease alert map,is for those of you who just can't get enough data and have nothing better to do than surf the web. 

MV

It's settling down.

Facts:

Influenza numbers: 1490 cases worldwide; 822 in Mexico with 29 deaths; 403 in the U.S. with 2 deaths; 73 in NYC with no deaths.

The genome of the flu virus does not contain the hyper-lethal genes of the 1918 epidemic.

Most cases of the H1N1 flu have been typical of seasonal flu.

It appears that this is a new flu, but a typical flu. More information will be gleaned when the flu season hits in a month or so in the Southern Hemisphere. 

"Swine flu" is passe. H1N1 is in. However, there is a report from Canada that a pig farmer went to Mexico and came back and infected his pigs. They all recovered. I'm sure they were worried.

The CDC rescinded the recommendation that schools should be closed if there is a documented case of H1N1 flu in a school. The recommendation that sick children should remain at home remains in effect. 

Tempest in a teapot, no......But....

After a scary week, we have a lot more information and we have some reassuring data. 

Here are some facts:

1. The total number of confirmed cases is 650-(397 in Mexico, 160 in the U.S.& 50 in NYC.)

2. There were 5 new probable cases in NYC. 33 probable cases are already pending. To date, "nearly all confirmed and probable cases have been mild, and all of the affected people have recovered or are recovering."

3. 13 people have been hospitalized in the U.S.

4. The virus does not have the virulence factors that were present in the great influenza pandemic of 1918.

5. This years injectable flu vaccine offers no protection.

6. There has been no spread outside of the initial risk groups. (People who traveled to Mexico or had contact with them or at St. Francis Prep in Queens.) 

7. There are no cases in Manhattan so far. 

8. The death rate from the flu may have been exaggerated. 

The health department used Survey Monkey to survey the students at St. Francis. You can look at the results. They are interesting.  http://www.nyc.gov/html/doh/downloads/pdf/cd/h1n1_stfrancis_survey.pdf

This flu may act like most regular flu infections and pose no greater risk if you are infected than the usual flu virus. That's not clear yet. It does appear that the efforts to contain the virus have been effective.

The basic goal is to prevent the virus from spreading widely. This containment will reduce the sources for a second wave epidemic next year and may buy time to prepare a vaccine. It appears that planning that was done after the SARS and avian flu epidemics may enable us to produce vaccine in a shorter period. It is estimated that a vaccine could be available within 4-6 months if everything goes well. That would be adequate time to vaccinate the public prior to the season onset, which is usually early in the new year. 

Health officials currently recommend keeping sick children home from school. 

School closings are important. Schools are filled with young susceptible unsanitary creatures. Transmission in a school can amplify and epidemic. The current plan is to close schools where there has been one case of Influenza A(H1N1) (its current name.) Schools which are feeders to or from that school may be closed (like the middle school that feeds from an elementary school.) Schools that are closed will be closed for 10-14 days. The kids will have to go home and not have play dates, go to the movies or any other public place. St. Francis Prep will open on Monday. 

Let's smell the roses--if they cause you to sneeze, it's allergies. Trust us.

MV

"Kevin threw up..."

At the Ascension School morning assembly in upper Manhattan, Kevin threw up. 6-7 kids went home with fever. 

Suddenly we had the first case of swine flu in Manhattan. That was repeated by the health commissioner the next day. Funny thing is, Kevin had a stomach bug and sending 6-7 kids home with fever is normal for a grade school at this time of the year. None of them had swine flu. 

Lots of parents called us asking if they should keep their kids home from school/preschool. 

Panic  strikes. Swine flu hasn't. To date, all 49 NYC cases of swine flu were associated with St. Francs Prep in Queens, had traveled to Mexico, or have had direct contact with the two groups. If this doesn't describe you, take a deep breath and smell the roses (they do not carry swine flu.) 

What we do know is that 2 out of 3 people diagnosed with swine flu have been under 18. The only death was a Mexican infant in Texas. We are not told how the child came to be hospitalized in Texas. 

The change to Level 5 means there has been a "sustained community-level outbreak." It does not mean the sky is falling.  

A school district in Madison County, Alabama closed for 10 days. That makes sense, since people with swine flu can shed virus for 10 days. The only problem is that there have been no reported cases in Alabama, nor any in the states surrounding Alabama. Closing borders now is closing the gate after the cows have gone. Closing schools when there's no flu around is like closing the gate before you buy cows. It's 100% effective but mindless. 

So.... Remember

1. Kids get sick normally

2. All sickness is not swine flu (H1N1-2009 is the p.c. term)

3. Keeping your kids home from school will keep them from getting swine flu, but if it is not circulating in the school, it will unnecessarily deprive them of an education with no health benefit.

4. The City Health Department will close a school if there is swine flu---public, private or parochial/religious.

5. If your child has a sudden illness with abdominal symptoms, high fever, aches and pains that are severe and mild respiratory symptoms, you should contact us. If you child has the sniffles and a low-grade fever, do what you would normally do. 

Remember-all of the cases in NYC have been non-life threatening and there has been only 1 hospitalization, a brief one requiring no intensive care. 

Oh, yes. Kevin is feeling better and the Ascension School is still open. 

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MV