Cutting through the H1N1 hype 

Cutting through the H1N1 hype

Flu epidemics can start off with a mild form, followed by a "second wave" caused by a more dangerous strain that can lead to an epidemic of severe illnesses during fall and winter crowding. The 1918-1919 flu epidemic started off this way. But after the onset of the second wave, more than 50 million people died, mostly from pneumonia.

Even though the 1918 flu was caused by the H1N1 virus, experts believe today's H1N1 virus is less virulent. Nevertheless, the President's council of scientific advisors holds that H1N1 flu is a "serious threat to our nation", because 30-50% of the US population may be infected and because H1 N1 flu is expected to cause between 30-90,000 deaths. The lower figure is less than what ordinarily occurs each flu season, and the higher figure exceeds it.

Ideally the first line of defense is vaccination. The CDC recommends these high-risk groups for H1N1 vaccine: Pregnant women; those 6 months through 24 years old; persons 25-64 who have chronic lung, heart, kidney disease, diabetes, or severe muscle or neurological disorders; household contacts & caregivers for children younger than 6 months; health care & emergency medical services personnel.

But should this recommendation be followed? The answer depends on how safe the vaccine is and how scary the fall H1N1 epidemic turns out to be, as the vaccine is not expected to be available until mid-October.

When 40 million people received swine flu vaccine in 1976, 500 persons came down with Gullain-Barre (nerve inflammation with paralysis) - equivalent to a risk of 1/100,000.

Unfortunately the safety study for the 2009 vaccine is too small to give an idea as to the risk of the vaccine. Although the mortality rate of the first wave of H1N1 flu so far (.7%) is much higher than the risk of Guillain-Barre with the 1976 H1N1 vaccine (.001%), if the "second wave" of H1N1 flu is mild, many people will probably opt out of receiving today's vaccine.

If the second wave is associated with a high rate of serious complications, most people will take their chances with the vaccine. Depending on the results of the safety study, this is probably what many physicians will recommend.

Keep in mind this discussion is about H1N1 flu. Just about all physicians subscribe to the CDC's recommendation that the previously mentioned risk groups should receive the annual flu vaccine, unless there is a reason not.

Other lines of defense are to avoid crowds, hand-wash frequently, clean contaminated surfaces, cover one's nose and mouth while sneezing or coughing, discontinue handshakes and hugs, and remain more than 6 feet away from someone with flu. If you are sick with a flu-like illness stay at home for at least 7 days (counting the day before symptoms began) and remain home until symptoms disappear. Consult a physician regarding anti-viral medications unless you're well into a mild flu.

If your child's school/day care has cases of H1N1, should you take him or her out? The problem is that the outbreak may continue to percolate as new cases pop up, so you could end up keeping your child out for a long time. I've not seen a recommendation to pull children from schools that have cases of H1N1, but if the school/day care appears to be a hotbed of infection, it make sense to call time out.

Were it shown the H1N1 vaccine is safe with little risk - and this may never be shown conclusively - and if the fall/winter outbreak of H1N1 is associated with a lot of severe illnesses, parents will probably want their children vaccinated, which will bring some confidence about how to react to outbreaks in schools and day care.

If we're in for a rough ride, an effective, safe vaccine delivered in sufficient quantity in a timely fashion may prevent much suffering. Otherwise intelligent, un-wasteful use of anti-viral drugs and application of time tested public heath preventive techniques may do the job, if we all pay heed.

This is a good time to heighten cooperation in the establishment of a city wide center, where folks with flu symptoms can be screened and treated with anti-virals as necessary, and the quite sick bedded down for short stays and given supportive care to keep our hospitals from being overwhelmed and staff from being exposed unnecessarily.

Old fashioned things can do a lot of good, like cooperating, staying alert and helping each other, just as New Yorkers did on 9/11.


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Ben Hubby, MD

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