An off the field opponent

Tuesday, September 22, 2009

All summer, alumni and fans have been waiting for a chance to cheer their college football team. Sportswriters, coaches and web junkies analyze practices and games trying to predict what team may hold an edge in the next game. All that time and effort invested and potentially all wasted because of a lowly virus. While an individual injury might be a difference maker, how does one handicap dozens of players coming down with influenza? The University of Wisconsin had almost half their team in the sick bay in the past couple of weeks and now it’s the University of Florida seeing its ranks depleted.

Not surprisingly, colleges and universities are fertile grounds to pass a virus around campus. When people from different regions of the country congregate together and share enclosed spaces like classrooms, dining halls, dorms and gym lockers, there is a great potential for a single ill person to infect many others.

In past years, influenza season was an inconvenience but this year’s new H1N1 strain is causing heads to turn. It’s not because it is especially deadly (the estimate is for 70-75,000 deaths in the US compared to the 35-40,000 in a “normal” year), it’s because of the people that are getting really ill. Instead of the elderly suffering, it is the young and pregnant. These are the invincible age group, where mortality is too abstract to consider. But H1N1 has changed the paradigm; it’s an old virus remodeled for today’s times. The senior population has experienced something similar and has some remaining immunity, while the younger generation has to battle the virus with no defense.

The problem for the health care provider on the front line is that today’s patient wants a solid diagnosis, even if it doesn’t matter. H1N1 is a prime example of an infection where the treatment can’t wait for the tests to come back.

The diagnosis of influenza, including H1N1, is based on history. Fevers, chills, muscle aches, runny nose and cough are common symptoms. This virus has another twist. Some people develop vomiting and diarrhea, not often seen with influenza, which usually limits itself to the upper airways. Physical exam is useful in assessing dehydration and making certain no other infection is present. But then the art of medicine is required. Testing doesn’t matter and one has to persuade the patient and their family that getting a swab, sending it to the state lab and waiting for confirmation of H1N1 won’t change what needs to happen at the bedside.

Anti-viral medications are helpful but usually are prescribed within the first 48 hours of illness to be effective, otherwise opportunity is wasted. Waiting for the test result puts the patient out of the treatment opportunity window. But the patient says: “aren’t their quick screening tests?” and the answer is yes, but… There are quick screen tests for influenza A and influenza B, but H1N1 is tricky. The screens may be falsely negative but the specific test for H1N1 could be positive. So regardless of the screen, if there is indication to treat, one should probably treat.

And then there is the cost of the swabs. One patient doesn’t really cost much, but what if 25-40% of a campus gets ill? How much does it cost to test 10,000 students? By the time the results are back, the epidemic is either over or spreading like wildfire and there is little to do, except give the standard advice:

• Avoid getting close to sick people
• Wash your hands
• Cough into your sleeve
• Rest. Drink lots of fluid. Use tylenol or ibuprofen for fever control
• Seek medical care if you are increasing ill, feel short of breath, have chest or abdominal pain, feel dizzy, get confused or have persistent vomiting

Influenza isn’t fair. It gives little warning that it is going to attack and when it does, it isn’t selective in its victims. And H1N1 has decided to do its damage even before the vaccines are ready to be rolled out. The sports axiom would suggest that it’s still early in the season but we’re already playing catch up.

And for those who are addicted to college football, who knows which elite team will be beaten, not on the field by an opponent, but by a little bug in their dorm.

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