Wednesday, October 21, 2009

The pressure to manufacture and distribute the H1N1 vaccine before the influenza virus began its autumn spread is ongoing but so far it seems that the virus may be winning. The race though is far from over, but in more than 40 states, the number of people being diagnosed clinically with the “swine” flu is growing.

Clinically is the key word, since testing for the influenza virus is no longer recommended. Instead, care providers are using history as the guide to whether H1N1 is the likely diagnosis. The most frequent symptoms are fever, cough, shortness of breath and fatigue. These are pretty non-specific complaints but in today’s setting of wide spread influenza, it is enough to be relatively certain that influenza is the cause. Less commonly, there may be chills, muscle aches, runny nose, sore throat and headache. Interestingly, H1N1 also may present with vomiting and diarrhea, two symptoms that tend not to be associated with the usual influenza pattern.

It’s important that the physician not ignore the potential for other illnesses that have similar complaints. These same symptoms of fever, cough and shortness of breath are similar to those of pneumonia and it is the history and physical examination that may lead to the request of more testing like a chest x-ray or blood tests to be done.

While a rapid test using a nasal swab can check for influenza A and B, it is not very accurate for the H1N1 virus; a specific test for that virus is required. The turnaround time for the test is 36 hours and by then, the decision to admit the patient for care or to use anti-viral medications has already been made. The Center for Disease Control has stopped reporting the number of cases in the US because it is becoming increasingly inaccurate. Most people with H1N1 flu aren’t seeking care and for those that do, it is rare to be tested.

Since so many people have become infected with the H1N1 virus, rushing to be seen at the doctor’s office or the hospital care may not be the best decision. The vast majority of people need only symptomatic care with fluids and fever control with acetaminophen or ibuprofen. It is the unusual patient who requires prescriptions for the anti-viral medications Tamiflu and Relenza. They include:

• Children under the age of 2 years.
• Adults 65 years and older.
• Pregnant patients.
• Patients who are immunocompromised including those with HIV/AIDS.
• Patients with compromised respiratory function including seizure disorders, spinal cord injuries and those with cognitive issues.
• Patients with lung disease like asthma, heart disease, diabetes, kidney or liver diseases.

And for these people, treatment should be started within 48 hours of the occurrence of symptoms.

The goal is to get the country’s population immunized before even more people are exposed and potentially sickened with the H1N1 virus. It seems that this virus is easily spread between people and it’s important for those who are sick to stay at home until their symptoms have resolved. Fever can be a good guide as to when it’s safe to come out of hibernation. The recommendation is to be fever free for 24 hours before becoming more social.

It seems that we are returning to the basics of medical care for this flu season. Diagnosis is made clinically and often can be done by the patient (or the parent) themselves. Fluids to prevent dehydration, and fever control are the cornerstones of treatment. And finally, even in today’s busy world, time to rest is the key to getting better. The symptoms for this influenza can last more than a week and there is no way to make it get better more quickly.

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