Calming advice about swine flu

June 19, 2009
by Dr. Laurence Degelsmith

Several years back, we had an abundance of people flocking to the emergency department with mosquito bites and fevers. Everyone was panicking over the new disease West Nile virus. I’m not sure we actually ever saw a case of it at Northern Westchester Hospital, but there was a lot of concern from the general public.

Interestingly, we are telling people the same thing now about swine flu that we told them years ago about West Nile virus: “You probably don’t have it, but even if you do have it, there’s nothing we’re doing about it and you’re going to be fine.” Reassurance is a drug we use quite often in the emergency department, probably more than most medications. Actually, there is a treatment for swine flu, unlike West Nile virus, but we don’t use it in most cases.

So what exactly is swine flu? The Center for Disease Control refers to swine flu as Novel Influenza A or Swine-Origin Influenza A (H1N1). This is a different strain than the Human Influenza A, which has two currently circulating strains, H1N1 and H3N2, which is what we’re used to seeing. There is also a Human Influenza B which is a different virus but causes similar symptoms to Human Influenza A but is much less common.

As of early June, there have been about 1360 documented cases of swine flu in New York State. Of those 1360, about 860 cases were in New York City and 500 from the rest of the state. At least 46 documented cases have been from Westchester County, but not one has been found at Northern Westchester Hospital at the time of me writing this article. That’s not to say that we haven’t seen any patients with swine flu, but rather we are just not testing most people so we don’t know how many cases pass through our doors.

Testing for swine flu begins by testing for Influenza A. This test is a simple nasal swab done in the emergency department and sent to our hospital lab. Any positive swab can then be sent to the state health department for further testing for swine flu. The health department decides which swabs they want to test. The decision to test for swine flu depends greatly on how sick a patient is. Usually, only hospitalized patients are tested for swine flu. Testing for swine flu is a multistep process that is time consuming and very expensive, plus the results also come back from the state lab too late to be of any clinical benefit to a physician treating the patient.

Why doctors are not routinely testing for swine flu

So why are we not routinely testing patients for swine flu? As we have all heard over the last several weeks, the swine flu virus is not overly dangerous. It’s probably milder than Human Influenza A and therefore full recovery is expected in almost all patients. A few people have died in New York State from the swine flu virus, but most if not all had underlying chronic medical conditions or were very young.

Tens of thousands of people die every year across the country from Human Influenza A and B. The few deaths thus far from swine flu are, of course, tragic, but I believe this small number of deaths demonstrates that this virus strain is not as dangerous as Human Influenza A or B. The New York State Department of Health as well as the Center for Disease Control have recommended not testing or treating generally healthy patients with suspected swine flu because such people will usually recover without any treatment.

The treatment for swine flu is one of two antiviral medications, Tamiflu or Relenza, but all they do is help shorten the course of the illness by a day or so. They can also decrease the severity of the symptoms a bit, but this is not that relevant in healthy people. Some infectious disease experts are worried about this virus developing resistance to the antiviral medications if used too often, just like bacteria developing resistance to antibiotics.

If a new, more dangerous strain of swine flu develops during the next flu season, we want to have a drug that can treat it without worrying about resistance. Therefore, the antiviral medications are recommended only for patients who are at high risk for complications of Influenza. Of note, this year’s strain of Human Influenza A is resistant to Tamiflu, which shows that it doesn’t take long for some viruses to develop resistance to the antivirals.

Who gets tested and who gets treated

So who gets tested and treated? Patients with symptoms suspicious of influenza who are sick enough to be admitted to the hospital are tested for all strains of influenza. The CDC recommends testing all patients who are at high risk of complications from influenza. These include patients over 65 or under 2 years of age and patients with certain chronic medical conditions including cardiovascular disease, cerebrovascular disease, diabetes and immunosuppressed conditions. Pregnant women and patients under 19 years of age on long term aspirin therapy are at higher risk and should also be tested. Patients in these categories who test positive for Influenza A should be treated for swine flu with Tamiflu or Relenza, even though few to none of these patients will eventually be tested specifically for swine flu.

The majority of the population can rely solely on Tylenol, Ibuprofen, chicken soup and any other over the counter remedy de jour. If you present to the emergency department with a fever, runny nose, cough or sore throat, expect to be told to put on a mask while you wait to be seen. We don’t want you infecting us or the other patients in the department not already sick. We will then decide if your symptoms are consistent with influenza.

Please don’t expect to get tested for swine flu or Human Influenza A if you don’t fall under the high risk complication category. Most patients merely get Tylenol or Motrin plus reassurance before being sent home. Some patients may get tested for strep or Lyme disease, which can also cause a fever, sore throat and muscle or joint aches.

In general, people with any form of influenza are contagious from the day before they develop symptoms until about one week after symptoms start, about seven to eight days total. I have personally seen many patients with flu-like symptoms whom I thought had influenza A or B. Those few that I tested for influenza were negative, which emphasizes the fact that there are many viruses out there in the community causing fever, cough, sore throat and aches that are not from the influenza family of viruses.

I hope this article answers the majority of questions people have about swine flu. In summary, if you have typical flu symptoms and are otherwise a healthy person, call your doctor and stay home. If you have trouble breathing, feel dehydrated or have doubts about your diagnosis, come on down and grab a mask on your way in. You will likely hear the words, “Yes, you may have swine flu. Go home, rest and stay away from other people. You’ll be fine in a few days.”

The Westchester County Department of Health has posted on its website and distributed to doctors and hospitals a memo originating with the NYS Department of Health that pertains to all school aged children in New York State. This memo recommends that all children with a fever and a cough or sore throat stay out of school or day care for at least seven days plus an additional 24 hours after there has been no fever. Even if a child is feeling better after four days, they should still remain at home for a total of at least seven days to prevent any possible transmission of a possible swine flu infection. A cough or sore throat without a fever is excluded from this recommendation.

I don’t know if the Westchester County schools are strictly following these guidelines. I have also heard from a reliable source from the county health department that this recommendation was probably overkill and unnecessary since it was never used for previous Influenza A or B outbreaks.

Laurence Degelsmith graduated from Horace Greeley High School in 1985, has an undergraduate degree from Washington University in Saint Louis, attended New York Medical College and did his residency in emergency medicine at the University of Michigan. He is an emergency department physician at Northern Westchester Hospital in Mt. Kisco and a member of the Chappaqua Volunteer Ambulance Corps.