Testing, prevention, treatment are the new normal this year

Testing, prevention, treatment are the new normal this year

By HARLAN SPECTOR

Plain Dealer

This fall, we find ourselves dealing differently with swine flu than we did six short months ago, when the virus was new, and nobody was sure what to expect.

Information is changing rapidly, and data collected about the H1N1 virus since spring has brought new recommendations on who should be tested, who should be treated with antiviral medications and how long students with flu should stay away from school.

While the U.S. Centers for Disease Control and Prevention continually tweaks the guidelines based on new data about how this flu is playing out, aspects of the virus remain a mystery. Experts still don’t know for sure why young people are more susceptible than the elderly. They disagree on how lethal H1N1 will be this season, and they worry about H1N1 becoming resistant to antiviral medications. Here is a look at what is known and how it has driven the latest guidelines:

Who gets tested?

Patients who seek medical care for flu symptoms want to know if they have swine flu.

Last spring, doctors routinely tested patients with flu symptoms, using rapid tests that determine whether it was flu type A — which could indicate swine flu — or type B. Samples of type A were then sent to the state health department to determine if it was H1N1.

Health officials say the practice is no longer necessary for most patients. Once H1N1 is established in an area, flu cases are assumed to be that specific virus. Experience in the Southern Hemisphere over our summer (their flu season) showed more than 90 percent of the flu cases were pandemic H1N1.

And the treatment is the same regardless of the flu type, doctors said.

Another emerging issue is reliability of rapid tests for influenza A. The CDC reported Sept. 25 that a study of rapid tests last spring showed that they accurately pointed to swine flu less than half the time. The findings confirmed an earlier CDC report showing that three major test kits accurately typed only 40 percent to 69 percent of the time.

“We didn’t know the limitations of this test until we did enough to know,” said Dr. Robert Hopkins of the University of Arkansas, an adviser to the American College of Physicians. “We’d love to give people the answers they want, but the science doesn’t give us the ability to do that all the time.”

Testing for H1N1 is still carried out in some cases. The Ohio Department of Health calls for testing when severe illness requires hospitalization or when a child dies, said Cuyahoga County Health Commissioner Terry Allan. But health-care providers use their own judgment on whom to test, said Dr. Frank Esper, a pediatric infectious-disease specialist at Case Western Reserve University.

Who gets treated?

When H1N1 first hit – before doctors knew how it was going to behave – antiviral medications were widely prescribed to sick patients. But doctors have since scaled back, after it became evident that swine flu was not causing severe illness in most people. The virus is playing out much like seasonal flu in terms of disease severity.

Antivirals Tamiflu and Relenza are still recommended for people with severe flu and those at high risk of complications. High-risk patients include pregnant women and people with chronic medical problems or weakened immune systems.

There are also fears that overuse of the drugs will encourage H1N1 to become drug resistant.

“The benefits of Tamiflu are not so much for a healthy person who can fight the flu,” said Daniel Janies, an associate professor at Ohio State University Medical Center, who studies drug resistance of H1N1. “The public-health benefits of not putting Tamiflu into the environment are large.”

Staying home

Health officials last spring advised that school students with flu stay home seven days after the onset of symptoms. Now they say students should stay home for 24 hours after they are fever-free without the use of medication.

“At that point, we were trying to prevent any transmission at all,” said Dr. Mary DiOrio of the Ohio Department of Health. “We didn’t know exactly how the virus would behave.”

The change came after the CDC found that illnesses were not as severe as feared last spring — most patients who were not hospitalized ran fevers for a few days, requiring absences, in most cases, of three to five days.

Two studies presented in September showed that people can still shed H1N1 virus several days after fever breaks. But it’s not clear how contagious they are.

School closings

When swine flu hit last April, Ely Elementary School in Elyria, acting on advice from the CDC, closed for a week after a 9-year-old contracted the viral infection. Schools across the country did the same when flu cases spread.

The CDC has since advised the nation’s 130,000 private and public schools that they don’t need to shut down, even in the case of an outbreak.

The CDC found that closing schools did not stop the spread of swine flu, said Elyria Health Commissioner Kathryn Boylan.

“The guidance now on closing school is it’s up to the school being able to operate,” said Boylan.

Young vs. old

In explaining why swine flu hits young people harder than older adults, some experts say it appears that people over 60 have developed resistance from exposure to flu viruses that circulated decades ago.

Most H1N1 cases known to federal health authorities have involved people age 5 to 24. Seasonal flu, on the other hand, is most dangerous for the elderly.

Another theory for the age paradox is that young people have an overcharged immune response to swine flu, which exacerbates complications. Their bodies produce excessive proteins, which causes inflammation in the lungs.

Esper of Case Western Reserve University said it’s believed that the 1918 flu pandemic elicited this type of reaction in younger people. The 1918 pandemic killed mostly people 20 to 40, he said.

“We still don’t know if that’s going on in this case,” Esper said of the hyper-immune response. Same for the built-in immunities in older people – it may explain why the elderly are less susceptible to swine flu, but the connection is unproven.

“It’s probably a fairly safe estimation that at least some of that is due to protective immunity,” said Hopkins of the American College of Physicians. “Two or three or five years down the road, we’ll have a lot better answers.”