Youth concussions leave parents and educators with “one opportunity,” Vicki Galliher often says, to manage recovery properly. If not done correctly, recovery from concussions can be prolonged, and the potential for long-term neurological risks may be magnified.

Ms. Galliher, the Athletic Training Coordinator at George Mason High School, is the driving force behind a critical trend in Falls Church City Public Schools: A long-standing but growing appreciation by school officials, educators, and parents for the role that cognitive rest–and individualized, fluid plans for academic accommodations–play in proper concussion recovery.

It’s not only the physical rest and return-to-play decisions that are important. Cognitive rest is critical as well–and this often means time out of school, modified academic schedules, and other changes at home and at school.
“I think we’re now more cognizant of how complicated concussions truly are,” says Dr. Seidah Ashshaheed, principal at Mary Ellen Henderson Middle School. “It is imperative that we do our part as a school by being informed and supportive [with cases of concussion].”

Christine Kilgore is a health care writer and mother of FCCPS students.

High School Concussions – A Frequent Occurrence

When I began researching the issue of concussions among youth in our community, I learned how frequently concussions occur among FCCPS students.

Examples abound: The high school football player who felt incredibly tired and slept long stretches, and was later determined to have a concussion. The lacrosse player who suffered his second concussion, prompting his parents to steer him to non-contact sports for six months. The hockey player who just felt “out of it” after a game in which he’d taken a hard hit.  The middle school soccer player who struggled with headaches and fatigue for weeks after a collision and concussion.

I also saw first-hand, in researching the science of concussions and concussion recovery, how much of the current knowledge of concussions has been acquired just in the last 10 years–and how fast it is evolving.  There are many uncertainties, but research has clearly shown that children and adolescents are more susceptible than adults to concussion in the first place, that they are slower to recover, and that they are at higher risk for “second-impact syndrome.”

Studies have shown that once an individual suffers a concussion, he or she is four  times more likely to sustain a second one. In addition, a growing body of research is showing that the cumulative effect of multiple concussions increases the risk of neurodegenerative health problems later in life.

I also learned, in trying to unravel my daughter’s health issues and hearing others’ stories, that concussions are under-identified and often arbitrarily treated in the medical community at large, despite an extensive “Heads Up” educational campaign launched by the Centers for Disease Control and Prevention in 2005.

Many physicians don’t appreciate that concussions can result from impacts to the body that jar the head, or from rapid accelerations brought to a sudden stop. Collisions or direct blows to the head are often involved, but aren’t a requirement.  Concussions can manifest in many different ways, and symptoms may not occur for days after the injury.

Even when a concussion is suspected, the message from physicians who have not been trained in these brain injuries may be vague–to “take it easy” for a week, for instance.

In reality, recovery should be much more deliberate and measured.  The pathophysiology of concussion isn’t completely understood, but most experts agree that concussions cause neurometabolic impairment and significant changes in the balance of neuro-chemicals in the brain. Such changes can effect one’s ability to think and learn, to stay awake and alert, to function well socially and emotionally, and to tolerate noise, light, and motion, among other things.

“The [concussed] brain is in an energy crisis, a metabolic crisis, so treatment must involve conserving the brain’s energy,” says Dr. Joel Brenner, a pediatrician at the Children’s Hospital of the King’s Daughters in Norfolk.

“We treat concussions completely differently than we did 5 years ago,”  said Dr. Brenner, who chairs the American Academy of Pediatrics’ Council on Sports Medicine and Fitness and has been working to educate physicians and others about concussion.  “We don’t grade concussions anymore, for instance, and we don’t send someone back after a week as a blanket statement . . . There has to be an individualized treatment plan.”

But before treatment can begin, one must identify the concussion, which can be difficult using traditional observation techniques.  Even an MRI or other standard imaging technique typically cannot measure the changes in the brain following a concussion.

To provide a better method of identifying a concussion, the medical profession is increasingly turning to “neurocognitive testing,” in which persons suspected of having concussions take tests to measure their cognitive abilities.  Ideally, athletes will have been tested before the season begins in order to establish their “baseline” performance, which can be compared against later performance to detect changes in the brain.

Neurocognitive testing, sometimes called neuropsychological testing, has been recommended in several major consensus statements and is widely regarded as the cornerstone of concussion assessment and recovery.  According to a recently published survey of high schools that participate in a national injury surveillance system, about 40% used neurocognitive testing in the 2009-10 school year,  up from 26% in 2008-09.

ImPACT – The “Gold Standard” of Neurocognitive Testing

George Mason High School’s concussion recovery protocol is based on use of the ImPACT test– a computerized neurocognitive exam with seven modules that measure aspects of cognitive functioning including memory, concentration, reaction time, and processing speed.

ImPACT, which stands for “Immediate Post Concussion Assessment and Cognitive Testing,” is not the only such system available, but it has fast become the gold standard.  It was developed at the University of Pittsburgh Medical Center by psychologists Mark Lovell and Micky Collins and neurologist Joseph Maroon, the Pittsburgh Steelers team neurosurgeon.  ImPACT is utilized throughout professional sports and among many colleges and high schools.  (While many high schools do not employ neurocognitive testing, let alone have an athletic trainer, the vast majority of those schools that do use neurocognitive testing have chosen ImPACT.)

At GMHS, Galliher uses ImPACT to test possibly-concussed athletes against a baseline established prior to the season.  The test takes approximately 20 minutes, with students sitting at a computer reacting to different on-screen tasks.  Comparing the before-and-after test results allows Galliher to document the presence or absence of injury and even quantify specific areas of dysfunction.  Used in conjunction with symptom reporting and clinical assessment, repeated ImPACT tests also can help guide recovery. (The test can be performed in the absence of baseline results, but its true value cannot be realized since each individual is different).

The George Mason athletic department advises all GM athletes participating in moderate-to-high-risk sports to complete baseline ImPACT pre-season testing. This year, boys tennis has also elected to participate (one of their players sustained a concussion last year during match play). Parents have the option of opting their child out of the baseline testing program, but Coach Galliher says she’s never had a parent refuse.

When Coach Galliher implemented the ImPACT protocol in 2003, George Mason was one of approximately 250 high schools nationwide that were integrating the protocol into their athletic programs. She had sought out the best of training, working at the University of Pittsburgh Medical Center’s Sports Concussion Program with the neuropsychologists who founded the software and testing protocol, as part of her overall ImPACT education and certification.

“The initial reaction [to the ImPACT program] was really positive because we were providing care not available elsewhere,” said Tom Horn, athletic director at George Mason. “And we were removing ambiguities in terms of whose call it is to return a student-athlete to play.”

Many GMHS parents have become believers.  “My son’s doctor completely missed the concussion,” said one father.  “My son collided with another player in a game last spring and didn’t feel himself afterward.  There was no loss of consciousness, no headache, no memory loss, so the doctor felt there was no concussion.  But when Coach Galliher readministered the ImPACT test, his performance was so diminished, there was no question he had a concussion.  And then we started to see more symptoms a couple days later.”

“Thank goodness she caught it,” the father said.  “If we had let him return to play at that time, it could have been very dangerous.”

For Ms. Galliher, the testing protocol also has worked hand-in-hand with symptom monitoring–and with physicians’ instructions, in some cases–in guiding academic planning, managing cognitive exertion, and determining when students can resume a full schedule of school attendance and studying. (In concussion treatment, complete cognitive recovery–the ability to function cognitively without any exacerbation of symptoms–is a prerequisite for reintroducing physical activity. It can take days, weeks, months, or longer for cognitive recovery. Prompt diagnosis and proper management lessen the risk of prolonged recovery. )

Ms. Galliher works with students and families on guiding the recovery process, meeting with students and parents and communicating with teachers and staff about each student’s limitations and progress. Last month at one point, she was working on 14 concussion cases at George Mason and Mary Ellen Henderson Middle School (“MEH”).

For the GM student who sustained a concussion in a hockey game last year, recovery meant several days at home followed by a flexible school schedule (going in late and leaving early) and a study regimen with maximal 10-minute study periods and no computer time (the subconscious mind picks up on the refresh rates of screens). Gradually school and study time increased until symptoms were gone and ImPACT results were back to baseline.

Others have been instructed to be more passive students for awhile, listening to discussions, for instance, but not taking notes or completing worksheets or homework. Some are instructed to retreat to quiet places for breaks, or vary their transit times in order to traverse the halls with fewer students. Many require significant limitations on smart-phone use and texting.

“There’s no standard protocol [in the medical world] for reintroducing cognitive learning as there is for reintroducing physical activity. For me, the whole process [of facilitating cognitive recovery for our students] has evolved…we’ve needed to develop and hone it,” Ms. Galliher said.  But with processes in place, “you can feel a palpable sense of relief from teachers and parents,” she said. “Before, you could see how stressed kids were about getting behind on schoolwork, how confused teachers were about giving homework, or not giving homework…no one knew what to do.”

Says one parent of an MEH student who recently sustained a concussion, complaining only of a headache several days later:  ”Coach Galliher taught us that the symptoms do not necessarily present as we thought.  And it was very important for us to learn that cognitive rest was important to his recovery.”  Says another parent of a GM student: “She is relentless and lays down the law” for proper recovery.

Ahead of the Curve

It is a sign of urgency–a sign of the rapidly increasing attention being paid to concussions in adolescent and teen athletes–that 35 states now have laws addressing student-athlete concussions.  (In 7 other states, bills are pending.)  Several bills addressing concussion safety and management for student-athletes were introduced in Congress in the past two years, but the states have raced ahead, following the lead of Washington State, which in 2009 passed the Zackery Lystedt Law, named after a teenager who suffered a major brain injury after returning to the football field too early.

Virginia’s law requires student-athletes to leave competition or practice when a concussion is suspected, and bars return-to-play on the same day–and until  athletes are evaluated and cleared by “an appropriate licensed health care provider” (a definition that includes licensed athletic trainers). The law also requires school divisions to develop policies and procedures for identifying and handling suspected concussions (including addressing academic needs and cognitive demands). Schools must also annually educate coaches and other school staff that advise student-athletes, as well as the students themselves and their parents or guardians.

The Falls Church City Public Schools approved a policy on “Student-Athlete Concussions During Extracurricular Activities” in June 2011 that establishes a “concussion management team” and addresses issues of concussion education and return-to-play decisions. The policy is based on one of the models developed by the Virginia School Boards Association in the wake of the new state law.

To a large extent, however, the new state law and FCCPS policy codify the approach that Coach Galliher and the George Mason athletic department have taken for years.  “Coach Galliher brought this to us much earlier,” said Craig Cheney, president of the GMHS Athletic Boosters Association and a former FCCPS school board president. “She’s brought a whole new level of knowledge to us as parents and to teachers. And fortunately, the advantage of a smaller school system is that we can disseminate knowledge much more easily and quickly.”

Ms. Galliher says most importantly, the law puts teeth into efforts to educate student-athletes and their parents. This year, for the first time, completion of an online certificate course about concussions is an annual requirement for each student’s participation in a school’s athletics programming.

“It’s a common perception that football is the main culprit, but for every concussion I’ve seen in GM football, I’ve seen another one in soccer, cheerleading, volleyball, and other activities,” Galliher noted.

Also for the first time, Ms. Galliher provided the same concussion education programming this past fall for MEH faculty and staff, at Principal Ashshaheed’s request, that she has regularly provided for GM staff. Matt Sowers, an MEH school counselor and head coach of the boys varsity tennis team at GM, said the session was informative and impressed upon him how “imperative” it is for educators to understand how concussions can affect students, and to stay on top of the latest knowledge on brain rest and treatment.

“We were amazed at how long [it can take for] full recovery,” he told the Falls Church Times.

Some of our state lawmakers, in the meantime, are discussing the possibility of introducing additional legislation to protect youth who participate in recreational athletic programs, according to Dr. Brenner, who worked with state officials on implementing Virginia’s concussion law.

The Future

“One of the biggest research questions right now is, what are long-term outcomes of these young athletes who have concussions–whether it’s one, two, three, or more?” said Dr. Brenner. “Will the 14-year-old who’s had two concussions, for instance, have any memory or attention problems when they’re 30 or 40? We don’t know this quite yet.”

My own review of the medical literature has shown me that research is indeed quickly moving beyond case reports of professional athletes (autopsy-based reports of chronic traumatic encephalopathy in former NFL players, for instance) to more systematic research on brain changes in athletes–both those who’ve sustained symptomatic concussions, and  those who incur repeated thumps to the head or other stresses to the brain.

Ms. Galliher is closely watching such research. “As recently as 3-4 years ago, the school of thought was that if you allowed for sufficient recovery, you wouldn’t be at any greater risk for a subsequent concussion,” she said. “But now, regardless of recovery time, we’re starting to see a potential impact of consecutive concussions–on seizure-like activity, for instance, and on [Alzheimer's-like neurodegenerative] changes.”

It is conceivable, said she and Mr. Horn, that in the future, science may identify particular thresholds that will lead to changes in practice parameters–like limits in the number of headers a soccer player should incur during practices.  For now, the goals of promoting safe play, ensuring early detection, and facilitating complete recovery are key for FCCPS.

“You can’t cast your brain like you can a broken leg, but you can minimize stimulation and let it rest….You have one opportunity to manage it correctly,” Ms. Galliher said.

NOTE:  Coach Galliher will lead a presentation and discussion of concussions and their impact on February 22nd at 7 p.m. in the GMHS Cafeteria. The program, “The Anatomy of an Adolescent Concussion: It’s Not Child’s Play,” is co-sponsored by the FCCPS Student Health Advisory Board and the George Mason Athletic Boosters.

May 25, 2010

Fairfax County Health Department officials have been working over the past several weeks to prevent the spread of pertussis in Mary Ellen Henderson Middle School, urging parents to keep children with symptoms at home until seen by a doctor and encouraging preventive medication in some children deemed to have had close contact with an infected student.

Pertussis, or whooping cough, is a bacterial, communicable illness that can be especially serious for infants and young children who have not yet completed the primary series of DTaP vaccine that protects against infection.

It is a reportable illness (physician and hospitals are required to report diagnosed cases) that, at least in Fairfax County, uniformly generates a public health response.  And paradoxically, it’s a vaccine-preventable illness whose rates have been rising since the 1980s rather than falling.

And then there’s the fact that pinpointing suspect cases among  children who are coughing from allergies, asthma, colds, and other infections is no easy feat.

As my 11-year-old daughter said recently, “everyone is coughing!”

Her class—the 5^th-grade—has borne the brunt of this episode.  The medical community has learned over the years that the immunity created through vaccination wanes over time—and for the past 4 years, students have been required by state law to have a booster dose of pertussis vaccine to enter 6^th grade.

For at least some families, getting the booster is still on the ‘to-do’ list—and consequently, the 5^th grade overall is the most susceptible to waning immunity and the spread of infection.

“We used to see kids in the 6^th and 7^th grade getting pertussis, but now we’re seeing less of that,” said Fairfax County Health Department’s Dr. Peter Troell in an interview last week. “Now we see cases still among the 5^th graders, and among some of the older high school kids who didn’t have to meet a [6^th-grade booster] requirement.”

It’s “not uncommon” for the health department to investigate cases of pertussis in schools, said Dr. Troell, medical epidemiologist for the health department.  “Generally, when we see pertussis, we see 1, 2 or 3 cases [in any school].”

Pertussis in adolescents and other individuals who were vaccinated earlier in life often is mild, and according to Dr. Amin Barakat of Northern Virginia Pediatric Associates, may even go “unrecognized” in mild cases.

Often, Dr. Troell explained, “those who are vaccinated have only a little bit of feeling bad before the cough onset, maybe a bit of a runny nose, and then go into a cough that’s milder than what’s described for the classic case of pertussis.”

It can be difficult sometimes to distinguish pertussis from, say, allergies that aren’t well treated, but generally the cough associated with pertussis is more persistent, he said.

Classic pertussis is characterized by a period of cold-like symptoms that progresses to bursts or spasms of severe coughing and characteristic whooping that can be severe enough to induce vomiting. Before killed whole-cell pertussis vaccine was introduced in the 1940s, whooping cough was a major cause of infant death worldwide. (The safety of whole-cell pertussis vaccines prompted development of the acellular vaccines used today.)

Today, there are still reports of major complications—from hypoxia and pneumonia to encephalopathy and death–among children who are unvaccinated or too young to be vaccinated. Vaccination and preventing spread through communities are thus key public health goals.

MEH Principal Dr. Ann McCarty informed MEH parents in mid-April about a case of pertussis and asked that children with persistent cough see their physician and, if pertussis is confirmed or suspected, stay home until 5 days of an antibiotic regimen is completed. This month, parents of children who were deemed through “contact tracing” to have had close contact with an infected student were asked by the FCHD to “see a physician for preventive medication.”

(In this case, prophylaxis is identical to the treatment—the same antibiotic regimens. Though not without any controversy, judicious use of antibiotic prophylaxis for household and close contacts is a common public health recommendation.)

The most accurate test for pertussis involves a nasophayngeal swab, Dr. Barakat says. Results can be ready in 48-72 hours.

The increase in pertussis since 1980 has disproportionately affected adolescents and adults, and for several years now the Centers for Disease Control and Prevention has recommended “catch-up” use of a pertussis-containing booster vaccine in adolescents who did not receive a booster at 11-12 years old. Adults younger than 65 who haven’t had pertussis-containing vaccine as an adult can also substitute one of their tetanus-diphtheria boosters with  a Tdap vaccine.

Such advice holds weight for me: A friend of mine had pertussis last summer and it wasn’t easy. Before being diagnosed and treated, she had a difficult time with posttussive vomiting. According to an infectious disease report I recently read, numerous studies have suggested that pertussis comprises 20-30% of all cases of persistent cough among adults lasting two weeks or longer.

Interestingly, though, pertussis is no longer contagious after a person has been coughing for more than 21 days, Dr. Troell said.

And certainly, there are many questions still challenging physicians and researchers—about pertussis pathogenesis and immunity in adolescents and adults, for instance, as well as how to best prevent and control outbreaks.

By CHRISTINE KILGORE AND MINA NOWROOZI
Special to the Falls Church Times

This past soccer season was a season unlike any other for a group of Falls Church-area girls—one in which teamwork took on almost unimaginable meaning.

The girls of Premier AC’s 97 Fusion, a U-12 travel soccer team, not only played soccer — they spent hours each week after soccer practices learning the “Diski” dance — a special dance created for the FIFA 2010 World Cup to be held this summer in South Africa. The dance captures both the culture of South Africa and the moves and rhythm of the game.

Their filmed interpretation of the “Diski” won them 1^st place in a Diski Dancing video competition sponsored by South African Tourism –and an 8-day tour of the World Cup’s host nation. The 14 girls will take their trip in late March.

“At the beginning I thought, ‘we won’t win,’ said 11-year-old Rebecca Davis of Falls Church City. The dance moves also “seemed a bit odd at first,” she said. “But as we practiced we got to the point we could even do it without the music.”

When she learned through a text message that her team had won, she screamed. “I then called a teammate,” Davis recalled, “and my teammate was so happy she started crying.”

Stacey King, the team’s coach, learned of the competition in mid-October while perusing the U.S. Youth Soccer Association web site. The contest criteria (to submit about one minute of video, for instance, and to use a specific soundtrack) were simple, and the challenge of working creatively with the dance’s five main moves was enticing.

King’s mind raced.  She envisioned ways of tying together the dance moves to simulate the flow of an international soccer game.  She solicited initial reaction from the girls and their families by email, and then called the team to the Falls Church Community Center to present her ideas in detail.

Together, she and the girls and their parents watched a brief South African video demonstration of the Diski’s five main dance moves, and discussed the hours of teamwork and energy that would be required if they were to stand a chance of winning the competition.

The girls and their families promised their commitment and gave King input about moves and scenes to include and not include in the video.

From then on, through early December, the team practiced for two hours every week, immediately after their team training sessions.  They also practiced for several hours between the games of a fall tournament, in a nearby gym that a parent had arranged to use.

And when it came time to film, they met four times in various locations, including during the snowfall on December 5 and in Washington, D.C., in front of the Lincoln Memorial and in the shadows of the Washington Monument.

“Everybody made it work,” said King. “The parents helped with arranging locations to practice, with filming and editing and other ideas, and with grabbing coats and supplies, and the girls never complained — they were always excited.

“It was a complete and total team effort,” she said.

Evelyn Loeb, Rebecca’s mother and the parent manager of the team, said the girls were so committed to the project that when King came down with the flu before one of the last scheduled soccer/Diski dance practices, “the girls carried it through on their own, directing and going through everything themselves.”

The team’s goal, said King, was for the progression of scenes in the video to represent “the flow and feel” of an international soccer game.

“And I wanted to make sure we represented the feel and culture of South Africa as best we could,” she said.

Viewers hear the South African national anthem at the beginning and see a team photo mimicking the typical “starting 11” photo taken at major games as well as a kick-off.  One scene simulates the often underappreciated role of the goalkeeper, King notes, and almost everything in the dance is done as if each girl has or is about to make contact with a ball.

The video includes a photo of a red “vuvuzela,” a stadium horn commonly blown by fans at South African matches, and shots of the girls sporting the colors of the South African national team (as well as the pattern of the South African flag on their faces).

Almost all of the girls on ’97 Fusion have played together under King’s direction for 2 ½ years.  In addition to Davis, three of the players — Clara Frost, Ella Howard and Annie Washa — are students at Mary Ellen Henderson Middle School in Falls Church City. The other girls attend schools in the greater Falls Church area and nearby areas.

“We’re all from different schools, so [by spending all the extra time together] we all felt so close,” said Caroline Stricker, an 11-year-old Falls Church City resident.

Stricker said she’s looking forward to going on the safari that is part of their South African itinerary, as well as trying new foods and seeing other sights.

She and her teammates, who have continued to meet for indoor training this winter, are learning about South Africa by studying different topics each week, from South Africa’s geography and ethnic makeup to its political history and variety of languages.  They are also working on collecting soccer supplies to distribute to young players who need them.

The girls will visit Cape Town and Johannesburg (including Soweto township, where they will visit a school), and will play a game against a South African youth soccer team. As part of their prize, each girl will be accompanied by one parent.  In several cases, King said, entire families have decided to come along.

South African Tourism partnered for the competition with the U.S. Youth Soccer Association, South African Airways, and Coca-Cola, a World Cup sponsor. The competition garnered entries from all over the United States.

Perhaps ironically for the winning girls, the nickname of the South African national soccer team —“Bafana, Bafana,” which the girls printed on their shirt backs for filming — means “the boys, the boys.”

Indeed, the FIFA 2010 World Cup features only men’s soccer. But the world’s best female soccer players will soon shine in the 6th Women’s World Cup to be played in 2011 in Germany. And in the meantime, the girls of 97 Fusion will travel to South Africa with exposure to and experience in soccer that not too long ago was hard to come by for girls.

Watch the winning video! It is wonderful!

The spread of novel H1N1 influenza appears to have increased significantly in Falls Church City in the past two weeks, just as the vaccine has begun trickling into local providers’ offices.

“With the number of children in our neighborhood coming down sick this past week, it now definitely feels like a race to either get sick or get the vaccination, and I’d rather have my children get the vaccination,” said Falls Church City resident Jackie Handly.

For the past several weeks, this Falls Church City mother of two has called her family’s physicians and searched the Internet almost daily looking for clinics—in or out of Fairfax County–that could provide her healthy 8- and 10-year olds with vaccine. It looks as if it may be a while.

Statewide, vaccine supply was down 47% last week compared to original projections, and physicians have been alerted by the state health department to expect continued delays. (The Centers for Disease Control allots the vaccine to each state based on state population; Virginia receives 2.517% of every allotment, according to the state health department.)

On Friday, Oct. 30, Fairfax County announced a second week of limited vaccine dispensing at its five health department clinics, including the Falls Church Clinic located on Leesburg Pike in the Seven Corners area (www.fairfaxcounty.gov/flu). The vaccines will be offered on a walk-in basis this Wednesday and Thursday, Nov. 4-5, to the first 300 individuals who are in one of the following high-risk groups: children 6 months through 6 years of age, pregnant women, and parents of children less than 6 months of age.

While still far from covering all priority groups—including all children and young adults 24 years of age and under—the county is gradually inching up its eligible age group since holding its first mass vaccination clinic at the Fairfax County Government Center on Saturday Oct. 24. (This clinic took the place, due to unexpected vaccine shortages, of the school-based vaccination clinics that had been planned for a host of Fairfax County middle schools.)

Approximately 4,300 pregnant women and children aged 6-36 months received the vaccine at this first mass vaccination clinic. Since then, in clinics held at each of the five district health offices this past week, over 6,250 individuals (including children up to age 5) were vaccinated, according to Glen Barbour, information officer for the Fairfax County Health Department, which serves Falls Church City.

Others have just recently found the vaccine in physicians’ offices. In communication sent to physicians and other providers on Friday, Oct. 30, Dr. Karen Remley, the state health commissioner, said that as of last week, novel H1N1 vaccine had been sent to every provider in the state registered to dispense the vaccine.

Local providers who spoke with the Falls Church Times said they have received only a fraction of the vaccine doses they requested and consequently have needed to narrow down the CDC target groups in deciding whom to offer vaccine to.

As of Oct. 31, most local primary care providers did not appear to be posting notices on their websites regarding vaccine availability or otherwise advertising availability, but rather contacting patients who have the highest risk of developing complications from novel H1N1 influenza. Several parents of children in Falls Church City who have high-risk conditions such as asthma and diabetes said their children have received the vaccine from their regular physicians.

Accounts and personal anecdotes of high levels of school absenteeism and full school clinics abound among families and students in the City. Local family physician Dr. Gordon Theisz, who estimates that his visits for influenza-like illness have at least doubled in the past few weeks, observed last week that novel H1N1 infection “seems to really be hitting the schools now.”

Late last week, the FCCPS communications office referred questions about absence rates and influenza flu-like illness in the schools to the Fairfax County health department.  Fairfax County spokesman Barbour said on Friday that the current absenteeism rate is about 6-7% in Fairfax County– up from about 3% at the beginning of October—and that the absenteeism rate in FCCPS  was mirroring this rate. “The number is no greater (in Falls Church City) than in Fairfax County schools and other school systems,” he said.

State-level data show that up to 14% of all emergency department visits and urgent care visits are for influenza-like illness—double what has been reported in the last two seasonal flu seasons. “The majority of them are children and young people,” Dr. Gloria Addo-Ayensu, Fairfax County’s health director, told the Falls Church Times late last week.

Novel H1N1 influenza is continuing to “behave very much like seasonal flu, where you have a spectrum of illness, from mild and moderate illness to very severe illness with hospitalizations and death,” Dr. Addo-Ayensu said. “What’s different is who’s getting ill and who’s getting severely ill.”

Many cases of H1N1 influenza can be treated at home, but individuals with conditions that put them at increased risk for complications—such as asthma, diabetes, pregnancy, morbid obesity, and neuromuscular conditions—should seek medical care promptly for flu symptoms, she said.

Falls Church City resident Melisa Atkeson did not hesitate to bring her 5-year-old son Ben to see the doctor when he “went from being not ill at all to being very ill” in little over 24 hours.

Ben came home from school one recent Thursday saying “he’d coughed so hard it hurt in his stomach,” she recalled. His fever went from 100-101 degrees in the late afternoon to 103 degrees at night, and by the next morning “he was really sick.” Ben has a history of asthma and respiratory issues, Atkeson said, “so we felt he really needed to be seen.”

“We started Tamiflu on Friday afternoon,” she recalled, “and by Saturday he was significantly better. By Sunday, you would not have known he’d been sick.”

“Even without Ben having had the respiratory issues, though, I think I would have still taken him to the doctor. I don’t tend to over-react, but this has worried me a lot more than other things,” said Atkeson.

Dr. Theisz said he reminds his patients that “when respiratory symptoms happen, they happen fast. Shortness of breath, chest tightness, any difficulty breathing—these are signs that patients should be seen.” He also explains to patients that the CDC is urging health care providers to save Tamiflu—the anti-viral drug most commonly prescribed for influenza—for patients at high risk for complications.

The unexpected delays in vaccine production have made vaccine distribution in the public health sector especially tricky, said Dr. Addo-Ayensu.  Planning vaccine clinics “has been challenging, to say the least, because our immediate goal is to vaccine the priority groups who are at high risk of complications while not over-promising the vaccine and inviting a whole lot of people only to have them disappointed and angry that they came and waited for hours.”

“It’s like the difference between going to the airport and the flight being overbooked by two people versus it being overbooked by 100 people,” she said. “If it’s 100 people, you can’t help but ask, what were you thinking?”

In addition to the Fairfax County Health Department website, the state’s website, www.vdh.state.va.us , as well as its telephone hotline, 1-877-ASK-VDH3, are good resources for questions about vaccine availability and other H1N1 issues.

Please share any experiences with novel H1N1 influenza by posting a comment, or e-mail Christine Kilgore at contact@fallschurchtimes.com with any questions/issues you’d like to see addressed in future stories.

VACCINE SHORTAGE: School H1N1 Clinics Cancelled — But Limited Doses Offered Saturday

The Fairfax County Health Department is planning to hold its first school-based H1N1 vaccination clinics on Saturday October 24 and Sunday October 25 at a host of Fairfax County middle schools, a public health official has announced.

“Our first priority is to the schools and to the kids,” said Glen Barbour, public safety information officer for the Fairfax County Health Department, which serves Falls Church City as well as the county.

The planned clinics are aimed primarily at children who attend public and private schools in the area, including the Falls Church City public schools, as well as home-schooled children.

Vaccination planning is fluid, and final details are contingent on how much vaccine the county receives each week. Depending on vaccine availability, it is possible that children who are not yet school-aged may be eligible to receive a vaccine at the school-based clinics. “That’s the hope,” Mr. Barbour said. On the other hand, if vaccine supplies are not large enough, there could be age restrictions even within the school-age range, he said.

The mass vaccination clinics are being planned for 9 middle schools for October 24 and 25: Franklin, Frost, Glasgow, Hughes, Key, Kilmer, Liberty, Longfellow, and Sandburg.

It is possible, based on vaccine supply in the next few weeks, that the County will add additional school-based mass vaccination clinics, Mr. Barbour explained. If the number of school-based clinics increases enough, then George Mason High School could be involved as a vaccine-dispensing site.

Fairfax County received its first vaccine shipment from the state this week, and is distributing the 1,900 doses largely to healthy, non-pregnant front-line health care workers and emergency services personnel.

[The vaccine received thus far is in the form of the live attenuated intranasal vaccine (the nasal spray), which is recommended only for individuals ages 2-49 who are not pregnant or do not have high-risk conditions or an immunocompromised state.]

At an informational session on H1N1 that was broadcast live on FCC-TV last week, Fairfax County Health Director Dr. Gloria Addo-Ayensu explained that health department officials have been discussing three possible tiers of school-based vaccine dispensing, with the top tier involving 25 schools and requiring the most available vaccine. In a sign of the fluidity involved in such a large public health effort, Mr. Barbour said on Thursday that the current plan involves 9 schools.

The county expects a “soft roll out” of weekly vaccine shipments initially that should progress quickly to a “steady flow” by mid-October, Dr. Addo-Ayensu said. Future shipments are expected to include inactivated vaccine (“flu shot”).

At a town hall meeting several weeks ago, Dr. Addo-Ayensu said that school-based vaccination clinics were part of a “plan B” vaccination effort that would be implemented if an insufficient number of physician offices and other traditional vaccine providers had not registered with the state health department to receive and administer novel H1N1 vaccine.

At this point in time, however, the community of traditional vaccine providers is still in flux, with some providers still registering with the state and others still waiting to receive final approval. Several local physicians in Falls Church City who spoke with the Falls Church Times said their practices were registered as vaccination dispensing sites and are ready to administer vaccine once they receive their first doses.

With respect to the school-based clinics, “our hope is still that people will contact their providers first,” Mr. Barbour said.

It is now clear that children aged 10 and older need only 1 dose of the FDA-approved H1N1 vaccine, the CDC says. Children aged 6 months to 9 years of age should receive 2 doses of H1N1 vaccine several weeks apart.

Dr. Addo-Ayensu shared another bit of good news at the session on Monday—the finding that “circulating H1N1 isolates are similar to the reference virus selected for vaccine production,” which means the vaccine should be highly effective in protecting its recipients, she said.

At this meeting on Monday, Dr. Addo-Ayensu was asked whether one should still get the vaccine if he or she has already been ill with novel H1N1 influenza. This depends, she answered, on whether the diagnosis of H1N1 infection was actually “a lab-confirmed diagnosis.”

If not, “then yes, you should still get the vaccine when it becomes available… because you can’t be sure (you’ve had H1N1 infection),” she said. This will often be the case, since physicians are confirming H1N1 influenza cases through testing only in patients who are severely ill.

Getting the vaccine after having already had H1N1 infection would not be harmful, and the risks of going unprotected if prior illness was not actually caused by H1N1 infection can be significant, she said.

Dr. Amin Barakat of Northern Virginia Pediatric Associates said he tells his patients that “it’s critical to be prepared through vaccination, especially since it’s a new virus—we don’t know how it will behave and change in the future.”

The CDC is currently instructing vaccine providers to focus on the key populations that have been most impacted the H1N1 influenza pandemic thus far:

• Pregnant women
• People who live with or care for children younger than 6 months of age
• Health care and emergency medical services personnel
• Individuals aged 6 months-24 years
• People aged 25-64 who have chronic health disorders or compromised immune systems.

“We’re seeing a lot of fevers and a lot of flu-like illness due to a non-specific virus that [appears to be] H1N1 infection,” said Dr. Amin Barakat, of the 8-pediatrician practice in the heart of Falls Church City.

Physicians and health officials are not confirming H1N1 influenza cases through testing unless a patient has to be hospitalized or is severely ill. But because almost all of the subtyped influenza A viruses reported to the Centers for Disease Control and Prevention have been H1N1 viruses (99% at the latest count), the presumption is that any flu-like illness is probably novel H1N1 influenza.

Falls Church City public schools are armed to keep transmission as low as possible with surgical masks on hand and instructions to isolate and send home any children or staff members who exhibit flu-like symptoms.

So far, such measures combined with increased attention to hand washing and “respiratory etiquette” among students—and instructions to stay home for at least 24 hours after fever has disappeared without the use of Tylenol and other fever-reducing medicines–may be paying off, at least for students in the FCCPS system, said Karen Acar, the FCCPS communications director.

“We haven’t seen a higher-than-normal absence rate (for this time of year) as a result of flu-like illness thus far,” she earlier this week. “We’re not seeing the kinds of outbreaks that other areas have seen.”

Under the guidance of the Fairfax County Health Department, schools routinely employ various surveillance measures to monitor absences and detect outbreaks of illness. But with the H1N1 pandemic underway, school clinic nurses and staff members who answer absentee calls have stepped up efforts to inquire about and record symptoms.

Dr. Gloria Addo-Ayensu, Fairfax County’s health director, told the Falls Church Times on Monday that hospitals in the county are “seeing more influenza-like illness” but are not overwhelmed as has been reported in other regions.

Virginia is 1 of 37 states, according to the CDC, that are reporting widespread flu activity. Thus far, H1N1 influenza has been no different in terms of severity from what was experienced in the spring and from what is normally seen with seasonal influenza. It differs from seasonal influenza, however, in that it disproportionately affects children, teens, and young adults.

The vast majority of novel H1N1 flu cases nationally and in Falls Church City have been mild, according to the CDC and local physicians.

There have been a number of deaths reported nationally, however, in children and young adults who reportedly were otherwise healthy. According to the CDC, 76 pediatric deaths related to H1N1 have been reported since April, 16 of them within the last week. (An additional 3 pediatric deaths are likely to be confirmed as H1N1-related, the CDC said Friday). Twenty-eight pregnant women also have died.

Local physicians stressed that they do not want residents to panic—just to be prepared and vigilant about staying home when sick and to receive H1N1 vaccine as soon as it becomes available.

Dr. Barakat said his patients with likely H1N1 influenza have had illness that has been “short-lived with no major complications like pneumonia.” Most children with flu-like illness, he said, have been staying home from school and other activities for 2-3 days.

Dr. Gordon Theisz, of Family Medicine in Falls Church, said he sees about 2-3 cases of influenza-like illness each day, which is similar to his experience this summer. “Some cases are bad, where people are quite ill, and some are milder,” he said. “My anecdotal observation is that my sickest patients have been between 15 and 25.”

Influenza is characterized by a fever (over 100 degrees Fahrenheit) plus cough and/or sore throat. Other symptoms include headache, muscle aches, extreme weakness, tiredness, diarrhea, and vomiting.

As Dr. Theisz stresses to his patients, influenza can cause any combination of these symptoms. In his practice, the vast majority of patients with influenza-like illness have reported having a sore throat at the start of their illness, he noted.

Cold viruses, on the other hand, are more likely to cause a runny or stuffy nose and rarely cause fever. Dr. Allison Bae, a family physician at Associates in Medicine in Falls Church City, said that at this point in time, “if a fever is over 101 or 102, it’s likely influenza.”

Individuals who have mild symptoms do not need medical attention, local physicians stress. However, those who are in high-risk categories—who are more likely to become severely ill or experience complications—should contact their physician at the first sign of flu-like illness.

High-risk groups include women who are pregnant and people with chronic conditions such as asthma, diabetes, chronic obstructive pulmonary disease, heart disease, and morbid obesity.

According to CDC data that Dr. Addo-Ayensu has routinely shared during her town hall meetings on H1N1, 32% of the individuals throughout the U.S. who were hospitalized through mid-June with H1N1 infection were asthmatics, for instance, even though only 8% of the population has asthma. Approximately 6% were pregnant women, even though only about 1% of the population is pregnant at any time.

Flynn Millard, a family nurse practitioner with the obstetrics and gynecology practice of Reiter, Hill, Johnson, and Nevin, which has an office in Falls Church City, said that she and her colleagues are seeing some influenza-like illness in their practice and are “right on board” with the CDC recommendations to empirically treat pregnant women who have flu-like symptoms with Tamiflu.

Just as with seasonal flu, complications can occur with novel H1N1 flu even in individuals who are not in high-risk groups. The American Academy of Pediatrics recommends that parents seek medical care if their child experiences fast breathing or trouble breathing, bluish or gray skin color, severe or persistent vomiting, or extreme irritability.

Children who are not drinking enough fluids, not urinating as much as usual, or not waking up or interacting should also be seen. So should children who have a fever following by a sudden mental or behavioral change, and children who have a significant change in fever pattern. Fever returning after being absent for a day is a warning sign.

For adults, warning signs include difficulty breathing or shortness of breath, sudden dizziness, confusion, severe or persistent vomiting, pain or pressure in the chest or abdomen, and flu-like symptoms that improve but then come back with a worsening fever or cough.

The local physicians who spoke with the Falls Church Times said they’re all following the advice of the CDC to dispense anti-viral medications to high-risk patients only. “Otherwise, there’s the possibility of shortage,” said Dr. Bae.

While the drugs must be taken early in the course of illness to be most effective, they are not indicated for preventive use, she and others stress. Preventive use appears to have been responsible for several cases of drug-resistant H1N1 influenza reported to the CDC.

Instructions to stay home for at least 24 hours after the end of fever stem from the fact that infected people are most contagious when they are febrile, Dr. Addo-Ayensu said during a town hall meeting in Falls Church City that was broadcast live on FCC-TV on October 5. (The program will be rebroadcast at various times through throughout the fall on FCC-TV, which is carried on Cox 12, RCN 2, and Verizon 35.)

It is still possible to shed virus even when one is fever-free, however, Dr. Addo-Ayensu said in an earlier town hall meeting.

Some infected children, as well as infected adults who have weakened immune systems, could possibly spread the virus for more than a week.

If outbreaks occur or severity of illness changes—which is still possible given the unpredictable nature of viruses and their tendency to change and swap genetic material—the Fairfax County Health Department may change its recommendations to schools, Dr. Addo-Ayensu said.

New strategies could include instructing high-risk students and staff members to stay home, requiring ill children to stay home for longer periods of time, active screening for influenza symptoms, and various levels of school dismissals, she said.

A study published in the October 1 electronic version of the Journal of the American Medical Association suggests that surgical masks are almost as effective for influenza protection as the fit-tested N95 respirators used by health care workers.

The study of several hundred nurses in Ontario hospitals caught Dr. Barakat’s eye. “Now I’ll say yes when people ask me” about using surgical masks if they have a long flight or if there’s an infected individual at home, he said.

Still, physicians stress, there is nothing as effective for influenza prevention as regular and thorough hand-washing—for 20 seconds with soap and water whenever possible. “Your Health is in Your Hands,” in fact, is the new slogan of the Fairfax County Health Department.

For more information on H1N1 influenza, including a self-care guide, see http://www.fairfaxcounty.gov/hd/flu/swineflu.htm.