Flu Virus Starting to Show in FC and Fairfax

Falls Church City appears to be clear thus far of any significant outbreak of pandemic H1N1 influenza, but if the experience at Northern Virginia Pediatric Associates is any indicator, the virus is circulating at increased levels among young people in the area.

“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.