thanks to Virginia Lee Adi ( http://www.************/profile.php?id=1016067473 ) for this gift of herbal tea to help heal my broken rib: taste is leafy, love the red color, not bitter, almost sweet. Virginia knows her herbs! Thanks for the book!

Fall is here, school is back in session, and once again it’s time to gear up for flu season. This year will have special challenges, as we are preparing for both seasonal flu and H1N1 (swine) flu.

[ [ [ [  MedHelp Note -- Dr. Choi is hosting a live HealthChat on Tuesday, October 20 at Noon EST! You can register here and ask questions LIVE: http://www.medhelp.org/health_chats/register/34  ] ] ] ]

The pandemic H1N1 flu (aka “swine flu”) began in April, and circulated in daycares, schools and camps over the summer but dropped off until very recently increasing to widespread levels again in many states. Virtually all the flu around now is the pandemic H1N1 virus. The H1N1 virus also predominated in the recent winter months of the Southern Hemisphere, which typically spreads north as we have our winter. There is concern that we are now experiencing a second wave of H1N1 this fall with the return of children to school.

You may have H1N1 if you have fever (temperature > 100 degrees) AND either cough or sore throat.  Fever is present in 94% of cases, cough in 92%.  Other possible symptoms include chills, runny nose, headache, muscle ache, and in less folks, nausea, vomiting and diarrhea.  Seventy percent of hospitalized cases have high risk conditions (including pregnancy), but 30% are apparently healthy young persons, so everyone needs to be careful to practice respiratory infection control.

Pandemic H1N1 flu affects the young with 5% occurring in persons older than age 50. It's mostly affecting children 5-14 years, but children 0-4 years are most frequently hospitalized (MMWR, 8/28/09). Those at higher risk include children with neuro-developmental disorders (e.g. cerebral palsy, developmental delay, MMWR, 9/4/09) and pregnant women who are four times more likely to be hospitalized for H1N1 infection (Lancet, 8/8/09). Those with asthma/COPD (emphesema/chronic bronchitis), diabetes, immuno-suppression (e.g. chronic steroids, chemotherapy or transplant patients), cardiac disease, pulmonary disease, renal failure, and chronic liver disease have increased risk. Obesity may be a separate risk factor. Persons > 60 may have some immunity to the H1N1 virus if they were exposed to H1N1 in 1976 or earlier outbreaks.

Since essentially all flu currently circulating is still pandemic H1N1, lab testing is not helpful at this time. If you get pneumonia after an ILI (Influenza-like-illness) or those with risk factors you may ask your doctor to test you and treat you with Tamiflu. Testing options for include the rapid influenza test (only 40-70% able to rule it out) or the H1N1 PCR test (more accurate in ruling it in). It is not useful to test if you've gotten over influenza or for screening for influenza for camp, vacation, school, or work to see if it's safe to go back. You could ask your doctor for a chest x-ray (CXR) if you have a ILI  (Influenza-like-illness) with shortness of breath, abnormal vital signs other than fever, or a pulse oximetry of 95 or lower on room air. This is especially so for those with risk factors.

Patients with ILI (Influenza-like-illness) AND risk factors AND no reason to have a fever from illness outside the respiratory tract may benefit from Tamiflu.  This is only useful when started within 72 hours of starting symptoms Since the vast majority of patients without risk factors recover fully, they don't typically benefit from Tamiflu. If you get pneumonia (seen on a CXR) soon after an ILI, consider asking your doctor for both antibiotics AND Tamiflu even if it's more than 72 hours after your symptoms started.  This is more helpful for those who are more sick.  Some very sick pregnant women with H1N1 and pneumonia have benefited from Tamiflu even starting a week after symptoms started.

Tamiflu is not recommended for prophylaxis-- to prevent getting H1N1. It is most appropriate for persons who have high risk conditions (e.g. pregnancy) and who are household contacts of suspected or confirmed H1N1 patients. There are a few reports of Tamiflu-resistant pandemic H1N1 viruses. With one exception, it has occurred in persons receiving Tamiflu for treatment or prophylaxis, a compelling case to limit unnecessary use.  Studies of anti-vira drugs (Tamiflu and Relenza with limited data sets) show no evidence of toxicity to either pregnant or breast-feeding moms (CMAJ 7/7/09). Because of the potential danger of H1N1 in pregnancy, CDC strongly recommends treatment of pregnant women with an ILI.

Folks with with ILI should stay home and isolate themselves as much as possible. In addition, they should consider these measures: surgical masks for patient and caregivers, gloves for caregivers, separate room for patient, keeping high risk persons out of the house, frequent hand-washing with hand sanitizer or soap and water.

Folks with fever plus cough, sore throat, or nasal congestion suggestive of influenza-like illness (ILI) should consider using surgical mask to prevent large respiratory particles from spreading to others and surfaces other folks touch.  Although N-95 masks plus gloves are recommended for health care workers, they have not been recommended for the general public.  They require careful fit testing to be effective (they spray a bitter tasting mist inside a plastic cone around your head-- if you taste it there isn't an effective seal with the mask).

Frequent hand washing is helpful, and when not available, alcohol hand rubs are very effective.  After many applications of the hand rub, a residue builds up that must be washed off to continue effectiveness of further applications.  Contaminated surfaces and door knobs can be wiped down with a virucidal product such as CavicideTM or Caviwipes XLTM or other cleansers.  

The new CDC recommendation for most persons states a person can end self-isolation at home when they are free of fever > 24 hours (when not taking anti-pyretics such as acetaminophen or ibuprofen). For health care providers and day care workers the old rule still applies: seven days after onset of illness or 24 hours after symptoms are gone, whichever is longer (resolution of symptoms means fever is gone and coughing much less). This gives a good idea of when to return to work, school, and lab testing is not necessary.

The seasonal flu vaccine is now available. This is the usual vaccine that protects against the three flu strains that have circulated in various forms over the last 30 years. The H1N1 vaccine may be available in late October.  Priority groups for the first round of H1N1 vaccination will probably include persons 6 months - 24 years, household contacts of infants < 6 months, pregnant women, persons 25-64 years with chronic medical conditions, and health care workers and first responders.

More details at: http://www.cdc.gov/h1n1flu/

Feel free to ask more questions in my upcoming Web Chat at 9am PST on 10/20/09. You can register at http://www.medhelp.org/health_chats/register/34.

Join me on a free Health Chat to discuss swine flu on Wednesday April 29th at 1PM EST. To register, go to: http://www.medhelp.org/health_chats/register/17

Due to the swine flu, the US has declared a public health emergency.  

We're early in the outbreak of this new virus, with most all patients in the US having mild illness who have recovered without treatment.  Only 1 of the 20 cases have been hospitalized.  Since the US strain is a genetic match to the Mexico strain, officials are concerned about the potential of deaths in America from swine flu.  In Mexico there have been many deaths from pneumonia that sounds like ARDS to me.

You can protect yourself by avoiding those who cough, ask those who do to cover their cough (not with their hands, eg. with a mask), practice good hygiene with hand washing and don't touch your own eyes, nose and mouth.

What's important is that if in the last week you have been to Mexico, San Diego, Imperial County or Texas, and come back with a flu like illness with fever, sore throat, cough, runny nose, and possibly vomiting and diarrhea, call your doctor.  You may benefit from Tamiflu or Relenza pills.  What your doctor will do is test you for flu and if you have an untypeable flu (one that we doesn't match those we've seen before) it could be swine flu.

I've been following the CDC on twitter at http://www.twitter.com/CDCemergency and at http://www.cdc.gov/swineflu/ which CDC has promised to update at 3pm EST daily.

To be prepared, make a plan for your family to consider how you would manage if your community was disrupted for 2 weeks:
- do you have food & water stored?
- if you have chronic illness, do you have enough for 2 weeks?
- how would you manage your children if they couldn't go to school for 2 weeks?
- do you have a communications plan with your family?  e.g. where to meet in case of disaster.

The American Public Health Assn has a great site at http://www.getreadyforflu.org/ with these and other good suggestions.

Expect daily changes, as this epidemic spreads, so far, touching San Diego, Imperial County, Texas (san antonio), Iowa, Ohio, New York (Queens), and many other countries.  It's scary, but you can get prepared!

Enoch Choi, MD

For more read my last post, "is this a cold or something more serious?" http://www.medhelp.org/user_journals/show/70703

On Tuesday Mar 17, 2009, 03:00PM (EST) I'll be on a webchat answering questions about colds and flu:

http://www.medhelp.org/health_chats/register/2

Can you tell the difference between the common cold and the flu? How about bacterial infections such as bronchitis or pneumonia? According to the CDC, flu activity is just starting to pick up in the U.S. and could continue into April or May. As an Urgent Care physician at Palo Alto Medical Foundation, I see dozens of these viral and bacterial illnesses every day and I'll be available to answer your questions live at March 17, 2009 3:00PM EST. Join me to learn about the flu vaccine, antivirals, antibiotics, and alternative preventative measures such as humidifiers, saline drops and sprays, herbal supplements, and honey and find out whether these treatments are suitable for children, the elderly and other high-risk groups.

This has been an unusual year in that the flu has been picking up in the last few weeks, and will last into early summer.  The symptoms of influenza include cough, sore throat, runny or stuffy nose, and fever. Other common symptoms are chills, headache, muscle aches, fatigue (a tired feeling), and loss of appetite.   Fortunately, this year, there's plenty of vaccine and you'll have protection as soon as a week after getting your shot.  They flu shot covers the flu virus strain very well this year.  The shot is a better choice, since it's been hard to find Relenza, the antiviral medication that this year's strain is sensitive to.  Tamiflu has been so overused that this year's flu strain is resistant to it - meaning it won't help you if you took it.  This is important because in a minority of cases, the flu can lead to death from complications of pneumonia.

The common cold has less severe symptoms than the flu.  It's more likely to have the the symptoms of cough, sore throat, runny or stuffy nose, and fever without the chills, headache, muscle aches, extreme fatigue (a tired feeling), and loss of appetite.  It gets better with time.

A bacterial infection such as bronchitis, sinusitis, or pneumonia is suspected when you have a persistent fever (>100.4 deg F), and copious pus in your bronchi, sinuses, or lungs, which can be heard by a doctor on examination.  Other signs such as facial pain radiating to your teeth or rapid breathing with shortness of breath can help with diagnosis.

No matter if viral or bacterial, there are over the counter remedies that help: humidifiers, saline drops and sprays, nasal rinses, and herbal remedies.

I'll be happy to chat more about this with you!