H1N1: A Novel Flu Affecting Moms and Kids
On March 17, 2009, Mexico confirmed the first case of what the Center for Disease Control and Prevention (CDC) deemed "the novel H1N1 influenza," or what most of the world calls the swine flu. On April 28, as the news media broadcast multiple stories per hour about how the swine flu was in pandemic proportions, Dr. Richard Besser, Acting Director of the CDC, discussed how the H1N1 is a worrisome threat, but that America should not forget that approximately 36,000 people per year die from influenza. The CDC and the World Health Organization (WHO) reported that as of July 24, 2009, the United States had 43,771 confirmed and probable cases and 302 deaths from the novel H1N1 virus.
The threat is real and it is here. Over the past couple months the media hysteria has decreased, yet the threat continues. The CDC continues to monitor this novel H1N1 virus and is helping the health care community to prepare for the possibility of 40 percent of the work force being affected this fall and winter; that situation would be a pandemic.
The CDC and WHO continue to work with researchers from around the globe to determine the medical impact of the virus on specific populations and age groups. One of the more recent recommendations made available is about the impact the H1N1 has on the neurological system of some children. There have been four reported cases of H1N1 being responsible for brain infections, edema, and seizures. The report states that drowsiness, weakness, and disorientation were reported in "some" of the children and two had seizures secondary to the infection. Seasonal influenza is responsible from approximately five percent of the reported cases of encephalitis and six percent of the flu-related deaths during the 2003–2004 flu seasons.
It is unknown what the neurological impact the H1N1 virus will be on children, but for some, seizures and neurological maladies may be part of the child's presenting signs and symptoms. The age groups affected vary greatly. The four children reported were seven, ten, 11, and 17 years of age. Two had previous medical histories including asthma and one had had a fever-related seizure. The other two had unremarkable medical histories and were considered healthy. Neurological complications including changes in mental status and unexplained seizures need to be evaluated immediately and started on antivirals as soon as possible. The prehospital component of this public health issue to assure the patients' ABCs are intact and provide any other treatment(s) as required. In many cases evaluation by their primary care physician may be more than medically appropriate, relieving EMS of the requirement to transport. Some patients will require EMS intervention and should not be assumed to be merely a seasonal running nose and fever. Per the current recommendations from both the CDC and the WHO, any child with influenza or influenza-like symptoms needs to be started on antivirals as soon as possible.
Another population at high risk of demise from the H1N1 is pregnant females and infants. There has been an increase in reported serious cases and a historical perspective that must be taken into account. The flu outbreaks of 1918–1919 and 1957–1958 produced an excessive number of deaths among these two groups. The current outbreak appears to be following the same trend. The number of spontaneous abortions and preterm births has increased over the past few months and it is assumed the H1N1 has a level of responsibility.
Many of the cases are not initially attributed to H1N1, but it has been shown that women with a history of pneumonia are highly susceptible to perinatal complications and death. The most common symptoms are those similar to flu like illness – cough, sore, throat, runny nose, fever, body aches, fatigue, vomiting, and diarrhea. Again, the CDC recommendation is that these women get started on antivirals as quickly as possible. EMS needs to assess in the pertinent medical history phase of their assessment whether or not the woman is taking oseltamivir (Tamiflu®) or zanamivir (Relenza®). Both are safe to take during the pregnancy and while breast feeding. Additionally she may take or be taking acetaminophen as part of the fever control regiment.
The infants of a flu-infected Mom are at high risk of also being infected from exposure to the virus external versus from the breast milk. These little ones are susceptible to complications of the respiratory disorders that alter their ability to breathe and feed. Like RSV and other viruses, the near complete obstruction of the nares can cause the child to deteriorate over a short period of time from inadequate respirations, inadequate nutrition, inadequate hydration, or all three.
The care of the infant may seem counterintuitive as the recommendation is for the breast feeding child to continue being breast feed even if the Mother is symptomatic of the H1N1. Mom must adhere to good hygiene practices, but the antibodies passed through the breast milk are probably of greater benefit than providing formula. If the mom is able to express milk and have a non- infected person feed the infant it might reduce the transmission potential even more. The likelihood of viremia secondary to a breast milk transmission is unknown, but it is rare in seasonal flu so the assumption is made that it is equally as rare with the novel H1N1. Like with older children and mothers who are infected, EMS must stay attentive for the possible deterioration of the infant and provide appropriate supportive care and transport when necessary.
Both the CDC and WHO stress the importance of great hygiene and proper cough etiquette as the primary actions to reduce the transmission of this novel infection. Washing your hands with soap and warm water before and after EVERY patient contact or other physical interaction is critical. Shaking hands with Mom and Dad during your introduction or assessing an ill child and then touching a non-infected person may make you the transmission vector.
Studious attention to hygiene cannot be overstated. Cough and sneeze etiquette are equally important. Covering your mouth and nose when you cough or sneeze is a must, and good hand washing is now mandatory. Anything you touch may be the exposure point for the next victim of the novel H1N1 virus. Cover your mouth and nose with your antecubital fossa. Bend your arm and place your mouth and nose in the bend of your elbow. The area covers the mouth and nares to prevent respiratory droplets or particles from being broadcast and it not a common point of contact to expose others. Good hygiene and etiquette are essential in preventing the spread of this and other infections.
EMS must stay vigilant to assure that complacency does not override quality patient care. With estimates that 40 percent of the American population will be affected and infected by the novel H1N1 flu during the 2009–2010 flu season, EMS will be responding to this crisis. Whether the response is to care for the infants, children, and adults that are symptomatic of the flu or to ensure the public has an appropriate response network, EMS will be an integral link in the public health and public safety of America’s citizens in the coming months. H1N1 may be an unusual form of an old malady or it may be something completely unique. It may also turn out to be a story we can look back on and claim victory because our preparation prevented thousands and maybe millions of illnesses and deaths. In public health preparation and possibilities, EMS is an integral part of the process.Robert (Bob) K. Waddell II has been involved in EMS for over 30 years, working as a volunteer EMT in rural Wyoming, a paramedic in the Front Range of Colorado, state training coordinator for Colorado, and founder of an international health education corporation providing EMS education and consultation for nations across the world. Bob is the secretary/treasurer for NAEMSE, former international chairman for the NAEMT Emergency Pediatric Care (EPC) course, and is vice president in charge of evidence-based disaster triage methodology for ThinkSharp, Inc.
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