There is no “bedside” test for H1N1.

Many of the symptoms of seasonal influenza and H1N1, at the start, look a lot alike. Each tends to begin with the same sorts of respiratory symptoms. Community outbreaks mean doctors’ offices are flooded with calls.

Pregnant Women:

Contradicting what would be standard advice for pregnant women, the CDC recommendation is that pregnant women should report any respiratory symptoms to their doctors and be started on anti-virals immediately based on a small study of pregnant women conducted during the first two months of  THE H1N1 pandemic.

Six of 34 mothers-to-be died.

The pregnant women’s risk of serious disease, complications and death clearly  is higher than expected.  Although prescribing anything “extra”  runs counter to standard OB practice, the experts do seem to be in agreement.

The CDC’s advice to OBs and their patients: Assume pregnant women have H1N1 and start them on anti-virals as quickly as possible, preferably within 24-48 hours of the onset of symptoms.

Patients Who Have Underlying, Serious Disease(s) Present:

There also appears to be agreement that these patients also have higher risks for H1N1 complications. Consult about  the personal risk of the patient and your household before your community has an outbreak of H1N1. Get your doctor’s advice now before the phones start ringing. What should you be ready to do? Example: You have a heart failure patient in your family. Heart failure patients have breathing difficulties, depending on how advanced their disease is. Patients with respiratory infections can have trouble breathing. What’s your doctor’s plan for keeping your patient as safe as possible?

Children:

(1) As stated above, there is no easy test to confirm what kind of influenza the patient has—-seasonal or H1N1.

(2) There are, or will be in your community, over-whelmed doctor’s offices, answering telephones non-stop. Children usually get respiratory infections first in day care centers, kindergartens or schools.

(3) Doctors err on the side of caution. When it comes to children, they definitely err on the side of caution.

(4) There are reasons to resist the temptation to toss anti-virals around like Christmas candy.

- Viruses can develop resistance to them as they are used more often.There are few anti-viral drugs which work, so their effectiveness must be protected by careful use when possible.

- These anti-viral drugs may deliver too little benefit for it to be useful to the patient, another reason for a doctor to hold back on prescribing them. That was the point of a study in this week’s issue of the British Medical Journal (BMJ).

That brings us to the flap this week.

A BMJ study this week said that giving anti-virals to children with mild seasonal influenza did not produce enough of a benefit for children to make the medicine useful. Noted.

However, how does a doctor know which kids’ H1N1 will be “mild” and which ones appear “mild” and then will become complicated?

Absent that bedside test, and during a community outbreak—-you know, suddenly “it’s going around” or “everybody seems to have this”—-there is no time to do more than respond to those who are sick as quickly as possible.

The BMJ has published a study which, while it satisfied its editors, does not help doctors in communities who are dealing with a lot of sick people at once. True, some have mild illness. However, the problem with H1N1 is that it rarely declares itself at the outset unless the patient is very ill from the beginning.

The BMJ owes community physicians more clarity than this week’s study produced.

In the meantime, WHO is standing behind its statement, dated May 21, on management of H1N1.

Summary:

We, not being doctors, may be missing something here. We think, however, we are not. The question about this comes from our very busy Department of Common Sense for Patients. Of course, no one thinks someone with mild respiratory disease needs anti-virals.

The question is: How do doctors and parents know the difference between which kids who start our with mild illness will stay mild versus the kids who look like their friends, only to get much sicker?

Neither WHO nor the BMJ studies or statements answers that question.

Or, if it does, it is in a secret code. Busy doctors do not have time for secret code. Neither do worried parents.

Physician’s First Watch

“WHO Emphasizes that Children and Adults with Severe H1N1 Disease Should Get Antivirals”

“The World Health Organization is reiterating its position that antivirals are appropriate for adults and children over age 1 who have severe novel H1N1 disease or who are at risk for H1N1 complications.

“The WHO took this step in response to a BMJ analysis, published earlier this week, calling into question the wisdom of giving antivirals to children with mild seasonal influenza.”

Source: Physician’s First Watch, August 13, 2009

Citation: WHO (World Health Organization, August 13, 2009

Citation: BMJ 2009;339:b3172