In a flu season that has been described in superlative terms (eg, Worst In Years), Massachusetts has perhaps been the poster child for just how widespread, virulent, and debilitating the virus has been. While the state reported a slight decline in flu activity in mid-January, Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP, who practices in the ICU and urgent care/emergency department settings of Good Samaritan Medical Center in Brockton, says, “We’re still seeing a lot of people who are very, very ill.”
Her description of the situation in Massachusetts will be familiar to clinicians in many of the 48 states that have reported widespread flu activity: “Emergency departments across the state are still packed. For the past three or four weeks, our ICU has been at full capacity every single day, and so has every other hospital in Massachusetts. There are just no beds to be had anywhere.”
The CDC’s FluView (www.cdc.gov/flu/weekly) for the week ending January 19 paints a national picture of epidemic proportions. About 26% of specimens tested by reporting laboratories were positive for influenza. The proportion of reported deaths attributable to pneumonia and influenza (9.8%) was above the epidemic threshold. Eight pediatric deaths were reported (although not all occurred during that particular week; there have been 37 pediatric deaths reported since flu season began). The cumulative rate (from October 1, 2012, to January 19, 2013) of laboratory-confirmed influenza-associated hospitalizations was 22.2 per 100,000 population; almost half of cases involved adults 65 and older.
In Massachusetts alone, about 11,000 people have already tested positive for flu. And as O’Rourke points out, “Those are just the folks who have shown up and been tested. There may be many more who are at home, just weathering it.”
All in all, it would be an understatement to say it’s been a pretty bad year for the flu.
Is It Really the Flu?
The CDC data focus on confirmed cases of influenza. But as O’Rourke notes, there are individuals who may not seek care (or, ironically, do not feel well enough to do so), as well as those who present too late in the course of illness for a flu test.
The CDC, though, also reports an increase in outpatient visits for influenza-like illness, which is defined as a temperature of at least 100°F, cough, and/or sore throat. While this description focuses on quantifiable symptoms, it does little to convey the malaise caused by the flu. When lifting your hand to pick up a glass of water on the bedside table seems like an insurmountable task, or standing upright long enough to shower becomes an unnecessary extravagance, you know you’re sick!
One of the confounding factors of this flu season has been the confluence of circulating viruses and infections. Besides influenza (three strains, no less), there have been outbreaks of norovirus and cases of mononucleosis, as well as the usual assortment of upper respiratory infections.
The distinguishing feature of flu, clinicians in the field say, tends to be fever. “If a child comes in with a high fever—101°F to 103°F—that child is more likely to have flu,” says Patrick E. Killeen, MS, PA-C, who practices at Danbury Hospital in Connecticut and holds academic posts in the Yale University School of Medicine’s Department of Pediatrics and the Quinnipiac University School of Health Sciences. “Whereas with RSV [respiratory syncytial virus] or rhinovirus, they have very similar symptomatology and x-ray findings, but they don’t have the high fever.”
Killeen and his colleagues have also observed that “children with the flu are more likely to develop secondary bacterial pneumonias. They’ve been sick for three or four days, they come into the hospital, and then their chest x-rays are showing significant infiltrate and they have high white counts.”
In the outpatient setting, Christopher M. Barry, PA-C, says a good history and physical examination can provide a lot of information. He echoes Killeen’s assessment that a quick-onset, high fever is often the first sign. But looking further, “We tend to see a person who just looks really sick. They often have a lot of nasal discharge, and sometimes the eyes have almost a glassy appearance. That gives us a little bit of a clue as well.”
At Jeffers, Mann, and Artman Pediatric and Adolescent Medicine in North Carolina, where Barry practices, they are fortunate to have access to a rapid antigen detection flu test. “We get a result back usually within five to 10 minutes,” he says. “So if there’s a suspicion, we typically run the test.”
At the other end of the age spectrum, O’Rourke has noticed that elderly patients tend to minimize their symptoms (as a general rule; this is not specific to flu). Many are appearing at urgent care centers and emergency departments when they’re already very ill.
“A lot of them are coming in with viral pneumonia,” she reports. “It quickly develops in them. They come in and they’re short of breath, they have really bad oxygenation, and they require a day or two in the ICU.”
Another observation that O’Rourke has made, and which has been noted extensively in national news broadcasts, is that “it’s a lingering illness this year; people are sick for a week, two weeks. Even though they may start to feel better, they’re still washed out, coughing, with chest symptoms that they need to pay attention to.”
To Treat Or Not To Treat
In some areas of the country (including Boston, where a state of emergency was declared), practicing clinicians have been so overwhelmed with patients that some have abandoned flu testing and decide to initiate antiviral treatment without a validated diagnosis. As Killeen says, “If it looks like flu and acts like flu, then people are going to treat it with [oseltamivir].”
With older patients, O’Rourke says, “I’m going to err on the side of giving it to them as opposed to not, because they are so vulnerable. A lot of them have comorbid conditions, such as diabetes or COPD, which puts them at greater risk. Any folks with chronic illnesses—asthma, HIV—you want to be more aggressive with their management.”
However, there may be patients for whom the gastrointestinal side effects of the medication do not sufficiently outweigh the benefits of a slightly reduced course of flu. “In many situations—and especially if we haven’t started treatment within the first 48 hours—we don’t necessarily recommend using an antiviral medication,” says Barry. “Even if we’ve caught it within 48 hours, if the child is otherwise healthy with no major underlying heart or lung issues, often I’ll leave it up to the parents.”
Barry has also learned to emphasize what antiviral medication can and cannot do in discussions with patients and families. “We try to make parents aware that it’s not a magic bullet,” he says. “It won’t cure the flu, boom, right there on the spot.”
While Killeen also supports the appropriate use of antiviral medications, he notes that there are some patients for whom clinicians will want to be more cautious about prescribing them. “A sickle cell patient, for example—if that person comes in with the flu, you have to think about other encapsulated organisms, like pneumococcus, that could be potentially detrimental to the patient, pending their vaccination status,” he says.
Clinicians have to rely on their clinical judgment when they don’t have the time or resources to confirm a flu diagnosis with a test. “If a pediatric patient comes in with petechiae and fever, that tells me, ‘No, it’s probably not the flu; we should be thinking about something else going on,’” Killeen says by way of example. “But absent other contradictory physical exam findings, then I would say we would treat [with antivirals].”
A Word (Or Two) Of Advice
For clinicians who have seen no abatement of flu season, or whose regions were late starters, here is some advice from your colleagues:
• Get your flu shot if you haven’t already. “Its efficacy varies, but in healthy adults you’re getting between 60% and 80% immunity,” O’Rourke notes.
• Wash your hands. “The quick alcohol hand rubs are great, but in flu season, I love soap and water,” says O’Rourke.
• Protect yourself and your other patients. Wear a mask. Ask patients with suspected cases of flu to do the same. If possible, do what Barry and his colleagues do: “We have anybody who has flu-like symptoms come in a separate entrance to our office, so we don’t have them in our main waiting area.”
• Stay home if you’re sick. This isn’t quite the no-brainer it seems. “[Clinicians] will come to work when they’re deathly ill, because they don’t want to burden their colleagues, they don’t want to miss out, and there’s a certain pressure for us to be the ‘soldiers’ who carry on,” O’Rourke observes. “If we’re sick, we’re not doing anybody any favors by coming to work. I think the better part of valor is to stay home and take care of yourself. We can’t be good caregivers to others if we can’t care for ourselves.”