All the brouhaha about swine flu

How important is Swine Flu really?

Is it likely to be a pandemic?

Is it going to kill millions of people like the infamous flu pandemic of 1918?

Unfortunately no one has the answers. Lots of speculations, guesses, and opinions. However a few regularly asked questions that have specific answers are what I am going to answer here, and provide a couple of excellent resources for self reading.

What are the symptoms of Swine Flu? Symptoms include at least 2 of the following:

• Rhinorrhea or nasal congestion;


• Sore throat;


• Cough; and


• Fever.

In addition, persons with swine flu may have other typical symptoms of influenza, including body aches, headache, chills, fatigue, and possibly diarrhea and vomiting.

Can you get this from eating cooked pork? No.

Can my pets get this? No.

Should I avoid traveling to swine flu affected areas at present ? Yes if you can avoid it.

Should I postpone my trip to US/ Mexico? It's too soon to know; follow travel-advisory information from the CDC closer to the event.

Will there be a vaccine? Work is under way to make a safe and effective vaccine that hopefully will be available by next flu season.

Is there enough medication? For those who may truly need it, yes, but most infected persons in the United States & worldwide (except Mexico) have not required intensive medical intervention.

What should I do to protect myself and my family? Take these everyday steps to protect your health:

• Avoid touching your eyes, nose or mouth. Germs spread this way.


• Try to avoid close contact with sick people.
  
• • Stay home if you are sick for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. This is to keep from infecting others and spreading the virus further.
  • Is the nation/state/city prepared for a pandemic? Public health authorities are more prepared than ever before, supported with some (more is needed) government funding and shaped over time by events, including the 1918 flu disaster, 2001 anthrax attack, the ongoing threat of avian flu, and Hurricane Katrina. The global community, however, is far from ready.

Is it time to panic? It is never time to panic. While it's no surprise that a circulating, airborne, invisible virus causes anxiety for many, panic serves no useful role in public health.

I am planning to travel to USA, what should I do? Avoid it if possible, otherwise take regular precautions like washing hands, covering mouth and avoid crowded places and report to a doctor if you have flu like symptoms. Talk to your doctor about carrying Tamiflu as a preacutionary measure if traveling to an area with high incidence of Swine Flu.

Should I take prophylaxis with TAMIFLU if am traveling to the USA? Chemoprophylaxis is recommended for 7 days after the last known exposure to a confirmed case of swine influenza A (H1N1) virus. The CDC recommends that the following populations receive chemoprophylaxis:

1. Household close contacts of a confirmed or suspected case who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).


2. School children who are at high risk for complications of influenza (persons with certain chronic medical conditions) who have had close contact (face-to-face) with a confirmed or suspected case.


3. Travelers to Mexico who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).


4. Border workers (Mexico) who are at high risk for complications of influenza (persons with certain chronic medical conditions, elderly).


5. Healthcare workers or public health workers who have had unprotected close contact with a person with confirmed swine influenza A (H1N1) virus infection during the infectious period. (Detailed guidance on this topic is available at http://www.cdc.gov/swineflu/recommendations.htm)

So the answer to that question is NO, if you are a healthy person traveling to USA, you may not take prophylaxis, because the risk of serious disease is virtually negligible.

What is the dose for Tamiflu? Tamiflu is NOT recommended for children less than 1 year. While a syrup form is available in the USA, I believe that none is available in India.
The dose is 2.5 mg/kg twice a day for treatment, while it is 2.5 mg/kg once a day for prophylaxis. For adults the dose is 75 mg once a day for prophylaxis and twice a day for treatment.

Here are a few excellent resources that will provide updated information about Swine Flu.

Medscape Resource Center for Clinicians

CDC Swine Flu Website

CDC FAQs

UPDATE: NEJM has created a new center of H1N1 virus, the one causing Swine Flu. You can get latest news about this here
NEJM H1N1 Influenza Center

Rotavirus presentation

This weekend I had a interesting presentation on Rotavirus presentation in our local IAP (Indian Academy of Pediatrics) meet of Pediatricians of Chandigarh, Panchkula & Mohali tri-city.


What is the rotavirus? Just the commonest cause of diarrhea in children, killing more than 1 lakh children in India alone!


You can get the entire presentation here. It was fun to read up this disease, since in office practice I tend to not get in a lot of academic reading about specific illnesses. While I am using the presently only available Rotavirus vaccine (Rotarix by GSK), there were still a few surprises for me. The large number of deaths worldwide caused by this virus were astounding, more so the fact (as you can read in the presentation ) that India has the largest number of deaths by far.


Since the presentation, I would probably be a bit more aggressive in suggesting this vaccine to affording parents with children under the age of 6 months. While the vaccination is at present slightly expensive (around INR 1,000 - 1,500 per dose), since it is imported and being marketed by a multinational, an Indian Rotavirus Vaccine is likely in the next few years, making a serious dent to the large number of preventable deaths due to rotavirus.

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A simple case of misdiagnosis .....

Being a doctor I always feel that there would be less chances of misdiagnosis in my case. I know the doctors, their reputation, and many are friends too. So this weekend when I developed pus in my tonsils, I first took a course of "mild" antibiotic Azithromycin. Since that did not work, I talked to an ENT specialist friend, and he recommended a course of Clindamycin, after having a look and saying that I had a lot of pus in both the tonsils. For those of you who have taken this medicine, you know the gastritis, loose motions etc. that are a part and parcel of taking it. However, I did take this as directed. However after 3 days of continuously missing my clinic practice due to fever, body aches and general malaise, I got a second opinion from another ENT specialist today. He had a look, and immediately exclaimed that this is a VIRAL tonsillopharyngitis, and it would recover faster with just a short course of oral steroids. No need for any antibiotics! This was amazing, and I am starting to feel better already :-)


I asked him and searched online for tips regarding how to differentiate the two conditions, since we do get a lot of purulent tonsillitis in my pediatric practice too.


While of course there are no hard and fast rules, generally viral tonsillitis would have small ulcers else where too, other than the tonsils, and the tonsils would not be angry red or enlarged. There would be more pain during speaking, and lots of malaise, but not very high fever nor toxic look in cases of children with viral tonsillitis. Small ulcerations on the other areas of the throat would be pathognomonic for viral tonsillitis, though in cases of doubt, a simple blood count would help differentiate the two conditions. Scratchy feeling in the throat, and other symptoms like cold, cough etc. are likely to occur. Generally the neck lymphnodes are not significantly enlarged nor painful in viral pharyngitis. Viral purulent tonsillitis is less common in children, and starts appearing in teenagers and older adults.


Strep tonsillitis is the most important differential between commonly occurring between 3-15 years age. Bacterial pharyngitis generally has higher fever, no flu like symptoms, and painful enlarged lymphnodes. There may be a petechial rash over the palate / uvula. Strep throat swabs are not easily available / routinely used in India at present, though this is likely to change, so immediate diagnosis is not possible, and antibiotics are generally given to everyone with purulent tonsillitis.


Well a lesson learnt about viral / bacterial tonsillopharyngitis, and that even simple conditions can be misdiagnosed leading to unnecessary suffering and missed work. While we do read about this, it really hits home when it happens to you I guess!


The other thing that I realized was that even for a "trivial" illness like tonsillitis, finding a better doctor can make such a difference, imagine how much difference it would make for serious and life threatening diseases?!