This is a guest post from Gergory Gahm, MD. It contains his opinion as a clinician and is not necessarily reflective of the views of CAFP or its membership. If any of our members would like to continue this conversation, be in touch and we’ll host the conversation.
We are buried in Influenza and almost certainly will be for three to six more weeks at minimum.
The major outbreak hitting across the country is now identified as A:H3N2. This is the third strain to hit the population in epidemic numbers this year, but it will hit older patients the hardest out of the three strains we have seen. The other two influenza strains we saw a lot this season, B and A:H1N1, tend to hit younger folks harder but are generally in decline (though I know of a significant second peak of Influenza B at a local college campus this week).
The CDC estimates that there have been at least 22 million flu illnesses so far this year in the US alone, with 210,000 hospitalizations and more than 12,000 deaths so far – and we are just now starting to see A:H3N2, which is the hardest one on older folks and kills the most people each year. In other words, as bad as it has been, it is about to get much worse. As a comparison, the WHO recently reported that a little over 600 deaths worldwide are attributable to 2019-nCoV (the novel Coronavirus), yet influenza has not sparked nearly the same level of concern.
Let me first repeat the two wisest pieces of advice I can give you:
- It is not too late to vaccinate. Vaccinate anyone who was not vaccinated. I would contend in future years for High Dose or Adjuvant vaccines for ALL adults, believing that we could raise vaccine efficacy from 55-60% to 75-90% efficacy and come much closer to real herd immunity; and
- For ANYONE with the sudden onset of a nonproductive cough or fever, reach for the Tamiflu first (or Relenza), then test. Do not wait for a flu swab result in the midst of an epidemic where every hour counts. If you sent a good swab (i.e., a vigorous, bilateral posterior pharyngeal swab) and it comes back negative, you can stop treatment. If it comes back positive, you have potentially prevented spread of millions or billions of influenza viruses marching insidiously from nasopharynx to carina to lungs. If you already have 2 cases or a confirmed influenza A positive case, there is no reason to continue testing – it is probably flu.
In Colorado, more than 40 facilities have had Influenza outbreaks in the past month and that number could double (or more) in the coming month. What to do when you have an outbreak is a complex question without a single best answer. The CDC would have you immediately prophylax everyone in the facility (including staff) with Tamiflu as well as get surgical masks on everyone.
Tamiflu is a tough question. As someone who has long been concerned about Antibiotic Stewardship, I see this enormous overuse of Tamiflu as the perfect recipe for rendering it resistant and useless that much quicker. On the other hand, if widespread use in a facility could actually prevent even a handful of cases, some of which might end in death, perhaps the short-term gains outweigh the long-term risk of resistance (though then, of course, we would have nothing to offer anyone at risk). My personal bias has been to quickly prophylax everyone with close contact to cases, expanding to hallways, wings, floors or entire facilities if and when the virus spreads, but I will not argue against wider use if you feel so compelled to do so. I would estimate that about half of facilities do not end up providing more than limited prophylaxis, with the other half eventually providing widespread prophylaxis.
Masks are a different story and one that I find a bit silly. We know from good research done on other coronaviruses like SARS, that surgical masks are not very effective at curbing the spread of viruses. On a case-by-case basis, a patient initially presenting with influenza with any sort of productive cough may benefit from having a mask for a day or two, but the hallmark of influenza is a nonproductive cough, so even this would be left to question whether or not there is any efficacy. Again, do what you feel obligated to do, but do not expect clinical benefits from anything short of an N95 mask.
Good luck, everyone.
Gregory Gahm, MD is a geriatrician on the clinical faculty for CU Med Center who serves as Medical Director for many long-term care facilities in the Denver area and has been studying influenza for about 30 years.