Pediatric INSIGHTS - Winter '10Children's Hospital of Pittsburgh of UPMC

H1N1: Is a Third Wave Coming?

virus

Historically, pandemics occur in three waves — from the great influenza of 1918 to the Hong Kong flu of 1968. So what does this mean for the H1N1 of 2009? Is a third wave of illness in the cards?

It’s pretty much anyone’s guess. “We assume there will be a third wave, but we’re not sure,” says Michael Green, MD, MPH, of the Division of Pediatric Infectious Diseases at Children’s Hospital of Pittsburgh of UPMC.

The first outbreak of H1N1 occurred in the spring of 2009 with a second surge hitting in the fall, about mid-October. If a third wave surfaces, illnesses are predicted to occur from mid-winter to early spring — at about the same time as the seasonal flu, according to Dr. Green.

A third wave is expected to be extremely mild because many people have either been vaccinated or exposed to the virus, making them nearly immune to another transmission.

“There may or may not be a third wave, but if there is one, we predict it will be of lesser magnitude, the majority of illnesses will be mild, and most children will do well,” says Richard Saladino, MD, chief, Division of Pediatric Emergency Medicine at Children’s Hospital.

Groups to monitor are those under 2 years of age and children with chronic lung disease, congenital heart disease, or other chronic medical conditions such as asthma, cystic fibrosis, or rheumatologic diagnoses requiring long-term steroid therapy. Also, children with a weakened immune system or those with diabetes or morbid obesity should be watched closely when flulike symptoms appear.

Is It H1N1 or the Seasonal Flu? Does It Matter?

Whether it’s seasonal flu or the H1N1, physicians should treat healthy children as usual — antipyretics if fever occurs and plenty of fluids to prevent dehydration. In most cases, symptoms will be mild to moderate and can be managed at home.

In healthy children, pediatricians should watch for a persistent high fever, worsening cough, or rapid breathing — all are indications that intervention may be needed by a pediatric specialist, whether the diagnosis is H1N1 or seasonal flu.

Children’s Responds to H1N1

During the H1N1 surge this autumn, Children’s Hospital formed a SWAT team of experts called the Pandemic Flu Taskforce. This multidisciplinary team (which included health care workers from Emergency Medicine, Infectious Diseases, Critical Care Medicine, Infection Control, and Nursing) responded to the needs of patients, parents, and the hospital staff.

Children with influenza-like symptoms were prescreened in the Emergency Department (ED). Those with mild symptoms were isolated and sent to an adjacent Flu Clinic to be treated. In addition, specialists from Infectious Diseases and Emergency Medicine conducted regular conference calls with local pediatricians to provide information and answer questions. Regular updates with recommendations for treating patients were also faxed to pediatric practices across the region.

Specifically for parents, Children’s hosted two online chats through the hospital website with Andrew Nowalk, MD, PhD, of the Division of Pediatric Infectious Diseases. Dr. Nowalk answered a variety of questions from an audience of more than 200 online participants. Additionally, Drs. Green and Saladino were members of a phone bank of medical experts providing parent callers with information about H1N1. The free service was hosted by WTAE-TV and carried live during two hours of local newscasts.

Tracking the Surge

Jim Levin, MD, PhD, Children’s chief medical information officer, developed a bio-surveillance program to follow the fall surge, tracking fever, respiratory symptoms, and the number of hospital admissions. The program he developed monitored when the surge hit and when it subsided to provide a snapshot of the duration and intensity of the illness. This work will aid in the response to future pandemics in terms of how we manage patient volumes with staffing, supplies, and other resources.

The surge began in early September and lasted about eight weeks. Visits to the ED also spiked during this period, growing from an average of 180 patients a day to more than 300 a day at the peak of the surge. Most patients arrived in the early afternoon and then again after midnight, according to Dr. Saladino.

Other statistics from Children’s Hospital show that 234 patients were admitted with H1N1, 49 were treated in the Pediatric Intensive Care Unit, and three deaths occurred. By early December, no additional cases of H1N1 were recorded, although the hospital continues to track and monitor for this illness.

Lessons Learned

The 2009 H1N1 fall surge taught some important lessons. Number one: Wash your hands. Good hand hygiene continues to be the number one way to stop the spread of infection.

Pediatricians learned how to better manage patients when a pandemic occurs — such as which patients should be seen in the office and which could be managed by phone to minimize the risk of exposure and spread of illness. At Children’s, our pediatric specialists developed strategies to allow us to screen children upon arrival at the hospital to determine who should be given a mask even before placing them in an exam room. This strategy helped minimize the spread of H1N1 to other patients and families as well as to our health care workers.

Data collected from the 2009 fall surge will provide useful insight for future planning. “By early October, we were testing about 50 patients a day and 60 percent were positive for H1N1. That gave us our local epidemiology. We were then able to stop testing, for the most part, except for those in the high-risk populations. Of note, in Pennsylvania, Pittsburgh got hit with the H1N1 earlier than Philadelphia and the eastern part of the state,” says Dr. Green.

The key to avoiding future outbreaks of the H1N1 and seasonal flu is immunization. Vaccinations are still available and their use should be encouraged, especially for children in high-risk groups.

In the end, the third wave may come and go with little to no effect, but pediatricians should keep paying attention to the events, advises Dr. Green. See below for important websites to visit for updates.

Stay Connected

Watch these websites for H1N1 updates: