Sunday, September 13, 2009
News, In this Issue..., Atlanta

Swine flu makes its mark on Atlanta

Children hit hardest. Emergency rooms innovate to meet demands

A woman is given a shot during trials of an H1N1 vaccine, developed in Australia, at University of Iowa Health Care last month.
David Greedy/Getty Images

By Christine Foster and Stephanie Ramage

Children’s Healthcare of Atlanta’s emergency patient load has more than doubled in recent weeks thanks to youngsters’ special vulnerability to swine flu or, as researchers refer to it, H1N1.

David Banks, an emergency physician at CHOA, says the emergency department normally sees about 180 patients in a 24-hour period this time of year.

“On the Sunday of the Labor Day holiday weekend, we saw 455 patients,” he says, explaining that the increase is driven by H1N1. “The problem is that the flu is hitting at this time of year, when we are not as prepared to do this.”

Banks’ colleague, Medical Director James D. Fortenberry, says CHOA doesn’t routinely test for H1N1 because the rapid test is inaccurate, but CHOA doctors know what they’re seeing.
“Almost everyone who has the flu right now has the H1N1 strain,” says Fortenberry. “Ninety-eight percent have H1N1.”

Usually, flu season begins in late October. To meet the additional demand, CHOA has staffed up. On Sept. 5, CHOA rolled out an online tool to help parents determine whether they need to bring in their kids.

Arthur Kellermann and his fellow Emory University emergency doctor, Alex Isakov, have been working on a similar online diagnostic tool to help people determine whether they might have H1N1 and whether a particular case merits a trip to one of the metro area’s already-slammed emergency departments. The idea is to alleviate patient load and lessen the likelihood of spreading the flu by exposing more people to it in the ER.

CHOA’s Banks says his ER’s numbers have declined a bit since Labor Day, leading him to hope that the worst of the epidemic has passed.

Emory’s Kellermann, however, warns that the biggest problem for hospitals and patients alike is metro emergency departments’ lack of capacity to handle the surge in patients that he believes H1N1 will cause over the next few weeks.

How bad it will get, and what that will mean to Atlantans, remain to be seen, but there are three things to keep in mind, says Kellermann.

First, younger patients have no pre-existing immunity to the newly recombined virus, so they are most at risk.

“Second, it is very contagious and in most cases it’s mild, but it makes some people sick as hell, and those cases scare the hell out of people,” he says. “Third, our health care system has little or no surge capacity.”
 

SWINE FLU IN SCHOOL

Though it seemed cases of H1N1 had subsided after its initially dramatic entrance onto the scene last spring, the swine flu is “back.”

“Basically, [H1N1] never went away,” says Artealia Gilliard, public affairs officer for the Centers for Disease Control and Prevention. “We’ve started to see an increase in cases again, but we don’t really know why.”

The CDC says cases are especially on the rise in the Southeast. Kellermann, professor of emergency medicine, associate dean for health policy, and a member of the Institute of Medicine, says Southerners can blame that on their kids’ short summer vacation.

“We went back to school early. A lot of schools in the rest of the country don’t start back until after Labor Day,” says Kellermann, explaining that children in close quarters provide an ideal environment for contagion. “The flu never left. It showed up at summer camps where kids were in dorms.”

According to the CDC, the H1N1 influenza virus was first referred to as the “swine flu” because it mimics some of the genes found in a virus that circulates in North American pigs. However, further study revealed it has ties to Eurasian influenza viruses that are also found in pigs, birds and humans.

Like the typical flu, H1N1 cases have ranged from mild to severe and cause a series of unpleasant symptoms such as fever, cough, sore throat, runny nose, body aches, sneezing, headaches, chills and fatigue. Diarrhea and vomiting have also been reported among patients. The virus may be transferred from person to person via coughing and sneezing, or simply touching a contaminated object and then touching your own mouth or nose.

Simply put, H1N1 is highly infectious.

“It’s the same virus it always was,” says Gilliard. “It’s not that it’s more contagious now, it’s just that most people don’t have an immunity to it, and that creates the potential to cause a lot of illness.”

According to a study on the CDC’s Web site, scientists have found that young children are at higher risk for catching H1N1, just as they would be for catching the ordinary flu. The elderly do not seem to have the same propensity for catching H1N1 at this time, though they are still at higher risk for the regular flu. That's because anyone who was exposed to the earlier version of the swine flu virus in the 1970s has some immunity.

The Georgia Department of Community Health recently released guidelines for control of H1N1 in schools and child care facilities. The department suggests sick students and teachers should stay home, but advises against closing a school simply due to an outbreak of H1N1 unless the number affected makes it impossible to stay open.

When more than 50 Emory University students were recently diagnosed with the virus, school officials moved them into the same dorm in order to help prevent the illness from spreading. But the school continued classes as normal.

Similarly, the Fulton County Schools system is managing the illness by offering flu shots, asking sick students to stay home and notifying parents when more than 10 percent of students are absent because of a flu-related illness.

According to FCS Communications Coordinator Susan Hale, the Fulton County Department of Health and Wellness is planning to administer vaccinations at minimum cost to students. Children who are Medicaid recipients will receive the vaccination for free.

That goes hand in hand with the DCH’s recently launched “Roll Up Your Sleeve” campaign to educate Georgians on the importance of common “seasonal” flu shots for high-risk individuals, such as children, young adults, women who are pregnant and those with chronic diseases. DCH has even organized several vaccination events for state employees.

“While the current data indicates that the severity of the illness caused by the novel H1N1 virus is not increasing, it is important that Georgians arm themselves with knowledge and take action to avoid getting or spreading the seasonal flu and novel H1N1 flu viruses,” DCH Commissioner Dr. Rhonda Medows said in a recent release.

There are two ways to develop immunity to H1N1: get sick or get vaccinated, says Gilliard.

Public service announcements have also urged people to wash their hands, cover their mouths, stay at home when they’re sick, eat healthy and drink a lot of water.

 “LIKE ANY OTHER DISASTER”

Meanwhile, the DCH’s Division of Preparedness and Response, the Atlanta-Fulton County Emergency Management Agency and the Georgia Emergency Management Agency are remaining low-key about their preparations for any kind of major unexpected outbreak. Instead, they are reminding people to prepare and plan ahead for more absenteeism in schools and businesses this flu season.

“We are preparing for this event like any other disaster, [calling for] lots of food and water stored at home and [being] prepared to work from home for an extended length of time,” says Atlanta-Fulton County EMA Deputy Director Pansy Ricks.
 
Those agencies are taking their cue from the CDC and other health organizations. They don’t seem overly concerned about a debilitating outbreak of H1N1.
 
“The [emergency management] concepts for seasonal flu and H1N1 are very similar,” says Dená Brummer, public affairs officer for GEMA. “Prevention is the key. If pro-active awareness campaigns can slow the curve of H1N1, existing medical support systems can handle the additional strain, business and government agencies can continue to function.”
 
Lightening the load for ERs so they can meet H1N1 demands and continue to provide timely treatment for illnesses is the idea behind Emory’s online emergency diagnostic tool, says Kellermann.

He explains that the H1N1 vaccine probably won’t be available until mid-October, and the first doses will be set aside for those under 5 years of age.

“That might not be soon enough for people in Georgia,” he says, acknowledging that lack of vaccine has exacerbated public worry. People feel less threatened by an illness if they can prevent it, even if most H1N1 cases are no worse than the usual seasonal flu. In the absence of widespread vaccine use, Kellermann and Isakov were looking for a way to use technology to empower people with information when they came up with the idea of using an online diagnostic tool.

The program is presently in “mock-up” mode, according to Isakov, executive director of the Emory Office of Critical Event Preparedness and Response. Once finished, he says, it can help keep people who don't need to be in the ER out of the ER.

“If they don’t have the flu when they get there, they might very well have it by the time they leave,” says Isakov. “So the web tool helps determine whether you’re a high risk—you need to go to the ER; an intermediate risk, meaning you have worsening flu symptoms; or a low risk for getting severely ill. For this last group--the majority of folks--the smartest course of action is to stay in bed, get lots of fluids, and take an over-the-counter drug like Tylenol for fever.”

Isakov admits other illnesses, some of them serious, have flu-like symptoms, but Emory’s web tool always has “go to an emergency department” as a fallback: Users are informed that this is only one step in the diagnostic process, and if their symptoms worsen, they should seek medical attention.

Kellermann and Isakov expect other health care providers around the country to take an interest in the program. Already, other states are watching Georgia’s swine flu trajectory for clues about how to handle the illness when it’s their turn.

“This epidemic is spreading in the Southeast,” says Kellermann. “And it has clearly started in Georgia.” SP

To check out Children’s Healthcare of Atlanta’s online flu diagnostic site, visit www.choa.org.