Pediatrician: ‘Flu just spread like wildfire’
From coast to coast, pediatricians in the United States say this year’s flu season ranks among the toughest they’ve seen.
The US Centers for Disease Control and Prevention reported 53 pediatric flu-related deaths from October, when the season began, through January 27. The season blossomed all over the country more or less simultaneously.
During the week ending January 27, the latest tracking data indicated that flu activity was still high and widespread across most of the nation and increasing overall. Hospitalizations are the highest seen by the CDC, even higher than in 2014-15, the previous high season.
“Flu just spread like wildfire” in California, said Dr. Tanya Altmann of Calabasas Pediatrics. “This flu season, I think, took us by surprise, as it hit a little bit earlier than it had in past flu seasons. The vaccine wasn’t as good of a match. Although it’s still helpful, it wasn’t as good a match as in previous years.”
CNN spoke with seven pediatricians across the country, all of whom said they are continuing to vaccinate their patients. They also said that patients who received the influenza vaccine and still got sick had less severe symptoms than those who were not vaccinated.
All have been able to maintain their stock of vaccine this season, though some have grappled with a short supply of tests to diagnose the illness. They said that despite criticism, Tamiflu and other antiviral medications have become a strong ally in the battle. And all seven believe that their patients are more aware of the possible dangers of flu this season than in the past.
Overall, the view from the front lines of children’s medicine this flu season has not been pretty.
‘Not just a regular season’
Atlanta pediatrician Dr. Jennifer Shu described the 2017-18 flu season as “the busiest season I’ve ever seen, and I’ve been in practice for over 20 years.”
“The severity of the flu that we’re seeing, as well as just how many — the sheer number of people that have it — is crazy. One of my friends, her son’s class had just three kids in it, because everyone else was out sick. He’s in high school. I’m hearing similar stories for all grades.”
Pediatrician Dr. Ari Brown, who is based in Austin, Texas, has also been in private practice for more than two decades and said, “except for the H1N1 (aka swine flu) year of 2009, this is the busiest flu season I have experienced as far as number of patients seen.”
This year, Brown said, she’s seen a few kids with a relatively uncommon flu complication called viral myositis. “The virus causes inflammation in the leg muscles, and the kids don’t want to walk. It is pretty dramatic, lasts a few days, then resolves,” she said. “I have seen it several times in the past 22 years of practice but never several in just one flu season.”
Chicago pediatrician Dr. Anita Chandra-Puri said this year’s flu season has been “pretty busy, but mostly because we sense there is more flu earlier in the season. Chicagoland has seen clusters of flu cases, and there have been a few schools that have closed for a few days due to large percentages of students absent.”
Florida pediatrician Dr. Lisa A. Cosgrove, based on Merritt Island, agreed. “It’s an incredible number of children that have been affected,” she said. “I’ve had several that have had pneumonia, but I have not had any that I had admitted into the ICU or that have had the fatal outcome, which is good.”
Dr. Dina DiMaggio said her practice, Pediatric Associates of New York City, also is seeing “a lot more patients than previous years.”
Dr. Ilan Shapiro, who practices in a Federal Qualified Health Center in Los Angeles, agreed with his colleagues.
“It’s not just a regular season,” he said. “We’re still seeing a lot of kids coming to our clinic.”
In San Diego, Dr. Jaime Friedman of Children’s Primary Care Medical Group sees signs of hope. She said that in her neck of the woods, flu season got “really bad” during the last weeks of December, and “we definitely felt busier than last year. We’re still seeing cases every day in my office, but it’s slowing down quite a bit.”
Vaccination for all
When it comes to the flu vaccine, patients are asking two big questions: Is it helpful? Are doctors still offering it?
Yes and yes, the pediatricians say.
“My kids both got the flu, but they weren’t hospitalized, and they did just fine. So I called it a win,” DiMaggio said. In her New York practice, though it’s later in the season, she is continuing to vaccinate patients. “We just got more flu vials to cover us until May, just in case, because we don’t know how long the flu season will last.”
Among her Chicago patients who had declined a flu shot, Chandra-Puri said, “the scare about the flu has prompted a few to get it now. I still find the majority of the refusers are refusing still. The year of the H1N1 scare was a far greater outcry to get the flu vaccine amongst the general refusers.”
Brown, who also has a supply of vaccine in her office, said “patients who did not make it in for flu vaccine earlier in the season are definitely asking for it.”
At least one worry has been allayed, Friedman said: concerns that fewer patients would get vaccinated after the CDC recommended that FluMist, the nasal spray form of the vaccine, not be used for the 2016-17 flu season and the current one.
“When they stopped doing the nasal vaccine for kids, we worried that those numbers would drop off because kids don’t like needles, but it really didn’t seem to. Kids are still getting their shots,” she said.
Shu said, “If they’re coming in with the flu, I’m still giving them a shot if they haven’t had it.” Of patients who get the virus after being vaccinated, “their symptoms seem much milder than the ones who haven’t had the vaccine.”
“In my practice, we’re exposed to flu all day long, and none of our employees — knock wood — have gotten sick with it yet,” Shu said, noting that the practice includes 12 employees. “Which I think is pretty amazing.”
Cosgrove’s thinking is much the same as Shu’s: “I get a flu vaccine every three months, and I haven’t had the flu in 25 years.”
“In Florida, flu is pretty much year-round,” she said. Visitors come from “all parts of the world” to see Disney World or board a cruise ship, so “we’re pretty used to treating it.”
This year’s vaccine is only about 30% effective against the most prevalent H3N2 strain, Cosgrove said, but she still encourages her patients to get the vaccination. (The vaccine is a better match for other strains, the CDC has said.)
Shapiro said that scaring patients with “‘you need to do this and you need to do that’ works for a couple of minutes, but it doesn’t work in the long term.”
So he explains to his patients that the flu vaccine is a dead virus and will not make you sick. The most likely side effect is “soreness for a couple of days.” And when patients tell Shapiro they’ve heard the vaccine doesn’t work very well, he tells them that is true.
“But I prefer to have that 30% to 40% better than 0%,” he explained. “The influenza virus is not a regular cold. It’s a horrible virus that actually can do a lot of bad things to your body, including putting you in the hospital.”
Tamiflu and antivirals
The CDC recommends that antiviral medication, such as Tamiflu, be prescribed for higher-risk patients, including children under age 2, adults over age 65, pregnant women and people with chronic illnesses.
“Many patients do want Tamiflu, but we triage patients based on their symptoms. If they’ve had three, four days of fever and they’re getting better, we’re not giving them Tamiflu,” DiMaggio said. On the other hand, those high-risk patients “definitely” get a prescription.
“Our group is following the higher-risk guidelines as detailed by the CDC,” Chandra-Puri said. However, there’s been a lack of the liquid preparations of Tamiflu or its generic in her area of Chicago, so “we have had to be very detailed on who is recommended to receive the treatment medication.” She also explains to parents that despite their fears over potential side effects, “the majority of children do well.”
Parents who’ve read that children in lower-risk categories have died from the flu will ask for the medicine, Shu said. “So we tell them that it is important to look out for warning signs that the flu is getting worse.” These signs, listed on the CDC website, include a worsening or persistent fever, labored breathing and an inability to eat. They indicate that a child may be developing complications without the medication, and in that case, a parent needs to contact their pediatrician.
Side effects of antiviral medication, Shu said, “can’t be taken lightly. Antivirals, in a decent number of people, can cause bad stomach pain and vomiting to the point where they can’t keep the medicine down.”
Hallucinations are another possible side effect, she said: “I have a lot of patients who do hallucinate with fever, so if you put an antiviral on top of their tendency to hallucinate, that can be scary for families. I know parents whose kids just want to run out the door when they hallucinate, so you just have to closely supervise kids when they’re sick and when they’re on the antivirals.”
As for the flu test, Cosgrove said it “is only about 63% accurate,” so there’s a good chance that a patient could receive a false negative. When she feels that a patient has the flu based on their symptoms — “the body aches, the high fever, the cough, the congestion” — she will treat them with Tamiflu.
“Most of the time, within two days of taking Tamiflu, the fever drops, and the symptoms go away, and they are much better,” Cosgrove said, adding that none of her patients has had hallucinations.
“Tamiflu is becoming hard to find in Georgia,” said Cosgrove, who practices telemedicine in that state along with Florida, Illinois and North Carolina. Some telemedicine patients live in rural areas with no access to pediatricians, but other patients use the service to avoid medical offices where they might pick up infections.
Brown said one patient “saw ‘purple people’ while taking it, so we decided to stop the Tamiflu. Mostly, it is kids feeling nauseated or actually vomiting.” Other than these instances, she has not seen “any seriously significant side effects.”
“I’d say the vast majority of parents whose kids have flu want Tamiflu prescribed if they are diagnosed within the initial 48 hours of illness,” she said. “Some of that stems from news reports of perfectly healthy people dying from flu and the higher number of pediatric deaths this year, which is certainly understandable.”
Along with shortage concerns, antivirals bring cost concerns, she said, though the generic form is “typically less expensive than in previous years.”
Altmann’s patients also ask about Tamiflu.
“With all medications, there are some side effects,” she said. “But I haven’t seen them in my own practice. I have given Tamiflu to my own family. Everyone I’ve given it to have responded very quickly and have done very well on it. I feel it’s very helpful.”
Ultimately, Altmann believes that when it comes to flu, “prevention is the best medicine.”
Keep it clean
“When you’re out and about, don’t forget germs are everywhere,” Altmann said. “Germs can live on surfaces for days, and that’s how most people get sick: by opening a door and then touching their face.” She recommends the vaccine in addition to hand sanitizer and good nutrition to boost the immune system.
Shu said she’s seen more flu awareness this year than in previous seasons.
“I think it’s important to just keep an eye out and continue to follow these news reports, because the flu season can last, typically, 11 to 20 weeks, and we’re just at week 11 right now,” she said. It’s unclear whether we’ve reached the peak yet, and in Atlanta, “it’s not getting worse, but it definitely has not gotten better yet.”
She recommends that anyone feeling ill stay home.
DiMaggio said “there’s a lot of pandemonium right now,” with people bringing their children in after just one or two hours of fever. That’s not required for most children, though exceptions include infants, very young children and higher-risk patients, such as those with underlying illness.
“My biggest advice: Just call your doctor. We’re here. Call your pediatrician. We’re here,” DiMaggio said. “Take the biggest step for prevention: Get the shot, and wash, wash, wash hands. And don’t send your kids to school if you think they’re sick.”
Brown is also seeing parents “bringing their kids in after two to three hours of illness to see if it is flu.”
“There is a point where it becomes panic beyond the reality of the situation,” she said. “While flu can be serious and even deadly, most people will feel crummy for a week and recover.”
She recommended the old-fashioned “drink plenty of fluids.”
However, patients should “seek medical care for some red flags: extreme lethargy, not urinating at least every eight hours, difficulty breathing/ or labored breathing,” she said.
There is some good news, Brown said: “Like Punxsutawney Phil and winter, we probably have about six more weeks of this, and it will be over!”