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Editorial OCTOBER
2009
The Flu and You
Ronald T. Burkman, MD
A significant amount of information has been circulating regarding
the occurrence of the usual seasonal flu as well as the pandemic
H1N1 flu in the United States. For those practicing obstetrics,
it presents at least 2 challenges, although the second challenge
is a significant opportunity as well.
Most of us are familiar with
the usual seasonal flu; we have somewhat less information regarding
the pandemic version. It is unclear how many cases are expected
and whether they will be of increasing severity. To date, the
H1N1 flu has been somewhat similar to seasonal flu relative
to morbidity and mortality. However, since most flu viruses
are more virulent and transmissible in cold dry air, at least
for the United States, the introduction
of the pandemic in the spring of 2009 may not allow accurate
predictions of its overall effect starting this fall.
A recent study in the Lancet of the H1N1 cases that occurred
among pregnant American women in the first 2 months of the
outbreak demonstrate that the hospital admission rate among
pregnant women due to this illness was more than double of
that seen in the general population.1 Further, there were 6
known deaths among pregnant women in this brief period, with
each presenting with pneumonia and progressing to acute respiratory
distress syndrome; all required mechanical ventilation. This
information and prior experience with seasonal flu have resulted
in the recent recommendation that pregnant women be considered
at high risk and, if H1N1 is suspected, promptly treated with
oseltamivir or zanamivir. However, these recommendations are
subject to change, due to some cases demonstrating resistance
to oseltamivir. In general, confirmation of the presence of
H1N1 virus should be made only if it is going to significantly
affect management.
An initial challenge we face is how to evaluate pregnant women
suspected of having H1N1 flu because of symptoms such as fever,
cough, myalgia, headache, and sometimes nausea, vomiting, and
diarrhea. Do all of these women need to be seen? Probably not,
but the ability to discern who might be having more significant
respiratory issues such as tachypnea is difficult to assess
over the telephone. If they are going to be seen in the office,
it is prudent to create a separate waiting area where they
can don masks to reduce the chances of infecting other patients.
Care providers should wear masks when seeing these patients
and have the patients wash their hands or use an alcohol-based
hand disinfectant. A single examination room should be designated
to examine these patients, with the surfaces wiped down with
disinfectant after each use. Hospitalized patients will require
isolation and close monitoring. Managing such patients will
be costly in both time and money, particularly if the pandemic
results in high numbers of cases.
But this pandemic also presents a challenge that is a significant
opportunity. Rather than spend all our efforts on managing
pregnant women with suspected flu, wouldn’t it be better
if we reduced the number of cases through vaccination? A 2008
publication indicated that unfortunately, between 1989 and
2005, pregnant women had the lowest
rate of seasonal flu vaccination (14.4%) of all adult groups
recommended to receive the vaccine.2 Yet vaccination
for both seasonal and H1N1 flus represents one of the few opportunities
where we can offer primary prevention of a significant illness.
Although there are many factors that contribute to this low
vaccination rate, there are at least
2 strategies that are likely to
be effective.
First, we need to educate our patients regarding the seriousness
of both types of flu. We need to point out that inactivated
flu vaccines have historically been safe for both the mother
and fetus, as well as breastfeeding mothers. Although there
are fewer data on the safety of the H1N1 vaccine, it is manufactured
in a similar fashion to seasonal flu vaccines. Further, recent
information suggests that, at least for adults, a single dose
of
15 μg of hemagglutinin antigen will be effective.3 At
each visit, women should be provided with educational material
to encourage them to accept vaccination if they have not already.
Reliable patient education material on this topic, including
free brochures and posters, is available on the CDC Web site.
Second, we need to reduce the barriers to getting both vaccines
once our patients indicate their willingness to accept them.
Ideally, the vaccines should be available in the office or
clinic so that administration can occur at a routine prenatal
visit. Sending our patients to their primary care providers
or to some public health facility will likely be viewed as
a significant hassle, leading to reduced numbers of women getting
vaccinated, since such facilities are likely to be inundated
by other patients requesting such immunizations.
These basic but important
suggestions may improve the woefully low rate of flu vaccination
among our pregnant patients. If we truly wish to practice
“primary preventive medicine,” we need to step
up to the plate now with action rather than
just words.
| H1N1 Information
on the Web |
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ACOG
CDC
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Ronald T. Burkman, MD, Editor-in-Chief
References
- Jamieson DJ, Honein MA, Rasmussen SA,
et al. H1N1 2009 influenza virus infection during pregnancy
in the USA. Lancet. 2009; 374(9688):451-458.
- Lu P, Bridges CB, Euler GL, Singleton JA. Influenza vaccination of recommended
adult populations, US, 1989-2005. Vaccine. 2008;26(14):1786-1793.
- Neuzil KM. Pandemic influenza vaccine policy: considering the early evidence. N
Engl J Med. 2009 Sep 10; [Epub ahead of print].
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