Makers Say Cold and Cough Medication Should Not Be Used in Children Under 4

The manufacturers of over-the-counter cough and cold medicines said that such products should not be used in children under 4.

The leading makers of the products decided to voluntarily change the label after consulting with the Food and Drug Administration (FDA), according to the Consumer Healthcare Products Association, an industry trade group.

While pediatric versions of cough and cold remedies will still be available in supermarkets and pharmacies, they will have a new label that warns against use in children under 4. The labels will still recommend an appropriate dose for older children.

“In addition, for products containing certain antihistamines, manufacturers are voluntarily adding new language that warns parents not to use antihistamine products to sedate or make a child sleepy,” Linda Suydam, president of the Consumer Healthcare Products Association, said in a statement.

Expect to see such label changes during the 2008–2009 cough and cold season, the group said.

The use of cough and cold medications in very young children has come under scrutiny in recent years.

In January 2008, the FDA said such products should not be given to children under 2 years of age. Some children, mostly under 2, have died due to the misuse of the remedies. The Centers for Disease Control and Prevention estimates that 7,000 children under 11 are treated in emergency rooms each year due to problems with cough or cold remedies.

Parents could accidentally administer an overdose to children by using multiple products that contain similar ingredients, or by giving children the incorrect dose.

The FDA met last week to discuss the issue, and is considering a ban on such products for children ages 2–6.

Manufacturers are trying to do a better job of educating parents and caregivers. In addition to other recommendations, they say that caregivers should:

• Follow dosing recommendations exactly and use the measuring device sold with the product• Avoid combining medicines that contain the same ingredients• Never use such products to make a child sleepy
• Avoid combining medicines that contain the same ingredients• Never use such products to make a child sleepy

CDC: H1N1 cases decrease as vaccine availability increases

Atlanta, Georgia Health officials on Friday reported a slight decrease in H1N1 flu activity nationwide.

The Centers for Disease Control and Prevention said 43 states now have widespread flu activity, compared with 46 states last week and 48 states at the beginning of November.

"It's still much greater than we would ever see at this time of year," Dr. Anne Schuchat, director of the CDC's

National Center for Immunization and Respiratory Diseases, said in a news conference.

Schuchat added that while some parts of the country are seeing a small decline in flu cases, other areas, including Maine and Hawaii, have seen a bit of a surge.

It's too early to know if the worst is over in terms of the flu season, she said.

"Even though we saw a little bit of a decrease this week, it is still higher than the peak activity in many years," she said.

Flu season doesn't usually start until December. But when the H1N1 virus emerged in April, the spread of the flu never stopped, effectively stretching last year's flu season into the new one.

The CDC also said 21 more deaths from H1N1 in children were reported in the past week, bringing the official toll of confirmed pediatric H1N1 deaths in the United States to 171.

Schuchat said the number doesn't reflect the true picture.

"We believe the estimates we provided last week give a better picture of the full toll that the virus has taken in the first six months of the pandemic," she said. Last week the CDC reported that it estimated 540 children had died from complications of this flu virus so far. In an effort to limit further spread of the virus as millions of Americans begin traveling for the holidays, the CDC has launched a public awareness campaign.

Schuchat urged everyone to take simple precautions.

"Travel only when you are well," she told reporters. "Wash your hands often. ... Cover your cough and sneeze with tissues or with your sleeve. ... And get vaccinated against flu, particularly if you're in a targeted population." More people will be able to get vaccinated, according to the CDC, because more vaccine continues to be available.

States have been able to order a total of 54.1 million doses of H1N1 vaccine so far, Schuchat said.

"That number is 11 million doses more than we were at a week ago."
In response to a report from Norway that a couple of people died from a mutated form of the H1N1 virus, Schuchat said the CDC is aware that the mutated form had been identified, but that H1N1 vaccine and antiviral medications still are effective against H1N1.

Some cases of H1N1 that show resistance to the antiviral Tamiflu have been identified in North Carolina and Wales. But Schuchat said Tamiflu-resistant influenza viruses have been "quite rare" so far. Tamiflu doesn't cure the flu, but can reduce symptom severity and duration of illness by about a day if taken within the first day or two of getting sick.

Majority of adult Americans don't want H1N1 shot

More than half of all adult Americans say they don't want to get the H1N1 flu vaccine, according to a new national poll.

The Opinion Research Corporation survey released Wednesday also indicates that the number of adults who have tried to get the vaccine but were turned away is higher than the number of adults who have gotten a swine flu shot

According to the poll, 55 percent of adults don't want to get the swine flu vaccine and don't plan to get a shot. Another one in five say they want to get inoculated but haven't taken any steps to do so; 14 percent want a shot and have tried to get it but have been unsuccessful. Just 7 percent have been inoculated for H1N1.

Why are more than half of all Americans shunning the vaccine?
"The perception that the vaccine has dangerous side effects is the top reason," says CNN polling director Keating Holland. "Roughly half of those who don't want a swine flu shot say that the possibility of side effects is one reason why they don't plan to get the vaccine. That works out to 28 percent of the adult population who don't plan to get inoculated due to the risk of dangerous side effects."

So far officials of the National Institutes of Health say they've seen no serious side effects in clinical trials and that study subjects who have been immunized have generated a good response.
The Centers for Disease Control and Prevention recommends the vaccine for certain high-priority groups because they are more likely to have serious complications if they develop swine flu. These groups include: pregnant women; caregivers and household contacts of children younger than 6 months; everyone between the ages of 6 months and 24 years; and people ages 25 to 64 with existing health problems.

Most frequently asked H1N1 question

One in four American adults say they don't plan on getting a shot because they are not in a high-risk group, with 21 percent indicating they don't plan on getting vaccinated because they only go to a doctor when they are sick. Most of those respondents are men.

What about the 14 percent who have unsuccessfully tried to get the vaccine?

"Some say they don't know where to go. That works out to 4 percent of the total adult population who want to get inoculated but haven't been able to locate a medical facility that is giving swine flu shots," Holland said. "A bigger group, 5 percent of the total population say that they found a facility with the vaccine but were turned away because they were not in a high-risk group or for some other reason. And 3 percent of all adults say they found a facility that had the vaccine but it ran out before they got there."

Add together those last two groups, and the number of Americans who actively sought the vaccine but were turned away for some reason is 8 percent of the total adult population, roughly the same number as the 7 percent who have been inoculated so far.

The Opinion Research Corporation poll was conducted November 13-15, with 1,014 adult Americans questioned by telephone. The survey's overall sampling error is plus or minus 3 percentage points.

All About Swine Flu

What exactly is the swine flu?

“Swine influenza is a known cause of flu in pigs. But once in a while, through mutations, it can acquire the ability to attack humans,” Ericsson explained. Formally named swine influenza A H1N1, this strain “appears to have components from human, pig and bird viruses,” he said.

How easy it is to become infected?

That’s not yet entirely clear. “We know it’s passed on through the ‘droplet route,’ which means that if I’m within three to six feet of somebody and they cough or sneeze I might get some of that spray inhaled through my eyes or nose,” he said. “If that happens, and if they have the flu, you can easily get it.” It’s less clear if you could be infected simply by being in a room where exhaled droplets might still be lingering. As with other flu viruses, people can sometimes become infected by touching something with a virus on it — a desktop, a doorknob — then touching their eyes, nose or mouth, according to experts at the U.S. Centers for Disease Control and Prevention. You cannot get swine flu from eating pork.

What can I do to protect myself?

“Cough etiquette is the critical thing. You should be cautious about your own behavior — covering your mouth and nose when you cough or sneeze in public,” Ericsson said. Avoiding crowds, and avoiding folks who are sick or don’t use “cough etiquette” is also important, experts say, as is avoiding handshakes, kissing, or touching your eyes, nose or mouth. Also very effective: frequent hand washing, using either soap and water or alcohol-based hand cleaners. The effectiveness of face masks is still “controversial,” Ericsson said. If a true pandemic emerges, then mask wearing “might not be a bad idea” in crowded environments, he said. “And if you are ill you should certainly stay home from work” to avoid spreading the illness, he added.

What are the symptoms of infection?

“Basic flu-like symptoms: a high fever, a bothersome dry cough, maybe a little gastrointestinal upset like belly pains or diarrhea, and general malaise,” Ericsson said. “Basically you will feel just plain rotten.” Flu symptoms typically appear within hours, experts say, whereas common cold symptoms emerge more gradually, are milder, and only rarely include high fever. “Typically, most people with any significant flu are going to have a fever of at least 101,” Ericsson said.

Why does swine flu appear to be more deadly in Mexico than in the United States?

“I suspect we just haven’t seen enough cases to see its full potential [in the U.S.] yet, and we’ll just have to wait and see,” Ericsson said. On the other hand, “Maybe it’s mutated since Mexico, and that is why it’s appeared to be less dangerous among the cases we’ve seen so far in the U.S,” he said.

Is there an effective, available vaccine?

The answer is no, not yet, although scientists at the CDC and elsewhere are beginning the vaccine process — which typically takes months. “The current flu shot isn’t going to do anything with [swine flu], because the virus is very capable of changing its clothes and wrapping itself up differently to evade our body’s defenses,” Ericsson noted.

If I get infected, is there an effective treatment?

Yes, according to Ericsson. The swine flu so far seems to be susceptible to two prescription drugs, Tamiflu and Relenza, which can shorten the course of the illness. Antibiotics, which only fight bacteria, are useless against the flu virus.

Is there enough Tamiflu and Relenza to cover all Americans?

“We’ve got stockpiles,” Ericsson said, “but if we ever get into a real pandemic there is a risk that these not unlimited resources may get used up.” That could mean prioritizing certain high-risk or otherwise important groups. And Ericsson stressed these two drugs won’t do much to help people who become infected but only fall mildly or moderately ill. “They should be reserved for people who fall seriously ill and are hospitalized, and for whom it could be a matter of life or death,” he said.

Bottom-line: How dangerous is the virus and how big is my risk?

Unfortunately a good answer to that question isn’t here yet. Right now, Ericsson said, “it’s a moving target, and we just don’t fully know the full story yet. But I would have to say that, at this point, I do not think the average American on the street is at any great risk.”

Vitamin C and Zinc can fight Colds?

The überhealthy don’t shrug off an impending cold—they attack it. Jenny Spring, 29, of Cambridge, Mass., takes a double shot of vitamin C and zinc at the first ominous sniffle or throat tickle that could be a sign of a cold or the flu. She sips the powdered drink mix Emergen-C (it packs 1,000 mg of vitamin C) once or twice a day, followed by a few blasts of Zicam, an over-the-counter zinc nasal spray. "I’ve warded off coughs and colds long enough that I don’t remember the last time I had one," she says.

Although vitamin C and zinc for cold prevention remain controversial, some studies show that C is especially helpful for people who are under extreme stress and that zinc can prevent viruses from multiplying. Experts say there’s no harm in trying—and just believing these remedies work may help too.

Make C work for you: Neil Schachter, MD, director of respiratory care at Mt. Sinai Medical Center in New York City, suggests a more conservative amount of vitamin C (500 mg a day) at the first sign of a cold. And the Institute of Medicine advises drawing the line at 2,000 mg daily to avoid gastrointestinal or kidney problems. As for zinc, it’s available in many forms. Don’t care for nose sprays? Dr. Schachter suggests taking zinc lozenges several times a day when a cold starts.

8 Ways Swine Flu is Changing Cough Society

Flu season is here, and this year, people are actually taking notice. The outbreak of the H1N1 influenza virus, commonly known as swine flu, has people reevaluating the way they live, travel, interact with each other, and even how they eat.

The World Health Organization (WHO) officially declared the virus a pandemic in June, and it announced in early September that at least 3,205 people have died from the virus. And while more than 60% of Americans say they are "not too" or "not at all" worried about swine flu affecting them or their families, according to a Washington Post–ABC News poll, the scare has left its mark on many parts of society, both in the United States and abroad. Here, eight ways swine flu is changing the world.

1.People may finally get flu shots.
In the 2005–2006 season, so many people did not get the vaccine that 18 million doses had to be thrown away. If this pandemic has a silver lining, it's that more people are making the decision to actively protect themselves against germs in general—and that's good news, since every year even the "regular" seasonal flu (and complications from the flu) kill about 36,000 Americans, and anywhere from 250,000 to 500,000 people worldwide.

An August Gallup poll found that 55% of respondents see themselves getting a swine-flu vaccine if one becomes available, up from 46% in May. And while the H1N1 vaccine won't be available until at least mid-October, seasonal flu shots this year are being administered earlier than usual—and recommended more strongly by health officials—in anticipation for increased interest.

Many drug stores, employers, and schools are already offering the seasonal flu vaccine, and some counties are administering the shots at no charge. On September 22, for example, CVS pharmacy will give free flu shots in New York City on the plaza of CBS's The Early Show.

Still, many people are skeptical of either shot's effectiveness, and probably won't get vaccinated or give the vaccine to their children. Pregnant women are especially at risk, but typically have very low rates of vaccination due to worries that the shots won't be healthy for their babies.

2. People are reconsidering cultural greetings.
The French are well known for offering la bise, a quick peck on each cheek, as a way of saying hello and good-bye. But with the fear of transmitting the H1N1 virus, some schools and companies—and even the health ministry's swine-flu hotline—recommend avoiding this practice. One mayor in a small French town has actually banned the kisses, telling National Public Radio, "What's the point in the preventative hand-washing when people are still kissing each other all the time?"

Spanish, Mexican, and Lebanese government officials have also discouraged kissing greetings, and school officials in New York have even discouraged students from exchanging high fives. John M. Barry, the author of The Great Influenza, warns that handshaking too could come under fire if the spread of the virus gets worse. "Any specialist would say that shaking hands is not a great habit if you're interested in controlling an infectious disease."

3. It's scarier than religion.
Swine flu is even changing some long-held religious practices: The Archdiocese of New York told Catholic New Yorkers they may refrain from the traditional handshaking at mass. One rabbi in Brookline, Mass., told National Public Radio that he suggested congregants at his temple greet each other with a "Buddhist bow" or an "Obama fist bump" during September's High Holy Days.

Muslims celebrating Ramadan in Kuwait and Lebanon have been advised not to hug, and, if the flu outbreak worsens, mosques could consider asking people to bring their own prayer mats to services. In Spain, Roman Catholics are being asked to refrain from kissing a statue of the country's patron saint, and Italy has banned the kissing of two vials thought to contain the blood of a saint.

4. Schools, workplaces, and day-care centers are changing policies.
Telling an entire country or religious congregation to stop shaking hands or kissing may prove tricky to control, however. "It's easier to implement when a school or an institution or a company collectively decides, 'We're not going to do this for the duration of this epidemic,'" says Pascal James Imperato, MD, a dean and distinguished professor of public health at SUNY Downstate Medical Center, in Brooklyn. And many are doing just that.

Colleges have updated handbooks to urge students and professors to stay home with even the slightest feeling of illness and to frequently clean often-touched objects in their dorms, such as remote controls and doorknobs. Offices are creating policies allowing employees to work staggered shifts or providing them with the materials needed to work from home. And day-care organizations have urged parents to consider making back-up plans should the centers need to cut their services with short notice.

5. People are scared to eat pork.
China, Russia, and Ukraine were quick to ban pork produced in the United States when the virus was first detected, and soon a total of 27 countries had followed suit. The boycotts have wreaked havoc on the pork industry, causing the government to actually bail out farmers who have been forced to sell their pork at lower costs, Time magazine reports.

The irony, of course, is that it's not at all possible for H1N1 to spread through eating infected bacon or hot dogs—and even so, there have been zero cases of infected pigs in the United States. The H1N1 virus actually has avian, swine, and human genes, and it may not even make pigs sick, scientists say. Unfortunately for pork producers, "swine flu" is a much more sensational and media-friendly name.


6. Tourism to Mexico has suffered.
When the first cases of swine flu were thought to have originated in Mexico, the Centers for Disease Control and Prevention initially recommended canceling all travel plans south of the border unless the trip was absolutely essential. Three weeks later, the warning was lifted.

The WHO now insists that international travel does not need to be restricted. Barry agrees: "At this point, the virus is everywhere," he says. "Where are you not going to go to avoid it? But that doesn't mean that there aren't people who wouldn't be a little panicked."

Those panicked travelers delivered quite a hit to Mexico's tourism industry, which was already in trouble due to violence- and drug-related publicity. Travel website TripAdvisor.com reported a 50% decrease in searches for Mexican destinations by May, according to SmartMoney.com. Hotels and airports sat empty in May, and airlines flying to Mexico have also reported millions of dollars in losses that they claim are flu-related.

The good news? If you still want to go, you can get flights and hotel rooms on the cheap.
Quickly after the virus first surfaced, consumers became caught up in the hype about the pandemic, says Dr. Imperato; they turned to whatever precautionary merchandise they could get over-the-counter. Logical purchases included face masks and antibacterial soaps, but plenty of other companies have cashed in on the marketing craze in over-the-top and even unrelated ways, as well.

There are flu kits (complete with full-body suits), swine-flu-spam computer-virus protection, a viral stop-the-spread online game, and, of course, all sorts of pig paraphernalia.

8. Coughing and sneezing are practically federal crimes.
Symptoms of sickness may not be against the law quite yet, but there does seem to be an abundance of dirty looks going around in response to simple public throat clearing. It seems that everyone is more aggressively cautious of coughing and sneezing in public, and perhaps rightly so.

A simple sneeze sends as many as 100,000 droplets of germs from your mouth and nose into the air within 3 to 5 feet at about 100 miles an hour, according to CNN's AC360°. The germs can then hang in the air for up to a minute, so even if the droplets don't land on a nearby person, he or she could still walk through the germy cloud and catch a virus. Even worse, coughing or sneezing into a hand and then touching a public space, like a subway pole, a door handle, or a shared computer keyboard, spreads the range of the germs. But even if you've seen dirty looks exchanged on the train or in the grocery store, it's probably a mild reaction compared to what Asian countries—which suffered through a deadly SARS epidemic in 2002 and 2003—are now experiencing. Jane Parry, a science journalist and researcher living in Hong Kong, notes that the emergence of H1N1 has strongly reinforced flu prevention techniques and attitudes about germ transmission.

"Handshaking fell out of favor during SARS, and it's totally acceptable now to not shake hands, especially if you are wearing a face mask," Parry says. "It's considered common courtesy now to wear a mask when you have a cold to protect others. Once swine flu came along, that expectation that you wouldn't cough near anyone else became even more pronounced. People would visibly reel away from you if you coughed."

In schools in Hong Kong, children with runny noses or coughs are required to wear masks, and any child with a fever is automatically sent home, Parry adds. Staff members working in food stores are also required to wear masks at all times, and Asian people are much more likely to wear face masks on airplanes, where air is filtered and recirculated through the cabin.

These measures may seem over-the-top to Americans, but is it possible they could become commonplace throughout the world? Only time will tell. For now, remember traditional cold and flu etiquette: Cough or sneeze into a tissue, or at least use your elbow and sleeve (instead of your hands) to cover your mouth.

Warning avoid spitting

London, England A UK health agency has warned footballers to stop their "disgusting" habit of spitting as it could lead to the spread of the H1N1 virus.

A spokesman for the country's Health Protection Agency was quoted by the Press Association as saying: "Spitting is disgusting at all times. It's unhygienic and unhealthy, particularly if you spit close to other people.

''Footballers, like the rest of us, wouldn't spit indoors so they shouldn't do it on the football pitch. If they are spitting near other people it could certainly increase the risk of passing on infections."

''It's about setting examples for young people who idolize them,' the spokesman was quoted as saying.

The warning comes after several football teams were struck by the virus commonly known as swine flu, including English Premier League football clubs Blackburn Rovers and Bolton Wanderers and French team Paris St. Germain.

The French football league sparked controversy last Sunday when it decided to postpone a match between PSG and Marseille because PSG players Ludovic Giuly and Mamadou Sakho and two members of the coaching team were diagnosed with the H1N1 virus on Saturday.

"What would people have said if the match had gone ahead and the Marseille team had caught the virus? The medical commission gives us their professional opinion. We have to follow it as much as we can," said Frederic Thiriez France's football league president.

The Health Protection Agency later tried to play down the spokesman's comments, saying he had been "misinterpreted."
Spokeswoman Louise Brown told CNN: "Spitting is not a major cause of spreading swine flu infections. Our general advice is that people who have swine flu should stay at home."

She added: "For people with flu, it is essential that they wash their hands if they have coughed or sneezed onto them in order to destroy the virus and help to stop infecting other people."

Global swine flu deaths slow – WHO

Death toll passes 6,250
First Posted 07:40:00 11/14/2009

GENEVA - More than 6,250 people have died in the swine flu pandemic, World Health Organization data showed Friday, as the global death rate appeared to slow.

The number of deaths from the A(H1N1) pandemic in the week to November 8 grew by about 179, against 224 a week earlier and a leap of about 700 in the last week of October.

The pandemic now stretches across 206 countries or territories worldwide, the WHO added in a statement on its website.

The UN health agency said the influenza season showed signs of peaking in North America, but was intensifying across much of Europe and Central and Eastern Asia.

"Very intense and increasing influenza activity continues to be reported in Mongolia with a severe impact on the health care system," it added.

But the WHO found after investigating the sudden reported surge in flu cases in Ukraine in recent weeks that the swine flu virus had shown no signs of becoming stronger.

"The initial analysis of information indicates that the numbers of severe cases do not appear to be excessive when compared to the experience of other countries and do not represent any change in the transmission or virulence of the virus," the statement said.

The Americas still account for the largest number of deaths, 4,512 since the pandemic virus was first identified in April in Mexico and the United States, an increase of 113 in a week.

However, the number of deaths reported in Europe stayed stable at least 300, with signs that the pandemic caseload was peaking in parts of Britain, notably Northern Ireland, as well as in Ireland and Iceland.

Sharp increases in cases were reported in several western and southern Asian nations, including Israel and Afghanistan in recent weeks, while growing numbers were reported in China and Japan.

Pandemic flu was largely on the wane in most of south and southeast Asia and in the warming southern hemisphere.

Respirator or face mask is it best for H1N1 protection?

A preliminary report suggesting that N95 respirators -- filtering devices worn over the mouth and nose -- protect against swine flu better than surgical face masks seems to be incorrect, researchers revealed during a meeting of the Infectious Diseases Society of America (IDSA).

In fact, surgical face masks, which are cheaper and easier to wear, may be just as good as N95 respirators. At the very least, researchers can't prove that one is better than the other. It's the latest wrinkle in a continuing debate over how to protect health-care workers from the H1N1 virus, also known as swine flu.

Raina MacIntyre, Ph.D., a professor of infectious diseases epidemiology and the head of the University of New South Wales School of Public Health and Community Medicine, in Sydney, Australia, says the research team didn't exactly retract the findings.

"We simply did the analysis of the same data differently for the final paper," she explains.

For the new analysis, the researchers removed a control group of nearly 500 health-care workers and made other statistical adjustments. Ultimately, the difference in infection rates between mask and respirator users was not statistically significant.

"[The study] still shows a likely superiority of N95s, with half the rate of infection compared to surgical [masks]," MacIntyre says. "But the study was probably underpowered to pick up statistical significance when we removed the control group."

"I would certainly wear an N95 respirator if I were exposed to infectious patients," she adds.

The N95 respirator is a tightly fitted facial mask designed to filter out even very fine airborne particles, according to the U.S. Food and Drug Administration. Looser-fitting surgical masks protect against large-particle droplets, splashes, sprays, or splatter, the FDA says, but they don't completely block the germs from coughs and sneezes.

To figure out which protective device is best, MacIntyre and her colleagues tracked hospital workers in Beijing, China, who wore surgical masks or N95 respirators, and compared rates of influenza and respiratory illness. Preliminary findings were presented at a meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy in September 2009. Final results have yet to be published.

The only other randomized clinical trial comparing health-care workers' use of respirators and surgical masks was published online in October 2009 in the Journal of the American Medical Association. Canadian researchers reported no difference in influenza rates among nurses using one type of protective device versus the other.

Both studies helped inform an Institute of Medicine (IOM) panel that, in September 2009, issued a report recommending the use of fitted N95 respirators by health-care workers who interact with patients with confirmed or suspected cases of H1N1. (MacIntyre was also a member of that panel.) However, because the two studies were preliminary, the committee said that it could not draw conclusions from either.

"The take-home message for me is that, in clinical settings, wearing a mask or an N95 appears to be essentially equivalent," says Mark E. Rupp, M.D., a professor of infectious diseases at the University of Nebraska Medical Center in Omaha and president of the Society for Healthcare Epidemiology of America (SHEA).

Data presented at the IDSA meeting also highlighted the problems with N95 respirators, Rupp says. Health-care workers say that the respirators are uncomfortable and more difficult to wear than face masks, and that they make it hard to speak with patients, among other problems, he explains. They're more expensive too.

Although respirator use made sense at the beginning of the swine flu pandemic, it now appears that H1N1 behaves similarly to seasonal influenza, Rupp says, so "it doesn't make much sense to be using different precautions for seasonal flu than we use for H1N1."

The SHEA would like to see federal guidelines revised, he says.

Still, government health and safety organizations are standing by the more stringent standard of protection.

IOM spokeswoman Christine Stencel says that the National Institute for Occupational Safety and Health and others have provided "convincing data" on the ability of the respirators to filter out a large percentage of tiny particles.

"Based on all the available evidence and data that the committee had to look at, [it recommended] that the N95 respirator afforded the best potential protection against airborne transmission of the virus, and therefore that was the recommendation for health-care workers in terms of respiratory protection," she says.

The Centers for Disease Control and Prevention developed its policy independently of the IOM and the MacIntyre study, explains CDC spokesman Jeff Dimond. However, it's similar in terms of respirator use. The CDC recommends that health-care workers in close contact with people with suspected or confirmed H1N1 influenza use a properly fitted, disposable N95 respirator, or something that offers similar or better protection.

The current recommendation is based on unique conditions associated with the existing pandemic, including low levels of population immunity to 2009 H1N1, the potential for health-care personnel to be exposed to H1N1 patients, and other factors, Dimond says.

In October 2009, the Occupational Safety and Health Administration (OSHA) said it would soon issue a "compliance directive" to ensure that health-care facilities have controls in place to protect workers from occupational exposures to swine flu. OSHA said its directive would closely follow the CDC's guidance.

In Rupp's opinion, the respiratory protection debate has distracted from other crucial flu-fighting measures. These include:

• Quickly identifying and isolating patients with influenza-like illness.

• Preaching respiratory etiquette programs. Patients who are ill should be asked to wear a surgical mask to contain their secretions, he says, and they should use tissues and wash their hands frequently to prevent touch contamination.

• Encouraging hospital visitors to stay home if they're sick and urging health-care workers to stay home when they're sick.

• Getting seasonal and H1N1 vaccines. "For health-care workers, that is by far the best way to protect them," he says.

World Health Organization says that the H1N1 is now the world's dominant flu virus

The H1N1 virus has now become the dominant influenza virus around the globe, with high levels and an increase of activity in many regions, the World Health Organization said Thursday.

In a weekly update, the WHO's point person on the H1N1 virus, Dr. Keiji Fukuda, also warned the public not to treat the virus like just another flu.

Like seasonal flu, H1N1 is more active in the winter than in the summer, and a majority of infected people get better on their own, Fukuda said. H1N1 also is as transmissible and infectious as seasonal flu, he said.

But unusually for influenza, Fukuda said, H1N1 continues at high levels over the summer months, and many of the serious illnesses and deaths are concentrated in people younger than 65.

Seven months into the pandemic, the virus commonly known as swine flu remains at high levels and continues to increase in North America, Fukuda said. Mexico, for example, has seen more cases from September to November than they saw in the preceding months from April, when the virus emerged, he said.

The virus is also becoming more active in Europe and Central and Western Asia, Fukuda said.

Health officials this week reported an outbreak of cases in Ukraine, which now has more than 250,000 cases of influenza-like illness, with 235 patients requiring intensive care, the WHO said.

Activity is picking up in East Asia, Fukuda said. Mongolia reported "a number" of cases over the past week, he said.

"East Asia is one of the parts of the world where seasonal influenza viruses have remained in reasonably high circulation," Fukuda said. "But even in that part of the world, the pandemic virus is becoming dominant."

More cases are being reported from a number of Caribbean countries such as Cuba and Haiti, he said.

In Central America and the Southern Hemisphere, however, activity levels have dropped as those regions enter the summer season, Fukuda said

"There are several regions in the world -- North America, Europe, Northern and Central Asia -- where we are clearly seeing pandemic influenza activity increase," he said, but "there is no one single place in the world where we are focused on."

Disease activity has been difficult to predict, Fukuda said.

"We really are not going to know what the future is going to bring, and so the main focus of our effort here is ... what steps are needed to make sure countries are as prepared as possible to deal with disease levels," he said.

H1N1 poses different challenges in different countries, but it does seem to be affecting indigenous groups more heavily than non indigenous groups, he said.

In Australia, for example, "aboriginal groups are disproportionately represented in people who end up in hospitals from diseases related to the pandemic," Fukuda said.

The WHO still doesn't know whether the effect on indigenous groups is because of the pandemic itself or because of underlying factors.

Because most people infected with swine flu tend to recover on their own and don't suffer major problems afterwards, some people are tempted to dismiss the infection and think it's not serious. But Fukuda said that's a dangerous mind-set.

"At WHO, we remain quite concerned about the patterns we are seeing, particularly because a sizable number of people develop complications [that lead to death]," he said. "We do see that the serious complications are concentrated in the younger age groups rather than the older age groups."

While the complications are most often seen in people who have chronic, underlying health conditions and in pregnant women, they also can develop in people "who are currently healthy and young."

But contrary to some reports, Fukuda said, the WHO has not seen big mutations in the virus since it first emerged. He said viruses being isolated now are "generally similar" to those isolated over the past several months, indicating they haven't changed much.

The WHO also has no evidence of widespread resistance to antiviral medication, Fukuda said. There have been sporadic instances of resistance to oseltamivir -- the generic name for Tamiflu, one of the main drugs used against influenza -- but such cases are still "isolated and infrequent," he said.

"Antivirals are quite useful against these infections," he said.

Fukuda praised as "innovative" the decision by Norway to distribute antiviral medication over the counter for a limited period of time. The move can help take stress off the primary health system and allow patients to get the medicine more quickly, he said.

Other useful protections against H1N1 are vaccines, which the WHO recommends against pandemic infections, Fukuda said.

"These vaccines now have been used in a significant number of countries ... and based on this experience, in which millions of people have now received vaccine, we in fact see that these vaccines are very safe," he said.


The only side effects are swelling and pain at the injection site, but "these are occurring at rates that are expected and usually seen with seasonal influenza vaccine," Fukuda said.

"WHO, along with other public health authorities, believes that these vaccines are very useful against pandemic infections and [we] do support their use," he said.

How to avoid germs in the time of H1N1

'On a recent flight from San Francisco, California, to Atlanta, Georgia, Dr. Julie Gerberding was thrilled to get bumped up to first class. The thrill, however, quickly disappeared: As she did her victory walk to the front cabin, she noticed that the woman in the seat next to hers was hacking up a lung.

"She was on her cell phone, saying, 'I feel miserable. I just know I have swine flu,' " Gerberding remembered. "I thought to myself, 'Oh, great.' "

For the duration of her transcontinental flight, Gerberding played viral roulette as she sat shoulder-to-shoulder next to Ms. Sneezy in a confined space.

Gerberding, the former director of the Centers for Disease Control and Prevention, had a few strategies for avoiding this woman's germs, some of which you can use on planes, trains, automobiles and anywhere else if you get stuck next to Typhoid Mary or, in this case, H1N1 Mary.

Gerberding's first step was to point the air vent in the ceiling toward the sick woman and away from herself.

"That helped point the germs towards her and away from me," she said.

She then pivoted her body -- she was sitting on the aisle seat -- away from Ms. Sneezy.

"There wasn't much else I could do. At some point, I just crossed my fingers," Gerberding said.

Actually, Gerberding realized later there was one more thing she could have done.

"I could have approached a flight attendant and said, 'The person sitting next to me has swine flu. Could you please offer her a mask?' In retrospect, I wish I had done that."

On airplanes, you're most likely to catch an illness from the people sitting in your row and in the row behind you, according to researchers at Purdue University, who developed an animation showing how germs move around an airplane.

"The bad news is if you're in that strike zone, you're at risk," Gerberding said. "If someone sitting right near you has the flu, there's a pretty good chance you'll get it. Flu is very transmissible."

Watch how easily germs spread

Gerberding adds that you probably won't catch the flu from someone sitting several rows away, since circulating air on planes goes through a HEPA filter. "

The good news is, if you're not right in that strike zone, you're probably at low risk," she said.

Whenever you're out in public, you can catch a germ from anyone within about six feet of you; that's how far some germs can travel, according to Dr. Rhonda Medows, commissioner of the Georgia Department of Community Health.

"Air droplet spray actually comes into your body. You're inhaling it. You're breathing those respiratory droplets," Medows said.

Another way you can catch a germ from someone is if you touch something a sick person has touched. For example, think about a busy escalator handrail.

"You and millions of others have touched it," Medows said. "And they could be sneezing, wiping their nose, coughing in their hands, and then they touch the handrail."

Watch secret -- and not so secret -- sources of germs

If you're healthy, your immune system should be able to fight off most of what's on a germy handrail, but even if you're in tip-top shape, chances are you have no immunity to the H1N1 virus, since it's so new.

Medows' strategy: After you touch something like a handrail, make a conscious effort not to touch your eyes, nose or mouth, and use hand sanitizer as soon as you can.

The National Institutes of Health offers more advice about preventing the spread of germs.

Charles Gerba, a microbiologist at the University of Arizona known as "Dr. Germ," says his research shows that another potential bastion of germs are water fountains. Some schools have actually shut down their water fountains for the duration of flu season.

But you don't have to avoid water fountains. Gerberding says that if you want to drink from a fountain, follow these simple steps: Don't let your lips touch the spout, and before taking a sip, let the water run for a few seconds to flush away germs. Also, wash or sanitize your hands afterward, since the bar or button that turns on the fountain has probably been touched by many other hands before yours.

Watch what you can do to avoid germs

You might be wondering why Gerberding didn't go back to her seat in coach or ask for another one when she saw she'd be sitting next to Ms. Sneezy in first class.

"It was a full flight ,so someone else would have had to sit next to her," she explained. "And I'm healthy, so I figured if someone had to be near her, better me than someone who's immune-compromised in some way."

By the way, Gerberding didn't get sick from Ms. Sneezy on that long flight from San Francisco to Atlanta. She says she doesn't know whether it's because of her germ-prevention strategies or just dumb luck.

Asthma and swine flu: Here's what to do

Nearly one-third, or 28 percent, of adults and children hospitalized with H1N1, also known as swine flu, have asthma. That's more than any other chronic condition, according to a recent analysis of cases published in the New England Journal of Medicine.

(The next most common complications on the list were diabetes and a weakened immune system, at 15 percent each.)

"Asthma was the most common underlying medical condition that we saw," says Seema Jain, M.D., a medical epidemiologist at the Centers for Disease Control and Prevention. Jain's team analyzed 272 people who were hospitalized with swine flu for more than 24 hours between April and June.

Twenty-five percent were admitted to the intensive care unit and 7 percent died. Overall, 29 percent of children and 27 percent of in adults in the study had asthma, while only about 8 percent of the U.S. population has asthma, according to Jain.
Richard Gower, M.D., the president of the American College of Allergy, Asthma and Immunology, says about 25 million people in the United States have the chronic lung condition, including 8 million children.

Asthma is more common in children than in adults, and swine flu seems to strike younger people more often than older ones - a complete flip-flop from seasonal flu.

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In the study, 45 percent of the hospitalized patients were under age 18, and only 5 percent were 65 or older. "If you are a young adult and you have asthma, you are in double jeopardy," says Gower.

For many people, swine flu symptoms include fever, congestion, and possibly nausea, diarrhea, and vomiting, which are some of the symptoms that differ from seasonal flu. (Seasonal flu rarely causes nausea or an upset stomach).Most of the time, swine flu symptoms can be successfully battled with time, liquids (chicken soup, anyone?) and bed rest.

But for people at high risk, including those with asthma, an H1N1 infection can be a different story

"Asthma is sort of an accident waiting to happen," says Gower, who is also an allergist/immunologist at Marycliff Allergy Specialists, in Spokane, Washington. People with asthma are at risk for breathing trouble with infections in general, not just H1N1.

The lungs of people with asthma tend to bronchospasm, meaning they tighten in response to triggers, such as pollen, pet allergens, bacteria, viruses, or other insults. In the case of an infection like H1N1, the lungs produce mucus in response to the germ, and the mucus can get trapped in the narrow airways, setting the stage for pneumonia.

10 best big cities for people with asthma

"You add an insult and it just triples, quadruples, gets 10 times worse very suddenly, and flares the asthma," says Gower. "The bronchospasm occurs and it squeezes the airways dramatically down to narrow, narrow passages -- and, in fact, closure -- and the mucus that is dramatically increased gets trapped and that's a setup for pneumonia."

So what should you be doing about H1N1 if you or your children have asthma?

Take your medication

People with chronic asthma often need to take controller medications that fight underlying lung inflammation. The problem is, they need to take this type of medication every day, even if they are feeling fine. It can help protect the lungs from triggers such as infections.

But many people forget to take the medicine or skip doses when they aren't having asthma symptoms.

If you have a young child with asthma, make sure they take their medication as directed, says Gower. It gets tricky if your child is a teen, because they are notorious for skipping asthma medication, and may lie about it too, he says.

Parents need to talk to teens and explain that although they may have gotten away with skipping asthma drug doses in the past, "this is a brand new ball game," he says. "They really should raise the threshold of their lungs by taking chronic medicines if they have chronic asthma."

How to tell if your child's asthma is under control

Gower also recommends that patients have -- and use -- a peak flow meter, which is a device that you can blow into to gauge lung function.

"It empowers the patient or the parents," says Gower. "Even if the patient says they are doing fine and they are giving their best effort to blow into the peak flow meter and it's going down and it gets into the yellow zone then into the red zone, that's a real warning sign that that asthma is getting worse no matter what you are doing."

Get vaccinated

Being in a high-risk group for H1N1 means that people with asthma should get the vaccine as soon as possible, says Gower.

"They have a vaccine that's good; it's made the same way as the regular flu shot that's been out for many, many years, so they really shouldn't worry more about the side effects on [the H1N1 vaccine] than the other one," says Gower. "I think it's very safe. I think they should take it if they meet any of the criteria."

Although there is a nasal spray version of the H1N1 vaccine, people with asthma should wait for the vaccine administered as a shot, according to the CDC. The nasal spray contains weakened H1N1 virus and is not recommended for high-risk individuals. The shot contains dead virus, which is safer for asthmatics.

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"People with asthma would be a group that would be considered high risk; they should wait for the shot to come out," says Jain. "Remember the seasonal influenza shot is available; they should be able to get that." People with asthma are also at risk from seasonal flu, she notes, so they should get that shot now.

Because of vaccine shortages, people may have to wait for an H1N1 vaccine. Only 28 to 30 million doses will be available in October 2009, according to the CDC. (Earlier in the year, it was estimated that there would be 120 million by then.) Children ages 6 months to 8 years will need two doses of the flu vaccine, which are given four weeks apart.

In the meantime, if you (or your child) have asthma, one of the best things you can do while H1N1 is circulating is to try to avoid infection in the first place, says Gower.

You may want to consider skipping parties or other events if there will be children attending who could be ill. "You can communicate by phone, congratulate them, but don't go over and step into the lion's dens, so to speak, of infection," he says. He also recommends that parents reinforce public health recommendations to wash hands, and to cover coughs and sneezes.

"You can teach your children that as well and protect others from them and protect them from others," he says.

Get rapid treatment if you do get sick

If you do have asthma and get sick with H1N1 symptoms, you should call your doctor, experts say. "They don't necessarily have to go in to see the physician, but they need to contact them if they have high risk conditions," says Jain.

However, if it's a child with asthma who is not doing well -- say, they have a fever of 103° or 104° and are getting worse -- Gower recommends getting help sooner rather than later.

How safe are asthma drugs?

"You can be exposed to things in the hospital, but if you're that sick, with H1N1 going around, and a respiratory flare, I think it's better safe than sorry," he says.

Jain also notes that her study found that early antiviral treatment of hospitalized patients really helped -- the sooner, the better.

Although most of the patients had antivirals in the hospital, they found that those who ended up in the ICU or who died tended to get antiviral drugs (such as oseltamivir, zanamivir, amantadine, and rimantadine) later than others.

"If you look at the timing of it, you'll see that patients in ICU or who died were not treated within two days," she says. "The median time of onset of illness to initiation of antiviral was three days versus five days, so basically the patients who were most sick had a delay in treatment."

However, zanamivir (Relenza) is not recommended for treating people with asthma because of a risk of side effects, including bronchospasm, according to the CDC.

Jain says it's important to focus on both vaccinations and rapid treatment for very ill patients.

"The main issue here is antiviral use; that's one of our main findings," she says. "We really would like to emphasize [that] there's vaccination, and that's an important message and that's out there, and you see that in the media, but I think the fact that antiviral also should be utilized in patients who are hospitalized is also key."

Pregnant mother, pregnant daughter fights H1N1

Lancaster,California - Nancy Brizendine's slow-paced life in California's Antelope Valley has become something of a slick race track.
The first stunner, at 42 years old, in her 11th year of taking birth control pills, was that Brizendine and her live-in boyfriend and fishing buddy were expecting a baby.

"I was shocked. I didn't even think I could get pregnant," Brizendine said.
But concern over having a baby in her 40s soon gave way to the joy of becoming a mother for the third time.

Then, about 2½ weeks ago, came another sudden turn. Brizendine, a medical assistant, caught the H1N1 flu virus.
"I had a cough, sinus infection, infected ear, fever, and that's when I went into urgent care and tested positive," Brizendine recalled. "There were times when I honestly could not get out of bed because I was so sick and achy."
Brizendine began worrying about how the swine flu would affect her baby, due in January.

"There are not a lot of studies at this point as to how the babies are affected," said Dr. Anthony Dulgeroff of the High Desert Medical Group, one of Brizendine's doctors.

"One would think that since the virus doesn't cross the placenta, probably not too much of a threat that we know of," he said. "There are very high fevers in the mother that could affect the baby, but we really don't know 100 percent."

Brizendine had been preparing for another baby. Her 22-year-old daughter, Kayla Yost, is expecting a girl at the end of this month.
While Brizendine battled the virus, Yost, too, suddenly showed all the signs of H1N1. She was hospitalized and in a battle for her life.

"I was coughing really bad," Yost recounted. "It was like nonstop. My stomach was in pain because the [cough] was so deep. I was hyperventilating because I could not breathe."
Dulgeroff says Yost could have died.
She had contracted pneumonia in both lungs. She was getting oxygen and food through tubes.

Her mother began thinking perhaps she'd been dealt a strange twist of fate.
"I thought, is God giving me this [unborn] baby because he is going to take my other baby?" Brizendine said, tears trickling down her cheeks. "It was hard because I had to sit there and cry."

Brizendine says she was torn over wanting to be there to help Yost and being concerned for her unborn daughter.
Brizendine recovered at home, but Yost remained hospitalized.
"I was just like, I got to get off the oxygen, the breathing treatment, and get out of the hospital," Yost said.

After seven agonizing days, Yost was released from the medical center in Lancaster.
Doctors say H1N1 seems to cause the most serious complications in young patients and pregnant women. Yost, at 22, was right in the center of the bull's eye.
Brizendine believes that her advanced age for a pregnant woman, 42, actually lessened the potential pain.

Doctors stress prevention for all pregnant women: Do everything to try to avoid getting H1N1.
"Wash your hands," Dulgeroff advised. "Try not to touch your face; avoid public and crowded places. Stay away from people who are coughing. Avoid medical buildings, unless you have to go to your appointments."

The mother and daughter recommend H1N1 shots for pregnant women.
"After going through the symptoms and everything," Yost said, shaking her head in disbelief. "You have to realize it's not just you, it's your baby, and you have to protect both of you."

During her decades as a medical assistant, Brizendine took peeks at the soap opera "Days of Our Lives" during her lunch break.
Brizendine plucked Yost's name from the show, and her soon-to-be-born baby, Sydney, also takes her name from "Days."

The mother and daughter giggled and rubbed their bellies as if for good luck, thinking about Sydney's niece -- Yost's daughter -- who will be called Bobbi Ann. She will be about a month and a half older than her aunt Sydney.
Both expectant moms feel relieved to have survived the ravages of the H1N1 virus.
Brizendine summed up her topsy-turvy 2009 and H1N1: "It's just crazy that we got it at the same time."

The mother and daughter live a mile from each other in the Antelope Valley town of Rosamond, where they like to joke that nothing ever happens.
That's until this year, when Brizendine and Yost, already close on so many levels, shared a story they will no doubt tell to the unborn girls.
It's the tale of how all four of them survived when the H1N1 virus came knocking on the door a couple weeks before Halloween.

Swine Flu to-do (and don't do) list

Swine flu vaccines are rolling out this month -- finally. Health-care workers in Indiana and Tennessee were the first to get the nose-spray version, while New Yorkers clamoring for the H1N1 vaccine finally had their chance too.
However, the onslaught of information about H1N1 -- be it playground rumors, employer signs telling you to cover your cough, memos from your kids' school, or scary-sounding news reports -- is making it pretty hard to figure out what you should be doing right now.

Although some people have already been vaccinated, it could be weeks -- depending on your age and risk factors -- before you even get a chance at the shot (or spray). So now what?

Sometimes it feels like you have two choices. A: Wring your hands endlessly about something over which you have no control. Or, B: Tune out the static and pretend this is all just a horrible dream. (Call it the ignore the whole sorry mess until my neighbor is sick approach.)

Well, guess what? There are a few things you should -- and should not -- be doing at the moment. Here's your guide.

Look up local flu outbreaks.

If you're getting most of your news from the Internet -- and about 40 percent of people say they do -- you may not be up on H1N1 activity in your community.
Take the time to check local flu activity on the online version of your local newspaper (remember those?) or health department, or check out Web sites like Google Flu Trends (though keep in mind that this map is based on search trends and could be skewed if lots of healthy people are searching for information). There's also FluTrends, which is produced by Rhiza Labs, and includes past cases and current activity, or the Centers for Disease Control and Prevention's (CDC) weekly flu update.

If your city or state is a bit of a hot spot, you may need to focus on some of these to-do points sooner than others. The good news is that some of the hardest hit areas in spring -- like New York -- don't seem to have that many H1N1 cases at the moment. (Experts estimate that up to 1 million New Yorkers may have had H1N1 in the spring, which would protect against subsequent infections.)

Don't panic.

For most people, an H1N1 infection is generally mild and can be cured with time, bed rest, and fluids. The virus is serious, though -- particularly for those in high-risk groups. So far this year, 28 pregnant women have died of H1N1, and 76 children died in the spring. "At least two-thirds of [the children] had underlying conditions, which we recognize as putting them at increased risk for complications," says Dr. Nathan Litman, the chief of pediatric infectious diseases at the Children's Hospital at Montefiore, in New York City. High-risk people, whether adults or children, tend to have chronic heart or lung conditions (including asthma), weakened immune systems due to disease or chemotherapy treatment, or diabetes.

That said, H1N1 will feel like seasonal flu for most people. "I'd say at the present time the swine flu looks no more serious than the routine seasonal influenza," says Litman.

Stay home.

Are you sick right now? Say, with flu-like symptoms such as fever, aches, stuffy nose, and chills? Sorry, but it's quite possible you already have swine flu. Experts say that flu activity is higher-than-normal for this time of year and almost all of it is due to H1N1. If you (or your child) are not in a high-risk group, it's best to stay put.

If a child is 2 or older "and has no risk factors for complications and has fever, runny nose, or cough, the best thing to do is to stay home," says Litman. "Plenty of fluids, Tylenol, Motrin, or Advil for fever, and it should run its course on its own."

If a child has difficulty breathing, is unable to take fluids, or starts to be less responsive, or after appearing to recover from the influenza develops a fever and starts coughing again, then see a doctor.
If you are pregnant and have flu symptoms, it might be best to call your doctor before going in to see him or her, says Litman.

"They may want to set up a separate location to be seen or separate times to see sick patients," he says. "You don't want the pregnant woman with influenza who is coughing and sneezing to go into the room with pregnant women who are well and just there to get routine prenatal care."

Understand the risks.

While the symptoms of H1N1 may be no different from seasonal flu, there are some key differences. H1N1 may be easier to catch than regular flu, and younger people may be more likely to come down with it than older people.

"From what I've seen, I actually believe it to be more contagious," says Litman. Often with the seasonal flu that's circulating, a percentage of the population has some immunity to it. With H1N1, it looks like most people -- other than the elderly -- have no immunity to it, and that may be why it appears more contagious, he says.

People who are older than 60 may have been exposed to a swine-flu-like virus in the distant past, which is giving them an edge with this pandemic. That's not to say they can't get sick, but "many of them appear to have immunity from a prior infection with a similar virus or cross reactions with a similar virus that help protect them against the swine flu," says Litman.

Get a seasonal flu shot. The regular seasonal flu shots are available now, and it makes sense to "get the jab" (as the Brits say). While most flu cases happening right now are caused by H1N1, "in two months or three months it may be the regular seasonal flu and we should be prepared for that," says Litman. "Since that vaccine is currently available, I recommend that everyone considered a risk group receive the seasonal flu vaccine." Seasonal flu can be just as dangerous as H1N1; about 36,000 people die, including about 80 children, of seasonal flu every year.

Get a pneumonia vaccine.

What, another shot? For the vaccine wary, this might just feel like one too many pinpricks. However, the pneumonia vaccine, a shot that can help prevent any illness caused by certain types of pneumococcus bacteria, including meningitis and ear infections, may be a good idea too.

The CDC has analyzed H1N1-related deaths and found many people who died had dual infections, including some with pneumococcus. The good news is that if you're up-to-date on your child's vaccines, they probably already have it. Approved in 2001 and called Prevnar, it's routinely given to children.
Another vaccine, Pneumovax, is available for adults, and is recommended for the elderly and those at high risk of infections.

Wash your hands.

Just about every expert is chanting a "wash your hands" mantra. And, in fact, washing your hands with soap and water or using an alcohol rub can help. However, when it comes to flu, just keep in mind that hand-washing may fall into the "can't hurt and may help" category. Because flu virus can hitch a ride on airborne water droplets, you can inhale the virus and get sick even if you wear gloves 24-7 or scrub-in like a brain surgeon. But again, flu viruses can live on surfaces for up to 48 hours. So, yes, wash up. Plus, good hygiene can protect you from other germs, like pneumococcus, which could make a simple case of flu much worse when added into the mix.
Don't stock up on face masks or Tamiflu.

If you're the type of person who hoarded cans of soup and bottled water in 1999 just in case the world ended in 2000, it can be tempting to grab a box of surgical masks "just in case." The CDC and most experts say that's not a recommended or a proven way to prevent infection, although some studies suggest that they can be helpful in homes with a flu-infected family member or when used by hospital workers in place of a N95 respirator.

And while it may seem perfectly harmless to stockpile antiviral drugs, it isn't. If Tamiflu is gathering dust in your medicine cabinet, then people who truly need it may find the pharmacies are fresh out. And the surest route to a drug-resistant flu virus is having people taking it "just in case" or for symptoms that would go away on their own.

Get a swine flu vaccine.

Or at least seriously consider it. Lots of people are not crazy about vaccines in general, and fully one-third of parents say they're going to skip them for their child, according to an AP poll. Understandable. Taking something that could cause side effects, when you feel (or your child feels) perfectly healthy is tough. But keep in mind that if you're thinking about waiting until swine flu is in full force in your community, it may be too late. It can take several weeks after vaccination before your immune system ramps up to full-protection mode.

If you or your child is perfectly healthy, you can get the nose-spray version, which contains a weakened, but not killed, virus. Unfortunately, if you're in a high-risk group, you may have to wait a bit for the version with killed virus, which is given in shot form. Those should be available in mid- to late-October.
While mulling over your options, try not to think of large federal agencies as faceless giants trying to impose vaccines on you. In fact, such agencies are staffed by scientists and doctors who are trying to protect the public.

"Each year approximately 30 percent to 40 percent of children between 5 and 19 years of age get influenza, that not only keeps them out of school for a few days, but they are also the epicenter of the epidemic -- they spread it to household contacts, other school contacts, and high-risk people in the community, like the elderly -- their grandparents," says Litman. "For their benefit and for the benefit of others, it's wise to get both the seasonal flu vaccine and swine flu vaccine."

Don't let the past haunt you. Although the 2009 virus has been tagged with the unfortunate moniker swine flu (just like the 1976 version), there is a world of difference between the two. For one, they are different viruses. And if you were alive in 1976, you were probably digging the bicentennial, groovy pants, and platform shoes, but your chances of getting swine flu were pretty much nil. (There were roughly 200 cases in Fort Dix, New Jersey, and the virus never spread.)

Fast forward to 2009, which is truly a pandemic -- there have been more than 340,000 confirmed cases worldwide and nearly 44,000 confirmed and probable cases in the U.S. alone. (The CDC estimates that more than 1 million people have contracted swine flu, but that their cases weren't recorded because they didn't seek treatment.) And the '76 version did have a problem with side effects, including Guillain-Barré syndrome (GBS), a rare condition in which the immune system attacks nerves, resulting in weakness and even paralysis (although most people eventually recover).
However, the vaccine production used in the 1970s now looks as outdated as your striped bell-bottoms and rockin' sideburns.

"Over the years there have been several improvements in vaccine manufacturing," says Dr. Claudia Vellozzi, the assistant director of the CDC's Immunization Safety Office. "That certainly plays a role in improved vaccine safety now, compared to 1976."
Of the 30 to 40 million people vaccinated for swine flu in 1976, about 1 in 100,000 did develop GBS. However, current research suggests there is little to no GBS risk associated with seasonal flu vaccine.

"There have been one or two studies that showed that if there is a risk, it's very small, or about one in 1,000,000 additional cases of GBS would be attributable to the flu vaccine -- but most studies have not supported any association," she says. (There are 2,000 to 3,000 GBS cases in the U.S. every year, unrelated to vaccines, says Vellozzi. The cause is unknown, but it can be triggered by infections.)
"In terms of our current vaccine, we expect to have a similar safety profile as our seasonal flu vaccine, which has a good track record," she says.

Be prepared.

If you do want to get an H1N1 flu shot, it's best to be patient. It may take weeks before everyone who wants one can get it. In the meantime, think about what you will do if you or a family member does get sick.
"Get immunized, wash your hands, cover your mouth and nose if you're sneezing or coughing, stay home if you're sick, and if any warning signs come up -- difficulty breathing, not responsive as usual, unable to take fluids, or after a day or two of the fever coming down and having more fever and cough again -- see the doctor," says Litman.

Emergency Rooms hustling to keep up with H1N cases

Nate Wordell, 7, just feels lousy: swollen eyes, cough, high fever, stomach ache and he's dehydrated. Nate has H1N1.

After toughing it out for three days at home, Nate's parents brought him to the emergency room at Children's Hospital Boston, Massachusetts. "The hardest thing for us was that we couldn't stay ahead of the medication or get him to keep any water down," says Nate's father, Michael Wordell of Auburndale, Massachusetts.
Hospitals from coast to coast are bracing for the influx of patients, just like Nate. Children's Hospital Boston has seen a 40 percent increase in patients this week alone.

"This could get pretty bad," says Dr. Anne Stack, clinical chief of emergency medicine at Children's Hospital Boston. "So we are trying to do as much as we can to prepare. But no one knows when it will end."

Many hospitals are creating alternative care sites in parking lots or in office buildings to handle an overflow of patients in the weeks ahead. Children's Hospital Boston has designated a conference room as a go-to H1N1 triage center. "We don't have additional space so we had to think outside the box," Stack says.

The conference room can be "flipped" in 24 hours, Stack says. "All we have to do is wheel in portable sinks, exam tables, computer equipment, cots and curtains. Everything is on standby. We're ready."

But some state health officials say emergency rooms are being unnecessarily strapped by children who don't actually need to be there. Most physicians don't test for the virus or prescribe medicine to healthy children who come in with flu-like symptoms.
"The children we are worried about are those who have influenza symptoms and chronic disease [neuromuscular, heart disease, lung disease] or kids under the age of 2. Their immune systems can't fight things off as well, and the severity of their symptoms can grow rapidly," Stack says.

These high-risk children often report having trouble breathing. That's because H1N1 virus lowers the lungs' ability to pump out enough oxygen.
Intensive care units are also preparing for an increase in patients by tapping into reserve medical equipment, machines like the heart-lung device called ECMO or Extracorporeal Membrane Oxygenation. ECMO helps the lungs heal faster by delivering small breaths into the lungs frequently, rather than large breaths less frequently.
This machine helps a child get 900 breaths a minute, which is one of the best ways we treat critically ill children with H1N1," says Dr. Jeffrey Burns, chief of the Division of Critical Care Medicine and director of the Medical/Surgical ICU at Children's Hospital Boston. Burns has treated over 40 critically ill kids so far this year.

Of the children who have died, two-thirds had underlying health conditions, according to the Centers for Disease Control and Prevention. "The children without a pre-existing condition who died appear to have developed a secondary infection after their system was compromised," Stack says.

However, some parents fear not seeking medical treatment will result in their child's symptoms becoming exacerbated and life-threatening. Experts advise parents be alert for symptoms that develop that are uncommon with influenza. The red flags are rash, trouble breathing, no urinating in six to eight hours, mental disorientation or the inability to keep liquids down.

"One thing to not worry too much about is a fever. A fever is one of our body's best defense mechanisms again infection. The H1N1 virus does not like to live at high temperatures, so it is a good protective mechanism," Stack says.

Until the rush of children to the ER slows down, hospitals continue to work on their contingency plans to handle the increase. "I can't stress enough that most parents don't need to bring [their] child to the ER. Lesson Number One is to stay home, manage the fever, watch for worrisome signs."

This is a lesson learned for seven-year-old Nate Wordell and his father. After a few hours in his hometown ER, he was given a prescription to be a "couch potato," then sent on his way home. "He'll probably be back playing with his siblings and back to his old self about two days from now," Stack says.

What is swine flu?

The H1N1 flu, often called "swine flu," isn't related to pigs. It's a new flu virus circulating among people. First seen in April 2009, the H1N1 flu virus has gone on to become a "pandemic," which means that it has been seen worldwide.

The 2009 flu pandemic is a global outbreak of a new strain of influenza A virus subtype H1N1, termed Pandemic H1N1/09 virus by the World Health Organization (WHO), that was first identified in April 2009. The disease has also been termed 2009 H1N1 Flu by the U.S. Centers for Disease Control and Prevention (CDC), and colloquially called swine flu.

The outbreak was first observed in Mexico, with evidence that there had been an ongoing epidemic for months before it was officially recognized as such.The Mexican government soon closed most of Mexico City's public and private offices and facilities to contain the spread of the virus. As the virus quickly spread globally, clinics were overwhelmed by testing and treating patients, and the WHO and the CDC eventually stopped counting all cases and focused instead on tracking major outbreaks. On June 11, 2009, WHO declared the outbreak to be a pandemic.
Only mild symptoms are experienced by the overwhelming majority of victims, but there are exceptions. Some persons are in higher risk groups, such as those with asthma, diabetes, obesity, heart disease, children with neurodevelopmental conditions, or persons who are pregnant or have a weakened immune system. And there are small subsets of patients, even among young persons previously healthy, in which the patient rapidly develops severe pneumonia, typically 3 to 5 days after initial onset of symptoms. Deterioration can be very rapid, with many patients progressing to respiratory failure within 24 hours, requiring intensive care and ventilation support. And there is a somewhat different pattern in which a child, including a child who is generally quite healthy, seems to be recovering and then relapses with high fever. This can be a secondary infection of bacterial pneumonia, which needs treatment with antibiotics.

Like other influenza viruses, novel H1N1 influenza is typically contracted by inhaling air that has been contaminated by an infected person coughing or sneezing, or by touching one's nose or mouth with hands that have previously touched contaminated surfaces and have not been disinfected.
Symptoms, which last up to a week, are similar to those of seasonal flu, and can include fever, sneezing, sore throat, cough, headache, and muscle or joint pains. To avoid spreading the infection, the CDC recommended that those with symptoms stay home from school, work, and crowded settings; in general, wearing facial masks was not recommended, except in health care settings.

Symptoms and severity

The symptoms of swine flu are similar to other influenzas, and may include a fever, coughing (typically a "dry cough"), headaches, pain in the muscles or joints, sore throat, chills, fatigue, and runny nose. Diarrhea, vomiting, and neurological problems were also reported in some cases. People at higher risk of serious complications include people age 65 and older, children younger than 5 years old, children with neurodevelopmental conditions, pregnant women, and people of any age with underlying medical conditions, such as asthma, diabetes, obesity, heart disease, or a weakened immune system (e.g., taking immunosuppressive medications or infected with HIV). Most hospitalizations in the US were people with such underlying conditions, according to the CDC.

A New England Journal of Medicine article on hospitalized United States H1N1 patients from April to mid-June found that 40% of them had chest X-rays consistent with pneumonia. And if the same pattern holds from the 1957-58 pandemic, then approximately two-thirds of these patients had viral pneumonia and one-third had bacterial pneumonia. However, antiviral medication was received by only 73% of the patients, whereas 97% received antibiotics. It is recommended that such patients receive both.

A study from Australia and New Zealand estimated that the demand for ICU beds due to viral pneumonia was much higher during the pandemic than in previous influenza seasons. A Canadian study reported that intensive care capacity in Winnipeg, Manitoba was "seriously challenged" at the peak of the outbreak, with full occupancy of all regional ICU beds. The average age of ICU patients was 32, 40, and 44 years in Canada, Australia/New Zealand, and Mexico respectively.

In adults

In adults, shortness of breath, pain in the chest or abdomen, sudden dizziness, or confusion may require emergency care. In both children and adults, persistent vomiting or the return of flu-like symptoms that include a fever and cough may require medical attention. And if it follows the same pattern as in children, a relapse with high fever may in fact be pneumonia.
Dr. Thomas R. Frieden, Director of the CDC, suggests that people with "underlying conditions" who come down with flu symptoms should consult their doctors first before visiting an "emergency room full of sick people," since it "may actually put them in more danger." This was especially true of pregnant women.

In children

Influenza-associated pediatric deaths reported to CDC, from 2005–06 to start of 2009–2010.
As with the seasonal flu, certain symptoms may require emergency medical attention. In children, signs of respiratory distress include blue lips and skin, dehydration, rapid breathing, excessive sleeping, seizures and significant irritability including a lack of desire to be held. Although "too early" to tell for certain, Dr. Frieden has noted that so far the swine flu "seems to be taking a heavier toll among chronically ill children than the seasonal flu usually does." Of the children who have died so far, nearly two-thirds had pre-existing nervous system disorders, such as cerebral palsy, muscular dystrophy, or developmental delays. "Children with nerve and muscle problems may be at especially high risk for complications," the CDC report stated. In children without chronic health problems, it is a warning sign if they seem to recover from the flu but then relapse with a high fever, Dr. Frieden added. The relapse may be bacterial pneumonia, which must be treated with antibiotics.
Researchers in Australia and New Zealand have reaffirmed that infants under the age of 1 year have the highest risk of developing severe illness from swine flu.

The United States authority on disease prevention, the Centers for Disease Control and Prevention (CDC), recommends that persons suffering from influenza infections:

• Stay at home
• Get plenty of rest
• Drink a lot of liquids
• Do not smoke or drink alcohol
• Consider over-the-counter medications to relieve flu symptoms
• Consult a physician early on for best possible treatment
• Remain alert for emergency warning signs.

Warning signs are symptoms that indicate that the disease is becoming serious and needs immediate medical attention. These include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Dizziness
• Confusion
• Severe or persistent vomiting

In children other warning signs include irritability, failing to wake up and interact, rapid breathing, and a blueish skin color. Another warning sign in children is if the flu symptoms appear to resolve, but then reappear with fever and a bad cough

The Mayo Clinic and Medline listed ways to help ease symptoms, including adequate liquid intake and rest, soup to ease congestion, and over-the-counter drugs to relieve pain. Aspirin was a very effective way to treat fever in adults, although in children and adolescents, aspirin is contraindicated due to the risk of Reye's syndrome. While over-the-counter drugs relieve symptoms, they do not kill the virus. Most patients were expected to recover without medical attention, although those with pre-existing or underlying medical conditions were more prone to complications.

The initial outbreak received a week of near-constant media attention. Epidemiologists cautioned that the number of cases reported in the early days of an outbreak can be very inaccurate and deceptive due to several causes, among them selection bias, media bias, and incorrect reporting by governments. Inaccuracies could also be caused by authorities in different countries looking at differing population groups. Furthermore, countries with poor health care systems and older laboratory facilities may take longer to identify or report cases. Dr. Joseph S. Bresee (the CDC flu division's epidemiology chief) and Dr. Michael T. Osterholm (director of the Center for Infectious Disease Research) have pointed out that millions of people have had swine flu, usually in a mild form, so the numbers of laboratory-confirmed cases were actually meaningless, and in July 2009 the WHO stopped keeping count of individual cases and focused more on major outbreaks.