Article by Bill Peckham

This year, besides the seasonal flu, we face a new flu virus that has already spread around the globe. You can take steps to protect yourself and your loved ones from both types of flu.

About influenza

Influenza, or “flu”, is type of virus that affects birds and mammals and can spread to people. In humans, there are two main types of flu: A and B, and both can circulate at the same time. Types A and B flu cause seasonal breakouts nearly every winter.

Type A flu viruses are divided into subtypes based on two proteins on the surface of the virus:

• Hemagglutinin (H)
• Neuraminidase (N)

Viruses spread by taking over cells in the host’s body. The H protein is like a ‘key’ used by the virus to get inside the host cell. Once inside it can take over the cell and produce more virus. The N protein is the ‘key’ used by the virus to break out and spread once it has reproduced.

There are 16 H proteins and 9 N proteins.¹ In theory, any H protein can combine with any N protein to form a new subtype of flu. In practice, most type A flu in humans is caused by the subtypes H3N2 or H1N1.² These are the two seasonal flu subtypes we have faced in recent years.

Flu subtypes can be further broken down into strains. Right now, we have two strains of H1N1, a seasonal strain and the new strain: pandemic H1N1. Pandemic H1N1 virus bears little resemblance beyond its name to the seasonal flu. It is a new combination of bird, human, and swine viruses.

We have all been exposed to the seasonal H1N1 virus over the years. But, the pandemic H1N1 strain is novel: it has changed enough that our immune systems can’t recognize or effectively fight it.

All flu viruses—and, so, all flu seasons—are unpredictable. The novel H1N1 virus is the first novel flu strain in more than 40 years. Since most of us have no immune protection against this new virus, it has spread very quickly. Within two months of its first appearance, the World Health Organization (WHO) declared a pandemic: a global outbreak.³

Update

Unlike a “normal” year, this year we had H1N1 flu through the summer. Now with schools starting, we’re seeing more cases. Places where schools started in August—ILINet Region 4 (FL, GA, AL, NC, SC, TN, KY, MS)—are seeing the largest numbers of cases. In other regions, cases are declining or increasing slowly.⁴

The novel H1N1 flu is causing severe illness. The Centers for Disease Control and Prevention (CDC) note:

“To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in stark contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older.”⁵

The CDC and WHO warn that pandemic H1N1 poses an extra risk for those with health problems—like chronic kidney disease (CKD).⁶ If you are on dialysis or have a transplant, take steps to avoid this year’s flu.

Avoiding the flu: Prevention

Keep up your healthy habits. Eat nutritious food, follow guidelines for fluid intake, get enough sleep and exercise, manage stress in your life. And take all the normal steps to avoid getting or spreading the flu:

• Wash your hands often, or use an alcohol-based hand rub
• Cough into your sleeve or a tissue
• Don’t touch your mouth, nose, or eyes unless you have washed your hands
• Stay at least 3 feet away from anyone who is coughing or sneezing
• Avoid those who have had the H1N1 pandemic flu until they stop coughing (with this virus, they are still contagious even after the fever stops)⁷

Read about seasonal flu, too, to learn more about how to avoid and care for yourself with the flu.⁸

Prevention: Flu vaccines

Each strain of flu needs a special vaccine. The seasonal flu vaccine is out now—get a shot when it is offered. It does not protect you against the pandemic flu strain, but you don’t want both at the same time. As always, seasonal flu can cause severe illness in people with CKD.

People on dialysis and living with a transplant (CKD-5) will be able to get the pandemic H1N1 vaccine. Other high-risk groups will have access first. The U.S. government has ordered 200 million doses. The first 3.4 million doses will be ready in the first week of October. Most will be a nasal spray, which should not be used by people with CKD 5. It will go to high priority, healthy people under age 50, e.g., first responders, healthcare workers who care for infants, etc.⁹

After the first 3.4 million doses, as many as 20 million doses will be sent each week into December to nearly 90,000 sites—like dialysis clinics.¹⁰ One dose will work in people over age 10.¹¹ The vaccine needs a few weeks to take effect. This means it may be 2010 before people with CKD-5 have vaccine protection against the virus. We will have to face the brunt of this flu season without the H1N1 pandemic vaccine.

Planning for disrupted dialysis care

Flu is highly unpredictable. Each strain is as unique as a hurricane. But unlike the dozens of hurricanes studied over the last 100 years, we’ve only seen three pandemic flu strains in the same period. With so little experience we can’t predict what will happen in any one city or state.

The President’s Council of Advisors on Science and Technology (PCAST) put out a report in August¹² with a plan for fall and winter:

• 60 to 120 million people have flu symptoms (15-30% of the population)
• Half of them seek medical care (7.5-15%)
• 1.8 million need to be in the hospital
• 300,000 need to be in the ICU
• 30,000 to 90,000 die

PCAST noted that this is a planning scenario, not a prediction. It is neither a best or worst case, but does show that this year the flu could disrupt medical care.

If 20% of people in your city were sick at the same time, it would disrupt other parts of the economy, too. Sick people stay home, and others may have to care for them. Most businesses could not keep normal hours with many people out sick or caring for others. Some areas will be harder hit than others.

One thing is certain: we who have CKD-5 must take the H1N1 virus seriously. We must prepare. I recommend that everyone read Dr. Peter Laird’s article on KidneyTimes about Preparation, Prevention, and Treatment.¹³ Pay special attention to the Preparing section. You can also read what Peter and I have written about Pandemic flu on my blog, Dialysis from the Sharp End of the Needle.¹⁴

The H1N1 virus is unlike anything you’ve seen in your lifetime. Thinking about widespread illness in your town is scary. If a lot of people are sick, there may be times when we have to take care of ourselves. We can do this if we prepare for the worst while hoping for the best.

Be prepared: In-center hemodialysis

Based on the PCAST planning scenario, dialysis clinics may have trouble staying open the normal hours. If many staff are out sick at once, dialysis care may be disrupted for a few days or a week. Prepare for several periods of disruption, totaling two weeks.

Clinics with staff shortages may choose to offer longer treatments less often so fewer staff can run each shift. So, for a week or two, instead of your 3-days-a-week-for-4-hours schedule, you might dialyze twice a week for 6 hours. You can do this safely by eating and drinking carefully. Once you’re on the machine, stay on as long as you can to get the most out of each run.

Have basic supplies on hand at home:

• Over the counter medications to treat symptoms (ask your care team before you take any new drug)
• A thermometer
• A blood pressure monitor
• Easy to prepare food

What would you want if you couldn’t go to the store for a week or two? Keep a stockpile of food on hand in case the grocery store closes. Buy food that is “renal friendly”, with at least a one year shelf life. The easiest way to build a stockpile is to buy only what you like to eat, and then rotate your “stock” by eating and replacing it. Coast Guard rations are renal friendly (people in life rafts can’t eat salty foods, for example) and have a 5-year shelf life. You can buy them at BestGlide.com.

Be prepared: Home dialysis

If you dialyze at home, build up a cushion of two extra weeks of PD or home HD supplies. Ask yourself what is the limiting factor for how many treatments you can do. Is it:

• Dialysate?
• Saline?
• Cartridges?

What you would do if your supply were late? Could you use less dialysate for each treatment? Do fewer treatments? Talk to your care team about the safest way to cut back if you need to. Talk to them about what to do “If ...”:

• You have flu symptoms?
• Someone in your home has the flu?
• You think you should seek medical help?

Going to the hospital should not be your first option—if you don’t have the flu, you could catch it. Ask your doctor ahead of time what you should do if you have flu-like symptoms.

It can be hard to distinguish between the flu and a winter cold; both share many symptoms, and pandemic flu doesn’t always present with the classic flu symptoms. You could have the flu and not have a fever and/or have diarrhea, which isn’t always a flu symptom. Here are some clues to help you decide:^15,16,17,18

• Onset – Slow (over several days) with a cold. Sudden (3-6 hours) with the flu.
• Fever – Rare with a cold. Usually present with flu (80%). A fever of 100° or more for 3-4 days would suggest flu.
• Cough – May have a hacking, productive (mucus producing) cough with a cold. The flu is more likely to cause a dry cough.
• Aches – A cold may may cause slight body aches and pains. Severe aches and pains are common with the flu.
• Stuffy nose – Common with a cold. Rare with the flu.
• Sneezing – Common with a cold. Rare with the flu.
• Chills – Rare with a cold. Up to 60% of people with the flu may have chills.
• Fatigue – Fairly mild with a cold. Moderate to severe fatigue with the flu.
• Headache – Rare with a cold. Very common (80%) with the flu.
• Sore throat – Common with a cold. Rare with the flu.
• Chest discomfort – Mild to moderate with a cold. Often severe with the flu.
• Diarrhea, vomiting – Rare with a cold. H1N1 pandemic flu can cause these.

Since you won’t know right away if you have a cold or the flu, take care to avoid spreading whatever has made you sick. Expect special precautions if you dialyze in-center and have flu-like symptoms. Staff will ask about your exposure to flu, and may swab inside your nose to collect a sample. They will report results to your nephrologist and, if required, to Public Health. Wear a surgical mask during your treatment if you wish or if staff tells you to. This might be required if you have a cough. Surgical masks protect others from you.

To protect yourself from others, you’d want the higher level of protection of an N-95 mask. You can buy N-95 masks at large drug stores, hardware stores (they’re used in dusty settings too) or some variety stores. Even N-95 masks are more helpful for keeping your germs from infecting others. They are not airtight, and stop only about 75% of H1N1 virus particles from reaching you.¹⁹

When a vaccine for the H1N1 pandemic strain becomes available people with health problems will be offered a shot. The vaccine is made the same way as the seasonal flu vaccine is normally made. Get the shot when it is offered.

Conclusion

Keep yourself and your family safe. Stay informed and don’t be distracted by uncertainty. These next months may be a challenge, but with planning and communication we can bridge disruptions to our normal routines.

References

1. Novel H1N1 Influenza (Swine Flu). Accessed 9/21/2009.
2. Ibid.
3. WHO: Influenza pandemic alert raised to level 6. Accessed 9/21/2009.
4. 2008-2009 Influenza Season Week 36 ending September 12, 2009. Accessed 9/21/2009.
5. Preparing for the second wave: lessons from current outbreaks. Accessed 9/21/2009.
6. Who’s afraid of the flu? Accessed 9/21/2009.
7. CDC recommendations for the amount of time persons with influenza-like illness should be away from others. Accessed 9/21/2009.
8. Dialysis, the flu, and you. Accessed 9/21/2009.
9. Swine flu expected to be dominant strain this year. Accessed 9/21/2009.
10. Ibid.
11. Ibid.
12. Report to the President on U.S. preparations for 2009-H1N1 influenza. Accessed 9/21/2009.
13. H1N1 pandemic flu 2009: Preparation, prevention, and treatment. Accessed 9/21/2009.
14. Dialysis from the sharp end of the needle. Accessed 9/21/2009.
15. Studies: Swine flu spreads long after fever stops. Accessed 9/21/2009.
16. Cold versus flu. Accessed 9/21/2009.
17. Cold and flu guidelines: The common cold. Accessed 9/21/2009.
19. Surgical face masks don’t stop influenza germs from spreading. Accessed 9/21/2009.

Copyright © 2009 Medical Education Institute, Inc. All rights reserved.