Unless you just woke from a coma, then you know that this is not an average flu season for the United States. In fact, it has actually been pretty rotten for a lot of people so far, with numerous reports of tragic deaths and of hospitals being inundated with patients seeking medical attention. Alabama has even declared a state of emergency to help deal with the surge in severely affected patients and overloaded healthcare facilities. But is the media’s flumaggedon frenzy a reasonable reaction?
Breaking down the season so far
The 2017-2018 flu season is certainly bad. Not 1918 Spanish flu pandemic bad, when 3-5% of the world population died as a result of the infection, but still pretty awful. It’s looking to be at least as bad as 2014-2015, the last severe (“moderately severe” per the CDC) season. But if the current pace of flu incidence and severity continues for much longer, it will easily be the worst in over a decade.
How long each season lasts varies significantly. Peak flu activity typically occurs most seasons at some point in December through February. The 2014-2015 season, for example, peaked in January. The current season has continued to be robust into February with only a “glimmer of hope”, per CDC officials, out of the West now that Oregon has joined Hawaii in no longer reporting widespread activity.
According to the latest data from the CDC, which covers the week ending on January 27th, the percentage of people presenting to a healthcare provider with a flu-like illness, at just over 7% of the population, is on par with what we experienced during the 2009 Swine flu pandemic, which started unusually early and peaked in October. That year, a novel flu strain emerged that caused more than the typical number of deaths in younger patients, presumably because of less immune response compared to older people who had been around during outbreaks of similar strains, but was overall not as severe as it had the potential to be.
The overall hospitalization rate is also higher than what is typically seen, and has also been on track with the 2014-2015 season. Since October, there have been at least 14,676 admissions involving laboratory-confirmed influenza, with many more admitted for flu-like illnesses and complications. The CDC data further reveals that 51 out of every 100,000 people in the United States has required hospital care so far this season. As would be expected, the likelihood of more severe disease, and thus the need for hospitalization, is higher in people over age 64 (227 per 100,000), who are more likely to have underlying health concerns, and lower in the generally healthy pediatric population. Still, more than 30 young children (0-4 years) per 100,000 have had a hospital stay so far.
What about all the reports of dead children?
The news outlets have put out many articles over the past few weeks that have covered tragic flu deaths, typically involving healthy children. This NPR article from last week is one of the weaker examples, combining anxiety provoking information without proper context. There is also a questionable nugget of advice to parents from Dr. Anne Schuchat, the acting director of the CDC, mixed in with what are otherwise reasonable observations on assessing a child’s clinical status at home. Parents should not be overly concerned just because of a high fever, however, which is not a helpful indication of illness severity in isolation.
This article from USA Today does a better job at putting the season into context. The author points out that the number of pediatric deaths so far this season are well below the total pediatric deaths seen in each of the last three, even the similarly severe 2014-2015 season. This is still true even after adding the 16 deaths that occurred in the last week of January, bringing the official total up to 53. Obviously even one death is too many, and parents should be educated on when to seek medical care and how to reduce risk of severe illness.
Again, this season is clearly not over, and may remain severe for several more weeks so additional pediatric deaths are almost guaranteed. In fact, although official data hasn’t been released for the first week of February, I easily found news reports of at least 3 more pediatric deaths being blamed on the flu. One important piece of information mentioned in the NPR article, which is based on CDC data, is that 80% of the children who have died so far were not immunized against influenza this season. Thankfully, although it is adding a bit to the overall level of anxiety, more so than in any previous season that I can recall there have been a slew of articles published imploring people to get their flu shot.
Another aspect of pediatric influenza mortality being heavily covered is that many of the deaths so far have been in otherwise healthy children. This is true, however the percentage of healthy children succumbing to the infection is not higher than in other years. The flu can be severe and it can become so rapidly in some patients regardless of their past medical history, but children with underlying health conditions such as lung, heart, and neurologic disease are still at higher risk for mortality.
This New York Times piece is pretty good.
No, you don’t need to worry about the flu if your child only has hives!
The overall impression from most of the articles I’ve read is that this season is worse than most when it comes to pediatric deaths, and there is significant anxiety, even some degree of panic, in the community. I have spoken to many pediatricians and ED physicians, both in person and through social media, who are seeing large numbers of worried parents bringing well or only mildly ill children specifically for flu testing and treatment.
Last week, a perfect example of the level of concern in the community “went viral” and came to my attention. It started as a Facebook post by a nurse in Nebraska whose 6-year-old son had been diagnosed with the flu after the acute onset of urticaria, more commonly known as hives. The post has been shared over a quarter of a million times and was the inspiration for a deluge of coverage in the mainstream press as well as the typical fluff human interest piece generators.
This article from People magazine represents the latter and is just awful, not that the more hard-news focused outlets were much better. In the People article, entitled “Mom Warns Parents About Rare Flu Symptom After Sick Son Develops Hives: It’s ‘Very Dangerous'”, the child’s mother describes how her son developed hives but had absolutely no other symptoms whatsoever. Despite this, she took him to her local hospital where, for some reason that I can’t determine, he was tested for the flu and was found to be positive. This completely healthy child with a benign but usually itchy rash was then, again for some reason I can’t understand, started on Tamiflu.
Hives are incredibly common in children and adults, with around 15% of the kids developing them at some point before the age of 10 years and a 20% lifetime prevalence in the general population. They are typically red, raised plaques that can be circular or have wavy margins. Sometimes they cover large portions of the body and coalesce into large lesions, and sometimes they are less than a centimeter in size. Individual hives tend to come and go fairly quickly as far as rashes go, changing size over minutes to hours and then completely disappearing over the course of a day as new lesions develop.
Hives tend to itch, often a lot, and sometimes to the point of interfering with normal activities of life. Thankfully there are very effective medications, like diphenhydramine (Benadryl) and less sedating 2nd generation antihistamines like cetirizine (Zyrtec), and the vast majority of cases resolve within a few days. The list of potential causes is extremely long, including allergic reactions to almost anything. They can be a sign of a severe allergic reaction known as anaphylaxis that requires urgent treatment, but as an isolated sign are rarely indicative of a serious condition.
Viral infections are a known trigger for hives, as well as a much more common and clinically distinct non-itchy rash we refer to as a viral exanthem, although influenza isn’t exactly well known for it. Hives are not at all part of any diagnostic thought process for flu-like illnesses/influenza, and testing a patient with for the flu with isolated itchy rash is a waste of resources. It’s actually worse than just throwing money down the toilet.
Even when flu is prevalent in a community, the false positive rate for testing can be 6-7%. Add in the extremely low clinical suspicion for influenza infection in a virtually asymptomatic patient, and that rate will be even higher. Furthermore, even a true positive does not mean that a child is ill. Presence of influenza virus is not the same thing as having the flu. Humans, especially young children, are frequently colonized with potential pathogens. This issue comes up repeatedly when interpreting testing for strep throat as well.
But what really concerned me about this was his mother’s reaction to the media coverage of the current flu season:
Seb is now doing well. But Willard says the seeing several news stories about fatal flu cases did have her worried that she might lose her son.
“I did think about it, for sure. Lots of kids have died,” she says. “People need to realize that this is something that’s very dangerous. Kids are resilient, but when they start to get sick, they go down very quickly and it’s hard to come back from that.”
First off, Seb was never not doing well. He had a classic case of acute hives that quickly ran its course. I have very low suspicion that his hives were caused by infection with an influenza virus and I am even more confident that the prescribed Tamiflu played no role in their resolution. Unfortunately his mother’s original post was seen by millions of people once amplified by terrible news coverage. The fact that she is a nurse was emphasized repeatedly in reports, which gives her concern more legitimacy that it deserves. People should seek medical care if they are very sick with flu-like symptoms, not just because they have isolated hives unless the itch is severe and unresponsive to OTC medications.
And finally, this jerk
While I’m not exactly pleased with much of the news coverage of this year’s flu season, because it is coming across as alarmist rather than simply encouraging the public to take the flu seriously and to get their flu shot, I wouldn’t go so far as to say it is dangerous. It may lead to some unnecessary ED visits and inappropriate Tamiflu prescribing, but this last bit of flu news you shouldn’t use is considerably worse.
Earlier this week, it was reported that Gloria Copeland, a televangelist with an reach of millions of followers (and their children), and wife of all-around great guy Kenneth Copeland, is telling her flock to avoid the flu vaccine. The implication of her message is, of course, that people who get the flu deserve it for not having enough faith. Their church, you may recall, was implicated in a 2013 measles outbreak in Texas.
Conclusion: Wash your hands, get your flu shot, stay home if you’re sick
I hope that I haven’t come across as downplaying the seriousness of the flu this season. It’s bad out there, largely because the predominant flu strain, H3N2, tends to cause worse illness and the vaccine isn’t a great match for it this year. But 10-20% reduction in risk of illness is still good, and there is clear evidence that the vaccine reduces the likelihood of severe disease if infected. And it is a better match for the other circulating strains. So get the shot now if you haven’t already.
While the season is rough, and the end isn’t in sight yet, there is no reason to panic. Pay attention to you or your child’s symptoms, especially if you have risk factors for more severe disease. And take them seriously if symptoms are worsening significantly, or bad and not improving after a few days, even if you don’t have risk factors.
Don’t panic at the sight of an itchy rash. Wash your hands too. A lot. And if you are sick with the flu, try to stay away from other people if at all possible until you are no longer having fever and you are clearly on the mend.