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Navigating the Fierce Flu Season: Insights with Dr. JB Cantey🤧 · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehmint, and this is Pediatrics Now.
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Cases, updates, and discussions for the busy pediatric practitioner.
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It's the height of flu season, and it's fierce this year, and no one knows that better than Dr. J.B.
0:17
Canty, who is back on the show with us today. He's with University Health and UT San Antonio. And Dr.
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Canty, I think it's so impressive that you're the first double-boarded doctor
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in neonatology and infectious disease, and you're a contributing writer for Red Book,
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and you also have a master's in public health with a focus on infectious disease
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in babies. Thank you for being back on the show.
0:43
Yes, Natalie, thank you for having me. I appreciate it. So I was in a meeting
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just a few minutes ago, and one of the doctors said, I think this is the worst since 2011.
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Have you been hearing things about like
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that or how bad is it it it
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is if you just take the flu by itself and
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and believe me flu is plenty by itself it has been a pretty aggressive season
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partly because we're seeing two different strains of influenza a circulate at
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the same time which is a little bit uncommon fortunately we're mostly caught
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up on the respiratory viral,
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naivete that a lot of kids had coming out of the COVID pandemic,
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where because we were isolating,
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because we were doing a fairly good job of masking, especially at the school-age
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child level, in 2021 and 2022, we saw kids getting a lot of different viruses
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that they hadn't had. They'd been protected from the last few years.
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This year, it's been, quote, just flu, but just flu has been pretty bad.
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Can you tell me about those two strains? Sure.
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So flu is particularly vicious because it has the chance to mutate.
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Because it has a chance to infect a lot of different individuals,
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both human and animal, it has a chance to change its genetics on the fly.
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And so what we look for every year is what type of flu is going to be circulating.
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It's been since 2009, H1N1 has been the predominant strain.
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Over the last few years, we've started to see H3N2 emerge.
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And this year, both of them are circulating in roughly equal proportions right
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now. So we're seeing kids get one type of flu, recover from it.
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And then because there's no cross-protection between the strains,
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they're then coming back two, three, four weeks later with the flu again.
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So it's been really challenging to deal with two strains at the same time.
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And H1N1, it's called the swine flu?
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Yes, that's right. And when it first emerged in the spring of 2009 here in the
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Northern Hemisphere, it was presumed to have jumped from pigs.
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The flu is capable of infecting a lot of different mammals and birds,
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so cows, chickens, geese, ducks, pigs, sheep.
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So we see a lot of this reassortment of genetic material.
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And when H1N1 showed up, it was
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assumed to come from pigs. So it was colloquially called the swine flu.
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It's still a term you hear a lot today. Right now, we're keeping our eye on
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H5N1, which is a type of avian flu that's also circulating in dairy cows.
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And just this week, we had our first confirmed human case in Nevada,
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which is not that far from here, obviously.
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So we're keeping a really close eye on H5N1. Hopefully we won't have a third
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strain circulating this winter.
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So H5N1 is the bird flu?
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It is a type of bird flu, yes. And is that the one that we're hearing so much
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about with the eggs? That is.
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H5N1 is the one that's making news right now because it's novel.
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And we worry about flu strains when they show up because if no one is immune
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to that particular combination of hemagglutinin, which is what the H stands for,
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or neuramidase, the protein that the N stands for, Those are the two identifying
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proteins on the surface of the flu that we use in the vaccine.
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So we're, you know, between people being infected with H1N1 and people who've
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gotten their flu vaccines over the past five or 10 years, got pretty good community
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protection against H1N1.
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But no one has seen H5 in a long time, and it's not in our vaccine.
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So if H5N1 were to jump into humans, really none of us would be.
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And this person who got it, do we know how he or she is doing?
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We don't. We know it was a dairy worker. That's been released by the state health officials.
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My understanding is it was not a fatal case, but I don't know if they were admitted
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to the hospital or if they were able to get through it at home.
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So, and I know you said you're keeping an eye on that.
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What should pediatric practitioners do when it comes to H5N1 and no doubt they're
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getting questions from parents? Any advice there?
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Yeah, no, I'm sure. I think I think anytime these new or emerging infections
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make the news, it puts a lot of burden on the pediatric community to answer
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questions that we don't necessarily have all the answers to yet.
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You know, obviously the most important thing, and I'll say this for virtually
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every infection, is wash your hands.
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If people are washing their hands with alcohol-based sanitizer or with soap
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and water, that's a very effective way to clear the flu off of our hands before
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we get it to our nose or mouth or ingest it.
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And so washing hands is a pretty good blanket way to keep ourselves healthy
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in the winter. We should definitely be encouraging people who are sick to see
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their healthcare provider, get tested for flu.
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If the public health authorities don't have samples to look at,
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we're never going to know if H5N1 is circulating or not.
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People come in with flu-like symptoms, with fever, with sore throat,
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with aches and chills, and get diagnosed as having influenza correctly,
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but without typing, we don't know if that's H1N1 or H3N2, which is what we've
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been seeing, or if it's the start of H5N1.
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So we would encourage people to continue to test their patients.
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And then go ahead and treat H5N1 is influenza A.
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It should be responsive to Tamiflu, to oseltamivir. And so the regular counseling
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that you would give to any patient with the flu still applies for H5N1,
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just really important from a public health standpoint that we recognize if it's
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circulating. And the only way we can do that is with testing.
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And do a lot of pediatric practitioners have a test for H5N1 at their fingertips?
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And if not, could there be more cases than the one that we just don't know about?
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No, and yes. So most point-of-care tests for influenza are antigen-based tests
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that won't necessarily give you typing information.
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Often that has to be done at a relatively advanced microbiology lab,
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either at the state level or at certain academic centers around the state.
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And so, yes, it is possible. I'm not saying it has, but it is possible that
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we've already seen other human cases of age 5 and 1 that went undetected because
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people correctly said, you know, hey, this looks like flu.
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It walks, talks, and smells like flu. You've got flu.
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And they're right, but they don't necessarily know which strain of influenza A that they're seeing.
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And what makes it possibly worrisome is that we just don't have the immunity
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to it, H5N1, because it hasn't been around for quite some time.
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Am I understanding it correctly?
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Yep. No, that's 100% correct. So because it hasn't been part of our vaccine,
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I'd actually have to go back and look and see when the last time it was included in a vaccine.
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But it has to have been decades and decades and decades at this point.
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And depending on when the last time it circulated, it's unlikely that anyone
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or maybe just our oldest Americans have seen H5 in the wild before.
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So no one's protected. And what that means is very high attack rates.
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So most people who get exposed to H5N1 are going to get it because they're not immune to it,
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and the severity of their disease is likely to be worse than someone who gets
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the flu but has been vaccinated against it where the symptoms might be very, very mild.
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And the people at highest risk for flu, as always, are going to be young children.
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Elderly population, and the immunocompromised population. So people with organ
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transplants, people with cancer, they are going to be incredibly vulnerable
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to H5N1 if and when it shows up.
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And sorry, and I should not neglect pregnant women.
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Women who are pregnant have a relatively lower T cell defense against viruses. That's intentional.
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That's a feature, not a bug. It's meant to protect the baby,
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but it does make pregnant women very vulnerable to influenza as well.
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I got the flu when I was pregnant with my third child and I was the sickest
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I've been in my life was that time when I was pregnant.
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Oh, I'm sorry. I'm sorry to hear that, but I absolutely believe you.
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That could not have been fun.
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Not fun. So with H5N1, is there anything else that we should be doing in terms
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of like not eating eggs or cooking eggs or anything?
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You hear so much on the news right now about eggs and eggs being stolen.
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Yeah, the chickens are a source of H5N1.
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And so I think being that the highest risk is going to be for people who are
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in direct contact with the birds when they're still alive.
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So agricultural workers, poultry workers, farmers, they're going to be a vulnerable
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population because they've got frontline exposure.
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But the virus can be passed along in raw or undercooked meat, raw eggs.
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And so and and probably no one on this podcast listening or hosting this podcast
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likes cookie dough more than I do, but you really got to be careful about exposure to raw eggs.
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Just make sure you're cooking it until it's firm all the way through.
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If you like your eggs runny, make sure you're cooking your chicken to the FDA
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recommended temperature so that you don't expose yourself to virus that you didn't know was there.
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That's great advice. And what is the advice for practitioners to say to patients?
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How often should you be washing your hands?
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I mean, it's hard to do, especially with children who are, you know,
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never think they have time to wash their hands.
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Generally, what we want to do is in a community setting, you want to do it if
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you've been around someone who's been sick.
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So if you're sitting at the lunch table at school and someone down the table
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from you is hacking and coughing, that's a good time to wash your hands.
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Before eating, always, always, always before eating, even if you just carry
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around a little pocket of, you know, pocket source of Purell.
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And then if your hands are visibly soiled, so if you've been out,
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you know, your kids have been out playing sports or they've been out at recess
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and they've got, you know, dirt on their hands, then using soap and water or
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an alcohol-based gel to kind of get all that off, not just for influenza,
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but just for infections in general.
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Those are probably the three time points that it makes the most sense.
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So dirty hands before you eat. And if you've been around someone that you think might be sick.
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A community pediatric practitioner asked me today, when is it time for Tamiflu? How do you know?
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Yeah, this is a big debate, and it's a little bit of a different answer when
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you're talking to one family or one patient than it is at the public health level.
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And I want to be careful that I'm separating these two. From an individual patient standpoint.
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The benefit of Tamiflu is it's probably going to shave one to two days off of
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your total duration of illness, and it's probably going to make the peak of
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illness a little bit better, a little bit better.
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It's not a wonder drug by any means, but it does help.
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From an individual patient standpoint, it's sometimes a little hard to get excited about Tamiflu.
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Some people have a lot of GI upset. They may have nausea or vomiting or some
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cases of diarrhea with the Tamiflu and definitely had patients tell me before
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that the treatment is worse than the disease.
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You know, they're vaccinated and they've got a pretty mild course.
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For people who are very, very sick with flu, shortening that or making the severity
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a little bit better is really meaningful. So I think you just kind of have to take it case by case.
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The CDC continues to recommend that Tamiflu be given to all inpatients.
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So if flu is bad enough where someone's going to have to come spend a night
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in the hospital or a couple of days, or certainly if they have to go to the
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ICU, Tamiflu or another drug in that class is recommended.
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For outpatient flu, it's really just got to be kind of shared decision making with the family.
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You know, how are they doing? Were they vaccinated? What's coming up for you
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in the next five to seven days?
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You know, do you have a big trip coming up and being healthy on Friday versus
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being healthy on Sunday is going to make a big difference?
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So I think it's got to be case by case. on the outpatient side.
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If that child has been vaccinated, then will likely not have as severe of a
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case, so might not need Tamiflu.
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Is that your point about asking about has the child been vaccinated for the flu?
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Right. And it's not that Tamiflu can't be given to people who are vaccinated. It absolutely can.
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But when you're trying to judge, you know, is the hassle, cost,
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side effects of this medicine going to be worth it, people who are vaccinated
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on average are going to have milder courses than people who are not vaccinated.
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Okay, got it. From a public health standpoint?
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Right. And then when looking at Tamiflu from a public health standpoint,
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you tend to hear people talk more about days of work missed, days of school missed.
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And so as Tamiflu has become more widely available and a little bit cheaper,
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there's been more of a public health push to use it more liberally.
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So if you can get, you know, child to school back a day sooner,
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which means mom and dad can go back to work a day earlier at a, at a, at a,
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almost a GDP standpoint, Tamiflu is pretty beneficial, but on a case-by-case
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basis, it may or may not make as big a difference depending on what's going
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on in that household with that family.
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So it's sort of a shrug-mg answer.
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It really depends on the family. If people feel strongly that they don't want
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it, I wouldn't push it on them.
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If they're outpatient, if people really, really want it because they want that
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day or they don't mind being a little bit nauseous in exchange for the fever
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going away faster, I would certainly prescribe it. So it's,
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It's an individualized decision, but it's not a super stressful decision on
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the outpatient side. If someone's admitted, they should get it.
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Is it too late? Here we are in February.
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Is it too late to get a flu shot? A mom was asking me that today.
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It's not. It's never too late to get a flu shot for two reasons.
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One, we never know exactly how flu season is going to go.
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You know, we usually think of it as a sort of November to February kind of window,
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but it really depends on what else is going on in the world.
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When other viruses are circulating, they can sort of out-compete flu and push
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it later than we normally see it.
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Or if a brand new strain pops up, it can come out of nowhere and kind of attack whenever it arrives.
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So H1N1 in 2009, when it showed up sort of famously, that was April and May,
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which is not usually the months we think about for a pandemic.
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Now, obviously, the flu vaccine isn't going to cover a new strain,
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but it's available. And oh, sorry.
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The other thing I should say is that if you don't get H1N1 or H3N2 this year,
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even though you weren't vaccinated, those strains may still be around next year.
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So the more flu vaccines you get over the course of a lifetime,
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the more tools your immune system has to deal with it.
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So, you know, I've gotten H1N1, gosh for
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15 years now so i feel pretty good about my protection
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against h1n1 even if i were to for some reason to
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have missed my vaccine this year which i which i never do that's great i got
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i got mine as well i saw an article in the new york times and i haven't read
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it yet but the headline said it's always flu season why it's always flu season
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is that kind of what you're saying that at any time any of us could get the flu.
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Yeah, at any time. And obviously, there's factors in the winter that make us
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all more predisposed to respiratory viruses where it's cold,
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we're indoors together, it's wet, it's rainy.
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So there's definitely a seasonal expectation for flu, but it can.
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The world is small and airplanes and cruise ships and trains being what they are.
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Not sure why through trains in there sorry trains but airplanes being
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what they are even if it's summer here it's winter in
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sydney australia or rio de janeiro or johannesburg
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and someone with the flu in a south southern
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hemisphere winter can absolutely get on a plane and land in san antonio and
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start spreading the flu in july so it's always flu season is probably a good
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slogan but we we definitely try to time the flu vaccine in september october
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november to try to maximize protection when we're most likely to see it,
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but there's no month of the year where I would be shocked to see influenza.
17:27
And how important is it to test for the flu in the pediatric world if it's a
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respiratory virus and the child's able to be taken care of at home with rest and fluids?
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What's your advice there?
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Yeah. And again, this is another one where individual practice and public health
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are a little bit at odds with each other.
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There's pretty good data from the pediatric hospital medicine field.
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So here we're talking specifically about admitted patients that which specific
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respiratory virus has landed a child in the hospital with bronchiolitis or viral
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pneumonia may not be critical as long as you rule out flu.
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So if it's flu, you can give Tamiflu, well, that's really it.
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If it's flu, you can give Tamiflu.
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Otherwise, it's supportive care. It's, you know, IV fluids and fever control
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and black and white movies and chicken soup, just like it is at home.
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If it's not flu, it really doesn't make that big a difference if it's para-influenza
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type 2 or human metanumovirus or adenovirus, because they're all going to get treated the same.
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On an outpatient level, if the decision is, and this is somewhat backwards logic,
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But in clinic, if someone is mildly sick and they've got fever and aches and
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it's day four of illness and you're not going to give them Tamiflu anyway,
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either because you've decided it's too late in the course or the family's sort
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of thrown up their hands and say they don't really want Tamiflu because they
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tried it two years ago and their child threw it up.
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It doesn't really matter if it's flu versus one of the others.
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So you can make an argument for not testing.
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However, if we don't test, that's less epidemiologic data that the state and
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the local health departments are going to get.
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And it makes it a little bit harder to plan policy in the future.
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So there's always this tug of war between cost and hassle versus public health data.
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And how much do we need to know versus how much is best for the sake of testing
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when it's not going to change care? So it's a struggle.
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As an infectious disease doc, I'm all for getting as much data as possible.
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But from a practical standpoint, what are you going to do with that information
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if you're not going to act on it?
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What about this? Mom was asking me, she said her son had the flu last month.
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Does she need to wait or how long? And if so, how long until getting him the flu shot?
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We assume so, yes. If someone's had the flu or any other respiratory virus,
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they're going to mount an antibody response.
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And we know in studies of vaccine efficacy and studies of vaccine dosing,
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these phase two, phase three studies that have to be done,
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that if you give someone a vaccine when their antibody level against that particular
20:08
antigen is really, really, really high,
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you may not mount as good of a response to the vaccine as you would want.
20:15
So generally for those situations, you'll see people delay vaccines.
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If someone gets intravenous immunoglobulin for a medical condition,
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we'll hold their measles, mumps, rubella, or their varicella vaccines for three,
20:30
four, five, six months, depending on the situation, so that that vaccine can get maximal efficacy.
20:35
With flu, there's that additional wrinkle of if waiting carries you out of flu
20:41
season and that vaccine may not be available anymore, you might miss a year of a vaccine.
20:46
And our vaccines are multivalent. So there's not just the flu A that you got.
20:51
There's also the other strain of flu A. there's one or two strains of influenza B.
20:55
So there's a lot of benefit to getting that vaccine, even if you've already,
20:59
quote unquote, had the flu this season.
21:00
So my vote would be to wait about a month unless that month is going to make
21:05
the flu vaccine unavailable, in which case just get it early and know that you're
21:08
still getting a lot of benefit out of it. Okay.
21:12
Another community pediatric practitioner was asking, when do you worry?
21:17
How many days into the flu if you're not getting better?
21:21
Oh, that's a good question. So for influenza itself, one of three things is going to happen.
21:29
Best case scenario, you get it, you get worse for three, four,
21:32
five days, and then you get better for three, four, five days.
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And, you know, seven to 10 days after your symptoms show up, you're better.
21:39
And it's kind of a miserable week, but that's the sort of normal textbook flu course.
21:46
There are certainly cases where influenza can just continue by itself to aggressively progress.
21:54
And the things that we worry about in terms of a mortality standpoint is if
21:59
the pneumonia becomes super, super bad, just from a viral standpoint where someone's
22:04
admitted, someone winds up in the ICU,
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heaven forbid, their lungs are so bad that they wind up needing respiratory
22:11
support with a ventilator.
22:13
There's also end-organ disease that flu is capable of causing that are rare,
22:21
but potentially fatal complications of influenza.
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There are two feared, rare but feared, end-organ complications of influenza
22:29
infection, one of which is myositis.
22:32
The flu can attack the muscle cells and cause the muscles to.
22:39
Lice and dump all of this muscle enzyme into
22:42
the bloodstream that can be so bad they actually cause
22:45
kidney damage or kidney failure for whatever reason the calves and the hamstrings
22:49
are are particularly affected so if you've got a child who had flu and it's
22:54
five or six days into it and they were starting to get better but now all of
22:57
a sudden they've got really bad calf pain leg pain They can barely walk and
23:02
they're peeing out, you know, really dark colored urine.
23:04
That's a child you need to be worried about. And that child needs prompt evaluation.
23:09
The other one is necrotizing encephalitis. So again, super rarely,
23:14
maybe one in 2000, one in 3000, but influenza can go to the brain and cause
23:19
almost like an encephalitis picture.
23:21
So altered mental status, confusion, lethargy,
23:26
stupor in the setting of flu needs to be taken very, very seriously and evaluated
23:31
promptly because that's a very rare but potentially fatal complication of influenza.
23:37
And then the third one, which is probably the most common thing that people
23:40
worry about when we talk about flu complications, is bacteria love to jump into the damaged airway.
23:46
Once flu's down there and caused a lot of inflammation, that opens up a lot
23:50
of damaged epithelial cells or blocked off areas where bacteria can proliferate.
23:55
So if someone's had the flu and they're three, four, five days into it,
23:59
and you thought they were starting to get better. And now all of a sudden they're worse again.
24:02
Their fever shoots up. Their respiratory distress gets worse.
24:06
Maybe the six-ray has suddenly changed where there's new fluid,
24:10
where there wasn't fluid before.
24:11
Those kids, we worry, do they have a bacterial super infection?
24:15
Do they have Staph aureus? Do they have Streptococcus pneumoniae?
24:19
Do they have some other bacteria that's taken advantage of the lungs already
24:23
being inflamed from the flu virus to make things worse?
24:27
So a change in the normal trajectory of flu should be evaluated quickly and
24:34
carefully because it's not usually uncomplicated flu cases that die.
24:39
It's these complicated cases with bacterial superinfection or a sudden jump
24:45
of the flu into other organs where we don't normally see it.
24:48
Sorry, that was a very long-winded answer. That's a great, great answer and so great to know.
24:54
What should we be telling parents about symptoms to watch out for in themselves
24:59
or grandparents or for kids that it's time to get to medical care fast?
25:06
Right. And this is really hard. It's so unspecific sometimes that health departments
25:12
will often use the term influenza-like illness, ILI, for patients who aren't tested.
25:17
So generally what we're looking for is some combination of fever.
25:21
Flu is very prone to attacking the throat.
25:24
So fever, sore throat, cough is often present.
25:28
And then chills and body aches, the myalgias,
25:33
which is just a fancy word for body aches, is sort of a nonspecific but important
25:38
sign that, you know, maybe this isn't just your normal upper respiratory infection
25:42
where you've got fever and a runny nose and a sore throat.
25:45
If you've got shaking chills or you've got body aches where it feels like you
25:49
worked out way too hard over the weekend and now you just want to lie on the
25:52
couch with a blanket, those body aches are concerning for influenza-like illness or influenza.
26:00
Now, that being said, adenovirus can cause those findings. A really bad case
26:05
of rhinovirus. RSV can do it.
26:07
EBV, the virus that causes mono, can often present with fever and pharyngitis
26:11
and body aches. So it's hard to tease out which of those kids has flu versus
26:17
which have something else.
26:18
And so then we look at other things. Has anyone else in the family been sick?
26:22
Has anyone you've been around tested positive for flu?
26:25
Is everyone in your school out with flu right now? So we're sort of reliant
26:29
on contextual clues to inform these symptoms.
26:35
But ultimately, the reference standard is going to be testing.
26:38
If you're not sure if this is mono versus flu and you're going to treat those
26:42
two things very different, test, swab the nose and see if you can find influenza
26:46
or another virus in the nasopharynx.
26:49
And with there's so many cases of flu right now, is it important to be saying
26:54
to parents if your child is having trouble breathing, go through some symptoms
27:00
there when they would need to go to the emergency room?
27:04
Yeah, absolutely. And this is what's so hard and it tends to make the urgent
27:08
cares and the waiting rooms of emergency departments really crowded in the wintertime is, you know,
27:14
most flu is going to be, especially in vaccinated patients, is going to be a
27:17
self-resolving illness, but we cannot miss the ones that are going to take a turn for the worse.
27:22
And so kind of strict instructions for what you should be worried about.
27:27
When do you want these patients to come back to you in your clinic?
27:30
When do you want them to do that step and just drive free to the ER?
27:34
So I'm not, you know, I think people listening to podcasts can roughly know
27:39
what they want to see back in their clinic versus what they would prefer goes on to the ER.
27:43
But it would be some families might hear, oh, your child has the flu.
27:50
We don't need to do antibiotics right now and just make sure they're drinking.
27:53
This should get better in seven to 10 days and interpret that as,
27:58
oh, my child's going to be fine, even though five days later they're lying on
28:01
the couch and they can't eat or drink anything and they're looking really dehydrated.
28:05
But my PCP said it was only going to be a few more days, so we're going to wait it out.
28:09
So I think return care instructions are important, but I don't want to...
28:15
I think the providers listening to this podcast probably know what their style
28:20
is and what they would want to see back versus what they would want to go to an emergency room.
28:25
Advice for parents if your child is taking a sudden downturn,
28:30
all of a sudden vomiting, high fever.
28:34
Was there one moment when they should go to the ER or when the child just wants to rest?
28:40
Yeah, no, I think you said it. Yes.
28:43
The two times that we definitely want to see the kids is when it first happens.
28:48
So if Tuesday was fine and on Wednesday the child's got fever to 103 and a sore
28:54
throat and some cough, that might be flu.
28:56
And if it is a child that the provider and the family decide on Tamiflu,
29:03
the earlier the Tamiflu gets in, the more helpful it's going to be.
29:06
So we definitely want to see patients for diagnostic purposes,
29:11
for therapeutic purposes, when their symptoms first appear, if possible.
29:15
And then, like you said, I think you said exactly right, if there's a sudden
29:18
change, you know, if there's something that is new and different and the family's
29:23
like, whoa, hold up, my doc didn't say anything about this, or he didn't look like this,
29:29
my child didn't look like this this morning or last night, don't hesitate to bring him back in.
29:34
Hopefully nine times out of
29:36
10, it's going to be fine. It's just going to be progression of the flu.
29:39
But if it's not, you'll be very thankful that you brought your child back.
29:43
If your parental instincts are screaming at you, something's changed,
29:49
listen to those instincts.
29:50
I have three kids and this hasn't happened before where my daughter, who's 13,
29:56
she last night she was saying how worried she is about getting the flu that
30:00
last week, 18 kids in her class were out all week with the flu.
30:05
And so she has this anxiety about getting it.
30:10
Yeah, no, I wish my boys had a little bit more anxiety about getting the flu.
30:14
It might help them wash their hands. But, you know, I think we do see these
30:18
waves roll through school districts.
30:20
And sometimes, you know, whole school districts or whole grades will shudder
30:24
because so many kids are out.
30:25
You know, vaccines will certainly help with that, but they're not perfect.
30:29
Hand washing will definitely help that.
30:31
I think you just, you know, I would tell my kids if they said something like
30:36
that, like, look, hey, guys, you know, you're immunized. the most important
30:39
thing is you just keep washing your hands and making sure you keep your distance
30:42
from anyone you think might be sick.
30:44
And she did get the vaccine. Thankfully, she even said she was walking.
30:49
She went to the office to use the phone, but the person sitting there said,
30:53
okay, so are you feeling really sick and you need to go home too?
30:56
You know, and she's like, I know.
31:00
But they have so many. She's proudly saying, no, I'm vaccinated.
31:03
I'm vaccinated. fluttering.
31:05
Yes. And, but the vaccine, how effective is it this year?
31:10
We know how, you know, it's so important to get the vaccine,
31:12
but what do you want to say about that? Because of course we don't want to discourage.
31:18
Yeah, exactly. So, so this is another one where public health and individual
31:23
patient results may differ.
31:26
So, and, and if I can be forgiven a little bit of a longer answer here.
31:31
So from a public health standpoint, what we're always shooting for with vaccines is herd immunity.
31:36
Can we vaccinate enough people with an effective enough vaccine so that this
31:43
particular germ, whatever it is, can't circulate in our community?
31:47
And the math behind that is a little bit complicated, but the short version
31:51
is the more infectious a virus or a bacteria is, the higher proportion of the
31:59
population has to be vaccinated to keep it from spreading.
32:02
And then you have to divide that number by the vaccine efficacy.
32:08
So what we want is really effective vaccines that everybody gets.
32:13
Measles, for example, is incredibly infectious. It has one of the highest infectivity
32:18
numbers in all of public health.
32:21
So even though we have essentially 100% effective vaccine, you know,
32:26
98% effective vaccine, we've got to keep 93 to 95% of the state vaccinated or
32:32
we're going to see measles.
32:33
And so, you know, two years ago, we were at 95%. Last year, we were 94%.
32:38
This year, we're at 93%. And guess what?
32:40
We've got measles in Houston, and we've got measles out towards the western
32:44
end of the state because our vaccine levels have dropped low enough where measles is spreading now.
32:49
For flu, flu is actually not, it's not nearly as contagious as measles is.
32:56
So for flu, if we had a 100% effective vaccine, we would only need to vaccinate
33:01
about 50% of the population to prevent us from having flu outbreaks every single year.
33:08
However, because they have to make the flu vaccine, you know,
33:12
six months, eight months in advance, and they have to sort of make their best
33:15
guess about what flu is going to look like in the winter,
33:18
our flu efficacy ranges from about 20% to about 50%.
33:24
Last year, it was about 40%. This year, it's probably about in that area.
33:28
We can sort of get early estimates based on the Southern Hemisphere.
33:31
And then usually by right about this time in February, we have a sense of how
33:34
it's performing in the US. So it looks like it's about 40% effective this year.
33:38
The problem is with the flu vaccine only being about 40% effective,
33:44
even if every single person in the country got vaccinated for influenza,
33:49
we would still have flu outbreaks because the vaccine efficacy is not good enough
33:55
to stop an outbreak from happening every single year.
33:59
All that being said, at the individual level,
34:03
you will still appreciate having your flu vaccine, because it's going to either
34:06
keep you from getting flu or if you get flu anyway, it's going to make your
34:10
flu significantly milder than it would have been had you not been vaccinated.
34:15
So people are always going to have stories like, oh, well, I got the flu vaccine
34:19
last year and then I still got the flu. Yeah.
34:22
One, it might've been the flu or it might've been a different recipe of virus.
34:26
Two, if it was the flu, I promise you, you're happy that you got it because
34:30
it would have knocked you on your butt otherwise.
34:31
And so I will always, always, always encourage people to get the flu vaccine
34:36
if there's someone who's eligible for it.
34:38
But I don't have any illusions that we're not going to have a flu outbreak every
34:43
single year until we have a significantly better flu vaccine.
34:47
Is there anything- Sorry, another long answer. Well, that is a great, great answer.
34:52
Is there any concern about any, you know, we talked about in a recent podcast
34:56
episode about the warning that's been put on the RSV vaccine.
35:00
Is there any concern? Do you have any concern about the flu vaccine and causing
35:06
any, I mean, is it, it's some of what you mentioned people get from the flu.
35:11
So it's, it's extremely rare to get it from the vaccine. Some of these conditions is, is that correct?
35:18
Yeah. I mean, the flu vaccine is incredibly safe. it's a, it's the intramuscular
35:23
flu vaccine is a conjugate inactivated vaccine.
35:26
So there's real, there's no live virus there. People aren't going to get,
35:30
you know, the flu from the vaccine itself. Now they may get achy.
35:35
They may have low grade fever chills as their immune system reacts to the shot.
35:39
And I generally tell people, Hey, I know it doesn't feel great, but that's a good thing.
35:44
That's getting ready for time.
35:46
Your immune system, putting its helmet on and its eye black and lacing up its boots to go out there.
35:51
What we did used to see with the live attenuated vaccine, so the intranasal
35:56
flu vaccine, flu mist, that is a live vaccine that's been inactivated to be essentially harmless.
36:03
But that can cause some trouble with people who have respiratory disease like
36:07
asthma or COPD, and it's not indicated for those people for that reason.
36:12
So with the live flu vaccines, you can get kind of a low-grade illness as that
36:18
attenuated virus replicates.
36:19
But with the intramuscular vaccines, they are incredibly safe,
36:23
and I would encourage absolutely everyone to get it unless they have a truly
36:27
anaphylactic reaction with the previous one.
36:30
If you've gotten your flu vaccine and your airway closed off or your lips swelled
36:36
up, then okay, then you're off the hook. But everyone else should definitely get it.
36:40
And I did not know that each time we get the flu shot, it contributes to our lifetime immunity.
36:46
So that's pretty amazing. mm-hmm the
36:50
the super as a liberal arts major the
36:53
the you know even if it's the same one even if
36:56
it's h1n1 and h3n2 again the
36:59
the vaccine has accounted for that real subtle
37:02
genetic drift that flu does every single year
37:06
so you're getting a slightly different angle a slightly different perspective
37:09
on the same virus and that's going to pay dividends down the road if you ever
37:12
see that particular strain again i always joke about it being like picasso's
37:17
studies you know where He might do 100 or 150 sketches before he actually does
37:22
the painting, and each one of those sketches is slightly different,
37:25
and each one of those helps make the final painting as good as it can be.
37:28
And that's a very liberal artsy metaphor for why it's important to get the flu
37:34
vaccine, even if the components don't really look like they've changed. I love it.
37:39
So back to H5N1, is it or could it be more dangerous to get that from eating
37:46
an undercooked egg as opposed to from a human? Or do we not know?
37:51
If someone is naive to H5N1, which we essentially all are,
37:56
we are not going to have any protection whether it comes from direct contact
38:01
with the chicken or direct contact with the dairy cow or eggs or house cats.
38:06
It's, you know, there are reports of it jumping to cats now or from another
38:11
human who's gotten H5N1.
38:13
What is going to determine how much it hits us is our initial inoculum.
38:18
So if you happen to ingest, you know, a few thousand copies influenza and it
38:26
starts replicating, your immune system is going to have a little bit of a head start.
38:30
Than if you get, you know, one, one or 10 million copies directly into your
38:35
airway because someone with H1, H5N1 coughs in your face.
38:38
So the more virus that is injected into you right at the beginning.
38:45
The sick, the faster you're going to get sick and the more catch up your immune
38:50
system is going to have to do.
38:51
So the problem is we don't really know which,
38:55
we don't know where all H5N1 is we
38:58
know some places that it is but we haven't we haven't ruled out
39:00
all the places that it isn't yet and we don't know what that means for inoculum
39:05
so it's a there's probably a lot of very cool science there but right now it's
39:10
a big mystery box for us and all we know for sure is if we're we're all naive
39:13
to h5n1 and it's going to be unfortunate if it starts spreading actively in
39:17
humans are you worried about h5n1,
39:21
I mean, I'm personally worried about H5N1 because I've had the flu.
39:25
The one time in my life I didn't get my flu shot back in college,
39:27
I got the flu and it was miserable. And I don't really want to ever experience that again.
39:32
I'm nervous for, I'm not that nervous because I am a relatively healthy,
39:40
non-pregnant 40-year-old male.
39:42
I am very nervous for toddlers and infants and my in-laws and my mother and,
39:49
you know, people who would be at higher risk for H5N1 if it starts circulating.
39:53
So from a public health standpoint and from a personal standpoint, I don't want to see it.
39:58
But healthy, non-pregnant, you know, middle-aged adults are not the ones that
40:02
would be at the highest risk.
40:03
The people who would be at the highest risk are going to be the very young,
40:06
the older population, pregnant women, and immunocompromised people.
40:10
And so I worry for them always.
40:12
The same advice that we heard a lot of during the pandemic, don't go to grandma
40:17
and grandpa's house if you have these symptoms, respiratory virus symptoms.
40:22
Yeah, I mean, I think if you've got H1N1 or H3N2 and you're feeling okay and
40:29
your grandparents are vaccinated and you have to absolutely see them, that's one thing.
40:35
If you knew for a fact that you had H5N1 or you'd been exposed to H5N1,
40:40
I would strongly, strongly beg people to stay away from anyone who might be high risk.
40:46
Stay away from the babies and the pregnant women, etc. Yeah, yeah.
40:52
Our culture, there's so many products to get rid of mucus.
40:56
Is it much better for us to have, I mean, that mucus is getting rid of the virus,
41:02
or do you want to say anything there about that?
41:05
Products that suppress your cough might make you a little bit less infectious
41:11
to other people, because if you don't cough on another person and you don't
41:14
wipe your nose and then, you know, touch them or touch something,
41:17
some surface that they're then
41:18
going to touch, that's going to make you a little bit less infectious.
41:23
But the products that thicken your secretions or clear your secretions or stop
41:29
you from coughing, they're not going to make you sick any less time.
41:33
They might make you feel a little bit better while you're sick,
41:35
but you're still contagious to other people.
41:38
So don't be like, oh, I'm totally okay to go out because I'm taking this over-the-counter
41:41
nasal decongestant. So now I'm not going to get other people sick.
41:44
Well, you're still infectious.
41:47
One product that prevents you from having as much nasal drainage,
41:50
I heard that once compared to, you know, if there's a fire and you're clearing
41:56
the smoke out, you're like, well, it's all good because we got the smoke out
41:58
of the way. Well, you're still on fire.
42:01
So, you know, just be mindful of who you're around and what you're touching
42:05
and everyone needs to be washing their hands.
42:07
But, you know, if it makes you feel better, great, but it's not going to make
42:10
you healthier any faster.
42:13
That's great advice. But if we clear out, to use the analogy,
42:16
the smoke or the mucus, does that open us up to a secondary infection?
42:22
That's a fair question. You know, mucus is, as gross as it is to talk about,
42:27
mucus is a physical barrier that protects our respiratory skin cells,
42:31
our respiratory epithelium.
42:32
So, you know, if our throat or our nasal passages are just raw from coughing
42:40
and from blowing our nose and wiping with tissue, maybe they help.
42:44
But if the mucus is blocking, you know, is serving as a barrier and protecting
42:47
us and you get rid of all your mucus, maybe it makes it worse.
42:49
I actually don't know if there's been any large scale studies on secondary bacterial infection, but...
42:57
That mucus is there for a reason, but if you can't breathe because you're so
43:01
congested and you need to deal with it, I totally understand.
43:04
And do you recommend using a sinus rinse if need be, that kind of thing?
43:10
From an infectious disease perspective, I'm neutral on it. I know our ENT colleagues
43:15
really like to use them in a lot of different scenarios.
43:17
Again, it's not going to make the viral replication end any faster.
43:21
If it makes you more comfortable in the meantime, go for it.
43:25
Okay that's great advice i so appreciate
43:28
this is when is it time to where you can go
43:31
back to work or school oh right
43:34
so you know again generally for
43:37
respiratory viruses and i think flu is no exception the cdc is going to recommend
43:40
at a minimum that your fever has resolved and ideally you know seven days from
43:46
onset of symptoms the the longer you can wait and the more minimal or resolved
43:53
your symptoms are, the less contagious you're going to be to other people.
43:55
But certainly by the time you've had a week to build up antibody and build up
44:01
your own immune system, even if you're not vaccinated, if your cough has gone
44:05
down, if your fever is resolved, your contagiousness has dropped significantly.
44:08
But if someone can wait an additional day or an additional two days,
44:12
every day out from flu is going to minimize infectivity.
44:17
Because when we cough, and I'm sure we've all had someone say this to us, like, it cough.
44:22
I'm not contagious anymore though, and they're coughing, but does anyone truly
44:26
know if they're contagious or not?
44:29
We learned a lot about it after.
44:33
After COVID, every time we have a new respiratory virus, when it showed up,
44:38
we learned a lot. And then when COVID showed up, we learned a lot.
44:41
And generally, it's the same lesson over and over and over again.
44:45
It takes us about five to seven days for antibody to start showing up.
44:50
Antibody peaks at about two weeks.
44:53
And symptoms resolve after five, seven, 10, 14 days.
44:57
So the farther into that process that you can isolate, the better.
45:00
But generally, the CDC is going to allow people to return to school,
45:05
return to work, you know, five to seven days after onset of infection and 24 hours fever free.
45:11
That generally winds up being where the recommendations settle every time we
45:14
have a new or emerging respiratory virus.
45:17
And if you're still coughing at that point, wear a mask.
45:21
My vote would be wear a mask. Yep. Obviously, it depends a little bit on work and school policies.
45:27
And mask wearing has become obviously somewhat controversial politically.
45:32
But from a public health standpoint, if you're still coughing,
45:35
a mask is a medical surgical mask, not necessarily an N95, but just a regular mask is a good idea.
45:42
And JB, is there anything else about this fierce flu season that you want to say?
45:47
Every year, the same myths appear and we battle them every year.
45:50
With varying degrees of success.
45:53
No, the flu vaccine isn't going to make you sick, but you might feel a little achy after you get it.
45:59
Yes, you can get the flu or other respiratory viruses after you're vaccinated.
46:03
It doesn't mean the flu vaccine wasn't helpful.
46:07
You know, Tamiflu is an individualized decision, but it remains in vitro effective
46:14
against virtually all influenza A.
46:16
So if H5N1 does start ripping through the country, Tamiflu is going to be a
46:20
big part of our defense against it because it would be anticipated to work.
46:26
People who are very, very high risk, babies, young infants, older generations,
46:32
pregnant women, immunocompromised women, they deserve support.
46:37
You know, a lot of those populations may not be eligible for flu vaccine,
46:42
especially babies younger than six months where we don't routinely give the flu vaccine.
46:45
If you've got a one month old niece or nephew or a two month old cousin or if
46:50
you have a baby yourself, I would strongly encourage you to get the vaccine.
46:55
You know, help your help your new family member out because they can't get it
46:57
themselves until they're six months old. So, you know, and we do this year after
47:01
year after year and flu drifts and drifts and drifts and changes slightly until
47:06
all of a sudden, boom, it shifts and it's a brand new one.
47:09
And that'll be H5N1 or maybe it's going to be a different one that we haven't
47:12
seen pop up on the radar yet.
47:14
The only guarantee with flu is that some new recombination is coming,
47:18
you know, whether it's a year or five year or 10 years down the road,
47:21
something's coming and we'll have to, you know, get the country as protected
47:24
as we can as fast as we can.
47:26
And earlier in this interview, you mentioned that H5N1 can be transmitted through a cat.
47:37
Could that be through a cat bite?
47:39
What should we worry about there?
47:42
Well, I mean, again, just because H5N, because flu in general is capable of
47:48
infecting so many different types of mammals and birds, we see it jump into
47:53
us in unexpected ways, you know, ducks, geese,
47:57
chickens, and obviously any place where humans and animals are interacting closely
48:02
is going to increase the opportunity for flu to migrate.
48:05
So we, you know, we generally talk about, you know, poultry farms as sort of
48:09
a breeding ground for flu, but you know, what else loves to eat birds is cats.
48:13
And there, there've definitely been a lot of cases of cats being identified
48:17
and, and I'm not throwing cats under the bus.
48:20
It could just as easily be other mammals, but you know, cats,
48:23
if a bird's infected with avian flu and the cat eats that bird,
48:26
it's obviously not going to cook it beforehand. It's just going to eat it.
48:29
And now the cat's got flu and that cat comes back into your house for snuggles
48:32
and now you've got flu. And so anywhere where birds, mammals,
48:37
humans are interacting, that interface is going to be an area where flu could
48:41
potentially emerge from.
48:43
And so it's just another way, another place we have to keep an eye on from a
48:46
public health standpoint.
48:47
And that makes a lot of sense. And we're doing this interview from San Antonio, Texas around this area.
48:56
And in Texas, when will the flu get better? When it should have been. We, we,
49:03
It's probably slightly too soon to say, I don't want to call it and then be
49:07
totally wrong next week, but we get both state and local data weekly.
49:12
It's publicly available. If anyone wants to Google it, they can find that report for RSV, for flu.
49:18
This week was slightly down compared to last week.
49:22
So I don't know if that's just random variation or if this is the beginning
49:26
of the end and we're going to see flu taper off here over the next month or so.
49:31
But we're still certainly, even if it's, even if we're starting to work our
49:34
way out of it, we're still right in the middle of it right now for,
49:37
for at least another month. So I would encourage people to continue to be careful.
49:41
But my hope is maybe we've turned the corner, but we'll know,
49:44
we'll know more once we have a few more weeks of data.
49:47
And then other parts of the country where it's much colder for longer,
49:51
it will probably last longer and elsewhere in the world.
49:54
Yeah, that's, that's our normal patterns. And, you know, every year is a little
49:58
different, but I would assume that San Antonio will clear a little bit faster
50:03
than, say, Minneapolis or New York City.
50:06
But, you know, you never know. And that's why it's important to track.
50:09
And we know it's a tough time for pediatric practitioners out.
50:13
You just seen 40 patients a day and so many respiratory viruses going on out there. So it's tough.
50:21
Absolutely. Yeah, every winter is, and this winter is no exception,
50:24
but having two strains of Flu-A circulate simultaneously has certainly put a
50:28
burden on our frontline providers.
50:31
And how are things going before we wrap up in your Okape clinic that you named
50:36
at University Health, where you see babies who are born into this world with infectious disease?
50:43
It's unfortunately, it continues to be really busy.
50:46
I would love for it not to be. We're still seeing, you have to go back almost
50:51
to World War II to see levels of congenital syphilis in the country that we're seeing right now.
50:57
So continue to see a lot of congenital
50:59
syphilis, continue to see a lot of perinatal hepatitis C exposure.
51:04
We're seeing more perinatal hepatitis B exposure.
51:08
We have two vulnerable populations in the greater San Antonio area that are
51:13
at high risk for hepatitis B based on the regions of the world that they've
51:17
immigrated from, where hepatitis B is more prevalent than it is in the U.S.
51:21
And so making sure those babies are protected and infected has become a big part of the clinic.
51:28
The other thing we've seen a lot of, and providers may be seeing it too,
51:31
is since the state has switched to requiring CMV,
51:36
human cytomegalovirus screening for all babies who refer their newborn hearing
51:40
screen, seeing a lot more detection of congenital cytomegalovirus and having
51:46
those families come to clinic and kind of talking them through what the virus
51:49
is and what it means for them long term.
51:51
That's definitely been a big increase since the screening law went into place.
51:57
And it makes me appreciate how much CMV goes undiagnosed in the absence of universal screening.
52:03
So, yeah. So, unfortunately, Okapi remains a bumping place these days.
52:07
Well, and I can't remember if I told you, I volunteer in the NICU.
52:11
And I just got my, well, a couple months ago, I got my hepatitis B vaccine.
52:15
So, it's a good one to have.
52:19
And I know you named it because of your Okapi. It's your kid's favorite.
52:25
Someone in your family, your niece and nephew, it's a favorite.
52:27
Animal or you love the animal.
52:29
Yep. Yep. It's a little bit of an in-joke and a little bit of a nod to my family
52:33
because I've got my niece. It's one of her favorite animals.
52:36
And an okapi, for those of you who haven't had the pleasure,
52:38
it's a half giraffe, half zebra.
52:41
And people used to joke about what a weird combination neonatology and infectious disease was.
52:46
And so I've adopted the okapi as my representative animal because it's two weird
52:51
things smashed together just like I am. So I appreciate it.
52:55
I love it. And I took my children to the San Antonio Zoo to see the Okapis and
53:00
they have a special interactive program.
53:04
I was amazed to see, to me, they looked more like horses with,
53:08
but zebras at the back than giraffes, even though they're related to the horses, but it was amazing.
53:14
Yeah, they're super, they're super cute animals.
53:17
And I told them about you and all the amazing work that you're doing.
53:20
We so appreciate all of your hard work and all of this wonderful advice.
53:26
As always, I appreciate you having me on. And I get to do the fun part.
53:30
I get to sit here and try to monitor public health data and help providers out.
53:35
It's the pediatricians and the family medicine docs who are having to staff
53:39
the volume of kids in San Antonio and the surrounding area with flu that are doing a lot of the work.
53:44
So for anyone who took the time
53:46
to listen to the podcast, we really appreciate what you guys are doing.
53:49
Dr. J.B. Canty with University Health and UT San Antonio, thank you so much
53:55
for being here again on Pediatrics Now.
54:00
My pleasure. Thank you.
54:03
Pediatrics Now is brought to you by University Health's new Women's and Children's Hospital.
54:10
And the Department of Pediatrics at the University of Texas Health Science Center at San Antonio.
54:16
It's also brought to you by CPAN, No Call Too Small.