The H1N1 Deal: An Interview With Dr. Saul Hymes

When I was in the first grade, at P.S.87,I had the pleasure of meeting Saul Hymes, a smart sensitive character. I am not surprised to discover that over 20 years later, Saul Hymes has now become Saul Hymes, M.D.: a clinical fellow in Pediatric Infectious Disease. Dr. Hymes is still in training, but I know he has a long career ahead of him.


Dr. Hymes was kind enough to let me pick his brain regarding the current issue of H1N1 or (as the media likes to call it) "The Swine Flu."


1. What is H1N1?

H1N1 is a new variant of the influenza virus. Why is it called that? The influenza virus is surrounded, like many viruses, by a protein coat. For the flu two of the components are the main ones our immune system recognizes to protect against the virus. They are called Hemaglutinin (H) and Neuraminidase (N). There are many variants of each that are numbered 1-16 for the H's and 1-9 for the N's though only a few of these are found in flu viruses that affect humans. There are also two main types of influenza or "the flu": Influenza A and Influenza B. H1N1/"swine flu" is a type of Influenza A so we can ignore Influenza B for now.

Every year a new main one (or two) seasonal flu virus emerges as the one that will cause the usual flu season around the globe. It is of a particular H & N type and this usually drifts slightly from year to year as the virus mutates and changes. As the H & N proteins are called 'antigens' this is called 'antigenic drift'. This is why you need a new flu shot every year. This year the expected seasonal flu types are H3N2 and...wait, this gets confusing...H1N1. Now, this H1N1 is not the same as the H1N1 everybody's worried about. This is why simply saying H1N1 is not enough.

The official name for the current H1N1 swine flu is the "novel pandemic 2009 H1N1 Influenza A". You'll notice that 'swine flu' is nowhere in there. This was a political decision made so people didn't go killing pigs, but this virus did indeed have its origins in both pigs and chickens. The reason it's so new or novel and that there's a separate vaccine and that everybody's so concerned, is that this virus underwent what's called 'antigenic shift' where instead of little changes in the H and the N, even though these are H1 and N1, as in the seasonal flu, they and the rest of the virus are different in other ways, making this a very different virus from the standpoint of immunity--thus the new vaccine, the presence of flu at an odd time of year, etc.

On the whole, however, this is simply a type of Influenza virus which can cause the same things influenza always does--illness ranging from mild upper respiratory infections, to more severe fevers, chills, and muscle aching, to bad pneumonia, to even worse effects in those more at risk. Thousands of adults and children worldwide die every year from the seasonal flu and many millions more are infected and recover as we all have year after year. The H1N1 "swine flu" is no different--most likely if you get it it will be mild. Some are unlucky and have more severe problems. There is no way to predict this in people who are otherwise healthy (those who are not are known to be more at risk) and that is why, as below, the vaccine is recommended.

2. What are the most common ways to catch H1N1?

H1N1 is transmitted the same way all influenza virus is transmitted--by spread of respiratory droplets, i.e. snot, mucus, spit when you cough or sneeze or even talk forcefully. So you can get it from close personal contact, from kissing, from being breathed on, from being coughed or spit or sneezed on, and sometimes from touching something immediately after someone with the flu has touched something if they just wiped their nose. That's why when you cover your mouth to cough it's better to use the crook of your arm. Your hand will just spread the virus more. And this is of course why kids get the flu and other viruses more easily--always rubbing and picking their noses, sneezing without covering, and being crowded with other kids in school and daycare.

3. Should we get vaccinated for H1N1? Should our kids get vaccinated for H1N1? Should parents get vaccinated for H1N1?

The short answer is, yes, all children should absolutely get vaccinated as they are at high-risk for flu-related complications. Parents should get it if they have children under 6 months who can't get the vaccine, if they are pregnant, if they are health care personnel, or if they have one of the illnesses below. This is pending availability of the vaccine.

The longer answer follows, though is still fairly straightforward and I will quote the CDC--Centers for Disease Control--here. "We recommend that vaccination efforts should focus initially on persons in five target groups whose members are at higher risk for influenza or influenza-related complications, are likely to come in contact with influenza viruses as part of their occupation and could transmit influenza viruses to others in medical care settings, or are close contacts of infants aged <6>

• Pregnant women,
• Persons who live with or provide care for infants aged <6>
• Health-care and emergency medical services personnel
• Persons aged 6 months-24 years even if completely healthy
• Persons aged 25--64 years who have medical conditions that put them at higher risk for influenza-related complications:
• Asthma
• Neurological and neurodevelopmental conditions [including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability (mental retardation), moderate to severe developmental delay, muscular dystrophy, or spinal cord injury].
• Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)
• Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)
• Blood disorders (such as sickle cell disease)
• Endocrine disorders (such as diabetes mellitus)
• Kidney disorders
• Liver disorders
• Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)
• Weakened immune system due to disease or medication (such as people with HIV or AIDS, or cancer, or those on chronic steroids)
• People younger than 19 years of age who are receiving long-term aspirin therapy

The CDC has also decided, while initial vaccine supplies are so limited, to limit the recommendations even further to a smaller group at even higher risk:

• Pregnant women,
• Persons who live with or provide care for infants aged <6>
• Health-care and emergency medical services personnel who have direct contact with patients or infectious material,
• Children aged 6 months--4 years, and
• Children and adolescents aged 5--18 years who have medical conditions that put them at higher risk for influenza-related complications.

Thus, if your child is over 4, for example, and their pediatrician has limited supply, your child would only get vaccine after everyone under 4 who wants it gets it.

Finally, who should NOT get the flu vaccine:

• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously. (For information, see General Questions and Answers on Guillain-Barré syndrome (GBS).
• Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

Otherwise, go get your vaccines as recommended above! The vaccine is safe and has been tested thoroughly--it is NOT experimental. It will NOT cause autism. There is NOTHING odd added to the vaccine. It is EXACTLY THE SAME in every way to the seasonal vaccine except that it is made from a different type of flu.

4. What specific precautions should we take to keep our children H1N1 free?

First and foremost, get your child vaccinated!!!

Then, the rest is really common sense for how anyone can avoid infection. Of course, some of this is easier said than done for younger kids:

-Cover your nose and mouth with a tissue

-Wash your hands well and often.

-Carry Purel around!

-Avoid touching your face, eyes, nose, mouth, etc.

-Avoid close contact with sick people

-Stay home until your fever is gone for 24 hours, unless you have to leave to get medical attention

-Follow public health advice re: school closure, avoid crowds, etc.

Links:

http://www.cdc.gov/h1n1flu/ (The CDC page on flu)

http://www.nyc.gov/html/doh/flu/html/home/home.shtml (For those who live in the NYC area)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm?s_cid=rr5810a1_e (For those who want to read more on vaccine recommendations)