In a flu season that has been described in superlative terms (eg, Worst In Years), Massachusetts has perhaps been the poster child for just how widespread, virulent, and debilitating the virus has been. While the state reported a slight decline in flu activity in mid-January, Nancy O’Rourke, MSN, ACNP, ANP, RnC, FAANP, who practices in the ICU and urgent care/emergency department settings of Good Samaritan Medical Center in Brockton, says, “We’re still seeing a lot of people who are very, very ill.”
Her description of the situation in Massachusetts will be familiar to clinicians in many of the 48 states that have reported widespread flu activity: “Emergency departments across the state are still packed. For the past three or four weeks, our ICU has been at full capacity every single day, and so has every other hospital in Massachusetts. There are just no beds to be had anywhere.”
The CDC’s FluView (www.cdc.gov/flu/weekly) for the week ending January 19 paints a national picture of epidemic proportions. About 26% of specimens tested by reporting laboratories were positive for influenza. The proportion of reported deaths attributable to pneumonia and influenza (9.8%) was above the epidemic threshold. Eight pediatric deaths were reported (although not all occurred during that particular week; there have been 37 pediatric deaths reported since flu season began). The cumulative rate (from October 1, 2012, to January 19, 2013) of laboratory-confirmed influenza-associated hospitalizations was 22.2 per 100,000 population; almost half of cases involved adults 65 and older.
In Massachusetts alone, about 11,000 people have already tested positive for flu. And as O’Rourke points out, “Those are just the folks who have shown up and been tested. There may be many more who are at home, just weathering it.”
All in all, it would be an understatement to say it’s been a pretty bad year for the flu.
Is It Really the Flu?
The CDC data focus on confirmed cases of influenza. But as O’Rourke notes, there are individuals who may not seek care (or, ironically, do not feel well enough to do so), as well as those who present too late in the course of illness for a flu test.
The CDC, though, also reports an increase in outpatient visits for influenza-like illness, which is defined as a temperature of at least 100°F, cough, and/or sore throat. While this description focuses on quantifiable symptoms, it does little to convey the malaise caused by the flu. When lifting your hand to pick up a glass of water on the bedside table seems like an insurmountable task, or standing upright long enough to shower becomes an unnecessary extravagance, you know you’re sick!
One of the confounding factors of this flu season has been the confluence of circulating viruses and infections. Besides influenza (three strains, no less), there have been outbreaks of norovirus and cases of mononucleosis, as well as the usual assortment of upper respiratory infections.
The distinguishing feature of flu, clinicians in the field say, tends to be fever. “If a child comes in with a high fever—101°F to 103°F—that child is more likely to have flu,” says Patrick E. Killeen, MS, PA-C, who practices at Danbury Hospital in Connecticut and holds academic posts in the Yale University School of Medicine’s Department of Pediatrics and the Quinnipiac University School of Health Sciences. “Whereas with RSV [respiratory syncytial virus] or rhinovirus, they have very similar symptomatology and x-ray findings, but they don’t have the high fever.”
Killeen and his colleagues have also observed that “children with the flu are more likely to develop secondary bacterial pneumonias. They’ve been sick for three or four days, they come into the hospital, and then their chest x-rays are showing significant infiltrate and they have high white counts.”
In the outpatient setting, Christopher M. Barry, PA-C, says a good history and physical examination can provide a lot of information. He echoes Killeen’s assessment that a quick-onset, high fever is often the first sign. But looking further, “We tend to see a person who just looks really sick. They often have a lot of nasal discharge, and sometimes the eyes have almost a glassy appearance. That gives us a little bit of a clue as well.”
At Jeffers, Mann, and Artman Pediatric and Adolescent Medicine in North Carolina, where Barry practices, they are fortunate to have access to a rapid antigen detection flu test. “We get a result back usually within five to 10 minutes,” he says. “So if there’s a suspicion, we typically run the test.”
At the other end of the age spectrum, O’Rourke has noticed that elderly patients tend to minimize their symptoms (as a general rule; this is not specific to flu). Many are appearing at urgent care centers and emergency departments when they’re already very ill.