What's Next?

It sounds like a screenplay. Like some science fiction film that could only come to life on the silver screen. The recent attack of the Swine Influenza A (H1N1) virus has instilled a scare not only among homes and businesses in numerous countries but in the health care community as well. It was not too long ago that the suspense-filled film Outbreak depicted how quickly and easily a virus can explode to pandemic status, and while bombs have not been considered an option to contain this virus--as in the film--surely ideas of drastic interventions to contain the spread was tossed around behind closed doors.

But it is not only the H1N1 virus that has us wondering what's up today with such health issues, it also includes the pervasive and explosive nature of asthma and allergy afflictions and antibiotic resistance ever rising among populations. Catching the common cold has become a sigh of relief, a minor health setback, almost a welcome alternative to other airborne health concerns.

What's plaguing us today? Why are we seemingly more susceptible to viruses and experience allergic reactions to foods more now than ever before. Or are we? It certainly seems to be the case, yet the H1N1 has certainly caught communities by surprise.

"Influenza viruses are notorious for catching us 'off-guard,'" said Heather L. Bell, D.O., an infectious diseases consultant and hospital epidemiologist for St. John Medical Center.

Bell said viruses are "very genetically diverse and do not have a mechanism to repair mutations (this adds to their virulence and survival), so every so often a new strain can emerge that we do not expect."

Bell said that while the medical community always plans "for the season ahead by looking at worldwide trends, sometimes by the time the virus gets to the United States, it has mutated and our choices for the vaccines are obsolete."

"Viruses are unique in nature in that they cannot live on their own," said James T. Phoenix, M.D., who is board-certified in internal medicine and affiliated with OMNI Medical Group on Wheeling Avenue. "They require a host in order to reproduce."

To simplify this better, viruses "hijack" cells and combine segments of their DNA with ours. From there, our cells go from healthy to viral and produce thousands or millions of copies of the virus until the cell is ruptured or destroyed. This continues until the body fights off the cells with negative antibodies or the immune system kicks into high gear.

The public's interest was sharply drawn to the status of the H1N1 virus on April 26, 2009, when then Acting Secretary of the U.S. Department of Health and Human Services Charles E. Johnson declared that a nationwide public health emergency exists after confirmed cases were reported in New York, California, Texas and Kansas. Earlier that month scientists at the U.S. Center for Disease Control and Prevention (CDC), upon examination of a child's flu virus sample from a month earlier in California, announced they had an unsubtypable influenza "A" virus--one that has not been reported previously anywhere in the world.

It was on that same day in Oaxaca, Mexico, that the first death was traced to this new strain of "Swine" flu.

And thus the H1N1 timeline began. By May, 10,000 cases worldwide were reported, and by July, the flu outbreak was now a public health threat and was said to have "significant potential to affect national security," said Kathleen Sebelius, who was appointed by President Obama as Secretary of the U.S. Department of Health and Human Services in March 2009. This month also, the virus was isolated and identified, and a vaccine development was underway.

This warning continued three months later.

Overall, deaths attributed to the flu in late October stood at 144, and Margaret Chan, the director of the World Health Organization, said "The virus is unstoppable."

People were donning masks, canceling plane flights and taking every precaution they could from this seemingly unstoppable viral strain. Web sites were created to educate the public on the virus, and an H1N1 Influenza Preparedness Summit had been held in July. Scientists, teachers, the government and even the private sector were combining forces to study the virus and educate people on how to contain this virus.

Toward the end of November, flu activity had dropped across the country as the vaccine supply hit a record of nearly 93 million doses.

Currently, more than 100 million doses of H1N1 vaccine have been produced, and with the onset of seasonal flu, millions of doses of seasonal flu vaccine have been made in a record eight months.

The H1N1 Code

Dr. Bell said the 2009 H1N1 influenza is a flu virus just like all the other seasonal flu-viruses, adding that it is not at all unique.

"We have actually seen it before in 1918 with the worldwide pandemic that killed so many millions of people," she said. While Bell admits everyone is at risk for any virus, specifically for the H1N1 virus, young people are at risk combined with healthcare workers, those with chronic diseases and pregnant women.

"This novel 2009-H1N1 tends to attack the young and healthy and seems to stay in your system a bit longer than the other influenzas we've seen," she said, adding that since the last time we encountered this flu was in 1918, "not many are alive today that have a natural immunity to it, so almost the entire population is at risk." Bell said what happens when the virus invades our systems.

"The flu virus attaches to the respiratory tissues and replicates there, so a lot of symptoms are respiratory based--cough, sinus pain and sniffles. Your body responds to the infection with a high fever to try to combat the virus by making your system 'inhospitable' for it. You usually will also have headaches, body aches and can have chills with the fever."

She is quick to mention that some will experience diarrhea and nausea; although it is not common. As opposed to the common cold, influenza usually begins with the sudden onset of moderate to high fever, muscle aches, headache, dry cough and exhaustion, while the common cold, caused by several different viruses, is experienced by a stuffy nose, sore throat, sneezing and cough, Bell said.

"There is a bit of an art at times in distinguishing the two, and sometimes a nasal swab or blood test is necessary to be sure," Phoenix, an OMNI group physician, said.

He said while the "common cold" is a term that includes a wide variety of different species of viruses, as Bell stated, they are easy to catch and pass on to others. Since they cause similar symptoms and are treated similarly, they are lumped together.

"Influenza is different because of the symptoms it causes, and the fact that it is constantly changing so that having the flu one year doesn't protect you the next year and may not protect you from some other strains circulating in the same year," he said. For example, he said the H1N1 virus is totally different than the "seasonal" flu this year--and vaccinating for one does not protect you from the other flu.

Phoenix said the "good news" about a cold or viral infection is that usually the body has all the "tools to fight it off without any help. The bad news is we have not developed any specific anti-viral agent that works reliably for the "common cold" because it is actually caused by a variety of different viruses that may have no common features to attach with medicine.

Staying flu-free is the key, yet the transmission of flu can be as easy as being in the wrong place at the wrong time. Someone sneezes close to you without covering her mouth and droplets from her seemingly innocuous sneeze infect you--this is the primary means of spreading the flu, said Bell. In addition, she offers staggering information for other means of transmission.

"The flu virus is thought to live on surfaces from a few seconds to 48 hours (depending on the type of surface); because of this, it is possible to get the virus by touching contaminated surfaces, such as doorknobs, shopping carts or public phones." The key, she said, to wash your hands frequently and take advantage of antimicrobial wipes when offered.

Healthy as a Horse

Flu has the potential to cause severe illness and life-threatening complications. As Bell explained, the virus "weakness your immune system because it is 'busy' fighting the virus." The respiratory tissues are most at risk, she said, for an "opportunistic bacterial infection to take advantage of a 'distracted' immune system." Moreover, she continues, this usually leads to a "Staphylococcal or Pneumococcal pneumonia a few days after the influenza virus." Since there are very few ways to predict who will get a secondary bacterial infection, Bell recommends the best way to prevent the pneumonia is to prevent getting the influenza: "Vaccinate, vaccinate, vaccinate," Bell urges, and those with decreased immune systems, "avoid crowds if at all possible." And, while a seemingly simple activity, she said to continue to wash your hands frequently.

It's good advice--something our mothers would hounds us to do when we were young. How simple can that be to wash your hands?

Jill Almond, Wellness Coordinator for the Tulsa City-County Health Department, agrees that the more we wash our hands, the better off we'll be.

She recommends washing with an antibacterial soap for 20 to 25 seconds, "lathering between all fingers and around the wrists." Warm or cold water are both effective, she said, but warm water will produce more lather. The trick is to keep ourselves free from contamination.

"We need to think about alternative ways to greet people," she suggests, without having to do the traditional hand shake. In addition, hand railings of all sorts, barristers and countertops at stores should also be places to avoid touching.

Another precaution especially when traveling is to avoid touching your eyes, mouth and lips. "It is important to be aware of what you are doing especially in areas with lots of people," she said.

Being educated and not scaring people in the process is important. She finds that some people will go immediately to the fear level without understanding the good or healthy fear that goes with an illness. Almond said the Health Department has plenty of 2009 H1N1 vaccines available as well as seasonal flu vaccines.

Seasonal flu, which usually begins in November and runs through March, seems secondary in concern this year. Still as the H1N1 peaks, it is important to be vaccinated for the seasonal flu, too.

Itching to Meet You

Another health concern that has been on the rise in recent years is the high number of people afflicted with allergies. Phoenix said "recent studies support this, with data showing that the number of visits by children to emergency rooms for food allergies has tripled since 1993."

Whether it is due to increased awareness or an actual increase in the number of people with allergic reactions, he said it is a growing problem.

He said that "one theory about why this is happening is the overuse of antibiotics and antiseptic soaps and cleaning products, which limit the small exposures to infectious particles or allergens, preventing children from developing a protective immunity to those things."

He added that when they do get exposed, they are more likely to have a significant reaction or infection. "There are probably multiple factors to this trend, but I believe this to be an important one, and one that parents can avoid."

A common problem today is with food allergies, with symptoms ranging from nausea to hives to full blown anaphylactic reactions that can be life threatening, Phoenix said. The body's immune system reacts to a protein in the food, triggering a cascade of inflammation with wide-ranging effects. Sometimes as children we may not have allergies, but we can grow into them as adults, Phoenix said.

While small children might have an in-born response to certain allergens, it is quite common to gradually develop an allergy to food or medication or any other potential allergen.

"Any time the body is exposed to foreign proteins or other material some level of immune response can occur," Phoenix said. "The body produces antibodies to that material, so that in the future the body will more quickly recognize it and be able to fight it off."

As he said, this does work to our advantage with infections, and is the rationale behind immunizations for flu and other diseases, but works to our disadvantage with food and other allergens. Throughout time, he said, it might reach a "tipping point beyond which a full blown allergic response happens."

He offers an example. "You may have been able to take penicillin as a child with no problem, but for some people this triggers a mild immune response that can grow with each exposure until at some point, usually without warning, a symptomatic allergic reaction can happen." And, the same goes for food or other environmental exposures. He said there is no way to predict who will have this or what allergen may cause it, and so the best you can do is pay attention to your body and be wary of anything that causes a mild response such as a few hives or a little mouth swelling, because the next time it could be worse.

Unlike taking a vaccine to stave off flu, the best way to prevent allergies is to avoid the exposure, said Phoenix. He said over-the-counter and prescription antihistamines, nasal sprays and other medications can be used if exposure is common or unavoidable, such as seasonal allergies, which will work to suppress the body's allergic response before it happens.

For more severe reactions, such as with food allergies, he recommended seeing an allergy specialist who can test for specific allergies and attempt to sensitize the body to those with allergy shots, gradually reducing the severity of the body's natural reaction. Phoenix said severe food or contact allergies might not be preventable with these measures, and some people might have to keep emergency injections of steroids or adrenaline in case of an accidental exposure.

The first line of treatment for allergic reactions, which might be unexpected, are over-the-counter medications such as antihistamines or topical hydrocortisone creams, Phoenix said. These are designed to "calm down the body's immune reaction" to an allergen. More serious reactions such as widespread hives or rash, or swelling in the mouth or gastrointestinal tract, prescription medications are usually required, and these obviously should be administered or prescribed by a physician familiar with their use.

Phoenix said in ERs, the most common medicine used for serious reactions are intravenous steroids which provide "a rapid and potent block to the inflammatory reaction triggered by the allergy." He said this can often be done on an outpatient basis, but sometimes might require hospitalization or even time in an ICU unit. "The key with any treatment is rapid response. If you try something at home that isn't working, you should seek medical attention as soon as possible, and if the reaction is widespread or causing difficulty breathing, prompt evaluation in an emergency room is essential," he said.

Like warding off flu, Phoenix said there are a variety of antiseptic products that can kill viruses, especially on surfaces or the exterior of our body, most recently a tissue by Kleenex that is said to be an anti-viral tissue. Phoenix said that while products of this nature (hand sanitizers most notably) are too toxic to ingest internally, they can work to kill viruses and bacteria in the environment. Still, he offers a word of caution. "If we are never exposed in small amounts to different infections, our bodies will not produce protective cells against them, and this can lead to more severe infections."

Phoenix said one of the reasons why it is suspected that children have more allergies now than they used to is the widespread use--or overuse--of "antiseptic products, which limit those small exposures and prevent them from developing defenses against material commonly in our environment, making it more likely that they will have a more severe reaction or infection when they actually experience a large exposure."

Fighting Against the Strain

Besides flu, common cold and allergies, Phoenix has another concern of interest: antibiotic resistance. He said with the overuse of antibiotics for respiratory and other infections throughout the last few decades, "we have inadvertently wiped out many of the 'weak' bacteria and therefore created an opportunity for bacteria that are more resistant to our commonly used antibiotics to fill in the gap." For example, he said we can no longer use penicillin-based products for many common infections. "The more severe infections that require hospitalization have developed an alarming array of resistance to even our most potent medication."

He said the implications of this are significant. "We have come to expect that with proper management we can pretty much manage any infection, but this could change," he said. "We may return to a time when we don't have adequate tools to fight infection and many more people will die from infections that used to be treatable." While drug companies continue to develop new antibiotics, research has slowed in this area and options are becoming limited, he contends. Still, he said it is important for both patients and doctors to be "judicious and responsible with the use of antibiotics to slow the progression of antibiotic resistance and prolong our ability to fight these infections quickly and reliably."

Being educated, keeping current on what's plaguing us today, washing our hands and being vaccinated are keys to staying healthy. Phoenix offers some basic advice to stay healthy: "The most important key to good health is moderation." He attributes many of today's common health problems to our excessive and often wasteful appetite for food and drink, resulting in obesity, diabetes, heart disease and a variety of other ailments that affect both the quality of our lives and our lifespan.

"A reasonable amount of the 'good' food, or alcohol, is safe and even recommended for our well-being, but this should be kept within reasonable limits that are different for each individual. Regular exercise, which doesn't have to be strenuous or expensive, is also key," he said. Moreover, he adds that these suggestions are those that most all nod in agreement to, but relatively few actually follow. He cautions to be wary of the "quick fix" diets which, as he said, are "invariably flawed." He concludes there is no substitute for "basic balance in what we take into our bodies and the calories we burn by activity and exercise. We all know what to do; we just have to do it."

With regard to viruses, Phoenix said there is really no way to stay free of them completely, and "frankly, you wouldn't want to. It is important for our immune systems to be exposed to them so that we develop defenses against them. In small amounts, too small to trigger an actual infection, or perhaps just a mild infection, they are actually helpful in this way." Bell agrees, saying she firmly believes everyone should be vaccinated for viruses, even though some hold-outs say they have the chance of getting sick from this preventative measure. "The shot is a killed virus and very safe," she states.

And, it seems there are plenty of seasonal influenza and 2009 H1N1 vaccines for everyone at this time--the Tulsa Health Department, doctors' offices and hospitals. Phoenix said the rationale behind vaccinations goes back centuries when people would expose themselves to small pox in the hopes that a mild infection would prevent a "more severe infection in the future, and even now in our more modern version of 'chicken pox parties' where kids are intentionally exposed for the same reason."

"Keeping the 'healthy population' healthy is key," said Bell. "Only vaccinating the sick is counterproductive; they don't always have enough of an immune system to help the vaccines work effectively.

"Keeping everyone healthy to avoid exposing the chronically ill to disease is the best preventative measure we can do."