How to deal with influenza?
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7467.633 (Published 16 September 2004) Cite this as: BMJ 2004;329:633All rapid responses
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How we deal with influenza
Editor- Because there is no specific treatment for influenza, your
editorial and the accompanying articles concentrate on vaccination and
chemoprophylaxis.¹ However I would like to plead for recognition that
fever may be used as a non-specific treatment of flu. Why do we fail to
realise that the fever is not just an unpleasant symptom of flu, but a
vital part of the body’s defence mechanism which we should encourage?
Infectious organisms are adapted to the temperature of the part of
the body they colonise, so it follows that they will grow best at that
temperature. Rhinoviruses, which infect the cooler upper airway and
sinuses, grow best between 33 and 35º C, so inhaling air at about 45º C
for twenty minutes will significantly improve the symptoms of a common
cold.² Conversely, treating the common cold with aspirin causes a
significant increase in the rate of production of the virus.³
On the other hand, the influenza viruses, which infect the whole
body, grow best at temperatures slightly below body temperature and at 40º
C they will die off after 12-24 hours. So it is not surprising that if
fever is suppressed in ferrets infected with the flu virus, their illness
is prolonged.4
Regrettably there appear to be no studies of the effect of lowering
or raising body temperatures in humans suffering from flu. But there are
obviously good reasons for trials of treating flu by raising the
temperature to 40º C and maintaining this for at least 24 hours.
The absence of such trials may be due to a deep-seated fever-phobia
stemming from pre-scientific medicine when fever was perceived as an
illness in itself. A famous 17th century physician, Thomas Sydenham said,
”Fever is nature’s engine which she brings into the field to remove her
enemy”. Both the public and the medical profession have still not realised
the full significance and potential of this statement.
1. Jefferson J. Editorial. BMJ 2004:329:633.(18 September)
2. Tyrell D, Barrow I, Arthur J. Local hyperthermia benefits natural and
experimental common colds. BMJ 1989;298:1280-3.
3. Stanley ED, Jackson GG, Panusarn C, Rubenis M, Dirda V. Increased virus
shedding with aspirin treatment of rhinovirus infection. JAMA
1975;231:1248-51.
4. Husseini RH<Sweet C, Collie MH, Smith H. Elevation of nasal virus
levels by suppression of fever in ferrets infected with influenza viruses
of differing virulence. J Infect Dis 1982;145:520-4.
Competing interests:
None declared
Competing interests: No competing interests
I wholeheartedly concur with the recommendations made by Tom
Jefferson, but the trick is in the implementation, which must be assiduous
and generalized. Possibly my experience in having a written Influenza
Management Plan for the Regional Municipality of Hamilton-Wentworth in
Omtario, Canada may be of assistance, as we had a wealth of experience. I
was Medical Officer of Health and Commissioner of Health Services at the
time in the mid 1990's as well as Director of the Public Health Teaching
Unit at McMaster University.
Unfortunately, I know only too well the consequences of poor
management of Influenza A at a preventative, treatment and occupational
level. I came down just after I had re-located to Scotland with acute
severe illness in December 1999 caught from a friend. I developed Acute
and Chronic Post Viral Fatigue Syndrome (PVFS) or Myalgic Encephalitis
(ME) from which I am only now recovering. My recovery is following
prescription of a drug nimodipine which is not usually prescribed for
these illnesses, as well as complementary treatments. I was in hospital
altogether for about a year and bed-bound for nearly 3 years.
We introduced, and promulgated, the following Influenza Management
plan with immediate success in reducing deaths and spread of Influenza A
in the community. The Medical Officer of Health was notified by the public
health laboratory of the first positive test result for Influenza in the
community as of October each year. This was immediately communicated to
the press and g.p.'s. Early diagnosis was made possible by the training
and introduction of the taking of nasopharyngeal swabs by various health
practitioners in various settings, including sentinel g.p. practices and
longterm care facilities. These are somewhat tricky and involve using a
special, flexible longer swab, which takes a sample from the back of the
throat. These need to be rapidly transported personally by staff to the
laboratory which tests them using the latest techniques, with immediate
results. These tests are done on anyone with potential influenza, and
latterly influenza-like symptoms such as those caused by the range of
viruses that Tom Jefferson indicates that can be harbingers of influenza
outbreaks.
Respiratory hygeine information was sent by fax to g.p.'s for
reminders, and to the community, including the washing of inanimate
surfaces with bleach. I would now recommend environmentally friendlier
products. If two or more cases had been confirmed, Amantadine prophylaxis
for residents in longterm care and communal homes, and in fact early
treatment, if the illness had been present for less that 24 hours, was
instituted rapidly by public health inspectors. A written protocol had
been previously agreed to by the managemant of these facilities and
supplemented the influenza vaccination program for staff and residents
both on a routine and emergency basis. Closure of facilites to visitors
and cohorting of staff and residents was implemented as necessary. The
province of Ontario has a Health Protection and Promotion Act which
provides the legislative power for the MOH to undertake these actions.
They are usually done on a consultation basis, however.
In young and school-age children, influenza often presents as an
acute gastro-intestinal illness, and these would be reported to the
department of public health routinely under legislation. Immediate
response was along the lines above of naso-pharyngeal sampling, immediate
testing, education and closure of schools as indicated.
The province of Ontario, under the Chief Medical Officer Dr. Richard
Schabas introduced a community influenza vaccination program, which was
expanded under his successor Dr. Colin d'Cunha. He will likely be known to
readers for his excellent management of the Sudden Acute Respiratory
Syndrome (SARS) outbreak in Toronto last year.
I myself have some reservations about a universal influenza
vaccination program. Unfortunately I suffered an acute and devestating
relapse from my CFS/ME , although I had til that time been making a good
recovery, in the days following my influenza vaccination, even though I
believe only a half dose was used. As conservative estimates of up to 2%
of populations have CFS, I believe a hazard exists. If CFS/ME were
notifiable illnesses then specific awareness and management of this,
albeit heterogeneous goup may be possible after research.
Currently I would add the introduction of the use of face masks by
the public, as they do in oriental countries, to prevent spread of active
respiratory disease. This is also particularly pertinent in international
air travel situations. Strangely I believe that current airline policies
of minimizing the use of air-conditioning and , in-fact oxygen pressures
potentiate the spread of respiratory illnesses. Thes need urgent
attention.
I also believe that respiratory and influenza-like illness are not
taken seriously in the workplace, and by g.p.'s. I was told by my Director
who happened to be a doctor, when I struggled back to work, having had to
talk the training g.p. at the practice I attended into giving me 2 weeks
off, that "I was lucky that I hadn't had meningococcal septicaemia" which
was my initial diagnosis. NO allowance was made for my illness or any kind
of graded back to work. It was full-on from the moment I walked in the
door. I had to leave the next day due to sudden onset of dizziness and
other illness and I haven't worked since. I hope now, as my recovery
hopefully continues to get back to some kind of work. I support the idea
also of anti-viral prophylaxis for individuals like myself who are at
risk, although I'd be pleased to be advised of the latest recommended
drug. I do take immune system builders prescribed by a Chinese herbalist
but have already had a viral infection followed by bacterial sinusitis and
bronchitis this year. I also notice people coughing EVERYWHERE. Something
can be done to avoid the enormous toll if the Ministry of Health acts
quickly for this season. If nothing else think of the saving of costs in
the workplace. However, I believe it takes months to recover from
Influenza.
Competing interests:
None declared
Competing interests: No competing interests
How to deal with influenza?
Editor - We strongly support Jefferson’s recommendation that efforts
should be concentrated in strengthening our capability to conduct
surveillance for influenza, and especially the identification of
circulating virus amidst non-specific respiratory illness (1). In North
West England, the Health Protection Agency has developed influenza
surveillance over the last four years to increase the coverage of the
National GP consultation system (run by the Royal College of General
Practitioners) within the region (2). This follows a successful pilot
scheme that detected a local epidemic of influenza A in Merseyside during
the 1998/1999 season (3).
This year, over 80 general practices are contributing weekly data on
influenza and influenza-like illness to local Health Protection Units.
The data are entered weekly onto a web-based data capture system and
converted to age-specific rates. The data can be viewed in real time
online by staff with NHSNet access and are also disseminated in a weekly
bulletin produced by the Health Protection Agency North West Office (HPA
NW). The bulletin’s distribution via e-mail is to a wide audience,
including Primary Care Trusts and Strategic Health Authorities and it is
also available on the HPA NW web-site (4).
A key development last season was to include in the bulletin data on
respiratory isolates identified in microbiology laboratories throughout
the region. There was good correlation between the period of influenza
virus isolation and increased consultations for influenza in primary care
(http://www.hpa-nw.org.uk/FluGraph.htm). These data indicate the
reliability of the surveillance system in distinguishing between increase
in influenza and increase in influenza-like illness, despite the low level
of circulating influenza compared with respiratory syncitial virus (RSV).
Surveillance beginning in October this year will again combine
consultation rates with virology data to provide a weekly snapshot.
Robust regional data are important as national data may mask local
variation (3) and feedback received indicates that this system is
particularly useful to health service staff involved in planning services.
It alerts them to local increases and facilitates bed management. In
addition, the data are used to determine when influenza is “circulating in
the community” and when antiviral compounds are appropriate.
A worthwhile surveillance system should result in timely intelligence
for action. We believe that the surveillance of influenza and influenza-
like illness in the North West is a good example of such a system.
1. Jefferson T. How to deal with influenza? BMJ 2004; 329: 633-634.
2. Regan, C. M.; Sopwith, W.; Syed, Q.; Painter, M.; Mutton, K.,
Paver, K. Surveillance of influenza in the North-West Region of England
2001-02. Euro Surveillance: Bulletin Europeen Sur Les Maladies
Transmissibles = European Communicable Disease Bulletin. 2002 Dec;
7(12):174-80.
3. Regan CM, Johnstone F, Joseph CA, Urwin M. Local surveillance of
influenza in the United Kingdom: from sentinel general practices to
sentinel cities. Communicable Disease and Public Health 2002; 5 (1): 17-
22
4. Health Protection Agency, North West Office. North West Influenza
Bulletin. http://www.hpa-nw.org.uk/Flu/Bulletin%201.pdf (accessed 12
October 2004)
Competing interests:
None declared
Competing interests: No competing interests