COMMENTARY

'Can’t Overhype' This Flu Season: ER Doctors From the Front Lines

Robert Glatter, MD; Ali S. Raja, MD, MBA, MPH; Alfred D. Sacchetti, MD

Disclosures

February 09, 2018

Troubling Statistics From the 2017-18 Flu Season

Robert Glatter, MD: Welcome, and thanks for joining us for a discussion of the 2017-18 flu season, from the frontlines of the emergency department. I am Dr Robert Glatter, assistant professor of emergency medicine at Northwell Health in New York and a member of the Medscape Emergency Medicine editorial board.

According to data released last week by the Centers for Disease Control and Prevention (CDC),[1] the 2017-18 flu season is shaping up to be more intense than the 2009 swine flu epidemic. It is now on track to equal or surpass the intensity of the 2014-15 flu season, in which 710,000 Americans were hospitalized and 56,000 died.

Both the 2014-15 and the 2017-18 seasons have been dominated by the same H3N2 flu strain. While the number of people contracting the flu nationally is actually increasing, it is the hospitalization rate, which is a predictor of the death rate, that has sharply increased in the past several weeks.

While persons over the age of 65 are the most likely to be hospitalized, persons aged 50-64—not infants and young children under the age of 5—are the #2 cohort accounting for the surge in recent hospitalizations. Flu intensity is now widespread throughout the United States, and hospitalization rates have recently increased on the West Coast and are starting to surge in the Northeast.

Here to discuss these and other trends with us is Dr Ali Raja, executive vice chair of the department of emergency medicine at Massachusetts General Hospital in Boston and associate professor of emergency medicine at Harvard Medical School, along with Dr Al Sacchetti, chairman of the department of emergency medicine at Our Lady of Lourdes Hospital in Camden, New Jersey. Welcome, gentlemen.

First-hand Experiences

Dr Glatter: I want to start off by getting an idea of how bad the flu situation is at each of your institutions, of what approaches (eg, flu tents) or protocols you may be implementing, and what kind of strains are you seeing.

Ali S. Raja, MD, MBA, MPH: As you pointed out, Rob, this is actually a really bad year for us. We have a 300% increase in the number of patients we saw last week compared with the same time last year.

We have a whole heck of a lot of patients with flu right now. Our hospital inpatient units are also full. One of the things we are doing on the inpatient side is starting to cohort patients who have the same strains of the flu. If there is an adult patient with H1N1, we will cohort them in the same room as another patient who has verified H1N1, which is something we would not normally do. But at this point, it has gotten so busy that we have to.

In the emergency department itself, we are following pretty good infection-control procedures, but we have not implemented flu tents. There is at least one other hospital in Boston that already has.

We have way overflowed our treatment bays. There are people in hallway stretchers and chairs.

Dr Glatter: You mentioned that you were able to subtype the flu strains. How quick is your turnaround time on your rapid diagnostic test?

Dr Raja: We have actually moved a little bit away from our rapid diagnostic test. We are now using a polymerase chain reaction (PCR) as our first-line test, because the rapid flu is not quite as sensitive as we and our inpatient teams would want. We've got about an hour and a half to 2-hour turnaround for our PCR.

Dr Glatter: That is excellent, and it's great to hear that you are cohorting patients. That is certainly a move that is going to help reduce patient mortality. Al, on your end, are you doing something in a similar fashion?

Alfred D. Sacchetti, MD: We are not quite as sophisticated as that. We are cohorting them, but only by type A or B. We are not getting down to a subtype on them. We do not have the flu tents. What we are doing, to the extent that we can, is that anyone who shows up with flu-like illness is being placed in masks in the waiting room as quickly as we can, and certainly in the treatment areas.

We have way overflowed our treatment bays. There are people in hallway stretchers and chairs. We are cohorting entire families in a specific area and all of them are wearing masks, except for the kids who are taking them off and throwing them away when they play. It is pretty much crowded all the way around.

Media Hype or Serious Health Risk

Dr Glatter: The media has been accused of trying to overhype this flu season. What are your thoughts on this? Is this something that is being overplayed right now? Is it truly a real danger that you are seeing in your departments?

Dr Sacchetti: I do not know that you can overhype it. You have to look around you and within your given family, where half of them are sick. If you go to work, how many of your colleagues are out? No matter how much they play it up, you have already seen it yourself. You do not need the media to tell you about that.

Dr Raja: I completely agree from what I've seen here in Massachusetts, and I'm assuming that's similar to what you've seen in New York and New Jersey. Our biggest month for the flu is typically February. When you look at the state of Massachusetts, our numbers are still increasing. We have not seen our peak yet. The CDC also estimates that the nation has not seen its peak.[1] I know that out in California there are some indications that maybe they have peaked and are starting to decline, but we have not seen that on the East Coast.

I agree with Al. I do not think that we can overhype this right now. I do not think there is a level of caution that I would consider too extreme.

Dr Sacchetti: The only possible bright spot is that we saw nothing and then it jumped up dramatically, quickly. One of the things that we've seen in the past is that when you get a really quick spread of the flu, you infect so much of the community that all of a sudden you wind up with some type of an inadvertent herd immunity.

What we are hoping to see is that the spread drops down because almost everybody is infected, and that we'll see a sudden drop-off as well. When you see the more gradual upsweep, it lasts longer. I did an interview for the local paper and they asked if I'd seen the flu. [At that time,] I said, "We have not seen any cases." The next day we got 12 of them. I called them back and said, "Oops, you may want to change that." It was like someone just flipped the switch.

We always see that with the respiratory syncytial virus (RSV) in infants: If it swings in really quickly, like where you will see a dozen to two dozen kids in a day, then all of a sudden it goes away quickly. I am hoping that maybe we will see the same thing with the flu. It clearly has not been that way in the rest of the country.

Mortality Risks

Dr Glatter: Another thing that has been played up in the media is the aspect that this is deadly flu, where patients get the flu and quickly die within 24-48 hours. There have been cases reported of this. Certainly, one issue is the cytokine storm we know about and sepsis, as well as the complications that older patients typically get, such as pneumonia.

Are you seeing any of these groups of patients, older or younger, that get flu quickly and then die?

Dr Sacchetti: We have had one death. That was someone who was seen at another hospital, diagnosed with flu-like illness, and came in to our hospital the next day with cardiac arrest. Otherwise, we have not seen the deaths. Ali, I do not know what is up at your place.

Dr Raja: No, that is true for us as well. We have seen a couple of geriatric patients who have died. We have definitely seen our fair share of pediatric flu patients. I have not heard of one who has died, although I have to admit that I do not follow them on the inpatient side as far as I might hope to.

One of the interesting statistics for this year, which I know you have both seen, is that the #2 group in terms of patients who are getting the flu this year is not the pediatric population. The geriatric population over the age of 65 is #1. Then you have this group of patients between the ages of 50 and 65 who are the second largest group getting the flu. That is a little surprising. We have all got our explanations, but I just wanted to point out that that is the group that we are really seeing getting the flu right now.

Dr Sacchetti: If you look at the numbers from last week, for a 100,000 population, the rate was 183 in the 65+ group. Then it goes to 44 in the 50-64 age range, and then down to 27 in the 0-4 range. It is pretty dramatic, the change there that we have never seen.

I do not think that we can overhype this right now. I do not think there is a level of caution that I would consider too extreme.

Dr Raja: On our end, we are seeing a mixture of cases, but a fair number of pediatric patients are actually coinfected with RSV and the flu. They are giving them quite a wallop. On your end, have you seen a coinfection type of picture?

Dr Sacchetti: We have not, but to be honest with you, leading up to it, every kid with an upper respiratory infection that we were worried about was getting screened for both. We were seeing a bit of RSV early on and no flu. Now it has just switched. We are seeing nothing but flu.

Dr Raja: We routinely screen for both as well in kids and have been doing so for the past couple of months. I have to tell you—more than the kids, I have been seeing older adults with complications, particularly pneumonia. Especially with the cold weather, snow, and ice that we have had over the past month or so and serious complications with people losing power, we have had people who have to take care of their older parents and have not been able to get them up out of bed.

We have had patients who have come in from nursing homes with pneumonia, and then you obviously worry that everybody at the nursing home is going to have the flu now as well. The geriatric population is still the one that I am most concerned about and, as Al pointed out, while the 50-to-65 age range group is #2, there is still a pretty wide gap between them and #1.

Dr Glatter: Our experience has been that we are seeing a lot of the 50-to-65 age group, as you mentioned—more than any other group—and that has really overwhelmed our department and put a strain on resources.

Links Between the Flu and Myocardial Infarction

Dr Glatter: Moving into the cardiac aspect, there was study in the New England Journal of Medicine last week[2] that looked at laboratory-confirmed influenza. It showed that there was approximately six times the risk of being admitted for myocardial infarction (MI) in the week after contracting the flu as opposed to periods before or after. Any thoughts on this study? Does this mimic any change in your practice in terms of screening patients in the emergency department for MI who actually have the flu?

Dr Raja: I have to say, I am not surprised by that and doubt that many of us actually were. What I was surprised by is that if you look at that study, it really showed that the risk was there for 7 days, and then it really dropped after that period of days. It is really surprising to see that the risk went away for MI so soon after having the flu.

With the various inflammatory markers, the cytokines you mentioned earlier, the issues with global hypoxemia and potentially cardiac hypoxemia, I am not surprised that there are MIs after a flu. I am just shocked that the risk declines as quickly as it actually does.

Dr Sacchetti: I agree with Ali on that one. The drop-off is amazing. But if you think about how everybody has been yapping at us about chronic inflammation as a risk factor for MIs and strokes, and you have plaque and get inflammation around it, it would make perfect sense that you can see it after the flu. You have this huge inflammatory response going on with the flu, but then the drop-off just does not make any sense, unless there is a specific inflammatory agent that drops, and that is what gives you the problem.

Advantages of Annual Vaccinations

Dr Glatter: I wanted to focus on looking at flu deaths in previously healthy people as well, because that really is an issue that patients are scared about. It is important to consider messaging to the public and trying not to scare people, but letting them know that they are not likely to die from getting the flu unless there is an overwhelming response. What is the best way to communicate that to people?

Dr Sacchetti: We have spoken about the media. People like the dramatic story. You will hear them talk about that statistic of 1 individual out of 100,000. I think that is one of the things that scares people, because they just heard about it and do not understand that the statistical relationship is that their risk is extremely low.

The one thing that I think you really have to stress is that these are not like MI patients who walk out the door, get a clot, and drop over in ventricular fibrillation. These people got progressively sicker and they had an opportunity to return [to the hospital]; that is what you really need to stress.

Dr Raja: I think that is exactly right. There's also one silver lining in this. I was talking to one of the student newspapers out of Boston University a couple of days ago. The reporter who had contacted me had just come from the student health clinic, where she had seen lines of perfectly healthy students, who otherwise might have completely ignored the flu shot, lining up right now—probably a couple of months too late, but—to get their flu shots.

The one thing that I really like about the media coverage—and again, I do not think that this is necessarily true that they're potentially overhyping that there are healthy patients who are getting very ill and dying from the flu—is that it's getting more healthy people vaccinated. Even getting vaccinated this late in the season is better than not getting vaccinated at all.

Dr Sacchetti: It's funny, because the one thing that came out in the media was that the vaccines are not working. It is a bad year for the vaccine, but it is an H3N2 and H1N1 vaccine. You can look at the data where they take islets from patients and inject them into ferrets, or whatever they do, to say that it is an appropriate antibiotic response.

What is interesting in our hospital, where there has been mandatory flu vaccination going back probably almost a decade, is that everybody has been getting these shots over that time. They have been getting variations of the H3N2 over that time. We have had zero nurses, techs, or docs get the flu, even though they have been living in basically a petri dish for the past couple of weeks.

I am wondering if maybe it is not the single flu shot but this accumulated exposure to a bunch of different flu vaccines over the past few years that is giving you enough antibodies that you either are not getting the flu or you are not getting very sick with it. Knock on wood, our guys have been fine. But watch—tomorrow I will go in and there will skeleton crew!

Dr Raja: I think that is exactly right. I cannot put my finger on it, but sometime over the past few weeks I saw a report of a publication that actually supported that exact statement, that it was thought that the serial exposure to the annual flu shot actually helped decrease the risk of getting the flu. The more often you can get it—not getting multiple shots in the same year but just being exposed to the various antigens over the past decade—is definitely a good idea.

Dr Glatter: Dan Jernigan from the CDC brought up a good point during a call this week about the importance of what age you were exposed to the flu and when you were born, which determines your antibody response to future flu strains.

What's Next for Flu Vaccinations?

Dr Glatter: What are your thoughts on a universal flu vaccine? This is certainly being researched and is in progress in trials right now. Do you think that is going to become a big player in the next decade?

I know of at least one vaccine in the United Kingdom... aiming at shifting the target away from the antigens to the code itself... That will be a game changer.

Dr Raja: I think that is going to be a huge deal. As we all know, there are a couple of major antigens that vary in the flu virus, which is why it is so hard to actually pin it down, due to the mutations and the adaptations.

That being said, I know of at least one vaccine in the United Kingdom, and maybe there are others out there, aiming at shifting the target away from the antigens to the code itself. If you can pull that off, that would be wonderful. It has already gained a little bit of traction, having been tested for safety, and that is great. It looks like it is safe, and now they are trying to find out whether it is effective. That will be a game changer, and I would not hesitate to say that it is probably within the next 5-10 years that we will see something like that.

Dr Sacchetti: I have to agree. If you get to a protein that cannot change on the virus, or it is ineffective, then I think you have solved your problem.

Dr Glatter: It will be interesting to see how pharma will approach this. This is a big-ticket item in terms of their arsenal every year. Once you have a universal flu vaccine or you only need one shot every decade, that could be an interesting play.

Dr Sacchetti: Whenever you hear it come up with the pediatric patients, they really do not make that much money on it. It is labor-intensive trying to make that vaccine every year. The other thing that has not changed is that we are still cooking it up in eggs. With all of this genetics-manipulating technology, you would think that we could get to the point where you would just generate the DNA or RNA sequence you want and just turn out the proteins.

Dr Glatter: Also, there is a high-dose flu vaccine that senior citizens have been asking us for. They're complaining that their doctors did not give them the high-dose vaccine and they got the flu. Is there any efficacy that you are seeing with this high-dose flu vaccine, and would you recommend it for seniors?

Dr Sacchetti: I am not that familiar with it. I know I have seen a couple of articles that say it is worthwhile to double-vaccinate the seniors, meaning, giving them one shot and then a couple of weeks later, give them a second shot. I have not seen anything on the high dose.

Dr Raja: I've seen the same stuff that Al has. But if it comes to the point where I am arguing with a patient about high dose versus non–high dose, that is an argument that I would love to have. Unfortunately, here in Boston—and this is probably the same as in New York or New Jersey—there are enough people who just do not want to get a flu vaccine in general. That is the argument l often have, which is telling patients, "Go get your flu vaccine; we can give it to you while you are here in the emergency department today." They come up with 10 reasons why they cannot get it. I would love to have an argument with the patient about high dose versus low dose instead.

Dr Glatter: The bottom line is that if you get the flu even though you got the vaccine, it is not going to be as severe. I think that is the message that patients need to understand, and that is really the bottom line.

Thanks again for joining us. This has been a great discussion.

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