What You Need to Know About H1N1 Flu and Seasonal Flu

By Jennifer Davis

09/18/09 Influenza, including H1N1 and seasonal flu, can pose special problems for people who have underlying medical conditions, like some kinds of arthritis; and there are two bugs to worry about this fall.

H1N1, dubbed “swine flu” when it arrived in the U.S. this spring, is currently resurging, sending kids who’ve just barely had a chance to crack open their new school supplies back home to their sickbeds.

And in a few weeks, the seasonal influenza, which tends to peak between November and February, should be back in circulation.

With all those germs around, it’s easy to feel anxious, but don’t put on a moon suit just yet. We’ve gathered some answers to help you stay healthy through this year’s season of dueling influenzas. 

Why all the fuss over H1N1?

H1N1 is virus that causes an illness that’s very similar to seasonal influenza. It was designated a pandemic by the World Health Organization, or WHO, earlier this year. While an influenza pandemic may sound scary, the designation is only meant to reflect how many different countries and regions of the world the virus has hit, not the severity of the illness.

In fact, the WHO says H1N1 fits into the moderate category, meaning that most people who get it will recover without the need for hospitalization or medical care. 

But in some cases, the flu can be deadly, and this strain is no exception. Out of the hundreds of thousands estimated to have been infected by H1N1 in the U. S.  this year, more than 9,000 have been hospitalized, and 593 have died, according to the most recent government data.

How can I protect myself from the flu?

Dr. Scott Zashin, MD, a rheumatologist in Dallas and clinical associate professor at the University of Texas Southwestern Medical School, stresses the importance of washing your hands for at least thirty seconds and using an alcohol-based sanitizer if soap and water isn’t available.

Mary Ryan, a nurse practitioner at the Kansas City Family Medical Center in Missouri, who is a member of Arthritis Today’s Medical Advisory Board, says good nutrition, adequate sleep and exercise are other simple ways to protect your health and keep your immune system strong.

She says it is also important to think about where you are going before you leave the house during flu season, especially if you have a compromised immune system. Being out in public and around crowds can put some people at risk of contracting the illness.

“We want people to be social and interact with people, but truly there is a risk, and you have to protect your immune system first,” she explains.

“Choose where you go. You might not want to go into a school to visit your grandchildren, but have them visit you on the weekend so you aren’t so prone to getting it. That’s the kind of thing that can really keep you healthy.”

Dr. Zashin says if you are on immunosuppressants, and you have a history of getting sick easily, you might want to buy some N95 masks. You can order them off the Internet, and he says they may be more effective in preventing exposure because of the way they’re formed to fit over the nose and mouth.

How can I tell if I have it?

People who get H1N1 may experience fever that is usually over 100 degrees, fatigue, lack of appetite, cough, sore throat, body aches, headache, chills and fatigue ­– roughly the same symptoms as with the seasonal flu.

Many who have posted their experiences with H1N1 on the Internet say it started with a mild cough that got progressively worse and a splitting headache or sore throat.

Additionally, the WHO says that some people with H1N1 will also get an extra surprise ­– diarrhea and/or vomiting – two symptoms that are rare with seasonal flu.

How long is a person with the flu contagious?

A person with seasonal flu can typically give the virus to others for about seven days, beginning the day before they start showing symptoms.

The H1N1 strain, though, appears to be a different story.  Two recent studies presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy, in San Francisco, suggest that people with this strain may shed the virus for as long as 12 days after they’ve been infected.

Current government guidelines recommend that infected people stay home from work or school for at least a day after their fever breaks, but researchers think it may be better for patients to stay home until after they stop coughing.

What should I do if I think I have the flu?

The Centers for Disease Control (CDC) says most healthy adults and kids will get better with “mom’s chicken soup” and plenty of fluids. (Follow CDC's seasonal influenza and H1N1 flu updates.) 

If you have an immune system that’s been suppressed by medication,however, you need to take the flu more seriously. Get to your primary care physician as quickly as possible, particularly if you have a fever. Your doctor can prescribe antiviral medications, like oseltamivir (Tamiflu) and zanamivir (Relenza). These medications disrupt the spread of flu viruses in the body by blocking their ability to reproduce, and they work best if taken within 48 hours. 

Perhaps surprisingly, the antiviral medications seem to offer the greatest benefits to people with underlying medical conditions. In a study published in the September 2009 issue of Lancet Infectious Diseases, these medications shortened the length of the illness in healthy adults by only about 12 hours compared with those who weren't treated with antivirals.  For people with diabetes and asthma, however, the medications shaved about a day off the length of time they were sick compared to those who were untreated.

Beyond antiviral therapy, experts say prompt medical attention is called for if someone who is sick is having trouble breathing, or if someone who is sick seemed to be getting better and then relapses a day or so later.

According to Thomas Frieden, MD, director of the CDC, this pattern of recovery and relapse is an indication of a secondary bacterial infection that may lead to pneumonia.

Also, children need emergency care if they are having trouble breathing, have a bluish tint to their skin or lips, are vomiting non-stop or are hard to wake up.

How can I tell if my body aches from the flu or a flare?

The flu tends to come on very quickly. It may start with a dry cough or a sore throat that progresses from a tickle to sandpaper in one day. The body aches usually come a few hours later.

Sometimes, a bad rheumatoid arthritis flare can start the same way, and it can come on as quickly. That’s because your body is responding much as it would if you had the flu, cranking out inflammatory proteins called cytokines that can make you feel achy and miserable.

According to John Hardin, MD, a rheumatologist and Chief Scientific Officer of the Arthritis Foundation, flares can make you miserable, but the aching and pain are typically, but not always, localized to the joints.

With the flu, however, you are more likely to feel uncomfortable all over. He describes this as the “sick inside” feeling. He says people coping with rheumatoid arthritis flares can feel beat up in their joints, but they don’t usually get the “sick inside” feeling.

Dr. Hardin says it would also be rare to get a sore throat or a cough with a flare, but much more common with the flu.

Those who have lupus, where flares may involve multiple body-wide symptoms, including fevers, are most likely to confuse the two. If you have lupus and are starting to feel bad, it may help to think back to previous flares. If you’re having a flare, your symptoms should be in line with what you’ve experienced before. But you may need a to see your rheumatologist or primary care physician to help sort out what’s going on.

What ages are at greatest risk of H1N1?

It depends on what you mean by risk. According to the CDC, children and young adults ages 5 to 24 are experiencing the greatest number of cases, but most of these are mild and manageable with bed rest, fluids and a lot of television. (OK, we threw the television in there.)

The H1N1 flu gets to be much more serious when it strikes infants and toddlers. Children under age four are at greatest risk for hospitalization. That’s why, if you have toddlers, you may have noticed the new public service announcements starring Elmo and Gordon from Sesame Street talking about the importance of hand washing and sneezing into the crook of an arm to prevent the flu.

So far, unlike the seasonal flu, adults over age 65 are experiencing the lowest rates of H1N1, and researchers think it’s probably because those born before 1957 have had prior run-ins with flu strains that have primed their immune systems to help them fight it off. 

That said, when seniors do get this flu, they appear to be at greatest risk of dying from it. The CDC says that adults over age 65 have the greatest case-to-fatality ratio.

Are there other high-risk groups? Should people with arthritis be worried?

According to the CDC, about 70 percent of people hospitalized with H1N1 have also had underlying medical conditions, a broad category that includes obesity and even pregnancy.

Having stiff and sore joints, by itself, does not seem to increase your risk of getting the flu, so people with osteoarthritis are probably not at any greater risk than the rest of the population.

But people who have inflammatory forms of arthritis, like lupus, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, vasculitis and polymyalgia rheumatica, among others, may be at greater risk for any kind of infection-viral or bacterial.

According to Jennifer Hootman, PhD, an epidemiologist at the Centers for Disease Control and Prevention, "Studies suggest that persons with systemic, inflammatory rheumatic diseases have a higher (about 2-fold) risk of getting any infection, including inflammation and pneumonia as well as higher risk of complications (hospitalizations and mortality)." 

This risk may be present whether you take medications that suppress your immune system or not.

And if you take certain medications, such as corticosteroids, biologic response modifiers or disease-modifying anti-rheumatic drugs, which lower your immune function, or if you have another health condition that tends to occur along with arthritis, such as heart disease and diabetes, your risk for influenza may be even higher.

In an attempt to find out who exactly is at greatest risk from the flu, Edward N. Janoff, MD, a professor of medicine and microbiology at the University of Colorado Denver School of Medicine, and a team of researchers scoured data published between 1966 and 2009 looking at susceptibility to influenza in people with HIV/AIDS, cancer, organ or bone marrow transplants and those on dialysis or steroids.

Their findings, published in the August 2009 issue of The Lancet Infectious Diseases, are that most immunosuppressed populations are at higher risk of influenza-associated complications.

But, “they’re probably at no greater risk from this virus than they are from seasonal influenza,” Dr. Janoff said. “I think they will experience this new flu similar to how they’ve experienced flu in the past.”

Dr. Janoff points out that so far there has not been a huge uptick in patients with immunosuppressive conditions getting severe complications or dying from the swine flu.

He says part of the reason is that they make up a very small minority of the population. He also says that typically people who are on treatment for rheumatologic diseases are on the low spectrum of people with immunosuppression issues – compared to patients dealing with AIDS or transplants.

Is it safe to get a vaccine?

Vaccines work by given the immune system a sneak preview of a virus, so that it can quickly recognize and respond to the real threat when it comes along.

Some research has indicated that people who take medications to suppress their immune systems ­– disease-modifying drugs, such as methotrexate, prednisone, and the biologics, including etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade) – might not get any benefit from a vaccine.

A study published in the August 2009 issue of Arthritis & Rheumatism addresses this question.

Researchers compared 54 patients with lupus and 54 without. They found that people with the condition had a diminished response to the vaccine because their immune systems are weaker.

But study author Albert Holvast, MD, a rheumatologist and clinical immunologist at the University Medical Center Groningen in The Netherlands, stresses that while they did find a decrease in immune
response to vaccinations in lupus patients, it was a partial decrease and only observed in a minority of lupus patients.

“A large number of lupus patients displayed a response to vaccination that met criteria that correlate to clinical protection from flu,” Dr. Holvast explains. “Our advice is to still take the vaccine. It is of importance that a majority of patients do show a response to vaccination. It can be expected that a flu vaccination will decrease the number of flu infections, and that it will make infections which occur despite vaccination more mild.”

Dr. Janoff agrees. He says the bottom line is that you don’t need to be afraid just because you are taking immunosuppressants.

“There’s a risk to this virus just like there’s a risk to viruses every year,” Dr. Janoff says. “But people in this target group know how they respond to colds and flus in the past and they need to take care of themselves to prevent getting sick.”

“There are definitely things they can do to modify their risk of getting it,” he adds. “I think people have a lot of control – more than they think. They’re not just out there as susceptible victims.”

Does it matter if I get the vaccine in a shot or as a nasal spray?

Yes. The nasal spray (sold as FluMist) contains live, but weakened, flu viruses, and it is not recommended for people who take medications that suppress the immune system, pregnant women, anyone younger than age 2 or older than age 49.

Flu shots contain flu viruses that have been killed, so they are safer for people who have less immune function.

How many vaccines do I need this year?

The CDC has estimated that a vaccine for the H1N1 strain will be ready by mid-October. Currently, officials think most people may need two doses of the vaccine, given 3-4 weeks apart, to get adequate protection. But that position may soon change.

New studies released on Sept. 10, 2009, by The New England Journal of Medicine, indicate that just one dose of the vaccine provides adequate protection. That’s good news for the needle-phobic and anyone hoping to get in on the first doses, since there should be more vaccine to go around.

Currently, the CDC is recommending the H1N1 vaccine for pregnant women, health care workers and emergency responders, people caring for children under 6 months of age, children 6 to 24 years of age, and adults 25 to 65 with underlying medical conditions ­– such as rheumatoid arthritis and lupus, asthma and diabetes.

The vaccine for seasonal influenza is available now, and it is recommended for children ages 6 months to 19 years, pregnant women, adults over age 50, adults who have chronic medical conditions, seniors in nursing homes or long-term care facilities, health care workers, and people who take care of anyone who is at risk for complications of the flu.

As health officials suspected, however, the seasonal influenza vaccine doesn’t offer any protection against the H1N1 virus, so if you’re at risk for both of them, you’ll need both vaccines. Keep in mind that they take about three weeks to be fully effective, so be sure to take other precautions, like washing your hands frequently, in the meantime.

Can I get both vaccines at the same time?

The CDC says it is safe to get them both at the same time, but they should be given on different sides of the body (i.e. one in the right arm and one in the left).

Will the vaccine contain preservatives?

The CDC says that manufacturers will make flu vaccines with and without the preservative thimerosal, a mercury-containing compound that has been the source of controversy in recent years because of concerns that children exposed to too much mercury may develop neurological problems, including autism. 

The CDC stresses that there is no evidence that thimerosal can harm pregnant women or fetuses, but the agency says manufacturers will make preservative-free versions, packaged as single-dose syringes, for those who want them.