Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

[HenryN]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

CDC says, "If influenza severity increases, schools should consider instituting active fever and respiratory infection symptom screening of students and staff when they arrive at school. At the beginning of the school day, all students and staff should be asked about suggestive symptoms such as fever, cough, runny nose, and sore throat during the previous 24 hours. Some persons with laboratory-confirmed influenza do not have a fever (between 10% and 40% of people). Therefore, absence of fever does not indicate absence of infection."

http://www.cdc.gov/h1n1flu/schools/technicalreport.htm

The frequency of H1N1 infected patients without a fever is MUCH higher than 10-40%. Mexico initially reported 30%, but most physicians associate fever with flu, so most who were infected but didn't have a fever weren't tested. Milder cases don't even call a doctor becasue the illness is mild and they don't have a fever (and they recover without seeing a doctor). Of those that do see a doctor, many or most are not tested because they don't have a fever. Outbreaks in Chile were later, so they tested more patients with no fever (because of data from Mexico and other reports of lab confirmed infections with no fever) and the frequency rose to 50%. In the US the CDC uses fever in their case definition, so most who are infected but have no fever are not tested. The 93% fever is pure artifact. Even when fever is part of the case definition, 7% don't have a fever.

The lack of a fever is why fever scans at borders don't do much and why H1N1 will spreads in schools, because most of those infected won't have a fever, and will assume they DON'T have swine flu and will come to school.

 

[vt.mathgirl]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

"now that would disturb the extra income plans of teachers."

ouch - sorry to say that I take this a bit personally - I don't think teachers are calling the shots here, and I certainly would rather just close down and be safe. I live in a 3 school household - I teach in one district, my husband in another, and my kids attend in a third. I can't tell you how many 7th grade foreheads I felt last year before sending kids down to the nurse's office. And yes, I worried all spring about bringing something home to my asthmatic daughter. It seems to me that most schools will be reactive rather than proactive. Status quo.

 

[Legadillo]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

In the US the CDC uses fever in their case definition, so most who are infected but have no fever are not tested. The 93% fever is pure artifact. Even when fever is part of the case definition, 7% don't have a fever.

:applause:


This is why I began the thread!

I was hoping people would understand that the case definition is limited and gives a false sense of control.

I spoke with one of the women from my church today who was confirmed with H1N1 and she stated she had no fever at all (she's still recoverng after almost a month), neither did others who also came down with it.

This sets me off, because she believed that it wasn't H1N1 because fever was often listed as a primary symptom. She thought she just had a bad cold and she went on to work and infected a client and put I don't know how many others at risk. Others spead it to God knows who else.

So, I am hoping that people will challenge more the definition, especially in schools.

Interestingly, even though many are aware that its spreading like wildfire here, there is hardly a mention of it in the news.

 

[AlaskaDenise]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

"now that would disturb the extra income plans of teachers."

ouch - sorry to say that I take this a bit personally - I don't think teachers are calling the shots here, and I certainly would rather just close down and be safe. I live in a 3 school household - I teach in one district, my husband in another, and my kids attend in a third. I can't tell you how many 7th grade foreheads I felt last year before sending kids down to the nurse's office. And yes, I worried all spring about bringing something home to my asthmatic daughter. It seems to me that most schools will be reactive rather than proactive. Status quo.

That was pointed out as the only actual economic disruption. Since parents already deal with summer vacation without economic disruption, an extended vacation shouldn't really disrupt the economy from their jobs. The only disruption I see is to the non-teaching summer jobs of teachers, should the school year need to extend very much into the following summer. Some of our teachers here have summer jobs around the visitor/recreation industry - if they had to teach that would be a small economic disruption.

.

 

[HenryN]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

:applause:


This is why I began the thread!

I was hoping people would understand that the case definition is limited and gives a false sense of control.

I spoke with one of the women from my church today who was confirmed with H1N1 and she stated she had no fever at all (she's still recoverng after almost a month), neither did others who also came down with it.

This sets me off, because she believed that it wasn't H1N1 because fever was often listed as a primary symptom. She thought she just had a bad cold and she went on to work and infected a client and put I don't know how many others at risk. Others spead it to God knows who else.

So, I am hoping that people will challenge more the definition, especially in schools.

Interestingly, even though many are aware that its spreading like wildfire here, there is hardly a mention of it in the news.

Yes, it is the misconception about the fever and the inclusion in the case definition that ensures the H1N1 spread like wildfire. Most have no clue and will go to school or work assuming that aren't infected because they have no fever.

 

[Legadillo]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

Commentary

Pandemic Flu Fever Failure Fuels School Cluster Explosions
Recombinomics Commentary 17:06
August 21, 2009


The standard definition of influenza includes a fever. But an odd feature of the new virus is the lack of fever in a significant proportion of documented cases, even after some patients become seriously ill. In Chile, it was about half, in Mexico City about a third and elsewhere, less, Dr. Wenzel said. Lack of fever has been noted by other observers in several Canadian cases.

Analysis of data from specimens yet to be tested may shed light on how often infected individuals who have no fever spread the virus.

The above comments from the NY Times pandemic influenza report suggest that H1N1 infections are markedly higher than confirmed cases, and the absence of fever can lead to significant silent spread (see map). As noted, most associate fever with influenza, so the initial observations in Mexico on the percentage of patients infected without fever were low. Milder cases would probably not seek medical treatment, and those who did would probably be mis-diagnosed, because of the absence of a fever. Even the 50% of H1N1 fever failures in Chile is likely to be an under-estimate.

Sequences have been published worldwide, including those from Mexico and Chile. All isolates are closely related and it is likely that differences in the frequency of infected patients without fever are tightly linked to testing. In the US, fever is used in the case definition, so the official numbers show that 93% of lab confirmed cases have a fever. However, this is almost certainly linked to the case definition. Thus, patients without a fever do not meet the case definition and are not tested.

The high frequency of infections without fever may be linked to the pandemic H1N1 PB2 gene, which is avian. The avian PB2 has optimal activity at 41 C, the body temperature of birds. In mammals, a high fever is usually detrimental to an infectious agent, but in influenza with avian PB2, the higher temperature may lead to an increased level of virus. Therefore some hosts may have a feedback mechanism that keeps the patient's temperature low, which may limit viral replication.

However, these patients may still be infectious, and the absence of a fever may lead to increased exposures because the patient may assume that there is no swine flu infection. The lack of fever likely had a serious effect on border checks which used fever as a diagnostic tool. Consequently the 50% of infections with no fever would pass through border fever scans undetected.

The absence of fever can also seriously impact students. Current policy is to keep schools open and monitor infections, which are largely linked to the presence or absence of a fever. A fever is included in instructions to parents for keep ill students at home, and is also used to determine when the student can return.

The emphasis on fevers will likely keep students in school, because they will assume that an absence of fever will mean that they do not have swine flu and are not infectious. Since serious cases have no fever, the absence of a fever is not likely to be linked to an absence of transmissible virus, and therefore these students are likely to silently spread pandemic H1N1.

A serious testing program of student with symptoms, but lack a fever is long overdue. The current approach, of using fever in the H1N1 case definition is likely to increase spread of H1N1 in schools in the upcoming weeks.
http://www.recombinomics.com/News/08210902/H1N1_Fever_NOT.html

 

[Niko]

Re: Going by typical H1N1 symptoms in kids not enough: Lancet

Re: Going by typical H1N1 symptoms in kids not enough: Lancet

The article was free for registered users: I posted it here Going by typical H1N1 symptoms in kids not enough: Lancet on Aug 26th.

The Lancet, Volume 374, Issue 9690, Page 605, 22 August 2009
<Previous Article|Next Article>
doi:10.1016/S0140-6736(09)61511-7Cite or Link Using DOI

Clinical characteristics of paediatric H1N1 admissions in Birmingham, UK

Original Text
S Hackett a, L Hill a, J Patel a, N Ratnaraja b, A Ifeyinwa b, M Farooqi b, U Nusgen c, P Debenham c, D Gandhi c, N Makwana b, E Smit a d, S Welch a

Our experience of the first wave of paediatric H1N1 swine-origin influenza admissions in Birmingham, UK, shows that presentations can be atypical, severity is often associated with underlying disease, and rates of secondary bacterial infection are low. We reviewed the 78 available case notes of 89 children positive for H1N1 influenza by PCR admitted to hospitals across our three Trusts between June 5 and July 4, 2009.
The median age of admission was 5·7 years (range 0·1—16·3); 50 of 89 were male. 29 of 71 patients did not fulfil the H1N1 influenza case definition as described by the UK's Health Protection Agency (HPA)1 (temperature ≥38°C or a history of fever and two other symptoms of cough, sore throat, rhinorrhoea, limb or joint pain, headache, vomiting or diarrhoea, or a severe or life-threatening illness).
12 of 64 did not have a temperature of at least 38°C or a history of fever. After fever, cough (49/67) and rhinorrhoea (45/73) were the most common symptoms (figure). Other symptoms included haematemesis, photophobia, earache, preseptal cellulitis, chest pain, apparent life-threatening episode, epistaxis, croup, rigors, apnoea, and acute abdomens (appendicitis and intussusception). 31 of 77 patients had significant pre-existing disorders including asthma, chronic lung disease, developmental delay, neuromuscular disease, immunodeficiency, prematurity, recurrent chest infections, and metabolic and endocrine disease.

Figure Full-size image (33K)
Proportion of patients with each symptom


Median length of stay was 24 h, irrespective of any underlying disease. Six children required high-dependency or intensive care; all had pre-existing disorders. Ten of 63 had possible or probable bacterial infections (one otitis media, six respiratory-tract infections, one preseptal cellulitis, one appendicitis). Antibiotics were prescribed in 22 of 61 patients, reflecting recent changes in HPA guidance. Oseltamivir was given to only 26 of 65 patients.
To have followed the HPA algorithm would have meant that 40% of children with H1N1 influenza would not have been diagnosed. Low numbers of suspected and confirmed bacterial infections suggest that uniform co-administration of empirical antibiotics is inappropriate.
Both H1N1 influenza and common respiratory viral infections are likely to spread commonly this autumn and winter in children, making clinical diagnosis of influenza more difficult. Clinicians should consider H1N1 influenza in the differential diagnosis of children with pre-existing disorders who present acutely to health services even if HPA diagnostic criteria are incomplete or an alternative diagnosis is suspected, especially if there are severe symptoms or underlying disease.
It is imperative that further data are collected prospectively on the clinical presentations and predictors of severity in H1N1 influenza.
We declare that we have no conflicts of interest.


References

1 Health Protection Agency. Human swine influenza: information for health professionals. http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1240812234677?p=1240812234677. (accessed Aug 12, 2009).

a Birmingham Heartlands Hospital, Birmingham B9 5SS, UK
b Sandwell and West Birmingham Hospitals, Birmingham, UK
c Birmingham Children's Hospital, Birmingham, UK
d Public Health Laboratory, Birmingham Health Protection Agency, Birmingham, UK


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[Legadillo]

Re: Should Fever Be the Main Screening Tool in School H1N1 Decision Making?

Fever Free Swine Flu in CNN's Anderson Cooper

Recombinomics Commentary 14:29
September 24, 2009


COOPER: Well, because I -- I mean, I had similar symptoms to you. I was -- the cough was the worst cough I've ever had, and it, like, even hurt my heart while I was coughing. And I went to you, and you were really sick. And I asked you, "Is it possibly it's swine flu?"

And you said, "Probably not, because usually swine flu has a very high fever right away."

GUPTA: That's right. And, you know, it's interesting because I think the next day, I think, maybe you had gone to a different province. And I was feeling miserable the next day, and I hadn't checked my temperature. You know, you're in the desert, and it's hot outside. I hadn't really thought about it.

I went there, and my temperature was around 102 degrees. So, you know, pretty high, certainly, for me, 98 being normal, 98.6. So that was the first sign. And then, you know, I had that same cough that you did, the light-headedness, and I was freezing cold. I don't know if you had that, as well.

COOPER: Yes.

GUPTA: That was really the most memorable part of it. I was freezing cold despite being in the desert. Are you coughing right now?

COOPER: I'm still coughing, I will say. Just a little bit.

The above comments describe similar symptoms in CNN’s Anderson Cooper and Sanjay Gupta. Gupta developed a fever and was subsequently lab confirmed, while Cooper had no known fever and therefore was not tested. Consequently, he still has no confirmation of swine flu, even though he is still coughing two weeks later.

The lack of testing in H1N1 infected patients with no fever is widespread. Although 50% of cases in Chile had no fever, and 30% of initial hospitalized patients in Mexico had no fever, the swine flu case definition in the US and most countries includes fever, so such patients are not tested. In the US, the CDC link distributed to schools has a table of symptoms in lab confirmed hospitalized patients, and fever is at the top, since it was found in 93% of patients. However, this high frequency is because of the case definition, which includes fever. Consequently, those without fever are not confirmed because they are not tested.

Instructions to schools cite fever and one or more additional symptoms. Thus, no fever means no swine flu and no testing. These students are said to have colds, allergies, strep throat, or a stomach bug, and many remain in school, infecting other students. Thus, they are not included in the number of students absent or in those who are absent and have flu-like symptoms, because the absence of fever excludes them from this category. Similarly, the forms used by schools to report students with flu-like conditions also lists fever as a requirement, so students with headache, cough, and running nose are not reported as students with flu-like conditions.

Anderson Cooper, who was high profile and on assignment in Afghanistan was not tested, even though his symptoms matched Sanjay Gupta who subsequently developed a fever and was swine flu confirmed. Dr Gupta’s first reaction to his co-worker’s symptoms was no fever means no swine flu.

Thus, the failure to recognize the frequency of H1N1 infections in the absence of fever leads to unnecessary spread in H1N1 in patients who assume they are H1N1 free.

http://www.recombinomics.com/News/09240902/H1N1_CNN_Cooper.html