Swine Flu at Camp

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I have long been concerned about potential overuse of the anti-flu drug Tamiflu, in fact there are sections on this topic in both my book on fear and my book on flu. But in my opinion, the current situation with H1N1 swine flu calls for the careful use of Tamiflu at large camp outbreaks. Use of the drug is warranted to help decrease shedding time in patients with mild cases and to prevent additional cases in their close contacts.

The CDC does not agree with me.

Here are the plusses_

1 - Since Tamiflu is highly successful at slowing spread, its use to squash outbreaks can help keep camps open which has the added benefit of keeping sick kids from bringing flu home to many different zip codes and thereby expanding the outbreak. People who are more at risk (including pregnant women, infants, and those with chronic conditions) may catch it that way. Even though this is a mild virus so far, with millions of cases around the world and only 700 plus deaths, there is always the chance that it will get worse; in fact a recent study shows that it lingers in the lungs of Ferrets (who react to flu like humans), causing lung infections.

2 - More circulating virus may increase the chance of a lethal mutation. The famous second mutation that may have occurred in 1918, when the virus became much more severe in time for the fall flu season, is extremely unlikely, but possible.

3 - Children seem more at risk for severe cases, perhaps because of a lack of immunity to an older H1N1 virus that was circulating before 1957. Older patients who have that immunity may have milder cases.

4 - Isolation of sick people and their contacts is the first priority, but use of Tamiflu (especially when there is no vaccine available), is a useful adjunct which may help to keep the camp open. Here are the minuses:

1 - Use of Tamiflu may increase the chance of resistance occurring. There are some excellent articles on recent Tamiflu resistance, which also demonstrate that resistance sometimes occurs spontaneously, without exposure to flu:

H1N1 swine flu - the non-sustained Danish and Japanese resistance cases were in patients taking Tamiflu prophylactically. (see New Scientistarticle)

The interesting case in early July of a girl from San Francisco who picked up Tamiflu resistance in Hong Kong but NEVER took Tamiflu. (see NY Timesarticle)

And the spontaneously generated resistance to seasonal H1N1 (NOT SWINE FLU) in last year's flu season which led to massive resistance to that strain. (See NY Times article)

2 - Tamiflu shortages could emerge (although the CDC has stockpiled 50 million dose courses, and it is difficult to envision a scenario where there is a shortage of this magnitude, especially with a vaccine in the offing.

3 - Potential side effects of Tamiflu, including nausea, or an allergic reaction. But side effects are rare, Tamiflu is a very well tolerated drug overall.

4 - By having the flu now, when it is mild, a person should be immune later on, during flu season, when the flu could return in a more severe form.

I must admit, some of what drove me to put my own 12 year old son on Tamiflu prophylaxis at Camp Modin where there were more than 80 cases was because I have a 4 year old son at home with asthma and chronic ear infections. I was worried about my older son bringing the flu home. But my own scenario was far from unique, which is why I recommended that all of Camp Modin take Tamiflu.

My article on the Modin Protocol I created was published in Slate on July 10th. (see Slate article)

This was followed by a front page article by Tamar Lewin this past Thursday July 23d in the NY Times which described the problem - and solution - at the camp. (see NY Timesarticle)

The following day, Dr. Anne Schuchat, director of the National Center on Immunization and Respiratory Diseases at the CDC, reacted to the Times article by disagreeing with camps using Tamiflu to control outbreaks. She said she "strongly recommended" giving the drug only to people already seriously ill, or to their family members who are pregnant, have asthma or have other conditions that could be life-threatening if they caught the flu.

Finally, on Saturday, July 25th, Donald McNeil wrote an excellent balanced article in the Times describing Camp Modin's use of Tamiflu, the rationale for my advice compared to the reasons for the CDC's disagreement. (See NY Timesarticle)

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of "False Alarm: The Truth About the Epidemic of Fear"and "Bird Flu: Everything You Need to Know About the Next Pandemic."Read more at www.doctorsiegel.com