Swine Flu 4.93: Off for the Summer?

It’s now about 7 weeks without a single positive flu test, which makes one wonder: where did it go?  It is certainly around in the Southern hemisphere, where it is winter now (about 1% of New Zealand’s largest cities population was seen with flu-like complaints during one week in July), and even in the Northern hemisphere, some countries are just starting seeing massive numbers of cases, and some states still have widespread flu.  So the question is, why are we not seeing any cases here in Brighton Beach?

Theory 1: Practically everyone in the neighborhood who was going to get the flu, has already done so.

–well, if that’s the case, we should be fairly safe come fall.

Theory 2: Transmission has been interrupted by “summer factors” — better ventilation, moister air, decreased crowding…

– in which case, more open windows, humidifiers, and a liberal school attendance policy should be helpful.  School un-crowding is especially important with swine flu because attack rates for this particular strain appear highest in the 5 to 24 year old cohort.

Theory 3: D-fense!  Vitamin D does appear to strengthen the immune response, especially against respiratory infections, and Vitamin D supplementation (along with A, C, zinc, and others which may be helpful) is certainly worth trying.  In my own practice I have been measuring 25-OH vitamin D levels in the serum of patients presenting for a variety of complaints, and an appalling number have come up deficient.  Although most, as expected, were either dark-skinned individuals or indoor WoW addicts, I did have a low Vitamin D level in a freckled sunburned redhead.  (Yes, I did read the riot act about hazards of sunburn).

Theory 4: An Unknown Factor.  No one knows why, in 1976, swine flu infected 100 soldiers at Fort Dix, and no one elsewhere.  If this flu strain plays a similar practical joke, that X-factor may be easier to find with modern molecular techniques.

Well, off to work…


Swine Flu 4.92: Flu Virus Sailed the Ocean Blue

It has been 6 weeks of relative calm: very few children with fever (and those who did, mostly had obvious hand-foot-mouth disease, pneumonia, or strep throat); not a single positive flu test in these 6 weeks, and that’s after having over 20 a day in June.  We are continuing to do flu tests, so watch this space: we’ll be among the first to know when flu returns.  It is now highly prevalent in the Middle East, the Southern Hemisphere, and other places it did not hit early.  Russia appears to have only a few cases so far, partly due to a vigorous screening and isolation program; whether it works in the long run remains to be seen.  My recommendation (Mexico is now the best and safest place to go on vacation) stands, as do all my previous advices.  I would like to re-emphasize one of them:  vitamin supplementation.  More than half of all the children I have so far tested are Vitamin D deficient (as opposed to none deficient for B12 and Folic acid), and Vitamins D and A are essential for proper immune response.


Mistakes in Choosing a Pediatrician

Babble.com just published an interview with me; my answers were, of course, edited for space, but they kept the most important points.  Here goes:


What are the 3 most common mistakes parents make when visiting the pediatrician?


Buzz up!

Expert: Dr. Anatoly Belilovsky, director of 365-day medical center, Belilovsky Pediatrics, in New York. His blog is www.belilovskypediatrics.com.

1. Choosing a doctor that’s the wrong fit.

“Every pediatrician is not going to fit with every parent personality. So often I hear, ‘Oh my friends said you’re great!’ and it turns out that that while that doctor may have worked for your friend, they’re the wrong fit for you. For instance, if you’re a parent that’s deathly afraid when your child gets a fever, which is a common complaint, you’ll want a pediatrician that displays a bit more empathy toward fevers, as opposed to a doctor that quickly assures you it’s nothing serious. Also, some parents require longer dialogues and explanations than others; find a doctor that complements that. References are a great way to find a trusted pediatrician but ask your friends in-depth questions before you visit: What’s so great about this doctor? Can you describe specific episodes? Why would you choose them for your son or daughter? And of course, don’t feel obligated to stick with a doctor just because a friend referred you. They might be great at what they do, but not a perfect match.”

2. Always wanting a prescription.

“Too often, parents bring their children to their doctor, expecting to leave with a prescription. And when they don’t, they consider it a waste of time. We have a model we follow: treat, counsel, educate. This means some cases require treatment, some only require education. Example: baby acne and bug bites. First-time parents often over-react to these problems, and expect a prescription, when pediatricians can really only offer advice. Of course, if you feel like a doctor is dismissing your child’s case, seek a second opinion. But realize not all problems require the same solution. Another tip: If you don’t understand your doctor’s verbal explanation, ask him to use an analogy or diagram. I once treated a child whose father didn’t understand hip dysplasia. I found out he was a marine engineer, so I made him a diagram, and all of a sudden, he understood!”

3. Delegating visits.

“This is a minor mistake compared to the first two, but still important. And this is sending your child to their pediatrician with someone who doesn’t know the whole story, for instance grandparents or nannies. Often, these people don’t know your child’s entire medical history or the details of the problem at hand, which makes our job more difficult. Later, we’ll get calls from parents who couldn’t be there in person, and it turns out there’s a whole different story we weren’t aware of. Or, we’ll try to reach parents, only to get a call the next day wanting to know what’s going on. It’s much easier for both parties to address issues in person and for parents to get the straight story from the horse’s mouth. Obviously, sometimes parents have to work or travel but, for instance, my practice is open seven days a week/365 days a year. If you’re really invested, you’ll find a time to bring your child that works with your schedule.”  

— As told to Andrea Zimmerman


Swine Flu 4.91: Heavy Thoughts

OK, we know that fat is bad.

(From the cheap seats: How Bad Is It?)

This is one view,

and here is another:

Short version: obesity was the single most important feature that all the people who ended up on life support in a Michigan hospital with complications of swine flu all had in common.

Come to think of it, my single worst swine flu patient was morbidly obese — he went on to need both Tamiflu and several antibiotics because of pneumonia.  Never ended up in a hospital, thankfully, but I saw him every day for nearly a week, and he felt miserable.

Swine flu will come back in the fall, count on it, and summer is a good time to get healthy.  I will reiterate my enthusiastic endorsement of Wellspring, and my  gratitude to them for a job well done last summer.



Swine Flu 4.9: Return to Sanity

Passed another milestone yesterday: 17 positive tests for Flu A — not our record (that’s 21), but for the first time, over 50% positive rate — meaning that of all children who came with a febrile illness, over half actually had swine flu.

At the same time, far fewer people are coming in with runny noses and nothing else, to us and, according to the news, to local emergency rooms, which is excellent news for everyone concerned.  Very few are asking for Tamiflu when inappropriate.  And only one school principal asked for a “confirmation” that a child DEFINITELY had “swine flu” and not seasonal Flu A.  I guess most have by now read the excellent Health Department Memo on the subject — except the part about not needing a letter to return to school; that seems to them to be so totally against nature that the idea of returning to school at parents’ discretion is just not flying; we are still writing back-to-school notes by the ream.

The places to watch now are South America, Australia and South Africa: their winter is coming, and flu tends to be far more contagious in winter and early spring.  They will predict how concerned we need to be about the return of this flu later in the year.  Then again, with more frequent vomiting and diarrhea than seasonal flu, the swine flu may behave like an enterovirus — which tend to have summer epidemics.  We’ll know soon.

I will say this once again: New York City Department of Health has done an amazing job in this epidemic.  Its actions and policies will become the model for what everyone else does when the epidemic reaches them.  The schools did not do as well.  At least one school principal asked EVERY child in their school to be checked by their physician over the Memorial Day weekend, thus failing (a) arithmetic (the ratio in New York being several thousand children per pediatrician), (b) biology (flu having no early warning signs before the start of symptoms, and the rapid test being useless in asymptomatic or early-symptomatic patients) and (c) common sense (which, come to think of it, has not been a part of educational system in years).


Swine Flu 4.8: 'Tis mad, 'tis true, 'tis true, 'tis pity, and pity, and pity 'tis 'tis true

9 positive A’s yesterday in the first 2.5 hours of work before running out of flu tests; shipment promised for tomorrow.  As per Health Department recommendations, will consider everyone with flu-like illness without another diagnosis to have Swine Flu.  As always, the problem is not Swine Flu, but the possibility of another, more dangerous, febrile infection masquerading as flu. Schools are back to the practice of sending children straight to the doctors.  Bad idea.

And, the weather in New York has been beautiful, as it had been in Mexico when their outbreak started; any idea that flu is caused by winter cold is a non-starter.  I did this interview a while ago:


“Alaskans and Canadians living year-round above the Arctic Circle have no more winter colds than folks who live in Australia. These are old wives’ tales from an era when we had no ability to treat fever or other complications of infection. Folks created myths to explain what happens to protect their children from getting sick.”

Cold Weather Myths
Cold weather’s association with colds probably evolved from confusion, similar to beliefs about the origin of malaria. “Bad air around swamps was once believed to cause malaria,” says Anatoly Belilovsky, MD, a pediatrician in Brooklyn, N.Y. “Mosquitoes, also plentiful in swampy areas, actually carried the disease. Cold air and respiratory disease are connected, but the connection is more complicated than just ‘cold causes colds.’”

On the contrary, cold weather appears to activate the immune system, according to a study by the Army Research Institute of Environmental Medicine, says Dr. Belilovsky. “Researchers examined the immunological responses to cold exposure and found that acute cold exposure, such as going outside without a jacket, actually appears to activate the immune system.” This occurs in part by increasing the levels of circulating norepinephrine, one of the body’s hormones, which works as a natural decongestant.

Weather as an Indirect Cause of the Cold
While simply stepping outside in cold weather without a jacket doesn’t cause a cold, hypothermia (the lowering of the body’s core temperature) suppresses immunity, which can lead to colds. “Most cold symptoms are produced by the body’s immune system physically responding to the rhinovirus,” says Belilovsky. “So, someone with a stronger immune system in the cold will produce more [mucus], while the one with the weaker immune system will sniffle longer, but less dramatically.” The person with the weaker immune system probably will have more complications, such as sinusitis or ear infections, Belilovsky adds.

Cold weather may be indirectly responsible for colds, however. Vasoconstriction, when blood vessels close to the outside of the body narrow, such as those found in the nose, leads to dryness. “This dryness compromises the nose’s ability to filter infections,” Belilovsky explains. “On returning to warm air, rebound vasodilation occurs, where your hands get pink and your nose starts running as blood returns to it.” The cycle continues if the runny nose is severe enough to cause mouth breathing. Bypassing the nose’s ability to filter inhaled air, combined with dry indoor air, allows the inhalation of virus-bearing mucus, which may trigger colds and lower respiratory infections.

Cold-Induced Asthma
“Cold-induced asthma can certainly masquerade as a recurrent cold when it is not severe enough to produce acute attacks,” Belilovsky cautions. People may think that going outside with a wet head or no jacket solely causes a cold, but people in the early stages of an illness may actually feel hot. As a result, they may go outside without proper clothing and return with a full-blown fever. This makes it appear that the cold weather triggered a cold, but it was already under way.

Cold temperatures are only indirectly linked to symptoms of the common cold. So bundle up and enjoy the winter.

Last Updated: 02/20/2009


Swine Flu 4.7: A Million is a Crowd

Just got a fax from NYC Health Department: it made a very sensible recommendation — to consider every child with unexplained fever to have swine flu and treat accordingly.  This means Tamiuflu for the young (2 and under), the old, the chronically ill, and anyone else who appears to be significantly sick.  School closings are not specifically recommended; panic is definitely not recommended, for individuals or for public officials (nudge nudge, wink wink, hint hint).  As of now, approximately 1% of our entire patient population has confirmed Flu A, and another 2 or 3% are suspected — if this holds true for the rest of the city, the cases must be in the tens of thousands, heading into millions by the end of next month.  Two fatalities so far: sad, but lower than what would be expected from a “regular” flu epidemic.

Several of the parents seen today were in acute danger of heart attacks from anxiety caused by the media’s shrill hysterics over the flu — a danger far greater than that to their children from the flu itself.  Enough, already, with hyperbole, before we run out of Xanax like we are running out of Tamiflu!

PS: 19 positive for Flu A today. Thus ends another day, as for tomorrow –

To-morrow, and to-morrow, and to-morrow,
Creeps in this petty pace from day to day…

And, while Tamiflu is quite effective, and Vitamin D does support the immune response and is also recommended, this homeopathic preparation, in particular, is not:

Eye of newt, and toe of frog, 
Wool of bat, and tongue of dog, 
Adder's fork, and blind-worm's  sting, 
Lizard's leg, and owlet's wing, 
For a charm of powerful trouble, 
Like a hell-broth boil and  bubble.         

With this, I bid adieu…


Swine Flu 4.6: The Undiscovered Country

Well, this is a new experience for us: a major, rapidly progressing epidemic that is being tracked in real time with the most modern tools.  It is, still excellent training for all involved for the event of a really dangerous epidemic (which this is NOT.)
Still seeing lots of sick children; 10 tested positive for Flu A on Thursday, 21 positive for Flu A yesterday (Friday); at least one of the positives was negative 2 days previously, on the first day of fever, underscoring the importance of not running to the doctor immediately as soon as symptoms start.  The CDC surveillance says swine flu now accounts for 73% of all flu tested.  The newest incidence and mortality curves continue to confirm my suspicions: there’s lots and lots of swine flu around, and it is no more dangerous than regular flu, and most probably less dangerous:

(from cdc.gov/flu/weekly)
Continue reading


Swine Flu 4.5: Told You So!

In War and Peace, I noted the similarity between medicine and military.  At no time in the 20 years that I have been a practicing pediatrician has this been more true.  We are right there in the trenches, with the enemy sniping at the people we are here to protect, and we have to make our decisions immediately, without waiting for the generals (CDC and the Health Department) to make up their minds about the intelligence that we ourselves are providing on the enemy.  Another unfortunate similarity is that truth appears to have been the first casualty of the flu pandemic, much as it is in war.  A cursory glance at local newspapers bears witness to the appalling mishandling of the situation by the media: the stories are all about panic while the sidebars mention, in passing and small print, that the panic is entirely unwarranted.  If the media are so capable of distorting what is happening within stone’s throw from their editorial offices, I think we can safely ignore what they are saying about our troops overseas, and believe only what we hear from the soldiers at first hand.

In Kennel Cough, I argued that letting children with mild symptoms miss school would be a good way to slow down epidemics.  Closing a number of schools in New York is, I suppose, just as effective, although a bit of an overkill.  There seems to be no end of effort that the educational establishment will expend to avoid the simple, and heretical, solution of simply trusting families to send or not send their children to school in accordance with their best judgment.

In Epstein’s Mother I deplored the schools’ insatiable appetite for doctors’ notes with often unacceptable requests.  A side example was a child who was told not to come back without a doctor’s note that there was no alcohol in her blood — a request that shows utter ignorance of technical (alcohol is completely gone the next day, which is when she came in) and legal aspects of this testing.   But far more egregious is the current practice of school personnel telling families to take their children with runny nose and low grade fever to the doctor IMMEDIATELY, and not to come back without a note of clearance.

OK, ready?  Deep breath taken.  Begin rant:

Is there no one in schools with the brains to realize that  we have a huge influx of TRULY sick children to evaluate and treat?  Yes, the flu really is here, and we give it the same attention we give any epidemic influenza — which is lots.  Yes, there is ample evidence that this “swine” flu is milder than seasonal flu, with lower mortality — but any flu can be fatal, and we absolutely need to see the children with high fever, vomiting, headache, body aches, lethargy, shortness of breath, severe cough, or any combination of these.  Having to pander to schools’ misguided directives places these children at risk.  Also, while we continue to do influenza tests, they rarely show positive results in the early phase, before high fever starts, so it is a waste of time even for the children who have contracted flu to be seen that early.  This is, once again, a shining example of educational establishment’s ignorance of any considerations outside their own policies, and of their utter disrespect for the families they serve.

I have met teachers, and I have met school administrators, and school nurses, and none of them so far have been stupid enough to have perpetrated the idiocies I have seen.  Do they check their brains at the schoolhouse door?  Is it confiscated by security at the mental detector?  Or is it the pattern of groupthink, well-known as the source of flash-mob occurrences, that causes the dumbest ideas of each member of any committee to be incorporated into that committee’s final product?
End rant/. Must get back to work.


Swine Flu 4.4: Graphic FAQ

Is there much swine flu in New York?

Yes; there is much swine flu everywhere:

From the CDC: During week 18, the following influenza activity was reported:

  • Widespread influenza activity was reported by eight states (Arizona, California, Delaware, Georgia, New Jersey, New Mexico, Texas, and Virginia).
  • Regional influenza activity was reported by 14 states (Alabama, Alaska, Colorado, Connecticut, Florida, Hawaii, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New York, Tennessee, and Utah).
  • Local influenza activity was reported by the District of Columbia and 15 states (Idaho, Illinois, Iowa, Kansas, Michigan, Montana, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Washington, Wisconsin, and Wyoming).
  • Sporadic activity was reported by 13 states (Arkansas, Indiana, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Vermont, and West Virginia).
On both of these graphs (from the CDC), there is an obvious jump in the number of flu cases all over the US.  Not all are swine flu, but it appears to be more prevalent now than any of the seasonal strains.INFLUENZA Virus Isolated
View WHO-NREVSS Regional Bar Charts| View Chart Data | View Full Screen

national levels of ILI and ARI

Is it more dangerous than “regular” flu?

No. The overall mortality is staying well below the 2007-08 and 2004-05 levels, while the pediatric mortality is far below what we were seeing in February of this year, from seasonal flu.

Pneumonia And Influenza Mortality

Influenza-Associated Pediatric Mortality

Should I worry?
Think back to February: there was a lot more flu around then, it was just as dangerous, if not more so, much of it was Tamiflu-resistant (swine flu is very sensitive to, and treatable by, Tamiflu), there were many more deaths from the “regular” flu than are reported from swine flu — the level of concern should not be any higher now than it was back in February.   All precautions you took then should be in force now; and you should have the same criteria for going to the doctor.
Are the schools handling this epidemic appropriately?
Mainly, yes; the only criticism I have is their policy of requiring a doctor’s note stating that a child DOES NOT have swine flu to return to school.  I have had a few children who tested negative on the first day of fever and positive on second or third, when virus shedding is much higher, and only the health department can test for the difference between seasonal and swine flu, so asking for such letter from a general pediatrician is grossly inappropriate.
I also would like to see how the schools handle make-up exams for the many children who will miss finals this year; if past experience holds, we are in for another avalanche of doctor’s notes which I will once again be tempted to sign, Epstein’s Mother.