I'm Pregnant with H1N1....Help!!

This has probably been the craziest flu season in a long time for patients and practitioners alike. In April 2009, when the first reported cases of the H1N1 novel virus hit the news I'm sure that no one could have anticipated how wide spread this problem would be.

I thought that I would make my comeback blog one that would dealt with a specific question concerning H1N1. What do you do if you are pregnant and have a confirmed diagnosis of H1N1? First lets establish the ground rules. As a physician I will suspect that a patient has the flu if they have:

• fever
• chills
• headache
• upper respiratory symptoms (cough, sore throat, running nose)
• muscle aches
• joint aches
• fatigue
• Nausea/Vomiting/Diarrhea (these symptoms are not very common with the seasonal flu)

After you have raised my suspicion I will swab your nose and send it for Influenza A &B. You may not know that the H1N1 is a variant of the Influenza A. The whole swine flu thing came from the fact that pigs can be infected by several different strains of influenza (bird, human, ducks, etc...). When you have a single host with several different viral strains a NEW (or NOVEL) strain can emerge that has not been seen before. This is part of the theory behind or 2009 flu virus.

If you are sick (see the above symptoms) the first thing to do is C A L L your OB doc. Right now ER's and Urgent care facilities are becoming a melding pot for sick patients. If your symptoms are mild and you don't have the following problems:

• Difficulty breathing
  
• Chest pain
• Persistent vomiting
  
• High fever not responding to Tylenol
• Baby moving much less or no movement

then the best thing to do is stay at home. You will need to be started on Tamiflu (this will help you fight the infection). Stay hydrated, get rest, and use Tylenol for symptom relief. If symptoms worsen and you experience the above then you must be seen quickly. We are trying to avoid pneumonia or other complications of the flu.

Handwashing is key. And if you are sneezing and coughing a lot then a face mask will probably be helpful for you to wear to decrease exposure to your family.

Breastfeeding (for the mom who has delivered) is a toss up. Thus far no one has brought any definitive proof showing that you should not breast feed your baby. The risk is that you could pass the virus to your newborn because of having an active infection. But we know that sooooo many good things are available in breast milk that not passing that on to the baby would be a crime. You can also use Tamiflu while you are breastfeeding.

Lastly, please...please...please get the H1N1 flu vaccine (the injection NOT the flu mist).

Would I give my daughter Gardasil?

Ok. This is a hot topic right now and getting plenty of press so I might as well jump on the bandwagon and throw out my two and a half cents.

Just as a little background, Gardasil hit the market in 2006 with much fanfare. The idea of vaccinating little girls and potentially little boys against high risk HPV (human papilloma virus) subtypes to prevent the sexually transmitted infection that causes cervical cancer. At one point the state of Texas had legislation heading to the books that would have made the vaccine mandatory for school-aged children.

The vaccine is effective against subtypes of the virus 6, 11, 16, 18. The first two are responsible for genital warts primarily whereas the last two are the major culprits behind agressive dysplasia (abnormally growing cells) and cervical cancer (the outcome if left unchecked). In 2008 there was approx. 11,000 new cases of cervical cancer. The pap smear has become one of the single most effective screening tools in modern medicine and has moved cervical cancer out of the top 3 causes of cancer related deaths for women. So the most natural step would be to try and prevent the known culprit from even getting a head start.

Now if you read my last blog about Herpes you know that it is very easy to spread STDs. It could not be any easier than with HPV. There is currently no testing for HPV in men and therefore no way to find out who is carrying the aggressive strain of the virus and stay away from him. The best way is to stay abstinent until marriage and then stay faithful to your spouse but of course this is not the way our free society views sex (sorry about the soap box...I'll put it away now).

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According to the package insert from Merck:

Serious Adverse Reactions in the Entire Study Population
A total of 237 subjects out of 25,274 total subjects (9- through 45-year-old girls and women; and 9-through 15-year-old boys) who received both GARDASIL (N = 13,686) and AAHS control (N = 11,004) orsaline placebo (N = 584) reported a serious systemic adverse reaction following any vaccination visit during the clinical trials for GARDASIL.
Out of the entire study population (25,274 subjects), only 0.05% of the reported serious systemic
adverse reactions were judged to be vaccine related by the study investigator. The most frequently reportedserious systemic adverse reactions for GARDASIL compared to AAHS control or saline placebo and regardless of causality were:
Headache [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Gastroenteritis [0.02% GARDASIL (3 cases) vs. 0.02% AAHS Control (2 cases)],
Appendicitis [0.03% GARDASIL (4 cases) vs. 0.01% AAHS Control (1 case)],
Pelvic inflammatory disease [0.02% GARDASIL (3 cases) vs. 0.04% AAHS Control (4 cases)],
Urinary tract infection [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pneumonia [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)],
Pyelonephritis [0.02% GARDASIL (2 cases) vs. 0.03% AAHS Control (3 cases)],
Pulmonary embolism [0.02% GARDASIL (2 cases) vs. 0.02% AAHS Control (2 cases)].

Deaths in the Entire Study Population
Across the clinical studies, 24 deaths were reported in 25,274 (GARDASIL N = 13,686; AAHS Control N= 11,004, saline placebo N = 584) subjects (9- through 45-year-old girls and women; and 9- through 15-year-old boys). The events reported were consistent with events expected in healthy adolescent and adult populations. The most common cause of death was motor vehicle accident (4 subjects who received GARDASIL and 3 AAHS Control subjects), followed by overdose/suicide (2 subjects who received GARDASIL and 2 subjects who received AAHS Control), and pulmonary embolus/deep vein thrombosis (1 subject who received GARDASIL and 1 AAHS Control subject). In addition, there were 2 cases of sepsis, 1 case of pancreatic cancer, 1 case of arrhythmia, 1 case of pulmonary tuberculosis, 1 case of hyperthyroidism, 1 case of post-operative pulmonary embolism and acute renal failure, and 1 case of systemic lupus erythematosus in the group that received GARDASIL; 1 case of asphyxia, and 1 case of
acute lymphocytic leukemia in the AAHS Control; and 1 case of medulloblastoma in the saline placebo group.
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In the past year there has been much horrible press for Merck. Gardasil has been "associated with" several adverse events from painful injection sites, neurologic issues, immune disease, blood clots, pulmonary embolism, and death. I used the "quotes" because there has not been any 1:1 correlation between the vaccine and death. The CDC is standing by the statement that Gardasil is safe and the risk outweigh the benefits. To date there are approx 12,000 adverse events reported of which a few deaths have been included.

The question is does the overall good that the vaccine can bring to millions outweigh the small percentage of bad outcomes?

Well if it were my daughter I would say.... NO! Even though I truly believe that this is a giant leap forward for prevention of cervical cancer I can't, in good conscience, tell my daughter or my patients to get the vaccine.