Swine Flu

By now, most of you have heard of the Swine Flu. It is important to note that Swine Flu is different from seasonal flu. The first cases of Swine Flu (H1N1) were reported in the United States in April 2009. On June 11, 2009, the World Health Organization declared a Phase 6 pandemic. Cases of H1N1 have now been reported in every country with the vast majority coming from the United States.

The new H1N1 virus is sometimes referred to as the Swine Flu because laboratory testing initially showed that several of the genes in the virus were similar to influenza viruses that normally occur in North American pigs. However, further studies have shown that this new virus is very different from that which is normally found in pigs.

Like all influenza viruses, swine flu viruses change constantly. Pigs can be infected with Avian (Bird) Flu viruses and human flu viruses as well as Swine Flu viruses. When influenza viruses from different species infect pigs, the viruses can swap genes and create new viruses that are a mix of swine, human and avian flu viruses. The new virus that has created this pandemic is the H1N1 virus. This virus contains two genes from flu viruses that normally circulate in pigs located in Europe and Asia that are mixed with one avian gene and one human influenza gene. Scientists call this a “quadruple reassertant” virus.

The reason that the H1N1 virus is causing a pandemic is because the virus has not circulated recently. This means that almost everyone is vulnerable to infection. Seasonal flu normally circulates in the fall and winter, but there is usually some immunity in the general population built up from previous exposure and vaccination.

When there is a novel (new) flu strain that has not recently circulated, the entire population is at risk. The following from www.flu.gov, shows the key differences between seasonal flu and pandemic flu:

Seasonal Flu:

> Outbreak follows predictable seasonal patterns; occurs yearly; usually in winter
> Usually some immunity in population from previous exposure
> Healthy adults usually not at risk for serious complications; infants and elderly at highest risk
> Health system can usually meet public and patient needs
> Vaccine developed based on known flu strains and available for annual flu season
> Adequate supplies of anti-virals are usually available
> Average U.S. deaths approximately 36,000 per year
> Symptoms: fever, cough, runny nose, muscle pain. Deaths often caused by complications, such as pneumonia
> Generally causes modest impact on society
> Manageable impact on domestic and world economy

Pandemic Flu:

> Occurs rarely
> No previous exposure; little or no preexisting immunity
> Healthy people are at increased risk for serious complications
> Health systems may be overwhelmed
> Vaccine not available in first stages of pandemic
> Effective anti-virals may be in limited supply
> Number of deaths could be quite high
> Symptoms may be more severe and complications more frequent
> May cause major impact on society, (school closings, travel restrictions, cancellation of larger public gatherings)
> Potential for severe impact on domestic and world economy

The seasonal flu vaccine is currently available and it is now up to you to make sure you and your loved ones are protected. Pregnant women are at increased risk from the seasonal flu and it is especially important that they be vaccinated. Vaccination of pregnant women also confers immunity to their babies for the first six months of life when they are too young to receive a flu vaccination. There is no protection against the H1N1 virus in the seasonal flu vaccine.

The Swine Flu vaccine should be available in mid to late October and will be targeted at several high risk groups:

Pregnant women – because they are at higher risk of complications and death, and can potentially provide protection to infants who cannot be vaccinated.

Household contacts and caregivers for children younger than 6 months of age – because younger infants are at higher risk of complications and cannot be vaccinated.

Healthcare and emergency medical services personnel

All people from 6 months through 24 years of age – because many of the cases have been in this age group and they often live, work and study in close proximity

Persons ages 25-64 years of age who have chronic health conditions like diabetes or asthma which put them at increased risk.

What can you do to stay healthy:

> Stay informed. Go to www.flu.gov and the CDC website for regular updates.
> Cover your nose and mouth with a tissue when you cough or sneeze.
> Wash your hands with soap and water. Make a “Flu Kit.”

This past weekend I made a flu kit for my house and for both my college-aged children who live on campus. I included Kleenex, hand sanitizer, acetaminophen, ibuprofen, a thermometer, cough drops, anti-nausea and anti-diarrhea over the counter medication. I also included both antihistamines and decongestants. I urge you to buy these things now because there is predicted to be a shortage in the coming months of these remedies if a true epidemic breaks out.

Until next time.....

Carol Swindle, M.D.

Herpes 101

Last week I saw a sixteen year-old patient who complained of painful sores on her outer vagina after recently becoming sexually active. She explained that she was in a serious relationship with an eighteen year-old boy and after much thought and consideration, had lost her virginity to him. They had used condoms but not during every encounter. On examination it was clear that she had a primary outbreak of herpes. She and her mom were understandably quite upset about this.

Herpes is a scary word and I realized when talking with my patient that most people don't have a clear understanding of what herpes is and how to treat the symptoms.

Herpes is a viral infection that is transmitted through intimate contact. Herpes simplex Type I is usually oral and sores break out around the lips and in the mouth. Herpes simplex Type II is usually in the genital area and sores can be found around the vaginal opening, on the labia, between the opening and anal area or on the buttocks. A primary herpes infection is the very first outbreak a person experiences. The sores usually appear 2-14 days after the person is infected. The primary infection is the worst infection a person will ever experience. It may be accompanied by low-grade fever, muscle aches, swollen lymph nodes, fatigue and other flu-like symptoms. A primary outbreak generally has more lesions and they are more painful than subsequent episodes. Treatment for herpes outbreaks includes antiviral medications like Valtrex, Famvir and Acyslovir and supportive care such as Tylenol, Motrin or prescription pain relievers.

One of the reasons that herpes is so easily transmitted is that the virus can live under normal skin and be shed with no outer lesions present. This is called asymptomatic shedding and is an important factor in the transmission of the virus. If one person in a relationship has herpes and the other does not, each year they are together there is about a 10% chance that the uninfected person will catch herpes even with condom use. For this reason, many patients with herpes take daily antiviral medication to suppress the virus and decrease their chance of infecting their partner. Suppressive daily therapy can also decrease the chance of recurrences. It is important to note that women with a history of herpes must take antiviral medications in the final month of pregnancy to prevent transmission to the baby.

Perhaps the worst aspect of genital herpes is that after the primary infection one can experience a recurrence of that herpes outbreak anytime. This is because after infection the virus can live in the nerve roots and cause recurrent outbreaks without any other exposure. An average person will have four to five recurrences in the year following their initial infection. The recurrences usually have fewer lesions and those are generally less painful. Most patients describe them as annoyances, but they can certainly be emotionally debilitating.

Over 45 million people in the U.S. have herpes but only 10% of the people infected are aware they have it. In the case of my sixteen year old patient, her boyfriend denied ever having any previous genital sores and had never been diagnosed with any sexually transmitted disease (STD). However, since he was her first partner and she broke out 2 weeks after having intercourse with him, there is little doubt that he infected her even though he was never aware of any symptoms and indeed never had had any.

One of the most difficult parts of dealing with the disease is the emotional burden that patients carry when learning they have herpes. There is a terrible stigma associated with having an STD that cannot be cured. Between 20-25% of people in our country have herpes, though most are unaware of it. The reality is that everyone knows multiple people infected with herpes but no one ever discusses it.

I think of it as an incredibly minor medical condition and really not of any health consequence at all unless the patient is pregnant. Herpes does not turn into any other disease, does not make you more at risk for any other disease and is basically just a nuisance. Over time the recurrences diminish and eventually completely stop. The most prudent way to prevent getting herpes is to only be in a monogamous relationship with an uninfected partner. However, we must realize that just because someone says they are uninfected does not necessarily mean that they are. If you are experiencing recurrent genital sores please make an appointment with your doctor to discuss possible therapies and also so your doctor can reassure you that this is common and easily dealt with.

As for my sixteen year-old patient, hopefully she is better educated about her diagnosis and how to manage her symptoms and will come to realize that having herpes doesn't have to be who you are, it's just something you have.

Until next time . . .

Carol Swindle, M.D.

Welcome to our Blog!

Dear Readers, 

Today I am starting a blog on the HWWC web page. I have been instructed to write about whatever I desire, and the people who told me that may certainly live to regret it. I decided that before I jump into any medical topic I will begin with some personal/biographical information.

My name is Carol Swindle and I have been an OB/GYN at HWWC for twenty-one years. I am a widow and the mother of two teenagers. I graduated from the University of Alabama School of Medicine and finished my training at Vanderbilt University.

Being a physician is an essential part of who I am. I love being a doctor—I enjoy seeing patients in the office, doing deliveries, performing surgeries—all the myriad number of tasks that make up my daily duties. In OB/GYN we are called upon to help with some very important questions ranging from birth control decisions to STD testing to hormone replacement therapy. I saw a patient on Thursday who reminded me that I had been her doctor for 20 years. She was 18 then in 1989 and came in for her first Pap smear. Since then I have discussed her upcoming wedding, newlywed years, delivered her child, tied her tubes and ordered her first mammogram along with other medical issues she has needed to have addressed. She thanked me for the care I had given her and we discussed what perhaps the next 20 years will bring. This is the true calling of being a physician—developing lasting relationships with patients that endure through the years. This is one of the absolute best parts of my job.

In this space I will try to write about interesting patients, medical topics or whatever is happening in my life. I will try to be "to the point" and not boring.  

Thanks so much and I look forward to talking with you all very soon.

Carol Swindle, M.D.