After slow start, flu season ramps up in Maryland

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It's nearly spring, temperatures in the 70s, yet the flu waited until now to ramp up in Maryland, killing three members of a Calvert County family.

Usually, flu season strikes earlier. By this time last year, the flu had been widespread and had already officially killed 34 people. The year before, the H1N1 pandemic disproportionately sickened children and triggered a scramble for vaccine.

Public health officials say this is the nature of influenza.

"Unlike other respiratory viruses, flu is a little more unpredictable," said Dr. Trish M. Perl, professor of medicine, pathology and epidemiology at the Johns Hopkins University and the senior epidemiologist for the Hopkins Health System. "Flu activity is just starting to pick up, and I can speculate as to why, but really flu is just more variable."

Maybe it has been slow this year because of the warm weather, Perl said, but there's not a lot of evidence to support that. Maybe people are not passing the virus around because they're not cooped up inside. Maybe some immunity has developed to the H3N2 and H1N1 strains that have been circulating for the past couple of years.

The first case of laboratory-confirmed flu came in December, the state Department of Health and Mental Hygiene reported, but far more cases have been reported in recent weeks, and health officials expect to see even more.

So far, 86 people have been hospitalized this year with lab-confirmed flu, and five have died, though officials say many more cases have occurred but have not been reported or lab-confirmed. Last year at this time, there were 1,042 hospitalizations and 34 deaths.

Most people get a fever, aches and a cough and wait it out at home for a few days, said Frances B. Phillips, the state deputy health secretary for public health services. But in any given year, up to 1,000 people are estimated to die in Maryland of the flu — and 36,000 die across the country.

The deaths of three members of the Blake family of Lusby were especially unusual because it was clustered in one family. The 81-year-old matriarch, Lou Ruth Blake, got the flu and died at home of undetermined complications. She had underlying health conditions.

Two of her grown children got the flu and another bacterial infection. That secondary infection was determined to be methicillin-resistant Staphylococcus aureus, or MRSA, a staph bacteria that can be difficult to treat because it's resistant to common antibiotics.

The siblings likely carried the bacteria on their skin or in their nasal passages. About 1.5 percent of the population are carriers but usually don't become sick, according to the U.S. Centers for Disease Control and Prevention.

But once the Blakes had the flu, the bacteria likely found a pathway into their bodies through the compromised linings of their respiratory system. They developed MRSA pneumonia and already were extremely sick when they arrived at Calvert Memorial Hospital.

A fourth Blake family member was also hospitalized because of the flu but recovered.

Their deaths weighed on the small town where the family has a large presence, and prompted state health officials to send an advisory to health care providers telling them about the Blakes and recommending they treat suspected flu sufferers quickly with antiretrovirals that can lessen the infection's severity.

Phillips, Perl and CDC officials say such co-infections, a flu virus and a second viral or bacterial infection, aren't common among flu sufferers but are documented. The most common complication among flu sufferers is pneumonia caused by the flu virus itself, but these patients don't always need to be treated by a doctor.

Among the co-infections, MRSA isn't a common bacterial culprit. Pneumococcus accounts for far more cases, though children and seniors are given vaccines for it, Perl said.

Doctors don't typically test for and treat carriers of MRSA. Some hospitals screen patients admitted to intensive-care units for MRSA and segregate them so they do not sicken other patients. But hospitals don't necessarily test for it among those coming to emergency rooms with flu symptoms.

"This is only performed when warranted by the clinical presentation of the patient," said Linda O'Brien, director of infection control for Calvert Memorial Hospital, where three Blake family members were taken. "So it is hard to say exactly how many flu patients may also be carriers of community-acquired MRSA. That being said, illness like what occurred in this family is extremely rare."

Rare, but not unheard of, officials say. A 2006 report in the journal Clinical Infectious Diseases found two other family clusters where at least two family members had invasive infections.

More typically in the last 20 years, the CDC has received reports of sports teams, military trainees, inmates and others who have close contact and poor hygiene sharing MRSA. But the bacteria mostly produces only skin infections, said Alex Kallen, a CDC medical officer.

The MRSA-flu link has also been established in research papers. Kallen wrote one that found MRSA caused 15 cases of severe pneumonia among flu sufferers in Louisiana and Georgia in 2003-2004. During the next two seasons there were fewer cases, but in two months of the 2006-2007 season there were 10 cases in the two states. All were hospitalized, and many died.

While the CDC tracks the flu and MRSA, and it collects reports of unusual cases, it doesn't officially track flu co-infections nationwide.

Dr. Seema Jain, a CDC medical epidemiologist, said the agency believes co-infections just aren't that common compared to flu cases in general.

"Co-infection can lead to severe disease, as seen in this cluster, but no one has exact numbers," she said of the Blakes. "There is no formal surveillance conducted for co-infection, but there has been tracking over time and certainly every year we see flu with bacterial-co-infections."

She emphasized that the best defense is a flu vaccination and preventive measures such as frequent hand washing.

"The flu season is getting off to a late start," she said. "We've not reached our peak yet. …It's not too late to get vaccinated."

meredith.cohn@baltsun.com

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