Swine Flu; More on Vitamin D

By Dr. Ed Hendricks on August 13, 2009

The following went out to all staff at the Center for Weight Management today. In view of the intense interest in the Swine Flu I’m posting it here for our patients and others. Please post your questions and comments.

Swine Flu or H1N1 Influenza:

Classes at Granite Bay High School started on Monday, August 10, 2009. Yesterday parents of students were notified that “Swine Flu” had been diagnosed in three students on the second day of classes. The H1N1 flu is now among us and we should be prepared to deal with it among our patients, our staff and our families.

A visit to CDC web pages today yielded the following information. “When the novel H1N1 flu outbreak was first detected in mid-April 2009, CDC began working with states to collect, compile and analyze information regarding the novel H1N1 flu outbreak, including the numbers of confirmed and probable cases of disease. From April 15, 2009 to July 24, 2009, states reported a total of 43,771 confirmed and probable cases of novel influenza A (H1N1) infection. Of these cases reported, 5,011 people were hospitalized and 302 people died.” The mortality rate during that time was 0.7% and the hospitalization rate 11%. A mortality rate of 0.7% means about 7 persons die out of 1,000 infected. This mortality rate is lower than usual for an influenza epidemic but these data are for summer months when the mortality rate is typically lower.

Of interest is the “secondary attack rate” meaning the rate of infection following close contact with an infected person at home, at work or at school. The CDC reports “a secondary attack rate in household contacts for acute-respiratory-illness (ARI) was 18 % to 19% and 8% to 12% for influenza-like-illness (ILI). ARI is defined as two or more of the following four symptoms: fever, cough, sore throat, and rhinorrhea (runny nose). ILI is defined as fever and cough or sore throat. In general, these household secondary attack rates are slightly lower than what occurs in seasonal influenza.” The secondary attack rate in the household can be lowered by the use of antiviral medications for the infected family member to reduce viral shedding. Secondary infection rates can also be reduced by treating contacts with an antiviral drug as discussed below.

Also of interest is that obesity may be a risk factor for flu complications.

Prevention: What can one do to avoid this flu? Wash your hands often, avoid infected persons if possible, get the vaccine as soon as it becomes available, and take vitamin D. More information about vitamin D is written below.

Symptoms: The symptoms of H1N1 flu virus in people are similar to the symptoms of seasonal flu, although vomiting and diarrhea has been reported more commonly with H1N1 flu infection than is typical for seasonal flu. Symptoms include fever (93%), cough (83%), shortness of breath (54%), fatigue/weakness (40%), chills (37%) and myalgias (muscle soreness) (36%).

Treatment: The swine flu or H1N1 influenza virus is sensitive or susceptible to the neuraminidase inhibitor antiviral medications, zanamivir (Relenza Inhalation Powder) and oseltamivir (Tamiflu). It is resistant to the adamantane antiviral medications, amantadine (Symmetrel) and rimantadine (Flumadine). For treatment and prophylaxis to be effective it should be initiated as soon as possible after exposure. If time lapse between exposure and therapy or prophylaxis was 2 or more days, choose Relenza over Tamiflu. Each Relenza prescription comes with an inhalation device – no special inhalation equipment is necessary.

Relenza Inhalation Powder treatment for adults & children ≥ 7 years infected with H1N1 influenza: 10 mg (two 5mg inhalations) twice daily for 5 days. Relenza prophylaxis if exposed to an infected person: 10 mg (two 5mg inhalations) daily for up to 10 to 28 days.

Tamiflu treatment for adults and adolescents ≥ 13 years infected with H1N1 influenza: 75 mg twice daily for 5 days. Tamiflu prophylaxis if exposed to an infected person: 75 mg daily for 10 days to 6 weeks.

As the recommendations indicate, either of these drugs can be used for prophylaxis during an epidemic for any patient or member of their family even in the absence of known exposure. At this point in the emerging epidemic we should not hesitate to write prescriptions for either drug if any patient requests them. I plan to prescribe Tamiflu for my family and hold it for use if needed. Later on in the epidemic the drugs may be hard to find or unobtainable.

Vitamin D₃:

            Vitamin D is an extremely important defense mechanism against influenza. Although definitive randomized placebo controlled clinical trials (RCTs) have not been reported, there is anecdotal evidence and limited trial evidence strongly suggesting that taking supplementary vitamin D is protective and reduces both the risk of influenza infection and the risk of complications if infection does occur. Vitamin D can be used as a supplementary, experimental treatment for and prophylaxis against influenza – it should not be used as the only agent in treatment or prophylaxis.

            Vitamin D is toxic only in high doses taken for long periods of time. Rather than wait for definitive evidence from RCTs I make the following recommendations. These recommendations are adapted after those of John J. Cannell, M.D. of the Vitamin D Council. Patients should be informed that their other physicians probably would disagree with these recommendations. since knowledge of the importance of Vitamin D supplementation is not stressed in mainstream medicine.

As a daily routine in the absence of flu symptoms or exposure:

1.     Every adult should take one 5,000 I.U. vitamin D capsule daily.

2.     Children should take one 1,000 I.U. vitamin D capsule daily for each 25 pounds of weight. Thus a child weighing 75 pounds should take 3 capsules, etc.

If exposed to the flu I recommend increasing the vitamin D dose as follows:

1.     Adults and adolescents should take one 50,000 I.U. capsule daily for 10 days. If re-exposed during the 10 days add another 10 days. (Don’t continue this dose indefinitely since this dose can produce vitamin D toxicity, but only after several months).

2.     Children should take 10,000 I.U. per 25 pounds body weight for 10 days. If re-exposed during the 10 days add another 10 days. (Don’t continue this dose indefinitely since this dose can produce vitamin D toxicity, but only after several months).

If influenza symptoms develop, I recommend increasing the vitamin D intake as follows:

Adults, adolescents, and children should take 2,000 I.U. per Kg body weight per day for 7 days.

Examples for different weights:

Vitamin D dose for a 250 pound patient

 Dose = 250 lb X 1 Kg/2.2 lb X 2,000 I.U./1 Kg = 236,367 I.U.

I’d round up to 250,000 I.U. or five 50,000 I.U. capsules per day for 7 days.

Dose = 200 lb X 1 Kg/2.2 lb X 2,000 I.U./1 Kg = 181,182I.U.

I’d round up to 200,000 I.U. or four 50,000 I.U. capsules per day for 7 days.

Vitamin D dose for a 85pound patient

Dose = 85 lb X 1 Kg/2.2 lb X 2,000 I.U./1 Kg = 72,272 I.U.

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