INFLUENZA/CHILD ABUSE
From the American Academy of Family Physcians’ 2006 Scientific Assembly, Washington, DC
| PANDEMIC INFLUENZA —Jonathan L. Temte, MD, PhD, Associate Professor, Department of Family Medicine, University
of Wisconsin School of Medicine and Public Health, Madison
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| Influenza: incubation period 3 days; each case produces 2 new infections; after 3 days, patient gets better, recovers, or
dies; after 6 days, more sick people and more mortality; can spread quickly through community; necessary conditions
for epidemic spread—exposure to pathogen; susceptible population; appropriate environment; enhanced person-to-
person contact
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 | Exposure to pathogen: at any given time, cases of influenza present throughout world; influenza tends to oscillate from
southern to northern hemisphere and shows seasonality; zoonosis—influenza adapted to living in animals (wild or domesticated),
transmitted to humans, eg, avian influenza
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| Susceptible population: infection produces immunity, but influenza virus mutates each year; antigenic drift—minor
year-to-year variation in viral antigens; antigenic shift—mix of genetic particles between 2 strains of influenza virus,
resulting in new proteins; frequency of occurrence unknown; immunization—can adjust population susceptibility by
immunization based on guess about antigenic composition of next circulating strain; surface proteins—hemaglutinin
and neuraminidase; important for immunity
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| Environment: climate plays big role; influenza seasonal; correlates across northern hemisphere with winter; in subtropical
areas, good correlation with monsoons; anthropogenic factors can create conditions that intensify adverse effects of
influenza
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| Enhanced contact: economic, social, and cultural context (eg, role of commute); physical spaces (eg, confinement in airplane);
mixing of persons of all ages at holiday time
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| Vectors of respiratory viruses: influenza childhood illness; attack rates up to 40%; variable symptoms; transmission
to parents, siblings, and grandparents; transmission by infected adults, especially health care workers; infants and elderly
suffer most morbidity and mortality
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| Epidemiology: equation—current number of cases (NT) equals number of cases sometime previously (RT), where T
equals time and R is intrinsic rate of growth; R considered number of new cases that develop from each existing case; eg,
if 2 new cases for every current case, R equals 0.69; leads to exponential growth; after period of stability, R declines rapidly
(number of susceptible people declines); leads to typical epidemic curve; if no preexisting immunity, “explosive” epidemic
results; if partial immunity introduced through vaccination, effect slowed; if 30% to 35% immunity present, large
part of population protected through herd immunity; can reduce R (number of secondary cases) through, eg, quarantine,
social distancing, handwashing, use of masks; when R reaches ≈1.2 new cases per case, epidemic ends
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| H5N1 influenza: in bird population, influenza virus mainly gastrointestinal (GI), but birds can be infected without getting
sick; however, H5N1 aggressive and birds die rapidly; now being seen in birds in Asia, Africa, Europe, and Russia;
at present, occasional bird-to-human transmission, but, except for 2 reports of transmission within family, no person-to-
person transmission; H5N1 kills ≈60% of infected humans, however, transmissibility low
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| 1918 influenza pandemic: caused negative population growth in United States; 500,000 deaths in United States and 50
million deaths worldwide; had uncertain effect on economy and unknown effect on social psyche
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| Current trends: 2006 not 1918—different population (larger and more mobile), technology, and climate; more vectors
in 1918, but more potential victims in 2006; currently, United States population has 38% fewer vectors (people 0-14 yr of
age) but 2.7 times more people >65 yr of age; amount of travel today leads to greater potential for contact; other factors
not present in 1918 that mitigate influenza—therapeutic use of O2 ; antibiotics; establishment of Centers for Disease
Control and Prevention (CDC); influenza vaccine; mechanical ventilators; antivirals; each of 4 pandemics occurred during
times of global cooling, but now in warming trend
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| Interventions: include public health, planning, personal protection, antivirals, vaccines, and extras (P3 AVE)
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| Public health: good surveillance; World Health Organization (WHO) key in global surveillance of avian influenza; CDC
tracks influenza trends through 4 complementary systems; Department of Health and Human Services has pandemic
influenza plan
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| Planning: clinic setup—exposures (where can transmission occur?); segregation of patients with respiratory symptoms;
personnel—presence (personnel most likely to come in); efficiency (minimum staff needed for comprehensive care);
need for laboratory and radiology facilities; patient education—eg, handwashing, covering mouth when coughing;
vaccine prioritization—eligible patients and staff; maintenance of supplies
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| Personal protection: handwashing—people who wash hands frequently have fewer reported respiratory illnesses, while
infrequent hand washers have more hospital admissions; water-based with soap or alcohol-based effective for influenza
viruses; masks—surgical masks reduce droplet spread; N-95 respirators reduce airborne and aerosol transmission;
high-risk procedures for exposure—nebulization; intubation; bronchoscopy; nasopharyngeal and posterior pharyngeal
sampling
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| Antiviral medications: evidence to support use for H5N1; oseltamivir (Tamiflu); zanamivir (Relenza); emergent resistance
to oseltamivir shown for H5N1; adamantines—amantadine and rimantadine effective against H5N1 but rapidly
produce resistance; neuraminidase inhibitors—no evidence of effectiveness against H5N1 but effective, in general,
against influenza (prophylactically for clinically diagnosed and laboratory-confirmed influenza); also effective in reducing
duration; earlier medications started, more effective they are; effective in children; H5N1 vaccine—8 million
doses in stockpile; pandemic influenza requires 2 doses of vaccine 1 mo apart for appropriate immunity; Cochrane
database—in general, vaccines effective in reducing influenza infection in adults and children; in event of pandemic,
current scheme for vaccine prioritization has volunteer health care workers at highest priority, followed by traditional
high-risk groups (eg, household contacts, pregnant women); patient education important; best way to prepare for pandemic
influenza outbreak is to practice every year during seasonal outbreaks; additional preparation—home plan
(who will provide care if family members become ill?); supplies (energy- and transportation-dependent; sufficient
drinking water for 4 wk; stockpile of food; medications)
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| CHILD ABUSE: CONSEQUENCES AND PREVENTION —Cathy Baldwin-Johnson, MD, Medical Director, The Children’s
Place and Medical Director, Providence Matanuska Health Care, Wasilla, AK
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| Child maltreatment: different types of abuse, ie, sexual, physical, emotional, and neglect (failure to provide child’s basic
needs, including helping child learn bonding and attachment); 3 million reports of harm per year, of which one third
substantiated; unsubstantiated does not mean abuse did not happen, just means not enough proof; neglect most common
form, followed by physical abuse; national average 12 per 1000 children; youngest children most vulnerable (<3 yr of
age; 16% of total); children of color disproportionately represented; 1 in 3 to 1 in 5 girls and 1 in 6 to 1 in 10 boys victims
of sexual abuse or assault by age 18 yr; relationships between child abuse and adult health—include depression, morbid
obesity, eating disorders, chronic recurrent headaches, higher utilization of health care, chronic GI problems, chronic
pelvic pain, borderline personality disorder, and suicide attempts; correlation between child abuse and poor social
outcomes—higher rates of teen pregnancy, juvenile delinquency, substance abuse, abusive behavior towards partner or
children, and revictimization; disproportionate representation in criminal justice system
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| Adverse Childhood Experiences (ACE) study: collaboration between CDC and Kaiser Permanente; involved
≈17,000 members; asked whether they experienced verbal, sexual, or physical abuse during first 18 yr of life and whether
they grew up with alcohol- or drug-abusing adults, violence or threats of violence against mother, mentally ill parent, or
divorced or separated parents, and whether family member had been incarcerated; each item rated same (1 point) and
points added; neglect added to questionnaires in phase 2 of study; results showed 25% had experienced physical abuse,
21% sexual abuse, >25% had substance-abusing parent, and 25% had divorced or separated parents; one third had ACE
score of 0, and 12.5% had score 4; ACE score correlates in strong graded fashion with—alcohol abuse, chronic lung
disease, depression, fetal deaths, poor health-related quality of life, illicit drug use, ischemic heart disease, liver disease,
sexual risk-taking, risk for intimate partner violence, smoking, suicide attempts, and unintended pregnancies; ACE score
and ischemic heart disease—dose-response relationship (patients with ACE score of 7, 3.5 times more likely to suffer
from ischemic heart disease); psychologic factors (eg, depression, anger) more important than traditional risk factors;
ACE score ≥5 meant child >5 times more likely to start smoking by 14 yr of age; higher ACE score also correlated with
number of doctor visits in year, more days missed from work, and perception of one’s health as poor; ACE score also correlated
with leading causes of death, ie, ischemic heart disease, cancer, stroke, chronic lung disease, osteoporosis-related
fractures; majority of people with ACE score of 0, have few (if any) risk factors for disease; majority of people with ACE
score of 4 have multiple risk factors for disease; evidence from ACE study suggests—adverse experiences in childhood
leading risk factor for adverse outcomes in adult health; risk factors (eg, overeating, physical inactivity, alcohol abuse,
smoking) may be coping mechanisms that patients use to self-treat for adverse experiences in childhood
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| Neurophysiology of trauma and stress: neurons designed to change in response to external signals; undifferentiated
developing brain critically dependent on environmental cues; development sequential; stress early in life permanently
alters neurotransmitter pathways and creates structural and functional changes in brain; changes in and of
themselves maladaptive and may contribute to further stress; scientific basis—sexually abused girls have higher levels of
urinary catecholamines and cortisol; pituitary-adrenal axis functions differently in women with history of sexual abuse;
correlation between history of abuse and electroencephalographic (EEG) changes in brain; loss of volume in hippocampus
in adults with history of child abuse (similar to combat veterans suffering from posttraumatic stress disorder
[PTSD]); child abuse public health issue—direct annual costs (eg, health care, law enforcement) related to child abuse
and neglect >$24 billion annually; indirect costs (eg, special education, lost productivity, adult criminality) >$70 billion
annually; total of $94 billion does not take into account long-term adult health effects of abuse
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| Interventions: include child abuse in differential diagnosis; explain neurobiologic link; remember patient may be self-
treating; patient coping mechanisms may include substance abuse dissociation, deliberate self-harm, and depression;
techniques of stress management—include relaxation exercises, meditation, yoga, positive imagery, exercise, biofeedback,
and medication; may backfire on patient by making him or her feel more vulnerable; may allow dissociation to occur
more frequently and bring back intrusive thoughts and flashbacks; exercise (increased heart rate, becoming hot and
sweaty) may physiologically create anxiety; helping adults— acknowledge traumatic nature of patient’s experience; assure
them not their fault; educate patients about impact of abuse experience on their lives and how some of their bad habits
may be their way of treating themselves; may need specialized treatment (eg, counseling, pharmacologic therapy);
helping children—recognize abuse and neglect and keep in differential diagnosis; ensure effective treatment and intervention
(notification of child protection agencies or law enforcement); document findings; ensure patient has access to
treatment and community resources; recognition—child’s statements; unexplained injuries; injuries inconsistent with age
or developmental status; anogenital injuries or symptoms; sexualized behavior or language in young children; early teen
pregnancy; abrupt changes in behavior; risk factors that make children vulnerable—social isolation; lack of parental
knowledge about child development; family violence; poverty; parental substance abuse; parental mental illness; young
single nonbiologic parent in home
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| Preventing child abuse: promote nurturing supportive stable families; give parents advice about parenting—
children need boundaries; boundaries must be enforced; parents need to monitor children; if parents not present, need
caregivers who provide same boundaries and monitoring; stabilizing factors—parental employment (financial stability),
adequate housing, access to health care and other services, and caring adults outside family; primary prevention
strategies—public awareness campaigns (eg, shaken baby education programs), parent education and support programs,
and family support and strengthening programs; secondary prevention strategies—focused parent education
programs for high-risk (eg, teenaged) parents; parent support groups; respite care for parents with high-needs children;
family resource centers in low-income areas; home visitation programs
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| What family physicians can do: watch for warning signs; promote health and disease prevention at every opportunity;
screen for risk factors; help educate parents about child behavior and age-appropriate expectations; positive parenting
tips—age-appropriate communication; age-appropriate expectations; alternatives to hitting and shaking; choosing child
care providers; involving community; volunteering; engaging legislators; financial support
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Educational Objectives
| The goal of this program is to educate the listener about pandemic influenza and the prevention and consequences of
child abuse. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify the necessary conditions for the epidemic spread of influenza.
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| 2. Discuss intervention strategies in the event of an influenza pandemic.
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| 3. Explain the relationship between child abuse and its impact on health and social outcomes.
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| 4. Recognize child abuse in a patient.
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| 5. Educate patients about how to prevent child abuse.
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Discussed on This Program
Amantadine HCl [Symmetrel]
Influenza virus vaccine [Fluarix, FluMist, Fluvirin, Fluzone]
Oseltamivir phosphate [Tamiflu]
Rimantadine HCl [Flumadine]
Zanamivir [Relenza]
Suggested Reading
Afifi TO et al: Physical punishment, childhood abuse and psychiatric disorders. Child Abuse Negl 30:1093, 2006;
Epub 2006 Sep 28. Bradt DA et al: Avian influenza pandemic threat and health systems response. Emerg Med Australas
18:430, 2006; Campbell S: Avian influenza: are you prepared? Nurs Stand 21:51, 2006; Clem A et al:
Avian influenza: preparing for a pandemic. J Assoc Physicians India 54:563, 2006; Hampson AW: Avian influenza:
A pandemic waiting in the wings? Emerg Med Australas 18:420, 2006; Lazenbatt A et al: Recognizing and
reporting child physical abuse: a survey of primary healthcare professionals. J Adv Nurs 56:227, 2006; O'Connor
T: Planning for an influenza pandemic. Nurs N Z 12:27, 2006; Prakash D: Avian influenza (bird flu)--action plan
to control future pandemic. J Indian Med Assoc 104:286, 2006; Rodger S et al: Who is caring for our most vulnerable
children? The motivation to foster in child welfare. Child Abuse Negl 30:1129, 2006; Epub 2006 Oct 2. Russo
T: Pandemic planning. Emerg Med Serv 35:51, 2006; Schuklenk U et al: Confronting an influenza pandemic: ethical
and scientific issues. Biochem Soc Trans 34:1151, 2006; Wynia MK: Ethics and public health emergencies: rationing
vaccines. Am J Bioeth 6:4, 2006; Zarocostas J: Violence against children is widespread. BMJ 333:822,
2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Temte and Baldwin-Johnson were recorded at the AAFP Scientific Assembly 2006 held September 27 to October
1, 2006, in Washington, DC. The Audio-Digest Foundation thanks the speakers and the American Academy of Family
Physicians for their cooperation in the production of this program.
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