As flu season approaches, we want to help you and your family stay safe, healthy, and informed. New “models” of flu appear each year. The Center for Disease Control and Prevention (CDC) examines the influenza strains that have affected Australia during its flu season and, from this research, evaluates which strains are likely to be most prevalent in the U.S. during the coming year. Admittedly, there has been varying degrees of accuracy in the CDC’s predictions over the past few years. However, their recommended vaccines have led to milder and shorter illnesses as well as fewer cases of influenza overall.

The SARS-CoV-2 (coronavirus) pandemic complicates flu season, making it particularly important to protect ourselves and our families against viral illness. It’s necessary to understand the differences between the flu and COVID-19. Different viruses cause each respective respiratory illness. Similar symptoms of the flu and COVID-19 mean that testing may be the only way to distinguish them, and prevention is key. Click here to learn more about the similarities and differences between COVID-19 and the flu.

Currently, it is impossible to predict the effectiveness of the 2020-2021 flu vaccine, but it is recommended that everyone, six months and older, get vaccinated to protect against the flu, to reduce the risk of a possible COVID-19 infection, and to minimize the potential co-infection of both the flu and COVID-19. It takes between 10-14 days for the flu vaccine to take effect. We recommend getting vaccinated by the end of October if possible. Even if you cannot make this deadline, get vaccinated at your earliest opportunity. It is better to have some immunity than none.

It’s especially crucial to protect people living with Duchenne. A 2005 CDC study found that children with neuromuscular disease are at a six-times greater risk of flu-related respiratory failure. Please get yourself, your child, and all of your family members vaccinated as early as possible.

What’s new for the flu in 2020/2021

CDC Recommendations:

• The influenza vaccine or “flu shot” is recommended and available for people living with Duchenne.
• The nasal spray (live virus) is available again for people ages 2 – 49 years old. It should be as effective as the vaccine. This is a live virus vaccine and is NOT recommended for people living with Duchenne.

The 2020/21 trivalent influenza vaccine will include protection against:

• Influenza A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus
• Influenza A/Hong Kong/2671/2019 (H3N2)-like virus
• Influenza B/Washington/02/2019 (Victoria lineage)-like virus

Some will receive the quadrivalent vaccine that also protects against the influenza B/Phuket/3073/2013 (Yamagata lineage)-like virus. This is unchanged from 2019-2020. For information about cell culture-based inactivated and recombinant influenza vaccines, access the full report here.

Additional information:

• There are several types of influenza vaccines available. Your medical provider will tell you which is most appropriate for you and/or your child.
• Pregnant women should receive the influenza vaccine.
• Some children, 6 months old – 8 years old, will need 2 doses of the influenza vaccine.
  • If your child is getting vaccinated for the first time, they will need 2 doses of influenza vaccine spaced at least 4 weeks apart.
  • Children who have only received 1 dose of influenza vaccine will also need 2 doses spaced at least 4 weeks apart.
  • Your healthcare provider can find more information on CDC’s Children & Influenza (Flu) page.
• For additional information on the 2020-2021 influenza season and vaccine, please visit CDC’s Frequently Asked Flu Questions 2020-2021 Influenza Season page, as well as CDC’s Information for Schools & Childcare Providers page.

Symptoms of the flu and COVID-19

As illustrated below, symptoms for flu and COVID-19 are quite similar. As a result, it is important to vaccinate yourself and all immediate family members against the flu. It is also critical to follow responsible health practices and wear a mask, wash hands frequently, and follow social distancing recommendations.

If your child has symptoms of either the flu or COVID-19, or if you are not sure which it might be, call your primary health care provider and follow their advice regarding testing and treatment.

SYMPTOMS OF THE FLU	SYMPTOMS OF COVID-19
Symptoms of flu may include: Fever, chills (though not everyone with flu will have a fever/chills) Cough Sore throat Runny or stuffy nose Body aches Headache Fatigue (tiredness) Sometimes diarrhea and vomiting	Symptoms of COVID-19 may include: Fever, chills (though not everyone with COVID-19 will have a fever/chills) Cough Shortness of breath or difficulty breathing Fatigue (tiredness) Body aches New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
Symptoms usually appear 1 to 4 days after exposure. A person with the flu is most contagious during the first 3-4 days after their illness begins. Although most people are ill for less than a week, some people have more serious complications that may require hospitalization.	Symptoms usually appear 2-14 days after exposure. A person with COVID-19 can remain contagious until at least 10 days after the onset of symptoms, or if asymptomatic, contagious at least 10 days after testing positive.

WHAT SHOULD I DO IF I THINK MY CHILD HAS THE FLU?

The influenza vaccine protects against certain types of the flu. Even against those certain types, it is not always 100% effective. People living with Duchenne are particularly vulnerable to the effects of the flu—especially the pulmonary effects.

Call your primary health care provider immediately if your child has flu symptoms. Rapid diagnostic testing checks secretions in the throat for the influenza virus and is 50-70% accurate for diagnosing influenza. Note: Most providers will send a negative specimen for culture, just to be sure that there is no virus present.

If the test is positive, a course of antiviral medication is recommended. The medication should be started as soon as possible after diagnosis and continued for 5 days. Ideally, the medication should be administered within 48 hours of the onset of symptoms. However, the treatment has been shown to have some benefit if begun later, especially for patients who are experiencing a longer or more complicated course.

ANTIVIRAL MEDICATIONS

Antiviral medications can lessen symptoms of the flu and shorten the time of illness by 1-2 days. They can also prevent serious complications of the flu, such as pneumonia.

There are two antiviral drugs recommended by the CDC:

• Tamiflu (Oseltamivir, pill or liquid)
• Relenza (Zanamivir, inhaled powder, not recommended for patients with pulmonary issues)

Side effects of antivirals may include: nausea, vomiting, dizziness, runny/stuffy nose, cough, diarrhea, headache, and some behavioral side effects; there are rare occurrences of neuropsychiatric events associated with Tamiflu.

There are other factors considered in a clinical decision to use an antiviral course of treatment. They include: the severity of the disease for the patient, the progression of the disease, underlying medical conditions, the likelihood of influenza, and time since onset of symptoms.

CDC RECOMMENDATIONS

The CDC recognizes that people living with neuromuscular disease are at higher risk for developing more serious complications from influenza. For that reason, prophylaxis (antiviral medication) may be suggested for people with Duchenne who are living with household members who have also been diagnosed with influenza.

If antiviral medication is the recommended course, antivirals should begin on the day the household member is diagnosed. Again, factors that impact a clinical decision to treat higher-risk outpatients with antivirals include: the severity of the disease for the patient, the progression of the disease, any underlying medical conditions, and the likelihood of developing influenza.

Currently, there is insufficient evidence to guide the widespread use of antiviral medications in the prevention or treatment of mild to moderate cases of COVID-19. While an antiviral medication may be prescribed for flu, this may not be the case for infection with COVID-19. It is vital to talk with your healthcare provider about the right course of treatment.

WHAT IF MY CHILD MISSED THEIR CORTICOSTEROID DOSE?

If you/your child is taking corticosteroids regularly (daily or every other day), it is very important NOT to miss doses.

If you/your child has missed 24 hours of corticosteroids—it is critical to contact your primary care/neuromuscular provider for IV corticosteroid dosing.

Missing 24 hours or more of corticosteroids can result in acute adrenal insufficiency, which can be a life threatening condition. For questions or concerns, please refer to the PJ Nicholoff Steroid Protocol (download).

BESIDES ANTIVIRAL MEDICATION, WHAT OTHER “OVER THE COUNTER” MEDICATIONS ARE SAFE TO GIVE A PERSON WITH DUCHENNE?

You should always check with your primary health care provider and/or your neuromuscular provider regarding the safety and dosing of any medications.

For children over 4 years, the following over the counter medications are generally safe for people with Duchenne:

• Tylenol (acetaminophen)
• Cough medicine without Sudafed—
  • Cough medicine with cough suppressant should be used if the cough is interfering with sleep
  • Cough medicine with expectorants, Mucinex, maximizing hydration, and cough assist during the day may help minimize coughing at night
• Cough drops
• Mucinex (check with your pulmonologist before using in patients with breathing dysfunction, as thinned secretions may cause aspiration and increased risk for pneumonia)
• Saline nose drops/spray

What Can I Do TO HELP MY COUGHING/BREATHING?

Caring for your child’s lungs when they have the flu is critical. Visit the PPMD website to find information on caring for the lungs, the understanding the importance of cough, and assisting cough during an illness.

WHAT ELSE CAN I DO TO STAY AS HEALTHY AS POSSIBLE?

• Wash hands often with soap and water for 15-20 seconds: Especially after using the restroom, changing diapers, preparing food, and eating.
• Use an alcohol-based hand sanitizer if soap and water is not available.
• Avoid sharing utensils with or drinking after someone who is sick.
• Avoid touching eyes, nose, and mouth with unwashed hands.
• Wear a mask and socially distance yourself whenever possible.

PEARLS OF CARE:

• Get all family members immunized against influenza.
• If you think you/your child with Duchenne has the flu, contact your primary care and/or neuromuscular provider immediately.
• Use antivirals as recommended (for your child’s flu treatment or for prophylaxis).
• Take recommended over the counter medications.
• Maintain cough and breathing.
• Do not miss more than 24 hours of corticosteroids; if more than 24 hours of corticosteroids are missed, call your primary/neuromuscular provider for IV or IM steroid coverage in order to prevent acute adrenal insufficiency, which may be life threatening. Please refer to the PJ Nicholoff Steroid Protocol for any questions or concerns.
• Go to the emergency room if necessary; take all of your medications and equipment with you.
• Continue to do what you can to stay as healthy as possible.

WATCH: Acute Pulmonary Management

Drs. Richard Shell, Lisa Wolfe, and O. Hank Mayer presented a session on acute pulmonary management as part of our recent PPMD Virtual Conference. Watch here for information on prevention, emergency planning, and lessons learned from COVID-19.

Please share these resources with others so that we can work together to keep each other and our families safe, healthy, and active all season long.