Questions Answers And Advice About The H1N1 Flu Pandemic

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					ORIGINALLY PUBLISHED SATURDAY, AUGUST 29, 2009

H1N1 guide
Questions, answers and advice about the H1N1 flu pandemic
Stay up to date at ottawacitizen.com/flu

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Do-it-yourself triage
How to prevent, spot and treat H1N1 flu

SYMPTOMS
What it is: The new H1N1 flu virus is a respiratory illness that causes flu-like symptoms. Who it affects: Youth more than other age groups. Half the people in Ottawa with swine flu have been children and teens. Severity: Most cases have been mild in Ottawa. How it spreads: In the same way seasonal flu does — person to person, through coughing, sneezing, or touching contaminated objects. People can infect others from the day before their symptoms develop to seven days after they become sick. Symptoms: Fever, cough, shortness of breath, muscle aches, fatigue, severe headache, sore throat, lack of appetite, possible nausea, vomiting, diarrhea. Severe symptoms: High fever, difficulty breathing.

PREVENTION
Wash hands frequently, with soap and water for at least 20 seconds. Stay at least two metres away from people who have flu-like symptoms. Carry hand sanitizer for use in crowded places. Do not share things that go in the mouth. Clean surfaces in your home on a daily basis. If you have to cough or sneeze, cover your mouth with the inside of your elbow. If the virus spreads, you might want to avoid crowds to avoid exposure. Masks are not a good form of prevention because most people use them incorrectly, and contaminate themselves when they put the mask on and take it off. If you’re sick, you can wear a surgical face mask to avoid exposing others, especially when you leave home. Also, caretakers should consider wearing a surgical face mask. After you take the mask off, throw it in the garbage and wash your hands. Surgical face masks can be purchased at your local pharmacy, and are usually labelled “N-95,” meaning that the mask has a 95-per-cent rate of filtration efficiency.

IF YOU HAVE …
1) mild flu-like symptoms: Stay home from work or school. Sleep, drink plenty of fluids, stay away from others. Avoid tobacco smoke, use cold compresses for comfort. 2) severe flu-like symptoms: go to your doctor or a hospital emergency room. 3) flu-like symptoms and a chronic medical condition, such as asthma, diabetes or cancer: speak to your doctor. Most people can battle the virus on their own, but people with a chronic illness might need antiviral medication early. 4) flu-like symptoms and are pregnant: Speak to your doctor about antiviral treatment. Pregnant women, especially those in the third trimester, are at greater risk for complications. If your symptoms are moderate and you can’t decide what to do: Call Telehealth Ontario at 1-866-797-0000, or the city’s Public Health Call Centre at 613-580-6744. am i better? Your bout with H1N1 is over when you feel well and no longer experience symptoms, usually 24 hours after the break of a fever. If a cough lingers, it’s fairly normal, and not a reason to stay home.

TREATMENT
Antivirals: Tamiflu and Relenza effectively treat the virus, but most patients recover without medication. Antivirals are best for moderate to severe cases, and people who have complications. Antivirals have been distributed to each province on a per capita basis. Prescriptions come from your doctor. Vaccines: Immunization is likely to begin in November. The federal government is purchasing 50.4 million doses of H1N1 vaccine from GlaxoSmithKline. Provinces and territories will be responsible for delivering the vaccines. As of yet, no decisions have been made on who will get priority for vaccines.

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FIND OUT MORE
Link to these helpful sites at ottawacitizen.com/flu: ■ City of Ottawa: www.ottawa.ca/residents/health/conditions/ swine_influenza ■ Ontario Ministry of Health and Long-Term Care: health.gov.on.ca/ english/public/updates/archives/hu_09/swine_flu.html ■ Public Health Agency of Canada: www.fightflu.ca ■ World Health Organization: www.who.int/csr/disease/swineflu/en

WHO TO CALL
■ Telehealth Ontario, 1-866-797-0000 ■ City of Ottawa Public Health Call Centre, 613-580-6744.

You can also reach the call centre by dialing 311. In addition to English and French, the city’s public health staff can communicate in Vietnamese, Cantonese, Mandarin, Arabic, Somali and Spanish. Sources: City of Ottawa, Public Health Agency of Canada. Compiled by Katie Daubs.

How to talk to your kids about H1N1 without scaring them to death
BY JOANNE CHIANELLO As kids flood back to school, you may be tempted to sit them down and give them a good talking to about H1N1. Resist. Haranguing kids to obsessively wash their hands or to shun schoolmates with a slight cough will only freak them out — and will likely not help them avoid the flu. Here’s how health professionals say you should talk to your kids about H1N1:
■ If your children don’t raise the issue, it’s up to you

“Children will often think they’re responsible for things they aren’t responsible for,” says Bourget. “That makes them insecure.”
■ Shield them. It’s inevitable that children will hear all kinds

of things about H1N1 — accurate and inaccurate — but limit their exposure to media reports and adult conversations about the flu. They aren’t appropriate for most school-aged children and can raise their anxiety levels, according to the U.S. Centers for Disease Control and Prevention.
■ Don’t brush off your kids’ fears about the seriousness

to do it. One way to approach the topic is to ask what they’ve heard about it, so you know what’s going through their minds. “They may or may not raise it, but they’re probably thinking about it,” says Dr. David Butler-Jones, Canada’s chief public health officer.
■ Answer all questions — and correct all misconceptions

— as clearly as possible. That means getting up to speed on H1N1 information yourself. Be concrete in your answers and do not avoid difficult questions. If you don’t know the answer, it’s OK to say, “I don’t know, but I’ll find out.” Then do it.
■ Calm down. “Kids pick up on our anxieties,” says Butler-

of H1N1, but do try to bring some perspective. If your son asks if people can die from this flu, don’t lie. But do impress upon him that deaths in Canada have been rare, and most of those who died were already sick with something else. “Children have a poor grasp of things like probability and numbers,” says Bourget. “Even very bright kids, if you ask them how many people live in Ottawa, they might say a thousand.”
■ Reminding children about good hygiene habits is never a bad idea, but badgering children to wash or disinfect their hands probably won’t lead to them doing it more often. Scaring them will not change their behaviour. Instead, reinforce those habits by practising good hygiene yourself at home. At school, teachers will also lead by example, directing the entire class to wash their hands before lunch. ■ If a classmate or friend gets sick — which is likely —

Jones. “If it sounds like we know what we’re doing, then they’re reassured.” This will be easier if you’re confident in the facts.
■ Avoid calling it ‘swine flu.’ “That can sound scary for kids, who often make visual associations,” says Dr. Virginia Bourget, a psychologist at the Children’s Hospital of Eastern Ontario. “A scary pig — that’s even worse than bird flu!” Try to stick to H1N1, or if that’s a bit too scientific, try influenza. Even plain old “flu” will do. ■ It’s not their job. Although you should answer their ques-

make sure you explain to your children that it doesn’t necessarily mean they too will get sick. And if they do, stress that you will take care of them the way you always do.
■ Children always need to feel safe and loved, and if

tions about the flu, you must make it clear that it’s not their job to worry about how to manage it — at home or at school.

they are worried about a situation like a flu pandemic, that need will increase. Make sure you let your kids know it’s OK to feel angry or afraid.

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How to wash your hands
The World Health Organization developed this method of handwashing for health-care workers to reduce the risk of transferring illness while providing care.

Wet hands with water ...

... apply enough soap to cover all hand surfaces.

Rub hands palm to palm ...

... right palm over back of left hand with interlaced fingers and vice versa ...

... palm to palm with fingers interlaced ...

... backs of fingers to opposing palms with fingers interlocked ...

... rotational rubbing of left thumb clasped in right palm and vice versa ...

... rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

Rinse hands with water ...

... dry thoroughly with a single use towel ...

... use towel to turn off faucet ...

... and your hands are safe.

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QUESTIONS & ANSWERS
There are some things we know for sure. PAULINE TAM gives the facts on swine flu.

SYMPTOMS AND SEVERITY
What are the symptoms of the new H1N1 swine flu virus? Fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. A significant number of people also report diarrhea and vomiting.

cations such as pneumonia; during a pandemic, many more people could be infected, possibly leading to many more deaths. How do I know if I have the H1N1 virus or seasonal flu? Without laboratory testing, it’s difficult to know exactly what strain of flu a person has. Often, several strains of flu are circulating at the same time, and the symptoms are usually the same. And because health officials are no longer doing large-scale diagnostic tests to determine which types of flu people have, health-care providers are preparing this fall to assess and treat patients with all types of flu-like illness. Only flu patients who are hospitalized will continue to be tested for H1N1. How long can an infected person spread the H1N1 virus to others? People infected with seasonal flu and H1N1 flu can infect others from one day before showing symptoms to seven days afterward. Who is at risk of developing complications from the H1N1 virus? As with seasonal flu, certain people who get H1N1 are at “high risk” of serious complications. This includes children under two, pregnant women and people of any age with certain chronic illnesses. In Canada, about 75 per cent of people who have died from complications linked to H1N1 have had one or more medical conditions. These include pregnancy, obesity, diabetes, heart disease, asthma, kidney disease, suppressed immune systems and neurocognitive and neuromuscular disorders.

One thing that makes H1N1 appear different than seasonal flu is that people over 65 do not seem to be at increased risk of complications. Laboratory studies by the U.S. Centers for Disease Control have shown that about one-third of adults older than 60 may have antibodies against the H1N1 virus, while those under 60 do not. It’s not known how much, if any, protection these antibodies provide against H1N1 flu. How does the new H1N1 flu compare to seasonal flu in severity and infection rates? Like H1N1 flu, seasonal flu can cause mild to severe illness, and at times lead to death. According to the Ontario Ministry of Health, between three and six million Canadians get flu every year, and between 4,000 and 8,000 Canad-ians, mostly seniors, die from flu, pneumonia and other related complications. Of the estimated 60,000 who are hospitalized, the largest groups are children under two and people over 65. To date, statistics show that H1N1 flu has caused a greater disease burden in people under 25. Meanwhile, relatively few cases and deaths have been reported in people over 64, which is unusual when compared to the seasonal flu. Is the H1N1 virus more deadly than seasonal strains of flu? Early estimates suggest the H1N1 virus is probably more deadly than seasonal flu viruses, but much less deadly than the pandemic virus that caused the Spanish flu of 1918. However, flu viruses mutate rapidly, and this virus could change in the coming months. The Spanish flu virus was mild when it first appeared in the spring of 1918, but when it

What is the difference between ordinary seasonal flu and a flu pandemic? The symptoms are the same, but they can be much more severe with a pandemic, which affects younger, healthy people who don’t normally suffer as much from seasonal flu. There are other differences: ■ Seasonal flu happens every year, while a pandemic happens only two or three times a century. ■ Seasonal flu is usually around from November to April; a flu pandemic can come in two or three waves, with each wave lasting about two months. ■ About 10 per cent of Ontarians get seasonal flu each year; about 35 per cent of Ontarians could get flu during a pandemic. ■ Most people who get seasonal flu recover within a few weeks; during a pandemic, more people who get the flu will recover more slowly. ■ Seasonal flu is hardest on people who don’t have strong immune systems (the very young, the very old and people with certain chronic illnesses); anyone could become seriously ill with flu during a pandemic. ■ In a normal flu season, up to 2,000 Ontarians die of flu-related compli-

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returned the next winter, it killed 30 people for every 1,000 it infected. In contrast, epidemiologists who analysed April’s H1N1 epidemic in Mexico recently reported that the estimated fatality rate of the H1N1 virus is four in 1,000, meaning this virus is considerably less lethal than the one that caused the 1918 pandemic, but somewhat more lethal than seasonal flu viruses, which have a fatality rate of two in 1,000. How serious could the next wave of the H1N1 pandemic be? Although it’s impossible to predict how severe the pandemic could be, experts from the University of Pittsburgh Medical Center believe it so far resembles the 1957-58 flu pandemic. Like the H1N1 virus, the 1957 pandemic virus circulated in the northern hemisphere during summer, while hitting the southern hemisphere during winter. Current disease patterns are also similar to 1957: illnesses are generally mild, and the virus strikes predominantly younger people. The H1N1 virus also appears to cause a similar fatality rate to the 1957 virus. As with the current pandemic, epidemiologists in 1957 weren’t sure if the outbreaks would intensify during the fall flu season. Even so, the 1957 pandemic caused minimal disruptions, in part because public health officials didn’t close schools, cancel public events or impose travel restrictions. In 1957, outbreaks intensified when the school year started in September, but flu cases levelled off by the end of November. Schools had absenteeism rates of up to 30 per cent, but the pandemic had little impact on workplace absenteeism except in schools and health-care facilities. Hospital admissions increased, but facilities had the capacity to handle the extra patients. While a vaccine was developed in time for the fall flu season, it had little impact because of limited availability and effectiveness. Why do some otherwise healthy people get seriously ill or die from H1N1? The answer isn’t clear. Some seemingly healthy people may have risk factors for complications that are undiagnosed. With H1N1, obesity appears to be a risk factor for severe illness, which is not commonly seen with seasonal flu. Researchers have speculated that during the 1918 Spanish flu, young, healthy people became very ill because they have strong immune systems, and their immune response to infection kicked into overdrive, leading to more inflammation and severe disease. Researchers at the Hospital for Sick Children in Toronto are investigating whether particular genes are linked to a severe response to the H1N1 virus. cine Watch”. If I have a family member at home who is sick with flu, should I go to work? People who are well but who have an ill family member at home with flu can go to work as usual. You should monitor your health every day, and take everyday precautions including washing your hands often with soap and water. What should I do if I get sick? Stay home and avoid contact with other people, except to get medical care. This means avoiding normal activities, including work, school, travel, shopping, social events and public gatherings. If you have severe illness or you are at high risk for flu complications, contact your healthcare provider, who will determine whether flu treatment is needed. What are the warning signs of severe flu that require urgent medical attention? In children, emergency warning signs include: ■ fast or troubled breathing ■ bluish or grey skin colour ■ not drinking enough fluids ■ severe or persistent vomiting ■ not waking up or not interacting ■ being so irritable that the child does not want to be held ■ flu-like symptoms improve but then return with fever and worse cough In adults, emergency warning signs include: ■ difficulty breathing or shortness of breath ■ bluish or grey skin colour ■ bloody or coloured sputum ■ chest pains ■ sudden dizziness or confusion ■ severe or persistent vomiting ■ high fever lasting more than three days ■ flu-like symptoms improve but then return with fever and worse cough ■ low blood pressure Are there medications to treat the new H1N1 infection?

PREVENTION & TREATMENT
What can I do to protect myself from getting sick? There is no vaccine currently available to protect against the new H1N1 virus. However, a vaccine is in production. As always, a vaccine will be available to protect against seasonal flu, but immunization against recent (2005 to 2009) seasonal flu viruses is unlikely to provide immunity against the H1N1 virus. Even though the seasonal flu vaccine won’t protect you directly against the H1N1 virus, it will prevent you from getting the seasonal flu, which could weaken your immune system and make you more susceptible to H1N1. What is being done to develop an H1N1 vaccine? The federal government has ordered 50.4 million doses of H1N1 vaccine from GlaxoSmithKline, which has a manufacturing plant in Ste. Foy, Que. The company has said its first supply of vaccine would likely be ready in mid-November. For more information on the vaccine, see “Vac-

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Yes. Antiviral drugs such as oseltamivir (Tamiflu) or zanamivir (Relenza) are prescription medications that fight the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current pandemic, antiviral drugs are being used primarily to treat hospitalized flu patients and people who have a condition that places them at high risk for serious complications. Should antiviral drugs be given to children with flu symptoms? There is an ongoing debate about whether antivirals should be given to all children with flu symptoms. A recent study by Oxford University researchers concluded that children under 12 should not be given Tamiflu or Relenza because their sideeffects outweigh any benefits. The study found that antivirals only led to a minor reduction in the length of time that a child with mild flu was ill and that Tamiflu caused vomiting in five per cent of children, which could lead to dehydration and complications. The Oxford researchers concluded that children with mild flu are better treated with rest and plenty of fluids. Meanwhile, WHO maintains that antivirals are appropriate for children who have severe H1N1 flu, or who are at risk for H1N1 complications.

CONTAMINATION & CLEANING
How long can flu viruses survive on surfaces such as books and doorknobs? Studies have shown that flu viruses can infect a person for two to eight hours after being on surfaces. On non-porous surfaces, they can survive for a few days. What kills flu viruses? Flu viruses are destroyed by heat as well as chemical cleaners with chlorine, hydrogen peroxide, detergents, iodine-based antiseptics and alcohol-based cleaners. Can I get infected with H1N1 virus through water in swimming pools, water parks and spas? There has never been a documented case of flu-virus infection linked to water exposure. No research has been completed on the susceptibility of H1N1 flu virus to chlorine and other disinfectants used in recreational water venues. However, recent studies have demonstrated that the amount of chlorine used to kill microbes in recreational water facilities, as recommended by the U.S. Centers for Disease Control, is adequate to disinfect avian flu A (H5N1) virus. Can H1N1 virus be spread at recreational water venues outside of the water? Yes. Recreational water venues are no different than any other group setting. The spread of H1N1 flu is thought to happen in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing. Sometimes, people may become infected by touching something with flu virus on it and then touching their mouth or nose.

VACCINE WATCH
When will it be ready? Who gets it first? Will there be side-effects? Will it even work? TOM SPEARS investigates.
The vaccine should be available this fall
The federal government has ordered 50.4 million doses of H1N1 vaccine from GlaxoSmithKline, which has a manufacturing plant in Ste. Foy, Que. The contract is worth more than $400 million and the federal government will pay for 60 per cent of the cost; provinces and territories will pay for the rest. Hospitals and clinics, however, are still waiting to hear when it will arrive. Most are betting on November. All countries are also waiting to hear from clinical trials, currently under way in many centres, as to whether this vaccine works best with one or two doses. Canada has a population of 33.6 million. The federal pandemic plan uses the estimate that 75 per cent of the population would want the vaccine. Ordering 50.4 million doses provides two shots for 75 per cent of Canadians. In an alternative, it could also provide one dose for everyone in the country, and a second dose for 50 per cent. In the event that everyone in the country wants the vaccine and everyone needs two doses of it, more could be ordered, health officials say.
continued on next page

Sources: U.S. Centers for Disease Control and Prevention, Science, British Medical Journal, New England Journal of Medicine, Biosecurity and Bioterrorism, Public Health Agency of Canada, Ontario Ministry of Health, The Ottawa Hospital

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Some people need it more than others
■ Pregnant women. The risk of

hat about risks?
That’s the catch involved in vaccinating children first. Normally a drug is tried first on healthy adults, in case there are side effects. In 1976, in fact, a vaccine against that year’s flu — also H1N1 — was withdrawn after widespread side effects, often in children. But vaccine problems have not recurred since then. A different type of risk is that one shot may not be enough. Two or even three jabs (one for the regular seasonal flu) may be required to build up enough immunity. Some parents are vocal in opposing shots for their children without more testing. The World Health Organization insists the speed at which the H1N1 vaccine is being developed and tested is not compromising safety. Even so, Dr. Marie-Paule Kieny, WHO director of the initiative for vaccine research, has indicated that minor side effects of a vaccine, including nausea and fever, are to be expected. She said “there is no doubt” that in any large-scale vaccination program, there will be cases of severe adverse reactions. Health Canada’s role will be to monitor all signs of adverse events and determine whether the side effects are linked to the vaccine.

Where do you get a shot?
Any place that offered flu shots last year will likely offer the new vaccine. But it may be offered first to high-priority age groups. Do: Watch for announcements from hospitals, your physician’s office, or municipalities that set up flu shot clinics in neighbourhoods. (The city of Ottawa’s H1N1 announcements have been at www.ottawa.ca, but so far it hasn’t set dates for clinics.) Don’t: Walk into your doctor’s office or an emergency department without checking and expect a vaccination to be ready and waiting. Hospitals and public health departments still have not heard when the vaccine will be available.

swine flu complications is higher during pregnancy. ■ Household contacts and caregivers for children younger than six months. Infants are at higher risk of flu complications and cannot be vaccinated. Vaccination would focus on those in close contact with them. ■ Health-care and emergency medical services personnel. ■ Babies, children and teens, from six months through 18 years of age. Yale University School of Medicine says children in school transmit flu faster than other groups and should get the first shots. ■ Young adults, from 19 through 24 years of age, who tend to live, work, and study in close proximity, and travel often. ■ People with health conditions associated with higher risk of medical complications from influenza, such as heart disease, lung disease and some types of cancer.

How many will choose to get a shot?
“We have tried to get every person to be vaccinated in Ontario (it is one of the only jurisdictions worldwide that provides free influenza vaccine to everyone) but the uptake is less than enthusiastic. Silly rumours and all,” says Dr. David Colby, medical officer of health for Chatham-Kent and a professor of medicine at the University of Western Ontario. “So, politically, it is difficult to get people to inconvenience themselves for the benefit of others, at least on a large scale.”

There may not be enough vaccine right away
The Canadian Public Health Agency would then have to pick groups that are either the most vulnerable, or essential in keeping the health-care system running. So far it has not decided, but has looked at starting with five- to 40year-olds. Children spread flu quickly, and young adults have been getting sick from H1N1 more often than any other age group. As well, priority would go to aboriginal groups, who are seen to be risk-prone because of crowded housing and above-average rates of obesity, asthma and lung diseases — health problems associated with a higher risk of dying from H1N1. Eventually the plan is to offer vaccination to everyone in Canada.

The clinical testing is still going on
The hope is to have a commercial vaccine ready in October. The U.S. Centers for Disease Control and Prevention have distributed a “seed” virus from the new flu strain so that vaccine manufacturers could develop test batches of vaccine. The first tests will take place in adults. Tests on children will follow. Data may also help in decisions about vaccinating people in highrisk groups, including pregnant women and people with weakened immune systems.

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Should I wear a mask?
Nurses, doctors and paramedics wear them, but no major health organization recommends masks for the general public
BY VITO PILIECI

It’s common to see photographs of people in flu zones wearing white surgical face masks, but medical experts are still debating their effectiveness when it comes to keeping the masses healthy. The best of these devices have been proven to drastically reduce a person’s chances of contracting an airborne illness. However, if used improperly, they can also increase a person’s risk of getting sick. The Public Health Agency of Canada does not recommend wearing masks, claiming that people often wear them incorrectly or contaminate themselves when putting the masks on or taking them off. Most masks, which can be purchased at pharmacies, are meant for one-time use and should not be worn for a period exceeding six hours. A recent warning from the World Health Organization offered similar advice, stating that “using a mask incorrectly … may actually increase the risk of transmission, rather than reduce it.” Both health agencies, as well as those of the city and the province, recommend that people wash their hands regularly and cough into their sleeves to reduce the chances of contracting or spreading any flu-like illness. However, one recent study found that, when used correctly, surgical masks of the N95 variety (a paper and fabric combination with a 95-per-cent filtration efficiency) can reduce the risk of contracting respiratory viruses and flu by as much as 80 per cent. The study was based on results

JANA CHYTILOVA, THE OTTAWA CITIZEN

Gaye Moffett, president of GEM Health Care Services, tests Sara Nayler to see if she is wearing an N95 surgical mask properly.

gathered by Raina MacIntyre, an epidemiologist and head of the school of public health and community medicine at the University of New South Wales in Sydney, Australia. MacIntyre conducted clinical trials during the winters of 2006 and 2007 involving 286 patients. The results were published in the journal of the Centers for Disease Control and Prevention earlier this year. Several health-care organizations in Ottawa, including GEM Health Care Services and Revera Health Care Services, offer services, includ-

ing mask fittings, to help people ensure they are wearing the masks properly. For its part the City of Ottawa does not recommend that the general public wear surgical masks in a bid to stay healthy. However, the city does say that health care workers and others who regularly deal with sick people should be wearing masks. It also recommends that people who are sick with the flu, or suspect they may be, wear a mask and either isolate themselves until their symptoms subside or seek medical attention.


				
DOCUMENT INFO
Description: What are the symptoms of the new H1N1 swine flu virus? Fever, cough, sore throat, runny orstuffy nose, body aches, headache,chills and fatigue. A significantnumber of people also reportdiarrhea and vomiting. What is the difference betweenordinary seasonal flu and a flupandemic?The symptoms are the same, butthey can be much more severe witha pandemic, which affects younger,healthy people who don’t normallysuffer as much from seasonal flu. How do I know if I have the H1N1virus or seasonal flu?Without laboratory testing, it’sdifficult to know exactly what strainof flu a person has. Often, severalstrains of flu are circulating at thesame time, and the symptoms areusually the same. And becausehealth officials are no longer doinglarge-scale diagnostic tests todetermine which types of flu peoplehave, health-care providers arepreparing this fall to assess and treatpatients with all types of flu-likeillness. Only flu patients who arehospitalized will continue to betested for H1N1.