Inside the Fight Against a Flu Pandemic
By Michael Scherer and Eben Harrell
TIME, Wednesday, Aug. 12, 2009
As they have for most of the past 87 years, hundreds of children from across the Eastern seaboard of the U.S. arrived in June at Camp Modin in Belgrade, Maine, carrying flip-flops, sleeping bags and swimsuits. But they also carried something new. First there was one fever, then six, then nine campers fell ill in a single day. By the end of the first full week, dozens of kids were sleeping on state-issued cots in a specially quarantined cabin, waiting out a pandemic flu virus that is barnstorming its way across the globe. Camp Modin was not alone; so far this summer, at least 80 camps in 40 American states, including a full quarter of Maine’s residential summer camps, have reportedly been hit by the bug known worldwide as H1N1. Across the Atlantic, Britain’s National Health Service spent most of July recording 100,000 new cases a week. Health officials in both countries were struck by a trend they regard as unusual and troubling: a flu outbreak in the middle of summer.
Just a few weeks after the Modin quarantine, senior officials from across the U.S. government gathered in the basement of the West Wing to begin planning for the siege to come. On the flat-screen televisions embedded in the soundproof walls, a PowerPoint slide flashed the human toll of previous epidemic flus: more than 600,000 Americans died in the 1918 pandemic; 70,000 «excess» deaths resulted from the Asian flu in 1957; and there were 34,000 deaths after the Hong Kong flu hit in 1968. Next to the 2009-10 H1N1 pandemic, the screens showed nothing but a series of question marks. The punctuation was designed to make a larger point. As a senior official in charge of responding to the crisis later told TIME, «You are going to see a spike in deaths.» (See pictures of the swine flu in Mexico.)
No one knows for sure what that spike will look like or how it will compare with the 250,000-500,000 people who die around the world each year from seasonal flu. But ever since the first case of H1N1 flu was reported in Mexico last March, health officials from Washington to Beijing have been girding for a difficult fall and winter. The World Health Organization (WHO) estimates that anywhere from 15% to 45% of the world’s population — 1 billion to 3 billion people — will catch the illness. «We know that influenza usually takes off in the winter months,» says Alan Hay, director of WHO’s World Influenza Center in London. «We assume that to be the case with H1N1. But there’s no way to know precisely how a pandemic will unfold.»
The good news is that H1N1 is not, so far, a particularly severe disease for those who are healthy. In laboratory-confirmed cases of H1N1 infection, only around 1,200 people have died out of more than 160,000 patients, according to WHO figures. With the exception of certain populations — including pregnant women, children with chronic diseases and people with respiratory ailments — H1N1 tends to be no worse than the seasonal flu. A few days in bed and lots of liquids, and most patients get better.
But hovering in the background of the current pandemic is the possibility that H1N1’s virulence might suddenly change. Flu’s hardiness as a recurring human scourge is the result of its unstable genetic structure. One flu virus can easily swap genetic information with another, or mutate as it reproduces in the human respiratory tract. The World Health Organization tracks flu viruses for changes in their genetic makeup that would make them more deadly. But even exhaustive 21st century virology can only help health officials react to what’s already happened. The best laboratory in which to study the flu virus is the human population itself. «If we get reports of a more severe infection with higher mortality rates, we can map the changes that made the virus more severe and monitor its spread. That could help health officials formulate policies,» says Hay of the World Influenza Center, one of four laboratories at the hub of the WHO’s global surveillance program. «But we’re always playing catch-up with flu. It’s impossible to stay ahead of this virus.»
Even without any significant mutations, H1N1 has so far behaved in confounding ways. The virus spread widely in Britain during the summer, but not in other European countries. No one knows why. Mexico reported a sharp increase in cases in late July after health officials there suspected that the virus had begun petering out with the onset of the hot summer months. And then there is emerging evidence that some patients present without fever, making diagnosing H1N1 harder.
See pictures of thermal scanners hunting for swine flu.
See the top 5 swine flu don’ts.
In China, where the first case of H1N1 was traced to a Mexican visitor in late April, only 2,264 cases of the flu have been reported. Still, officials in Beijing, criticized for their handling of previous viruses such as the outbreak of SARS in 2002 and 2003, are taking no chances. Chinese crews wearing masks and medical suits now walk through all international airplanes upon arrival, testing passengers’ temperatures with pistol-grip thermometers. When one student from St. Mary’s School in Medford, Ore., tested positive on a trip to China in mid-July, 65 fellow pupils and seven chaperones were isolated in a Beijing hotel.
Some medical professionals question the value of such stringent measures. This late in a pandemic, they say, the spread of H1N1 is inevitable. «They are not effective at all in my opinion,» says Dr. Lo Wing-lok, a Hong Kong–based infectious-disease expert. «By picking up these few cases, there isn’t any real impact in control of the flu.» Hugh Pennington, a microbiologist at the University of Aberdeen, puts it more bluntly: «We are already in a pandemic. There’s no containment option now.» (See the 5 things you need to know about swine flu.)
If H1N1 is too widespread to contain, we’re less sure how it will move through the coming northern winter. In the southern hemisphere, where it is winter now, the virus has been spreading fast, but with a low mortality rate. On Aug. 5, Argentina reported that deaths from H1N1 had more than doubled to 337 from 165 two weeks earlier, with around 700,000 suspected cases of the disease so far. The impact has been widespread. Attendance has dropped at Patagonian ski resorts, and flu fears have crippled the Buenos Aires theater business. Across the region, countries are reporting that H1N1 has become the dominant strain of the season, but has remained stable genetically. The lack, so far, of a mutated virus is crucial for vaccine manufacturers, who have been working since April on a vaccine based on the Mexico outbreak. The first human trials began in Australia on July 22.
While the World Health Organization concocts the recipe for the flu vaccine, private companies manufacture and sell the doses, mostly to governments. At current capacity, they can produce around 900 million doses of H1N1 vaccine a year: a total that is «woefully inadequate for a world of 6.8 billion people,» according to WHO head Margaret Chan. While some companies have donation schemes for the developing world — British pharmaceutical giant GlaxoSmithKline, for example, is donating 50 million doses to WHO — the lion’s share will go to wealthy countries, despite the fact that underlying health conditions make populations in the developing world particularly vulnerable.
Developing countries need to be clever about managing the doses they receive, for instance by immunizing front-line health workers, says Richard Coker of the Communicable Diseases Policy Research Group at the London School of Hygiene and Tropical Medicine. Even so, he says, most developing countries will struggle to cope with even a mild pandemic. Indian doctors in Pune were overwhelmed earlier this month when, days after India reported its first fatality in the pandemic, thousands of people mobbed public hospitals in the hope of being tested. «We’ve looked at the pandemic preparedness plans in developing countries and we’ve found that almost across the board the resources just aren’t there to implement plans effectively. It’s going to be very difficult for these countries,» says Coker.
Places such as Japan, Hong Kong and Western Europe, which are planning mass vaccination programs, face different challenges. These programs are difficult to implement. Last year, for instance, only 40% of the U.S. population took the time to get a regular flu shot, despite its widespread availability. Most forms of the H1N1 vaccine are going to require health officials to administer at least two shots spaced four weeks apart. What’s more, because the serum won’t be ready until at least mid-October, full immunity may not kick in until early December — after the second doses are administered and an additional couple of weeks pass, a time lag that could allow the virus to take off. The target groups for the first round of vaccines will likely include pregnant women, people with children, adults with chronic illnesses like diabetes and asthma and, if more stocks are available, children. «In all likelihood, this flu will hit before vaccine is available for people,» explains U.S. Homeland Security Secretary Janet Napolitano, who is tasked with managing Washington’s emergency response. «We are asking people to be resilient.»
If the virus doesn’t mutate into something more deadly, health officials in the northern hemisphere face another decision: whether to keep schools open. Young students are known by influenza epidemiologists as «super spreaders» because they shed more flu virus when ill, are unlikely to practice good hand hygiene, and are in close contact with parents and peers. Writing in the August edition of British medical journal the Lancet Infectious Diseases, researchers from Imperial College in London predicted that early and prolonged school closures could ease the burden on hospitals by reducing the number of cases at the peak of the pandemic. They cited a previous study in France that predicted that up to 18% more people would become ill with seasonal flu every year if schools never broke up for the summer.
But the researchers also conceded that closing schools could have unintended consequences. Up to one-third of healthcare workers in developed economies are the main carers for dependent children. Close schools and many of those people would have to take time off, compromising the effectiveness of health services. Mass absenteeism could also damage already fragile economies. The U.S. government has said that the decision on whether to close schools will rest with local officials. In China, no plans to close schools have been announced, but the authorities have urged educators to limit all unnecessary travel and gatherings. But plans may change suddenly in countries that see infection rates soar, or if the virus mutates.
See pictures of thermal scanners hunting for swine flu.
See the top 5 swine flu don’ts.
Fortitude and Pandemonium
However the pandemic plays out, the chief mantra for everyone — wash your hands, cough into the crook of your elbow rather than your palms, stay home if you’re sick — will be repeated endlessly over the coming months in ad campaigns, public-service announcements and the global media. A certain fortitude is required of the global population as well. At the height of the spring flu outbreak, hospitals in the U.S. were overwhelmed by crowds, including large numbers of the so-called worried well, who, when they showed up en masse, had the ability to delay services for the seriously ill.
In America, the sheer size of the pandemic response has begun to hit home for people like Kevin Sherin, the public-health director in Orlando, Fla. He oversees a school system with about 175,000 students, a county with more than 1 million residents and a tourist industry that cycles through 49 million visitors in a typical year. He says he has eight nurses in the schools and 20 other nurses ready to do immunizations. But if they each spend five minutes per injection, it would take them a month and a half — working 24 hours a day — to deliver the vaccine to all the local students. «For most of the local health departments, they are not going to have the resources to do the job,» Sherin says. «We are really going to be relying on volunteers to help us.» In addition to turning to private-sector doctors and nurses to aid the effort, Sherin is looking into renting empty storefronts, reopening vacant schools and even using the downtown Amway Arena, home to the Orlando Magic professional basketball team, for mass-vaccination campaigns. «It could be a little bit of pandemic pandemonium in the beginning,» he says. (See the 5 things you need to know about swine flu.)
Back to Normal
Meanwhile, things have calmed down at Camp Modin. No child was hospitalized, even though about 1 in 5 of the campers and staff came down with the illness. Quarantined campers were carefully screened for any rise in body temperature, and Tamiflu was broadly administered, despite federal recommendations. The pandemic was integrated into normal camp life — just another reality like bug bites and sunburn. «The kids made light of it. It was just the flu,» says Howie Salzberg, the camp’s director. To help pass the time, quarantined kids were given access to television, DVDs and video games, causing some healthier campers to feel jealous. «They were saying, ‘How do I get sick?'» Salzberg says.
If the global experience this fall mirrors what happened at Camp Modin, the virus may go down in history as a case study in preparedness. But with a once-in-a-generation bug on the loose and schools opening in the coming weeks, the drama known as H1N1 may just be starting.
With reporting by Elizabeth Dias and Sophia Yan / Washington, and Austin Ramzy / Beijing
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