Don't call it swine flu -- at least not anymore. But the 2009 H1N1 strain of influenza is among us. It's in every state and territory of the U.S., on six continents and in most countries around the world. As we swing into fall, when the weather increases transmission rates and more people congregate in places like schools, experts say widespread infection is inevitable.
As much as 40 percent of the world's population is expected to get sick. Not even Ron Weasley is safe: Rupert Grint, the 20-year-old British actor famous for playing ginger-haired wizard Weasely in the Harry Potter movies, had a minor case in July. (He got better.)
If you're going to get sick, Pittsburgh may be among the best places to be, with a multidisciplinary team of researchers studying the virus and its infection patterns from all angles. The Center for Biosecurity at the University of Pittsburgh, for instance, helps advise policymaking groups like the federal Centers for Disease Control and Prevention about handling all sorts of major biological threats, from bioterrorism to large-scale flu infection.
In particular, the path taken by viruses fascinates the center's visiting fellow, Dr. Amesh Adalja. Adalja, from a family of doctors in Butler, is a 33-year-old physician and epidemiologist who thrills at chasing down the medical mysteries of infectious diseases. Like many who track bugs, he'd been intensely studying the avian flu when H1N1 hit, and quickly switched gears.
As of the end of July, the World Health Organization had reported 1,154 deaths from H1N1, and 162,380 cases worldwide. In the U.S. so far, more than 430 people have died, with more than 6,500 people hospitalized for suspected H1N1 influenza. On June 11, the WHO declared it a global pandemic; the director general, Dr. Margaret Chan, said that "further spread is considered inevitable."
The bottom line is that lots and lots of people are going to get sick this fall.
But don't freak out, say Adalja and other experts. It's not the next Black Death. H1N1 as we know it is quite contagious but seldom fatal. Most people who become infected will recover, with or without the help of potent anti-viral drugs Tamiflu and Relenza, and a vaccine should be available by mid-October.
"The virus is going to be everywhere," says Adalja. "People need to be prepared to see widespread illness, which doesn't mean widespread death. You have to strike a balance between panic and preparedness. The majority of people are going to be fine."
Creepy words like "swine flu" and "pandemic," and visions of subway cars full of people in face masks, certainly aren't reassuring. But in any given year, about 36,000 people can be expected to die from regular seasonal flu.
Public-health experts say common-sense precautions like washing our hands go a long way toward addressing the problem. Still, challenges remain: Who gets vaccinated first? Who should get antiviral drugs, and when? Do we close down schools and theaters? Do we all need a face mask and a pocket-sized bottle of anti-bacteria goo? Or should we all just calm down?
This year's novel H1N1 influenza virus, formerly known as swine flu, came to prominence in Mexico this spring, and was identified as a new virus in April. According to the CDC, it's thought to spread like most viruses, from contact with an infected person's coughs or sneezes, and possibly through touching a surface that an infected person has coughed or sneezed on.
Symptoms include fever, sore throat, body aches, headaches, chills, fatigue, vomiting and diarrhea. Patients are sick and contagious before they display symptoms, and can expect to be sick for five to seven days.
The virus was initially called "swine flu" because it displayed genetic characteristics of influenza viruses typical to pigs. It's called H1N1 because of its genetic profile -- influenza strains are categorized by two specific proteins, hemagglutinin and neuraminidase.
Every influenza virus, despite what it's popularly called, is identified by its hemagglutinin and neuraminidase profiles. For instance, the 1968 influenza virus commonly called the Hong Kong Flu was a H3N2 virus.
"Two [viruses] getting together and shuffling -- that's what makes flu unique," says Adalja, who besides doing research also pulls shifts in area emergency rooms. "Every pandemic is heralded by an antigenic shift." That is, the virus mutates so that previous vaccines or immunities conferred by surviving infection are no longer effective.
While the 2009 H1N1 virus contains genetic markers common to pigs and birds, it spreads from human to human. "You can have a human virus infect a pig and bird flu can infect a pig. You get a part-human-part-avian flu -- pigs are the mixing vessel."
Along with profiling infectious diseases, Adalja is a major fan of calling things as he sees them. You've probably seen his name before -- he's a passionate letter-to-the-editor writer on topics from the true nature of republicanism to a woman's absolute agency over her reproductive system. (As a pro-choice Republican who signs his letters from Butler, he manages to engender teeth-gnashing replies from all sides.)
Adalja also loves debunking myths: It's absolutely not possible to pick up H1N1 from eating spareribs, for instance. And the Kabul Zoo's decision to quarantine the only known pig in all of Afghanistan this May? Laughable.
"No pigs were sick," Adalja says.
So why is the virus grabbing headlines and causing a run on face masks?
"A lot of people confuse the word 'pandemic' with widespread death. It means 'widespread illness,'" says Adalja. "It came along and freaked everyone out and the media got a hold of it."
Still, all flus are not created equal.
Typically, influenza strikes the physically weakest among us -- young children and the elderly. The Asian flu of 1957, a pandemic that killed 69,800 people in the U.S., killed mostly old people. The 1968 Hong Kong flu, which killed 33,800, mostly struck those over 65.
But the most deadly influenza strain, the 1918 Spanish flu, which the Centers for Disease Control and Prevention calls "the catastrophe against which all modern pandemics are measured," hit the young. Between 20 and 40 percent of the world's population got sick. Fifty million people died, and healthy adults between 20 and 50 were the most likely victims, along with people in high-risk groups.
H1N1 tends to hit similar demographics.
"It's not the super-old. Seasonal flu has primarily stricken adults over 65," Adalja says. "Fifty-two-year-olds and older are spared."
One possible reason for that could be what docs like Adalja call, somewhat poetically, "original antigenic sin."
"You'll always respond best to the first virus of childhood," he says. The first time your cells are exposed to a particular infection, they'll form a defense to it, creating an immunological "memory." That's why it's rare to get chicken pox more than once, for example.
Previous influenzas of the H1N1 type included the deadly 1918 Spanish Flu, the 1957 Hong Kong Flu and a 1976 swine-flu scare that made headlines for killing a young soldier, but never really left Fort Dix. So people who were exposed to those pandemics or pandemic scares, Adalja says, have some immunological memory of the virus and how to fight it, granting them some protection.
Ounces of Prevention
Even for most who lack such immunity, preventing infection remains a simple, low-tech matter of everyday hygiene. That means things your mother always told you, like covering your coughs and staying home when you are sick.
"It's the basics, I mean, geez!" says Cheryl Herbert, director of infection prevention at Allegheny General Hospital. "I've been doing this job for more than 30 years, the basics don't change. Wash your hands, cover your cough. Clean stuff. People tend to get a bit panicky."
The wearing of surgical masks is of dubious value. "It's debatable how effective it is in public settings," says Adalja, though he adds, "It's definitely effective in health-care settings."
"It's a false sense of security," says Cheryl Herbert of wearing a mask in public.
Vaccines, meanwhile, will be available in October, and public-health experts do recommend that certain types of people get them. According to the Centers for Disease Control's Advisory Committee on Immunization Practices, those include: pregnant women; those who live with or care for children younger than 6 months old; health-care workers, people between 6 months and 24 years old; and people from 25 to 64 with compromised immune systems or underlying complications like diabetes or heart disease.
It's too early to say how vaccines will be made available here. "Right now we still do not know how it's going to get rolled out -- will it come out like seasonal flu vaccine, through doctors, or mass-vaccination clinics?" asks Megan Casey, a nurse epidemiologist at the Allegheny County Health Department. The ACHD, with guidance from the state and CDC, will make those determinations.
Prioritizing, by the way, would be necessary only if the vaccine were in short supply. "At this point what the CDC is telling us is that we don't expect to see a shortage," Casey says.
Pregnant women are a priority for two reasons. First, pregnancy is accompanied by some degree of immunosuppression. Secondly, vaccines aren't typically given to babies under 6 months old -- which is why people who care for them are encouraged to get vaccinated. But a baby born to a mother who's been vaccinated will carry that immunity for about 6 months, according to the New England Journal of Medicine.
"Pregnant women represent a uniquely vulnerable population that is known to suffer disproportionately negative outcomes during times of influenza epidemics and pandemics," said Dr. Richard Beigi in a statement. Beigi directs pandemic influenza preparedness at Magee-Women's Hospital of UPMC, the region's largest hospital for delivery and neonatal care.
Recommendations to vaccinate raise red flags with an increasingly vocal movement questioning the safety of vaccinating children and pregnant women. Groups like the Constitution Party and Generation Rescue, actress Jenny McCarthy's autism-awareness group, say vaccines are dangerous and put children at risk.
But most doctors say it's much more dangerous not to vaccinate.
"Theoretical safety concerns with influenza vaccination during pregnancy are lacking, and published literature, as well as ongoing research, confirm the safety of influenza vaccine during pregnancy," Beigi says. "The proven maternal, fetal and neonatal benefit of maternal influenza vaccination far outweigh any unproven and/or theoretical concerns for safety."
Adalja goes a step further, calling those theoretical concerns "myths." For instance, thimerisol, an ingredient commonly found in vaccines, is the subject of increased scrutiny for a potential link to autism. But Adalja calls it "perfectly safe" and says that scares like that "make it that much harder to craft effective policy."
"The primary risk to a developing fetus is if the mother is infected," he says. "The best way a pregnant woman can protect her fetus is to get vaccinated."
Health-care workers present a unique epidemiological challenge. They are in the trenches, spending their days among the sickest people. In a June article on the Clinician's Biosecurity Network Web site, Adalja pointed out that, among health-care workers, half the illnesses reported to the CDC had been contracted at work.
"You've got to maintain health care -- people will still have babies and heart attacks, whether there's a pandemic or not," says Allegheny General's Herbert. "You start with a good firm plan, make it feasible for [health-care workers] to come and work. You have to be creative, you have to talk about how they could get it or not get it. You have to make sure all of your employees can get the shots, free of charge. You have to have plans to provide antivirals to employees."
AGH and its umbrella group, West Penn Allegheny Health System, hold biweekly meetings among hospital administrators with different specialties to keep abreast of how the pandemic is progressing, and what the best practices are. But Herbert emphasizes that the effects of pandemics ripple far beyond attempts to keep nurses and doctors healthy.
"You have a lot of employees in hospitals," she says. "They have kids at home, they have families. We go through the what-ifs. What if schools close? How will employees come to work with no one to watch their kids? Do you offer a day-care space? In an emergency, you have more opportunity to be flexible. How are you going to feed them? Where do you put them to sleep? How long can a hospital feed people?"
And these aren't the only contingencies to plan for. In a global economy, many of the front-line defenses against the spread of infection, like face masks or gloves, aren't made in the U.S.
"Say the pandemic hits there first -- no one's making masks, the plants are shut down," Herbert says. "A prolonged worldwide epidemic can present problems like that that no one wants to talk about."
One solution might be stockpiling supplies like germicides and facemasks, which she says hospitals will "go through like crazy." But most hospitals don't have the capital to have millions of dollars of stock sitting around.
Faced with a pandemic, Herbert says, emergency-room doctors are being advised to have "a higher level of suspicion for influenza disease." Positively or negatively identifying a flu as H1N1 takes weeks, because nasal swabs have to be sent to state-government testing facilities. So, she says, it's best to just assume that patients with the flu have H1N1 and to follow appropriate protocols, like putting them in isolation and giving them antivirals, if the time since infection has been short enough.
Another challenge, of course, is schools. Fall is not only flu season -- it's also when crowds of kids sneeze all over each other all day long.
(Summer's high heat and humidity slow the spread of infection, which is why H1N1 has dropped off the radar somewhat since peaking in early spring. Both Adalja and Herbert point to the clusters of summertime infections as signs that this virus is especially nasty.)
But closing schools probably won't stem the tide of new infections.
"Closing schools is rarely indicated," said CDC director Dr. Thomas Freiden in an Aug. 10 teleconference with U.S. Department of Education Secretary Arne Duncan.
"Realistically we believe some schools will close this fall," said Duncan. "It's hugely important to us that those students continue learning, through home schooling, using the phone and Internet. Bottom line: We need to make sure our children keep learning."
"The only real reason to close a school is too many [students] are sick to have a school day," says Adalja. "It's closing the barn door after the animals have left. If you close schools, they'll all go to the mall together and spread it there."
School closures cause "a definite harm of lost learning," Freiden said. The decision to close schools has to be "a local decision, based on local resources."
"We've not had to close schools. The CDC has not recommended school closings," says Janet Yuhasz, health-services coordinator for Pittsburgh Public Schools. "We stay in communication with our local public-health authorities. We don't have a tremendous amount of risk. Of course everybody is vulnerable. We are monitoring children and staff."
Yuhasz, too, advocates calm and common sense.
"We've had very, very minor activity, a couple kids that were confirmed positive," she says. The children all recovered, she adds.
Meanwhile, on the collegiate level, initiatives include an H1N1 link on the University of Pittsburgh Web that points students toward CDC guidelines for preventing infection, and toward the university's Student Health Service.
Faced with a pandemic, the public seems to tread a fine line between being too scared -- and demanding protective measures that are ultimately ineffective -- or not caring much about the disease at all. The scenario plays out both here and abroad.
For instance, last month at Narita Airport, in Tokyo, disembarking passengers were greeted by immigration officials in face masks, and a box of disposable masks sat at the passport kiosk, with signs in many languages exhorting passengers to help themselves. An elderly woman on the subway fixed a mask onto her face while carrying her groceries home, and a young jazz guitarist wore one loading into a club before a gig. And in Tokyo, hotel elevators bristled with signs, again in several languages, instructing guests to wash their hands and report any symptoms to hotel management.
"In countries like Japan and China, they tend to be much more concerned. They take these things very seriously," says Adalja. "That filters down more to the person on the street level. The Asian countries are more concerned -- they're quarantining people."
In many U.S. cities, by contrast, the sight of someone in a face mask still draws stares.
"I think people have a poor understanding of the science," says Adalja. "You're infected one day before you have symptoms. People think you can wall it away. It's easy to put the walls up -- microorganisms don't realize there's a wall there."