April 26, 2009

UPDATE #3:
Swine Flu Outbreak - An International Health Emergency

Affiliated Physicians has been closely monitoring the developing Swine Flu outbreak.

This is what we have as of Sunday night:

The influenza virus has exchanged genetic material, as it always does, this time shuffling swine flu, avian flu, and human flu viruses. It has produced an entirely new H1N1 virus-being called "Swine Flu"-which is at the top of the news at this hour.

The virus is being spread from person-to-person. There is no issue of the virus requiring human contact with animals as in the recent Avian flu outbreak, which peaked in 2006-2007.

This virus cannot be contained to an isolated area. In preparation drills imagining an extended Avian flu outbreak, there was hope that a closely monitored rural village in Asia found to harbor a developing virus could be isolated, and the outbreak contained. With serious cases first reported in Mexico just on Thursday, April 23, already 20 swine influenza cases in the U.S. in California, Kansas, Ohio, Texas, and New York City have been confirmed. Canada and New Zealand are reporting swine flu cases. All of these viruses originated from the same genetic combination event, in one location, but the virus has already spread around the world. More cases will be reported, but the speed with which it will spread cannot be determined at this time.

Flu severity in the U.S. has so far been "mild." New York City Health Department officials were contacted when approximately 200 students from St. Francis Prep in Queens fell ill. Some had traveled recently to Mexico for spring break. They would have been infected either during vacation, or more than likely, during air travel. Two hundred students affected means efficient and rapid person-to-person spread. The incubation period of the virus is reported to be typical of influenza, 24 to 48 hours. The number of deaths in Mexico, particularly in young healthy adults, suggests that something different happened there than is happening in the U.S. so far.

"Mild" influenza means few deaths and hospitalizations, but influenza is inherently a significant illness. (High fevers, shaking chills, severe body aches, a deep and painful cough.)

A strain of the H1N1 subtype was responsible for the 1918 Spanish Flu. This is not of medical significance, but we will read about it, and it will make people nervous. In addition, the 1918 Spanish Flu began with a mild wave in springtime, and returned with a ferocious second wave in the fall. There is no predicting whether the current outbreak may follow a similar pattern, but people will read the history and be concerned.

You could make a pretty solid argument that we've already gone from WHO Stage 3 to Stage 5. The definition of a World Health Organization Pandemic Stage 4: "Small clusters of illness with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well-adapted to humans." Stage 5: "Large clusters of illness but human-to-human spread is still localized, suggesting the virus is becoming increasingly adapted to humans, but may not yet be fully transmissible (substantial pandemic risk)." Stage 6: "Increased and sustained transmission in the general population." The CDC has "severity" categories for pandemics, so a widespread Stage 6 event with mild illness and few deaths would be a Category 1 pandemic.

No new flu vaccine manufacturing techniques are available for production on a large scale. This virus arrived too soon. We will see old-fashioned incubation in chicken eggs, but because seed viruses have become available in April, we may have large quantities of vaccine available already by this flu season if everything goes well. This would be separate from the need of the population for regular seasonal flu shots, and it is not known if our industrial capacity is capable of doing both.

If there is a mild first wave there will be months for companies to try to prepare for a possibly severe second wave. But we have to expect the see panicked people with flu-like illnesses in our offices and with corporate clients from Day 1.

The new H1N1 strain is sensitive to our anti-viral drugs.

In summary form:

What we know:

The influenza virus has exchanged genetic material.

Spread human-to-human
Not geographically containable
Cases in the U.S so far are mild
Something different may be happening in Mexico, where there are many deaths
Not resistant to Tamiflu or Relenza

What we may assume:

Speed with which it will spread is not knowable, but further spread is inevitable
WHO Pandemic Stage should soon be raised to 4. A Stage 5 is easily accomplished.
Vaccine may be available in large quantity by autumn
The 1918 flu had a mild spring first wave followed by a ferocious autumn. We will be reminded of this repeatedly
Good chance there will be time for companies to prepare before it is truly dangerous, but we will see people in the office (and corporate clients) panicking with flu-like illness from right now

This is a developing story and one that Affiliated Physicians will monitor closely. It is important for companies to:

Communicate to their employees
Review and Update their Pandemic Plans
Encourage the use of proper hygiene
Review how social distancing and "work from home" capabilities would be implemented
Review the decision to purchase/distribute antiviral medications.

Some good links:

Affiliated Physicians will send updates as necessary.

For more information on Affiliated Physicians' Pandemic Flu services, visit us online at www.affiliatedphysicians.net