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Experts Say Prepare For Possible H1n1 Flu Resurgence In Fall
Officials monitoring the new strain of H1N1 influenza aren’t just looking south of the border to Mexico, where the outbreak of the so-called swine flu was first identified. They also are looking south of the equator.
That’s because flu season is just beginning in the Southern Hemisphere, and how H1N1 spreads there — and whether it exchanges genetic material with another, perhaps more dangerous, virus — could foreshadow what might happen next fall in the Northern Hemisphere, Richard Besser, MD, said at a briefing this month.
“We’ll be looking at the virus to see [if it] has mutated into something more severe,” said Besser, acting director of the U.S. Centers for Disease Control and Prevention. “Has it picked up any of the factors that we know have been associated with severe disease in the past? Has it developed any resistance? What is happening in terms of the age distribution of who is getting sick?”
Possible Vaccine
Officials also are laying groundwork for possible production of a vaccine against the new virus. Five different virus isolates have been sent to eight labs around the world so researchers can identify which would be the best vaccine candidate and to grow the virus for vaccine development and testing. At the same time, manufacture of seasonal flu vaccine is being accelerated to clear the way for production of any new vaccine, says Health and Human Services Secretary Kathleen Sebelius.
A spokesman for one of the manufacturers, Christopher Bona of Baxter International in Deerfield, Ill., says if the strain is similar to other pandemic strains the company has worked with, it would probably take 12 to 16 weeks to manufacture a vaccine.
But even when production is begun in earnest, availability wouldn’t be widespread at first. “There are capacity limitations,” says Victoria J. Davey, RN, MPH, deputy chief officer for public health and environmental hazards at the Department of Veteran Affairs in Washington, D.C. She says in the case of a novel virus, the goal is to have a vaccination for everyone — millions of doses just for the U.S. “That takes some time.”
If a new vaccine is deemed necessary, officials will work with scientists to determine how people get it and who should get it first. Those decisions won’t be made until there is a vaccine ready to go, Sebelius says.
However, HHS and the Department of Homeland Security have developed pandemic flu guidelines that prioritize vaccination administration in the event of a severe, moderate, or mild pandemic. Under the 2008 guidelines, top priority for vaccination at any severity of pandemic is assigned to public health personnel; healthcare providers in inpatient, outpatient, home, and long-term-care settings; law enforcement, emergency medical service, and fire department personnel; manufacturers of pandemic vaccine and anti-viral medicines; pregnant women; and infants and toddlers.
Davey warns that even if the current H1N1 epidemic seems mild, or if the virus wanes this summer, nurses should stay focused on preparedness.
“There’s so much that we don’t know about H1N1,” says Davey. “We have to view this period as time we need to take to prepare more.”
Davey is a doctoral candidate at the Uniformed Services University of the Health Sciences in Maryland. Her dissertation focuses on epidemic modeling, especially of pandemic flu. She says two circumstances particularly concern her. First, a flu virus’s genetic makeup can change quickly. Second, she said, “We could be very, very early in this epidemic.”
Noting that she is not speaking on behalf of the VA, Davey cites several scenarios that could develop. For instance, there could be a sharp up-slope in the curve representing the epidemic, although right now it’s fairly flat. “I’ve seen a model where the curve goes up exponentially and we have a peak of a flu pandemic by midsummer,” she says, adding that while flu viruses in North America generally don’t thrive in heat and humidity, there have been summer outbreaks, including the 1918-19 flu pandemic that killed an estimated 50 million people worldwide.
Another scenario is that summer will be quiet, but by fall, after schools reopen, the virus resurges, possibly changed. “It might be followed by normal seasonal flu, which could be very, very hard on us,” she says. Seasonal flu causes about 200,000 hospitalizations and 36,000 deaths in the U.S. annually.
The third scenario, one she doubts will happen, is this all simply goes away. “Historically, pandemics of the 20th century peter out for a year or two, then come back as either the same or a better-adapted, more-pathogenic virus,” she says.
Growing Knowledge
A report published May 7 by The New England Journal of Medicine, examining more than 600 early cases, indicates that unlike seasonal flu, the H1N1 cases so far have been concentrated in patients younger than 18, and a higher percentage of patients are experiencing vomiting and diarrhea than with seasonal flu.
Severe complications have been noted among pregnant women. Consequently, the CDC is urging use of the anti-viral medicines Relenza and Tamiflu, which are neuraminidase inhibitors, to treat H1N1 (as well as seasonal flu) in pregnant women. “Experts who have looked into this situation really strongly say that the benefits of using antiviral drugs to treat influenza in a pregnant woman outweigh the theoretical concerns about the drugs,” says Anne Schuchat, MD, of the CDC, adding pregnant women also are strongly advised to receive the seasonal flu vaccine. The World Health Organization notes the new virus does not appear to be sensitive to another class of anti-viral medications, the adamantanes.
The FDA asks that facilities storing Tamiflu and Relenza that are near or past expiration dates consider keeping the medicines while HHS evaluates whether they are needed. Organizations are urged to contact the FDA’s Emergency Operations Center at 301-443-1240 with information on the amount of the anti-virals they have near or past expiration.
A report released May 11 by the journal Science indicates the new virus, as it occurred in Mexico, was not as severe or transmissible as that of the 1918 pandemic; rather, with a case fatality ratio estimated at 0.4%, it was more the magnitude of the 1957-58 flu pandemic. “But remember that in 1918 the first wave was fairly mild, and it was the next wave that was so devastating,” Schuchat cautions. “We are definitely taking this very seriously.”
Karen Patterson is a freelance writer.
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