2009 swine flu pandemic

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The 2009 flu pandemic is a global outbreak of a new strain of an influenza A virus subtype H1N1, referred to as the "novel H1N1"[1] first identified in April 2009, and commonly called "swine flu". It is thought to be a reassortment of four known strains of influenza A virus[2]: one endemic in (normally infecting) humans, one endemic in birds, and two endemic in pigs (swine). Transmission of the new strain is human-to-human, with cooked pork products safe to eat as the virus cannot be transmitted by eating foods.

The outbreak began in Mexico, with evidence that Mexico was already in the midst of an epidemic for months before the outbreak was recognized. Soon after, its government closed down most of Mexico City's public and private offices and facilities to help contain the spread. In early June, as the virus spread globally, the World Health Organization (WHO) declared the outbreak to be a pandemic, but also noted that most illnesses were of moderate severity. The virus has since spread to the Southern Hemisphere which entered its winter flu season, and to many less developed countries with limited healthcare systems. Because the virus was spreading with unprecedented speed, and many clinics were overwhelmed testing and treating patients, WHO stopped requiring countries to report all cases, but is still monitoring unusually large outbreaks.[3][4]

The virus typically spread via coughing, sneezing or touching contaminated surfaces and then touching the nose or mouth. Symptoms, which could last up to a week, were similar to those of seasonal flu, and may have included fever, sneezes, sore throat, coughs, headache, and muscle or joint pains. The U.S. Centers for Disease Control and Prevention (CDC) noted that although this was a very serious virus, cases worldwide were usually mild, and most hospitalizations and deaths had been of persons that also had underlying conditions such as asthma, diabetes, obesity, heart disease, or a weakened immune system.[5] As of September 2009 the CDC estimated that 1 million people in the U.S. have been infected with 600 deaths.[6] As the virus spreads easily between people, through the air or surface contact, those who get the flu are recommended to stay home from school or work and avoid crowds to avoid spreading the infection further. Wearing facial masks is of limited benefit as they are designed for industrial use and do not filter out viral or other biological agents.[7]

In an attempt to slow the spread of the illness, a number of countries, especially in Asia, quarantined airline passengers with flu symptoms, while some also pre-screened passengers. As of August 2009, WHO did not expect to have a full vaccine before the end of 2009, and vaccines available sooner would be limited and given first to healthcare workers, pregnant women, and other higher risk groups. Two or three injections would be required for maximum immunity from both the swine flu and seasonal flu. There was also concern if the new virus mutated further, it could become more virulent and less susceptible to any new vaccine.

Historical context

Annual influenza epidemics are estimated to affect 5–15% of the global population. Although most cases are mild, this still causes severe illness in 3–5 million people and around 250,000–500,000 deaths worldwide. In industrialized countries severe illness and deaths occur mainly in the high-risk populations of infants, the elderly, and chronically ill patients.[8]

In addition to these annual epidemics, Influenza A virus strains caused three major global epidemics during the 20th century: the Spanish flu in 1918, Asian flu in 1957 and Hong Kong flu in 1968–69. These pandemics were caused by strains of Influenza A virus that had undergone major genetic changes and for which the population did not possess significant immunity.[8][9]

The great majority of deaths in the 1918 flu pandemic were the result of secondary bacterial pneumonia. The influenza virus damaged the lining of bronchial tubes and lungs of victims, allowing common bacteria from the nose and throat to infect their lungs. Subsequent pandemics have had many fewer fatalities due to the development of antibiotic medicines that can treat pneumonia.[10]

20th century flu pandemics
Pandemic Year Influenza A virus
subtype
People infected
(approx)
Deaths
(est.)
Case fatality rate
1918 flu pandemic 1918–19 H1N1[11][12] 0.5 to 1 billion (near 50%) 20 to 100 million[13][14][15] >2.5%[16]
Asian flu 1956–58 H2N2[11] 2 million[15] <0.1% ?[16]
Hong Kong flu 1968–69 H3N2[11] 1 million[15] <0.1%[16]
Seasonal flu Every year mainly A/H3N2, A/H1N1, and B 5–15% (340 million – 1 billion)[17] 250,000–500,000 per year[8] <0.05%
      Not a pandemic, but listed to compare the several flu strains endemic in humans which produce seasonal flu with the rare new strain that results in a flu pandemic

The influenza virus has also caused several pandemic threats over the past century, including the pseudo-pandemic of 1947, the 1976 swine flu outbreak and the 1977 Russian flu, all caused by the H1N1 subtype.[9] The world has been at an increased level of alert since the SARS epidemic in Southeast Asia (caused by the SARS coronavirus).[18] The level of preparedness was further increased and sustained with the advent of the H5N1 bird flu outbreaks because of H5N1's high fatality rate, although the strains currently prevalent have limited human-to-human transmission (anthroponotic) capability, or epidemicity.[11][19]

People who have contracted flu prior to 1957 may have some immunity. A May 20, 2009 New York Times article stated: “Tests on blood serum from older people showed that they had antibodies that attacked the new virus, Dr. Daniel Jernigan, chief flu epidemiologist at the Centers for Disease Control and Prevention, said in a telephone news conference. That does not mean that everyone over 52 is immune, since some Americans and Mexicans older than that have died of the new flu.”[20]

Initial outbreaks

Semi-logarithmic plot of laboratory-confirmed A(H1N1) influenza cases in 2009 according to WHO reports.[21]

It is not known where the virus originated.[22][23] Analysis has suggested that the H1N1 strain responsible for the current outbreak first evolved around September 2008 and circulated in the human population for several months before the first cases were identified as being due to a new strain.[22][24][25]

Mexico

The virus was first reported in two U.S. children in March, but health officials have said that it apparently infected people as early as last January in Mexico.[26] The outbreak was first detected in Mexico City on March 18, 2009,[27] Immediately after the outbreak was officially announced, Mexico requested material support from the U.S., and within days of the outbreak Mexico City was "effectively shut down." Some countries canceled flights to Mexico while others halted trade. Calls to close the border to contain the spread were rejected.

Some experts today assume that Mexico already had hundreds of thousands, and possibly millions, of cases before the outbreak was officially recognized, and was therefore in the midst of a "silent epidemic".[28] As a result, Mexico was reporting only the most serious cases, possibly leading to a skewed initial estimate of the case fatality rate."[27]

United States

The new strain was first diagnosed in two children, neither of whom had been in contact with pigs, by the CDC, first on April 14, 2009 in San Diego County, California and a few days later in nearby Imperial County, California[29] (it was not identified as a new strain in Mexico until 24 April[30]).

Response

  Deaths
  Confirmed cases
See also: H1N1 live map, WHO updates

The Public Health Agency of Canada announced that their National Microbiology Laboratory (NML) had mapped the genetic code of the swine flu virus, the first time that was done.[31]

U.S officials noted that six years of worrying about H5N1 avian flu did much to prepare for the current swine flu outbreak, noting that after H5N1 emerged in Asia, ultimately killing about 60 percent of the few hundred people infected by it over the years, many countries took steps to try to prevent any similar crisis from spreading further.[32][33] The CDC would now use the current lull to take stock of the United States's response to the new H1N1 flu and attempt to patch any gaps in the public health safety net before flu season starts this autumn.[34]

Pigs and food safety

The novel H1N1 virus is a type of swine influenza, derived originally from a strain that lived in pigs and this origin gave rise to the common name of "swine flu", largely used today by mass media. Despite this origin, however, the current strain is transmitted between people and not from swine.[35] The U.S. agriculture secretary has made it clear that despite its common name, "swine flu," there is no risk in eating cooked pork products and the virus has not been found in American hogs.[36]

Virus characteristics

The virus was a novel strain of influenza which contained genes from five different flu viruses. Originally thought to have originated in Mexico, experts[who?] believed that it most likely came from pigs in Asia and circulated for years before infecting humans. As a result, some virologists[who?] called for additional surveillance of the pork industry.[37]

In July 2009 the CDC noted that most infections were mild, similar to seasonal flu, recovery tended to be fairly quick, and deaths to date had been only a tiny fraction of the amount of people who die every year from seasonal flu.[38] The new virus strain was reported to be "unstable", capable of mutating into a more virulent strain. The CDC noted that the 1918 flu epidemic which killed hundreds of thousands in the United States was preceded by a wave of mild cases in the spring, followed by more deadly waves in the autumn.[39] Researchers from University of Maryland mixed swine flu and seasonal flu and concluded that the Swine flu was unlikely to get more lethal.[40]

Symptoms and severity

CDC's CAPT Dr. Joe Bresee describes symptoms.

The symptoms of swine flu are similar to other influenzas, and may include a fever, coughing, headaches, pain in the muscles or joints, sore throat, chills, fatigue and runny nose. Diarrhea, vomiting and neurological problems were also reported in some cases.[5][41] People at higher risk of serious complications include people age 65 and older, children younger than 5 years old, pregnant women, and people of any age with underlying medical conditions, such as asthma, diabetes, obesity, heart disease, or a weakened immune system (e.g., taking immunosuppressive medications or infected with HIV).[42] Most hospitalizations in the U.S. were people with such underlying conditions, according to the CDC.[43]

As with the seasonal flu, certain symptoms may have required emergency medical attention. In children signs of respiratory distress included blue lips and skin, dehydration, rapid breathing, excessive sleeping, seizures[44] and significant irritability that includes a lack of desire to be held. In adults, shortness of breath, pain in the chest or abdomen, sudden dizziness or confusion may have indicated the need for emergency care. In both children and adults, persistent vomiting or the return of flu-like symptoms that include a fever and cough may have required medical attention.[41]

Some experts suggest that people with "underlying conditions" who come down with flu symptoms should consult their doctors first before visiting an "emergency room full of sick people may actually put them in more danger." This was especially true of pregnant women. [42]

Flu infections can also cause pneumonia, a life-threatening illness. Reports of deaths among healthy young people during the first weeks of the 2009 flu pandemic were attributed to pneumonia.[45][46]

Prevention

In late August 2009, WHO predicted a large rise in swine flu cases during the remainder of 2009 and into 2010. WHO advised that there would be a period of further global spread of the virus, and most countries could see swine flu cases double every three to four days for several months until peak transmission was reached. The accelerated spread of swine flu posed the greatest threat in developing countries, placing underequipped and underfunded health systems under severe strain.[47]

Although most flu symptoms are mild and last only a few days without treatment, health officials worldwide were also concerned because the virus was new and could easily mutate and become more virulent. To combat the virus, WHO and the U.S. government geared up for a massive vaccination campaign in late 2009, one not seen since Jonas Salk discovered the polio vaccine in 1955.[48] Officials also urged communities, businesses and individuals to make contingency plans for possible school closures, multiple employee absences for illness, surges of patients in hospitals and other effects of potentially widespread outbreaks.[49]

The Mayo Clinic suggested personal measures to avoid seasonal flu infection were applicable to the 2009 pandemic: vaccination when available, thorough and frequent hand-washing, a balanced diet with fresh fruits and vegetables, whole grains, and lean protein, sufficient sleep, regular exercise, and avoiding crowds.[50] The leading health agencies stressed that eating properly cooked pork or other food products derived from pigs was safe.[51]

There is general uncertainty among health professionals about the value of wearing either facial masks or more expensive respirators to prevent infection. Some experts stated that "masks may give people a false sense of security" and shouldn't replace other precautions. Masks may benefit people in close contact with infected persons but it was unknown whether they prevented swine flu infection.[7] According to mask manufacturer 3M, masks will filter out particles in industrial settings, but "there are no established exposure limits for biological agents such as swine flu virus."[7]

A survey of Americans done in late June by the Harvard School of Public Health found that roughly 90 percent said they would be willing to avoid shopping malls, movie theaters, public transportation and worship services for more than two weeks if health officials told them to. It also found that parents were worried about closures of schools or day care centers, with 43 percent saying they would lose pay or have money problems if they had to stay home a week or more because they were sick or had to care for someone.[52] In the U.K. the government established a National Pandemic Flu Service with a hotline and website, enabling persons with symptoms to get advice or obtain drugs without first getting a prescription from a doctor.[53]

Travel precautions

Chinese airline checking passengers for fever

WHO stated that containment was not a feasible option and that countries should focus on mitigating the effect of the virus. It did not recommend closing borders or restricting travel.[54]

Schools

In California, school districts and universities are on alert and working with health officials to launch education campaigns. Many planned to stockpile medical supplies and discuss worst-case scenarios, including plans to provide lessons and meals for low-income children in case elementary and secondary schools close. University of California campuses are already stockpiling supplies, from paper masks and hand sanitizer to food and water, and are considering screening students for fever when they check into dorms.[55] The CDC has also advised that schools set aside a room for people developing flu-like symptoms while they wait to go home and that surgical masks be used for ill students or staff and those caring for them.[56] To help prepare for contingencies, some medical experts in the U.S. suggest that every county should create an "influenza action team" to be run by the local health department, parents, and school administrators.[57]

The early days of the swine flu outbreak led to numerous school closures in a number of countries. However, as the virus was milder than initially feared, schools reopened and the closures stopped. Among countries that reported school closures were the United States, India, Australia, Hong Kong, Mexico, Guatemala, Argentina, Brazil, and Costa Rica.

Rather then close schools, the CDC recommends that students and school workers with flu symptoms should stay home for either seven days, or until 24 hours after symptoms subside, whichever is longer.[58] If the outbreak suddenly turns severe, additional measures such as school closings would then be considered.[56]

Colleges and universities

In the U.S. the Department of Health and Human Services (HHS), Department of Education (ED) and the Centers for Disease Control and Prevention (CDC) have published new guidelines along with a "Toolkit" for Institutions of Higher Education (IHE) to plan for and respond to the upcoming flu season. Government officials are especially concerned because the virus appears to disproportionately affect young people between ages 6 months to 24 years of age, making them one of the top priority groups when it comes to the new H1N1 vaccine.

The new guidelines provide a list of strategies to keep learning facilities open while reducing exposure of students, faculty, and staff. The new guidelines state that the most important actions are to encourage and facilitate good hand washing and covering coughs and sneezes, flu vaccinations for people at risk; and to separate sick people from healthy people as soon as possible. [59]

The CDC recommends that colleges should consider suspending classes this fall if the virus begins to cause severe illness in a significantly larger share of students than last spring. They have also urged schools to suspend any rules, including penalizing late papers or missed classes, or requiring a doctor's note, to prevent students from venturing out while ill.[60]

Airlines

The president of the Association of Flight Attendants told members of a U.S. Congressional subcommittee that all flight attendants should be given training in how to handle a person with flu and help in communicating to passengers the importance of keeping clean hands. She also said that flight attendants need to be provided gloves and facemasks to deal with flu-stricken passengers. Other medical experts add that airlines should also ensure that passenger cabins are always properly ventilated, including during any flight delays in which passengers are kept aboard the plane. But they also add that although the aviation industry in the U.S., along with the CDC, have tried to reassure passengers that air travel is safe, they have so far done too little to try to limit infection risks.[61]

U.S. airlines had made no major changes as of the beginning of June 2009, but continued standing practices that included looking for passengers with symptoms of flu, measles or other infections, and relying on in-flight air filters to ensure that aircraft were sanitized. Masks were not generally provided by airlines and the CDC did not recommended that airline crews wear them. Some non-U.S. airlines, including Asian carriers, stepped up cabin cleaning, installed state-of-the-art air filters and allowed in-flight staff to wear face masks.[62]

Workplace

The U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), with input from the U.S. Department of Homeland Security (DHS), has developed updated guidance for employers of all sizes to use as they develop or review and update plans to respond to 2009 H1N1 influenza now and during the upcoming fall and winter influenza season.

These guidelines, posted on their website along with a video, recommend that all employers balance a variety of objectives when determining how best to decrease the spread of influenza and lower the impact of influenza in the workplace. It states that employers should consider and communicate their objectives, which may include reducing transmission among staff, protecting people who are at increased risk of influenza related complications from getting infected with influenza, maintaining business operations, and minimizing adverse effects on other entities in their supply chains. [63]

The CDC estimates that as many as 40% of the workforce, in a worst-case scenario, might be unable to work at the peak of the pandemic due to the need for many healthy adults to stay home and care for an ill family member,[64] and advising that individuals should have have steps in place should a workplace close down or a situation arise that requires working from home.[65]

The CDC futher advises that persons in the workplace should stay home sick for 7 days after getting the flu or 24 hours after symptoms end, whichever is longer.

In the UK, the HSE has also issued general guidance for employers.[66]

Quarantines

Some countries, such as China, began quarantining foreign visitors suspected of having or being in contact with others who may have been infected. In May the Chinese government confined 21 U.S. students and three teachers to their hotel rooms.[67] As a result, the U.S. State Department issued a travel alert about China's anti-flu measures and was warning travelers about traveling to China if ill.

Other governments have taken or threatened similar quarantine actions: In Hong Kong, an entire hotel was quarantined with 240 guests; Australia ordered a cruise ship with 2000 passengers to stay at sea because of a swine flu threat; [68] Egyptians who went on the annual Muslim pilgrimage to Mecca risked being quarantined upon their return.[69] Russia and Taiwan said they would quarantine visitors showing symptoms; Japan quarantined 47 airline passengers in a hotel for a week; India ordered 231 passengers to receive antiviral drugs. Some governments, including India and China, have also suggested pre-screening "outbound" passengers from countries that are thought to have a high rate of infection.

Vaccination

WHO does not expect the swine flu vaccine to be widely available until the end of 2009. In the U.S. initial quantities of vaccine will become available in mid-October and the CDC recommends that the first doses should go to priority groups such as pregnant women, people who live with or care for babies under six months old, children six months to four years old and health-care workers. Although the seasonal flu vaccine provides little or no protection against H1N1 swine flu, health experts recommend immunization to help prevent people from being infected with both at once. Two injections will be required three weeks apart for the swine flu and a third will be needed for seasonal flu to provide maximum immunity.[70]

Treatment

Children

The experts agree that children who are sick should be kept home, especially if they're running flu-like symptoms such as high fever, vomiting or diarrhea. They should also be kept away from other children. While most experts suggest seeking medical care if a child becomes sick, they also stress not to take children with flu-like symptoms to the emergency department. "That's the worst thing. They may not have swine flu but they could get it [there]," one expert stated. Instead of rushing to the emergency department, "people need to call their physicians or call a hotline." They also state that any child who has been sick should be fever-free for at least 24 hours (without the aid of medications) before returning to school.[56]

Home treatment remedies

The Mayo Clinic and Medline list a number of ways to help ease symptoms, including adequate liquid intake and rest, soup to ease congestion, and over-the-counter drugs to relieve pain. Aspirin, for instance, "is very effective for treating fever in adults" [71] although in children and adolescents, aspirin is not usually given due to the risk of Reye's syndrome.[72] While over-the-counter drugs relieve symptoms, they do not kill the virus.[73] Most patients were expected to recover without medical attention, although those with pre-existing or underlying medical conditions were more prone to complications.[74]

In one article, Health magazine advised readers not to try to prevent or treat influenza, colds, or sinus problems by taking antibiotics, large doses of vitamins and minerals (such as vitamin C or zinc), or by taking herbal remedies such as echinacea.[75]

Antiviral drugs

See also: CDC guidelines on prescribing antivirals

According to the CDC, antiviral drugs could be given to treat those who become severely ill, two of which are recommended for swine flu symptoms: oseltamivir (Tamiflu) and zanamivir (Relenza). To be most useful, they were to be given within two days of showing symptoms and "may shorten the illness by a day or so," according to the Mayo Clinic. To help avoid shortages of these drugs, the CDC recommended Tamiflu treatment primarily for people hospitalized with swine flu; people at risk of serious flu complications due to underlying medical conditions; and patients at risk of serious flu complications. WHO likewise recommended that Tamiflu only be given to particularly vulnerable people and noted that healthy people who catch mild to moderate cases of swine flu didn't need the drug at all.[76]

The CDC warned that the indiscriminate use of antiviral medications to prevent and treat influenza could ease the way for drug-resistant strains to emerge which would make the fight against the pandemic that much harder. In addition, a British report found that people often failed to complete a full course of the drug which encouraged resistance.

Both medications can cause side effects, including lightheadedness, nausea, vomiting, loss of appetite and trouble breathing and it was recommended that patients discuss possible side effects with their doctor before starting any antiviral medication. Children may be at increased risk of self-injury and confusion after taking Tamiflu.[71] WHO warns against buying anti-viral medications from online sources, estimating that half the drugs sold by online pharmacies without a physical address are counterfeit.[77]

Data reporting and accuracy

The initial outbreak received a week of near-constant media attention. Epidemiologists cautioned that the number of cases reported in the early days of an outbreak can be very inaccurate and deceptive due to several causes, among them selection bias, media bias, and incorrect reporting by governments. Inaccuracies could also be caused by authorities in different countries looking at differing population groups. Furthermore, countries with poor health care systems and older laboratory facilities may take longer to identify or report cases.[78]

The last WHO update, issued on July 6, showed 94,512 confirmed cases in 122 countries, with 429 deaths. Many epidemiologists have pointed out that, in reality, millions of people have had swine flu, usually in a mild form, so the numbers of laboratory-confirmed cases were actually meaningless.[4] Partly as a result, on July 16, WHO announced that it "will no longer issue the global tables showing the numbers of confirmed cases for all countries". [3]

Nomenclature

The initial outbreak was called the "H1N1 influenza." In July 2009 WHO experts changed the name to pandemic H1N1/09 virus to distinguish it from the current seasonal H1N1 virus, and as of August, 2009, the CDC began referring to it as the novel H1N1 virus.

See also

References

Sources and notes

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