Swine of the Times As Flu Season Begins, Americans Get Ready for H1N1

Dr. Robert Hoffman remembers the flu pandemic of 1957. More important, his immune system might remember it, too.

By now, virtually everyone is aware of H1N1, a form of so-called ‘swine flu’ that has been sweeping the world since the spring, and has doctors and scientists concerned as the U.S. enters its flu season this fall.

It hasn’t mutated into a highly lethal strain — most cases have been mild — and might never make that jump. But one population that’s normally highly susceptible to the flu, senior citizens, has been virtually unaffected by H1N1.

“The elderly don’t seem to be getting desperately ill as you might expect — maybe because this resembles something they saw in their youth,” said Hoffman, chief of Infectious Diseases at Mercy Medical Center. “It doesn’t resemble any recent strains, but it possibly resembles something that was around in the 1950s, and that might provide some immunity for people today. That’s one hypothesis, anyway, but it hasn’t been tested yet.”

That has created two sets of guidelines for vaccinations: one for normal, seasonal flu and one for the H1N1 vaccine, which is not ready for distribution yet but should be within a matter of weeks.

“One difference is in the major groups of people who should be vaccinated,” said Carol Wojnarowski, a registered nurse and manager of Infection Control at Holyoke Medical Center. “Physicians at the CDC [Centers for Disease Control and Prevention] have stated that older people may have some past immunity for this type of virus, and they are not showing the severity of illness right now that, say, pregnant women and young people are showing.”

She put emphasis on the words ‘right now,’ however. “Our season is just beginning to unfold, and though we’ve had the disease in the summer months, it is not clear that the volume or severity of the disease over the summer will be a true picture of how severe the winter is going to look.”

For normal seasonal flu, people over 65 are routinely vaccinated, but with H1N1, the priority group includes not just pregnant women and young people, but those with underlying conditions such as lung disease, as well as health care workers.

“Not only are health care providers at risk because they get exposed to illnesses more frequently,” Hoffman noted, “but if they get sick, who’s going to take care of everyone else?”

The questions remain: How many Americans will need that care this fall? And how serious will their illness be?

Origin of a Strain

Novel influenza A (H1N1) is a new flu virus, originating in a swine population, that first caused illness in Mexico and the U.S. in March and April, and spreads in the same way that regular seasonal influenza viruses spread, mainly through the coughs and sneezes of people who are sick with the virus, or by touching infected objects and then touching one’s nose or mouth. According to the CDC, H1N1 causes a wide range of flu-like symptoms, including fever, cough, sore throat, body aches, headache, chills, and fatigue, while many people also have reported nausea, vomiting and/or diarrhea.

By late April, the U.S. government had declared a public health emergency and began aggressively implementing the nation’s pandemic response plan. By mid-June, all 50 states had reported H1N1 cases, and on June 11, the World Health Organization signaled that a global pandemic was underway.

Importantly, this designation reflects the spread of the disease — more than 70 countries had reported cases — and not necessarily the severity. Throughout the summer (flu season in the southern hemisphere), H1N1 continued to cause illness alongside seasonal influenza, but it had not mutated into something more harmful. And in the U.S., which continued to report the largest number of H1N1 cases worldwide, most people infected with the new virus have recovered without requiring medical treatment.

Over the past few years, scientists’ chief worry when it comes to flu pandemics has been that of avian flu, which has demonstrated a mortality rate of about 60{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} among humans — mainly people in Asia who work very closely with poultry stock. However, no bird-flu strain has adapted to jump freely between humans — a frightening scenario to be sure.

Although strains of swine flu have proven deadly on a widespread level in the past, it’s typically less feared, but much more transmittable between people, which is why only two months separated its first detection last spring and the worldwide pandemic alert. And now, it’s ready to re-emerge as part of flu season in the northern hemisphere.

“In an ordinary year, we’re going to have a sweep of influenza across the world, and typically 30,000 to 35,000 people will die of influenza-related illness, so it’s always an illness of consequence,” Hoffman said. “Typically, it affects the very old and very young; people over 65 and under 5, but especially those over 75 and under 2, are considered at high risk. In the normal course of events, people from the age of 10 or 12 to 50 or 60 might get the flu, but they’ll get over it and move on with their lives.”

But the fact that the elderly are susceptible to common flu strains doesn’t necessarily make it wise to vaccinate them en masse, Hoffman argued, although that has been the pattern.

“Our typical recommendations have been focused on immunizing very old and very young people, and probably more for political than medical reasons,” he said. “The same problems that make the very old susceptible to influenza also comprise the reason why they respond very poorly to vaccines: that is, their immune system isn’t working the way it should. So we get the worst response to the vaccine from people 75, 80, 85 years of age, but that’s who we’ve traditionally been giving the influenza vaccine.”

One issue, he said, is that the elderly vote in higher numbers than any other group, and they tend to mobilize around health issues. On the other hand, “2-year-olds can’t vote, and it’s difficult to get them lined up for shots. We have enough trouble getting them immunized against things we’ve always said they should be immunized against, and then you’re adding another immunization on top of that.”

On the plus side, Hoffman said, the rise of H1N1 might begin to change those immunization patterns because hardly anyone of advanced age is contracting the virus — again, perhaps because of exposure to a cousin strain decades ago — meaning there’s no reason to vaccinate the elderly population against swine flu.

Whether amid the threat of a swine flu pandemic or in a typical flu season, Hoffman suggested that the best way to keep everyone healthy is to thoroughly vaccinate the 2- to 5-year-old set.

“These are children who spend a large part of the day in preschool or nursery school, they get hugs and kisses from big brothers and sisters, mommy and daddy, and especially grandparents,” he said. “It’s pretty easy to see how the problem is generally made worse for the elderly by exposure to these little ones.” Because the vaccine is typically effective on young children, he added, immunizing them would go a long way toward keeping older people healthy because they simply wouldn’t be exposed as frequently.

Viral Media

In the meantime, the CDC recommends that anyone identified with H1N1 should stay home and avoid contact with other people for at least 24 hours after the fever dissipates. That means avoiding normal activities, including work, school, travel, shopping, social outings, and other public gatherings. Besides keeping away from others, the CDC also stresses basic flu hygiene, such as covering coughs and sneezes, disposing of used tissues, and cleaning hands after each cough or sneeze.

People who are well but who have an ill family member at home with H1N1 can go to work as usual, the CDC says, but they should monitor their health daily and take everyday precautions, including washing their hands often with soap and water, especially after they cough or sneeze. Alcohol-based hand cleaners are also effective. If they become ill, they should notify their supervisor and stay home — all this even though H1N1 doesn’t appear to be as serious as first feared.

Of course, “there’s always a fear that this flu might get aggressive and adopt the genetic characteristics of existing flu,” Hoffman said, “but right now, it looks like it merely overwhelms existing flu and outproduces it, and doesn’t combine with any existing influenza virus. It overcomes it and causes a lot of generally mild disease in lots and lots of people. And when both viruses enter a community, only swine flu walks out upright.”

Wojnarowski said it’s still uncertain whether a dangerous mutation is likely.

“They won’t know that until the season unfolds and they capture some viruses by culturing and sending them off to the lab; that’s where it becomes concrete and we start to know these things,” Wojnarowski said. “Right now, we don’t want people to be fearful, but we do want them to take preventative steps that have low personal risk: handwashing, covering your cough, vaccinations. In work environments, wipe off the phone and other high-touch areas with a general housecleaner. That’s enough prevention to help lower the volume of cases.”

She especially recommends getting the necessary shots, especially for high-risk populations. “The injection is a dead virus, and you have approximately 10 days to build up your own antibodies,” Wojnarowski said. “The benefit is, if you get the flu, it may be very, very mild, and if you don’t get the flu, you won’t be a source of transmission for other people.

“That, to me, is huge, and it’s something people don’t realize,” she continued. “People often say, ‘well, I’ll get the flu, and I’ll be sick for a couple of days. So what?’ But when we transmit it to others, it can have serious consequences, especially for pregnant women, infants, people with asthma or any other respiratory challenge, people on immune-suppressive drugs. For them, it can be devastating. If you’re at work with the flu, in eight hours you can give off a lot of virus. So it’s not just about you.”

Hoffman stressed that it’s a good idea for people in high-risk groups to get both vaccines, one available now and the other, by government accounts, sometime in October. But he thinks swine flu will be the peskier issue. “It appears that’s what we’ll be seeing the most of this year.”

Pesky, of course, is a long way from deadly. And only time will tell how much of a problem we’ve got on our hands. Speaking of which, keep washing them.