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Summit focuses on H1N1’s second wave: Will pandemic peak before vaccine arrives?

“The bottom line is it is here, and it is coming, and it is coming fast,” Dr. Michael Osterholm told attendees at the Minnesota Department of Health conference.

Given our state’s topography, you don’t hear the word “summit” used in Minnesota unless you’re talking about beer.

But the Minnesota Department of Health (MDH) held a summit Monday to present an update on the H1N1 novel influenza virus. More than 600 public and private health officials, hospital and clinic staff, and school and business representatives packed the Earle Brown Heritage Center in Brooklyn Center to talk about a virus that has shocked public health officials with how quickly it has spread.

The final step for any influenza virus hoping to reach pandemic status is developing the ability to be easily transferred from one human to another. The novel H1N1 virus, formerly known as the swine flu, has got that part down. It spent the last several months tearing through the southern hemisphere with — pardon the pun — breathtaking speed.

As Ruth Lynfield, MD, state epidemiologist and medical director for infectious diseases at MDH, pointed out to conference-goers, it took only six to eight weeks for H1N1 to spread across the world this spring, whereas it took the Spanish influenza of 1918 four to six months to cover the globe. But that doesn’t mean that the H1N1 virus is inherently more contagious than the Spanish flu, since H1N1’s record-setting pace has to be taken in the context of changes in human travel. Ninety years later we get around, and we get around fast.

Modern transportation: one speedy getaway car
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, was the summit’s most prominent speaker. As a nationally and internationally recognized expert on emerging infections, Osterholm is quite familiar with how high-speed travel has changed the dynamics of highly contagious infections such as influenza or SARS. Modern transportation doesn’t cause the genetic mutations required to foster a breakout virus, but it does provide one speedy getaway car.

Dr. Michael Osterholm
Dr. Michael Osterholm

“Look, by the time we had clearly identified Mexico and H1N1 as the source of this disease, we already had 90,000 individual arrivals from Mexico at MSP,” Osterholm told me during a session break. By that time, the virus had unknowingly spread to at least 30 other countries.

In fact, speed was perhaps the major theme of Osterholm’s presentation.

“The bottom line is it is here, and it is coming, and it is coming fast,” Osterholm told conference attendees. After the virus’ initial appearance in the United States this spring, H1N1 activity trickled off over the summer, just as seasonal influenza typically does. But the virus came back early and with a vengeance in southeastern states, where mid-August school startups provided the necessary critical infective mass. Universities scattered throughout the country have been experiencing outbreaks as well. And what began in the schools is now out in the community, what Osterholm described as “a rolling ball going down the hill for all of us.”

Arriving early, peaking fast
By now the H1N1 virus has established that it is going to follow its own rules. Seasonal influenza usually peaks in late February or early March, but Osterholm noted that current, mid-September flu incidence rates are already at last year’s midwinter peak. He believes that within the next month, H1N1 infection rates will exceed the peaks of the very active 2007-08 flu season. “I honestly believe that the next six to eight weeks will be the peak. By early to mid-October I think we’re going to see the peak in the Northern Hemisphere.”

Mid-October? Isn’t that when the vaccine is supposed to begin arriving? Yes, and that’s what has Osterholm worried.

“I still believe, and I wish I was wrong, and I hope everybody proves me wrong on this — it would be the most wonderful night of my life — but I’m afraid too little vaccine is going to get here before the peak really hits.” Although he expressed absolute confidence in the state’s ability to dispense the vaccine when it arrives, “It all depends on when they get it, and how much,” Osterholm explained. “This train has left the station, and it’s moving and gaining speed, and I’m afraid right now the virus has the upper hand.”

The somber news continued. “One of the major misconceptions of the situation is that this is a mild pandemic,” Osterholm pointed out. “In fact it is a very mild illness for the vast majority of those who get it, maybe well into 98-99 percent range. But for that other 1 percent, this disease can be hell,” Osterholm cautioned. “So it’s a bit of a difficult message here, because for a vast majority they’re going to do just fine. But for some people, this is just going to be tough.”

Demographics are different
For H1N1, “some people” will most likely be those under the age of 50. That’s the opposite of seasonal influenza, which is the hardest on people over the age of 65. About 36,000 Americans die of the flu each winter, and though those are real numbers, real people, as Osterholm explained, “Many of these people were elderly and frail and on the edge anyway, and what’s happened is that flu takes them over.”

“But when we’re talking about deaths today,” Osterholm continued, “we’re talking about many fewer deaths, but we’re talking about deaths hitting basically that younger population, largely under that age 50, which shouldn’t be dying. Pregnant women shouldn’t die [of the flu].” For those looking at H1N1’s lower mortality rate, Osterholm points out who it is that is dying and soberly states, “This is a whole different ball game.”

But Osterholm did bring some good news. The virus remains genetically unaltered, non-mutated since it first emerged in Mexico. The vaccine is coming, and it should be safe and effective. And we live in Minnesota.

Yes, that’s good news. “If anything like H1N1 has to happen, I can’t imagine any other place in the world it’s better to be to respond to it than to live in Minnesota,” Osterholm proclaimed at the beginning of his presentation. “I can tell you from all the travel and work that we [the Center for Infectious Disease Research and Policy] do, we’re as prepared, if not better prepared, than any other place in the world.”

Preparing for H1N1’s second wave
As prepared as Minnesota is, Osterholm cautioned that we still have a lot work to do. That’s what the bulk of the conference was about: encouraging everyone involved in health care, from hospitals to individuals, from nursing homes to preschool, to be prepared. Dr. John Hick, Hennepin County Medical Center’s medical director for bioterrorism and disaster preparedness, encouraged health-care deliverers to take serious stock of what resources would be most stretched by the pandemic. Based on what’s happened in areas of the country where the virus is now active, the heaviest burden will fall on outpatient care — emergency rooms, urgent cares, clinics — and contingency plans need to be made. That includes the possibility of setting up free-standing flu clinics, both to deal with the volume and isolate potential flu cases from those with other serious medical problems.

As Hick and multiple other presenters emphasized, public education will be critical to keeping the mildly ill (again, that’s the vast majority of those who will be infected) isolated at home, rather than contagious at work or school. That will also keep them from clogging up the medical system, delaying care for the minority of patients who will really need it. Public-health experts from MDH spoke about the need to encourage individuals at high risk for a serious H1N1 infection to make a plan of action now, including in some cases obtaining a prescription for anti-flu medication that can be filled quickly if the need arises.

Businesses of all types, not just health-care organizations, need to make contingency plans as well. According to Osterholm, flu-related absenteeism has run as high as 35 percent for some manufacturers in Southeast Asia, and so Minnesota businesses need to make plans for supply-chain disruptions and the possibility of similar work-force losses. Dr. Joshua Riff, medical director of clinics for the Target Corp., described how complex it is for any retailer to try to anticipate the logistical challenges of a pandemic that is sure to arrive … sometime … but when? And businesses like Target could be pulled in several opposing directions during the pandemic, with a work force potentially diminished by illness but also coupled with an increased demand for over-the-counter and prescription medications, as well as for certain food staples.

Planning for significant absenteeism
Cathy Hockert, continuity of government planning director for the state of Minnesota, described efforts state government is making to prioritize services under the likelihood of significant absenteeism. That includes setting up a system to identify which employees are sick, and figuring out ahead of time how badly each employee would be missed, and if someone can be cross-trained to fill in that job.

As complex and fluid as the current pandemic situation is (or may become), the conference’s lecturers all had a clear message: H1N1 is coming, and though we can’t stop it, there are a lot of simple things we can do to lessen its severity. We can slow its spread by practicing good hygiene and by staying home from work and school at the first sign of illness. Slowing the virus’ spread may help us avoid a peak of activity that could easily overwhelm our health-care system, and it might also buy us some time while we wait for the vaccine to arrive. Speakers encouraged a statewide consciousness that combines thoughtful concern and due diligence, not paranoia and hysteria. That includes continuing to do public things, unless the public thing has been canceled.

“I’ve already received calls from NFL professional football teams, college teams, etc., about what to do if they start seeing a key number of players becoming infected,” Osterholm recalled. He thinks that in the next month or two it’s inevitable that a few games will be canceled, stoking public paranoia. “And I worry that the public may interpret this to mean that somehow public health [officials] are saying, ‘Stay out of public places completely.’ ”

Osterholm was clear that that is definitely not the message. “If you’re well, go to the game and have a good time. If the game is canceled, it’s being canceled solely on the basis they just can’t field a team, or another team doesn’t want to go play and get infected.”

I get the point, but professional sports being canceled? That gives me the willies. What next, a Hollywood quarantine?

For more information, go to MDH’s H1N1 website and the federal Centers for Disease Control and Prevention’s site.

Dr. Craig Bowron is a Twin Cities internist and writer who reports on medical topics for MinnPost. He can be reached at cbowron [at] minnpost [dot] com.