Resurging Swine-Flu Pandemic Expected to Hit Locally by Thanksgiving

TELLURIDE – That flu shot we deliberate about getting every fall has morphed into an increasingly complex enterprise.

This year, health officials recommend that everyone in the high-risk category for the swine flu that surfaced in April in central Mexico (and has, to date, infected 42,000 Americans, 300 of whom have died) get three shots – before the flu season is officially upon us.

Locally, San Miguel County Health Officer David Homer, M.D., said of the 2009-2010 flu season: “Thanksgiving is probably when it comes to us.”

Each year, in the United States, on average, 36,000 people die from flu-related complications (with at least another 200,000 people hospitalized due to flu-related causes) from “seasonal” flu. Of those hospitalized, 20,000 are children younger than 5 years old. More than 90 percent of related deaths, and about 60 percent of hospitalization, occur in people older than 65.

But this year, being prepared for the possible onslaught of the flu virus will require more than the usual precautions. In addition to being vaccinated for seasonal flu, for those deemed at high-risk of contracting the H1N1 swine-flu virus, a grand total of three vaccinations are recommended, starting with the standard influenza A vaccination for “the regular seasonal flu.” It’s followed by an additional two vaccinations, administered one month apart.

Those swine-flu vaccines are still in the laboratories, but 45 million doses will be sent out to health-care providers Oct. 15.

At the helm of last week’s meeting of the county’s Pandemic Task Force, Homer warned, however, that swine-flu vaccine availability will be limited.

“We won’t have enough to go around,” he said.

But what’s even more unusual is this flu season’s targeted swine-flu demographic, in a year when, Homer said, young adults ages 19-24 will be at the front of the swine-flu vaccination line.

Traditionally, influenza puts at risk the very young, the elderly and those with compromised immune systems. This flu season, however, while anyone with a faltering immune system will get high priority for a swine-flu vaccination (people born before 1957 have a higher immunity, thanks to exposure to a similar strain of H1N1 flu circulating that year), every healthy person over age 52 goes to the end of the vaccination line.

“There may be some confusion there,” San Miguel County Health Officer David Homer, M.D., told members of the Pandemic Task Force gathered last week in the third-floor conference room at the Telluride Fire Protection District headquarters, about the fact that three shots, one for seasonal flu and two for the swine-flu virus, are recommended for those most vulnerable members of the population.

As for the efficacy of flu tests, he was skeptical. “There are a lot of false negatives,” he said, hovering at rates of about “fifty percent.”

The seasonal flu vaccine takes effect two weeks after immunization.

The swine-flu vaccine, however, needs three weeks to be effective. With a mid-October availability, and with two shots, one month apart, required, effective immunization can’t transpire at the earliest until Thanksgiving.

“Where do we stand on Tamiflu?” Homer asked the group, referring to the oral neuraminidase inhibitor used for blocking the spread of the influenza A and B virus between cells in the body, rendering the virus less virulent.

“We have doses for people on the front lines,” responded Sharon Grundy, M.D., in family practice at the Telluride Medical Center.

San Miguel County Nursing Director June Nepsky expects to receive an initial 200 doses of the swine-flu vaccine by mid-October, and that the Centers for Disease Control “recommends you give it when you get it,” she said.

After that: “We’ll get it in incremental amounts,” she added.

Highest on the priority list as the vaccine arrives, she said, will be “families with kids, teachers, pregnant women, health-care givers” and children under six months old; after that, children up to 5 years old are relatively high risk, as are young adults ages 19 to 24, and anyone between the ages of 25 and 64 “with chronic health and medical conditions.”

“We want to be realistic,” said Nepsky, in requisitioning a fair share of flu vaccines for a county with just 8,200 residents (1,300 of them children).

Information management will be especially crucial as the swine-flu virus winds its way through the county, to which end parents phoning in reports of sick children (and employees calling in sick to work) will be asked to describe the symptoms so we can “try to track it,” said County Emergency Preparedness Response Coordinator Trisha VanHeltebrake.

To that end, an algorithm, or step-by-step problem-solving procedure, is in the works, so far with this key provision: “You don’t go to your provider – you call your provider. You follow the algorithm,” said Homer.

In other words, stay away from the doctor’s office.

“We don’t want people to come in” who might expose patients and staff to the virus, Homer explained. Seriously ill patients will be isolated, if necessary, in a clinic set up at Telluride High School, and sent to Montrose, should their conditions worsen.

Also part of the algorithm: Schools, offices and businesses are urged to ascertain beforehand what measures they will take in the event they are running at 30 percent capacity – the approximate measure, Homer said, of the population expected to get swine flu.

For health-care facilities, that means “knocking off non-essential female and wellness exams” and tests for longer-term diseases like cancer, in favor of treating flu victims.

In business and government offices, it means setting up a protocol for affected individuals to work from home, and ascertaining beforehand at what level of employee absences the office shuts down.

In places like schools (“conjunctivitis moves through a school like wildfire,” observed American Red Cross Adult CPR/First Lead Wilderness First Responder Trainer Peter Muckerman), relatively simple precautions – making hand sanitizers as prevalent as they are nowadays in nursing homes and hospitals and keeping kids well-drilled to keep washing their hands until they have sung the “Happy Birthday” song in its entirety and to keep their hands away from their eyes, noses and mouth.

While swine flu is not expected to hit in large numbers until winter draws near, just this week the State of Florida reported a total of 3,500 cases, prompting State Epidemiologist Barry Inman to report on what he explained is, because it circulates between pigs, birds and humans, technically considered a “quadruple reassortant” virus, with symptoms that include “fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue” and a significant number of victims reporting “diarrhea and vomiting.

“About 70 percent of people who have been hospitalized with this novel H1N1 virus have had one or more medical conditions previously recognized as placing people at ‘high risk’ of serious seasonal flu-related complications. This includes pregnancy, diabetes, heart disease, asthma and kidney disease.” This summer, in Spain, a total of 69 swine-flu cases were laboratory confirmed, but another 25,000 suspected.

Locally, health officials walk a fine line, Homer said this week, between “being accused of crying wolf and not being prepared.

“We don’t want another Katrina,” he said, referring to the hurricane (and its deadly inadequately planned-for aftermath) that devastated the Gulf Coast in 2005.

Colleges and universities across the country are planning for the possibility that anywhere from dozens to hundreds of their students could fall ill with H1N1 HYPERLINK "http://health.nytimes.com/health/guides/disease/the-flu/overview.html?inline=nyt-classifier" flu as classes start over the next few weeks, the New York Times reported Sunday. Administrators concerned that students and staff members who are pregnant, obese or have asthma or other conditions that put them at higher risk of contracting the virus could overwhelm local hospitals are already moving to slow down transmission.

Although “30 percent of the population” is expected to get the swine flu, Homer emphasized that facility congestion might be problematic, but as for the swine flu, he said: “I don’t think people are going to die from it.”

What will happen: People with flu symptoms will stay home until 24 hours after their fever has abated. Because the H1N1 virus attacks the respiratory system, oxygen will be stocked, and federal funds have been requisitioned for a $50,000 oxygen manufacturing system. County officials have already held an emergency response dry-run, using the commissioners’ meeting room as command center, complete with emergency generator-powered telephone, satellite and internet lines that were up for six hours.

Homer is philosophical about the mounting precautions.

“The bird flu got us going” in 2004, he said, which according to the World Health Organization led to 438 cases, including 262 fatalities, in Southeast Asia. Then came “9/11 and the code-orange alert and Katrina,” and citizens of the brave new world became accustomed to the indispensability of disaster-planning in the 21st century.

Good planning takes time. “I try to get one thing accomplished, per meeting,” Homer said, of the progress of the task force, adding that virtues of a dry run versus tabletop exercises are now being assessed.