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Format: 04/18/2014
Format: 04/18/2014


Pittsburgh City Paper: Sick Days

Wednesday, September 2nd, 2009

By Melissa Meinzer

Don't call it swine flu -- at least not anymore. But the 2009 H1N1 strain of influenza is among us. It's in every state and territory of the U.S., on six continents and in most countries around the world. As we swing into fall, when the weather increases transmission rates and more people congregate in places like schools, experts say widespread infection is inevitable.

As much as 40 percent of the world's population is expected to get sick. Not even Ron Weasley is safe: Rupert Grint, the 20-year-old British actor famous for playing ginger-haired wizard Weasely in the Harry Potter movies, had a minor case in July. (He got better.)

If you're going to get sick, Pittsburgh may be among the best places to be, with a multidisciplinary team of researchers studying the virus and its infection patterns from all angles. The Center for Biosecurity at the University of Pittsburgh, for instance, helps advise policymaking groups like the federal Centers for Disease Control and Prevention about handling all sorts of major biological threats, from bioterrorism to large-scale flu infection.

In particular, the path taken by viruses fascinates the center's visiting fellow, Dr. Amesh Adalja. Adalja, from a family of doctors in Butler, is a 33-year-old physician and epidemiologist who thrills at chasing down the medical mysteries of infectious diseases. Like many who track bugs, he'd been intensely studying the avian flu when H1N1 hit, and quickly switched gears.

As of the end of July, the World Health Organization had reported 1,154 deaths from H1N1, and 162,380 cases worldwide. In the U.S. so far, more than 430 people have died, with more than 6,500 people hospitalized for suspected H1N1 influenza. On June 11, the WHO declared it a global pandemic; the director general, Dr. Margaret Chan, said that "further spread is considered inevitable."

The bottom line is that lots and lots of people are going to get sick this fall.

But don't freak out, say Adalja and other experts. It's not the next Black Death. H1N1 as we know it is quite contagious but seldom fatal. Most people who become infected will recover, with or without the help of potent anti-viral drugs Tamiflu and Relenza, and a vaccine should be available by mid-October.

"The virus is going to be everywhere," says Adalja. "People need to be prepared to see widespread illness, which doesn't mean widespread death. You have to strike a balance between panic and preparedness. The majority of people are going to be fine."


Hog Wild

Creepy words like "swine flu" and "pandemic," and visions of subway cars full of people in face masks, certainly aren't reassuring. But in any given year, about 36,000 people can be expected to die from regular seasonal flu.

Public-health experts say common-sense precautions like washing our hands go a long way toward addressing the problem. Still, challenges remain: Who gets vaccinated first? Who should get antiviral drugs, and when? Do we close down schools and theaters? Do we all need a face mask and a pocket-sized bottle of anti-bacteria goo? Or should we all just calm down?

This year's novel H1N1 influenza virus, formerly known as swine flu, came to prominence in Mexico this spring, and was identified as a new virus in April. According to the CDC, it's thought to spread like most viruses, from contact with an infected person's coughs or sneezes, and possibly through touching a surface that an infected person has coughed or sneezed on.

Symptoms include fever, sore throat, body aches, headaches, chills, fatigue, vomiting and diarrhea. Patients are sick and contagious before they display symptoms, and can expect to be sick for five to seven days.

The virus was initially called "swine flu" because it displayed genetic characteristics of influenza viruses typical to pigs.


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It's called H1N1 because of its genetic profile -- influenza strains are categorized by two specific proteins, hemagglutinin and neuraminidase.

Every influenza virus, despite what it's popularly called, is identified by its hemagglutinin and neuraminidase profiles. For instance, the 1968 influenza virus commonly called the Hong Kong Flu was a H3N2 virus.

"Two [viruses] getting together and shuffling -- that's what makes flu unique," says Adalja, who besides doing research also pulls shifts in area emergency rooms. "Every pandemic is heralded by an antigenic shift." That is, the virus mutates so that previous vaccines or immunities conferred by surviving infection are no longer effective.

While the 2009 H1N1 virus contains genetic markers common to pigs and birds, it spreads from human to human. "You can have a human virus infect a pig and bird flu can infect a pig. You get a part-human-part-avian flu -- pigs are the mixing vessel."

Along with profiling infectious diseases, Adalja is a major fan of calling things as he sees them. You've probably seen his name before -- he's a passionate letter-to-the-editor writer on topics from the true nature of republicanism to a woman's absolute agency over her reproductive system. (As a pro-choice Republican who signs his letters from Butler, he manages to engender teeth-gnashing replies from all sides.)

Adalja also loves debunking myths: It's absolutely not possible to pick up H1N1 from eating spareribs, for instance. And the Kabul Zoo's decision to quarantine the only known pig in all of Afghanistan this May? Laughable.

"No pigs were sick," Adalja says.

So why is the virus grabbing headlines and causing a run on face masks?

"A lot of people confuse the word 'pandemic' with widespread death. It means 'widespread illness,'" says Adalja. "It came along and freaked everyone out and the media got a hold of it."

Still, all flus are not created equal.

Typically, influenza strikes the physically weakest among us -- young children and the elderly. The Asian flu of 1957, a pandemic that killed 69,800 people in the U.S., killed mostly old people. The 1968 Hong Kong flu, which killed 33,800, mostly struck those over 65.

But the most deadly influenza strain, the 1918 Spanish flu, which the Centers for Disease Control and Prevention calls "the catastrophe against which all modern pandemics are measured," hit the young. Between 20 and 40 percent of the world's population got sick. Fifty million people died, and healthy adults between 20 and 50 were the most likely victims, along with people in high-risk groups.

H1N1 tends to hit similar demographics.

"It's not the super-old. Seasonal flu has primarily stricken adults over 65," Adalja says. "Fifty-two-year-olds and older are spared."

One possible reason for that could be what docs like Adalja call, somewhat poetically, "original antigenic sin."

"You'll always respond best to the first virus of childhood," he says. The first time your cells are exposed to a particular infection, they'll form a defense to it, creating an immunological "memory." That's why it's rare to get chicken pox more than once, for example.

Previous influenzas of the H1N1 type included the deadly 1918 Spanish Flu, the 1957 Hong Kong Flu and a 1976 swine-flu scare that made headlines for killing a young soldier, but never really left Fort Dix. So people who were exposed to those pandemics or pandemic scares, Adalja says, have some immunological memory of the virus and how to fight it, granting them some protection.


Ounces of Prevention

Even for most who lack such immunity, preventing infection remains a simple, low-tech matter of everyday hygiene. That means things your mother always told you, like covering your coughs and staying home when you are sick.

"It's the basics, I mean, geez!" says Cheryl Herbert, director of infection prevention at Allegheny General Hospital. "I've been doing this job for more than 30 years, the basics don't change. Wash your hands, cover your cough. Clean stuff. People tend to get a bit panicky."

The wearing of surgical masks is of dubious value. "It's debatable how effective it is in public settings," says Adalja, though he adds, "It's definitely effective in health-care settings."

"It's a false sense of security," says Cheryl Herbert of wearing a mask in public.

Vaccines, meanwhile, will be available in October, and public-health experts do recommend that certain types of people get them. According to the Centers for Disease Control's Advisory Committee on Immunization Practices, those include: pregnant women; those who live with or care for children younger than 6 months old; health-care workers, people between 6 months and 24 years old; and people from 25 to 64 with compromised immune systems or underlying complications like diabetes or heart disease.

It's too early to say how vaccines will be made available here. "Right now we still do not know how it's going to get rolled out -- will it come out like seasonal flu vaccine, through doctors, or mass-vaccination clinics?" asks Megan Casey, a nurse epidemiologist at the Allegheny County Health Department. The ACHD, with guidance from the state and CDC, will make those determinations.

Prioritizing, by the way, would be necessary only if the vaccine were in short supply. "At this point what the CDC is telling us is that we don't expect to see a shortage," Casey says.

To read more, visit the Pittsburgh City Paper web site.

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