It was early in the week of April 19 that word of an influenza outbreak in central Mexico reached Dr. Dora Anne Mills, the head of the Maine Center for Disease Control and Prevention. Like many Mainers with school-aged children, Mills was on vacation that week with her family, in North Carolina.
Click here for “What you need to know about H1N1.”
Mills monitored the e-mailed messages from the federal agency. But because the U.S. Centers for Disease Control and Prevention in Atlanta sends out a more or less constant stream of such alerts to state public health officials, she said in a recent interview, the preliminary news from Mexico didn’t alarm her much.
“Then on Thursday, the 23rd, I got an urgent call” from the CDC, she said. She was being summoned to an evening conference call with senior CDC officials and her counterparts in all 50 states.
“That definitely caught my attention,” she said.
The CDC laid out the facts: The swine flu emerging as a human epidemic in Mexico had all the makings of the influenza pandemic that public health officials for years have been talking about and planning for. Its rapid spread, the severity of the illness it was causing, its tendency to target otherwise healthy young people, and its unusual genetic makeup — all pointed toward a deadly flu outbreak.
“The bottom-line message was, ‘You’d better get ready,’” Mills said.
Ready to respond
In Maine, planning for a deadly influenza outbreak has been going on for several years. By the morning of Monday, April 27, when all eyes were on the outbreak, Mills’ staff of epidemiologists and other public health and emergency response leaders was briefed and in action. An incident command system had been set up in conjunction with the office of Gov. John Baldacci, the Maine Emergency Management Agency and the Maine National Guard.
The state’s public health laboratory had increased its capacity to test for the virus, almost doubled its staff of certified microbiologists and rearranged its physical layout to support an efficient, assembly-line process of testing. Emergency contracts had been signed with private courier services to ensure the speedy delivery of suspected H1N1 specimens to the lab from any site in the state.
Two 24-hour phone banks had been set up, one for the general public and one for health care providers. The Maine CDC — the first public health agency in New England to do so, Mills said — had added a new page to its Web site, specifically to provide information about the H1N1 outbreak.
“The main concern I had was that you might think that because this was happening in Mexico and Southern California, we would have a while before it reached Maine,” Mills said. “But as a parent of school-aged kids, I knew thousands of families would be on their way home from the April public school vacation. … I knew we had to expect to see it here very quickly.”
On Wednesday, the 29th, Mills announced the identification of three swine flu cases in Maine.
The 2009 H1N1 swine flu epidemic is just about three weeks old in this country. Its arrival has set off a series of well-rehearsed events, including daily media briefings, hot lines for medical providers, school closings and travel advisories. Less prescribed has been the response from the general public, which has ranged from near-panic in areas such as Southern California, where there have been many cases, to a kind of watchful skepticism in less hard-hit regions. But even in Maine, where, as of Friday, just 14 cases of H1N1 had been identified, some stores have been hard-pressed to keep up with the demand for alcohol-based hand cleaner, paper masks and other protective gear. (Two of the probable Maine cases have been ruled out by the U.S. CDC.)
Though it continues to spread quickly — especially among younger people — the virus in this country has been relatively mild, no worse than seasonal influenza. Accordingly, public health experts have dialed down the alarm, revoking some early recommendations such as closing a school if even one child or staff member were to become ill with the virus.
But other recommendations stay in place, including heightened vigilance for flulike symptoms such as fever, cough, sore throat and achiness — especially in conjunction with recent travel to Mexico or other areas where human illness due to the H1N1 virus is common. Some churches have stopped offering a shared chalice of wine during Holy Communion, and health care workers are urged to be more wary of patients with respiratory symptoms.
Despite the lower-than-expected severity of the illness, officials caution against complacency.
“No one is saying this is over,” said Maine state epidemiologist Dr. Katherine Gensheimer. In part because of the virus’ unique makeup — it includes strains that affect pigs, birds and humans, making it a versatile and enduring foe — Gensheimer said there’s no telling how the epidemic will play out.
“We can’t predict anything,” she said. “No one can say what’s going to happen.” The virus could simply run its course and disappear. It could percolate in the population at its current level for the indefinite future. It could return in the fall with a vengeance, merging into a powerful, superflu union with the anticipated strain of the seasonal flu virus, or possibly delivering a dynamic — and deadly — one-two punch during the winter flu season.
“No one has a good handle on this,” said Gensheimer. “We are going forward as if there is something serious to contend with.”
No natural immunity
The 2009 H1N1 flu outbreak is no surprise. The public health community has for years been sounding the alarm about a predicted worldwide influenza epidemic. The primary focus has been on the likelihood of a deadly virus arising in birds in Southeast Asia, changing to infect humans, and traveling across the globe in a matter of hours and days via travelers. The swine flu’s sudden emergence in Mexico has caught some public health officials off-guard, but the response to the dangers it poses is the same.
Due to the unusual makeup of the virus, most people have no natural immunity to it. Its genetic similarity to the strain of influenza that caused the infamous “Spanish” flu of 1918 and 1919, which killed millions around the globe and brought business, social and government functions to a virtual standstill in some regions, has public health officials on high alert.
Countless hours and millions of dollars in federal disaster preparedness funding have been invested in education and planning in an attempt to circumvent widespread illness and death as well as the social unraveling that resulted from the Spanish flu.
How much is enough?
On Thursday, April 30th, in an update on its Web site, the Maine CDC instructed “everyone” to make preparations:
“These preparations include activating a pandemic influenza plan. Every hospital, other health care institution, emergency management agency, school, business, agency or organization should activate their pandemic influenza plan. Every individual and family should also activate their plan.”
At the Scarborough corporate offices of Hannaford Supermarkets, which has 51 grocery stores, two distribution centers and 7,500 employees in Maine, director of business continuity Cory Hedman said the company’s pandemic plan rolled out smoothly — but in a limited way.
As a key player in maintaining supplies of food, water, pharmaceuticals and other necessities in the event of all kinds of disasters, the grocery store chain understands the importance of complying with public health recommendations and of communicating efficiently with employees and customers, he said.
One of the first steps Hannaford took was to notify all employees that if they had recently returned from Mexico, whether on business or pleasure, they were to stay at home for seven days — paid.
Hedman didn’t know how many workers were affected by this enforced absenteeism. But the stay-at-home policy is essential to limiting the spread of influenza among employees and customers, he said.
If the outbreak continues to spread, or if it comes back stronger in the fall, Hannaford is prepared to execute more extreme strategies, Hedman said. These could include requiring employees to wear gloves and face masks at work, installing protective plastic shields between employees and customers, and — in the event of fuel shortages or widespread illness among drivers — streamlining delivery trucks to provide more essentials and fewer frills to the stores that serve Maine’s far-flung communities.
According to Kathy Knight, director of the Northeastern Regional Resource Center in Brewer, all Maine hospitals have pandemic plans. But, like Hannaford’s, those plans are based on the premise of a much more severe illness than H1N1 has caused, at least so far, she said.
The resource center is one of three such organizations in Maine charged with developing and coordinating regional disaster plans that include health care facilities, emergency responders, public safety providers and other groups.
Knight said that in response to the Maine CDC order, hospitals identified emergency operations centers and provided extra information to clinical staff. But they have stopped short of discharging patients early to free up beds for flu victims or calling in extra staff, as their plans call for.
“We now realize there has to be much more flexibility in our planning,” Knight said. “All-or-nothing responses aren’t going to be appropriate.”
Knight said the relatively mild H1N1 outbreak has provided a wake-up call to some organizations that do not have pandemic plans, including some nursing homes and home care agencies.
“Denial doesn’t work anymore,” she said. “It’s obvious this can happen to us, because it has happened to us.”
An opportunity to evaluate
At the Maine CDC, Mills said states must establish a way to provide appropriate information and directives that reflect the relative severity of an outbreak without directly conflicting with more stringent national guidelines.
“In a rapidly evolving situation like this, at what point do you update things without inundating people with too much information?” she asked. “It’s a balancing act.”
Meanwhile, public health officials stress that H1N1 flu remains a real threat. Even if it never becomes as deadly as the feared avian influenza, it is capable of causing serious illness and death, especially in people with underlying health disorders.
Each year in the United States, seasonal influenza results in an estimated 36,000 deaths and more than 200,000 hospitalizations. The H1N1 flu has the potential to be at least as serious, especially since there currently is no vaccine and no immunity against the virus. Because of these factors, a U.S. CDC spokesman said Friday, the agency “anticipates that there will be more cases, more hospitalizations and more deaths associated with this new virus in the coming days and weeks.”