As reported by The Hartford Courant, July 19, 2009.

Experts: Swine Flu Is Waning, Will Return in the Fall

By Arielle Levin Becker

Some good news about the swine flu: It's on the wane, doctors and health officials say.

But don't get too comfortable, they're quick to add. It will be back.

State Epidemiologist Dr. Matthew Cartter said the outbreak seems to have peaked at the end of June. "So it's giving us time to look toward the fall," he said.

That's because experts expect that as children go back to school, colleges reopen, seasonal flu re-emerges and weather becomes more favorable to influenza, the virus will return, bringing a host of potential complications.

How will schools handle the disruption if they have to close early in the year? If there's a vaccine — as health officials hope — who will get it and how will it be distributed? What if the virus develops a resistance to antiviral drugs — something that reportedly happened in at least one case already?

"We're preparing for the worst and hoping for the best," said Tom Skinner, a spokesman for the federal Centers for Disease Control and Prevention.

Experts expected the virus would slow down in the summer. Influenza viruses do better with colder temperatures and less humidity. Skinner said swine flu cases are on the wane across the country, but the extent that it has shown up at all in the summer is unusual.

As of Wednesday, there were 1,581 laboratory-confirmed cases of novel influenza A H1N1 virus, swine flu's official name, in Connecticut. That's likely just a small fraction of the actual number of cases because many people with mild symptoms recovered at home without seeking care from a doctor or hospital. Statewide, 111 people with confirmed cases have been hospitalized and seven people, all of whom had underlying health problems, have died.

Most cases have been mild, though a recent study suggests that the virus may be more virulent than initially thought. While seasonal flu typically infects only the upper respiratory system, the H1N1 virus appears to infect cells in the lungs, which could cause pneumonia. Experts said it's still too early to know what that could mean for patients, and Cartter said the H1N1 virus should not be taken lightly.

"It certainly is as severe as seasonal flu, which kills 36,000 Americans every year," he said. "And it's probably more severe."

Testing Limited

Back in April, when the outbreak began, someone with flu-like symptoms who showed up at a doctor's office was likely to be tested. That has changed.

Testing has two purposes.

First, there is public health surveillance — trying to determine where the virus has hit, whether the strain is susceptible to antiviral drugs and whether it had any unusual characteristics.

Second, there is testing for individual clinical cases.

At the beginning of the outbreak, health officials needed to learn about the virus and determine where it was occurring. But as it became widespread, state labs across the country began shifting their focus to the more severe cases. Connecticut's lab now handles only specimens from hospitalized patients and health care workers.

Other patients can get tested for swine flu through commercial labs if their doctors request it, just as they would a blood test. Rapid flu tests are also available, though they are not designed to test for swine flu and can give false positives or negatives.

And doctors say for mild cases, the testing is not always necessary.

"For the vast majority of people, knowing that they have novel H1N1 influenza won't change what their doctor will do," Cartter said. "Most people get better all on their own and a doctor can order or prescribe antivirals without a test result, based on clinical judgment."

Cartter said he can identify with the desire to know. His two children were recently ill, but despite his curiosity, he followed the state guidelines and didn't get them tested. "I will have to remain curious," he said.

In the spring, most people who were tested had seasonal flu, not swine flu. Distinguishing between the two strains was important because the seasonal flu strain was resistant to the antiviral drug Tamiflu while swine flu is not, said Dr. Richard Garibaldi, hospital epidemiologist at the UConn Health Center. But now seasonal flu is largely gone.

"Now, when there's only one virus in the community, we just assume that if someone has flu-like symptoms that they have the swine flu," he said.

At St. Francis Hospital and Medical Center in Hartford, the majority of people being tested are inpatients or those who are in the emergency room and severely ill, said Dr. Rolf Knoll, the hospital's chief medical officer.

Most people who come in to the hospital with mild flu symptoms have had them for several days and aren't feeling better. "The antivirals don't do much good at that point," Knoll said.

Instead, in those cases, doctors are more likely to treat the symptoms with anti-inflammatory drugs and advising people to rest, stay hydrated and try to stay away from other people.

Planning for Fall

Swine flu could make a resurgence as early as September, Cartter said, hitting just as the school year begins.

Recommendations about whether to close schools depends on the outbreak's severity. Evidence from past pandemics suggests to have a lasting effect on stopping transmission of illness, schools must close for as many as four to six weeks, Cartter said.

If the severity of the outbreak doesn't change, Cartter said, officials will work with schools and other public health agencies to try to keep schools open and address parent concerns — something he said may be more challenging than closing them. When the outbreak began in the spring and schools closed amid flu fears and widespread absences, officials learned that "keeping schools open is actually much harder than closing schools."

State and federal officials are also planning for a potential vaccine for swine flu. The earliest one would be available is likely not until mid-October or early November, after the virus's resurgence is expected to begin. That leaves challenges like figuring out how to inoculate healthy people while keeping them away from sick people — something that requires flexibility.

"If a busy pediatrician's office is seeing lots of sick kids, it's going to be difficult for them to find the time to give children vaccine," Cartter said.

It is not clear how much vaccine will be available, so officials will also have to determine who should get it first. Those targeted first will probably be students in schools, pregnant women, people with medical conditions that increase their risk of flu complications, health care and emergency service workers, and possibly school staff, Skinner said.