WHO declares public health emergency as US swine flu cases rise

Apr 25, 2009 (CIDRAP News) – Health officials from Kansas and New York today announced more confirmed and probable swine influenza cases, as an emergency panel of the World Health Organization (WHO) met but stopped short of raising the global pandemic alert level.

The WHO said in a statement today that the emergency panel, after reviewing data on the US and Mexican outbreaks, identified several gaps in the information about clinical features, epidemiology, and virology. "The Committee nevertheless agreed that the current situation constitutes a public health emergency of international concern," the WHO said.

Many public health officials had speculated that the group might advise raising the pandemic alert level from phase 3 to 4, but it has yet to take that step.

Based on the determination of the committee, Margaret Chan, the WHO's director-general, advised all countries to intensify their surveillance for unusual influenza-like illnesses and severe pneumonia.

At a media teleconference this morning, Chan said the WHO would like to know, for example, how many of Mexico City's 800 severe illness cases were caused by the new swine flu virus and how many were caused by other pathogens. "We may need a few more days to gather other evidence," she said.

"Nonetheless, this is a serious situation that must be watched very closely," she said.

The US Centers for Disease Control and Prevention (CDC) tonight updated its number of confirmed swine flu cases, adding one more patient from California and the two announced by Kansas today, raising the total from 8 to 11.

No new totals were available about the number of Mexican swine flu cases or fatalities. Several media reports said Mexican government officials cancelled a number of cultural events and ordered crowds to stay away from two popular soccer matches that were scheduled for today.

Cases in Kansas and New York
At a press conference late this afternoon, the Kansas Department of Health and Environment (KDHE) said that the two patients who tested positive for the swine flu A/H1N1 strain circulating in the United States and Mexico are both adults who live in the same household, one of whom had recently traveled to Mexico. Neither was hospitalized. One of the patients is still sick and is being treated, and the other is recovering.

Kansas officials said they first received a report of unusual flulike illness yesterday afternoon. After preliminary tests conducted overnight were positive this morning, KDHE officials flew the samples on Gov Kathleen Sebelius' plane to the CDC in Atlanta, which confirmed the swine flu findings by midafternoon.

Shortly before Kansas announced its findings, the New York City Department of Health and Mental Hygiene announced that 8 of 9 samples obtained from students sickened at a private high school were positive for an untyped influenza A strain.

Thomas R. Frieden, MD, MPH, the department's commissioner, told reporters that those findings suggest human swine flu. He said the samples are on their way to the CDC for confirmation and that results should be available tomorrow.

Several media outlets have reported that the school is Saint Francis Preparatory School, located in Queens. The school's Web site said on Apr 23 about 75 students reported to the medical office with symptoms including headache, upset stomach, and dizziness.

The New York City health department has received calls about students from Manhattan, not associated with Saint Francis, who were sick and undergoing medical evaluation after traveling to Mexico for spring break, Frieden said. The department is also investigating a respiratory illness outbreak at a daycare center in the Bronx and is sending specimens for testing.

Frieden said about 200 students had been absent and that health officials have spoken with about 100 of them. Illnesses had a short incubation period (1 to 3 days), symptoms have been mild, none of the students were hospitalized, and most of the teens report feeling better.

If the CDC confirms the findings tomorrow, Frieden said he'll recommend that the school not reopen on Monday. "Schools can become amplifiers," he said.

So far, the New York City department of health, based on its syndromic surveillance, hasn't detected an increase in respiratory illness patterns in the city. "But we're monitoring that every 12 hours," he said.

CDC: 'Time to prepare'
Earlier in the afternoon, before Kansas and New York announced their findings, the CDC briefed reporters on the status of the swine flu investigation. At that point, it had no new cases to report, just the seven that the agency has confirmed at that point.

However, Anne Schuchat, MD, director of the CDC’s National Center for Immunization and Respiratory Diseases, said to expect more case announcements as state surveillance progresses. She pointed out that the CDC yesterday issued outbreak notices for travelers and technical bulletins on the swine flu virus for laboratory workers, infection control officials, and healthcare workers.

"Many of these actions are really taken with an abundance of caution—you'll see a lot going on," she said

Schuchat said the CDC isn't resting easy about the mild cases seen so far in the United States. "That may change. This is the time to prepare, to think ahead, and be ready for some uncertainty," she said.

Though the WHO hasn't elevated its pandemic alert level, the CDC continues to prepare for more serious outbreak scenarios, she said. "It's easy to focus on phases, but it's important to know we are preparing. We're not trying to focus on the classification," Schuchat said.

Mild cases may mean little
Michael T. Osterholm, PhD, MPH, director of the University of Minnesota Center for Infectious Disease Research and Policy, publisher of CIDRAP News, also urged public health officials to view the data about the severity difference between the US and Mexican cases with caution.

Though subsequent passages of the virus through populations could lead to a milder disease, it's difficult to base conclusions about the mild severity of US cases on such a small number of patients, he said.

Health officials don't know yet how many mild cases of swine flu occurred in Mexican patients, and without that information, it's difficult to draw firm conclusions about the true rate of severe cases, he said.

"Milder cases, on one hand, are good, but that may mean little," Osterholm said, adding that, during the first wave of the 1918 influenza pandemic in the spring, many cases were mild, but by late July and early August, the virus caused widespread, severe illness.

Preparing emotionally and physically for a possible pandemic
Peter Sandman, PhD, a risk communication consultant based in Princeton, N.J., told CIDRAP News that a key task for the public health community right now extends beyond tangible items such as stockpiles of food, drugs, and supplies. "Preparing is also envisioning how bad a pandemic could be," he said, adding that some degree of anxiety and feeling a knot in the stomach is a crucial part of an adjustment reaction.

Evidence has shown that those who can envision what could happen down the road do better at coping with a crisis situation, Sandman said. "The time to do that is now."

See also:

Apr 25 WHO statement

Apr 25 KDHE press release

Apr 25 NYCDHMH press release

Saint Francis Preparatory School Web site

Apr 24 CIDRAP News story "Labs confirm same swine flu in deadly Mexican outbreaks"

Apr 23 CIDRAP News story "More US swine flu cases, Mexico illnesses raise pandemic questions"

CDC swine flu investigation page

CDC swine flu information

Peter Sandman article "Adjustment reactions: the teachable moment in crisis communication" (Spanish version also at this link)

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