The Swine Flu Support Center

In this 76th hour of the swine flu emergency, President Obama urges that we take "the utmost precautions." And the World Health Organization (WHO) has raised the pandemic flu alert level to 5 out of 6, warning that this international outbreak will pose a prolonged threat.

What do "utmost precautions" mean for all of us? What follows is a crib sheet on what we've learned so far about the swine flu, what we still don't know, and a few steps we can each take to reduce the likelihood of getting sick.

1. How long before everyone gets sick? How fast can a pandemic strike?

In 1918, the so-called Spanish pandemic flu spread across the United States in less than one month. Today, with international jet travel, experts say a pandemic flu strain will probably spread even faster. It's still too soon to tell how quickly this swine flu strain will spread. "Flu is like fire," Angela McLean, director of Oxford University's Institute for Emerging Infections, tells The Daily Telegraph.  "You have an outbreak and it spits out sparks. You have to wait to see whether the sparks die out or start new fires."

"What happens next is chiefly up to the virus," adds John Barry, author of The Great Influenza, in The New York Times. "What's important to keep in mind in assessing the threat of the current outbreak is that all four of the well-known pandemics seem to have come in waves," Barry continues. 

In the 1918-1919 pandemic, according to the CDC, the first mild wave started in March and swept through the United States, Europe, and Asia. A second much deadlier wave spread from September to November 1918 . And a third severe and lethal wave arrived in early 1919.

2. Will we all die from swine flu?

No. In the next few weeks, here are two key concepts that will probably become very familiar. First, CFR, which stands for Case Fatality Rate, the probability that someone infected with, say, swine flu will die from it. So far, we don't really know the CFR's for this strain of swine flu. Another key concept is virulence: the severity of the disease produced by a virus. Around the world, scientists are urgently trying to figure out the CFR's and virulence of this swine flu. So far, public health experts say, the data is confounding.

The 1918 Spanish flu pandemic had CFR's of 2.5 percent or higher, according to the CDC. The virus was very virulent. An estimated 500 million people -- one-third of the world's population -- were infected. Some 50 million people perished, and some experts put the death toll as high as 100 million. The pandemics of 1957 and 1968 had CFR's of 0.5 percent or less. A typical flu season has CFR's of around 0.1 percent or less.

3. Are there enough antiviral medications to go around?

No surprise, pharmacies and online suppliers report a big run on antiviral medications. That's because the government says this swine flu strain is treatable with two antiviral drugs: Tamiflu (oseltamivir) and Relenza (zanamivir). Manufacturers of both drugs - Roche based in Switzerland and GlaxoSmithKline based in London - say they're already increasing production.

The US government has stockpiled enough antiviral treatments to take care of 50 million people while different states have 22 million treatment courses. Homeland Security Secretary Janet Napolitano says the government will release 25 percent of its emergency stockpiles -- some 12 million doses - of Tamiflu and Relenza to various states just in case.

If it needs to ramp up significantly, Roche (maker of Tamiflu) says it has an annual production capacity of 400 million treatment courses.

4. When will the vaccine arrive?

Baxter International, manufacturer of flu vaccines, has already requested samples of the swine flu virus to begin work on a vaccine. On a fast track, it will take between four to six months to create and distribute a new vaccine. On a global level, if a pandemic strikes this year, according to CIDRAP, manufacturers could produce 2.5 billion doses of vaccine in the first 12 months, but it would take four years to produce enough vaccine to meet total global demand.

5. What can I do to protect myself?

If swine flu spreads widely, no single step will protect you 100 percent, the CDC says, but a combination of steps can slow down the likelihood of transmission. Collectively, these preventive actions can help buy precious time to manufacture more antivirals and produce and distribute a vaccine.

There are basically three things you can do to reduce the chance of infection, according to the CDC:

• First and foremost, wash your hands. Sounds easy, but an estimated 80 percent of infections are passed around by germy hands. So wash them regularly with soap and water for 20 seconds each time. And if you can't wash your hands, use a hand sanitizer with more than 60 percent alcohol content.
• Second, avoid large crowds and unnecessary social contact. So-called "social distancing" doesn't mean you need to seal yourself inside your home. Just try to minimize your time in large groups and your close contact with sick people or others who have traveled to infected areas. If you're sick, definitely try to stay home and away from others.
  
• Pay attention to your health and get help if you experience flu symptoms. One reason that early swine flu death rates in Mexico may be higher than the US is that people delayed getting help.

Swine flu symptoms are similar to regular flu: Fever, body aches, sore throat, cough, runny nose, vomiting, diarrhea, and lethargy.

It may be tempting to stock up on (or take) Tamiflu and wear a protective face-mask, but will they make a difference? Probably not. For starters, unnecessary use of antiviral drugs can help produce resistant strains. So you should only take those drugs if you're getting sick and a physician prescribes them.

Snug-fitting medical masks approved by the FDA - like dental or surgery masks - are better than nothing if you need to come in close contact with infected people or you're in crowded situations, but the CDC says that information on their effectiveness is limited.

In the weeks ahead, there will be plenty of hysteria (and misinformation) about the swine flu. If possible, try to focus on what you can control: Your hygiene; your contact with others; and your health. Given the nature of a pandemic threat and the challenges that will confront every level of government and the entire health care system, it's essential to be as well informed, well prepared, and self-reliant as possible.

A single sneeze propels 100,000 droplets into the air at around 90 mph, landing on door knobs, ATM keypads, elevator buttons, escalator railings, and grocery cart handles. In a subway station at rush hour, according to British researchers, as many as 10 percent of all commuters can come in contact with the spray and residue from just one sneeze (or sternutation). That means as many as 150 commuters can be sickened by one uncovered achoo.

No wonder health officials are extremely concerned about the new strain of swine flu that has infected at least 20 Americans in five states, killed some 80 people in Mexico, and has traveled to the other side of the world in New Zealand. Understandably, US authorities - following the lead of the World Health Organization (WHO) - have declared a "public health emergency."

"This virus has, clearly, a pandemic potential," says Margaret Chan, director general of WHO. Why? The virulent new H1N1 swine flu strain spreads quickly and efficiently from human to human. It's "a completely novel virus," says the CDC (Centers for Disease Control and Prevention). This latest variant is a mixture of human virus, bird virus, and pig viruses from all over the world. Experts say it's particularly worrisome because people are getting sick without any encounters with pigs. Even worse, young, healthy people (ages 20-40) are dying at a striking rate, a telltale sign of the worst flu epidemics.

Swine flu fears aren't new in the United States. In February 1976, a 19-year-old army private at Fort Dix, New Jersey, died within 24 hours of becoming infected with swine flu. Soon, 500 soldiers were afflicted and the US government began a controversial nationwide vaccination campaign. Ultimately, some 40 million Americans were inoculated. As a result, several hundred people developed Guillain- Barré syndrome, a serious neurological condition, and the immunization program was stopped.

What's going to happen this time? Without question, the disease will spread farther and wider. At this point, as the CDC says, it can't be contained or controlled. (The flu shot from last fall, for instance, won't combat this strain).

What can you do to protect yourself? "No single action will provide complete protection," the CDC notes, but taking a few steps can help reduce the likelihood of transmission of swine flu (or many other infections).

1. Sanitize -- i.e. Wash Your Hands Frequently. It may sound obvious, but hand-washing with soap and water for around 20 seconds is the single best thing you can do (if you're going to go out into the world and interact with other human beings). The CDC estimates that 80 percent of all infections are spread by hands. If you can't wash your hands regularly, try hand-sanitizers with 60 percent alcohol content.

2. Avoid -- i.e. Engage in "Social Distancing." That's the fancy term for reducing unnecessary social contact, staying away from crowds, and avoiding people if you're sick or if you're concerned that they may be infected. It may not be especially practical when you have to go to, say, work, but experts believe it's worth repeating: Isolation and avoidance reduce your chances of getting infected or infecting others.

(Researchers in the UK - mentioned above and sponsored by a cold remedy company - found that 99 percent of commuters suffer at least one cold per winter. By contrast, 58 percent of people who work from home and 88 per cent of those who walk to work caught a cold last winter).

If you need to go someplace crowded, the CDC says, try to spend as little time as possible and try to stay six feet away from potentially infected people. Wearing a surgical or dental facemask - cleared by the FDA as a medical device - "can help prevent some exposures," the CDC says, but they're not foolproof.

3. Be Alert -- i.e. Recognize the Symptoms and Get Help. Swine flu symptoms are similar to regular flu: Fever, body aches, sore throat, cough, runny nose, vomiting, diarrhea, and lethargy. If you don't feel well, seek medical attention. So far, it's important to note, this swine flu is treatable (and absolutely survivable). It's resistant to two of four antiviral drugs approved for combating the flu: Symmetrel and Flumadine. But two newer antivirals - Tamiflu and Relenza - appear to work.

What are the chances of a global pandemic? "The situation is uncertain and unpredictable and likely to be a marathon more than a sprint," says Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention.

"We expect there to be a broader spectrum of disease here in the U.S.," adds Dr. Anne Schuchat, interim deputy director for the agency's Science and Public Health Program. "I do fear that we will have deaths here."

Swine flu will dominate news headlines in the days ahead. Every case around the world will be carefully tracked and tallied -- and deservedly so. It may not sound like much, but the best defense involves some very simple steps: Every sneeze should be covered -- preferably with the crook of an arm - and every hand should be washed ... and washed again.

 

1. Is History Repeating Itself?

The word pandemic comes from Greek roots meaning "all the people." Not surprisingly, the first known medical reporter to file a story about a flu epidemic was Hippocrates around 412 BC. For centuries, flu disasters have struck just as naturally and inevitably as tsunamis, earthquakes, and hurricanes. Indeed, over the past 300 years, there have been 10 major flu pandemics (an average of 22 years apart), according to the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota. Experts believe we're well overdue for another pandemic.

It's too soon to tell if this swine flu outbreak will turn into a pandemic, but the World Health Organization (WHO) has raised its pandemic alert level from 3 to 4 (on a scale of 6 being the worst). The swine flu outbreak has taken a "significant step" toward becoming a pandemic, but "we're not there yet," says Dr. Keiji Fukuda, assistant director-general for health, security, and environment at the WHO.

A lot has changed since the devastating Spanish Flu pandemic just 91 years ago when an estimated 50 million died around the world. Back then, most scientists believed mistakenly that the flu was caused by bacteria. Back then, there were no antiviral drugs to combat the flu, let alone antibiotics, which were developed in the 1940s. Back then, there were no jet airplanes that could cross the world (and spread the virus to every continent) in a single day. In the intervening years, a lot of progress has been made preparing for the inevitability of another pandemic. WHO launched its flu surveillance program in 1947. Vaccines and antiviral drugs are stockpiled around the world. But will all that be enough? We'll get to the scary answer to that question at the end of this article.

2. Are there enough antiviral medicines to keep us safe?

Walgreen purchasing managers met last weekend to make sure they're ready for a spike in demand for personal hygiene products like face masks and hand sanitizers. No surprise, there's also a run on antiviral medications. That's because the government says the swine flu strain is treatable with two antiviral drugs: Tamiflu (oseltamivir) and Relenza (zanamivir). Manufacturers of both drugs - Roche based in Switzerland and GlaxoSmithKline based in London - say they're increasing production.

The US government has stockpiled enough antiviral treatments to take care of 50 million people while different states have 22 million treatment courses. Homeland Security Secretary Janet Napolitano says the government will release 25 percent of its emergency stockpiles -- some 12 million doses - of Tamiflu and Relenza to various states just in in case.

If it needs to ramp up significantly, Roche, for instance, has an annual production capacity of 400 million treatment courses, according to the company.

3. How long will it take to create a new vaccine?

Baxter International, manufacturer of flu vaccines, has already requested samples of the swine flu virus to begin work on a vaccine. On a fast track, it will take between four to six months to create and distribute a new vaccine. On a global level, if a pandemic strikes this year, according to CIDRAP, manufacturers could produce 2.5 billion doses of vaccine in the first 12 months, but it would take four years to produce enough vaccine to meet total global demand.

4. Do face masks protect against swine flu?

They're the instant symbol of the outbreak, but do they work? Snug-fitting medical masks approved by the FDA - like dental or surgery masks - are better than nothing if you need to come in close contact with infected people or you're in crowded situations, but the CDC says that information on their effectiveness masks is limited.

"The risk for infection can be reduced through a combination of actions," the CDC says. "No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent hand-washing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings."

The CDC continues: "When it is absolutely necessary to enter a crowded setting or to have close contact with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene."

5. How deadly is the flu?

Every year in the US, between five to 20 percent of us are infected with regular strains of flu, 200,000 of us end up in the hospital, and around 36,000 of us die from it. The victims are typically the very young, the very old and the very immune-suppressed or ill.

"During the worst week of the 2007-2008 season, the regular flu had a mortality rate of about nine percent," according to a blog posting by Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes - and Why. By comparison, Ripley writes, in swine flu outbreaks, the mortality rate is around 14 percent.

The mortality rate of the Spanish flu pandemic of 1918 was 2.5 percent, according to The Daily Telegraph, while the mortality rate of the 1957 and 1968 pandemics was 0.5 percent.  (The dreaded Ebola virus, for comparison, has a mortality rate that can reach 90 percent).

Obviously, the flu isn't a death sentence - far from it - but the body count escalates in a pandemic because so many millions are infected.

So, what goes wrong when young, healthy people die from the flu? The key is something called the "cytokine storm," according to Dr. Michael Osterholm, director of CIDRAP. In a fascinating November 2005 online interview with The Washington Post, Osterholm explained: "A cytokine storm is the release of a chemical in the body that stimulates the human immune system to respond to the virus infection. In these serious illnesses and deaths, it's actually been an over vigorous immune response elicited by this infection that result in the organ damage and ultimately the death of the individual. Ironically this means that those with the strongest immune systems may be at highest risk for a serious outcome if infected with the (bird flu) H5N1 virus. At the same time, it is surely possible that those with weakened or immature immune systems, such as the very young or very old, and those with underlying immune conditions, may experience serious illness associated with the annual influenza illness, which often involves damage to the respiratory tract and subsequent secondary bacterial infection."

6. Is the world ready for a new pandemic?

In his online interview with the Post, Dr. Osterholm says that despite a lot of progress, the world still isn't very well prepared for pandemic. "The vast majority of the 6.5 billion people on the face of the Earth today do not have any access to intensive care or medicine," he says. "In addition, for most of the developed world, we too will not have access to mechanical ventilators, drugs, or other medical interventions that we might expect. We have little to no surge capacity or the ability to care for large numbers of new illnesses in any of our healthcare facilities today."

"For example," Osterholm says, "in the United States, we only have 105,000 mechanical ventilators in our hospitals. Today an average of more than 80,000 ventilators are in use every day and during the regular influenza season we find almost all of the 105,000 mechanical ventilators in use. Our national strategic stockpile maintained by the federal government has only an additional 4,500 mechanical ventilators for use in an emergency. We will run out of mechanical ventilators overnight. This is true for many of our antibiotics and antiviral drugs, as many of these are made outside of the United States in a single plant and where the raw ingredients needed to make the drugs come from many other countries."

Dr. Osterholm goes on: "With the first onset of pandemic influenza, I believe many of our borders will be closed to transportation and commerce and in this global just-in-time economy, many essential products and services will disappear overnight. ...The only things they will have left to protect themselves will be respirator masks. Again, because of the global just-in-time economy where two companies own a very large percentage of the international market share for production and sales of masks, and which have virtually no surge capacity for production, we will soon also run out of them. Finally, our hospitals, which are now operating in an almost constant full capacity, will not be able to handle the surge of patients with influenza. Therefore already many communities are planning for the care of these patients in auditoriums, gymnasiums, and even arenas where many cots can be lined up in endless rows. When one considers the above information, how can anyone think that this will be a whole lot different than?"

(Bonus) #7: Should you be scared?

Over the last few years, I've interviewed hundreds of the world's most effective survivors and thrivers. Many of the members of the Survivors Club share an outlook - a mentality - and an approach to dealing with crisis. Sure, they get scared (and freaked out) too.  But they turn fear and anxiety into motivation and purpose.  They confront all kinds of adversity with a mixture of realism and optimism.  They seek out information; they adapt to new challenges; they make Plan <em>and</em> Plan B; and they take action.

No one in the world wishes or wants this swine flu outbreak to morph into a full-fledged pandemic with mass casualties. But it's absolutely essential to think the unthinkable and, given the nature of a pandemic threat, to be as well prepared and self-reliant as possible.

From The Washington Post online, Dr. Osterholm gets the last words: "The potential for pandemic influenza to be a catastrophic event in our human history is just too great of a risk for us to wait until the night before to get prepared. While this may all sounds scary to those reading this, our job in public health today is not to scare you out of your wits, but to scare you into your wits. We need you to let your federal, state, and local leaders, including those both elected and in the private sector, know that planning at the international, national and local level must be one of our highest priorities."

How contagious is swine flu? How dangerous? What else can you do to protect yourself? What follows are key questions and answers from the Centers for Disease Control:

What is swine flu? 

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A influenza viruses. Outbreaks of swine flu happen regularly in pigs. People do not normally get swine flu, but human infections can and do happen. Most commonly, human cases of swine flu happen in people who are around pigs but it’s possible for swine flu viruses to spread from person to person also.

Is this swine flu virus contagious? 

CDC has determined that this virus is contagious and is spreading from human to human. However, at this time, it not known how easily the virus spreads between people.

What are the signs and symptoms of swine flu in people? 

The symptoms of swine flu in people are similar to the symptoms of regular human flu and include fever, cough, sore throat, body aches, headache, chills and fatigue. Some people have reported diarrhea and vomiting associated with swine flu. In the past, severe illness (pneumonia and respiratory failure) and deaths have been reported with swine flu infection in people. Like seasonal flu, swine flu may cause a worsening of underlying chronic medical conditions.

Can the swine flu be treated with antiviral drugs?

Like some garden-variety flu, according to The Wall Street Journal, this swine flu is resistant to two drugs known as amantadine and rimantadine. Earlier this week, the CDC reported that the swine flu was being tested for susceptibility to Tamiflu and Relenza, two newer drugs. Update: CDC says Tamiflu and Relenza work against this strain of swine flu, the WSJ reports.

Does the flu vaccine protect against the swine flu?

The CDC reported earlier this week that the seasonal flu vaccine “might not” provide protection against the flu. The agency says it has created a “seed vaccine” specifically tailored to this swine flu. That could be used to manufacture a targeted vaccine if officials deem it necessary to do so.

How serious is swine flu infection?

Like seasonal flu, swine flu in humans can vary in severity from mild to severe. Between 2005 until January 2009, 12 human cases of swine flu were detected in the U.S. with no deaths occurring. However, swine flu infection can be serious. In September 1988, a previously healthy 32-year-old pregnant woman in Wisconsin was hospitalized for pneumonia after being infected with swine flu and died 8 days later. A swine flu outbreak in Fort Dix, New Jersey occurred in 1976 that caused more than 200 cases with serious illness in several people and one death.

What can you do to protect yourself?

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hands cleaners are also effective.
• Avoid touching your eyes, nose or mouth. Germs spread that way.

Try to avoid close contact with sick people.

• Influenza is thought to spread mainly person-to-person through coughing or sneezing of infected people.
• If you get sick, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

For more information, the CDC has set up a toll-free hotline: 1-800-CDC-INFO.