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    <recommendedItem id="20100101_19_414"
                     title="H1N1 Vaccination Still a Good Idea, CDC Says"
                     score="0.012"
                     href="http://www.medpagetoday.com/InfectiousDisease/SwineFlu/tb/18325?impressionId=1265811345384"
                     
      &lt;p&gt;Although pandemic H1N1 influenza activity appears to have leveled off, the CDC remains wary of what the future may hold.&lt;/p&gt;
&lt;p&gt;No states were reporting widespread influenza activity, and only six  --  Alabama, Georgia, Maine, New Jersey, New Mexico, and Virginia  --  were reporting regional activity, Anne Schuchat, MD, director of the CDC&apos;s National Center for Immunization and Respiratory Diseases, told reporters on a conference call today.&lt;/p&gt;
&lt;p&gt;Influenza-like activity remained below the baseline level for this time of year for the third straight week, Schuchat said.&lt;/p&gt;
&lt;p&gt;&quot;That&apos;s fairly similar to what we would normally see at this time of year with seasonal flu,&quot; she said.&lt;/p&gt;
&lt;p&gt;However, she said that the H1N1 virus continues to circulate, causing severe disease and death in some cases.&lt;/p&gt;
&lt;p&gt;Although total activity is down, Schuchat noted that the proportion of deaths attributed to either flu or pneumonia is higher than the epidemic threshold, and has been for the past three weeks. The reasons were unclear, but she said there are no indications that the virus has become more virulent.&lt;/p&gt;
&lt;p&gt;But, she said, &quot;H1N1 vaccination remains a good idea.&quot;&lt;/p&gt;
&lt;p&gt;The most recent results of the CDC&apos;s National H1N1 Flu Survey revealed that about 70 million people, or 23.4% of Americans, have been vaccinated so far. About 76 million doses of the vaccine have been used because of the requirement that children younger than 10 get two.&lt;/p&gt;
&lt;p&gt;About 37% of children up to age 18 have been vaccinated. For those younger than 10, 37% have received their second dose.&lt;/p&gt;
&lt;p&gt;Vaccine supply remains ample, Schuchat said, with about 124 million doses shipped around the country up to this point.&lt;/p&gt;
&lt;p&gt;Citing an &quot;unprecedented&quot; effort to monitor safety, she said there have not been any major safety concerns identified.&lt;/p&gt;
&lt;p&gt;&quot;So if safety was the reason that you were waiting, I think you can be reassured on that front.&quot;&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_302"
                     title="WHO Calls H1N1 Response Imperfect"
                     score="0.004"
                     href="http://www.medpagetoday.com/InfectiousDisease/SwineFlu/tb/18165?impressionId=1265811345384"
                     
      &lt;p&gt;The World Health Organization says its response to the H1N1 pandemic could have been better, but was not unduly swayed by drug manufacturers.&lt;/p&gt;
&lt;p&gt;&quot;We are under no illusions that this response was the perfect response,&quot; Keiji Fukuda, MD, the agency&apos;s top flu expert, told a hearing being held by the Council of Europe&apos;s health committee.&lt;/p&gt;
&lt;p&gt;But he added, &quot;The influenza pandemic policies and responses recommended and taken by WHO were not improperly influenced by the pharmaceutical industry.&quot;&lt;/p&gt;
&lt;p&gt;The council&apos;s hearing is a response to criticism by some European politicians, as well as elements of the media, that the danger of the H1N1 pandemic was exaggerated, perhaps to allow drug companies to score multimillion-dollar contracts for vaccines and antivirals.&lt;/p&gt;
&lt;p&gt;In North America, many experts defended the response to the outbreak, which WHO last April declared a phase six pandemic  --  the highest level. The phases reflect that an infectious agent is widely spread and causing disease in the community, but they say nothing about the severity of the disease.&lt;/p&gt;
&lt;p&gt;&quot;I do not believe that the record supports the claim that health officials in the U.S. or WHO exaggerated the threat,&quot; said Andy Pavia, MD, of the University of Utah in Salt Lake City.&lt;/p&gt;
&lt;p&gt;Pavia said in an e-mail that health officials had a choice  --  to assume the threat was minor or to react strongly.&lt;/p&gt;
&lt;p&gt;&quot;The choice is obvious,&quot; Pavia said, &quot;and I would not want to be in a position of explaining to the families of victims why we planned for the mildest outcome.&quot;&lt;/p&gt;
&lt;p&gt;For the most part, illness caused by the disease has been mild, although several thousand people have died around the world and many more were sick enough to require intensive care.&lt;/p&gt;
&lt;p&gt;But the relatively low number of deaths has prompted Wolfgang Wodarg, MD, a German member of the council&apos;s Parliamentary Assembly, to dub the outbreak a &quot;false pandemic&quot; and call for this week&apos;s hearing.&lt;/p&gt;
&lt;p&gt;&quot;What we have experienced now is that millions of people have been vaccinated unnecessarily,&quot; Wodarg said. &quot;This is damage done to people, in order to earn money.&quot;&lt;/p&gt;
&lt;p&gt;Fukuda, on the other hand, said today the pandemic &quot;is a scientifically well-documented event.&quot;&lt;/p&gt;
&lt;p&gt;&quot;The labeling of the pandemic as &quot;fake&quot; is to ignore recent history and science,&quot; he said, &quot;and to trivialize the deaths of over 14,000 people and the many additional serious illnesses experienced by others.&quot;&lt;/p&gt;
&lt;p&gt;Utah&apos;s Pavia echoed that sentiment. Ask any front-line doctor if the H1N1 flu was mild, he said, &quot;and prepare to get your head handed to you.&quot;&lt;/p&gt;
&lt;p&gt;One of them was Daniel Hinthorn, MD, of the University of Kansas Medical Center in Kansas City, Kan. &quot;As a physician who saw many patients with this disease, I believe it was very serious in many people,&quot; he wrote in an e-mail. &quot;The threat was not exaggerated, at least to my mind.&quot;&lt;/p&gt;
&lt;p&gt;Even last month, as flu activity in the U.S. declined, he said his hospital treated 11 inpatients for the flu, including six in intensive care, while &quot;lots of others&quot; were being seen in emergency wards and clinics.&lt;/p&gt;
&lt;p&gt;On the other hand, to say the threat was exaggerated &quot;is merely to say the obvious,&quot; argued Philip Alcabes, PhD, of City University of New York City. By the time a vaccine was available, &quot;this outbreak was far less serious than feared,&quot; he said in an e-mail.&lt;/p&gt;
&lt;p&gt;But &quot;reality-based skepticism about swine flu&quot; doesn&apos;t mean that people would refuse immunization  --  not if an outbreak was a real public danger, caused by a &quot;highly transmissible agent, likely to be virulent, highly preventable with reliably effective vaccine.&quot;&lt;/p&gt;
&lt;p&gt;He warned that public health professionals must avoid &quot;falling in love with the most dire forecast and then pushing high-tech precautions against the worst-case scenario.&quot;&lt;/p&gt;
&lt;p&gt;When that happens, &quot;people have to be excused for wondering whether the officials, the media, and the pharmaceutical companies were in cahoots on swine flu,&quot; he said.&lt;/p&gt;
&lt;p&gt;But several experts argued that preparing for a worst-case scenario was the responsible thing to do.&lt;/p&gt;
&lt;p&gt;Sometimes, &quot;mother nature throws us a break,&quot; argued Howard Markel, MD, PhD, of the University of Michigan in Ann Arbor.&lt;/p&gt;
&lt;p&gt;&quot;We responded to a threat without knowing the future,&quot; he said in an e-mail. &quot;A far worse outcome might have occurred if we did not take the threat seriously and H1N1 turned out to be worse than we initially predicted.&quot;&lt;/p&gt;
&lt;p&gt;The public health response should be compared to the use of seat belts or auto insurance, according to Gregory Poland, MD, of the Mayo Clinic in Rochester, Minn.&lt;/p&gt;
&lt;p&gt;Every day, he said in an e-mail, he puts on his seat belt before driving. &quot;I don&apos;t finish each day and say &apos;What a waste, I didn&apos;t have an accident,&apos;&quot; he said.&lt;/p&gt;
&lt;p&gt;&quot;It is (and remains) unpredictable as to whether this virus could further mutate or change in a manner such that it could literally turn deadly within weeks,&quot; he said. &quot;If this pandemic had been deadly (and you don&apos;t know until you are into it) and we weren&apos;t prepared, the criticism would have been overwhelming.&quot; Poland said.&lt;/p&gt;
&lt;p&gt;He and others also noted that the flu season isn&apos;t over yet.&lt;/p&gt;
&lt;p&gt;&quot;This argument should be taking place at the end of the flu season in late March, not now,&quot; said Peter Katona, MD, of the University of California Los Angeles. &quot;Flu is unpredictable, and this is the heart of the argument.&quot;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_1294"
                     title="IVW: Pandemic Vaccines May be Too Little, Too Late"
                     score="-0.005"
                     href="http://www.medpagetoday.com/InfectiousDisease/SwineFlu/tb/13943?impressionId=1265811345384"
                     
      CANNES, France, April 28 -- If the swine flu outbreak develops into a pandemic -- and that&apos;s a big if -- the earliest the public would see a vaccine against the disease would be September, a researcher said here at the conference on Influenza Vaccines for the World.
              &lt;br&gt; 
              &lt;br&gt;And that&apos;s if the government asks industry to start production today, said Klaus Stohr, D.V.M., vice president and global head of Novartis Vaccines and Diagnostics and former head of the World Health Organization&apos;s global influenza program.
              &lt;br&gt; 
              &lt;br&gt;&quot;What we have seen the last two or three days is that the current pandemic vaccine system is not ideal not only in terms of timing . . . but also in terms of vaccine production,&quot; he said.
              &lt;br&gt; 
              &lt;br&gt;Any hopes that the version of H1N1 in the current seasonal vaccine would provide protection against the swine flu seemed to be dashed by preliminary data from Novartis-run tests.
              &lt;p&gt; 
              &lt;p&gt;Dr. Stohr said the findings suggested the H1N1 viruses contained in seasonal vaccines all the way back to 1980 are more closely related to each other than any are to the new virus, although he cautioned that more study was needed before concluding that there wouldn&apos;t be cross-protection.
              &lt;p&gt; 
              &lt;p&gt;He said that the outbreak of swine influenza A H1N1 has not changed &quot;the assessment that pandemic vaccines are too little, too late, and that they are not going to be a solution even for countries that have domestic vaccine production.&quot;
              &lt;p&gt; 
              &lt;p&gt;Based on the current state of the swine flu investigation -- ongoing clinical, epidemiological, and virological studies -- it would take about two weeks for vaccine strain preparation, he said.
              &lt;p&gt; 
              &lt;p&gt;Seed virus preparation would take another three or four weeks, putting the start of bulk production at the end of June, Dr. Stohr said.
              &lt;p&gt; 
              &lt;p&gt;Standardizing reagents would not be available for another eight weeks, and quality control would tack on an additional one to two, he said.
              &lt;p&gt; 
              &lt;p&gt;Only then, in early September, would Novartis and other vaccine makers start distributing vaccine, he said.
              &lt;p&gt; 
              &lt;p&gt; 
              &lt;p&gt;Any decisions regarding pandemic vaccine production, he said, are complicated by the fact that nobody knows whether the virus will cause a pandemic, become endemic in humans causing continuous small outbreaks, or fizzle out and disappear.
              &lt;p&gt; 
              &lt;p&gt;If the virus were to &quot;disappear&quot; though, that would not necessarily eliminate the need to prepare for its re-emergence if it remained in an animal reservoir, Dr. Stohr said.
              &lt;p&gt; 
              &lt;p&gt;A possible solution would be development of a tetravalent seasonal flu vaccine, he said.
              &lt;p&gt; 
              &lt;p&gt;Further complicating decision-making is the looming threat of an H5N1 avian flu pandemic.
              &lt;p&gt; 
              &lt;p&gt;&quot;The absolute risk of H5N1 to cause a pandemic has not changed,&quot; he said. &quot;It remains a strain with high pandemic potential.&quot;
              &lt;p&gt; 
              &lt;p&gt;Swine flu, however, has bumped it down to number two on the list, he said.
              &lt;p&gt; 
              &lt;p&gt;The swine flu outbreak serves as &quot;a stark reminder of the unpredictability of the timing and of the speed by which the pandemic situation can change,&quot; he said.
&lt;p&gt;
&lt;p&gt;&lt;a href=&quot;http://www.medpagetoday.com/InfectiousDisease/SwineFlu/&quot; title=&quot;Swine Flu Coverage&quot;&gt;&lt;img src=&quot;/images/swine.jpg&quot; border=&quot;0&quot;&gt;&lt;/a&gt;

    </recommendedItem>
    <recommendedItem id="20090101_19_2954"
                     title="Special Report: Surveillance Gap Slowed H1N1 Pandemic Response"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/ICAAC/tb/16039?impressionId=1265811345384"
                     
      &lt;/a&gt;&lt;p&gt;SAN FRANCISCO  --  No one was watching the pigs.&lt;/p&gt;
&lt;p&gt;That was one of the key factors that slowed the response to the 2009 H1N1 pandemic flu, experts said here at the Interscience Conference on Antimicrobial Agents and Chemotherapy.&lt;/p&gt;   




&lt;p&gt;Although the world was better prepared for a pandemic flu than it had ever been, the H1N1 strain blindsided scientists, who had expected the next pandemic to arise from an avian strain, probably the highly pathogenic H5N1 influenza that has been raging among poultry.&lt;/p&gt;
&lt;a name=&quot;top&quot;&gt;
&lt;div class=&quot;APL&quot;&gt;

&lt;span class=&quot;bbr_hd&quot; style=&quot;font-size:11px;&quot;&gt;In this story: &lt;hr width=&quot;90%&quot; style=&quot;border:thin dotted #9b9b9b; border-style: none none dotted;&quot;/&gt;&lt;ul&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#CDC&quot;&gt;The CDC moves into action&lt;/a&gt;&lt;/li&gt;&lt;br&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#vaccines&quot;&gt;Will the vaccines be accepted?&lt;/a&gt;&lt;/li&gt;&lt;br&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#video&quot;&gt;Michael Smith sits down with CDC&apos;s Nancy Cox, PhD&lt;/a&gt;&lt;img src=&quot;/images/cam.gif&quot;&gt;&lt;/li&gt;&lt;br&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#wave&quot;&gt;The second wave has already begun&lt;/a&gt;&lt;/li&gt;&lt;br&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#study&quot;&gt;Researchers will have much to study&lt;/a&gt;&lt;/li&gt;&lt;br&gt;&lt;li class=&quot;APP&quot;&gt;&lt;a href=&quot;#data&quot;&gt;Planners will get new data, too&lt;/a&gt;&lt;/li&gt;&lt;/ul&gt;&lt;/span&gt;&lt;/div&gt;
&lt;p&gt;Instead, it came from pigs. And it was missed because flu surveillance  --  good and getting better in birds  --  was spotty at best in swine, according to Nancy Cox, PhD, chief of the CDC&apos;s influenza division.&lt;/p&gt;
&lt;p&gt;Indeed, Cox said here, experts still don&apos;t know where and how the so-called triple reassortant H1N1 strain arose or how it got into humans. There is a gaping hole in the genetic record of several years between genes in the current H1N1 pandemic flu and their nearest known ancestors, she said.&lt;/p&gt;
&lt;p&gt;&quot;We still haven&apos;t found that missing link and we may never find it,&quot; she said.&lt;/p&gt;
&lt;p&gt;That gap in surveillance led to a major gap in pandemic planning, according to Jon McCullers, MD, of St. Jude Children&apos;s Research Hospital in Memphis, Tenn.&lt;/p&gt;
&lt;p&gt;Planners had assumed  --  because they were watching the birds  --  that they&apos;d have enough warning of a pandemic strain to get mitigation schemes in place to slow its spread, perhaps even long enough to get vaccines ready before the flu really took off.&lt;/p&gt;
&lt;p&gt;That part of the planning &quot;basically failed completely,&quot; McCullers said. &quot;The thing was all over the world by the time the CDC figured out we had a few cases in the U.S.&quot;&lt;/p&gt;
&lt;p&gt;But that&apos;s the flu for you. The &quot;mantra,&quot; according to Cox, is that &quot;flu is unpredictable.&quot;&lt;/p&gt;
&lt;p&gt;Indeed, one measure of its unpredictability is the basic fact that the pandemic flu is an H1N1 strain of influenza A.&lt;/p&gt;
&lt;p&gt;While the world&apos;s experts were focused on avian flu, the current pandemic strain was quietly evolving far from the microscope.&lt;/p&gt;
&lt;p&gt;&quot;No one really worried about an old H1 or H3 (virus) coming back out,&quot; McCullers said. That was one reason for watching the birds, not the pigs  --  there was a semiconsensus that old pandemic subtypes can&apos;t make a comeback because they leave a residue of immunity in the population.&lt;/p&gt;
&lt;p&gt;But that&apos;s clearly wrong, McCullers said. The current strain has enough genetic differences in its hemagglutinin and neuraminidase genes  --  the H and N in H1N1  --  that its nearest relatives last circulated in humans in the 1930s. Anyone who has immunity is likely very old indeed.&lt;/p&gt;
&lt;p&gt;In fact, the current pandemic may be evidence that the H1, H2, and H3 subtypes  --  the only subtypes known to have caused pandemics  --  are the only ones that &lt;em&gt;can&lt;/em&gt; cause a pandemic.&lt;/p&gt;
&lt;p&gt;It&apos;s an intriguing scientific question, McCullers said, and one that needs study before the next pandemic  --  if only so we don&apos;t get blindsided again.&lt;/p&gt;
&lt;p&gt;Intriguingly, the CDC had been aware of several cases over the past five or so years in which a triple reassortant flu virus, arising from swine, had caused illness in humans. But although there is some swine surveillance in the U.S. and other developed countries, there is almost none elsewhere, Cox said,&lt;/p&gt;
&lt;p&gt;And even in the U.S., there were no earmarked funds for swine flu, it wasn&apos;t a reportable disease, and it didn&apos;t cause a huge economic burden. &quot;There just hasn&apos;t been the emphasis on swine,&quot; Cox said. &quot;This is perhaps a gap that should have been closed earlier.&quot;&lt;/p&gt;
&lt;a name=&quot;CDC&quot;&gt;&lt;/a&gt;&lt;p&gt;Nonetheless, the CDC&apos;s experience with swine flu played a central role in the initial response to the pandemic.&lt;/p&gt;
&lt;a href=&quot;#top&quot;&gt;Go back to top of page&lt;/a&gt;&lt;br&gt;
&lt;p&gt;&lt;strong&gt;The CDC moves into action&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The first two index cases in the U.S. were children in San Diego. Using isolates from the second case, Cox said, the agency immediately began creating a vaccine seed strain, although it wasn&apos;t used in the long run to make the current vaccines because it grew too slowly.&lt;/p&gt;
&lt;p&gt;The agency had not done that for previous cases in which children were infected with a triple reassortant swine flu, but the situation was different this time:&lt;ul&gt;&lt;li&gt;The virus was novel.&lt;/li&gt;&lt;li&gt;Neither child had been exposed to swine.&lt;/li&gt;&lt;li&gt;And there appeared to be evidence of more cases in the community.&lt;/li&gt;&lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;&quot;That is exactly the situation in which you need to act very quickly,&quot; Cox said. &quot;You need to pull out all the stops.&quot;&lt;/p&gt;
&lt;p&gt;The decision was justified within days, when Canadian scientists, working with Mexican doctors, showed that the two U.S. cases were identical with a strain that was causing disease in Mexico City.&lt;/p&gt;
&lt;p&gt;Officials began rolling out the plans they had painstakingly crafted over the previous five years.&lt;/p&gt;
&lt;p&gt;Test kits were deployed, surveillance was ramped up  --  and the public was kept informed step by step and sometimes, it seemed, minute by minute.&lt;/p&gt;
&lt;p&gt;The CDC &quot;did an excellent job of disseminating information in very rapid, timely, and efficient ways,&quot; McCullers said, including daily press conferences, a Web site, e-mail, and even more modern methods like Twitter.&lt;/p&gt;
&lt;p&gt;One misstep  --  which may be coming back to haunt officials  --  was initially to call the pandemic strain &quot;swine flu.&quot; That caused some people to fear eating pork and even led to the slaughter of pigs in Egypt.&lt;/p&gt;
&lt;p&gt;But it also conjured up the 1976 swine flu pandemic, when a highly touted vaccination campaign was halted midstream amid concern that the drug was causing Guillain-Barr&amp;#233; syndrome.&lt;/p&gt;
&lt;a name=&quot;vaccines&quot;&gt;&lt;/a&gt;&lt;p&gt;That connection, experts here said, was causing a backlash against vaccines to combat the current pandemic flu even before they were approved this week. (See &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/15988&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/15988&quot; target=&quot;_blank&quot;&gt;FDA Approves H1N1 Vaccines&lt;/a&gt;)&lt;/p&gt;

&lt;a name=&quot;video&quot;&gt;&lt;/a&gt;

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&lt;a href=&quot;#top&quot;&gt;Go back to top of page&lt;/a&gt;&lt;br&gt;
&lt;p&gt;&lt;strong&gt;Will the vaccines be accepted?&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The CDC, using focus groups, is finding that resistance to the vaccine is based on the fear of Guillain-Barr&amp;#233;, the idea that the vaccine is &quot;experimental,&quot; and the perception that the H1N1 pandemic mainly causes mild disease, Cox said  --  the risk-benefit balance is off in many people&apos;s minds.&lt;/p&gt;
&lt;p&gt;&quot;If H5N1 had emerged, the public perception of risk would have been much greater,&quot; she said.&lt;/p&gt;
&lt;p&gt;But Cox and other experts argue that the vaccines are not experimental  --  they&apos;re made in exactly the same way seasonal flu vaccines are made and there have so far been no signs of anything untoward.&lt;/p&gt;
&lt;p&gt;The fear of Guillain-Barr&amp;#233; is &quot;overblown,&quot; McCullers said, and some scientists question whether the 1976 link to the syndrome &quot;was even real.&quot;&lt;/p&gt;
&lt;a name=&quot;wave&quot;&gt;&lt;/a&gt;&lt;p&gt;Whether the public&apos;s reluctance will persist once the second wave strikes is anybody&apos;s guess, especially if the disease pattern is the same as it was in the spring  --  widespread mild disease, with a small percentage of serious cases needing hospital care, and some deaths, usually among those with an underlying medical condition.&lt;/p&gt;
&lt;a href=&quot;#top&quot;&gt;Go back to top of page&lt;/a&gt;&lt;br&gt;&lt;p&gt;&lt;strong&gt;The second wave has already begun&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The pandemic flu produces severe disease preferentially in younger people, for reasons that remain unclear. But the first death in the second wave appears to be a teen in Memphis, and experts fear a relatively large number of such cases as the weeks roll on.&lt;/p&gt;
&lt;p&gt;CDC modeling, Cox said, suggests we&apos;ll see three times the number of pediatric deaths than were recorded in the 2003-2004 flu season, when 154 children died of influenza.&lt;/p&gt;
&lt;p&gt;&quot;There is a perception that this is a mild disease,&quot; she said, &quot;but it can be life-threatening.&quot;&lt;/p&gt;
&lt;p&gt;A clinical challenge will be for pediatricians, family physicians, and internists to understand the use of antiviral drugs in a young population, as well as to be aware of the signs of severe disease.&lt;/p&gt;
&lt;p&gt;There had been a fear that the virus might mutate over the summer and return in a more virulent form, as did the 1918-1919 pandemic flu. But that now seems unlikely, McCullers said.&lt;/p&gt;
&lt;p&gt;The differences between the first and second waves of the 1918-1919 pandemic flu appear to have arisen because the virus was not well adapted to humans in the first wave, he said. It had the potential to cause serious disease, but needed to adapt better before it could do so  --  something it did between the two waves.&lt;/p&gt;
&lt;p&gt;In contrast, the current flu &quot;is fully adapted already,&quot; McCullers said, and hasn&apos;t changed over the summer months.&lt;/p&gt;
&lt;p&gt;It is also lacking virulence factors that appear to be associated with severe disease, he said.&lt;/p&gt;
&lt;p&gt;For instance, he presented data here showing that the second reading frame of the PB1 gene in flu  --  dubbed &lt;em&gt;PB1-F2&lt;/em&gt;  --  produces a proinflammatory protein that may play a key role in the bacterial super-infections that are often a primary cause of death from flu.&lt;/p&gt;
&lt;p&gt;In 1918-1919, for instance, it&apos;s estimated that 95% of deaths were caused by bacterial infections on top of the flu, he said.&lt;/p&gt;
&lt;p&gt;That strain and others that are highly pathogenic  --  such as the H5N1 avian flu  --  &quot;seem to be very good at causing inflammation of the lung,&quot; McCullers said.&lt;/p&gt;
&lt;p&gt;On the other hand, the seasonal H1N1 flu strain that has been circulating doesn&apos;t have a fully functioning &lt;em&gt;PB1-F2&lt;/em&gt; gene and the H3N2 seasonal strain does not seem to cause excessive inflammation either.&lt;/p&gt;
&lt;p&gt;&quot;One of the reasons we&apos;re not seeing exceptionally severe illness . . . is lack of this protein,&quot; he said. &quot;That&apos;s not to say we&apos;re not going to see bacterial superinfections, but they&apos;re going to be less frequent.&quot;&lt;/p&gt;
&lt;a name=&quot;study&quot;&gt;&lt;/a&gt;&lt;p&gt;That&apos;s pretty much a consensus  --  that the disease pattern this fall will be much the same as in the spring  --  although all experts hedge their bets, citing the &quot;unpredictability&quot; of the virus.&lt;/p&gt;
&lt;p&gt;On the other hand, no one hedges when talking about the scientific opportunities.&lt;/p&gt;









&lt;a href=&quot;#top&quot;&gt;Go back to top of page&lt;/a&gt;&lt;br&gt;


&lt;p&gt;&lt;strong&gt;Researchers will have much to study&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;&quot;We are going to learn an awful lot,&quot; said Don Low, MD, of Toronto&apos;s Mount Sinai Hospital, who was one of the architects of the Canadian response to the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) in Toronto.&lt;/p&gt;
&lt;p&gt;Among other things, we might finally get hard data on how much mortality is caused by the seasonal flu  --  usually &quot;extrapolated&quot; from limited testing, he said, to be about 30,000 to 40,000 deaths a year in the U.S.&lt;/p&gt;
&lt;p&gt;Given the intense interest, it seems likely that testing has thus far captured almost every person who died of the H1N1 flu in Canada and the U.S. during the spring, when little seasonal flu was circulating.&lt;/p&gt;
&lt;p&gt;But this fall, it is possible that both pandemic and seasonal flu strains will circulate at the same time  --  and expanded testing will capture and classify all the deaths from repiratory causes, Low said.&lt;/p&gt;
&lt;p&gt;That should help sort out which of the plethora of viruses that circulate in what Low called the &quot;respiratory season&quot;  --  parainfluenza, respiratory syncytial virus, adenovirus, rhinovirus, and good old flu  --  is actually the most deadly.&lt;/p&gt;
&lt;p&gt;&quot;For the first time, we might get some real true numbers,&quot; he said.&lt;/p&gt;
&lt;a name=&quot;data&quot;&gt;&lt;/a&gt;&lt;p&gt;Interestingly, for at least part of the Mexican outbreak, there was a parallel epidemic of parainfluenza, according to Guillermo Ruiz-Palacios, MD, of the National Institute of Medical Sciences and Nutrition in Mexico City. In 66% of severe cases of H1N1, patients were found to be co-infected with parainfluenza, he told a special symposium on the pandemic.&lt;/p&gt;&lt;/a&gt;&lt;a href=&quot;#top&quot;&gt;Go back to top of page&lt;/a&gt;&lt;br&gt;
&lt;p&gt;&lt;strong&gt;Planners will get new data, too&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The second wave also offers a unique chance to pose and answer some questions about how to deal with pandemics, McCullers argued.&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s kind of a trial run, where we&apos;re not going to have a lot of deaths, and we get to figure out what was good about our pandemic planning and where we still have some work to do.&quot;&lt;/p&gt;
&lt;p&gt;One suggestion, he said, is that researchers might conduct randomized trials of school closings. Since children are a reservoir for the flu, the theory has been that shutting the schools and keeping children apart might slow the progress of an epidemic.&lt;/p&gt;
&lt;p&gt;Indeed, considerations such as those motivated the Mexican government to close schools  --  and later to shutter nonessential businesses  --  during the first weeks of the outbreak there this spring.&lt;/p&gt;
&lt;p&gt;The problem is, no one has ever had the chance to test whether such &quot;social distancing&quot; methods have any effect, McCullers said. &quot;But we can test it right now,&quot; he added, &quot;so next time we won&apos;t have to say we don&apos;t know if it works.&quot;&lt;/p&gt;
&lt;p&gt;The key thing is to make sure the research gets done, Low said, and is not lost in the urgency of the moment. &quot;Doing research in the heat of an outbreak is difficult, but it has to be done,&quot; he said.&lt;/p&gt;
&lt;p&gt;Research so far indicates that the virus has not changed genetically over the summer, which is one reason for thinking the coming weeks will see mainly mild disease. But even mild disease  --  if there&apos;s enough of it  --  can be a problem, Low said.&lt;/p&gt;
&lt;p&gt;In the spring, he said, there was very little bacterial superinfection, in line with McCullers&apos; research. And &quot;excellent care&quot;  --  including high-pressure ventilators, extracorporeal membrane oxygenation, and antiviral drugs  --  kept many of the more severely affected patients from dying.&lt;/p&gt;
&lt;p&gt;But that was with between 5% and 10% of the population infected. &quot;If instead of 5% to 10%, it is 20% to 30%, that&apos;s going to be the test of the system,&quot; McCullers said.&lt;/p&gt;
&lt;p&gt;It may be that we&apos;ll never know how many people get the H1N1 flu  --  many will be mildly ill and not see their doctors. On the other hand, although we have an idea how well the pandemic strain spreads in spring and summer conditions, we don&apos;t know what will happen in traditional flu season.&lt;/p&gt;
&lt;p&gt;It&apos;s flu, experts said here. Expect the unexpected.&lt;/p&gt;

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