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So far, region's experience with H1N1 flu has been mild, but there's still a chance for third wave

This article first appeared in the St. Louis Beacon, Jan. 7, 2010 - In late October, the Parkway School District was being hit hard by the H1N1 virus. Nurses and teachers were getting sick. There were days when 6, 8 or as many as 13 percent of students in a given school were absent.

"We certainly felt the flu here," said Lisa Harnacker, manager of health services at the Parkway School District. "But as fast as those numbers went up, they seemed to drop off quickly."

Through November, December and now at the start of the new term, absences are low across the district, Harnacker reports. Custodians are still wiping door handles. Posters about washing hands are still plastered on classroom doors. Close to 17,000 doses of the H1N1 vaccine have been administered across the district -- with more to come for children under 10 who require a second dose.

While all is mostly quiet on the flu front, Harnacker knows that can quickly change. "This is not a usual flu season, and I do expect another wave in late February or early March," she said. "I'll be keeping a close eye on attendance."

The experience at the Parkway schools seems to mirror the H1N1 trends both across the nation and regionally. Confirmed cases of the flu, as well as flu-associated hospitalizations and deaths, peaked in the United States from the middle of October to early November. Those numbers have generally been decreasing ever since, according to weekly reports compiled by the Centers for Disease Control and Prevention.

As 2010 begins, health officials say the H1N1 virus has done less damage than was initially feared. While an estimated 10,000 people have died of the so-called swine flu since April, that number is unlikely to reach the predicted 30,000 to 90,000 fatalities made over the summer by the President's Council of Advisors on Science and Technology. Seasonal flu typically kills about 36,000 Americans each year.

The Regional Outlook

In Missouri, 11 deaths attributed to H1N1 have been reported, according to Kit Wagar, a spokesman for the Missouri Department of Health and Senior Services. They have come from all across the state and the age spectrum: three victims in their pre-teens or teens, two in their 20s, one in the 30s, three in their 40s and two in their 50s.

"There's been no pattern at all to this," Wagar said. "Probably a majority of victims had underlying health problems, or their body overreacted or didn't react quickly enough."

Through the week ending Jan. 2, the state reports that roughly 28,000 cases of flu have been documented this season -- the vast majority of which are H1N1. Last year, through the first 12 weeks of the flu season, just 300 cases had been reported, Wagar said. (The season typically peaks here in January or February.)

Estimating the number of flu cases and deaths is an inexact science because many people with flu-like symptoms don't seek medical help. The CDC monitors flu trends and uses statistical modeling to come up with its hospitalization and death counts. Wagar said many more people than reported have suffered from H1N1.

Still, Wagar said, Missouri "hasn't been hit as hard" by the virus as have other parts of the country. "For [the flu] being reported on an outrageous scale compared with a traditional year, we still have been pretty lucky compared" with other states, Wagar said.

Flu cases peaked in Missouri toward the end of October, when 1,682 cases were reported in one week. "I don't think a lot of people realized how bad it was getting for emergency rooms," Wagar said. "They were getting overwhelmed."

But the flu numbers have dropped off significantly here since then. Wagar remains concerned about another increase in cases coming later in the winter.

"Pandemics tend to come in waves," Wagar said. "The one in April wasn't that bad. We had a huge wave that peaked the last week of October. What worries us all is the possibility of a third wave that will be that much bigger."

In St. Louis, the number of flu cases reported is eight to nine times greater than in a typical year, said Melba R. Moore, health commissioner of the St. Louis Health Department. But Moore said the flu season turned out to be "milder" than expected based on data from the spring.

In St. Louis County, more than 2,100 flu cases have been confirmed this season, according to Craig LeFebvre, a spokesman for the St. Louis County Department of Health. Flu numbers in the county also saw a spike in May and then to a greater extent in October. Since then, totals have generally been down.

Vaccination Campaigns Continue

After a period in the fall when the supply of H1N1 vaccine couldn't meet demand, Wagar said he is now confident that everyone in the state who still wants the vaccine can get it. In all, more than 1.6 million doses of the H1N1 vaccine have been shipped to Missouri through the state's health department. Retailers such as Walgreens are also getting the vaccines directly from suppliers.

"We are pleased with the number of people who have been vaccinated, but a lot more people are left," Wagar said. "To establish herd immunity, you have to reach people who aren't in the priority groups. Sure, numbers are down, but the number of people visiting hospitals with flu-like symptoms is still 50 percent higher than normal."

Added LeFebvre: "We are concerned that people will believe that the event has come and gone," he said. "People who most wanted or needed the vaccine in most cases have been able to get it. Now we're moving to the population who may need persuasion to get the vaccine."

The St. Louis County Department of Health has received 270,000 doses of the H1N1 vaccine thus far. LeFebvre said demand is still there from county residents. "We've gone from an extreme shortage to now receiving shipments all the time," he said. "We haven't reached a point where arriving shipments are piling up. People are still lining up at clinics every day."

St. Louis County is offering the vaccine for free at the North Central Community Health Center, 4000 Jennings Station Road, in Pine Lawn, and the South County Health Center, 4580 S. Lindbergh Blvd., in Sunset Hills. There are also Wednesday clinics through January at Greensfelder Recreation Complex in Queeny Park, 550 Weidman Rd., in Ballwin.

The St. Louis Department of Health has received nearly 125,000 doses of the vaccine and has administered roughly 86,000 doses thus far. Moore said she's confident that there's enough supply to meet the current demand.

One area of focus: Vaccinating students who are coming back from winter break. Moore said more than 100 St. Louis Public Schools have completed in-school vaccination clinics, with dozens more to go.

Hospitals Respond

Keith Woeltje, an associate professor of infectious diseases at Washington University and medical director of infection prevention at BJC Health Care, said that overall, "St. Louis got lucky in that it has not be a terrible H1N1 season thus far."

Unlike the seasonal flu, which typically hits the elderly the hardest, H1N1 often sets its sights on young people. So it's no surprise that of all the medical facilities that are a part of BJC Health Care, St. Louis Children's Hospital has been slammed the most with flu cases. At the height of the pandemic this fall, the hospital opened an extra triage area to control the flow of patients visiting the emergency room.

"Other than that, the volume of patients was up, but not out of control," Woeltje said. "And other than Children's, most of the hospitals weren't severely affected."

He said hospitals are continuing to ask employees and visitors with flu symptoms to stay away so that they don't infect patients, many of whom already have weakened immune systems. With plenty of H1N1 vaccines now in their possession, several hospitals have set new rules about their employees getting the shots or sprays.

At Barnes-Jewish Hospital, employees, including nursing students and residents, are required (with a few exceptions) to get both the seasonal flu and H1N1 shot by Jan. 31, according to Kathy Holleman, a BJC spokeswoman. The vaccines went first for people who worked with patients who are in the high-risk category for H1N1, and since December have become available to everyone.

Employees of SSM Health Care have been asked either to receive both the seasonal flu and H1N1 shots or sign a declination saying they will not be getting vaccinated. Deena Fischer, a spokeswoman for SSM Health Care-St. Louis, said there are enough doses for all employees to get the H1N1 vaccine.

As of late December, Fischer said at the adult hospitals the employee vaccination rate for the seasonal flu was about 65 percent, with about a 10 percent declination rate (before the supply of vaccine fell short). Nearly everyone at SSM Cardinal Glennon Children's Hospital had received the vaccine.

A similar seasonal flu and H1N1 vaccine declination policy is in place for employees of St. Louis University Hospital and those who work for an on-site vendor. Three-fourths of employees chose to be immunized for the seasonal flu, and about 70 percent for H1N1, according to Staci Harvatin, a hospital spokeswoman.

At the St. Louis VA Medical Center, veterans and center staff are encouraged to get the H1H1 shots -- but they aren't required for employees. Marcena Gunter, a spokeswoman for the medical center, said the abundance of the vaccine (available at the John Cochran and Jefferson Barracks sites or at community-based outpatient clinics) should satisfy demand from patients and employees over the coming months.

Lessons Learned

While the flu season is far from over, plenty of people are already weighing in on the handling of the pandemic. A Washington Post commentary co-authored by former Missouri Sen. Jim Talent criticized the government's response to H1N1, saying that the technology and systems needed to respond to emergencies related to disease are outdated, leading to vaccine shortages and long lines at clinics. Others have been critical of the reliance on foreign vaccine makers and the massive recall of children's vaccine doses.

Jeffery Lowell, senior adviser to the mayor of St. Louis for medical affairs who helped organize a regional medical response system that involves both health departments and hospitals, said the St. Louis region has responded well to the H1N1 pandemic.

"We couldn't control vaccine technology or production based on foreign drug manufacturers, but in terms of hospitals and health departments coordinating as a region, I'd say 'A' or 'A-'."

Lowell said health officials were challenged to set policies, such as distributing vaccines and immunizing students and health workers, in an ad hoc way, and "the public health component of government shined.

"It can be explained that the flu just moved on, or that our measures for protecting the community were effective, or both," he added.

Woeltje, the infectious disease specialist, said one of the takeaways from the fall flu wave is the importance of taking pressure off hospital emergency rooms, and of isolating patients with flu symptoms immediately. He said the vaccination efforts continue to be critical.

"We don't know what will happen next, but if people continue to get vaccinated it can help the third wave from being significant," he said. "If [the H1N1 flu] does come back in the spring, we should be even better prepared because we've already dealt with it."