Going Viral

Six months have passed since the first case of H1N1 cropped up in North Carolina. Meanwhile, the more familiar seasonal flu is only now about to start making its annual appearance.

Take your best shot: Buncombe County's Disease Control Supervisor preps a dose of the H1N1 vaccine. The Health Department has administered 5,600 doses so far, but the novel strain may be back for another round as winter nears. Photo by Jonathan Welch

Initially, the H1N1 vaccine was in short supply and vaccinations were sporadic, but the Buncombe County Health Department now reports increased availability and is scheduling more vaccination clinics, particularly in schools around the county. So far, the Health Department has administered about 5,600 doses. To date, only one death in Buncombe County has been confirmed to be H1N1 related.

But holiday travel, which crowds too many people into enclosed, confined spaces, creates ideal transmission scenarios. Xpress spoke with county Disease Control Supervisor Sue Ellen Morrison to get the news from the front lines of the fight against H1N1.

Mountain Xpress: Who is most vulnerable to the H1N1 flu?
Sue Ellen Morrison:  That's been one of our challenges: trying to get the information conveyed that it is different from the seasonal flu. With seasonal flu, you typically see the very young and the very old impacted. With H1N1, we have seen the very young and healthy middle-aged people hit very hard. It's not the 65 and older as much as the younger age groups. What they think is the reason for that is that there has been some past immunity — that the swine flu circulated in some strain similar to what we see now. So the push has been for people under 65 years of age to get vaccinated. The highest rate of hospitalizations have been pregnant women and children 0-4. Also, up to 24 years of age, we have seen them having some poor outcomes too.

What do we know about the local impact so far?

It's still widespread. From the reports that we've been getting from physicians' offices, I don't see anything different than what we're seeing nationally. The [N.C. Influenza Sentinel Surveillance report] that comes out weekly is showing that there is a slight decrease for influenzalike illness. I'm going to emphasize slightly. We don't know where this is going; we don't know if it's going to level off at this point, hang there for a while. Could it go back up?

According to the CDC, we are on the second wave of this: We are hoping that it will decrease. But we know that waves can span a course of time. And remember, we are just starting to go into our seasonal flu. December and March are usually our big seasonal [flu] time.

[Locally], we are [tracking] numbers of people who go to their physicians each week who have flulike illness. They are testing people who are admitted to the hospital and end up in intensive care, and they are doing H1N1 testing on those who have died. Those are the only confirmatory tests we have right now.

What does it mean to move in waves?

[A wave is] when the spread of this disease gets ahead of our ability to control it. The vaccine wasn't available initially. Now we think the decline is because of vaccine efforts and educating people. A third wave is possible. This is a new strain, so we are not sure what its characteristics are going to be. If H1N1 were to mutate, then we're not sure how it would impact these waves. But right now we haven't seen a mutation of this strain.

We have a novel virus, so we don't have a lot of comparison data with this, except to look at other times we have seen circulating viruses. Usually a wave runs anywhere between six to 12 weeks. So you can see it go up and go down.  The first wave really began in April, when a lot of these cases started to get reported. There was a spike and there was a decrease over time, and now it's gone up again. From what the CDC is saying, we are beginning the decrease of that second wave.

Is fever the biggest symptom? How do you know when it's H1N1?

Fever is really the indicating symptom. If people are not feeling well and it's lingering, if they are running a high fever, they need to find out what the cause of that is. Now physicians know that this is the only circulating strain right now, so in all likelihood it is H1N1.

But confirmatory tests [are the only way to know for sure]. They'll take that swab, send it out to a state lab and, days later, the lab will give them a result. Sometimes they'll do [a test] in the doctor's office. That will tell them you have a type of flu, but it won't tell them if it's H1N1. There's not a test that can be done in the office where they can tell right then that it is H1N1.

What sort of recovery time have you seen?

Generally speaking for a healthy person, they can get over that in three to five days. Sometimes you hear about people being sick for two weeks. That's not uncommon. You can get really sick from the flu. And flu can lead to pneumonia, and that's usually what kills someone. Hospitalization is not something to take lightly. I think people find it very easy to pass this and say, "Oh, it's just the flu." We see healthy children die of the [seasonal] flu every year — and healthy adults too. The flu kills 36,000 every year.

How are you getting the vaccine out into the community?

The seven clinics that we held [Nov. 19], we did an all-call, when we work with the school system and they do an automated phone message that goes out to the homes of all county students. We are being creative and trying to find out the best ways to get the vaccine out to these people. We pushed a lot of vaccines out to physicians' practices. We focused on high-risk practices like OBs and pediatrics and specialty practices, because those that have chronic conditions are part of the target group. We are going to meet today to see what is our next plan of action. We want to see how much vaccine is left. We don't know if we've saturated a certain age group or target group and should move into other areas.

The state sent out a small amount originally; we got rid of it very quickly. And because we didn't take too long to turn the tables on this vaccine, they continue to send more. I think that's why we've continued to get more vaccine each time. They see our efforts; we don't keep it in-house very long.

Do you think our community is getting more vigilant regarding H1N1?

Yeah, I do. I find it interesting that when you go into grocery stores, you see hand wipes for wiping down the handle on the cart. I've seen hand sanitizer when I've gone into banks. I do think people are getting more on board. Every time I see that I smile. I'm really appreciative that people are getting the word and they are taking it to heart. And they are trying to get their co-workers to do the same. We have talked about hand washing constantly throughout this process. We've worked with school systems to relax a little bit their policy on absenteeism. We've even heard that businesses are getting more on board of relaxing their policies for when you are sick.

Is mist the primary form of vaccine right now?

The majority of what we have right now is the mist. It's licensed for use for ages 3 though 49. So you can't take that to some clinics, because some people are going to be older and they can't take it. If you have any chronic conditions, you really should not get the mist: You should get the shot form. That's why we targeted just mist at the schools.

One of the questions that has come up is, if a child got the seasonal flu vaccine in school, when can they get the H1N1 vaccine? If they got the seasonal shot, they can get the shot or the mist for H1N1 any time. The difference is, if they got the seasonal mist, then they have to wait a minimum of two weeks to get the second mist. If they are both shots, you can get them both vaccines at the same time.

Have you heard worries about the vaccine?

I've heard people concerned that [the mist] is a live vaccine. They want to know if there was a rush to production. There have actually been as many studies done on this novel strain as there have been on seasonal flu. Today's live vaccines are not the same as they were years ago. It's not going to have as full a punch. The injectable form takes about two weeks to be effective; the live vaccine takes about seven to 10 days.

The other thing that has come up is the injectable form. There are people who seek out the preservative-free vaccine. But people need to know that preservatives are a stabilizer. Every time you put a needle [into the vaccination bottle], you have to have something to stabilize that vaccine. [The preservative] is a mercury, but it is an ethylmercury, not a methylmercury. I don't think people understand the difference between those two. Methylmercury is what is in a tuna sandwich. If you were to eat a tuna sandwich in front of me right now, it has five times more mercury than what's in a shot. This is a different kind of mercury, and it's a fraction. But if you ask for preservative-free, we do have that. We usually use it for children or pregnant women.

Is the holiday travel season a concern for transmission of H1N1?

Yes. If people are sick, they need to stay home. They are not going to get better. Usually, they are going to get worse, and then you have to find health care wherever you are going. And you are going to expose who else on the flight? On planes, trains and automobiles, people need to be thinking about who is around them. I heard one of the airlines is going to relax on their policy on cancellation. I'd like to see that continue. Even cruise ships right now are asking people, "If you are sick, stay home." Because the likelihood is you are going to pass it on, and it's going to spoil their vacation too. They're also encouraging people to carry hand sanitizer and tissues along with them.