Swine Flu Symptoms Spread; Nations Impose Quarantines, Issue Travel Advisories

As Mexico City canceled all of its public events after 20 confirmed deaths and as many as 81 potential deaths from what World Health Organization officials fear might be the start of a pandemic new combination strain of H1N1 swine flu, communities throughout the United States are reporting outbreaks of a milder version.

From California to Texas to Kansas and New York, public health authorities have confirmed 11 cases of swine flu and continue to investigate possible additional cases in which swine flu symptoms are being reported, including an outbreak that struck 8 students from a private school in New York.

Half of the tissue samples taken from victims of the deadly Mexico City outbreak genetically matched the flu strains identified in California and Texas, according to the Centers for Disease Control, proving that the Mexican and American flus are related.

WHO Declares Public Health Emergency of International Concern

WHO's Emergency Committee yesterday declared the Mexico and US outbreaks "a public health emergency of international concern," potentially opening the door to issuance of advisories against travel to those destinations. The goal of travel advisories is to prevent the spread of disease. In the absence of more data on the swine flu outbreak, WHO declined to increase the outbreak's level 3 classification on WHO's 6 level international alert system. WHO is continuing to monitor the outbreak's pandemic potential.

WHO's Director-General Margaret Chan confirmed at a virtual press conference yesterday that no cases of this swine flu had been reported outside Mexico and the U.S. However, that situation is changing rapidly. By today, reports of suspected swine flu symptoms surfaced in New Zealand, Spain, France, and Israel. Tokyo is testing the temperatures of passengers arriving from Mexico for signs of fever, AP reported today.

The swine flu virus route of exposure is person to person transmission. If the flu continues to spread in this way, as today's news seems to indicate, it will meet the criteria for WHO raising the pandemic alert level to stage 4, which requires sustained capability of the virus to pass from person to person. Stage 5 is declared when a pandemic is imminent and stage 6 when a full scale pandemic is underway.

This new flu strain combines genetic material from pigs, birds and humans in a manner never before seen by public health authorities. The swine flu symptoms may include respiratory symptoms, body aches, fever, fatigue, coughing, sore throat, pneumonia,vomiting and diarrhea.

Asked whether this flu outbreak presented parallels to the deadly 1918 Spanish flu epidemic, Chan said that while both outbreaks superficially seem to inflict severe disease on a high proportion of healthy young adults, it has not yet been confirmed that H1N1 is actually responsible for the large number of illnesses being reported in young adults in Mexico. WHO is awaiting further data on those cases.

Some countries are not waiting for further data but have issued warnings against travel to affected parts of the U.S. and Mexico. Russia has banned pork imports for areas of the U.S. and Mexico where the swine flu has been reported; however WHO representatives and other health authorities say that eating pork presents no risk.

Public Health Response to Swine Flu Symptoms

New York's governor today announced that enough Tamiflu to treat 1,500 swine flu patients is being flown into New York City. Chan told reporters that preliminary data indicate that Tamiflu is effective in fighting the swine flu symptoms.

According to Associated Press, one couple in Kansas agreed to voluntary isolation after suffering a mild form of swine flu upon the husband's return from a business trip to Mexico.

Mexico's government has taken a coercive approach, giving President Felipe Calderon's Health Department plenary power to isolate flu victims, inspect homes, and inspect inbound travelers and luggage. Mexican soldiers and health workers are said to be patrolling airports and bus stations on the lookout for travelers displaying swine flu symptoms.

The U.S. Embassy in Mexico passed on to Americans the Mexican government's advice to avoid crowds, subways, handshaking and kissing as a greeting, keep a distance of 6 feet from other people and avoid visiting Mexican hospitals except for medical emergencies. The Embassy closed all nonessential consular services as a result of the flu outbreak.

The Mexican government's assumption of plenary power to seek out and isolate persons displaying swine flu symptoms raises the specter of the emergence of new Typhoid Marys, or perhaps, Typhoid Marias.

Although no cases of swine flu have yet been reported there, Russia, China and Taiwan have all announced intentions to quarantine anyone presenting swine flu symptoms.

Coercive Isolation and Typhoid Mary

"Typhoid Mary," whose real name was Mary Mallon, was an impoverished Irish domestic worker who was quarantined in 1907 by U.S. public health authorities when they realized that while healthy herself, she was a typhoid carrier and had sickened numerous wealthy New Yorkers who employed her as a cook. The quarantine was lifted after 3 years on condition that Mary refrain from returning to work as a cook. 5 years later, Mary assumed the name Mary Brown and resumed her old occupation, sickening 25 more people with typhoid. Public health authorities tracked her, then quarantined her for the rest of her life, 23 years. While Typhoid Mary's confinement was deemed necessary to protect public health at the time, later generations came to view her confinement as overzealous action on the part of a government influenced in part by Typhoid Mary's lowly status as an Irish immigrant domestic worker who sickened more powerful, wealthy citizens and in part because she was an assertive woman.

Newsday described how Mary Mallon came to be identified as the cause of the typhoid outbreaks. A family who had employed her briefly was worried that if they could not identify the source of the typhoid outbreak that had sickened several family members, their house would not rent. They hired sanitary engineer George Soper to solve the mystery. Soper concluded that the former cook Mary Mallon, whose brief stay in the household coincided with the outbreak, must be a healthy typhoid carrier. He strode into her new place of employment, unannounced, and told her she was spreading death and disease through her cooking and he wanted samples of her feces, blood and urine for tests, Newsday said. According to Soper's writings, "she seized a carving fork and advanced in my direction."

Soper researched Mary's work history and presented a statistical case to the New York Health Commissioner documenting typhoid outbreaks that occurred in household's employing her. The New York Health Commissioner carried her kicking and screaming to a hospital where she was confirmed to be a healthy typhoid carrier, the confined as a public health threat. Typhoid Mary had no recollection of ever having typhoid and apparently never did believe she was a carrier.

Ironically, while the government isolated Mary Mallon so she couldn't go to work as a cook, she baked and sold cakes to the hospital employees at the facility where she lived in lifetime quarantine.

Sources: http://online.wsj.com/article/SB124058255179552887.html; http://www.who.int/mediacentre/news/statements/2009/h1n1_20090425/en/index.html; http://news.yahoo.com/s/ap/20090424/ap_on_he_me/med_swine_flu; http://news.yahoo.com/s/ap/20090426/ap_on_re_us/us_swine_flu_states; http://www.bloomberg.com/apps/news?pid=20601087&sid=a9Vdmq5kT9Rc&refer=home; http://health.yahoo.com/news/ap/med_swine_flu.html; http://www.usembassy-mexico.gov/eng/eacs_warden_090425update_FluOutbreak.html; http://www.pbs.org/wgbh/nova/typhoid/mary.html; http://www.newsday.com/community/guide/lihistory/ny-history-hs702a,0,6698943.story; http://www.guardian.co.uk/world/2009/apr/25/flu-pandemic-flu; http://terrance.who.int/mediacentre/audio/press_briefings/VPC_25APR2009swine_influenza.mp3; http://news.yahoo.com/s/ap/20090426/ap_on_re_au_an/swine_flu_world.