At the Ready

By Robin Tricoles

Students and faculty aid the CDC during the H1N1 outbreak


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When it comes to disease outbreaks, Rollins has the expertise and manpower to help. Last spring, as H1N1 avian influenza spread, first in Mexico and then across the globe, the CDC put out a call asking students to assist. Within three days, 85 RSPH students had volunteered.

Nick Schaad was among the students authorized to help man the CDC's Emergency Operations Center at the height of the H1N1 outbreak. Schaad volunteered as part of the Student Outreach Response Team, whose members help bridge the gap between classroom theories and the realities of public health practice.

Once the CDC began to identify influenza clusters, students began conducting phone surveys. "I was involved in the St. Francis prep school survey in New York," says Schaad. "Students and staff members who were sick with any flu-like symptoms were identified. We called them and asked about the size of their household, what they might have done to protect themselves, and any recent travel. Our goal was to learn as much as possible about H1N1 in advance of the fall flu season."


“I was involved in the St. Francis prep school survey in New York. . . Our goal was to learn as much as possible about H1N1 in advance of the fall flu season.” —Nick Schaad, student volunteer at the CDC


Schaad's experience at the CDC re-enforced what he learned during his first year at Rollins. "I had a class in survey methods, and it applied directly to my work at CDC, everything from the training we went through to how we phrased the survey questions. My work at CDC also helped me get ready for my practicum this summer. I worked in northern Sri Lanka with the CDC's International Emergency and Refugee Health Branch to conduct surveys on mortality and general health."

Like the students they teach, RSPH faculty are helping and learning as much as they can regarding H1N1. In April, the CDC tapped three faculty members to serve on Team B. A strategic concept developed by the CDC in the early 2000s to cope with the growing complexity of public health emergencies, Team B includes experts from outside the CDC to quickly review and inform the agency's efforts.

Keith Klugman was a natural choice for H1N1. Klugman, a physician and microbiologist who holds the William H. Foege Chair in Global Health, is regarded as the world's leading expert on bacterial pneumonia. Understanding the bacterial complications of viral flu is vital to diminishing its lethality. RSPH experts Ruth Berkelman (emergency preparedness) and Carlos del Rio (infectious disease) also served on Team B.

"My role included the bacterial complications of influenza," says Klugman. "We reviewed and commented on the CDC's policies before they were made public. Members also had an opportunity to identify aspects of the epidemic for which we thought CDC ought to develop policy, and the CDC has been very responsive to our suggestions."

A key policy area that must be developed: methods to get the most out of available immunizations once flu season begins. One method includes vaccinating young babies for flu and for pneumococcal infections. Not only does this immunization protect babies, it protects adults as well.

"Young babies and children seem to be the key to flu transmission," says Klugman. "If you can immunize the majority of young infants, you may reduce the transmission in the population as a whole."

Klugman cautions that H1N1's epidemiology may be different from that of past flu viruses. So far, this strain seems to affect younger people more than older and thus affects which demographic group should be targeted for immunization.

Along with collaborators at Harvard, Klugman is developing a model to measure the impact of vaccinating particular populations against pneumococcal disease. The model will show not only the vaccination's economic impact but how it affects morbidity and mortality associated with influenza pandemic. Influenza is often associated with pneumococcal pneumonia, especially in the young and elderly.

"We used the 1918 flu pandemic as a model but updated it to include the introduction of antibiotics," says Klugman. "The model showed that vaccinating children would be highly cost-effective in the advent of a pandemic and even during an endemic flu season. What's more, in the pandemic model, the vaccine, depending on certain assumptions, can save many hundreds, thousands, or even millions of lives depending on the extent to which the influenza is leading to complicated bacterial pneumonias.

"Evidence from 1918 clearly shows that the great majority of deaths were due to bacterial complications of the flu," he adds. "In other words, the flu itself could occasionally cause death on its own. But it caused death mostly by facilitating a synergistic lethality between itself and bacteria."

Much has changed in fighting flu since 1918. The bacteria that caused so many deaths still exist but are susceptible to antibiotics. Yet vulnerable people and populations especially are likely to suffer.

"I'm concerned about deaths related to bacterial infections in the developing world," says Klugman. "As H1N1 influenza spreads into Africa and into parts of Southeast Asia, then questions about access to antibiotics become important. I would expect morbidity and mortality associated with bacterial super infections to increase."

Experts have yet to know how the H1N1 virus interacts with HIV, a great concern in Africa. "Certainly there is a massive interaction between HIV and bacterial infections," says Klugman. "If bacterial infections increased in asssociation with flu, HIV-infected people would be at particular risk."

"Evidence from 1918 clearly shows that the great majority of deaths were due to bacterial complications of the flu." —Keith Klugman, William H. Foege Chair in Global Health


A world of unknowns

Health officials worldwide are concerned about H1N1's responsiveness to treatment, its virulence, and its lethality when combined with underlying bacterial infections, especially in the developing world. Thus far, WHO has categorized the H1N1 pandemic as moderate.

"The major risk in the Southern Hemisphere and the poorer parts of the world depends on what treatment is available should one become very ill," says Klugman. Patient access to respirators is just one example.

"We're witnessing the evolution of the flu," he adds. "It's generally been moderate. By mixing with the circulating flu in the Southern Hemisphere, it could mutate and become resistant to the first line of flu drugs. It could also become more severe." By September, nearly 600 deaths from H1N1 had occurred in the United States, where the peak flu season has yet to begin. Says Klugman, "We must remain ever vigilant."

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