Swine Flu Sticker Shock
Recombinomics Commentary 15:08
August 28, 2009

"We probably had four or five guys that eventually had the flu and haven't been at practice. And you had four or five other guys who sort of had the upper respiratory thing without the fever - and really not the flu - and they've been able to manage their way through it."

This year's widespread flu outbreak has become a problem for football teams at all levels across the South. High schools teams are considering canceling games in several states.

Ole Miss cancelled a fan day. Tulane had more than 20 players miss practice last week because of a flu outbreak on the team. The Green Wave's team physician, Greg Stewart, told the Tulane Rivals' site WaveReport.com that, "It's an average of five days, usually," for the virus to work its way out of the system.

"We're very hopeful that this does not become an issue for college football or sports this fall," Saban said. "Hopefully, the management things we're doing will help us not have an issue or a problem."

The above comments on swine flu at the University of Alabama begin to describe the extent of pandemic H1N1 (swine flu) at schools throughout the United States, with similar issues throughout the northern hemisphere.  The students and parents are experiencing "sticker shock" when they realize that swine flu is widespread and spreading rapidly (see map), leading to 10-20% absenteeism, even though agency reports and media stories have largely disappeared over the summer.  Although there were reports of outbreaks at summer camps, most assumed these were isolated incidents.  The CDC had ceased reporting cases in daily or weekly updates.  Instead on August 5 they switched to national aggregate numbers for hospitalized and fatal cases.  State agencies followed suit.  Many even stopped reporting fatal cases, and instead linked to aggregated CDC numberss.  This information dearth led to a dramatic reduction in media coverage, leading to the widespread belief that swine flu had largely "disappeared".

However, the start of the school year created an environment where spreading cases could not be denied.  Even though most states had ceased testing mild cases and limited testing to hospitalized or clustered cases, the flu-like conditions were hard to miss.  Moreover, since seasonal flu was virtually non-existent in August, almost all influenza infections were swine flu, even though many school administrators and nurses erroneously interpreted an influenza A positive result as "normal" or seasonal flu (over 99% of influenza A positive patients in August have swine flu). 

Similarly many also assumed that swine flu was associated with fever, due in part to the fever association with seasonal flu, as well as CDC documents (see table showing 93% of hospitalized H1N1 patients had fever), and guidelines which emphasized fever as a determination of who should not come to school, as well as a marker as to when students could return to school.  However, over 50% of swine flu infections do not produce fever, so many infected students remain in school, thinking they do not have swine flu (and health departments refuse to test students for H1N1 because they have no fever).

Moreover, as noted above, infected students without fever are assumed to have an "upper respiratory infection" that is not swine flu.  Others are said to have strep throat or a "stomach virus", even though swine flu produces a sore throat and gastro-intestinal problems.  Thus, even when 10-20% of students are infected with H1N1, administrators and nurse assume that many of the ill students are not infected with H1N1, and are ill because of other microorganisms.  The same is true for students who do not have fevers.  They assume that they don't have H1N1 and are not infectious, so they attend school. 

In addition, the spread may be facilitated by Tamiflu resistant H1N1, which some student take prophylatically when roommates are ill, or take Tamiflu to shorten recovery times.  Similarly, some schools are recommending prophylactic Relenza, but most still rely on Tamiflu as a first line drug.

Thus, it is likely that the H1N1 will continue to spread, as more schools open for the fall and levels within the schools reach critical mass. 

It is likely that the explosion of cases will impact sporting events, as teams will have too many ill players to field a team. 

The cancellation of these games is likely to produce a new wave of "sticker shock".

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