In June, the World Health Organization (WHO) declared swine
flu--officially known as the H1N1 virus--the first influenza
pandemic since 1968. The following month, the WHO told countries to
stop reporting individual swine flu infections because the number
of victims had rapidly exceeded 1 million people and the virus had
spread to almost every nation in the world. The flu continues to
spread. A WHO scientist estimates that H1N1 could infect 2 billion
people in two years. Since emerging in April, it has become one of
the fastest spreading contagious diseases on record.
H1N1 will return to the U.S. this fall with the flu season. This
year's flu season may be more severe than normal, but the U.S. has
the capacity to respond to the extra strains. Federal, state, and
local governments should continue to improve their pandemic
response and risk communication programs. They still need to do
much to improve cross-state planning, continuity of operations,
situational awareness and information sharing, and community
However, an effective public response will likely be the most
important factor in mitigating the effects of the flu season. The
public should follow the guidelines of a responsible national
vaccination strategy and adopt behaviors, such as washing hands
properly, to limit the spread of the disease and minimize its
What Is Swine Flu?
Swine flu, identified as the H1N1 strain, contains a unique
genetic makeup that distinguishes it from other influenza viruses.
H1N1 includes gene segments from North American swine, bird, and
human flu strains and from Eurasian swine flu--a unique combination
that had not been previously reported. New influenza viruses are
often created through "molecular reassortment," in which two
distinct virus strains invade the same cell and, in the process of
using the cell to replicate themselves, mingle their genes creating
a hybrid strain.
The Centers for Disease Control and Prevention (CDC) in the U.S.
Department of Health and Human Services (HHS) has concluded that
many H1N1 symptoms are similar to seasonal flu symptoms: fever,
cough, sore throat, runny or stuffy nose, body aches, headache,
chills, and fatigue. The CDC anticipates complications similar to
seasonal flu. Indeed, the majority of reported cases exhibited
symptoms found in influenza-like illness, such as fever and cough.
However, some patients reported vomiting and diarrhea, which are
unusual for the seasonal flu.
H1N1 transmission modes also match those for seasonal influenza.
The CDC has concluded that H1N1 most likely spreads from person to
person by "large particle respiratory droplet transmission" (for
example, via coughs or sneezes in close range of an uninfected
person). Additionally, transmission can occur through contact with
a contaminated surface. The virus can live on surfaces and infect
individuals for up to eight hours after being deposited.
Therefore, the CDC has warned that "all respiratory secretions
and bodily fluids" should be considered potentially infectious.
These materials can contain live viruses, which can infect the
human body, usually entering through the nose or throat. As with
other influenza viruses, infected individuals can begin infecting
others before beginning to show symptoms and can still be
infectious up to a week after onset of the illness.
Like other forms of "common" influenza, H1N1 has proved
resistant to amantadine and rimantadine, older antiviral drugs.
Antiviral drugs stop flu from developing by inhibiting the virus
from entering cells, thus preventing them from replicating.
However, some flu viruses mutate and develop a resistance to
antiviral drugs. In 2006, the CDC recommended against using
amantadine and rimantadine for seasonal flu after a sample of cases
in 26 states showed over a 92 percent resistance rate. The
current strain of H1N1 has not yet become resistant to newer
antivirals, such as Tamiflu (oseltamivir) and Relenza
(zanamivir). Of course, this may change in the future
because the virus continues to mutate. Indeed, a seasonal flu
strain that appeared in the 2008-2009 flu season proved resistant
During the initial H1N1 outbreak, no vaccine was available.
Vaccines differ from antivirals in that they can be a prophylactic,
preventing an individual from contracting a disease in the first
place by stimulating the body's immune system to produce antibodies
that will kill the virus. Vaccines are developed from dead or
inactivated virus, but the virus must first be identified before a
vaccine can be developed. Furthermore, because flu viruses
constantly mutate, the formulation of flu vaccines must be changed
almost yearly to remain effective against currently circulating
strains. The H1N1 strain had not been identified before the
outbreak in April 2009, thus no vaccine was available.
The medical response to H1N1 will probably appear nearly
identical to the response to seasonal flu. Individuals will be
treated with the same antivirals. Indeed, individuals with flu-like
systems are unlikely to be tested for H1N1 because the medical
protocols will be so similar. In addition, individuals will be
encouraged to receive both seasonal flu and the H1N1 vaccine when
it becomes available.
The principal fear is that the current strain of H1N1 could
mutate into a highly lethal strain that causes a pandemic. A
pandemic is a disease outbreak that affects a wide geographical
area and infects a high proportion of the human population. Dr.
Peter Palese, the Chair of Microbiology at Mt. Sinai hospital in
New York City and an international expert on infectious influenza,
has noted that H1N1 belongs to the same virus group as the 1918
Spanish flu, which killed millions worldwide.
Moreover, the H1N1 strain is transmitted human to human,
enabling it to spread easily. H1N1 has also displayed an "unusual
robustness" by emerging outside the annual flu season, which occurs
during the colder half of the year. Furthermore, the virus has
become more virulent and/or deadly through "mutations and/or
acquisition of gene derived from other human or influenza
viruses." These factors raise serious concerns about
the prospects of another deadly global pandemic.
On the other hand, Dr. Palese notes that certain factors
mitigate against the likelihood of plague on the scale of 1918. In
"1976 there was an outbreak of an H1N1 swine virus in Fort Dix,
N.J., which showed human-to-human transmission but did not go on to
become a highly virulent strain." While the new strain of H1N1 is
more complex, it still may not be more deadly than other seasonal
influenzas. Furthermore, the virus lacks "an important molecular
signature (the protein PB1-F2) which was present in the 1918
virus.... [H1N1] doesn't have what it takes to become a major
killer." Research suggests that without the virulence marker the
new strain will not be highly pathogenic.
While H1N1 nightmare scenarios are not inevitable, the disease
will certainly become more widespread. H1N1 is more contagious than
seasonal influenza. Common influenza has a "secondary attack rate"
(the rate of infection following close contact with an infected
person) ranging from 5 percent to 15 percent. The WHO has estimated
that the new H1N1 strain's secondary attack rate is 22 percent to
33 percent. In fact, the disease has spread so widely
and rapidly that the WHO has classified the current H1N1 strain as
a global pandemic. In short, many more people could contract the
flu during this flu season than normal. More people will miss more
days of work and school.
In addition to potentially being more contagious than seasonal
flu, H1N1 could cause severe complications. Seasonal flu kills an
average of about 36,000 people in the United States each year.
Another 200,000 are hospitalized. As of August 21, the CDC reported
522 deaths from H1N1-related illness in the United States and 7,983
hospitalizations. A White House advisory panel concluded that a
second wave of H1N1 cases during the upcoming flu season could
cause 90,000 deaths and hospitalize 300,000. Thus, the 2009-2010
flu season could be two or three times more severe than normal. On
the other hand, the CDC has concluded that this advisory estimate
may be excessive. Indeed, Dr. Peter Gross, chief medical officer at
Hackensack University Medical Center, has concluded that "the
mortality is no worse than the seasonal flu and, if anything, might
be slightly less." If there are more deaths this year than
during a normal flu season, it could simply be the result of more
people catching the flu rather than the flu being more deadly.
Furthermore, younger people are unusually susceptible to H1N1.
For seasonal flu, people 65 and older are usually considered as
part of the high-risk group and account for about 90 percent of
flu-related deaths and 60 percent of flu-related hospitalizations.
Yet H1N1 has affected younger populations at higher rates than is
usual for seasonal flu. The CDC has concluded that more deaths have
occurred among people under 25 years old. In contrast, an estimated
one-third of older adults have some antibodies against H1N1.
Beyond the older and younger groups, the groups most vulnerable
to severe and life-threatening complications from influenza
infections are the most vulnerable to other types of flu. These
include pregnant women and people with medical conditions such as
asthma, diabetes, suppressed immune systems, heart or kidney
disease, and neurocognitive or neuromuscular disorders. For these
reasons, when H1N1 flu vaccine becomes available, priority will
probably be given to vaccinating younger individuals and others
with particular medical conditions--the most vulnerable
While the disease will undoubtedly spread widely, limiting
transmission and infection to the maximum extent possible is the
most vital component of the strategy to respond to H1N1. The fewer
individuals who get sick, the lighter will be the burden placed on
medical providers. The fewer high-risk individuals who get sick,
the lower is the likelihood for serious medical complications and
death. Events surrounding the outbreak of H1N1 this spring hold
lessons for the right actions to deal with future outbreaks.
Sickness and Response
Mexico was the epicenter of the spring swine flu outbreak,
and the U.S. media chronicled its progress. Mexican Secretary of
Health José Ángel Córdova initially told
reporters that the virus "constitutes a respiratory epidemic that
so far is controllable." However, the actions taken by the Mexican
public health department belied that optimistic tone and may have
contributed to the subsequent global alarm about the influenza.
Mexican officials effectively shut down all cultural life by
closing museums and canceling soccer games and religious services.
In addition, they requested that citizens avoid cinemas and other
large public events and abstain from shaking hands and kissing one
another on the cheek. Perhaps most significantly, officials closed
down all of Mexico City's schools for the first time since the
earthquake of 1985, leaving 7 million students idle.
Citizens mostly complied with the government's requests and avoided
public interaction, leading some observers to describe Mexico City
as a "ghost town." Restaurants, schools, and other public
venues did not reopen until early May.
The sudden outbreak in Mexico, the unexpected deaths among young
people with no previous medical complications, and the unsure flow
of information from and response by Mexican officials soon garnered
significant press attention in the United States and sparked
widespread speculation. At least one Member of Congress publicly
called for closing the border.
Subsequent research has confirmed that attempting to control
land borders cannot significantly control the spread of the new
strain of H1N1. A research team lead by Dr. Kamran Khan at St.
Michael's Hospital in Toronto has shown that the spread of swine
flu around the globe perfectly matched air travel patterns. Between
March and April, 2 million people flew out of Mexico. They traveled
to 1,000 cities in 164 countries, and where they went, the flu
went. Even if closing the land border with Mexico were possible, it
would not have stopped the disease from spreading. Four of every
five air travelers leaving Mexico landed in the United States. Even
if the flu had not directly entered the United States by plane, it
would have arrived soon thereafter. Indeed, it had gone global
before Mexican officials recognized that they had a serious
problem. An infected individual can infect others before he or she
feels sick or develops a sniffle. Thus, infected individuals likely
crossed U.S. borders by land and air before H1N1 was
Closing the border would not have stopped the disease, but would
have created more suffering than the disease itself. For example,
in 2003, China implemented a "panic" response to the outbreak of
Severe Acute Respiratory Syndrome (SARS). By some estimates,
China's overreaction cost the mainland economy 1 percent of its
gross domestic product (GDP), some $50 billion. It cost Hong Kong
2.5 percent of its GDP.
Mexico is America's third largest trading partner. In 2008,
trade between the two nations totaled $367 billion.
"Stopping that trade would be like firing a shotgun blast into the
heart of Mexico's economy and the foot of our own,"
but do little to mitigate the spread of the disease.
Swine Flu in the Homeland
The first documented cases of swine flu in the United States
involved seven people infected from late March to mid-April. Five
were in Imperial and San Diego Counties in California. Two were in
San Antonio, Texas. Unable to classify the virus, state
laboratories sent the specimens to the CDC. Similar to the
situation in Mexico, the CDC did not believe these patients had any
contact with pigs. Noting that the cases involved a father and a
daughter and two 16-year-old schoolmates, the CDC concluded that
the virus was transmittable through human contact.
Eschewing the drastic tone adopted by Mexican officials,
American officials initially minimized the flu's potential
severity. On April 23, Dr. Anne Schuchat, director of respiratory
diseases for the CDC, stated that all seven patients had recovered
and that "so far this is not looking like very, very, severe
influenza." Furthermore, although "we don't yet know the extent of
the problem," "[w]e don't think this is a time for major
concern." This assessment proved correct.
However, U.S. authorities were not idle. Their response was
guided in part by planning and coordination over the past few years
in anticipation of a potential Avian flu pandemic. The U.S.
response also reflected caution in dealing with a new form of
influenza and public unease inflamed by media reporting and
The first official U.S. response was on April 26, when HHS
declared a public health emergency. This decision, which
Secretary of Homeland Security Janet Napolitano said "sound[ed]
more severe than really it is," was a required first step for the
federal government to begin providing special assistance to state,
local, and tribal governments. For example, the
declaration allowed the CDC to release antiviral medication,
personal protective equipment, and respiratory protection devices
from its national stockpiles.
The CDC began distributing to state and local emergency
responders 12 million courses of antivirals (about 25 percent of
the national stockpile), personal protective equipment, gloves, and
masks. The DHS prioritized shipment to states with confirmed cases:
Arizona, California, Indiana, New York, and Texas. By April 30, the
antivirals and other materials had reached New York City, Indiana,
Texas, Kansas, Ohio, Illinois, New Jersey, and the District of
Columbia. By May 4, all states had received their shares of the
stockpile. The government also pre-positioned antivirals for all
sectors of the Border Patrol and Coast Guard and provided guidance
to federal government employees on antiviral usage. To replenish
the stockpile, HHS released funds to purchase 13 million more
The HHS emergency declaration also gave the federal government
the authority to control the movement of people and livestock
across U.S. borders, establish quarantines, and close certain
public transportation systems. Although the federal government
prudently avoided excessive restrictions, Customs and Border
Protection and the Transportation Security Administration isolated
immigrants and travelers who were believed to be infected with the
swine flu. The U.S. Department of Agriculture examined the food
supply to confirm that it posed no threat of spreading swine flu.
The CDC explicitly outlined its response strategy on May 12, a
few weeks after the outbreak. Noting that the virus had spread to
almost every state in the country, the CDC never sought to contain
the virus's geographic distribution. Instead, it decided to
concentrate on "reducing illness and death and mitigating the
impact...as well as focusing our efforts on areas where they can
have the most impact." This involved distributing antiviral drugs
to those most vulnerable to H1N1, such as individuals with
underlying medical conditions and those severely affected by the
virus. Again, this proved to be prudent and realistic response. The
strategy matched the facts of how the disease spreads with the
risks involved, and it exploited the national capabilities that
been established over the past several years to manage pandemic
The U.S. government also made a significant effort to conduct
"risk communications," attempting to implement response measures
while dampening panic, despite the exaggerated commentaries and
scare stories in the media and on the Internet. Federal health
responders consciously sought to meet the recommendation of the
national strategythat "trained" and "credible" government
spokespersons transmit important information about the disease to
the public. DHS officials "conduct[ed] daily
conference calls with Homeland Security advisors, state and local
elected officials, Fusion Centers, our private sector partners, and
The CDC also employed new methods to ensure transparency and
disseminate public information since the flu outbreak. Almost
daily, CDC staff held open telephone briefings. The CDC updated
its Web site and increased staffing to manage its information line
(1-800-CDC-INFO), reducing both waiting time and dropped calls.
Each day the CDC received 4,000 calls, more than 2,000 e-mails, and
6 million to 8 million hits on its Web site. The agency also
sought to exploit the latest communication technologies by creating
a Twitter site and an RSS feed.
In addition, all 50 states and the District of Columbia had
their own pandemic flu plans in place, including plans to receive
and distribute emergency vaccines, antidotes, and
pharmaceuticals. A February 2009 report from the
Government Accountability Office noted federal efforts to
collaborate with state and local partners. Federal officials
sponsored pandemic summits with all 50 states. The DHS established
coordinating councils to share pandemic information across sectors
and levels of government. HHS complemented these efforts by
convening influenza pandemic workshops in five influenza pandemic
regions. Similarly, the Federal Executive Boards, which operate
under the White House's Office of Personnel Management, were tasked
with organizing joint activities for federal, state, and local
officials. Many boards arranged for influenza pandemic training and
exercises for their members.
Federal spokespersons also provided preparedness guidance to the
private sector. The DHS communicated with sectors in private
industry, providing daily updates and urging them to regularly
evaluate their continuity-of-business plans.
National responses to the initial appearance of H1N1 proved
generally adequate. Government did not overreact. At the federal,
state, and local level officials took prudent steps, using the
programs and instruments established to deal with pandemics.
Nevertheless, substantial doubt remains whether the U.S. has
adequate capacity and mechanisms to deal with a deadly global
pandemic or widespread bioterrorism attack.
A December 2008 report by the Trust for America's Health
assessed the readiness of states in 10 key areas. Although a number
of the findings were positive, the report noted significant gaps in
effective response. For example, 26 states do not have laws
limiting liability for businesses and non-profits that help during
an emergency. An HHS assessment also found notable
gaps. For example, most states have not considered the impact of a
pandemic on workers, provided information to help them plan for
such an event, or evaluated which state benefits could be used to
help workers during a pandemic. Coordination of national
efforts is still a work in progress.
The national response to H1N1 identified additional shortfalls.
For example, despite an active communications strategy and tactics
during the crisis, some inconsistent CDC guidance caused confusion.
Some practitioners found CDC guidance difficult to translate into
practical decisions. This was particularly evident in school
closures. The CDC initially supported school closures, but on May
5, Acting Director Richard Besser announced that decisions to close
schools would henceforth be "local decisions." On May 22, the
CDC's online guidance explicitly stated that school closures were
"less effective as a control measure."
CDC instructions resulted in inconsistent local decisions
causing confusion and panic. For example, in Texas, officials
closed the 80,000-student Fort Worth school district after several
cases were confirmed in the area. Fearing that the situation was
rapidly escalating, the mayor of neighboring Brownsville ordered
its 52 schools to close. However, the school district refused to
comply and opened schools as normal, a decision that led to much
Despite such controversies, shortfalls in national capacity, and
gaps in integrated national planning and response, nationwide
efforts proved adequate to H1N1 response. While national
capabilities may still fall short of what is necessary for a deadly
global pandemic, they should prove sufficient to deal with the
increased levels of flu activity expected this fall.
The Coming Concern
When H1N1 returns this fall, flu sickness will likely be much
greater. More people than usual will die, and more severe illness
could appear among groups (for example, children and young adults)
that normally do not suffer severe complications from the flu. Yet
the nation will not face a deadly global pandemic. An effective
public response could significantly augment the national response
and lessen the burdens on the society as a whole.
Vaccine Strategy.By most estimates, H1N1 vaccines will
not become generally available until October, which is after the
beginning of the U.S. flu season. One H1N1 vaccine will require two
doses given 12 weeks apart. That means full protection will not be
available until after February, well after the flu season has
peaked. Another vaccine in development requires only one dose and
may provide a basic level of immunity within weeks. In
either case, however, H1N1 flu vaccine may not be available in
quantity to affect the spread of the disease at all this flu
season. If stocks are available in time to make a difference,
public health officials at all levels of government need to educate
Americans on the national vaccination strategy, and Americans will
need to listen. The most critical element of the national strategy
is not that every individual has to be vaccinated, but vaccinating
a sufficient percentage of the population will prevent a recurring
pandemic. In addition, as many individuals in high-risk categories
as possible should be vaccinated. The national strategy also needs
to adjust to the availability of the vaccine.
Under an appropriate strategy:
- Individuals should receive seasonal flu vaccines. Even
though the seasonal flu vaccine will not prevent H1N1 or even
protect individuals against every strain of seasonal flu that might
appear this fall, it will reduce the burden on medical providers
and productivity losses due to illness.
- The individuals most likely to spread the disease should be
vaccinated first. A study by scientists Jan Medlock and Alison
Galvani concludes that the vaccines should first be used to limit
transmission within schools and to the parents of school children,
who would then spread the flu to everyone else. This strategy would
focus on children (ages five to 19) and adults (ages 30 to 39).
This would require an estimated 63 million doses.
- If more vaccine is available, the most vulnerable groups
should be vaccinated next. Vulnerable groups should be
vaccinated according to CDC guidance, including pregnant women,
people who care for babies, children and young adults (ages six
months to 24 years), people with chronic diseases that make them
vulnerable to complications from flu illness, and health care
- Other individuals should be vaccinated as flu vaccine
becomes available. When sufficient vaccine becomes available,
vaccinating 30 percent of the population is necessary to limit the
threat of pandemic. Once a responsible level of national
vaccination is reached, it would make more sense to ensure that
other nations have adequate vaccine supplies rather than seeking to
vaccinate the entire population.
Prophylactic Strategy.Without vaccines, the single
greatest contribution the public can make is to limit opportunities
for infection. Public officials have distributed ample guidelines
on appropriate preventative measures. These include:
- Washing hands frequently and thoroughly with soap and water and
avoiding touching mouth, noses, and eyes with unwashed hands or
after touching surfaces;
- Not sharing water bottles and drinking containers;
- Avoiding people who are sick and exposure to coughing and
- Coughing or sneezing into one's sleeve;
- Staying at home if one feels sick; and
- Seeking medical attention when appropriate, such as high fever,
shortness of breath, chest pain, seizures, persistent vomiting, or
inability to retain liquids.
Response Strategies.Individuals, families, businesses,
and community groups can help to mitigate the effects of the flu
season. Their plans should focus on contingencies if individuals
need to stay home from school or work or if key personnel are not
available for several days. The best and most effective responses
will likely be developed and implemented locally. The greater the
scope and severity of the pandemic, the more individuals in
communities will need to rely on each other. Many of the resources
needed to sustain their communities will also be available
Many consider the efforts of Seattle and King County,
Washington, as a model for preparing for pandemic influenza. In
response to the SARS outbreak in Asia, county leaders implemented
several key actions. Such activities would be appropriate to
address any flu outbreak. Specifically, Seattle and King
- Established Vulnerable Population Action Teams "to reach
individuals who may not or cannot access information from
traditional sources that serve the general public," which included
usingthe Community Communication Network to reach vulnerable
populations through familiar contacts.
- Conducted a two-day seminar for health care providers on
business resiliency issues, such as regional hazards, essential
services and critical functions, surge capacity, evacuation, and
- Created an e-mail alert system that allows individuals to sign
up to receive e-mail alerts.
- Translated key documents, such as biohazard and disaster
response fact sheets and preparedness check lists, into many
languages, including Spanish, Chinese, Vietnamese, Korean, Russian,
Somali, and Cambodian.
- Developed and distributed Speak First: Communicating
Effectively in Times of Crisis and Uncertainty, an advanced
training practice kit on public health risk communication, and
Business Not as Usual: Preparing for Pandemic Flu, a video
for businesses, government, and community-based organizations.
The Nation Responds
The U.S. has the capacity to weather the upcoming flu season.
Fear and panic are the greatest enemies, but they can be defeated.
Federal, state, and local governments need to continue to refine
and improve the capacity and efficiency of their pandemic planning
and response. Public response will likely be the most significant
factor in deciding how the nation fares in the months ahead. The
outcome will depend largely on Americans adhering to a responsible
vaccination strategy, adopting appropriate behaviors to limit the
spread of contagion, and preparing to keep their communities
resilient during a flu pandemic.
James Jay Carafano, Ph.D., is Deputy Director
of Kathryn and Shelby Cullom Davis Institute for International
Studies and Director of the Douglas and Sarah Allison Center for
Foreign Policy Studies, a division of the Davis Institute,
at The Heritage Foundation. Richard Weitz, Ph.D., is Senior Fellow
and Director of the Center for Political-Military Analysis at the