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Widespread Pandemic H1N1 School Outbreaks in Southern US
Recombinomics Commentary 22:15
August 20, 2009

A total of 122 Camden County High School students visited the school nurse's office and several of those were sent home because they were displaying flu-like symptoms on Monday, she said.

There are also two elementary schools - Mamie Lou Gross Elementary and St. Marys Elementary - that reported sending home a high number of students home after they were confirmed to have flu-like symptoms. Mamie Lou Gross Elementary off Harrietts Bluff Road has been reporting fevers and St. Marys Elementary students are suffering from stomach symptoms.

"When I spoke with the office at Mamie Lou Gross Elementary, they had 12 students waiting to see the school nurse at that moment," Smiley said. "There have been a lot of fevers hitting these schools very hard."

Elaine Smiley, health systems coordinator for the school district, said about 10 percent of the estimated 1,000 Camden Middle School enrollment was absent Tuesday from the outbreak.

School nurses have also seen an increase in children who have flu-like symptoms, including fevers of more than 100 degrees, lethargy, lack of appetite and coughing, she said. Other symptoms include runny nose, nausea, vomiting and diarrhea.

The above comments describe large outbreaks of swine flu at the elementary, middle, and high school level of a school district in southern Georgia (see map).  Although some officials have noted that many of the students were influenza A positive, but had not been swine flu confirmed, 99% of influenza A cases in the United States at this time of year are swine flu, and the symptoms described signal a large and widespread outbreak.

Outbreaks such as the one described above are usually associated with seasonal flu in the dead of winter, but these outbreaks began in the summer, right after the start of the new school year.  Similar outbreaks are being described throughout the southern United States, where many schools have started a new school year (see map).  Large outbreaks are expected nationwide, as students return to the school in the next few weeks.

Most schools are following CDC recommendations and remaining open, while offering guidance centered on keeping ill students at home.  However, these guidelines are tightly linked to a fever, which is in the CDC H1N1 swine flu case definition.  The association of fever with swine flu infections is tenuous, and some countries like Chile, are reporting 50% of patients without fever, even in more severe cases.  Similarly, initial data from Mexico also noted that 30% of confirmed cases did not have a fever, raising concerns that these figures are low, and most infections have no or low fever. 

The above figures are likely to be significant undercounts, because most physicians, as well as patients, associate a fever with flu.  Thus, mild cases are unlikely to seek medical treatment, and those that do seek treatment are unlikely to be tested because of no fever.  The CDC includes fever it the pandemic H1N1 case definition, so the frequency is high, but even with fever in the case definition, 7% of confirmed cases have no fever.

Thus, the policy of keeping schools open, and using fever as one of the key symptoms, may lead to extensive spread by patients who have low or no fever.  Moreover, most of the students have mild illnesses, so they are not tested, which may allow important genetic changes to silently spread.  One such change is H274Y, which confers Tamiflu resistance.  Many of the confirmed cases have quickly developed resistance, raising concerns the H274Y is widespread, but present as a minor species which is largely undetected in samples collected prior to Tamiflu treatment.  Media reports described Tamiflu resistance in patients in Texas along the Mexican border, and such cases may be silently spreading, due in part to limited testing.

Thus, these initial outbreaks in multiple school districts across the south raises concerns that similar large outbreaks will be reported in northern regions, and worldwide, as the new school season begins nationwide.

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