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School Undercounts Raise Pandemic Concerns
Recombinomics Commentary 17:34
October 26, 2009

"It's been a combination of things," Soper said. "We do know we have the H1N1 flu up here, but there's also the seasonal flu, bronchitis, strep throat, pneumonia, it's just a combination of - the perfect storm."

The above comments represent one of many examples of media reports calling H1N1 infections something other than swine flu.  Other media favorites include "bad cold", "stomach flu/bug", "allergies".  This confusion is largely traced to a misunderstanding of the meaning of an influenza A positive sample, or attempts to classify swine flu patients who don't have a fever, but have one or more symptoms associated with swine flu. These misconceptions create serious media undercounts of H1N1 infections.

Although the official seasonal flu season has begun, there have been virtually no confirmed seasonal flu cases in the US, in part because the season is very young, and in part because of a crowding out of seasonal flu by swine flu.  Consequently, many physicians use an influenza A test to diagnose swine flu because over 99% of influenza A positive samples are swine flu.

Confusion and misdiagnosis can largely be traced to the use of fever on the swine flu case definition.  A high percentage of swine flu infections do not produce a fever, but since "fever" is in the case definition, many try to apply an alternate designation for such cases.  However, these feverless cases appear at the same school and at the same time as the cases with fever, supporting multiple presentations of cases with the same etiology.

As the pandemic evolves, the number of infected students has increased at an alarming rate, leading to attack rates approaching 100% and massive school closings.  In Michigan, 196 schools were closed on Friday (see map) and many schools throughout the country are reporting absenteeism rates well above 10-15%, which have been used in the past to close schools.  Now many school closings are driven by a high absenteeism rate among teachers and staff, which prevent the school from functioning properly.

The high levels of infections will doubtlessly lead to more strain on the health care system, which were a factor in the declaration of a health emergency.  The increases in cases lead to a lack of treatment, which produces more hospitalizations, heroic efforts, and deaths.

The high frequency of cases also raises re-infection concerns, which are supported by anecdotal evidence, increasing the likelihood that the current disruption and school closings will continue.

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