In April, David Rosenthal helped direct Harvard’s response to the “swine flu” when Boston’s first confirmed case emerged in a Harvard dental student only two weeks after the new strain of H1N1 influenza A virus was first identified in Mexico. Rosenthal, director of Harvard University Health Services, and his colleagues on the medical advisory committee he chairs are preparing for the possibility of a fall resurgence.
About the time the H1N1 cases were peaking for Harvard in early June, the World Health Organization (WHO) declared the first full-fledged pandemic in 41 years.
On July 16, the WHO advised countries to stop counting the exponentially expanding H1N1 cases. Yet some form of consistent limited surveillance and testing is crucial to identify the people at highest risk and the most effective health measures, wrote Marc Lipsitch, HSPH professor of epidemiology, and his co-authors in the July 9 New England Journal of Medicine and the Aug. 12 Lancet. Lipsitch is an adviser for Harvard and the U.S. Centers for Disease Control and Prevention (CDC).
In mid-August, Focus spoke on the telephone with Rosenthal, who is also an HMS professor of medicine at Brigham and Women’s Hospital, for an update on Harvard preparedness strategies, lessons learned, and decision-making in a context of urgency, uncertainty and limited information. An edited version of the conversation follows.
How is Harvard preparing for the upcoming flu season?
Under the provost, Harvard has an established incident support team (IST). The IST provides a platform for handling emergencies. Then there are 25 to 30 local emergency management teams. The Medical School has one. So do all schools and many larger departments. Major emergencies shift up to a crises management team (CMT), involving the provost and president. We work closely with the Cambridge and Massachusetts public health commissions and the Boston Public Health Commission.
We have created a smaller group composed of members of the IST and CMT specifically to deal with swine flu issues, such as: What would be the level of disease in the community that would prompt us to recommend to the provost to stop classes? We are also considering how we would care for a large number of sick students if we saw a real spike in H1N1 cases on campus, but the pressure on that issue was reduced a bit after the CDC changed the isolation recommendation from 7 days after a person feels well to 24 hours.
We will strongly recommend a regular flu vaccine to students, staff and faculty. We’ll start seasonal vaccines earlier than the usual October for high risk and November for low risk. We expect a swine flu vaccine in October, which we will administer separately. We’re told it will be necessary to give two shots.
We have a website with updates and frequently asked questions: huhs.harvard.edu (under “Announcements” on right, click on “H1N1 Influenza”).
How worried do we need to be about the H1N1 flu strain?
The good news, as we learned with the Dental School cases, is that it is more like the seasonal flu. You’re still sick, but only for 24 to 48 hours, then a full recovery.
What do I expect? I’m gearing for worse and hoping for the better. It sounds like we always get what’s been circulating in the Southern Hemisphere once fall arrives. Things are hectic right now in Australia, New Zealand and Argentina. If we start to see people coming in with symptoms early in the fall, we probably will screen to see if we have a resurgence of H1N1. But again, the severity of the illness does not appear to be what we once feared.
What went through your mind in April when the H1N1 cluster was found on the Longwood campus in April?
We were anticipating that eventually we would see H1N1. Having a cluster of dental students was a little bit of a surprise. The epidemiology and help from the Boston Public Health Commission confirmed the first student we had seen and isolated. The issue then was it took so long to document H1N1. It took 96 hours. But the dental and medical students were working and communing together and taking care of clients, and a decision had to be made quickly. That was the reason we temporarily closed the Dental School, canceled Medical School clinical rotations, and closed the dining hall at HSPH. About seven days later, when no one else got sick, we felt secure that we were not seeing a rapid spread.
What surprised you most about how the whole scenario unfolded?
The surprising thing was the good news. By the time we saw a second dental student afflicted, we already knew the first student was better within 48 hours and wanted to go back to work. We said no, you can’t.
What have you learned?
We can always do better, and we’re trying. The provost and president have really made getting organized for flu season a priority. We’ve got good messaging prepared to go out on an urgent basis. We have learned the most important thing is to make rational decisions and to be prepared to make them quickly. When it strikes, there’s always something you’re learning.
What’s the worst-case scenario?
There is less anxiety about a worst-case scenario now because of what we have learned about the nature of H1N1 as it has unfolded over the spring and summer. This is not a repeat of the 1918 pandemic. We’re not seeing the high percentages of death. In healthy people, it’s turning out to be a relatively tolerable illness. But every year, five to 20 percent of the population gets the flu.
But the full-blown, or level three, scenario would be where the disease affects the operations of the community, and we decide it would be prudent to close the University. I don’t expect H1N1 to get to that point.
What’s the most important thing individuals can do?
Hygiene. Hygiene. Hygiene. The Dental School has done a great job in educating dental students about good hygiene, and it remains the best way to prevent the spread.
Hand washing. Wash your hands before going in a food line and handling common utensils and after going to the toilet. That’s why we have all the hand sanitizer dispensers around.
Cough etiquette. Cough into your elbow or sleeve. Not out into the air. Not into your hands.
Get the flu shot! If you’re sick, don’t go into the clinics or into work.
