WASHINGTON (AP) — The most pivotal moments in the swine flu saga are yet to come.
Will it sweep through impoverished Southern Hemisphere countries in the next few months? Will it roar back in the rest of the world in the fall? And who will be vaccinated if it does?
In the weeks since swine flu grabbed international attention, and even years before that, some important actions have helped shape the course of this outbreak and the ways the world will handle future epidemics.
It's not clear if this new swine flu strain is a brush fire, sparking up around the globe only to fizzle, or if it will worsen when the regular influenza season hits.
No matter how this story ends, at the very least it has offered a real-world drill to find gaps in the playbook.
"We've been given an opportunity to take a look at this before it really got bad, and we need to," said Dr. Michael Osterholm of the University of Minnesota, a prominent pandemic flu specialist. "We better damn well do it now because one day we are going to really be in it for more than a week. If it's not this virus, there will still be another one."
For this virus, the coming months will bring a series of big decisions: Do manufacturers start brewing millions of swine flu vaccine doses? Will they be stockpiled unless the new flu returns or given along with or soon after regular flu shots? Will rich countries share enough with the developing world? Who gets in line first — the younger people that this strain so far seems to target or the elderly who usually are flu's most vulnerable?
"You may only have one chance to get out ahead of it," Dr. Richard Besser, acting chief of the Centers for Disease Control and Prevention, told The Associated Press. "It's important for people to understand that all of these decisions will need to be made with incomplete science."
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THE FIRST TURNING POINT
A different virus was the world's wake-up call. SARS (severe acute respiratory syndrome) started in China, and once it broke out of the mainland in early 2003, it took just weeks to infect more than 8,000 people from 37 countries. The virus killed more than 770 people before it disappeared.
Governments started scrambling to put together plans to handle the next global disease threat. Soon after, bird flu hit Asia, reinforcing the need.
Had the new swine flu hit sooner, before all that pandemic planning, it almost certainly would have spread faster. Even if it proves no more dangerous than garden-variety flu, that's deadly enough; a pandemic is more about geography than super-lethality. By the World Health Organization's tally, between 250,000 and 500,000 people worldwide die each year because of regular winter flu.
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UNCOVERING THIS THREAT
As early as February, people in the Mexican hamlet of La Gloria were suffering unusually strong flu symptoms. When officials arrived to investigate in mid-March, nearly half the 3,000 villagers came out seeking medical help. About 450 were diagnosed with acute respiratory infections and given antibiotics. Mexico was investigating, but not until April 12 would the outside world — the CDC and Pan American Health Organization — start getting official word of the unexplained illness that eventually would be blamed for dozens of deaths throughout Mexico.
By then CDC already was on the trail of swine flu in California. The virus had spread before anyone knew it existed.
Preparation had paid off. In its pandemic planning, the U.S. starting in 2005 put money into researching better influenza detection. Studies of new methods found two unrelated children in San Diego with a strain of Type A influenza that turned out to be a never-before-seen type of swine flu. Puzzled, CDC announced the cases and started hunting more. On April 23, the agency confirmed five more illnesses in California and Texas and put all states on alert.
"At what point does unusual become concerning and at what point does concern lead to action?" Besser said. "We had to make that call."
That same day, CDC and a Canadian lab that Mexico had consulted delivered the bad news: The new flu was in Mexico, too.
Could Mexico have signaled a problem sooner? The Pan American Health Organization dismisses the question as one for historians.
"We would have done everything the same if we had it to do over again," said Hugo Lopez-Gatell Ramirez, deputy director of Mexico's Intelligence Unit for Health Emergencies.
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AGGRESSIVE ACTION
With the diagnosis, Mexico's government immediately ordered the closure of all schools, museums, libraries and theaters in Mexico City. The following days brought increasingly drastic actions. Schools nationwide and other businesses shut down, streets mostly emptied and soldiers handed out millions of face masks.
With a handful of known illnesses at first, the U.S. raced antiflu drugs from a government stockpile — enough for 11 million people — out to every state. After a large outbreak at a New York City school, apparently spread by students who vacationed in Mexico, U.S. schools started closing. Ultimately about 468,000 students around the country were affected before the CDC decided that schools should reopen because the virus was mild.
Overall, "what happened was not overreaction. It was a prudent response," said Michael Leavitt, the Bush administration health secretary who led development of the U.S. pandemic flu plan and advised other governments on theirs. "If imminent information about terrorism is known to authorities, they need to react. A pandemic is sort of nature's terrorist."
Young children tend to be initial spreaders of regular winter flu, taking it home to family and friends, which is one reason that school closings are included in pandemic plans. But in this case, travelers were early spreaders.
"I'm not saying that was the right approach or the wrong approach, but what we've learned is we need to be proportionate in our response with what the risk is in our community," said flu specialist Osterholm.
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PANDEMIC OR NOT
The World Health Organization, following its post-SARS guidelines, declared an international emergency the day after Mexico's outbreak made headlines, to spur countries to check where else the new flu had spread — eventually to two dozen countries and counting.
Days later, the WHO issued an unprecedented warning: The world was close to a full-fledged pandemic. Sustained spread in regions beyond North America, rather than smallish outbreaks, would tip the scale.
For years, the U.S. had run drills. What would it do if bird flu started rapidly spreading in Asia? Close the borders to buy a little time. Reality brought a surprise.
The new swine flu started in North America, too late to close any borders. While the U.S. joined other countries in discouraging travel to hardest-hit Mexico, and some nations discouraged travel to the U.S. and Canada, too, once flu starts spreading in numerous places, such actions have little effect.
Asia remained largely untouched. China, no doubt recalling the harrowing days of SARS, tried to keep it that way by quarantining dozens of Mexicans for days.
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STILL TO COME
What happens to all those antiflu medicines that were shipped to U.S. states but not used? They're waiting, under guard, in case they're needed come fall. Leavitt, the former health secretary, said that's the next weakness. Flying in drugs is easy; getting them to the sick is hard.
"The further into a pandemic you get, the more spontaneity that's required and the more lack of preparation reveals itself," he said.
Then there's the vaccine dilemma.
Makers could be told to start brewing doses in a few weeks. But that will take months and require testing, led by the U.S., of initial shots to see if they induce immunity, with one dose or two, and seem safe. The last mass vaccination against a different swine flu, in the U.S. in 1976, was marred by reports of a paralyzing side effect — and that time the flu didn't return.
"One of the lessons of the '76 experience is to take account of the uncertainty," said Institute of Medicine President Harvey Fineberg. "Be able to take account of new information to modify your course."
If vaccine is ordered, would developing countries get a fair share? The WHO is calling vaccine makers together in late May to push for fair access. Regardless, any shots will come too late for the Southern Hemisphere, where influenza season is about to start.
World authorities will closely track the new swine flu there, for help deciding whether to order vaccinations for the rest of the world starting in the fall. The big worry is that the virus will mutate, becoming more severe.
"The thing that's keeping me up at night right now is that feeling of dodging the bullet, in the sense that people are taking a sigh of relief too soon," the CDC's Besser told the AP.
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