Medical Examiner

Cabin Fever

Trying to stop the spread of swine flu at summer camp.

Can swine flu be contained at summer camps?

For three summers, my 12-year-old son, Joshua, has attended Camp Modin, a beautiful camp in rural Maine. This year, when we dropped him off at the northbound bus, something was different: The counselors were taking children’s temperatures before letting them onboard. It seemed a wise precaution, as the new influenza A H1N1 swine flu strain continues to spread and the weather in Maine in June was cool this year, which would facilitate an outbreak of the virus. But as a physician who has studied the flu for many years, I was still worried. An infected person can be contagious even if he doesn’t have a fever.    

My concern was justified. Three days after camp started, I called the camp director, Howard Salzburg, and discovered that he was beside himself. One of the parents, another physician, had used Tylenol to deliberately suppress his child’s fever so he wouldn’t be held back. There were already 16 cases of the flu, confirmed by the Maine Center for Disease Control and Prevention to be the H1N1 swine flu strain. Desperate to contain the infection, Howard had created a quarantine bunk for the sick and was having all the bunks cleaned with hospital-grade disinfectant. One other tool could help stem the spread of infection—but using it would go against CDC protocol.

The Centers for Disease Control has a national policy to reserve the anti-flu drug Tamiflu, which works by blocking the flu virus from detaching from one human cell and spreading to the next one, for only severe cases. But with the new pandemic strain circling the globe and more than 1 million people already infected, it seemed to me it was time for our public health authorities to employ a more aggressive strategy. Clinical trials have shown that Tamiflu, when taken within 48 hours of exposure, is 92 percent effective at preventing flu in adults and 82 percent effective in children. Since we don’t yet have a vaccine, it was clear that the best strategy was to use the drug, which decreases the severity and the duration of the illness and helps prevent people who are in contact with flu patients from getting sick themselves. I e-mailed the camp parents to let them know that Tamiflu is well-tolerated and safe and that I was starting my son on a 10-day course of it; it would be wise, I recommended, for them to do the same. Prescriptions were soon flooding the camp’s fax machine; out of the 350 campers, 250 campers were started on the drug, as were more than 100 staffers.            

At the same time that the prescriptions were pouring in, the Maine CDC asked to speak to me, since this was not its usual protocol. It was holding Tamiflu in reserve for the sickest cases. But our children had no immunity to this new strain of flu. Though most of the stricken Modin campers were only mildly ill, we’ve seen that the majority of the severe cases and deaths caused by this strain are occurring among children with chronic illnesses like asthma. Since campers could have had those conditions but not yet have been diagnosed, it made a lot of sense to use Tamiflu to reduce the amount of circulating virus. I also explained to the director that most of the studies using anti-virals as a preventative, conducted in nursing homes, were likely applicable to the camp environment, since kids were crammed in bunks just as patients in nursing homes live close together.

Andrew Pelletier, the head epidemiologist for the Maine division of the CDC, said that his caution was informed by federal directives. The Tamiflu protocol was based in part on fear of a shortage. Supplies in Maine were plentiful—the camp had been able to procure more than 400 courses of Tamiflu with ease. But the CDC was reluctant to dip too far into the supply, worried that not enough would be available if and when the new flu becomes more widespread. Runs on Tamiflu and premature use of the drug, as people attempt to hoard it in case they or their families became sick, were another cause for concern. I’m sure you are also concerned about resistance developing from overuse of the drug, I told him, but with a vaccine not yet ready, using Tamiflu to control outbreaks at camps is exactly what we should be doing.

The CDC allowed Modin to proceed, and the results were even more dramatic than I’d anticipated. Many studies examining control of the flu used amantadine, an older anti-viral drug against the yearly flu. Camp Modin was perhaps the first experiment in close quarters with Tamiflu against the new pandemic strain. When the camp started using it, the total number of cases was 40, and the daily incidence was 14. Two days later, the number of new cases was four. (Look at the Modin statistics here.) There were soon more than 80 campers and staff with the flu—all cases were mild, and the first three were confirmed as H1N1 swine flu strain by the CDC—but no one on Tamiflu as a preventive measure became sick, not even the counselors and nurses who were caring for the quarantined bunk. While my son took his daily Tamiflu dose and enjoyed the wilds of Maine, the quarantined kids watched TV and played video games for a week before being allowed to return to their regular bunks. I couldn’t tell without blood tests whether Tamiflu prevented infection altogether or just kept kids from getting sick. But it didn’t really matter; after a week, the camp collectively exhaled; the outbreak was over.                 

As cases of flu began to appear at other camps in Maine, word of Modin’s successful containment spread, and pediatricians were again asked to fax prescriptions to Maine for Tamifu. It is clear that especially in advance of a vaccine, Tamiflu is an effective way to squash H1N1 outbreaks and protect the most vulnerable. If we use it properly now, we may not need it as much in the future. It is definitely time for the CDC to change its protocol.