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In Mexico, an Unusual Flu Season Was a Sign of Something Ominous

By Joshua Partlow and William Booth
Washington Post Foreign Service
Sunday, May 3, 2009

MEXICO CITY, May 2 -- For seven tense days, the nation's top epidemiologist, Miguel Ángel Lezana, waited for the answer to a deadly mystery. When the news finally came April 23, it was as bad as he had feared.

That afternoon, Lezana learned in a conference call with his counterparts in the United States and Canada that 26 of the roughly 50 saliva swabs and lung samples sent to Winnipeg, Manitoba, had tested positive for a previously unknown swine flu virus.

"At that moment, we learned that we have this new strain in Mexico," said Lezana, director of the National Center for Epidemiology and Disease Control. "We started to move ahead immediately. I'm talking about hours. The response was immediate."

The positive test for swine flu launched a public health emergency in Mexico that has led to the shutdown of all nonessential government and commerce as the nation struggles to contain the outbreak.

But the first confusing signs that something was very wrong in Mexico stretched back weeks.

Evidence was mounting in the spring that this was no ordinary flu season. There were 3,000 more cases of serious flu than usual in Mexico this season, and the number of "outbreak clusters" was more than double. Previously healthy adults were dying from severe cases of pneumonia from San Luis Potosi to Oaxaca.

By March 10, authorities first heard reports of a mysterious influenza-like illness in the desert village of La Gloria, a dust-blown settlement in hog-farming country a three-hour drive east of Mexico City. Although the flu season usually should have ended, residents were beginning to feel feverish and achy at an alarming rate. By the end of the outbreak on April 10, 616 people -- nearly 30 percent of the village -- were sick.

"That was a very high attack rate," Lezana said. "Very high."

Teams of health care workers entered the village in early April to investigate. They took nasal and throat swab samples from 50 of the ill. Other medical teams distributed medicine and fumigated the entire village.

The health workers sent the samples to state and federal public health labs. Weeks later, a single patient in La Gloria, 5-year-old Édgar Enrique Hernández, tested positive for swine flu.

One reason for the delay in understanding the outbreak was the fact that the national testing laboratory in Mexico City was unable to identify the new strain found in La Gloria.

As medical researchers were trying to understand the situation in La Gloria, they received information about another outbreak, this time in the southern city of Oaxaca, where a cluster of patients was showing severe respiratory distress.

Shadow of SARS

Buried in the red clay of a cemetery in Oaxaca is the body of the first person known to have died of swine flu.

María Adela Gutiérrez, 39, worked a temporary job for the government, going door-to-door gathering information for the tax collection agency. By early April, she had complained of fatigue and later told her husband she had a sore throat. She saw a doctor and took antibiotics but kept working.

On April 9, she was admitted to the General Hospital in Oaxaca. Her fingers and toes were blue, as her body was starving for oxygen.

Doctors placed her in intensive care and sent samples to a local laboratory, which returned a misdiagnosis of possible coronavirus, similar to the one causing severe acute respiratory syndrome, or SARS. Her ward was quarantined. She died April 13.

The virus hunters in Mexico, along with their counterparts in the United States and Canada, initially feared that the Oaxaca case could be SARS.

On April 16, Hugo López-Gatell, one of Mexico's top epidemiologists, said he and other health officials convened an "extraordinarily urgent" meeting in Mexico City to discuss the developments.

At the time, officials did not know whether they were seeing an unusually long flu season, a new problem or the result of an increase in nationwide flu notification centers over the past year.

"We had many indications of the growing duration of flu season. The increase in cases. Severe pneumonia. Deaths. An abnormal distribution of the age curve with infected young people," López-Gatell said. "There were two hypotheses. One was: This is real. The other was: caution. Because we doubled the number of monitoring sites so obviously, we have more notification centers. There are going to be more cases."

On April 21, the U.S. Centers for Disease Control and Prevention reported two cases of a previously unknown swine flu strain in California.

"We wondered, 'Could we have a new virus?' " López-Gatell said.

The confirmation that arrived April 23 set off a chain reaction in the Mexican government. Scientists informed Health Secretary José Ángel Córdova. He informed President Felipe Calderón, who called an emergency cabinet meeting that night, Lezana said.

By the next day, the government had begun closing schools, the start of a piece-by-piece powering down of public life in Mexico City and across the country intended to contain the virus.

Nonstop, Joint Efforts

Within a day of the discovery of the new strain, CDC experts were in Mexico City helping their counterparts enhance laboratory testing of the virus. A dozen new rapid-testing DNA analyzers are now working round-the-clock on a backlog of 1,000 samples.

"They were under tremendous pressure, working 16 hours a day. But they did it," said Miguel Cruz, an emergency operations officer with the CDC who was sent to Mexico City.

Cruz and other members of a team helping the Mexicans are headquartered in a building in southern Mexico City. On the third floor, in the carpeted, glass-walled "situation room," health officials scour computer maps of Mexico and hold video conferences to try to understand the spreading virus. Wall clocks track the time in Tijuana, Mexico City, Washington and Tokyo.

"We're mainly working on trying to improve the information we're getting," said Steve Waterman, a team leader at the CDC who is in Mexico.

"That's the big question. Is it stabilizing or not? And it's too early to say," he said. "But I think we're getting systems in place, so we're going to be able to get a handle on that soon. . . . I think we're getting closer to understanding the outbreak."

Mexican scientists said the virus has been spreading primarily within families and among co-workers, often in dense, poor neighborhoods of Mexico City. At one point last week, Health Ministry documents show, 77 percent of the confirmed swine flu cases were in Mexico City; if the surrounding state of Mexico were included, the proportion jumped to 93 percent.

"When you have this huge accumulation with crowded people in a rather small area, you have a greater opportunity to spread the disease," Lezana said. "Besides, it's an area -- in general -- of low-income, poor people, urban poor, very crowded, so those might be some of the main explanations for that."

The number of confirmed dead in Mexico stood at 19 on Saturday, unchanged from the day before, Córdova said at a news conference in Mexico City. Confirmed swine flu cases, including the deaths, rose from 397 to 473.

"We are in a stabilization phase," Córdova said Saturday. "It is too soon to say we are past the most complicated moment."

Special correspondent Anne-Marie O'Connor contributed to this report.

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