Major Swine Flu Outbreak at U.S. Air Force Academy Affords Unique Opportunity to Study Virus Behavior

Researchers Report New Insights into Epidemiology, Viral Shedding and Control Measures

San Diego, October 20, 2009 – With the 2009 influenza season upon us, characterization of the epidemiology and duration of shedding for the nH1N1 virus is critical. Investigators from the U.S. Air Force Academy and the U.S. Air Force School of Aerospace Medicine Epidemiology Consult Service capitalized on a unique opportunity to gain valuable insights about the natural behavior of the nH1N1 virus, including shedding patterns, during a recent large-scale swine flu outbreak at the U.S. Air Force Academy (USAFA). Their results are reported in an article published online on October 20, 2009 by the American Journal of Preventive Medicine. It is the first published study of its kind.

Findings from serial nasal washes indicated the presence of viable virus shedding among about one quarter of confirmed nH1N1 patients sampled on Day 7 from symptom onset. Further, being afebrile and asymptomatic did not guarantee the patient was no longer shedding viable nH1N1 virus; in fact, 19% of those who reported being symptom-free for greater than 24 hours were still found to have viable virus shedding. While viable virus shedding does not necessarily mean the virus can be transmitted, these findings do indicate that the virus may persist even after the individual is feeling well and has returned to work. Furthermore, the results of this study may assist development of appropriate protocols for isolation in high-risk settings or if the scale and/or severity of the current nH1N1 situation increases. The current study also provides groundwork to other investigators for further study of the shedding characteristics of the virus.

In July, this novel H1N1 outbreak represented one of the largest recognized nH1N1 clusters at a U.S. college to date. Lead investigator Catherine Takacs Witkop, MD, MPH, of the U.S. Air Force Academy, comments, “Characterizing virus–host interactions and the epidemiology of nH1N1 is important in both planning assumptions and in defining effective control measures. Studies of seasonal influenza suggest that viral shedding occurs for as long as 7 days after symptom onset. No similar studies on shedding of nH1N1 have been published. In addition, there are no published studies of the epidemiology of nH1N1 infection among military training populations or institutions of higher education.”

On June 25, 2009, 1376 new basic cadet trainees (BCTs) arrived at USAFA to begin a 6-week military training program prior to their first academic year. Between July 6 and 7, respiratory complaints increased and two cadets were identified as positive for influenza A. Due to a high level of suspicion that the responsible virus was nH1N1, identification, treatment and containment efforts were initiated immediately.

There were 134 confirmed and 33 suspect cases of nH1N1 infection identified with onset date from June 25 to July 24, 2009. Fever, cough and sore throat were the most commonly reported symptoms. Among the at-risk BCTs, 11% were infected during the outbreak period. Twenty-nine percent (31/106) of samples in patients with temperature <100°F and 19% (11/58) of samples in patients reporting no symptoms for at least 24 hours contained viable nH1N1 virus. Of 29 samples obtained 7 days from illness onset, 7 (24%) contained viable nH1N1 virus.

A total of 228 cadets were placed in separated dorm areas during the outbreak period. There were no confirmed or suspect cases among healthcare personnel.

Investigators determined the outbreak was likely propagated by a social mixing event, which has implications for colleges and universities across the country. Measures undertaken to stem the spread of the virus, quick response and mitigation efforts enacted immediately upon outbreak recognition, good communication and a public health campaign contributed significantly to the subsequent rapid decline of the outbreak.

Writing in the article, Dr. Witkop and co-authors state, “The USAFA outbreak provided a unique opportunity to gain valuable information about the natural behavior of the nH1N1 virus....Novel H1N1 is now endemic in all 50 U.S. states. University- and college-based outbreaks of nH1N1 have occurred and more can be expected this fall as students gather from diverse geographic areas, reside in dorm settings and attend mass gatherings such as football games, pep rallies and student assemblies. The combination of aggressive separation of ill BCTs, public health education and prompt implementation of healthcare infection control practices limited the duration and scope of the nH1N1 infection at USAFA. Comprehensive plans and rapid implementation are critical. Isolation procedures implemented at USAFA may not be practical in other university settings; however, preparedness planning, public health education activities and healthcare infection control practices implemented at USAFA can be adopted in other university settings.”

The article is “Novel Influenza A (H1N1) Outbreak at the U.S. Air Force Academy: Epidemiology and Viral Shedding Duration” by Catherine Takacs Witkop, MD, MPH, Mark R. Duffy, DVM, MPH, Elizabeth A. Macias, PhD, Thomas F. Gibbons, PhD, James D. Escobar, MPH, Kristen N. Burwell, MPH and Kenneth K. Knight, MD, MPH. Following advance online publication on October 20, 2009 (DOI 10.1016/j.amepre.2009.10.005), the article will appear in the American Journal of Preventive Medicine, Volume 38, Issue 2 (February 2010) published by Elsevier.

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Full text of the article is available upon request; contact to obtain copies. To schedule an interview, please contact Dr. Witkop directly at 719-333-6239 or at

About the American Journal of Preventive Medicine 
The   American Journal of Preventive Medicine is the official journal of   The American College of Preventive Medicine and the   Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials.

The American Journal of Preventive Medicine is ranked 12th out of 105 Public, Environmental & Occupational Health titles and 16th out of 107 General and Internal Medicine titles according to the 2008 Journal Citation Reports© published by Thomson Reuters.

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