TALKING UNTIL WE ARE “FLU” IN OUR FACES (TAKING MICROBIOLOGY FROM THEORY TO REALITY)

Julie Trachman

Over the years of my teaching microbiology courses at various levels, I have frequently incorporated information regarding relevant current microbial issues – often taken from newspaper articles and / or television news reports such as New York Times reports regarding the 1999 West Nile virus outbreak in New York City (Jacobs). Prior to my experience with Writing Intensive (WI) biology courses, these microbiology-oriented headline topics were relegated only to discussion. After my experience of teaching a WI introductory biology course and while developing my WI microbiology course, I made it a habit of incorporating writing assignments based on N.Y. Times articles (or similar news articles) into the course assignments such as an article on the death of a woman in her 40s in Brooklyn from meningitis caused by Neisseria meningitidis (Pérez-Peña) – initially as extra credit assignments and subsequently, as required assignments. I chose assignments and reading material judiciously, wanting students to explore microbiology principles in the context of pertinent microbial infectious diseases agents such as enterohemorrhagic Escherichia coli (the spinach outbreak in fall 2006 [Gardiner]), the lethal methicillin- resistant Staphylococcus aureus (that killed the seventh grader in Brooklyn in fall 2007 [Hu and Kershaw]) and N. meningitidis (every semester when our students register they are asked their vaccination status against this microbe). Having students read and write about articles relevant to their course material is in accord with writing to learn goals (Bean 2; Elbow 1; Paul and Elder 2) and General Education principles (AACU 12). All of this was done with the hope that students would take this information into their future course work and future careers and perhaps even have an effect on their personal choices such as getting vaccinated against one of the most notorious and feared causes of meningitis, the bacterium N. meningitidis.

However, this past semester of fall 2009 was different. I had a real mission here. In all of the years I had been teaching, never before had we had to deal with a flu pandemic in the here and now (New York City outbreak in April 2009 [McNeil A1]; flu pandemic in June 2009 [McNeil and Grady A12]). And most of us have no personal memories of just how terrifying a flu pandemic can be. The flu pandemic of 1918 resulted in the deaths of an estimated 675,000 Americans and more than 20 million deaths worldwide (Tortora, Funke & Case 694). More recent pandemics resulted in a smaller number of deaths but these numbers are still significant: 70,000 deaths in the U.S. in 1957-8 and 34,000 deaths in the U.S. in 1968-69 (Tortora, Funke and Case 371).

In discussing during the first couple of weeks of class, the emergence of the swine flu with my Bio 310 Microbiology and Bio 230 Anatomy and Physiology 1 (A & P 1) students, it became readily apparent that many misperceptions were held in abundance and many students were reluctant to even contemplate getting one or both flu shots for themselves and / or family members. Some students, who were working in the health care industry as nurse’s aides and in health clinics, were even willing to risk their jobs. Early in the semester it had been mandated by New York State that all health care workers needed to be vaccinated by November 30, 2009 (the mandate was eventually revoked). Many students did not realize the rationale for the need for two separate shots, not knowing that the seasonal flu strains were immunologically different than the swine flu strain. Several students countered that they would get the flu if they got vaccinated – claiming that they got the flu when vaccinated previously. Others were suspicious of the swine flu vaccine because the virus was “new” and the swine flu vaccine, therefore, was “new” too even though the flu vaccine industry had years of experience preparing the seasonal flu vaccine. After the vaccination campaign started in Oct. 2009, some students voiced concern about side effects of the flu vaccine, having heard on various news programs about paralysis occurring in some recently vaccinated individuals.

We were dealing with wrong notions that had to be dispelled as quickly as possible since many our students fell into the age group of those most at risk (in their early 20s) and many had children at home (also considered a high-risk group) and some of my students were even pregnant, making them that much more vulnerable to the ill-effects of the swine flu virus. Furthermore, it was difficult to ensure that students who became infected with the swine flu would stay home and not risk transmitting it to their classmates or to the faculty and staff.

Our students are a heterogeneous group of students with respect to their ethnicity, with many being Hispanic and African-American. Many students and / or family members are recent immigrants to the United States; therefore, attitudes about Western medicine may vary. Scientific educational backgrounds of students in these pre-Allied Health Science classes also vary considerably, with even a few students coming back to school after working in non-science fields. Therefore, I considered the problem here to be primarily an education /awareness issue regarding the value of vaccination, in particular flu vaccination. If this were a simple matter about a limited outbreak, I might have just given my microbiology students an article or two and let them write something up. However, this was a serious issue pertinent to the entire campus because vaccination does not just protect the one who was vaccinated – vaccines protect the many via the process of herd immunity (also known as community immunity).

With the cooperation of all of my microbiology colleagues (and considerable able assistance from Prof. Katherine Neuhoff), we took advantage of the Natural Sciences department’s Open House to provide students an opportunity to hear in- depth information about the various forms of the flu, how the flu virus replicates, and why vaccination is needed. Just having students hearing about hand washing with or without antisepsis (i.e. alcohol in the hand lotions) and how to cover one’s sneezes so the flu virus does not spread through the air, was really inadequate in our minds. Our goals included increasing student knowledge about the differences between swine flu and seasonal flu, the underlying reasons why pandemics arise and about the protective role vaccines have. Two 1 ½ hour-long presentations were held that week.

The first session was held on Tuesday evening of Nov. 17, 2010 with a mix of approximately 70 students, primarily microbiology students from my WI microbiology class and Prof. Neuhoff’s microbiology class. A few students from the other microbiology classes were there as well as a smattering of students from my A&P 1 class.

Prof. Neuhoff had prepared a handout containing numerous diagrams and tables that gave us a jumping-off point to talk at length about the structure of the flu virus, how the flu virus replicates, and the two mechanisms behind its incredible ability to change its immunogenic characteristics (its antigenic variation) leading to the ability of the flu virus to cause pandemics. This allowed the two of us to segue into discussion about the seriousness of previous flu pandemics and how the 2009 flu pandemic could be have a different outcome than others because of the avail- ability of the swine flu vaccine. We also discussed with them honestly the potential pitfalls about the swine flu vaccination, since rumors had begun to surface about this swine flu vaccine causing paralysis. We made the students aware that a particular type of paralysis (as a result of Guillain-Barré syndrome) had been associated with the 1976 flu virus vaccination campaign (Cheng); however, this paralysis could also occur as a result of infection with the flu virus itself and infection by other viral and bacterial agents.

The second session held on Friday Nov. 20, 2010 had more A & P 1 students in the mix (as well as 2 professors in attendance at least part of the time). All told there were probably about 50 individuals in attendance for the Friday sessions. This time, however, I was the sole lecturer. Sizing up the different nature of the crowd, I ended up only somewhat relying on the handout prepared by Prof. Neuhoff. There- fore, in part to accommodate the larger number of A &P 1 students, I spent more time on the basics of viruses and less on the specific details of previous flu pandemics. I wanted these students to get a sense of why the flu virus is so different than other viruses and how this relates to the flu vaccination strategy being used today.

My WI microbiology students had two subsequent required assignments focusing on the flu and my A&P students were told ahead of time they had an opportunity to write about what they learned by attending the talk itself as an extra credit assignment. The handful of submissions I received from my A&P 1 students indicated that they did learn something useful about the flu from attending the talks, such as who was most at risk for having serious infections with the swine flu as compared to the seasonal flu and they now had some understanding of what a virus is and how it replicates. However, my primary intent for these talks was that I wanted to ensure that my microbiology students were giving much more serious consideration to flu vaccination and that in doing so they were deepening their understanding of the underlying microbiology principles like herd immunity and the nature of antibody – antigen specificity. To enhance their learning, my microbiology students had received 3 news articles on the flu (Calmes and McNeil A1; Zimmer D1; Neersgard) prior to the talk. Soon after the talk, I asked the microbiology students in one of the assignments to relate what they learned in the talk to textbook content on the flu virus and immunology principles (Tortora, Funke & Case) and news article content. I also asked them about their position now on the flu vaccine and asked whether their position changed from the beginning of the semester and if it had why.

In the second assignment, I asked the microbiology students to apply the terminology appearing in the epidemiology chapter (Tortora, Funke & Case) to the flu wherever relevant, providing them with some guidelines. I can not assess how useful the talks were for those students from the other microbiology classes although I was told anecdotally they found the talks interesting. From my students’ essays, I could tell that the flu talk and other information provided to them had some value – to themselves and to us (society). Granted some students were still reluctant to become vaccinated; however, they seemed to be considering the ramifications more intelligently. A few of the students were much more willing to be vaccinated and indeed in some cases had recently become vaccinated were even now encouraging family and friends to become vaccinated. Again, to reiterate, the value was to the students and to us (members of society) – and many of the students themselves now recognized this point. To quote from the essay of one of my microbiology students:

“When I first started this class not me or my son had ever been vaccinated for either the influenza or swine flu, but with the knowledge that I have obtained during this semester, it has enlightened me and from now on I will definitely make sure that me and my son get vaccinated every year. I understand now, how important it is to be vaccinated, not only for me and my family but the whole community. For the more of us that are vaccinated the less opportunity the virus has from spreading, a phenomenon know[n] as community immunity. That is because the vaccinated individuals protect the unprotected ones by stopping the chain of transmission in its tracks and drastically lower- ing the probability that the unprotected one encounter the virus.”

(excerpt taken from essay of my former microbiology student, Ms. Julissa Lopez, submitted Dec. 2009 and reprinted with her permission)

At last count as reported in Dec. 2009 (McNeil A26), there have been close to 10,000 deaths in the United States attributed to the swine flu pandemic since April 2009, and with approximately 213,000 sick enough to be hospitalized and approximately 50 million infected. How many more will be added to these numbers, it is impossible to know. We do not know if there will be a third wave of flu infections this coming January (January 2010) as had occurred in the 1918 and 1957 pandemics. Of course, we have the availability of modern medical technology to help those who become infected and who might require hospitalization. We are also fortunate in that we do have one chemotherapeutic agent, Tamiflu, in our arsenal, which at least for the moment still works against this swine flu strain. However, as mentioned previously, this virus undergoes antigenic variation. The same underlying mechanisms that can lead to changes in immunogenicity can make the virus resistant to Tamiflu or more lethal.

As of December 2009, only about 50 million Americans are vaccinated (Mc- Neil A26). But hopefully, because of the aggressive vaccination campaign that has already occurred and further education of our public, an even larger percentage of individuals will become vaccinated. That, in reality, is our best recourse – because of the afore-mentioned herd immunity. And in all likelihood given how the flu virus undergoes antigenic drift, which lead to subtle changes that accumulate over time and how infrequently the flu virus goes through dramatic antigenic shifts, the swine flu vaccine that is now being used will offer us some protection for some years to come as variants of this swine flu circulate in the human population. We can hope that people will think of not just themselves but others as well and become vaccinated, so that the tragedies of other flu pandemic will be averted where many thousands had died in the U.S. alone.

Addendum: As of April 2010, there have been approximately 12,000 deaths in the U.S. attributed to the 2009 swine flu pandemic (McNeil A13). During the winter months of 2010, there were very few reported cases of swine flu; however, in the last month, there has been an upsurge in swine flu cases in southeast U.S. The Centers for Disease Control (CDC) has expressed concern that there might still be a third wave of the swine flu attached to this pandemic, which might occur in the spring / summer months of 2010 (The New York Times News Service). Regarding the safety of the swine flu vaccine, it has been reported recently that there might be a very slight increase in complications such as Guillain-Barré syndrome occurring in individuals vaccinated against swine flu; however, the increase was deemed so small that the CDC was not certain as to whether the risk was real or potentially due to the more stringent monitoring for complications that occurred with the advent of swine flu vaccination program. Studies are continuing by the CDC to access the long-term of safety of the swine flu vaccine (Maugh).

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