Plenty of flu caution as Mexico returns to work

MEXICO CITY – In gleaming office towers and gritty markets, Mexicans returned to work Wednesday after a five-day swine flu shutdown, and dozens returned to a heroes' welcome from "humiliating" quarantines in China. But Mexico's death toll rose, feeding fears of more infections now that crowds are gathering again.

The World Health Organization urged countries not to quarantine visitors or impose trade restrictions without scientific reasons. But China defiantly justified its quarantines as protection for its densely populated cities. And even impoverished Haiti turned away a Mexican ship carrying desperately needed food aid because of flu fears.

In Mexico City, friends and co-workers greeted each other with back slaps, firm handshakes — and dollops of hand sanitizer. Some high-rises stationed doctors in their lobbies who questioned returning employees and required visitors to fill out forms stating they had no flu symptoms. Maitre d's in surgical masks stood at attention amid rows of sidewalk tables that were pulled out and washed down for the first time in days.

"We're returning to normal," said Eugenio Velis, 57, a graphic artist sipping coffee with friends in the trendy Condesa neighborhood.

But Ernesto Viloria, 40, worried about his children using public transit and returning to school.

"Nothing can be the same," insisted Viloria, who works in finance. "The virus continues, even though it's declining, and we have to pay attention."

Mexico's government said the shutdown reduced the spread of the virus at its epicenter. Deaths have slowed as the country mobilized an aggressive public health response to the epidemic that has sickened thousands in 24 countries.

Sweden and Poland were the latest countries to confirm swine flu cases, both in women who had recently visited the U.S.

In Mexico, the confirmed death toll reached 42 Wednesday — mostly as backlogged cases got tested, but also two new deaths on Tuesday. It also confirmed more than 1,100 nonfatal cases. Eighty percent of Mexico's swine flu infections have been in and around the capital, and a majority of the dead were between 20 and 39 years old.

There was some concern that Mexico was relaxing too quickly, especially with high schools and universities reopening Thursday, and primary schools reopening next week. While "filter teams" prepared to screen out sick students and teachers, epidemiologists warn that the virus has spread throughout Mexico, and could bounce back.

"We have seen a tendency (of the outbreak) to diminish but not disappear," Health Secretary Jose Angel Cordova acknowledged.

Indeed, this swine flu seems to have a long incubation period — 5-7 days before people notice symptoms, according to Dr. Marc-Alain Widdowson, a medical epidemiologist from the U.S. Centers for Disease Control and Prevention now tracking the flu in Mexico City. And that means the virus can keep being spread by people who won't know to stay home.

While restaurants opened, Mexico City's government indefinitely closed bars, discos, gymnasiums, movie theaters and dance halls. Sports halls and arenas were allowed to reopen only at half capacity. Archaeological sites began reopening Wednesday, with museums to follow.

From gritty taco stands to the Cartier store on Mexico City's version of Rodeo Drive, people were glad to be back at work.

Jesus Cortez, 43, manned El Taquito Veloz, "The Speedy Little Taco," in the rough Tepito neighborhood, offering roasted pork on a spit as its specialty — tacos al pastor. Nearby, workers sliced chunks of meat from a boiled steer's skull, flanked by cilantro branches.

"People are just starting to come back out, but they're still afraid," Cortez said. "We're going to have to open on Sundays now, and we're going to have to work really hard. If not, we're not going to make enough money."

Cartier manager Paula Guerra, 34, waited out the furlough in Valle de Bravo, a lakeside retreat for Mexico City's well-to-do, and returned Wednesday blowing air kisses to her employees through her surgical mask. But she, too, was hoping to make up for lost sales — in Mother's Day merchandise.

Rafael Ramirez, 65, rushed to the just-reopened Metropolitan Cathedral to pray to a Christ statue known as the Lord of Health, which the church brought out from storage for the first time in 300 years.

"I gave thanks that the city is returning to normal, and prayed so countries stop looking down their noses at us," Ramirez said.

Mexico has protested Chinese quarantines and China's cancellation of direct flights between the countries as discriminatory.

First lady Margarita Zavala was up before dawn to greet 136 Mexicans who were flown home from China on a government charter. None had flu symptoms, Mexican diplomats said.

While Zavala pointedly removed her face mask and smiled broadly as she welcomed the Mexicans home, the scene in Shanghai was far different: 119 returning Chinese gamely waved their country's flags as health workers in full body suits escorted them into a weeklong quarantine.

Several Mexican passengers said they were treated well in China. Others begged to differ.

"It was discrimination and humiliation in my case," said Myrna Berlanga, who said she was taken off a flight from the United States and put in a mobile laboratory for five hours without food, water or a bathroom. "They took me out because of my passport."

Haitian officials said they would not accept a Mexican navy ship carrying 77 tons of rice, fertilizer and emergency food kits, said Mexico's ambassador, Zadalinda Gonzalez y Reynero. She said Haiti asked for the ship to come "on another occasion."

Haitian officials had no immediate comment.

In San Diego, Calif., the U.S. Navy canceled the deployment of the USS Dubuque, an amphibious transport ship, after a crew member was confirmed to have swine flu. About 50 others were suspected cases, and all crew members were being treated with anti-viral drugs.

The ship was to leave June 1 on a humanitarian mission to the South Pacific, Navy spokesman Lt. Sean Robertson said.

And the Philippines urged boxing idol Manny Pacquiao to postpone a triumphant return home after beating Ricky Hatton in Las Vegas, saying a motorcade in Manila could risk spreading the virus through adoring crowds. There are no confirmed cases in the Philippines.

In Washington, officials with the U.S. Centers for Disease Control and Prevention said they identified genetic characteristics of the virus and were in position to produce a vaccine if one is needed.

Dr. Dennis Carroll, a special adviser on pandemics with the U.S. Agency for International Development, said investments to stave off an avian flu epidemic aided the quick swine flu response.

Canada, meanwhile, said researchers at the National Microbiology Laboratory in Winnipeg, Manitoba, genetically sequenced three samples of the virus from Mexico and Canada, a breakthrough they hope will answer questions about how it spreads and mutates.

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Associated Press writers Margie Mason, Mark Stevenson, Lisa J. Adams and Juan Carlos Llorca in Mexico City and Jonathan M. Katz in Port-au-Prince contributed to this report.

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Nation's first face transplant patient shows face

CLEVELAND – Five years ago, a shotgun blast left a ghastly hole where the middle of her face had been. Five months ago, she received a new face from a dead woman. Connie Culp stepped forward Tuesday to show off the results of the nation's first face transplant, and her new look was a far cry from the puckered, noseless sight that made children run away in horror.

Culp's expressions are still a bit wooden, but she can talk, smile, smell and taste her food again. Her speech is at times a little tough to understand. Her face is bloated and squarish, and her skin droops in big folds that doctors plan to pare away as her circulation improves and her nerves grow, animating her new muscles.

But Culp had nothing but praise for those who made her new face possible.

"I guess I'm the one you came to see today," the 46-year-old Ohio woman said at a news conference at the Cleveland Clinic, where the groundbreaking operation was performed. But "I think it's more important that you focus on the donor family that made it so I could have this person's face."

Up until Tuesday, Culp's identity and how she came to be disfigured were a secret.

Culp's husband, Thomas, shot her in 2004, then turned the gun on himself. He went to prison for seven years. His wife was left clinging to life. The blast shattered her nose, cheeks, the roof of her mouth and an eye. Hundreds of fragments of shotgun pellet and bone splinters were embedded in her face. She needed a tube into her windpipe to breathe. Only her upper eyelids, forehead, lower lip and chin were left.

A plastic surgeon at the Cleveland Clinic, Dr. Risal Djohan, got a look at her injuries two months later. "He told me he didn't think, he wasn't sure, if he could fix me, but he'd try," Culp recalled.

She endured 30 operations to try to fix her face. Doctors took parts of her ribs to make cheekbones and fashioned an upper jaw from one of her leg bones. She had countless skin grafts from her thighs. Still, she was left unable to eat solid food, breathe on her own, or smell.

Then, on Dec. 10, in a 22-hour operation, Dr. Maria Siemionow led a team of doctors who replaced 80 percent of Culp's face with bone, muscles, nerves, skin and blood vessels from another woman who had just died. It was the fourth face transplant in the world, though the others were not as extensive.

"Here I am, five years later. He did what he said — I got me my nose," Culp said of Djohan, laughing.

In January, she was able to eat pizza, chicken and hamburgers for the first time in years. She loves to have cookies with a cup of coffee, Siemionow said.

No information has been released about the donor or how she died, but her family members were moved when they saw before-and-after pictures of Culp, Siemionow said.

Culp said she wants to help foster acceptance of those who have suffered burns and other disfiguring injuries.

"When somebody has a disfigurement and don't look as pretty as you do, don't judge them, because you never know what happened to them," she said. "Don't judge people who don't look the same as you do. Because you never know. One day it might be all taken away."

It's a role she has already practiced, said clinic psychiatrist Dr. Kathy Coffman.

Once while shopping, "she heard a little kid say, `You said there were no real monsters mommy, and there's one right there,'" Coffman said. Culp stopped and said, "I'm not a monster. I'm a person who was shot," and pulled out her driver's license to show the child what she used to look like, the psychiatrist said.

Culp, who is from the small town of Unionport, near the Pennsylvania line, told her doctors she just wants to blend back into society. She has a son and a daughter who live near her, and two preschooler grandsons. Before she was shot, she and her husband ran a painting and contracting business, and she did everything from hanging drywall to a little plumbing, Coffman said.

Culp left the hospital Feb. 5 and has returned for periodic follow-up care. She has suffered only one mild rejection episode that was controlled with a single dose of steroid medicines, her doctors said. She must take immune-suppressing drugs for the rest of her life, but her dosage has been greatly reduced and she needs only a few pills a day.

Also at the Cleveland Clinic is Charla Nash of Stamford, Conn., who was attacked by a friend's chimpanzee in February. She lost her hands, nose, lips and eyelids, and will be blind, doctors said. Clinic officials said it is premature to discuss the possibility of a face transplant for her.

In April, doctors at Harvard-affiliated Brigham and Women's Hospital in Boston performed the nation's second face transplant, on a man disfigured in a freak accident. It was the world's seventh such operation. The first, in 2005, was performed in France on Isabelle Dinoire, a woman who had been mauled by her dog.

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Ga. man stable after 1st US double hand transplant

PITTSBURGH – Teams of surgeons performed the nation's first double hand transplant on a man whose hands and feet were ravaged by a bacterial infection a decade ago and who hoped to once again be able to hold his daughter.

Jeff Kepner, 57, of Augusta, Ga., underwent surgery lasting just under nine hours Monday at the University of Pittsburgh Medical Center, where surgeons worked on each hand simultaneously, a hospital spokeswoman said.

He was in critical but stable condition Tuesday at the hospital's transplant intensive care unit, spokeswoman Amy Dugas Rose said.

Rose did not have information about the donor. The hospital was expected to release more details later this week.

Kepner, a native of Lancaster, Pa., told the Sunday News of Lancaster before his surgery he was looking forward to holding his 13-year-old daughter, who was 3 when he lost his hands and feet.

His surgery was done using a technique developed at UPMC called the Pittsburgh Protocol, which aims to reduce the amount of toxic medication that must be taken to suppress the immune system so the body doesn't reject the new hands. The toxic medication can lead to an increase in the risk for diabetes, infections and other complications.

Under the protocol, Kepner was given antibodies the day of the transplants and will be given bone marrow from the hand donor over the next several days. Instead of a variety of anti-rejection medications, he should have to take just one.

Eight double hand transplants have been performed abroad. Last month, French physicians performed the world's first simultaneous partial face and double hand transplant.

Five U.S. hand transplants have been done at Jewish Hospital Heart and Lung Center of Louisville, Ky.

In March, UPMC performed its first hand transplant, on a Marine who lost his right hand when a quarter-stick of dynamite blew up in it during a training exercise in Quantico, Va.

The first U.S. hand transplant was performed in January 1999, on a New Jersey man who lost his hand in 1985 in an M-80 firecracker blast.

The first hand transplant was done in Ecuador in 1964, but the patient's body rejected the hand after two weeks.

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Texan dies of swine flu; Mexico ready for business

MEXICO CITY – Mexico emerged from its swine flu isolation Tuesday as thousands of newspaper vendors, salesmen hawking trinkets and even panhandlers dropped their protective masks and joined the familiar din of traffic horns and blaring music on the streets of the capital.

There were still signs, however, of the virus that set off world health alarms. A Texas woman who lived near a popular border crossing was confirmed as the 28th person — only the second outside Mexico and the first U.S. resident — to die from the virus.

Across Mexico, people were eagerly anticipating this week's reopening of businesses, restaurants, schools and parks, after a claustrophobic five-day furlough.

"We have a lot of confidence nothing is going to happen," said Irineo Moreno Gonzales, 54, a security guard who Tuesday limited takeout customers to four at a time at a usually crowded downtown Starbucks. "Mexicans have the same spirit we've always had. We're ready to move forward."

The Texas woman, the second to die of swine flu in the U.S., lived not far from the Mexico border and had chronic medical conditions, as did the Mexico City toddler who died of swine flu last week during a visit to Houston, Texas, health officials said.

The 33-year-old woman was pregnant and delivered a healthy baby while hospitalized, said Leonel Lopez, Cameron County epidemiologist. She was a teacher in the Mercedes Independent School District, which announced it would close its schools until May 11.

Mexico's government imposed the shutdown to curb the flu's spread, especially in this metropolis of 20 million where the outbreak sickened the most people. Capital residents overwhelmingly complied, and officials cautiously hailed the drastic experiment as a success.

But by Tuesday, pedestrians — many wearing protective masks, many not — were back to dodging the familiar green-and-white VW taxis cruising for fares and noisy heavy trucks bearing bottled water.

Some officials worried about a sudden rush toward normalcy, though no Mexican swine flu deaths have been confirmed since April 29.

"The scientists are saying that we really need to evaluate more," said Dr. Ethel Palacios, the deputy director of the swine flu monitoring effort here. "In terms of how the virus is going to behave, we are keeping every possibility in mind. ... We can't make a prediction of what's going to happen."

Palacios acknowledged the enormous responsibilities that come with balancing the public's health and economic welfare.

"One of most the important things is that you need to know that these measures do have an impact not only on health but also on other aspect of life and society," Palacios said.

With 840 people sickened in Mexico at last count, public celebrations of Cinco de Mayo were banned, and politicians' homage to the soldiers who fought off the French 147 years ago were subdued.

For the first time in decades, Mexico canceled the popular re-enactment of its May 5, 1862, victory over invading French troops in the central state of Puebla. Another traditionally boisterous Cinco de Mayo party in Mexico City's central plaza, the Zocalo, will wait for another year, as will military ceremonies across the nation.

Cinco de Mayo celebrations generally attract bigger crowds in the U.S., where many Mexican-Americans gather to embrace their heritage. These crowds prompted concerns Tuesday about spreading the virus.

Denver's annual festival, which typically draws 400,000, will be held as planned this weekend, with hand sanitation stations installed at the urging of city health officials. Los Angeles won't skip its weekend celebration on historic Olvera Street. But in Chicago, the Mexican Civic Society of Illinois canceled its annual festivities because of flu concerns.

Swine flu has now sickened more than 1,600 people in 21 countries, including nearly 500 in the United States. The World Health Organization said it was shipping 2.4 million treatments of antiflu drugs to 72 countries "most in need," and France sent 100,000 doses of antiflu drugs worth $1.7 million to Mexico.

Mexican Finance Secretary Agustin Carstens unveiled plans Tuesday to stimulate key industries and fight foreign bans on Mexican pork products. He said persuading tourists to come back will be a top priority.

Carstens said the outbreak cost Mexico's economy at least $2.2 billion, and he announced a $1.3 billion stimulus package, mostly for tourism and small businesses, the sectors hardest hit by the epidemic. Mexico will temporarily reduce taxes for airlines and cruise ships and cut health insurance payments for small businesses.

U.N. Secretary-General Ban Ki-moon said he will ask governments to reverse trade and travel restrictions lacking a clear scientific basis.

About 20 Chinese businessmen and students, each wearing surgical masks, left Tijuana on Tuesday on a Chinese government flight after being stranded when China canceled all direct flights to Mexico.

Mexico, meanwhile, was collecting more than 70 Mexican nationals quarantined in China with its own charter flight.

Four U.S. citizens were quarantined in China, the U.S. Embassy in Beijing said Tuesday, and about 200 passengers who flew from the United Kingdom were under quarantine in a Brunei hospital after three of them arrived with fevers.

Mexico City recovered a bit of its ebullient self Tuesday, one day before the official reopening of stores, restaurants and factories. Only essential services like gas stations and supermarkets have been allowed to operate since April 27, and the weekend's professional soccer games will again be staged in empty stadiums.

High schools and universities were being scrubbed down to reopen Thursday. Younger children return to school on Monday.

Many people shunned their surgical masks Tuesday; a boy selling music CDs on a subway train planted a wet kiss on the unprotected cheek of a girl hawking tiny flashlights. A fruit salad vendor dished up slabs of freshly cut mango and coconut without mask and gloves.

The government is requiring businesses to keep a distance of 2 meters (yards) between customers to prevent the disease from spreading. The rule seemed unlikely to survive in the overcrowded capital.

"It's a little senseless, that people ride into town all jammed together on the subway, and the minute they enter a restaurant, they have to be 2 meters apart," said Nahum Navarette, manager of Yug, a vegetarian restaurant that was still serving only takeout on Tuesday, its dining room deserted.

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Associated Press Writer Katherine Corcoran contributed to this report.

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Experts: Mild swine flu could quickly turn deadly

WASHINGTON – A flu virus is a powerhouse of evolution, mutating at the maximum speed nature allows. A mild virus can morph into a killer and vice versa.

One change already made this year's swine flu more of a problem, helping it spread more easily among people. The big question is: What mutations are next? That's why scientists are watching it so closely.

"There are no rules to flu viruses; they are just so mutable," said Dr. Paul Glezen, a flu epidemiologist at the Baylor College of Medicine in Houston. "The fact that it changes all the time really confounds our efforts to control it."

Think of flu's evolution like a family tree: In the current flu's distant ancestry are last century's three pandemics. But its more immediate relatives are swine flu strains that were no big deal to humans.

The good news right now is that this flu has lost some of the most dangerous genetic traits of past pandemics. The bad news is that it's gained something its parents didn't have: the ability to spread from human to human.

Flu reproduces about every eight hours, said Dr. Raul Rabadan, professor of computational biology at Columbia University. That means this morning's flu is a parent by the afternoon, a grandparent by the evening, and a great-grandparent by the next day.

Instead of complex double-helix DNA — nature's basic biological instruction book — flu has a simpler, single strand of genetic code. Normal DNA has a spellcheck-like system that reduces mistakes in replicating the code; the flu virus does not. So mutations come more often. If the mutations are good for the virus, they multiply, and voila, you have a new and sometimes nastier flu.

Scientists are trying to piece together swine flu's ever-changing genome, its genetic ancestors and the random mutations that in this instance turned a simple pig disease into something that scares billions.

They also don't know how the virus is going to mutate next.

In the world's most devastating global flu epidemic in 1918, the first wave of cases in the spring were mild. Then, the virus evolved and came back in the fall as a strain that proved truly deadly, flu experts say. So scientists today are watching to see if that could happen again.

Also troubling is the possibility that this virus could develop resistance to anti-flu drugs, and flu trackers are watching for such changes, Centers for Disease Control and Prevention flu chief Dr. Nancy Cox said.

It's impossible to know where this swine flu strain began exactly, Cox said. But flu trackers do have clues to its closest ancestral genes.

"Its two parents were swine viruses that we know and love," said virologist Dr. Richard Webby, a researcher at St. Jude Children's Research Hospital in Memphis, Tenn.

The mother of the swine flu was a surprising genetic event that went unnoticed except by a few scientists a little over a decade ago. Three influenza strains — some pig, some bird, some human — combined in pigs to form two new strains of swine flu. This new flu was unusual. Virus hunters called it a "triple reassortment."

That 1998-99 flu in pigs first hit a farm in North Carolina, then spread to Iowa, Texas, Oklahoma and eventually to at least 23 states. No more than 4 percent of the swine died. But the disease was in more than one-quarter of tested pigs. A handful of people who were in close contact with the hogs got slightly sick when they caught this flu from pigs, but they didn't die and didn't spread it to others.

In 2005, a 17-year-old Wisconsin boy caught that triple reassortment flu virus from "respiratory secretions" of a pig he had been helping his brother-in-law butcher, according to the CDC. He recovered and didn't pass it on to others.

There have been about 10,000 generations of that virus since. Six of the eight genetic segments of the current swine flu can be traced to that triple combination, Rabadan said.

The rest of the swine flu parentage is more of a mystery. The other two of the eight genetic segments can be traced to pig viruses in Europe and Asia that were seen from time to time in the 1990s, Rabadan said. Scientists don't quite know if those other two segments combined with the triple reassortment at the same time or separately.

How the triple reassortment genes and the European and Asian genes met and mixed is not known, Webby said.

The three global flu epidemics of the past, including the 1918 event, all passed on traits to ancestors of this flu, Rabadan said. But there have been many changes in the thousands of generations since.

A specific gene for virulence that was seen in the 1918, 1957 and 1968 pandemics was notably absent in this swine flu, said Dr. Peter Palese, a prominent flu researcher for Mount Sinai Medical Center in New York. He said when he removed that gene from other viruses of the past, they weren't as dangerous.

Rabadan suggests the way to think of this flu is like a homemade car with parts from different vehicles. The parts have all been in several different vehicles before. Sometimes the combination of parts is a dud and the car doesn't move. And sometimes you get a race car. A pandemic is a race car.

All eight of the new flu's genetic segments have been in different viruses before. But this is the first time this specific combination has been seen. The big question is: Why is this particular swine virus spreading so fast among people when past swine viruses haven't?

One possibility is that it's just this particular combination of the eight parts that makes it spread among people, Webby said. But a more logical explanation is that a small mutation within the individual genetic segments changed things.

These tiny changes are possible because there are about 13,000 individual letters, or bases, in the flu genetic code, Rabadan said. That's tiny compared to more than 3 billion in humans.

One prime suspect is the surface protein hemagglutinin, the "H" in the virus' H1N1 name. It is "probably the most important gene determining virulence and immunological characteristics," according to Palese.

In flu viruses, scientists have so far identified 16 hemagglutinins. Only three — H1, H2 and H3 — commonly infect humans. The other surface protein, neuraminidase, has nine variations. Palese said scientists are seeing more different types of flu strains because of better surveillance and increases in bird, pig and human populations.

"These genetic processes of mutation and genetic reassortment occur all the time," he said, "and every once in a time, it's a lottery winner."

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US no longer advising schools close for swine flu

ATLANTA – U.S. health officials are no longer recommending that schools close if students come down with swine flu, the government said Tuesday.

Last week, schools were advised to shut down for about two weeks if there were suspected cases of swine flu. Hundreds of schools around the country have followed the government's guidance and closed schools, giving students an unexpected vacation and leaving parents scrambling for child care.

"We no longer feel that school closure is warranted," said Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention.

Health and Human Services Secretary Kathleen Sebelius said the swine flu virus had turned out to be milder than feared and the government decided to change its advice. So far, the virus has not proved to be more infectious or deadly than the seasonal flu.

The CDC said parents should still make sure to keep sick children with flulike symptoms at home for seven days.

As the threat seemed to diminish, health officials also considered the problems the closings were creating for parents, Besser said. Officials were hearing about children getting dropped off at libraries, or parents who couldn't take sick leave to care for their children.

"The downsides of school closure start to outweigh the benefits," Besser said.

The change in guidance was made in consultation with the White House and other officials, Besser and others said.

An estimated 726 public and nonpublic schools were closed Tuesday for flu-related reasons, in 24 states and the District of Columbia, according to the Education Department. In total, these schools enroll approximately 468,000 students on a typical day. (There are more than 100,000 schools in the U.S., with about 55 million students.)

The number of confirmed swine flu cases in the United States is now over 400, with hundreds more probable cases. The CDC knows of 35 swine flu-related hospitalizations and one death, a Mexican toddler who died in Texas.

Nearly two of every three cases are under the age of 18, CDC officials said.

Local school officials still have the ultimate say in whether to close or not, CDC officials noted.

In the new guidance, the CDC recommends that when children or school staff are sick, they stay home. Those who do go to school should practice good hygiene — like coughing into their sleeve or shoulder instead of their hands or the air, and washing their hands well and often.

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On the Net:

CDC swine flu web site: http://www.cdc.gov/h1n1flu/

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Mexico gets some bustle back after flu shutdown

MEXICO CITY – Traffic is picking up again, cafes are reopening and cleanup crews are getting universities ready to resume classes. Mexico City has some of its customary bustle back, and the president promises life is returning to normal after a five-day shutdown to contain the spread of swine flu.

Mexico still called off Cinco de Mayo celebrations Tuesday, including the biggest one of all — a re-enactment of the May 5, 1862, victory over French troops in the central state of Puebla. And health experts warned that Mexico and the rest of the world needed to remain on guard against the virus.

Saying the outbreak is waning in Mexico, the epicenter of an illness that has sickened hundreds around the world, President Felipe Calderon announced it was nearly time to reopen businesses. Universities and high schools will open their doors Thursday, and younger schoolchildren are to report back to school May 11.

"The school schedule will resume with the guarantee that our educational institutions are in adequate hygienic condition," Calderon said. He urged parents to join educators in a "collective" cleansing and inspection of schools nationwide.

"This is about going back to normalcy, but with everyone taking better care," Calderon said.

Already more vehicles prowled the streets of the capital Monday than over the weekend, and fewer people wore surgical masks. Some cafes even reopened ahead of time.

Health Secretary Jose Cordova said infections were trending downward after Mexico's 27 deaths, including a Mexican toddler who died in Texas. He said those infected appeared to pass the virus on to an average of 1.4 other people, near the normal flu rate of around 1.3.

Cordova said soccer stadiums and concert halls could reopen — but only if fans were kept 2 meters, about 6 1/2 feet, apart.

However, world health officials stressed that the global spread of swine flu was still in its early stages and a pandemic could be declared in the days to come. Experts inside Mexico's swine flu crisis center warned that the virus remained active throughout Mexico and could bounce back once millions return to work and school.

"It's clear that it's just about everywhere in Mexico," Marc-Alain Widdowson, a medical epidemiologist from the U.S. Centers for Disease Control and Prevention, told The Associated Press.

Widdowson said it is too early to say the outbreak is over in Mexico, but the signs of progress are clear.

"What we have not seen in Mexico City is a huge, runaway epidemic, and I think that's totally clear. The hospital capacity has not been exceeded. So there hasn't been anything like the kind of picture that people might expect from a severe flu," he said. "I think that gives us optimism."

Scientists said the virus is spreading in the U.S. and that chances of severe cases could rise there as well, even as a New York City school reopened after the swine flu hit following a spring break trip by some students to Mexico.

"We are by no means out of the woods," said Dr. Richard Besser, acting director of the CDC.

As of Monday, Mexico had 802 confirmed cases, and U.S. cases grew to at least 380 in 36 states. Globally, the virus had infected more than 1,445 people in 20 countries, the World Health Organization said, including South Korea which reported its second confirmed case Tuesday. Experts said the known cases were almost certainly only a fraction of the real total.

The latest figures from Mexico suggest the virus may be less lethal and infectious than originally feared. Only 38 percent of suspected cases have turned out to be swine flu, and no new deaths have been reported since April 29. But Cordova acknowledged that about 100 early deaths in which swine flu was suspected may never be confirmed because mucous or tissue samples were not collected.

WHO was studying whether to raise the pandemic alert to 6, its highest level, which would mean a global outbreak had begun. WHO uses the term pandemic to refer only to geographic spread and not to the severity of an illness. The two most recent pandemics — in 1957 and 1968 — were relatively mild.

"We do not know how long we will have until we move to Phase 6," WHO Director-General Margaret Chan said. "We are not there yet. The criteria will be met when we see in another region outside North America, showing very clear evidence of community-level transmission."

The Southern Hemisphere is particularly at risk. While Africa still hasn't reported any swine flu infections and New Zealand is the only country south of the equator with confirmed cases, winter is only weeks away. Experts worry that typical winter flus could combine with swine flu, creating a new strain that is more contagious or dangerous.

"You have this risk of an additional virus that could essentially cause two outbreaks at once," Dr. Jon Andrus said at the Pan American Health Organization's headquarters in Washington.

Still, the U.N. health agency urged governments to avoid unproven actions to contain the disease, including group quarantines of travelers from Mexico and bans on pork imports.

"Let me make a strong plea to countries to refrain from introducing measures that are economically and socially disruptive, yet have no scientific justification and bring no clear public health benefit," Chan said in a video message to the U.N. General Assembly in New York.

China, Argentina and Cuba are among the nations banning regular flights to and from Mexico, marooning passengers at both ends. Mexico and China both sent chartered flights to each other's countries to collect their citizens, with a chartered Mexican plane landing in Shanghai early Tuesday. Argentina also chartered a flight to bring Argentines home.

In a televised message to the country late Monday, Calderon had harsh words for countries that he said are treating Mexicans unfairly. "Stop taking actions that only hurt Mexico and don't contribute to avoid the transmission of the disease."

Economy Secretary Gerardo Ruiz said Mexico would raise the issue at the World Trade Organization if other countries didn't drop restrictive measures.

Chinese authorities quarantined Mexicans and other passengers who came in close contact with them, even those who didn't show symptoms.

Among them was Olivier Dolige of France, one of 274 guests and employees kept inside a Hong Kong hotel where a Mexican tourist came down with swine flu. Dolige celebrated his 43rd birthday under quarantine Tuesday, telling The Associated Press in a phone interview he invited other guests to share in champagne being sent by the French consulate.

"The day has started very well," said Dolige, who was visiting Hong Kong for a trade fair. He said he had come to terms with the quarantine. "I feel good. I feel very good."

The American Embassy in Beijing said Tuesday that four U.S. citizens were quarantined in China due to swine flu fears. Embassy spokeswoman Susan Stevenson said two of the Americans were in Beijing and the other pair were in the southern province of Guangdong.

Stevenson declined to go into specifics of the individual cases, citing privacy reasons, but said only two of them remained in quarantine.

In Tokyo, 37 passengers and two flight attendants on a flight from Los Angeles were detained in a hotel after Japanese officials suspected one traveler of having swine flu. They were released about 10 hours later when the passenger, a Japanese woman coming back from Las Vegas, tested negative for swine flu, American Airlines spokesman Tim Smith said.

About 200 passengers who flew from the United Kingdom to Brunei were under quarantine in a Brunei hospital over swine flu fears Tuesday after three of them showed fever symptoms, an official said.

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Swine flu leaves Southern Hemisphere out in cold

SAO PAULO – The Southern Hemisphere has been mostly spared in the swine flu epidemic. That could change when winter starts in coming weeks with no vaccine in place, leaving half the planet out in the cold.

So far, the most affected nations have been in North America and Europe, which are heading into summer. But flu is spread more easily in the winter, and it's already fall down south. Experts fear public health systems could be overwhelmed — especially if swine flu and regular flu collide in major urban populations.

"You have this risk of an additional virus that could essentially cause two outbreaks at once," Dr. Jon Andrus said at the Pan American Health Organization's headquarters in Washington.

There's also a chance that the two flus could collide and mutate into a new strain that is more contagious and dangerous.

"We have a concern there might be some sort of reassortment and that's something we'll be paying special attention to," World Health Organization spokesman Dick Thompson said.

Flu spreads more readily during the winter because people congregate indoors as the weather gets colder, increasing the opportunity for the virus to hop from person to person, said Raina MacIntyre, public health director at the University of New South Wales in Australia. Colder temperatures also may make it easier for the virus to infect people.

"The highest peaks of influenza activity occur in winter," MacIntyre said. "For us in the Southern Hemisphere, it's particularly concerning."

And while New Zealand is the only southern nation with confirmed swine flu cases, "it's almost inevitable that it will come to Australia," she said.

Humans have only limited natural immunity to this new blend of bird, pig and human viruses, but the strain has killed relatively few people in its current form compared to traditional flu, which kills about 36,000 people each year in the U.S. and more than 250,000 worldwide.

The timing is particularly challenging for vaccine makers. A vaccine for swine flu is still months from being produced, and will likely be available just as flu season is ending in southern countries.

"The vaccine won't come in time for South America," said Dr. Gonazalo Vecine of Sao Paulo's prominent Hospital Sirio-Libanes.

In addition, many companies may switch to making swine flu vaccine instead of seasonal flu vaccine, jeopardizing the southern countries' regular flu vaccine stocks. That could mean fewer seasonal flu vaccines available for next year's Southern Hemisphere winter.

"This is a concern we are working on," Andrus said. "We want to prevent it from being a potential barrier to getting it to the people who need it most."

Even in normal years, vaccine makers don't have the capacity to make enough courses for more than a fraction of the world's population.

Some experts think health officials in Southern Hemisphere countries should be more concerned with seasonal flu than with swine flu.

John Mackenzie, a flu expert at Curtin University in Australia, said countries should focus on regular flu vaccines for high risk populations, including the elderly and those with chronic illnesses, since this swine flu appears relatively mild so far.

"Governments have to step up their actions to protect their populations, especially in the absence of a (swine flu) vaccine," Thompson said. "Latin American countries may have a somewhat stronger surveillance system than in Africa. Africa's going to need some additional support and surveillance."

In Africa, which has yet to confirm a swine flu case, an outbreak during traditional flu season will make diagnosing and treating the two viruses a challenge, said Barry Schoub, director of South Africa's National Institute for Communicable Diseases.

Even in the absence of cases, officials are preparing. O.R. Tambo International Airport in Johannesburg, the gateway to the region handling millions of travelers each year, has plans to get a thermal image detection system running to check passengers for fever. A supply of masks has been provided to that airport and others, as well.

Hospitals have been given guidelines on how to handle suspected cases. South Africa, the richest country in the region, is poised to assist its neighbors should they need help with testing or treatment.

South Africa has stockpiled about 100,000 courses of the antiviral drug Tamiflu, which appears to help people afflicted with swine flu, and has access to more if needed, Schoub said.

Other countries said they're well-prepared, too. Australia has a stockpile of 8.7 million courses of Tamiflu and Relenza to treat its population of 22 million, MacIntyre said. Brazil says it is well-prepared but has Tamiflu for just 9 million people in a nation of more than 190 million.

Argentina, population 40 million, has 500,000 treatments with another 110,000 on order. Chile, with 16 million, has 300,000 treatments and has asked for 500,000 more.

And in Bolivia, one of the hemisphere's poorest nations, top epidemiology official Eddy Martinez wouldn't say how much Tamiflu it has in hand. If Bolivia needs more, it will go to the WHO, which is sending millions of courses of the drug to 72 developing nations.

The greatest risk to South American nations are its most vulnerable populations, who live in slums ringing big cities and have little access to health care.

"You can't talk about at-risk countries, but rather populations at risk, and that's the families of eight people who live together in a single room," said Dr. Mauricio Espinel, an epidemiologist at Ecuador's University of San Francisco.

___

Associated Press writers Kristen Gelineau in Sydney, Maria Cheng in London, Donna Bryson in Johannesburg and Gonzalo Solano in Quito, Ecuador, contributed to this report.

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Helping doctors ask about drug, alcohol problems

WASHINGTON – If more doctors started asking, would more drug and alcohol abusers 'fess up so they could get help?

It's a huge irony of health care: Go to the emergency room and you'll be asked about a tetanus shot, even though "most of us have never seen a case of tetanus," says Dr. Gail D'Onofrio, emergency medicine chief at Yale-New Haven Hospital.

Yet although up to half of ER visits involve illegal drugs or alcohol, typically "we don't ask it. It makes no sense whatsoever," says D'Onofrio, who teaches new doctors to break that chain of silence.

A new program from the National Institute on Drug Abuse aims to help health workers past the stigma and ensure that more patients are asked for simple clues to addiction at every visit — not just in the ER, but anytime they see a doctor.

It's a step-by-step computerized guide that takes patients' answers to various behavior questions, analyzes their risk for a serious substance use problem and tells doctors what next steps to take.

A patient admits to experimenting with heroin? A few more questions about how often, when and if he felt cravings can guide how big his risk is for ongoing drug use and what intervention is needed — plus remind the doctor to administer an HIV and hepatitis test.

Someone else insists she's a social drinker? If she's ever had four or more drinks in a day, she may have a bigger problem.

The goal: To get substance abuse treatment for more of the 23 million Americans estimated to need it. Only about 2 million today get that help, NIDA says.

Better would be finding people early, when substance abuse is just taking hold and a doctor intervening might keep it from getting worse. A government study last year found that some simple doctor steps — brief in-office counseling or referral to a specialty center — could help slash drug use by patients coaxed to come clean.

They have plenty of opportunity. Studies suggest people with brewing drug or alcohol problems actually see the doctor more often than their sober counterparts. They have a lot of injuries, and a tougher time with problems ranging from high blood pressure to liver disease.

"There are all sorts of people who are using alcohol, drugs, who are continuing to work and do their jobs and slowly spiraling down, who are not the hard-core users," says Dr. Brian Jack, a family medicine specialist at Boston University Medical School. "Those are people who are in the clinics every single day for all sorts of different things."

Hence the push for better substance abuse screening. The American College of Obstetricians and Gynecologists in December urged its members to ask every patient about alcohol or drug use. Top-level trauma centers must screen trauma patients as part of their accreditation. The government adopted new insurance payment codes last year so doctors could bill for screening time.

The new federal program, called NIDAMED, aims to break another barrier: How doctors not trained in addiction medicine can tell the difference between experimenting and abuse, and what they should do for a patient with a problem. Already, New York City officials have told the government they're planning to incorporate NIDAMED into the health department's electronic medical records, enabling more than 1,000 providers in underserved parts of the city to use it.

Don't patients just lie? Sure, some do. "Help your doctor read between the lines," says patient information accompanying NIDAMED.

There are consequences. Lie about what's in your system and you might be prescribed a legal drug that could trigger a deadly interaction. Lie if you're pregnant and you can hurt your baby. The key, say doctors who routinely screen, is earning patients' trust and explaining they're not being judgmental: Substance use is a medical problem.

"We're not the police," says D'Onofrio. Medical information is confidential.

"Get to know them as a person and treat them as a person, and care, frankly," adds Jack.

Dana Moulton of Boston recalls long ago being hospitalized with hepatitis and concealing that he was trying to kick a nearly 20-year heroin addiction. But one doctor sat by his bedside, talking about a mutual love of books and eventually coaxing Moulton to reveal his struggles in methadone treatment. Moulton credits that doctor's help with his success in going drug-free a decade ago.

"It was the first time someone did not stigmatize me, showed me genuine concern about my health issues despite the fact that I was a substance abuser," recalled Moulton, now 58 and with Massachusetts' substance-abuse office. "He dealt with me as a human being."

___

EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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Leading US health expert urging cautious approach

WASHINGTON – U.S. officials said Monday that it's too early to say the swine-flu threat is receding, even though there are some signs the outbreak may not be as serious as originally feared.

Homeland Security Secretary Janet Napolitano said the outbreak could die down with warmer weather only to roar back during fall flu season. And she said the public shouldn't be alarmed if the World Health Organization declares that the new virus has officially begun a pandemic, meaning it has spread pretty much globally.

That word describes "geography, not severity" and thus wouldn't change U.S. steps to stem infections that have been confirmed in about 300 people in more than half the states, she said.

Another top U.S. health official said "there are encouraging signs" of a leveling off in the severity of the threat, but added that it's still too early to declare the problem under control.

"I'm not ready to say that yet," Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention, said when asked about indications by Mexican health authorities that the disease has peaked there.

"What we're seeing is an illness that looks very much like seasonal flu. But we're not seeing the type of severe disease that we were worrying about," Besser told network television interviewers. He noted that roughly 36,000 people die each year in this country from the winter flu, so it's still a serious matter.

About 300 cases of swine-flu virus have been confirmed in 36 states so far, according to a count by The Associated Press.

"We are by no means out of the woods," Besser said. "In previous pandemics, there have been waves and you don't know what this virus is going to do."

U.S. confirmed cases from CDC or states: New York, 90; Texas, 43; California, 29; Delaware, 20; Arizona, 18; South Carolina, 15; Illinois, nine; Colorado, Louisiana, Massachusetts and New Jersey, seven; Florida, five; Alabama and Maryland, four; Indiana, Ohio, Oregon, Virginia and Wisconsin, three; Connecticut, Kansas and Michigan, two; and one each in Nebraska, Iowa, Kentucky, Minnesota, Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Pennsylvania, Rhode Island, Tennessee, Idaho and Utah.

There has been one death in the United States, a toddler who succumbed to the disease after he was brought to this country from Mexico.

Besser said health authorities also are concerned about indications that the flu had so far struck the young more heavily than older people, and that there still may be deaths from it.

He also said he didn't think it was necessarily time to ease off on school closings and other steps that have been taken to contain the spread of the infection.

"We're seeing infections in almost every state," Besser said, "and as that occurs, those who have underlying problems (such as the elderly and people with compromised immune systems) may be affected more. ... It may be that this disease is starting first in children, and then moving to the elderly, so there's still much that we do not know."

Besser said that as a parent and a pediatrician, he thinks it's best for kids to be in school, whenever possible, and that adjustments in school shutdowns might be possible "as we learn and see that this virus is not more serious than ordinary flu."

Asked whether the food supply has been compromised, he said, "It may be that pigs have more to fear from people than people have to fear from pigs."

"With each day some of the uncertainty goes away, we learn more, and we're seeing encouraging signs," Besser said. "The encouraging signs have to do with severity." He summed up the situation by saying he was "precautiously optimistic" about trends now surfacing.

But he hastened to add that people still need to take everyday precautions, like vigorous and frequent hand washing, covering their noses and mouths when they sneeze and staying home when they're sick.

Besser said that what now ensues in the Southern Hemisphere, which is just entering flu season, will be "critically important for us to understand as we think about the decisions around vaccination."

The CDC chief was interviewed on CBS's "The Early Show" and NBC's "Today" show.

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Amid swine flu, sales of antiviral drugs surging

TRENTON, N.J. – Americans frightened by the swine flu are snapping up two antiviral medicines that treat the virus, whether they have it or not.

New data show more than a quarter-million prescriptions for Tamiflu pills alone were filled at retail U.S pharmacies in the week ending last Friday. That's 34 times higher than the week before — as the regular influenza season wound down — and more than double the peak of last winter's flu season.

News accounts of the mysterious new type of influenza first surfaced about 10 days ago and have picked up ever since, as the number of deaths in the epicenter of Mexico has increased and as new cases have been reported in the U.S. and in many other countries.

The prescription figures from health care marketing consultants SDI of Plymouth Meeting, Pa., show that in the week ending last Friday, 257,459 prescriptions were filled at U.S. drugstores for Tamiflu, one of two medicines shown to work against swine flu.

The SDI data, released late Monday, also show prescriptions for a second antiviral drug effective against swine flu, Relenza, jumped to 13,710, 10 times higher than the prior week.

By comparison, there were barely 130 confirmed U.S. cases of swine flu reported as of Friday afternoon and less than 800 around the world confirmed by Saturday.

Both Tamiflu, made by the Roche Group, and Relenza, made by GlaxoSmithKline PLC, require a prescription.

Health authorities do not recommend taking the drugs as a preventive in people not exposed to someone infected with swine flu. However, both drugs have been shown to reduce chances of getting regular, seasonal influenza when a household member has the flu and relatives take it before onset of symptoms.

Unnecessary use of the two drugs could contribute to the virus becoming resistant to treatment in the future and, if shortages occur in pharmacies, could mean people who become sick can't get it right away. The medicine works best when taken within two days of the start of symptoms.

This past winter, Tamiflu turned out to be less effective against the seasonal flu strains then circulating. Sales dropped off, but picked up for Relenza.

The new SDI figures indicate many patients are convincing their doctor to write a prescription and then are filling it at a pharmacy.

Two older antiviral medicines that work against seasonal influenza but not against swine flu also saw significant, but much smaller, sales jumps last week.

Altogether, 287,481 prescriptions for the four antiviral drugs were filled last week, more than 13 times the number filled a week earlier.

During peak flu season, when sales of Tamiflu and Relenza crested in the last week of February, only 23,892 Relenza prescriptions and 108,424 for Tamiflu were filled.

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Mexico plans shutdown as World flu alert raised

MEXICO CITY – Mexico readied a "temporarily closed" sign — taking the drastic step of ordering a suspension of nonessential federal government and private business activity as it tried to squelch a swine flu epidemic. The World Health Organization ratcheted up an alert and warned that "all of humanity" is threatened.

The dire warning showed that world health officials are very worried about the potential for massive numbers of deaths worldwide from the mutated virus, even though the epidemic so far has claimed only a confirmed eight lives in Mexico and one in the United States. Roughly 170 deaths are suspected of having been caused by the virus in Mexico.

The Phase 5 alert, indicating a pandemic could be imminent as the virus spread further in Europe, prompted Mexico to announce the partial May 1-5 shutdown, Mexican Health Secretary Jose Cordova said late Wednesday.

In Washington, President Barack Obama promised "great vigilance" in confronting the outbreak which has sickened nearly 100 people in 11 states and forced schools to close. A Mexican toddler who visited Texas with his family died Monday night in Houston, becoming the first fatality in the U.S., and 39 Marines were confined to their base in California after one came down with the disease.

The virus, a mix of pig, bird and human genes to which people have limited natural immunity, has also spread to Canada, New Zealand, Britain, Germany, Spain, Israel and Austria.

"It really is all of humanity that is under threat during a pandemic," WHO Director General Margaret Chan said in Geneva. "We do not have all the answers right now, but we will get them."

In a televised address, Mexican President Felipe Calderon praised "the heroic work" of doctors and nurses and asked his countrymen to literally stay in their homes between May 1 and May 5, saying "there is no safer place to protect yourself against catching swine flu, than in your house."

"In recent days, Mexico has faced one of the most serious problems in recent years," Calderon said Wednesday night. He brushed aside criticisms that his government's response was slow, stressing several times that authorities had reacted "immediately."

School in Mexico has already been canceled until May 6. During the shutdown, essential services like transport, supermarkets, trash collection and hospitals will remain open.

Calderon said authorities would use the partial shutdown to weigh whether to extend the emergency measures, or "if it is possible to phase out some" restrictions.

The outbreak appeared to already be stabilizing in Mexico, the epicenter. Confirmed swine flu cases doubled Wednesday to 99, but new deaths finally seemed to be leveling off after an aggressive public health campaign was launched when the epidemic was declared April 23. Although 17 new suspected deaths were reported, only one additional confirmed death was announced Wednesday night, for a total of eight countrywide. The virus is believed to have sickened as many as 2,955 people across the country, though hospital records suggest the outbreak may have peaked here last week.

The WHO said the global threat is nevertheless serious enough to ramp up efforts to produce a vaccine against the virus. It declared a Phase 5 outbreak — the second-highest on its threat scale — for the first time ever, indicating a pandemic could be imminent.

In the U.S., eight states closed schools Wednesday, affecting 53,000 students in Texas alone.

Obama said his administration has made sure that needed medical supplies are on hand and he praised the Bush administration for stockpiling 50 million doses of antiviral medications.

"The key now is to just make sure we are maintaining great vigilance, that everybody responds appropriately when cases do come up. And individual families start taking very sensible precautions that can make a huge difference," he said.

Ecuador joined Cuba and Argentina in banning travel to or from Mexico and Peru banned flights from Mexico. The Panama Canal Authority ordered pilots and other employees who board ships passing through the waterway to use surgical masks and gloves. An average of 36 ships per day use the canal, most from the United States, China, Chile and Japan.

In France, President Nicolas Sarkozy met with Cabinet ministers to discuss swine flu, and the health minister said France would ask the European Union to suspend flights to Mexico.

The U.S., the European Union and other countries have discouraged nonessential travel to Mexico. Some countries have urged their citizens to avoid the United States and Canada as well. Health officials said such bans would do little to stop the virus.

Medical detectives have not pinpointed where the outbreak began. Scientists believe that somewhere in the world, months or even a year ago, a pig virus jumped to a human and mutated, and has been spreading between humans ever since.

China has gone on a rhetorical offensive to squash any suggestion it's the source of the swine flu after some Mexican officials were quoted in media reports in the past week saying the virus came from Asia and the governor of Mexico's Veracruz state was quoted as saying the virus specifically came from China.

One of the deaths in Mexico directly attributed to swine flu was that of a Bangladeshi immigrant, said Mexico's chief epidemiologist Miguel Angel Lezana.

Lezana said the unnamed Bangladeshi had lived in Mexico for six months and was recently visited by a brother who arrived from Bangladesh or Pakistan and was reportedly ill. The brother has left Mexico and his whereabouts are unknown, Lezana said. He suggested the brother could have brought the virus from Pakistan or Bangladesh.

By March 9, the first symptoms were showing up in the Mexican state of Veracruz, where pig farming is a key industry in mountain hamlets and where small clinics provide the only health care.

The earliest confirmed case was there: a 5-year-old boy who was one of hundreds of people in the town of La Gloria whose flu symptoms left them struggling to breathe.

Days later, a door-to-door tax inspector was hospitalized with acute respiratory problems in the neighboring state of Oaxaca, infecting 16 hospital workers before she became Mexico's first confirmed death.

Neighbors of the inspector, Maria Adela Gutierrez, said Wednesday that she fell ill after pairing up with a temporary worker from Veracruz who seemed to have a very bad cold. Other people from La Gloria kept going to jobs in Mexico City despite their illnesses, and could have infected people in the capital.

Cordova, the Mexican health secretary, said getting proper treatment within 48 hours of falling ill "is fundamental for getting the best results" and suggested the virus can be beaten if caught quickly and treated properly. But it was neither caught quickly nor treated properly in the early days in Mexico, which lacked the capacity to identify the virus, and whose health care system has become the target of widespread anger and distrust.

In case after case, patients have complained of being misdiagnosed, turned away by doctors and denied access to drugs. Monica Gonzalez said her husband, Alejandro, already had a bad cough when he returned to Mexico City from Veracruz two weeks ago and soon developed a fever and swollen tonsils.

As the 32-year-old truck driver's symptoms worsened, she took him to a series of doctors and finally a large hospital. By then, he had a temperature of 102 and could barely stand.

"They sent him away because they said it was just tonsillitis," she said. "That hospital is garbage."

Gonzalez finally took her husband to Mexico City's main respiratory hospital, "dying in the taxi." Doctors diagnosed pneumonia, but it may be too late: He has suffered a collapsed lung and is unconscious. Doctors doubt he will survive.

Swine flu has symptoms nearly identical to regular flu — fever, cough and sore throat — and spreads like regular flu, through tiny particles in the air, when people cough or sneeze. People with flu symptoms are advised to stay at home, wash their hands and cover their sneezes.

___

AP writers Frank Jordans in Geneva, Tom Raum and Lauran Neergaard in Washington, Olga Rodriguez in Oaxaca, Mexico, Paul Haven and E. Eduardo Castillo in Mexico City, and Mike Stobbe in Atlanta contributed to this report.

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World takes drastic steps to contain swine flu

From Egypt's order that all 300,000 pigs in the country be slaughtered to travel bans and putting the kibosh on kissing, the world is taking drastic — and some say debatable — measures to combat swine flu.

Egypt ordered the pig slaughter even though there hasn't been a single case of swine flu there and no evidence that pigs have spread the disease. Britain, with only five cases, is trying to buy 32 million masks. And in the United States, President Barack Obama said more of the country's 132,000 schools may have to be shuttered.

At airports from Japan to South Korea to Greece and Turkey, thermal cameras were trained on airline passengers to see if any were feverish. And Lebanon discouraged traditional Arab peck-on-the-cheek greetings, even though no one has come down with the virus there.

All this and more, even though world health experts say many of these measures may not stop the disease from spreading. On Wednesday, the World Health Organization raised its pandemic alert to the second-highest level, meaning it believes a global outbreak of the disease is imminent.

"Scientifically speaking, the main thing is that every virus behaves differently," said Joerg Hacker, president of the Robert Koch Institute, Germany's top public health authority. "At the moment, the main issue is to get to know this virus, how it works."

In Germany, where officials confirmed three cases, Lufthansa announced that starting Thursday it will put a doctor aboard all flights to Mexico, the epicenter of the outbreak.

Experts said that makes sense: The doctors will be able to field questions from uneasy passengers and tend to anyone who might fall ill.

The World Health Organization said total bans on travel to Mexico — such as one imposed by Argentina, which hasn't had any confirmed cases — were questionable because the virus is already fairly widespread.

Roselyne Bachelot, France's health minister, said she would ask the European Union to suspend all flights to Mexico at a meeting Thursday in Luxembourg.

Travel bans were effective during the 2003 outbreak of SARS in Asia, because that illness can be transmitted only by people who already show symptoms. With flu, by contrast, the incubation period ranges from 24 hours to four days, meaning people often are infectious before they have symptoms.

Health officials don't know enough about swine flu right now to say what the precise incubation period is, but if it's similar to other flu, people are likely able to spread it before they're sick.

"WHO does not recommend closing of borders and does not recommend restrictions of travel," said Dr. Keiji Fukuda, the Geneva-based organization's flu chief. "From an international perspective, closing borders or restricting travel would have very little effect, if any effect at all, at stopping the movement of this virus."

Nor will killing pigs, as Egypt began doing Wednesday, infuriating pig farmers who blocked streets and stoned Health Ministry workers' vehicles in protest. While pigs are banned entirely in some Muslim countries because of religious dietary restrictions, they are raised in Egypt for consumption by the country's Christian minority.

Unlike bird flu, where the H5N1 strain that spread to humans was widespread in bird populations and officials worried about people's exposure to infected birds, WHO says there is no similar concern about pigs — and no evidence that people have contracted swine flu by eating pork or handling pigs.

"There is no association that we've found between pigs and the disease in humans," WHO spokesman Dick Thompson said.

But that hasn't stopped governments from banning pig products. Macedonia ordered a halt to all live pig imports and on Tuesday, Mexico City closed down all its popular streetside taco stands for at least a week.

Dr. Nikki Shindo, a WHO flu expert, said the agency will consider requests to stop calling the disease swine flu, since the virus is not food-borne and has nothing to do with eating pork.

U.S. Agriculture Secretary Tom Vilsack and others have suggested a new name, arguing that swine flu implies a problem with pork products. China, Russia and Ukraine are among countries that have banned pork imports from Mexico and parts of the United States affected by swine flu.

But some anti-flu measures have merit, such as Obama's admonition Wednesday that more American schools might have to be closed temporarily if swine flu cases spread. Already tens of thousands of students in Texas, New York, California, Chicago and elsewhere are out of school.

The WHO said closing schools and public places, along with banning or restricting mass gatherings, can be a way to contain the spread of disease. Epidemiologists call it "social distancing," and the idea is simple: If you keep people who have the virus away from others, you can stop the chain of transmission.

"That's a technique we would be recommending in a pandemic," said WHO's Thompson. "We would recommend it to nations as a useful technique to be applied given the special circumstances of each nation."

Officials in Hong Kong, which has no confirmed cases, said workers were scrubbing public toilets every two hours in an effort to improve hygiene.

"Not only will we be stepping up our usual efforts, but also we will make special efforts to make sure that our back alleys, public housing estates, recreation and transportation facilities are thoroughly cleansed and disinfected," said Gabriel Leung, undersecretary for the Food and Health Bureau.

Experts, however, said it's debatable how much good disinfecting public places will do. It probably helps cut down on bacteria and kill viruses lurking on surfaces, but it's unclear whether it would stop person-to-person transmission.

Ditto the advice to stop kissing on the cheek, which was among the earliest measures — along with refraining from handshakes — to be recommended by authorities in Mexico.

WHO's Thompson was noncommittal on the "don't kiss" advice, saying only: "There are different national circumstances that health officials are going to know far better than we will. It's up to them to make that call."

But at a news conference announcing the elevated pandemic level, WHO chief Margaret Chan went further, suggesting it was time to rethink the traditional three kisses on the cheek popular in Switzerland and elsewhere in Europe. "Perhaps instead of having the traditional three hugs to say hello and welcome your friends, maybe you don't do that anymore," she said. "Don't hold each other and hug their face three times."

The flu virus is airborne and spread through tiny particles — mostly through sneezing and coughing. That helps explain why governments worldwide have been distributing millions of face masks, even though the U.S. Centers for Disease Control and other agencies have questioned their effectiveness.

Some doctors warn masks might even be harmful, causing people to take risks — like venturing into crowds or neglecting to wash hands — in the mistaken belief the mask protects them. More expensive high filtration masks like those used by health professionals can filter out fine particles carried in the air, but even these must be used properly to give real protection.

Other measures, such as installing thermal cameras at airports to screen passengers from infected countries, are simply inconclusive. Scanners were set up across Asia during the SARS outbreak, but officials aren't sure they caught any cases. WHO says the usefulness of such devices is debatable.

Amid the flurry of measures being taken, fear mingled with a sense of fatalism.

"You can't protect yourself — not in the way that people are traveling nowadays," said Karin Henriksson, 56, of Stockholm.

"Then you would have to put the entire population in quarantine. And you can't do that, can you?"

___

Kole reported from Vienna; Cheng, an AP Medical Writer, from London.

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Scientists struggle to understand swine flu virus

ATLANTA – Mexico's health secretary may have thought he was allaying fears about swine flu when he suggested that the nation's swine flu death rate was 6 or 7 percent. In reality, that would mean a monstrous killer virus — and no experts are close to saying that. The secretary's comment reflects how much remains unknown about the new flu virus — most notably how lethal it is and why it seems so much deadlier in Mexico than anywhere else.

American health officials believe they are getting closer to answering those questions, or, at least, to ruling out wrong-headed theories.

"We've begun to knock off hypotheses," said Dr. Scott F. Dowell, director of global disease detection with the U.S. Centers for Disease Control and Prevention.

Among the factors disease detectives have discounted are Mexico's air pollution, secondary infections and poor health care. But they still do not know why so many Mexicans have died, although it could be because many more people actually have had the virus than health officials realize.

In Mexico, the virus is suspected of killing more than 150 people and sickening more than 2,400. Recent information suggests swine flu-related hospital admissions and deaths may have peaked and are declining, but no other country has shown any numbers close to those seen in Mexico.

The only other country to report a swine flu death is the United States, and that involved a toddler from Mexico who was visiting Texas with his family.

The leading theory remains that the virus itself is not significantly different in Mexico, but that the outbreak has for some reason just hit harder there, infecting more people overall. The more people who are infected, the more likely there will be severe cases and even deaths.

When the Mexican health secretary spoke this week about a 6 or 7 percent death rate, his figures were based on the number of deaths divided by the number of suspected infections. But authorities cannot be certain how many people have been infected, especially those who suffered only mild symptoms.

Mexican authorities have not tried to count mild cases, focusing instead on the severely ill and the dead. So the death rate may be much lower than 6 or 7 percent — and probably is, according to some experts.

A 6 to 7 percent death rate would make the Mexican swine flu nearly three times deadlier than the worst flu pandemic in the last 100 years — the 1918 Spanish flu, which killed an estimated 20 million to 50 million people worldwide.

That seems unbelievably high for this new virus, said Richard Webby, a flu researcher at St. Jude Children's Research Hospital in Memphis.

Webby and others do not believe the swine flu in Mexico is different from what's been seen in U.S. patients. The virus samples in both countries match.

The CDC sent four epidemiologists and one lab scientist to Mexico over the weekend to investigate the disease there, and the agency expects to send a half-dozen more people this week, said Dowell, of the CDC.

Among the hypotheses being ruled out as explanations for Mexico's higher death rate:

• A second infection complicating the flu cases. A common danger in flu is that the patient is co-infected with pneumonia or other bacteria, which can lead to death. But lab tests of 33 Mexican patients, including seven who died, did not find that problem.

• Low-quality health care. CDC investigators have not seen any obvious problem. They have found capable doctors and well-equipped, high-quality hospitals, Dowell said.

• A medicine is compounding the problem. Investigators have looked into whether patients who got sick had taken some over-the-counter medicine or folk remedy that actually made things worse.

Such a problem has sometimes occurs in children recovering from flu who are given aspirin — a severe illness called Reye's syndrome, which causes vomiting, lethargy and even seizures. But there's no evidence of something like that in Mexico, Dowell said.

• Altitude or air pollution: Mexico City's altitude and its infamous air pollution have raised speculation that those factors may have made people more susceptible to the virus. But severe cases are being reported over much of Mexico, including coastal communities and places with cleaner air, making that theory unlikely.

The CDC has also been investigating when the swine flu first hit Mexico.

Some have wondered whether it's possible people have been getting sick with the virus for months, but the illness went undetected because special swine flu tests were not used to diagnose patients.

But CDC officials say no, the flu probably did not hit Mexico until March at the earliest. An analysis of hundreds of samples from Mexico that were collected from January to March never turned up the swine flu virus, Dowell said.

There's also the question of where it started — a standard inquiry of public health investigations since at least the mid-19th century.

One of the heroes of public health history is John Snow, a London physician who helped end an 1854 cholera outbreak by determining that cases were clustered around a water pump and that the disease was spread through water. The pump handle was removed, and the cholera deaths subsided.

But flu is different because it's spread by human-to-human contact. Scientists know it's more difficult to pin down the origin of a novel strain of influenza to a specific country, let alone a village or pig farm.

Knowledge of the origin is also less useful than in a cholera outbreak.

"Flu, unlike cholera, spreads around the world in a matter of weeks. You can't remove the pump handle" to stop the epidemic, said Dr. Andrew Pavia, a University of Utah pediatrics professor who leads the Infectious Diseases Society of America's pandemic flu task force.

A current theory is that the outbreak started in the town of La Gloria on the eastern coast of Mexico, because a 5-year-old boy was the first known case. He first suffered flu-like symptoms in late March. However, Mexican health officials have downplayed claims the outbreak started in La Gloria, because mucous samples of other patients from there found nothing.

Dowell said the place of origin is a secondary concern at the moment.

"That probably will be useful in the long term. But for the present, our team in the field is focused on things that will make the most difference for mitigation" of the outbreak, he said.

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Associated Press Writer Olga R. Rodriguez in Mexico contributed to this report.

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Little boy, far from home, 1st US swine flu death

HOUSTON – He was not yet 2, far from home and dying. The first victim of swine flu in the U.S. was a Mexican toddler who struggled to survive for weeks in Texas hospitals — long before it was known doctors were dealing with an international outbreak.

Now the hunt is on to find anyone who came into contact with the little boy while he visited relatives in the border city of Brownsville from his home in Mexico City.

The state's health director, Dr. David Lakey, at an Austin news conference, called it "highly likely" that the boy contracted the disease in Mexico before his trip to the U.S.

Officials in Brownsville are trying to trace his family's trip to find out how long they were in the area, who they visited and how many people were in the group, said Cameron County Judge Carlos Cascos.

The boy, who was 23 months old, had "underlying health issues" before he flew to Matamoros, Mexico, on April 4 and crossed into Brownsville to visit relatives, state health officials said.

He developed flu symptoms four days later and was taken to a Brownsville hospital April 13 and transferred the following day to Texas Children's Hospital in Houston, where he died Monday night.

The U.S. Centers for Disease Control and Prevention on Wednesday confirmed that he had been infected with the swine flu virus. The cause of the death was pneumonia caused by the virus, Cascos said.

Health officials insisted the boy posed no contagion threat to Houston. He had no contact with other patients at Texas Children's Hospital and none of the staff was exposed, said Dr. Jeffrey Starke, the hospital's director of infectious disease.

This case "shouldn't trigger any undue alarm in the community," Starke told a news conference. "The child did not acquire the virus in Houston, Texas."

Dr. Brian Smith, regional director of the Texas Department of State Health Services, said antiviral treatments were given to family members who had close contact with the child and none had contracted swine flu. He said that with the virus' short incubation period, health officials would have begun seeing secondary cases among the child's close contacts by now, but none has appeared.

Although the boy wasn't initially identified as a swine flu case, Starke said concern grew over the last several days as news of the virus intensified.

Officials refused to release any further information about the boy or his family, including his name or any details on his other health issues, citing privacy laws.

Starke said the child was "critically ill the entire time the child was under our care," and that he was transferred to Houston because the hospital in Brownsville, an impoverished border city of 140,000, couldn't provide the kind of care he needed.

Swine flu is suspected of killing more than 150 people and sickening over 2,600 in Mexico, Canada, New Zealand, Britain, Germany, Spain, Israel and Austria.

The virus has spread to 11 U.S. states from coast to coast. Total American cases surged to nearly 100, including a Marine at the Twentynine Palms base in southern California.

According to the CDC, more than 20,000 children younger than age 5 are hospitalized every year because of seasonal flu. In the 2007-08 flu season, the CDC received reports that 86 children nationwide died from flu complications.

Authorities have confirmed at least 93 swine flu cases in the United States. They've identified 16 cases in Texas, 51 in New York, 14 in California, three in Maine; two in Kansas, two in Massachusetts, and one each in Indiana, Ohio, Arizona and Nevada. The CDC also said Michigan had two, but state officials maintained only one was confirmed.

Texas Gov. Rick Perry announced a disaster declaration Wednesday for the entire state. The declaration will allow officials to begin emergency protective measures and seek reimbursement from the federal government.

Texas officials also are postponing all public high school athletic competition until May 11. Schools serving more than 130,000 kids across Texas were closed.

As for future action, Perry said closing the border with Mexico is an option, but he doesn't want to play a "what-if game."

"There's no need to panic," Perry said. "I urge our citizens to act responsibly in the course of this situation. Heed the advice of local and state health officials."

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On the Net:

CDC: http://www.cdc.gov/swineflu

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