The swine flu crisis worsened Monday, with President Barack Obama calling the threat of spreading infections cause for concern but "not a cause for alarm," the World Health Organization raising the international alert level, and the number of cases and deaths increasing and extending beyond North America.
In Mexico, the epicenter of the outbreak, the suspected death toll from the flu reached 149 Monday, while the confirmed toll stood at 20; nearly 2,000 are believed to be infected. The United States issued a new travel advisory urging Americans to avoid nonessential travel to the country. In the United States, there were 48 cases of swine flu diagnosed, none of them fatal: 28 in New York, 11 in California, six in Texas, two in Kansas and one in Ohio.
There are also confirmed cases in Canada, Scotland and Spain, and suspected cases in New Zealand, France and Israel.
In Florida, where there have been no reported cases, state health officials were instructing physicians to test patients who have even mild flu symptoms (respiratory issues, fever, coughing, gastric distress) and encouraging people to wash their hands frequently, avoid close contact with those who are ill, and stay home from work or school if they don't feel well.
"We are prepared," said Susan Smith, spokeswoman for the Florida Department of Health. She said the state has an adequate stock of at least 120,000 doses of the antiviral drugs effective against swine flu. Additional doses are expected from the Centers for Disease Control and Prevention, which ordered the release of a quarter of the U.S. stockpile of 50 million doses.
The World Health Organization raised its six-phase pandemic alert level from three to four, meaning there is sustained human-to-human spread in at least one country. Level six is a full-fledged pandemic affecting at least two regions in the world.
U.S. and Florida officials warned the situation in the United States is likely to get worse.
"We are proceeding as if we are preparatory to a full pandemic," Janet Napolitano, head of the Homeland Security Department, told reporters.
Many European and Asian countries were checking for signs of fever among passengers arriving from North America. The health commissioner of the European Union urged Europeans to postpone nonessential travel to Mexico and U.S. areas affected by swine flu.
Local infectious disease expert Dr. John Sinnott just returned Monday from China, where he said he saw some of the precautions firsthand.
"They are screening everyone at the airport for fever. If you have a fever you cannot enter the country," said Sinnott, associate dean and director of the Division of Infectious Disease and International Medicine at the University of South Florida's College of Medicine.
Sinnott said what he has learned about the swine flu situation worries him.
"It's in several different countries. It's spread within closed groups quite readily. It's spread to different parts of Mexico. It would seem like the cat is out of the bag," he said.
"It is only a matter of time before it comes to Florida."
Dr. Mark Walters, an associate professor at USF St. Petersburg, said that as with previous high-profile outbreaks, including SARS and bird flu, people are wondering whether the swine flu epidemic "is the real McCoy."
A key, he said, is whether it's being spread from human to human.
"That certainly seems to be happening at this point," said Walters, a veterinarian who wrote the book Six Modern Plagues and How We're Causing Them.
Walters described the World Health Organization's Level 4 alert level as "pandemic knocking loudly at the door."
Local health officials urged watchful caution Monday, getting information out to physicians, the public and the media. Some school districts sent notes and other communications to parents urging basic precautions such as careful handwashing and keeping kids home if they're sick.
In Hillsborough, officials at schools and day care centers with many students from Mexico reported nothing out of the ordinary on Monday. Roy Moral, principal at Cypress Creek Elementary School in Ruskin, said families from Mexico don't do a lot of traveling to their native country this time of year.
"If they're traveling to other places, it's to other (U.S.) states to find work," Moral said.
At Tampa International Airport, passengers on JetBlue Flight 1724 from Cancun, Mexico, said they hadn't heard much about the outbreak in that country.
Gary Lavigne, in Cancun for his son's wedding, said hotels and health officials in Mexico didn't warn him about the flu. He saw reports on the news while he was there, but didn't think twice about it since most of the sick seemed to live elsewhere in the country.
"If it's going to happen, it's going to happen,'' said the Land O'Lakes man. "But Mexico City's a long way from Cancun."
In Plant City, more than half of the 30 passengers who had reserved bus trips to Texas and Mexico canceled because of the outbreak, said Alma Carvajal, a terminal director with El Expreso Bus Co.
Drivers and other employees were instructed to wear medical masks and rubber gloves, and minimize contact with passengers.
Some El Expreso passengers interviewed Monday as a bus arrived from Mexico said immigration officials were looking for signs of illness at the U.S.-Mexico border.
Miguel Guzman spent two weeks in San Luis Potosi, a region with reported swine flu deaths, before traveling to Houston and then, two weeks later, home to Tampa. The truck driver said his mother and two brothers live in San Luis Potosi, but he's not sure what the situation is.
"They told me there was a flu," he said. "I have no idea what's happening."
Times staff writers Steven Nohlgren, Justin George, Saundra Amrhein and Victoria Bekiempis contributed to this report, which contains information from the Associated Press. Richard Martin can be reached at firstname.lastname@example.org or (727) 893-8330.
The acting head of the CDC said Monday that the government was warning Americans to avoid nonessential travel to Mexico. Most airlines are allowing customers to change travel plans to the country without any penalty or fee. Carnival Cruise Lines, Tampa's dominant cruise operator, said it had no plans to change itineraries of routes from Tampa that include stops in Cozumel.
Mexico closed all schools until May 6. In Mexico City, surgical masks were given out and events canceled. Meanwhile, it was learned that the first confirmed fatality worked as a door-to-door census-taker. The World Bank is loaning the nation more than $200 million.
A Chinese tourist who failed an initial temperature screening, left, has his temperature double checked by health workers upon his arrival in Hong Kong. Tampa International Airport officials said they would wait until today to announce any flu screenings.