With nearly 34,000 confirmed cases of the H1N1 "swine flu" virus in the United States -- and an estimated one million people infected when untested cases are taken into account -- college and university health centers across the country are on high alert. Colleges certainly have not been immune to the virus, with many across the country reporting confirmed cases. But with campuses much emptier during the summer months, the million dollar question is what will happen when students return in the fall.

Initial indicators seem to suggest that H1N1 is "not mutating wildly," according to Robert Winfield, chief health officer for the University of Michigan and the university's health service director. This means that the virus is not developing significantly higher levels of morbidity and mortality among those whom it infects. "What will happen in the fall, likely, will be moderately contagious, with low mortality and morbidity," he said.

But that does not mean that H1N1 will disappear any time soon. In fact, the World Heath Organization -- which declared an H1N1 pandemic in early June -- recently identified three cases of the virus that were resistant to antiviral drugs. At a high level meeting of the WHO in Mexico at the beginning of July to discuss H1N1, WHO director Margaret Chan urged that, "we need to watch very carefully what happens during the current winter season in the Southern Hemisphere."

This reinforces the sentiment that no one really knows for sure what impact H1N1 will have in the fall until the season arrives. With this in mind, many colleges and universities are preparing as best they can to respond to the virus once flu season officially starts in the fall, according to Anita Barkin, director of student health services for Carnegie Mellon University and chair of the Pandemic Planning Task Force for the American College Health Association. She said that colleges need to be prepared for any form the virus can take. Thus, many colleges are changing their old pandemic plans -- based mostly on the pandemic that took place in 1918 -- to revolve around the symptoms that showed up this spring.

"The pandemic planning that has taken place in the past has been based on the 1918 scenario, but the current situation with H1N1 is that it hasn't looked like the 1918 scenario in terms of it being a milder illness with less mortality. Even if we have an influenza outbreak that is milder, in terms of the majority of people being able to recover from it, we may still have a lot of sick students on our campuses," Barkin said. "We're going from [the question of] how quickly can we evacuate campus and 'how many body bags might we need' in an 1918 scenario to a greater focus on the capacity to provide on campus care for the many students who become ill."

According to Barkin, colleges are preparing plans for how they can provide food and hydration to sick students, isolate ill students until they recover, and cancel or suspend classes if necessary. One big decision, she said, is when "do you continue with business as usual?" and "at what point you say we can no longer continue to carry on because we have so many ill in our community?" Much of this planning requires flexibility and situation-specific response.

"I think there's a lot of activity this summer. On the student health listserv, there's a lot of discussion about planning, asking what different schools are doing," Barkin said. "There's certainly increased activity and interest in using the summer as a good opportunity to get ahead on planning."

The Centers for Disease Control and Prevention gives guidelines for how universities should respond to H1N1. Most recently, it has recommended that institutions not cancel classes due to the flu, but that they educate about the virus and have people who report symptoms isolate themselves for seven days. The CDC's web page for higher education institutions was last updated in May. Joe Quimby, senior press officer for the CDC, said he was not aware of more recent information.

The current impact of swine flu on college campuses may be another clue about the H1N1 outlook for the fall, and at the very least it is providing worthwhile practice for pandemic response. Dickinson College, in Pennsylvania, is one location for the Johns Hopkins University Center for Talented Youth -- a summer camp for high schoolers. The 380-student program was suspended last week after 32 students reported swine-flu like symptoms. "We could no longer guarantee the health of the students. It also became very distracting," said Charles Beckman, communications director for the summer program.

"The jury is still out on what's going to happen in the fall. The reality we dealt with in the spring provided good material in the fall," Beckman said, noting that the closing of the camp could provide a sort of "real fire drill" for once students return to campus. Christine Dugan, a spokeswoman for Dickinson, said that the college is not changing its pandemic response plan specifically as a result of the outbreak, but, like any other college, is constantly reevaluating how it would deal with H1N1 during the year. She stressed that Dickinson is following CDC guidelines.

At the University of Michigan, a similar outbreak occurred at its Summer Discovery Program, though the camp was not suspended. About 15 students and one counselor reported symptoms; test results are still pending. According to Winfield, the university is isolating the students for seven days, but is providing treatment to the students, which breaks with CDC guidelines. The CDC recommends that campers, along with with the rest of the population, should allow time to recover on their own, and only receive anti-viral drug treatment if they become seriously ill.

"We broke with the CDC consciously and are providing treatment because the students are from all over the world and expectations of us are high," Winfield said. "The students are from Italy, Turkey, Honduras, and so on, and we decided with these small numbers to treat for flu."

Cases of H1N1 virus have been reported at a number of other summer programs and classes on college campuses, including the College of William and Mary, Cornell University, and Duke University.

By the time official flu season hits, there may be a means of avoiding the spread of H1N1 virus altogether -- through a vaccine. According to an e-mail sent last week to the members of ACHA by its president, James Turner, five manufacturers are beginning to produce a vaccine. "Under the best case scenario," the e-mail states, "225 to 315 million doses of H1N1 vaccine could be available by late October, and another 300 million doses available by the end of 2009." This all depends on whether the vaccine passes safety testing, but college health administrators are already planning ahead.

For now, the waiting game continues.