Multiple outbreaks for the same pandemic: Local transportation and social distancing explain the different "waves" of A-H1N1pdm cases observed in México during 2009.

Influenza outbreaks have been of relatively limited historical interest in Mexico. The 2009 influenza pandemic not only changed Mexico's health priorities but also brought to the forefront some of the strengths and weaknesses of Mexico's epidemiological surveillance and public health system. A year later, Mexico's data show an epidemic pattern characterized by three "waves''. The reasons this three-wave patterns are theoretically investigated via models that incorporate Mexico's general trends of land transportation, public health measures, and the regular opening and closing of schools during 2009. The role of vaccination is also studied taking into account delays in access and limitations in the total and daily numbers of vaccines available. The research in this article supports the view that the three epidemic "waves" are the result of the synergistic interactions of three factors: regional movement patterns of Mexicans, the impact and effectiveness of dramatic social distancing measures imposed during the first outbreak, and the summer release of school children followed by their subsequent return to classes in the fall. The three "waves" cannot be explained by the transportation patterns alone but only through the combination of transport patterns and changes in contact rates due to the use of explicit or scheduled social distancing measures. The research identifies possible vaccination schemes that account for the school calendar and whose effectiveness are enhanced by social distancing measures. The limited impact of the late arrival of the vaccine is also analyzed.