While some believe the world is overreacting to the threat of influenza A/H1N1, experts feel a proper plan of action is essential
IT’S OFTEN SAID we now live in a global village, and confirmation, if it were needed, came in the past week when a new flu virus which originated in Mexico was detected in several countries and continents within a matter of days.
Last Saturday, people were hearing for the first time about the threat posed by this novel virus – a mix of swine, avian and human influenza – when the director general of the World Health Organisation (WHO) Margaret Chan declared “a public health emergency of international concern”.
At that stage cases had already been confirmed in two US states and there had been several deaths from respiratory infection reported in Mexico in previous days and weeks. It was becoming clear this was a brand new virus, to which people therefore had no immunity and for which there was no vaccine.
Within days there were cases of what was first termed swine flu, but which is now being referred to by WHO only as influenza A/H1N1, confirmed in several European countries including the UK, Spain and the Netherlands, as well as in places as far apart as New Zealand, Israel and Peru. The first probable case in the Republic was detected on Thursday.
Suddenly people around the world began wearing masks, some airports began screening passengers who may have had high temperatures, places such as Egypt began to needlessly slaughter pigs, and countries such as Ireland began to dust down and activate their pandemic plans. In the midst of all this whirlwind of activity, not surprisingly, some wondered if it was all a bit of an overreaction.
Ryanair boss Michael O’Leary, a man never slow to offer an opinion, told reporters at the races in Punchestown he suspected “a couple of Disprins and a few Strepsils will fix the problem”, while the professor of public health at UCD Pat Wall drew attention to the fact that more than 36,000 people a year die from seasonal flu in the US every year and “we don’t stop travelling to the US” as a result. He also expressed the belief that the new flu strain will probably peter out coming into the summer and by the time it returns next winter, if it does, a vaccine will have been developed to counteract it.
“Even if it spread like a bushfire we have drugs now that we did not have in the past,” he added, referring to the fact that antivirals have been stockpiled by the State to treat almost half the population in the event of a flu pandemic, which is certainly reassuring. Most specialists hope Prof Wall turns out to be right, that the virus will peter out sooner rather than later, but they stress there is no way of knowing at this point what the impact of this new virus will be and advise against complacency. Prof Angus Nicoll, head of the influenza programme at the European Centre for Disease Prevention and Control, puts it simply: “As yet we really don’t know just how severe this virus is . . . and to what extent it is going to cause death.”
It was much more likely than seasonal influenza to go through the community because it was “a totally new virus” to which people had no immunity, he said. He added that while some comfort was being initially taken from the fact that cases occurring outside of Mexico seemed to be milder, it was not yet clear if this meant all cases elsewhere would be mild. It could have happened, he said, that people in Mexico who got a mild form of this flu virus and who therefore weren’t hospitalised hadn’t been tested for it and a “biased” picture of the outcomes for all those who fell victim to the virus in Mexico was then being presented. At this stage over 170 deaths, though most not laboratory confirmed, have been reported in Mexico.
Prof Bill Hall, chair of the Irish influenza pandemic expert group, stresses a lot more has yet to be learned about this virus. As more cases are seen in the US, however, “we are starting to appreciate that this probably is not a mild disease as previously thought in all patients, and some individuals have developed severe respiratory disease requiring hospitalisation”.
“I don’t think, however, that we have enough numbers or a large enough experience to really get a clear definition of the total morbidity and mortality associated with this virus,” he added. The virus itself could also be changing, he said, becoming more or less virulent; while it is currently treatable with antiviral drugs, this may change too.
SO, HOW WELL prepared are we if this virus causes, as the WHO now expects, a flu pandemic? Dr Tony Holohan, the Department of Health’s chief medical officer, says the country is well prepared and points out we “have been planning for this eventuality for a number of years”. A national pandemic preparedness plan, in place since 2007, was recently updated. “We currently have antiviral stockpiles for 47 per cent of the population which is amongst the highest levels worldwide,” he says.
Leaflets are now being prepared, which will be delivered to every home in the State next week, on what to do in the event of an outbreak of H1N1 here. TV ads putting out the same message will be broadcast, special masks have been stockpiled for healthcare staff but the public are being told the general use of masks is not advised as regular masks provide little protection and may only lead to a false sense of security. Influenza surveillance in the community and in hospitals has been stepped up and GPs and hospital staff have also been told about the symptoms to watch out for, which are the same as the symptoms of seasonal flu, and what steps to take if they suspect a case of H1N1.
When the State’s pandemic plan was published in 2007 it was estimated that in “a worst case scenario” a pandemic could result in two million people in the Republic becoming infected, 78,000 people being hospitalised and around 53,000 deaths. If the pandemic was less severe, the pandemic expert group, which prepared the plan, estimated that one million Irish people would be infected, around 6,000 people could be hospitalised and 4,000 deaths could occur. But the figures were modelled on what happened during previous pandemics and did not take into account the fact that antivirals are now available and proving effective against the current virus.
Prof Nicoll believes the current virus, given there is no background immunity in the population, will have an attack rate of 40 to 50 per cent but expects most of these will get a mild dose. He predicts those who will get more severe doses are older people and those with chronic diseases.
The HSE’s head of health protection Dr Kevin Kelleher recalled yesterday how he had told an Oireachtas committee just three years ago that if we had a pandemic the health service would “probably” not be able to cope and would be overwhelmed. But he says things have changed in the interim. “That is a totally different position today and I think the possibility of the health service being overwhelmed is much less than when I was discussing it three years ago. We have made great strides. We have one of the highest levels of availability of antivirals in the developed world . . . we’ve had our hospitals and our community services, general practices, everybody, planning what they need to be doing over the past three years . . . we are in a very very good position,” he said.
One of the fundamental things now for the public, he added, is to be aware of how to reduce the opportunity for flu to be passed on. His advice is: “If you are going to sneeze make sure you sneeze into a tissue, make sure you dispose of that tissue in a bin, and then wash your hands afterwards.”
Anyone with symptoms after travelling back from an affected region at this point is advised to contact their doctor by telephone in the first instance. If their illness is mild they will be ordered to stay at home and will be treated there. If most people who succumb can be treated at home this would help overcome the problem of the dearth of isolation facilities in our public hospitals. But it will also mean a lot of work for GPs and public health doctors, who will have to stay in touch with the people being treated in their own homes as well as tracing people they have been in contact with. Much of this work has to be done out of hours but there is still, despite years of campaigning, no properly structured out of hours public health doctors service in the State. The doctors’ union the Irish Medical Organisation (IMO) hopes the issue, which was a problem as far back as when SARS broke out in 2003, can finally be resolved at the Labour Relations Commission next Tuesday. Though it stresses that, given the nature of the swine flu threat, all public health doctors are currently providing an out of hours service on a “good will” basis.
While GPs may have been informed what symptoms to watch out for and the steps to take if they uncover a suspected case of H1N1, the IMO’s GP leader Dr Ronan Boland said early yesterday GPs, at that point, had still not been issued with protective masks or prophylactic antiviral treatment. He said he was aware of one Dublin GP who had difficulty getting what she needed to “swab” a patient who had presented with flu like symptoms earlier this week after returning from Mexico.
“I think the level of preparedness is not all that it might be . . . there is an element of catch-up. I have had a number of telephone calls from doctors, including one who dealt with a suspected case, and doctors are worried about the protection of themselves and their staff, and to date protective gear and prophylactic treatment has not been provided. Perhaps plans for these are imminent but I will be seeking to clarify this with the HSE in the next 24 hours.”
Darragh O’Loughlin, a Galway pharmacist and vice president of the Irish Pharmacy Union, said most pharmacists don’t have antivirals in stock. The HSE had taken steps, he said, to ensure stocks are kept in quarantine until they are absolutely needed. The last thing that people wanted was for everyone with snuffles now to go looking for Tamiflu and for the country to find stocks were used up later in the year if we had a second more severe wave of infection, as happened in the 1918 pandemic, he said.
“People are planning on the basis that it’s quite mild at the moment but that if it hits us again in the autumn it will be more severe.”
Asked how well Europe is prepared for a pandemic, Prof Nicoll was cautious. “We are far better prepared than we were some years ago but you can never be prepared enough for a pandemic. We are lucky that we have had this prior warning . . . we are lucky that all the plans are laid in place,” he said.
How well these plans work remains to be seen. Much will depend on how severe the pandemic, which the WHO says is imminent, will be, though this quite clearly is something nobody can predict. It’s really in the lap of the gods.
TIMELINE
March 18th: Surveillance started picking up an influenza-like illness in Mexico. It seemed to spread quickly
April 16th: Mexican authorities notified the World Health Organisation (WHO) of the growing outbreak.
April 23rd:By now there were more than 854 cases of pneumonia in Mexico city. Of those, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of influenza-like illness, with three deaths, had been reported. And from Mexicali, near the border with the US, four cases but no deaths, had been reported.
April 24th:The WHO said the spread of the virus was "of high concern". Seven cases were confirmed in the US.
April 25th (last Saturday): After an emergency meeting the WHO director general declared it a public health emergency of international concern.
April 26th:The US reported 20 laboratory-confirmed cases. The WHO said it was sending experts to Mexico to work with the health authorities there.
April 27th:The US reported 40 laboratory-confirmed cases, six cases were reported in Canada and the first case in Europe was reported in Spain. The WHO raised the phase of pandemic alert, which in total has six phases, from 3 to 4
April 28th:Cases in the US rose to 64 and other countries like New Zealand, the UK and Israel also began reporting cases.
April 29th: The first death of an infected person outside Mexico was reported in the US. This was the death of a Mexican child who was undergoing treatment for an underlying condition in Texas. Cases were also confirmed for the first time in Austria and Germany. The WHO raised its pandemic alert level from 4 to 5, to indicate a pandemic was imminent.
April 30th: First cases reported in the Netherlands, Switzerland and Peru. The first probable case was reported in the Republic of Ireland.
More information on signs and symptoms of this infection is available at hse.ie and who.org.