Swine Flu – Epidemic, Pandemic Or Purely Panic???

The news of outbreak of swine flu or H1N1 virus has gripped the world with fear and at the moment if various agencies are to be believed, this virus is on the rampage and spreading like a wild-bush fire. The people in the infected areas as well as uninfected areas have become skeptical and are running for cover against the H1N1 virus.

Even here closer to home in India, where 63 cases of the infection have been reported, people are shrouding themselves in apprehension and where a normal innocent sneeze is looked down with utter contempt. With the rising fear, I decided to go the internet and find out what I can about the swine flu or H1N1 virus? In my quest I came across a rather interesting article that had appeared in some U.A.E newspaper and had been written by Jonathan Gornall.

In the end, it turned out to be an expensive wager. In January 1976, a number of new recruits at the US army’s Fort Dix training camp in New Jersey succumbed to influenza, as was to be expected during a cold US east coast winter. Some shook it off and some were admitted to hospital and all but one recovered – Private David Lewis, 19, from Massachusetts, who refused bed rest, took part in a tough hike then collapsed and died.

That might have been that. But according to an account in the 1983 book ‘The Epidemic That Never Was’, the state’s chief epidemiologist casually bet the senior army doctor at Dix that the camp was in the grip of a flu epidemic. The resulting analysis, carried out on samples to decide the winner, triggered a healthcare disaster.

While most of the tested cases revealed the expected strain of the virus, prevalent in the US since 1969, four, including that of the dead man, were of something else. They were passed on to the government’s Centers for Disease Control (CDC) in Atlanta and on Feb 12 the laboratory there confirmed the presence of swine flu, not witnessed in cases of human-to-human transmission since the 1920s. Further tests found 500 soldiers had been infected.

What happened next was a sobering lesson for the public health authorities around the world trying to come to terms with the implications of the current outbreak of swine flu.

Flu viruses come in a variety of strains, all of which are prone to mutate, and it is the appearance of a fresh strain that catches human immune systems flat-footed, infecting even healthy young people. The 20th century saw three major flu pandemics –in 1918, credited to a strain of H1N1, which some estimates say killed upwards of 50 million worldwide; in 1957, caused by H2N2, in which two million died; and in 1968, when a strain of H3N2 killed one million.

H1N1 is the most common flu virus, responsible for the majority of human cases, but the panic in 1976 was generated by the fact that the Fort Dix virus was a strain similar to the 1918 killer. It was, perhaps, unwise of the CDC to highlight the link in a press conference, but it did and the media was quick to convert the detail into sensation: “The possibility was raised today,” reported The New York Times on Feb 20, “that the virus that caused the greatest world epidemic of influenza in modern history – the pandemic of 1918–19 – may have returned.”Some commentators believe that President Gerald Ford, then being closely tracked by Ronald Reagan in the presidential primaries, which had begun in Iowa on Jan 27 with a 45-43 per cent split barely in the president’s favor, was driven by his advisers into a decision informed as much by politics as health concerns. Whatever the truth of that, his government ordered the mass inoculation of all 220 million American citizens.

Within two months of Private Lewis’s death, hundreds of people had been infected with swine flu and up to 30 were dead. What had killed them, however, was not the flu but a paralyzing nerve disease brought on by the inoculation. The program was abandoned amid a flurry of lawsuits. When the dust settled, it was found that the only casualty from swine flu had been the young soldier.

Then, as now, in matters of public health, public opinion rather than common sense is often the impetus for action – action that can supersede the primary tenet of medicine: “First, do no harm.”

As it was in 1976, the specter of 1918 has been evoked repeatedly in the coverage of the current swine flu outbreak, but all such comparisons are invidious. In 1918, says Prof Anne Hardy at the Wellcome Trust Center for the History of Medicine at University College London and co-editor of the journal Medical History, science and the world was a lot less well equipped to deal with such a catastrophe.

“Today, we have a much better surveillance system; the World Health Organization sponsors influenza surveillance centers worldwide, so there is a rapid response to identify the emergence of new strains, so we can see it coming better. We also have the potential to develop vaccines and most recently we have the anti-virals, which do offer us a therapeutic response that was unavailable in 1918.”

No one can now be sure, but it seems likely that the 1918 outbreak, like that of 1976, began among a small group of American soldiers. It is thought that in 1918 the infection traveled from Camp Funston in Kansas to France. If true, this was one of the most calamitous ironies of history; men who had volunteered to help end the slaughter of the First World War in Europe were the unwitting conduits of a killer that within a year or so would claim up to an estimated 50 million lives – killing more people than the entire conflict and more than any single outbreak of disease in human history, including the Black Death and Aids.

Public and media reaction to the latest outbreak of swine flu, says Prof Hardy, and to Sars in 2003 and “bird flu” in 2005 (a strain of the H5N1 virus) – both of which came and went with much apocalyptic fanfare but little impact – has been “fairly disproportionate”.

The problem, she thinks, is that “we have become so insulated from infectious diseases that the public is easily scared by the prospect, especially of fatal diseases”.

Dan Gardner, the author of the book ‘Risk: The Science and Politics of Fear’, agrees. Modern western societies, he told the BBC World Service, live in fear, yet “It is one of the grand paradoxes of our time that we are by far the healthiest and safest people who ever lived; we could certainly do with a dose of stoicism.”

Yet media and official reporting, he says, “leaves spaces in which irrational fears may fester. Let’s start with the operative terms: epidemic and pandemic. There was a Harvard study a couple of years ago which asked Americans ‘What does the term flu pandemic mean?’ A large majority did not know, yet here we have a story in which government officials and the media are repeating this phrase as if the audience knows what it means.”

The result, he says, is that “whatever baggage we’ve got attached to this term is more likely to come up than is the scientifically accurate meaning of the term”.

It doesn’t help that official-speak is often stripped of cautionary meaning as it passes through the media headline filter. On Monday, when the WHO raised its threat level to phase 4, most media organizations reported only that it had been raised to the “third highest level”, without explaining what the levels meant. In fact, phases 1 to 3 are “predominantly animal infections; few human infections”. Phase 4 is characterized as “sustained human-to-human transmission”. Wednesday’s announcement by Dr Margaret Chan, WHO’s director general, that the alert had now reached phase 5, “widespread human infection”, required only “human-to-human spread of the virus into at least two countries in one WHO region”.

On Sunday the US department of health and human services earned headlines when it declared a Public Health Emergency, but such PHEs are not uncommon, being declared recently for flooding in North Dakota, the presidential inauguration and several hurricanes in 2008.

The WHO has come in for criticism that it is over-reacting, while some commentators have expressed contempt for the role of the media and suspicion about the position of the pharmaceutical industry. Writing in The Guardian newspaper in Britain, Simon Jenkins, a former editor of The Times, attacked all three, dismissing swine flu as “a panic stoked in order to posture and spend”, a reality that “won’t sell papers or drugs, or justify the WHO’s budget”.

The World Health Organization, he wrote, “always eager to push itself into the spotlight, loves to talk of the world being ‘ready’ for flu pandemic, apparently on the grounds that none has occurred for some time. There is no obvious justification for this scaremongering”, while “epidemiologists love the word ‘could’ because it can always assure them of a headline”.

It is true that the WHO has appeared to cry wolf before, which makes it increasingly harder to take its pronouncements completely seriously. In 2006, at the height of what turned out to be the avian flu non-event, it said that up to one in four people in the UK alone could be infected. This week, Prof Neil Ferguson, a member of the WHO flu taskforce, said 40 per cent of people in Britain could be infected if the country was hit by a flu pandemic.

But, says Dr Hardy, the roots of scientific foreboding are genuine and run deep. Since 1918, she says, “epidemiologists have been afraid that something similar would happen again”. Influenza epidemics have a common cycle of 10, 15 and 20 years, and in each period one strain of virus tends to be dominant. After that, a new one comes on line “and every time there is a worry that it is going to be another big one”.

It is not only flu that keeps them awake at night. New diseases are constantly emerging and, although a lot just disappear, “some of them survive and enter the repertoire, and there is an underlying anxiety among the scientific community that sooner or later something will come out of the bag that they can’t handle.”

It remains unclear whether this strain of swine flu – described as a new subtype of H1N1, not previously detected in pigs or humans – will fulfill their worst fears, but for now the signs are that we are in the grip of another false alarm rather than on the edge of an abyss. Unheard against the background noise of a popular press rehearsing worst-case scenarios, the British Medical Journal pointed out that of the 100 deaths that had then been reported in Mexico, only 20 had been confirmed as having been caused by the new virus. When a limited batch of 14 samples were sent to the US for analysis, the CDC found only seven were from the new strain.

It is, says Prof Hardy, also “very interesting” that relatives who came into contact with Scotland’s first known infected couple – recovering after catching the flu while honeymooning in Mexico – had developed only very mild symptoms, “almost suggesting that although it is communicable between human beings, it is only rather weakly so”.

Certainly, at the time of writing, the only reported death outside of Mexico was that of a 12-year-old boy – who was from Mexico – in Texas.

Yuen Kwok-Yung, a microbiology professor at the University of Hong Kong, told Reuters that this might be attributable to “deficiencies” in the country’s healthcare system “and widespread antibiotic resistance that is typical of developing countries, resulting in victims dying of secondary infections”. In addition, the virus could be adapting to its human hosts and becoming more benign as it spreads.

Whatever the explanation, the good news is that the virus is sensitive to OSELTAMIVIR and ZANAMIVIR and, in many cases, appears to clear up by itself. Andrew Pekosz, associate professor of microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told National Geographic that the cases outside Mexico had so far proved to be no more serious than an average dose of flu.

And it remains a fact of life that flu – ordinary, seasonal flu, with or without a swinish prefix – is a major killer.

Flu epidemics are commonplace, defined by a predictive threshold of infection and death that rises and falls with the statistical expectations of the season. In the US, for example, the flu season runs over the winter from week 40, the end of September, to week 20, just into May. Deaths are monitored by the government’s 122 Cities Mortality Reporting System, which tracks the total number of deaths in 122 cities each week – accounting for approximately one third of all deaths in the US – and highlights the number attributed to pneumonia and influenza.

In February 2007, at the height of the flu season, an otherwise healthy 15-year-old girl in Texas developed a temperature of 102°F and a mild chest infection. The next day her doctor prescribed the anti-viral drug Oseltamivir, better known as Tamiflu, and for two days she was confined to bed, vomiting and continuing to suffer from a high fever. On the third day she was taken to hospital, where her blood pressure was found to be abnormally low. Within 12 hours she was dead. The post mortem examination revealed extensive bleeding and death of tissue in the lungs.

This sad case vignette was painted by Dr W Paul Glezen, of the Departments of Molecular Virology and Microbiology and of Pediatrics, at Baylor College, of Medicine, Houston, in a paper published in December in the New England Journal of Medicine. The point made starkly in Prevention and Treatment of Seasonal Influenza was that, even in the 21st century and in the most advanced nation on earth, flu is a common killer, though usually avoidably so; the victim was one of a dozen children who died in Texas alone during the 2006-2007 flu season, most of whom had not been vaccinated.

Countrywide, reported Dr Glezen, the total number of deaths of children and adolescents reported to the Centers for Disease Control and Prevention was 76, a number “likely to be a substantial underestimate”.

According to a paper by researchers at the National Center for Infectious Diseases and Centers for Disease Control and Prevention, published in the Journal of the American Medical Association in 2003, in the eight flu seasons between 1990 and 1999 influenza viruses were associated with no fewer than 51,203 deaths in the US. Against a background of such common mortality, it may seem surprising that the WHO and national authorities have taken such aggressive action with swine flu, but, says Dr Hardy, we should spare a thought for the decision-makers.

One CDC doctor who was involved in the 1976 swine-flu fiasco later recalled the dilemma they faced: “As for ‘another 1918’, I didn’t expect that,” the doctor told the authors of The Epidemic That Never Was. “But who could be sure? It would wreck us. Yet, if there weren’t a pandemic, we’d be charged with wasting public money, crying wolf and causing all the inconvenience for nothing … It was a no-win situation.”

The bottom line is that, as in 1976, no one knows yet what they are dealing with, but they are taking no chances. “The biggest question, right now, is this: how severe will the pandemic be, especially now at the start?” Dr Chan, WHO director general, said. “We do not have all the answers right now, but we will get them.”

It was possible that the “full clinical spectrum of this disease goes from mild illness to severe disease”, but there was a danger that swine flu could prove to be a burden chiefly on the poor – and that introduced a moral obligation on the rest of the world community.

“From past experience,” she said, “we also know that influenza may cause mild disease in affluent countries, but more severe disease, with higher mortality, in developing countries. No matter what the situation is, the international community should treat this as a window of opportunity to ramp up preparedness and response.

“Above all, this is an opportunity for global solidarity as we look for responses and solutions that benefit all countries, all of humanity. After all, it really is all of humanity that is under threat during a pandemic.”

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