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Monday, July 20

H1N1 Swine Flu: Pandemonium Weekend in United Kingdom

Pandemonium Update from July 20 edition, The (U.K.) Sun:
Meanwhile today it was revealed that security teams will be drafted in to guard supplies of swine flu drug Tamiflu. The ring of steel will be put up outside distribution centres to stop thefts and protect staff from desperate patients. More than 100 centres will be set up at pharmacies and clinics across London. Police have been involved in drawing up plans for the centres whose locations have been kept secret.
Reference my comments below about the Tamiflu honor system. Sir Liam really, really needs to re-think the phone-in system.
NO SMIRKING WARNING: So how's your government's pandemic planning coming along?

Friday Pandemonium Edition

Sir Liam Donaldson, the U.K.'s chief medical officer, got the weekend off to a roaring start by ordering the country's National Health Service to prepare for 65,000 deaths in the U.K. in the next few months with a death toll at 350/day at the pandemic's peak this winter.

Is the British government blowing the situation out of proportion? About two weeks ago, when Health Secretary Andy Burnham was quoting mathematical projections that 40 Britons could die every day from swine flu, maybe the answer would have been yes.

At that time the government was trying to turn on a dime: go from assuring the public that swine flu was nothing to worry about to preparing the public for what might have to be a mandatory vaccination program.

Today, studying the outbreak pattern in England, I'm afraid I've had cause to remember my May warning that highly populated island nations are a sitting duck during a pandemic.

So while gossip has it that Sir Liam tends to be an alarmist about infectious disease outbreaks, frankly if I were in his position right now I'd also come down on the side of abundant caution:
Sir Liam revealed that there are 652 swine flu victims in hospital in England, 53 in intensive care.

In the last week alone, there have been 55,000 new cases of flu-type illness - more than twice the figure for last week.

All areas, except Yorkshire, are experiencing 'exceptional' numbers of cases and there are ten local hot-spots, mostly in London.

It means the swine flu outbreak, still only in its early stages, is already worse than last year's winter flu, which was itself the biggest outbreak for nine years.


Sir Liam said: 'What we have unveiled are a range of planning scenarios. It does not mean that we think that will come to pass.'

In one planning assumption the death rate would be 0.1 per cent of those who catch swine flu.

In the worst-case scenario it would be 0.35 per cent. Assuming 30 per cent of the population get the disease, there could be up to 65,000 deaths.

This compares with 6,000 from normal seasonal flu and 21,000 in the last flu epidemic in the winter of 1999/2000.

A death toll of 65,000 would be double the number who died during the pandemics of 1957/8 and 1968/9.

It would make the outbreak the worst since the Spanish flu of 1918/19, which killed hundreds of thousands in the UK.

John Oxford, virologist at Barts Hospital in London, said last night: 'It's fair for the NHS to put these assumptions on the table, but I would predict that the number of deaths will be much, much lower - at the bottom end of their scale.

'There is no reason for people to get into a flap over this. I've seen the preparations and I'd rather be in England than anywhere else in the world.'

Dr Steve Field, chairman of the Royal College of General Practitioners, said last night: 'People should not panic. The virus seems to be very infectious, but in the vast majority of cases it is causing only mild symptoms. There is no cause for alarm at the moment.'
It's those "hot spots" or cluster outbreaks, as they're also called, which could be reflecting exponential spread of the infections.

The British government won't bite the bullet and institute quarantines and other strong NPIs (non-pharmacological interventions) to tamp down the clusters. So they've thrown together a stop-gap measure in the attempt to placate reality:
To relieve what he called the 'enormous' pressure on the NHS, Sir Liam announced that a phone and internet service would start from the end of next week, allowing people to get Tamiflu without seeing their GP.

The National Flu Pandemic Service will operate from a series of call centres manned by 2,000 staff from agencies, most of whom are expected to be students and temps.

People will be able to ring a single number - to be released shortly - if they believe they have swine flu.

Operators will ask a range of questions and, if the answers suggest the person may have swine flu, they can prescribe Tamiflu.

At present, people who ring NHS Direct still have to call their GP to get the drug.

The Department of Health confirmed that call centre staff would not be medically qualified, but said they would receive training on symptoms and there would be medically-trained people on site.

From next week, patients will also be able to get Tamiflu prescriptions over the internet.

Those prescribed Tamiflu through the new service will be told to stay at home and nominate a 'flu friend' to pick up the drugs from local depots.

The new flu line will initially be available only in England. The aim is to take the pressure off family doctors, who will be dealing with the most serious cases.

Critics fear the scheme will give the 'worried well' access to Tamiflu even if they do not need it - depleting the NHS stockpile.

But Sir Liam said he was trusting people not to abuse it.

Ministers have been stung by accusations they were too slow to respond to previous crises such as foot and mouth.

They are determined to be seen to be making all possible preparations for swine flu. [...]
I have a bridge in Brooklyn I'd like to sell Sir Liam

The Worried Well are not the biggest problem. It won't take Pakistani dope dealers in the U.K. even four minutes to figure how to rip off the phone-in system and sell Tamiflu on black markets in poor nations. That's because the black-market distribution networks are already in place, stretching from their end of the AF/PAK heroin pipeline throughout Asia and the Middle East.

And it won't just be Pakistanis; every crook in the U.K. who's plugged into a 'black' or deviant globalized business network will have gang members, friends and relatives snuffling to the phone-in line that they're deathly ill, and describing their swine flu symptoms.

I give the phone-in system three weeks before the locusts pick the national stockpile of Tamiflu clean.

Sir Liam sticks his foot in his mouth again, and a lesson from the Google office panic in India

The phone-in scheme and Sir Liam's talk about an honor system ignore the realities for people in poorer countries, who are already scrambling to obtain Tamiflu. Supplies are very tight in many countries.

I interject that I'm not going to sit here day after day and give the same warning to Sir Liam. But within hours of my admonishment that he shouldn't say in public that the British were at the front of the swine-flu vaccine queue, his comments set off an international row. WHO's Margaret Chan accused the Western nations of hogging all the vaccine.

Just a few days ago an Indian hospital ran of out Tamiflu when panicked Google employees who'd been exposed to swine flu at the office descended to demand Tamiflu.

There weren't enough capsules to go around and with no means to quickly test every employee for the disease, the doctors were only giving out enough Tamiflu for prophylactic doses, and only for a couple days -- not long enough to stave off swine flu.

And the lower prophylactic dose is an engraved invitation to swine flu to mutate into another Tamiflu-resistant strain if the person is already infected, beep this is a recording.

Say, why not try a pandemic-fighting strategy that works?

And that is another problem with the phone-in system described by Sir Liam. Tamiflu is most effective if administered within six hours of onset of symptoms; after 48 hours of the infection the medication is no longer effective.

There was a news report over the weekend that thermometers had been cleaned off the store shelves in the U.K. I assume, I hope, the situation will be quickly rectified. But if people dose themselves at the wrong time with the Tamiflu they've obtained from the phone-in system they're not only wasting Tamiflu, they're also risking not having the stuff on hand if they really do become ill with the virus.

So I would advise that the ministers spend a little less time trying put on a show of activity, and invest more time in thinking.

Stop and consider: Mexico's President Felipe Calderón broke the back of the swine flu outbreak in Mexico City by declaring a five-day government holiday in the city and asking city businesses to close shop during the period.

This fact is so well known that I won't even take time to find a news link to support my statement. But a few weeks ago, at the swine flu summit in Cancun, Calderón was practically pinned with a medal for his quick thinking and bold action to fight swine flu in Mexico City.

The holiday, which he created by extending the regular weekend and Cinco de Mayo holiday by two extra days, rendered Mexico City a ghost town for five days. And it cost Mexico millions USD if not billions. But by gum it stopped the spread of the virus in one of the world's most populous cities.

This being the Novel 2009 Swine Flu Virus we're talking about, of course the little anarchist only laid low. Then it popped up again -- in two rural areas of Mexico, if recall.

I haven't had time to keep up on the outbreak in Mexico so I don't know how Calderón responded to that theater of war opening up. And probably the virus eventually popped up again in Mexico City.

But the wholesale 'social distancing' created by the holiday threw a lot of sand in the virus's gears. And slowing down the rate of infections is the name of the game for pandemic fighters beep this is a recording.

As for what a swine flu holiday would cost the British economy -- how much money are they going to be losing if only part of Sir Liam's worst-case scenario comes about?

Shut down the cluster outbreaks in London by declaring a holiday, at least in London. And once you isolate the outbreaks, that's where you plug in the Tamiflu.

And you're really going to slow the virus if you combine a five-seven day holiday with quarantine of cluster outbreaks, although I might be dreaming if I think the Labor government would follow advice to quarantine.

However, they've just got to bash the infection outbreaks back over the line long enough for a vaccine to be administered and take effect. Yet surely the government realizes at this point that their vaccination program is running into snags that could delay it by several weeks or even months. So don't base planning on an assumption the vaccination program will be in high gear by the end of August.

Back to the drawing board?

On Friday Novartis pharmaceutical whined that the swine flu virus virus they're growing to make a vaccine doesn’t yield much of the antigen:
Lab workers are harvesting one dose or less of the component they need from each egg in which the virus is grown, said Eric Althoff, a spokesman for the Swiss drugmaker. That’s between a third and half of the typical yield for a seasonal flu vaccine, he said.

The low yield may slow production of a pandemic vaccine because it means drug makers like Novartis, Baxter International Inc., Sanofi-Aventis SA and GlaxoSmithKline Plc can extract less of the protective ingredient from each egg. Baxter’s Chief Executive Officer Robert Parkinson and a spokesman for Sanofi also said yesterday the amount of swine flu virus growing in each egg is lower than for seasonal flu.
What happened to Novartis' super-duper cutting edge cell technology, which made culturing the vaccine in eggs unnecessary?

Just last month they'd announced they'd finished the first batch of vaccine ahead of schedule:
"The speed advantages of our cell-based production approach and our unwavering commitment to address this public health emergency have resulted in our ability to provide the fastest possible response to this outbreak," said Dr. Andrin Oswald, CEO of Novartis Vaccines and Diagnostics.

"This achievement is also a testament to the technical skills and innovation of Novartis Vaccines and Diagnostics people and our partners. I believe it highlights our reputation as a leader in influenza vaccine research, development and production."
Like a fool I believed them and touted the breakthrough in a Pundita post. Moving right along:

Pandemic Pandemonium Weekend, Saturday Edition

Swine flu vaccine fears as first jabs available before full details of clinical safety trials are known
The first swine flu vaccine will be given to the public before full clinical data about its safety is available, it has been revealed.

The first samples of the pandemic vaccine will arrive at the end of this month and a decision whether to approve it would then be taken within five days.

But a spokesman for the European Medicines Agency has confirmed that no clinical trial data from human volunteers on the vaccines will be available until September at the earliest.

Last night the Department of Health insisted that the vaccine would be safe and warned that any suggestion otherwise would create unnecessary panic.[...]
Don't panic, you say?

Then came the bombshells:
[I]n Britain it was being reported that pregnant women are to be given advice to avoid travelling on trains and stay away from crowds.

Parents would also be advised to keep babies away from crowds and to limit the movements of their other children to stop them bringing the virus home.

The advice was based on a joint statement from the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.

However, last night the Department of Health said it was not issuing any such warnings, despite predicting last week that thousands more fatalities were expected after the UK death toll reached 29.

In another development, the National Childbirth Trust was accused of scaremongering by the Royal College of General Practitioners after reportedly advising women to consider postponing becoming pregnant.
Sunday Edition, from the same bombshells report as above:
Doctors want guards to protect wards

Doctors want guards on the doors of hospitals and intensive care units in case the families of swine flu victims become violent if they are refused treatment.

There is already a chronic shortage of intensive-care beds, particularly for children, across the country. But doctors anticipate that demand could soon exceed capacity as the number of serious cases of swine flu rises.

Bruce Taylor of the Intensive Care Society - which represents ICU staff - said: ‘Violence from patients’ families is on a list of things that staff might have to worry about as this pandemic progresses.

'We may be forced, in terrible situations, to limit patients who we’ll admit and families will understandably be annoyed. There may be circumstances where security staff are necessary.’

A spokeswoman for the Department of Health said: ‘Decisions on whether this is necessary should be taken locally.

‘It is part of pandemic planning to prepare for worst-case scenarios but it is important to say that this is not a prediction.’
"Annoyed" was perhaps a poor choice of words but to continue, from the same report:
One in five workers may soon be off sick

As many as one in five people could be off work because of swine flu within a fortnight.

Experts yesterday predicted up to 20 per cent of the 29 million workforce could take time off because they are ill or have to care for relatives who have been struck down.

The under-30s are most likely to be affected because figures show they are the ones taking most time off with flu-like symptoms.

The Health Department said last week that one person in eight could be off work with swine flu in a worst-case scenario. However, absence management specialist FirstCare, which provides its data to the Government, says the situation is escalating more rapidly than anticipated.

It says in the past few days the number off sick with flu-like symptoms, coughs and colds has leapt from around one in 630 to one in 200. That rises to one in 150 when taking into account staff forced to look after sick relatives.

If the rate of absence continues at the same pace, one in five will be staying at home by the start of August.

The Federation of Small Businesses said such a scenario would be ‘devastating’ and could cost the economy around £1.2 billion a day.
Now wouldn't it have been simpler to do as the Chinese did and stage the first line of defense at U.K. international airports? Not that I enjoy pounding away, day after day, at the same point. But what WHO termed China's "resource intensive" swine-flu fighting method is looking more cost effective by the hour, isn't it?

That was the weekend.

The Monday morning hangover

Burnham to give swine flu update

(UKPA - late Sunday night) - Health Secretary Andy Burnham is to update MPs on swine flu following a weekend of confusing signals over advice for high-risk groups.

In a statement to the Commons before Parliament rises for the summer recess, he is expected to provide the latest information on the outbreak ahead of the launch of a new flu hotline at the end of the week.

It follows attempts by health officials to allay fears over the impact of the illness on pregnant women and young children over the weekend.[...]
See RBO blog's Swine Flu Reader for all my previous posts on swine flu, which are also published at RBO. The recent posts provide additional information about the swine flu outbreak in the U.K. and the government's approach to handling it.
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