When pandemic flu strikes

The possibility of an influenza pandemic hit the international headlines recently. If, or when, this happens, Malta will not be spared and action has started being taken to draw up a plan of action. CYNTHIA BUSUTTIL reports.

The World Health Organisation has for some months been warning that an influenza pandemic, which could kill millions around the globe, is on the way.

With influenza experts agreeing this is not a matter of "if" but "when", the WHO has urged countries to draw up an influenza preparedness plan. The organisation believes the appearance of the avian influenza (H5N1) shows the world has moved closer to the next pandemic.

"While it is impossible to accurately forecast the magnitude of the next pandemic, we do know that much of the world is unprepared for a pandemic of any size," the WHO said last December.

Experts have had no qualms in comparing the upcoming pandemic to the 1918 Spanish Flu, which killed millions all over the world.

Tanya Melillo, who is chairing a committee working on an influenza pandemic plan for Malta, said that based on previous pandemics, experts believe the first wave of the pandemic would last about eight weeks, although it could take as long as 20 weeks. There would then be an inter-pandemic period lasting a few weeks before the second wave starts.

The committee's report is expected to be ready by the end of the year. Asked what would happen if the pandemic struck before this report was completed, Dr Melillo pointed out that only two countries had actually finished and publicised their plan, with the rest still working on it and discussing a number of issues. "Although experts say it will happen, we are not presently in the situation where it will happen within the next few months," she added.

As things stand now, St Luke's Hospital struggles with overcrowding, especially during the winter months. (According to the Financial Times, 30 million people all over the globe could need hospitalisation when a pandemic strikes.) Dr Melillo explained that other places would used as hospitals for flu patients as one hospital might not be enough. A second hospital would be used for emergency operations and to treat other medical conditions unrelated to influenza as well as births.

The committee is currently working on guidelines that will be distributed to all doctors in Malta.

"Patients will only be admitted to the designated flu hospital if they have a doctor's referral and if they satisfy the criteria for admission to hospital," she explained.

During an influenza pandemic, the main objective is to limit the spread of disease and Dr Melillo said certain public health measures will need to be taken. "These may include the quarantine of ill patients, closing down schools and churches and prevent mass gatherings," she said.

Dr Melillo said an influenza epidemic is usually preceded by an increase in school absentees. Indeed, children are the main focus of spread since they are the ones who least tend to cover their mouths when they coughed and sneezed and also the least who tend to wash their hands.

"While adults are able to spread the infection for six days, children can keep on spreading the virus for up for 14 days," she said.

If schools have to close down for a couple of weeks, children will be able to catch up with the scholastic year syllabus later on during the holidays, Dr Melillo said. Other options were also being considered including - if the pandemic occurred during the warmer months - the possibility of allowing children who were not ill to go to school as long as all classes took place out in the open. There was also the option that during the pandemic period children could learn through programmes on television, radio and via the internet.

In case of a pandemic, anti-virals can be used as a temporary solution because they should ease the severity of the disease as well as the mortality rate. Malta is presently in the same situation as most other European Union countries - all are estimating the numbers of anti-virals that would need to be stockpiled and drawing up a priority list as to whom these anti-virals should be administered.

"So far, only a few countries actually have anti-virals stocked. The World Health Organisation has committed itself to ensure there will be an equitable distribution of both anti-virals and pandemic vaccine so that small countries like Malta will be given the chance to obtain the amounts they need," she said.

Dr Melillo said her committee was in contact with all medicine agents in Malta who could put anti-virals on the market. However, importers were hesitant to stockpile for the private sector unless there is a demand for it. When anti-virals were launched here four years ago there was no demand for them, which led to a lot of money being lost, she explained.

What is avian influenza?

Avian influenza, which is also know as bird flu, is an infectious disease that affects mostly birds but can also target mammals. Wild ducks, in particular, are the natural reservoir of avian influenza viruses and are also the most resistant to infection, while domestic poultry - including chickens - are particularly susceptible to epidemics of rapidly fatal influenza.

Although bird flu viruses do not usually infect humans, several cases of human infection have occurred since 1997. A worrying aspect is the high death rate for human infection from bird flu - which stands at about 70 per cent. It is also thought that although in most cases humans got infected after contact with infected poultry or contaminated surfaces, some human-to-human transmissions have taken place.

The first probable case of person-to-person transmission of the virus occurred last year when an 11-year-old Thai girl fell ill after handling dead chickens. Her mother, who came from another city to take care of her daughter in hospital, developed pneumonia and an aunt who provided unprotected nursing care developed a fever a few days after the mother first fell ill. Both mother and daughter died while the aunt survived.

The reported symptoms of the avian flu are the same as ordinary flu in the first stages and include headache, fever, muscle and joint pains. But as the illness progresses, complications, like pneumonia and severe respiratory diseases, could also arise and could lead to death.

Although there is currently no vaccine to protect humans against the H5N1 virus, efforts to develop this vaccine are underway. According to the United States' Centre for Disease Control and Prevention (CDC) research studies to test a protective vaccine for humans are expected to start next month. The CDC said the vaccine would probably not be available in the early stages of a pandemic, adding that once a potential pandemic strain of influenza virus is identified it takes several months before a vaccine is widely available. Work on the specific vaccine for the H5N1 virus is currently underway by scientists.

The impact of a pandemic

According to the WHO an influenza pandemic occurs when a new influenza virus, to which human beings have no immunity, appears. This results in several, simultaneous epidemics all over the world, with an enormous number of deaths and illness.

"With the increase in global transport and communications, as well as urbanisation and overcrowded conditions, epidemics due to the new influenza virus are likely to quickly take place around the world," the organisation said.

In the past, new strains of influenza have caused pandemics that led to high death rates. The most serious took place in 1918 and 1919. Dubbed the Spanish Flu, because it got more media coverage in Spain than in other countries, the pandemic caused as many as 50 million deaths.

The Spanish Flu struck Malta too. Statistics collected by the disease surveillance unit show a peak in the incidence of influenza during the time. The statistics indicate that more than 18,300 confirmed cases of influenza were registered between 1918 and 1919 when the population stood at just over 224,300.

The WHO said that although health care had improved in the last few decades, epidemiological models showed that in a best case scenario a pandemic today could lead to anything between two million and 7.4 million deaths worldwide. If the virus is a very virulent strain, deaths could be dramatically higher.

"In high income countries alone, accounting for 15 per cent of the world's population, models project a demand for 134 - 233 million outpatient visits and 1.5 - 5.2 million hospital admissions," it said.

However, the impact of the next pandemic is likely to be worse in low-income countries.

A pandemic cannot be stopped but its impact can be reduced through preparedness. The WHO has urged all countries to either develop or update an influenza pandemic preparedness plan so that they would be able to respond when the pandemic starts.

Preventing the flu

The best way to prevent influenza is to take an annual jab, which is available in autumn.

However, a vaccine against avian influenza has not yet been identified.

But people can also protect themselves against the flu through anti-viral drugs.

When contacted, the medicines regulatory unit confirmed that a number of anti-virals could be put on the local market. One product was in possession of a central European registration and another was registered in Malta while a third could be brought to Malta through mutual recognition with another European country.

At the same time, the active ingredient of a particular anti-viral - which had a longer shelf-life and cost a fraction of the price of the finished anti-viral marketed product - did not need a marketing authorisation and any pharmacist is legally empowered to reconstitute it in a laboratory as a "magistral formulation" with the instructions made available by the pharmaceutical company that manufactures the active ingredient.

There were two vaccine preparations which had a provisional marketing authorisation and could therefore be put on the local market.

A number of habits could also prevent the spread of influenza. These include avoiding close contact with people who are sick and keeping your distance from others when you are sick, staying home when sick and covering your mouth and nose with preferably a disposable tissue when coughing or sneezing. The regular washing of hands will also help, as is avoiding touching eyes, nose and mouth, since germs are often spread when a person touches something that is contaminated with germs and then touches his eyes, nose or mouth.