Feature

As the world continues to come to terms with the first global flu pandemic since the Hong Kong Flu of 1968, and as the outbreak continues to gain further traction over the autumn and winter months to come, this series of weekly ‘Swine Flu Update’ articles will attempt to provide both informed editorial analysis and key national – and supranational – updates.

With the Healthcare Protection Agency (HPA) estimating that there were around 110,000 new cases of Swine Flu in the UK for the week ending July 26th, the virus is doubtless continuing to gain considerable momentum. GP consultation rates continued to grow above those of a typical seasonal flu outbreak and the under 5s and 5-14 year olds continued to be age groups most predominately affected by the infection. The total number of deaths as a result of the virus in the United Kingdom currently stands at 31. Figures for deaths worldwide now stand at upwards of 800 victims.

Yet beyond all of the rising numbers – that are arguably to be expected in the event of such an un-controlled outbreak – what are the real key developments of the past week? What of the H1N1 vaccine currently in development and when will it be available? Are pregnant women really at a greater risk and how does the World Health Organization’s advice stack up against that of National Governments? These are the questions that really matter.




In terms of the vaccine itself, the good news is that clinical trials have now begun in the USA and Australia and several manufacturers have also begun to test the vaccines on healthy human volunteers. Not only will these tests monitor for the potential immunogenicity of the vaccine, but they will also screen for any adverse reactions, in addition to testing the vaccine’s efficacy when used in conjunction with the vaccination for seasonal influenza. And whilst distribution of the vaccine is likely to occur well before the conclusion of the first wave of clinical trials, sufficient results should be available for analysis right before the point of initial dispensation in September or October.

Further to the aforementioned updates from The National Institute of Allergy and Infectious Diseases (NIAID) in the United States, the World Health Organization (WHO) has also revised its strategic guidelines for worldwide vaccination, following a special meeting of the Strategic Advisory Group of Experts (SAGE) on July 7th. Whilst the UK government has ordered enough of the vaccine to eventually cover the entire population, the first batches of the vaccine - expected to arrive in late autumn – will be enough to cover at least 50% of the population in the form of 30m double-doses.

In the case of pregnant women, new research now forces us to consider that pregnant women may be considerably more at risk of contracting a particularly severe strain of the disease than the majority of other risk groups. Specifically, and in the U.S. alone, pregnant women constitute 6% of all swine flu deaths since April- a particularly concerning statistic given that pregnant women only make-up 1% of the entire national population. Therefore, whilst the WHO has yet to deliver any concrete recommendations on the matter, alongside care workers and other front-line civil servants, pregnant women are likely to be at the top of the list for early access to the vaccine. Pregnant women are also typically more susceptible to seasonal influenza, especially during the third trimester, where the female body undergoes considerable changes – particularly in relation to the immune system.

The latest advise from the The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists recommends that pregnant women exhibiting flu-like symptoms be treated through a course of the antiviral, Relenza. A statement from the Royal College of Midwives read: “Pregnant women have got a strong instinct to protect their baby, but we have to be realistic about the kinds of adjustments people can make. If they normally have to travel on the Tube or on crowded trains in rush hour they might be better to come in later or earlier, but of course it is difficult to avoid crowds entirely. This is about being sensible and being aware of the risks”.

So whilst it’s not clear precisely clear how the WHO intends to address the problem, it is doubtless clear that a differentiation exists and that pregnant women should take the same sensible, commonsensical precautions as everyone else.

Alongside these developments, last week also saw the launch of the Government’s new ‘National Pandemic Flu Service’ or ‘Fluline’. Finally inaugurated after several weeks of somewhat predictable delay, the new telephone hotline and internet service will allow up to 200,000 people a day to seek necessary re-assurance over any troubling flu-related symptoms. If needed, patients will also be able to obtain unique prescription reference numbers allowing their friends or family to collect the prescribed anti-virals from their nearest distribution centre on their behalf. And whilst only running for 15 hrs a day initially, the service could subsequently be extended to service round-the-clock requirements in the near future. In hailing the inauguration of the groundbreaking new service, Prime Minister Gordon Brown said "I think the evidence is that people are responding to the scheme. There have been some teething troubles, (but) people are getting through. The collection points are working well”.

In terms of the economy, the number of people taking time off from work with flu-esque symptoms continues to grow rapidly. A development that The British Chambers Of Commerce contends will have a “clear impact” on the UK economy - stunting productivity and delaying future economic recovery. The group’s director-general, David Frost, said that "If the projected figures for the number of people contracting swine flu comes to pass, companies will be hit by intense periods of staff absence”. Mr. Frost also added that "Both supply and demand could be impacted and businesses need to be prepared."

At a special meeting of the Strategic Advisory Group of Experts (SAGE) on July 07 2009, the WHO considered the potential options for vaccine use. They came up with some recommendations that were endorsed by the WHO Director-General, including:



• All countries should immunize their health-care workers as a first priority to protect the essential health infrastructure. As vaccines available initially will not be sufficient, a step-wise approach to vaccinate particular groups may be considered. SAGE suggested the following groups for consideration, noting that countries need to determine their order of priority based on country-specific conditions: pregnant women; those aged above 6 months with one of several chronic medical conditions; healthy young adults of 15 to 49 years of age; healthy children; healthy adults of 50 to 64 years of age; and healthy adults of 65 years of age and above.


• Since new technologies are involved in the production of some pandemic vaccines, which have not yet been extensively evaluated for their safety in certain population groups, it is very important to implement post-marketing surveillance of the highest possible quality. In addition, rapid sharing of the results of immunogenicity and post-marketing safety and effectiveness studies among the international community will be essential for allowing countries to make necessary adjustments to their vaccination policies.

• In view of the anticipated limited vaccine availability at global level and the potential need to protect against "drifted" strains of virus, SAGE recommended that promoting production and use of vaccines such as those that are formulated with oil-in-water adjuvants and live attenuated influenza vaccines was important.

• As most of the production of the seasonal vaccine for the 2009-2010 influenza season in the northern hemisphere is almost complete and is therefore unlikely to affect production of pandemic vaccine, SAGE did not consider that there was a need to recommend a "switch" from seasonal to pandemic vaccine production.*


*The information above is a copy of the latest WHO regulations and guidelines for Swine Flu and can be found in more detail at the WHO Website, here.




• There is no sign that the virus is changing, and it is not becoming more severe or developing resistance to anti-virals

• The small number of deaths has mainly been in adults and older children with underlying risk factors

• There has been a decrease in the estimated number of cases in 5-14 year olds. Estimated cases have continued to increase in other age-groups and in the North

• As of July 28th, there were 793 people with swine flu hospitalised in the UK

• There have been 27 swine flu related deaths in England to date. With the four in Scotland, the UK total is 31

• Over 150,000 people were given Tamiflu through the National Pandemic Flu Service in its first week*

*The information above is a copy of the latest NHS key updates for Swine Flu and can be found in more detail at the NHS Swine Flu Website, here.




• WHO Twitter – ‘WHO's official Twitter channel. Who is the directing and coordinating authority within the UN system for public health’.

• NHS Swine Flu Overview – ‘This page brings together the latest science and developments on the swine flu pandemic into a single accessible resource for both health professionals and the general public’.

• NHS Swine Flu Vaccine – Detailed information on the development of the H1N1 vaccine, along with logistical updates on clinical trials in the U.S. and Australia, efficacy and WHO recommendations.

• The Lancet H1N1 Flu Resource Centre – With over 40 journals, Lancet is one of the leading scholarly resources on the topic of Swine Flu – if not any healthcare issue. With free, unlimited access for all, this is one powerful research resource.

• Nature – A number of interesting feature articles and blogs pertaining to the topic of Swine Flu.

• Fergus on flu – Great Swine Flu blog from the BBC’s Chief Medical Correspondent.

• Microsoft Bing Swine Flu Tracker – ‘Map of 2009 Swine Flu H1N1 outbreaks and migration paths reported from news and government agencies. The map lists reported dates and paths of infected persons traveling’.

• Facebook Group for H1N1 – With over 3,500 members – and literally hundreds of personal accounts on the current outbreak, this Facebook Group provides an interesting view into the potential future impact of Social Media on healthcare related issues.