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Waiting for the killer flu
Once the pandemic starts, it will be very important to stop mass gatherings, including closing schools and churches.
The world is bracing itself for an influenza pandemic that could kill millions around the world. An average of three influenza pandemics have taken place each century since the 16th, at intervals of 10 to 50 years. Cynthia Busuttil spoke to the chairman of the National Influenza Pandemic Standing Committee, Tanya Melillo about preparations being made for the pandemic.
What is Malta doing in preparation for another pandemic?
The National Influenza Pandemic Standing Committee is preparing the plan and has made recommendations to the government. The most important recommendations right now are to stockpile antivirals, to place an order for the pandemic vaccine, to get protective clothing for all health care workers and to obtain the equipment needed to be able to diagnose the influenza virus once the pandemic hits.
Does Malta have the equipment to determine whether the avian flu has arrived here?
We can detect whether we have influenza A or B but we are not yet capable of defining it more accurately. We need special equipment to be able to do this.
Could there be any arrangements with countries for them to test if the virus is present in Malta once there is a suspected case?
We are considering this possibility but the likelihood is that during a pandemic every country will be so flooded with its own work that it would not be able to spare human resources and equipment for tests in other countries.
Recently, the international media reported that the influenza pandemic could hit 20 per cent of the world's population. How realistic is this figure?
It is realistic. In fact most countries, including Malta, have been asked by the WHO to formulate their preparedness plan for the pandemic on a 25 per cent attack rate.
Would the next pandemic be similar to the one in 1918 when an estimated 40 million people died?
In 1918, the fatality rate was 2.2 per cent, with 40 million people killed worldwide in less than a year and with peak mortality rates in people aged 20 to 45. Today, many countries are working on a 0.4 or 0.5 per cent fatality rate.
In fact, historical data of the 1918 Spanish Flu in Malta, gathered by Paul Cassar, showed 493 deaths in seven months in 1919 and a further 656 in February and March 1920. Workings done on a 25 per cent clinical attack rate would result in 100,000 people falling ill in Malta, with 700 needing hospitalisation because they would either develop primary viral pneumonia - which usually happens within the first 48 hours and has a high mortality rate - or secondary pneumonia. Most of these will survive with the help of antibiotics but there can be complications. We are estimating 400 deaths and well over 20,000 consultations with GPs over a three- to five-month period.
Is it true that the virus is changing and becoming more virulent?
Earlier this month the WHO expressed an increased concern about the level of the threat related to avian flu. Since April of this year the alert level has gone up to a pandemic alert three, which means that there has been human infection with a new subtype, but no human-to-human spread or at most some instances of human-to-human spread to close contacts. The WHO alert is three-phased - there is the inter-pandemic period (phases one and two), the pandemic alert period (phases three, four and five), which we have started, and then the pandemic period starts.
Is there a time-frame for these phases?
No, it depends very much on the virus and its capabilities to adapt to humans. During the next three phases we will start seeing larger clusters of influenza cases caused by increased human-to-human transmission.
Can something be done to kill the virus before it becomes more virulent and starts spreading from person to person?
Viruses tend to be very resilient to ways of destroying them, and this particular virus seems to know how to go about changing its make-up in order to invade mammalian hosts. Originally it used to be present in wild geese but never caused them symptoms. Now it's killing them. The virus has managed to move through all the bird family, has killed many types of birds, and has been found in tigers, cats, pigs and even in humans. It knows how to adapt itself very well in order to survive.
Can the virus be attacked through antivirals as soon as it starts spreading?
The World Heath Organisation has a stockpile of antivirals which it will use once transmission is established. The problem is that information is not always reaching the WHO very quickly. Because of the vastness of Asia, where the pandemic is likely to start. Even if the spread of the virus is contained within a particular area with the help of antivirals, it may already be spreading in another region or has already travelled to another country because of rapid spread through travel, especially aviation.
Will a pandemic strike overnight or will it take some time?
The likely scenario is that it will take a couple of months for the pandemic to strike. It is expected to start with outbreaks somewhere in South-East Asia. This will be investigated by the WHO, which will then declare that the pandemic has started. Within two months, it will spread through neighbouring countries, and that is when other countries in Europe will start implementing their plan. Within two to four weeks it will spread to other continents and by four weeks most countries will have cases. So basically, once a pandemic has started it is likely to hit our shores within two to five months.
Can countries close their borders to people coming from affected areas?
One of the first things countries will do is restrict people coming in from affected countries, but this might not always be possible. We are lucky that Malta is an island and everyone has to come in either by plane or ship, but in most other countries people travel overland. We saw what happened with Sars - it spreads really quickly.
People travel a lot today. By the time the pandemic is declared, you could already have had people who took it to the rest of the world.
Influenza has a very short incubation period, of only one to three days, and an infected person can transmit the infection to all those persons who are within a one-metre radius.
Are the influenza experts close to creating a vaccine for avian influenza?
Yes, there will be a vaccine for the H5N1 virus in the very near future. But we will not know whether the H5N1 viral strain will be the cause of the pandemic until this starts and the viral strain is identified.
It is likely that the avian virus will mutate causing a genetic change of the virus currently circulating in Asia, which could lead to the avian flu virus transforming into a new human strain of influenza capable of human-to-human transmission. The H5N1 vaccine could bring about some immunity but we will not know how effective that immunity is to the pandemic strain. It is impossible to produce vaccines en masse right now and have them readily available - we have to wait until the pandemic starts.
Is there any assurance that although Malta is a small country, it will still be able to get vaccines?
Some countries are currently negotiating with the vaccine companies. It is being done on a first-come-first-serve basis. We already know that once the pandemic is declared, it will take the manufacturing company two months to produce the vaccine, and already the next three months have been taken up by orders from some countries.
Has Malta started to stockpile antivirals?
No, but they will be available in the private sector later this year. At the moment there are none on the local market. The advantage of taking antivirals within 48 hours of developing symptoms is that they reduce viral shedding, shorten the period of illness, reduce the severity of symptoms and lead to a reduction in secondary lower respiratory tract complications and hospitalisation. If people have antivirals stored, they should still consult a doctor before taking them.
How important is it for people to start taking the annual influenza jab, and does it in any way protect against the H5N1?
As from this year the WHO has asked all countries to increase their vaccination coverage, mainly to make the vaccine manufacturers increase their production in preparation for the pandemic vaccine.
Malta will be increasing the coverage as from this year. Until last year, those over 65s and those in high risk groups were entitled to the influenza vaccine. For the coming season it is being given also to all over 55s, and also to infants from six to 24 months, because we know that these are the two age groups who are hit the hardest during the normal epidemics.
Some pandemics have a worse effect on healthy young adults. In fact, in the 1918 pandemic it was people within the 15 to 35 bracket who were hit the hardest. The experts are concerned because they are seeing similarities between this avian virus and the 1918 Spanish Flu. In Asia the avian flu has been affecting mostly children and young workers. In fact they found elderly people who were positive to the avian virus but had no symptoms.
What are the symptoms of influenza that people should look out for?
What distinguishes it from a common cold is that it is more acute when it starts, and you have a high temperature, usually over 100C, associated with general aches and pains all over, as well as a cough and headache. That is why it will affect the economy so much, because people will be ill and will have to spend anything between six and 12 days in bed.
Is it possible for Malta to avoid the pandemic?
It is very unlikely for any country to avoid being hit; this has never happened in the past. We know there are measures that can help slow down the spread of disease, including closing your borders for a particular time, restricting travel from the affected areas and quarantine of passengers.
Once the pandemic starts, it will be very important to stop mass gatherings, and this would include closing down schools and churches. We know that children are the ones who usually start epidemics. Statistical data show that there is usually an increase in school absenteeism just before an epidemic starts. In fact, studies have shown that schoolchildren are efficient transmitters of influenza in the community and around 40 per cent become infected every winter. Closing schools should be seriously considered once the pandemic starts.
Many countries are seeing the closing of schools as a big problem because it might mean parents will not able to go to work in order to take care of their children since their family members live long distances away. But for Malta it is not a big problem since we have good family networks and everyone lives close to each other. It is very important especially for health care workers to find support. If their children are being cared for, their mind will be at rest and they can work.
Once the pandemic starts, will there be a recommendation that people whose work is not essential should stay home?
We will try to keep things as normal as possible. But what is likely to happen is that some activities will not be able to continue.
As the chairman of the National Influenza Pandemic Standing Committee, what are the biggest challenges you face in preparing this plan?
There is lack of awareness about the threat we are likely to face. The WHO is very concerned about the imminence of a pandemic within the next few years. The pandemic will have an impact on the health of the Maltese population, the economy and the provision of health care services and other essential services.
Another challenge is the organisation and management of our general hospital to cope with the increased capacity needed of health care workers and beds. There is also the challenge of finding a solution to providing a good primary care service in such a scenario since the bulk of the work will be at community level.
The problems are multi-fold. There will be panic by the general public, a massive workload on private GPs, a number of GPs will fall ill and be unable to take care of their patients, the need for GPs to see patients as soon as symptoms start in order to prescribe antivirals, and the logistics on how to provide antivirals to these patients.
One possible solution would be for every local council to identify a suitable place to convert into a flu clinic to provide a primary care service to all the people of the locality during the pandemic. The local council would organise this service with private GPs working in that town, and a roster organised by GPs to ensure that the patients are able to be seen by a doctor seven days a week. The doctors would be able to cope with the workload, and if a few doctors fall ill, patients would still be seen.
Moreover, doctors would be able to have adequate periods of rest to be able to provide the service for such a long period (three to five months). This will be a one-stop-shop, with patients being registered by a clerk in a room, then seen by a nurse in the next room where particulars are taken and their temperature checked. Then a doctor in the next room sees them and those who are eligible for antivirals will collect them from the pharmacist in the next room.
The local council could also set up hot lines for the residents to provide general information on preventive measures.
Human infections with avian influenza have taken place on 11 occasions since 1959. The virus erupted in its highly pathogenic form in Hong Kong in 1997 and jumped directly from birds to humans.
At the end of 2003, large numbers of chickens died and in January last year there was a rapid escalation of concern as human cases were detected again.
Dr Melillo said all the prerequisites for a pandemic have been met apart from the sufficient human-to-human transmission. Last year, the virus expanded to tigers, cats, pigs and wild birds.
"With the virus endemic in Asia having established a permanent ecological niche in poultry, the probability that the potential will be realised has increased," she said.