How prepared are we? Novel Influenza A/H1N1 continues to spread...

In the global context "we have never been so prepared," Dr Margaret Chan, Director-General of the World Health Organization (WHO), commented on the outbreak of A/H1N1 influenza in April 2009. However, with ever increasing numbers of people travelling and increased levels of globalisation, the world is becoming a small place and an easy place for the spread of influenza. The question of preparedness has changed in orders of magnitude since the end of the First World War.

Since the 1918 "Spanish Flu" pandemic there have been several serious outbreaks and experts say that the cyclical nature of influenza pandemics means that they will occur on a regular basis. In 1957-58 "Asian flu" H2N2 resulted in 70,000 deaths and between 1968-69 "Hong Kong flu" H3N2 caused the deaths of 34,000 people. With 6 Billion people on the planet, many of whom are considerably more interconnected than ever before, are our surveillance systems and antiviral treatments enough to prevent another catastrophe like Spanish Flu almost 100 years ago? If A/H1N1 Flu is to be the next big outbreak or just a warm up for something much bigger, how prepared are we?

Surveillance

In order to prevent a pandemic or in order to prevent a pandemic becoming serious, surveillance is key. This helps experts to understand the epidemiology and virulence of a particular influenza strain as well as understanding how to prevent a pandemic from spreading. Various systems exist presently to monitor influenza strains in preparation of an outbreak. The WHO Global Influenza Surveillance Network was established in 1952 and consists of over 120 National Influenza Centres in over 90 countries that monitor influenza activity and isolate influenza viruses in every region of the world. This network feeds into the Global Outbreak Alert & Response Network (GOARN) which is a WHO-led technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance.

In Europe the European Centre for Disease Prevention and Control (ECDC) runs a project called the European Influenza Surveillance Scheme (EISS) that has been providing weekly updates on the Influenza situation in Europe since 1996. The WHO Europe regional office also feeds into the EISS. The first European influenza surveillance project was the Eurosentinel scheme (1987-1991), this was followed by the ENS-CARE Influenza Early Warning Scheme (1992-1995). The European Centre for Disease Prevention and Control an executive agency of the European Commission, works to identify emerging health threats and to neutralise them early on.

So global surveillance is fairly thorough and well-established, the early warning systems that drew the world’s attention to the A/H1N1 Flu pandemic and allowed a swift response are testament to this. However surveillance without action is useless, how prepared is the world to act in cases of global outbreaks of Influenza.

Action

"Tests, Vaccines, Medications, & Masks" this is the mantra of the US Center for Disease Control and Prevention’s (CDC) Pandemicflu.gov initiative. Vaccinations are only any good if the pandemic that hits the population is the same strain that the population has been vaccinated against. In the case of A/H1N1 Flu, this vaccination does not exist, whereas for seasonal flu the population is fairly well-protected. Regular testing is important and particularly so in the case of a suspected pandemic. In the case of A/H1N1 Flu in Spring 2009, testing regimes were put to the test. Medication and masks are the last line of defence before isolation against an influenza pandemic. Precautions such as masks, gloves and other physical preventative measures can be cheap but there are still doubts as to their effectiveness. The Severe Acute Respiratory Syndrome (SARS) outbreak in July 2003 saw millions of people in China wearing masks that spread fear around the world of an imminent pandemic. It remains unclear whether surgical masks or masks such as the N95 (that claims to provide 13x more protection than not wearing one) are actually effective or not. Some would claim that all they do is spread fear.

While the A/H1N1 outbreak of spring 2009 saw an unprecedented stockpiling of antivirals known to be effective against A/H1N1 Influenza, such as oseltamivir and zanamivir (AKA. Tamiflu and Relenza respectively) they are known to be no cure for the disease. Antivirals can help slow the spread and can help to assist quick recovery from infection but cannot outright cure the disease. The stockpiling of antivirals may help, and with the potential for A/H1N1 Flu to return in the winter of 2009 it reassures a nervous population to know that their government has taken the appropriate precautions.

The final measure is isolation, this raises the issue of restricting the free movement of individuals to defend the health of others even if they have done nothing to warrant such treatment. This same question was recently asked in South Africa when it became clear that treatment of extremely resistant tuberculosis (XDR-TB) was impossible with any drugs currently available. Now with a global pandemic, isolation may be an unrealistic method of controlling the spread but could early interventions and isolation prevent a spread in the first place?

The world is prepared or at least the WHO is fairly confident that the world is prepared. The systems are in place and in Spring 2009 those systems got a road test that seemed to be successful. Perhaps this success has more to do with the changing of the seasons than global pandemic preparedness measures. Only time and continuous vigilance will tell.

For more information

 Please visit the WHO A/H1N1 surveillance page
 Please visit the ECDC website
 Please visit the CDC website

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