SWINE flu, or more technically influenza A (H1N1), is now officially a pandemic. Addressing the press on June 11, Dr Margaret Chan, the director general of World Health Organisation (WHO) said, “On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6. The world is now at the start of the 2009 influenza pandemic.” She added that currently, it was of moderate severity but cautioned that it was early days yet and the virus can “change the rules of the game” at any time.
The virus has now spread to 74 countries, with evidence of community spread in Australia, the UK, Spain, Japan and Chile, among others.
The declaration of pandemic has little to do with the increase in severity of the disease. Thomas Frieden, director of the US Centre for Disease Control and Prevention clarified, “The declaration of a pandemic does not suggest there is a change in the behaviour of the virus, just that it is spreading in more parts of the world.”
As we had noted in our earlier article, the criteria of going up to level 6, the final stage of declaring a pandemic has been fulfilled for some weeks. However, many experts held that WHO should qualify the severity level of the pandemic. WHO took some time to add the severity level to the pandemic level before making the formal declaration. Otherwise, WHO’s pandemic alert focuses on that it should be a) new b) infectious c) and have spread to two WHO regions at the community level. Even a relatively benign infection can qualify as a pandemic under this classification if the above criteria are met.
As it stands today, there is little cause for immediate panic. Out of 30,000 odd infected by swine flu, only about 145 (June 12 WHO figures) have died. This is comparable in severity to seasonal flu infections, whose annual death toll worldwide is 200,000 to 300,000. If this level of severity continues, then it is unlikely to be more than a mere blip in global health scenario. WHO’s chief flu expert Keiji Fukuda in his June 9 briefing said that with more around the world becoming infected, immunity to the virus will build up. At that point, this A (H1N1) variant will be just another seasonal strain, joining three others—including a human A (H1N1) strain—that are currently circulating.
In fact by creating an artificial panic, many countries could divert resources away from their more urgent heath needs.
In India, while primary health centres and hospitals lack vital life saving medicines, under the pressure of headlines, Indian government stocked up on Oseltamivir earlier and may do so again. To compound this folly, the Indian government head disregarded the generic version of the Oseltamivir being manufactured by Cipla during the outbreak of bird flu and decided to buy the more expensive one from Roche under the “mistaken” belief that Roche really had a valid patent. Ultimately, the Indian Patent Office did not grant Roche a patent for Oseltamivir, paving the way for generic manufacturers such as Cipla to meet not only Indian requirements and also supply to other countries.
This is the fourth flu pandemic in the last 100 years. The first great outbreak was the Spanish flu in 1918, which killed an estimated 40 million. The second one was in 1957 and the one following in 1968. Though with swine flu, the severity of the infection is comparable to the more familiar seasonal flu, this flu virus, unlike the seasonal flu virus affects younger people more. About half the deaths are in the age group 30-50, unlike seasonal flu where the elderly population are more at risk.
Every time a new flu virus appears, it is the fear of a Spanish flu like virus that scares the world. While infectious diseases such as tuberculosis, typhoid, etc., remain as major killers in the developing world, the developed world has managed to control these diseases. The one killer, which stills kills large numbers in the developed world, is influenza. That is why the global media resonates so strongly on flu outbreaks, while remaining relatively immune to the death toll of other diseases.
The Director General, in her press briefing, also focussed on the preparedness of the world to meet the threat from swine flu. The science has worked very well – the gene sequence was done within weeks, the seed virus for vaccines prepared quickly and now the vaccines could be out in bulk by September. This would mean that we would be ready for the flu season in the northern hemisphere that starts around that time.
However, what Dr Chan did not say is that the world was preparing for a different flu than that has actually arrived.
After the bird flu and SARS that struck the world in 2003, the global preparations had been for a deadly bird flu variant (H5N1) originating from Southeast Asia. Instead, we have the swine flu (H1N1), relatively mild and coming out of North America. Nature, the premiere science journal quoted Eric Toner, a physician and preparedness analyst with the university of Pittsburgh Medical Center’s Center for Biosecurity in Pennsylvania, “Many nations built their plans around the idea that a pandemic strain would evolve in southeast Asia, that we would recognise it early, and that we would be able to contain it. None of that turned out to be true. …The idea that one could trap it at the early stages was certainly not successful.”
Interestingly, this description also gives away the underlying vision of global heath agencies – it is how to insulate the developed north from the diseases arising out of the third world. However, if the disease originates breaks out in their heartland, they are far less prepared. And the preparedness of the third world does not count, all that they are expected to do is not to export their diseases to the developed world.
How was the developed world planning to meet the flu pandemic? Based on earlier expectations, the main plans were for culling chickens and not how to deal with human infections. Also, vaccines and flu medicines are in short supply in the poorer countries. Even if they are available, most people cannot afford them. The situation is not improved by the indulgence that the poorer countries continue to show the drug MNC’s – most of them have granted Roche-Gilead the Oseltamivir patent, which India has not.
India has certainly the expertise to manufacture the flu vaccine but has shot itself in the foot by closing down its public sector vaccine manufacturing facilities, therefore severely curtailing its manufacturing capacity.
The fear now is that as countries stock up for medicines and vaccines, the poorer countries are going to be squeezed out of the market by the richer ones. With the virus now moving to the tropics and the southern hemisphere, the third world may suffer the consequences of global planning based largely on insulating the richer north from the poorer south. If the virus takes an ugly turn and comes back in a much more virulent form, it is the global south that will then pay the price of such lop-sided planning. Let us hope that this variant of the flu virus will not change its current behaviour and we will be better prepared for the next round of battle between the virus and us.
Earlier Flu Pandemics (http://www.nature.com/avianflu/timeline/past_pandemics.html) 1890 First recorded recent influenza pandemic 1918 The “Spanish Flu” pandemic, caused by the H1N1 influenza virus kills more than 40 million people The origin of H1N1 has been the subject of many studies – some suggest it may have gone directly from birds to humans, while others suggest it may have involved incubation in an intermediate host, such as the pig, or another as yet unidentified animal host. 1957 Asian flu pandemic kills 100,000 people, due to the H2N2 influenza virus. 1968 Hong Kong flu pandemic kills 700,000 people, due to the H3N2 virus. Both H2N2 (1957 pandemic) and H3N2 are likely to have arisen by exchange of genes between avian and human flu viruses, possibly following dual infection in humans. (Source: Nature)