Pandemic flu – what are we missing? David Steven

July 28, 2009 | More on Global system, UK | No comments

For governments, managing risk is a pretty thankless task. Today, the House of Lords Science and Technology committee published its report on pandemic flu. Here’s the finding you won’t see widely reported:

We know from the evidence we received prior to the outbreak of swine flu that there has been a significant amount of work undertaken to ensure UK pandemic preparedness. According to Ms Merron, the WHO recognised the UK “as one of the best-prepared countries in the world”. Professor Lindsey Davies, National Director of Pandemic Influenza Preparedness at the DoH, told us that “No other country in the world has done more than we have to ensure that we protect the population and that we minimise the pandemic’s impact”-other countries are now coming to the United Kingdom for advice.

Instead, the spotlight will be firmly on where the government has got it wrong:

Guardian: “Committee concerned over delays, failures and preparedness for expected ’second wave’ of virus in autumn.”

Telegraph: “Committee says Government has failed to offer reassurance that NHS services can deal with a “second wave” of swine flu.”

Sun: “NHS can’t cope with swine flu.”

Independent: “The spy who blew the whistle on his former colleagues is now living in a squat, dressing as a woman, and railing against the ‘Zionist empire’.” [Sorry - seem to have got my wires crossed here.]

Of course, none of these stories is a surprise. The Committee made sure the bad news got out over the weekend, leaking the bad bits to the BBC. Ministers have been on the defensive ever since.

Three reasons why this matters. First, it feeds cynicism about the public sector, helping convince ordinary punters that civil servants are such morons that they haven’t done anything useful to prepare for the pandemic.

Second, it creates a cartoonish view of the nature, and limitations, of any response to a serious pandemic. With an attack rate of 30%, our social, economic and health systems are certain to degrade to a degree (though hopefully, in a controlled way). Resilience relies on individuals, families, communities and networks of all kinds to pull together.  Expecting the government to ride around dolling out magic bullets is both a self-indulgent and ultimately self-defeating strategy.

The final point, though, is perhaps the most serious one. The Lords’ criticisms are aimed mostly at patchy implementation of a good strategy. But what if the strategy itself is faulty – not just the detail of its execution? That would be a much more serious matter.

Two possible gaps are, I think, worth exploring.

First, the UK may be doing too little to prepare for a low(ish) probability/high impact scenario, where flu becomes a lot more deadly between now and winter. What if the case fatality rate (CFR) reaches 2%, as it did in 1918, or even higher (unlikely – but why not?)? Are we ready for a pandemic that is very suddenly much worse that we thought?

It’s happened before. According to the World Health Organization:

During the previous century, the 1918 pandemic began mild and returned, within six months, in a much more lethal form. The pandemic that began in 1957 started mild, and returned in a somewhat more severe form, though significantly less devastating than seen in 1918. The 1968 pandemic began relatively mild, with sporadic cases prior to the first wave, and remained mild in its second wave in most, but not all, countries.

DOH planning assumptions include reference to a pandemic with a 50% attack rate and a 2.5 CFR – leading to 750,000 deaths (on Twitter – Mike Bennet is focused on this risk) . I suspect we are thinking less about a ‘black swan’ pandemic today than we were twelve months’ ago – simply because there’s now so much to do to combat what is still fairly mild flu.

The Lords alludes to this concern in footnote 17 to annex three of its report, where they make reference to concerns of John Beddington, the Government Chief Scientist, that we should be planning for a higher mortality rate.

Beddington co-chairs the Scientific Advisory Group for Emergencies (SAGE), which is advising the government on flu responses. I would dearly love to know if this group has had further thoughts on increased virulence, but it meets in secret and even MPs are not able to see its minutes. According to Gillian Merron, Minister for Public Health:

We will not be placing copies of the minutes of each SAGE meeting in the Library at the present time. The majority of SAGE work is directly commenting on or providing input to the formulation of Government policy. In addition, in order for SAGE to work effectively, members need to be free to discuss issues openly, including confidential evidence in their deliberations. The publication of the minutes may therefore prejudice the effective conduct of public affairs. However, we will keep the publication of minutes under review.

This is a dumb move. Despite the barrage of criticism that surrounds government deliberations, it is vital that scientific advice is widely shared and robustly debated. It’s the only way of ensuring an effective response to some potentially catastrophic risks.

The second criticism was one I made when I appeared on a panel with the virologist, John Oxford, at RUSI’s resilience conference in 2008 (my talk). UK plans to manage the pandemic through a call centre model were already far advanced at the stage and I found them quite impressive.

But are we prepared for the consequences of others being less well prepared than we are ourselves? Or is our planning predicated solely on what happens within the UK’s national borders?

The last flu pandemic was in 1968, when global systems were much less tightly linked and just-in-time inventory strategies had not spread far beyond Japan. How will globalization – already under the cosh due to the economic crisis – fare if countries see 20% or more of their workers stay at home?

And then there’s the potential impact on fragile states. During the last pandemic, the developing world had only 680 million people living in towns and cities. Today, the figure is around 2.5 billion.

Here’s Alanna Shaikh on the possible impact of flu on megacities:

The dense living conditions let the flu spread quickly, especially since poor people have less immune resistance to infectious disease. In addition, pollution and living conditions will make the flu more severe in people who contract it, and people often lack access to quality health care services. In my opinion, Mexico City’s huge size was a major factor in why swine flu was so much more severe in Mexico than in the United States…

That high transmission rate will be compounded by substantially increased death rates from swine flu in megacities. The risk factors for death from swine flu are asthma, cardiovascular disease, obesity, and diabetes. All of these things are more common in the megacities of the developing world. Asthma is a particular risk factor, and it’s made worse by air pollution.

The death rate will be made worse by lack of health care. Megacity slums are consistently deficient in access to good health care. Residents may be unable to afford health care, facilities may be poorly equipped or staffed, or there may simply be no health care provider available.

So, a lot of factors are going to come together in an ugly interconnected way. More sick people being hit harder by the virus, and no health care providers to look after them. It could be devastating. My grim guess, however, is that misery and death from swine flu in megacity slums will be ignored, just as we ignore misery and death in the slums from everything else.

The only part of Alanna’s post that I disagree with is the last sentence. If flu is really bad in states that are already struggling to function, then state failure could be the pandemic’s most destructive legacy. British citizens would then be affected more by what was happening in Lagos than London, or Karachi than Manchester.

Addendum: While we’re considering potential wild cards, I’ve been wondering whether an swine flu pandemic makes avian flu less or more likely to emerge, or whether the two are independent. Could we have swine flu this year? Avian flu next?

I’m not really sure there’s an answer to this question, though the current pandemic will mix a lot viral bits and pieces together. According to WHO:

In these early days of the outbreaks, some scientists speculate that the full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread. This, too, could alter the current disease picture, which is overwhelmingly mild outside Mexico.

Apart from the intrinsic mutability of influenza viruses, other factors could alter the severity of current disease patterns, though in completely unknowable ways, if the virus continues to spread.

Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses as the normal influenza season in that hemisphere begins.

The fact that the H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a pandemic. At present, H5N1 is an animal virus that does not spread easily to humans and only very rarely transmits directly from one person to another.

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