Henry Wadsworth Longfellow’s poem ‘There was a little girl’ tells us that ‘when she was good she was very good indeed, but when she was bad she was horrid’. This gives a good perspective of our current and very new cohabitant on planet Earth: swine influenza, known to the cognescenti from the prototype virus used for vaccine and isolated in the USA as A/California/4/09 H1N1.
A ‘Very Good’ Virus
We already have a double perspective on the community and medical effects of the virus from the winter outbreak just finishing in a highly developed country, Australia, and also in less-developed Argentina. We can overlay the data obtained from the summer outbreaks in the USA and UK and, of course, the starting position (according to current knowledge) of the border of Mexico and the USA. We know that this virus is not an out of control 1918 H1N1 infection (Spanish influenza), nor is it as bad as the pandemic H2N2 virus in 1957, nor the 1968 H3N2 pandemic visitor of 1968.
Most people between childhood and their pension will shake off the infection fairly easily and, most graciously, the over 65s are immune. It is normally this group that succumb quickly to epidemic and pandemic influenza. With age comes a waning immune response and a raft of underlying medical problems, whether the pensioners realise this or not. And most persons of any age can suffer high blood pressure or elevated cholesterol levels, both of which enhance stroke risk and cause heart disease, and yet many coast along oblivious to the problems. In short, so far we have a virus, which compared to all previous pandemics within living knowledge is ‘very good’.
The scientific explanation of this ‘good’ state of affairs is that the H1N1 family of viruses circulated across the world from 1918 until 1957, and then returned in 1977, according to the present data. The ‘return’ is a story in itself, but probably relates to an accidental laboratory escape virus. Probably every person on the planet has, at one time or another, been infected with an H1N1 virus. Hence the store of immune memory is significant. After all, swine H1N1 is still a member of the H1N1 family, albeit a cousin six times removed. This may reassure us that we will not have an uncontrolled outbreak, as in 1918. Then the virus was brand new, having recently jumped from a bird or animal reservoir, so there was no immune memory at all to the family (except, possibly, in the over 70s). As a result, it could wreak the havoc that it did.
A Cause for Concern?
And now the ‘horrid’. Respiratory physicians in the USA, Canada, Australia and the UK have noted with dismay how quickly younger patients, already hospitalised with problems of breathing and general lassitude, may suddenly deteriorate and have to be moved to intensive care. Moreover, special techniques such as extra-corporeal membrane oxygenators are needed, as 60 per cent of patients in intensive care develop acute respiratory distress syndrome. From there, the outcome can be too close for comfort. So this is a relatively benign virus – but one with a sting in its tail. Also, some children have succumbed to neurological problems; an unpleasant reminder of 1918. Recent laboratory descriptions of the pathology of this new virus in animal models show the swine virus to be more deadly than seasonal influenza. The swine virus causes diffuse alveolar damage leading to pneumonia in the models as it does in fatal human cases, at least a third of whom have no underlying prior predisposing medical condition such as asthma or diabetes.
The world may never be the same after this pandemic year. Everyone has woken up to the fact that influenza, both epidemic and pandemic, kills outside the 65-plus age groups. The author recalls that Sir Charles Stuart-Harris, well experienced in looking after chronic bronchitis in the polluted steel city of Sheffield, would also note the first sixteen year-old to die quickly of influenza in the ward and to judge the intensity of the epidemic in waiting. Close on the teenager’s heels, the elderly bronchitics would succumb. But the point to always remember is that about 10 per cent of the deaths in yearly epidemic influenza are perfectly happy younger members of society. Since, however, most general practitioners are in suspended belief about the killing power of influenza, the word influenza rarely, if ever, appears on the death certificate. In sharp epidemic years like 1999-2000, 20,000 citizens in the UK quietly choked to death with influenza invading their respiratory tree. But these figures are only found from summaries of ‘excess deaths’.
Current radio, television and newspaper reports of the gathering swine pandemic reflect the anxiety in the modern community of death in young people. It seems that 20,000 grandparents can vanish in a puff of smoke, but should four young pregnant women die or six children die then the fat is in the fire. This morbid fascination with young death from which we have been shielded by childhood vaccination compared to our grandparents era, is seen in recent commemorations of soldiers’ deaths in Afghanistan. The entire village of Wootton Basset watch parades for the funeral of five soldiers; but in 1915, and not 200 miles away from that village, 30,000 soldiers died in Picardie on a single day. So in modern terms, young life is exceedingly precious.
There is, of course, nothing wrong with this attitude per se, but we must be careful that it does not lead to irrational behaviour when we face this winter outbreak of swine influenza, which inevitably will appear to target the young. Given half a chance, this swine virus would wreak destruction on the elderly, but as we have noted, they have immune memory of a cousin of the current swine virus, which probably circulated in the 1940s. We should not expect the winter outbreak to be more deadly than the summer epidemic. Rather, there will be a more widespread outbreak because the northern winter favours the spread of influenza and other respiratory viruses. It is even likely that the UK will have fewer problems this winter than Europe. After all, you cannot have the virus twice, and millions have already been infected in the UK in the summer outbreak.
A pandemic cannot be averted just by poring over mathematical models or by waving magic wands, distributing Tamiflu or Relenza, vaccinating sectors or increasing hygiene, or by lengthy COBR sessions or, worst of all, by pronouncements by ministers. We will only negotiate this pandemic with the help of everyone in the country. Every person in the UK will need to do his or her duty. In fact, a step up in sensible hygiene practices will benefit every family in the world. Virus droplets contaminate hands and surfaces and lead to onward spread. But the virus is easily killed by disinfectant, hand wash or sprays for surfaces. Also, social distancing (or keeping one-and-a-half metres away from an infected person) will be an important contribution. The NHS helpline has been planned with all this in mind. Patients will keep away from doctors’ surgeries and send a friend to collect Tamiflu quickly. There is urgency here and the golden rule with the anti-virals is the sooner the better.
It would be quite easy for unease to spread, perhaps about the perceived safety of the vaccine or the minor side effects of the neuraminidase inhibitors. In reality, the vaccines are perfectly ordinary products which have been used to immunise billions of people over the last twenty-five years. Nurses and doctors must face up to their responsibilities and gladly accept the vaccine. Already, we are seeing opinion polls in magazines suggesting nurses will refuse the vaccine. But there is a new science afoot called forensic microbiology. For the first time in history, genetic analysis can link a patient’s virus with a nurse or doctor or vice versa. Of course, no NHS employee would wish to get infected at work and take the virus home, or bring a virus into the hospital or surgery and infect someone under their care. Nevertheless, patients can now sue, and with a more litigious society this might be the deciding factor, rather than an appeal to honour and duty and professionalism.
Likewise, 55 million people have been treated with Tamiflu over the years. We are unlikely to uncover anything drastically new and dangerous. The cohesiveness of the Home Front was a most important factor in the UK social crisis in 1939-45 and the robustness of personal behaviour was exemplary. There was no panic in the influenza pandemics of 1957 and 1968. We will all be very much dependent, even in our hugely self-analytical and scientific society, on personal behaviour during the next thirteen months or so. Mexico has assessed its large-scale interventions in April, closing schools, restaurants, and football matches, to name a few. Preparing for a second wave, schools will be kept open, masks not encouraged. Emphasis will be placed on hand and surface disinfection, social distancing, antivirals and vaccine. This approach avoids economic catastrophe, is sensible and has a good chance of working.
With all the preparations to hand, the dedicated thought of perhaps 10,000 individuals who have already worked on detailed pandemic influenza plans for the last four years, and the vaccine supply coming from the great European manufacturers, it is likely that deaths and society disruption in the UK will be minimal this winter. The author does not agree with the Department of Health’s high level estimates of 65,000 deaths. Far lower figures are likely – even less than epidemic years.
As a nation we have done it before, and once more facing the pandemic threat the UK is more robustly prepared than any other nation. In fact, the UK may be the safest place to stay over the coming winter flu season. It will be too much of a risk to be caught elsewhere in the world.
John S Oxford
Professor and Scientific Director
Retroscreen Virology Ltd
London Bioscience Innovation Centre