The best laid plans: assessing the impact of pandemic flu

By Jennifer Cole, Head of Emergency Management, RUSI

On 2 July, Secretary of State, Andy Burnham, announced that it was time for the UK to move from the containment phase of pandemic flu response to the treatment phase. This is a predetermined stage in the management of the outbreak and no more indicates a failure to keep the disease under control than the World Health Organization moving from phase five (a pandemic is imminent) to phase six (the pandemic has arrived) on 11 June indicated a failure to prevent the pandemic from happening in the first place. Rather, it indicates a measured and managed response that is proceeding along a predetermined trajectory based on extensive and effective emergency planning.

As David Nicholson, Chief Executive of the NHS, highlighted in his letter to all NHS staff last week, once the new strain of H1N1(A) influenza appeared, it was never the case that a pandemic could be contained indefinitely. Its spread could, however, be slowed down and this is precisely what the containment phase did, giving time for it to be studied, analysed and understood. The change in emphasis we see now alters the focus of the response, enabling the National Health Service, the Health Protection Agency and general practitioners to redirect their efforts from gathering intelligence on the disease to treating its symptoms.

The WHO Global Influenza Preparedness Plan must not be underestimated. It has ensured that the world was not only ready for pandemic flu when it arrived, but was actively looking for it. WHO has a network of more than 120 National Influenza Centres in over ninety countries that monitor influenza activity, isolate viruses and report immediately the detection of any unusual activity. This enabled the new strain to be identified quickly (though there are still lessons to be learned that could improve this further) and national authorities to be alerted as soon as possible, ensuring a timely and efficient response across the globe.

An over-reaction?

Since the first case was reported in the tiny Mexican village of Veracruz on 2 April, the spread of swine flu has been registered, monitored, tracked and analysed first by Mexico and then by countries across the globe. During this time, the actual number of cases has been tiny; in even the most badly hit countries, less than one in 150,000 of the population have been affected so far. Slowing the spread by closing schools, quarantining sufferers in their homes and treating them in hospital isolation wards has helped to buy time in which to decide how the disease is best treated before there are huge numbers of cases to treat. What may seem like an over-reaction is in fact anything but, as Dr Margaret Chan, Director-General of the World Health Organisation made clear in an address on 2 July.

In the UK, the containment period has been a time for information gathering. Doctors and healthcare professionals swabbed all suspected incidences; GPs visited suspected cases at home; sufferers and their close family were given anti-virals such as Tamiflu. In general, swine flu sufferers were given special treatment well above and beyond that offered to sufferers of seasonal flu. Doing this has been time-consuming and costly. Many GPs have been required to work eighteen hour days; special swabbing clinics have been set up across the country, including nine in the Greater Glasgow and Clyde area alone. Such a response is justified if indeed swine flu is significantly different from other strains of influenza, but unnecessary if it is not. Until we are sure of what we are facing, the best response has been to err on the side of caution.

We now know that swine flu is not a severe illness: in most cases, a Paracetemol and a few days in bed are all that is needed. We know that its effect on one of the sections of society who were potentially the most vulnerable - the elderly - is not as severe as it might have been as its similarity to the strains responsible for two previous flu pandemics, in the 1950s and 1960s, has ensured some immunity amongst the over-65s.

This is all good news, especially as it appears that the members of the UK public are already realising for themselves that they need only react in the way they would to any other kind of flu. When official figures for the UK stood at just over 2,000 UK cases, GPs already suspected the true number to be more than five times that number as the public began to realise than most people will recover without needing help from trained medical professionals, nor prescription drugs such as Tamiflu and Relenza. The fact that these drugs had been stockpiled, and could be distributed quickly and efficiently to early cases, before this was known, was entirely appropriate. The first people to be diagnosed, when things were less certain, are unlikely to think that the measures were unnecessary.

Swine flu lingers on

Swine flu has not gone away and will not disappear for a good few months yet. It is not a severe illness, but any strain of flu causes some victims to need hospitalisation, and this year there will be more of them. Hospitals across the UK are gearing up for a long, hard winter. Many businesses may still be badly hit by significant numbers of their workforce going sick (even if they are not very sick, and not absent for all that long) and should now be reviewing their business continuity plans to ensure that they can manage when this happens. To do otherwise is to be complacent in the face of an outbreak that can be easily managed within the existing plans, but which needs to be managed and planned for nonetheless.

The containment phase has also given us a good indication of the areas of pandemic planning in which more work is needed. As the military maxim goes, no plan survives first contact with the enemy and this is just as true in emergency management. The past few weeks have revealed the imperfections of previous pandemic planning. Not everyone who was supposed to have a plan did, and some plans had not been completed to the level they should have been. To give just one example, not all Primary Care Trusts have identified suitable buildings to use as Tamiflu distribution centres; some do not meet the security requirements of the police because the police had not been consulted during earlier planning stages. The situation we have seen unfolding over the past two months has, however, provided an excellent dry run that will enable these cracks to be filled in before the next wave, or even the next pandemic, hits.

Not a ‘special case’

Swine flu will continue to spread, but we now know that we do not need to treat it as a special case. We do not need to widely distribute anti-virals which, if used frivolously now, may enable viruses to develop a resistance to them. We know that there is little reason to vaccinate anyone against this strain of flu who would not have received the seasonal flu vaccine in any case, avoiding the problems of the side effects outweighing the actual danger of contracting the disease, as was seen in the United States during an outbreak of swine flu in the 1970s.

We know all this precisely because of the weeks in which swine flu has been singled out for special treatment - not because that special treatment was never required. During Pandemic Stage Five, when it was already becoming apparent that the virus was relatively mild, the World Health Organization was put under pressure not to progress to phase six; no one wanted to be accused of crying wolf. The plan was always about the emergence of a new virus and how quickly it spreads, however, not the severity of the disease and, quite rightly, the WHO stuck to the plan. For responders at every level, from the WHO itself to Primary Care Trusts, the last ten weeks have been a wake-up call, a time to consider what would happen if a more serious pandemic hit, which may still happen at any time. Taking pandemic flu plans off the shelf, dusting them down, evaluating them in the face of a real disease and adjusting them where necessary has not done anyone any harm.

The views expressed above are the author's own, and do not necessarily reflect those of RUSI