Br i efi ng Pa p er (09-02)

M ay 2 0 0 9

The Scottish Parliament: The H1N1 Outbreak and the Threat of Pandemic Influenza

The Present Outbreak

1 The influenza virus has only eight genes.The novel strain of H1N1 influenza (called swine flu when it was first reported from Mexico) has six genes derived from US swine flu and 2 from Eurasian. It has the ability to cross species barriers (from pigs to humans and vice versa) and to spread from human to human. It is currently spreading across the globe through international movement by infected individuals. By the 22 May, the World Health Organisation (WHO) had reported 11,168 confirmed/probable cases worldwide (US 6,552; UK 117; Scotland 13; Japan 294; Canada 805; Spain 113) and 88 deaths. Only 3 continental US states have not reported cases.The US Centers for Disease Control and Prevention (CDC) suggests that the reported cases may represent 1/20 of infections.We are sceptical of the report in Sundays Independent (May 24th) that there may be underreporting (not every patient seeks advice, not every doctor submits a sample) of as much as 1 in 300 cases.We are reassured that in the UK there have not as yet been the significant school outbreaks experienced in the USA.

In any case, the best protection remains vaccination and the maintenance of current policies to track and contain outbreaks and develop vaccines. Planning for Outbreaks 3 The emergence of a new virus from pigs capable of spreading from human to human as readily as seasonal flu took the pandemic planners by surprise. The working assumption of the UK Pandemic Plan was that the next pandemic would originate from a bird virus originating in South East Asia.With the benefit of hindsight it is clear that greater attention should be paid to influenza viruses in pigs and from a diverse series of sources, and their transmission to humans. We must not simply depend on the investigation of severe or unusual human cases as has been the case in the past. Surveillance is crucially important and the present outbreak will need to be very carefully monitored for virulence and transmission patterns as it travels through the current Southern Hemisphere flu season. 4 As a result of the concerns about avian flu following the Cellardyke incident in April 2006 (see Avian Influenza An Assessment of theThreat to Scotland published by the Royal Society of Edinburgh, December 2007 (http://www.rse.org.uk/enquiries/avian_flu/index.htm)) and because of the Skehel Report on pandemic flu prepared for the Royal Society and the Academy of Medical Sciences in 2006 (http://www.royalsociety.org/document.asp?id=5574), Scotland, like the rest of the UK, was, and continues to be, well prepared for an outbreak of pandemic flu.The NHS Boards and Health Protection Scotland are to be commended on the success so far of their containment strategy for the current outbreak of H1N1 influenza. It is essential that Scotland continues to exercise a very high level of vigilance to protect the country from the catastrophe of a virulent pandemic.

Its Virulence 2 Fortunately all the recent data from the CDC indicates that the new virus is neither more virulent nor more transmissible than seasonal flu.The new virus does not produce the PB1-F2 protein, a virulent factor in the 1918 pandemic virus.The probability that the H1N1 virus could readily mutate into a 1918-like strain is low, but the only thing certain about influenza is that nothing is certain (WHO High-Level Consultation - May 18th) and we must not be complacent. Strains of influenza can and often do mutate into more dangerous virulent forms.Although in previous major outbreaks (1918 and 1957) the virus did return in a more virulent form in the autumn, for there to be a second wave, there must be a first, which has not yet happened in the UK or Scotland.

Br i efi ng Pa p er
5 It is often said that public information needs to be controlled to avoid panic. On the contrary, the evidence is that provision of clear information is an antidote to panic.The warnings given by government were appropriate in view of uncertainty about the potential behaviour of the new viral strain, especially because of its ability to cross species barriers. Not to have been frank about the possible outcome resulting from the spread of this new viral strain would have been irresponsible. Targeted antiviral prophylaxis1 (TAP) is being used to manage the epidemic.Two antiviral drugs,Tamiflu and Relenza, are available and many countries have large stocks available.There is a slight concern that the UK has chosen only to stockpile Tamiflu as there is always the possibility of a virus acquiring resistance through mutation. However, although the above approach will both reduce the symptoms and reduce the spread of the infection, the disease can only be prevented by widespread vaccination. It is therefore of the greatest importance to develop an effective vaccine against H1N1. Work has already begun in both the UK and the USA where there are public health laboratories and companies standing by to produce vaccines on the very large scale required, although it is unlikely that a vaccine will be available in less than six months. Recommendations to the Scottish Government

The Scottish Government should give its unqualified support to the international programme to develop an effective vaccine against H1N1. Scotland must have access to rapid diagnostic testing to inform an effective surveillance programme so that individuals with flu symptoms can be investigated at an early stage to ascertain whether they have succumbed to a new variant of the virus. There is a need to engage both GPs and members of the public to maximise the effectiveness of the surveillance programme. Since the present outbreak in Scotland appears to be the result of infected individuals returning from abroad we need to consider whether air passengers with flu symptoms should be discouraged from travelling. The isolation of infected individuals, for example through the closing of schools and the restriction of attendance at public events, has proved effective and should be part of the Governments containment policy. The role of targeted antiviral prophylaxis (TAP) needs to be fully assessed. The Scottish Government needs to collaborate with the other parts of the UK in maintaining a strong virology science base so that we continue to be well positioned to combat new strains of influenza as well as the emergence of other zoonotic2 diseases of viral origin.

Learning from the Outbreak 7 The current events in Scotland (and elsewhere) are providing a real life test of plans for pandemics and it is crucial that we learn from them. Never before has the importation of a new influenza virus been studied so early in its progress and in such detail and with so much media attention.The targeted use of antivirals is new. It is also crucial that when the current outbreak subsides that both the science of the outbreak and the response by international agencies and governments are reviewed in detail.There would be much merit in such a review being conducted independently and in depth to ensure that lessons are learned.

Further enquiries should be addressed to the RSEs Consultations Officer,William Hardie (Email: evidenceadvice@royalsoced.org.uk) Responses are published on the RSE website (www.royalsoced.org.uk).

1 A prophylaxis is a measure taken to maintain health and prevent the spread of disease 2 Zoonotic diseases are those that can be passed from animals, whether wild or domesticated, to humans.

The Royal Society of Edinburgh (RSE) is Scotlands National Academy. It is an independent body with a multidisciplinary fellowship of men and women of international standing which makes it uniquely placed to offer informed, independent comment on matters of national interest. The Royal Society of Edinburgh, Scotland's National Academy, is Scottish Charity No. SC000470