‘Swine flu’, to do or not to do?
On 11 June 2009 the World Health Organization (WHO) declared a H1N1 (swine) flu pandemic. I was interested in Charles's comments on the potential severe acute respiratory syndrome (SARS) epidemic (Clin Med August 2003) and so I rang to ask if we could meet and discuss what he thought about the management of the current problem.
‘Do you think the authorities have got it right, Charles?’
‘We were told that everyone was potentially at risk, and now we are told that they are. So if potentially everyone is going to get it, the aim should be management with least harm, Coe!’
‘Do you think we are achieving that?’
‘Before replying to that perhaps you might clarify two points. First is the disease as mild as they say and will it stay so?’
‘At present, yes. Any errors are likely to exaggerate the severity. In the numerator there was probable over-attribution of mortality in the early stages and the denominator is necessarily underestimated in any disease with non-specific features in which there are mild cases: by how much no one knows. Whether it will turn more virulent is anyone's guess. And the second matter?’
‘How soon will a vaccine be available and how effective will it be?’
‘I do not know the answer to that and I do not think anyone really does. However, I do believe that the authorities are reasonably confident that an effective vaccine will be available and the logistics practicable within the next three or four months.’
Charles looked thoughtful. ‘The answers to these questions are critical to deciding whether they have acted wisely. Do you think they may be overoptimistic with respect to the logistics of vaccination and the danger of adverse mutation?’
‘I don't know, but I have a gut feeling they might be, Charles.’
‘Let's assume they are, accepting that if things progress more favourably many of the arguments against the present strategy are substantially weakened. Who is right or wrong can only be proved if at all with the aid of hindsight.’
‘Fair enough!’ I replied.
‘Ideally the epidemic should spread at a measured pace so services are not overwhelmed and the country not brought to a standstill. I believe the authorities should have taken advantage of the season during which it arrived in this country. While the disease remains mild, it would seem inappropriate vigorously to try and prevent spread at a time when it is likely to be slower and when the general health of the population is at its best. This would have the advantage of leaving a cohort of immune people that would reduce the rate of progression at the time it is likely to get out of hand and who would maintain the services when the epidemic is at its height.’
‘And the health service struggling with the consequences of the newly introduced 48-hour week!’ said I, but conceding, ‘I suppose it would be politically very difficult to appear complacent. Think of the first death in a young person which would inevitably be presented as due to inaction on the part of the authorities!’
‘Yes but those in public life must be prepared to accept unfair approbation when there are inevitable adverse consequences of decisions which are nevertheless correct.’ Insisted Charles, relenting, ‘Actually I do have a lot of sympathy with those in that dilemma. Having said that there is one aspect of the policy for which I cannot see any justification.’
‘What is that?’ I asked.
‘It is the prophylactic use of antivirals. Am I correct in understanding that they are effective if given in the first few hours after symptoms start and that sometimes they do have albeit mild side effects?’
‘Quite right, Charles!’
‘Then, if they are held by contacts for use with the first symptom there is no disadvantage to those who get the flu and a price to pay by some of those who don't!’
‘Perhaps not the only price!’ I suggested, ‘Surely it must compromise the study of the epidemiology by hiding cases and increasing the risk of long-term carriers. Furthermore it is well recognised that the development of resistance to antibiotics and similar agents is a function of their total prescription.’
‘It also might give the wrong message and lead people to believe that they should be taken in response to potential contact. While the stocks of anti-virals may be sufficient to treat all overt cases, they would soon run out to a demand for them at each and every contact.’
Charles continued, ‘The arguments against are so strong that one can only conclude that it was part of a King Canute
approach, which can only be justified if the tide can be held long enough for an effective vaccine to be produced and distributed in time.’
‘The recent announcement that now a pandemic has been declared, prophylactic antivirals will no longer be prescribed in Scotland might be seen as admission of this!’
‘Yes!’ replied Charles, ‘But to return to the strategy of slowing progression of the epidemic surely this itself has its hazards. From the point of view of the virus, progress is then less efficient. It has to produce more of its self and in more steps to achieve the same result. Surely this increase in numbers and, in particular, the lengthening the chain of infection must increase the risk of adverse mutation, be it to drug resistance or increased virulence.’ Then smiling he added, ‘On reflection, perhaps after all the authorities in their small way are unwittingly doing their bit to shorten the chain!’
‘How so, Charles?’
‘Our only local case so far was a school boarder sent home from a distant school. In my time schools would have been quarantined for infectious diseases and the pupils not sent away to infect the rest of the population!’
Touché, but should there be a lighter handle on the tiller? I must say that I agreed with most of what Charles had to say. As we cannot conduct a controlled experiment we will never know the answer, but the study of the pattern of any eventual mutations might give us some clues.
- © 2009 Royal College of Physicians
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