Theme: Few viruses have claimed so many victims in the past as influenza. The possibility of a new pandemic has created a more than justified alarm both socially and in terms of its possible impact on the world’s economies.
Summary: The World Health Organisation has reported that only 40 countries in the world have drawn up prevention plans against the flu pandemic. However, the influenza of 1918 and other pandemics were due mainly to lack of foresight. This situation could be avoided on this occasion, and a considerable part of how successful the fight against this pandemic may be will stem from efficient and coordinated information during its initial stages. And it is no less important to be aware of the global nature of the phenomenon and we must therefore look beyond the purely domestic front.
Analysis: Although we are accustomed to consider flu as a bothersome but, essentially, inoffensive disease –unlike lethal viruses such as HIV or Ebola–, the truth is that few viruses have claimed so many victims in the past. Three pandemics of this illness have marked the last 100 years of history and the globalisation of communications along with intensive poultry farming in industrial facilities, plus the existence of subsistence economies in the rural world or on the outskirts of large cities –where human beings and fowl share their daily lives–, have led to a situation in which the possibility of a new pandemic has triggered alarm at many levels. This alarm is more than justified and is causing anxiety both socially and in terms of its possible impact on the world’s economies. We must recall that, here, the figures speak for themselves: the influenza pandemic of 1918 (the misnamed ‘Spanish flu’) caused the death of at least 50 million people, which some estimates bring to 100 million. Since 1997, recurrent outbreaks of the H5N1 strain of avian flu (the most lethal known to date) have caused tens of millions of deaths among birds either by direct infection or by culling as a means to prevent the virus from spreading. At least among birds, the pandemic is now already under way and has undoubtedly demonstrated its lethal effects. This strain can change in diverse ways, with the evident danger that a mutation may occur that will enable the infection of human beings once an efficient stain starts to spread.
In recent months we have become aware of the constant spread of the virus, carried by wild birds on their annual migration, and which reached Europe not so long ago and which will inevitably reach Spain shortly. Although birds carry a strain of the virus that cannot easily infect humans, mortality among birds (spread mainly by wild duck) and in those cases of human infection, is extremely high. Almost one half of H5N1 victims died (the majority children and young adults) and they did so quickly, which represents a high degree of aggressiveness and mortality –even higher than in the 1918 flu, which infected one third of humanity and claimed the lives of a proportion of these–. Perhaps we could take the following data as a basis for comparison: during its first 25 years, the AIDS virus killed more than 25 million people. The flu of 1918 reached this figure in barely 25 weeks.
Although all those who have died were in close contact with birds, it is no less true that the deadliness shown by the virus gives an idea of the possible implications of its spreading as a pandemic. There is no vaccine for this possible pathogen, because the preparation of vaccines requires, first of all, that the strain in question be available. Although the World Health Organisation (WHO) launched an unequivocal warning some time ago (the pandemic will arrive sooner or later, it is merely a matter of when and how it will appear), the response of a number of governments in developed countries was notably uneven, particularly in terms of prevention and information. In the majority of countries, the response simply did not exist or was clearly insufficient. It is important to stress that the uncertainties associated with the possible behaviour of a flu virus capable of developing as a pandemic cannot be used as an excuse for failure to act. Although it is true that we cannot know with any certainty whether the virus will be as lethal as it has been so far, there is nothing that indicates that it will be insignificant. Frederyck Hayden, a virologist, said recently: ‘unless the virus modifies its pathogenicity dramatically, we will be facing a very lethal strain’. Given that scientists have been warning for decades of the possibility of a new pandemic similar to that of 1918, lessons from the past should help us in the immediate future.
It is extremely important to be prepared for the possible consequences of the pandemic, but even more so to prepare for the immediate harm that will be caused to particularly relevant groups in health management and those considered to be the driving force of economy and its maintenance, such as the transport or energy sectors. During the flu of 1918, the loss or absence of sufficient health personnel to meet the avalanche of flu cases collapsed hospital services and the same occurred with many other infrastructures, to the point that work absenteeism and the collapse of basic services paralysed entire cities. Even the pandemics of 1957 and 1968, which were far less lethal, caused considerable economic losses. In this regard, it is not sufficient to announce basic protection techniques (which are mainly ignored by the majority of the population) but to prepare for possible crisis scenarios beforehand. We must particularly bear in mind that today’s globalisation of the economy could be a factor that amplifies the deficiencies that have been foreseen earlier.
The possibility that a lethal strain of the virus may appear in the near future must be considered quite probable. Variations in the avian flu virus that have appeared to date have proved to be incapable of spreading among humans, but the possibility of an increase in the number of humans infected (encouraged by the spreading of the virus from farm birds to wild birds) represents a serious threat. Here, the recent arrival of the virus in Africa should be taken very seriously. Given the particularly deficient health conditions in the majority of African countries, along with a population with low immunity and a subsistence economy where it is normal to keep animals in the home, the possibilities of an efficient strain emerging increase significantly. In this regard, it is important to maintain strict measures to eliminate infected or potentially infected birds, because these represent the source of the disease.
The ease of infection requires an appropriate planning of containing measures to avoid propagation. It is impossible to predict exactly when a pandemic might emerge, but the basic rules on immediate response are clear. Each community and family will have its own special idiosyncrasies, but in all events they must take precautions and organise themselves at least during the first two months (for when it is expected that vaccines will be available).
Some examples of these measures are:
(a) Knowledge of a basic set of rules on prophylaxis and prevention, which will curtail the opportunities for the virus to spread, such as frequent washing of hands or abstaining from touching one’s face and eyes to avoid the possibility of infection by contact.
(b) To avoid crowds insofar as possible, as this is the Achilles heel of the disease’s capacity to spread. Each community should propose specific strategies and appropriate recommendations for its members.
(c) To facilitate and encourage working from home whenever possible. This measure is particularly relevant because it maintains economic activity and helps to contain propagation.
(d) In addition to preventing the direct effects of the virus by the use of inhibitors such as Tamiflu (Oseltamivir) or Relenza (Zanamivir) or other drugs, account must also be taken of the appearance of other diseases (particularly pneumonia, which was responsible for one half of the victims of the 1918 pandemic) which would be lethal for segments of the population especially sensitive to decreased immunity, particularly children and the elderly. These effects should be prevented by an adequate administration of medication to combat pneumonia and adequate access to stocks of these antibiotics. It is advisable to have personalised medical information, and to consult one’s general practitioner on the type of antibiotics most suitable for common infections in each country.
Administration and access to medication that blocks the action of a virus should be made rationally and during the first stages of the pandemic, as soon as it becomes known. The importance of these treatments lies not only in their capacity to block the disease in each patient, but also as a strategy to halt its progress and thus have a timeframe in which to develop efficient vaccines. It is important to have plans available in sufficient time, given that the storage of antivirals is always restricted to the (limited) production capacity of their manufacturers. In all events, the storage of large quantities of antivirals to meet the needs of the population over a period of months is totally unrealistic, and would lead us to consider only their use with patients and not as a tool for general prevention. To this is added the problem of logistics in ensuring adequate distribution once the epidemic has taken its first steps, which must reach all those who need it and this must be done in sufficient time. In this regard, Spain is a good example of how to address the alarm at all levels, at least insofar as the Ministry of Health and Consumer Affairs has prepared for the eventualities to be borne in mind at different stages of the pandemic. These measures include the transfer of information among the various government departments, fluidity of which will be crucial when the time comes. Perhaps the greatest concern will be felt in day-to-day life when we ask our neighbours what they know about bird flu and its possible consequences: ignorance is widespread and this should be a matter for reflection. Without the need to cause unnecessary alarm, it would be advisable that the information made available to the public should offer appropriate guidelines on how to predict individual needs suited to each case.
Some will think this concern is excessive and that the virus will pass by or will not necessarily be so harmful. We may recall the SARS epidemic which now seems remote and which, in its day, caused considerable concern, but did not finally become a real problem. The example is appropriate: this disease did not become a world problem precisely because of the extraordinary measures adopted to prevent its spreading. Without these, it is certain that the disease would have caused serious problems world-wide and the death of numerous people. However, the WHO has reported that, right now, only 40 countries in the world have drawn up prevention plans. The 1918 pandemic and others were also effective due, to a great extent, to lack of foresight. This situation could be avoided on this occasion, and a considerable part of how successful the fight against this pandemic may be will stem from efficient and coordinated information during its initial stages. And it is just as important to be aware of the global nature of the phenomenon and we must therefore look beyond the purely domestic plane: insofar as possible, efforts to help those countries with no adequate health and information infrastructures must be increased.
Conclusion: We must not forget that the final success of any epidemic lies in its mathematical efficiency: in its initial stage, it spreads slowly and can be controlled, but once it has reached a certain number of victims, the pandemic is fully under way, with all its consequences. The best strategy at that time is to apply strict measures of control to avoid human exposure to the virus. Only in this way can we effectively reduce the probability that an infectious strain will spread among human beings. Computer simulation models show that the infection will spread quickly in the absence of appropriate medication: by way of example, it has been calculated (at the National Laboratory in Los Alamos, in cooperation with Emory University, in the United States) that forty people infected, with the complicity of present-day communications networks that have virtually eliminated geography as a factor, would lead to explosive propagation which would need only two months to spread across the entire country and effectively infect 30% of its population. World-wide, the pandemic could spread two or three times around the planet, each time with a duration of several months, possibly reaching it peak in each community five months after its arrival. We live on a large planet, but the pandemic would spread over a small world. It is now more important than ever to prepare for all of its possible aspects.
Ricard V. Solé
Laboratorio de Sistemas Complejos (Complex Systems Laboratory), Universitat Pompeu Fabra, Barcelona
Documents of Interest
WHO web page for the most important issues about avian influenza: http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.htm
Recommended strategic actions of the WHO: http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_05_8-EN.pdf
Web page of the Spanish Ministry of Health and Consumption about avian influenza: http://www.msc.es/ciudadanos/enfLesiones/enfTransmisibles/gripeAviar/home.htm