Tuesday, April 28, 2009

Swine flu: amended advice: DON'T PANIC (YET)!

Last Friday I advised readers not to panic over swine flu. Four days have passed, and that advice remains in place, although the WHO has raised its alert level to phase four (out of a maximum of 6), so I have raised my personal advice with a "yet".

The reason for my personal relaxed state (and as a green, I am constitutionally inclined to look at the worst-case scenario) is based on several factors.

First, we know that Mexico has about 150 deaths to date, we do not know exactly how many cases they have had. 2,000 have been treated in hospital to date, but there must be many thousands who did not go to hospital. So the death rate in Mexico would be lying around the 5% mark, possibly lower. Which is bad, but there are other factors to add in.

One of the key factors is that some Mexicans will be getting the virus fresh from the pig's mouth. Or rather, the pig's bottom. There are in Mexico huge open air lagoons filled with fragrant pig slurry, on which clouds of fat flies are partying. The flies carry the virus to the local humans, who get a dose of virgin pig virus. Humans can pass it on to other humans, but it is possible that the dose acquired in this way is smaller, and it is also possible that the virus is not stable, and could lose its virulence in its passage through humans. We just do not know.
The outbreak of swine flu in 1976 killed one soldier, probably because he was stupidly forced to do a 50 mile march while suffering with flu, but fizzled out. The vaccination programme that followed caused more deaths and problems than the virus, because it produced severe side effects. (Guillain-Barre syndrome).
There was an outbreak of swine flu in the Phillipines in 2007, and that simply fizzled, it seems.

Third, the virus is treatable with available antiviral medications, Oseltamivir ("Tamiflu"and Zanamivir ("Relenza"), at a cost of £16 per course. Zamanivir has less side effects, but cannot be used in asthmatics. H1N1 has become resistant to the older antivrials Amantadine and Rimantidine.

So, let us just wait and see. This is not to be complacent. There are many things that decision- makers have done, and more that they should be doing:

  1. Firm advice to STAY HOME IF ILL!
  2. Monitor microbial air quality in all passenger jets, and improve airliner hygiene.
  3. End the ridiculous Medical Certificate Requirement, because:
General practice is swamped by people with minor self-limiting respiratory tract infections who need certificates. In attending, they leave their bed of sickness, diverting energy and nutrients from their immune systems, thus prolonging the illness, they spread the contagion to reception staff, and to others in the waiting room, and to the doctors and nurses. It leads to the stupidly long waiting times to see your GP, and also leads to mistakes, when hard-pressed, hurried GPs mistake the one presentation of a serious illness as one of the hundreds of trivial cases.

If people stayed home if ill, the NHS would save millions of pounds a year in antibiotics savings, and in freed-up consultation times. But there is no point in even suggesting it to the NHS Executive, because (a) they will have naught but that which is beaten out on their own anvil (i.e. they do not listen to real clinicians) and (b) the DTI would raise a howl of protest because they think everyone will be taking sickies.

Listen, if business thinks it has a problem with malingerers, that is a problem for business to sort out. Routine certification is a total waste of time for everyone involved, but we are doomed to continue the irrational process, and indeed to do it in spades with this latest wheeze where the GP has to say what the patient is capable of doing.

There is just one dark blob on the horizon. Most of the Mexican deaths have been young healthy adults. This raises the possibility of a Cytokine Storm, a deadly over-reaction of the defence cells. If this does emerge, doctors should make a trial of naltrexone, and old established drug which can in theory damp down this over reaction.

So there is plenty of good changes that could come about from this outbreak.

DON'T PANIC! We'll tell you when to panic.

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