Governments and the medical community were asked to think fast when it came to the H1N1 influenza pandemic (otherwise known as swine flu) that started in 2009, and they did. Now, however, reports are being launched around the world into if such a reaction was justified.

Communities want to know if swine flu ‘jabs’ were really warranted, along with the community closures and scaremongering that came with it, from washing hands to stockpiling on costly vaccines. Countries such as France are now trying to sell excess stock in Tamiflu and other swine flu immunity drugs as the threat has supposedly died down.

But while the excitement over swine flu has died down, medical professionals the world over have warned that governments and medical staff must still be vigilant. The nature of this flu virus is such that the next pandemic could be a lot sooner than the normal 30–50 years’ grace you expect between outbreaks.

Dr Alan McNally, senior lecturer in molecular microbiology at Nottingham Trent University, is one professional standing by this warning.

“For the first time ever, we produced a vaccine against pandemic flu.”

During a public seminar in January 2010 at the BioCity bioscience incubator in Nottingham, UK, he explained how in a normal year there can be anything from three to five million severe cases of influenza that can lead to 250,000 to 500,000 deaths, but sometimes this increases dramatically when a new variant of the virus comes along. He argues that the swift action seen in relation to the outbreak reduced the risk of a real epidemic breaking out, and reduced deaths.

The argument for swine flu protection

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Out of the flu pandemics, the most severe occurred in 1918 and 1919 with the now-infamous Spanish Flu, which killed 40 million people, far more than the approximately nine million people killed in 1914–18 during the war. H1N1 has been minor in comparison but had the potential to be just as bad.

“It was very frightening how quickly H1N1 spread,” McNally said. “This was because of modern travel where someone could leave this seminar, [for example], and be the other side of the world by tomorrow.”

The makeup of H1N1 was also novel to humans, so there was a lack of background immunity, another reason for the mass concern. The flu symptoms that people exhibited, though, were fairly typical of a normal seasonal flu. Most of the fatalities were limited to high-risk groups who had a weakened immune system, such as pregnant women, those with an underlying medical condition and under 16s who had virtually no background immunity. As a result, the number of confirmed deaths was relatively small compared with a seasonal flu.

“Despite criticism of its use, Tamiflu played an important role in keeping swine flu at bay.”

According to McNally, the low death rate was also partly because of the reaction many governments and medical bodies had to the risk of the virus. “This was due to the excellent science and screening that we have now,” he said. “We have never been better prepared – it (swine flu) was discovered within one month of it first infecting humans. That is very quick.”

McNally also said humans overall have never been healthier and lived in such good living conditions, and we have antiviral drugs.

“For the first time ever, we produced a vaccine against pandemic flu,” he said. “We were very well positioned. It wasn’t an overreaction but a success for modern medicine. It had the potential to be a serious pathogen. This wasn’t a storm in a teacup but a major episode.”

H1N1 going forward

Since the outbreak, the number of cases of the normal seasonal flu has shrunk to almost zero and H1N1 has become the dominating circulating virus. “It is unlikely now that it will now cause a catastrophic pandemic but it will drift to become the dominant seasonal human flu,” said McNally.

The genetic makeup of it is also different from previous seasonal influenza outbreaks in such a way that it is easier for it to mutate into a new variant. “It is likely, therefore, that we will get a brand new pandemic in a much shorter time that the 40 odd years we have come to expect,” he said. “This virus is more likely to acquire new H types and cause a new pandemic in the next four to five years.”

To counter this, McNally says work is being done at his and other universities to develop handheld detectors that could see if influenza is present and what type it is within 30 to 60 minutes, so that medical professionals can be even better prepared for the next outbreak.

“It is likely that we will get a brand new pandemic in a much shorter time that the 40-odd years we have come to expect.”

What about Tamiflu?

The issuing of drugs to those suspected to have the H1N1 virus, however, has been one of the major contending points of debate for the way swine flu was handled. While medical devices may be being developed, the logistics of treating the influenza still need to be ironed out.

McNally is critical of how the government in the UK, in particular, handled the outbreak. “The policy of giving Tamiflu to everyone within a two-mile radius of someone who had H1N1v was just ridiculous,” McNally said. “We created Tamiflu-resistant strains very quickly. This hopefully is one of the lessons we will learn from the outbreak.”

Despite this, Professor Robert Dingwall, who until late 2009 was director of the Institute of Science & Society at the University of Nottingham but is now in the process of setting up an independent research and consultancy practice, said that the most important task was to delay the spread and the impact of the pandemic long enough for the vaccine to be developed. He says that despite criticism of its use, Tamiflu played an important role in keeping swine flu at bay.

The stage at which it was administered, however, could have been handled better in Dingwall’s eyes. “Tamiflu is only effective if you take it very quickly,” Dingwall said. “It is only worth giving it to people in the first 48 hours and preferably in the first 12 hours [after they get swine flu]. After that, you might as well give them a packet of Smarties.”

“The UK was the only country that had enough antiviral drugs to cover 80% of the population in July last year.”

“The first line of defence is what society can do to maximise survival and minimise disruption until we have a vaccine,” he said. “The challenge is to slow the movement of the virus. The policy of dishing out the Tamiflu did help in this and gave the medical scientists a chance to catch up. This is what helped stop the second wave being very strong.”

Overall, he said the UK Government should be praised for the way it handled its distribution of the drug – a method based on plans drawn up by the Cabinet Office five years ago that mapped how to deal with outbreaks equivalent to that of the Spanish influenza.

“In Britain, we made a pretty good job of it,” he said. “The UK was the only country that had enough antiviral drugs to cover 80% of the population in July last year.”

With the likelihood of another pandemic within the next decade and possibly earlier, we should take forward what we learned from the swine flu example and be ready with an even better action plan based on early detection and containment.