Most companies in Britain unprepared for possible second wave of swine flu

• Julia Kollewe
• guardian.co.uk, Monday 31 August 2009 18.37 BST
• Article history

Most companies in Britain have not been affected by the outbreak of swine flu, research has found, confounding fears that the virus could derail the country's fledgling economic recovery.

But the survey of 450 companies by the British Chambers of Commerce (BCC) found that fewer than half of firms had contingency plans in place to cope if the swine flu outbreak gets worse, despite warnings of a second wave in the autumn.

The report, the first of its kind, said 83.7% of businesses had not been affected by the spread of swine flu and only a third believed the disease could threaten the UK's recovery from recession.

As a result, many have failed to draw up contingency plans for dealing with large numbers of workers taking time off if they contract the H1N1 virus.

There had been fears that businesses, shops and distribution centres could be forced to shut if the virus spread rapidly. Airlines and other transport services could also be disrupted.

The BCC's findings refute claims that workers are using the virus as an excuse to take sick days. Anecdotal evidence shows employers are more likely to tell staff to stay away if they have symptoms.

The TUC general secretary, Brendan Barber, said: "This shows that, contrary to what some have been claiming, workers are not using swine flu as an excuse to take time off work."

He called on employers not to become complacent about the threat to their staff simply because infection levels had declined in recent weeks. The government's chief medical officer, Sir Liam Donaldson, has repeatedly warned of a second wave of swine flu in the autumn.

Barber said: "Employers should be using this time to work with their staff to ensure they have contingency plans in place to deal with any possible resurgence of the virus in the autumn."

A BCC spokesman said: "We haven't seen any evidence of employees skiving en masse because of swine flu." But he said the government needed to exercise caution in its plans to allow employees infected with swine flu to stay off work for 14 days without a doctor's note, rather than seven days.

GPs have been seeing a high number of patients at the start of the week and Donaldson said the National Pandemic Flu Service for England received most calls from patients on Mondays.

But he shrugged off the idea that workers were faking sickness: "I think people traditionally hold on to their illnesses over the weekend, then see their GP on Monday."

As schools reopen, health authorities are bracing themselves for another rise in swine flu. The UK and the US governments say they will not close schools except under exceptional circumstances after experts claimed closures did not reduce the number of cases, but spread them over a longer period.

Obesity linked to swine flu deaths Study of pandemic reveals that weight problems and pregnancy are significant factors in fatal cases

• Jamie Doward, Home Affairs Editor
• The Observer, Sunday 30 August 2009
• Article history

Obesity has emerged as a possible contributing factor in fatal swine flu cases, according to ground-breaking research looking at deaths caused by the pandemic in countries around the world.

The claim is made by a team from the French Institute for Public Health Surveillance, which has studied the characteristics of 574 deaths associated with the pandemic H1N1 influenza up until the middle of July. According to the team's findings, published in medical journal Eurosurveillance, underlying disease was found in at least half of all fatal cases.

Mortality patterns were in many cases similar to those associated with normal, seasonal flu. But the team observed: "Nevertheless two risk factors are noticeable: pregnancy and obesity."

Pregnancy is already a well-documented risk factor in seasonal influenza and in previous pandemics. The study found that 16 women – representing 10% of all female deaths that were studied – were pregnant or had recently delivered at the time of their death. Half of these also had other health issues. 

But the conclusion that obesity may be a factor in some swine flu deaths opens up a new line of investigation for epidemiologists. Where an underlying disease was found to be present after someone had died of swine flu, in more than one in four cases the deceased had a metabolic condition – diabetes and/or obesity.

The team, which concluded further research needed to be done to establish the link between obesity, severe influenza and mortality, also found significant demographic variations among those affected by the pandemic.

"Compared to younger age groups, the elderly seem to be protected from infection to some extent, perhaps due to previous exposure to strains akin to influenza A(H1N1)v virus," the team claim.

There has been a view that fatal cases involving the pandemic have tended to occur among the young, according to the team. And they found the average age of those who have died was 37. More than half of all deaths occurred among the 20- to 49-year-old age group. Overall, 12% of deaths occurred in cases aged 60 years or more.

According to the latest update from the Health Protection Agency (HPA): "In the last seven days, cases reported globally have increased by 8% and the number of deaths by 21%." However, the HPA suggested flu rates in England were now coming down.

Concerns remain, however, that infection rates will start to increase again come the autumn.

The French team warns: "The pandemic… is far from over, and deaths will unfortunately continue to occur. As in previous pandemics, available data show that age groups are not equally affected."

Weekly pandemic flu media update

27 August 2009

KEY POINTS

More points....

• This week there has been a further reduction in the rates of flu-like illness and related activity.
• Weekly GP consultation rates continued to decrease over the last week in England.  
• The majority of cases continue to be mild. There is no sign that the virus is changing. It is not becoming more severe or developing resistance to anti-virals.
• Interpretation of data to produce estimates on the number of new cases continues to be subject to a considerable amount of uncertainty. HPA modelling gives an estimate of 5,000 new cases in England last week (range 3,000 to 12,000). There has been a decrease in estimated number of cases in all age groups and in all regions.
  This estimate incorporates data from National Pandemic Flu Service and GP consultations.
  

Following the move from laboratory testing for confirmation of swine flu to clinical diagnosis of cases, the level of flu in the community is being monitored using a range of surveillance mechanisms, including the RCGP consultation rates, QSurveillance®, and the National Pandemic Flu Service.

A more detailed UK weekly epidemiology update can be accessed at:
www.hpa.org.uk/swineflu/surveillance&epidemiology

Figure 1: Current estimated weekly RCGP consultation rates of flu-like illness

Figure 2: QSurveillance® - weekly consultation rate for flu-like illness in England, Wales and Northern Ireland (all ages)

VIRAL CHARACTERISTICS

Viral characteristics (including antiviral susceptibility (as at 26/08/09): Testing for antiviral susceptibility is carried out by the Agency's Respiratory Virus Unit, Centre for Infections, in Colindale. 719 viruses have been analysed for the marker commonly associated with resistance to oseltamivir in seasonal influenza (H274Y); none were found to carry this marker. In addition, 210 specimens have been fully tested for susceptibility; all were found to be sensitive to oseltamivir and zanamivir.  

SEVERITY
Disease severity continues to be monitored. The disease is generally mild in most people so far, but is proving severe in a small minority of cases.

Swine flu hospitalisations in England: 218 patients (currently hospitalised as of 8am on 26 August).

Deaths - the number of deaths related to swine flu in England is 57. (This figure represents the number of deaths in individuals with swine flu but does not represent the number of deaths that can be attributed to swine flu).

INTERNATIONAL SUMMARY

Confirmed cases and deaths reported by ECDC (Update 17:00 CEST 25 August 2009)

Grand total of cases confirmed *

254,947

Total deaths reported

2,594

* This figure represents the number of laboratory confirmed cases and is therefore not representative of the actual number of cases worldwide.

In the last 7 days, cases reported globally have increased by 8% and the number of deaths by 21%.

Europe
In the latest Euroflu bulletin, all countries reported low or moderate intensity indicating a normal or slightly increased proportion of their populations were affected by respiratory illness.  Widespread activity was reported for Austria, Israel, England and Swedenhttp://www.euroflu.org/index.php. The majority of new confirmed cases are being reported from Germany (ECDC).

General infection control practices and good respiratory hand hygiene can help to reduce transmission of all viruses, including swine flu. This includes:

• Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of virus from your hands to face or to other people.
• Cleaning hard surfaces (e.g. door handles) frequently using a normal cleaning product.
• Covering your nose and mouth when coughing or sneezing, using a tissue when possible.
• Disposing of dirty tissues promptly and carefully.
• Making sure your children follow this advice. 

Further information on swine flu is available on the Health Protection Agency's website at www.hpa.org.uk/swineflu.

Swine flu vaccine arrives in UK but roll-out will have to wait

Swine flu vaccine must sit in storage for over a month while manufacturers wait to see whether it will be given a licence

• Sarah Boseley, health editor
• guardian.co.uk, Thursday 27 August 2009 19.04 BST
• Article history

The first batch of swine flu vaccine has arrived in the UK, but it must sit in storage for more than a month while the manufacturers wait to see whether it will be given a licence, the chief medical officer said today.

The news of the delivery of around 200,000 packs of the vaccine came as it was announced that the UK death toll from swine flu has risen to 66 after 11 fatalities in the past week.

The vaccine packs made by Baxter Healthcare – one of two drug companies with whom the government has signed contracts – have been delivered ahead of the drugs being approved, in contrast to the normal process for new drugs and treatments.

The European Medicines Agency will now decide whether to licence this vaccine and one made by GlaxoSmithKline. Both manufacturers hope to have their licence by early October, which will mean the roll-out can begin later that month. ..

When the vaccine is available, many people may be reluctant to be immunised because of fears it has not been tested properly, recent surveys of health care workers and the public suggest.

A Canadian study published on Monday indicated that a successful vaccination campaign would need to win over people who believe that alternative therapies and a good diet are a better option than vaccines.

Today the chief medical officer, Sir Liam Donaldson, said the health professionals he had spoken to seemed to want the vaccine as soon as it became available. "It still remains the case that this disease is not a killer but it can kill," he said.

While the vaccine sits in storage, the epidemic in the UK continues to abate.

Donaldson, who repeated warnings of a second wave of swine flu in the autumn, said the number of cases was currently down to what would be normal levels of flu if this was winter – although clearly this was abnormal for summer.

In the last week, the Health Protection Agency said there were an estimated 5,000 cases of swine flu - although the true figure could be anywhere between 3,000 and 12,000. There have been three swine flu deaths in England, seven in Scotland and one each in Wales and Northern Ireland over the last week. There were 218 people hospitalised with swine flu in the last week, which is a fall, but is high for the summer.

..

..

In contrast to most countries, only 22% of deaths in the UK have been among healthy people, said Donaldson. Figures from the World Health Organisation suggested 40% of those who had died were previously healthy. The proportion ending up in intensive care in the UK also appeared to be lower, he said.

More than 460,000 packets of the antiviral Tamiflu have been given out via the government's National Pandemic Flu Service for England since it launched in July.

Swine flu: Doctors who refuse vaccine 'putting patients at risk'

Doctors and nurses are potentially putting patients at risk if they refuse the swine flu vaccine, experts have warned.

By Kate Devlin, Medical Correspondent
Published: 7:30AM BST 26 Aug 2009

Officials said that NHS staff had a duty to take the jab, to ensure they did not pass on the virus to those who were already sick.

The warning follows a spate of surveys which suggest that many healthcare workers will refuse the vaccine, despite being on the Government's “priority list”.

 

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• Swine flu: Doctors on alert for rare nerve disorder

• Children and elderly not swine flu vaccine priority

Up to half of GPs and one in three nurses say that they do not plan to take the vaccine, some because of concerns over safety.

Vivienne Parry, a member of the Joint Committee on Vaccination and Immunisation, (JCVI) who advise ministers on vaccines, said that health professionals should protect “vulnerable patients” from the virus.

She said: “This (protection) aspect does not seem to feature at all in medical staff responses about flu vaccination, which is extremely concerning.

“Indeed the word ‘patient’ hardly seems to figure at all in responses in this and other surveys of healthcare workers, even though 75 per cent of deaths fromswine flu are in those with serious underlying medical conditions who are in regular contact with healthcare workers.”

Prof David Salisbury, the Department of Health's director of immunisation, toldGP magazine, which carried out the poll, that frontline health workers had a “duty” to have the vaccine.

“They have a duty to their patients not to infect their patients and they have a duty to their families,” he said.

More than two thirds of GPs who told Pulse magazine that they would turn down the jab believe that it has not undergone enough tests.

Doctors have been warned to look out for possible signs of Guillain Barre Syndrome, a rare neurological condition, which can cause paralysis and even death.

A vaccine used against flu in America in 1976 caused a number of cases of the condition.

However, the World Health Organisation (WHO) insists that the production of vaccines has become much safer since then.

Human trials are currently underway and will be scrutinised by the regulatory authorities before the vaccines will be licensed for use, probably in October.

Earlier this month a poll of almost 1,500 Nursing Times readers revealed that one in three said that they would not have the swine flu vaccine.

Uptake of the seasonal flu vaccine among NHS staff has been traditionally low, and just 16 per cent of all those employed by the health service took the vaccine last year.

Another study published online by the British Medical Journal shows that half of 8,500 healthcare workers in Hong Kong say that they would refuse a swine flu vaccine, because of safety concerns and worries that it would not work very well.

Researchers said that the figures were surprisingly low given the impact the SARS (Severe Acute Respiratory Syndrome) virus had on the area.

However, some experts insisted that the polls did not prove that NHS staff were “irresponsible” or had serious concerns about the safety of the vaccine.

Prof Robert Dingwall, Director of the Institute for Science and Society at the University of Nottingham, said that it was important not to blow the apparent reluctance of healthcare workers to have the vaccine “out of proportion”.

He said: “(These polls) identify a communication challenge for those managing the pandemic but they are not evidence of a crisis of confidence in the vaccine or of professional irresponsibility by health workers."

Doctors may refuse swine flu vaccine

Several studies suggest up to 60% of GPs would oppose being immunised because they are concerned the safety trials will be rushed

• Sarah Boseley
  Health editor
• guardian.co.uk, Monday 24 August 2009 16.01 BST
• Article history

Half of GPs said they believe swine flu is too mild to justify taking a vaccine … a nurse prepares a syringe during a mass immunisation exercise at Bolton arena in 2006 to test procedures in case of a flu pandemic. Photograph: Martin Rickett/PA

Many GPs, as well as their patients, may be reluctant to be immunised against swine flu once a vaccine is developed, surveys suggest today.

A survey of GPs published on Healthcare Republic, the website of GP magazine, found that up to 60% of GPs may decline vaccination. Although the numbers who responded were small – 216 GPs – they are in line with a much bigger survey of nurses published a week ago by Nursing Times, which found that a third of 1,500 nurses would refuse vaccination.

A Canadian study published today in the journal Emerging Health Threats suggests the public, too, will have reservations that must be overcome if a vaccination campaign is to be successful in the autumn or winter. The study, which used focus groups to establish the likely response of different people to a vaccine, pointed to the need to win over people who believe that alternative therapies and a good diet are a better option than vaccines.

But the biggest problem in persuading people and healthcare professionals to have the jab may be the relative shortage of evidence from trials about its safety and efficacy. Because of the urgent need for a vaccine, testing will be limited.

Among the GPs who responded to the survey published by Healthcare Republic, 29% said they would not choose to have the vaccine and 29% said they were unsure whether or not they would.

The biggest reason given by those who said they would not have it was concern that the safety trials would not be adequate: 71.3% said they were "concerned that the vaccine has not yet been through sufficient trials to guarantee safety". Half – 50.4% – said they "believe that swine flu is too mild to justify taking the vaccine". Only 8.7% said they did not believe they were at risk.

Professor David Salisbury, director of immunisation for the Department of Health, commented on the website that frontline health workers have responsibilities to other people. "They have a duty to their patients not to infect their patients and they have a duty to their families," he said. "I think you solve those responsibilities by being vaccinated."

The Department of Health played down the results, saying that the small number of responders could not accurately be said to reflect the opinions of all GPs. But a spokesman added: "GPs will have an important role in the height of a pandemic. Getting the swine flu vaccine will protect them and their patients. That's why we're offering GPs the vaccine as a priority. Of course, vaccination will be optional, but the vaccine is being carefully assessed for safety and will be licensed before it is used."

Many of those questioned in focus groups for the study in Emerging Health Threats felt uneasy about vaccination for an illness perceived as mild. Others felt they could protect themselves through handwashing, keeping their distance from other people and even a good diet.

The survey results appeared as the department of health announced 14 new fast-tracked research projects into various aspects of swine flu, costing £2.25m. These include work to establish how long somebody with the virus is contagious and to establish the "safe distance" from a patient. Other projects will look at whether closing schools – which was the early response to the epidemic – stops spread and whether facemasks for healthcare workers are worthwhile.

Pandemic (H1N1) 2009 - update 62 (revised 21 August 2009) - WHO

Laboratory-confirmed cases of pandemic (H1N1) 2009 as officially reported to WHO by States Parties to the IHR (2005) as of 13 August 2009

The countries and overseas territories/communities that have newly reported their first pandemic (H1N1) 2009 confirmed case(s) since the last web update (No. 61) as of 13 August 2009 are:

Ghana, Zambia, and Tuvalu

Map of affected countries and deaths as of 13 August 2009 [png 313kb]

Region	Cumulative total
	as of 13 Aug 2009
	Cases*	Deaths
WHO Regional Office for Africa (AFRO)	1469	3
WHO Regional Office for the Americas (AMRO)	105882	1579
WHO Regional Office for the Eastern Mediterranean(EMRO)	2532	8
WHO Regional Office for Europe (EURO)	Over 32000	53
WHO Regional Office for South-East Asia (SEARO)	13172	106
WHO Regional Office for the Western Pacific (WPRO)	27111	50
Total	Over 182166	1799

*Given that countries are no longer required to test and report individual cases, the number of cases reported actually understates the real number of cases.

Qualitative indicators (Week 31: 27 July - 2 August 2009 and Week 32: 3 August - 9 August 2009)

The qualitative indicators monitor: the global geographic spread of influenza, trends in acute respiratory diseases, the intensity of respiratory disease activity, and the impact of the pandemic on health-care services.

Interim WHO guidance for the surveillance of human infection with A(H1N1) virus
A description of WHO pandemic monitoring and surveillance objectives and methods can be found in the updated interim WHO guidance for the surveillance of human infection with pandemic (H1N1) virus.

The attached maps display information on the qualitative indicators reported for weeks 31 and 32. Information is available for approximately 50 to 60 countries each week. Implementation of this monitoring system is ongoing and completeness of reporting is expected to increase over time.

List of definitions of qualitative indicators

Geographic spread of influenza activity during week 31 and 32

Geographic spread of influenza activity during week 31 [png 157kb]

Geographic spread of influenza activity during week 32 [png 269kb]

Trend of respiratory diseases activity compared to the previous week during week 31 and week 32

Trend of respiratory diseases activity compared to the previous week during week 31 [png 155kb]

Trend of respiratory diseases activity compared to the previous week during week 32 [png 266kb]

Intensity of acute respiratory diseases in the population during week 31 and week 32

Intensity of acute respiratory diseases in the population during week 31 [png 153kb]

Intensity of acute respiratory diseases in the population during week 32 [png 262kb]

Impact on health care services during week 31 and week 32

Impact on health care services during week 31 [png 151kb]

Impact on health care services during week 32 [png 259kb]

Weekly update

As of this week, there have been more than 182,000 laboratory confirmed cases of pandemic influenza H1N1, 1799 deaths, in 177 countries and territories have been reported to WHO. As more and more countries have stopped counting individual cases, particularly of milder illness, the case number is significantly lower than the actually number of cases that have occurred. However, through the WHO monitoring network, it is apparent that rates of influenza illness continue to decline in the temperate regions of the southern hemisphere, except in South Africa where pandemic influenza H1N1 appeared slightly later than the other countries of the region. Active transmission is still seen in some later affected areas of Australia, Chile and Argentina even as national rates decrease.

Areas of tropical Asia are reporting increasing rates of illness as they enter their monsoon season, as represented by India, Thailand, Malaysia, and Hong Kong, four places in the region which have active surveillance programs. Tropical regions of Central America, represented by Costa Rica and El Salvador, are also seeing very active transmission.

In the northern temperate zones, overall rates are declining in both North America and Europe though the virus is still found across a wide area throughout both regions and pockets of high activity are being reported in 3 U.S. states and a few countries of Western Europe.

It has been noted throughout the temperate zones of the southern hemisphere, which are now passing out of their winter season, that when pandemic H1N1 began to circulate, the relative importance of seasonal strains, represented by H3N2 in nearly all countries, rapidly diminished and pandemic H1N1 became the dominant strain. Some seasonal H1N1 strains were reported but were even less common than seasonal H3N2. It is too early to tell if this co-circulation of multiple strains will continue into the coming season of the Northern Hemisphere but it appears very likely that pandemic H1N1 will be the dominant influenza virus in the early part of the winter months.

Many countries including Australia, Canada, New Zealand, and the U.S. have noted that their indigenous peoples appear to be at increased risk of severe disease related to pandemic influenza. While it still has not been clearly determined how much of the increased risk observed in these groups is due to issues related to access to care, high rates of chronic medical conditions that are known to increase risk, or other factors, countries with indigenous and other vulnerable populations should carefully evaluate the situation and consider ways to mitigate the impact of the pandemic in the coming season in these populations.

WHO has also been notified of 12 cases of oseltamivir resistant virus. These isolates have a mutation in the neuraminidase (referred to as H275Y) that confers resistance to oseltamivir, though the viruses remain sensitive to zanamivir. Of these 8 have been associated with oseltamivir post exposure prophylaxis, one with treatment of uncomplicated illness, and two have been from immunocompromised patients receiving oseltamivir treatment. These isolated cases have arisen in different parts of the world (Japan 4, USA 2, China, Hong Kong SAR China 2, and 1 in Denmark, Canada, Singapore and China), and there are no epidemiological links between them. There is also no evidence of onward transmission from these cases.

Virology data update as of 8 August 2009

Download update (.pdf)