When I Was Young

To prepare for a pandemic is to prepare for surprises

05:55 AM May 12, 2009

AS THE Influenza A (H1N1) outbreak backstory seeps out, there are some vitally important lessons that can be learned. Huge investment in pandemic preparedness and contingency plans, improvements in surveillance and response systems and stockpiling of drugs and vaccines have followed recent avian influenza outbreaks. But do we have effective global disease surveillance and control systems that can prevent a disaster?

In the face of a potential pandemic, huge numbers of potential deaths are bandied about, based on highly suspect data and assumptions and resulting in wild speculation and panic. The counter move is to keep quiet, cover up and assure the populace. Neither approach helps, as we don't know what will happen, when and to whom. This acceptance of uncertainty and ignorance in a public debate is tough. But it is also vital. Otherwise, inappropriate public policy arises and misguided signals are given.

Preparing for a pandemic means preparing for surprises - and being ready to respond rapidly and flexibly under conditions of uncertainty requires a new set of skills, bureaucratic routines and incentive systems in the public agencies charged with protecting the world from emerging infectious diseases.

As Emery Roe and Paul Schulman argue in their recent book High Reliability Management, reliability must be a feature of any system operating in a complex, uncertain world. This requires, they argue, high reliability professionals who can track between local understandings of what is happening on the ground and the broader policy situation, liaising between agencies and across scales.

These professionals are currently absent from the international effort - creating a vacuum at the heart of the response - because authoritative knowledge consists of accepted expertise that does not acknowledge uncertainty, ignorance or complexity.

In a potentially global pandemic situation, global assessments are also based on global statistics, but in reality major structural inequalities affect the likely outcomes of rapid disease spread. We don't know why disease virulence and mortalities are high in Mexico, but apparently lower elsewhere. This may have a complex medical, viral cause. But it also may be to do with access to healthcare and effectiveness of response.

The swine flu story is also revealing how poor surveillance and reporting systems mean an outbreak can quickly get out of control - there were big gaps in detection and reporting that date back to February. But local people knew of the disease, and have strong hypotheses about its origins. Anselma Amador from La Gloria, the village where the first known case of swine flu occurred told The Guardian: "We are not doctors, but it is hard for us not to think the pig farms around here don't have something to do with it ... The flu has pig material in it and we are humans, not pigs."

These explanations are dismissed by the health minister and pig farming company, but why are such leads not being followed up? And why are such early-warning approaches, based on local knowledge about disease incidence and its dynamics, not part of the standard surveillance system?

In South-east Asia local understandings of avian flu and its spread have been vitally important. Medical doctors, epidemiologists, virologists, veterinarians and other specialists need to work hand in hand with local people for surveillance to be effective.

Another strong lesson from the avian flu experience is that attention to the changing structure of the livestock industry is essential to understanding how diseases emerge and spread. While it is easy to blame big agribusiness and industrial farming techniques, the situation is more complex.

While the "livestock revolution" is celebrated as a source of economic growth in the developing world, rapid restructuring of the livestock sector has major downsides and implications for how industries are regulated and diseases managed. As the details begin to emerge on the swine flu outbreaks, a more comprehensive assessment of the political economy of agriculture - and the pig industry in particular - in Mexico will be essential in learning lessons for the future.

Right now, of course, the spotlight is focused on the international public health response. Preparing for a pandemic means preparing for surprises - and being ready to respond rapidly and flexibly under conditions of uncertainty. As the experience with avian influenza has shown, this may require more than simply the top-down, "active and aggressive" technocratic responses being urged. The Guardian

From TODAY, Comments – Tuesday, 12-May-2009

Well, I have been posting to my others blogs lately, cursively, furiously… actually, I have been updating my health at home and away blog with updates on the development of swine flu, with a dash of some e-mail hoax here and there, and some other tidbits of info. So hope to spend some time in this blog soon…

Till then!

I REFER to the report, "Singapore ready to tackle swine flu" (my paper, April 28).

The World Health Organization has described the swine-flu outbreak as "a public-health emergency of international concern".

It is a stark reminder of the Sars epidemic in 2003.

A pandemic on top of the global recession would batter the Singapore economy and lead to even more unemployment.

The Government has a duty to educate Singaporeans on tackling disease threats.

We must never be complacent, especially with respiratory diseases such as human flu, Sars, bird flu, swine flu and tuberculosis.

A normal person can survive without food or water for some time. But if he cannot breathe because his lungs are infected, he will die.

While many know that washing one's hands and not coughing openly are good hygiene habits, few pause to think about the consequences of sharing food, when individuals use their utensils to eat from common dishes.

A 1994 Ministry of Health (MOH) publication confirmed that through sharing food, "we are likely to share saliva as well, (along) with any bacteria or viruses (that are) in it".

Saliva can transmit many micro-organisms.

Among them are the viruses that cause hand, foot and mouth disease (HFMD), human flu, Sars, bird flu and swine flu, and those that are linked to liver cancer (hepatitis B virus) and nose cancer (Epstein-Barr virus).

The micro-organisms also include bacteria that cause tuberculosis and meningitis, and a bacterium that is linked to stomach cancer (Helicobacter pylori).

Few Singaporeans know that adults can also contract HFMD through close contact or the sharing of food.

The disease is then passed on to their children in the same manner.

Health risks aside, stop and think: How can you possibly enjoy your food when it contains others' saliva?

The MOH publication also had a simple recommendation: It suggested that serving spoons, separate soup bowls and sauce dishes be used both at home and in public eating places.

Regrettably, this important piece of public-health advice was never widely publicised.

Thus, many Singaporeans remain unaware of the health risks of sharing food.

A 2004 report in The Straits Times quoted Health Minister Khaw Boon Wan as saying: "There is nothing wrong with communal eating... But I think we can make it hygienic just by using serving spoons."

For years, Chinese restaurants in Australia have been routinely providing customers with serving spoons.

This is not so with most restaurants here, where it is a constant hassle to ask waiters to provide serving spoons for each dish.

These actions are urgently needed:

Public campaign

The Health Promotion Board should mount an "Eat the Hygienic Way" campaign to inform Singaporeans about hygienic eating habits, such as using serving spoons, to complement its "Eat the Healthy Way" campaign.

Make serving spoons compulsory

The National Environment Agency could issue a compulsory directive to hawkers and restaurants, requesting that they provide serving spoons to customers.

Mr See Leong Kit

From myPaper, My Say – Wednesday, 29-April-2009

By MARGIE MASON,AP Medical Writer AP - 2 hours 44 minutes ago

MEXICO CITY - Now that the swine flu virus has passed from a farmworker to pigs, could it jump back to people? The question is important, because crossing species again could make it more deadly.

The never-before-seen virus was created when genes from pig, bird and human viruses mixed together inside a pig. Experts fear the virus that has gone from humans back into pigs in at least one case could mutate further before crossing back into humans again. But no one can predict what will happen.

"Could it gain virulence? Yes," Juan Lubroth, an animal health expert at the U.N. Food and Agriculture Organization in Rome, said Sunday. "It could also become milder. It could go in both directions."

Canadian officials announced Saturday that the virus had infected about 200 pigs on a farm _ the first evidence that it had jumped to another species. It was linked to a farmworker who recently returned from Mexico, where 19 people have died from the virus. The farmworker has recovered, and the mildly infected pigs have been quarantined.

Agriculture officials believe the worker may have sneezed or coughed near the pigs, possibly in a barn. About 10 percent of the herd experienced loss of appetite and fever, but all are recovering.

Experts say pork _ even from infected pigs _ is safe to eat.

Lubroth stressed that sick people should avoid contact with swine, but said healthy farmworkers don't need to take any extra precautions because the chance of catching flu from a pig is small.

Unlike the H5N1 bird flu virus, which infects the blood, organs and tissue of poultry, most swine flus are confined to the respiratory tract, meaning the risk of a human getting infected by a pig is "probably 10 or a 1,000 times less," Lubroth said.

But pigs are of special concern because they share some basic biological similarities with humans, and they have served as "mixing vessels" in which various flu strains have swapped genetic material. That's what happened to create the current swine flu strain.

Scientists are unsure when the virus leaped from pigs to humans _ possibly months or even a year ago _ but it was identified as a new strain about a week and a half ago. Since then, nearly 800 cases have been confirmed worldwide. The only death outside Mexico occurred when a Mexican toddler died in a Texas hospital.

There have been sporadic cases of pigs infecting humans with influenza in the past. Most cases resulted in mild symptoms, typically among people who were in close contact with sick pigs. A few deaths have been recorded, and limited human-to-human transmission also has been documented, but nothing sustained.

Dr. Tim Uyeki, an epidemiologist with the U.S. Centers for Disease Control and Prevention who has worked on SARS and bird flu outbreaks, said there may be more pig-to-human cases that have gone unnoticed because surveillance among swine populations tends to be weaker than among poultry stocks.

Given that the past three flu pandemics _ the 1918 Spanish flu, the 1957-58 Asian flu and the Hong Kong flu of 1968-69 _ were all linked to birds, much of the global pandemic preparedness has focused on avian flus.

"The world has been watching and preparing and trying to prevent a pandemic from an avian influenza reservoir," he said. "The focus has been on birds, and here is a virus that's coming from a swine reservoir. Now it's a human virus."

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From Yahoo! News; source article is here.