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Pandemic flu: What we know, what we don't, and what we should be worried about

By Sandhya Srinivasan

The swine flu pandemic is relatively mild in India so far, but in India and elsewhere what governments must do to prevent the occurrence of such outbreaks is strengthen public health systems, regulate corporate livestock farming, and ensure access to essential drugs and vaccines

swine flu pandemic is relatively mild in India

On June 11, 2009, the World Health Organisation declared “the start of the 2009 influenza pandemic” – the spread of an epidemic over a large part of the world. As of June 15, this particular mutation of Influenza A (subtype H1N1) had caused 35,928 laboratory-confirmed infections in 76 countries across the world and 146 deaths in nine countries – including 108 in Mexico and 45 in the US.  

On June 15, Indian minister for health and family welfare, Ghulam Nabi Azad, asked for students to defer non-essential travel to countries affected by this flu.

Despite such statements, there is no cause for panic as the vast majority of cases have been mild, and an effective treatment exists. However, we should take a hard look at the circumstances in which epidemics occur, and the factors that determine our ability to respond. 

So far, most cases of this H1N1 influenza have been mild, except in Mexico, where the epidemic seems to have started, and in the US. However, we do not know how it will play out. The biggest concern is the potential impact of the pandemic in developing countries. In the words of the WHO director-general, Margaret Chan, “it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems”. 

The People’s Health Movement (PHM) has identified more specific concerns about an influenza pandemic in developing countries. The PHM, a global network of health organisations working on the right to health and health care, has called on governments to strengthen public health systems, regulate corporate livestock farming, and ensure access to essential drugs and vaccines. Indeed, these are major challenges in India, whether or not H1N1 spreads in this country. 

What is A (H1N1) and why should we be worried?

The new strain of influenza A is different from the virus that causes seasonal influenza in humans.  

Seasonal influenza constantly circles the globe, affecting 3 to 5 million people and causing 250,000-500,000 deaths annually. The influenza virus, which is transmitted through droplets in the air, mutates constantly, one reason that it is monitored by a global surveillance network that tracks the virus’s mutations, predicts the dominant strain circulating for the coming season and recommends the composition of the season’s influenza vaccine. In developed countries, this influenza vaccine is recommended for the elderly and immune-compromised. Despite this vaccination programme, some 33,000 people die every year in the US from seasonal influenza.

However, different influenza viruses can infect various species including pigs, birds, horses and seals, says Shahid Jameel, group leader, virology, at the International Centre for Genetic Engineering and Biotechnology in Delhi. Dr Jameel notes that while viruses are generally restricted to the species that they infect, sometimes a mutation of a virus enables it to “jump” species.

So humans can, on occasion, get infected with viruses that normally infect animals or birds. Such zoonotic infections occur in people who live or work in close contact with them. Some poultry workers were infected during the outbreaks of Highly Pathogenic Avian Influenza (H5N1), a more severe form of an influenza that affects birds (with 433 cases and 262 deaths from 2003, when tracking first started, to June 2, 2009). Likewise, workers in pig farms are at risk of infection with swine flu.  

Sometimes a mutation of an animal (or bird) virus that occasionally infects humans enables it to move from one human to another. Once the virus transmits from humans to other humans easily, the conditions are set for a pandemic.  

The biology of certain animals can aid the process of mutation. Pigs are relatively easily infected with both human and bird flu viruses and this species can serve as a “mixing ground” to create a “reassortant” virus strain with genetic material from all three species.  The new virus strain may then infect birds or human beings and start a new chain of infection within a species. 

This particular H1N1 virus is a reassortant containing genetic elements of viruses that have been circulating in humans, birds and pigs for years. Dr Jameel points out that some components have been traced back to the 1918 flu pandemic.  

This H1N1 has been relatively mild, with a case fatality rate of 0.5% – other than in Mexico where 2% of people who fell ill died. (The case fatality rate for seasonal influenza is 0.1%.) Unlike seasonal influenza, severe infections – and deaths – have mostly been in young and middle-aged adults, possibly because the elderly may have been exposed to a similar virus decades earlier.  

However, this new virus spreads faster than seasonal influenza. And people with underlying, chronic diseases, poor nutrition and low immunity are more likely to develop serious illness.  

Also, flu viruses are unpredictable. H1N1 has appeared at the tail end of the flu season in the northern hemisphere. It is likely to circle the globe – mutating as it replicates – and when it comes back in the next season, it could be much more deadly. It could combine with the less infectious but much more dangerous Highly Pathogenic Avian Influenza, H5N1. While H5N1 has not spread much from human to human, it has killed 60% of humans in whom it has caused disease. “If the mild H1N1 and the virulent H5N1 get a chance to come together, they can potentially produce a reassortant that transmits and kills efficiently,” says Dr Jameel. “There is a real possibility for this scenario if the current H1N1 continues to spread.”  

So we could have a highly infectious and deadly virus which can have the impact of the 1918 flu in which 40 to 50 million people died. With better surveillance and health services, the WHO has projected that between 2 million and 7.4 million people could die in a similar pandemic today. 

Are we prepared?  

On June 11, Margaret Chan called on countries with few reported cases to “remain vigilant”. But neither the WHO nor the Indian government has made public the procedures for monitoring for H1N1, whether imported or any local outbreaks. In India, about 30 people have laboratory tested positive for H1N1 flu. All of them seem to have acquired the infection outside India. But is our monitoring machinery effective? At least till two weeks ago, screening was restricted to requiring disembarking passengers to declare any symptoms. Thousands of passengers lined up dutifully to have these declarations stamped and signed by doctors. No one knows how these were followed up and whether anyone who had symptoms after they landed in the country reported back to the medical authorities.  

“I think in the Indian situation we should look at other outbreaks and epidemics and how the system has responded,” says Abhay Shukla, national joint convenor of Jan Swasthya Abhiyan, the People’s Health Movement’s India chapter. “For example, some time ago, in Saharanpur, western Uttar Pradesh, hundreds of children died of what seems to be encephalitis but we still don’t know the exact cause of death.” Dr Shukla points out that private doctors and nursing homes, used by the majority of people, do not bother to report notifiable diseases.  

Industrial farming and disease 

Another cause of concern in epidemics of infectious disease is the “factory farm”. Public health specialists have repeatedly drawn attention to commercial farming practices that increase the risk of animal to human transmission of disease. It’s cheaper and simpler to house animals and birds in small cages. But this factory model also allows diseases to spread like wildfire. Practices such as the extreme over-crowding of domestic farm animals and manufacturing feed from remnants of slaughtered birds or animals create all the conditions for a disaster whose impact is felt for years, even decades.  

The outbreak of H1N1 reportedly started in a pig farm in Perote, Veracruz, Mexico, owned by the US-based Smithfield Foods, the world’s largest pork packer with hog farms in nine countries. Smithfield has denied that cases of swine flu on its farm have anything to do with the latest outbreak (the WHO has not issued a statement on the outbreak’s exact origin). But Smithfield is not very popular in the communities where it has factories. It has been fined repeatedly for discharging untreated faecal matter from its hog farms into rivers – itself a cause of disease, though not of influenza. Some years ago, it was forced to stop the use of “gestation chambers”, cages for pregnant sows in compartments so small that they could hardly move. However, an investigation of the company’s farms found that animals continued to be kept in extremely overcrowded conditions.  

“This modern method of farming is creating problems,” says Dr Jameel. “When industrial farmers cram animals together, they create a situation ripe for disease transmission. The virus moves faster through densely populated areas.”  

Such conditions can also encourage the development of a more lethal virus.  

“When you create conditions enabling transmission, you are allowing the virus to replicate,” says Dr Jameel. “Every time the virus replicates there are random mutations. “But the right mutation can make the virus more virulent.”  

Poultry farms also provide the perfect breeding ground for disease outbreaks, and public health experts have suggested that industrial chicken farms set off the H5NI epidemic among birds. Birds are housed in small spaces encouraging the rapid spread of any infection. They are transported to the market in cages covered with bird faeces and feathers which may be contaminated. Conditions in India are no better. Commercial chicken meal is manufactured using a combination of grains and “other products” which in the US, at least, includes “poultry byproduct” (which could include faeces) and “poultry fat”.  

But influenza is just one of many epidemics nurtured by the food industry.  

The neurological disease spongiform encephalopathy or Creutzfeld Jacob Disease is usually found in the elderly. In the 1990s, cases were reported of a new version of CJD (nvCJD), seen in young people. It was eventually traced to eating beef from cattle suffering from bovine spongiform encephalopathy or BSE, also called “mad cow disease”.  

At the centre of the nvCJD epidemic is the use of animal protein in livestock feed. The meat industry maximised the use of slaughter house waste by adding these “rendered remains” to cattle feed. These rendered remains included brain tissue infected with the CJD prion, the protein that that caused the disease.  

Mad Cow Disease has a long incubation period and cattle infected with BSE were being slaughtered before they developed symptoms of the disease.   

“Cattle are not built to consume meat, here they are giving mashed brains of cattle,” says Dr Jameel.  

Since 1998, the US has banned the use of most – but not all – waste products from mammals in cattle feed.  

Health and health services 

Can India take on an epidemic of a highly infectious virus causing a severe infection? The virus’s impact could be most severe in people with low immunity – whether because of underlying disease or because of simple malnutrition. This puts the majority of Indians at greater risk of severe illness leading to long-term disability or death. How will a health system that is unable to provide care for existing problems possibly cope with an epidemic of severe influenza?  

Past experience tells us that government health services will move “sluggishly” in the case of an epidemic, says Dr Shukla, citing the example of the chikungunya epidemic in 2005. Government hospitals are the last choice of most people looking for treatment. “Most patients landed up in private nursing homes where they were hospitalised and forced to spend thousands of rupees on irrational treatments like saline infusions, getting impoverished in the process.”  

Nor did the public health system even check this mosquito-borne epidemic, and the virus spread across large parts of the country. “Imagine what would happen in an air-borne epidemic such as the flu,” says Dr Shukla. “A weak health care system will not be able to control its spread. Patients will go to private hospitals which do not bother to notify the authorities of such cases.”  

Finally, while the government says it has adequate stocks of anti-viral drugs, will these drugs reach those who need them? “Today, four years after launching the National Rural Health Mission, and substantial boosting of state health budgets - money is no longer a constraint – the Jan Swasthya Abhiyan community-based monitoring system found that 55% of essential drugs were not available in primary health centres that it visited in Maharashtra,” says Dr Shukla. This includes simple drugs like paracetamol. There was also evidence of corruption in the procurement of medicines. What can we expect if the H1N1 pandemic reaches India?  Will treatment be limited mostly to those who can afford the drugs?  

Will India get the flu vaccine?  

While drugs are needed to treat those who are severely ill, they do not reduce the virus’s transmission as it infects before the patient exhibits any symptoms. A vaccine for H1N1 would limit its transmission, says Dr Jameel. Slowing down transmission would also reduce the chances of the virus mutating into one that causes a more severe infection. Various centres around the world are working on isolating the vaccine strain in their region and creating a version that mimics the original virus but does not cause disease in humans.  

Vaccine manufacturers will need virus samples from many sources and for this they will depend on country governments and WHO collaborating centres that receive and test virus samples. In return, developing country governments are asking for an assurance that the vaccine will be made available to them at an affordable price.  

Ninety per cent of vaccine manufacturing capacity is located in Europe and North America. 

Margaret Chan has stated: “WHO has requested manufacturers set aside future influenza A (H1N1) vaccines for United Nations agency procurement. In addition, donations are expected from countries holding advance purchase agreements for influenza A (H1N1) vaccine, and tiered-pricing arrangements will be discussed with the vaccine manufacturing industry in order to make vaccines more affordable for developing countries.”  

The problem is that many essential vaccine technologies are covered by intellectual property rights owned by pharmaceutical companies. Glaxo Smith Kline, Sanof Aventis and Novartis are among the biggest vaccine manufacturers. According to the Third World Network, an international non-profit network on development issues, “The scope of protection includes patents on cell lines and production systems, trade secrets on the safety profile of cell lines and other formulations.”  

Seeing the money to be made from a pandemic flu vaccine, manufacturers are lining up for government contracts. But they have refused to commit to making technologies available or providing vaccines at reasonable prices. 

On May 16, 2009, vaccine manufacturers met with country representatives at the Intergovernmental Meeting (IGM) on Pandemic Influenza Preparedness on the eve of the World Health Assembly to discuss an H1N1 vaccine. But the meeting left many questions unanswered.  

According to TWN, the bone of contention was a framework on benefit-sharing that assured developing countries sufficient and affordable anti-viral drugs and vaccines. This framework would include a Standard Material Transfer Agreement (SMTA), a contractual agreement between the providers and the recipients of biological materials that sets out the terms of use of these materials.  

However, says Sangeeta Shashikant of TWN, “While countries are requested to give up on their sovereign rights over the biological materials, a right recognised under the United Nations Convention on Biological Diversity, manufacturers are unwilling to share their intellectual property protected technology and know-how.”

In the past, both vaccine manufacturers and WHO laboratories have tried to patent biological materials that were given to them for the public good. TWN notes that after the 2008 bird flu outbreaks, the US Centres for Disease Control, a WHO collaborating centre, applied for a patent for a new vaccine against influenza that incorporates genes from a H5N1 strain isolated from an Indonesian who died in the 2005 bird flu outbreak. The same patent application mentions other vaccines with genes of flu viral strains from Thailand, Hong Kong and South Korea. 

TWN has demanded that WHO collaborating centres that receive virus samples should not claim patents over the samples. Companies that receive virus samples must ensure that vaccines are available and affordable to developing countries, give royalty free licences to use patented technology, contribute to a fund for vaccines/drugs, and build capacity in developing countries. This should have been spelled out in the SMTA. 

“There was a lot of rhetoric at the May 15 meeting but nothing was finalised,” says Shashikant. “The US had initially agreed but then refused to sign an SMTA. During the World Health Assembly, the US, the European Union, Australia and Japan did not want to continue the process. Right now “discussions are in the hands of WHO’s director-general, and the extent to which developing countries get a fair deal is in the hands of the DG,” says Shashikant.  

Regulating environmental causes of disease, strengthening health systems and ensuring access to essential drugs and vaccines are the challenges identified by the People’s Health Movement and they are not limited to influenza A (H1N1). Access to health care and medicines is a critical issue whether or not this virus spreads in India. So is access to food, as up to half the population suffers from some degree of malnutrition, reducing their ability to withstand illness. We are already in the midst of a silent epidemic – of infectious diseases such as tuberculosis and malaria, and chronic illnesses like hypertension and diabetes.

Masks are not enough. 

InfoChange News & Features, June 2009