Swine flu: Cause and epidemiology What governments / community and other stakeholders can do to stop the spread

This paper provides a brief outline of the recent swine flu epidemic that has led to the loss of lives especially in Mexico. It traces the early origins of swine flu, its progression and impacts of the outbreak in 2009. The implications of swine flu potentially infiltrating the African continent are examined. The transmission, symptoms and prevention of swine flu are also examined; including what communities, government and service providers (i.e. airlines and hospitals) can do to contain and prevent possible infection. Recommendations and conclusions are outlined on how all stakeholders can help work together to limit and prevent and outbreak.

Introduction
Origins, progression and contemporary transmission of swine flu There has been an overwhelming concern since news of the swine flu outbreak on several continents, especially Mexico and the United Stated gripped the global. Cases of swine flu (i.e. also known as H1N1), which initially killed many people in Mexico, were confirmed around the world. Swine flu is a respiratory disease, which infects pigs. There are many types, and the infection is constantly changing. The swine influenza virus is classified as either Influenzavirus C or one of the subtypes of Influenzavirus A. The swine influenza that infected humans in the U.S. and Mexico is a novel influenza A virus that has not previously been identified in North America.

The onset of the 2009 swine flu is reminiscing of the 1918 N1H1 avian flu virus, the worst plague in human history. The avian flu jumped the species barrier from birds to humans and went on to kill as many as 50 to 100 million people in the 1918 flu pandemic. The current swine flu virus originated in August 1998 in a North Carolina pig factory in which all the thousands of breeding sows fell ill. North Carolina is the home of the nation’s largest pig production operation. A new human-pig hybrid virus was discovered that had picked up three human flu genes. By the end of 1998, the virus acquired two gene segments from bird flu viruses, becoming a pioneering hybrid of a human virus, a pig virus, and a bird virus that triggered outbreaks in Texas, Minnesota, and Iowa. According to the current analysis, published 30 April 2009 in the journal of the European Centre for Disease Prevention and Control, it is from this pool of viruses that the current swine flu threat derives three-quarters of its genetic material. However, the 2009 flu outbreak is due to a new strain of subtype H1N1 not previously reported in pigs. Following the 2009 outbreak, it was reported in pigs at a farm in Alberta, Canada, with a link to the outbreak in Mexico. The pigs are suspected to have caught this new strain of virus from a farm worker who recently returned from Mexico, then showed symptoms of an influenza-like illness. One can easily state that neo-liberal ideology, the free market approach and resultant globalisation and migration have caused the transmission of infection across national borders.

Until now swine flu has not normally infected humans, but the latest form has shown that medical science clearly has limitations in its knowledge regarding cross-infection to humans. Indeed experts scrambled to develop a vaccine due to concern at the potential for a pandemic to affect people globally. Outbreaks in humans are now occurring from human-to-human transmission. Although the Food and Agricultural Organisation (FAO) and World Health Organisation (WHO) have reaffirmed that influenza viruses are not known to be transmissible to people through eating processed pork or other food products derived from pigs, and although influenza A viruses are inactivated by heating, nevertheless some countries banned import and sale of pork products as a precaution against swine flu. The Egyptian government also decreed that 300,000 pigs in the country had to be slaughtered as a precaution against the spread swine flu despite the fact that no cases of the swine flu virus have been reported there, bearing in mind that it is spread by people, not pigs. Not only has there been a lack of understanding on how to respond to the crisis, but culling of livestock has somewhat impacted on the economic status of poor farmers. The WHO confirmed that the virus was being passed from human to human but said it had not rapidly spread from infected individuals to their surrounding communities. Nevertheless, from December 2005 through February 2009, 12 cases of human infection with swine influenza were confirmed. All but one person had contact with pigs. However, there was no evidence of human-to-human transmission in those cases.

Contemporary swine flu impacts
The virus, to which people have limited natural immunity, spread too many countries. The outbreak was first detected in Mexico City, where surveillance began picking up a surge in cases of influenza-like illness during the month of March 2009. Initially, in Mexico, swine flu killed at least sixteen people and raised fears of a possible pandemic; while the WHO stated that the flu had killed about sixty Mexicans. However, a recent media report in April 2009 noted that the WHO stated that at least eighty-one people had died from severe pneumonia caused by the illness in Mexico, and tests on suspected cases were also taking place in Scotland, France and Spain. Swine flu cases worldwide as of 20 May 2009 were noted to have soared past 10,000, as confirmed by laboratories. The WHO has confirmed that swine flu has sickened more than 11,000 people in 41 countries and killed 85. Mexico has reported seventy-five deaths, the United States ten, and one in both Canada and Costa Rica as on 21 May 2009. The Utah Health Department reported 122 cases of swine flu in Utah, with first death of a twenty-nine-year-old man with swine flu. Reports were also noted of the Swine flu claiming its first death of a fifty-five-year-old man in New York on the 17 May, with the US Centres for Disease Control and Prevention (CDC) stating on 15th May that there have been 4,714 confirmed or probable cases in the United States. Despite a somewhat decline in deaths resulting from swine flu, precautions are still been taken by many countries. Eight states had previously closed in Texas affecting 53,000 students, while President Barack Obama stated that school closings might be necessary to keep crowds from spreading the flu. Mexico had already closed schools nationwide until 6 May. Japan joined New York in reporting increasing swine flu cases among students and shutting schools.

Swine flu and Africa
Although swine flu has not been confirmed in Africa as yet, fear is also rife amongst African civil society and governments with African nations scrambling to prevent swine flu impacting on a continent already hostile with the burden of AIDS and malaria. There is fear that if the virus hits the African continent it could wreak much more devastation than in North America or Europe. The WHO warned the virus would have a bigger impact on Africa than it has had anywhere else should it break out on the continent. The WHO also noted that the virus poses a high pandemic risk. While Africa at the moment appears not to be affected, the continent is highly vulnerable according to the United Nations. In Algeria, Ghana and Togo, health authorities were closely observing the development of the disease and had increased health checks. In South Africa, two suspected cases of mild swine flu were detected in people who had visited Mexico. Despite these two suspected cases, the Africa Regional Office of the WHO (AFRO) noted that so far no cases of swine influenza A/H1N1 have been reported in Africa, although programmes to combat the potential spread to Africa of the swine flu were officially reported in nine countries. Some African countries like Niger have not ruled out an outbreak of swine flu, with the Niger’s minister for Livestock and Animal Industries Issiad Ag Khato stating that there was still a risk of swine flu infection.

Transmission and symptoms of swine flu in pigs and humans
Transmission of swine flu can occur between animals (i.e. pigs), from animals to humans, and between humans. The main route of transmission is through direct contact between infected and uninfected animals. These close contacts are particularly common during animal transport. Pigs raised in close proximity to each other via intensive farming may also increase the risk of transmission. The direct transfer of the virus probably occurs either by pigs touching noses or through dried mucus. Airborne transmission produced by pigs coughing or sneezing is also a means of infection. The virus usually spreads quickly through a herd, infecting all the pigs within just a few days. When infected people cough or sneeze, infected droplets get on their hands, drop onto surfaces, or are dispersed into the air. Another person can breathe in contaminated air, or touch infected hands or surfaces, and be exposed. People who work with pigs, especially people with intense exposures, are at increased risk of catching swine flu. The meat of the animal poses no risk of transmitting the virus when properly cooked, so the possibly of infection is there. Symptoms of swine flu in humans appear to be similar to those produced by standard, seasonal flu. These include fever, cough, sore throat, body aches, chills and fatigue. Other symptoms include headaches, muscle and joint pain, runny nose, and sometimes vomiting or diarrhoea. Seasonal flu often poses a serious threat to public health and each year it kills 250,000 – 500,000 around the world. So far, most cases of swine flu around the world appear to be mild, albeit with diarrhoea more common than it is with seasonal flu. The WHO has noted that so far most people who develop symptoms of infection have not needed drugs to make a full recovery. However, around one in ten needs hospital treatment.

Although the majority (about 90%-95%) of people that get the disease feel terrible (as noted in symptoms above), they recover with no problems, as seen in patients in both Mexico and the U.S. However, caution must be taken as the swine flu is still spreading and may become a pandemic. So far, young adults have not done well, and in Mexico, this group currently has the highest mortality rate, but this data could quickly change. The first traceable case in Mexico, termed “patient zero,” was a 5-year-old child in Veracruz who has completely recovered. Investigators noted that large pig farms were located close to the boy’s home. The first death in the U.S. occurred in a 23-month-old child who was visiting Texas from Mexico but apparently caught the disease in Mexico.

Prevention
Although vaccines are available for pigs to prevent the swine influenza, none so far exists to protect humans, although scientists are working on a formula, but there are ways that people can help prevent the spread of infection.

What the public and communities can do?
Anyone with flu-like symptoms who might have been in contact with the swine virus such as those living or travelling in the areas of Mexico that have been affected should seek medical advice. But patients should not go into doctor surgeries in order to minimise the risk of spreading the disease to others. Patients should rather stay at home and call their healthcare provider for advice. Avoid close contact with people who appear unwell and who have fever and cough. General infection control practices and good hygiene can help to reduce transmission of all viruses, including the human swine influenza.

Further steps that can be taken as a precaution to safeguard against swine flu:
• Wash hands constantly whenever in contact with someone, at work, or even at home. This is one of the biggest and easiest steps to do in order to prevent from contracting any sickness via human contact.
• Disinfect desks, tables, keyboards, counters, furniture, playpens, toys, work areas, bathrooms, and everywhere else in your house. This will help prevent viruses & germs from living on tabletops and toys. This will also prevent individuals and children from contracting the swine flu and any other types of viruses.
• Try to avoid sick people unless it is someone that needs taking care of. However, people must take self-precautions for protection, as the flu is transmitted through any type of human contact. When dealing with someone who is sick, you should wash your hands, and wear some gloves to reduce the risk of transmission.
• Parents should protect their children and be involved in what is happening in their children’s school. Parents will need to know if the school is on alert for any type of sickness. The school environment is one of the easiest ways to contract any virus. Children will need to wash their hands and avoid sharing lunches with other kids to prevent contracting a sickness.
• Wearing an optional surgical mask will help decrease the likeliness of being infected. According to WHO, Patients and caregivers should be trained to wear and dispose of masks during the infectious period of the patient, if supplies are available. Where supplies are limited, it is more important in the home that the patient wears the mask than the caregiver. The mask need not be worn all day and only when close contact (within approximately 1m) with the caregiver or others are anticipated. Masks should be disposed of safely if wet with secretions. Tightly-fitting scarves or a reusable mask made of cloth covering the mouth and nose could be used if masks are unavailable. They should be changed if wet and washed with soap and water.
• Children and elders are at high risk of contracting and dying from the swine flu because of their weak immune systems so they should be given priority protection.
• It is also recommended that people maintain healthful habits such as getting ample sleep and exercise, drink fluids and eating well.
• Sick people must stay at home from work, school or other public activities to avoid the spread of infection. However, according to the WHO, home confinement of ill people in crowded settings may not be practicable. If however there is no option, restricting contact with others should be encouraged as much as possible. Adequate supervision within the household of the ill person should be ensured with preferably only one caregiver to limit potential exposure.
• Cover your nose and mouth with a tissue whenever you cough or sneeze. And immediately dispose of the tissue after use.
• Avoid touching your eyes, nose, or mouth as the flu virus can enter your body that way.
• Avoid direct contact with pigs.

What governments and other stakeholders can do?
It is imperative that national governments are prepared for any potential events related to swine flu and implement proper measures in place to effectively deal with any threats. In addition, there need to be proper communications between government departments, health authorities, hospitals and airports to help contain any potential outbreaks. For example, local authorities in Shanghai have stepped up monitoring at hospitals and airports to guard against the arrival of a disease that seems to be spreading around the world. Hospitals were ordered to enhance vigilance in their fever clinics and remain on the lookout for sick people who either recently visited the countries where swine flu had been reported or people have been in who had been in contact with pigs. The WHO has produced numerous publications and reports for National Focal Points for the International Health Regulations and competent national public health authorities at points of entry, as well as airport operators, aircraft operators, airport personnel, crew members and other stakeholders involved in air transport.

Some of the important national government African responses have been the formation of inter-ministerial crisis committees and development of plans for action, media coverage to inform citizens, screening arriving and departing passengers (especially passengers coming from risk areas), banning or suspending pork imports from European countries, educating passengers at cross borders, and setting up quarantine facilities to monitoring visitors entering through airports and other border points who may come from infected areas such as from the United States, Canada, Israel, Spain and UK. Unfortunately, these measures are not uniform across Africa and some countries have not as yet taken any precautions (i.e. Burkina Faso, Chad, Mozambique, Niger, and Somali). Egypt, Gabon and Ghana have either slaughtered pigs or banned/suspended imports of pork into their countries, which may not be totally effective. However, with most countries, national governments need to strengthen education and support for local communities on what citizens can do if a pandemic had to occur in their local communities (as described above).

What hospitals and health-care facilities can do?
It is essential that health care facilities implement proper protocols at their institutions to prevent and minimise infectious cases. The WHO recommends basic procedures that hospitals and clinics, especially in low resourced areas, can take to limit infection, a few of which include the following:

• Staff need to separate patients with respiratory symptoms from those presenting with other symptoms at both the outpatient and inpatient levels
• Confinement in a separate respiratory ward for patients admitted with suspected pandemic influenza;
• Maximum separation of beds and head-to-toe positioning of patients in inpatient wards if space is limited;
• Ensure good ventilation of outpatient and inpatient areas;
• Inpatient treatment in low resource settings should include: treatment of dehydration with IV or oral rehydration fluids; supplemental oxygen therapy (if available) by face mask rather than nasal prongs; antibiotics for secondary bacterial infections; non-aspirin antipyretics for pain and fever;
• Nutritional supplementation must be supplied as needed.
• Antiviral use should be prioritised for treatment of sick health-care and other essential staff; and treatment of sick individuals from the community.

Steps airlines and airports can take to prevent spread of identified and suspected cases?
There are steps that airlines and cabin crew members can take for suspected traveller/s with swine flu. The WHO recommends measures that crew members during flight can take to help prevent or isolate a case (refer to Box 1 below). Although airlines are allowing passengers to change ticket destination which were booked to risk countries such as Mexico, they have not cancelled flights to these countries where swine flu has been detected. This suggests that airlines and their cabin crew members need to be more aware and trained in procedures to combat swine flu. Cruise lines on the other hand have been nervously cancelling some Mexican ports of call. They are normally familiar in handling outbreaks on board, and have plenty of antibacterial hand wash dispensers installed all over the ship.

Recommended procedures for airline cabin crew members to contain swine flu
1. If medical support from the ground is available, contact ground support immediately and/or page for medical assistance on board (as per company policy).
2. If medical ground support and/or an on‐board health professional is available, crew should follow their medical advice accordingly.
3. If no medical support is available:
a) Relocate the ill traveller to a more isolated area, if appropriate, and space is available. If the ill traveller is relocated, make sure that the cleaning crew at destination will be advised to clean both locations. (All surfaces potentially contaminated by the ill traveller should be cleaned and disinfected according to the WHO Guide to Hygiene and Sanitation in Aviation) .
b) Designate one cabin crew member to look after the ill traveller, preferably the cabin crew member who has already been dealing with this traveller. More than one cabin crew member may be necessary if more care is required.
c) When possible, designate a specific lavatory for the exclusive use of the ill traveller. If not possible, the commonly touched surfaces of the lavatories (faucet, door handles, waste‐bin cover, counter top, etc.) must be cleaned and disinfected after each use by the ill traveller.
d) If the ill traveller is coughing, request him/her to follow respiratory etiquette:
i. Provide tissues and the advice to use the tissues to cover the mouth and nose when speaking, sneezing or coughing.
ii. Advise the ill traveller to practice proper hand hygiene. If the hands become visibly soiled, they must be washed with soap and water.
iii. Provide an air‐sick bag to be used for the safe disposal of tissues.
e) If available on aircraft and tolerated by the ill traveller, a medical (surgical or procedure) mask should be, and the ill traveller asked to wear it. If a mask is used, replace with a new mask as soon as it becomes damp / humid. After touching a used mask, (e.g. for disposal), proper hand hygiene must be practised immediately. Single masks should not be reused and must be disposed safely after use.
f) If there is a risk of direct contact with body fluids, the crew member should wear disposable gloves. Gloves are not intended to replace proper hand hygiene. Gloves should be carefully removed and safely disposed. After the removal of gloves, hands should preferably be washed with soap and water or, if the hands are not visibly soiled, cleansed with an alcohol‐based hand rub.
g) If the ill traveller cannot tolerate a mask, the designated cabin crew member(s) or any other person in close contact (less than 1 metre) with the ill person should wear a medical (surgical or procedure) mask. The airline should ensure that the cabin crew member has adequate training in its use to ensure that risk is not increased (for example by more frequent hand‐face contact or adjusting and removing the mask).
h) Store soiled items (used tissues, disposable masks, oxygen mask and tubing, linen, pillows, blankets, seat pocket items, etc.) in a biohazard bag if one is available. If not, use a sealed plastic bag and label it “biohazard”.
i) Ask accompanying traveller(s) (spouse, children, friends, etc.) if they have any similar symptoms. The same procedure should be followed for all ill travellers.
j) Ensure that hand‐carried cabin baggage is removed along with the ill traveller, and comply with any public health authority requests.
4. As soon as possible, advise the captain of the situation.
5. Unless stated otherwise by ground medical support or public health officials, ask all travellers seated in the same row, and two rows in front and two rows behind the ill traveller (i.e. a total of five rows) to complete a passenger locator card if such cards are available on the aircraft. If not available on board, this action should be taken immediately upon the arrival of the aircraft at next airport.

The pilot of an aircraft must also inform air traffic control, as early as possible before arrival, of any cases of illness indicative of a disease of an infectious nature or evidence of a public health risk on board. This information must be relayed immediately/as soon as possible by air traffic control to the competent authority for the destination airport. The relevant competent health authority shall take action according to the national public health surveillance and response procedures, the airport emergency plan regarding public health events and international requirements. Some of these actions may include coordinating with the airport operator/airport authority to provide a parking area for the aircraft, facilitating and supervising agreements with appropriate agencies, health care units, airport authorities, airlines and service providers, for the management of arriving traveller(s) displaying symptoms of infection, including coordination for customs and immigration clearance. There should also be the availability of appropriate transport for travellers suspected of having an illness to a designated facility for further evaluation, quarantine, isolation and treatment as necessary. Infected travellers must be treated in accordance with national law and international requirements – including the WHO International Health Regulations of 2005.

Conclusion
For countries to be effective at combating swine flu will require co-operation between all levels of government and with service and tourism providers, airlines, healthcare centres, communities and civil society generally (and other identified stakeholders). It is difficult to say how dangerous swine flu really is, but many people have already died in Mexico. The exact causes of deaths have not been precisely verified. Mexicans who died may have sought treatment at a much later stage, compared to those in other countries. All of the other countries so far are highly developed industrialized countries. Living conditions and nutritional standards of those who died in Mexico may have been lower, compared with those who survived in Mexico and abroad. Due to the uncertainty of swine flu impacts, it is even more essential that nations and their governments take precautions to prevent the spread of swine flu. The WHO has warned that the outbreak may have a pandemic potential and countries are advised to step up surveillance and preparation in case the infection spreads rapidly. Therefore, government organizations must also focus on getting the message out to local communities about how to respond to the threat of influenza through education and awareness campaigns.

Leonard, L. (2009) Swine flu: Cause and epidemiology – What governments/community and other stakeholders can do to stop the spread. Ugandan Parliamentary briefing, Royal African Society, United Kingdom, 25 May

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