Plug the gaps and restock

Khaw: How Singapore can learn from the experience so far

by Neo Chai Chin

05:55 AM May 13, 2009

THE Influenza A (H1N1) virus creeps closer to Singapore, with Thailand reporting two cases yesterday. And while no cases have been reported here so far, it will take a full year - as the virus evolves and moves from the northern to southern hemisphere and back again - before Singapore can "decide if we can relax", said Health Minister Khaw Boon Wan.

Yesterday, he unveiled his Ministry's three-part game plan for the coming weeks and months, while stressing the likelihood that "H1N1 is going to be here with us permanently; it may not simply disappear like Sars".

First, the Government is replenishing stocks of personal protective equipment, as well as Tamiflu and Relenza antiviral drugs - and the private sector is strongly urged to follow suit.

General practitioners (GPs) and companies who did not stock up on these essentials and had to scramble, "learnt the hard lesson of being caught unprepared" when Singapore moved to Orange alert two weeks ago, said Mr Khaw.

On the "grumbling" about a shortage of N95 masks and Tamiflu, Mr Khaw said GPs "are supposed to have stocked up during peacetime". They should, for that matter, take advantage of the window of respite now when stocks are more readily available.

Second, the Ministry of Health (MOH) will do a post-mortem and plug holes in its flu plan - particularly, the gaps in the response of the primary healthcare sector that were exposed by the H1N1 alert.

For example, the MOH will tighten its communications system with GPs by ironing out technical problems and getting their updated mobile numbers for SMS updates.

Third, teams of public health experts and scientists will be sent to "battle-scarred" affected countries in North America to study their experiences.

'Don't play with Singaporeans' lives'

What of recent suggestions that Singapore allow the virus to enter in order to build some herd immunity? Or to adopt an all-or-none approach in tackling the virus - quarantining all visitors from affected countries, for example?

The MOH does not consider countries like Spain and South Korea as affected countries because the human-to-human transmissions have not reached a sustained level of community spread, said Dr Lyn James, director of the MOH's communicable diseases division.

The five deaths reported outside Mexico have been of people with underlying medical conditions, she noted.

Mr Khaw said that while it was okay to experiment with immunity as individuals or family units, he could not risk lives when there remains incomplete information about the virus.

"I don't think we should play around with Singaporeans' lives in such a casual manner," he said.

And as the world slowly uncovers more about H1N1, the public's focus "should not be over the number of new cases" but the severity of these cases, he said. "Do the patients develop complications, pneumonia, severe respiratory failure? Who are those that are vulnerable to developing complications, so that we can focus on treating them early?"

Singaporeans should also not be alarmed to see more people down with flu - the seasonal variety kills 600 here yearly - as flu season in Singapore peaks at mid-year and again at year-end. Mr Khaw gave the sombre reminder that we should "expect some deaths due to H1N1 at some stage".

"Last week, I did a house-to-house visit in Sembawang," recounted the Minister. When constituents were asked if H1N1 concerned them, "all said they were not worried" - a response that, in turn, made him "very worried".

"While I appreciate the confidence of my residents, such a high expectation that we can keep out H1N1 is unrealistic," he said, urging Singaporeans to maintain good personal hygiene and, if they are sick, to avoid crowded places and to see a doctor.

Meanwhile, life must go on: Families who are going on holidays abroad in June should avoid affected countries, check the Ministry's website for updates and take the usual "commonsensical precautions".

From TODAY, Singapore – Wednesday, 13-May-2009

Swine flu goes person-to-pig; What's next?

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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Irate pig farmers clash with police in Egypt

By MAGGIE MICHAEL,Associated Press Writer AP - Monday, May 4

CAIRO - Egyptian police and armored cars charged into a crowd of a 1,000 irate pig farmers armed with stones and bottles, leaving 12 people injured as residents of a Cairo slum resisted government efforts to slaughter the nation's pigs to guard against swine flu.

Cairo security chief Maj. Gen. Ismail Shaer said 14 people were arrested. Seven police were among the injured in the clashes with largely Christian garbage collectors who raise pigs on the refuse and live in the teeming slums of Manishyet Nasr outside the capital.

The farmers blocked the road leading to their pig pens and hurled rocks and bottles at police, who responded by charging them with armored cars and firing tear gas. Some 200 policemen then surrounded the neighborhood backed by a half dozen police trucks.

Egypt last week ordered the slaughter of all the country's 300,000 pigs even though no cases of swine flu have been reported here. The World Health Organization has said the move was unnecessary because the virus is being spread through humans.

On Sunday the organization reiterated its message that pork, ham and sausages are all safe to eat.

Authorities have now expanded the rationale for the slaughter beyond swine flu to a larger campaign against unsanitary pig farming conditions, particularly in the Cairo slums where the garbage collectors live.

The campaign has been met from the start by protests and resistance from pig owners. The consumption and raising of pigs is largely restricted to the country's Christian minority, estimated at 10 percent of the population. Muslims consider pork unclean and generally do not eat it.

"We were surprised by the tremendous objection by the garbage collectors. They fired guns, and they threw stones and bottles," Maj. Gen. Mohammed Nabawi, head of the Cairo Beautification Authority, told The Associated Press. He said that healthy pigs are being slaughtered for their meat while the pregnant and babies are being destroyed.

Cairo's predominantly Christian population of garbage collectors, known as the zabaleen, roam the streets of the sprawling city's wealthier neighborhoods collecting its garbage. They bring the refuse back to their homes and dump it in their courtyards, sorting through it for material to recycle. Pigs and other animals feed off the organic matter while the rest is reprocessed in crude workshops.

Isaac Mikhail, the head of the garbage collectors association, said 65,000 pigs live in the slum of Manishyet Nasr, providing a livelihood for some 55,000 people in the area.

He said farmers were enraged when the government slaughtered 600 of their pigs and then only paid them half of the going market rate of about 55 cents a pound ($1.20 a kilogram).

"If the government wants to slaughter (the pigs), they should pay a just price. How can people live?" he asked, estimating that a quarter of a million people in Cairo, a city of 18 million, are involved in pig farming.

Milad Ladid, a 33-year-old running a recycling workshop, couldn't understand why Egypt was killing its pigs when no one else in the world was.

"In Mexico, and elsewhere in the world, where they had infected people, no one decided to slaughter pigs. Why us? Why are we slaughtering pigs here while we have no reported cases?" he said.

Pigs flowed around Marzouqa Moussa, a middle-aged woman standing outside her small home, where she also sorts through trash.

"We bring the garbage here and sort it and we feed the pigs," said Marzouqa Moussa, a middle aged woman dressed in a dark robe, surrounded by dozens of pigs. "We were born here and we live here," she added, gesturing toward her simple living area adorned with a picture of Jesus Christ next to a room piled high with reeking garbage bags. A third room of the house was given over to the pigs.

The introduction of modern garbage services in many parts of the city over the last five years has already cost the zabaleen some of their livelihood.

In 2008, President Hosni Mubarak ordered all animal rearing, particularly pigs and chickens, to be moved out of populated areas for hygienic reasons. The order was never implemented, however, and authorities say the current crisis is a perfect opportunity.

Pig raising will be restarted in two years at specially constructed farms in the countryside using newly imported animals, officials from the Ministry of Agriculture told Egyptian media.

"Everything Egypt has decided to do _ despite the noise it caused here and there _ first and foremost aims at protecting human health, and the health of the Egyptian people which is worth all the efforts and the measures taken," presidential spokesman Suleiman Awwad said Sunday.

He added that the measures had the full support of the leaders of Egypt's Christian community.

The Egyptian government has come under criticism in past years for being caught flat-footed by crises.

Egypt was severely affected by the outbreak of bird flu in 2006 with more than two dozen fatalities in the past two years. Some 25 million birds were slaughtered and the rearing of poultry in households largely ended.

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From Yahoo! News; source article is here.

Politics play big role in world health decisions

By MARIA CHENG and ALEXANDER G. HIGGINS,Associated Press Writers AP - Monday, May 4

GENEVA - At the U.N. agency spearheading the fight against swine flu, key decisions are based on more than just health issues _ politics plays a big role, too.

With global powers like the United States and China all lobbying for their own national interests behind the scenes, measures such as travel bans, border closures, and raising alert levels can meet stiff political opposition. Some have even wondered if granting the World Health Organization beefed up powers to independently tackle health crises might help, giving it authority to make key decisions or send doctors into a country to investigate the spread of a disease.

WHO's mandate is to direct and coordinate U.N. health policy: It makes recommendations and global assessments on issues including HIV/AIDS, malaria, and tuberculosis, and also coordinates responses to health crises like disease outbreaks and humanitarian disasters. But its recommendations are not binding _ and countries are free to disregard WHO's advice.

"WHO is in an incredibly difficult position," said Richard Horton, editor of the Lancet medical journal. "On the one hand, its entire modus operandi is that it responds to government requests. But in this situation, what governments might want may not align with what WHO thinks is best."

Horton cited the 2003 SARS outbreak as a prime example. When the illness began spreading in Toronto, WHO issued a recommendation advising against nonessential travel to Canada's largest city. Similar recommendations were made for cities including Hong Kong, Beijing and Taipei.

The recommendations sharply cut travel to affected economies, dealing them a big economic blow _ but the aggressive WHO action was credited with being key to containing the illness.

The advisory incensed Canada, and Toronto's then-mayor publicly lambasted the agency, declaring it had no right to issue such guidelines. A delegation of Canadian diplomats and journalists flew to Geneva and camped out at WHO's Geneva headquarters, forcing the agency to reconsider _ and eventually lift _ the advisory.

"I suspect the reason WHO has been very reluctant to make any comments about travel (during the swine flu outbreak) is because of that experience with Canada during SARS," said Horton.

By issuing the controversial advisories, WHO's director-general at the time, Gro Harlem Brundtland, proved she was ready to confront countries.

WHO's current chief, Margaret Chan, has been both praised and criticized for her less confrontational leadership _ which only recently helped to end a decades-long standoff between China and Taiwan to allow the island to participate in global health meetings. Critics contend that her unwillingness to publicly pressure member states can undermine efforts to protect global health.

Notably, Chan has come under scrutiny for being publicly neutral over Indonesia's refusal to share bird flu samples with the scientific community _ which leaves a gaping hole in experts' ability to see how bird flu is evolving.

"Indonesia's behavior isn't helpful, but WHO did not confront them about it," said Adam Kamradt-Scott, a global health governance expert at London's School of Hygiene and Tropical Medicine. He said Chan, as the head of WHO, can only do what her member states allow her to do.

"Avoiding open fights is kind of the sine qua non of working for an international organization," Dr. Jeffrey Koplan, an ex-director of the U.S. Centers for Disease Control and Prevention. "But when it comes to protecting public health, I don't think she would hesitate for a second to do whatever is necessary, including being at odds with a WHO member state."

Koplan said chastising countries publicly can only lead to "short-term victories" and that it is essential for the WHO chief to keep open channels of communication with all countries.

WHO'S flu chief, Dr. Keiji Fukuda, insists the agency's discussions on how to react to outbreaks are "focused purely" on medical issues, such as how the disease is being transmitted.

But he conceded in a press conference this week that the agency's experts are "very aware" that raising the global alert level has quite significant political and potentially economic implications for all countries."

He added that Chan "did listen to all of these considerations but the main focus and most of the discussions really focused on what do we know about the epidemiology and what can we infer about it."

Many international health experts doubt whether granting WHO enhanced powers to fight disease would make a difference to curbing international disease threats. And most member nations bristle at the idea.

A delegate from an Asian country that has faced bird flu outbreaks said he did not want more powers for WHO than those granted by the International Health Regulations, which require countries to report major disease outbreaks and public health events to WHO.

He spoke on condition of anonymity because he was not authorized to speak to the press.

WHO can request information from countries about rumored or suspected outbreaks, but it cannot unilaterally enter a country to respond to a health crisis without an invitation from the government.

Some have wondered whether it's time to grant WHO such powers when faced with potential health catastrophes that may cross borders.

"Some countries might support that idea, but the problem is how to do it in reality," said Sandra Mounier-Jack, a global public health policy expert at the London School of Hygiene and Tropical Medicine.

When investigating outbreaks, WHO doctors rely on governments to help track down cases and strengthen surveillance systems. Mounier-Jack said it would be almost impossible for WHO to conduct these kinds of investigations if countries were not willing to work with WHO.

"Countries have to feel that WHO is there to help them, not to punish them," she said. "Many countries require visas for entry, so WHO could not just go in without their authorization."

Mounier-Jack suggested that instead of giving WHO more power, the agency could put pressure on countries via the media and the global community. She said it wasn't ideal, but that it had worked in the past, citing the SARS outbreak.

When China hid cases during that outbreak, WHO had no way of forcing the country to come clean, except by loudly voicing their concerns in the press. That eventually worked, and China agreed to allow in WHO teams to help stop the epidemic.

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AP Medical Writer Maria Cheng contributed from London; AP Writer Bradley S. Klapper contributed from Geneva.

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Swine flu could worsen global recession: analysts

AFP - Sunday, May 3

SINGAPORE (AFP) - - The swine flu outbreak could shatter fragile signs of a global economic rebound, but the gravity of its impact depends on the death toll it inflicts and the panic it generates, analysts said.

For Asia, where some countries are in recession, the crisis has revived memories of the severe acute respiratory syndrome (SARS) outbreak in 2003 that killed hundreds, halted travel and sent economies reeling.

Asia's first case of the A(H1N1) virus was confirmed in Hong Kong Friday, the epicentre of the 2003 SARS outbreak when close to 300 people died.

"The global economy faces yet another huge challenge," research firm Moody's Economy.com said in a market analysis.

"The recent outbreak of swine flu in Mexico and its rapid spread to other countries could interrupt trade and investment, exacerbating the worldwide recession for an uncertain period."

The World Health Organization has raised its flu alert level to five out of six, signalling a pandemic was "imminent" as more nations announced cases.

At least 19 confirmed deaths from the virus have been reported in Mexico and one death in the United States.

If the swine flu outbreak is similar to SARS, the impact will be sharp but would last only for several months, economists said.

"The risk here is if swine flu is actually more lethal than SARS and containment measures are not effective," Leong Wai Ho, a Singapore-based regional economist with Barclays Capital, told AFP.

"Under that scenario, the impact is likely to be prolonged and more profound."

Song Seng Wun, a regional economist with CIMB-GK Research, said swine flu could stamp out any tentative signs of recovery from the worst global economic crisis since the Great Depression.

"If it stays as a flu bug... perhaps it may not do too much damage to the current signs of stabilisation," he said. "But if things were to take a turn for the worse, the early shoots of recovery may be snuffed out."

Song said business confidence has begun to show signs of revival after governments worldwide rolled out stimulus packages to fight the recession and some companies were starting to receive more orders.

"If there's any knock to the fragile business confidence at this point, it may easily die out again," he warned.

Swiss banking giant Credit Suisse said the economies most vulnerable to a fallout from swine flu would be "those having sizeable tourism, retail and transportation sectors" like Hong Kong, Malaysia, Singapore and Thailand.

Moody's said the world's poorer nations, where infections might be harder to detect and treatment may not be readily available, will bear the brunt of the impact should the outbreak escalate into a pandemic.

This could affect efforts to reduce poverty, Moody's said.

For more developed economies like Singapore, Hong Kong and Taiwan, "weak confidence may be a bigger threat than the disease itself," it added.

Private consumption, a key economic growth driver after exports have fallen, could suffer if swine flu forces people to stay indoors.

This could hinder an economic rebound in the same way as SARS, which came as the region recovered from the impact of the technology crash in 2001 and the Bali bombings in 2002, analysts said.

"The economic effects of consumers and travellers staying at home will most likely be larger than the costs of fighting the virus," Moody's said.

Economists said that Asia and other major economies such as the United States and European nations are better prepared now to tackle the threat.

"For a start, swine flu appears to respond well to treatment using existing drugs," said London-based Capital Economics, noting that most of the deaths have been in Mexico where the health care system is relatively poor.

"Secondly, the world is now much better prepared to deal with these sorts of crises, thanks to the experience of SARS and persistent threat of avian flu," the research consultancy said.

It noted that the main economic damage so far "has typically come from panic measures to control a potential pandemic rather than the impact of the disease itself."

 

From Yahoo! News; source article is here.