Real danger still ahead

Should the spread of swine flu escalate according to the World Health Organization’s (WHO) projections, it could create havoc in South Africa. State resources will come under immense pressure and already struggling state health services run the risk of collapsing altogether. It could also bring a fresh argument into the national health service debate.

If the impact of an intensifying pandemic is as severe as some predict, it may create a platform for a good case to be made for new legislation that could compel the private sector to assist the public health sector in times of declared endemic and pandemic catastrophes, but that will be of no help right now.

Although South Africa is nearing the end of its winter and therefore its annual flu season, the worldwide swine flu pandemic continues to pose a major threat locally that could seriously impact on the economy and state resources should it spread as rapidly as the WHO is presently warning.

The WHO has issued a warning that the globally swine flu, or H1N1, will spread much more rapidly in coming months and governments must step up preparations to counter it. The WHO has accordingly also altered its guidelines for the administering of antiviral drugs.

The WHO projects that there will soon be a period of escalated spreading of the virus. In most countries, this will take the form of swine flu cases doubling every three to four days for several months until peak transmission is reached, reports Sapa-AP/Mail & Guardian, quoting the WHO's Western Pacific director, Shin Young-soo.

Shin told a symposium of health officials in Beijing that there will “seem to be an explosion in case numbers” at a certain point, with “more cases and more deaths”.

It now says all children younger than five, pregnant women and people with underlying symptoms that could promote complications, who display any signs of the flu must immediately be given medicines such as Tamiflu or Relenza and should not be made to wait for laboratory test results, regardless of the level of seriousness of their symptoms.

The medicines work best if administered within 48 hours after the first symptoms appear. People with symptoms of other underlying health problems such as asthma, other respiratory diseases, tuberculosis, HIV, heart problems and diabetes, as well as pregnant women and young children, are most at risk of dying.

But South Africa’s state health sector possesses only 100 000 doses of a generic version of Tamiflu called Oseltamivir, despite the state health services having to cater for 40 million people. Therefore, if the rapid escalation of the pandemic as predicted by the WHO should materialise, it would create a major health crisis. Current estimates are that up to 30% of South Africa’s population may become infected, but state health preparations do not correspond in any way to these projections.

In South Africa, of the nine people who have died since a sudden escalation on 28 July, three were pregnant women, one was diabetic, and three were young people aged between 15 and 22.

While the private pharmaceutical sector in South Africa has been accused by state organs of selling antiviral drugs unnecessarily to people with flu symptoms, the opposite occurred in the state sector, which this past week led to the death of a 20-year-old woman.

Annique Pretorius of Pretoria was admitted to a state hospital, discharged, and readmitted and tested only after three days. She received no drugs despite her weakened condition and allegedly died as a result.

Most of the reported swine flu deaths in South Africa so far occurred in state hospitals that are notoriously run-down, under-staffed, under-resourced and ill-prepared for any kind of health emergency.

However, the private health sector in South Africa has also come in for much criticism, not only from the state sector but also from the general public. Accusations have been made about private medical practitioners “ripping off” patients by charging R1 500 to have a blood test done and of pumping them full of antiviral drugs before any symptoms have been confirmed, thus allegedly creating immunity to these drugs in such patients.

As of 19 August 2009, there were over 3 400 confirmed cases of swine flu in South Africa. Gauteng had the highest infection rate with over 1 800 cases, followed by the Western Cape with over 800 cases and KwaZulu-Natal with over 350 cases.

Last week Health minister Aaron Motsoaledi announced that the government would step up its response to the swine flu pandemic with the launch of major awareness campaigns countrywide. The Department of Health subsequently set up a hotline as well as a dedicated e-mail address for public queries about swine flu. However, there has been no word from the government on how it would address the most pressing need should there be an escalation, namely the availability and provision of antiviral drugs.

The WHO has declared the swine flu strain a pandemic. It killed almost 1 800 people worldwide through last week alone. The most recent report of the European Centre for Disease Prevention and Control said the H1N1 flu has spread to 178 countries and territories around the world, with 227 562 people affected and 2 073 deaths reported. It also said that nations in the southern hemisphere continue to see complicated developments of the pandemic with rapidly increasing numbers of new cases and fatalities.

Argentina reported that 404 died of the flu, Brazil 192, Australia 102 and New Zealand 14. In East Asia and Southeast Asia, the disease is developing in a complex manner with new infections and deaths rapidly increasing.

Meanwhile the southern hemisphere – which currently is in its winter and flu season – is serving as something of a guinea pig for the northern hemisphere, which is watching how the pandemic develops in the south with much interest, as northern countries await the onset of their winter.

It is reported that health officials and drug makers are meanwhile looking into ways to speed up production of a vaccine before the northern hemisphere enters its flu season in coming months. Estimates for when a vaccine will be available range from September to December.

The WHO earlier estimated that as many as two billion people could become infected over the next two years, which is nearly one-third of the world's entire population.

A rapid escalation of infected people and resultant deaths could impact with immense consequences on all economic sectors. Massive movements of people internationally, such as anticipated with next year’s Fifa Soccer World Cup in South Africa, could easily complicate matters, particularly as many visitors will be coming from the northern hemisphere winter into the southern one. And any rapid escalation could also exacerbate the situation regarding South Africa’s high HIV-infection rate, with combination H1N1/Aids-related deaths likely to impact even more in most economic sectors.

Also worrying is that seasonal changes have not altered the spread of swine flu as is the case with most other flu strains. In the northern hemisphere, it has continued to spread during summer, proving to be resilient.

While the WHO has stressed that until now most cases have been mild and required no treatment, there are fears that a rash of new infections could overwhelm hospitals and health authorities, particularly in poorer countries. The last big flu pandemic – the Hong Kong flu of 1968 – killed about one million people. Ordinary flu is said to kill about 250 000 to 500 000 people each year.

For now, however, while swine flu appears to be rapidly spreading in South Africa as in the rest of the world, the full potential impact and eventual outcome still remains pretty much an unknown factor. While the WHO predicts massive escalation, past experiences, such as with the “bird flu” of a few years ago, have shown that actual outcomes are often far less severe than the predictions. But the opposite is also often true. What does seem certain though is that South Africa is not very well positioned to deal effectively with any rapid escalation of the pandemic, and any such development is likely to lead to a serious crisis with severe health, social and economic consequences for the country.