2009 – H1N1

31/08/2015

25 April 2009 – Geneva

Overall … I consider [the British government’s] response to have been proportionate and effective. There is much good practice on which to build. I heard nothing but praise and admiration from those interviewed for the health service and health protection staff right across the UK who led the response to the pandemic. Their dedication and professionalism … despite the additional pressures of the pandemic must be acknowledged and congratulated.

Deirdre Hine1

Swine ‘flu caused quite a panic in 2009. The associated virus – H1N1 – had been responsible for the great 1918 pandemic that killed an estimated 50 to 100 million people in the wake of the First World War.2 After almost a century without such a devastating pandemic, there were legitimate concerns from health authorities that the disease could cause similar levels of destruction.

Of course, we know that this didn’t happen. Around 18,000 people died directly of the disease, with an unsubstantiated number of others who died of complications related to it. Because Armageddon never came, the World Health Organisation and other authorities were accused of fear-mongering. Even its own advisers accused WHO of wasting ‘huge amounts of money by investing in pandemic scenarios whose evidence base is weak’.3

The H1N1 virus under an electron microscope. (Source)

The H1N1 virus under an electron microscope.
(Source)

And yet, as quoted at the beginning of this piece, it turned out that caution was probably advisable. Influenza is a killer; and certain strains of the virus are more virulent than others. We are, if history is any indicator, “overdue” a mass pandemic. Understandably, given the monitoring systems in place, WHO gets a bit jittery when such virulent strains appear to be making a comeback.

There is a common-sense belief in “the boy who cried wolf” – if authorities continue to predict doom and nothing dramatic ever happens, then the public will not listen to warnings when disaster actually arrives. Yet a 2007 study into tornado alarms seems to contradict this assertion. People do respond to alarms “just in case”; and when one factors in “near misses” and other data, the rates of “false alarms” are probably not as high as originally supposed.4

(We see similar attitudes towards opinion polling, especially given their supposed “inaccuracy” in the 2015 General Election and 2016 European Union Referendum. In both cases, the margins for error in the polling data were around 1.5 to 2 per cent5 – and when these are factored in, the polls were, in fact, broadly accurate.)

H1N1, then, represented a number of issues in a modern, globalised Britain. A distrust – or at least scepticism – about the ability of experts to communicate risk to the public. Underlying concerns about the vulnerability of an interconnected world to pandemic infectious disease. And governments toeing the line between unduly panicking their citizens whilst protecting them from infection.

In June 2009, WHO declared H1N1 to be a Phase 6 pandemic – that is, it was present and infecting people in most regions of the world.6 However, it did declare the outbreak to be “moderate” – that is:

1. Most people recover from infection without the need for hospitalization or medical care.
2. Overall, national levels of severe illness … appear similar to levels seen during local seasonal influenza periods … .
3. … Hospitals and health care systems in most countries have been able to cope … .7

The UK put in place a number of pandemic measures during 2009 and 2010 in order to cope. It had done so since 2002, preparing for the possibility of an influenza pandemic. The British health authorities had in mind a more virulent strain – possibly avian flu, which had caused significant damage in Asia during the mid 2000s.8 This included the stockpiling of anti-flu drug “Tamiflu”, which has since received immense criticism for being ineffectual against most of the more virulent forms of the virus (including H1N1).9

Dame Deirdre Hine’s 2010 report, however, shows that without the benefit of hindsight the Labour government probably did the right thing. As she noted, this was the first UK-wide crisis that required co-ordination across the four devolved governments. There were also two ways to attack a potential crisis – prepare for the worst (i.e. over-prepare “just in case”) or prepare for the most likely outcome. The government went for the ‘reasonable worst-case scenario’, which meant they were probably “over prepared”, but had enough slack in the system to cope if the situation had been worse. Where they had caused public confusion was by publishing their estimates and suggestions before the final plans were put in place.10

The question remains, however – how will people respond to the next pandemic? Ebola may have been dramatic, but it did not really affect most Westerners. Similarly, the Zika virus is an unknown quantity. The press coverage and government responses have mostly been cautious. When there is another flu pandemic, how bad will it be? Will people take the threat seriously? Will governments under prepare having been burnt in the past (and operating under externally and self-imposed resource constraints)? Only time will tell.

With special thanks to Sue Taylor at the Centre for History in Public Health for pointing me in the direction of useful material on the crisis.
This post was written on 17 August 2016.
Banner image from Wikicommons.
  1. Dierdre Hine, The 2009 Influenza Pandemic: An Independent Review of the UK Response to the 2009 Influenza Pandemic (London : Cabinet Office, 2010) < https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61252/the2009influenzapandemic-review.pdf > (accessed 17 August 2015).
  2. See: ‘1918 flu pandemic’, Wikipedia < https://en.wikipedia.org/wiki/1918_flu_pandemic > (accessed 17 August 2016); ‘2009 flu pandemic’, Wikipedia < https://en.wikipedia.org/wiki/2009_flu_pandemic > (accessed 17 August 2016).
  3. Smitha Mundasad and Paul Rodgers, ‘Billions wasted on swine flu pandemic that never came’, Independent on Sunday, 16 May 2010, 36.
  4. Lindsey R. Barnes, et al., ‘False alarms and close call: a conceptual model of warning accuracy‘, Weather and Forecasting 22 (2007), 1140-1147.
  5. Anthony Wells, ‘Understanding margin of error’, YouGov (21 November 2011, 11.55) < https://yougov.co.uk/news/2011/11/21/understanding-margin-error/ > (accessed 17 August 2016).
  6. ‘2009 flu pandemic’.
  7. ‘What is phase 6?’, World Health Organisation (updated 11 June 2009) < http://www.who.int/csr/disease/swineflu/frequently_asked_questions/levels_pandemic_alert/en/ > (accessed 17 August 2016).
  8. Hine, The 2009 Influenza Pandemic; ‘Global spread of H5N1’, < https://en.wikipedia.org/wiki/Global_spread_of_H5N1 > (accessed 17 August 2016).
  9. James Gallagher, ‘Tamiflu: Millions wasted on flu drug, claims major report’, BBC News (10 April 2014) < http://www.bbc.co.uk/news/health-26954482 > (accessed 17 August 2016).
  10. Hine, The 2009 Influenza Pandemic, esp. 4-8.
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