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2009 swine flu pandemic in the United Kingdom

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Main article: 2009 flu pandemic
Further information: 2009 flu pandemic by country
Outbreak map
2009 swine flu outbreak in the United Kingdom
  Deaths
  500+ cases
  50+ cases
  5+ cases
  1+ cases
DiseaseSwine flu
Virus strainH1N1
OriginThought to be Central Mexico
Arrival date27 April 2009
Deaths1
Confirmed cases1,121[needs update][1]
Known in country transmission291[needs update][2][3]
Under investigation607[needs update]‡[1]
‡ Cases under investigation have not yet been either confirmed or ruled out as being due to this strain of influenza by laboratory tests, although some other strains may have been ruled out.

The 2009 flu pandemic, involving an outbreak of a new strain of influenza commonly known as swine flu, reached the United Kingdom in April 2009.[4] The virus was identified as a combination of several strains of Influenzavirus A, subtype H1N1. The origins of this new strain are unknown and it has not been isolated in pigs.[5] By mid-June there was found to be sustained spread between humans in two different regions of the world although it was not unusually virulent, leading the World Health Organization (WHO) to declare an influenza pandemic (phase 6, the highest state of influenza pandemic alert)[6].

The first cases were confirmed on 27 April in passengers returning from Mexico. The first case of person to person transmission within the UK was announced on 1 May.[7]

In response to the worldwide outbreak, Foreign & Commonwealth Office advised against all but essential travel to Mexico.[8] A number of government agencies issued guidance on what to do if anyone suspected they were infected, and the public were assured of the plans in place for an influenza pandemic.[9]

In early May, England's chief medical officer Sir Liam Donaldson warned that it was too early to assume the swine flu outbreak was mild because no one in the UK had died, and that there may be a resurgence of the virus in autumn and winter.[10] On 11 June 2009, the WHO announced there was a pandemic of H1N1 flu, the first pandemic in 40 years. However, it was announced that the UK was better prepared for this pandemic than in earlier years.

Outbreak timeline

2009 UK Swine Flu Outbreak Milestone
27 Apr First two UK H1N1 cases confirmed in Scotland after a flight from Mexico.[11]
29 Apr Paignton Community and Sports College closes for about a week in first school closure.[12]
1 May First two UK person to person transmissions confirmed.[13]
2 May Further schools are temporarily closed from this date.[14][15][16][17]
7 May HPA issues advice on exclusion from schools and workplaces.[18]
8 May HPA issues "advice on actions to be taken in a school in the event of a probable or confirmed case of “swine flu” being identified in a school pupil",[19] in which closure for 7 days is advised when appropriate.
The virus from European samples isolated and its full genetic fingerprint determined by UK researchers,[20] following similar work in the US on the virus in the American continent.
11 May First two schools closed reopen.[21][22]
17 May One hundredth confirmed case.[23]
19 May More than half of the UK cases are in London[1], and more than half are contracted in the UK.[2]
22 May HPA staff no longer routinely meet flights from Mexico. Contact tracing of passengers deemed to be at risk of swine flu carried out on the basis of risk, as for other communicable diseases.[24]
26 May The largest single outbreak so far, with 50[25] confirmed cases identified at a Birmingham primary school (later increased to 74[26]).
31 May The first case confirmed in Wales.[27]
6 June More than 500 confirmed cases in the UK.[28]
13 June Over 1,000 cases of swine flu confirmed in the UK.[1]
14 June First death reported at a hospital in Scotland

Reported cases

Cases by region
Last update: 14 June 2009 at 9:7 (UTC)
Region Cases
Laboratory
confirmed† 		Under
investigation‡ 		Confirmed
Deaths
Totals[1] 1,121[needs update] 607[needs update] 0
East of England 47[1] — 0
East Midlands 13[1] — 0
London 140[1] — 0
North East 22[1] — 0
North West` 19[1] — 0
South East 90[1] — 0
South West 14[1] — 0
West Midlands 229[1] — 0
Yorkshire and Humber 15[1] — 0
Northern Ireland[29] 8 — 0
Scotland[1][30] 420[needs update] — 0
Wales[31] 3 — 0
† Confirmed cases is the cumulative total number of cases diagnosed, including patients who have recovered
‡ Cases under investigation have not yet been either confirmed or ruled out as being due to this strain of influenza by laboratory tests, although some other strains may have been ruled out.

Laboratory-confirmed
cases of AH1N1 Influenza
in the United Kingdom
up to 2 July 2009

Health Protection Agency
update bulletins

Detailed reports

On 25 April 2009, a member of British Airways cabin crew was taken to Northwick Park Hospital in Harrow and quarantined after falling ill with flu-like symptoms on a flight from Mexico City though he was later found not to have swine flu.[32]

On 26 April, two people were admitted to Monklands Hospital in Airdrie, North Lanarkshire, with mild flu-like symptoms after returning from Mexico.[33][34] The next day, the Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon, confirmed that these were cases of the swine influenza A (H1N1) virus.[11] The two people involved were later named as Iain and Dawn Askham, a newly-married couple who had been on their honeymoon in the resort of Cancún in the Mexican Caribbean.[35] Authorities in both Scotland and England stated that there were no plans to trace the fellow airline passengers who may have travelled alongside the couple, since the authorities do not classify them as "close contacts".[36] These cases along with one in Spain are the first confirmed cases in Europe.[37]

At noon on 29 April the government officially made public three more confirmed cases in the UK, including the first cases in England. These were two adults (one in Redditch, and one in London), and a 12-year-old girl in Torbay, Devon. All three new cases had recently arrived back from Mexico.[38] The girl's school, Paignton Community and Sports College, closed for seven days as a result of her diagnosis.[12]

On 30 April, Newcastle University advised their students and staff of a confirmed case in a household where a non-student shares a property with two students, antiviral drugs were administered and the university stayed open.[39] The total number of new confirmed cases for 30 April was three, one on Newcastle (previously mentioned) and two more in London.

The first UK person-to-person transmission was confirmed on 1 May. The victim, from Falkirk, was infected after contact with the first Britons to develop the flu.[40] The same day it was confirmed that a 12-year-old girl from Downend in South Gloucestershire had been diagnosed with swine flu. She was on the same flight as the Scottish couple who tested positive earlier in the week.[41][42] A 42-year-old man, in South Gloucestershire, is the second "onward transmission" case in the United Kingdom; officials said the two Gloucestershire cases were not connected.[13] The man, who lives in Chipping Sodbury, was believed to have caught the virus from someone who had visited Mexico or United States.[43][44]

On 2 May the Department of Health confirmed that an adult in the North West and a child in the South East had contracted the virus.[43] The total number of UK confirmed cases stood at 15.[45]

On 3 May, Scottish health authorities reported a case in Ayrshire, where a man reportedly caught the virus in the U.S. state of Texas.[46]

On 4 May nine new cases were confirmed.Two cases are adults, from London and the West Midlands. Both of these cases had recently returned from Mexico. Two cases are siblings of school age in London, who are close contacts of a previously confirmed case in a returned traveller to the US. Five further cases are of school age from London. These five all attend one school.[47]

On 5 May one new case was confirmed in South East England, a traveller returning from Mexico.[48]

Since then and as of 23 May there have been a few new cases (only once more than 10) confirmed every day, a few hundreds under investigation, and no deaths. Most UK cases are in London. A large proportion of cases are from person-to-person infection within the UK, but the HPA daily updates include a significant minority of travellers infected elsewhere[1].

As of 26 May, The majority of cases were in school children and young adults[49] and the number of people who contracted the disease in-country increased to 125, Which is the highest in Europe and triple the second highest, Spain, Which has 42 people who have contracted the disease in-country.[50]

On 28 May, sixty four people connected with a primary school in Birmingham have being diagnosed with Swine Flu .[51]

On 8 June the HPA issued a report stating that the majority of cases are in school age children and young adults[3], which has not been the case in most pandemics with the notable exception of 1918[52].

Public information campaign

The Department of Health announced on 29 April 2009 that they intended to send an information leaflet on swine flu to every household in the UK.[53] On 5 May they started to deliver leaflets to all households in the UK.[54] On 29 April, Alan Johnson announced that television and radio advice would also be broadcast starting on 30 April.[55] On 30 April 2009, a swine flu information line was launched with advice on setting up "flu friends" (this is not the National Flu Line service mentioned below).[55]

The Department of Health Pandemic Plan (revised November 2007) states "UK health departments (directorate in Scotland) will run a national door drop and advertising campaign in Phase 5, alerting the public to the heightened risk, emphasising the need for personal preparation and socially responsible behaviour. A public information film will demonstrate how to slow the spread of the virus, and the National Flu Line service will be available. Information materials will also be available through primary care, pharmacies and on the Department of Health website."[56] The National Flu Line service is due to be launched in late 2009.[57]

There are government websites with general information and the latest updates on human swine flu in the UK,[1] Northern Ireland,[29] Scotland,[30][58] and Wales.[31]

The HPA website includes frequently updated advice for the public,[59] advice on exclusion from schools and workplaces[18] (and a document specifically for schools),[19] and information for health professionals.[60]

Control measures

Main article: Prevention and treatment for the 2009 swine flu outbreak

As of 11 May 2009 UK epidemiologists at Imperial College London consider that H1N1 swine flu is spreading fast enough to justify the preparations for a pandemic. It is showing "sustained human-to-human transmission", thereby justifying the WHO's pandemic phase 5 rating. It is estimated that on average each person who contracts flu passes it on to between 1.4 and 1.6 other people, no worse than the three influenza pandemics of the twentieth century. Early analysis suggests that the spread is likely to be similar to the earlier pandemics. Up to the date of the study, clinical severity is similar to 1957 and less than 1918. However, the clinical severity of the outbreak and how the virus will evolve cannot yet be predicted. [61]

Travel to and from affected areas

On 27 April, the Foreign & Commonwealth Office advised against all but essential travel to Mexico[8] and stated that British citizens in Mexico... "may wish to consider whether they should remain in Mexico at this time". On 28 April the Mexican Tourist Board estimated that there were "a few thousand" British tourists in Mexico.[62]

British Airways is continuing to fly to Mexico City four times per week. It is offering passengers the option of cancelling their flights, or rebooking to another destination with no cancellation fees.

Holiday companies Thomas Cook and Airtours said that between them they had about "3,000 holidaymakers in Mexico" as of 28 April 2009.[63] The first British tourists being brought back early from Mexico on 28 April 2009 told reporters that they had received little or no information about health precautions, either from the Mexican authorities, hotels, or from local tour guides.[64]

A leaflet is being distributed at all ports of entry into the UK providing passengers arriving in the UK with information on swine flu.[65]

Until 21 May HPA staff met travellers arriving from Mexico. This was discontinued on 22 May, but advice remained that travellers from affected areas who become unwell within seven days of arrival, and contacts with symptoms of a confirmed or probable case, should stay at home and contact their GP or NHS Direct. Contact tracing of passengers deemed to be at risk of swine flu will be carried out on the basis of risk, as for other communicable diseases.[24].

Preparations

Tamiflu, influenza antiviral drug

Information, advice, and guidance both general and for specific cases (schools, workplaces) is being made available and updated by the HPA (see Public information campaign section above).

As of 13 June 2009 the government estimated that the UK has enough anti-viral drugs for 50% of the population but has plans to raise that figure to 80%[66].

There is a pandemic plan covering topics from distributing the drugs and setting up helplines to closing schools and banning public events which was tested in a large exercise in 2007.[9][56][67] There is also a specific response plan for London.[68]

It should be noted that oseltamivir (Tamiflu) and zanamivir (Relenza), the two antivirals known to be effective, must be taken within 48 hours of onset of symptoms or earlier to be effective;[69] the positive effects are greatest if treatment is started within six hours.[70] To be effective stockpiled supplies must be made available to patients within this timescale, regardless of weekends and holidays.

On 5 May 2009 plans were announced for pupils unable to sit examinations at schools affected by flu to be assessed in other ways to ensure that children are not disadvantaged.[71]

Testing suspected cases

Genetic analysis

Samples from suspected cases have been analysed by the National Institute for Medical Research in London, which is also examining samples of the U.S. strain of the disease.[72]

By 8 May 2009 the US Centers for Disease Control and Prevention had made genetic information on the swine flu virus available, and the virus from European samples had been isolated and its full genetic fingerprint determined by UK researchers.[20] The genetics and effects of the virus in general are discussed in the article on the 2009 swine flu outbreak.

Diagnosis

The fastest way for laboratory confirmation of swine flu is by the PCR method, described as a real-time method. According to the WHO there are four laboratories in the UK able to perform PCR to diagnose influenza A (H1N1) virus infection in humans: Regional Virus Laboratory, Royal Victoria Hospital, Belfast, NI; Regional Virus Laboratory, Gartnavel General Hospital, Glasgow, Scotland; Health Protection Agency, Centre for Infections, Enteric, Respiratory, & Neurological Virus Laboratory, London; WHO Collaborating Centre for Reference and Research on Influenza, National Institute for Medical Research, London.[73]

Another laboratory confirmation is a fourfold increase in virus-specific antibodies 10 to 14 days later.[74]

Hygiene recommendations

The Health Protection Agency in guidance included in its regular updates[1] recommends infection control practices and good hygiene to help reduce transmission of all viruses, including swine flu. These include:

  • Covering nose and mouth when coughing or sneezing, and using a tissue when possible.
  • Disposing of dirty tissues promptly and carefully.
  • Maintaining good basic hygiene, for example washing hands frequently with soap and water to reduce the spread of the virus from your hands to face or to other people.
  • Cleaning hard surfaces, such as door handles, frequently using a normal cleaning product.
  • Making sure children follow this advice.
  • Anyone with swine flu or being investigated as a possible case will be given antivirals and asked to stay at home and limit their contact with other people.
  • Where antivirals are prescribed the course of treatment must be followed and completed, although it may sometimes cause nausea.

Professor Steve Field, chairman of the Royal College of General Practitioners, said on 28 April that people in the UK were "perfectly safe at the moment", and did not need to start wearing facemasks or stop eating pork.[75]

Possible use of facemasks

Alan Johnson, Health Secretary at the time of the outbreak

Health Secretary Alan Johnson told MPs on 27 April that "Although we are aware that facemasks are being given out to the public in Mexico, the available scientific evidence does not support the general wearing of facemasks by those who are not ill, whilst going about their normal activities."[76]

Professor Steve Field, chairman of the Royal College of General Practitioners, said people in the UK were "perfectly safe at the moment", and did not need to start wearing facemasks or stop eating pork.[77]

The Head of Pandemic Planning at the Royal College of General Practitioners, Dr Maureen Baker, stated on 27 April that "Masks become ineffective when they become damp or after a few hours. There has been a lot of debate on the use of facemasks and some authorities say that, in the community, the most effective use is to give to patients who may have symptoms when they present in the surgery — that should help reduce the infectivity of that patient to surgery staff and other patients. I expect the Department of Health will issue guidance on use of facemasks if we move into a pandemic phase."[78] Masks may not protect the wearer from inhalation of the virus, but might protect other people from picking up the virus from the wearer.[9]

Professor John Oxford, a virologist at leading London hospital, The Barts and the London, said: "Really, there is very little evidence that masks actually offer much protection against flu."[79]

It is reported that the UK government is urgently seeking to acquire more facemasks.[80][81][82]

Aside from their obligations under health and safety legislation, employers can help to minimise the spread of the virus and support good infection control practice by positively encouraging any employee who reports feeling unwell with influenza-like symptoms to stay at home until their symptoms resolve, by sending people home who develop influenza-like illness at work (avoiding public transport and wearing a face mask if possible) and by ensuring that stocks of surgical facemasks are available in the workplace for symptomatic staff to wear until they get home.

— DoH Pandemic Flu Plan[56], November 2007

References

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  2. ^ a b "Outbreak of influenza A/H1N1 virus". European Centre for Disease Prevention and Control. Frequently updated site. Information may lag HPA figures. Links to daily situation reports. {{cite web}}: Check date values in: |date= (help)
  3. ^ a b [http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1244442493055 Swine-lineage Influenza A H1N1 UK update 08 June 09]
  4. ^ Dominic Rushe (3 May 2009). "Swine flu by another name isn't so catchy". The Sunday Times. Retrieved 2009-05-04. Sadly I don't think this name change is going to stick. Flu epidemics used to get named after their country of origin. Mexico has so far been unbelievably lucky in its attempts to dodge this one. The Israelis tried to pass the name back last week – they don't like the swine appellation either. But they soon backed off after a furious Mexican response. Nobody worried about the affect on tourism or pig sales when the Spanish flu killed more than 50m people in 1918.
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    Northern Ireland Department of Health, Social Services and Public Safety update on confirmed swine flu cases: 19 May 2009 (this link will be updated to reference the latest update)
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    Welsh Assembly Government update on confirmed swine flu cases: 23 May 2009 (this link will be updated to reference the latest Welsh Assembly Government update)
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