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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
2009 swine flu pandemic in the UK
DiseaseSwine flu
Virus strainH1N1
Arrival date27 April 2009[1]
OriginCentral Mexico[2]
Deaths65†
Weekly consultation rate16/100,000†
Government flu websiteHealth Protection Agency[1]
† 27Aug09[needs update] QSurveillance data from HPA[1] on influenza and influenza-like illness
Daily consultation rate for influenza-like illness in the UK.
04Sep09 - QSurveillance data from HPA. [3]

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.[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]

5-14 year olds are the age group predominantly affected.[7] Laboratory tests have demonstrated that older people have some immunity.[8]

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.[9]

On 11 June 2009, the World Health Organization (WHO) announced there was a pandemic of H1N1 flu, the first pandemic in 40 years. On 25 June the chief medical officer said tens of thousands of cases could be emerging each week by the autumn, but that there might be a vaccine by August.[10]

A sharp decline in new cases in the UK was reported in the first week of August. [11] The Health Protection Agency estimated that there were 30,000 new cases of swineflu in England that week compared with 110,000 cases in the previous week.[1] Cases fell progressively, down to 4,500 in the last week of August.[1] This decline in cases during the summer had been predicted, but a large surge is expected in the autumn to coincide with the normal flu season.[11]

Outbreak timeline

2009 UK Swine Flu Outbreak Milestone
27 Apr First two UK H1N1 cases confirmed in Scotland after a flight from Mexico.[12]
29 Apr Paignton Community and Sports College closes for about a week in first school closure.[13]
1 May First two UK person to person transmissions confirmed.[14]
2 May Further schools are temporarily closed from this date.[15][16][17][18]
7 May HPA issues advice on exclusion from schools and workplaces.[19]
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",[20] 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,[21] following similar work in the US on the virus in the American continent.
17 May One hundredth confirmed case.[22]
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.[23]
26 May The largest single outbreak so far, with 50[24] confirmed cases identified at a Birmingham primary school (later increased to 74[25]).
13 Jun Over 1,000 cases of swine flu confirmed in the UK.[1]
14 Jun First death, of patient with underlying health problems, reported at the Royal Alexandra Hospital in Paisley, Glasgow, Scotland.[26]
26 Jun Second death, of patient with underlying health problems, of a six-year-old girl at Birmingham Children's Hospital in the West Midlands region. Her death was reported on 29 June.[27]
30 Jun 6,000 cases of swine flu confirmed in the UK.[28]
2 Jul The HPA announced that the containment approach to reduce spread was no longer appropriate given the clusters of cases around the UK, and would be replaced by a treatment phase in which everybody presenting symptoms would be treated if necessary without laboratory confirmation, but contacts would not be traced. Daily reports of confirmed cases are no longer being published.[29]
6 Jul Three deaths in the UK bringing the total to seven. The new victims include two 9-year-old girls. NHS stated all three had "serious underlying health problems". The victims are from South London and Dewsbury in West Yorkshire.[30]
9 Jul The government announced that there are now over 9,000 cases of Swine flu in the UK and 14 patients have died,[31] 2 in Scotland, 5 in London, and the remainder elsewhere in England.[32]
10 Jul A 15th person has died from swine flu in Essex. Unlike previous cases, they had no underlying health conditions.[33]
13 Jul 2 more people die with swine flu in England.[34] One, a 6-year-old girl, who died of septacemia, and a middle-aged doctor. Initial reports that he died of Pulmonary Embolism were disproved on his final Post Mortem, which concluded that Swine Flu was a contributing factor in his death.[35].
16 Jul It emerges that 12 more people have died. The total now stands at 29. 85,000 people are estimated to be affected by swine flu as of 16 July, with 55,000 new infections in the preceding week according to HPA modelling.[36]
23 Jul The National Pandemic Flu Service goes live in England for the first time.[37] Shortly after it goes live, the Service gets over 2,000 hits per second. Scotland, Wales and Northern Ireland can opt in for the service if the rate of infection increases.
21 Aug The first swine flu related death in Wales has been confirmed after a 55 year old women died.
8 Sep 4 more people, including 2 children are infected in Edinburgh.

Reported cases

Until 2 July 2009 the HPA published daily reports[1] of laboratory-confirmed cases with breakdown by region, by age, and by source of infection (travel, community, etc.). From that date routine laboratory testing of all suspected cases and reporting of figures was discontinued. As of 8 July 2009 figures shown in this article are laboratory confirmed cases reported on 2 July.

Deaths are often reported as occurring "after contracting the swine flu virus" without flu being necessarily the cause of death of people with underlying health problems.

Researchers at Imperial College London said in July 2009 that the best estimate was that about 0.5% of those who get swine flu bad enough to seek medical help may die from it, a figure very similar to the estimate for seasonal influenza.[38]

Cases by region
Figures for laboratory confirmed cases in England and Scotland are as of 2 July 2009, after which routine testing was discontinued. Deaths are of people with swine flu, not necessarily caused by swine flu.
Last update: 9 September 2009 at 22:15 (UTC)
Region Cases
Laboratory
confirmed† 		Confirmed
Deaths
Totals[1] 11,159 49
East of England 411[1] 1-5[39]
East Midlands 147[1] 0
London 1,939[1] 22[40]
North East 55[1] 1
North West 97[1] 0
South East 598[1] 1[41]
South West 198[1] 0
West Midlands 2,582[1] 8[42]
Yorkshire and Humber 143[1] 3[43]
Northern Ireland[44] 85 1
Scotland[1][45] 1,217 5[46]
Wales[47] 66 7[48]
† The cumulative total number of cases, including patients who have recovered.

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.[49]

On 26 April, two people were admitted to Monklands Hospital in Airdrie, North Lanarkshire, with mild flu-like symptoms after returning from Mexico.[50][51] The next day, the Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon, confirmed that these were cases of the swine influenza A (H1N1) virus.[12] 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".[52] These cases along with one in Spain are the first confirmed cases in Europe.[53]

At noon on 29 April the government reported three more confirmed cases in the UK, including the first cases in England. All three had recently returned from Mexico.[54] The secondary school, Paignton Community and Sports College, closed for seven days.[13]

By 26 May the number of people who had contracted the disease in-country increased to 125, the highest in Europe and triple the second highest, Spain.[55]

On 28 May, sixty four people connected with a primary school in Birmingham were diagnosed with swine flu .[56]

On 8 June the HPA issued a report stating that the majority of cases are in school age children and young adults,[57] which has not been the case in most pandemics with the notable exception of 1918.[58]

On 25 June the chief medical officer Sir Liam Donaldson said certain areas were seeing rapid community spread which meant that it was no longer practical to attempt in those areas (initially parts of London, the west Midlands and east Berkshire[59]) to put a ring around the outbreaks by tracing the people with whom confirmed cases have come into contact and giving them drugs to try to prevent flu developing. In these areas, anti-viral drugs may in the future only be given to people showing symptoms, and tracing of contacts will stop. The contingency plans always envisaged the containment phase would not last indefinitely.[10] The start of the treatment (as against containment) approach was announced on 2 July 2009.[29]

Every year in late June and early July the Wimbledon tennis championships are held in London, attracting worldwide interest and with many hours of UK television coverage every day. On 1 July 2009 it was reported that 28 Wimbledon staff had been asked to stay at home with flu-like symptoms. Two named players are reported to have caught the virus.[60]

A study published in the August 2009 issue of The Lancet (available on 20 July) suggests that prolonging the school holidays could reduce the spread of the virus by up to 17%. This would be disruptive, and would not reduce the overall number of infections, but could delay the spread and buy time for preparation of a vaccine. The government's advice is that schools should not be closed, but that the evidence will be reviewed in August as school summer holidays end.[61][62]

Public information

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.[63] On 5 May they started to deliver leaflets to all households in the UK.[64] On 29 April, Alan Johnson announced that television and radio advice would also be broadcast starting on 30 April.[65] 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).[65]

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."[66] After criticism of the lateness of its launch, it was announced in late July that the National Flu Line service was to be launched on 24 July 2009.[67][68]

There are government websites with general information and the latest updates on human swine flu in England,[1] Northern Ireland,[44] Scotland,[69][70] and Wales.[47]

The HPA website includes frequently updated advice for the public,[71] advice on exclusion from schools and workplaces[19] (and a document specifically for schools),[20] and information for health professionals.[72]

During the initial containment phase of the swine flue outbreak the HPA published detailed information in daily and weekly reports linked from its Epidemiological data page on its website.[1] On 2 July, when the policy of containment was dropped in favour of treatment of presumed cases, the daily updates of laboratory confirmed cases were stopped.[73] A weekly epidemiological update and pandemic flu update are published each Tuesday, with much detailed information including regional information and breakdown by age.

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.[74]

Travel to and from affected areas

On 27 April, the Foreign & Commonwealth Office advised against all but essential travel to Mexico[75] 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.[76]

Holiday companies Thomas Cook and Airtours said that between them they had about "3,000 holidaymakers in Mexico" as of 28 April 2009.[77] 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.[78]

A leaflet is being distributed at all ports of entry into the UK providing passengers arriving in the UK with information on swine flu.[79]

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.[23]

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%.[80]

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.[66][81] There is also a specific response plan for London.[82]

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;[83] the positive effects are greatest if treatment is started within six hours.[84] To be effective stockpiled supplies must be made available to patients within this time-scale, regardless of weekends and holidays. The HPA reported in its 24 June 2009 weekly epidemiological report that all 17 samples of the virus laboratory tested for resistance that week were found to be sensitive to oseltamivir and zanamivir, but resistant to amantadine.[85] The first case of resistance of the virus to oseltamivir, in Denmark, was reported on 29 June 2009.[86]

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.[87]

The Department of Health has listed all the pandemic flu guidance that it had published as of 8 June 2008.[88]

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.[89]

By 8 May 2009 the US Centres 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.[21] 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.[90]

Another laboratory confirmation is a fourfold increase in virus-specific antibodies 10 to 14 days later.[91]

From 2 July 2009 when a treatment, rather than containment, approach was adopted, the official clinical diagnostic criteria became: "fever (pyrexia ≥38°C) or a history of fever, and also influenza-like illness (two or more of the following symptoms: cough; sore throat; rhinorrhoea; limb or joint pain; headache; vomiting or diarrhoea) or severe and/or life-threatening illness suggestive of an infectious process".[92]

"Laboratory confirmed" cases

Professor Neil Ferguson, an epidemiologist at Imperial College London, who advises the Government and the World Health Organisation, said on 8 June 2009 that HPA statistics were at best accounting for half of cases.[93]

In the USA mathematical modelling based on surveys estimated that there were about 1 million cases of H1N1 flu on 25 June 2009, compared to 28,000 reported officially.[94][95] Such a study has not been carried out in the UK.

As of 2 July 2009 GPs will diagnose based on clinical observation and routine swabbing will stop,[96] and the HPA will "no longer be providing a daily update of the numbers of cases confirmed through laboratory tests"[97]

Hygiene recommendations

The Health Protection Agency in guidance on its website[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.

For people belonging to a high-risk group it is particularly important that they start taking antivirals as soon as possible after infection. High-risk groups include people with long-term conditions, those over 65, children under five and pregnant women.[92]

Immunity

A study at the U.S. Centers for Disease Control and Prevention published in May 2009 found that children had no pre-existing immunity to the new strain but that adults, particularly those over 60, had some degree of immunity. Children showed no cross-reactive antibody reaction to the new strain, adults aged 18 to 64 had 6-9%, and older adults 33%.[8] The large proportion of cases in the UK affecting children and young adults is consistent with this pattern of resistance.[98][99]

Vaccine

Main article: 2009 flu pandemic vaccine

The usual seasonal flu vaccines give little or no immunity against the new strain of flu. There is an international program to produce a vaccine which will be effective against the new H1N1 strain. The chief medical officer Sir Liam Donaldson said on 25 June that it seemed likely that the UK would receive the first batches of vaccines slightly earlier than expected, possibly from August rather than the autumn as first expected, although some industry sources do not expect supplies to be available so soon. The government has contracts for 132 million doses.[10] There are risks involved in shifting resources to the new vaccine: it will not be possible to produce the seasonal flu vaccine, and it is possible that the virus will mutate to make a vaccine developed before the mutation ineffective.

Possible use of face-masks

Alan Johnson, Health Secretary at the time of the outbreak

The then Health Secretary Alan Johnson told MPs on 27 April that "Although we are aware that face-masks are being given out to the public in Mexico, the available scientific evidence does not support the general wearing of face-masks by those who are not ill, whilst going about their normal activities."[100]

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 face-masks or stop eating pork.[101]

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 face-masks 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 face-masks if we move into a pandemic phase."[102] Masks may not protect the wearer from inhalation of the virus, but might protect other people from picking up the virus from the wearer.[81]

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."[103]

It is reported that the UK government is urgently seeking to acquire more face-masks.[104][105][106]

The advice given by authorities in several countries on the use of face masks has been summarised in an article, with many references, published on 4 June 2009.[107]

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 face-masks are available in the workplace for symptomatic staff to wear until they get home.

— DoH Pandemic Flu Plan[66], November 2007

See also

  • GISAID the Global Initiative on Sharing Avian Influenza Data (also covers novel A/H1N1 swine flu)

References

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    Northern Ireland Department of Health, Social Services and Public Safety update on confirmed swine flu cases: 29 June 2009 (this link will be updated to reference the latest update)
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