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15 Kislev 5763 - November 20, 2002 | Mordecai Plaut, director Published Weekly
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NEWS
Is A Flu Pandemic on the Way?
by N. Katzin

The flu virus is making its way towards Israel and Europe. According to official forecasts, the flu season could arrive at any time. Years of experience show a flu outbreak is bound to strike this year, just as every year, leaving hundreds of thousands of people bedridden with high fever, body aches and other symptoms.

Some flu patients, particularly the elderly and the chronically ill, are expected to develop complications that lead to thousands of mortalities every year. Hospitals will be filled to capacity and before long beds will spill out into the corridors. Children's wards will be even more packed due to the appearance of a relatively new strain we will discuss below.

But this is merely a description of the annual routine, which pales in comparison to the serious alerts. Saddam Hussein? Nope. Al Qaeda? Wrong again. Today Europe is terrified of a much worse threat: a deadly worldwide flu epidemic called super flu.

The forecasted epidemic, which the epidemiologists call a pandemic, is liable to claim hundreds of thousands of victims in Europe alone. And if Europe is overtaken, in the age of the global village the entire world would also be at serious risk. Virologists and experts from across the continent were summoned to an emergency conference in Malta recently to discuss preparations for the anticipated epidemic.

European experts have little to say to allay our fears. "It's not a question of if, but when," warns Albert Austrahaus, Professor of Virology at the University of Rotterdam and one of the heads of the conference in Malta. Sounds frightening? Certain Israeli health officials have been heard to express satisfaction over the scare headlines. They increased the public's response to calls for vaccination.

Thirty Years Since the Last Pandemic

Following requests by the World Health Organization, the Israeli health system is also preparing for the possibility of a worldwide pandemic outbreak. If it's any consolation, Dr. Alex Leventhal, head of public health services at the Ministry of Health, says the danger is nothing new. "There have been concerns in recent years, every year, with or without headlines . . . I have not found any supporting evidence in scientific sources for this new warning. Every year there are fears that a new flu strain not found in the vaccination might appear. From this perspective nothing has changed this year. There is nothing new under the sun."

Nevertheless the Health Ministry is not taking the warnings lightly. Dr. Leventhal, who heads a special Health Ministry committee set up to formulate a contingency plan for Health Ministry readiness, explains that flu epidemics have a cyclical nature and according to statistics there has been a high risk of an outbreak over recent years.

The last outbreak took place in 1968 and was called Hong Kong fever. Since then there has not been a pandemic outbreak, because three strains of flu were always observed and were included in flu shots. The exception was the Sidney virus four years ago, which was not included in the vaccine and caused a relatively high disease and fatality rate, but besiyata deShmaya not of epidemic proportions.

If and when a new strain not included in the vaccine appears, the disease rate could be massive, both because the vaccination will not help defend against the flu and because the population will have no immunity against it.

Children Under Eight at Higher Risk

Dr. Amnon Kiro, an expert in the study of monitoring influenza and director of pediatrics at the Ministry of Health in Tel Aviv, explains how disease rates for the coming year are predicted. "As the flu season approaches, an assessment is performed according to what transpired over the winter in the southern hemisphere, during our summer months. For example, Madagascar posted particularly high flu activity; 155 mortalities were observed there as a result of the flu wave. A World Health Organization study found the virus, the Moscow strain, was not so aggressive and the high mortality rate there was attributed to malnutrition and inferior health conditions.

In the southern hemisphere the flu abates in September and then the first new viruses begin to appear in the northern hemisphere. The flu generally arrives in Israel around the middle of November. According to this year's initial forecast, the anticipated active strains are Moscow A, New Caledonia A and Hong Kong B.

Due to the Hong Kong virus, newer than the other two, the disease rate during the coming winter could be higher than usual. Since it has been inactive for seven years, children under the age of eight face an increased risk of contracting this type of flu because they have never been exposed to it. Adults, on the other hand, have some immunity against it.

The Hong Kong virus was already active last March, during relatively warm weather, therefore increased activity is expected from it this winter. Not that Hong Kong A or the other two viruses are particularly aggressive.

Preparing a Pandemic File

If the three current viruses are not any worse than usual, why is a pandemic outbreak expected to develop? What has changed?

According to Dr. Kiro, a historical survey shows the flu virus activity appears in cyclical outbreaks. Unlike most viruses, against which a single vaccination provides resistance for an entire lifetime, the flu virus constantly undergoes genetic changes, evolving rapidly. To be more accurate its mantle changes and our immune systems fail to recognize the new mutation as a hostile force.

Every 20 to 30 years a significant genetic alteration takes place. The virus becomes unrecognizable to the immune system, the body lacks antibodies against it and, if the change takes place suddenly, the flu shot for that year will not include the new strain, and it is liable to cause a deadly, wide- scale epidemic.

The 1918 strain, known as Spanish flu, was particularly deadly. To this day scientists are unsure how it caused such a large number of fatalities: tens of millions dead in Europe and 100 million around the world. Other pandemics broke out in 1957 and 1968, causing 40 million deaths.

The last outbreak took place in 1997, but was stopped in time. Then, too, the entire world was in a state of trepidation over the bird flu, which was spreading quickly around Hong Kong and had caused a number of fatalities. The panic that erupted led the authorities in Hong Kong to take action immediately. They destroyed hundreds of millions of birds, thereby stopping the epidemic in its tracks.

The thirty-year cycles between pandemics indicate the next outbreak could come at any time. Every year the likelihood of a pandemic increases. European influenza researchers are convinced the next outbreak is unavoidable.

According to Dr. Kiro, "The World Health Organization and health ministries in various countries have prepared a `pandemic file.' Important findings are transmitted to five centers worldwide: in Geneva, London, Atlanta, Rio de Janeiro and Tokyo. Flu laboratories with top experts perform precise genetic classification of the virus and pass the data on to the companies that manufacture the vaccine.

"We estimate that with the appearance of the new, unrecognized virus, we will have four months, which will allow us to prepare millions of vaccines. To accomplish this, we need a monitoring and response system that can function faster than the new virus's contagion rate. As of now we are under the impression the matter is in control."

Only 50 Percent are Vaccinated

Drugs against influenza, relegated to the realm of fiction until the last decade, have become part of the array of medications at our disposal. But the flu vaccine is still the most effective means of fighting the illness.

The flu vaccination season started over a month ago, but vaccination is available even after the flu season is already underway. Now the various kupot cholim have finally realized the economic importance of the vaccine and have begun to encourage their members in high-risk groups to get vaccinated.

While in the past the official recommendation was for those over the age of 65, today vaccination is recommended for everyone age 50 and over, following epidemiological studies that showed the rate of complications is also higher starting at that age.

Vaccinating hundreds of thousands of people within a short period is no easy task. According to Dr. Michael Rosenblatt, deputy director of medicine at Klalit Health Services, says, "This is the largest routine community project in existence, held annually at this time of the year. The problem, of course, is that the virus changes from year to year. The level of antibodies does not remain for an extended period, therefore the vaccine has to be re-administered every year. It is a never-ending project.

"Our target population is the 450,000 people in the risk groups. We would very much like to reach a vaccination rate of 70 percent of the population, a goal similar to that of other countries that has had a major impact in terms of reducing the disease rate."

As of now the rate of vaccination is around 50-55 percent of the population at risk, although presumably the recent headlines regarding the super flu have boosted vaccination rates. Dr. Rosenblatt estimates vaccination rates are similar at other kupot cholim as well. These figures, of course, represent the national average. Some segments of the population have a vaccination rate of nearly 100 percent while others hover around the 0 mark.

Vaccination is of great importance both for the individual and the public. In most cases influenza is not a particularly severe disease, notes Dr. Rosenblatt. "One or two weeks of fever and other symptoms and it's over with. But in some cases there are complications that can be dangerous, which makes it important for individuals to get vaccinated.

"From the public's standpoint influenza is a disease that spreads very quickly and the fewer cases of flu circulating, the fewer people will be contaminated and contract the disease. From a medical standpoint the most pressing matter is to vaccinate segments of the population more prone to illness, those who will not be done with the illness after a few days of fever but will develop severe complications."

A Question of Budget, not Medical Expediency

The various kupot cholim offer flu shots to members at different prices. Maccabi provides the vaccine for people over the age of 55 and the chronically ill at no cost; for others the price is NIS 12. Meuchedet offers free vaccination for members age 50 and over and patients in risk groups; other members pay NIS 12. At Leumit the vaccine is free for members aged 50 and over, holders of supplementary insurance policies and risk groups; others pay NIS 11.

Providing free flu shots for everyone is in the health funds' best interest, but the matter is really a question of budgeting policies, explains Dr. Rosenblatt. "Last year the Health Ministry determined vaccines should be part of the basket of services and indeed they were given to the elderly at no cost. This year vaccination is not included in the basket of services and Klalit decided on a policy of adding it . . . Klalit also focuses on the 65 and over population group, not 50 and over. Our experience has shown the population group more prone to illness also has a high rate of vaccination."

Many parents are undecided whether to vaccinate their children. Recently the US Department of Health issued instructions to vaccinate children between the ages of six months and two years against influenza, but the Israeli Ministry of Health has not adopted this policy.

According to Dr. Leventhal, Israel generally follows directives issued by the World Health Organization. "At this age children generally overcome the disease relatively easily. All people age 50 and over should be vaccinated. Personally I always make it a point to get my shot every year, but even within the health system I don't see everyone getting vaccinated."

From a medical perspective there is no debate: experts unanimously recommend parents vaccinate their children to spare them an illness that may not be easy and could involve complications, particularly this year since the disease rate is expected to be higher among young children.

The cost of vaccination is not high and the side effects, if any, are minimal. If you have not yet gotten vaccinated it is recommended you do so and that you take the younger children with you, since they are generally the ones who introduce the chain of infection into the family.

 

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