Port Louis — Three medical practitioners give their opinions on the way the H1 N1 flu epidemic has been handled by the authorities and how a worsening of the situation could be prevented.

In 1971, Visconti produced a beautiful film based on a novella by Thomas Mann: "Death in Venice". For our purpose we will disregard the main plot of the film which is set in 1911 Venice, and only consider the background: an epidemic has started spreading around Venice, and the health authorities go into denial mode. They are obviously worried about the possible effects of the cholera epidemic on the tourist industry, in a city which is very dependent on the revenue from its tourists. Is it possible that the Mauritian Government draws everyone into its own confused thinking whenever it has to conciliate the imperatives of public health with the economic interests of the tourist industry?

Frankly it is quite difficult to imagine any other explanation for the mindless somersaults in the handling of the H1N1 influenza cases presently affecting Mauritius. The Ministry of Health claims to have ample supplies of H1N1 vaccines and anti-viral treatment: so why wait until there are reported deaths to start the appropriate campaign, when there have been confirmed cases of the disease since February, a good five months ago. Once there are reported deaths from H1N1 fl u, then the Ministry has to come out with available figures but when the figures are deliberately kept low, then the death rate looks alarming. This particular conundrum last year has already produced at least one victim in the form of an arrested newspaper editor.

Be that as it may we do need to draw lessons from this mishandling of the situation. The main problem has been the lack of communication with the public - on the nature of the disease, on the implications of an epidemic of such a disease: very few people seem to have grasped the fact that the H1N1 fl u is clinically not very different from ordinary seasonal influenza that we get every winter. The only differences are a more rapid propagation of the H1N1 fl u because the population does not have the same resistance to this new virus as to the seasonal type, and occasional cases of severe lung affection leading to respiratory distress. Obviously when cases of seasonal fl u are added to cases of H1N1 fl u, the much higher number of affected people will produce a higher incidence of morbidity and mortality related to any fl u-like illness. Already there were reports of a record number of attendances at hospital and dispensary, two months ago.

The lack of communications has also produced another erroneous impression: even the state TV and radio continue to refer to "128 cases", when this is simply the number of lab-confirmed cases from a sample of 1437 tests: the number of cases of H1N1 infections in the population is clearly much higher. This has led to sterile debates between the ministry and private doctors: but it has also exposed the total impossibility of dealing with such epidemics in the absence of a proper family doctor system which is integrated into the public health system. People with influenza either consult a private doctor or go to a clinic, or attend the government services: these are separate channels without communicating structures for prevalence studies or indeed for treatment.

In more general terms, recent epidemics have exposed the dangerous shift of resources from preventive medicine to curative: the flashy cardiac specialist lives in a different world from the humble epidemiologist. This shift has happened in parallel with the increasing privatization of health care: the private sector thrives on disease. We need a system that guarantees health.

History repeating itself

It is interesting to note how history tends to repeat itself. In 1918, the "Spanish flu" pandemic, which was a deadly strain of avian flu, killed 50 to 100 million people in the years 1918 and 1919. I was curious to know why it was termed "Spanish flu" and thought that the outbreak started from there but then discovered that Spain was the only European country where the press were reporting about the flu unlike other European countries who were covering up information in order to protect the morale of the troops and of the population.

In June 2009, the World Health Organisation (WHO) declared an H1 N1 pandemic and in March 2010 a worldwide update by WHO states that 213 countries have been afflicted by the flu causing at least 16,931 deaths. In May 2010, another worldwide update by the WHO mentions over 18,138 deaths. A closer look at the statistics for Mauritius shows that only 33 laboratory confirmed cases of pandemic flu were detected in 2009 and 4 deaths reported. In Reunion Island where the demographic population is almost half of that of Mauritius, over 3000 positive cases were diagnosed with a death toll amounting to zero. With regard to chikungunya, official figures for Mauritius state that in 2006, 11,000 persons were affected by the virus whereas during the same year in Reunion, 110,000 to 260,000 persons were estimated by WHO to have been infected by the virus.

The discrepancies between the prevalence and death toll of both H1N1 and chikungunya in Mauritius and Reunion are puzzling. Bearing in mind that there is no specific treatment so far for viral infections be it AIDS, flu, chikungunya, among others, the best remedy is through prevention by vaccination when available and information coupled with preventive measures.

Had our local press not acted like the Spanish press and not revealed the recent casualties of H1N1 in our country, the population would have been kept in the dark and in ignorance. What threatens mankind and human survival is no longer hypothetical nuclear wars but natural calamities and microscopic threats for which we, doctors, have no remedy save preventive measures through precise and reliable information.

A vaccination policy

By Dr Zouberr JOOMAYE, Specialist in Internal Medicine

The aim of a massive vaccination program is to create immunity against an infective agent liable to be responsible for an epidemic situation. The father of vaccination is Louis Pasteur, the French scientist. Vaccination against influenza has existed for several years and is believed to confer immunity in around 80 % of people. Specific vaccination preventing A H1 N1 influenza was elaborated in 2009 after the recent pandemic. Thousands of people have been vaccinated in Europe and the USA without major side-effects of the vaccine being noted.

In Mauritius, the outbreak of A H1 N1 in 2009 led to at least 100 000 cases with several deaths. The epidemic was only controlled following the establishment of fl u-clinics and the closure of schools, a very drastic measure. Vaccination together with the promotion of hygienic measures are the pillars of a preventive campaign against influenza. It has been recently brought to public knowledge that the first case of A H1 N1 had been detected as early as February 2010 and that the MOH had at its disposal 170 000 doses of vaccines for H1 N1 since April 2010. Vaccination for influenza is usually indicated as from the month of April before the arrival of winter and this takes into account the fact it takes 15 days at least after injection for the vaccine to be effective.

The role of the MOH is to ensure the appropriate use of the vaccine available through a well defined vaccination program. It is undeniable that the most vulnerable group of patients are those suffering from respiratory disorders such as bronchial asthma, chronic bronchitis and respiratory failure. The mortality rate in these patients is the highest. Other risk groups include diabetics, patients with cardio-vascular diseases, renal failure and other chronic inflammatory and neoplastic disorders. A nominative priority list should have been established based on data available from our public hospitals where 80 % of these patients are being followed up.

Considering that 22,000 patients go into the public health sector daily for either emergencies or follow-up, it is difficult to explain that only 6,000 doses of vaccines have been used on Mauritians since April 2010.

For sure, no individual should be compelled to get himself protected. But relevant, clear and precise information regarding the necessity of being vaccinated is rarely unsuccessful. Had the whole stock of vaccines been used, we would surely have had fewer cases of influenza this winter, and may be zero mortality...

However it is never too late to start the elaboration of a vaccination plan for the coming years, as H1 N1 is now endemic in Mauritius and the protection lasts only one year after a dose. Gouverner, c'est prévoir n'est-ce pas?