Swine flu: The Fear

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IT WAS just an ordinary night out with his buddies. Iain Askham was around at his best man's house to share stories of his Mexican honeymoon and the two men and two teammates stayed up until midnight while the duty-free tequila flowed.

Three days later, as the world now knows, it emerged that the fiery spirit was not the only thing that Askham and his new wife Dawn, from Polmont, had brought back with them.

Early last Tuesday, TV satellite vans pulled into Jeffrey Terrace, opposite the Askham's modest semi. On Friday, the same vans appeared in Thistle Street, another unassuming side-street to the north-east of Falkirk town centre. By midday the residents of the modern brick tenement block at the end of the road had banks of cameras trained on their windows whether they wanted them or not. Welcome to Thistle Street the latest media epicentre of the 2009 swine flu outbreak.

Holed up in a top-floor apartment was 24-year-old Graeme Pacitti, a local hospital clerical assistant, who, with hindsight, was unfortunate enough to have been one of those sharing a drink with Askham on his return from the holiday resort of Cancun.

Iain, 27, and Dawn, were confirmed last week as Britain's first cases of swine flu now sweeping across the world. Caught, they believe, while travelling back to the UK aboard their holiday flight from Mexico from other infected passengers, Iain may have passed the virus on to Pacitti on the night out with their friends from the same football team. With governments, scientists, health officials and the public waiting to find out from tests whether Pacitti was the first case of human-to-human transmission of the new H1N1 virus within Britain, he was, despite being ill, very much in demand.

When it was confirmed on Friday afternoon that Pacitti did have swine flu, it took the British outbreak – 15 cases confirmed so far with another person-to-person transmission emerging later in the day – into another dimension.

No longer could it necessarily be contained to holidaymakers like the Askhams who had returned from Mexico. If Pacitti, and 42-year-old project manager Barry Greatorex from Gloucestershire, had caught it by sitting with friends or colleagues then all those they came into contact with in the aftermath could also have been infected. An alarming pandemic in which hundreds if not thousands were struck down by the virus suddenly came one step closer.

In the Thistle Fish and Chicken Bar at the end of the street in which Pacitti is a regular customer, the owner, who declined to give his name, said: "The main thing is that he's alright. He's a big, strong fit lad so he should be OK. I am not worried for myself though but it could be a worry for people with kids. Meanwhile, it has to be business as usual."

It's an attitude shared by many in Falkirk, which has now unwittingly become one of the focal points of the growing global outbreak. Yesterday, more than 650 cases had been confirmed worldwide with many hundreds more suspected. The source, Mexico, has had 101 deaths linked to swine flu and there are hundreds more suspected cases. Its huge capital, one of the biggest cities in the world, was virtually closed down this weekend. Altogether 17 countries have confirmed cases, stretching from the US and California, where governor Arnold Schwarzenegger has declared a state of emergency, to New Zealand.

In Scotland, there are now three confirmed cases and tests on 19 suspects remain outstanding. Families across the country are being treated with anti-viral drugs and quarantined in their homes until the medical all-clear can be given. Of the Askhams, however, there was little to report. Last week, they spent five days in isolation in Monklands Hospital in Airdrie before being declared fit to go home. But after being smuggled under coats into their semi-detached home on Friday by representatives of the newspapers which had bought their story, they disappeared from public view, their house shuttered and closed.

So how did two honeymooners take centre stage in an emerging flu pandemic that still has unknown consequences for the world? How did Scotland become a "laboratory" for scientists to observe the progress of a disease with the potential to cause mass fatalities? And will the first case of human-to-human transmission in the UK – called "significant and concerning" by Scottish health secretary Nicola Sturgeon – be an isolated incident or can we expect many more?

The Askhams – Iain is an IT worker with ScottishPower and 24-year-old Dawn works in the dispensary for Boots in Falkirk High Street – were married on April 4 at the Three Kings hotel in Shieldhill. Iain is a keen amateur footballer who plays for five-a-side team FC Mallard and a number of team-mates attended the wedding.

Two days later, the couple flew out from Birmingham for their two-week honeymoon in the Mexican resort of Cancun, one of the Latin American country's famous Caribbean playgrounds. It was a holiday the couple say they have been saving for for years and they spent the days lazing by the swimming pool, just leaving the Royal Hotel Cancun for a trip to see Mayan ruins.

Dawn said: "We had a really chilled holiday and everything went so well. We just spent our time relaxing and enjoying the food and the sights. It was all about resting and kicking back.

Iain added: "The holiday was the best two weeks of our life. We just lazed about. Our whole day revolved around meal times. We were like an old married couple. It was like a dream, the best time ever."

Unknown to the Askhams and thousands of other foreign holidaymakers, on April 2 – two days before the wedding – and far to the south, a four-year-old boy, Edgar Hernandez, who lived near a pig farm, contracted the H1N1 virus. He is believed to have been the first human swine flu sufferer in Mexico but he survived the illness and the medical authorities were not alerted.

Then, four days later, on April 6, a health alert was declared in his home town of La Gloria after flu struck down 60% of the residents. The town is close to a giant American-owned pig farm, but although no link between the facility and the outbreak has yet been established, some scientists believe it, or another similar meat-rearing plant, could have been where the swine flu mutated into a form that could infect humans and then be capable of further spread between humans. The flu could have spread to farmworkers who infected their relatives and friends. One of the features of life in rural Mexico is the large numbers of economic migrants who seek more profitable employment in the capital, resorts such as Cancun, and further afield in the US.

Over the next fortnight, according to epidemiologists, the virus spread throughout Mexico with, by April 17, three days before the Askhams flew home, two cases being confirmed in children as far north as southern California.

The Askham's flight was an overnight journey back to the Midlands. As they settled into their seats in row 38, Iain noticed that five men sat close to them appeared to be ill. "There were five guys sat right by us who were coughing and sneezing all the way back, right from when we got on the plane from Mexico. I actually said to Dawn, 'I think we going to be getting off this plane with the plague."

He described the passengers as British Asian. "They were really ill," he said," especially the one sat directly behind us. Two other nearby passengers asked to be moved. "We didn't ask to be moved because we would have felt a bit rude asking for an upgrade. It wouldn't be like me or Dawn. I didn't want to make a fuss."

The plane, carrying First Choice and Thomson customers, touched down at Birmingham early on Tuesday, April 21. The couple waited eight hours for a connecting flight to Edinburgh and were back home in Scotland that evening after being picked up by Dawn's mother Linda Colston.

On Wednesday, they visited their parents and Iain played football with his mates from FC Mallard. On Thursday, Dawn returned to work at Boots where she dispensed medicines but didn't serve customers directly. By Friday she was feeling unwell and was sent home by her manager at around 11am.

Meanwhile, on the Thursday evening, Iain, who still had the rest of the week off, went to the house of his best man, Neil Gardner, for a drink. Two other friends, including Pacitti, were there. The next morning, he recalls, "I woke up with more than a hangover. From Friday onwards, I was just in bed. It was like getting cramp at football but all over."

That same Friday, in Mexico, the government revealed 20 deaths believed to be from swine flu with 40 more fatalities under investigation. Mexico City shut schools, museums, libraries and theatres to prevent citizens from congregating. A day later, with the virus spreading to New York, the World Health Organisation declared the outbreak a "public health emergency of international concern" and asked countries around the world to be vigilant. It added the outbreak had "pandemic potential," meaning it had the ability to spread quickly across continents.

That Saturday, Dawn's mother, concerned about the couple's condition, phoned the out-of-hours doctor service. The GP arrived, assessed their condition and sent the couple straight to the infectious diseases unit at Monklands Hospital. Treated with anti-viral drugs, they stayed, in isolation, for five days before being discharged with a clean bill of health on Thursday.

In the meantime, those people who had been in contact with them for any period of time were traced and tested for the virus as were other suspected cases which also emerged around the country. All the other cases had recently been on holiday in Mexico. One couple from Edinburgh, Peter and Jennifer Marshall, found themselves quarantined in their home. This weekend, throughout the UK, more than 600 people are suspects although only 15 cases have been confirmed, including a 12-year-old English girl who came home on the same flight as the Askhams.

Unanswered questions remain. Why has the strain been lethal in Mexico but has, so far, produced only mild symptoms in other countries? The only death outside Mexico was a young Mexican boy on holiday in the US. The alarming scenario is that the outbreaks in other countries may not yet be as advanced. But, more reassuringly, it may be discovered that the death rate associated with this particular strain is not as deadly as first thought. Mexico yesterday revised down its estimate of flu-linked deaths, with health minister Jose Angel Cordova explaining, based on samples tested, the mortality rate was comparable with that of seasonal flu.

The extent of human-to-human transmission is also unknown. Last week, the WHO raised its alert system from four to five – the second highest – when it had evidence of such transmission not only in Mexico and the US but also in Spain. This means according to the WHO's experts, a pandemic is imminent. The alert will be raised to level six only when there is irrefutable evidence that a pandemic has taken hold.

Pacitti began to feel ill two days after meeting Iain Askham, but the Falkirk fan felt well enough to attend a Scottish Cup semi-final at Hampden last Sunday. That evening, he was contacted by doctors tracing his friend's contacts and told to stay at home until test results came back. His mother Lesley, brother Allan, 19, and Lesley's partner Andrew O'Connor, were similarly quarantined.

By Monday, he had classic flu symptoms of a soaring temperature, bad headaches and a sore throat. On Friday, despite being well on the mend, he became Britain's first case of human-to-human transmission.

While Pacitti and his family continued their life behind closed doors, yesterday, his stoic home town played host to the first day of the 10th Big in Falkirk National Street Arts Festival. It has become one of the largest cultural events in Scotland, attracting more than 100,000 people over the weekend to theatre, music and pyrotechnic displays in Callendar Park.

Linda Gow, the council leader, said: "Of course there is concern and people are talking about it but they have seen the government's advertisements and listened to the advice. Everyone is being pragmatic about it. We have read there is going to be a pandemic but so far there have only been a few cases. If that rises dramatically then perhaps the attitude will change, but not yet."

Even the first confirmed case of human-to-human spread in the area had not made any dent on shopping in the narrow pedestrianised High Street yesterday. At Boots, Dawn's workplace where her close workmates were tested and found to be negative for the virus, it was business as usual.

Outside, Amy Carruthers, 64, said she was aware of the outbreak but she had shopping to do. "I feel sorry for the boy who's got it but it looks like he will get better. I'm not getting worried about it because at my age you can catch flu at any time anyway. I'll be trying to avoid anyone coughing and sneezing for a while but I'm not going to panic."

Planning for worst with 'bouncy castle morgues'

IT IS one of the biggest urban areas in the world – a sprawling home to more than 17 million people – but this weekend it is at an eerie standstill. In Mexico City, restaurants, factories and shops are closed, public events cancelled and citizens told to stay indoors for five days.

Despite the dwindling toll of suspected deaths, the epicentre of the swine flu outbreak remains in shut-down mode in an attempt to stop its spread.

Some 5,300 miles away, St Andrew's House in Edinburgh is a hive of activity as Scottish Government ministers, officials and health experts try to establish the extent of infection, its severity, and what to do about it.

They are considering many of the same questions millions of Scots are asking this weekend. Just how might life in Scotland have to change over the next few weeks and months if more people fall ill? Will Scots also be told to stay inside, batten down the hatches and prepare for the worst? Will it be business as usual? And how will schools, businesses and public gatherings function if a flu pandemic strikes – however relatively mild the new H1N1 strain may turn out to be?

The dramatic events of the last few days have come out of the blue for most members of the public, who a week ago would never have expected to be facing a new infection spreading across the globe.

But behind closed doors, Government officials, police and planners have been quietly preparing for this for years.

Not only have millions of doses of flu drugs been stockpiled in warehouses, but details of how hospitals, GP surgeries, schools and buses and trains will run have been analysed, drafted and decided. Estimates of the number of cases right up to a worst-case scenario of 63,700 Scots dead have already been made, and determinations about whether to go into "shut-down" or carry on as normal have been made based on mathematical modelling of the benefits of each action based on the disruption to society versus the number of lives saved.

And should huge numbers of people catch swine flu – even if they shake off the bug in a few days – these are the rules which will govern civil life in Scotland for the foreseeable future.

The Scottish Government's blueprint is its publication Pandemic Flu: A Scottish framework for responding to an influenza pandemic. This scenarios within are Health Secretary Nicola Sturgeon's "worst-case scenario", she said at a briefing last week.

But one of the most surprising aspects of Scotland's plan is how dramatically it differs to the route taken by officials in Mexico. Far from mass closures, the prevailing attitude will be very much business as usual for those unaffected by the illness.

For example, although it is unclear whether international borders would remain open – that is something that will be decided based on the situation by bodies such as the Government and the World Health Organisation – public transport would still run, some public gatherings may still go ahead. Medical emergencies such as cancer cases and heart attacks would still be treated. And employees would still be expected to go into work.

The Scottish Government is unlikely to impose any restrictions on public transport unless "it becomes necessary to do so as the pandemic develops for public health reasons in which case it is likely to be on an advisory basis".

Scots may be advised to minimise non-essential travel but will be expected to continue using public transport for essential journeys, "adopting personal hygiene measures", such as using a face mask, where possible.

Healthy employees will be expected to turn up to work, although business leaders predict high staff sickness levels could prove devastating. CBI Scotland's assistant director, David Lonsdale, warned four out of five firms affected by a major incident close within 18 months and told firms to "prepare and plan ahead".

The biggest affected sectors will be health and education. Hospitals and GP surgeries would run differently in a pandemic. For example at health clinics flu cases would be segregated and made to wait in a separate area. Hospitals would have segregated areas from accident and emergency right through their establishments. Hospitals could halt routine operations. Medical students and retired staff may even be drafted in to help.

If hospitals become full, patients could even be treated in temporary facilities such as church halls or sports centres.

Schools and nurseries are likely to close, as children are likely to be one of the worst-hit groups, dubbed "super-spreaders". The Scottish Government believes closing schools would reduce the number of cases by 10% in the general population and by 50% among school children alone.

Although there will be no blanket ban on public gatherings, events will be considered on a case-by-case basis. But in a worst-case scenario, a question mark hangs over this year's Open Golf Championship at Turnberry in July and the Edinburgh Festival.

If some of the worst fears are realised, and the country's infrastructure slows down to the extent that supplies of essentials such as fuel are disrupted, it is likely that priority will be given to some workers. A list of professions has been compiled which would qualify for petrol. At the top are the police and armed forces.

It then moves down through the health professions to essential operations at nuclear sites. Key transport workers and environmental health officials are included. Supplies of food would be maintained by ensuring professionals in farming and food manufacturing were given fuel priority.

And if the death toll means there are too many bodies for mortuaries to cope with, with current capacity at 2,513 spaces, inflatable body storage tents, known as "bouncy castle mortuaries", will be set up.

Sturgeon believes contingency planning is going well and is holding weekly meetings with leaders of public bodies and businesses. She said yesterday: "We have been gearing up to the challenge and planning ahead. We are relying on our partners to make sure these plans can be effectively delivered. I do believe that we are very well prepared."

The effectiveness of Mexico's closed-doors strategy will soon become evident. Whether Scotland's well-planned strategy, of hoping for the best but planning for the worst, will run as efficiently as it does on paper, remains a hypothetical question, for now.

Kate Foster

Medic at the forefront of crisis

AS SCOTLAND'S Chief Medical Officer, spearheading Scotland's response to swine flu is the biggest challenge to have faced Dr Harry Burns, right.

He reassured the public over the bird flu crisis, when a swan with the infection was found dead at the harbour in Cellardyke, Fife, in March 2006, but the fact the virus did not pass on to humans meant his role then, unlike now, was limited.

Burns, from Barrhead, Renfrewshire was appointed to the post of CMO in July 2005, a former director of public health, and executive director of NHS Greater Glasgow whose work led to the creation of the Glasgow Centre for Population Health. He trained as a surgeon and lectured on the subject at hospitals in Glasgow.

Burns is the chief medical adviser to ministers, and responsible for alerting doctors to urgent issues of a public health or clinical nature, earning a salary of between 75,607 and 101,905 for the role. In the past week he has been in constant contact with the Health Secretary and medical colleagues around the world.

Speaking at the time of his appointment, John Elvidge, the Scottish Government's Permanent Secretary, praised Burns' "integrity and expertise".