Under the Spotlight Synopsis: This article provides a brief overview of the swine influenza of current concern Swine Influenza Introduction
With the recent extensive news media coverage of a potential swine influenza (or ‘swine flu’) pandemic, a substantial volume of information is available through public health and other internet-based sources. Accordingly, the main aims of this article include providing a succinct overview of the key features of swine flu, whilst highlighting data relevant to the potential morbidity and mortality implications of this condition in Australia. What is swine influenza?
Swine influenza (or ‘swine flu’) is an acute respiratory condition that affects pigs (or ‘swine’). It is a very contagious disease caused by one of several swine influenza A viruses. Whereas influenza B and C viruses only affect humans, influenza A is often found in birds (for example, the avian flu) and other mammals. In certain cases, pigs become infected with more than one type of influenza virus (for example, avian and human viruses), enabling genes from the different viruses to mix. The resulting ‘reassortant’ virus (such as the current swine flu) contains genes from several other viruses, resulting in the emergence of a genetically-unique virus subtype, an event commonly described as ‘antigenic shift’. Swine influenza viruses are usually of the A/H1N1 subtype; however, other virus subtypes are also known to be circulating in swine populations, including H1N2, H3N1 and H3N2. Swine influenza: a case of déjà vu?
Since the outset of the 20th century, the world has witnessed three major influenza pandemics, including an influenza H1N1 pandemic in 1918, H2N2 in 1957 and H3N2 in 1968. The influenza pandemic of 1918-19 (often described as the ‘Spanish flu’ pandemic) resulted in more fatalities than the First World War, with an estimated 20 to 30 million deaths globally.
Another outbreak of swine influenza A/H1N1 was reported in the US state of New Jersey in 1976, with approximately 240 people (mainly military recruits) infected, resulting in one death. The same subtype of swine influenza caused the pandemic of 1918, which resulted in tens of millions of deaths worldwide. During the outbreak in 1976, there was immediate concern in the US regarding another potential A/H1N1 pandemic, resulting in the vaccination of approximately 40 million Americans before the vaccine program was abandoned. Incidentally, a swine influenza epidemic did not eventuate at the time. The ‘pandemic potential’
In general, influenza is a seasonal illness that occurs from June to September in southern hemisphere countries (such as Australia) and from December to April in the northern hemisphere. Most seasonal influenza epidemics result from small changes to the human virus subtypes (antigenic drift) or the emergence of new virus subtypes (antigenic shift). When antigenic shift occurs, the exposed human population has no inherent immunity to the new virus subtype, resulting in worldwide epidemics (or pandemics). The majority of people in Australia (indeed worldwide) are unlikely to have previously acquired immunity that might prevent infection with the current strain of the swine influenza virus. Recipients of previous swine influenza vaccines (for example, during the 1976 vaccination program in the US) are also considered unlikely to have inherent immunity against the current virus subtype. Should the current swine influenza virus subtype develop efficient human-to-human transmission, an influenza pandemic would become an increasingly likely possibility. Symptoms
The symptoms of swine flu are similar to ‘typical’ influenza symptoms, including:
Other less common manifestations of swine flu have also been reported, ranging from asymptomatic (or symptom-less) infections, to severe pneumonia resulting in death. As swine flu symptoms resemble signs of other conditions, a symptomatic individual may in effect have an entirely unrelated underlying cause, so a laboratory test is required to confirm (or otherwise exclude) a diagnosis of swine influenza. Diagnosis
According to the World Health Organisation (WHO), the rapid antigen tests used for detecting influenza A viruses should also be able to diagnose swine influenza; however, the relatively low sensitivity of such tests may yield false-negative results, hence testing in an accredited clinical laboratory is required to confirm suspected cases.
In a clinical laboratory setting, the only reliable (and currently available) method to confirm swine influenza A/H1N1 infection, includes an appropriate virus isolation protocol, followed by at least sequencing part of (ideally, all of) the sample virus genome. The US Centers for Disease Control and Prevention (CDC) recently reported that the new swine influenza A/H1N1 virus cannot be detected by the existing CDC influenza subtyping PCR (or Polymerase Chain Reaction) assay kit. CDC scientists are currently working to develop a modification to the current diagnostic kit, by incorporating testing procedures derived from recent confirmed swine influenza cases. The CDC is also preparing a specific ‘Swine Influenza PCR Testing Kit’ that will be made available to National Influenza Centres worldwide. Prevention and treatment
No vaccine is presently available to contain the spread of the swine influenza virus subtype of current interest. It is also unknown whether seasonal human influenza vaccines might offer protection against the current swine influenza virus strain. According to the CDC, the following measures are recommended to minimize the risk of infection:
covering the nose and mouth when sneezing or coughing disposing of tissue paper in an appropriate container washing hands with soap and water, especially after sneezing or coughing not touching the eyes, nose or mouth avoiding physical contact or close proximity to symptomatic individuals remaining at home (avoiding work or school) should relevant symptoms arise
Other recommendations include the use of protective devices (for example, face masks) as a precautionary measure, where practicable. Several of the antiviral drugs used in the treatment of seasonal influenza, have also proven effective against the current swine influenza. The two main relevant drug classes are the adamantanes (including amantadine and remantadine) and influenza neuraminidase-inhibitors (including oseltamivir and zanamivir). The latter drugs are marketed under their more common brand names of Tamiflu® (oseltamivir) and Releneza® (zanamivir), with Australia currently holding substantial reserves of both drugs. Swine influenza samples obtained from US-based patients, revealed susceptibility of the virus subtype to oseltamivir and zanamivir; however, the same subtype was resistant to treatment with amantadine and remantadine. National and local public health authorities in the US and Mexico have recommended the use of oseltamivir or zanamivir, for the prevention and treatment of swine influenza. Prognosis
As at April 28th 2009, seven countries had officially-notified the WHO of laboratory-confirmed cases of swine influenza A/H1N1 infection. Mexico had officially notified the WHO of 26 laboratory-confirmed cases, including seven deaths.
Of the 64 laboratory-confirmed cases in the US, no deaths attributable to swine influenza have been reported to date. Other countries with laboratory-confirmed cases and no deaths include New Zealand with 3 cases, Canada with 6, the UK with 2, Spain with 2 and Israel with 2 cases. The CDC recently reported that the majority of laboratory-confirmed swine influenza cases in the US resolved with a full recovery, with affected patients not requiring intensive medical intervention or the use of antiviral drugs. What does all this mean for Australians?
Influenza is a serious and contagious respiratory illness caused by influenza viruses, which each year affects millions of people worldwide. Whereas most infected individuals recover within a week, a prolonged disease course, complications or even death may occur in certain cases, including young children, pregnant women, the elderly, patients with chronic medical conditions and other immuno-compromised individuals. According to the Australian Institute of Health and Welfare (AIHW), infectious diseases such as influenza, are not a major contributors to the burden of disease in Australia and similar developed countries, due to effects of substantive public health initiatives such as improved sanitation, immunisation programs and the widespread availability of antibiotics. Nonetheless, the burden of infectious diseases remains significant in Australia, with almost 4% of all deaths attributed to infections in 2007 and a similar percentage of hospitalisations due to pneumonia in 2005-2006. According to the AIHW, a total of 10,687 laboratory-confirmed influenza cases where reported in 2007. Australia leads the Organisation for Economic Co-operation and Development (OECD) countries in vaccinating the elderly against influenza, with a 2006 national survey revealing that 77.5% of Australians aged over 65 years were vaccinated against influenza that year, the highest vaccination coverage rate out of all OECD countries. Swine influenza and COPD
In Australia, 20 specific health conditions were identified as leading causes of 74% of all deaths in 2005, with chronic obstructive pulmonary disease (COPD) among the top ten leading causes of death across both genders. Furthermore, pneumonia and influenza were leading causes of death in Australian females. During the three years from 2003 to 2005, influenza and pneumonia mortality rates were reportedly higher among Australian residents born in the UK or Ireland, compared with Australian-born individuals. Influenza infection and pneumonia often worsen the symptoms of COPD in affected individuals, resulting in decreased lung function which could cause hospitalisation and (in severe cases) even death. Fortunately, estimates from a recent National Health Survey by the AIHW, indicated that individuals affected by COPD were relatively more likely to receive influenza vaccination. COPD is recognised as a major cause of mortality in Australia, reflecting the progressive deterioration in lung function associated with this condition. COPD was the underlying cause of 4,886 deaths in 2005 and listed over 7,000 times, as an associated cause of death, often when coronary heart disease or lung cancer were
identified as primary underlying causes. The relevant mortality rate among Australian males was almost double that for females. Chronic respiratory diseases (such as COPD) are often worsened by concurrent acute respiratory infections like influenza. As such, hospitalisations for COPD in Australia typically occur during the winter months, with approximately a third of admissions recorded between the months of June and August. Public healthcare expenditure on COPD in Australia reportedly exceeds several hundred million dollars annually. Potential impact on insurers
According to a recent research report by the Insurance Information Institute in the US (Weisbart, 2006), a severe pandemic (for example, the equivalent of the ‘Spanish flu’ pandemic of 1918) could cost US life insurers upwards of US$133 billion in additional claims, whereas the cost of a ‘moderate’ pandemic (for example, similar to the 1957 or 1968 outbreaks) could exceed US$31 billion. The numbers and severity of swine influenza cases have varied widely in the current outbreak, with several deaths and other severe cases reported in Mexico, whereas early cases in the US followed a relatively mild course. Nonetheless, leading medical experts have warned that influenza viruses are very difficult to predict, especially in terms of the extent and timing of potential antigenic drift and/or antigenic shift. It remains unclear as to why the swine influenza cases reported in Mexico are more severe than cases in the US, where among the first 20 laboratory-confirmed cases, only one patient required hospitalisation and subsequently underwent a full recovery. Although scientists at the CDC and the WHO continue to investigate this anomaly, one explanation might be the ‘mortality bias effect’, whereby individuals have a tendency to report severe illness or death before reporting mild illness, resulting in an increased total mortality rate. In the context of the mortality bias effect and assuming a low per-case mortality rate, the actual number of unreported swine influenza-positive cases in Mexico, may significantly exceed the figures notified through official channels. A recent actuarial research report (Matic, 2007) provides a detailed analysis of the potential impact of an influenza pandemic on Australian life insurers, by applying actuarial profit-testing techniques and focusing on solvency and profitability. Several useful insights are highlighted in the report, including a conclusion that the (large) size of a policy and not an increased mortality rate in the elderly, would be a greater potential issue for a life insurer during a pandemic. Other conclusions relevant to insurers are also detailed in the report, specifically the main pandemic characteristics of potential interest, including:
the overall case fatality rate the duration of a pandemic the prospect of elevated mortality rates following a pandemic
The report also indicates several strategies that insurers may undertake in anticipation of a potential pandemic, including:
recognizing and acknowledging that a pandemic might eventuate understanding the likely impact of a pandemic on different insurance products a strong financial position, ideally superfluous to minimum capital adequacy
Readers are encouraged to refer directly to the complete report (Matic, 2007) for further information. Potential impact on insurance products
The potential impact of a swine influenza pandemic on different insurance products will vary, in accordance with the specific underlying risk exposure of each product type. Some issues for further consideration and analyses include:
the immediate impact on major medical insurance products, in view of
anticipated increases in claims for medical expenses
considering the current course of disease in developed countries, short-term
disability products are more likely to be impacted than long term care products
self-insurers may experience similar outcomes, in addition to increasing costs
Underwriting guidelines may require adjustment to reflect the shifting medical risk landscape. During a swine influenza pandemic, underwriters could be required to specifically focus on chronic respiratory diseases (for example, COPD) and other health conditions associated with increased risk of morbidity and mortality, in the event of concurrent swine influenza infection. Following a swine influenza pandemic and as survivors contemplate recent events, insurance product sales could be expected to increase, with corresponding increases in applications for underwriters to consider. Post-pandemic, underwriters could also be required to investigate a large number of applicants who had recently recovered from an acute (and in some cases chronic or life-threatening) swine influenza infection, with medical risk considerations including issues such as permanent lung and/or heart damage, in addition to other long-term effects that might reflect sub- standard risk. The loss of operational and/or strategic staff, coupled with increasing claims volumes, may significantly limit an insurer’s ability to deliver adequate customer service during a high-stress event such as a swine influenza pandemic. Any delays in the processing of benefit entitlements arising from the aforementioned limitations, may result in a public outcry, adverse news media exposure and increased reputational risk for an insurer. In the event that sub-par customer service emerges as a trend among multiple insurers within the same market, other unaffected insurers may also become exposed to reputational risk by association. Accordingly, it is in the interest of all insurers to establish proactive measures (for example, business continuity and disaster recovery plans) that would facilitate operational viability and stability during a pandemic. Additional information
The author of this article is Aamer Fattah, an experienced medical scientist with several medical science qualifications, including a degree in clinical virology and prior experience collaborating with prominent virologists and key scientists from the CDC. For additional information or any questions regarding this article, you are welcome to contact Aamer directly by e-mail at: [email protected].
References Australian Institute of Health and Welfare 2008. Australia’s health 2008. Cat. no. AUS 99. Canberra: AIHW. Centers for Disease Control and Prevention. Guidance for Clinicians & Public Health Professionals. Atlanta: CDC. 29 April 2009: http://www.cdc.gov/swineflu/ Rudolph M.J. Pandemic Influenza’s Impact on Health Systems. Health Watch. January 2007:15-17: www.rudolphfinancialconsulting.com/MaxRudolph-pandemic.pdf. Weisbart S. Pandemic: can the life insurance industry survive the avian flu? New York: Insurance Information Institute. 17 January 2006. World Health Organisation 2009. Guidance to Influenza Laboratories Diagnosing Swine Influenza A/H1N1 Infections of current concern. Geneva: WHO. 25 April 2009: http://www.who.int/csr/disease/swineflu/en/index.html. World Health Organisation 2009. Swine influenza frequently asked questions. Geneva: WHO. 29 April 2009: http://www.who.int/csr/disease/swineflu/en/index.html. World Health Organisation 2009. Viral gene sequences to assist update diagnostics for swine influenza A (H1N1). Geneva: WHO. 25 April 2009: http://www.who.int/csr/disease/swineflu/en/index.html.
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