91Èȱ¬

I doubt the latest fall in H1N1 swine flu cases will warrant more than the briefest of mentions in the media, but this blog is there to report the good as well as the bad. And perhaps I should say the ugly, as I am typing this with a large amount of purple silicone goo in each ear. Before you wonder whether this is some strange 91Èȱ¬ festive ritual, I am in fact having ear-pieces made for each ear - the clear plastic things which allow the editor or the director in the gallery to shout, cajole or bark instructions to me during live broadcasts.

Back to swine flu and there is more reassuring news today from across the UK. Cases of swine flu appear to be falling throughout the country. It means the second wave of the pandemic is on its way out, though there is still a chance of an upsurge in seasonal flu after Christmas.

Generally then, there is less flu about and most people who get it either are not aware they are infected or have a very mild disease. There were an estimated 9,000 new cases of swine flu in the past week in England, compared with 11,000 the week before. In Scotland there were around 8,000 cases, down from nearly 9,000 the week before. Cases are continuing to fall in Wales and Northern Ireland.

But there is another side to swine flu. In England there are more than 500 people in hospital with swine-flu-related conditions, more than 100 of them in intensive care. And there've been almost 300 deaths since the outbreak began in April. In the past week another 16 people have died across the UK. That's a tiny number compared to what was feared. But Sir Liam Donaldson, the Chief Medical Officer said:

"You can take a cold statistical view and look at the 300 deaths and throw your hat in the air. Or you can look at the families who may not have a child or a father or mother around the table this Christmas. If we can prevent those deaths then that is a reason to throw your hat in the air."

The numbers immunised against H1N1 swine flu continue to rise. I can't give you UK-wide figures at present, because the four nations don't collect their data in the same way, but I do have the statistics for England: three million people in the first priority groups have received the jab, including 101,000 pregnant women. 343,000 front line health workers have been vaccinated, about three times the number given the seasonal flu jab last year.

Two-thirds of primary care trusts in England have now reached agreement for GPs to immunise the under-fives and the others are said to be "very close" to signing up. The rise in immunisation may well help curb any third wave of swine flu.



As usual, have a look at the bold red line, which is good for showing trends and you'll see that flu-like illness rates with GPs have fallen below the baseline threshold of 30.0 per 100,000. This simply confirms that there is not that much flu about.

This is useful because it shows, contrary to what some might have imagined, that the second wave of flu this autumn has been bigger than the first in early summer. The peak in July was higher but it fell more quickly, whereas the second wave is craggier and longer-lasting.



This shows that, as well as having more cases, the second wave has seen many more hospitalisations.



The picture in the United States where consultations due to flu-like illness continue to fall - reassuring as in the previous two waves our peaks followed a few weeks after theirs.

Useful resources:

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The goo is out of my ears and my blog is done. I wish you all a peaceful and swine-flu free festive period. I will try to blog over the festive period as and when there is news to report.

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The UK government's principal medical advisor, Sir Liam Donaldson is to step down next May. He has been chief medical officer for England since 1998 and the main architect of the government's policy on dealing with swine flu.

After the emergence of the avian flu in south-east Asia six years ago he helped bring about an awareness in Whitehall of the potential threat to public health from flu pandemics. This eventually led to the stockpiling of antiviral drugs and detailed planning being put in place across government departments and the NHS.

Since the emergence of H1N1 swine flu he has spearheaded the government's strategy, carrying out weekly briefings for journalists on the pandemic and giving unprecedented access to public health data charting the spread of the infection.

The Health Secretary Andy Burnham said:

"Sir Liam has fulfilled his duties in this important public office with great distinction, wisdom and good humour. He has brought courage and foresight to the role of improving the nation's health. His bold and once-controversial proposal to turn public places smoke-free shows the difference he has made."

The Department of Health said that Sir Liam originally planned to leave his post when he turned 60 in mid-2009 but agreed to stay on to supervise the response to the swine flu pandemic. He has told ministers that if the pandemic should suddenly worsen, he would be prepared to extend his tenure beyond May 2010.

As well as charting policy on flu, Sir Liam also played a key role in shaping policy in many other areas of medical research and public health, including stem cell research, the introduction of smoke-free public and work places and organ donation.

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New figures from the Department of Health in England suggest that 2.3 million people in the priority groups have now been immunised against H1N1 swine flu.

That includes 81,000 pregnant women. 308,000 front-line health workers have been given the jab, compared to 124,000 last year for seasonal flu.

a lot of people are still to be immunised, or will not bother to have the jab.

There are 9.5 million people in priority groups for the jab in England and 2 million front-line health care workers.

Health officials say they are encouraged by the uptake, but the Chief Medical Officer for England, Sir Liam Donaldson said it would have been higher but for two factors:

"The uptake had been influenced by the disgraceful junk science that was thrown at the MMR jab. The legacy of that is potentially putting lives at risk."

And he said the lack of a "fear factor" was another important element.

He contrasted the introduction of the swine flu jab with another vaccine against a strain of meningitis, introduced in 1999. "Take Meningitis C", he said:

"Parents were terrified of the disease and where there is a big public fear factor you will get a high uptake. Most people don't think swine flu is a big risk. But there is no need to expose yourself to. We don't force people to have vaccines in this country. It's not compulsory (unlike in the USA where you have to be immunised before going to school). If you are in an at risk group and you choose not to have the vaccine, then that is up to you."

Remember that the UK has provisional orders for up to 132 million doses of swine flu vaccine (based on the expectation that two doses would be needed).

Clearly we aren't going to need all of those, and the Department is not saying whether they have to buy them, or whether there is an opt-out clause (all such contract details are confidential).

But it begs the question as to whether any other groups will be offered the jab in the New Year. I think it unlikely, given that the H1N1 swine flu virus is likely to be incorporated into the seasonal flu jab for next winter.

Sir Liam Donaldson said "the next policy decision would be to see whether the swine flu vaccine should be made available to anyone", but he made it clear that this was not something that was being considered for now.

One vaccine enough for children

In case you missed it, the advice from the Department of Health is that one dose of vaccine is sufficient for the under-fives. So that means people of all ages need just one jab (unless they are immuno-compromised).

, the EMEA, which warned that young children may experience fever after their second dose of Pandemrix (the main swine flu vaccine) and that the first dose triggered a good immune response.

More local deals are being struck between doctors and NHS managers over immunisation plans for children. GPs across London have signed up to a deal to ensure children between six months and under five get the jab via their local surgery. Other deals around the UK are said to be imminent.

Swine flu cases decreasing

Swine flu cases are decreasing across the UK.
England - estimated 11,000 new cases this week (22,000 last week)
Scotland - estimated 8,900 cases (12,300 last week)
Northern Ireland and Wales - cases continuing to fall

Deaths from H1N1 swine flu

191 England
13 Northern Ireland
54 Scotland
25 Wales

The estimated cumulative number of cases of swine flu in England is 795,000 (range 380,000 - 1,670,000) but the Health Protection Agency has estimated one in five schoolchildren has been infected, so this figure may be revised upwards at some point.

Whatever the figure, swine flu remains a mild illness for the vast majority. Nonetheless there were more than 600 people in hospital in England with suspected swine flu on 9 December and 133 were in intensive care.

As ever this is very good at showing trends and if you follow the bold red line you'll see that H1N1 swine flu cases are continuing to dip and are no way near as high as they were in July. All very reassuring.

I thought I'd show you this as it lists all the health conditions suffered by patients who died from H1N1 swine flu in England. You can see that asthma, COPD (chronic obstructive pulmonary disease) high blood pressure, diabetes, kidney disease and diabetes are all major risk factors.

The figures in brackets list the number of patients who had only that single health problem - clearly many had numerous ailments. Of those who died only one in four had received antiviral within the first 48 hours of symptoms.

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PS: I told you last week that my son Hugo had suspected swine flu. Within 48 hours I'd been sent a swab kit from the HPA and I dutifully sent it back. Well, there was a letter waiting for me at home last night with the result. It was positive for the swine influenza virus, so he definitely had it.

I was delighted; that might sound odd, but after seeing him poorly, and giving him Tamiflu, I'm pleased that I can tick H1N1 off the list of winter viruses that he might have to contend with. I must take my hat off to the HPA for such a speedy test result. Hugo went back to school this week, sang in the carol concert and is much better. Thanks again for all your kind comments.

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New research has estimated that there have been 26 deaths out of every 100,000 cases of swine flu in England.

The authors say this makes the first pandemic of the 21st Century "considerably less lethal than was feared in advance". No surprises there, but it is the first time we've had a figure for death rates in this country.
was carried out by a research team at the Department of Health.

It concludes that swine flu has a fatality rate of 0.026% or put another away, about one death in every 3,800 people infected.

That would make it 10 times less lethal than flu pandemics in the 50s and 60s and 100 times less dangerous than . So-called Spanish flu is thought to have killed at least 50 million people, more than died in the World War I.

It's worth pointing out that all estimates of deaths from flu pandemics are subject to very wide variation. Increases in fatality are usually worked out more than a year later by analysing trends in death rates and calculating the likely proportion due to flu.

This is the first time that individual deaths from a pandemic flu virus have been counted. The Centers for Disease Control and Prevention estimate for deaths in the United States is similar at 0.018%.

The Chief Medical Officer, Sir Liam Donaldson said improvements in nutrition, housing and health care might explain some of the apparent decrease in fatality from one pandemic to the next.

But even the comparatively low death rate of 0.026% may itself be a huge overestimate. That's because huge numbers of those infected have probably had swine flu without knowing it.

Recently the Health Protection Agency estimated that up to one in five schoolchildren have had the virus, half of them without showing symptoms.

Two thirds of those who died from swine flu would have been eligible for vaccination and the authors say this demonstrates the importance of immunising those at high risk of complications.

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A collection of local deals between family doctors and NHS managers appear in the offing following the failure of national talks designed to get under-fives immunised at GP surgeries.

A Department of Health spokesman said GPs across north east England had agreed to deliver the vaccine to children at £5.25 a dose - the same amount they are paid for doing the priority groups.

Dr Richard Vautrey, deputy chairman of the BMA's GP committee, said he expected deals to be made across the UK.

Which raises the question why a national agreement was not possible? I have already touched on the reasons for the failure of the talks.

GPs wanted targets for booked appointments to be relaxed. Government sources said doctors were asking for more money. But both sides were publicly remaining polite about the other - an acknowledgement that they know they have to make this work somehow.

Whilst it is possible to immunise children over five in school programmes, GPs are really the only show in town for mass immunisation of young children.

Both sides said they were hopeful that the breakdown in talks would not lead to delays in immunising children aged six months to under five. But where local agreements are not struck, it could surely have some impact on timing.

If you have a child under five, please let me know when you get a call-up to bring them in to be immunised.

Tamiflu

More questions have been raised about the effectiveness of the antiviral drug Tamiflu. This is a topic that the British Medical Journal looked at in July, arguing .

have "modest effectiveness against the symptoms of influenza in otherwise healthy adults." This is not really a surprise - it is well known that the drugs reduce symptoms of flu by only about a day.

But the BMJ also questioned the quality of the trial data - dating back a decade - supplied by Roche, the manufacturers of Tamiflu. And the researchers said a "paucity of good data" had undermined findings for Tamiflu's effectiveness in preventing complications of flu. These are more serious charges. Roche says it stands by the data.

It's worth remembering that all these studies are not looking at how effective Tamiflu is in treating H1N1 swine flu, but at seasonal influenza. We know that the H1N1 virus is mild for most people, and they will recover without the need for antivirals.

But we also know that a small minority, of mostly younger people, can get serious complications from the pandemic virus, and this is where antivirals may have a key role in reducing serious illness.

Observational data during the current pandemic from American hospitals suggests the longer the gap between symptoms emerging and patients taking Tamiflu, the greater the likelihood that they would be hospitalised.

there was an urgent need for research looking at their effectiveness.

New York autopsies

Finally I draw your attention to some .

Scientists looked at clinical data from 34 people who died from the H1N1 virus earlier this year. All but two of the deaths occurred in New York City. They found that as well as damage to the upper airway, in many cases the virus had caused tissue damage deep in the lungs.

Researchers said the damage was similar to that caused by the 1918 and 1957 pandemics. They also note that most of those who died were under 50 and had existing health problems and were obese.

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The government's plans to offer a swine flu vaccine to all children aged between six months and under five appear in .

The British Medical Association, which represents GPs across the UK has refused to sign up to the plan which would have seen family doctors offering the jab to more than three million children.

Neither the Department of Health nor the BMA has revealed why an agreement with the GPs was not possible. GPs are still immunising priority at-risk groups - those with existing health conditions and pregnant women. Doctors get £5.25 for each person immunised.

One source said the payment per vaccination was not what scuppered a deal, but that it collapsed because GPs wanted flexibility over government targets for patients booking general appointments during the swine flu immunisation campaign.

Doctors get incentive payments for a variety of targets - including those for offering an appointment within 48 hours and booking ahead.

The source said GPs were given lee-way as a result of the extra pressure of work involved in vaccinating the initial priority groups, but the same flexibility was not being offered with young children.

Nonetheless the Health Secretary, Andy Burnham has said that immunisation for under-fives will start in the run up to Christmas.

Young children are being recommended to have the swine flu vaccine because they are the most likely group to catch flu, and the most likely to require hospital treatment.

So if you are a parent with children under five, who will immunise your child? It's really not clear at all. According to the Department of Health it's now up to Primary Care Trusts to organise it.

You might get an invitation from your GP if they can be persuaded to do it, or it might involve a trip to hospital, to a pharmacy, a health clinic or you might get a visit from a health visitor or district nurse. Clear, simple and straightforward it is not.

The Department of Health said:

"We hope many GPs will still decide to vaccinate under-fives. But where GP practices do not wish to vaccinate this group, PCTs will determine whether vaccinations will be offered through other local GP practices, their directly managed staff (eg health visitors, district nurses etc) or by arranging with alternative providers (eg community or hospital paediatric services, pharmacies etc). Parents of children in the priority group will receive information about swine flu vaccinations as soon as these plans have been finalised."

But Obi Amadi from the Health Visitors' Association said:

"I'd be very concerned because we haven't got enough health visitors to the basics of working with families under five. So this is going to be another thing we are expected to juggle. We are going to be spread even more thin."

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At the weekly briefing for journalists the Chief Medical Officer for England, Sir Liam Donaldson revealed his "worry list" regarding H1N1 swine flu. It went like this:

1. The continuing flow of under-5s into hospital (which is why the push to vaccinate this group is a priority)
2. The continuing deaths from swine flu
3. That we might have a bad winter ahead with normal seasonal flu and other winter ailments
4. The "fear of mutation", the biggest worry of all - though there is no sign of that yet

This week has seen another fall in the number of cases of swine flu so I asked whether it was possible to say that we were over the worst with the pandemic this winter. Sir Liam's response was:

"We are not claiming victory because there are too many things to worry about. I won't be confident until March to say it's over for this winter because in the 1957/8 pandemic we saw a further peak after Christmas among older adults and with seasonal flu we often see a peak early in the New Year."

• The estimated number of cases of swine flu in England this week is 22,000 (range 11,000 to 47,000)

• The estimated cumulative number of cases in England is 790,000 (range 370,000 to 1,650,000) but given that one in five schoolchildren may well have had swine flu that estimate is probably several million out

• 747 people were in hospital in England at at 0800 on 2 December, of whom 161 were in intensive care

Deaths linked to H1N1 swine flu:
• England 178
• Wales 25
• Scotland 54
• Northern Ireland 13
• UK total 270

So bearing in mind that we may have had 5-10 million cases in the UK (a wild guess of my own I admit, based on school children etc), then 270 deaths is a very small proportion. That low death rate is no comfort of course to those who have lost family or who currently have relatives in hospital, but it is worth mentioning as this blog is there to inform and not to alarm.

Vaccination

The Head of Immunisation, Professor David Salisbury said that H1N1 swine flu had so completely replaced seasonal H1N1 flu that the WHO had already recommended that the pandemic strain replace it in next year's standard trivalent flu jab for the southern hemisphere, which is already under production. He predicted the same would apply in the northern hemisphere in 2010, although the WHO strain selection recommendation would not be made until February.

Professor Salisbury was also loathe to claim the worst was over:

"We have no way of knowing what will happen with seasonal flu early next year and what the pandemic virus might do, especially as immunity expands in the population, which may force the swine flu virus to drift. It makes us very cautious."

• 275,000 front-line health workers have been immunised in England - twice the number immunised the whole of last winter against seasonal flu. While that is a dramatic improvement, there are two million health workers on the target list, so there is a long way to go

• 1.6 million doses of vaccine have been given to the priority groups (up from 1 million last week)

• 11.2 million doses of GSK vaccine have been distributed throughout the UK to GPs, PCTs and hospitals

• 500,000 doses of Baxter vaccine have been distributed to health services

The hope must be that this will be resolved very quickly - I will investigate this further, although the department says the details of the contract negotiations are confidential.

A few graphs to end on:

Look at the red line - which is pretty static - and continues to be reassuring.

This shows that almost six out of 10 deaths are among the under-45s.

17% of deaths are among people who had been without any health conditions.
55% of deaths were among those with severe health problems.

I thought I'd show you this as it clearly displays that the second peak of flu in the United States is now on the wane. It's interesting that the US second wave was bigger than the first (the reverse of the UK). Likewise France is in the midst of a big peak of flu having had almost no first wave this summer.

More information on swine flu across the UK:

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PS. Many thanks to all of you who've sent get well wishes to my son and all the excellent suggestions for keeping him amused during his time off school with suspected swine flu. Hugo is now pretty much recovered and has started on his Christmas cards so is very busy (why do eight-year-olds have so many Christmas cards to send?).

Yesterday, a home swab kit arrived from the Health Protection Agency, so we'll know in a couple of weeks whether he really had H1N1 swine flu. My guess is yes, but I'll tell you whether I was right.

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A brief update from the World Health Organization's Dr Keiji Fukuda. He estimates that more than 150m doses of H1N1 pandemic vaccine have been distributed in 40 countries and the safety profile continues to be similar to seasonal flu vaccines.

He could shed no light on when the H1N1 swine flu strain would be incorporated into the normal trivalent seasonal flu jab or when the pandemic might be declared to be over: "It's fair to say that we haven't got through the pandemic and there could be unexpected events."

So what about viral drift, where all strains of flu change? Again Dr Fukuda would not be drawn on whether the H1N1 strain might become more or less virulent:

"There are examples of where flu viruses become less serious, as in the 1918 virus which became less lethal. There are also examples of flu viruses which become more pathogenic. It's not possible to second guess which way the drift will take us."

"With the 1918 pandemic, the way we estimated deaths was to look at the death data in several countries and then use modelling to work out how many were linked to flu. People do not count seasonal influenza deaths on a one by one basis, but with this current pandemic, there is so much interest, that we are counting cases. But it's too early to work out overall deaths and it will take one to two years to make the estimates. When we have those, then we will be in a much better position to see how this pandemic stacks up with seasonal flu and other pandemics."

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Perhaps this post should be called Fergus With Flu, as I am off work looking after my eight-year-old son Hugo. He is on antivirals and seems to have the classic symptoms of swine flu. I have a cough and cold which may or may not be swine flu, but am steering clear of colleagues for a bit as they wouldn't thank me for spreading a virus. Had it not been for my son's symptoms, I might well have carried on as normal.

Lots of you have shared your personal experiences of swine flu, so here are mine. Our son had a temperature of 38.7C yesterday morning along with a dry cough, cold and he was generally unwell. I went to the and filled out the questionnaire and got a unique authorisation number for antivirals. So far, so good.

Then I put in our postcode and was informed that my collection point was in Slough, but it was open only from 7-10pm every day. It was now 8am and I didn't want to wait 11 hours to get his antivirals. I rang our very good GP practice in Windsor and they referred me to Berkshire East Primary Care Trust, who in turn referred me to a national helpline. The national helpline suggested I go to Reading, or Wokingham.

In the end, we did get the Tamiflu in Reading, 15 miles away, and Hugo got his first dose by mid-morning. By contrast, Reading has 13 antiviral collection points and Wokingham has four. They are open throughout the day, and both have collection points open on Sundays. Why Slough and Windsor don't have at least one collection point open during normal hours completely mystifies me. Tyron Brown, the Project Manager for System Resilience at Berkshire East PCT told me that they "monitored volumes daily" and would expand the service if required.

Hugo is a very robust lad, but yesterday he was really quite poorly and refused food. But today is a different matter and he woke up and went straight to get his advent calendar (to eat the chocolate on 1 December). He still has a hacking cough but is definitely on the mend. Any suggestions as to how I keep him amused for the next couple of days would be gratefully received.

Update 1358: The Director for Public Health for East Berkshire, Dr Pat Riordan, has called me to say that, in the light of my post, she is going to improve access to antivirals for the residents of Slough and Windsor.

A new daytime antiviral collection point is to be set up somewhere in the locality. As Dr Riordan put it to me: "I do listen to all suggestions and comments. It's not appropriate to have people hanging around half a day for their Tamiflu. We want to provide an effective and efficient service."

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