Thursday, August 06, 2009

Swine flu in Israel

Wrong on H1N1


When mid-summer headlines warn that 700 young Israelis may die in the course of 2010 from the H1N1 virus, it is natural to feel anxious. A quarter of Israelis, say health experts, may contract swine flu, leaving a third of the population sick at home. Some 150,000 Israelis could find themselves hospitalized. If the epidemic gains momentum, authorities would have to close schools, kindergartens and daycare centers. Gatherings from classical concerts to football matches might be canceled. Commuters would be dissuaded from using crowded buses. We could see people walking down the streets wearing surgical masks.

Two basic questions come to mind: How concerned should Israelis be? And is the government of Prime Minister Binyamin Netanyahu - he's also health minister - managing preparations for the crisis effectively? The two issues are obviously connected.

Experts surmise that the death rate from swine flu is not likely to go beyond that of regular influenza. That still means more people will die - many hundreds as usual of the regular flu, and hundreds more of swine flu. The difference is that H1N1 appears to be particularly risky for people between 15 and 49, whereas regular influenza tends to be most harmful to the elderly and those whose immune system is compromised. People over 40 seem to have acquired immunity due to previous exposure that makes them less susceptible to H1N1 virus.

Israel's public health system is positioned to provide citizens with protection on par with those of other advanced societies where sanitary conditions are good and adequate supplies of expensive antiviral drugs are readily available. Contingency plans for more hospital beds and enhanced emergency services are in the works. So, based on what we know today, there is no reason for panic.

YET AUTHORITIES face a dilemma that brings us back to the question of the government's approach to the epidemic. Scientists are at work perfecting a vaccine that could be available in early winter. But there are no guarantees that H1N1 will not mutate into a different strain by the time the vaccine is disseminated. Moreover, people will require two inoculations against H1N1, and getting them to come back for their second jab could prove problematic. Those who need to be vaccinated against the regular flu would have to get three separate shots. The Center for Disease Control in the US is urging people over 65 who routinely take the seasonal vaccine to do so as soon as it is available. We trust Israel's health funds will follow the CDC's lead.

An H1N1 vaccine that is rushed from the laboratory to the pharmacy could have unanticipated side-effects. But the critical public policy decision pending is whether to purchase in advance the not-yet-perfected vaccine and do so in huge quantities. Netanyahu has ordered that NIS 450 million already earmarked for the purchase of medications that would expand the arsenal of treatments available for cancer, mental illness, heart disease and other serious disorders be redirected for battling H1N1. And he has ordered that masses of Israelis be vaccinated. But many may refuse, as is their right. The Health Ministry would then be stuck with expensive vaccine.

In contrast, US health officials plan to focus their vaccination efforts on pregnant women, people who live with or care for children younger than six months, health care and emergency services personnel, people between the ages of six months and 24 years, and people aged 25 through 64 who are at higher risk for H1N1 because of chronic health disorders or compromised immune systems.

Israeli health experts are divided over the wisdom of Netanyahu's approach. Deputy Health Minister Ya'acov Litzman favors something closer to the US approach, which would protect those most vulnerable and avoid decimating the expanded health basket for other diseases.

The main reason to vaccinate citizens in a nationwide program is to lower the pool of people who could prove to be a reservoir of new infection. Is Netanyahu's judgment to give priority to eradicating H1N1 at the expense of other public health concerns the right call? Not if you believe that H1N1 is already an epidemic/pandemic that cannot be eradicated, but that it is only a serious condition for a relatively small and identifiable population. That seems to be the scientific consensus. A poll of family doctors in Israel found that most oppose Netanyahu's approach.

We urge him to rethink his plan for mass inoculations at the expense of the expanded health basket.

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