Swine flu and young people

DJS, Times, 17th July 2009

The death of an apparently healthy 6-year old child has helped bring swine flu back onto the front pages, and the Health Protection Agency says that 5-14 year-olds remain the age group predominately affected – 1 in 600 of them went with flu-like symptoms to their GP just last week, that’s 1500 a day. A child’s death naturally provokes our shock and our sympathy, particularly as such events are now so rare that they are unfamiliar to most people. Statistically, being 7 years old is the safest age to be in England and Wales - there’s 650,000 7-year olds and around 60 die each year, that’s 1 in 10,000.

So what do young people die of, and what might swine flu do to those risks? The Office of National Statistics reports that out of 6.3 million children between 5 and 14 in England and Wales, 721 died in 2007. The aggregate statistics rather coldly amalgamate these 721 individual stories, each of which will endlessly be gone over by their parents and others who were touched by their short lives. We tend to hear about the 135 accidental deaths, including 34 pedestrians, 18 cyclists, 5 on motorbikes, 22 in cars, 2 in trains, one falling out of a tree, 8 drownings, 1 electrocution, 3 in fires, 6 accidental poisonings. These events are so rare that it is unsurprising they make local or even national news. We also hear about the 24 homicides in this age-group - around half committed by the child’s parents - though not of the 16 suicides.

But most deaths are from natural causes, and although we might see photos of plucky children fighting their disease, if the feared event actually happens then families are generally left to grieve in private. Many are from genetic or pre-existing conditions, and there were 170 classified as cancer, 15 as asthma, 15 as epilepsy and so on. Deaths from simple infections are very uncommon: these included 2 from chicken pox, and only 2 deaths of children aged between 5 and 14 were primarily classified as ‘Influenza’ in 2007, and these may have had other problems.

A brief look in any churchyard movingly shows that a child’s death was not always such a rare event. When Dickens published Oliver Twist in 1838, if you were lucky enough to reach 5 years old (a quarter of those born didn’t), you had a 1 in 10 chance of dying before you were 15. That’s around 100 times the risk that children face now.

So is swine flu going to put us back into Dickensian levels of risk? It is difficult to estimate how many children might die if no vaccine were available: there have been around 500 deaths out of 100,000 confirmed swine flu cases worldwide, which works out at a 1 in 200 death rate, but the main UK research team has recently warned that the only thing we can be confident about is that this figure is wrong. The true denominator will be many more than 100,000, as these will only be the most severe cases who have reached hospital, but the numerator will be wrong as well as there will have been many deaths that have been attributed to a different cause. What with the inevitable gap between being confirmed as having swine flu and dying, and changes in the treatment and severity of the disease, the job of assessing the odds on a case dying start becoming a matter of judgement. It would help if there were decent data on what was happening to ordinary families who did not necessarily go to their GP or even call NHS Direct, and we might ask why plans were not already in place to collect such data on a proper sample of families - if can collect TV viewing figures from a representative subset of families, why can’t we know about illness?

As this is not an academic article I can make some fairly conservative assumptions to get a very rough picture of what we could be faced with if a vaccine did not become available. Suppose we are only hearing about a fraction of cases, and so rather than the apparent 1 in 200 mortality rate, let’s say that only 1 in 1000 of those infected die. Suppose only 1 in 10 of 7-year-olds got infected in the next year, much below the current projections. This would mean around 65,000 cases, of which 1 in 1000, or 65 7-year-olds, would die. That would double the number of children that died in this country.

This would be serious, even under my very cautious assumptions. This would be the child mortality that existed in the country 25 years ago. A 7-year-old boy would face the same risk as 22-year-old men now, who as a group face the threats of drink, drugs and driving. It is hardly surprising that doctors are drawing up emergency plans to prevent intensive care being overwhelmed, and hospitals are wondering what to do when staff either can’t or won’t come to work.

But this gloomy projection assumes that we sit here and do nothing. In fact the impressive effort to produce a vaccine is yielding results and the Department of Health is planning to have every child between 3 and 16 vaccinated against the current strain of swine flu by Christmas. It will be interesting to see if this extraordinary enterprise is accompanied by accusations that the vaccine is damaging children, in which case objectors might be asked of they would really prefer the alternative.

However no vaccine is perfect, and there is an unavoidable gamble that an important mutation does not occur with, for example, seasonal H1N1 flu virus which is already resistant to Tamiflu. In two other recent stories we have heard about an 18-year-old killed in Afghanistan and a 19-year-old that survived 12 days in terrible weather in the Australian bush, reflecting both the vulnerability and the resilience of teenagers. Gordon Brown has asked to be ready for ‘difficult times’, and we may need to brace ourselves for further deaths of young people from both war and pestilence.