No rationale for travel restrictions

As of 1st May 2009, WHO does not recommend travel restrictions related to the swine flu outbreak: “Limiting travel and imposing travel restrictions would have very little effect on stopping the virus from spreading, but would be highly disruptive to the global community.”

The statement points out that both mathematical modelling and the historical records of previous influenza pandemics show that restricting travel has almost no benefit in stopping the spread of disease. Influenza A(H1N1) has now been confirmed in many parts of the world, including the UK and the Republic of Ireland. The focus now is to minimize the impact of the virus by rapid diagnosis and appropriate medical care. Identifying the signs and symptoms of influenza in travellers is not effective in reducing spread as the virus can be transmitted from person to person before the onset of symptoms. But it can help with monitoring and treatment.

Travellers can protect themselves and others by following this simple advice which can limit the spread of many communicable diseases, not just influenza: if you are ill, delay your travel and if you fall ill after returning home, seek medical advice.

Phase 5 Pandemic Alert

The worldwide swine flu situation continues to evolve rapidly and WHO raised the pandemic alert level to phase 5 last night.

By 7 pm yesterday, nine countries had officially reported 148 cases of swine influenza A/H1N1 infection. The US Government had reported 91 laboratory confirmed human cases, with one death. Mexico had reported 26 confirmed human cases of infection including seven deaths.

The following countries have reported laboratory confirmed cases with no deaths – Austria (1), Canada (13), Germany (3), Israel (2), New Zealand (3), Spain (4) and the United Kingdom (5).

Further information on the situation will be regularly updated on the WHO website.  WHO advises no restriction of regular travel or closure of borders. It is considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention, in line with guidance from national authorities.

There is also no risk of infection from this virus from consumption of well-cooked pork and pork products. Individuals are advised to wash hands thoroughly with soap and water on a regular basis and should seek medical attention if they develop any symptoms of influenza-like illness.

The UK-specific advice is available at:  

Advice specific to Northern Ireland is available at: 

There is specific advice for children at

UK cases of swine flu

Now that cases have been reported in the UK, people in Northern Ireland are starting to report symptoms. Thus far, none of them have been found to have swine flu, but you should remain vigilant.

WHO raises pandemic alert level to Phase 4

The World Health Organization describes the development of a potential pandemic as a series of 6 phases. We have been at Phase 3 for some consideable time, but overnight the level was raised to Phase 4. This is a significant escalation and you should consider carefully whether you need to travel to affected areas, or to surrounding areas. If you have already booked travel, it is unlikely that your insurers will re-imburse you unless your national government specifically advises against travel to your destination. The UK government is now advising against all but essential travel to Mexico, but you will need to check how your travel agent and insurer view this. You should check the FCO website regularly and you can sign up for email alerts on your destination countries. The following description of the phases is taken (with some editing) from the WHO website. Phases 1-3 correlate with preparedness and response planning activities, while Phases 4-6 signal the need for response and mitigation efforts as well as post-pandemic recovery activities. In nature, influenza viruses circulate continuously among animals and birds. Although they have the potential to develop into pandemic viruses, in Phase 1 no viruses circulating among animals are reported to cause infections in humans.  In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat. In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in sustained human-to-human transmission. Limited human-to-human transmission may occur when there is close contact between an infected person and an unprotected caregiver.

In Phase 4 there is verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause community-level outbreaks. The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any affected country needs to decide whether a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion. Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short. Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way. 

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. Although pandemic activity appears to be decreasing, additional waves may occur and countries need to be prepared for a second wave. Previous pandemics have been characterized by waves of activity spread over months. In the post-pandemic period, influenza disease activity returns to levels normally seen for seasonal influenza. It is expected that the pandemic virus will then behave as a seasonal influenza A virus.

Swine flu outbreaks in Mexico and North America

The authorities in Mexico, the USA and Canada have confirmed human infections with a new strain of influenza, swine flu A/H1N1. This virus has the potential to cause a global outbreak of flu (pandemic). Suspected cases are also being investigated in France, Spain, Israel and New Zealand. 1,400 cases of a severe respiratory illness have been reported in Mexico City. Other affected areas include San Luis Potosi, Mexicali and Oxaca and at least 90 people have died across Mexico. The World Health Organization (WHO) has reported suspected cases in 19 of Mexico’s 32 states. Laboratories in the US and Canada confirm that 20 of the Mexican cases had swine flu H1N1. It is uncertain how many of the other cases are attributable to this new strain of influenza. School and university classes in Mexico City have been suspended. Four people in Nova Scotia, Canada, have confirmed H1N1swine flu infections and two in British Columbia (on the other side of Canada) may also be infected. All suffered only a mild illness, and none required hospital treatment.  In the USA, 20 people have been infected in 5 states: California, Kansas, New York, Ohio and Texas. Most of these suffered only minor illness and none were fatal, but two cases required hospital treatment.

Most of the cases are in adults aged 25-44 years. A few have occurred in health care workers. Symptoms are initially like flu, with fever, cough, headache and muscle pains. Severe cases progressed rapidly within 5 days.

Review your need for non-essential travel to Mexico City and other affected areas in Mexico. At present, there are no restrictions on movement, but you should be aware that if governments impose travel restrictions, you may find it difficult to get into or out of the affected area/country.

If you have not had an annual flu vaccination, you should consider having one to prevent ordinary seasonal flu, particularly if you are in what is called a “high-risk” group. In addition, to prevent respiratory infections (including flu) and to avoid spreading illness, you should:

  • Maintain good personal hygiene.
  • Wash your hands regularly and avoid touching your face.
  • Cover coughs and sneezes with a mask or a tissue.
  • Avoid obviously sick people.
  • Stay at home if you are unwell, and seek medical attention if you develop flu-like symptoms.
  • Obtain prompt medical attention for young children with fever or influenza-like symptoms.
  • If you do travel to an affected area, seek medical attention if you develop symptoms and tell the doctor that you have recently been in an area that has reported swine flu.

We are monitoring the situation and will update this note as more information becomes available.

Health Risks of Travellers

Travellers need to be aware of the specific risks that might affect them while they are away from home. In this posting, we shall briefly look at the common risks without going into any great detail.

Various surveys show that the most frequent infectious disease among travellers is traveller’s diarrhoea. It affects at least 20% of visitors to the third world and can affect over 60% of travellers to certain destinations. Those staying with friends and relatives have a different risk from tourists. Even among tourists, the risk depends on whether you are trekking, staying in a plush hotel or sailing in and out again on a cruise liner.

Malaria is the next most common infection and arguably the most important one worldwide. It can affect up to 4% (1 in 25) of people visiting West Africa if they do not use anti-malarial drugs as part of their prevention.

Other infectious diseases include influenza (flu), dengue fever, rabies from animal bites and scratches, tuberculosis, hepatitis and typhoid fever. We plan to post items on each of these over the coming weeks.

Let’s remember that accidents are the most frequent cause of death in visitors to developing countries. 0.001% (1 in 1000) of travellers to these countries suffer a fatal accident. Non-fatal accidents are, of course, more frequent.

Northern Ireland’s New Travel Health Service is Northern Ireland’s newest travel health service. We are based on the Antrim Hospital site at J7 off the M2 and just a few minutes north of Belfast. Contact us on 028 9332 3341 or text to 0778 222 4890.