How useful is the government's emergency plan? Reem Leila reports Egypt is working closely with the World Health Organisation on strategies to combat the threat posed by swine flu. Together they have formulated a national emergency plan to boost rapid containment procedures and build capacity to cope with any significant outbreak of the virus. "We are doing everything that is necessary," says Abdel-Rahman Shahin, official spokesman at the Ministry of Health, who urges the public not to panic. The most immediate concern of officials is that the colder weather that will come when summer ends could bring a new wave of the virus. Training exercises -- which involve simulating the conditions of a pandemic -- are being organised in all 29 of Egypt's governorates. Meanwhile, the government is intensifying surveillance and has embarked on a campaign to raise public awareness around the issue. "There is no need for people who have flu symptoms to rush to ministry hospitals or private labs," says Shahin. "Private labs are not equipped with the polymerase chain reaction [PCR] tests which are the only way to detect the swine flu." Instead, Shahin advises that an ear, nose and throat (ENT) clinic should be the first port of call, where doctors should be able to differentiate between seasonal flu symptoms and swine flu. "If there is any suspicion that swine flu might be the cause then patients will be referred to a ministry hospital." Patients below the age of five or above 65 are especially vulnerable, as are those with renal and liver disease, cardiac problems, hypertension and diabetes. "Doctors must take such factors into consideration when diagnosing patients," says Shahin. He points out that the vast majority of the 145 fatalities caused worldwide by the virus were patients whose health was already impaired by other illnesses. Maged El-Shennawi, an ENT specialist at Qasr Al-Aini hospital, is far from confident that the advice to visit ENT clinics is warranted. "It is impossible to clinically differentiate between the symptoms of seasonal influenza and swine flu. Only the PCR test can identify it." But PCR tests are only available at Ministry of Health hospitals and labs. The tests, says El-Shennawi, cost LE2,000, though ministry hospitals should provide them for free. "The problem," he complains, "is that I do not have the authority to transfer suspected cases to ministry hospitals." "There are 126 hospitals affiliated to the Ministry of Health," says Shahin. "Of these 99 will conduct swine flu tests and the remaining 27 will test for bird flu." Only three of them, though -- the Imbaba, Abbasiya Fever Hospitals and the Chest Hospital -- are located in Greater Cairo. A recent Cabinet Information and Decision Service Centre (IDSC) report identified the officials who will be charged with making critical decisions in the event of a pandemic, including when to call in the army to maintain order in affected areas, man checkpoints between governorates, and when to restrict access to public services in order to contain infections. The Ministry of Health has 700 mobile units equipped with laboratory and x-ray facilities ready to cover any infected area. "In cases where an area has heavy rates of infections it will be quarantined," said Shahin, "although we cannot guarantee the infections will remain localised." The government's contingency plans also include designating areas for mass graves. "People need not be afraid. The grave designations are a precautionary measure. It is very possible they will never be used. Most people recover from infection without the need for hospitalisation or medical care." John Jabbour, a consultant for emerging diseases at the WHO, believes Egypt's preparations are on the right track. "We have seen very good progress from the Health Ministry and governorates. Their plan encompasses the macro and micro dimensions at the national and sub- national levels, from the top executive level of the state down to the single role of every village doctor and the response team assisting him," Jabbour said. The WHO has repeatedly advised the Health Ministry to carry out field simulation exercises. Initially the IDSC advised against these for fear of causing panic among residents. "Field exercises are difficult to carry out because they are bound to rumours that an actual pandemic has hit the area where the field exercise is occurring," said Jabbour, quoting IDSC officials. Both the WHO and Health Ministry expect a vaccination for the H1N1 virus to be available in the near future, though not before six months. Currently, vehicles used for public transport are being cleaned on a daily basis. Under an agreement between both the ministries of health and transport buses and underground train carriages are sterilised daily with water and disinfectant soaps. "Once a day is not ideal but it is better than nothing. We cannot ask them to do more as the process is very costly," said Shahin. For the time being the WHO has classified Egypt as a transition country -- i.e. all confirmed swine flu cases have originated abroad or are a result of victims coming into contact with people who contracted the illness abroad. Jabbour points out that antiviral drugs generally should be reserved for patients who are at high risk or are already suffering severe symptoms. He also advises that Egypt continuously monitor the situation so that it can make a timely transition from focussing national efforts on containment to mitigation, including appropriate non-pharmaceutical intervention.
