Scotland is proving to be a world hotspot for swine flu – so are the authorities doing enough to prevent a deadly pandemic

IN DUNOON on Friday afternoon the high street radiated a sense of quiet, busy calm. The pretty Victorian town was full of tourists, day-trippers and locals going about their daily lives.

The local hospital, too, was less than busy. You would never know that Dunoon was swine flu central – the worst-affected town in Scotland, which per head of population is one of the worst-affected countries in the world.

A week ago the hastily erected temporary buildings behind Dunoon Hospital were a scene of chaos. The lines of locals worried they had contracted swine flu stretched around the corner and hard-pressed staff struggled to cope as they handed out hand gel and face masks.

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The town's branch of the Royal Bank had been shut, and so had most of its schools after Fraser Whyte and 12 fellow Rangers fans from the sleepy Cowal town brought the virus back to Dunoon after attending the final-day league decider against Dundee United at Tannadice. Every hour seemed to bring a new confirmed case.

A week later, and with the World Health Organisation now confirming a global pandemic, Dunoon seems determined to look on the bright side. "People have kept it in perspective," says Willie Ferguson, who runs J Bell & Co, a traditional outfitter on the main street. "No-one's died here, no one's going to die. There's talk of a few cancelled hotel bookings, but then people didn't go on holidays to Northern Ireland during the Troubles even though there was virtually no chance of getting blown up by a bomb.

"You do get worried about what people think of us though. I came back from London a couple of days ago and as I was coming through the airport I handed over my passport. I waited because I thought he'd see the PA23 postcode and take me to one side, but he just waved me on. It's strange how you begin to think."

There's a huge sense of disconnect between the swine flu statistics and the reality on the ground. The figures say that more than 1,000 people in the UK have caught the disease, and that more than 110 are in or around Dunoon. Of the handful of schools to have fully or partially closed, four of them are here: the town's Grammar School, plus Inellan Primary, Toward Primary and Kirn Primary.

The reality, says the Grammar School's headmaster, Stewart Shaw, feels altogether different. "We'll open again on Monday (tomorrow], and although we've lost two weeks of school, it's largely been precautionary and as a result of the reaction to swine flu within the community," he says.

"There has been no sense of panic, and although we've lost out on some things – we couldn't send a team of kids to the youth games in Oban and we cancelled the primary induction programme – most of the important things have gone ahead. The Leavers Dance was held on the evening of the day when NHS Highland said they wanted to close the school, and we'll have the prize-giving this week. Even the German exchange trip has gone ahead, as has a workshop from the National Centre for Excellence in Traditional Music." In a nearby street is a car displaying a sticker of the ubiquitous "Be Calm and Carry On" wartime poster.

This weekend Scotland's swine flu cases continue to rise and now stand at a higher rate per head of population than Mexico, where the pandemic began, and the US.

So how well have the Scottish authorities handled the outbreak? Is the high number of cases a reflection of officials' complacency, of strategic errors, or something else? And what now are the medical and political challenges facing those charged with protecting the public?

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When honeymooners Iain and Dawn Askham flew home to Polmont near Falkirk, from their holiday in Cancun, Mexico in April, confirmation of swine flu in the couple triggered a well-rehearsed public health response.

Scotland swung into a "containment" strategy, which meant not only were the couple tested, quarantined and treated with the antiviral Tamiflu, but great efforts were made to track down friends and family to test them and offer them antiviral treatment as well, as a preventative measure.

When further cases emerged, for example in schools, the presence of the virus in one pupil was enough to warrant sending home their whole year group for a week with a course of Tamiflu.

Health Secretary Nicola Sturgeon has repeatedly insisted this strategy has helped limit swine flu but with cases rising rapidly, there are serious questions about whether it has really been effective.

For example, despite an initial slow response to the outbreak, Mexico City's government eventually closed down schools, cinemas, restaurants and bars in early May, telling residents to stay at home. Those who did venture out wore medical masks.

Professor Mark Woolhouse, an expert in infectious disease at the University of Edinburgh said that while the Scottish Government's initial response was "perfectly reasonable" it has failed and now it must change tactics in order to prepare itself for potentially many more cases.

He explained: "In terms of the containment strategy, it hasn't worked, clearly. When the outbreak started there was a lot of uncertainty and the general perception is that this is the summer, it's not flu season, so it was a reasonable expectation that it would peter out. It has not done that."

Woolhouse believes the cause of the problem may be that many more people had the virus than was initially thought in the early stages and they were not caught, perhaps because their symptoms were so mild they did not suspect they were ill.

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However Dr Dean Marshall, chairman of the British Medical Association's Scottish GP committee puts Scotland's relatively high number of cases down to coincidence and bad luck. And he is satisfied with the way health officials have responded.

He said: "We are fairly happy with how things have gone. It's something where we have some planning in advance. It is only coming into the public awareness in the last few months, but we have been planning for years.

"There was a view this was going to happen at some point and the test will be when we get past the planning phase and into the implementation phase," he added.

"I don't think there's any particular reason for the number of cases in Scotland. I think it's coincidence more than anything. It's not about how we have contained it in Scotland, I think we've just been unlucky. More worrying is why have some previously healthy people been hit hard by it, although I don't think there's many of them."

Now, health officials are instructed to become more "flexible" in their approach to swine flu. Swabs will no longer be needed to diagnose suspected cases in cluster areas or where a suspected patient has been in contact with a known case. Instead a diagnosis will be made on the basis of symptoms, and this can be done over the phone.

Antiviral treatment will be cut down among those who do not have the virus, and their use will be restricted to household contacts or, in a school, to those at surrounding desks. And among those confirmed with swine flu, doctors will restrict their contact follow-up to those most at risk of complications.

So, with this latest plan swinging into action, what are the challenges now facing the Health Secretary and her staff? Not only does this make it increasingly unlikely the true number of cases will ever be known, it also signifies just how uncontrollable swine flu has become.

Woolhouse has his eye on this coming winter.

"Obviously there's a significant chance it will increase again in the autumn and we will have much more swine flu this winter," he said. "We do need to change what we are doing so the fact they are considering changing the response is appropriate at this time. The ground has moved under our feet and we have to respond to it quickly and appropriately," he added.

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"It's important to control the use of Tamiflu so you don't risk the virus developing resistance to it. Thinking ahead to the winter, it hasn't even petered out so it is already defying expectations."

Dr Rowland Kao, an expert in infectious diseases in the Faculty of Veterinary Medicine at the University of Glasgow says the government's big challenge is to keep swine flu in the public's minds, after the initial panic of the move into pandemic phase has subsided.

"There tends to be an initial scare and then nothing happens for a few months and people will move on," he said.

"It might appear to go away in Scotland but by the autumn cases may increase again. At that point people would have forgotten about the recommended protective measures. Whatever the Chief Medical Officer says now, people are going to forget, so a high level of awareness is critical.

"We have an excellent chance to mitigate the spread of any new incursions. We are likely to have enough time to develop and deploy a vaccine, and we have to calculate the risks of this against seasonal flu in terms of which vaccine is prioritised.

"The message for now is not to panic, and to follow the CMO's recommendations for reducing the risks to yourself and others."

Back in Dunoon, there is irritation at the unwanted infamy that swine flu has brought to the town.

"We just want it all to go away," said one middle-aged woman. "We feel like some sort of freak show. The truth is that people aren't that bothered about it. They're talking about up to half of the country getting it and now that we've all calmed down people are even saying that it'd be good to get it now while it's in a mild form so that you don't get it in the winter, or when it's become resistant to the drugs."

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Even hairdresser Lyn Rodgers, whose shop on the main street sports a home-made sign asking those with sniffles or cold-like symptoms to stay away, plays down the risks.

She says she put up a virtually identical sign when there was a lot of flu around; that she works with cancer patients at a Maggie's Centre one day a week and doesn't want to pick up swine flu and unsuspectingly pass it on to vulnerable cancer patients.

Rodgers says the only effect of the outbreak she has noticed in the town is the absence of the usual coaches of day-trippers when she came back across on the boat on Monday. Perhaps she should have waited a couple of days, because by Friday the tourists had started to come back.

"We did think twice about coming here," said Jim Williams from Cardiff, who was up for a week with his wife Brenda, "but we've been coming here for years and life's too short to worry about a little dose of swine flu. To be honest the only surprising thing about coming here has been how little Dunoon has changed. It's almost like swine flu was never here."

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