Bird flu has claimed 55 people in Indonesia, with the death of a 67 year old woman. The world's fourth most populous nation (after China, India and the U.S.), Indonesia has had 72 cases since June 2005 and the most deaths (WHO). Only Vietnam has registered more cases (93 cases), but fewer deaths (42) (WHO).
A look at this bar chart shows how the epicenter of human bird flu has shifted from Vietnam (clade 1, Vietnam southeast asia, magenta color) to Indonesia (clade 2, Indonesia, yellow color). You can also clearly see the start of the new flu season. The chart does not include the three most recent Indonesian cases, which would bring the October bar to 8, two short of last October (but we are only halfway through the month).
Source: WHOPRO
The recent fatality from West Java developed symptoms on October 11 and died four days later (Bloomberg). Complicating her case was encephalitis. Whether this was due to H5N1 infection has not been confirmed, to our knowledge, but viral encephalitis from this virus was well described in the 1918 pandemic and has been reported with H5N1 on one other occasion. The woman was also described as having multiorgan failure, a syndrome that may be from dissemoinated viral infection or from a cytokine storm like reaction. The tissue tropisms of various strains of H5N1 in different hosts is not well understood, and may be related to the mode of infection or entry point of the virus. But the acquisition of neurotropism in birds is not clearly related to any particular factor as far as is known.
So why did this latest case develop encephalitis? There is a chance that the encephalitis was unrelated to the virus or a complication with some other agent. But there is also an excellent chance that this is encephalitis from H5N1. Inevitably this will lead to speculation the virus has mutated to a new and dangerous form.
At the moment we can't say. The outcome could be due to some host factor, i.e., a peculiarity of the patient. The evidence here is that the virus could have changed pathogenicity, i.e., the kind and type of disease it produces. The virus was already highly virulent (caused severe disease), with two thirds of the cases dying. Thus it isn't a change in virulence or, as far as we know from this case, in transmissibility, although we do not as yet know how the patient acquired the virus or if there are any secondary cases. The point we are making is that pathogenicity, virulence and transmissibility are different things, and this case, if it points to anything at this point, points to a change in pathogenicity, not virulence or transmissibility. Additional data would be required to raise those questions.
It is important to keep our eye on what is happening. It is equally important to be precise about what we see and what it might mean.
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Antivirals list neurological clinical signs as a side-effect of treatment. The dosages of antivirals in use in H5N1 greatly exceed label directions...
...could antivirals be playing a role in this?
(but antivirals weren't a factor when they had similar brain problems in 1918)
crfullmoon. I agree that H5N1 appears almost identical in expression to H1N1 and I agree that there were viral encephalides in 1918 as a direct result of H1N1.
But we are using antivirals that play with brain chemistry in the same way the anti-depressants play with brain chemistry...and we all know what happened when principled authorities brought up the issue of antidepressants and suicides.
Antivirals in the case of H5N1 have been given in off-label or experimental dosages to a relatively small sample size.
The bottom line is that this is a variable that wasn't there in 1918 but is there today and deserves our full consideration...
...because in a pandemic, we are going to be administering long-term antivirals to healthcare workers without any data to back up the dosage or duration of treatment.
I believe this will be in retrospect, cruel and unusual punishment on a physiological and brain chemistry level. Healthcare workers deserve better.
Reveres,
This is not relevant to this post (and some may not consider it strictly public health, either, although I'd argue that it could potentially affect the mental health of many) - but I would be interested to hear your thoughts.
http://bioethicsforum.org/20060608adreger.asp
"Healthcare workers deserve better" They sure do; we all do.
Could have gotten a lot of practical preparation done on the community level for coping the first half year of a pandemic, and beyond, if authorities had been honest with the public.
(Sometimes people are on antidepressants because they were already suicidal; better brain imaging (PET scans, ect)before and during use, and, testing genetically which individuals do better on what antidepressants, should be being made available. Nutrition may play a part, too. As is, current mental health treatment is like treating diabetes with insulin without having any way to monitor blood sugar. But I digress)
crfullmoon. Like Viox, the pharmaceutical industry was not happy when challenged with respect to suicide as a side-effect of their anti-depressants...and in fact their argument was that "sometimes people are on antidepressants because they are already suicidal.
If you would like to learn more about the issue research British Psychiatrist, Dr. David Healy.
By the way, he was fully vindicated in the end and precautions have now been taken, decades after the fact.
Like antidepressants, antivirals have been linked to suicides and like antidepressants, the issue has disappeared.
The problem is that the suicides occured with normal doses and currently antivirals are being suggested at a multiple of the on label dose. Antidepressants are also being suggested as preventatives for extended periods of time, another experimental and untested use of a drug that does not appear to have been fully tested before release.
Does this sound familiar? It should.
attack rate: It was off topic and I don't know if is public health or not (I'd say yes) but it was damned interesting. I don't know if I'll blog it yet but I encourage others to read it, too. Too coments up from this.
Off-topic shout-out to SF Bay Area folks: there's a local meeting on "Disaster Preparedness and the Role of Telecommunications":
http://www.geocities.com/Wellesley/8321/nxtevent.html
http://laughingsquid.com/squidlist/events/index.php?com=detail&eID=7505…
Tom, there have been a few cases of encephalitis from various influenza strains during the last 20 years or so. We know that this is the result of a route of entry through the cranial nerves--I'm trying to find the relevant paper in my collection. It is damned difficult to treat--plasma exchange, pulse steroid therapy, etc., have been tried with some success.
Am I missing something in the post, or where is the bar chart? I tried the WHO links to no avail. Love those bar charts...Thanks, reveres.
Dinkers: I see the bar chart. It should be there. And the link should work. What browser are you using? Try Firefox.
Neurotropism? Autoimmunity?
http://scienceblogs.com/effectmeasure/2006/07/the_vaccine_news_how_good…
Antivirals list neurological clinical signs as a side-effect of treatment. The dosages of antivirals in use in H5N1 greatly exceed label directions...
...could antivirals be playing a role in this?
Mamah Komariah was apparently already unconscious (or slipping in-and-out of consciousness) before she was brought to the hospital:
"Since Thursday (5/10), Mamah suffered hot high. Moreover, had an opportunity to not make himself [herself] aware [i.e. was unconscious or in-and-out of consciousness], so as Itang [her husband] brought him [her] to RS Saint Yusup, on Saturday early afternoon."
http://www.flutrackers.com/forum/showpost.php?p=37476&postcount=20
My guess, then, would be that she was already suffering the neurological problems before be given any anti-virals. This is, of course, just a guess.
Thanks Theresa. I guess there were four points to my comments.
First, neurological and psychological complications from antivirals is a variable that must be considered.
Secondly, I think shoving reports of a connection between antivirals and psychological problems aside, will have ramifications for healthcare workers in a pandemic.
Thirdly, the dosages being used and the preventative dosages and time periods being considered have no testing to back them up at all...and a pandemic is not the placeto be doing experiments with the psyche of stressed out healthcare workers...
...and fourth, they don't work anyway...resistance appears so quickly in seasonal influenza...they will be useless within a few weeks and may actually aid selection by the virus.
Risk without benefit...something forgotten when there is money falling from the sky into the chosen one's hands.
Antibiotics are boring, in fact there is nothing interesting about prednisolone, oral electrolytes and anti-fever drugs either...but they work.
I would like them to spend 20$ per person in North America and stockpile these medications like they would in war time...it is a small price to pay for peace of mind and to save our children who are the target of H5N1.
Where exactly are they going to get these medications in the middle of a pandemic when the demand for antibiotics alone may be millions of times the present demand...
...and where is the Canadian Medical Association and the American Medical Association in this?
I have great respect for health care workers...I saw firsthand that they were treated shamefully during the SARS outbreak in Toronto, Canada...and I do not want to see a repeat of such a disgrace in the future.