There will be an update from CDC later today and WHO's expert committee established under the new International Health Regulations (IHR) meets via teleconference this morning North American east coast time at 10 am (4 pm Geneva time) to consider whether the swine flu situation merits declaring it “a public health event of international concern.” If they do, WHO Director General Margaret Chan may respond by raising the pandemic threat alert level from the current phase 3 (new virus: no or limited human to human transmission) to phase 4 (new virus, evidence of increased human to human transmission). It's conceivable, but not likely they would go to phase 5 (new virus, evidence of significant human to human transmission). Phase 6 is acknowledgement of an existing pandemic (new virus, evidence of efficient and sustained human to human transmission). The level of alert is not just an academic exercise because under the IHR this allows WHO to institute measures like travel advisories which were forbidden before the IHR were revised and went into force last year. For more background on this see our posts here, here, here, here and here.
One of the puzzling things about this outbreak is the stark contrast between the clinical and epidemiological picture in Mexico and the US, with reported Mexican cases winding up on ventilators and dying with severe lower respiratory disease while US cases have been mild with uneventful recoveries. Partial comparisons of the genetic sequences of the Mexican and American cases shows them to be essentially the same (two flu isolates, even from within the same patient, are rarely identical, but most of the changes are not biologically significant). Is this difference real or only apparent? At ProMed, Moderator PC (Peter Cowen, ProMed's Animal Disease Moderator) makes the following excellent points:
According to the above information are now 8 confirmed cases of the novel influenza A H1N1 virus infection in the USA, all mild, occurring in counties with known increased population flow/transit between the USA & Mexico. According to the official report from WHO, there have been now more than 854 cases of pneumonia reported from the capital (Mexico City) of which 59 have died (case fatality rate [CFR] 6.9 per cent). In San Luis Potosi (central Mexico) there were 24 cases of influenza-like illness (ILI) reported with 3 deaths (CFR 12.5 per cent) and in Mexicali, (near the border with the United States), there have been 4 cases of ILI reported with no deaths.
It should be noted here that the data from Mexico refers to inpatient hospitalized cases, whereas the ILI surveillance sites in the USA are predominantly from sentinel reporting outpatient facilities. This difference in surveillance sites may account for an apparent disparity in severity of the illnesses in cases reported in Mexico vs those presently reported in the USA. As more uniform active surveillance (case finding) is implemented, these disparities may lessen.
The absence of direct connection between the cases in the USA and the cases in Mexico does not rule out the outbreaks being linked, as the population flow between the 2 countries is high and 12 isolates from Mexico are reported to be genetically identical to those isolated in the USA. One suspects the epidemic curve is already multiple generations past the "index case". The virus has apparently been circulating in Mexico for several weeks, and in the USA for at least 2 weeks according to the above reports. (Comments of Mod PC to ProMed notice of latest MMWR Dispatch)
There are a lot of questions in the Comments threads, some of which I answered as well as I could as we went along, many more that came in during the night. The situation and available information is moving fast, which will answer some questions but inevitably suggest more. I'll do my best to get to some of them, but I won't get to all. Many are excellent questions that have no answers . . . at the moment.
Let me just say this: One way or another, it's not looking like 1976.
[sarcasm]Gee, why would they raise the phase level to 5?
It's not a "new" virus. It just contains a "never seen before" combination of gene segments from viruses that infect pigs, birds and humans.
There is no evidence of "significant human to human transmission". It's just spread to at least 5 cities 2 of which are over 1,400 miles apart in a pattern that the director of the CDC thinks is no longer containable.[/sarcasm]
Anyone depending on the WHO for timely action is making a potentially fatal error.
I've noticed stories about meningitis - note the Miama area fatal infections. (I am a layperson - no health expertise.) But before this story broke, just a couple days ago, a neighbor mentioned she had several friends that had been hospitalized for meningitis in the past month, one of whom died and one of whom was in a coma. (Her apparently healthy dog died suddenly a few days ago as well.)
I know these are just anecdotes, but is there a possible connection between this flu and meningitis? I recall reading something about sporadic meningitis cases and novel influenza.
A report from my area: I live in central Texas a couple counties away from the 2 boys who had the swine flu in Sequin (San Antonio TX cases). And I know no one who is suffering any flu-like symptoms - no one in my office, none of my friends, and there's been nothing noted in the local news, no one has mentioned flu going around. My brother who also lives nearby did return from San Diego at the weekend with cold symptoms, but they are mild and probably completely unrelated. There isn't any panic here at all - just puzzlement.
Re: 1976 U.S. Swine Flu (SIV) outbreak...
Well Ren, I'd have to both agree and disagree with your comparison. As yet, we don't have the epidemiology on the 2009 swine virus -- though, it is probable this particular virus can easily be transmitted (like previous SIVs) via human to human (H2H) interaction and contact -- and bejeezus-allah help us all if this gets to recombine with that other transgenic disease with a high CFR, H5N1...
In 1976, poor old president Gerald Ford listened darned seriously to public health officials suggestions the entire U.S. population be vaccinated against the circulating SIV strain and a heckuva lot of public money was utilized for that very purpose. The swine influenza (SIV) pandemic never eventuated. But a vaccine aint exactly the same as an influenza antiviral. Influenza antivirals did not exist in 1976 -- they began circulating during the early years of the 1980s HIV/AIDS epidemic...
Unlike 1976, investing in public health is not a 2009 priority for American governments -- but, generically produced antivirals are what is needed -- but, who gives a rats ass about pragmatic medical science when it's far more exciting to behave like moronic xenophobes (I'm pre-empting the Republican 'action-plan' for dealing with a pandemic -- media-destroy the Democrats, close borders, cease trade, nail the windows shut and rant and rave three Hail Mary's whilst blaming Mexican gays and lesbians for SIV:*)
Ren, privately I feel this timeframe appears similar to a movie narrative being made by a Mr G. Lucas during 1976, Star Wars. I've been joking all week with a U.S. med student friend currently working in India that I feel like Princess Leia with a laser pistol:*) "Someone has to save our skins. Into the garbage chute, fly boy" -- Princess Leia
Antiviral drugs are the only medical intervention we have against the influenza virus... Our best and only hope in pandemic preparedness (irrespective of transgenic viral composition) is the mass generic manufacture of current antivirals for national government stockpiling...
Turning once again to Crof's H5N1-Blog "Branswell: Canada plans changes in pandemic-drug mix" (April 19, 2009) posting a few days ago!?! The news article was a reprint of a Canadian Press report by Helen Branswell, "Canada planning to change breakdown of flu drugs in pandemic stockpile".
Quoting Dr. Arlene King, the senior official responsible for pandemic influenza planning at the Public Health Agency of Canada, the article expressed current epidemiological understandings of H5N1 and stated that nation will adjust the mix of antiviral drugs in an emergency pandemic stockpile -- a response to scientific concerns over the vulnerability of the main drug, Tamiflu, to the development of viral resistance.
The article went on to state that only up to a quarter of a given Western nation population (except Great Britain at fifty percent) can be treated with antiviral drugs from government stockpiles during the first pandemic wave. This would mean, as Australia's Dr. Buddhima Lokuge et.al. states (see eMJA article), Australian government stockpiled antivirals "will be limited and reserved for those on a confidential rationing list." The United States public are in the same boat and face an identical government policy situation -- selective rationing:*)
So, it is up to us -- everyday people -- to put our collective hands up and sing loudly to our elected political representatives an 80s GenX song (parental demographic undeniably with the most to lose from a novel transgenic disease with a high CFR in those under the age of fifty). Yes, Moving Pictures' classic tune "What about me" (1981) is an "Aussie battler" anthem appropriate to this incredibly serious public health issue -- "what about the generic antiviral manufacturing option:*?"
eMJA -- "Pandemics, antiviral stockpiles and biosecurity in Australia: what about the generic option?" By Dr. Buddhima Lokuge, Peter Drahos and Warwick Neville. The Medical Journal of Australia 2006; 184 (1): 16-20 http://www.mja.com.au/public/issues/184_01_020106/lok10852_fm.html
Excerpt: "The Doha Declaration on the TRIPS Agreement and Public Health, signed by trade ministers of all WTO member countries on 14 November 2001, states in paragraph 4 that âthe TRIPS Agreement does not and should not prevent members from taking measures to protect public healthâ. The same paragraph continues: â[T]he Agreement can and should be interpreted and implemented in a manner supportive of WTO membersâ right to protect public health and, in particular, to promote access to medicines for all.â
Currently, antiviral agents are the only medical intervention available for influenza-affected patients. Privately, therefore, Australians are likely to demand universal access to this therapy and have a high level of willingness to pay. Clearly, if the manufacturers cannot meet demand at cost-effective prices, then there are health, economic and ethical arguments for a âgovernment useâ licence to be issued and for generic capacity to be developed and deployed rapidly in Australia.
To date, decision-makers have determined not to pursue this option or to even publicly discuss it. Furthermore, in view of limited supplies and likely overwhelming demand, a rationing system has been developed to determine a priority allocation list for these limited resources. For reasons of security, and also because of political pressures, the list of recipients has not been made publicly available. However, this process raises procedural and ethical questions in view of the fact that options for expanding access (eg, generic manufacture) are not being pursued by decision-makers, who are likely to be included in the list of essential public servants with access to national stockpiles.
The policy of not pursuing generic production is further complicated by the fact that Australian taxpayers contributed to the early research that led to the discovery of the influenza target enzyme and subsequent development of antiviral therapies. (A 2003 study by Allens Consulting found that nearly 20% of the output of the biotechnology firm Biota, which developed the first neuraminidase inhibitor, could be attributed to Australian Government funding.)
Ultimately, the questions of how to ensure adequate stockpiles, whether the generic antiviral option should be pursued, and whether governments have the resolve to use compulsory licences that are available under international and national laws to protect the health of nations is a contest of principles.
It is a contest between patent monopolies, involving intellectual property rights, and the right to optimal access to essential medicines.
Currently, decision-makers appear reluctant to challenge the interests of patent owners and the pharmaceutical industry.
At a time of [international] pandemic alertness, they have, in a self-censoring fashion, failed to put the issue of compulsory licences and generic production on the table. We hope this article initiates an alternative debate..."
The whole planning thought process from the WHO in regards to the WHO Phases was that each member country develop their own set of trigger points that deals with their realm of responsibility. The U.S. did that with the USG Stages.
I am not so concerned that the WHO hasn't upped the Phase as I am that the U.S. hasn't upped the Stage. Per their definitions, we should be at USG Stage 4. Since most State and local jurisdictions plans are based off of either the WHO Phases or USG Stages, one of the two needs to move.
Check my post on stages, and intervals.
The CDC intervals have suddenly become more practical.
WHO chief Chan says Mexico Swine Flu Has 'Pandemic Potential
WHO: Mexico Swine Flu Has 'Pandemic Potential'
WHO chief Chan says swine flu found in Mexico, US has 'pandemic potential'
GENEVA April 25, 2009 (AP)
The head of the World Health Organization says the swine flu outbreak in Mexico and the United States could develop into a pandemic.
WHO Director-General Margaret Chan says the outbreak involves "an animal strain of the H1N1 virus, and it has pandemic potential."
Chan says it is too early to say whether a pandemic will actually occur.
The global health body has advised countries around the world to look out for similar outbreaks following the discovery of related strains on both sides of the Mexico-U.S. border.
At least 62 people in Mexico have died from pneumonia after contracting a flu-like virus. WHO says some tested positive for a strain that sickened at least seven in the southwestern U.S. No deaths have been reported in the U.S.
THIS IS A BREAKING NEWS UPDATE. Check back soon for further information. AP's earlier story is below.
"What it tells us is the virus is active and if we continue to get environmental conditions that favour the breeding of it, the likelihood of an outbreak is obviously greater."
Informing not inflaming
News reports Saturday seem to indicate WHO is staying at Level 3. Even in my small town on Northern BC (pop 70,000), many folks travel to Mexico during any given month. Health authorities in Canada and the US have still not called for travel advisories. BC-CDC, at least, says it is developing one. The glacial pace is frustrating.
Viral gene sequences to assist update diagnostics for
swine influenza A(H1N1)
25 April 2009
WHO published a Guidance to influenza laboratories on response to swine influenza
A(H1N1) infections1. Due to the fact that it is a new reassortant virus, diagnostics has to
be updated accordingly.
The full genome sequence of the newly identified swine influenza virus
A/California/04/2009 A(H1N1) has been made available by the WHO Collaborating
Center in CDC, Atlanta, USA on the GISAID sequence database2 and has the following
Further update on availability on other public sequence databases will be provided when
1 http:// â¦. Link to the first
Proteins: PA (716aa)
"One of the puzzling things about this outbreak is the stark contrast between the clinical and epidemiological picture in Mexico and the US"
Could this be due to the difference in altitudes? Mexico City is 2240 m above sea level, while San Diego is on the ocean, and San Antonio is only at about 200m.
Could a plausible consideration be, that the difference in how sick one gets with this disease could be dependent on populations that have received the pneumovax in contrast with those who have not?
Margaret Chan Conference audio almost 15Mg
Margaret Chan said that the Emergency Commitee gathering later today will consider the necessity to raise the Pandemic Level.
Anyone wonder why the CDC is "depositing" potentially pandemic sequences with a private company (GISAID) instead of NCBI?
Let's see. CDC is paid for the US taxpayers. NCBI is paid for by the US taxpayers. Both the CDC and NCBI are funded by HHS. GISAID is a shadowy private "company" run by a mystery man.
Very well put .Its only after reading this post can I see the point that Jove may have claimed it is open but where it mattered they probably were more "PyriteOA".
I guess we are all guilty of naivete and assuming things . If the "open-access" label mattered to any of us as content producers or content consumers we should have done our homework and looked for the fine print: just as it probably would have benefitted Jove to put all their cards on the table . I am not saying they did not as I dont know. Personally I dont care much about open-access . I think it is like good morals , its better praticed than preached.
Jove was and is an innovative concept . I hope they survive . It was great to see them popularize "video" as a means for formal publication. Regardless of the outcome of the current licensing chaos , this will be their lasting contribution to science and publishing .
Paid Jove or Free Jove , I hope where this will all end is when we realize that for 80% of the protocols , it probably helps as much to have a handycame home video of the process as it does to have a multi-thousand dollar production .
I hope we as a community have more video of all sorts . And then maybe no one will care whether you pay for the high quality stuff ( on Jove) or watch a home-video version for free on youtube.
What it tells us is the virus is active and if we continue to get environmental conditions that favour the breeding of it, the likelihood of an outbreak is obviously greater."
Informing not inflaming
It surprises me that no one has mentioned this, so i'll end years of quietly lurking and say it myself: a possible explanation for the difference in clinical picture here vs Mexico lies in the sample size here. 8 of 8 confirmed "swine flu" cases here have not involved serious lower respiratory infection or death. But about 60 of about 1,000 generally unconfirmed cases of "swine flu" in Mexico have. If those all confirm, that's about a 6% CFR. From what i've read, we don't have data yet on the CFR of confirmed cases in Mexico, and we don't have a satistically significant sample here for measuring phenomena in the single percentage digits.
This tells me that there is no confirmed or statistically significant difference in the clinical picture between US & Mexico.
The medical history of the Mexican dead and recovered? Only one of the 8 to date confirmed USA cases had an autoimmune disease and she got really sick (and recovered). Do the Mexican dead mostly have a sickly history and the recovered in good health? Even if health demographics are now being infected this would suggest if it goes global, that drugs stocks should not be used for healthy populations assuming non-mutating.
Phillip: The Mexican dead have largely been characterized as healthy, comparatively young adults...before they got dead.
I don't know how "statistically significant" this information might be, but the last two weeks reports from the CDC on the "Flu Activity and Surveillance" web site,
Showed a spike in the Pnumonia and Influenza Mortality, and in the Pediatric deaths.
Any comments Revere? I haven't seen this bell rung anywhere else, although I've mentioned it in several places.
Kudos and sincere thanks to the editors! I just stumbled across here and am thankful for this community forum.
Dean's post jogged a memory.
From John Barry's work, The Great Influenza: "In 1918 the immune systems of young adults mounted massive responses to the virus. That immune response filled the lungs with fluid and debris, making it impossible for the exchange of oxygen to take place. The immune response killed" (page 250). This was probably ARDS. Question: Any pathology reports coming through?
Again from John Barry: "Bacterial pneumonias developed a week, two weeks, three weeks after someone came down with influenze...It is impossible to know what percentage of the dead were killed by a viral pneumonia and ARDS and how many died from bacterial pneumonia. Generally speaking, epidemiologists and historians who have written about this (1918) pandemic have assumed that the overwhelming majority of deaths came from secondary invaders..." (Pages 251-252). If there are pathology reports of secondary pneumococcus, the polyvalent pneumococcal vaccine (Pneumovax)could be quite useful.
Thanks to Snowy Owl for the latest gene sequencing on this H1N1. Looks like quite a bit of rapid antigenic shift in this curious mutt of a virus.
Be well and safe.
A likely explanation for the source of the outbreak:
nell: CDC says syndromic surveillance in the US so far doesn't show anything. I don't know what that's based on.
Jon: I assume you mean factory farming. Could be. Whether it is likely or not we don't know.
I'll try to get to other questions at some point.
Pathogenic viruses can be spread between pig, bird, and humans via insects. Some species of black flies (Simulium spp.) for example, are the vector of vesicular stomatitis virus. It might be a good idea to test those flies and any other vector that bites both pig and human and bird.
I also note that unsubtypable reports in week 14 and 15 went up..,
CDC new something earlier????
Dylan: do you have the source that characterizes Mexican dead as previously healthy?
Philip: That's what WHO and the Mexican health authorities have been saying all along and the reason there is so much alarm at WHO. We have yet to see the descriptive epi for this outbreak, so that's what we are going on. But Dylan was completely correct.
Thx. I was just hoping Dylan or someone might have some Mexican figures as specific as USA confirmed cases. "The majority of these cases have occurred in otherwise healthy young adults", is what WHO released yesterday. Guess I'll just do what the thread says.
As well as the difference in sample size maybe accounting for apparent difference in mortality, the US cases all seem to be outside the 20-40 age group most affected by pandemic type flu.
"According to the newspaper, the Mexican health agency IMSS has acknowledged that the orginal carrier for the flu could be the âclouds of fliesâ that multiply in the Smithfield subsidiaryâs manure lagoons."
Thanks for the link, Jon Schultz.
Assuming the feces of pigs have virus, how do the flies transmit to humans? The possible path is by contaminated foods.
The research by PCR to detect the feces and flies are not difficult. If the transmission is via air through respiratory tract, then the samples of PCR tests on pig and pig farm workers would be able to find the answer.
Remember the latest MRSA survey, about 50% of pig and workers are carriers in some farms of the US.
It deserves the survey on swine flu virus on the pigs and workers in Mexico quickly.
I see a couple major problems with this. Mexico has reported a number of deaths less then 70 and the united states a number of infections at all is less then 15. In mexico those who were fatally affected by the new strain died of a 2ndary bacterial infection due to massive fluid build up in the lungs from the viral infection, or also it seems a few cases died from dyhdration from improper care while being sick and some also died of kidney failure caused by extream feaver... These same kind of deaths happen every year when the new flu strain comes to town, simply not all in 3 week period.
Oddly enough with less then 900 reported cases and less then 70 deaths total the mortality percentage of just over 7%. The 2007-2008 flu season cause about 36,000 deaths over the given late September - early May offical flu season (roughly 30 weeks) giveing the death toll of about 1200 people a week on average. We seem to be jumping the gun on this one with only a avrage of about 20 a week.
The Swine flu has cropped in North America before. Once after the Spanish-American War (1898), but little is recorded about the outbreak. Acording to older members of my family, in the 1960's an outbreak was tracked orginally orginated from verterns returning from Vietnam, again little was recorded. Then comes there swine flu scare of 1976, where more people were sickened by the Vacc. then by the actul Virus. In 1976 there were 6 suspected cases though the entire United States,only one of which ended in death, and none were ever actully proven to be Swine Flu. I would like to point out that these outbreaks were not documented and if massive body counts were not likely to have been racked up by these outbreaks because they likely would have been recorded.
The most disturbing part of the stories is that a majority of the fatal cases have been among formerly perfectly healthy people, between the ages of 20-40, which is strange for a flu virus, which trditionally effects the very young and very old. However the number of fatalities is small and is considered too small to make an accurate census of how differnt age groups are affected.
Here comes the theory however. The largest number of cases, as well as fatalities, are limited to Mexico City. Only 4 fatalities have been reported else where in mexico. The US as i write this has 11 confirmed cases and possiably 200 more suspected cases, but flu is discribed as mild and short lived, with a down time of 24-72 hours. Nobody had been hospitalized or even reported sever sympotoms, one was perscribed anti-viral medication due to a possiable compromised immue system. So look at it like this, a rock is cast into a pond and where it strikes the most disturbance in noted. From there ripples go out, and the farther away from the center the bigger the wider the ripples and the less severe. I would say that this situation was likely caused by an initial sever infection in mexico, in a population familiar with the strain and effects. It is possiable that the virus could spread out of control, but like the ripples in the pond the farther the viris moves the weaker it seems to get. A suspected case in New York was reported as no more strenous then the common cold.
I myself sit at home with your standard stomic bug, which had to come hot on the heals of a early summer cold. Seems alot like bureaucratic hysteria, like maybe the WHO were to fed up waiting for a bird flu epidemic that they decided to go out and find one. I will worry when I here Larry Underwood on the radio, and here the name Captian Tripz on TV, until then it's just a slow news day.
I have created a simple website which has more information about Swine Flu. I thought it might be of interest to you: swine-flu-information.com
While others have speculated that geography may have something to do with case fatality rate, it has little to do with the distance from the epicenter, especially in today's mobile society.
Your analogy of the ripples from a stone in the pond is likely more accurate in describing the genetic shift from each transmission. We hope that eventually, between building immunity and changes in virus virulence, that the ripples become less defined and the ability of the virus to cause medical problems begins to diminish. In fact, that usually is NOT the case either, as historically, successive waves can be more severe. But eventually, it will diminish (we hope).
The news media is covering this, but the fact is that a pandemic's potential dwarfs any other news item. I keep watching the news thinking this (swine flu's pandemic potential) is so much bigger than anything else being covered. Regrettably, it's hardly a slow news day.
Sorry, the above post was by me. Patch
this is definitely scary stuff, sounds a lot more serious than the peanut butter salmonella scares at the very least
I am a nurse and I work mostly in the community. I see a great many respiratory illnesses where I live and work (Lake County, IN) due to the polluted air courtesy of the steel mills and oil refineries right on the Lake Michigan shoreline. I am wondering if the large difference right now in mortality rates in Mexico city and elsewhere might partially be attributable to the extremely poor air quality/high amount of particulate and other pollutants in Mxico City that are not seen to such an extreme degree in some of the areas where the illness has not manifested to such an extreme. Poor air quality leads to a higher susceptibility of secondary infections and complications of primary infections in the respiratory system. This is observable on a daily basis here where I am. The closer one lives to the lake, the more likely a simple cold or other minor respiratory ailment will develop into pneumonia because the lungs are weaker due to the air pollution that compromises their structures and affects the immune system's ability to respond.
I've seen that suggested before. I wonder where would that put smokers? Perhaps a higher percentage of smokers as well?
The best defense is washing your hands frequently, and if you are out in public, wear a FDA approved respirator.
The FDA approved respirators are available to the general public directly from 3M Corporation through their on-line store. There are two styles of NIOSH N95 certified respirators at www.Shop3M.com: a flat-fold (Model 8670F) that stores easily in a purse, and a cup style (Model 8612F). Additional information, including product usage instructions, is available at www.my3MN95.com.
I am from Chicago and I my family would like to know if we should take an early vacation. We have a wooded property in a very rual area of Indiana. Would there be less of a chance of contracting the virus in a less populated area? Especialy one where the closest neighbor is a mile away?
The other question I have is about Tamiflu. Over the Counter or Prescription? The news has seemed to deem this the miracle drug.
For Monotreme and anyone else who thinks the CDC is somehow funneling the genomic sequence of this flu virus to a private company at the expense of public knowledge, go here http://www.ncbi.nlm.nih.gov/genomes/FLU/SwineFlu.html to see the data in the public database. Drop your conspiracies, folks, the CDC is not the bad guy here.
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