SWINE FLU: Pandemic Updates

[Francois Cellier]

It's day #7, and I am having a relapse. Not very serious, just annoying. I got throat ache again, but no fever (so far). Oh well.

[donquixote99]

Get well fast! Keep in touch.

[Fredfredson]

Francois

Please take it easy.

One doesn't want to push things with this bug.

F

[Fredfredson]

The following post is very important.

It looks like this bug is changing, and not in the direction of being more benign.

F


Media Myths Cloud Joint Hearings on Pandemic Vaccine
Recombinomics Commentary 17:17
November 19, 2009


Look at Ukraine, for example, where public awareness went from "zero" this summer to "panic" this autumn. Late last month, politicians began to speak of mass illness and mass death. The government quarantined several provinces, shut down parliament and banned mass gatherings. When the dust began to settle last week, it appeared that, yes, there had been a small outbreak of swine flu, but also that, no, most of the people who got sick didn't have the H1N1 virus. Swine flu death rates in Ukraine are no higher than those for flu or pneumonia in other years.

The above Ukraine comments are from a Washington Post story cited by Senator Joe Lieberman on the first day of joint hearings on the pandemic vaccine shortfall. He was "surprised" that there were an estimated 22 million cases in the United States and the emphasis was on shortfalls linked to over promises on delivery dates and amounts of vaccine.

However, the hearings failed to capture the events in Ukraine, which was deemed a "non-event" in the above piece by op-ed writer Anne Applebaum, even though the importance of Ukraine was hard to miss. Even the most casual observer could look at the WHO H1N1 updates and see that some in Ukraine was attracting significant attention. WHO began issuing updates last April, when H1N1 was discovered in patients in Mexico and the United States. Thus the first two updates named the two countries in the title. However, subsequent updates were just number, with no county named. Initially these updates came out daily and then settle down to one update a week. The 72nd update was on Oct 30, but two days later a new update was issued on Ukraine. Another Ukraine update was issued on Nov 3 Two days later a second Ukraine update was released and on Nov 17, the date of the above article a third Ukraine update was issued.

In addition to media reports quoting WHO spokesperson, Ukraine also came up in WHO weekly teleconferences on Nov 5 and 12. These notices were carefully worded to exclude large changes in the virus, but left open small changes, including receptor binding domain changes. Such changes were of interest because hundreds of patients had died at a rate and level markedly higher than any other European country, and the descriptions of the fatal cases were detailed, noting severe hemorrhage, as well as the total destruction of both lungs. Patients had been arriving at emergency departments coughing up blood and dying within a few days. Moreover, most of the patients were previously healthy young adults.

The gruesome descriptions and the large number of fatal cases led to wild speculation by conspiracy theorists on one hand and media and political reports such as the one above, claiming that the Ukraine outbreak was small and not unusual.

However, the careful wording of WHO updates clearly left open the possibility of small changes including the receptor binding domain and the D225G change had been predicted, based on the high number of fatalities involving lung hemorrhaging and disintegrating.

Yesterday, the sequences from 10 isolates were released at GISAID by Mill Hill and the predicted change, D225G was confirmed. This change had been "in play" and was appearing on multiple H1N1 genetic backgrounds signaling recombination and selective advantage. The recent update of demographics for the 10 patients demonstrated that the four isolates with D225G were the four patients who had died, further raising concerns that D225G on a Ukrainian H1N1 background, or other H1N1 backgrounds could lead to more severe cases and deaths. Moreover the same change had been observed during the 1918-1919 pandemic, which also involved swine H1N1 jumping and adapting to humans.

Thus, the genetic change(s) in H1N1 in Ukraine is of considerable concern, media reports and Senator comments, notwithstanding.

[Fredfredson]

There has been quite a flury of posts at Recombinomics since the release of the Ukraine sequences by the WHO.

Too many to post individually.

Please check them out if you are interested in these developing H1N1 changes.

F



1918 RBD D225G in Lung Cases in Ukraine and Norway (11/21/09 13:02)

Evidence on D225G in Lung Cases in Norway and Ukraine (11/21/09 11:40)

WHO Confirms D225G in Lung Cases in Norway and Ukraine (11/20/09 23:55)

D225G in Fatal H1N1 Lung Cases in Norway and Ukraine (11/20/09 19:05)

Large Tamiflu Resistant Cluster in Wales UK (11/20/09 17:50)

H1N1 D225G in Russia Raises Pandemic Concerns (11/20/09 15:05)

D225G in Fatal H1N1 Cases in Norway? (11/20/09 15:19)

Ukraine Dead Increase to 354 - Fatal H1N1 Cases Have D225G (11/20/09 13:38)

[Fredfredson]

Trying to understand the Norwegian swine flu mutations
Posted on: November 21, 2009 6:03 AM, by revere

http://scienceblogs.com/effectmeasu...ct +Measure%29


The Norwegian Institute of Public Health is reporting sporadic occurrences of a mutation in a portion of the flu virus that is involved with the process by which it attaches to cells. I use the word "sporadic" because at this point there is no evidence that the cases where the genetic change has been found are epidemiologically linked. Therefore we don't see it spreading from person to person but rather arising in people after they have been infected. At least that's how it appears from reports, but we have only preliminary information at this point. According to WHO, the mutation has been seen before, again sporadically and as early as April, in Brazil, China, Japan, Mexico, Ukraine, and the US. Should we be worried about it?

For me that's not exactly the right question because I worry about everything when it comes to influenza. Just like auto accidents, flu infections come in a huge range of severity from barely visible scratches to fender benders to whip lash to multiple disabling injury to death. I don't take the potential of being hit by a car lightly either. Any instance could kill me or someone I love. The right question is whether I am especially worried about this report. Not yet. As more information becomes available I might get more worried or dismiss it entirely as the kind of change we see when a virus isn't very fastidious about how it reproduces. Because it's not about the specific mutation but about the biology and we don't know how to read the biology from the genetic sequence. Much of what we thought was important with respect to transmissibility or virulence or something else has been shown wrong by the virus itself. Every time we think we have a fix on it, it shows us otherwise. Here's what we wrote two months ago when the Dutch found the E627K mutation in PB2 in one of their isolates:

:
Even though this virus has been described as relatively stable genetically, individual viruses, even within the same patient, often have small differences in the thousands of letters that make up their genetic code. Influenza A virus is a very sloppy reproducer, and while its only objective in life is to make a copy of itself it often does single task very badly. But it's like the guy who was asked how he could sell his gasoline for a penny less than he paid for it, his answer was, "volume." The flu virus makes so many copies of itself when it infects a host cell that it can afford to make a lot of mistakes. Usually those mistakes are disastrous for the copy and it doesn't replicate any more. Very many of the little mistakes are just little mistakes and don't affect the virus at all. And some of them turn out to be good for the virus and possibly bad for the host in that they allow the virus to replicate faster, infect more and different kinds of cells and increase its ability to transmit from one host organism to another (transmissibility). (Effect Measure, October 1, 2009)

The Dutch mutation was thought to strongly determine whether the virus would be more avian or more human, but swine flu went ahead and infected humans all over the globe with the version thought to be more avian. It apparently hadn't read that it needed this mutation to be adapted to humans and so far E627K hasn't taken root. In the case of the Norwegian mutation (D225G) we don't even have a theory about its significance, although it is in the part of the virus that binds to the host cell for entry.

What are the possibilities? This change isn't likely to make this virus more transmissible. It's already transmissible as hell and doesn't need any help in that department. It isn't in the part of the viral protein that the vaccine is directed against, so I doubt it would make the vaccine unusable. The same is true for antiviral activity, even though resistance to antivirals is likely to emerge via other mutations. CDC and the UK are both reporting some instances of Tamiflu resistant virus spreading from person to person. What the virus means for virulence, however, is unknown. The Norwegians speculated it could make the virus more prone to infect the lower respiratory tract but they are speculating. That would seem to be the major concern at the moment but there isn't much to go on.

Having said these somewhat reassuring things, however, I don't want anyone to be reassured. We are in the early stages of a pandemic with a dangerous virus and there is just too much we don't know to be able to be either alarmed or reassured by any particular piece of news. In our view focusing on particular mutations is not especially valuable in the current state of our knowledge. The flu virus isn't especially big but it is still too complicated for us to understand. There are eight genetic segments, each of which undergoes both mutation and reassortment, i.e., some of the internal segments mix and match between viruses and new combinations emerge.

The best way to think about this is that these eight functional segments act as a team. When one member of the team acquires a new skill, the value of that skill depends upon how the whole team works together. Sometimes a superstar isn't the best thing, but a group of less talented but smoothly working players is what is needed. But there's no rule about this. Some years teams make it to the Superbowl because of having one or two outstanding athletes ("stars") while other years it's the team that makes the fewest mistakes and works best together that wins out. We don't know how to predict this for sports teams, an easier problem than for the team of eight in the influenza virus.

The mutation is being widely reported to be D222G (this is H1 numbering; it is 225 in H3 numbering). What this designation means is that in the spikes of hemagglutinin protein on the outside of the virus (parts of which elicit the primary immune response), the amino acid 222 places in from one end has changed from "D" (aspartate) to "G" (glycine). Does this change in one of the team members make the virus operate much better? Does it change the biology in any way, and if so, in what way. We don't know. And what does "better" mean in terms of the virus? We aren't sure of that either. The bottom line for the virus is that it make more copies of itself, but the factors that allow it to do that (e.g., should it become more virulent or less virulent?) are unpredictable and largely unknown. This is what this statement by WHO means:

:
The significance of the mutation is being assessed by scientists in the WHO network of influenza laboratories. Changes in viruses at the genetic level need to be constantly monitored. However, the significance of these changes is difficult to assess. Many mutations do not alter any important features of the virus or the illness it causes. For this reason, WHO also uses clinical and epidemiological data when making risk assessments.

In other words, when it comes to genetic sequences, it's not what the sequence says but what the sequence does. And we can only know that by watching. This is the first time we have watched a pandemic unfold in real time and we still don't know how to interpret many of the things we are seeing.

The virus will tell us, eventually. We'll just have to stay tuned.

[Fredfredson]

CDC: H1N1 declining but still widespread

CIDRAP >> CDC: H1N1 declining but still widespread

Robert Roos News Editor


Nov 20, 2009 (CIDRAP News) – Pandemic H1N1 influenza activity is showing further signs of declining around the country but remains very widespread, the Centers for Disease Control and Prevention (CDC) reported today.


The virus was widespread in 43 states last week, compared with 46 a week earlier, the CDC said in its H1N1 Situation Update. Visits to doctors for flu-like illness dropped for the third week in a row, and flu-related hospitalization rates began to decline as well. But both variables remained above normal for this time of year.


Another 21 flu-related deaths in children were reported last week, including 15 involving confirmed H1N1 infections, the CDC said. That raised the total of confirmed H1N1 pediatric deaths to 171.


"We are beginning to see some declines in influenza activity around the country, but there's still a lot of influenza everywhere," said Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases, at a news briefing today.
Flu activity is "still much greater than we would ever [normally] see at this time of year," she said.


All 10 federal regions are starting to see declines in flu activity, but activity is still increasing in some states, including Maine and Hawaii, Schuchat reported.


She stressed that the pandemic remains unpredictable and that she didn't know if it has peaked: "We don't know if these declines will persist, what the slope will be, whether we'll have a long decline or it will start to go up again."


On the vaccine supply front, Schuchat said a total of 54.1 million doses have been made available, an increase of 11 million over a week ago. As of 2 days ago, 93% of the available doses had been ordered by the states, she added.


Meanwhile, manufacturers reported that 94.5 million doses of seasonal flu vaccine had been distributed as of Nov 13, she said. The CDC has predicted that the seasonal vaccine supply will total about 115 million doses.


Regarding the deaths in children, Schuchat said about two thirds of the children had an underlying condition such as asthma, cerebral palsy, or muscular dystrophy. A common factor in those who were previously healthy has been bacterial co-infections, which point to the importance of pneumococcal vaccines, she noted.

H1N1 mutation in Norway

Schuchat also commented on reports that surfaced today of a mutation in H1N1 viruses found in three patients in Norway. The World Health Organization (WHO) said today that the mutation was found in the first two fatal H1N1 cases in Norway and in one patient with severe illness.

"What I can say is the mutation that was identified has no implications for how good the match of the vaccine is and it has no implications for treatment with antiviral medicines, but it's important to track and look for changes," Schuchat said.

She further said the mutation has been seen sporadically around the world in both severe and mild cases. "There's some theoretical reasons why this particular mutation might lead an influenza virus to live easier in the deep part of the lungs and cause lower respiratory infections, but we've actually seen lower respiratory infections in severe viral pneumonia without this mutation," she said. "So I think it's too soon to say what this will mean long term."


The WHO said the mutation does not appear to spread and the public health significance of the finding is unclear.



"Although further investigation is under way, no evidence currently suggests that these mutations are leading to an unusual increase in the number of H1N1 infections or a greater number of severe or fatal cases," the agency said.
The statement said the mutated virus remains sensitive to oseltamivir and zanamivir, and studies show that existing pandemic vaccines provide protection.

See also:
Nov 20 CDC Situation Update
CDC H1N1 Flu | Situation Update
Nov 20 WHO statement
WHO | Public health significance of virus mutation detected in Norway

[Fredfredson]

Saudi reports 4 pilgrim deaths from swine flu ahead of hajj

Agence France-Presse
November 22, 2009

Saudi reports 4 pilgrim deaths from swine flu ahead of hajj - INQUIRER.net, Philippine News for Filipinos

MECCA - Four pilgrims in Saudi Arabia for the annual hajj pilgrimage have died of swine flu, the health ministry said in a statement carried by the official SPA news agency on Saturday.
It said a Moroccan woman, a Sudanese man and an Indian man -- all aged 75 -- had died from A(H1N1), as had a 17-year-old girl from Nigeria. The ministry said the four had not followed "recommended procedures, especially vaccination against swine flu."

Health authorities in the kingdom have mobilized for the world's largest gathering since swine flu began spreading across the globe after it was first reported in April.

Hundreds of thousands of pilgrims from across the globe have already gathered in the country to perform the hajj in the holy Muslim cities of Mecca and Medina.

The peak day in the hajj is Thursday, November 26, when pilgrims gather at Mount Arafat, where the Prophet Mohammed gave his final sermon.

For the hajj, thermal cameras were installed at air and sea terminals in Jeddah where most pilgrims arrive, some 15,000 health workers are deployed, and hospitals have hundreds of extra beds available.

In Medina and Mecca, as well as in Jeddah, the government has taken measures to identify the virus in suspected cases.

The health ministry also has mobile units which can instantly send to a central monitoring centre the locations of infections, to monitor outbreaks.

On November 11, the Saudi authorities reported that 70 people had died in the country from the disease and said that more than 7,000 proven cases had been recorded.

On Friday, World Health Organization data showed that around 6,750 people had died from swine flu worldwide since the virus was first uncovered in Mexico and the United States in April

[Fredfredson]

INFLUENZA PANDEMIC (H1N1) 2009 (111): NORWAY, MUTANTS
************************************************** ***
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[1]
Date: Fri 20 Nov 2009
Source: Norwegian Institute of Public Health [edited]
< Mutation of pandemic influenza A(H1N1) in Norway - Folkehelseinstituttet >


Mutation of pandemic influenza A (H1N1) 2009 virus in Norway
------------------------------------------------------------
The Norwegian Institute of Public Health announced today [20 Nov
2009] to have found a mutated version of the influenza pandemic
(H1N1) 2009 virus in 3 patients in Norway who had tested positive for
the new flu.

The Norwegian Institute of Public Health has analysed virus from a
number of patients as part of the surveillance of the pandemic flu
virus. The viruses have many similarities, but some mutations have
been observed. This is normal and most of these mutations will
probably have little or no importance.

However, one mutation has caught special interest. It has been found
in 2 patients who died from the new influenza A (H1N1) and in one
patient with severe influenza disease. These were the 1st 2 patients
who died from the new influenza in Norway. Some of those who died
later have been examined without finding the same mutated virus. The
mutation could possibly make the virus more prone to infect deeper in
the airways and thus cause more severe disease.

- We have analysed approximately 70 viruses from confirmed Norwegian
cases and found the mutation in only these 3 patients, says Director
General Geir Stene-Larsen at the Norwegian Institute of Public Health.

- Based on what we know so far, it seems that the mutated virus does
not circulate in the population, but might be a result of spontaneous
changes, which have occurred in these 3 patients.

- There is no indication that this change in the virus is of any
importance for the effect of the vaccine or the effect of antiviral
treatment, concludes Stene-Larsen.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[2]
Date: Fri 20 Nov 2009
Source: The Washington Post [summ., edited]
< MSM: Norwegian scientists raise concerns about mutated form of swine flu « Dprogram.net >


Norwegian scientists raise concerns about mutated form of swine flu
-------------------------------------------------------------------
Scientists in Norway have identified a mutated form of the swine flu
[influenza pandemic (H1N1) 2009 virus infection] virus that is
raising concern because it was found in 2 patients who died of the
flu and a 3rd who was severely ill with the disease, officials
announced Friday [20 Nov 2009]. In a statement, the Norwegian
Institute of Public Health [above] said the mutation "could possibly
make the virus more prone to infect deeper in the airways and thus
cause more severe disease."

Scientists have analyzed about 70 viruses from confirmed Norwegian
swine flu cases and found the mutation in only those 3 patients, Geir
Stene-Larsen, the institute's director general, said in the
statement. "Based on what we know so far, it seems that the mutated
virus does not circulate in the population, but might be a result of
spontaneous changes which have occurred in these 3 patients," the
statement said.

The institute has been analyzing H1N1 virus from "a number of
patients as part of the surveillance of the pandemic flu virus," the
statement said. "The viruses have many similarities, but some
mutations have been observed." While the existence of mutations is
normal, and most "will probably have little or no importance," the
statement said, "one mutation has caught special interest." The 2
patients who had the mutation and died were the 1st swine flu
fatalities in Norway. The 3rd patient found to have the mutated form
of the virus also became severely ill.

According to the institute's statement, the change in the virus did
not appear to impair the efficacy of the vaccine or antiviral treatment.

Officials from the World Health Organization and the US Centers for
Disease Control and Prevention could not immediately be reached for comment.

[Byline: Rob Stein]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[In Eurosurveillance 14(46), 19 Nov 2009, Fereidouni SR, Beer M,
Vahlenkamp T, and Starick E describe "Differentiation of two distinct
clusters among currently circulating influenza A(H1N1)v viruses,
March-September 2009"

(< Eurosurveillance - View Article >).
"Analysis of all complete genome sequences of the pandemic influenza
(H1N1) 2009 virus available as of 10 Sep 2009 revealed that 2 closely
related but distinct clusters were circulating in most of the
affected countries at the same time. The characteristic differences
are located in genes encoding the 2 surface proteins --
haemagglutinin and neuraminidase -- and 4 internal proteins -- the
polymerase PB2 subunit, nucleoprotein, matrix protein M1, and the
non-structural protein NS1. None of the changes in the sequences
seemed to be located in regions of the genome responsible for known
phenotypic differences or biological functions."

Most sequences from Mexico, Texas, and California belonged to cluster
1, whereas most sequences from New York belonged to cluster 2.
Whether these differences were due to the geographical region, the
date of isolation or other reasons needs to be elucidated in further
epidemiological investigations. Virus sequences of both clusters have
been reported from most countries on different continents.

How the Norwegian viruses relate to these clusters as well as their
biological relevance remain to be established. - Mod.CP]

[Fredfredson]

Translated from:
Âðà÷-ðåàíèìàòîëîã: «Ïðîöåññ ïåðåøåë â íåêîíòðîëèðóåìûé» - Õàðòèÿ&#039;97 :: Íîâîñòè èç Áåëàðóñè - Áåëîðóññêèå íîâîñòè - Ðåñïóáëèêà Áåëàðóñü - Ìèíñê

Swine Flu : Norway: Mutati&#111;n c&#111;nfirmed

4:37 21/11/2009

ICU physician: "The process went into an uncontrollable"

Gomel physician Eugene Lopanov gave interview about the epidemic of swine flu in Belarus. In Belarus, 895 people were hospitalized with pneumonia in just 1 day. Health officials give official information portioned and very rarely. Doctors went underground and spread their
views of the situation only in the internet or in their personal blogs. And they do it anonymously. Some doctors who were on their duties in the hospitals for days in a row instead of having some rest turn their computers on and write "reports from the field of battle".Maybe they do that for themselves, maybe they are hoping to be heard by society. One of those doctors agreed to meet the correspondent of "Komsomolskaya Pravda in Belarus". We contacted him through his "Livejournal" blog. The doctor agreed to a meeting, not concealinghis real name and place of work. Eugene Lopanov, resuscitation specialist from the Dobrush regional hospital, described the clinical picture of the dangerous virus and about what helps patients to survive.

In three hours 30 people with pneumonia arrived.

- Eugene, tell us, as a doctor who has to take the blow of swine flu,is there an epidemic in Belarus?

- The epidemic exists - it's indisputable. At first a large number of patients with a viral infection visited doctors, and no one knew what it was, then it turned out that we were dealing with influenza A/H1N1. In Dobrush all started with two patients in early November. And then it became like an avalanche. In principle, we reacted in a timely manner. When the first patient was admitted, I realized immediately what it was. We warned the Head of the Hospital and deployed additional beds in the therapeutic department. We decided that patients with mild pneumonia would be put in the infectious disease clinic, patients with more severe disease would be
put into the maternity hospital, and the most severe cases should be admitted to the intensive care unit. I remember very well my shift on November 7th, I think. In three hours thirty patients with pneumonia arrived. Given that Dobrush is a small town ...

- Did they all have the same symptoms?

- Yes, the symptoms of influenza. And the clinical picture looked like bronchopneumonia. One patient was admitted with symptoms that could be anything, even pulmonary embolism. But for some reason the bloody-foamy sputum was in a large quantities - like never seen
before. We realized that that was a viral infection. In the next hospital room there was another patient with exactly the same physique. Stout, healthy, sturdy - they were admitted with the same clinical symptoms!

- What was the course of this viral infection?

- Like usual flu, acute viral respiratory infection. It begins with weakness, malaise. Body temperature may rise differently in different people - to 37, 38, 39 degrees. Shortness of breath increases, there is a cough, pain between the shoulder blades, arthralgia, diarrhea is possible, problems with the digestive system. People usually went to doctor when they were short of breath, cough appeared. The worst thing was when they came already with sputum containing blood - this is aggravating factor, suggesting that the destruction of the lung tissue started.

We worked in war conditions

- The first blow fell on the family doctors - Eugene continues. - It was important to prevent the disease progression. The patients were examined, no one denied, the workload was very large - we had virtually the entire population to serve. And the conditions were like in a war. No money, facilities and time. Some people behaved inadequately - some did not want to be treated, thinking that the illness would go away by itself. And then (if the disease was getting worse) the panic started, relatives came in stress.

And all that was because of ignorance. If doctors would say on TV : do that and that if you start feeling sick - all would have passed more smoothly. For example, almost everyone who came to us, took antipyretic (fever reducers). And they blocked all the processes of developing immunity. You should not take pills, if the temperature is below 39! Body must fight. We bring down the temperature by an elementary physical cooling: wipe the patient, put the ice in the area of major vessels, if necessary, and use a fan.

We had enough Tamiflu all the time, it was originally a reserve. But when the disease has already started to progress, there is not big necessity to take Tamiflu. It's necessary to give another treatment then, because of appearance of the bacterial infection and growing multiorgan failure. Currently, there is little useful information on the new flu, little research findings. It's good that there is the Internet and the remarkable statistics collected by a professor in Mexico, Dr. Guillermo Dominguez-Cherit. We understood the structure of morbidity, who are more susceptible to disease, what are principles of treatment and what results they gave. In our practice we understood that patients need nursing care, stimulation of immunity - in order for the body to start fighting. But Tamiflu, Relensa, Arpetol can help only at the early stage of the disease.

- Describe what happens to the body during viral pneumonia and how it differs from ordinary pneumonia.

- The process affects virtually the whole tissue of the lungs, the patient has bloody sputum, respiratory distress syndrome occurs (RDS) when there is a problem of oxygen delivery to tissues, and carbon dioxide is not removed from the tissues. Some patients have very rapid ("lighting-like") disease progression, similar in the rate to an allergic reaction. In the X-rays it looks like polysegmental pneumonia. Patients have increased load on the heart, liver,
kidneys. If left untreated - a person dies. At the first stage -statistically up to 28 days - from respiratory disorders, and later death usually occurs from multiple organ failure. The process is very fast, it's about 6 days from the moment the disease starts before visit to the doctor, and after entering the hospital it's only 1-2 days to the intensive care unit. That is a person is admitted to the hospital one day, and the next day he is in intensive care unit with RDS. The disease is like a fire - if not extinguished in time, it will burn everything.

Note that virus affects everybody differently. Everything depends on immunity, also psychosomatics plays an important role: a person's attitude to his life, his diet, if he is optimistic or not. Mosty the cases of severe disease are in those who carry some negative energy.Or did something wrong. For example, who was a boss and acted in a mean way. Someone who was left by her husband. In general, those with tormented conscience.

There were pneumonias before, too, but they went much easier. Well, in someone who, say, spent too much time in cool temperature. And now we have young people 20-40 years in full health who become sick. Boom - and viral pneumonia. In principle, this is the same "Spanish flu". But it's not a pneumonic plague - that's for sure. The structure of the virus is one to one - "Spanish flu", which is also H1N1. Only the mutation occurred, the virus developed a slightly different way to join the cell.

By the way, according to world statistics, deaths from the virus reaches 2,5% of the sick, and in seasonal influenza 0,1%.

- In the medical environment, do doctors talk about where this virus came from?

- Nobody really knows, but the arguments go as far as that is a military weapon. It is argued that the virus makes animals sick, and then it acquires the properties of infecting people. Some say that it's a process of natural selection.

- What is happening now, is the flow of people in the hospital still big?

- We see a decline. Because many are already sick. Someone got immunity, someone is not infected yet.

- Have you seen a happy recovery? From ICU, from the ventilation apparatus- to the recovery?

- As far as I know, only in our Dobrush there was such a case. I didn't hear about anybody else who survived the disease after mechanical ventilation. The man who survived was admitted to the intensive care unit being conscious. Then he was on the ventilator for about a week. In such cases, nursing care is important. We looked after the man seriously, all his relatives gave moral support. And most importantly - they believed. They simply clenched their fists and said that he must live. And he himself wanted to live. You look at many patients and realize that they're in another world already. They talk as if not to you. And this man obviously wanted to stay here. While still conscious he was running to the window all the time, looking outside. He told me when he was intubated, he felt that the coffin lid was closed and the last nails were hammered. It was some time that no one had hoped. And suddenly a miracle happened. A man has been transferred from the intensive care therapy, he is conscious. He had a laboratory-confirmed influenza A/H1N1. We made X-rays, the clinical picture was resolved, lungs are airy, some small foci remain. Pneumonia still persists, he receives antibiotics.

The rate of detection of swine influenza - only 10 percents

- Was there some sort of advice on the treatment of patients with viral pneumonia from the Ministry of Health?

- Yes, in about a week after all that started. They wrote us how to treat patients with H1N1, advice on drugs. Basically, the same what we did from the beginning. Timely treatment with antibiotics played very important role. It was also a chance, all was done empirically, when one antibiotic failed we tried another one..

Generally, the policy of the Ministry of Health aims to ensure that there is no panic. So that people wouldn't buy medicines and self-medicate. This is right. The problem is that they are treated not by doctors, but by pharmacists. But one shouldn't be silent about the existence of epidemic. The problem exists in reality, people get sick, there are fatalities.

- What do you know about any cases of influenza A/H1N1 and mortality from viral pneumonia?

- I must say that the detection of the flu in the laboratories according to the world statistics is about 10 percent. That is, the number of sick with swine influenza is ten times more than laboratories identify. The reasons for negative test are misguided smear, poor transport conditions and so on. In Dobrush I do know about two confirmed H1N1 cases. But those that come with the same symptoms we consider to have the same virus... and treat everyone equally whether lab confirmed or not.

We didn't have deaths, thank God. And in Gomel severity of patients is much higher - not enough ventilators. Important role was played by the quality of the apparatus for ventilation. It is noticed that the patients do not have encephalopathy as a result of exposure to the virus, therefore, it's recommended to provide mechanical ventilation in conscious, with the support of regimes that virtually inaccessible by Belarusian machines. I myself learn about fatal cases from the news if they say something. Only about a week ago we were told by chief pulmonologist that more than 20 people had died the Gomel region. I heard about the death of a pregnant woman. It is possible that this was because the body defenses in pregnancy are weakened.

- Do you think doctors can become ill with swine flu?

- I believe it's impossible to avoid the flu even if you wear 10 masks and change then every 5 minutes, when all around there are patients sick with the virus. But still you need to protect yourself somehow. Somehow the disease will find you ultimately. Our entire ICU medical staff suffered infection to some extent and I had it too. It depends on the person how strong his immune system is. In general, the load on doctors has increased tremendously. In principle, we are all exhausted: the nurses and doctors and paramedical staff. It's a very hard work for all of us.

- Your forecasts, how will the epidemic develop in the near future?

- Very difficult to say, everything is unpredictable. "Spanish Flu" raged for two years. The epidemic began in the spring in Mexico. Now there are drugs, some knowledge of - the process should be faster. Many stay home, but someone didn't become sick yet, and re-infections will start. Mortality will increase soon, because now there is a lot of patients on mechanical ventilation who have RDS - in whom process became uncontrollable. In general, these patients have a poor prognosis. But the main thing is to believe and pray that everything will be fine.

[Francois Cellier]

My throat ache stopped after only one day, and I didn't get any fever. I am still having a bit of a sore throat, but otherwise, I am OK.

[Ms Digabit]

The above post is concurrent with what we have been hearing from our intensive care unit. Rapid onset affecting respiratory systems quickly degenerating into viral pneumonias. Renal failure followed rapidly with system failure.
We currently have 5 ventillated patients ranging in age with this flu on the unit,.

As frontline staff we were all offered the vaccine and there has been 100% uptake.

Unfortunately I couldn't have the vaccine, as I have allergy to the suspension it is in....

I am on day 8 of the flu. 104-106 temps for 3 days aches and pains with overall weakness and hallucinations. They say you know it's a flu or a cold by the £10 test..... That being if you can walk the floor and pick up a dropped £10 you have a cold, if you cannot, you have flu. I don't think I could have managed to pick up a tempting £100 this week.......it rapidly decended to my chest as a pneumonia. Now controlled and rapidly improving, although I did refuse the drs offer to go to hospital thinking I could manage it myself at home which has worked out, thank goooness.
Needless to say I have been overwhelmed by the incredible speed of this thing and I think it will take a good while to feel 'normal' once more.
I would advise EVERYBODY to have the innoculation if available. I Believe I am of average fitness person and this has wiped me out.

[Fredfredson]

Ms Digabit

I'm glad you are getting a bit better.

Sounds like a real nasty bout.

Thanks for the post "from the trenches".

I hope you get better soon.

F

[Fredfredson]

My throat ache stopped after only one day, and I didn't get any fever. I am still having a bit of a sore throat, but otherwise, I am OK.

Excellent!

F

[Fredfredson]

China to punish those concealing swine flu info
(AP) –

The Associated Press: China to punish those concealing swine flu info

BEIJING — China's health ministry said it will punish officials who underreport cases of swine flu after a doctor famous for exposing the extent of the 2003 SARS epidemic said he believes the true number of swine flu deaths is being covered up.

China's official count of swine flu cases is nearly 70,000 reported illnesses and 53 deaths, although even Beijing acknowledges the outbreak is much larger than the numbers show.

Health Ministry spokesman Deng Haihua said in a statement posted Thursday on the ministry's Web site that nine teams have been sent to 12 provinces to inspect local efforts to contain and treat the pandemic. Deng's statement warned officials not to hide or underreport cases or delay the reporting of swine flu details.

On Thursday, Dr. Zhong Nanshan, director of Guangzhou's Institute of Respiratory Diseases, said in the Guangzhou Daily newspaper that he believed local government officials were covering up swine flu deaths to make it appear as though their handling of the epidemic had been successful.

"I totally don't believe the total number of swine flu deaths have been reported nationwide," Zhong was quoted as saying. He said the number could be far higher.

There has been a dramatic spike in Chinese swine flu cases recently, and those reported by the government are only "minimum numbers," Dr. Michael O'Leary, WHO's top representative in China, has told The Associated Press.

The WHO, however, has said it wants China and other countries to focus on monitoring trends in the pandemic, not tracking every single case.

China's Health Minister Chen Zhu told the AP on Wednesday that China was vaccinating 1.5 million people a day against swine flu as part of a massive effort to try to reach as many as 90 million people — about 7 percent of the country's population — by the end of the year.

[Fredfredson]

Interesting post from a Flu Tracking Board:

Quote:

I think people have gotten it stuck in their heads that because this "started in the spring" similar to 1918, that somehow when we missed the historical September/October "Death Wave" we were somehow out of the woods. I'm not saying we're not. I'm not saying we are. I'm just saying that this ballgame ain't nearly over, and we have no idea what the final score is going to look like.

I agree wholeheartedly with what you say. The funny thing is the spring wave of 2009 probably would not have even made the radar in 1918. It may be more like what was seen in 1916 or 1917, where retrospectively we see they had more than the usual flu activity. Some speculate the new strain actually emerged in humans before 1918 and then adapted or mutated into the killer of 1918. What we had in the spring may be more comparable to what has been called the 'herald waves' of the 1918 pandemic, and what's going on around the world right now might be equivalent to either one of the herald waves or the first 'mild' wave from the spring of 1918, with the second wave and later waves yet to come. We are by no means out of the woods.

[Fredfredson]

The boiling cauldron – transmission, virulence, resistance

[Fredfredson]

The boiling cauldron – transmission, virulence, resistance

When shall we three meet again.
In thunder, lightning or rain?
Opening lines of Macbeth, by William Shakespeare


Many virologists have a recurring nightmare: a virus arises which is easily transmissible, highly lethal and resistant to antiviral drugs. It spreads before an effective vaccine can be developed and deployed. Bodies pile up faster than they can be disposed of. Civilisation cracks under the strain.
Such a virus does not yet exist, but the ingredients to make this nightmare real exist, today.

Transmission
The novel H1N1 virus has spread to nearly every corner of the world since it was first reported in April 2009. The vast majority of outbreaks have occurred among children. There have been very few examples of large scale outbreaks among adults. There are several reasons why this may be so (discussed here). However, it is possible at any time for H1N1 to become even more transmissible – through mutation, recombination or reassortment. The virus is now under intense selection for increased ability to transmit from one human host to another.

Virulence
A mutation associated with very severe symptoms and deaths has recently been identified.
From The New York Times, November 21,2009

[/quote]Norway reported finding a mutated virus in three people who died or were severely ill. The mutation, known as D222G on the receptor binding domain, allow the virus to grow deeper in the lungs.

[snip]

The D222G mutation allows the virus to bind to receptors on cells lining the lungs, which are slightly different from those in the nose and throat. Henry L. Niman, a flu tracker in Pittsburgh, has been warning for a week that D225G — the same mutation under a different numbering system — has been repeatedly found in Ukraine, which is in the grips of a severe outbreak and where surprising numbers of people have died with lung hemorrhages.[/quote]

Dr. Schuchat of the CDC suggests that the same mutation has been found in mild cases. If so, she should provide the accession numbers of the relevant sequences along with the case history of the patients. It is especially important to note whether these “mild” cases involved patients who received antiviral medication. If so, then such cases would not constitute evidence against the idea that the D225G mutation causes severe symptoms and death. A virus may be highly virulent, but still susceptible to Tamiflu.
One might also ask Dr. Schuchat why the CDC is looking for clusters of hemorrhagic pneumonia in the US?
and
What was the lethal mutation that killed two Americans?

Resistance
Having tracked patient deaths in countries all over the world, I have become convinced that the antiviral drug Tamiflu makes a huge difference in the case fatality rates (CFR) from pandemic H1N1. Simply put, countries with lots of Tamiflu have lower CFRs than countries without much Tamiflu. Tamiflu may also be slowing down the transmission of the virus by breaking chains of infection. Without antivirals, we would be defenseless against a new, more virulent virus. And, unfortunately, the cracks in our antiviral defense are getting bigger.
From Mail Online, November 20, 2009

[/quote]A strain of swine flu resistant to Tamiflu has spread between patients in a British hospital.
Five patients on a unit at the University Hospital of Wales in Cardiff were diagnosed with swine flu resistant to the drug.
The infection is believed to be the first confirmed case of a person-to-person transmission of a resistant strain in the world.[/quote]

From MyNC.com, November 20, 2009

[/quote]State health officials annouced late Friday that three of four people infected with drug-resistant H1N1 have died at Duke University Hospital.
The four patients tested positive for what officials said is a mutation of H1N1 that is resistant to Tamiflu, one of two medications used to help fight the virus. The patients were diagnosed with the flu during October and November and all were hospitalized in the same unit at Duke University Medical Center.[/quote]

Some strains of influenza that are resistant to Tamiflu are still susceptible to another antiviral called Relenza. But supplies of Relenza are even more limited than stocks of Tamiflu.
How fast could pandemic H1N1 convert from a virus that is almost always susceptible to Tamiflu to one that is almost always resistant to Tamiflu? Very fast indeed. “Regular” H1N1 made this transition in a few months.
From Dharan, et al. (2009) Infections With Oseltamivir-Resistant Influenza A(H1N1) Virus in the United States. JAMA. 301: 1034-1041.

[/quote]Although oseltamivir-resistant A(H1N1) viruses circulated widely in the United States, during the 2007-2008 influenza season, the national adjusted overall proportion of oseltamivir-resistance among all influenza viruses was low (2%), and national recommendations for use of antiviral agents were not changed during 2007-2008. However, early surveillance data from 2008-2009 suggest that the prevalence of oseltamivir resistance among A(H1N1) viruses will most likely be higher (>90%) during the 2008-2009 season.[/quote]

The Witches Brew
The worst case scenario would be for the new pandemic H1N1 virus to develop greater transmissibility, greater virulence and resistance to Tamiflu. Today, all the ingredients for this to happen exist. Whether they will come together remains to be seen. But each passing day that the virus is allowed to spread unchecked, the probability of this catastrophe will increase.
I hope that the people who are supposed to plan for a worst case scenario are paying attention.


Because sometimes nightmares come true.

[Francois Cellier]

From SwissInfo

New swine flu vaccination guidelines released

swissinfo.ch and agencies
November 22, 2009 - 3:58 PM


The Swiss Health Office has approved the H1N1 vaccine Pandemrix for infants at least six months old despite receiving no green light from regulator Swissmedic.

In its latest announcement, the office said it was recommending Pandemrix for infants because a single dosage was sufficient to protect a child.

Swissmedic has only approved Pandemrix for those aged 18 or older. That differs from the European Union, where the vaccine from GlaxoSmithKline has been approved for babies six months and older.

At first, the Health Office had waited for Swissmedic's approval before launching its vaccination programme. The green light came at the end of October, a good month after the EU had approved the vaccines. The delay was heavily criticised in the media.

The authorities also said new research had shown that children between three and nine years of age who have already received a shot of the vaccine Focetria would not need a second injection.

A second dosage is still required for children and people over 60 who have been vaccinated with the alternative drug, Celtura.

Adults between 40 and 59 can get the two shots at the same time. Doctors will determine whether pregnant women should get vaccinated on a case-by-case basis.

[Francois Cellier]

The Swiss Health Office has no authority to make such a recommendation before Swissmedic has approved the drug for use in infants.

However, it doesn't matter. The entire sorry affair has been so badly mishandled here in Switzerland by all actors involved that the public has lost all and any trust in these recommendations. By now, the percentage of people who are still willing to get the vaccine, should it ever be released in large enough numbers, is below 10% here in Switzerland.

Besides, the Swiss doctors are hesitant to order the vaccine, even if it would be made available, because the vaccine has to be used within one day after delivery and has been packaged in such large units that most doctors would have to throw away most of their doses due to a lack of customers.

... talking about a royal screw-up!