Scott McPherson's Web Presence

My last blog focused on the return of H5N1 avian influenza in humans in 2009.  Just scroll down to read it... I'll wait.

OK, welcome back.  What is happening is a veritable explosion of bird flu across Asia and the Middle East in 2010.  We have over 400 residents of West Bengal (India) under Tamiflu blankets; human cases seemingly every third day in Egypt, and at one point we had three confirmed cases in one day; and a quite sudden acceleration of H5N1 in poultry and wild birds across most of southeast Asia. 

Now Indonesia, a nation which has thankfully turned away from insanity with the appointment of a new health minister. is back in the timely reporting category.  Hey, anything was better than the last two years under Supari!  They could have had a zombie epidemic and the rest of the world could have been blissfully unaware -- until the undead came down Broadway.  And speaking of zombies -- where the Sam Hill is that World War Z movie?  Brad Pitt and Plan B, don't make me come down there and read you the Zombie Riot Act.  Why do you think Zombieland was such a financial success?   And a bit of movie trivia -- Zombieland's central character (right) was named Tallahassee, by the way.

But I digress.  Anyway, Indonesia has now reported two confirmed human H5N1 cases.  One case is in West Java, and one is in Jakarta.  Regrettably, the West Java case -- a 25-year old of unknown gender -- died.  I am sure that if you go to www.flutrackers.com, you will find plenty of stories about the deaths. 

And just this morning, news of a third Indonesian bird flu patient arrives via proMED.  This patient, a woman in Lampung, accompanies a huge die-off of birds in the province.

While this is taking place, the Western press is reporting about the roasting of public health officials over regarding what some misguided souls proclaim to be a "false pandemic" of H1N1v.  As the public health officers of the civilized world circle the wagons in the West, swine flu continues to insinuate itself throughout Asia.  Ans as it does what the flu does, it will absolutely have multiple opportunities to rub elbows with bird flu in towns and villages.  It has already had multiple opportunities with each and every confirmed human H5N1 case since April of 2009. 

Everyone is asking him/herself, "What virus was shed by those who are testing positive for bird flu?  Who might have walked into a cloud of H5N1 particles expunged by someone?  And what if that person, in turn, also acquires H1N1v swine flu?  Deep in the lungs of those dual-flu victims, what terrible reassortment experiments might be churning?  And what is the form and substance of that mutation, if it survives?"

Wait, you ask.  Why should swine flu mix with bird flu?  Recall that swine flu is only one-third swine.  It is also one-third human, and one-third avian.  Look at the number of flocks of turkeys all over the world that have acquired swine flu.  (interesting that I can only recall turkey flocks having acquired H1N1v).

For these flocks to have acquired a human strain of flu surely must tell us that H1N1v retains enough of an avian genetic footprint that direct infection from humans to birds is not just possible -- it has happened.  Numerous times.

Follow my logic here.  If birds can catch swine flu from humans, then it means swine flu retains enough of its bird ancestry that reassortment with bird flu is absolutely possible.  All it takes is enough exposure, in enough hosts, all over the world, to cook a strain that can both infect humans and kill in greater numbers than swine flu.

Sure, the swine flu pandemic was not what we were fearing.  But let's finish the sentence.

The swine flu pandemic was not what we were fearing -- yet.  We have a long, long way to go.

I just got a news story in my Google Alerts folder.  Opening it and clicking on the accompanying link, I was shown something I had not seen in ages and ages -- namely, the WHO statistics for H5N1 bird flu for 2009.

Now, you know how fond I am of saying that influenza plays "King of the Mountain."  That image of children trying to topple the reigning King at the top of the dirt pile (growing up in southern Florida, with all its construction and fill dirt, that game was enormously popular) is exactly what I try to convey with regards to flu strains.

Pandemic viruses play that game quite well.  In fact, I have not bothered to even get my seasonal flu shot yet, because I believed that there would be no seasonal flu until very late in the season.  based on the stats I have been getting from various flu sources, I was right on the money.

So there is virtually no seasonal flu, anywhere in the world, save for some Influenza B that I recently read was either in China or Japan.

But there is one flu strain that keeps on trucking, unabated by events that combine to make seasonal flu virtually nonexistent.  And that is H5N1 bird flu.

It can be argued, possibly successfully, that H5N1 isn't seen in people enough for swine flu to even care about it.  H1N1v just casts a look over its shoulder at H5N1 and ignores it.

But I was really, really surprised to find that 2009 was a pretty good year, or a pretty bad year, depending on whether you are a researcher or the virus itself.  Globally, there were 72 cases of H5N1 in humans, with 32 deaths.  That is still a 44.4% case fatality rate, or CFR. The two extremes for CFR were Egypt, with 39 reported human cases and 4 deaths, for a 10% CFR; and Indonesia, with 20 reported cases and 19 deaths, a whopping 95% CFR.  Of course Indonesia has just gotten over years of governmental madness courtesy of their former health minister.  This somewhat refreshing reporting of cases may skew the CFR heavier, as certainly more human bird flu cases must have been encountered and just not reported.  Or reported and covered up.  Who knows?

In fact, the year 2009 shaped up as the fourth-worst year for human H5N1 cases on record, surpassed by (in order) 2006, 2005 and 2007 in terms of the sheer number of confirmed human cases. From 2008 to 2009, confirmed reported human bird flu cases jumped by 63% while deaths stabilized.

In 2010, we already are reading about more accounts of bird flu in poultry, in all the usual spots.  This recent news, when combined with the 2009 data, should make us all more concerned than ever that a hybrid virus is more than just hypothetically possible.  A glance at the WHO chart also shows us that the areas of the world where human H5N1 cases proliferate are also areas where the H1N1v virus is just beginning to make its inroads. China has recently announced it expects a constant flow of H1N1v human cases throughout 2010.  China had 7 reported human bird flu cases in 2009, its third-highest year on record and the highest number since 2006.

Indeed, in those areas where H5N1 is assumed to be endemic, human cases are on par with previous years.  For example, Egypt's 2009 human bird flu total (39) was 500% higher than 2008's (8).  Vietnam's 5 cases was not statistically different than the previous two years.  And in each and every one of those nations, H1N1v insinuates itself further and deeper rural villages and farms. 

In the midst of all this, we read news reports accusing the WHO of generating a "fake pandemic".  What are these people ingesting?   A key indicator of a pandemic (you know, other than a genetically novel virus)  is a rising of pediatric mortality.  Pediatric mortality in 2009 was three or five times the running average for a normal flu season, according to different sources.  Our own CDC now says upwards of 11,000 Americans died of swine H1.  The overwhelming majority of them were under age 55.  And this virus is far from finished. 

To its credit, the WHO fired back to the flat-Earthers who claimed that the raising of the pandemic level to Phase Six was inspired by the drug companies, and some even claim this virus was genetically engineered.  These are the same drug companies who do not make a lot of money from vaccines.  To even insinuate that drug companies make huge sums of money from vaccines is to show a colossal lack of understanding about how drug companies make their fortunes.  Vaccines represent a huge downside financial risk to their bottom lines, precisely for the reasons we are seeing and reading about today.  Stories abound regarding this nation and that nation trying to renegotiate its vaccine buying agreements in an effort to reduce its purchases.  It is a wonder that drug companies even make vaccines anymore.

But that is a rant best saved for another time.  I wanted to close this blog by saying that we need to watch Asia and Egypt like a hawk.  Because H5N1 had a very good year on the books in 2009.  It continues to be productive and it has not read the memo that it is supposed to roll over and play dead while swine flu takes center stage.

Happy New Year to readers of this blog, who have been doubtless wondering if I have fallen off the planet somehow.  A combination of holiday mirth, coupled with a Special Legislative Session and a few days out of town, left me with little time to blog.  On top of that, I have not seen much reason to blog.  As I have said many times before, I really do not blog unless I have something I have to say which might add something to the ol' knowledge base.  My fellow bloggers have done such a splendid job that I have not had anything really lucent to say.

Oh yes, plus I went and got sick at Disney World!  My wife had this delightful idea to hold a family reunion at Disney World over the New Years holidays.  We rented a house, packed it with relatives and took in three Disney theme parks in three days.  That totaled 38.5 hours in three days, or almost an entire work week in just three days' time.

What I noticed was the conspicuous lack of hand sanitizing stations.  In fact, the only stations I noticed were 1) few, and 2) were only at the Magic Kingdom.  With so many persons appearing from so many different nations, plus the people who came over as part of a Disney Cruise, I found it interesting that there were not hand sanitizing stations at every ride entrance or at every eatery. 

Also, I have been to Hell, and it is being caught in line indoors at Toy Story at Hollywood Studios.  No way out.  Screaming kids in the hundreds.  And a six-foot tall Mr. Potato Head in Don Rickles' voice, telling bad jokes while you move less than 30 feet in more than 40 minutes.  I finally acted decisively, found an emergency exit, and ushered my party to safety and myself to sanity.  This included my wife, who was in a wheelchair suffering from terrible knee pain caused, no doubt, by strenuous walking the previous two days at Epcot and the Magic Kingdom.

So over the past several days, I have been laboring through rhinovirus C, or Ad14, or whatever it is that I caught at Disney.  Same with my wife.

OK, now on to the top question of 2010:  What the Sam Hill is going on with this flu pandemic?

As best as I can make out, the flu has pretty much subsided in the United States.  Despite the record cold temperatures (and as I write this, Tallahassee continues to have sub-20 degree mornings), flu has all but disappeared.  Only one state apparently reports widespread flu activity, and only time will tell if returning college students and resumption of classes at all grade levels, combined with this ungodly weather, will spark the predicted Third Wave of swine flu.

But there are two nations whose flu activities remind me that this pandemic is still stretching its tendrils across the globe:  India and China.  By all accounts, India has reported around 1,100 flu deaths.  China reports even fewer deaths.  If you are thinking what I am thinking, you are saying, "Dangit!  Who is Marvel going to cast in the role of Captain America?!?! They better get this resolved, since the film is due in mid-2011!"

But I am also thinking, "No way India, with a billion people living in varying conditions of comfort and health, can only have a thousand dead from H1N1v.  Ditto China."

Obviously the reporting of cases and deaths is spotty in those countries.  But it also tells me that this virus is still insinuating itself into those regions of the world, where things travel by the older standard.

Think about it:  H1N1v was borne on the wings of airliners and within the airways and lungs of spring breakers to the four corners of the North American continent.  It travelled across the pond to our British friends and from there, to Europe.  But once the virus hit eastern Europe and Asia, it began to circulate under a more conventional (slower) timetable.

In fact, this timetable coincided with the "second wave" of H1N1v that began in the fall here in the US.  While the second wave has seemingly subsided, Asia still appears to have not even crested its first wave! 

In Florida, we fear the Category 4 hurricane, but we absolutely fear the Category 4 hurricane that moves slowly across the state.  The slower the storm moves, the more damage it is capable of creating.  I want to apply that line of thought to this virus.  The slower this virus moves throughout Asia, the more opportunities it has to infiltrate remote hamlets and villages.  The more opportunities it has to intersect with H5N1.  And the more opportunities it has to mutate/evolve and gain lethality.

Influenza's goal is not to mutate itself out of existence.  Its goal is to co-exist with a host organism.  If H1N1v is such a "mild" virus today (and I think several thousand American families would vehemently disagree with anyone who would call swine flu a mild flu), then its goal is not to become milder.  Its proclivity would be to enhance its ability to make people sick.  It will enhance either its lethality or its target population, or both. 

That is one reason why I think it is important for seniors to begin receiving their swine flu shots now, along with the rest of us who have not done so already.  Suddenly, entire nations are (foolishly) raffling off their reserves of H1N1v vaccine. 

Finally, I redirect you to the words of John Oxford, who foresees a very difficult spring of 2010.  Combine his words with the admonitions of the WHO.  The WHO is saying it may take until the end of 2011 for this pandemic to conclude (meaning, to turn into seasonal flu).  Professor Oxford said that selective mutations of H1N1v will begin to take root once about 30% of the world's population had been exposed to the current virus.

But I am not afraid.  After all, I have been in close contact with Mr. Potato Head.

The old adage was, once you were infected with a strain of influenza, you were golden.  Immune.  Bulletproof.  Superman.  Hence, the absolutely pointless, silly and criminally reckless Swine Flu parties conducted on both sides of the Atlantic.

Well, in light of some stories beginning to circulate, you might parrot the words of former FSU player and ESPN legend Lee Corso: "Not so fast, my friend!"

You see, we are beginning to see evidence of reinfection with swine H1N1v, even after clinical tests proved the victim already HAD the swine!  From the Charleston, West Virginia Daily Mail:

First came the headlines, Dateline Norway: 

UPDATE 1-Norway says found H1N1 mutation in flu victims

* 3 H1N1 cases found with potentially significant mutation * Two cases found among first fatalities in Norway

* Says disease's mutation could cause more serious illness

* WHO says mutated virus sensitive to antivirals, vaccines

(Adds WHO statement in new paras 4-6; CDC comment paras 15-17)

OSLO, Nov 20 (Reuters) - Norwegian health authorities said on Friday they have discovered a potentially significant mutation in the H1N1 influenza strain that could be responsible for causing the severest symptoms among those infected.

"The mutation could be affecting the virus' ability to go deeper into the respiratory system, thus causing more serious illness," the Norwegian Institute of Public Health said in a statement.

There was no reason to believe the mutation had any implication for the effectiveness of flu vaccines or antiviral drugs made by groups such as Roche , GlaxoSmithKline, Novartis (NOVN.VX: and AstraZeneca, the authorities said. ( I would add BioCryst as well, makers of peramivir).

The World Health Organisation said that the mutation did not appear to be widespread in Norway and the virus in its mutated form remained sensitive to antivirals and pandemic vaccines.

A similar mutation had been detected in H1N1 viruses circulating in several other countries, including China and the United States, in severe as well as in some mild cases, it said.

"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 WHO said in a statement.

H1N1, a mixture of swine, bird and human viruses, has killed at least 6,770 people globally, according to its latest update.

In Norway the mutation was found in the bodies of two people killed by the virus and of one person made seriously ill. The two infected by the mutated virus who died were among the first fatalities from the H1N1 pandemic in Norway, the institute said.

It was unclear whether the mutated virus was transmitted among humans, the health authorities said.

"Based on what we know so far, it doesn't seem like the mutated virus is circulating in the population, but rather that spontaneous changes have happened in the three patients," director Geir Stene Larsen at the public health institute said in the statement.

Norway has seen relatively more fatalities in the flu pandemic compared to the size of the population versus other European countries, with 23 confirmed deaths.

Public health authorities have said this could be due to the country being hit early in the pandemic's northern hemisphere winter wave, before a mass vaccination programme got underway.

"Nevertheless, it is important to study if there's still something about the Norwegian fatalities that separate us from other countries, and that make us learn something that strengthens our treatment of the seriously ill," director Bjorn-Inge Larsen at the Norwegian Directorate of Health said.

Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention said, "This mutation has been seen sporadically."

She said it is sometimes seen in patients who have mild influenza symptoms.

"I think it is just too soon to say what this might mean long term," Schuchat told reporters in a telephone briefing. (bold mine) (Reporting by Richard Solem; Additional reporting by Stephanie Nebehay in Geneva and Maggie Fox in Washington; Editing by Matthew Jones and Louise Ireland)

Then the attention turned to Wales and North Carolina, where Tamiflu-resistant H1N1v has apparently spread person-to-person.  Now Chinese superscientist and national hero Zhong Nanshan warns that the conditions are ripe for an H1/H5 hybird to emerge, possibly from China itself.  From the Reuters story:

Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases in China's southern Guangdong province, said the presence of both viruses in China meant they could mix and become a monstrous hybrid -- a bug packed with strong killing power that can transmit efficiently among people.

"China, as you know, is different from other countries. Inside China, H5N1 has been existing for some time, so if there is really a reassortment between H1N1 and H5N1, it will be a disaster," Zhong said in an interview with Reuters Television.

"This is something we need to monitor, the change, the mutation of the virus. This is why reporting of the death rate must be really transparent."

And finally, China itself reports at least eight cases of mutant H1N1v within its borders.

And our response should be:  So tell me something I didn't already expect?

Tamiflu-resistant H1N1 seasonal flu runs about 99%.  Of course, there is no seasonal flu right now of any kind, anywhere in the world.  that is one of the key differences between seasonal H1 and pandemic H1:  Pandemic H1 can be beaten back by Tamiflu.

As for mutant H1N1v:  Of course we would see mutations in the virus!  That is why we need annual flu shots!  Seasonal flu mutates beyond the ability of vaccines to protect us.  This is referred to as "antigenic drift" and is well-known to all who have read this blog for any duration.  I only mention it for all the new readers who are picking this blogsite up every day.

But the mutations in Norway are of special concern.  That is because these mutations cause the virus to penetrate deeper into the lungs of its victims.  And as you probably can guess, deeper is much, much worse.  Once the virus lodges itself in the bottom of the lungs, it becomes much harder to eradicate. 

This is one of the hallmark signs associated with H5N1 bird flu.  Yes, bird flu is exceedingly hard to catch.  But once caught, if medical help and liberal doses of antivirals are not immediately administered, there is diminished hope of recovery.

So the revelation that the "Norwegian mutation" caused death in two patients and severe illness is disconcerting.  But to me, not unexpected.  After all, what disease is moderating itself these days?  This virus is already pretty "mild" in the overwhelming number of cases. Down for a few days and then back to work, or school, or whatever.  So anyone who thought this virus might become even milder has, at best, a 50% chance of being right. 

Or a 50% chance of being wrong.

I err on the side of a tougher disease in the long run.  I ask the question again:  What disease is moderating itself these days?  Ebola?  SARS?  MRSA?  Dengue?  Adenovirus? They have even detected a relatively new strain of rhinovirus, called Rhinovirus C, in Pennsylvania.  A newspaper in Philadelphia reported that tests showed a roughly equivalent number of people catching rhinovirus as catching influenza.  Only this rhinovirus (C) is quite a doozy.  And I have often wondered how many of the people testing negative for H1N1v might actually been suffering from Adenovirus 14. 

In what is an interesting revelation, the WHO is also reporting that similar mutations to the Norwegian Mutation have been detected in Mexico, the United States, Brazil, Japan, and the --- Ukraine.

If you did not notice how the WHO parsed its language during the Ukranian Outbreak, it said:

17 November 2009 -- Preliminary tests reveal no significant changes in the pandemic (H1N1) 2009 virus based on investigations of samples taken from patients in Ukraine. Analyses are being performed by two WHO influenza collaborating centres as part of the global influenza surveillance network.

Preliminary genetic sequencing shows that the virus is similar to the virus used for production of the pandemic influenza vaccine, reconfirming the vaccine's efficacy at this time.

The parsing of those words is important.  Saying there were no significant changes means there were changes but not changes that, in the opinion of two collaborating WHO centers, meant anything.  They also said that the virus had not drifted beyond the target as specified by the original virus used for the manufacture of vaccine.

Now here is the AP story on China:

China reports 8 cases of mutated swine flu virus

By GILLIAN WONG (AP) – 2 hours ago

BEIJING — China has detected eight people infected with mutated forms of the swine flu virus, a health official said Wednesday, but flu drugs and vaccines still work against it.

Flu viruses mutate easily, and scientists have been closing watching for signs that the swine flu virus is changing, which could make it more dangerous or more infectious.

Shu Yuelong, director of the Chinese National Influenza Center, told the official Xinhua News Agency that the mutated swine flu virus found in China was in "isolated" cases in the mainland, is not resistant to drugs and can be prevented by vaccines.

The report did not provide any more details, such as when the cases were detected and if they were linked to any deaths. Calls to the National Influenza Center rang unanswered while the Health Ministry did not immediately respond to a faxed list of questions.

The World Health Organization's spokeswoman in Beijing, Vivian Tan, said the agency had no information on the cases mentioned in the Xinhua report Wednesday.

On Friday, the WHO said it was looking into two deaths and one severe case linked to variant swine flu in Norway, after that country's Institute of Public Health announced that the mutation could possibly cause more severe disease because it infects tissue deeper in the airway than usual.

The same mutation has been found in both fatal and mild cases elsewhere, including in Brazil, Japan, Mexico, Ukraine, and the United States, said the WHO. (bold mine)

Tan said the agency is aware of three such cases in China that occurred in June and July that were similar to the cases being investigated in Norway.

"We are concerned, but realize that influenza viruses, including A/H1N1, are relatively unstable and change easily, especially as they infect more people," Tan told The Associated Press. "Some mutations can have minimal effects on how a virus functions, while other mutations can create important changes with significant public health impact."

China's Health Ministry said Wednesday that 51 swine flu deaths were reported last week, bringing the total number of fatalities in the country to 104.

 OK, let's recap.  This is the kind of informed analysis you come to this site for, right?

H1N1v produces mutant offspring practically every time it replicates itself.  That is because, as an RNA virus, it does not have the double helix quality control of a DNA virus.  That is why there is no universal flu vaccine.  And that is why, eventually, even the H1N1v pandemic vaccine will become ineffective.  Be it three months from now, or three years, it will inevitably be ineffective.

But there have been key mutations spotted in multiple nations almost simultaneously.  These mutations have the effect of pushing H1N1v deeper into the human lung, similar to the effect of H5N1 bird flu.  It is not known if any of the 4,000 deaths in this country are due to this mutant strain of H1N1v, although that should be the very next question anyone asks the CDC. 

In order for this mutation to become more pronounced, it must have some sort of indefinable quality that makes it the preferred strain of virus.  It has to break out more frequently, in more places, and infecting more people.  It has to move efficiently -- something the Norwegian doctors do not think is happening.  Remember that influenza's goal is coexistence, not slaying its host.  Inasmuch as you can ascribe any thought process to something that science does not even want to classify as a life form!

But if this mutation becomes more pronounced, and happens in more and more places, the potential exists for it to make some headway and become the dominant substrain of H1N1v.  I don;t know what we call it at that point; I think the protocol would be to call it A/H1N1/Norway/2009 or something along those lines.

All this serves as a reminder that this pandemic is a looooong way from being over.  Weekly case numbers are misleading and produce false hope.  The Florida Department of Health is not even producing an update until December 3, which I think is a jolly good idea.  By the way, Florida's average age at death from swine flu is now north of 55.  Seven died last week in the Sunshine State, and none of them were under the age of 38. 

So do not be surprised if you continue to hear about mutations, especially mutations that seem to cause more serious disease.  There was a 50/50 chance it would wind up that way.  It should ,however, spur you and your loved ones, co-workers, friends and teammates to all seek the H1N1v vaccine.  It is safer than the virus.

But scientists need to tell us where those mutations took place, and how it affected the death totals.  For instance, southern Brazil had a mutation in the early stages of the pandemic, specifically in Sao Paulo.  Brazil also had a higher case fatality rate in the southern portion of the nation, where Sao Paulo is located.  Coincidence? 

Likewise, in the United States, were any deaths attributable to this mutation?  How about in the Ukraine, where there was something akin to panic in the streets and their public health people were claiming a fusion of H1N1v with parainfluenza and pneumonic plague?

Lots of unanswered questions.  Lots of room for speculation.  And lots of pandemic activity remaining to be played out on the global stage.

We would be wise to heed Zhong's words.  And we need to recognize this pandemic is anything but "mild."