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The following is the third and concluding chapter of FSU student Christin Foster's experience with swine flu during her recent trip to South America. The series wraps tomorrow with some final observations.

Argentina’s Catch-22

Malaly, my friend in Buenos Aires (in photo, standing on the right), came down with the swine flu at the same time that I did. She experienced the same symptoms I did and yet received a totally different treatment in Argentina. As such, I believe that Argentina serves as an excellent example of what not to do during a pandemic.

The Kirschner government had an inefficient approach to the swine flu. At the time when Malaly and many other Argentines were becoming sick, the government bought all of the Tamiflu and would not distribute it to sick people unless a clinical test came back positive for the swine flu. This caused great strain on doctors and medical facilities. Additionally, at this point in time, it took two weeks to get the results back on a swine flu test and so by the time one was clinically diagnosed with it, he was either completely healed or dead.

Therefore, despite Malaly’s high fever and symptoms, she was given a test for swine flu and then sent home with prescription painkillers and antibiotics to prevent pneumonia. That was all the doctor could do. She too was placed in quarantine for a week.

The Chile program ended and I returned to Argentina for vacation the day that Malaly was released from quarantine. She was scheduled to start exams the next day at the university. She stayed up all night studying only to be sent home from the university the next morning. The school administrators told her that she was not allowed to set foot in the university until she had an official note saying that she was in good health to return to school. She drove back home, picked me up and we drove to what I can best explain to be a Ministry of Health in Education building.

Malaly spoke to the doctor at the Ministry to ask for a note of good health to be allowed back in school. The doctor refused to give her the note because Malaly had not been given Tamiflu. Because she had not been given Tamiflu, Malaly had not “legally” had the swine flu and therefore he could not legally write her a note of good health. However, she was not given Tamiflu because the government had control of the antiviral drug and she still had yet to have her swine flu test results back. It was a swine flu catch-22. Malaly returned home with no note and with no way of taking her finals at the university.

The television stations in Buenos Aires were flooded with news of the swine flu and of the Congressional elections that took place on June 29. The Kirschner government was greatly criticized for its reaction to the pandemic, among other things, and lost significantly in the elections. Former President and Senator Nestor Kirschner, President Cristina Kirschner’s husband, stepped down as head of the political party after the devastating loss at the polls.

The swine flu was also a big topic of interest. The country was still in the process of figuring out how to handle the illness and it did so publicly. There was talk for days of closing the schools early for winter holidays. The news channels also kept a live tally of the number of casualties from the swine flu. Every time you would look up at the TV screen the tally would have increased. Entire towns were shut down to try to stop the spread. Less and less people were out in the streets of Buenos Aires and Malaly’s friends were often too scared to leave their homes. There were billboards on almost every street in Buenos Aires instructing people on how to stay protected from the swine flu. The schools were eventually closed. It seemed as though the black plague was going through Argentina and not just a strain of the flu.

Instead of decreasing the spread of disease and increasing the availability of medical care, the Argentine government created a state of fear and panic. Not only did the news scare the Argentine public, and rightfully so with a live death tally, but the government also mismanaged the medications and disrupted an otherwise effective system of medical care. It was a complete contrast to the experience I had in Chile and I felt fortunate for being treated in Santiago and not Buenos Aires.

Swine Flu Survivor

Having the swine flu in South America was an incredible experience. I learned a lot about public health from observing first hand the contrast between how the pandemic was handled in Chile and in Argentina. Fortunately, regardless of the difference in treatment, both Malaly and I healed just fine and are now back to life as usual.

 Tomorrow:  Lessons learned and cautionary tales gathered from Christin's experiences.

The following is the second chapter of FSU student Christin Foster's experience with swine flu during her recent trip to South America. The series concludes tomorrow.

Quarantine

After picking up my prescriptions from the pharmacy and Gatorade from the market, I returned to the apartment for bed rest. In order to prevent my spread of the virus, I was placed in quarantine for a week. Quarantine for me meant that I was not allowed to leave the apartment. Corinna was placed in the second bedroom in the apartment. It was determined that due to her exposure, she would either get the swine flu or not and so placing her in another apartment would not make a difference. The other two flatmates were moved into another apartment and placed in quarantine for 24 hours.

After two days on the medications, my fever had broken and I had the energy to walk around the apartment. However, my lung irritation remained. I came to learn that quarantine not only prevented me from infecting others but it also provided a better environment for my lungs to heal as the cold weather outside would have done more damage than good. All food was brought to me in the room. Corinna was kind enough to make sure that the hotel brought me breakfast in the morning and helped make sure I had lunch and dinner each day.

The program handled my illness extremely well. It not only went to great lengths to prevent other students from being infected, but also did an excellent job taking care of me. I took my final exams at a table in the apartment with no problem. Studying with the swine flu was difficult but I was appreciative to be able to finish out the program.

Typhoid Mary

I experienced firsthand the stigma associated with the swine flu. The maid service for the hotel was terrified to come to my room. Normally, the maids were required to come clean the room and bring clean towels each day. However, after I contracted the swine flu, the maids would fight over who had to come take care of my room and would sometimes just flat out refuse to come. Finally one very nice woman from the maid service either drew the short straw or decided I was not that frightening and would come take care of my room. Eventually she even showed up without the surgical mask.

My program also experienced repercussions from my illness. The day after I was diagnosed with the swine flu the program took students to ski in the Andes. There was a major debate whether Corinna should be allowed to attend. It was finally decided that Corinna, having no symptoms and being an advanced skier, was allowed to go on the trip. However, other students bombarded her with dirty looks upon entering the bus. All the students were also required to wear surgical masks on the bus to and from the mountains.

When I was finally let out of quarantine, my treatment as Typhoid Mary continued. The first morning out of quarantine I decided to venture up to the breakfast room. I sat at a table in the back corner and had Corinna get my food from the breakfast buffet in order to be as careful as possible. A few students from my program were also eating breakfast at the same time. While some were friendly and compassionate, others seemed more concerned by my presence. Instead of a warm greeting or a “how are you feeling”, I was greeted with dirty stares that said “what exactly do you think you’re doing out of your room?”

That treatment carried over to next day when I went to the business center of the hotel to check my email. The computers where located in a small back room off the lobby and each computer was placed in a little cubicle. I chose a cubicle towards the back. About five minutes into using the computer, one of the hotel managers approached me with a can of Lysol. He proceeded to not only Lysol the cubicle where I sat but me as well. Even weeks after being sick, my husband’s coworkers in Tallahassee continued to ask him if he was concerned about me returning to the US and infecting him and his office with the swine flu.

The BBC published an article called “The Etiquette of Swine Flu”, which teaches those with the swine flu and those who know someone with swine flu how to behave properly regarding the illness. I believe that it is worth everyone checking out. http://news.bbc.co.uk/2/hi/uk_news/magazine/8120771.stm

Tomorrow:  Argentina's Catch-22

Christin Foster is a law student at Florida State University (go 'Noles!). I had the good fortune to meet her recently at one of my H1N1 presentations. Actually, I met her mother first, at a presentation I was giving for a group of state agency inspectors general and auditors. Her mother asked several very good questions and then reaffirmed to the group every statement I had made about the then-still-developing situation in Argentina. How did she know so much about what had gone on there, I asked? because her daughter had caught swine flu there, she responded.

The next day, I was giving another presentation, this time to the local Certified Public Managers meeting. Following the presentation, Christin and her father came up and introduced themselves. Again, she indicated I had nailed it perfectly on the situation in South America with swine H1.

Christin began telling me aof her experience. I asked herif she had written a journal of her ordeal, and she said she would be happy to write a narrative of her experiences.

What follows is a series of her journal entries. I will post portions of her writings daily, over the next three days. It gives a much-needed perspective on how other nations are handling - and not handling - the still-young H1N1v situation.

I have changed and edited nothing. Sit back andread aboutthe swine flu experiences in South America of Christin Foster.

Summer in South America

My first year of law school at Florida State University College of Law had just come to an end. I decided to study abroad for the summer on American University Washington College of Law’s Summer Chile Program. The program focused on international trade and human rights law and split time between Chile and Argentina. I chose this program for a few reasons. First, I love Argentina. I was an exchange student to Buenos Aires in high school and have returned to visit almost every year for 9 years. I have maintained a close relationship with my host family in Buenos Aires and Malaly, my host “sister”, remains one of my best friends to this day. Second, I am interested in international law and a professor at FSU Law recommended that I attend a program that focuses on international law for the summer. Third, American University Washington College of Law is highly ranked for international law and the Summer Chile Program is well established. The summer program was wonderful. However, I came to learn almost as much about public health in South America as I did about law.

The first two weeks of the program took place in Santiago, Chile. We stayed in a hotel called Renta Home, which provided two bedroom apartments where four students could stay. We were supposed to be taking our law classes at the University of Chile Law School but students were holding a strike at the school, which made it impossible for us to hold classes there. Instead, we took classes at a university called Diego Portales, which was another law school in Santiago. We took classes there for a week until a few cases of the swine flu popped up at the law school. For liability and safety purposes, classes were moved to a conference room at Renta Home.

The third week of the program took place in Buenos Aires, Argentina. We stayed in the “microcentro” or downtown of the city and took our classes at the beautiful and prestigious University of Buenos Aires College of Law. The week in Buenos Aires was wonderful. The program allowed us enough free time to really explore and enjoy the beauty of Buenos Aires. This also provided me with plenty of time to spend with Malaly and her wonderful family. I spent almost every afternoon with Malaly and had a great week. The night before returning to Chile for the final week of the program, I went out for dinner and drinks with Malaly and her friends. She and I now believe that we were infected with the swine flu that evening.

Swine Flu

The first morning back in Chile I woke up with lung pain. It felt as though my lungs were irritated and it hurt to breathe. I made the assumption that my lung irritation must have been attributed to the exposure to the high volume of second-hand cigarette smoke in Argentina, as smoking is culturally accepted in the country. With no other symptoms, I carried out my day in Santiago as usual.

My roommate, Corinna, and I went to the gym about five blocks from the hotel. Due to my lung discomfort, I opted to walk on the treadmill for 30 minutes rather than do any strenuous exercise and then took advantage of the gym’s great shower facilities. I thought that the steam might help alleviate the pain in my lungs. It did not.

By 6:00pm a fever and body aches had started to set in. I was unable to eat dinner and crawled into bed at 7:30pm. The body aches and chills grew more severe as the night went on. Most of the night was spent in complete delirium. I estimate that my fever reached 104 degrees. I spent part of the night lying on the tile floor of the bathroom to try to keep cool. The fever and body aches were so intense and caused me to be so weak that it was an arduous task to open a Tylenol Cold & Flu packet.

The next morning showed more (of) the same: lung pain, fever and severe body aches. I made an effort to shower and go to class, unaware how sick I really was. However, I was unable to stand for more than a few minutes at a time, which eliminated my plans for the morning. I crawled back into bed and was awakened by Corinna returning from breakfast with one of the program coordinators. Corinna and I were given surgical masks, put in a cab and taken to the hospital in Santiago. Corinna was included in the hospital visit because of her exposure to my illness.

Clinica Aleman was a nice hospital in Santiago. The waiting room of the ER was full of people wearing surgical masks. I later realized that most of the people in the waiting room also had the swine flu. I only had to wait about 10 minutes before being called back into a room. The doctor came in, took my temperature, which was still around 102 degrees, and listened to my lungs. He then proudly announced, “esta chica tiene la gripe porcina,” which was my official diagnosis of swine flu. I immediately responded, “QUE!?” I was completely shocked that I had somehow contracted the swine flu, but the doctor confirmed the diagnosis.

The concern then became Corinna’s and my other two roommates’ exposure to my virus germs. The doctor recommended quarantine for 24 hours for Corinna and the other roommates and stated that if they did not come down with symptoms in that time that they were in the clear. The doctor then prescribed strong painkillers for my fever, an expectorant to help my lungs, Tamiflu and bed rest. I was sent out of the room to wait with the other gripe porcina victims in line for the Tamiflu.

Fortunately, due to Chile’s good health care system, the whole procedure in the hospital took roughly an hour and only cost $100.

Tomorrow:  Quarantine.

It has been a few days since I was able to sit down and study the latest news coming from South America. A combination of heavy work and helping my wife through her latest round of chemotherapy combined to distract me for over a week.

Once I was able to concentrate on the latest developments, I was shocked but not surprised. Needless to say, the news is quite disconcerting.

I want to take you back to my blog of July 17th, when I predicted that deaths due to confirmed H1N1v in Argentina would exceed those in the United States by the end of July. It took an extra week, but that gap has finally been closed --depending on how you parse your words.

The latest information coming from the CDC indicates a confirmed total of 353 deaths from swine flu. But Argentina just released new, two-week numbers which raise their death toll to 337.

But wait, there's more. According to the Guardian UK newspaper story, the Argentine government is waiting for positive pathology on another 400 deaths. If even a third of these are confirmed H1N1v, that will catapult Argentina to the top of the world's death list. Hat-tip to Cindy of Nerstrand, MN.

So what, you might ask. Well, two things should leap out at you. First, Argentina has just under 41 million people, according to the CIA. That means Argentina has just over one-seventh the population of the United States, yet it now effectively leads the world in deaths. If the United States had, say, 2,600 deaths from swine flu, that would be a comparable ratio relative to population.

Second, recall that this is Argentina's flu season. The Guardian article discusses that 750,000 confirmed cases of swine H1. I am sure that is just an estimate and not actual swabs. But the number of deaths could be double what is being officially reported, if the 400 unknown results become positive.

This strains further an Argentine government that was the textbook example of how NOT to handle risk communication. In my recent Fox News Channel interview, I was asked if all my warnings could incite panic -- especially my instruction to pregnant women that if they feel anything remotely like flu symptoms, they need to get hold of their doctor, pronto.

No, I responded. It is the absence of information that produces panic, not the presence of honest data. I also reminded the reporter of the work of Dr. Peter Sandman and his advice to treat the American people as adults and give them the skinny exactly as it is.

It was also gratifying when, the very next day, the CDC issued the exact same advice/warning.

Anyway, back to the Argentine government. When H1N1v broke out, they acted as if the virus never existed. No, not here. Move along. When it became painfully apparent the virus was in Argentina and people were dying from it, only then did the government do an about-face and started engaging their pandemic plan.

It is absolutely amazing how governments full of well-educated people can make such terribly dumb decisions.

Further, there seems to be quite the debate raging as to whether or not the virus has indeed mutated in South America.  Back in June, the Brazilian research facility Instituto Adolfo Lutz has been in existence since 1892, and was renamed to honor the former University of Bern (Switzerland) scientist. Its core competencies include (from its Website):

Currently, the Adolfo Lutz Institute is recognized internationally for its competence to respond to incidents in their area of expertise, having been accredited by the Ministry of Health and National Public Health Laboratory and Reference Laboratory Macroregional. It Collaborating Center of the Joint FAO / WHO for monitoring of contaminants in food. Reference Center for Analytical Quality Control of Mycotoxins and Residues of Pesticides, National Coordinator of the Program for Monitoring of foreign substances in food, the National Reference Center for Laboratory Diagnosis of AIDS; Collaborating Center of the Pan American Health - OPS areas of arbovirus, influenza virus and production of immunobiological and PAHO Collaborating Center for Cell Cultures.

Anyway, this prestigious WHO collaborating center (think if St. Jude had found such a change!) has typed the first known mutation of the virus' hemagglutinin (the "H" in "H1N1").  Hemagglutinin is what sticks the virus to the cell wall in your respiratory tract (think of those velcro ping-pong balls that stuck to felt dartboards from back in the day).  An antigenic change in hemagglutinin could make the virus much easier to catch (search umbrellas and coneson this blogsite for a full description of this phenomenon).

The (236 year-old) patient was hospitalized on April 24 at the Institute of Infectious Diseases Emilio Ribas (Brazil) and is fully recovered.

Respiratory secretion sample of this patient was subjected to molecular rt PCR methodology (§ reaÃthe polymerase chain in real time) with probe specific for the new subtype H1N1 by the team of molecular biologist Claudio Sacchi, and the result for the new viral subtype .

Following the research the team of virology Terezinha Maria de Paiva, the Institute Adolfo Lutz, São Paulo, isolated at the end of April that the new strain is now known as A / Paulo/1454/H1N1 are following the rules of the World Health Organization . The virus isolation was performed in cell culture using the MDCK cells successfully in the first passage. In section electron microscopy of the Adolfo Lutz, Marli Ueda and Jonas Kisielius identified several virus particles from the infected culture. also the first observation.

The isolation of the virus provided the sequence of the genetic material of the Brazilian strain, experiments being performed by Dr. Cecília Luiza Simões dos Santos of the Instituto Adolfo Lutz.

The initial molecular characterization of strain A / Paulo/1454/H1N1 are involved the determination of complete sequences of two gene segments, segment 4, which encodes a protein Hemaglutina (HA) responsible for viral infectivity and for which antibodies are produced protectors, and segment 7, which encodes the matrix protein (MP) M1 and M2. The complete sequences of the genes HA and HB, the first determined for strains isolated in Brazil, are available in GenBank, a database that U.S. shared sequences obtained worldwide, which can be consulted by their respective numbers of access: GQ247724 (HA gene) and GQ250156 (MP gene). Molecular analysis indicated that while the virus segment 7 of A / Paulo/1454/H1N1 are shown to be completely conserved when compared to the reference strain A/Califórnia/04/H1N1, segment 4 showed a discrete number of nucleotide changes and of amino acids, with similar rates of around 99, 7% and 99.5% respectively. Detection of amantadine-resistance marker, comprising the amino acid asparagine (N) located at position 31 (N31) of the M2 protein in strain A / San Paulo/1454/H1N1, corroborates the literature that point be the new virus resistant to this class of antiviral compounds.

The debate started just after the sequencing of this new substrain of H1N1v was announced, and it continues to rage on flu sites such as Flutrackers to this very hour.  The issue is this:  Do these changes have a lot in common with the hemagglutinin from 1918?  At first glance, the answer is yes.  There was a lot of swine involvement in the 1918 virus, and so it would not be surprising to see this unique virus sort of "run home to Momma" when it comes to picking up mutations.  Swine flu is a much closer antigenic descendant to the 1918 pandemic strain than is our seasonal H1N1!  The fact that some of these mutations were first typed in the "Brevig Mission, Alaska" trip of Johan Hultin, circa 1997-98, and came conclusively from the 1918 virus, are somewhat unsettling. 

It remains to be seen if this Brazilian mutation is responsible for the larger numbers of infected and dead in Latin America relative to population. Sao Paulo is Brazil's southernmost metropolis.  It is about 800 miles from Buenos Aires, the capital of Argentina.  The area also borders the capitals of Uruguay and Paraguay.

Let us shift to Mexico, which is reporting a new spike in human H1 cases.  Are these cases the vanguard, the herald of the Second Wave?  Or are these outbreaks simply vestiges of the first wave of the virus?  Nobody knows yet, but there are more reports coming from the border region with Texas which indicates more Tamiflu resistance than originally thought.

This can be explained by the sudden and massive insertion of Tamiflu into the region in the Spring.  Remember that Tamiflu does not break down in groundwater, nor does it break down in water treatment plants.  So it is not surprising that the massive administration of Tamiflu in towns on both sides of the Mexican border might produce NA 274Y Tamiflu resistance.

We have seen this antiviral resistance many times before, both in seasonal H1N1 and in some cases of H5N1 human infection. Of course, the seasonal strain's resistance is far, far more prevalent.

One thing is sure:  South America has suffered the most of all the regions of the world in this, the first wave of the H1N1v swine flu pandemic. 

This morning, I was scanning my inbox, and happened upon a proMED email that had lodged itself in my SPAM filter.  It was from yesterday and concerned a suspected H5N1 bird flu infection in Vietnam.

From the proMED report:

The deputy director of the Department of Preventive Health in the central province of Ha Tinh, Nguyen Luong Tam, confirmed on 26 Jul 2009 that a 30-year-old man died of bird flu at the General Hospital.

The man had been rushed to hospital the previous day with pneumonia, high fever, headache, muscular and joint pain, cough, breathing difficulty, and vomiting. Doctors diagnosed him as having avian influenza and isolated him. They found his lung to be seriously damaged. He died on 26 Jul 2009. Health workers later found diseased poultry at the man's house. He also had contact with a female relative, a teacher at Ngo Thoi Nhiem private High School in District 9, where 73 students and 5 teachers have contracted swine flu [that is, influenza pandemic (H1N1) 2009 virus infection]. (bold mine)

So there we have it:  The first reported instance where H5N1 bird flu is in very close physical proximity with H1N1 swine flu.  A dead man with confirmed H5N1 had contact with a female relative, a teacher at a school that itself is overrun with swine H1N1v.

It is precisely this type of elbow-rubbing between H5N1 and H1N1v that has everyone from Atlanta to Memphis to Geneva to Tokyo very, very alarmed.  You can bet the WHO has Boots On The Ground in that district as we speak.  Ditto the Vietnamese government, which does the best it can do to quell bird flu (among other things, to be sure).

It is only a matter of time before we get similar stories out of Indonesia, Egypt and China.