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A few years ago, back in January 2009 (and six months before the swine flu pandemic),  I wrote a blog regarding H5N1 and the potential for chickens to be asymptomatic carriers of a pandemic candidate virus. 

If you performed a Find and Replace using "H7N9" for "H5N1" in that blog post, you would instantly have a very topical blog.  So please read that blog from four years ago, and change the virus subtype in your head as you go along.

Now, I vector you to today's disclosure that 64 human H7N9 cases exist in six different provinces, including two fabled cases in the city of Beijing.  There are 14 deaths.  As I mentioned in one of my earliest blogs on the subject of human H7N9, barely a week ago:

Dr. Yin of the Bill and Melinda Gates Foundation.  Apparently Dr. Yin is the Foundation's leader in China.  And it was quite satisfying, knowing Bill and Melinda are spending funds in  China, including, but not limited to, surveillance.  Dr. Yin's statement is worth paraphrasing.  He said, basically, if you don't test for H7N9, you won't find it.  But if you do test for it, you'll find it.  The inference is that there have been numerous unexplained and undiagnosed severe respiratory ailments there this season.  Retroactive testing of samples, based on Dr. Yin's inference, will yield a significant increase in the number of H7N9 human cases. 

Indeed, with more than 400 labs across China testing away, they are finding more cases in more geographic locations.  Simultaneously, more deaths are being reported.  Fortunately, the deaths are not increasing in proportion to the number of confirmed cases.  We all believed that the case fatality rate would not be as high as the initial reports would have indicated; the sample was too low and the data, therefore, did not support (yet) a high CFR.

But I found it interesting that as of this morning, the WHO has not yet established a pandemic alert system for H7N9. Dedicated Web page, yes.  But the WHO has not started an alert system. 

WHO has an alert system in place for H5N1, and had one for pH1N1, a.k.a. The Virus Formerly Known As Swine Flu.  Perhaps it is too early for such an alert system.  After all, the virus is only in one region of one nation (albeit a region that is host to more than 300,000,000 Chinese).  I also understand the reluctance the WHO must feel regarding this disease.  The WHO took significant credibility hits after swine flu, some referring to the WHO as "chicken little."  These criticisms are unfair and undeserved.  No one had any idea that pH1N1 would have been as mild as it was.

And "mild" is a misnomer.  The words "mild virus" are of great consolation to virus experts, public policymakers and public health professionals who look at The Big Picture; but those words are of little consolation to the parents of children who died during the pandemic. 

A Reuters story from June of last year paints that smaller picture.

(Reuters) - The swine flu pandemic of 2009 killed an estimated 284,500 people, some 15 times the number confirmed by laboratory tests at the time, according to a new study by an international group of scientists.

The study, published on Tuesday in the London-based journal Lancet Infectious Diseases, said the toll might have been even higher - as many as 579,000 people.

The original count, compiled by the World Health Organization, put the number at 18,500....

The results paint a picture of a flu virus that did not treat all victims equally.

It killed two to three times as many of its victims in Africa as elsewhere. Overall, the virus infected children most (4 percent to 33 percent), adults moderately (0 to 22 percent of those 18 to 64) and the elderly hardly at all (0 to 4 percent).

Even though the elderly were more likely to die once infected, so few caught the virus that 80 percent of swine flu deaths were of people younger than 65.

In contrast, the elderly account for roughly 80 percent to 90 percent of deaths from seasonal influenza outbreaks. They were probably spared the worst of 2009 H1N1 because the virus resembled one that had circulated before 1957, meaning people alive then had developed some antibodies to it.

The relative youth of the victims meant that H1N1 stole more than three times as many years of life than typical seasonal flu: 9.7 million years of life lost compared to 2.8 million if it had targeted the elderly as seasonal flu does."

So swine flu was much more of a force than anyone (especially the critics) thought it was.

Here in April of 2013, we have a big problem.  No one knows how long this new H7N9 virus was circulating among wild birds, poultry and (especially) people in China.  In fact, we didn't know Diddley until March 31st, when the Chinese sprung the news upon the world.  Exactly when the Chinese knew it had H7N9 in people is cause for speculation, but I think we can excuse the Chinese for demanding confirmation before telling the whole world (to their credit) that a new pandemic candidate was emerging within their borders.

In fact, nothing may have ever been known, had the cases involving the three male family members not caused some doctor or technician to begin testing for something.  My guess is they speculated it was  seasonal influenza or H5N1 bird flu, then moved to SARS, then moved to the new novel coronavirus NCoV, and then reverse PCR testing revealed the presence of H7N9. 

Thank the Maker that someone had the curiosity and the desire to test in a wider spectrum!

Adding to the drama is the report from Beijing last week that a 4-year-old boy tested positive for H7N9.  He is not sick and displays no symptoms, yet he is an asymptomatic carrier of bird flu. This means wider testing is essential -- of humans, pigs and birds.  The testing net needs to be cast very widely in order for everyone to get their arms around the problem. 

And that, folks, is why I believe the USA's CDC opened its Emergency Operations Center at Level 2.  Since the CDC EOC alert levels only go from 3 to 1, the opening at Level 2 was considered by some to be controversial.

Knowing now what we do, and analyzing their decision in the current light, we should say this was an important and prudent decision.  Because, folks, we don't really know if this virus has come to America or not. And the only way we are going to know anytime soon is through weekly surveillance of mortality and morbidity.

From Wikipedia:

 United States

On April 9th, 2013 the Centers for Disease Control and Prevention (CDC) activated its Emergency Operations Center (EOC) in Atlanta at Level II, the second-highest level of alert.^[30] Activation was prompted because the novel H7N9 avian influenza virus has never been seen before in animals or humans and because reports from China have linked it to severe human disease. EOC activation will "ensure that internal connections are developed and maintained and that CDC staff are kept informed and up to date with regard to the changing situation."^[31]

From the Medscape article:

The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, received a specimen of the H7N9 virus from China yesterday. On April 9, the CDC activated the Emergency Operation Center (EOC) at Level 2 (there are 3 levels, with 1 as the highest) to support the management of the emerging H7N9 situation, Sharon KD Hoskins, MPH, senior press officer at the CDC told Medscape Medical News in an email.

Researchers used real-time reverse-transcriptase-polymerase-chain-reaction assays, viral culturing, and sequence analyses to test the patients' respiratory specimens for influenza and other respiratory viruses.

....In an accompanying perspective, Timothy M. Uyeki, MD, MPH, MPP, and Nancy J. Cox, PhD, from the Influenza Division, National Center for Immunization and Respiratory Diseases at the CDC, commented on the article, noting that this outbreak "is of major public health significance."

"The hemagglutinin (HA) sequence data suggest that these H7N9 viruses are a low-pathogenic avian influenza A virus and that infection of wild birds and domestic poultry would therefore result in asymptomatic or mild avian disease, potentially leading to a 'silent' widespread epizootic in China and neighboring countries," Drs. Uyeki and Cox write. The HPAI H5N1 virus usually causes rapid death in infected chickens.

I am not certain, but I am pretty confident that most labs in the United States are currently incapable of subtyping anything other than the prevaling seasonal flus of pH1N1, H3N2, B, and swine H3N2 (nice call, CDC). Anything other than these substrains are lumped into one or more catagories of A: "Subtyping not performed," or A "Unable to subtype."   However, the CDC is also beginning to catalog incidences of other novel influenzas.  From their April 6th report:

Novel Influenza A Virus

No new human infections with novel influenza A viruses in the United States were reported to CDC during week 14.

A total of 312 infections with variant influenza viruses (308 H3N2v viruses, 3 H1N2v viruses, and 1 H1N1v virus) have been reported from 11 states since July 2012. More information about H3N2v infections can be found at http://www.cdc.gov/flu/swineflu/h3n2v-cases.htm.

Assuming few, if any, US labs can currently quickly detect H7N9 bird flu, the only other capability the CDC has is to monitor and initiate surveillance of the public's health.  This means both ramping up a central monitoring presence dealing with day-to-day issues, and also ramping up state health departments to begin watching for unusual spikes in ILI, or Influenza-Like-Illness.

By activating their EOC at level 2, the CDC is able to pull in disparate elements and to begin the process of surveillance in earnest. Things you just cannot do sitting at a desk, you can do in a central coordinating facility, open-air, with people at their posts.  Having been in the State of Florida EOC many times, including pandemic exercises, actual hurricane tracking and the afternoon of 9/11 (and for days afterward), the ability to sort information and make decisions does not happen in a better environment.

On April 2nd, I formally activated the State of Florida CIO Association's Pandemic Committee.  It had stood in informal recess since the Swine Flu pandemic was declared over in 2010.  However, I decided that once the chickens were not doing their duty and dying, we had a real conundrum on our hands!

In fact, just last week, the Florida Department of Health announced that they were beginning monitoring the China H7N9 situation.  I suspect other state health organizations are ramping up, if for no other reason than to give the CDC timely and accurate information, should there be spikes in respiratory illness.

So what would a spike look like?  The spike would look something like this:

  
Hmmm.  This is the actual CDC Pneumonia and Influenza Mortality chart for April 6th, 2013. 

The top black line represents the epidemic threshhold.  The bottom black line represents the seasonal baseline.

The red line represents the actual reported cases.  As you can see, the red line is at the highest point since a spike at the beginning of calendar 2011, six months after the end of the Swine Flu Pandemic. In fact, the chart had suddenly spiked to a level higher than at any point since 2009.

Not sure of what was going on, but knowing this occurred before my rebirth as a flu blogger, I reached out to Mike Coston (again). I asked Mike about what had happened? 

Mike told me that the CDC immediately looked into the situation. In fact, he blogged on both the mortality spike and the CDC's response. Apparently, what happened is that H3N2 drifted.  If you need a primer on antigenic shift vs. antigenic drift, click here.

Anyway, what happened is that, apparently, the H3N2 seasonal flu drifted.  And seniors, who may not have been vaccinated as often as recommended, had no immunity to the drifted virus -- immunity they might have had, if they had goten regular flu shots.  H3N2 is a nasty bug for anyone, but especially for the elderly, who died in numbers sufficient to trigger the uptick that you just saw.

A similar uptick, especially coming now as flu season wanes, would trigger a pretty quick CDC response.  This is why the CDC activated.  This is why state departments of health are getting ready to ramap up their surveillance. 

To recap:

• The chickens are not doing their duty and dying.
• China has no real idea how widespread the virus is.
• Nobody else does, either.
• There is currently no reason to suspect there is H7N9 in North America.
• That having been said, there is always the possibility that infected, asymptomatic travelers have come into the United States via any of the Pacific ports of call and airports. Unlikely, but not impossible.
• Certainly, we would have seen the virus in Hong Kong before we would have seen it here.
• Currently, there is no inexpensive, routine way to test in doctors' offices or public health departments in the USA for H7N9. 
• H7N9 would appear as "Type A, Unable to subtype" or "Type A, subtyping not performed."
• We have a long way to go with this situation.

This week, an elderly Central Florida woman named Catherine "Cay" Thompson died of swine (H1N1/2009) influenza.

The news report, a capsule of which can be found here, says the Lake County (just north of Orlando) woman had recently traveled to California.  the new report also says local health officials are "shocked" that a flu case should come so early in the season.

A more detailed Orlando Sentinel account can be found here.

There are a few takeaways to these articles that just jump out at me.

First, are we surprised that a (previously) pandemic virus would still be circulating in the United States outside of flu season?  Pandemic viruses do not follow the seasonal pattern.  When do we determine that a pandemic virus loses its characteristic ability to infect people outside of "flu" season?  We all know the WHO said "stand down, please" to the H1N1/2009 pandemic, declaring it over well before now.  But when exactly does a virus lose its ability to infect outside of flu season?  I would imagine that occurs when the virus burns through the population enough to establish more of a seasonal-looking infection pattern.  I would also imagine that occurs due to natural mutations in the virus itself.  But since the WHO declared the 2010 vaccine formula would be used again in 2011, it would seem that any evolution in the virus, to this point, and based on surveillance, was very minor.

The Sentinel article states the woman and her church group traveled to California, and she fell ill while there.  She then returned early back to Florida.  It does not state how long she was in California before she fell ill, but we all know that influenza takes several days to manifest symptoms.  She died on August 25th, and I cannot find a church calendar that would shed light on when she might have first been exposed to the virus.

Even with these gaps in the travel calendar, I think we can draw up a theory.  The answer to how this unfortunate woman contracted influenza may be found, not from the visit to California, but much, much closer to home.  Orlando, as everyone knows, is a massive tourist destination.  South Americans love Disney just as much as the Brits and the Europeans and the Chinese and the Japanese.  And, indeed, India is struggling with swine flu right now.  But it is amazing how we fail to look south and, instead, default to looking to our left and right for answers.  It's flu season right now in the Southern Hemisphere.  And it is officially Hot as &@%%$ in Florida right now.  Well, actually, pretty much everywhere.  So the chances of a flu virus circulating in 90-degree-plus temperatures is remote.

In my opinion, it is far more likely that this woman actually contracted influenza at the Orlando International Airport, rather than being infected in California.  One sneeze from a Chilean or Argentine would have done the trick.

The other takeaway from this story is the woman's apparent lack of immunity to H1N1.  We all know that pandemic viruses disproportionately attack the young, sparing the elderly, who -- hypothetically -- have been previously exposed to a similar strain of the returning pandemic virus.

But this was not the case with Mrs. Thompson.  There are references in the stories to her immune system, and how the virus overtook it.  But Mrs. Thompson, being 80 years of age, would have had to have lived through the transformation of the Spanish Flu (1918 A/H1N1) and its many mutations.  She would have lived through the near-pandemic 1943, 1947 and 1951 attacks of H1N1.  She would have lived through the transition from H1N1 to H2N2 in 1957.  And she would have gone through two waves of the swine flu, which attacked Orlando pretty hard, precisely because of its status as a global vacation destination. She also appeared to be in relatively good health, based on her levels of activity within the church.

Where I am going with this blog entry is that we should take a closer look at the virus that felled Mrs. Thompson.  It would be wise for public health experts and scientists to tke a look at Mrs. Thompson's killer through an electron microscope, because the death of an otherwise-healthy 80-year old woman from swine H1N1 should not be simply relegated to statistic status.

It has been a long time since I blogged anything about the flu.  For starters, I am busier than ever at work, which cuts severely into my blogging time.  But also because I just have not felt the muse.  The swine flu pandemic was blessedly mild overall, although there are thousands of families still coping with the loss of a loved one due to H1N1/2009 who would harshly disagree with my assessment. But it wasn't 1918, so we breathed a sigh of relief.

There are many seemingly divergent storylines currently out there, which I will just list at random.  I am not so sure they are not somehow interconnected, however.

First has to be the continued number of human bird flu infections and deaths in Egypt.  Overlaying this ongoing problem is the sudden departure of Mubarak, the takeover by the Egyptian military, and what this portends for both transparency and NAMRU's operations within the nation. 

Second is the realization that this year's seasonal flu vaccine was way off the mark.  I began to notice last month that my employees were getting sick from flu, and I knew they had received their vaccinations in the late fall.  My deputy, in fact, was tested type A-positive last month.  That's pretty specific.  Here in Tallahassee, doc-in-the-box and emergency rooms were positively overrun with flu cases.  Things are looking better, but the WHUMP! of flu cases in January was much more severe than at the same time last year.  And last year was the dang pandemic!  Almost everyone who got flu this year who I am personally acquainted with, had, in fact, received the vaccine months prior.

Third is the ongoing Siege of Japan by H5N1 in poultry.  We all have read the articles about the culling of hundreds of thousands of birds in Japanese poultry farms.  this has spread to the mainland, especially South Korea.

What is clear to me is that the H1N1/2009 pandemic was not sufficient to push the other subtypes off the radar.  This runs contrary to previous pandemics where a dominant substrain was capable of, and able to, sufficiently supplant  the previous Big Dog of Flu.  H1N1 was replaced by H2N2, which was replaced by H3N2, and so on.  Swine flu was not able to eradicate H3N2, nor was it able to eradicate B.  for that matter, I do not know what research existed prior to the mid-1950s to actually track Influenza B.  for all I know, Influenza B has been around since the Chinese domesticated ducks some 4,000 years ago. 

Or, since B mutates more slowly than A, and is therefore not capable of producing pandemics (so says Wikipedia), it is not subject to the King of the Mountain game like Influenza A.

But someone apparently blew the call on the vaccine this season.  I get the feeling the only strain they got right was, in fact, the pandemic strain! 

The other strain that H1N1/2009 did not push off the radar is H5N1.  In fact, so far this year, bird flu activity seems to be much more intense than at the same time last year.  Human cases and deaths in Egypt seem to be at the same levels as last year, but H5N1's overrunning of the Japanese poultry industry is disconcerting.

Finally, there seems to be some concern that this year's flu outbreaks are more severe than last year's.  Again, this is not scientific, but my people got hit and hit hard by the virus.  Their symptoms were severe, with one person requiring hospitalization.  In one case Tamiflu did nothing, although there is a chance it was not administered in time.

H1N1 had a comeback in the late 1940s and early 1950s, with several epidemics (the Liverpool Flu of 1951, for instance) that were considered equal to, or more severe than, the 1918 pandemic, depending on location.  Shortly afterward, H2N2 (re)appeared, seemingly wiping H1N1 off the face of the Earth.

I openly wonder if the appearance of swine flu in 2009 was, in fact, the Beginning of the End of H1N1 as it was in the 1950s, and we are at the brink of the introduction of a different substrain of flu.

The world press is beginning to focus on the province of Bak Kan (or Bac Can), Vietnam.  Bak Kan is in the extreme north of Vietnam, near the Chinese border.  Last week, I blogged on the potential H5N1 bird flu cluster that was threatening to emerge within that province. Just scroll down to read my previous blog.

Following my blog, a second story appeared regarding a second human infection.  It was dated at 6:01 PM, 04/09/2010.  It appears below, and the link to the VOV story is in the headline:

Another A/H5N1 infection case reported in Bac Kan