Entries in Politics and government (199)
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:
The healthcare centre in Cho Moi district has reported nine suspected cases, eight of them from Na Tao hamlet. (bold mine) All nine showed symptoms of high fever, breathing difficulty and coughing.
The first A/H5N1 case was detected in Bac Kan on April 5. The patient, Trung Van Hoa, 22, was also from Na Tao hamlet.
At present, local authorities and health agencies are intensifying emergency measures to sterilise infected areas and strictly monitor new outbreaks of the disease.
Cho Moi district has been given 700 doses of Tamiflu vaccine(bold mine) and enough medical equipment to ensure that necessary checkups and treatment can be provided to local patients.
Now today, a copyrighted story has appeared via the Canadian Press. It has also been picked up by AP and has gone worldwide. Here is that story:
By Tran Van Minh (CP) – 5 hours ago
HANOI, Vietnam — Two Vietnamese from a poor, mountainous area have been infected with bird flu, and 11 others were quarantined with flulike symptoms, health officials said Tuesday.
A 22-year-old man and a 27-month-old girl remain hospitalized after testing positive for the H5N1 virus, said Hoang Van Linh, deputy director of northern Bac Kan province's health department. He said the 11 others, some of whom were relatives of the confirmed cases, had fallen ill with fever, coughing and shortness of breath.
They were given the antiviral Tamiflu and have since recovered. He said they were tested for bird flu, but the results have not come back.
Dead chickens were reported at the homes of the two patients, and the toddler's family is believed to have slaughtered and eaten some of the infected poultry, according to the Ministry of Health's Web site. Ly Quoc Khach, an infectious disease official from the provincial health department, said all 11 people, members of the Tay and Nung ethnic minorities, had contact with the sick birds, and he said he did not believe there would be any reason to fear possible human-to-human transmission if they did test positive.
The 22-year-old man remains on a respirator after being hospitalized April 2, while the toddler, who was admitted two days later, is in stable condition, Hoang said. All of the sick people's homes in Ma Tao commune have since been disinfected, and the infected poultry have been slaughtered, Ly said.
Vietnam has been hit with a spate of fresh H5N1 outbreaks among poultry, and two people have died from the disease this year, according to the World health Organization, which confirms 59 deaths since late 2003.
The disease remains rare among people, with most cases linked to direct contact with infected poultry. But experts have long feared the virulent virus could mutate into a form that allows it to spread easily among people, possibly igniting a pandemic.
Copyright © 2010 The Canadian Press. All rights reserved.
OK, time for award-winning commentary again. Note that the Vietnamese press is listing three -- NOT two -- confirmed H5n1 cases. Note also that the VoV article speaks of a Tamiflu blanket that has been applied over the entire district of Cho Moi, which includes the hamlet (and apparent epicenter of this bird flu outbreak), Na Tao.
Note that the total of suspected human bird flu patients is up to 11. If we include the three previous cases, we have as many as 14 possibles. This would make this the largest bird flu human cluster since 2008.
Bird flu is cropping up all over Asia again. China is seeing a re-emergence, no doubt facilitated by illegal trade in smuggled birds (Google my blog of, oh, I dunno, maybe 2007 on that topic). A veritable Ho Chi Minh trail of smuggling activity exists between China and Vietnam, the irony of which is not lost on Americans.
But I digress. The Vietnamese government has acted quickly and decisively on the issue of Bak Kan. They have applied a Tamiflu blanket over an area comprising 700 villagers. They have eleven villagers in quarantine with clear symptoms of influenza, and three confirmed human cases.
The next thing to look at is the timeline. The first human case in Bak Kan was March 30th of this year. The toddler was admitted two days after the first case. The third confirmed case was "four or five days before being diagnosed with the virus," meaning some time possibly between the 30th of March and the 5th of April (the story was written on the 9th).
The epicenter of the epicenter appears to be a commune within the hamlet. Now I suppose it is possible that people would have eaten diseased poultry at the same time. But the onset of symptoms is staggered by several day between the first and third cases. This would cause me to speculate that you cannot exclude human-to-human contact. And the simple fact that 700 surrounding villagers are currently on Tamiflu as a preventative would seem to support that hypothesis.
Hopefully, the reasonably transparent Vietnamese government will be very forthcoming with samples of this virus. In light of the fact that H1N1v, aka swine flu, is still traversing those same remote hamlets of Asia, and in light of the jarring re-emergence of H5N1 bird flu across eastern Europe and Asia, we need to know: Has bird flu mutated?
Yesterday, Vietnam confirmed yet another human bird flu case. This time, however, this case bears watching, because it could signal something far more disconcerting than just a single human case.
From the proMED report:
The Director of the Bac Kan provincial Health Department, Nong Quoc Chi, confirmed an A (H5N1)-infected case on [5 Apr 2010]. The patient, [male], 22, from Na Tao hamlet, Nhu Co commune, Cho Moi district, is currently in critical condition. He is being treated at the [National Institute of Tropical and Infectious Diseases]. The patient got sick on [30 Mar 2010] with symptoms of high fever and cough. He was admitted to Bac Kan provincial hospital, and then sent to the [National Institute of Tropical and Infectious Diseases] on [3 Apr 2010] where he tested positive for the lethal strain of A (H5N1) virus.
At present, 4 other people in Nhu Co commune show similar symptoms of high fever and cough. They are under quarantine and being treated at Bac Kan provincial hospital.
The patient in question was taken ill on the 30th of March, and then sent to Hanoi when his condition worsened. The four suspected human bird flu cases are currently in quarantine at the provincial hospital in the provincial capital of Bak Kan. (Or Bac Can, as shown on map at left).
There are many unanswered questions. The most obvious of these is whether these four suspected cases are bird flu, or swine flu?
If these cases are indeed bird flu, has there been human-to-human chain transmission, or were these people all infected during the same timeframe by a single vector? Were they all infected by sick poultry, or were they sickened by a human infection?
OK, let's assume these four people were all H1N1/swine flu infections. That is not good news! That would mean that, once again, bird flu and swine flu had "rubbed elbows" in rural Vietnam. Search my Blogsite for the earlier known case, back in 2009.
According to the Vietnamese Department of Preventive Medicine and the Environment, there are no outbreaks of H1N1 anywhere in Vietnam. From VOA News:
At a meeting reviewing the flu epidemic situation in Hanoi on March 31, the Deputy Director of the Department of Preventive Medicine and the Environment, Tran Khac Phu, confirmed that 11,208 people in the country had been infected with the virus as of March 31 and 58 of them had died.
Regarding the A/H5N1 flu, Phu said that there were no more confirmed cases last week, and the total number of such cases so far this year stands at five, including two deaths.
The A/H1N1 virus epidemic appears to have subsided and the country has not detected any mutations in the virus, said Associate Professor Dr. Nguyen Tran Hien, Director of the Central Institute of Hygiene and Epidemiology.
However, Hien urged localities to closely monitor for the A/H5N1 virus as it is still being found on poultry in several areas.
According to the World Health Organisation (WHO), by March 30, there had been 492 confirmed cases of A/H5N1 infection in 15 countries, resulting in 291 deaths.
Vietnam is actively looking for bird flu cases, so perhaps this is why they feel so confident that no H1N1 outbreaks have occurred. But this may be at odds with the WHO Vietnam report of February 10, 2010. that WHO report stated, matter-of-factly:
Pandemic (H1N1) 2009 is continuing to spread throughout Viet Nam. The spread of the virus to all countries, worldwide, is considered inevitable.
As of 10 February 2010, Viet Nam's Ministry of Health has received reports of 11,186 laboratory confirmed cases, including 58 deaths. (Bold WHO's)
It is important to note that this pandemic is currently referred to as of “moderate” severity based upon the global situation. The overwhelming majority of patients are recovering without the need for hospitalization or even medical care, the levels of severe cases are similar to the levels we expect for seasonal influenza, and the health care systems are able to cope with the number of people seeking care.
With the increasing spread of H1N1 in Viet Nam, we expect that there will be a number of people who have serious complications and some will die.
All-righty then! Is Vietnam's swine flu rate climbing or falling? This is not an unimportant question, because it is becoming apparent that Vietnam, more than any other nation save Egypt, may have the potential to be that flashpoint where H5 and H1 reassort. Vietnam has had, to date, prior to this report, 5 bird flu cases with 2 deaths. Egypt, in contrast, has had 18 human bird flu cases with 6 deaths. Both areas are of huge concern.
Let's all keep our eyes on this developing situation.
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:
Tuesday November 24, 2009
CDC confirms Kanawha County pediatrician had swine flu -- twice
by Zack Harold
Daily Mail staff
Novel? Rare, but not without precedent. From proMED's commentary on the incident:
Studies in humans (as opposed to mouse models) performed over 20 years ago with natural infection by different influenza A subtypes suggest that influenza reinfection is not so uncommon, as the CDC has
indicated: rates of reinfection with influenza A/H3N2 have been as high as 63 percent in consecutive seasons in one family study, which included young children (1976/77 and 1977/78) (1); with influenza
A/H2N2 as high as 27 percent (17/62) within 6 months (2). This same report also found a reinfection rate of 17 percent with A/H3N2 amongst students in 1970 and of 32 percent and 69 percent in 2 groups of students in 1972, and of 32 percent in 1983 -- with the A/H3N2 viruses showing various degrees of antigenic drift. With A/H1N1, reinfection rates of 9.3 percent and 20 percent were reported for 2 other student groups in 1980 (2).
The related question, of course, is how long one can expect the A/H1N1/2009 vaccine-induced immunity to last -- though of course, running parallel to this is ongoing A/H1N1/2009 viral mutation that may require a change in vaccine antigen-specificity and re-immunisation at a later date, anyway.
Now allow Dr. Henry Niman to explain a possibile cause:
The above comments on lab confirmed re-infection of two family members two months apart by swine H1N1. These confirmations are supported by many anecdotal reports of similar re-infections. The timing of these infections allowed for easy identification, because at the time there was no seasonal flu, so identification of infections was straight-forward. Moreover, such infections in school aged children and parents are common because H1N1 infections exploded when school began.
At the time however, the H1N1 virus was evolving slowly, reflecting an ease of infection of a naïve population. The jump from swine H1N1 into humans allows for infections with low doses of virus. Low concentration of virus produces a mild infection and a weak antibody response. The rapid spread creates widespread antibody, but the low level allows for re-infection from individuals with a higher viral load. A higher viral load can be created in a school environment, where some students could be infected multiple times because of frequent contact with infected students.
Thus, the increased viral load could overcome the weak immune-response and re-infect those infected earlier, leading to a second wave. However, the higher viral load leads to more serious infections, especially for these not infected in the first wave. Consequently more previously health young adults develop more serious symptoms, leading to an increase in hospitalizations and deaths. The higher viral load, especially when combined with receptor binding domain changes such as D225G can lead to the type of cases seen in Ukraine, where a high percentage of young adults develop infections that destroy both lungs in a matter of a few days.
So we have an interesting situation here. Apparently, some people were only marginally infected -- ever so slightly infected -- with H1N1v swine influenza. Possibly not enough titers of virus entered their system for them to get really, really sick. And this could explain why so many swine flu sufferers only experience only mild symptoms.
But either due to a drift of the virus, or a deeper infection with substantially greater titers of virus, or even both -- a woman and her son both became re-infected with swine flu. Clearly, this case will be looked at with great interest by global health authorities.
By the way, this is perhaps why the CDC is advising anyone with unconfirmed H1N1v to go ahead and receive the vaccine. If you did not get enough titers of virus the first go-round, the theory is you need more virus in the form of the vaccine to complete the process.
Sort of like under-10's getting two shots to further boost immunity. Just get the shot, everyone. If you can.