Entries in pandemic (25)

Elderly Central Florida woman dies of swine flu and why that bears closer inspection

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.

Making sense of the recent flu news

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.


Songbirds, not just fowl, represent avian flu threat to US

Over at Flutrackers, there is a thread regarding the prevalence of avian influenza in American birds. 

Avian influenza virus (AIV) is an important public health issue because pandemic influenza viruses in people have contained genes from viruses that infect birds. The H5 and H7 AIV subtypes have periodically mutated from low pathogenicity to high pathogenicity form. Analysis of the geographic distribution of AIV can identify areas where reassortment events might occur and how high pathogenicity influenza might travel if it enters wild bird populations in the US. Modelling the number of AIV cases is important because the rate of co-infection with multiple AIV subtypes increases with the number of cases and co-infection is the source of reassortment events that give rise to new strains of influenza, which occurred before the 1968 pandemic. Aquatic birds in the orders Anseriformes and Charadriiformes have been recognized as reservoirs of AIV since the 1970s. However, little is known about influenza prevalence in terrestrial birds in the order Passeriformes. Since passerines share the same habitat as poultry, they may be more effective transmitters of the disease to humans than aquatic birds. We analyze 152 passerine species including the American Robin (Turdus migratorius) and Swainson's Thrush (Catharus ustulatus).

We formulate a regression model to predict AIV cases throughout the US at the county scale as a function of 12 environmental variables, sampling effort, and proximity to other counties with influenza outbreaks. Our analysis did not distinguish between types of influenza, including low or highly pathogenic forms.


Analysis of 13,046 cloacal samples collected from 225 bird species in 41 US states between 2005 and 2008 indicates that the average prevalence of influenza in passerines is greater than the prevalence in eight other avian orders. Our regression model identifies the Great Plains and the Pacific Northwest as high-risk areas for AIV. Highly significant predictors of AIV include the amount of harvested cropland and the first day of the year when a county is snow free.

Although the prevalence of influenza in waterfowl has long been appreciated, we show that 22 species of song birds and perching birds (order Passeriformes) are influenza reservoirs in the contiguous US.

OK, insightful analysis time.  We always associate bird flu with ducks, or chickens, or turkeys or geese, but rarely do we associate it with songbirds and other smaller birds.  This study makes a clear association between those birds (called "passerines") and bird flu. 

The distribution of those avian flu cases is seen in this map (thanks Laidback Al!):


Now let us look at a map of the principal migratory bird routes over North America:


There is a veritable swarm of migratory bird routes over the Great Plains and Mississippi River delta, and a very strong west coast migratory route.  So it is no coincidence, in my mind, that these migratory superhighways also contain the areas where avian flu has been most strongly detected since 2005.

Now you also notice those "down arrows" leading South of the Border.  This map helps illustrate what happens south of us:

We've got birds encroaching from the south as well as from the north.  This does not just figure into the avian flu equation:  There is this little thing called a major dengue fever epidemic that is raging in many, if not most, South American nations.  And as I mentioned recently, Key West, Florida has enough dengue in it to sicken a man this year.

This all leads into the current status of H5N1 sentinel activity.  With massive budget cuts, waning interest, and competition for attention from swine flu and other diseases, do we have as good a handle on things as we did in 2006 and 2007?  I would like to think so, but I doubt it.

Imagine the encounter:  A researcher goes into his/her supervisor's office, requesting additional funds for H5N1 monitoring.  What, the supervisor says?  You want me to divert $$ from certain necessary projects over to bird flu monitoring?  All while my departmental budget is being cut to ribbons?! No stinking way!

Or words to that effect.  I wish it were not so, but I am pretty certain I am right.

In the midst of all this, the Mexican government recently issued an alert to be watchful for an H5/H1 hybrid virus.  My first impulse was to say, What do they know?  What have they heard?  But is may have been nothing more than speculation.  Nonetheless, vigilance is important, now more than ever.  For H1N1v may not have been the pandemic everyone feared, but it was substantial in terms of its effect on the young; far worse than, say, 1977.  Yet H1N1v, being 1/3 avian, can still hang out with avian flu viruses and reassort.  It is precisely this scenario that should cause us to view this latest report with concern. 

Trust Fineberg's committee to deliver accurate, relevant, honest WHO appraisal

Wow.  It has been more than two months since my last blog entry.  that must mean that H1N1v, or swine flu, is gone, right? 

No. It means I am incredibly busy these days, and have not had much to say about pandemics nor about infectious disease.  Well, that is not entirely true.  For example, dengue fever has established a beachhold in Key West, Florida, where a Navy person recently was confirmed to have contracted dengue from within Key West's city walls. 

Also, and as most of us surmised, swine flu is still worming its way through the developing world.  India seems to be under the gun with outbreaks of H1N1v, and I am not sure what the genetic makeup of this new virus might be. 

Additionally, recent reports regarding testing of the H1N1 vaccine on mice and subsequent attempts at infection with 1918 Spanish flu are encouraging.  It appears that there is some conferred immunity from the 1918 pandemic virus with the H1N1 swine flu vaccine.  This is important, because if you recall from reading this Blog, the 1977 recurrence of H1N1 was believed to be the result of a Soviet lab accident.  So this pandemic may have been serendipitous in that it is helping immunize the planet against another Spanish Flu. 

Anyway, the article that prompted me to write this blog actually deals with the WHO analysis of itself.  The WHO has been the subject of much scrutiny as the result of what has been to date, a very mild pandemic.  Some are inferring that Big Pharma actually orchestrated this pandemic in order to make a lot of money on vaccine and antivirals.

Believe me, Big Pharma has more and bigger things to make money on than vaccines.  Anyone who really believes Big Pharma would drop everything it was doing to go and make vaccine just does not understand how drug companies make their money today.  Druf companies see vaccine production as a necessary evil; a component of what they do, but not nearly as profitable as making and selling drugs dealing with everything from erectile dysfunction to hair loss.  

In fact, accusing drug makers of profiting unnecessarily from vaccine production may actually cause drug makers to forego vaccine production in the future.  Now some, including those misguided but WRONG individuals who think vaccines cause autism, might rejoice in that thought.  But the simple truth is that drug companies see vaccine production as an important public health duty.  And accusing them of orchestrating an overly aggressive response to a flu pandemic is placing blame in the wrong place.

Is there a right place to place blame?  In my opinion, no.  There is no blame.  The WHO acted correctly.  Now there are protocol adjustments to make, and my previous blogs have covered the principal problems, dealing with severity.  The WHO needs to adopt the US "Saffir-Simpson" standard for pandemic severity.  I am sure that concept will get an airing and eventual adoption. 

But the absolute best news I gleaned from today's article about the WHO oversight committee deals with the committee itself.  First, the AP story of today: 

2 experts resign from WHO swine flu review panel

(AP) – 1 hour ago

GENEVA — The World Health Organization said Tuesday that two members of an expert panel reviewing the global body's response to the swine flu outbreak have resigned over concerns about perceived conflict of interest.

John MacKenzie and Tony Evans stepped down because their close association with the UN health organization during the outbreak could be seen as conflicting with the panel's ability to remain independent, WHO said.

"Both have been closely engaged in deliberations at WHO which our committee is charged to review," said panel chairman Harvey Fineberg. "They each concluded it would be better to avoid the position as reviewer of their own earlier actions."

Mackenzie, a professor of tropical infectious diseases at Curtin University in Australia, and Evans, medical chief of the Montreal-based International Civil Aviation Organization, were on the emergency committee that advised WHO's Director-General Margaret Chan before she declared swine flu a pandemic.

WHO convened the panel in April to conduct a "credible and independent review" of how it and national authorities handled the outbreak. Concerns were raised at the time that several panel members were trusted WHO advisers and government employees who could end up whitewashing any failures.

The review panel will present a final report next year.

Harvey Fineberg is Dr. Harvey Fineberg, head of the Institute of Medicine in Washington, DC.  He also is the former head of the Harvard school of public health, and former Harvard provost.  But to flubies, Harvey is best-known as the co-author of the seminal study of the 1976 swine flu debacle, along with the late historian Richard Neustadt.  Harvey is also a pen pal of mine, and I engage him occasionally as a sounding board for ideas that, depending on his thoughts, eventually appear here as blogs.

Harvey may be the most-qualified person in the world to assess the WHO's handling of the 2009-10 swine flu pandemic.  His 1976 study should be required reading for anyone who is interested in public policy when it comes to public health and infectious disease policy.  I am equally certain his committee's analysis of the WHO's conduct during this latest pandemic will also be compelling reading. 

Vietnam's Na Tao hamlet: Ground Zero for latest bird flu cluster

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

Bac Kan province has confirmed a second A/H5N1-infection case in Na Tao hamlet, Nhu Co commune, Cho Moi district.  The patient, Nguyen Thi Thanh Thu, 27, visited a bird flu-infected area four or five days before being diagnosed with the deadly virus.

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:

Bird flu sickens 2 in Vietnam; 11 others quarantined, recovering from flulike symptoms

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.

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?