6 Alabama kids were on life support with flu

indigo girl · Dec 30, 2006

CDC asked to probe severe pediatric flu in Birmingham:

(hat tip Flutrackers/Sonny)

http://www.ledger-enquirer.com/mld/ledgerenquirer/news/local/16346098.htm

oramar · Dec 30, 2006

I would like to see some viral sequences released from some of these kids. Maybe they have been, and I just have not heard about it yet.
That might give us some clues as to why this strain is so virulent. I know that this information exists in some data base somewhere. Is it too much to ask that it be shared with the public?

I got a feeling all the info you are wishing for will eventually show up on CDC web site but it takes a while.

Home Health Columnist / Guide · Dec 30, 2006

Purfect reason why I and kids get flu shot each year.....

indigo girl · Dec 30, 2006

Here is more information about the specific flu strains, nicely highlighted by our friends at Flutrackers, a site devoted to following the spread of infectious diseases:

http://www.flutrackers.com/forum/showpost.php?p=56217&postcount=1

Actually, I am looking for specific information on each virus. I am interested in the specific gene sequences. Some of these are known to be associated with increased virulence. As different strains of flu viruses combine and move about in populations of infected hosts, we can expect to see these key sequences appear, and can track how these viruses are evolving. It is not enough to know just whether or not it is an A or B virus. This information exists in databases somewhere.

indigo girl · Dec 30, 2006

If the information on the particular gene sequences is available, we would be able to make predictions based on the type of polymorphisms that are showing up. It just adds to the knowledge base. All information like this about infectious disease is valuable in predicting virulence, for making vaccines based on particular strains, in showing us how viruses evolve and pick up sequences that make them more dangerous.

This is the kind of information that I am seeking. I had to go back and pull this from an old thread on H5N1, an avian flu, but it pertains to all influenza viruses. This discussion below however, will be about reading sequences on H5N1 because the information came from a forum site devoted to education on that subject. Flu viruses combine so that you can have seasonal flu viruses that interchanged genetic material with each other that can make them more pathogenic. The information obtained from sequencing can tell us what polymorphisms tend to make a flu more dangerous.

A viral sequence is a list like a book that contains chapters, and sections, that contain the information about the genome of the virus. The chapters contain:

allthewordsclumpedtogetherlikethis.

So when someone like Dr. Niman of Recombinomics is working with this, he selects phrases from each chapter that he knows from experience are going to occur. The phrases are called polymorphisms, and they can be worded in different ways, but frequently come up in exactly the same way. Then he searches the data base within the chapter, and looks for the occurrences of the key phrases, occurring at a certain distance from the start of the chapter resulting in a list of exact matches, either a long or short list. This is sorted into youngest to oldest in order. The example I am giving was given in Flutrackers. These are all avian flu viruses, but they are not all H5N1, but it does not matter because they can and do hybridize.

DQ186975 A/swine/Bakum/5/95 MP (7) 1007 1995 H1N1

DQ102483 A/swine/Bakum/5/95 MP (7) 783 1995 H1N1

U65569 A/Tochigi/44/95 MP (7) 982 1995 H3N2

AF073201 A/Turkey/Utah/24721-10/95 MP (7) 1002 1995 H7N3

AJ458339 A/Wuhan/359/95 MP (7) 1028 1995 H3N2

U65571 A/Aichi/69/94 MP (7) 982 1994 H3N2

CY004904 A/blue-winged teal/Alberta/293/1994 MP (7) 1027 1994 H4N6

AY497136 A/Chicken/Hidalgo/232/94 MP (7) 985 1994 H5N2

CY005832 A/chicken/Hidalgo/28159-232/1994 MP (7) 1027 1994 H5N2

AY497129 A/Chicken/Mexico/31381-7/94 MP (7) 985 1994 H5N2

Starting at the bottom with some chickens in Mexico in 1994, and you see the same phrase repeated in a blue-winged teal in Alberta, same year, and in humans in China, same year, but occurring as H3N2, a seasonal flu.

In 1995, you see the same phrase in humans in China again, and same year, in swine in Bakum, both occurrences are in a virus, H1N1, that both people and swine can get. This phrase occurs all over the world in people, birds, and swine.

The phrases are not random choices. The lists Dr. Niman is posting are giving the latest acquisitions and shows where they come from. "Only poymorphisms with a limited distribution in closely relates sequences are probed. Generally, there are only a few to a dozen such acquisitions, depending on the gene. Thus, the number of 2006 or 2005 isolates that have the sequences are limited, and the list pretty much shows how the sequences traveled prior to aquisition by the sequence being analyzed.

The transfer of polymorphisms is like a baton in a relay race and can involve several birds in multiple flyways. Moreover, the changes accumulate and may be linked to multiple seasons, which is why the polymorphisms show a general trend, but there is significant mixing and matching (although some polymorphisms become dominant and widespread). The sequences are better than banding, because each isolate has multiple data points and has evidence for multiple exchanges."

Avian flu viruses are classified by a combination of two groups of proteins: the hemagglutinin or H proteins, of which there are 16 (H1-H16), and neuraminidase or N proteins, of which there are 9 (N1-N9). The virus we are concerned about here is the H5N1 virus.

If a pandemic occurs, it won't matter how it gets here, by bird or by human, we presume, but the exchange of genetic information is occurring. Birds get around distance wise far more more than most of us do. Some of the migratory routes of these birds are globe-spanning. Some believe that genetic diversity, coupled with the increasing targets for more recombination may make a pandemic likely.

Dr. Niman has remarked that, the HPAI (highly pathogenic avian influenza) H5N1 in North America would most likely come from the Qingahi strain of H5N1 which is in long range migratory birds. He believes that that was what those goslings on Prince Edward Island died of in June.

The difference between LPAI (low pathogenicity - not likely to cause mortality) and HPAI (highly pathogenic - associated with sickness and mortalities) is the HA clevage site. HPAI has multiple basic amino acids (R or K) at the cleavge site, like RERRRKKR for the most common H5N1 in Asia, or GERRRKKR for the Qinghai strain, or RERRRKR for the Fujian strain. Therefore the HPAI generates a bigger insert on testing, and that is why Dr. Niman wants to know the size of the inserts on those dead birds tested on Prince Edward Island. A larger insert would indicate HPAI.

LPAI has only 1 R at the cleavage site.

LPAI is low pathogenic avian flu and HPAI is highly pathogenic flu currently occurring as H5N1.

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This is from another site, and offers more explanation on reading viral sequences. Someone had asked on that site, and this was an attempt to answer specific questions which you will see as you scroll down the page. If you click on the links, you will get a little primer on gene sequences:

CurEvents.com - A Global Current Events Discussion Forum - View Single Post - Reading gene sequences for idiots

gr8greens · Dec 31, 2006

Indigo, thanks again for all you do here. And as for the "retraction" by ommission by the media re: the original statements made by the doctor. All one can say is hmmmmmmmmm. What aren't they telling us.

Ohmygosh, please keep us posted as you seem to be the only "feet on the ground" we have here!

indigo girl · Dec 31, 2006

This very annoying link takes a long, long time to unload. In fact every time I have tried to find links to this story, it has taken forever to get this information such as it is from this site. But, here you have it. The story has changed as these stories frequently do. This doctor says that these kids had underlying medical conditions prior to getting the flu. Maybe they did, but why didn't any of the docs say this in earlier versions of this story? They distinctly said that these kids were healthy prior to getting the flu.

http://www.al.com/search/index.ssf?/base/news/1167473710252640.xml?birminghamnews?nstate&coll=2

OK. I can buy it, but I still want to see more info on the subtype of this flu.

No reason not to tell us this that I can think of.

Ohmygosh · Jan 1, 2007

This very annoying link takes a long, long time to unload. In fact every time I have tried to find links to this story, it has taken forever to get this information such as it is from this site. But, here you have it. The story has changed as these stories frequently do. This doctor says that these kids had underlying medical conditions prior to getting the flu. Maybe they did, but why didn't any of the docs say this in earlier versions of this story? They distinctly said that these kids were healthy prior to getting the flu.
al.com: Search
OK. I can buy it, but I still want to see more info on the subtype of this flu.
No reason not to tell us this that I can think of.

As far as I am aware there was no underlying medical condtion in the child I spoke of. But, please understand that the information I get comes from non-medical people.

Pediatric Critical Care Columnist · Jan 7, 2007

We here in Edmonton, Alberta have a kid on ECMO for influenza A. At first we were looking for hantavirus because she was SO sick. She seems to have turned the corner, but I find it very interesting that we were unable to obtain Tamiflu for her... there's supposed to be a stockpile of it in the province in case of pandemic...

indigo girl · Jan 7, 2007

We here in Edmonton, Alberta have a kid on ECMO for influenza A. At first we were looking for hantavirus because she was SO sick. She seems to have turned the corner, but I find it very interesting that we were unable to obtain Tamiflu for her... there's supposed to be a stockpile of it in the province in case of pandemic...

janfrn,

I think that some will be surprised at how little Tamiflu may be available.

Certainly not enough for a pandemic with a CFR of over 50%. There will be no prophylaxis doses for HCW. It is not possible.

Your kid should have been able to get Tamiflu or Relenza if your province was being truthful about their pandemic preparations. I am finding that in some cases, plans are just plans. They are mandated to do planning but there is no realistic follow through, and appropriate expenditure of what it is going to take.

BTW, a company down in Birmingham, Alabama was just awarded a contract to develop a parenteral antiviral drug for patients like this.

Can you imagine how we will give this kind of critical support to many cases at once? I would have some serious questions to ask of your pandemic planners about the inability to obtain Tamiflu for this patient.

Pediatric Critical Care Columnist · Jan 7, 2007

It boggles the mind, doesn't it? Our staffing levels are so tight that one ECMO patient strains us to the limit at times, so I can't imagine. As for the Tamiflu, well we have this fabulous Internet based reporting system for incidents like this, and once it's been activated, the cat's out of the bag, so to speak. The instant that the report is completed, it's sent to our manager, our medical director, the health region's administration, the health region's risk managment office and a couple of other high level responsible parties. I have a feeling this one will be looked at very closely.

indigo girl · Jan 7, 2007

janfrn,

I wonder if I could pick your brains, so to speak since PICU is not my area of expertise. I am trying to understand how these kids can get so sick from a seasonal flu.

Would you know if her monocytes, and lymphocytes disappeared?

Would she have gone into DIC? If either if these things occurred, is this a result of septic shock and have you seen this from influenza before?

It is all so puzzling, but to me very fascinating though sad for this child and her family. Did this child have an underlying condition that could have predisposed her to such an devastating event?

I am guessing that your kid has H1N1, the same virus as in 1918 since she is so sick. This is a subtype of influenza A.