Swine Flu Updates and Issues - page 6

More evidence today from an article in the New Scientist Magazine that indicates that overly narrow testing criteria for the H1N1 virus in Europe may be hiding community transmission of the virus.

The UK, along with many other EU countries, have recommended testing people with symptoms only if they have been to affected countries or had contact with a known or suspected case in the past seven days.

The `useful fiction' that community transmission of the H1N1 virus has yet to occur in Europe (or Asia, or Africa . . . .) has been bolstered by the relatively small number of positive H1N1 tests coming out of those regions.

Of course, by failing to demonstrate community transmission in another WHO region, the politically dicey decision to raise the pandemic alert level again can be postponed.

Swine flu has killed four people in New York State, and hospitalized more than 100, including no more than 10 patients currently on ventilators in the city.* The outbreak seemed to be waning in recent weeks, but yesterday the city closed 6 additional schools, bringing the total to 13.

The 24-year-old was pregnant when she started showing flu-like symptoms. She was in the hospital for a week, where doctors performed an emergency C-section because of complications. Avalos died on Sunday. She was one of the two people in El Paso who've now also been confirmed with having swine flu.

"What we know is that both individuals that passed away had the infection but they also had other medical conditions that may have caused their death," said Dr. Luis Escobedo.

The city's Public Health Department held a press conference to address the two deaths and answer question about why these two people, one in their 20s and one in their 40s died of complications

Health Department officials explained how tests for both victims were conducted upon arrival to the hospitals, but they initially tested negative for influenza. The Health Department became involved and confirmed both cases as swine flu.

Bates said both had been given rapid flu tests — a nasal swab that is often the first step in determining whether a patient might have the flu — but that results came back negative. After they died at an El Paso hospital, further tests confirmed they had swine flu.

Bates and officials with the Centers for Disease Control and Prevention said rapid tests will sometimes return negative when a patient is actually infected. CDC officials said they did not have data about whether rapid flu tests may have missed, if they were given, in 15 other swine flu deaths nationwide.

Dr. Tim Uyecki, a medical epidemiologist at the CDC, said that there are unfortunately limitations with rapid tests and that it's not as simple an issue as positive versus negative.

"The sensitivity of the test is not as high as you would like," Uyecki said. "The challenge is how to interpret a negative result when there's a lot of influenza going around."

Swine flu is now in every state and territory with the Northern Territory recording its first case.

The national tally climbed to 255 overnight, 47 more cases than at the same time yesterday. In Victoria, which has been hardest hit by the virus, there are 173 confirmed cases.

There is growing pressure to upgrade the pandemic alert from the "contain'' phase to the "sustain'' phase with the results of another 262 tests in that state still pending.

One of the Federal Government's top flu advisers, Professor Raina MacIntyre called on health authorities in Victoria to close all schools and childcare centres in a bid to slow the spread of the virus. There are ten schools closed.

The Federal Health Minister, Nicola Roxon has resisted this call so far but said this morning the time would come when it became impossible to keep quarantining people.

There are presently more than 3000 people in voluntary home quarantine.

The latest surveillance report (week 20) from the CDC, clearly indicates that swine H1N1 activity is on the rise in the United States, as seasonal flu levels continue to decline. Consequently the ratio of swine H1N1 to seasonal flu (H1N1, H3N2, influenza B, combined) is greater than 10 to 1. Thus, the vast majority of influenza infections in the United States are now swine flu, which is clear from the latest figures, even though reporting agencies in the United States are limiting testing...

...the replication rate for the virus is optimal at 41 C, the body temperature of a bird. This is in marked contrast to seasonal flu, which has E627K, which optimizes replication rates at 33 C. Consequently, the swine H1N1 increased activity as the weather warms in the northern hemisphere, and seasonal flu has declined as summer months approached.

These increases in the United States have begun to affected surveillance programs by countries outside of North America. An increasing number of cases link back to the United States. However, the programs in these other countries also grossly underestimates the number of cases, because the case definition includes travel from an H1N1 infected region, so local cases are not tested unless they link back to imported cases. However, this airport surveillance program misses the vast majority of imported cases because cases infected within a few days of travel are not symptomatic, and a high percentage of cases do not develop a high fever. Moreover, the rapid test used to confirm cases has a low sensitivity. Consequently, most imported cases are not detected, and local infected patients are also not tested because they do not meet the case definition.

Another Bronx public school is closing down after a high number of flu-related illnesses were reported among students.

The school is set reopen on June 8th.

At this point, there have been no reports of confirmed cases of H1N1 at the school. The absentee rate at the school reached as high as 88 percent last week.

Parents and students say they are relieved the school will be closed for cleaning.

The agency, having spent the past five years alerting the world to the dangers of a pandemic, is now looking for a way to declare one without causing panic. WHO Director-General Margaret Chan and colleagues spent seven hours yesterday consulting experts on how to explain that swine flu is global, but not severe, said three people familiar with the agency’s plans.

Chan has to navigate a delicate path between raising alarm about a virus that in most cases causes little more than a fever and a cough, and underestimating a bug that could kill millions. Moving to the top of WHO’s six-step pandemic scale may spur some countries to restrict travel, ban public events and adopt other measures that aren’t needed for mild flu, worsening the deepest economic slump since the Great Depression.

The Geneva-based agency, sometime in the next 10 days, will declare the first flu pandemic in 41 years, said the people, who spoke on condition of anonymity because the WHO’s deliberations are private. WHO is using the time before the announcement to help member states prepare.

“We held a series of consultations with public health officials and academics around the world to understand their concerns and get their advice about moving to level 6,” said Dick Thompson, a WHO spokesman in Geneva. “We are not at phase 6. We’re just exploring the issues associated with announcing a pandemic.”

As far as scientists are concerned, a flu pandemic isn’t defined by its severity. The key criteria is geographic. The WHO’s guidelines say a pandemic is imminent when a new virus causes outbreaks “in at least two countries in one WHO region” and it’s in progress when it’s widespread in “at least one other country in another WHO region.” The new H1N1 flu strain, discovered in April, has turned up in 64 countries as far removed as Japan, Iceland and New Zealand.

Nature magazine, in a May 6 editorial entitled “between a virus and a hard place,” said the biggest danger posed by a flu pandemic is complacency, not overreaction.

Pregnant women who will likely be in direct contact with patients with confirmed, probable, or suspected influenza A (H1N1) (e.g., a nurse, physician, or respiratory therapist caring for hospitalized patients), should consider reassignment to lower-risk activities, such as telephone triage.

If reassignment is not possible, pregnant women should avoid participating in procedures that may generate increased small-particle aerosols of respiratory secretions in patients with known or suspected influenza, including the following procedures:

Endotracheal intubation
Aerosolized or nebulized medication administration
Diagnostic sputum induction
Bronchoscopy
Airway suctioning
Positive pressure ventilation via face mask (e.g., BiPAP and CPAP)
High-frequency oscillatory ventilation

Any new disease is cause for concern, especially when it's potentially fatal. But the AH1N1 swine flu has confounded expectations by proving unusually benign for the elderly.

Of 538 confirmed cases of AH1N1 in New York City, only six have occurred among people ages 65 and over.

"Normally flu would go right through long-term care facilities," said Dr. Stephen Morse, professor of clinical epidemiology at Columbia University. "In a normal year, the elderly would have a much greater risk."

Still, Mayor Michael Bloomberg has consistently emphasized that all of the city's AH1N1 flu fatalities have involved "underlying conditions" that exacerbated each victim's risk.

The list of conditions is long enough to worry almost any elderly person and includes heart disease, lung disease, diabetes and a weakened immune system. Even obesity is now being discussed as a condition that can lead to complications for this flu.

The World Health Organization signalled Tuesday it will not attempt to rewrite the definition of a pandemic to make disease severity part of the criteria for a pandemic declaration - something it hinted is coming soon because of swine flu.
But the Geneva-based agency said it will try to help countries mitigate anxiety over the declaration of a pandemic by devising a severity index and issuing advice on what countries should and shouldn't do in response to it.

The WHO's top flu expert said the idea is to help countries - some of which appear to feel locked into pandemic plans designed to respond to a far more severe pandemic - to "better calibrate their actions."

"I think that some of the things that we would like to do is improve how we're able to communicate information, how we're able to provide guidance on what can be done in this situation so that actions that are really unnecessary and potentially anxiety provoking and unhelpful can really be modified or curtailed," he said.

Asked for examples of drastic or unhelpful actions, Fukuda pointed to the culling of pigs and shunning of pork products seen earlier in the swine flu outbreak.

The WHO's criteria for declaring a pandemic is based on the geographic spread of a new virus to which people have little or no immunity. The six-step pandemic alert scale says a pandemic will be declared when it is clear such a virus is spreading in the community in countries in two different WHO regions.

Currently the WHO says only North America has sustained community spread, though a number of countries appear to be on the cusp. Fukuda, who said a Phase 6 call is edging closer, mentioned Britain, Spain, Japan, Australia and Chile by name.
Confirmed community spread in any one of those, except Chile, would tip the balance for a pandemic call. (Though it is in the Southern Hemisphere, Chile is in the same WHO region as North America.)

In the end, Fukuda said, the consensus was that the current definition of Phase 6 should stand. But it was also agreed that a statement on severity should accompany the call, one that would hopefully help people understand that all pandemics aren't like the 1918 Spanish Flu.

He said the WHO will try to find a useful way to assess severity, suggesting a three-point scale is under consideration. The severity rating could change over time, he said, if the virus begins to behave differently or it takes a higher toll in different parts of the world.

...in the Southern Hemisphere - which is going into its winter - the virus is behaving as it has in the Northern Hemisphere. The disease patterns and unusual age distribution of cases appears to be the same, Fukuda said.

But there is early evidence which, if borne out, may support the experts' belief swine flu is a pandemic strain. Fukuda said initial testing from Chile suggests the new virus has virtually crowded out the previous human strains of influenza. "This has been one of the patterns that has been seen with the earlier pandemics. So I think that it bears very close watching," he said. New strains have a biological advantage, because so many people are susceptible to them. In the 1957 pandemic, the new H2N2 virus became dominant, forcing the previous virus, an H1N1, back into nature. When H3N2 emerged in the 1968 pandemic, H2N2 disappeared.

This is one of several features about this virus that gives flu experts pause, Fukuda said, pointing also to sustained spread in the Northern Hemisphere in what is typically flu's off season and high attack rates and severe illness in a demographic group - young healthy adults - not typically at high risk from flu. These features too were seen in earlier pandemics.
"We have an unusual situation right here," he said.

...the vivacious 20-year-old had succumbed to swine flu in Chicago, leaving behind two daughters, newborn Patricia and 1-year-old Annalycia.

Huber's Journal Star obituary lists her cause of death as swine flu, although Amy Poore with the Cook County (Ill.) Department of Public Health told The Associated Press that Huber's death was not one of that state's three H1N1 fatalities.

But Caitlin's cousin said Tuesday he had spoken with her parents-and she had died of complications from H1N1 flu during childbirth.

A pregnancy may heighten a person's risk for pneumonia while fighting a pandemic flu, according to the CDC.

Two adults are in critical condition in Winnipeg hospital and 10 children have also been admitted for care following an outbreak of a flu-like illness in a remote northern Manitoba community.

One of the two adult women was pregnant and has lost the baby, said David McDougall, chief of St. Theresa Point First Nation.

"There's a good number that got sick with the same, similar symptoms," he said. "But the severe cases have been [flown] to Winnipeg. It's a respiratory illness and it's very dangerous, potentially dangerous especially for young people."

It is not yet known if this is swine flu, which spread to many countries this spring, McDougall said.

"Right now they have determined that it is a form of influenza, influenza A, but the strain hasn't been determined yet.

The community, only accessible by airplane or winter ice roads, is located about 500 kilometres from Winnipeg in the far northeast corner of the province.