It has been my own personal project to follow H5N1 for the last 3 years simply because it interests me. Attracted to this type of information like a magnet, I've been watching this relatively new influenza virus to see where it will go, how it will change itself, and possibly change our world. I have followed its country by country outbreaks, and watched for the important viral mutations such drug resistance or changes that allowed it to more specifically target mammals.
Keeping in mind at all times that we will be cleared impacted as HCW, as well as being members of our communities, and having families of our own to care for, I wanted to start the new year by opening a single focused pandemic thread that would also look at what we are doing nationally to prepare for a future pandemic. Is this the virus to spark the next pandemic? No one can answer that question. We can look back at the past to the last few pandemics, and in particular to the most devastating one in 1918, and extrapolate useful information about them, but we can not predict the future. We can only make comparisons with our situation now, and learn what worked to lessen morbidity and mortality in those past events. And, we can look at those other viruses, and compare them with what we are seeing now. For example, H5N1 is a Type A virus. We know that all pandemics are caused by Type A viruses. It is also an avian virus. The deadly 1918 virus, H1N1 was also an avian virus.
For this thread, as in the previous threads, I will be making use of news sources, scientific studies, govt bulletins such as the MMR, as well as flu forums and blogs devoted to this subject for my sources. Because press information, particularly the foreign press, is not always available for later access when I am looking back to check recent historical information, the use of these blogs and forums are important because archived information quoting the media and all other sources is always fully and easily available there with no worries about information disappearing or no longer being available. They also fully document their sources or I would not be using them.
With this link from Avian Flu Diary, a well researched source that I highly recommend, we can read the words of outgoing HHS Secretary Leavitt on our state of preparedness. Leavitt has done an admirable job during his tenure, but admits that there is much left to do.
A scant 33 months ago, I sent my first message about a race that HHS had just begun. As I said then, it was a race against a fast-moving virulent virus with the potential to cause an influenza pandemic. Since then, we have mobilized experts and resources across the country and around the world. I now send you this final message, as I look back at the unprecedented progress we have made in energizing a national pandemic influenza preparedness movement in those 33 months.
Today, many people mistakenly think influenza pandemics are a thing of the past, but influenza has struck hard in the era of modern medicine – much harder than most people realize. And it will strike again. Pandemics are hard things to talk about. When one discusses them in advance, it sounds alarmist. After a pandemic starts, no matter how much preparation has been done, it will be inadequate.
Awaiting confirmation from one of the WHO affiliated labs to make the official announcement.
...comments describe the first lab confirmed H5N1 case in Nepal. The sample has been sent for third party confirmation. Since Weybridge confirmed H5N1 in Nepal poultry, it seems likely that the sample was sent to Mill Hill in England.
This report provides more specifics to reports of human cases in Nepal. An earlier report described 5 patients in critical condition...
If confirmed, the case would cast serious doubt on India's claim that there are no human H5N1 cases there.
People living in villages bordering China fear bird flu has made inroads into Sankhuwasabha district as well.
They are panicking ever since chickens started dying from an unidentified disease two months ago. The villagers maintain that the affected birds are exhibiting some symptoms that are common among bird flu-infected chickens.
Over 3,000 chickens have died in bordering VDCs, including Kimathanka, Hatiya and Chaipuwa in course of two months, and the number is increasing, said veterinarian Pushpa Bahadur Budathoki.
About 300 miles from the US border, I think this is. A low pathogenic avian influenza has been identified though it took them long enough to announce this. Makes you wonder how long they would take if it was highly pathogenic. I still feel uncomfortable with this diagnosis, and may explain why further when I have more time, but the link below addresses this somewhat.
The agency said tests to date indicate that the strain involved in this case is "low pathogenic."
Pathogenicity refers to the severity of the illness caused in birds.
Technically a correct statement, however, as may be happening in China recently, birds can be infected with highly pathogenic H5N1 and present only mild, or even no symptoms of illness, known as asymptomatic infections.
Highly pathogenic avian influenza if slightly different at the nucleotide level so an analysis of the hemagglutinin, the HA gene, will provide the definitive answer. That said, it is more likely than not low pathogenic H5N1 since that is what North America has historically dealt with.
Now we are hearing that there has been no human case of bird flu in Nepal, but that they did send viral samples to Weybridge Lab for confirmation. They are claiming that they sent even samples that have already tested negative.
Ministry of Agriculture and Cooperatives today clarified that not a single case of bird flu had been detected in Kathmandu valley so far.
"Since we don't have any reference lab in Nepal, we have been sending samples to London even if they tested negative here," MoAC spokesperson Hari Dahal told mediapersons at his office today.
Dahal claimed that the government would not conceal the information about bird flu. "Instead, we will inform people and request them to maintain safety measures," he added.
He, however, admitted that the samples were taken to the central lab for test. "We have sent the samples for further testing in Weybridge Lab of London as a regular procedure even though it tested negative here," he said.
Unlike Nepal, Egypt has a WHO affiliated reference lab in country which is the US
Naval lab, NAMRU 3. If this case is reported as positive for bird flu, then it is indeed positive.
A two-year-old Egyptian girl has been infected with the bird flu virus, becoming the country's 53rd case of bird flu in humans, state news agency MENA said on Sunday.
MENA cited a health ministry spokesman as saying the girl, Sherouk Mohammad Said of Menoufia province, contracted the virus through exposure to household poultry, some of which died of the disease. The spokesman said Said began suffering flu-like symptoms on Friday and was hospitalised the same day. She has been treated with the antiviral drug Tamiflu and is in a stable condition, according to MENA.
A 29-year-old man in southwest China is in critical condition after testing positive for bird flu, making him the country's sixth confirmed case of the virus this month, state media said Sunday.
The man fell ill on January 15 in Guizhou province, and tested positive for the H5N1 virus on Sunday, the Xinhua news agency said.
Authorities are monitoring others who came in contact with the man, but no one else has been found ill, Xinhua said.
Highly pathogenic avian influenza (HPAI) is associated with greater mortality in poultry. Low path (LPAI), in contrast would mean lesser mortality. Virologist Henry Niman is making a case for the possibility of a mix of both types of virus in the same flocks that may have been missed during the testing of the current outbreak in British Colombia.
We do know that the current outbreak of bird flu in Canada is an H5 virus, but which one? And, is it just an LPAI, or both types together as he suggests. Finding the HPAI version of H5N1 in North America would of course, be very bad news since this is the strain causing human fatalities.
Niman is further suggesting that the same type of situation may have occurred already in a 2004 poultry outbreak also in Canada. Low path viruses can evolve into highly pathogenic ones though I don't think that it happens very quickly. But, it did then.
Since a biological assay for pathogenicity takes 10 days, it is likely that the low path designation is based on the sequence of the HA cleavage site.
However, low path avian influenza usually does not produce symptoms in the infected birds. Frequently there is a drop in egg production or the influenza is detected through routine surveillance. In this case, the turkeys had respiratory distress and there was a “slight” elevation in mortality, raising concerns that the H5 was a mixture that included high path that was not present in the sequenced isolate(s).
This quarantine zone extends to the Canadian / US border...
This is what worries me. H274Y is a piece of genetic material that would indicate that a flu virus is resistant to Tamiflu. Tamiflu is our main defense against bird flu. H5N1 (avian influenza) is usually not resistant to bird flu but, it could become resistant if patients are infected with both the seasonal flu (H1N1) and H5N1.
The latest series of confirmed H5N1 cases in China indicate the H5N1 has achieved more efficient transmission to humans. Two of the cases are linked to contacts who had bird flu symptoms. In Beijing, a nurse recovered and test results have not been released. In Hunan, the mother of the confirmed case (2F) died of pneumonia when the daughter developed symptoms. Thus, in both clusters the index case died, but the contact survived. This was also reported in the cluster in northern Vietnam. The index case (13F) died of pneumonia, which her sister (8F) and neighbor (5M) survived. The survival of these cluster members is consistent with human to human transmission, which involves a low viral load, leading to milder cases.
Milder cases in China and Vietnam (see updated map) remain a concern. In China, all seven recent confirmed cases were admitted in critical condition. One is recovering, one is stable, and the other five are dead. This high case fatality rate suggests milder cases are not being detected / reported.
On the reporting front, the only H5N1 in poultry has been two outbreaks in Jiangsu in asymptomatic birds. Although some of the recent human cases have been linked to poultry exposure, there has been an absence of linkages to dead, dying, or H5N1 confirmed poultry.
This lack of poultry links raises concerns that the poultry is asymptomatically infected, which can be due to a vaccine mismatch.
Clade 7 has a large number of receptor binding domain changes flanking position 190, which is also true for the Tamiflu resistant H1N1 seasonal flu, which has spread throughout the northern hemisphere.
The co-circulation of clade 7 H5N1 and clade 2B H1N1 which has H274Y is an additional cause for concern, with regard to Tamiflu resistance on N and exchanges of receptor binding domain changes on H.
More information on the H5N1 clade linked to human cases in China and Vietnam would be useful as would release of H5N1 sequences from the recent cases in both countries.
It's looking like H5N2, not H5N1. This outbreak is actually closer to the US border than I had thought, like 10,000 yards or so.
Canada's National Centre for Foreign Animal Diseases in Winnipeg, Man., confirmed that the virus was an H5, the OIE report said. It said gene sequencing showed that the virus was 99% similar to an H5N2 virus recovered from a green-winged teal in California in 2007.
The CFIA said all birds on the farm would be euthanized and disposed of and that the agency would oversee cleaning and disinfection of the barns, vehicles, equipment, and tools.
From An Interview with One of the Reveres on Public Health and Pandemic Preparedness
In epidemiology an effect is the endpoint of a causal mechanism. An effect measure is an estimate of the influence of a particular factor on a population's health. The Editors of Effect Measure are senior public health scientists and practitioners. Their names would be immediately recognizable to many in the public health community. They prefer to keep their online and public lives separate to allow maximum freedom of expression. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.
The health of our citizens is dependent upon our public health infrastructure. We take it for granted that everything will always work the way it is supposed to, that it will always be there to protect us. Most of us never think about how the economic decisions being made by government can impact our health in the future.
I like to think of the Reveres as watch dogs, warning us about how the consequences of bad decisions can come back to haunt us as they suggest in this link about what is happening in the state of Utah.
Utah could become the only state in the country without a state health department.
Republican lawmakers are considering handing the duties of the health department -- from tracking and responding to communicable diseases and trying to reduce obesity and cancer rates to inspecting child care facilities -- to other agencies.
Not unexpectedly, this interview is largely about our public health infrastructure because our population's ability to survive a widespread disease outbreak is dependent upon this.
DemFromCT: We started Flu Wiki together with the late Melanie Mattson in 2005. Are we any better prepared now for a pandemic than we were then?
Let me take this in two parts: the public response and the government/public health response. As far as the public and the news media goes, there's a lot of "flu fatigue" out there and with all that's going on it's more and more difficult to get their attention except with scare headlines. But I'm going to surprise a lot of people and say I think in terms of public awareness, the short answer is "yes," we are better off.
I wanted to keep the pressure on government to play an appropriate and meaningful role and I thought that placing the burden on individuals to protect themselves and their families was the wrong message. I am optimistic the new administration will be more receptive to the task of rebuilding public health infrastructure, both its human capital and its material substance, and will revive the idea of fulfilling the mission of public health. If this happens and combining it with a new spirit of public service I think there is less risk of letting government off the hook by pushing individuals and communities to take up the burden. But there is still a long way to go. Preparedness advocates are still a marginalized minority in their communities and often feel extremely frustrated at their inability to convince others of the potential danger.
As far as government response, however, I am not confident we are better off. There has been a lot of planning on paper, but like a military plan that never survives the first engagement with the enemy, the pandemic plans on paper will be out the window in the first week of a catastrophic disease outbreak. This always happens, but it will be more severe today than four years ago because of the deterioration of local and state public health and its distorted priorities during the Bush years. There has been a lot of stockpiling of antivirals (Tamiflu and Relenza), but whether they will work for bird flu or whether the virus will quickly develop resistance we don't know, although the signs are that this could be a big problem. There is as yet no vaccine matched to a pandemic strain because we don't know what that strain will be, and in any event the time to produce a vaccine is long enough so that we will have to endure at least one wave of a pandemic and after even after that, if a vaccine can be produced there will not be enough to go around or adequate ability to distribute it. That's a consequence of the lousy shape our health care and public health systems are in. And they continue to get worse.
DemFromCT: We have often talked about 'rebuilding public health infrastructure'. Last week we discussed one aspect of that (the lab capability). What else does 'rebuilding public health infrastructure' mean?
Over at Effect Measure we've been saying for years that the best way to prepare for an influenza pandemic is not with antivirals or vaccines (although both have important uses) but by strengthening the public health and social service infrastructure to make it robust and resilient. Our view is that preventing a pandemic is technically difficult or impossible so the main task is to prepare to manage the consequences. The consequences of a large proportion of our population being sick or dying extends to almost every part of our society.
A state public health laboratory is not part of the public health infrastructure but most of us consider the laboratory system to be an essential element of infrastructure. Similarly for our disease surveillance system, which provides us with the "situational awareness" we need to make decisions about disease outbreaks or resource allocation. It's public health infrastructure.
Then there are things of ambiguous status. What about the vaccine production system? A no-brainer you'd say? I had a long discussion about this with a like-minded colleague over the lunch table but we couldn't agree. He is an economist who doesn't consider the vaccine system to be part of infrastructure, whereas I argued it was. I'm less sure about the nation's drug manufacturing capacity.
"Initially, we did not know but remained suspicious of the patient's symptoms. After her death, the hospital's medical team sent a sample of her blood to the Health Ministry and the laboratory test result *confirmed* she was infected with the H5N1 virus," he told The Jakarta Post.
Urip said the hospital's medical team had doubted she was infected with the disease after learning the patient was not exposed to poultry at her work place or in her home village in Lumajang.
"This case has received a serious level of attention from the medical team because it is a new phenomenon," Urip said.
The absence of a poultry link is cause for concern. The level of H5N1 in poultry in Indonesia is high, but the lack of OIE reports since 2006 from Indonesia limits specifics.
Similarly, the delays in reporting confirmed cases by Indonesia and WHO complicates analysis in humans. The WHO has not issued a situation update for confirmed cases, and since Indonesia has imposed a news blackout on cases, the updates lag disease onset dates by weeks or months.
The latest lab confirmation of a patient without known poultry exposure suggests the undercount in Indonesia is markedly higher than reported confirmed or suspect cases.
What makes a pandemic severe, as opposed to mild or moderate, is the rate of deaths and other serious complications from the disease. The more people die or develop serious complications, the more severe it is. Severe pandemic influenza occurs on a scale that distinguishes it from other public health disasters in terms of its global nature and duration. It is experienced over years, not days, weeks or months, and threatens core public health, social and economic infrastructures. Unlike a mild pandemic, a severe pandemic has the potential to disrupt normal health care and business operations and therefore interfere with the distribution of essential goods and services globally. Unlike other disasters, states and communities cannot count on receiving federal assistance in a severe pandemic. For purposes of this project, we assumed that a severe pandemic could resemble the one that occurred in 1918-19.
What kinds of resources might be scarce during a severe pandemic, and what resources are discussed in this project?
Food, medicines and supplies of all types could be scarce at times during a severe pandemic. During the peaks of a severe pandemic as many as 40% of the workforce could be absent due to illness, death, caretaking duties at home or fear. Large workforce shortages could result in interrupted services, manufacturing, and distribution chains for many resources. Health care resources are likely to be in particularly short supply, because demand will be very high.
This project recommends how to ration five kinds of health-related resources as examples of those that will be scarce: antiviral medications (both for treatment and prevention), N95 respirators, surgical masks, pandemic vaccine and mechanical ventilators.
What is the Minnesota Pandemic Ethics Project?
The project's goal is to propose ethical frameworks and procedures for rationing scarce health resources in Minnesota during a severe influenza pandemic. The frameworks recommend how to decide in what order different groups of Minnesotans should be prioritized to receive resources. There are also recommendations about how to implement the ethical guidance provided by the frameworks. The preliminary recommendations have been developed by a broad-based panel and work groups of more than 100 Minnesotans. An important part of this project is to gather public input so that the final recommendations include broader perspectives.
Why your comments matter
The Minnesota Department of Health will use the project's recommendations as part of its pandemic planning process. A severe pandemic would affect everyone, and it is very important that rationing decisions reflect Minnesotans' values and input. We want to hear from persons from all walks of life. We also are interested in hearing from non-Minnesotans because responding to a pandemic involves close collaboration with others, including other states and countries.
With contact with sick fowl, it is not so unexpected for this farmer to become ill. It is just surprising that more people that work with poultry do not become infected. And it is when the birds do not appear sick, but the people become ill, that it becomes alarming.
A 21-year-old female farmer was confirmed infected with bird flu in central China's Hunan Province, said the provincial health bureau on Saturday.
Shu was transferred to a hospital in Changsha, capital of the province, on Thursday. So far she has been in a stable condition and become better.
An investigation found that Shu had contact with fowls that died of disease before becoming sick.
Hunan has launched an emergency response against the virus. Those who had close contact with the patient are under medical observation, but none of them has been found ill so far.
Treating contacts with Tamiflu, indicates that the doctors suspected bird flu and treated prophylactically. Indonesia has not added these deaths to their mounting number of cases.
...it appears that two patients - sisters - died last week from that area after being admitted to Persahabatan Hospital, in East Jakarta.
Both were `strongly suspected' of being infected with the bird flu virus. Health officials, according to the second article, are taking blood samples in the area.
Contacts of the victims were provided with Tamiflu.
If any results of these tests are known, they haven't been disclosed by the Ministry of Health.
indigo girl
5,173 Posts
First Case of Bird Flu Reported in Nepal
http://www.recombinomics.com/News/01250902/H5N1_Damak.html
Awaiting confirmation from one of the WHO affiliated labs to make the official announcement.
Meanwhile, also in Nepal:
http://crofsblogs.typepad.com/h5n1/2009/01/nepal-worries-about-h5n1-from-china.html