Pandemic Awareness/Preparation

Nurses COVID

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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.

http://afludiary.blogspot.com/2009/01/hhs-releases-6th-pandemic-planning.html

afludiary.blogspot.com said:

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.

Specializes in Too many to list.

New type of flu found in two U.S. children: CDC

An interesting and surprising report on an unusual H1N1 influenza strain in California.

http://uk.reuters.com/article/healthNews/idUKTRE53K4XU20090421

A new type of swine flu has infected at least two children in California and while both have recovered, U.S. health officials said on Tuesday they were looking for more cases.

They say it is possible the children were infected by other people and not by pigs, and said they have consulted with officials in Canada, Mexico and at the World Health Organization although there is no evidence that the new virus is circulating widely.

In a special alert, the CDC asked doctors in California's San Diego and Imperial counties, on the border with Mexico, to test anyone with flu-like symptoms and send the samples in for testing.

"Both of these kids came to our attention because they were seen in clinics which do routine surveillance for influenza infections," the CDC's Dr. Lyn Finelli told reporters in a telephone briefing.

Swine Influenza A (H1N1) Infection in Two Children --- Southern California, March--April 2009

Flu season is almost over in the US. I am wondering if we will be seeing this new variant of H1N1 again next flu season?

http://www.flutrackers.com/forum/showpost.php?p=220161&postcount=12

On April 17, 2009, CDC determined that two cases of febrile respiratory illness occurring in children who resided in adjacent counties in southern California were caused by infection with a swine influenza A (H1N1) virus. The viruses from the two cases are closely related genetically, resistant to amantadine and rimantadine, and contain a unique combination of gene segments that previously has not been reported among swine or human influenza viruses in the United States or elsewhere. Neither child had contact with pigs; the source of the infection is unknown. Investigations to identify the source of infection and to determine whether additional persons have been ill from infection with similar swine influenza viruses are ongoing. This report briefly describes the two cases and the investigations currently under way. Although this is not a new subtype of influenza A in humans, concern exists that this new strain of swine influenza A (H1N1) is substantially different from human influenza A (H1N1) viruses, that a large proportion of the population might be susceptible to infection, and that the seasonal influenza vaccine H1N1 strain might not provide protection. The lack of known exposure to pigs in the two cases increases the possibility that human-to-human transmission of this new influenza virus has occurred. Clinicians should consider animal as well as seasonal influenza virus infections in their differential diagnosis of patients who have febrile respiratory illness and who 1) live in San Diego and Imperial counties or 2) traveled to these counties or were in contact with ill persons from these counties in the 7 days preceding their illness onset, or 3) had recent exposure to pigs. Clinicians who suspect swine influenza virus infections in a patient should obtain a respiratory specimen and contact their state or local health department to facilitate testing at a state public health laboratory.

Specializes in Too many to list.

Unrelated cases of swine flu in Calif. children have U.S. officials on alert

http://www.google.com/hostednews/canadianpress/article/ALeqM5gkfP4auwE6t3ik_obgTg9PH2t6mg

"The investigation is not finished. It's ongoing. But of course not having that direct swine link does raise additional questions and does suggest that there may have been human-to-human transmission. And so it basically ratchets it (concern) up a bit," said Dr. Nancy Cox, head of the CDC's influenza division.

"I think this is one of those situations where everyone will want to stay tuned."

U.S. officials notified the World Health Organization of the cases last Friday, as required under the International Health Regulations. That treaty stipulates that countries must notify the WHO when they see cases of infectious diseases that pose an international threat, such as novel subtypes of influenza with pandemic potential.

http://www.recombinomics.com/News/04220902/H1N1_CA_Swine_H2H.html

H274Y is a single nucleotide polymorphism (SNP) that confers the property of osletamivir (Tamiflu) resistance in influenza viruses.

Tamiflu is the major drug in use for treating as well as preventing influenza.

The CDC has the viral sequences on this novel influenza strain. Making them public would give us more useful information for tracking where the virus came from, and if has acquired any SNPs that would be of concern such as H274Y.

Although both cases recovered without hospitalization, the spread of the swine H1N1 in a human population is cause for concern. The virus can adapt and spread more efficiently. Moreover, co-infection of H1N1 swine flu and osletamivir resistant H1N1 season flu can lead to acquisition of H274Y by the swine flu via recombination or reassortment. Swine H1N1 with human H1 and N1 have been reported. Moreover, the swine flu can also infect swine and acquire more polymorphisms that could lead to increased virulence.

The 1918 pandemic strain has polymorphism from swine and human H1N1 in all eight gene segments. Similar swapping of polymorphism in human co-infected with season and swine H1N1 can lead to rapid evolution. Therefore, release of both sets of sequences, as well as new sequences, which will likely be detected in the near term in the United States and Mexico, would be useful.

Specializes in Too many to list.

Important flu paper on immune response

http://scienceblogs.com/effectmeasure/2009/04/important_flu_paper_on_immune.php

This work makes a major advance in the science of antibody response to avian influenza/H5N1 ("bird flu"). The advance has two aspects. One is the information the work generated. Even more important is the second part: opening up specific new questions for further research.

Unlike much H5N1 work, this isn't based on experiments in mice, as important and fruitful as such work is and has been. Instead it examines the antibody response of victims of a 2004 bird flu outbreak in Vietnam. Of 18, 13 died. Blood samples were obtained from the survivors during their recoveries. These patients lived long enough to get a response from the part of their immune system that makes antibodies. What did that antibody response look like?

We still don't know if the antibodies in the survivors had anything to do with their survival. It may be that it is the other way around. The fact that they survived allowed enough time for their bodies to make antibodies. Do any of these targets involve viral clearance? Which ones? Which ones involve protection against the virus? Many of these antibody targets aren't seen in seasonal flu cases. Which ones are the result of the very severe pathology of bird flu rather than the virus itself? Can any of these antibodies be used to detect past infections that weren't apparent at the time?

It's clear this paper is hardly the last word on the subject. On the contrary, it is more like the first word. There is much I left out of interest (PLoS Medicine is open access so you can read the paper and the accompanying editorial; the Editor's explanation at the end is quite understandable), but of greater importance is the door to further research it opens.

This is very interesting research and tremendous fun to read. Fun or not, though, it is about a deadly serious problem. So any progress is welcome. And this is real progress.

Specializes in Clinical Research, Outpt Women's Health.

"How does your workplace rate? Have you had any training at all to prepare staff for the possibility of an infectious disease outbreak? Do you know if your facility has Tamiflu available for staff? Mine does not. I asked the head pharmacist already.

No Tamiflu in stock..."

That would be No and No. I work at a university with a med school, PA school, Graduate Sciences and Public Health schools.

Specializes in Too many to list.
"How does your workplace rate? Have you had any training at all to prepare staff for the possibility of an infectious disease outbreak? Do you know if your facility has Tamiflu available for staff? Mine does not. I asked the head pharmacist already.

No Tamiflu in stock..."

That would be No and No. I work at a university with a med school, PA school, Graduate Sciences and Public Health schools.

Well, you have plenty of company then, unfortunately.

As part of my clinical ladder requirement, I have opted to provide some education on an internet site that my hospital gives us access to. I think that some very basic information should be available to staff such as an understanding of what the CDC and HHS's game plan for the general public is, namely the mitigation strategies, and the reason for why these strategies are necessary.

My goal would be to get people thinking about what the problematic issues might be. Does our hospital's emergency plan address these problems? Do staff have any personal planning that they could be doing in advance of a disease outbreak situation that we might all be involved in?

In my area, our staff has to prepare every year for the possibilty of having to work during a hurricane. There is a system in place for telling us who comes in, what to bring with us, and for how long, and how to plan for the care of our families and pets. It's not a huge leap to make for staff to think of a different type of emergency that requires planning for.

The Tamiflu issue will be addressed only if enough staff members become educated enough to question how the facility is planning on protecting them, and become informed that the federal guidelines are saying that employers should provide this drug to their critical workers. Of course, these are only guidelines not requirements yet, but as the nursing polls indicate, many of us will not work without adequate protection...

Specializes in Clinical Research, Outpt Women's Health.

One of the reasons I am back for your updates is that it seems to have fallen completely out of the news. As though tehre is no more risk...........

Specializes in Too many to list.

Influenza is not always in the news unless something unusual happens. The situation in Egypt made the New York Times recently.

The swine flu cases in California are also being reported in the media.

There is a situation going on in Mexico right now that was being followed for the last two days by Flutrackers via translations. Now the story is being picked up by the English speaking press first in Canada, and no doubt here soon as well. Dr. Niman of Recombinomics has posted on the swine flu cases in California, and predicted that we might see cases in Mexico next, but it is not known at this time if this is the same respiratory disease or something else entirely.

As you can see, it is somewhat alarming to read some of this. It would be nice to have a real diagnosis.

http://www.calgaryherald.com/Health/Canada+alert+after+respiratory+illnesses+reported+Mexico/1523180/story.html

Mexican health authorities contacted PHAC last Friday to inform them of the respiratory conditions, which were reported in the south and central areas of Mexico. The cases elevated from flu-like symptoms to severe respiratory conditions in about five days, with "a high proportion" of cases requiring assisted ventilation.

PHAC, in an April 20 report, said Mexican officials informed the Canadian health agency that the "case-fatality rate was relatively high" and that most cases involved healthy adults between the ages of 25 and 44. A number of health-care workers were also affected.

Although no cause has been confirmed, some samples were positive for influenza A and B.

UPDATE

They seem to be giving flu vax to HCW in the affected areas in Mexico which would lead one to believe that this is an influenza. There have not been that many victims though so it's just a situation worth watching unless there is an increase in cases.

Specializes in Too many to list.

Egypt - Case #67 Diagnosed and Two Deaths from H5N1

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aBQ9cmxVYmZw

http://crofsblogs.typepad.com/h5n1/

The six year old boy died on Tuesday, and now another child, a 4 yr old has been diagnosed. None of the toddlers died. The little 6 yr old was treated late, and that may be have been why he did not recover. Hopefully, this newest case has been started on Tamiflu promptly.

Sadly, the 25 yr old woman died today. She had already lost her unborn baby to this disease.

The Health Ministry reported the 67th infection earlier today, saying 4-year-old Ahmed Kamaleddin has contracted the virus. He was in the hospital in what was described as stable condition.

Kamaleddin was given Roche Holding AG's drug Tamiflu as a treatment, the news agency quoted Shahine as saying.

Roche, of Basel, Switzerland, says the antiviral medicine can reduce the severity and duration of flu symptoms if taken within 48 hours of the onset of disease. Early treatment for the H5N1 avian flu, the type that can be fatal in humans, may improve survival, some uncontrolled studies have shown.

UPDATE

http://crofsblogs.typepad.com/h5n1/2009/04/egypt-woman-dies-of-h5n1.html

...the young woman's name was Hadia Saleh Rageb. For some reason, it always seems important to me to record the names of the people infected and too often killed by this disease.

I agree with this. RIP, Hadia Saleh Rageb. I wish we knew what you were going to name your baby.

The six year old boy's name was Ali Mohamed Ali.

Specializes in Too many to list.

Acting Crown attorney in a coma in an Ottawa hospital

http://www.standard-freeholder.com/ArticleDisplay.aspx?e=1502582&auth=

I can see why the Canadians are more than a little concerned about what is going on Mexico. What is puzzling to me is that no organism is named for the cause of his condition. This man is age 47, not exactly the age where you would expect him to end up on a vent from a respiratory infection. What the heck?

Acting city Crown attorney Guy D. Simard, 47, is in a coma after contracting an unknown illness during a recent trip to Mexico, a family member said.

Simard is in Ottawa General Hospital, where he admitted himself after gradually feeling worse since he returned from the trip on March 22.

"We don't know, the hospital doesn't know (what he contracted)," said Lise Lavictoire, Simard's aunt.

Lavictoire confirmed that Simard is on a respirator and awaiting a blood transfusion.

"They're doing other tests," she added. "They said he's very strong, so they have hope."

Crown attorney Simard's condition improving

http://www.standard-freeholder.com/ArticleDisplay.aspx?e=1514728

He is getting better according to this. So what is the cause of this illness? Valley Fever or something endemic to Mexico? Just wondering...

Crown attorney Guy Simard is making a strong recovery from a life-threatening illness.

Simard was the area's head legal prosecutor for only a few months when a serious respiratory infection that turned into pneumonia sent him to the hospital in his home of Hawkesbury two weeks ago.

His condition took a turn for the worse after spending the night in the hospital, prompting doctors to have him airlifted to an Ottawa hospital.

Simard is still in the intensive care unit, but his colleague Murray MacDonald, director of prosecutors for Eastern Ontario, said his successor as Cornwall Crown attorney is expected to be moved out of the ICU any day now.

Specializes in Clinical Research, Outpt Women's Health.

I would be interested to know exactly what area of Mexico he was in......

Specializes in Too many to list.
I would be interested to know exactly what area of Mexico he was in......

Yes, that would be good to know. This link below says the cases are occurring in south and central Mexico. Funny though, how the Canadians are putting out an alert but nothing here? How very odd. Last time I checked, we still had a border with Mexico...

http://www.cbc.ca/health/story/2009/04/23/respiratory-illness-flu-mexico.html

A severe respiratory illness appears to have infected hundreds in south and central areas of Mexico, according to Mexican health officials.

The illness has killed at least 20 people in Mexico, mostly men between the ages of 25 and 44, according to a public advisory sent out by Canadian health authorities.

Hundreds of people have also reportedly been hospitalized and health-care workers have also been infected.

Officials said there are not yet any reports of the illness outside of Mexico.

The cause of the illness has not been confirmed. Mexican health officials said samples so far have tested positive for influenza A and B.

People infected with the virus initially suffer flu-like symptoms that include fever, cough, sore throat, muscle and joint pain and shortness of breath. The illness then elevates to a severe respiratory illness within about five days.

Specializes in Too many to list.

The California swine flu cases

http://scienceblogs.com/effectmeasure/2009/04/the_california_swine_flu_cases.php

Back to the swine flu cases which may or may not be connected to what is going on in Mexico. Those intrepid public health officers at Effect Measure explain what there is to know at this time, and point out that the public health warning system did a good job which is exactly what we want it to do. Now what about Mexico? Are they staying up on that too?

Late yesterday afternoon a Morbidity and Mortality Weekly Report (MMWR) Dispatch appeared on CDC's website that is unique in my experience. MMWR is usually heavily vetted and edited and nothing gets out of there fast. Indeed, in recent years, nothing at all got out of CDC very fast. And yet here is this Dispatch, with text referring to the same day of issue (April 21), reporting on two young patients with febrile respiratory illnesses, one of whose cases CDC only learned about on April 13, 8 days earlier. April 17 CDC determined that the two children, both from the San Diego, California area, were infected with a swine flu virus of a novel kind. That was five days ago. The extremely rapid publication of this MMWR is apparently a consequence of the new International Health Regulations. It's good to see CDC take them so seriously. Are you listening Indonesia?

The discovery in both cases seems to have involved an element of luck. The first patient was seen at a clinic where some kind of investigational diagnostic device was in use. It detected influenza/A but was negative for the two subtypes of seasonal flu (H1N1 and H3N2) and for bird flu (H5N1). This made it a novel influenza virus, requiring notification of the San Diego County Health Department and further testing in more specialized laboratories, which verified it was an unsubtypable influenza A strain. The next day (April 14) CDC identified it as an H1N1 swine flu virus. Three days later (April 17) CDC received a second specimen from a 9 year old girl who had been seen at an outpatient facility that was part of an influenza surveillance project. This virus, too, had been initially unsubtypable.

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