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.

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H1N1 in Mexico

http://www.flutrackers.com/forum/showpost.php?p=221156&postcount=19

No one thought it was bird flu, of course, but the question was which flu was it? So now we know it is an H1N1.

"We are still expecting more details but so far we have no indications that this is avian flu," WHO spokesperson Sari Setiogi told Dow Jones Newswires, speaking by telephone from Geneva.

"We have been in constant contact with the Mexican government and from what we know now this is not the H5N1 strain but caused by the H1N1 strain, which is part of the normal influenza A, but the severe form of influenza," she said.

Ms. Setiogi said that although this particular strain of influenza is known to have caused fatalities "it's uncommon and doesn't happen frequently," especially not so late in the year. Mexico's season for influenza A normally ends in December, she added.

Setiogi said the WHO is "on alert" about the growing influenza outbreak in Mexico and expects the number of cases in both Mexico and other countries in the region to grow in the coming weeks.

"We are right now on alert and monitoring the developments of this unusual influenza activity. We are still gathering information while the Mexican authorities are doing their investigations, but we are expecting more cases to be reported," she said.

http://www.allheadlinenews.com/articles/7014917250

More than 800 people are believed to be infected with swine flu in Mexico, which canceled classes in all levels on Friday. Mexican officials have confirmed 20 deaths, but as much as 60 people are suspected to have died due to the epidemic.

The Public Health Agency of Canada has issued a travel advisory warning that people who recently returned from Mexico could be infected.

The World Health Organization has said the exposures in the Latin American nation was among healthy adults.

"Because these cases are not happening in the very old or the very young, which is normal with seasonal influenza, this is an unusual event and a cause for heightened concern," WHO spokesman Gregory Hartl told CBC.

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It's Official - It's Swine Flu in Mexico as Well

The CDC Media Conference call just ended. It was a somber call. Few questions if any from anyone in the room. Most were via reporters on the telephone. Questions were answered by Dr. Richard Besser, the Acting Director of CDC, I think they said. The following comments are from my notes, and are based on his responses to the questions of the media which included NPR, WebMd, Reuters, CBC, Associated Press, Washington Post and others I forgot to write down.

He said that the Swine Flu is present in Mexico as well as in the US, but the disease is presenting differently so far. There have been 8 cases in the US, all mild but one. One US case traveled to Mexico.

Seven out of 14 viral samples from Mexico tested positive for Swine Flu, and these were from people with virulent cases. It is unknown if they survived or not.

There is no restriction on travel to Texas, California or Mexico at this time, but a disease outbreak notification is posted.

The CDC's concern has grown since yesterday, and there is much uncertainty. They have some interim guidelines. They have a website up: cdc.gov/flu/swine and a phone # 1 800 CDC INFO for questions.

Guidelines are interim and fluid as they learn more about the situation. Recommendations will likely change with what they learn.

There will be local approaches made to try to halt the virus that we may learn from. Trying to contain the virus is "not likely" as there are already unconnected cases in two different states meaning cycles of human to human transmission.

You should not travel if you are sick. Don't get on a plane if you have the flu.

People outside of the affected areas should be paying attention as well. As the situation continues, the CDC expects people to begin thinking about their own preparedness. "This is a teachable moment. We are moving quickly on this and we are very aggressive in our approach as is the WHO."

In response to questions about the WHO changing their pandemic threat level. For a virus to have pandemic potential, it must meet three conditions: it must be new, it must cause severe disease, and it must be transmissible. The WHO is going to meet to decide if they need to change their threat level. CDC has been in touch with Dr. Margaret Chan of the WHO.

The CDC labs are working on analysis of the viral sequences. This may tell us why some people have severe disease. The eipdemologists will also be looking for other things like co-factors.

The CDC will be sending teams into Mexico, and to Texas and California as well to assist in the investigation.

The clinical picture can include vomiting and diarrhea as well as respiratory symptoms.

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60 Mexico flu deaths raise global epidemic fears

http://www.google.com/hostednews/ap/article/ALeqM5gzz357patY4-QaJFvo9O95zMM_EQD97P0JAG0

The government has 500,000 flu vaccines and planned to administer them to health workers, the highest risk group.

There are no vaccines available for the general public in Mexico, and authorities urged people to avoid hospitals unless they had a medical emergency, since hospitals are centers of infection.

They also said Mexicans should refrain from customary greetings such as shaking hands or kissing cheeks, and authorities at Mexico City's international airport were questioning passengers to try to prevent anybody with possible influenza from boarding airplanes and spreading the disease.

But the U.S. Centers for Disease Control and Prevention said Americans need not avoid traveling to Mexico, as long as they take the usual precautions, such as frequent handwashing.

Mexico's Health Secretary, Jose Cordova, said only 16 of the deaths have been confirmed as the new swine flu strain, and that government laboratories were testing samples from 44 other people who died. At least 943 nationwide were sick from the suspected flu, the health department said.

"We certainly have 60 deaths that we can't be sure are from the same virus, but it is probable," Cordova said, adding that samples were sent to the CDC to look for matches with the virus that infected seven people in Texas and California.

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Swine flu: bits and pieces at the end of the day

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

The Reveres think that the WHO will raise their pandemic threat level. Now that would be news! It's been an interesting day.

The number of people who are actual cases of swine flu in Mexico is yet to be determined. It is almost certain that many of the reported 943 cases are not swine flu, and of the specimens sent to laboratories in Canada and the US, half or less were determined to be that virus. On the other hand, there are definitely many swine flu cases in Mexico, some of the severely ill, and the unusual age distribution of young adults is a sign of infection with a new flu virus. There is ample room for serious worry. WHO is convening its expert panel under the International Health Regulations to determine if the pandemic threat level should be increased from phase 3 to phase 4. In our view, this isn't even a close call. We are in phase 4 and if WHO doesn't call it they risk being considered irrelevant and without credibility.

The Editors of Effect Measure are senior public health scientists and practitioners. 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.

Mexico: Vaccination program stopped

http://crofsblogs.typepad.com/h5n1/2009/04/mexico-vaccination-program-stopped.html

This is all translated from Spanish. They have decided that it is pointless to vaccinate in Mexico as this is a new virus that

will not be covered by the current vaccine, and will not help stop the spread of the virus.

[The capital's health secretary, Armando Ahued, said that WHO recommends dropping influenza vaccination, because it won't stop the illness; number of flu patients in District hospitals rises in 24 hours from 79 to 97.]

[The city government did an about-face on its plan to use a vaccination campaign against influenza, for the concrete reason that the vaccine won't stop the outbreak that was started by a new swine-flu virus.]

[Armando Ahued, health secretary of the Federal District, announced this morning that WHO had recommended to the Mexican government that the vaccine be dropped because it would have no effect against the epidemic.]

This morning and also in a conference, Ahued had said that he would ask the federal government for a donation of flu vaccine to use in a plan to immunize capital residents, but in the end the plan won't go ahead.]

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Comparisons between 1976, 2009 swine flu not appropriate

http://www.scottmcpherson.net/journal/2009/4/24/comparisons-between-1976-2009-swine-flu-not-appropriate.html

Another voice heard from in the Swine Flu discussion is Scott Mcpherson, the Chief Information Officer [CIO] of the Florida House of Representatives. He is always entertaining and informative. His point about Tamiflu resistance is right on the money. It's a big concern though you probably will not hear that from CDC. Some 98% of the H1N1 seasonal flu in the US has been Tamiflu resistant this year. That seemed to be a surprise to some scientists, but it should not have been.

The Swine Flu is also an H1N1 virus. It is not yet Tamiflu resistant. Vaccinating against H1N1 for the reason that he is proposes actually is a good idea though it will not protect against Swine Flu.

The press is taking the time to remind people that in 1976 the United States went overboard in its preparations for a possible swine flu pandemic. The reason for this is obvious. However, these comparisons are inappropriate and reveal a not-surprising lack of depth on behalf of the people reporting the news.

In 1976, a vaccine was developed in a record period of time. In 2009, there is no vaccine commercially available to combat H1N1 swine flu. However, it is absolutely critical that Mexicans and people in the American Southwest get vaccinated against seasonal H1N1, so the swine virus does not get the chance to reassort with human H1N1 and produce a Tamiflu-resistant strain any faster than is possible.

Posted this elsewhere, but here's the link to the NYTimes article about the sick students who traveled to Mexico recently:

http://www.nytimes.com/2009/04/25/nyregion/25sick.html?hp

It's important to note that at this moment, there is no certainty that those kids have swine flu; it's under investigation. But it does show how a pandemic *could* quickly become global, given our ability to travel so easily.

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Japan Begins to Screen Incoming Passengers from Mexico

http://www.flutrackers.com/forum/showpost.php?p=221703&postcount=1

Here is a translation provided by flutrackers. Japan is using thermal scanners to check passengers arriving from Mexico for elevated temps. I guess this is better than nothing, but the thing about flu is that you are contagious even before you start showing symptoms so it is not going to stop the virus.

The WHO Meets Today

It is interesting to read how the WHO spokesperson has left them lots of wiggle room. My understanding was that when a virus is novel, virulent, and very transmissible it is time to raise the pandemic threat level, because that would indicate that there is the risk of it becoming an international concern if it is thought that it cannot be kept from leaving the country, or the continent in this case. Well, we shall see what they decide. They may hold off for now, and change their minds later though it may be too late to provide a warning by then which will make them look foolish.

I am thinking that they are desparately trying to figure how far the virus has already traveled perhaps by looking closely at that school in New York to see if the virus made it that far. They are going to look in ERs and pediatric wards across the US according to this article.

Keep in mind also that there will be hugh economic consequences for Mexico and the US, and times are tough already. Probably all of that mess has to be considered, but if you are looking just at the international public health aspects, they should raise the threat level. The Japanese clearly are not going to wait around for the WHO to decide.

http://www.bloomberg.com/apps/news?pid=20601087&sid=a7HjmHgtSUGI&refer=home

The World Health Organization will hold a teleconference with flu experts at 4 p.m. Geneva time to decide whether the situation is “a public health event of international concern,” said Gregory Hartl, a WHO spokesman.

WHO Director-General Margaret Chan may raise the level of pandemic alert if today’s meeting recommends that it is globally significant, Hartl said.

U.S. hospitals are being asked to collect samples from patients with flu-like symptoms, said Schaffner, chief of preventive medicine at Vanderbilt, in a telephone interview yesterday.

“They are asking us who work in hospitals to go to our emergency rooms and our pediatric wards to gather specimens and start testing them,” Schaffner said. “This has a sense of urgency about it.”

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Flu Patients In New York Had Been In Mexico - Report

http://www.nasdaq.com/aspx/stock-market-news-story.aspx?storyid=200904251106dowjonesdjonline000311&title=flu-patients-in-new-york-had-been-in-mexico-report

The way these stories are worded is interesting. If they say not confirmed, it does not mean it is not the same virus, and it does sound rather reassuring, but does not really tell you anything. This is what the CDC said about the Mexican cases when asked if they were the same virus as the US cases. So we are looking for some firm data, that is if they tell us this. If the students have already recovered, and it sound like they have, then they have to do antibody testing to look for a match. PCR can give false negatives if you have been treated with Tamiflu, though they probably did not need Tamiflu as these cases were mild or if you are not sick anymore.

Some 75 at a New York private school who have been treated for flu-like symptoms recently traveled to Mexico, but no swine flu case has been confirmed, U.S. media reported Saturday.

Swine flu: while we wait . . .

http://scienceblogs.com/effectmeasure/2009/04/swine_flu_while_we_wait.php#more

There will be an update from CDC later today and WHO's expert committee established under the new International Health Regulations (IHR) meets via teleconference this morning North American east coast time at 10 am (4 pm Geneva time) to consider whether the swine flu situation merits declaring it “a public health event of international concern.” If they do, WHO Director General Margaret Chan may respond by raising the pandemic threat alert level from the current phase 3 (new virus: no or limited human to human transmission) to phase 4 (new virus, evidence of increased human to human transmission). It's conceivable, but not likely they would go to phase 5 (new virus, evidence of significant human to human transmission). Phase 6 is acknowledgement of an existing pandemic (new virus, evidence of efficient and sustained human to human transmission). The level of alert is not just an academic exercise because under the IHR this allows WHO to institute measures like travel advisories which were forbidden before the IHR were revised and went into force last year.

... difference in surveillance sites may account for an apparent disparity in severity of the illnesses in cases reported in Mexico vs those presently reported in the USA. As more uniform active surveillance (case finding) is implemented, these disparities may lessen.

The absence of direct connection between the cases in the USA and the cases in Mexico does not rule out the outbreaks being linked, as the population flow between the 2 countries is high and 12 isolates from Mexico are reported to be genetically identical to those isolated in the USA. One suspects the epidemic curve is already multiple generations past the "index case". The virus has apparently been circulating in Mexico for several weeks, and in the USA for at least 2 weeks according to the above reports. (Comments of Mod PC to ProMed notice of latest MMWR Dispatch)

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Readers in Mexico have been emailing the BBC.

http://news.bbc.co.uk/2/hi/talking_point/8018428.stm

These accounts are startling. The first one is from a resident physician in Mexico City.

I work as a resident doctor in one of the biggest hospitals in Mexico City and sadly, the situation is far from "under control". As a doctor, I realise that the media does not report the truth. Authorities distributed vaccines among all the medical personnel with no results, because two of my partners who worked in this hospital (interns) were killed by this new virus in less than six days even though they were vaccinated as all of us were. The official number of deaths is 20, nevertheless, the true number of victims are more than 200. I understand that we must avoid to panic, but telling the truth it might be better now to prevent and avoid more deaths.

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I just want to add that there no way to know if those comments sent to the BBC are for real, but if they are, it is very, very sad indeed.

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Do we need to take a collective breath?

http://pandemicchronicle.com/2009/04/collective_breath/

SophiaZoe does not blog often but when she does, her commentary is always valuable and well thought out.

...If there is a statistically meaningful amount of those subclinical cases, the potential pandemic threat would be greatly diluted, raising the likelihood of a mild pandemic.

A mild pandemic would require very little, if any, official governmental or international intervention. A mild pandemic would call for the same level of personal health responsibility we ask of people during normal seasonal influenza.

The World Health Organization is meeting (or has met) today to begin deliberations on raising the Pandemic Threat level, currently at three.

Thrice surprised

http://pandemicchronicle.com/2009/04/thrice_surprise/

We can take a lesson from what happened to one family in Texas.

I imagine it was terribly shocking to be told your child had contracted this strange thing called Swine H1N1 (what the heck is that?!) and oh, by the way, your entire family is required to remain at home... indefinitely. Now, that "indefinitely" is not really "indefinitely", it's just until the authorities are confident the individual members of the family are either recovered from illness or beyond any window of infection.

What would my reaction be if two hours from now I found out that I could not leave my home until further notice... sometime in the future? Would I have enough "stuff" in my home to carry my family through the quarantine comfortably? Would I have enough dog food for my beloved Chessies? Do we have enough medications and "personal items" that each member requires? Do we have enough "stuff" to keep our minds and bodies occupied during this emotionally stressful time?

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School closure in Texas

http://www.mysanantonio.com/news/Health_officials_close_Cibolos_Steele_High.html

State health officials have closed Steele High School in Cibolo, where two of eight U.S. cases of swine flu attended classes, to halt the spread of the new swine flu virus.

A third student has been listed as a probable case. All three suffered mild illness, with the third student still recovering.

"The purpose is to reduce the risk to students, staff and the community," said Dr. Sandra Guerra, regional medical director for the Texas Department of State Health Services.

It was unclear how long the school might be closed. Saturday morning one official said at least a week, but health officials were conferring throughout the day.

Health officials also are recommending public gatherings in Guadalupe County be postponed.

Guerra said students should avoid contact with one another while school is out, which "would defeat the purpose" of closing the school to interrupt the spread of the new virus...

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