Influenza Virus Mashup

An editorial in The Lancet Infectious Diseases: WHO failing in duty of transparency. The conclusion:

Rather than the 4 million deaths predicted in the worst case scenarios, 15 000 people are estimated to have died from pandemic influenza so far. WHO is right to have sought advice from a range of experts, some of whom will inevitably have ties with pharmaceutical companies. 

However, the lack of transparency raises concerns that WHO did not take into account possible conflicts during its decision-making process and points to a system struggling to balance a relationship between drug companies and global health. WHO must address the failings of transparency in this event to recover public trust and restore its credibility.

Via the Daily Observer: H1N1 pandemic vaccination campaign begins. Excerpt:

The Ministry of Health and Social Welfare in collaboration with the World Health Organisation (WHO) yesterday started its nationwide vaccination campaign of Influenza A (H1N1) which is expected to last till 30th of July. 

The pandemic (H1N1) that was discovered in 2009 is a new influenza that never circulated among human beings before but after its outbreak in Mexico, North America, people have virtually no immunity to it. 

The week-long campaign is expected to cover a total of 170, 000 people across the country with priorities given to medical health workers, pregnant women, children from 10-11 years and people with chronic diseases and diabetics.

(Tue, 27 Jul 2010 13:20:00 +0000)

# 4759

I’m going to be away from my desk for a few hours, but I wanted to draw my reader’s attention to an excellent post this morning by Maryn McKenna on her (new) Superbug blog on Whooping Cough, or Pertussis.

Whooping cough: Back, with a vengeance

This has become a hot topic in the past month due to the epidemic of Pertussis occurring in California this year.

On Sunday, Dr. Greg Dworkin (aka DemFromCt) posted  a terrific piece on Pandemics, Pertussis and Vaccine on the Flu Wiki, and also on Daily Kos.

And I’ve written a couple of posts over the past month about it myself.

California Whooping Cough (Pertussis) Update

California: Pertussis Epidemic

Via the Press Information Bureau: Weekly data of influenza A H1N1. The total confirmed cases is 34,669. Thirty-eight deaths from confirmed H1N1 occurred between July 19 and 25.

Via CIDRAP, Lisa Schnirring offers some useful background: Egyptian woman hospitalized with H5N1 infection. Excerpt:

Egyptian officials have confirmed H5N1 avian influenza in a 20-year-old woman who is hospitalized in critical condition in Cairo, according to MENA, the country’s news agency.

Health ministry spokesman Abdel Rahman Shahin said the woman, from Qalyubia governorate, about 30 miles north of Cairo, was admitted to the hospital Jul 21 with fever and breathing difficulties, Daily News Egypt reported yesterday, citing MENA. He said the woman is undergoing treatment with oseltamivir (Tamilfu) and is under careful monitoring. 

Reports have not said if the woman had contact with sick or infected birds. 

If the World Health Organization (WHO) confirms the woman’s infection, she will be listed as Egypt’s 110th H5N1 case-patient. The country’s 109 confirmed cases include 34 deaths. 

In the first 4 months of 2010 Egypt reported 19 human H5N1 cases, 7 of them fatal. The newly confirmed case is the country’s first in nearly 4 months. 

Earlier this month the Egyptian government instituted a ban on the sale of all live poultry to help prevent the spread of the H5N1 virus, which is endemic in the country, according to the Daily News Egypt report. The only exception is licensed slaughterhouses that employ veterinarians to assess the health of the birds and supervise slaughtering, cleaning, and sales of the birds. 

The pace of H5N1 detections in Egyptian poultry has slowed since the end of May, with only 11 reports since Jun 1, according to Strengthening Avian Influenza Detection and Response (SAIDR), a project, funded by the US Agency for International Development with assistance from Johns Hopkins University. SAIDR is designed to help Egypt coordinate avian flu efforts with its international partners.

We have a persistent problem with covering something like H5N1. As a general rule I try to link to the nearest news source for a human case or an outbreak in animals.

But those sources tend to be in countries whose media don’t like to annoy their governments. So we’re lucky if the story is reported at all, and we almost never get follow-up stories. 

Suspected bird flu? We rarely hear the test results. Poultry culled? How many nearby poultry escaped?

Even if it’s a good-news story, we don’t get a follow-up. Back in 2006, I was following the case of a little Chinese girl in Sichuan province who caught H5N1 and then recovered. (The link will take you to a four-year-old rant about this same problem.)

I’ve often wondered what became of her—and whether the local medical authorities have done any kind of monitoring of her and other H5N1 survivors. Is she generally healthy? Has she suffered any delayed effects?

Whatever the answers, they would throw light on this rare disease. And then we could begin to understand it.

Instead, governments and media alike tend to treat H5N1 cases like fatalities due to meteorites: strange, inexplicable events having no long-term consequences. That’s been the standard governmental and media response ever since 2003, so I’m grateful that CIDRAP, at least, takes the trouble to provide more details than we usually get.

Via Express India.com: 19 more swine flu cases; alarm bells sounded.

With 19 more people testing positive for swine flu, the total number of patients has gone up to 61 in the city. 

“At present, 21 patients are admitted in the isolation ward of the Infectious Diseases Hospital in Beleghata, two of them in critical condition. The situation is being monitored daily,” said Ashim Biswas, H1N1 Nodal Officer of the Health and Family Welfare Department. 

Swine flu had subsided for some time after it hit Bengal last year. This year it resurfaced in June. However, the fact that none of this year’s victims had visited any foreign country has triggered panic among the people. A majority of them have not traveled anywhere in the recent past, indicating that the disease must have some local origin. 

Even State Water Resources Minister Nandagopal Bhattacharya was detected with the H1N1 virus a few days ago. He is undergoing treatment at the Apollo Gleneagles Hospital near Salt Lake.

(Tue, 27 Jul 2010 10:03:00 +0000)

# 4758

One of the first steps taken by many countries to reduce the spread of novel H1N1 last year was the closing of schools in affected communities.

By early May (2009) it was apparent that the severity of this particular influenza virus was less than originally feared, and many public health agencies moderated their recommendations  (see CDC No Longer Recommending School Closures For A/H1N1).

But a future, more severe pandemic, the extended closing of schools will once again likely be considered to help reduce the spread of the virus.

It isn’t an easy decision, however.  School closings are controversial, and the issues complex  (see The Debate Over School Closures).

Working parents rely on schools to watch their kids for much of the year during the day, and many low income families benefit from the school lunch program.  And of course, when schools are closed during a pandemic, some kids may congregate elsewhere and spread the virus anyway.

 

Many parents, however, would take exception to the notion of sending their kids to school during a pandemic.  Not only would it, in their estimation - endanger their children – it increases the odds of them bringing the virus home to the rest of the family as well.

So it is important to get some approximation of the benefits that school closings would generate.  To that end we’ve seen several studies over the past year that have produced varying estimates.

Study: Student Behavior During Pandemic School Closings

School Closures Revisited

Study: Effect Of School Closures On Viral Transmission

Today we’ve another study appearing in BMC Infectious Diseases, this time from the School of Computer Science and Software Engineering at the the University of Western Australia.

Here is the abstract (slightly reformatted for readability).

Developing guidelines for school closure interventions to be used during a future influenza pandemic

Nilimesh Halder , Joel K Kelso  and George J Milne

BMC Infectious Diseases 2010, 10:221doi:10.1186/1471-2334-10-221

Published: 27 July 2010

Abstract (provisional)

Background

The A/H1N1 2009 influenza pandemic revealed that operational issues of school closure interventions, such as when school closure should be initiated (activation trigger), how long schools should be closed (duration) and what type of school closure should be adopted, varied greatly between and within countries. Computer simulation can be used to examine school closure intervention strategies in order to inform public health authorities as they refine school closure guidelines in the light of experience with A/H1N1 2009 pandemic.

Methods

An individual-based simulation model was used to investigate the effectiveness of school closure interventions for influenza pandemics with R0 of 1.5, 2.0 and 2.5. The effectiveness of individual school closure and simultaneous school closure were analyzed for 2, 4 and 8 weeks closure duration with a daily diagnosed case based intervention activation trigger scheme. The effectiveness of combining antiviral drugs with school closure was also investigated.

Results

Attack rate was reduced from 33% to 19% (14% reduction in overall attack rate) by 8 weeks school closure activating at 30 daily diagnosed cases in a community for an influenza pandemic with R0 = 1.5; whereas combined with antivirals, 19% (from 33% to 14%) reduction in attack rate was obtained.

 

For R0 >= 2.0, school closure would be less effective. An 8 weeks school closure strategy gives 9% (from 50% to 41%) and 4% (from 59% to 55%) reduction in attack rate for R0 = 2.0 and 2.5 respectively; however, school closure plus antivirals would give a significant reduction (~15%) in over all attack rate. The results also suggest that an individual school closure strategy would be more effective than simultaneous school closure.

Conclusions

Our results indicate that the particular school closure strategy to be adopted depends both on the disease severity, which will determine the duration of school closure deemed acceptable, and its transmissibility.

 

For epidemics with a low transmissibility (R0 < 2.0) and/or mild severity, individual school closures should begin once a daily community case count is exceeded. For a severe, highly transmissible epidemic (R0 >= 2.0), long duration school closure should begin as soon as possible and be combined with other interventions.

George E. P. Box, Professor Emeritus of Statistics at the University of Wisconsin, is often credited with coining the familiar adage:

“All models are wrong, but some models are useful.”

While imperfect, we use computer models every day to try to mathematically simulate real-life events;  everything from highway traffic flow to weather forecasting.

The authors describe some of the limitations to their study, including:

As the model is based on a population in a developed country the outcomes may not be applicable to populations in a developing country, where populations may be less mobile and have higher population densities.

 

We have focused on the reduction in the number of daily symptomatic cases and the cumulative illness attack rate as they are used for determining intervention effectiveness rather than focusing on influenza-related adverse events such as hospitalizations and deaths.

 

We also do not take account of possible antiviral drug resistance [40] [41] that may arise due to the implementation of antiviral drug strategies, as our main goal is to suggest refinements to policy guidelines for school closure.

In this case, the authors based their modeling on a medium sized (pop. 30,000) town in Western Australia. 

They find a substantial reduction in the spread of a future pandemic influenza can be achieved by the (extended) closing of schools at the optimum point in the local spread of the virus.

Gauging when and how long to close schools, however, may require information that isn’t always immediately available.  Such as the R0 (basic reproductive number) of the virus, the CFR (Case Fatality Ratio) or, the number of people actually infected in a community. 

Despite the fact that life is messy, and computer models aren’t perfect at depicting it, the entire report is worth reading.

This is how the authors sum up their study.

Conclusions 

Our simulation results give guidance as to public health policy decisions in the refinement of school closure strategies to be used in a future influenza pandemic. We have systematically evaluated school closure operational issues to determine when schools should be closed and re-opened to achieve the maximum reduction in influenza spread.

 

We found that the optimal timing of school closure depends both on the duration of school closure (which we assume will depend on the severity of the influenza strain, with strains that are more severe in terms of serious infection outcomes making longer periods of school closure acceptable) and on the transmissibility of the influenza strain (which influences the rate of growth and spread of the epidemic).

 

Accurate early estimates of epidemic characteristics such as the basic reproduction number and disease severity are thus necessary to achieve the maximum case reduction from school closure.

 

We found that a policy of allowing schools to close individually was much less sensitive to the precise timing of the intervention than a policy of simultaneous community-wide school closure, a valuable observation given the difficulty in determining the true degree of epidemic spread in the early stages of an outbreak.

(Mon, 26 Jul 2010 15:36:00 +0000)

# 4757

A little over a month ago I wrote a blog called A Carrington Event, about concerns that NASA and FEMA, and many facets of our government have over potential large scale disruptions due to solar storms.

Since we know huge solar flares have affected the earth in the recent past, it is a fair assumption that one or more will affect us again sometime in the future.

This isn’t science fiction.   Although no one knows when the next major solar flare will head in our direction.

The largest storm observed since the invention of the modern astronomy was in 1859 – now known as the Carrington Event.   Another tremendous flare lashed out at our planet in 1921.

Both of these events occurred before we developed an infrastructure highly dependent upon sensitive (and highly vulnerable) electronics.

Smaller, but disruptive solar storms have caused serious power outages and communications disruptions in recent decades.

In 2009 the National Academy of Sciences produced a 134 page report on the potential damage that another major solar flare could cause in Severe Space Weather Events—Understanding Societal and Economic Impacts.

You can read it for free online at the above link. 

Last year Space.com produced a spectacular 18 minute video entitled Attack of the Sun, which may be viewed on YouTube.

As you can see, this isn’t some esoteric plot device for a cheesy direct-to-DVD Sci-Fi movie, or prophesy driven 2012 drivel: space weather is a serious threat than can, and does, affect life on earth.

This report from Nextgov (Hat Tip FEMA Director Craig Fugate on Twitter).

NASA braces for solar storms that could bring critical systems to a halt

By Aliya Sternstein 07/23/2010

A House committee on Thursday approved a three-year authorization bill for NASA that includes a plan for issuing warnings about impending space storms that could knock out navigation systems, power and smart phones.

 

Because of technology’s increasing reliance on satellites, many of the gadgets and systems Americans use on a daily basis are vulnerable to so-called space weather, according to NASA officials. The phenomenon refers to environmental conditions on the sun that can influence the performance and reliability of Earth-based and extraterrestrial digital systems.

 

The House Science and Technology Committee’s legislation, H.R. 5781, which authorizes funding and missions for NASA, includes a long-term strategy for a sustainable space weather program. The White House, through the director of the Office of Science and Technology Policy, would have to define individual agency responsibilities for carrying out the line of attack.

 

According to NASA, the nation faces increasing uncertainty as Earth approaches the next peak of solar activity in 2013. The sun’s magnetic field could produce turbulent solar wind, or charged particles streaming at high velocities. Other risks include solar flares, which are sudden eruptions of magnetic energy, as well as coronal mass ejections, emissions of plasma from the sun that disturb magnetic fields on Earth.

 

Just a few of the devices and services that could go down during bad space weather include credit card transactions, air travel networks, the transmission of geothermal and wind power, most mapping applications, and telemedicine systems that send patient images from hospitals to physicians.

(continue . . . )

As I pointed out last month, I wouldn’t advise anyone to lie awake at night worrying about solar storms.  But it is another good reason to take general preparedness seriously.

And if you are well prepared for an earthquake, a hurricane, or a pandemic . . . you are automatically in a better position to weather the disruptions caused by a solar storm.

 

Some resources to get you started on the road to `all threats’ preparedness include:

FEMA http://www.fema.gov/index.shtm

READY.GOV http://www.ready.gov/

AMERICAN RED CROSS http://www.redcross.org/

 

And a few of my (many) preparedness essays include:

An Appropriate Level Of Preparedness

Inside My Bug Out Bag

Red Cross Unveils `Do More Than Cross Your Fingers’ Campaign

The Gift Of Preparedness

 

You can search this blog for more preparedness information by clicking this link.

(Mon, 26 Jul 2010 09:59:00 +0000)

# 4755

DemFromCt, who is both a physician and one of the founding editors of The Flu Wiki , also finds time to write a column on the Daily Kos as well.

Yesterday he posted a terrific piece on Pandemics, Pertussis and Vaccine on the Flu Wiki, and also on Daily Kos. 

Given the reduced traffic this site sees on Sundays, I decided to wait till this morning to plug this piece to try to give it a little more exposure.

Highly Recommended.

(Mon, 26 Jul 2010 12:26:00 +0000)

# 4756

Twelve days ago I posted the Dengue Surveillance numbers out of Puerto Rico showing the rapid spread of the disease (see Puerto Rico: Dengue Running Above Epidemic Threshold).

Today, updates from Puerto Rico, Trinidad, and the Dominican Republic . . .  plus a little background on the hemorrhagic form of the disease.

The latest summary shows a slight leveling off of cases over the past two weeks in Puerto Rico, but the rate of detection remains very high – roughly 400 suspected cases a week.

(Note: Contents of link will change over time)

This represents an increase of 2 deaths and about 1200 suspected cases in the past 3 weeks.

Further south, in Trinidad and Tobago, the Associated Press is reporting on 3 recent deaths due to Dengue.

Jul. 25, 2010

Trinidad: 3 Deaths From Severe Form Of Dengue

3 Die From Hemorrhagic Variant Of Dengue Fever In Trinidad And Tobago

(AP) PORT-OF-SPAIN, Trinidad (AP) - Health officials in Trinidad says three people have died from a severe form of mosquito-borne dengue fever.

The health ministry says its epidemiologists have confirmed three deaths from the hemorrhagic form of dengue and are investigating two others.

(Continue . . .)

Meanwhile the Trinidad and Tobago Guardian is reporting a serious outbreak of Dengue in the Dominican Republic. 

Region on dengue alert

Published: 26 Jul 2010

The dengue fever situation in the Dominican Republic, where they have declared an epidemic, is worse than the rest of the region.

 

A report on BBC Caribbean.com said that across the Caribbean, health officials were tallying growing numbers of cases and advising residents to take precautionary measures. The report said officials were worried that mosquito-borne dengue fever was reaching epidemic stages in the region. The report noted that dozens of deaths had been reported and officials said they were concerned it could get much worse as the rainy season advances.

(Continue . . .)

Although Classical Dengue - or  Dengue-like illness – is usually a non-fatal illness producing severe flu-like symptoms (and body aches) – in a small percentage of cases the virus can be serious or even fatal.

In the 1950s, a new form of Dengue was identified in Southeast Asia  – DHF (Dengue Hemorrhagic Fever) – that while still relatively rare, if left untreated, can have a fatality rate as high as 50%.

 

Since there are 4 different serotypes of the Dengue Fever virus, a person can become infected several times over their lifetime.  

Although the process is not fully understood, the evidence suggests that  those having a prior Dengue infection are at greatest risk of developing DHF. 

One of the theories (greatly simplified, so even I can understand it . . .  scientists may want to avert their eyes) is the body’s immune system falsely `recognizes’ the new infection as being the old virus and attacks it, but its antibodies are unable to successfully inactivate it.

 

In response, the immune system releases a flood of cytokines that have the unfortunate side-effect of increasing the permeability of endothelial tissues (the lining inside blood vessels) which can lead to blood and fluids leaking into surrounding tissues.

 

This `leakage’ can lead to Hypovolemic shock, anemia, and sometimes death.

Treatment is mostly supportive while the body builds the proper antibodies to fight the infection; blood transfusions, IV fluids, Oxygen, and rehydration.  

Crof at Crofsblog and  Arkanoid Legent are both providing nearly daily coverage of Dengue outbreaks around the world.  You’ll also find extensive coverage on Chen Qi. 

 

These are my `go to’ sources for up-to-date Dengue information.

A few of my recent blogs on the subject include:

MMWR: Dengue Epidemic In Puerto Rico

MMWR: Travel Associated Dengue Surveillance 2006-2008

MMWR: Dengue Fever In Key West

Dengue Resurfaces In Key West

The Threat Of Vector Borne Diseases

While not yet a major public health issue in the United States and most of Europe, many officials believe it is just a matter of time before this mosquito borne disease makes greater inroads into these areas.