Posted on 06/24/2009 8:04:24 AM PDT by metmom
Within minutes, six-year-old Rubjit Thindal went from happily chatting in the back seat of the car to collapsing and dying in her father's arms.
"If we had known it was so serious, we would have called 911,'' Kuldip Thindal, Rubjit's distraught mother, said in Punjabi yesterday. "She just had a stomach ache -- she wasn't even crying.''
Rubjit was pronounced dead at hospital barely 24 hours after showing signs of a fever. Later, doctors told her parents she had the H1N1 influenza virus. She is believed to be the youngest person in Canada with the virus to have died.
(Excerpt) Read more at news.guelphmercury.com ...
From Australian Government, Department of Health and Ageing
It seems the Australian govt is counting deaths from midday to midday - not midnight to midnight. So dates might become a little confused that way.
Deaths as at 12pm 11th August
The total number of Australian deaths associated with Pandemic (H1N1) 2009 is currently 95, with 1 confirmed death in the ACT, 32 deaths in NSW, 4 in the NT, 18 in Qld, 9 in SA, 4 in Tas, 19 in Victoria and 8 in WA.
Deaths at at 12pm 12 August
The total number of Australian deaths associated with pandemic (H1N1) 2009 is currently 100, with 1 confirmed death in the ACT, 32 in NSW, 4 in the NT, 21 in Qld, 9 in SA, 4 in Tas, 21 in Victoria and 8 in WA.
So the correct number of deaths for Australia for 12th August is 5.
Deaths as at 12pm 13th August
The total number of Australian deaths associated with pandemic (H1N1) 2009 is currently 102, with 1 confirmed death in the ACT, 32 in NSW, 4 in the NT, 21 in Qld, 9 in SA, 4 in Tas, 21 in Victoria and 10 in WA.
So 2 deaths for 13th August
Kenya: Six Swine Flu Cases At School Confirmed
12 August 2009
http://allafrica.com/stories/200908120943.html
Nairobi — Public Health and Sanitation minister Beth Mugo on Wednesday said six out of nine samples taken from a school in Keiyo District tested positive for swine flu.
An outbreak of the disease has been reported in the region, with 250 pupils of Kapirsis Primary School reported to have developed symptoms on July 31.
They had headaches, fever and cough.
Samples were taken from a section of the school population and sent to the Kenya Medical Research Institute last week for testing.
Mrs Mugo, who issued a statement in Parliament, said they had all been treated and were stable and no new cases had been reported.
Some of the teachers and parents also reported and were treated for similar illness.
UK:
Swine flu increased GP workload by up to 400%
Workload increased by up to 400% in some areas because of swine flu, according to GPC West Midlands.
Hong Kong:
Swine flu strikes three more at public pools
Mary Ann Benitez
Thursday, August 13, 2009
http://www.thestandard.com.hk/news_detail.asp?we_cat=4&art_id=86304&sid=24930900&con_type=1&d_str=20090813&fc=7
Two lifeguards and a security guard at public swimming pools have been struck by human swine flu (H1N1), three weeks after two other lifeguards came down with the virus.
Common areas where the affected staff could have caught the virus are being cleaned and disinfected, and the Leisure and Cultural Services Department said it is business as usual at the pools.
The latest cases involve a security guard at Tseung Kwan O swimming pool, a lifeguard at Hin Tin swimming pool, Sha Tin, and another at Kowloon Park in Tsim Sha Tsui.
The security guard and the Kowloon Park lifeguard were confirmed with H1N1 yesterday, while the Hin Tin lifeguard’s test came back positive on Tuesday. They had been on sick leave days before the tests came back, a spokeswoman for the department said, adding that cleaning and disinfection of the pool’s public areas, first-aid room and lifeguard rest room have been stepped up.
On July 20 and 23, two lifeguards at Tsuen King Circuit Wu Chung swimming pool in Tsuen Wan were confirmed to have swine flu.
[snip]
Meanwhile, a professor of infectious diseases has called for automatic testing for swine flu of people with “exacerbated” chronic bronchitis and emphysema or chronic obstructive airway disease, on admission to public hospitals to avoid another tragedy like that of a 54-year-old man who died on Monday. H1N1 was only confirmed after he died.
David Hui Shu-cheong, head of infectious diseases at Chinese University, said: “We are now in the peak season for H1N1, so such patients should be tested on admission.”
Meanwhile, a 58-year-old man was critically ill with swine flu last night.
Commentary
Additional Spread of Tamiflu Resistant Pandemic H1N1
Recombinomics Commentary 20:07
August 12, 2009
http://www.recombinomics.com/News/08120901/H274Y_More.html
Charles Penn, a scientist with the Geneva-based agency, says the WHO has also been alerted informally to the discovery of a small number of other Tamiflu-resistant viruses but he won’t say where they were found.
The above comments describe additional cases of Tamiflu resistance (H274Y) but provide no detail on the circumstances or locations. Who has acknowledged the resistance that was evident in the sequences released from Singapore and Hunan, China, as well as the examples previously described in Denmark, Canada, Hong Kong, and Japan (3 times). However, the number and location of additional cases and circumstances remains unclear.
Media reports have described H274Y in Thailand, but it remains unclear how many cases were found. In addition, there were reports of resistance along the Texas / Mexican border, but those reports were denied. However, the denial only addressed the cited locations. There was no statement that the rumored cases were false. The media report was quite detailed about the cases (at least two), which raised concerns that the resistance was widespread, because multiple cases were reported in the same general area.
To date there are no reports of resistance developing during treatment. Several cases were discovered in patients receive prophylactic Tamiflu, but the development of symptoms on the fifth day or prophylactic treatment suggested the H274Y discovered was already present as a minor component and the preventive treatment led to the discovery of the H274Y.
All reported cases have H274Y, which matches the change in seasonal H1N1 and each pandemic sequence represents a different genetic background, raising concerns that the H274Y is spreading via recombination in mild cases which are not tested and in cases were the virus is a mixture dominated by wild type. Consequently, new isolates are being discovered, although reports are clearly being delayed.
The Singapore sequence, deposited at GISAID last week was from the third patient confirmed in Singapore, an American (28F) who became ill in flight from Honolulu to Singapore. Her cases was mild and she was discharged on May 31, three days after confirmation. Similarly, the sequence from Hunan was also released last week, from a patient (63F) which was confirmed June 13. These long delays, and the WHO refusal to give detail on the additional cases, increase concerns that the H274Y is widespread and it presence is either not being detected, or not being reported.
Details on the number and locations of the other isolates, as well as the circumstance surrounding the detection, would be useful. The patient from Hong Kong was not linked to Tamiflu, and circumstances surrounding cases in Singapore, China, and Thailand suggest that the H274Y was discovered during routine surveillance and therefore collected in the absence of or prior to oseltamivir treatment, raising additional concerns of spread of evolutionarily fit pandemic H1N1 with H274Y.
Have you seen this story?
Not Found The requested URL /Projects/swinefluphl.php" was not found on this server. Apache/1.3.37 Server at publichealthlaw.net Port 80
I’m not sure which Posting you mean. Please give me a number, okay?
Not Found The requested URL /Projects/swinefluphl.php" was not found on this server. Apache/1.3.37 Server at publichealthlaw.net Port 80827 posted on Thursday, August 13, 2009 2:54:52 PM by jurroppi1 (We need to reward the people that carry the water instead of the people that drink the water!)
Two Tamiflu-resistant swine flu cases have been found in King County, Washington, the first known U.S. cases, according to KING5-TV.
thanks for the ping WestCoastGal:)
here’s another article
Maine:
National Guard drill at high school to prepare for possible H1N1 riot
http://www.sunjournal.com/node/105339/
UK:
Swine flu vaccination to start in Oct
Yesterday, 07:03 pm
Daniel Fineren
http://uk.news.yahoo.com/22/20090813/thl-uk-britain-flu-vaccine-acc9995.html
Britain’s swine flu vaccination programme is to start in October for at-risk groups, Chief Medical Officer Liam Donaldson said on Thursday, with most vaccines coming from drugs firm GlaxoSmithKline.
A first batch of 300,000 vaccines will arrive this month with 54.6 million expected by December, Donaldson said, adding that exact supply levels would depend on the manufacturers.
“We are getting a lower supply from Baxter than we had envisaged so the majority of our vaccines will come from Glaxo,” Donaldson told reporters.
Earlier this month, the World Health Organisation said it expected the first vaccines to combat H1N1 flu to be ready for use in some countries from September.
Donaldson said the treatments would need to be approved by European medical regulators before vaccinations begin.
“In October we expect, provided the licence is granted, to be able to give the first shots of vaccine,” he said.
The pace of new H1N1 infections in Britain has eased in recent weeks, with doctor consultations for flu-like illness falling by 34 percent last week.
The majority of cases have proven to be mild and the government plans to slash the number of flu call centre staff from around 1,600 to less than 600 by August 23 because of the sharp drop in suspected infections.
But health experts expect another surge later in the year.
“We have seen an increase in the proportion of deaths among previously healthy people,” Donaldson said, adding that five of the eight new deaths in England over the last week were of otherwise healthy people.
“It is causing more deaths in healthy people than seasonal flu,” he said.
Fears the strain could become resistant to anti-viral drug Tamiflu have underscored the need to get vaccines to market quickly.
The government plans to immunise about 11 million people seen as most at risk first because it does not expect to have enough doses for the whole population before winter.
The first to be immunised will include about 5 million people aged over six months in current seasonal flu risk groups, all pregnant women, contacts of people with compromised immune systems, and about 2 million health and social care workers.
Healthy people over 65 will not be prioritised because they appear to have some natural immunity to the virus, the Department of Health said.
Scotland:
SWINE FLU JABS ON WAY FOR 1.4M SCOTS
Friday August 14,2009
http://www.express.co.uk/posts/view/120520/Swine-flu-jabs-on-way-for-1-4m-Scots
SWINE flu vaccinations will be offered to 1.4 million Scots from October, Health Secretary Nicola Sturgeon announced yesterday.
Pregnant women, those with chronic health conditions, such as asthma and diabetes, and others with weakened immune systems will be among the first to be immunized.
Frontline NHS and social care workers, pensioners and those in high-risk groups from seasonal flu aged over six months will also be offered the vaccine.
Anyone sharing a house with someone who suffers chronic disease, such as HIV, or is undergoing chemotherapy treatment, could also be vaccinated
Similar measures will be carried out in England and Wales in a massive winter campaign.
Ms Sturgeon said: “At this stage, and this is subject to change, we anticipate being able to commence the vaccination programme in mid-October.” The Scottish Government has said it will secure enough vaccine for the population – but early supply will be limited.
The October start date depends on licensing of vaccines but suppliers said they could be ready by late September. The impending return of children to school will be monitored for its impact on the virus.
At a briefing in Edinburgh yesterday, Ms Sturgeon said: “We will be working with schools to put a focus on hand hygiene and respiratory hygiene messages. It remains the case that that’s the best way of reducing the spread of infection. Obviously, we will be looking at the impact of the schools reopening on any spreading of the virus.”
Meanwhile, a pregnant woman who was seriously ill with the virus and received specialist treatment in Sweden is now back in Scotland. However, Sharon Pentleton, 26, of Saltcoats, Ayrshire, remains in intensive care at Crosshouse Hospital.
http://content.nejm.org/cgi/content/full/361/7/680
Volume 361:680-689 August 13, 2009 Number 7
Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico
Rogelio Perez-Padilla, M.D., Daniela de la Rosa-Zamboni, M.D., Samuel Ponce de Leon, M.D., Mauricio Hernandez, M.D., Francisco Quiñones-Falconi, M.D., Edgar Bautista, M.D., Alejandra Ramirez-Venegas, M.D., Jorge Rojas-Serrano, M.D., Christopher E. Ormsby, M.Sc., Ariel Corrales, M.D., Anjarath Higuera, M.D., Edgar Mondragon, M.D., Jose Angel Cordova-Villalobos, M.D., for the INER Working Group on Influenza
PubMed Citation
ABSTRACT
Background In late March 2009, an outbreak of a respiratory illness later proved to be caused by novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in Mexico. We describe the clinical and epidemiologic characteristics of persons hospitalized for pneumonia at the national tertiary hospital for respiratory illnesses in Mexico City who had laboratory-confirmed S-OIV infection, also known as swine flu.
Methods We used retrospective medical chart reviews to collect data on the hospitalized patients. S-OIV infection was confirmed in specimens with the use of a real-time reverse-transcriptase–polymerase-chain-reaction assay.
Results From March 24 through April 24, 2009, a total of 18 cases of pneumonia and confirmed S-OIV infection were identified among 98 patients hospitalized for acute respiratory illness at the National Institute of Respiratory Diseases in Mexico City. More than half of the 18 case patients were between 13 and 47 years of age, and only 8 had preexisting medical conditions. For 16 of the 18 patients, this was the first hospitalization for their illness; the other 2 patients were referred from other hospitals. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, and bilateral patchy pneumonia. Other common findings were an increased creatine kinase level (in 62% of patients) and lymphopenia (in 61%). Twelve patients required mechanical ventilation, and seven died. Within 7 days after contact with the initial case patients, a mild or moderate influenza-like illness developed in 22 health care workers; they were treated with oseltamivir, and none were hospitalized.
Conclusions S-OIV infection can cause severe illness, the acute respiratory distress syndrome, and death in previously healthy persons who are young to middle-aged. None of the secondary infections among health care workers were severe.
This case series describes the clinical and epidemiologic characteristics of the first 18 persons with pneumonia and laboratory-confirmed S-OIV infection (also known as swine flu) hospitalized at the National Institute of Respiratory Diseases (INER) in Mexico. We also describe apparent transmission of this infection to health care workers during the initial days of the outbreak.
Methods
INER is the Mexican national tertiary care and research center devoted to respiratory diseases. The 178-bed facility provides clinical services primarily for the uninsured population of Mexico City and neighboring states. We retrospectively reviewed medical charts and radiologic and laboratory findings. This study was determined to be exempt from the requirement of institutional review, because it was conducted as part of a public health investigation into retrospective data. All tests and procedures were performed at the request of the physicians in charge of the patients. All study patients had influenza-like illness with opacities found on the chest radiograph (revealing pneumonia) and had laboratory-confirmed S-OIV infection. We also reviewed clinical data from a group of 21 hospitalized patients with influenza-like illness and pneumonia but with a negative result on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) testing for influenza A (H1N1).
Microbiologic Studies
Nasopharyngeal-swab specimens were collected at admission, and bronchial-aspirate samples were obtained after tracheal intubation. Specimens were placed in transport medium and kept at a temperature from 2 to 4°C. RT-PCR testing was done in accordance with published guidelines from the U.S. Centers for Disease Control and Prevention (CDC).7 Primers and probes for S-OIV were recently developed and distributed to the Mexican Secretariat of Health and its affiliated national institutions by the CDC. In addition, respiratory specimens from all patients were tested with the use of a multiplex PCR assay for respiratory viral and atypical bacterial panels (Seagene) for the detection of influenza A, influenza B, adenovirus, respiratory syncytial virus, parainfluenza (types 1, 2, and 3), human metapneumovirus, rhinovirus, Legionella pneumophila, Chlamydophila pneumoniae, and Mycoplasma pneumoniae.
Statistical Analysis
Data analysis was conducted using STATA statistical software.8 We compared clinical characteristics on admission between patients positive for S-OIV who died and those who survived and between patients who were positive for S-OIV and those who were negative for S-OIV. The risk of death was analyzed by means of a univariate Cox proportional-hazards model; odds ratios were calculated and Fisher’s exact test was performed for dichotomous categorical variables. Continuous data were tested by means of the Wilcoxon rank-sum test. All reported P values are two-sided and were not adjusted for multiple testing.
Results
Study Patients
The number of emergency room visits for pneumonia or influenza-like illness increased considerably at the INER in Mexico City during the last week of March 2009, peaking in late April and decreasing during the first week of May (Figure 1). From March 24 through April 24, 2009, a total of 214 emergency room consultations for cases of pneumonia or influenza-like illness were registered, 98 of which required hospitalization. Of these cases, 18 confirmed cases of S-OIV infection, with pneumonia and influenza-like illness, are the focus of this report.
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Figure 1. Emergency Room Consultations for Pneumonia or Respiratory Infection, Including Influenza-like Illness, at the National Institute of Respiratory Diseases of Mexico.
Patients with the reported cases were admitted between March 24 and April 24 (gray vertical lines). The Ministry of Health issued an epidemiologic alert on April 17 and a full sanitary alert, with closing of schools and cancellation of many public activities on April 23, after it was confirmed that the patients were infected with the novel influenza A (H1N1) virus.
Characteristics of the 18 study patients with confirmed S-OIV infection are listed in Table 1, and Table S1 in the Supplementary Appendix (available with the full text of this article at NEJM.org). The ages of the patients ranged from 9 months to 61 years (median, 38 years). More than half the patients were between 13 and 47 years of age, and 90% were less than 52 years of age. Nine patients (50%) were male.
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Table 1. Characteristics of the 18 Study Patients Who Had Confirmed Infection with Novel Swine-Origin Influenza A (H1N1) Virus.
All patients resided in the Mexico City greater metropolitan area. Eight patients had preexisting medical conditions: arterial hypertension (in three patients), non–type 1 diabetes mellitus (in three, one of whom also had hypertension), asthma (in two), and obstructive sleep apnea (in one). Only three of the patients had undergone seasonal influenza vaccination in 2008–2009; all three survived without requiring mechanical ventilation. None of the patients had a history of pneumococcal vaccination. Among the 14 patients whose occupation was recorded, 6 were students, 2 were taxi drivers, 3 were housekeepers, 1 was a locksmith, 1 was an employee of a billiards parlor, and 1 was a physician who did not have clinical duties and was not an INER employee.
The time between onset of symptoms and admission to the hospital ranged from 4 to 25 days (median, 6) (Figure 2). All patients had fever, with temperatures higher than 38°C, cough, and dyspnea or respiratory distress. Four of the five children (all under 14 years of age) had diarrhea, and only two patients (11%) reported wheezing. The median Acute Physiology and Chronic Health Evaluation II score9 was 14 (range, 4 to 32), and the median Sequential Organ Failure Assessment score10 was 6 (range, 1 to 13); both were higher, indicating more severe abnormalities among the patients who died than among those who lived (Table 2).
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Figure 2. Clinical Courses of the Study Patients.
The median time of presentation to the hospital was 6 days after the onset of symptoms. Most deaths occurred in patients who required mechanical ventilation on admission. Patient 15 was discharged from the hospital on June 8, 2009.
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Table 2. Survival and Death among the 18 Study Patients Who Had Confirmed Infection with Novel Swine-Origin Influenza A (H1N1) Virus.
Twelve patients sought medical care at other institutions as outpatients before hospitalization at INER and were treated with one or more antibiotics: ceftriaxone (five patients), amikacin (three), azithromycin (one), amoxicillin–clavulanate (two) or other macrolides (three), or another agent (two). Except for two patients transferred from other health centers, the reported hospitalization was the first hospitalization related to the disease.
Laboratory Results
At the time of admission, all 16 tested patients had elevated lactate dehydrogenase levels; levels in 10 patients exceeded 1000 IU per liter (range, 1086 to 6309). Ten of the 16 patients had increased creatine kinase levels, which were above 1000 IU per liter (range, 1099 to 5122) in 5 patients. Eleven of all 18 patients (61%) had lymphopenia (<1000 lymphocytes per cubic millimeter), 2 patients had more than 10,000 leukocytes per cubic millimeter, and 2 patients had mild thrombocytopenia at admission. Patient 3 had myocardial ischemia, as revealed on electrocardiography, with myocardial infarction documented on autopsy. Three patients had elevated creatinine levels (1.8 to 4.6 mg per deciliter [159 to 407 µmol per liter]) at admission. Four patients had d-dimer levels greater than 1000 IU per liter, and 11 patients had elevated aminotransferase levels (aspartate aminotransferase, 50 to 65 U per liter; alanine aminotransferase, 43 to 147 U per liter). Results of other routine tests were within normal limits.
The following bacterial cultures obtained within 24 hours after admission were negative: cultures of blood specimens from six patients, of bronchial aspirate samples from two patients, and of pleural-fluid specimens from one patient. Three of these patients had received antibiotics within 24 to 48 hours before admission. No other respiratory viruses or atypical bacteria were identified by means of PCR assay in any patient tested.
All 18 patients had radiologically confirmed pneumonia (Figure 3A, and Figure S2 and S3 in the Supplementary Appendix) with bilateral patchy alveolar opacities (predominantly basal), affecting three or four lung quadrants in 11 patients. Also common were linear, reticular, or nodular shadows (interstitial opacities). Findings on chest radiographs were consistent with the acute respiratory distress syndrome in all patients requiring mechanical ventilation.11
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Figure 3. Initial Radiograph of the Lung and Lung-Tissue Sample from Patient 3.
The radiograph (Panel A) shows bilateral alveolar opacities in the base of both lungs that progressed and became confluent. The specimen (Panel B, hematoxylin and eosin) shows necrosis of bronchiolar walls (top arrow), a neutrophilic infiltrate (middle arrow), and diffuse alveolar damage with prominent hyaline membranes (bottom arrow). Bacterial cultures were negative on admission, and no evidence of bacterial infection of the lungs was found. The patient ultimately died.
Treatment
None of the patients had received oseltamivir before admission; 14 received it in the hospital, at a dose of 75 mg twice a day for a minimum of 5 days; 11 began receiving it at admission (a mean of 8 days after the onset of symptoms) and 3 between 2 and 10 days after admission. Four patients who survived did not receive oseltamivir. After admission, 17 patients received ceftriaxone and 10 received clarithromycin. Additional antibiotics were prescribed in several patients, on the basis of their clinical course: three were given levofloxacin; seven, vancomycin; five, cefepime; five, imipenem; and two, dicloxacillin.
Clinical Course during Hospital Stay
Respiratory distress requiring intubation and mechanical ventilation developed in 10 patients within the first 24 hours after admission. These patients had a median oxygen saturation of 71% (interquartile range, 64 to 77) in the absence of supplementary oxygen (2240 m above sea level), and treatment of eight patients involved positive end-expiratory pressure at or above 16 cm of water. Two additional patients required mechanical ventilation during their stay in the hospital (Table S2 in the Supplementary Appendix). Duration of mechanical ventilation ranged from 7 to 30 days in patients who survived and from 4 to 17 days in patients who died. Norepinephrine infusion was begun in 9 of 18 patients (50%) during the period of hospitalization, and 5 patients received corticosteroids (hydrocortisone at a dose of 300 mg per day or methylprednisolone at a dose of 60 mg per day). Of the six patients in whom renal failure developed, five died. Seven patients had multiorgan system failure. None of the patients had disseminated intravascular coagulation or neurologic complications. Four patients had ventilator-associated pneumonia, each case with a different cause: Acinetobacter baumannii, Achromobacter xylosoxidans, methicillin-resistant Staphylococcus aureus, or Escherichia coli.
Of the 18 patients, 7 died, and 11 recovered and were discharged from the hospital. Patients died within 10 to 23 days (mean, 14) after the onset of illness and between 4 and 18 days (mean, 9 days) after admission. Figure 3B shows a lung-tissue specimen from the autopsy of Patient 3, a 43-year-old patient who died after a 14-day illness complicated by acute renal failure and myocardial infarction. Pathological evaluation of the lung showed diffuse alveolar damage, thick hyaline membranes, and prominent fibroblast proliferation.
Patients with confirmed S-OIV infection had more severe disease, including a higher death rate (Table S2 in the Supplementary Appendix), than did hospitalized patients with negative test results. The median time from illness onset to collection of samples for viral testing was 9 days (range, 3 to 46) among the 18 patients who were positive for S-OIV infection and 10 days (range, 3 to 27) among those with negative test results (P=0.50).
Clinical Infection in Contacts and Health Care Workers
Patients identified a total of 82 family contacts, 20 of whom had respiratory symptoms within a week after the patient was hospitalized. Of the 20, 4 required hospitalization, including 3 contacts of Patient 6; 1 contact who had Down’s syndrome died in another hospital from respiratory failure. Patient 2, in whom severe respiratory failure developed, is the mother of Patient 9, who had milder disease and received early treatment with oseltamivir.
Influenza-like illness or respiratory symptoms developed in 22 of 190 health care workers caring for the first three patients with confirmed S-OIV infection in the emergency room and the intensive care unit, including 19 of 104 workers who were within 2 m of a patient or had direct contact. These 22 workers received oseltamivir for 5 days and were sent home for 3 to 7 days. They had mild-to-moderate disease, and none required hospitalization. Three of the 22 workers, who were nurses in the emergency room, had nasopharyngeal-aspirate samples that were positive for S-OIV. After infection-control measures were strictly enforced — with patients confined and isolated in three hospital areas and N95 respirators used in addition to goggles, gowns, and gloves, as well as liberal use of gel-alcohol hand sanitizer — no more health care workers had influenza-like illness, although 26 additional workers received oseltamivir for 5 days because of varied respiratory symptoms.
Discussion
This case series of the first 18 patients hospitalized in Mexico City with S-OIV infection documents the clinical findings of severe illness or death associated with S-OIV infection that were seen during the beginning of the S-OIV pandemic. The patients, most of them previously healthy, had an influenza-like illness that progressed during a period of 5 to 7 days, had pneumonia, and had findings during the first day of hospital admission that fulfilled the criteria of acute lung injury or the acute respiratory distress syndrome.12 Seven patients died, all from multiorgan system failure. The most consistent laboratory characteristics were increased lactate dehydrogenase level, a total leukocyte count within normal limits, lymphopenia,13 and increased creatine kinase level, most likely due to myositis (or myocardial ischemia, in one patient).
The patients described were part of an epidemic of influenza-like illness with pneumonia seen at our institution and other Mexican hospitals, and only a fraction of them tested positive for S-OIV. A false negative test in patients who had infection with S-OIV would be more likely if the test were delayed or if patients had limited viral shedding. In general, patients who tested negative for S-OIV had a milder clinical course than those who tested positive but were as much a part of the burden of the epidemic as those who were not tested.
Risk factors for severe S-OIV illness are still unknown, but most of our patients were young to middle-aged and had previously been healthy. The majority of the S-OIV infections reported in other countries have been mild, influenza-like illnesses.2 Mexico has also reported a large number of persons with mild disease, through the national surveillance system for influenza, but the full spectrum of clinical illness has not been determined. Other countries will probably report more severe infections as the pandemic spreads and the number of infected persons increases. One contributing factor for death in our patients may have been delayed admission and delayed initiation of oseltamivir. For seasonal influenza, the elderly and young children are at higher risk for severe disease; however, more than half of our patients were between 13 and 47 years of age, which was similar to the age distribution reported in national data of H1N1 infections in Mexico.6 During the 1918 pandemic, a large number of deaths were associated with bacterial infection,14 but concurrent bacterial infection does not appear to be a major contributing factor to the severity of illness in our patients, possibly in part because most received antibiotics before hospitalization.
Mortality among the patients requiring mechanical ventilation was 58%, and although four patients had nosocomial pneumonia, in most of our patients, lung damage was most likely due to the primary effect of infection with influenza virus. Possible mechanisms of damage include direct injury to the respiratory epithelium15 with a secondary cytokine storm. We do not currently know whether our patients, especially those who died, had viremia, as was reported in association with H5N1 infection, a very aggressive variety of influenza.13,16,17,18 Coinfection with other respiratory viruses could also explain the increased pathogenicity among our patients19,20; however, no other common respiratory viruses were found in our patients. Only three of the patients had received influenza vaccine in fall 2009, since most patients were within the age groups for which vaccine was not recommended in Mexico. It is currently unknown whether seasonal vaccination offered any protection against S-OIV infection, however. We did not find a factor that, before the onset of illness, predicted a worse outcome or death among our patients.
Since 2000, the WHO has prompted countries to prepare for a potential influenza pandemic. In Mexico, pandemic influenza planning began in 2001. Activities included the introduction of yearly influenza vaccination and a program to develop the country’s national vaccine production. In 2006, a strategic reserve of oseltamivir, antibiotics, and protective items for health care personnel was established. This reserve is the source of the oseltamivir prescribed to our patients and to most hospitalized patients in Mexico. The experience in our institution highlights the need to reinforce precautions and use of personal protective equipment to prevent the infection of health care workers.
In conclusion, S-OIV infection can cause serious illness and death in young, previously healthy persons. Future studies should identify predictive factors for severe disease and, especially, the effectiveness of early oseltamivir treatment and protection offered by having undergone seasonal influenza vaccination.
No potential conflict of interest relevant to this article was reported.
We thank Celia Alpuche, M.D., from the Mexican national reference laboratory (Instituto Nacional de Referencia Epidemiologica); the CDC for providing training and primers for the real-time RT-PCR assay for the swine influenza; the Canadian National Microbiology Laboratory; Michelle Weinberg for careful review of a draft of the manuscript; and all the patients and the personnel of INER who cared for them.
* Members of the INER Working Group on Influenza are listed in the Appendix.
Chinese mainland A/H1N1 flu cases exceed 2,500
www.chinaview.cn 2009-08-14 21:49:34
http://news.xinhuanet.com/english/2009-08/14/content_11883861.htm
BEIJING, Aug. 14 (Xinhua) — The Chinese mainland confirmed 114 new cases of A/H1N1 influenza in the 48 hours ending 3 p.m. Friday, bringing the total infections to 2,537, the Ministry of Health said.
Among the newly confirmed, 46 were “imported cases” and the rest were infected on the Chinese mainland, according to the ministry.
More than 2,280 of the infected have recovered and discharged from hospitals.
Oh, good grief. They want it to be a pandemic and people to panic, fer cryin’ out loud.
How ridiculous can this get?
Why is A (H1N1) death rate in Malaysia four times the global case fatality rate?
Health Minister Datuk Liow Tiong Lai should explain why Malaysia’s A (H1N1) death rate is four times the global case fatality rate.
Malaysia’s death toll from A (H1N1) flu has topped 56 since the first fatality three weeks ago.
The influenza A (H1N1) mortality rate in Malaysia is close to 2% instead of the 0.1% to 0.4% as estimated by the Health Ministry. It reflects an unusual phenomenon. Without finding out the crux of the problem, assuming that 5 million of people are infected, probably 100,000 of them will die, instead of 5,000 to 28,000 as estimated by the World Health Organization (WHO).
http://www.mysinchew.com/node/28218?tid=12
So, these test cases of vaccinations for swine flu.
Are they using the same vaccine that would be used in the US? The one with the squalene in it?
Or are they going to use a safe one, tell us it’s safe, and have Americans get the dangerous one with all the side effects?
Nothing would surprise me with the duplicity involved in all this.
It isn’t like we haven’t been lied to before.....
CDC update: US death toll at 477
Total U.S. Novel H1N1 Flu Hospitalizations and Deaths
Posted August 14, 2009, 11:00 AM ET
Data reported to CDC by August 13, 2009, 2:00 PM ET Reporting States and Territories*
Hospitalized Cases........Deaths
..... 7,511 ........................477
http://www.cdc.gov/h1n1flu/update.htm#iligraph
Note: An increase of 41 deaths over last week’s update.
Canada FluWatch updated for August 2-8:
1,366-1,315 = 51 new hospitalizations.
240-227 = 13 new ICU admissions.
August 2, 2009 to August 8, 2009 (Week 31)
http://www.phac-aspc.gc.ca/fluwatch/08-09/w31_09/index-eng.php
Summary of FluWatch Findings for the
Week ending August 8, 2009
The overall influenza activity remains similar to the previous week; the reported activity level (4 regions reported localized activity) and the national ILI consultation rate (15 consultations per 1,000 visits) are comparable to last week. While the proportion of influenza positive tests decreased this week (5.5% vs. 9.9%), the overall number of influenza outbreaks increased (4 vs. 0).
* As of 8 August, 2009, a total of 1,366 hospitalized cases and 240 cases admitted to an intensive care unit (ICU) had been reported to the Public Health Agency of Canada. This week, six deaths were reported for a total of 66 deaths since the beginning of the pandemic. More than 90% of the hospitalized cases and approximately 85% of the deaths have been reported by only 4 provinces (Alberta, Manitoba, Ontario and Quebec).
* The overall Pandemic (H1N1) 2009 influenza activity is decreasing across Canada. The peak period of laboratory-confirmed hospitalizations and deaths occurred between weeks 24 to 29 (June 14, 2009 to July 25, 2009) while the peak period of symptom onset date or specimen collection date due to Pandemic (H1N1) 2009 occurred two weeks before, from June 1, 2009 to June 18, 2009.
* The proportion of females affected, the median age and the proportion of cases with underlying medical conditions increase with increasing severity of illness (on a gradient from all cases, to hospitalized cases, to ICU-admitted cases, to deaths).
* While cases under 15 years of age have the highest hospitalization rate, they have a comparatively low mortality rate except for children under 1 year of age. Adults over 65 years of age have a low hospitalization rate, but a comparatively higher mortality rate.
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