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Massachusetts:

MetroWest towns holding pneumonia clinics
By Charlie Breitrose/Daily News staff
The MetroWest Daily News
Posted Jun 30, 2009 @ 11:56 PM

http://www.metrowestdailynews.com/news/x726977744/MetroWest-towns-holding-pneumonia-clinics

MetroWest health officials, concerned that the H1N1 (swine flu) virus pandemic still lacks a suitable vaccine, are offering a vaccine for one of the most serious flu complications - pneumonia.

Public health departments in a number of area towns will hold free vaccination clinics for pneumonia this month to protect those most vulnerable to the potentially deadly illness.

According to the state Department of Public Health, pneumonia played a lead role in many of the deaths during the influenza epidemic of 1918 and 1919 - 7 to 20 percent of flu cases developed pneumonia, and 20 to 36 percent of those died.

Natick held its first summer pneumonia clinic last week, and more are planned, said Public Health Nurse Leila Mercer. Normally, residents receive flu vaccinations in the fall.

“This is in response to the declared pandemic (of swine flu),” Mercer said. “People have been thinking about the swine flu, and even though we don’t have a swine flu vaccine, we do have the bacterial pneumonia vaccine.”

State officials recently increased the list of people to whom towns can provide free pneumonia shots. Among the most vulnerable are people over 65, and 19- to 64-year-olds who smoke or have asthma. People who have had pneumonia in the past or those who have a reduced ability to fight infections, including those with leukemia, HIV, AIDS, or spleen problems, are encouraged to get a vaccine.

Vaccines are also recommended for people with heart disease, lung disease, sickle cell, diabetes, alcoholism, have a cochlear implant, had an organ transplant, take radiation drugs or are on a longterm steroid regimen.

Last week’s clinic drew 20 people, Mercer said. Others are scheduled for July 8 at Town Hall from 4 p.m. to 6 p.m., and on July 20 at the Kennedy Senior Center from 1 p.m. to 2:30 p.m. The clinic in Natick is open to anyone.

Marlborough will hold some clinics, including one at the Senior Center, said Public Health Nurse Nancy Cleary, but the dates have yet to be determined. People can still stop by the Public Health Department’s office in the Walker Building any Tuesday from 2 p.m to 4 p.m. to get a shot, Cleary said.

“Before we get into all the clinics for the swine flu and regular flu season, I think this is a good interim period to address this so people understand why it is important to get the pneumonia vaccine,” Cleary said.

While the vaccine will help prevent a serious side effect of the flu, it won’t prevent it, said Kitty Mahoney, Framingham’s chief public health nurse.

“The new state guidelines say to target anyone at risk of pneumonia because that’s the one serious complication we are seeing with H1N1,” Mahoney said. “But people should know it is not a protection against H1N1. We will give out that shot when the CDC makes it available, probably in the fall.”

Framingham will hold a clinic for people who are in at-risk categories on July 14, from 4 p.m. to 7 p.m., in the Memorial Building, said Mahoney, who is also president of the Massachusetts Public Health Nurses Association.

The vaccine clinics in Milford and Franklin are run by the Visiting Nurses Association. Paul Mazzuchelli, health officer for the Milford Board of Health, said they will not have pneumonia shots this summer.

“The next vaccine clinic we have scheduled is in the fall right around flu season, probably mid-September or early October,” Mazzuchelli said. “What we usually do is we offer pnuemococcal with our flu clinics. Usually, over recent years, the responses been very low.”

(Charlie Breitrose can be reached at 508-626-3964 or cbreitro@cnc.com.)

The Viral Dynasty Of The Spanish Flu
Posted on: Tuesday, 30 June 2009, 13:20 CDT

The influenza virus that terrorized the world in 1918-19 founded a viral dynasty that lives on, according to a study published on Tuesday by the New England Journal of Medicine.

The authors of the study insist that we have been living in an influenza pandemic era since 1918. They believe that the 2009 “swine flu” virus that had people panicking across the globe was just another guise of the same old viral family.

“The 1918-1919 influenza pandemic was a defining event in the history of public health,” says director Dr. Fauci of the National Institutes of Allergy and Infectious Diseases and a co-author of the study.

“The legacy of that pandemic lives on in many ways, including the fact that the descendents of the 1918 virus have continued to circulate for nine decades.”

Influenza viruses have eight genes, two of which code for virus surface proteins hemagglutinin (H) and neuraminidase (N), which allow the virus to enter a host cell and spread from cell to cell. There are 16 H subtypes and 9 N subtypes, making 144 possible HN combinations.

But only H1N1, H2N2, and H3N2 are known to be fully adapted to infect humans. Other combinations such as the H5N1 bird flu virus have only occasionally infected small numbers of humans.

Since its debut in 1918, the virus “has drawn on a bag of evolutionary tricks to survive in one form or another — and to spawn a host of novel progeny viruses with novel gene constellations, through the periodic importation or exportation of viral genes,” the authors said.

Jeffrey Taubenberger, the senior investigator at NIAID’s Laboratory of Infectious Diseases, says that all of the influenza A viruses adapted for humans “are descendants, direct or indirect, of that founding virus.”

“The eight influenza genes can be thought of as players on a team: Certain combinations of players may arise through chance and endow the virus with new abilities, such as the ability to infect a new type of host,” said David Morens, an author of the study.

That is likely what caused the 1918 pandemic, he added.

It remains a mystery as to what factors determine whether infection in a new host yields a dead-end infection or sustained, human-to-human transmission, like the virus of 1918. Research on such topics is in high gear, but they have yet to find any definitive answers, notes Dr. Morens.

What is understood is that the human immune system rallies its defense against the influenza virus’s H and N proteins, mostly in the form of antibodies. But as people develop immunity to new variants of the flu, the virus reacts by making changes that will challenge the antibodies’ ability to recognize it.

For nearly a century, the immune system has been battling the 1918 influenza virus and its progeny, as it constantly attempts to outwit its enemy and anticipate its moves.

It is unlikely that the 1918 flu is anywhere near its end, however virologists remain optimistic. They note that the pandemics that have occurred repeatedly since 1918 have actually been gradually becoming less severe.

The Asian flu killed four million people in 1957, and then the Hong Kong flu of 1968 killed 2 million people. That is a stark contrast to the mere 311 reported deaths that have occurred from the swine flu pandemic at hand, according to the latest WHO figures released on Monday.

This trend is partly the result of advances in medicine and public health measures, but it may also be indicative of viral evolutionary pathways that cause increases in the virus’s ability to spread from host to host, along with a decrease in its tendency to kill those hosts. “Although we must be prepared to deal with the possibility of a new and clinically severe influenza pandemic caused by an entirely new virus, we must also understand in greater depth, and continue to explore, the determinants and dynamics of the pandemic era in which we live,” conclude the authors.

http://www.redorbit.com/news/health/1713405/the_viral_dynasty_of_the_spanish_flu/

Acquisition of H274Y Tamiflu Resistance in Pandemic H1N1
Recombinomics Commentary 02:09
July 1, 2009

In the context of tracing contacts of a cluster of 3 imported cases in Denmark, a female contact who initially tested negative on PCR, was given prophylaxis with oseltamivir (75 mg per day). Five days later, despite reportedly having complied with treatment, she developed flu-like symptoms and was tested positive for A(H1N1)v. Sequencing of the virus showed a single mutation H275Y (H274Y in N2 nomenclature) in the neuraminidase gene. The presence of the resistance marker and the phenotypic (in vitro) resistance was confirmed by a WHO collaborating Centre. The virus is not a re-assortant and is presumed to remain susceptible to zanamivir (another neuraminidase inhibitor). All other virus isolated as part of this cluster investigation, including the presumed source patient, did not show the mutation.

According to the available epidemiological and virological data, this reported event in Denmark is almost certainly secondary resistance acquired during post-exposure prophylaxis. This is supported by the time sequence and the absence of similar genotypic markers in viruses isolated in the other cases of the cluster.

There is no evidence in this case that the isolated resistant virus has transmitted to other persons, meaning that the risk of spread of a resistant virus is nearly zero.

Secondary resistance, arising due to treatment, must not be confused with more complex mutations including the H274Y substitution resulting from primary resistance. Such primary resistance was first observed in seasonal A(H1N1) influenza virus in the 2007-2008. It spread worldwide generally displacing other seasonal A(H1N1) viruses (98% resistance in EU in 2008-2009

The above risk assessment by the European Centre for Disease Control indicates the oseltamivir resistance identified in a female contact of a pandemic H1N1 confirmed traveler was due to the acquisition of H274Y. The report also indicates the sequence from the likely source of the pandemic H1N1 infection of the contact did not contain H274Y, supporting the acquisition during prophylactic treatment leading to a low risk assessment for spread.

However, there are alternate explanations for the failure to detect H274Y in the sequence from the traveling contact. If the contact was infected with two versions of H1N1, sample collection prior to oseltamivir treatment would generate the sequence of the dominant wild type species. The local contact, who developed symptoms five days after the start of treatment , would test positive for H274Y because the prophylactic treatment would lower the level of wild type RNA. Thus, potential spread of resistance would reside in patients in the originating country, who could travel to Denmark and re-introduce the H274Y.

Alternatively, the local contact could have been infected by another source in Denmark, since there were no symptoms during the first five days of prophylactic treatment. Although Denmark has reported a relatively low level of H1N1 in residents, like most countries in Europe, testing is focused on airport travelers and contacts, while testing for community spread is limited. However, since many passengers will be infected shortly before flight, many will be asymptomatic. Others will be asymptomatic because of an infection that does not produce a high fever, while others will have symptoms reduced because if medications. Thus, the number of passengers evading detection at airports will be large, leading to H1N1 spread in the community.

The evidence for H274Y acquisitions via recombination are linked to the recent patterns of spread in H1N1 seasonal flu. Although the report notes the dramatic primary spread of H274Y between 2007-2009, it simply calls such spread complex and fails to address the appearance of H274Y on multiple genetic backgrounds in the absence of Tamiflu treatment. It is the jumping of H274Y from one genetic background to another (recombination) that has raised concerns that such jumps will lead to acquisition of H274Y on a pandemic H1N1 background, because the H274Y level is near 100% in seasonal flu and pandemic H1N1 is accelerating its spread through the human population, increasing the frequency of dual infections involving swine and seasonal H1N1.

Thus, the acquisition of H274Y is expected and it is likely that there will be more examples of sequences like the resistance described in the above report. Release of the sequences from the cluster would be useful, as would the travel history of the traveler thought to have infected the contact who developed resistance via H274Y.

These data should launch more aggressive surveillance worldwide. Although countries have been promptly depositing sequences, the number of sequences remains low. Denmark has only deposited one sequence, which was from a patient infected in April.

The start of flu season in the southern hemisphere should lead to rapid evolution and the widespread acquisition of important polymorphisms, such as PB2 E627K, which was reported in Shanghai, but present only in the original sequence and the first clone, and NA H274Y, as found in the above patient from Denmark.

http://www.recombinomics.com/News/07010901/H274Y_Swine_Acquisition.html

China:

Recovering swine flu patient dies

http://www.shanghaidaily.com/article/?id=406118&type=National

A SWINE flu patient died yesterday in east China’s Zhejiang Province but the cause of her death was not yet known, local health authorities said late yesterday.

The 34-year-old woman was found dead at 7:35am in her ward lavatory at the No.1 People’s Hospital of Xiaoshan District in Hangzhou, the provincial capital, according to the Hangzhou municipal health bureau.

The patient was recovering as her temperature had been normal for a week. She coughed occasionally, but other flu symptoms had disappeared. She was admitted to the hospital on June 23.

If she is found to have died from the disease, it would be China’s first death from it.

Liang Wannian, vice director of the Health Ministry’s emergency office, warned on Monday that China is “very likely” to have its first death from the H1N1 flu in the foreseeable future, as the number of the flu cases rises.

“The possibility of a wide spread of the virus in China in autumn and winter is also becoming more likely,” the official said.

The Chinese mainland confirmed 57 new H1N1 cases yesterday, with the total number hitting 867.

China:

Recovering swine flu patient dies

http://www.shanghaidaily.com/article/?id=406118&type=National

A SWINE flu patient died yesterday in east China’s Zhejiang Province but the cause of her death was not yet known, local health authorities said late yesterday.

The patient was recovering as her temperature had been normal for a week. She coughed occasionally, but other flu symptoms had disappeared. She was admitted to the hospital on June 23.

If she is found to have died from the disease, it would be China’s first death from it.

“The possibility of a wide spread of the virus in China in autumn and winter is also becoming more likely,” the official said.

The Chinese mainland confirmed 57 new H1N1 cases yesterday, with the total number hitting 867.

Swine flu hitting young, healthy adults hardest (Canada)
http://www.theglobeandmail.com/news/national/swine-flu-hitting-young-healthy-adults-hardest/article1203826/

The young and healthy who feel invincible from the H1N1 “swine flu” influenza pandemic may not be as bulletproof as they think, warn public health experts.

Nearly two-thirds of Canadians hospitalized due to swine flu, and half of those who have died, had no underlying health conditions.

Experts do not yet understand why the new strain affects some healthy people so severely, ravaging their lungs with an aggressive pneumonia and forcing them to spend weeks in hospital, attached to breathing machines.

“They are ending up on ventilators and it can last from weeks to months,” said Michael Gardam, director of infectious diseases at the Ontario Agency for Health Protection and Promotion. “I would like people to be concerned about H1N1, without panicking. More concerned than they are about seasonal flu.”

A new study tracking the epidemic in Mexico also found the flu strain hits those between the ages of 20 and 50 the hardest, with a higher death rate than other age groups.

In recent weeks, as swine flu has faded from the world’s radar, infectious disease specialists worry that people have become complacent about the pandemic, which is expected to infect one third of the population, or about 10 million Canadians. (In contrast, seasonal flu affects about one in 10 people.)

“You should not be worried that your child will suddenly die of H1N1,” Dr. Gardam said. “But you should be prepared that a family member will get sick.”

[snip]

The Grade 1 student from Brampton, Ont. died in her father’s arms June 15 en route to the hospital, a day after first complaining of achy arms and legs, and a slight fever. Doctors await autopsy results to find out whether she had an underlying health condition that contributed to her death.

According to the Public Health Agency of Canada, two-thirds of 94 hospitalized cases where information was available showed the patients were perfectly healthy before being admitted.

Of the 25 Canadians who died with H1N1, 13 had other health problems. These can range from obesity, diabetes and mild asthma to chronic lung or heart disease. Also at risk are smokers, those who are immune-compromised, and pregnant women, who have a greater chance of developing complications.

“By the time you add up all these underlying health conditions, you end up with a large chunk of the population,” Dr. Gardam observes.

Epidemiologists are studying cases of healthy people who have become severely ill after contracting the virus, to gain insight into why they are vulnerable.

“[We are] trying to understand from a medical standpoint why they would be affected this way by the virus, and whether this is a signal that the virus is changing and becoming more virulent,” David Butler-Jones, Canada’s chief public health officer, said in a statement. “It is because of these severe cases, although a minority, that we must remain vigilant, both at the government level by continuing to investigate these cases, and at the individual level, by taking personal action to prevent infection.”

The other troubling characteristic of the swine pandemic is that, unlike other flus, it is not tapering off in the summer months.

Instead, Canada is experiencing five times the rate of flu activity it normally does at this time of year, all of it H1N1. “The other flu bugs have vanished. But not H1N1,” Dr. Gardam says.

The other key difference is the age of those infected: most are aged 20 to 50. With seasonal flu, one quarter of those infected are over the age of 65, Dr. Butler-Jones says.

In Mexico, 87 per cent of the deaths, and 71 per cent of the cases of severe pneumonia due to H1N1 occurred in people between the ages of 5 and 59. With seasonal flu, usually one third of those affected are in this age group.

Doctors speculate that this could be because the H1N1 virus resembles a strain of flu that circulated before 1957, to which older people have been exposed, says Colin Lee, associate medical officer of health in Ontario’s Simcoe-Muskoka region.

The first detailed study of the swine flu outbreak in Mexico, H1N1’s original epicentre, was published last week in the New England Journal of Medicine.

“The features of the H1N1 epidemic are somewhat similar to past influenza pandemics in that circulation of a new influenza virus is associated with an unseasonal wave of disease affecting a younger population,” wrote authors Gerardo Chowell-Puente, an epidemiologist at Arizona State University, and Stefano Bertozzi of the National Institute of Public Health in Mexico

Patient suspect Avian Flu Died

Tuesday, July 07, 2009, 12:49:00

Padang, Padek - bird flu threat still lurk Sumbar. A patient suspect HIN5 virus, origin Sungaibuluh, District Dharmasraya died.
Victim is known berinisial RK, 7.5, dies after treatment for five hours in space Isolation Irna C RSUP In Diseases Dr M Djamil Padang, Saturday (4 / 7).

The more surprising, a day after RK buried, a nurse in the room RK isolation experienced suspect bird flu. Nurses berinisial M is now in the middle of treatment room isolation Irna C RSUP In Diseases Dr M Djamil Padang. He showed symptoms of bird flu suspect.

“RK has been critical condition when entering RSUP Dr M Djamil Padang, Saturday (6 / 7), pukul 05.00 WIB. Only one five hours later, the patient died at around 10:00 WIB, “said Director General RSUP M Djamil Padang Aguswan, accompanied the Head of room Irna C Diseases In Emi Erawati to Padang Ekspres in space work, yesterday.

RK was undergoing treatment in hospitals Adnaan WD Payakumbuh, since Monday (29 / 6), the chance of being on holiday at her grandmother’s house. After that, the RK and then taken to the hospital Yos Sudarso Padang. “From the results of the rays lungs, showed symptoms of bird flu. Patient’s body temperature reached 37.5 centigrade accompanied by shortness of breath, “said Aguswan.

When referred to Dr M Djamil RSUP, the condition of the patient is not comfortable with the tool sadarkan bantu oxygen. Until now, Dr M Djamil RSUP Padang can not ensure whether the RK-positive bird flu or not.

“We are still awaiting results of the examination throat swab and a blood test sent to RK Labor MOH RI,” said Aguswan. Since 2006, Dr M Djamil RSUP handle the nine patients suspect bird flu from a number of areas in Sumatra, such as Padangpariaman, Limapuluh City, Agam and Dharmasraya. Previously, a patient suspect bird flu died years ago in 2007. (nia)

http://www.padangekspres.co.id/index.php?mib=berita.detail&id=8229