Influenza type A/H1N1 (swine flu) updates

[Ninong]

Influenza Type A, Subtype H1N1 (Swine Flu)

Some of you may remember that we had a thread on Influenza A/H5N1 (Bird Flu) back in 2005. Both A/H5N1 (avian flu) and A/H1N1 (swine flu) are subtypes of Influenza A. One very big difference is that A/H1N1 has been confirmed as passing from human to human while A/H5N1 was never positively confirmed as being transmitted by human to human contact. There may have been two or three cases that were believed to have resulted from human transmission but that was it. Most of the people who came down with avian flu had some sort of contact with infected fowl. That's why China ordered the destruction of millions of chickens and other fowl.

If A/H1N1 has an incubation period of only one to two days, as reported, and is being tranmitted via human to human contact, then that probably means that it incubates in the throat instead of in the intestinal tract like H5N1. That would make it highly contagious.

My maternal grandfather and grandmother died within 12 hours of each other in the 1918-1919 flu pandemic (commonly called "Spanish" flu). They were both in their early 30's at the time and in perfect health. All of the type A influenza pandemics since then are decendants of the 1918 H1N1 virus.

Besides the CDC link that I provided above for the 1918-1919 flu pandemic, I might as well put in the link to the WHO's daily updates on A/H1N1 (swine flu).

This new strain of swine flu that is hitting right now appears to combine elements of human flu, avian flu and swine flu all rolled up into one new package. Based on reports in the press so far, the deaths in Mexico appear to have resulted from secondary severe pneumonia infections. The 1918-1919 strain of A/H1N1 killed in two ways: by causing the immune system to go into overdrive or by secondary pneumonia infections. The reason healthy people in their 20's and 30's were more likely to die from this disease than very young or very old people was because they have stronger immune systems. The very young and the very old who did die usually died from the secondary pneumonia infections and not from their immune systems attacking their bodies.

One very encouraging bit of news about this new swine flu is that it apparently responds to both Tamiflu and Relenza. So far there have been no fatalities in the U.S. As of this morning, we have 20 confirmed cases and dozens of suspected cases in at least five states. It takes several days, at least, for the WHO to confirm that a case is actually this new strain of swine flu. Local labs can confirm that it is in fact Type A/H1N1 but then the specimen has to be sent to the WHO or the CDC to verify that it is an identical genetic match with this new strain. So far none of the cases in the U.S. have been severe.

We really don't know how many cases there are in Mexico. We know that it has been confirmed in 19 different Mexican states and that 81 people have died from it as of this morning. It is believed that there are more than 1,000 cases in Mexico but that number may be much too low. If so, that would actually be good news because a mortality rate of 81 out of 1,000 is really horrible (8.1%) but a mortality rate of 81 out of 10,000 would be only eight-tenths of one percent. Regular type A influenza has a mortality rate of one-tenth of one percent. The 1918-1919 strain of H1N1 had a mortality rate that ranged from 2% to 20%. Some communites in the Third World were devastated. In the U.S., we lost more than 500,000 people. Worldwide at least 50 million, but possibly as many as 100 million, people died. The world's population then was 1.5 billion and an estimated 500 million people came down with the "Spanish" flu.

I see a lot of people wearing those cheapy surgical masks. I really wonder just how effective those masks are against something as small as a virus.

Anyway, I figured I might as well open this thread just so we can keep track of things in case this situation gets out of hand. So far I am very encouraged by the news that has leaked out. Sometimes it's hard to figure out what's really going on from press reports because they have a tendency to ignore the really important points and emphasize the sensational points. The really important points so far, at least in the U.S., are that it responds to both Tamiflu and Relenza and that it has not been severe at all, nothing like the 1918-1919 flu strain, which was incredibly virulent.

P.S. -- Here are those links again:

WHO swine flu website

CDC daily updates on swine flu

CDC article on 1918-1919 flu pandemic

Swine flu FAQ

HHS pandemic flu website

[Ninong]

U.S. Human Cases of Swine Flu Infection

State, number of laboratory confirmed cases:

California 7
Kansas 2
New York City 8
Ohio 1
Texas 2

TOTAL COUNT 20 cases

As of April 26, 2009 9:00 AM ET

[Ninong]

Stop Calling It Swine Flu

The World Animal Health organization (OIE) in Paris is pissed that the WHO is calling this "swine flu."

They would like to point out that it is "a virus which includes in its characteristics swine, avian and human virus components." They claim that there are so far no proven links "between human cases and possible animal cases including swine."

"The virus has not been isolated in animals to date. Therefore, it is not justified to name this disease swine influenza."

They do have a point. I think what they're really worried about is that people will stop eating pork. There have been no reported links to eating pork. Obviously pork must be cooked to a temperature of ~165F for lots of other reasons if you want to stay healthy.

Because it originated in either Mexico or Southern California, the OIE people think it should be called "North American influenza."

[Ninong]

U.S. Human Cases of Swine Flu Infection

State, number of laboratory confirmed cases:

California 7
Kansas 2
New York City 28
Ohio 1
Texas 2

TOTAL COUNT 40 cases

As of April 27, 2009 1:00 PM ET

[Samper]

Sell Travel....

I am glad that we have atleast a few drugs to combat this. I wonder how how fast they can crank them out. According to U.S. Chamber of Commerce - How much TAMIFLU is the US government stockpiling? there are enough antivirals to treat 25% of the U.S. population and these can be in each state within 12 hours. This Antivirals - State Allocations is the most recent stockpile information I could find and the amounts of antivirals that will be distributed to each state in the event of an emergency. I wonder if these numbers are any different as it was current on 9-30-08.

Looking at a timeline of influenza outbreaks since 1918 it appears that a few strains become more and more frequent within the last ten years. I wonder what this same timeline would look like if we were able to extend it back in time. I loved my microbiology professor but he was always on a soap box about us being due for something devastating.

[Samper]

I take that back. Secretary Leavitt said "Our ultimate goal is to stockpile sufficient quantities of antiviral drugs to treat 25% of the US population.”

[Ninong]

Samper,

We have no HHS secretary right now because the Republicans in the Senate are filibustering Gov. Kathleen Sebelius, President Obama's nominee, because of her pro-choice stand. Leavitt was George Bush's HHS secretary. He left office on Jan. 20, 2009.

President Obama had included $900 million for stockpiling medicines for a pandemic in the federal stimulus package but it was deleted at the insistence of Senators Arlen Specter (R-PA) and Susan Collins (R-ME). They refused to vote for it if the administration did not remove the $900 million for preparation for a pandemic. They said that had absolutely nothing to do with an economic stimulus because, as every Goppie knows, the economy will not suffer at all if we are hit by another "Spanish" flu pandemic that shuts down public transportation and floods our hospitals with hundreds of thousands, maybe even millions, of sick people.

Unfortunately, the Democrats have only 58 seats in the Senate right because loser Norm Coleman refuses to give up in Minnesota. He not only intends to appeal to the Minnesota Supreme Court, but he intends to take 10 ten days to prepare his appeal. He knows he won't win but he refuses to accept the unanimous ruling of the appeals court against him. He is doing this on orders from GOP leaders in Washington, DC, who want to delay seating Al Franken as long as possible.

Once the Democrats get Franken seated, they will need only one Republican vote to give them the 60 votes needed to cut off a filibuster. I think the Democrats should insist that if the Goppies want to filibuster, then they should have to do it the old fashioned way but occupying the podium in the Senate 24/7 until they get too tired to continue. Huey Long used to read passages from the Bible and even recipes from his wife's favorite cookbook.

I don't know how large our stockpiles of Tamiflu and Relenza are right now but I don't believe it's anywhere near the "ultimate goal" voiced by former Secretary Leavitt. I would be surprised if it's even half that amount.

I know that the U.K. has enough of these drugs to treat 50% of their population and their government said today that they have placed orders to double that amount so that they can cover 100% of their population. The only two companies making the only two anti-virals that have proven effective against this particular strain of A/H1N1 are EU companies. Tamiflu is made by Roche and Relenza is made by Glaxo.

We might have to stand in line if we expect to get a lot of Tamiflu and Relenza anytime soon. This issue came up a few years ago in hearings when we learned that all of the American drug manufacturers were refusing to make flu vaccines and other anti-virals to treat influenza because they said their wasn't enough profit in it for them. The problem is that you have to make a whole lot of vaccines and then, if there is a mild flu season, you have to trash most of your inventory. I'm talking specifically about the vaccines here, not anti-virals like Tamiflu and Relenza. That's because you have to guess which strain of influenza might be prevalent next season and begin production at least six months in advance. If you make 50 million doses and you only sell 30 million, then you end up throwing away the other 20 million.

It will probably take 8-10 months to produce a vaccine against this new strain of A/H1N1. It's brand new. It has never been seen before. There is no way that we would have any siginificant amounts of the vaccine before the start of the flu season in November. it will take months of research and development to design the vaccine and then months more to produce it. And there is not enough capacity to produce enough vaccine to treat a significant percentage of the world's population, should a real pandemic break out.

I have no idea what the shelf life is for Tamiflu and Relenza. You might look that up when you're looking up exactly what our supply is right now?

If we have enough Tamiflu and Relenza to cover more than 15% of the U.S. population I would be surprised.

I see where Gov. Rick Perry, of the "Republic" of Texas, has decided to hold off on secession for the time being because he would like the federal government's help in dealing with the swine flu cases popping up in his state. He's asking for a "handout" from the feds, imagine that. I guess he got tired of "teabagging."

[Ninong]

Samper,

You and I discussed this exact same topic in October 2005, remember? I suggest you reread my responses #9 and #11 to you in that thread.

You pointed out that President Bush was requesting $7.1 billion for emergency funding to "meet our goals" and I pointed out that the Republicans, who controlled Congress in 2005, had already voted it down. They said they would rather wait for the "emergency" first.

I also pointed out that at that time (Oct. 2005) we had only enough Tamiflu to cover 1% of the U.S. population.

See what you can find out about our present situation. How close are we to that "ultimate goal" of 25% coverage?

[Ninong]

Samper,

You were taking too long, so I found that info for you.

According to this article in tomorrow's L.A. Times:

Homeland Security Secretary Janet Napolitano announced that the government would release 25% of its emergency stockpiles -- about 12 million doses -- of Tamiflu and Relenza to various states in case they were needed. However, many questions remain about how to best use the drugs.

The U.S. population is 306 million (world population is 6.7 billion), so if we have a total of only 48 million doses, that means we have only enough Tamiflu and Relenza, combined, to treat 15% of our population!!! That may be an improvement over the 1% figure for Tamiflu stockpiles back in October 2005 but it's nowhere near enough should a major pandemic break out.

I assume that when they say "doses," they mean a packet with ten 75mg Tamiflu capsules. That would be a full "course of treatment" -- two capsules per day for 5 days. Tamiflu must be given within 48 hours of the onset of symptoms to be effective. Relenza is administered with an inhaler but it too must be started within 48 hours of onset of symptoms.

Of the several different antivirals, only Tamiflu and Relenza have proven effective in treating this new strain of A/H1N1, and obviously nothing has proven effective in treating the really virulent cases in Mexico.

The U.K. has enough Tamiflu on hand right now to treat 50% of their population and they just placed orders today to double their stockpiles so that they will have enough to treat 100% of their people.

P.S. -- Here's a perfect example of the misleading information the media is putting out. CNN keeps repeating the statistic that 36,000 people die of regular flu in the U.S. every year without telling people that that's out of 3.6 million who come down with the regular flu. The mortality rate for regular flu in the U.S. is one-tenth of one percent. The mortality rate for this new strain of A/H1N1 in Mexico may be as high as 7-10%. It's extremely difficult to know because Mexico completely dropped the ball on this. They ignored all of the WHO guidelines for tracking and reporting on flu pandemics. No one knows how many people down there came down with it or when it actually started. There were hundreds of people, mostly school children, who came down with the flu in Vera Cruz in early March. They're saying 1,600 suspected cases but the true number is almost certainly much higher than that, which would reduce the mortality rate.

[Ninong]

Here are the most recent newly revised numbers out of Mexico:

149 deaths, 20 confirmed as swine flu and the rest suspected.

1,995 people in Mexico hospitalized with pneumonia suspected as resulting from swine flu.

Mexico has closed all schools nationwide until May 6.

P.S. -- The reason only 20 of the deaths in Mexico have been confirmed as being swine flu is because it takes time for them to send specimens to the WHO in Canada and wait for the test results.

[Ninong]

U.S. Human Cases of Swine Flu Infection

State, number of laboratory confirmed cases:

California 10
Kansas 2
New York City 45
Ohio 1
Texas 6

TOTAL COUNT 64 cases

As of April 28, 2009 11:00 AM ET

[Ninong]

WHO Scientific Review on the current outbreaks of human infections with swine influenza to be held on 29 April

WHO is convening a Scientific Review on 29 April in response to requests from the scientific community for more detailed scientific information on swine influenza.

Experts from the affected countries will provide an update on the current situation and discuss what is known about the disease from a virological, epidemiological and clinical perspective.

A report from the review will be posted on the WHO swine influenza page shortly after the meeting.

P.S. -- We are now at Level 4 on a scale of 1-6.

[lostcreekreefer]

It is interesting to see the panic evoked by this virus (I am referring to people in the area where I live). Influenza is one of those rarer viruses that can infect multiple animal species. Various strains tend to hang out in their preferred host species (be it a person, a pig, a horse or a bird). On rare occasions you can get somebody simultaneously infected with more than one strain of the influenza virus, and both or all 3 viral strains are replicating within the host and THEN you get a very new strain with a unique combination of surface antigens (they all sort out during the process) that none of us have seen, so it easily spreads 'cuz it's new (to us). That's just the way it works, the process takes people in close proximity to birds or pigs or.... Maybe this strain or one very much like it was around 50-60-70 years ago, but all of those folks have passed away, so now you have a nice large immunologically naive (lacking experience) population to infect...good news if you are the virus, bad news if you're a member of the naive population (all of US!). Moral of the story...we have massively better health care in 2009, drugs that work and epidemiological knowledge of how this virus works. My understanding is that simple hand washing frequently during the day when you're in contact with other members of the naive population, avoid hand to nose contact, avoiding geographic areas with high rates of infection (wait on travel if you can) and less or no gathering together of large populations (like the soccer matches in Mexico that had NO spectators...it would be like a NASCAR race with no mobile homes in the infield & empty stands!) for a while should help to slow or stop the spread of the disease. I like living in Montana (no large populations....we're out in the sticks) manly for that reason. It is a virulent virus, but at the same time we can use some common sense (wash your hands & avoid groups for a while) and it will get better over time.

[Ninong]

U.S. Human Cases of Swine Flu Infection

State, number of laboratory confirmed cases:

Arizona 1
California 14
Indiana 1
Kansas 2
Massachusetts 2
Michigan 2
Nevada 1
New York City 51
Ohio 1
Texas 16 + 1 death

TOTAL COUNTS: 91 cases + 1 death

As of April 29, 2009, 11:00 AM ET

The one death was a 23-month-old Mexican boy who was visiting with his family in Texas. He died in a Houston hospital.

It is important to remember that these are only laboratory confirmed cases.

Mexico, for instance, has only 26 laboratory confirmed cases plus 7 laboratory confirmed deaths, according to the WHO as of yesterday. Mexico's actual numbers are much, much higher than that. They have more than 2,000 people who have been hospitalized with severe cases and more than 180 deaths suspected as being from H1N1 virus.

There have been no estimates (that I have seen) of the total number of people infected in Mexico who may have had mild cases that did not require hospitalization. The first reports of flulike symptoms were from La Gloria (Veracruz) Mexico, where 500 people out of a population of 3,000 became ill. The government sent in people to spray for flies. They have only one laboratory confirmed case of H1N1 there and that's that little five-year-old boy who came down with it in March and recovered within four or five days. Two people died from flulike symptoms there but so far it's just this one little boy whose specimen came back positive for this particular strain of H1N1.

It's really not certain if it originated in La Gloria or in Southern San Diego county, California. There was one reported case in San Diego country before this little Mexican boy became ill but there could have been other cases in La Gloria in February that were H1N1 that haven't been tested. As of yesterday, Mexico had only 26 laboratory confirmed cases and 7 laboratory confirmed deaths. Their actual numbers are much, much higher than that.

[Ninong]

It is a virulent virus, but at the same time we can use some common sense (wash your hands & avoid groups for a while) and it will get better over time.

It may die down over the next few weeks and then come back stronger than ever in the fall, which is exactly what happened in the 1918-1919 H1N1 pandemic.

We really don't know yet why the cases in the U.S. appear to be milder than the cases in Mexico. The laboratory confirmed cases in the U.S. are all identical matches for the laboratory confirmed cases in Mexico, so it's the same virus.

What we really need is a specific vaccine but that takes time to develop and most of the companies that manufacture flu vaccines are located in Europe. The available supply will be extremely limited compared to the potential worldwide demand. Governments where production facilities are located can be expected to act to protect the needs of their own citizens first.

[lostcreekreefer]

they are bantering around figures of 6 months for isolation, attenuation, testing & vaccine production. Not much help now, but like you said Ninong, mebbe this fall...

[Ninong]

Supplies of the new vaccine will be extremely limited; however, since only 39% of Americans believe in evolution, they will be the only ones needing the vaccine. A new virus would violate the laws of special creation, so obviously all of those nice folks who don't believe in evolution should have nothing to worry about.

[Ninong]

Level 5: "Pandemic Imminent"

The WHO in Geneva, Switzerland has just raised the alert level to Level 5 on a scale of 1-6. This was just announced by Dr. Margaret Chan, head of the WHO, at a late night press conference in Geneva.

Dr. Margaret Chan, the U.N. agency's director-general, said the decision means that all countries should "immediately" activate pandemic preparedness plans.

"This change to a higher phase of alert is a signal to governments, to ministries of health and other ministries, to the pharm industry and the business community that certain actions now should be taken with increased urgency and at an accelerated pace," Chan said.

[Ninong]

U.S. Human Cases of Swine Flu Infection

State, number of laboratory confirmed cases:

Arizona 1
California 14
Indiana 1
Kansas 2
Massachusetts 2
Michigan 1
Nevada 1
New York City 50
Ohio 1
South Carolina 10
Texas 26 + 1 death

TOTAL COUNTS: 109 cases + 1 death

As of April 30, 2009, 10:30 AM ET

P.S. -- Don't forget, those are laboratory confirmed cases only. And, by laboratory confirmed, they mean a match for this particular strain of H1N1.

For example, in the San Francisco Bay Area, there are dozens of cases right now that have been confirmed as Type A influenza -- because that can be done at local labs -- but they're still waiting on confirmation from the CDC that these cases are an exact match for this particular strain, what HHS wants us to call "The 2009 H1N1 influenza virus" instead of swine flu.

The same goes for Mexico. You can't go by Mexico's laboratory confirmed cases because they aren't getting everybody sampled and tested by the WHO. Mexico has more than 2,000 people hospitalized with serious flu illness that they suspect is this strain of H1N1 and they have had more than 160 deaths that they attribute to this strain, but very few specimens have been laboratory confirmed. According to the WHO, Mexico has only 97 laboratory confirmed cases, including 7 deaths.

Sooner or later we are going to have to go with estimates based on the number of people who get sick and the number of deaths because the WHO and the CDC won't be able to test all of the specimens from all of the people who get this if it really takes off. Right now it looks like it's spreading all over the world at a very rapid rate. There are at least 500 cases in the U.S. right now but only 110 have been laboratory confirmed.

So far, there are 11 different countries with laboratory confirmed cases of the 2009 H1N1 flu virus: U.S. 109 cases plus 1 death, Mexico 90 cases, plus 7 deaths, The following countries have laboratory confirmed cases but no deaths: Austria (1), Canada (19), Germany (3), Israel (2), Netherlands (1), New Zealand (3), Spain (13), Switzerland (1) and the United Kingdom (8). There are several other countries with suspected cases and there have been deaths that are suspected as being from the 2009 H1N1 flu virus that have not yet been laboratory confirmed.

The actual number of cases is much, much higher than the WHO's laboratory confirmed numbers.

[Ninong]

Here's the latest update from the CDC. Notice that they're still calling it "swine flu." HHS wants us to stop calling it that because it's hurting pork sales and exports. They say we should call it "The 2009 H1N1 Influenza Virus."

Swine Influenza (Flu)

Swine Flu website last updated April 30, 2009, 10:30 AM ET

In response to an intensifying outbreak in the United States and internationally caused by a new influenza virus of swine origin, the World Health Organization raised the worldwide pandemic alert level to Phase 5 on April 29, 2009. A Phase 5 alert is a “strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.”

The United States Government has declared a public health emergency in the United States. CDC’s response goals are to reduce transmission and illness severity, and provide information to help health care providers, public health officials and the public address the challenges posed by this emergency. CDC is issuing and updating interim guidance daily in response to the rapidly evolving situation. CDC’s Division of the Strategic National Stockpile (SNS) continues to send antiviral drugs, personal protective equipment, and respiratory protection devices to all 50 states and U.S. territories to help them respond to the outbreak. The swine influenza A (H1N1) virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. In addition, the Federal Government and manufacturers have begun the process of developing a vaccine against this new virus.