A doctor vaccinates a patient in a municipal vaccination centre in Nice, southeastern France. — Reuters pic
WASHINGTON, Sept 17 — The death rate from the pandemic H1N1 swine flu is likely lower than earlier estimates, an expert in infectious diseases said yesterday.
New estimates suggest that the death rate compares to a moderate year of seasonal influenza, said Dr Marc Lipsitch of Harvard University.
“It’s mildest in kids. That’s one of the really good pieces of news in this pandemic,” Lipsitch told a meeting of flu experts being held by the US Institute of Medicine.
“Barring any changes in the virus, I think we can say we are in a category 1 pandemic. This has not become clear until fairly recently.”
The Pandemic Severity Index set by the US government has five categories of pandemic, with a category 1 being comparable to a seasonal flu epidemic.
Seasonal flu has a death rate of less than 0.1 per cent — but still manages to kill 250,000 to 500,000 people globally every year.
A category 5 pandemic would compare to the 1918 flu pandemic, which had an estimated death rate of 2 per cent or more, and would kill tens of million of people.
An estimate published in the journal Eurosurveillance last month by the French Institute for Public Health Surveillance put the mortality rate far higher, at 0.4 per cent for all age groups.
Lipsitch took information from around the world on how many people had reported they had influenza-like illness, which may or may not actually be influenza; government reports of actual hospitalizations and confirmed deaths.
He came up with a range of mortality from swine flu ranging from 0.007 per cent to 0.045 per cent.
Either way, having new information about how many people were infected and did not become severely ill or die makes the pandemic look very mild, he said.
“The news is certainly better than it was in May and even better than it was at the beginning of August,” Lipsitch said.
But another expert cautioned this does not mean the pandemic will not have severe effects on people and communities because it will infect more people than seasonal flu usually does in any given year.
“This is not a severe pandemic,” said Dr. Jeffrey Duchin of Seattle & King County Public Health and the University of Washington.
“We are going to see probably twice as many people die from the flu as we do in a typical flu season. That is tens of thousands of people. And many of these people are going to be younger.”
H1N1 swine flu was declared a pandemic in June after flashing around the world in six weeks, in part because most people have virtually no immunity to it. Experts all said a true death rate would not be clear for weeks because it is impossible to test every patient and because people with mild cases may never be diagnosed.
This lack of information made the epidemics in various countries and cities look worse at first than they actually were, Lipsitch said. People sick enough to be hospitalized are almost always tested first. “Yes, there’s been hype, but I don’t think it’s been an outrageous amount of hype,” Lipsitch said.
Seasonal flu is usually far worse among the elderly, who make up 90 per cent of the deaths every year. In contrast, this flu is attacking younger adults and older children, but they are not dying of it at the same rate as the elderly do during seasonal influenza, Lipsitch said. — Reuters
World Health Organisation (WHO) said (September 4, 2009) that thus far the pandemic H1N1 flu virus continues to spread extensively in many parts of the world but has not become more serious.
The WHO said it had counted 2,837 deaths worldwide but noted that not every case was being counted any more.
WHO is closely monitoring the strain, commonly known as swine flu, and has not detected any mutation which might signal that it has become more deadly.
WHO spokesman Gregory Hartl told a news briefing, “We are continuing to see increased number of deaths because we are seeing many, many more cases.” About 250,000 cases have been laboratory-confirmed worldwide, but this is far fewer than the true number according to the WHO which has stopped requiring its 193 member states to report individual cases.
Its previous update of Aug. 28 showed at least 2,185 deaths, meaning an additional 652 deaths were reported in the past week. The virus could eventually infect 2 billion people, or a third of the world’s population, according to WHO estimates.
Every year, seasonal influenza kills between 250,000 and 500,000 people globally, it says. But H1N1 is causing a year-round flu season and may infect more people than a usual seasonal virus, potentially adding up to more deaths.
“In the best case scenario we have today, we will still have a moderate virus that is projected to cause several million deaths,” Dr. Tammam Aloudat, senior health officer at the International Federation of Red Cross and Red Crescent Societies, told a separate news briefing. “Which means that even in the best case scenario, we do have an emergency on our hands, an emergency of a scale different from what we have seen before in the modern era,” he said.
PREDOMINANT VIRUS
Tropical regions of many countries in South and Southeast Asia are reporting “increasing or sustained high levels of respiratory disease”, although Thailand has reported a declining trend, according to the WHO’s latest weekly update.
In Latin America, countries including Ecuador, Venezuela, Peru and Brazil are reporting more respiratory disease, while outbreaks seem to have peaked in Chile and Argentina, it said.
Japan is seeing an early start to its regular flu season. In Canada and the United States, influenza activity remains “low overall”, despite increases in the southeastern US region.
Drugmakers are racing to develop vaccines amid experts’ warnings that a “second wave” of the virus is approaching as weather cools in the northern hemisphere and the traditional flu season starts.
Yesterday, Novartis AG said a single dose of its vaccine might protect against the virus, raising hopes that potentially tight supplies could go further when mass immunisation starts this month.
Hartl has called the preliminary results “encouraging”, noting any vaccine that can be administered in one dose would substantially increase the number of overall doses available. — Reuters
The public health measures taken in response to swine flu may be seen as alarmist, overly restrictive, or even unjustified, says a US expert in a paper published on bmj.com today.
Peter Doshi, a doctoral student at the Massachusetts Institute of Technology, argues that our plans for pandemics need to take into account more than the worst case scenarios, and calls for a new framework for thinking about epidemic disease.
Over the past four years, pandemic preparations have focused on responding to worst case scenarios. As a result, we responded to the H1N1 outbreak as an unfolding disaster. Some countries erected port of entry quarantines. Others advised against non-essential travel to affected areas and some closed schools and businesses.
Pandemic A/H1N1 is significantly different than the pandemic that was predicted, says Doshi. Pandemic A/H1N1 virus is not a new subtype but the same subtype as seasonal H1N1 that has been circulating since 1977. Furthermore, a substantial portion of the population may have immunity.
Actions in response to the early H1N1 outbreak were taken in an environment of high public attention and low scientific certainty, he argues. The sudden emphasis on laboratory testing for H1N1 in the first weeks of the outbreak helped to amplify the perceived risk.
He also points out that, since the emergence of A/H1N1, the World Health Organisation has revised its definition of pandemic flu.
The wisdom of many of these responses to pandemic A/H1N1 will undoubtedly be debated in the future, he writes. What the early response to the pandemic has shown, however, is that the public health response to, as well as impact and social experience of a pandemic, is heavily influenced by longstanding planning assumptions about the nature of pandemics as disaster scenarios.
If the 2009 influenza pandemic turns severe, early and enhanced surveillance may prove to have bought critical time to prepare a vaccine that could reduce morbidity and mortality, says Doshi. But if this pandemic does not increase in severity, it may signal the need to reassess both the risk assessment and risk management strategies towards emerging infectious diseases.
He suggests that future responses to infectious diseases may benefit from a risk assessment that broadly conceives of four types of threat based on the disease’s distribution and clinical severity.
For example,
the 1918 pandemic was a type 1 epidemic (severe disease affecting many people),
while SARS was a type 2 epidemic (infecting few, mostly severe disease),and
the H1N1 pandemic may prove to be type 3 (affecting many, mostly mild).
Public health responses not calibrated to the threat may be perceived as alarmist, eroding the public trust and resulting in the public ignoring important warnings when serious epidemics do occur, he warns.
The success of public health strategies today depends as much on technical expertise as it does on media relations and communications. Strategies that anticipate only type 1 epidemics carry the risk of doing more harm than they prevent when epidemiologically limited or clinically mild epidemics or pandemics occur, he concludes.
Contact: Peter Doshi, Doctoral Student, Program in History, Anthropology, and Science, Technology and Society, Massachusetts Institute of Technology, Cambridge, MA, USA Email: pnd@mit.edu
There is no doubt that there have been vigorous debates regarding this A/H1N1 flu pandemic, with many claiming that the overall official responses had been alarmist and over the top, starting with the WHO, and most national health authorities.
However, it is clearly mainly due to "hindsight wisdom", that one finds this highly infectious disease, so much more benign than it was feared to be, thus far. At least this seems to be the case in most Western countries, where antiviral medications have been generously dished out to anyone having ILI (flu-like illness).
That it is very contagious cannot be denied, but it is also becoming increasingly clear that most people exposed to this infection appear to have quite mild symptoms with some having none at all.
The difficult question is who amongst us have such supposedly natural immunity or who would have very mild subclinical infections at all. According to some, the similarity of the viral genome to the 1987 flu pandemic might have given immunity to many people already previously exposed--thus the milder uptake.
However, it cannot be denied that in other countries where flu outbreaks are less than perennial or seasonal in their occurrence, the outbreak has been experienced with greater ferocity of more severe ailments. Pneumonia and multi-organ breakdown appear to have afflicted more Malaysians than ever before... so this is certainly new.
The number of cases still being admitted to ICUs for critical care and mechanical respiratory support, and even dying, attest to the more virulent nature among some of our patients who have contracted this disease.
Thus, for Malaysia at least, we have much to learn about this enigmatic flu outbreak, but we do know that among the sickest patients, we have to marshal in even more appropriate and urgent life support care, so as to save more lives.
My contention is still that what we have done is appropriate and necessary, and we did modify our stance repeatedly as we learn more about the ailment.
One possible criticism may be that we had perhaps erred on the side of extreme caution and possibly some delay in dissemination of changing urgent decision pathways, including use of definitive treatment a little too late sometimes--but we have done as best can be under the circumstances.
Our weaknesses and shortcomings have been exposed, and as someone cynically had said: "that this is a timely stress test for checking the capacity and effectiveness of our entire health care system!"
Thursday's meeting (28 August 2009) with the Minister of Health, Dato' Sri Liow Tiong Lai and the Director General of Health Tan Sri Mohd Ismail Merican, was certainly a high point in timely dialogue between two seemingly disparate and separate sectors of the health service for Malaysia, particularly in the context of the current outbreak of the A(H1N1) influenza.
Among the many doctors (>60) who attended were several enthusiastic representatives from the MMA, PPSMMA, FPMPAM, PCDOM, APHM, AFPM, as well as several other interested medical practitioners from the Klang Valley, and even as far away as from Penang. It underscores the importance of such a meeting to help demystify the approach to the swine flu which has taken Malaysia by storm.
More importantly, the meeting was rather civil and accommodating with both sides cautiously trying to understand some of the undercurrents of unease which has permeated the relationship, especially whenever some untoward event related to the H1N1 occurs. The most recent recriminations took place when a woman teacher died after some supposedly possible delay in her treatment, when she had come down with the flu.
The difficulty in obtaining the antiviral drug (oseltamivir) was once again highlighted, and the restrictions in its use, were exposed, although in theory, the algorithm for managing the flu patient had been disseminated. Clinical judgement regarding moderate or severe symptoms and signs are not as clearcut as many would like to have believed.
The epidemiology of the Flu thus far was given by Dato' Dr Abdul Hassan, Director of Communicable Diseases, MOH. Dr Chris Lee gave a quick but comprehensive summary of the management guidelines as agreed to by the MOH and its task force and experts.
Clarifications were sought, with the plea by most private medical practitioners to further simplify the management of referring patients with suspected more serious complications to hospital sooner. Examples of patients being given the round around when referred for further action at various hospitals were given, which demonstrated that on the ground, practical issues still dominate the actual situation about whether the individual patient gets the treatment without too much delay. Some bureaucratic hiccups still take place, which may make the patient and doctor experiences very frustrating.
There was a further plea by the FPMPAM president, that there should not be too much finger-pointing at the private sector doctors, every time something bad or untoward occurs, because this is felt to undermine the credibility and morale of private doctors, who very often are not really to blame, and where circumstances and actual issues are the bugbears which create an environment of miscommunication and confusion.
However, in the light of the wide community spread of this H1N1 flu, there was a pledge on both sides to work harder to address these problematic areas, and ensure smoother and perhaps more constructive management of very ill patients.
Because, the MOH did not have a system in place to monitor or survey the usual flu like illness, in the country, it was felt that this makes it very hard to know if this current flu outbreak was really out of the ordinary, or perhaps just a little more virulent for some. Thus, it was agreed that GPs will assist the MOH by completing daily update notifications of all ILI, to help us maintain a closer surveillance and scrutiny of the situation on the ground.
Closer collaboration with the district MOH offices was also urged, with the plea for the MOH to circulate to all neighboring doctors any current or changed protocols so that GPs can be alerted to these more timely and accurately--the district MOH offices were felt to be the best community area to disseminate these updates.
Current changes will be notified at the MOH special H1N1 wbsite, and all doctors are urged to keep themselves apprised of changes or modifications regularly.
It was further announced that a National A(H1N1) Pandemic Influenza Conference 2009 would be organised very soon on 12 September 2009 at the Renaissance Hotel KL. This will be jointly organised by the MMA, the MOH and FPMPAM.
KUALA LUMPUR: Private doctors now have a clearer picture on how to deal with people having influenza-like symptoms.
This followed a dialogue cum briefing by Health Minister Datuk Seri Liow Tiong Lai and Director-General of Health Tan Sri Dr Ismail Merican on Thursday.
Malaysian Medical Association president Dr David Quek said the session gave them a wider view of what was expected of them in terms of managing and treating patients with influenza-like illness (ILI).
He said although doctors were doing their best to treat patients and refer those suspected of having influenza A (H1NI) to hospital, they were in a dilemma as there were no proper guidelines initially from the ministry and the World Health Organisation.
However, after four months of closely monitoring and analysing the situation, the ministry came out with its clinical guidelines on who should be treated with anti-viral drugs and also recently by the WHO.
Dr Quek said although there were policies, directives and guidelines on the handling of the H1N1 pandemic, interpretation was a problem.
He said no one, including WHO, knows much about the new virus and everyone is doing their best to handle the situation.
"There may have been slip-ups earlier in the management of cases but now doctors are clearer as to what is expected of them although we would much prefer that we be given a free hand in managing the cases."
He said the district and state health departments should explain clearly to private doctors and hospitals in their areas of the clinical guidelines.
The Federation of Private Medical Practitioners' Association of Malaysia president Dr Steven Chow said they had asked all doctors to submit the daily information on ILI cases to the ministry and said the ministry should make anti-virals affordable.
Meanwhile, Dr Ismail said another 391 people have contracted the H1N1 virus while death toll remains at 71.
The World Health Organisation (WHO) has said the swine flu virus is not affected by any variation in the temperature, the Press Trust of India (PTI) reported.
Citing cumulative report of swine flu cases and deaths from different nations around the globe, WHO said the H1N1 virus has infected people from several countries with varying temperatures.
As per a WHO report, nearly 1,800 deaths registered from across 177 countries and territories around the globe.
Dr S J Habayeb, WHO representative in India, said, "H1N1 virus has no relation to weather. Swine flu cases have been heard from countries with cold and hot temperatures."
Citing example, he said, "Swine flu cases have been equally reported from Texas, New York and California, though the temperature varies in all the three places. Texas is warmer than New York."
According to WHO, North and South America reported highest number of A/H1N1 cases, where more than 1,500 deaths have been reported.
This has been followed by European countries with over 32,000 people testing positive for the virus and more than 50 deaths reported from all over the continent.
The third most affected area is the western pacific region with over 27,000 cases already testing positive for H1N1 and 50 deaths reported from there.
It is followed by the South-East Asian region. Nearly 13,000 positive cases and 106 deaths have already been reported from different countries in this region.
Finally, the Mediterranean region has over 2,000 cases and eight deaths have been reported from there so far.
Dr Jai P Narain, Director, Communicable Diseases, WHO, said, "If cases are being reported in hot and humid climate like India, the same is also being heard about in cold country like Australia."
"All depends on the immune capacity of the people. All five continents have been affected equally," he said. - Bernama
BEIJING — The global spread of swine flu will endanger more lives as it speeds up in coming months and governments must boost preparations for a swift response, the World Health Organization said Friday.
There will soon be a period of further global spread of the virus, and most countries may see swine flu cases double every three to four days for several months until peak transmission is reached, said WHO's Western Pacific director, Shin Young-soo.
"At a certain point, there will seem to be an explosion in case numbers," Shin told a symposium of health officials and experts in Beijing. "It is certain there will be more cases and more deaths."
WHO has declared the swine flu strain a pandemic, and it has killed almost 1,800 people worldwide through last week. International attention has focused on how the pandemic is progressing in southern hemisphere countries such as Australia, which are experiencing winter and their flu season.
But it is in developing countries where the accelerated spread of swine flu poses the greatest threat as it places underequipped and underfunded health systems under severe strain, Shin said.
Governments must act quickly to educate the public, prepare their health systems to care for severe cases and protect those deemed more vulnerable to prevent unnecessary deaths, he said.
"We only have a short time period to reach the state of preparedness deemed necessary," Shin said. "Communities must be aware before a pandemic strikes as to what they can do to reduce the spread of the virus, and how to obtain early treatment of severe cases."
Pregnant women face a higher risk of complications, and the virus also has more severe effects on people with underlying medical conditions such as asthma, cardiovascular disease, diabetes, autoimmune disorders and diabetes, WHO chief Margaret Chan said in a video address.
WHO earlier estimated that as many as 2 billion people could become infected over the next two years — nearly one-third of the world's population.
Health officials and drug makers, meanwhile, are looking into ways to speed up production of a vaccine before the northern hemisphere enters its flu season in coming months. Estimates for when a vaccine will be available range from September to December.
WHO has stressed that most cases are mild and require no treatment, but the fear is that a rash of new infections could overwhelm hospitals and health authorities, especially in poorer countries.
The last pandemic — the Hong Kong flu of 1968 — killed about 1 million people. Ordinary flu kills about 250,000 to 500,000 people each year.
Swine flu is also continuing to spread during summer in the northern hemisphere. Normally, flu viruses disappear with warm weather, but swine flu is proving to be resilient.
WASHINGTON, Aug 22 – The A(H1N1) flu is still spreading widely across the United States, officials said on Friday, with 75 per cent of serious cases and 60 per cent of deaths among people under the age of 49.
The US Centres for Disease Control and Prevention has officially confirmed 7,963 hospitalisations and 522 deaths from the pandemic H1N1 flu, CDC's Dr. Jay Butler told reporters in a telephone briefing.
“It is important to remember that at this time of year we don’t normally have influenza,” Butler said.
He said the government expected to have 45 million to 52 million swine flu vaccine doses by mid October, when vaccination is expected to begin, and 195 million by the end of the year. – Reuters
Malaysian Medical Association (MMA) president Dr David Quek estimates that the current H1N1 pandemic plaguing the world is expected to run for another year or two.
Quek, however was quick to say that the majority of cases would be mild and it was those in the high risk group that needed to be cautious.
Speaking to Malaysiakini, he said "Every doctor has to be more proactive and practice more responsible and cautious medical professionalism during this trying period, which is expected to run into at least one to two years."
Doctors, he said have to be acutely aware that the initial symptoms could deteriorate into something more serious.
"Doctors must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for further more specialised care."
When asked if the medical profession's governing body was not doing enough, the MMA president said "Most of our doctors are actively engaged in looking after many flu-like illness patients. But they find many constraints due to lack of access to specific treatment modalities."
He said that the lack of available and reliable testing and difficulty in confirming such illness as A(H1N1) flu compounds the situation.
Many patients demand to know for sure if they have the flu but the doctors are thus left quite alone to fire fight angry and worried patients with very few resources or reassurances or specific therapies.
He said that it was the Ministry of Health, (MOH) that takes the lead in such matters but it needed the cooperation of all sectors to handle this situation.
While the MOH comes out with the guidelines and policies, implementing it on the ground required all parties to come together.
"The main 'leader' is of course the Ministry of Health (MOH) but the rest of us have to join forces with them to come up with a contingency plan. It is becoming increasingly clear that this is no easy task, and translating policies down to proper and appropriate practical responses and ground-level implementation can be challenging, and would be less than clockwork precision," he said.
Keeping abreast critical
Quek also advised doctors in the private sector to keep themselves updated and not just depend on official handouts as these may be late filtering down to the ground.
"It would be good if every doctor keeps a constant and close tab on the H1N1 pandemic and remains fully aware of the developments and changes, which are evolving daily. Every doctor has to be learning on the trot, so to speak, to keep up with the progress of this outbreak and its management, so that we can serve our patients better.
He said that "logging to the Internet regularly for more updated information will certainly help, instead of lamenting that not enough is being disseminated via the media thus far. Every doctor has to be more proactive and practice more responsible and cautious medical professionalism during this trying period."
Doctors he said "must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for more specialised care.
Quek called for an easier access to antiviral drugs and their responsible use and monitoring to help allay public fears of delayed treatment.
But, he warned that this should be tampered with care and not with over-exuberance "in dishing out to one and all."
"There is genuine fear that the precious antiviral drug might be used indiscriminately, just for prevention - this would be a very bad move, which could inadvertently create a worse outcome of drug resistant bugs," Quek said.
Self-qurantine and common sense
He said that in the light of the very quick deterioration of some young patients who have died, it might be prudent to use antiviral treatment earlier and more aggressively.
While there is no specific H1N1 vaccine as such, he expects one to be available by the end of the year.
"We look forward to the specific H1N1 vaccine, when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front line, heart or lung patents and frequent travelers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types", he said.
In a wide ranging interview, Quek said that most of the affected cases would be mild ones and strongly advised those exhibiting flu symptoms to self-quarantine to help curb the spread of the disease.
As a cardiologist, he said that he had a patient who came to see him and was coughing. When he asked her to take a weeks's quarantine, she was reluctant despite him giving her a medical certificate.
"I informed a young coughing patient who came to my heart clinic that she should probably come back later when she was better because her complaint was not serious. But she was incensed and was upset when I told her to self-quarantine for at least one week. She flatly refused although I was willing to give her MC (medical certificate) for the week."
The patient, he said, was actually exposing the others who were in the high risk group with heart ailments.
Quek concluded by said that the people should join forces with the authorities and medical personal to help in curbing the current pandemic by looking out for the tell-tale signs in both themselves and their loved ones.
Taking proper and commons sense measures, could go a long way, he says, in helping curb the H1N1 spread.
Below is the full text of a question-and-answer session with Malaysian Medical Association president David Quek, who has been keeping a close eye on the H1N1 pandemic.
SINGAPORE, Aug 22 — Resistance to Tamiflu has been detected in a patient in Singapore who was down with the pandemic Influenza A (H1N1) bug. Similar cases have also emerged in Hong Kong, China, Japan, Canada, the United States and Denmark.
When the novel strain first appeared in April, the antiviral worked well against it. The World Health Organisation (WHO) feels that these instances of it not working are isolated cases of resistance that have developed because Tamiflu had been used at lower, prophylactic doses in people who might have been exposed to the bug.
Because these so-called contacts were, in fact, already infected, the lower doses turned out to be suboptimal, which allowed resistance to emerge. There is no proof that resistance is circulating in the community at large, the WHO asserts.
Yet there is at least one documented case of a 16-year-old girl who fell ill while travelling from San Francisco to Hong Kong on June 11. Though she declined Tamiflu, an isolate from her was found to carry the H274Y mutation, which signals Tamiflu-resistance.
She was, however, not the world’s first case of such resistance, an honour belonging to a woman seen in Denmark in late June. When she got home from Britain, she was given Tamiflu prophylaxis. Yet she still fell ill on the fifth day of taking Tamiflu. H274Y was detected in her isolate.
Could she have been infected in Britain by someone carrying mainly Tamiflu-sensitive bugs but also a small population of resistant bugs? In that case, suboptimal Tamiflu dosage might have suppressed enough of the sensitive bugs to prevent any clinical symptoms. Over the five days, however, the resistant bugs could have replicated enough to predominate and thus cause clinical illness.
But if this is so, then the mutation must already have been circulating in Britain — which, however, has not reported any cases of Tamiflu resistance yet. Alternatively, she might have caught the resistant bug in Denmark itself, during the five days when she was well and ambulant.
One reason for suspecting community circulation of the resistant bug is that 98 per cent of all seasonal H1N1 bugs now carry H274Y. If patients are infected with both strains, that mutation could jump from seasonal flu to pandemic flu. But the WHO insists there is no evidence this has occurred, so all resistant cases must have emerged because of suboptimal Tamiflu dosages.
There are signs of community circulation in the US, at least. First, the genomics of the Hong Kong isolate where no Tamiflu was used suggests that the infection originated in the US.
Second, it was revealed only this month that a May 30 isolate taken from a young American woman returning to Singapore from Honolulu carried H274Y.
Flying on May 26, she fell ill on board the plane, was hospitalised here on May 27, was confirmed to be a H1N1 case on May 28, but was discharged on May 31 feeling well.
Although her May 28 sample was Tamiflu-sensitive, her May 30 sample had H274Y. Two days is probably too short an interval for resistance to develop from any suboptimal dosages of Tamiflu. At any rate, as a confirmed case, she would have been given the full dosage.
Thus it is entirely possible that she was infected in the US with both the sensitive and resistant strains, which her immune defences could have cleared quickly, so she was discharged fairly quickly.
Third, on Aug 15, the US authorities sent out an urgent report to physicians that two intensive care patients in Washington state who had been infected last month and treated aggressively with Tamiflu were found to have bugs with H274Y.
These four cases suggest that H274Y may already be circulating in the US. It is possible we are seeing relatively few of these isolates for a technical reason: All published genomes are consensus sequences of DNA. That is, the base that is considered to occupy a specific position on the genome is the one that occurs most frequently. But it needs do so 100 per cent of the time.
If a base occurs in only 10 per cent of viral particles, it isn’t likely to show up in the published sequence. It is only when a base occurs in, say, half the cases that it might appear in the consensus sequence.
If H274Y were found in, say, 10 per cent of viral particles, it won’t appear in the consensus sequence of samples taken from a patient prior to Tamiflu being used. Once Tamiflu is employed, the population of sensitive bugs would be drastically reduced. However, those with H274Y would flourish.
Thus, although it was already around prior to Tamiflu being used, the resistant bug would not be detected. After the drug is employed, however, the resistant bugs can grow to greater numbers than the sensitive ones, rendering them detectable.
Of course, if more samples are taken before Tamiflu is used, H274Y might be detected more often. Such comprehensive surveillance, however, would consume too much resources.
History suggests it was limited testing that enabled Tamiflu-resistance in seasonal Influenza A (H1N1) to creep up on the world unawares. The first instance of that was detected in Norway in spring last year.
By the 2008/2009 season, however, it was found in 98 per cent of bugs worldwide. Yet a re-testing of old samples showed that H274Y was already widespread by the autumn of 2007. This means it was circulating in the community before it was first detected in Norway last year.
Is history repeating itself? If so, Singapore should be stocking up on Relenza, the other antiviral that still works. — Straits Times
WHAT are the current and potential problems doctors might be facing in combating the spread of the swine flu?
It would be good if every doctor kept a constant and close tab on the H1N1 pandemic, and remained fully aware of the developments and changes, which are evolving daily. Logging on to the internet regularly for more updated information would certainly help.
(Pic by Barky / sxc.hu)
Every doctor has to be more proactive and practise more responsible and cautious medical professionalism during this trying period, which is expected to go on for one to two years. Importantly, they must assiduously look out for lung complications, quickly identify high-risk profiles, and refer these patients promptly for further specialised care.
Easier access to antiviral drugs and responsible use and monitoring would help allay public fears of delayed treatment, but this should be with care. There is genuine fear that the precious antiviral drug might be used indiscriminately for prevention; this could inadvertently create the worse outcome of drug-resistant bugs.
However, in light of the very quick deterioration and death of some young patients, it might be prudent to use antiviral treatment earlier and more aggressively.
We look forward to the specific H1N1 vaccine when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front line, heart or lung patients, and frequent travellers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types
We are facing some problems with health insurance companies. This is especially the case in private hospitals, where many insurance companies are refusing to reimburse for the treatment because it appears that pandemic illness is excluded from the contract for medical insurance. Hence, it is good that Etiqa health insurance has come forward to state publicly that the H1N1 flu is a reimbursable illness.
Is the government's current logistics capable of handling this outbreak, or a second or third wave of the flu as predicted?
It is difficult to say at this time. We certainly hope that this second or third wave will not take place. It is almost a certainty that the community spread of the A(H1N1) flu in Malaysia will escalate, and more and more Malaysians will come down with this flu.
However, the MMA wishes to reiterate that most of these infections would be quite mild and require only symptomatic treatment, bedrest and close watch at home. Only a minority (perhaps 2% to 5%) may require hospital care or more.
If these very severe complications occur in a staggered manner, then we can cope with the problem. But if a huge unprecedented outbreak of very severe complications takes place, this can easily overwhelm the system. That said, contingency plans of equipping general wards with intensive care capacities, or even field hospitals, have been made.
There are also structured plans to increase the country's intensive care bed capacity to at least twice the number available now (which is around 300 beds only). However, training sufficient staff and specialists to provide such care may require more time and expert guidance.
Should all doctors advise their patients to self-quarantine if they display symptoms?
Yes, this is the message that we have been advocating: it is best for all doctors to advise their patients to self-quarantine if they display flu-like symptoms. This is the first and most basic step in curbing the spread of the disease.
Would the MMA describe the current A(H1N1) pandemic as "out of control"?
At this juncture, the MMA does not believe that the situation is out of control and that we need any health curfew. The health minister yesterday announced that the government would only consider declaring a health curfew if the mortality rate due to influenza A(H1N1) outbreak goes above 0.4%. According to their calculations, currently, the country's mortality rate is between 0.1% and 0.4%.
Some have suggested that we shut down the country by imposing a nationwide health emergency lockdown. But this is quite futile as the disease is already in place within the community.
Microscopic view of influenza virus particles (Pic by Dr FA Murphy, Centers for Disease Control and Prevention; source: ah1n1.com)
How long should a shutdown go on for? One week, 10 days, or longer? What about the economic implications and the day-to-day running of the country and businesses? What happens when another surge appears? Do we need to have repeated cycles of national curfew?
It makes no practical sense to even consider this at this time. The actual numbers, while alarming to some, are still manageable.
So why do the growing numbers seem to imply that we are getting more and more infections, with what appears as a disproportionate number of deaths?
There is no clear or adequate answer to this. I do not believe that the Health Ministry is to blame for the forthright transparency, which it has been practising right from the outset.
There is organisational acknowledgement that our viral testing may have been less than adequate, and there have been long queues and frustrations from many worried patients, some of whom were sent home with no tests offered. Thus, there were and are many flu patients in the community who have not had confirmatory tests performed. This under-reporting would add to the lower numbers of laboratory-proven or confirmed A(H1N1) flu infections.
The World Health Organisation has estimated that for every confirmed case, there are at least another 20 patients who would have been infected. This means that most of these are not serious enough to be counted. Many would have had mild or even no symptoms. In this context, the actual numbers would have been grossly underestimated.
So it is unfair to state that the Health Ministry is manipulating the numbers to justify the growing death rate, which we have already predicted would happen simply based on the attack rate of this contagious flu.
We must inform the public that this pandemic will continue for at least another year or two, with the intensity likely to become less serious and less feared with time, unless the dreaded second wave of reassortment into a more virulent form of the H1N1 virus takes place. There is no indication that this second wave has taken place yet, even in Mexico, USA, UK or Australia.
Also, the complication rates appear to have plateaued, and most health authorities have learnt to cope with this and the expected number of deaths. The scenario in Malaysia is probably still evolving, with the peak still to come, but I would predict that the mortality rate would become less frightening as we cope with the complications better.
It is possible that many more Malaysians in the country have come into contact with this flu and are suffering very mildly from it. Most would have got better without much concern. It is those few who seem to get complications so quickly that make us afraid.
As with most communicable diseases, we will overcome this outbreak in time, but we need to be patient, vigilant and socially responsible, and work together.
THERE has been much alarm over the rising number of cases and the fatality rate of the A(H1N1) virus, and rightly so, because the A(H1N1) is infectious.
Unfortunately, 67 have already died in Malaysia. But if you were to be objective, 67 deaths, out of a possible 70,000 to 80,000 cases, amounts to a death rate of 0.08%. This is still a bit higher than the usual seasonal flu death rate of 0.04%, but surely not anywhere near panic-inducing proportions.
But while alarm and widespread panic is unnecessary, there exists the pressing need to restrategise and implement mechanisms and Standard Operating Procedures (SOP) for the prevention of secondary bacterial pneumonia.
A closer look at the deaths reveal that 80% were A(H1N1)-associated, or were incidentally found to have contracted the virus, the virus by no means causing the death.
We can call this A(H1N1)-associated death or death with incidental A(H1N1) infection. So, if the certification of death is proper, it may be that only 15 deaths were actually due to A(H1N1), giving a fatality rate of 0.02%.
The flu itself is usually a mild disease in the majority of cases. From all available clinical epidemiological evidence, the bulk of patients dying in flu pandemics are from secondary bacterial pneumonias. This has been shown to be the case in all flu epidemics and pandemics.
This is why we need to consolidate measures that are already in place. This should include a national level SOP whereby all affected patients with secondary bacterial pneumonias would be immediately triaged for intensive tertiary level care.
Indeed, we should all be vigilant, because there is an infectious disease in our midst. Good personal hygiene is crucial, now and at all times, even after this crisis. If you are not well, as always, seek medical advice.
But there is certainly no need to panic and there is no national emergency here.
There is already too much misinformation and misperception of the situation out in the lay media without having to distract the public with the hype about a national emergency.
"..Most cases described during the three pandemics of the 20th century and during seasonal influenza involve transient illness not requiring hospitalisation. Most deaths are described in the very young or the elderly or those with underlying disease. The 1918-1919 pandemic, however, was characterised by a high mortality rate in healthy young adults and an estimated CFR of 2-3% [5]. Even with a low CFR, seasonal influenza epidemics cause significant morbidity and mortality with an estimated three to five million cases of severe illness and about 250,000 to 500,000 deaths worldwide [6].
To date, the CFR attributable to the current H1N1 pandemic has been estimated at around 0.4%, based on surveillance data from Mexico and mathematical modelling [7]. This CFR is higher than that of average seasonal influenza but remains of the same order of magnitude. Whether this will change before the expected epidemic peak in the northern hemisphere in the autumn is unknown.
Evaluating CFR during a pandemic is a hazardous exercise. Aside from the issue of whether or not a death has been caused by the influenza infection, cases tend to be detected initially among severely ill patients with a higher probability of dying. This leads to an overestimation of the computed CFR at the beginning of an outbreak. The computed CFR subsequently evolves as the case reporting strategy is adapted to the situation. When the situation no longer requires exhaustive reporting of cases, the computed CFR will inevitably increase and grossly overestimate the true CFR..."
I searched the WHO and CDC websites, but couldn't find A(H1N1) statistics by country. Wikipedia has compiled the figures below, from the European Centre for Disease Prevention and Control website (daily updates, as of Aug 19, 2009) and Pan American Health Organization website, and in some cases from national websites:
1) these figures cannot be used to asess the virulence of the virus circulating in the reporting country (case fatality rate, A(H1N1) deaths divided by laboratory-confirmed cases), since the pandemic has reached the stage where lab confimration of cases would overwhelm testing capacity, and most countries are now reporting only lab confirmed fatalities, i.e. the CFR is inflated to varying degrees in different countries).
2) among Malaysia's 68 reported fatalities (lab confirmed), up to 11 cases remain ambiguous as to A(H1N1) causality, although they were virus positive. perhaps our legislators (and the media) could request clarification from the relevant authorities
3) were there unregistered migrant workers among the Malaysian fatalities? if so, was treatment delayed because they were hesitant to identify themselves to health agencies or healthcare providers?
4) since the case fatality rate is not useful at this point for tracking virulence, surveillance has now shifted to unusual clustering, changes in transmission patterns, in patient profile, in natural history of the disease, etc which might suggest an evolutionary shift. Prof Adeeba's observations of rapid decline in cases with pneumonia complications deserve close attention.
Semi-logarithmic plot of laboratory-confirmed A(H1N1) influenza cases in 2009 according to WHO reports.[102]
‡Qualitative indicators as defined by WHO[103]. Parameter values:
Geographic spread
Trend
Intensity
Impact on health care services
W(idespread)
*** (very high)
sev(ere)
R(egional)
+ (Increasing)
** (high)
L(ocal)
= (Unchanged)
* (low - moderate)
mod(erate)
N(o activity)
- (Decreasing)
(low)
low
‡‡Many countries are not recommending laboratory tests for all suspect cases. As far as known, the affected numbers have been put in brackets. Comparisons in time or between these countries should not be made. The number of confirmed cases is lower than the total number of cases,[104] and may grossly underestimate the true infection rate.[105]
********************* CHAN Chee Khoon, ScD Professor & Convenor Health & Social Policy Research Cluster Women's Development Research Centre (KANITA) Universiti Sains Malaysia 11800 Penang, Malaysia tel : + 60 4 6533437 fax : + 60 4 6566379 mobile: + 60 (0)17 4808317 email : ckchan50@yahoo.com
A doctor vaccinates a patient in a municipal vaccination centre in Nice, southeastern France. — Reuters pic
SINGAPORE, Aug 22 — Resistance to Tamiflu has been detected in a patient in Singapore who was down with the pandemic Influenza A (H1N1) bug. Similar cases have also emerged in Hong Kong, China, Japan, Canada, the United States and Denmark.
