H5N1

Ukraine: A little good news from WHO

Via WHO/Europe: Health facilities in Ukraine well prepared for pandemic (H1N1) 2009 influenza. The whole report:

On Wednesday, 11 November, the last WHO regional investigation team returned to Kyiv. While the teams have yet to finish drawing conclusions, they found health facilities in Ukraine well prepared and highly motivated to deal with the influx of cases. 

In separate meetings with the Prime Minister and the President of Ukraine on Monday, 9 November (also attended by the ministers of Foreign Affairs and Health), the WHO mission thanked the Government for its openness and providing unrestricted access to facilities and data. 

The discussion focused on further action needed to combat the disease, particularly vaccinating the main risk groups in the population. WHO once more offered its full support in all necessary activities. 

On 11 November, the Ministry of Health arranged and led a teleconference in Kyiv, connecting 486 hospitals and nearly 10 000 doctors in all 27 regions of Ukraine to facilitate sharing of clinical experience and lessons learned in fighting the pandemic (H1N1) 2009 virus. 

Clinicians in the worst affected areas had detailed discussions on what therapies they had used and how these could be adapted for the future. The participants discussed a wide range of issues and developments, including primary, obstetrical and intensive care and the essential supplies and equipment that were currently available and being mobilized.

This is encouraging, after days of sensing something really dysfunctional in Ukraine's response to H1N1. 

But I wonder about those "separate meetings with the Prime Minister and President"...do they refuse even to be seen together under the same roof? And when will we get some reliable data on confirmed H1N1 cases and deaths?

Ukraine: 239 deaths? Or 16?

Via RIA Novosti in Russia: Flu death toll in Ukraine rises to 239 - Health Ministry. True? Your guess is as good as mine, and the story doesn't help matters. Excerpt:

The number of deaths in Ukraine from flu viruses has risen to 239, with 26 passing away over the past 24 hours, the Health Ministry said Thursday. 

The ministry said earlier that 15 regions in the ex-Soviet republic had already crossed the flu epidemic threshold, while 11 provinces were close to it. The Ukrainian government imposed quarantine in nine western provinces in late October in an attempt to curb the spread of flu. 

All educational establishments in the capital Kiev were closed, and people were obliged to wear medical masks in all catering establishments, shops and social services facilities across the former Soviet republic. 

Eighty-five cases of swine flu (H1N1 strain), including 16 deaths, have been confirmed in the country.

So have 239 died, or have 16? And from H1N1, or from "flu viruses"? It all depends on how much of the story you read. And maybe what you want to believe.

US: "Mr. Fielding, tear down this wall"

Via LA Daily: Mr. Fielding, Tear Down This Wall. Excerpt:

The folks at Neon Tommy, the USC School of Communication and Journalism publication, have written an open letter to Dr. Jonathan Fielding, the county's director of public health, asking him to be more forthcoming about how the county is dealing with the 57-death swine flu outbreak here. So far they've heard crickets. ​ 

Neon Tommy recently obtained the county's H1N1-related death certificates, but not without a fight. But the publication finds that Fielding, a public official accountable to the tax payers of the county, is less than willing to deal with their pesky questions. 

On Wednesday on KCRW (89.9 FM) show Which Way L.A. Fielding declined to address direct inquiries from Neon Tommy's Callie Schweitzer. Oh how we love aloof public servants who think they are above dealing with the press and the democratic process. Maybe we should call it the department of private health. 

Apparently Neon Tommy feels the same and has written open letter to Fielding which reads, in part: 

"What is the process for hospitals and physicians reporting swine flu deaths? What exactly are the 2,000 health department workers devoted to the influenza epidemic doing? What's the process for fixing death certificates so that they accurately list H1N1 after post-death tests, which can take up to eight weeks?"

Infection and death from influenza A H1N1 virus in Mexico: a retrospective analysis

Via The Lancet: Infection and death from influenza A H1N1 virus in Mexico: a retrospective analysis. The abstract:

Background 

In April, 2009, the first cases of influenza A H1N1 were registered in Mexico and associated with an unexpected number of deaths. We report the timing and spread of H1N1 in cases, and explore protective and risk factors for infection, severe disease, and death. 

Methods 

We analysed information gathered by the influenza surveillance system from April 28 to July 31, 2009, for patients with influenza-like illness who attended clinics that were part of the Mexican Institute for Social Security network. We calculated odds ratios (ORs) to compare risks of testing positive for H1N1 in those with influenza-like illness at clinic visits, the risk of admission for laboratory-confirmed cases of H1N1, and of death for inpatients according to demographic characteristics, clinical symptoms, seasonal influenza vaccine status, and elapsed time from symptom onset to admission. 

Findings 

By July 31, 63 479 cases of influenza-like illness were reported; 6945 (11%) cases of H1N1 were confirmed, 6407 (92%) were outpatients, 475 (7%) were admitted and survived, and 63 (<1%) died. Those aged 10—39 years were most affected (3922 [56%]). Mortality rates showed a J-shaped curve, with greatest risk in those aged 70 years and older (10·3%). Risk of infection was lowered in those who had been vaccinated for seasonal influenza (OR 0·65 [95% CI 0·55—0·77]). Delayed admission (1·19 [1·11—1·28] per day) and presence of chronic diseases (6·1 [2·37—15·99]) were associated with increased risk of dying. 

Interpretation 

Risk communication and hospital preparedness are key factors to reduce mortality from H1N1 infection. Protective effects of seasonal influenza vaccination for the virus need to be investigated.

Health officials cite growing flu alarm in Asia

Via the New York Times: Health Officials Cite Growing Flu Alarm in Asian Nations. Excerpt:

Emergency supplies of antiviral drugs are being sent to Ukraine, Afghanistan and other countries in Eastern Europe and Central Asia, where hospitals report that they are being overwhelmed by patients with swine flu, the World Health Organization said Thursday. 

Ukraine in particular has “a shortage of ventilators and they have counted more than 100 deaths by now,” Dr. Nikki Shindo, a medical officer with the organization’s global influenza program, said at a news briefing. 

Alarmed by deaths that health authorities believe could have been prevented with rapid treatment, the agency said it was revising its guidelines and urging more people to take antiviral medication even before they are sure they have the flu. 

The new guidelines say that anyone with flu-like symptoms for three days, along with people in several high-risk groups — pregnant women, children under 2 and people with underlying respiratory problems — should not wait for laboratory tests to confirm the diagnosis but should be treated right away with drugs like Tamiflu. 

“The pandemic virus can cause severe pneumonia even in healthy young people,” Dr. Shindo said, adding that “the virus can take life within a week.” 

“The window of opportunity is very narrow to reverse the progression of the disease,” she said. “The medicine needs to be administered before the virus destroys the lungs.” 

Although antiviral medications are most effective when used within 48 hours after symptoms start, Dr. Shindo said the drugs should be given even after that if a person is very sick. 

Dr. Shindo said the guidelines, similar to those in use in the United States, had not been adopted sooner because the agency was not yet confident, as it is now, about the safety and efficacy of the antivirals, Tamiflu and Relenza. Doctors there were also worried about shortages. 

The agency said the countries most affected were Afghanistan, Mongolia, Belarus, Ukraine, Azerbaijan and Kyrgyzstan. The first four have already been sent supplies; the other two are to receive them soon.

India: 514 deaths

Via India's Press Information Bureau: Consolidated status of influenza AH1N1 as on 12th November 2009. This is a table listing confirmed cases and deaths, by state and nationally. For November 12: 

Today's confirmed H1N1 cases: 154

Cumulative cases: 15,016

Today's confirmed H1N1 deaths: 6

Cumulative deaths: 514

New Zealand: 20 deaths

Via Newstalk ZB, a radio station: Swine flu victim dies, brings toll to 20. Excerpt:

A 43-year-old woman from Timaru is the 20th New Zealander to die with swine flu, after battling it for three months. 

The Ministry of Health says it was advised of the death on Wednesday. The woman was in an intensive care unit in Auckland. 

Deputy director of public health Dr Fran McGrath says swine flu is still a risk. 

"While for the majority of people it's a moderate illness, or even a very mild illness, there are some people for whom it can develop into a very severe illness and it can develop quite quickly."

Bulgaria: 12 deaths, 634 cases

Via Novinite.com: Bulgaria Swine Flu Fatalities Increase, 12 Deaths Confirmed. Excerpt:

Medical authorities have announced on Thursday that the total number of confirmed deaths from swine flu in Bulgaria has risen to twelve. 

This followed an announcement earlier on the same day which confirmed that another person, a citizen of Razgrad, had also died of complications caused by the virus. 

Tests carried out by the National Reference Laboratory (NRL) have now confirmed that a 33-year-old woman who died in a Shumen hospital on November 8, had contracted swine flu. 

Krasimira Yankova, who came from Radko Dimitrievo, a village near Shumen, died of double pneumonia on Sunday, becoming the 11th victim. Initial rapid tests had failed to show evidence of swine flu, but the test samples sent to the NRL confirmed the presence of the A(H1N1) virus, according to Dr.Victor Minchev, Director of the Shumen general hospital. Medical staff are now trying to track down anyone who may have been in contact with the victim. 

Bulgaria's Chief Epidemiologist, Dr. Angel Kunchev, has stated that 634 cases of swine flu have been positively identified with a total of 1673 cases being tested. 

Dr. Kunchev has explained that, from a medical point of view, there is no point in mass testing for the A(H1N1) flu, because 90% of the cases have that virus.

Canada: Flu may have levelled off

I've posted a new Hook item at The Tyee about today's press conference with our provincial health officer: Kendall: Flu may have levelled off. The item includes the surprising news that Canada has suffered 26 more flu deaths in the past 48 hours—and 24 of them have been in Ontario. 

This is a real spike; the November 10 tally showed Ontario with no new deaths from November 5-10, and only 37 cumulative deaths from the beginning of the pandemic last spring. I'll try to learn more about this.

The best pandemic book yet

The Tyee has just published my review of Alan Sipress's book The Fatal Strain: What Bird Flu Can Teach Us about Swine Flu. In my opinion it's the best book yet on the current pandemic and its origins. Excerpt:

As Sipress says, "I would come to learn that every Asian country with major outbreaks in livestock had hidden them from view, for months or even longer... But even then, when it became untenable for governments to keep up the lie, they often chose to discount the danger rather than mount a serious campaign to defeat it. Instead of attacking the virus, they too often went after the scientists, journalists, and other whistle-blowers who tried to reveal the threat." 

This may explain one frustrating aspect of blogging bird flu: The lack of media coverage and local blogs in the hot zones. During SARS, blogs in China had covered the outbreak in detail -- not only local Chinese blogging in English, but foreign teachers telling the world how the disease was affecting their own schools and communities. 

So it's now clear, thanks to Sipress, that the hot-zone countries were systematically lying to the world, and WHO couldn't do much about it.

US: CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States

The CDC has published CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States. The full document is quite long and contains links to several PDFs. Here's an excerpt, followed by my comments:

Method to Estimate 2009 H1N1 Cases, Hospitalizations and Deaths 

CDC has developed a method to provide an estimated range of the total number of 2009 H1N1 cases, hospitalizations and deaths in the United States since April, 2009, as well as a breakdown of these estimates by age groups. This method uses data on influenza-associated hospitalizations collected through CDC’s Emerging Infections Program (EIP), which conducts surveillance for laboratory-confirmed influenza-related hospitalizations in children and adults in 62 counties covering 13 metropolitan areas of 10 states. 

To determine an estimated number of 2009 H1N1 hospitalizations nationwide, the EIP hospitalization data are extrapolated to the entire U.S. population and then corrected for factors that may result in under-reporting using a multiplier from “Estimates of the Prevalence of Pandemic (H1N1) 2009, United States, April–July 2009.”.  The lower and upper hospitalization estimates also are calculated using the EIP hospitalization data. The national hospitalization estimates are then used to calculate deaths and cases. Deaths are calculated by using the proportion of laboratory-confirmed deaths to hospitalizations reported through CDC’s web-based Aggregate Hospitalization and Death Reporting Activity (AHDRA). 

Cases are estimated using multipliers derived from “Estimates of the Prevalence of Pandemic (H1N1) 2009, United States, April–July 2009.”  The lower and upper end of the ranges for deaths and cases are derived from the lower and upper hospitalization estimates. The methods used to estimate impact may be modified as more information becomes available. More information about this methodology is available.  

Throughout the remainder of the 2009 H1N1 pandemic CDC will update the range of estimated 2009 H1N1 cases, hospitalizations and deaths every three or four weeks. While EIP data is reported weekly during influenza season, because the system is based on reviews of patients medical charts there are sometimes delays in reporting and it can take some time for all the data to fill in. 

CDC will continue to provide weekly reports of influenza activity each Friday in FluView and will update the 2009 H1N1 Situation Update each Friday as well. 

The estimated ranges of cases, hospitalizations and deaths generated by this method provide a sense of scale in terms of the burden of disease caused by 2009 H1N1. It may never be possible to validate the accuracy of these figures. The true number of cases, hospitalizations and deaths may lie within the range provided or it’s also possible that it may lie outside the range. 

The underlying assumption in this method is that the level of influenza activity (based on hospitalization rates) in EIP sites matches the level of influenza like illness (ILI) activity across the states. 

This methodology is not a predictive tool and cannot be used to forecast the number of cases, hospitalizations and deaths that will occur going forward over the course of the pandemic because they are based on actual surveillance data. 

The Numbers 

•CDC estimates that between 14 million and 34 million cases of 2009 H1N1 occurred between April and October 17, 2009. The mid-level in this range is about 22 million people infected with 2009 H1N1. 

•CDC estimates that between about 63,000 and 153,000 2009 H1N1-related hospitalizations occurred between April and October 17, 2009. The mid-level in this range is about 98,000 H1N1-related hospitalizations. 

•CDC estimates that between about 2,500 and 6,000 2009 H1N1-related deaths occurred between April and October 17, 2009. The mid-level in this range is about 3,900 2009 H1N1-related deaths.

Let's take the CDC mid-level estimates for cases and deaths. They give us a case fatality ratio of .017, which is mercifully small. 

Suppose the CFR had been 2 percent, about what the US suffered during the Spanish flu of 1918-19. That would have taken the lives of 440,000 Americans between last April and October 17, and millions more around the world.

If the CFR had been the 60 percent experienced by victims of H5N1 avian flu, the US death toll so far this year would have been 13,200,000.

In either case, we would not be living in the world we see around us today.

This is why I get a little impatient with the folks who complain about the hype surrounding H1N1. They don't realize how lucky we've been, and how the reasonable worries about higher CFRs drove the public-health authorities to hope for the best but plan for the worst...because the worst could have been truly horrific.

Canada: Not much economic harm from H1N1

Via the Globe and Mail: H1N1 economic hit likely mild: TD. Excerpt:

For all the misery the H1N1 pandemic is causing people felled by the flu bug, the outbreak is unlikely to reach the point where it depresses overall economic activity in Canada, the Toronto-Dominion Bank said Thursday. 

“In the unlikely case of a more severe outbreak, increased employee absenteeism due to illness could have a negative – albeit temporary – impact on hours worked and, therefore, economic activity,” TD economist James Marple said in a report on the possible economic impact of H1N1. 

At this point, however, the economic prognosis is not that dire, Mr. Marple said.

 “Fears about H1N1 have heightened concern over the state of North American economies. While the impact on human lives should not be understated, at the current stage we do not believe the disease will reach a large enough scale to have a noticeable effect on aggregate economic activity,” he said.

UK: Swine flu cases drop in England

Via BBC News: Swine flu cases drop in England. Excerpt:

The number of new swine flu cases in the past week fell by nearly a quarter to 64,000 in England, figures show. 

But experts warned against assuming the pandemic had peaked, saying it could be a "half-term effect" - flu rates tend to be higher when schools are open. 

Chief Medical Officer Sir Liam Donaldson said next week's figures should give a fuller picture. 

Meanwhile, in other parts of the UK there were slight rises as the number of deaths hit 182. About 21,500 people are estimated to have caught the virus in Scotland up from 17,500 the week before. Figures were much lower in Wales and Northern Ireland.

US: For children with flu, a trip to the ER?

Via the New York Times, Dr. Howard A. Zucker writes: For Children With Flu, a Trip to the E.R.? Excerpt:

The H1N1 virus, commonly called swine flu, is more likely to afflict youngsters and poses special challenges in this age group, since children with the flu are more apt to develop respiratory distress than adults with the illness. And the younger the child is, the greater the likelihood that increasing respiratory distress will require emergency care. 

In fact, children younger than 2 are more than twice as likely to require hospitalization for H1N1 than those ages 2 to 4. And 2- to 4-year-olds are 20 percent more likely to require hospitalization than children 5 to 17. 

Each child is different in how he or she responds to colds and flu, but grunting, flaring of the nostrils and pulling in of the muscles between the ribs with each breath can be signs of respiratory problems that may ultimately require hospitalization. It is wise to at least call the pediatrician when such symptoms occur. 

It is also prudent to seek medical attention early if there is an escalation of these symptoms, even if they occur over a few hours. A child whose breathing is labored requires prompt medical attention. 

A heightened sense of concern is warranted when a child of any age develops confusion, bluish tinge to the skin, irritability that is inconsolable and increasing shortness of breath. These serious symptoms merit emergency care, including a visit to the emergency room or a call to 911. 

Deciding whether to seek emergency care can be a hard call. I would tell friends that they should call 911 if their children are having a lot of respiratory distress and look gravely ill. It is often good to ask, Is this the worst that your child has ever looked?

Belarus: 165 H1N1 cases

Via Charter'97: Epidemic grows: 165 swine flu cases. Excerpt:

According to official data, the number of A(H1N1) pandemic have increased by 63 in Belarus over the last four days. 

According to the Ministry of Health of Belarus, 165 laboratory confirmed cases of A(H1N1) flu have been detected since May 2009 BelaPAN reports. 

As of November 9, the Republican Scientific and Research Center of Epidemiology and Microbiology, 128 laboratory confirmed cases of diseases caused by A(H1N1) virus. 

Deputy minister of health and chief sanitary officer Valyantsina Kachan said on November 8 that 102 cases were recorded in Belarus. According to official information (as of November 4) 7 persons died from swine flu. 

Thus, in accordance with official statistics, the number of patients suffering from swine flu has increased by 63 over four days.

Iran: 58 deaths

Via Xinhua: Death toll of A/H1N1 flu reaches 58 in Iran. Excerpt:

Iran's Health Ministry said the influenza A/H1N1 has claimed the lives of 58 people across the country as the national tally of infections passes 2660, local satellite Press TV reported on Thursday.     

"More Iranians died last week from the A/H1N1 flu, raising the number of A/H1N1-related deaths in the country to 58," said the director of the Health Ministry's Center for Disease Control Mohammad-Mehdi Gouya.     

Iran's Ministry of Education officials have closed many schools around the country amid rising fears of an A-H1N1 flu epidemic. On Tuesday, officials closed more than 100 schools in Iran's northwestern province of Zanjan, the report said.

Finland: H1N1 is nationwide

Via YLE: Swine Flu Epidemic Nationwide. Excerpt:

The H1N1 swine flu has reached epidemic proportions nationwide. As of Thursday 2940 cases had been confirmed, but estimates are that tens of thousands of people have contracted the disease. 

The Ministry of Social Affairs and Health is now recommending that employers be more lenient than normal in granting leaves of absences due to illness. This, it says, will help in focussing health care resources on swine flu patients and the vaccination programme. 

Most cases of the swine flu in Finland are relatively mild, although certain groups, such as people with serious pre-existing medical conditions are at risk. 

The Ministry of Social Affairs and Health reported Thursday that slightly more people are expected to come down with the H1N1 virus than is normal for seasonal flu viruses. 

So far, the vaccination programme has provided protection to healthcare sector workers and pregnant women. Finland ordered 5.3 million doses of the vaccine last summer. 794,000 doses have been delivered and the remainder is arriving at a rate of around 200,000 doses a week.

Korea: 64 deaths

Via Xinhua: S Korea reports 12 more A/H1N1 death cases. Excerpt:

South Korea on Thursday reported 12 additional death cases related to A/H1N1 flu, raising the country's death toll from the new contagious disease to 64.     

Among the latest victims, a 18-year-old woman who has long suffered from chronic disease and eight others were considered as "high-risk" patients. 

However, the remaining three, including a six-year-old boy and a 39-year-old woman, both lived in Seoul, and a 56-year-old woman in ChungCheong Province, were not considered to be high-risk, according to the government's central disaster relief headquarters.     

Out of the 64 who died from the A/H1N1 flu, 53 patients were regarded as "high-risk" patients and 11 others were not, the health authorities said.     

Meanwhile, around 150,000 students from 380 schools across the nation received A/H1N1 vaccinations on Thursday.

Canadians think H1N1 risks exaggerated: poll

Via CBCnews.ca: Canadians think H1N1 risks exaggerated: poll. Excerpt:

Canadians are evenly split over the federal government's handling of the swine flu, but more than half believe concerns over the risk of H1N1 are exaggerated, a new poll by EKOS indicates. 

In the poll, conducted exclusively for CBC News, Canadians were asked their opinion of the public level of concern over the risks associated with the virus. 

Fifty-three per cent said the level of concern about swine flu is exaggerated, considering the real risks involved with the virus. Thirty-seven per cent said the concern was consistent with the level of risk, and 10 per cent said the level of risk was understated. 

More men than women thought the risk was exaggerated, as did younger Canadians compared with older ones, the poll said. 

A third of Canadians surveyed said they will definitely get the H1N1 vaccination, but a quarter said they will not. Ironically, older Canadians aged 65 and up are more likely to get the shot than younger Canadians who are considered at higher risk. Canadians in Atlantic Canada and Quebec were also more likely to get the shot than those in other regions. 

The poll also found that while 39 per cent of Canadians approve of the government's handling of the virus's threat, 39 per cent disapprove. About 22 per cent did not know or had no response. 

Canadians had a more favourable view of their provincial or municipal governments' handling of the issue, with 42 per cent indicating their approval and 35 per cent disapproval.

Canada: Cost of vaccinating the nation hits $1.5-billion and climbing

The front page story in today's Globe and Mail is by Paul Waldie and Caroline Alphonso: Cost of vaccinating the nation hits $1.5-billion and climbing. Excerpt:

Vaccinating Canadians against H1N1 is costing the country nearly twice as much as health officials expected and the tally could easily climb above $2-billion before the pandemic has subsided. 

The national inoculation program is only a few weeks in, but $1.51-billion is already being spent, according to a review of estimates from federal, provincial and territorial governments. 

The actual figure is likely much higher because many provinces are still revising their costs while others have yet to release total estimates. 

Even at $1.51-billion, the vaccination effort is proving far more expensive than health officials estimated. In September, provincial and territorial health ministers predicted the cost of buying the vaccine and delivering it at around $16 a dose, or $806-million in total based on the 50.4 million doses ordered. The total cost is currently running at about $30 a shot and climbing. 

"I think we said right from the beginning that the on-the-ground part of this was probably always the biggest obstacle," said Kumanan Wilson, public-health policy chair at the Ottawa Hospital Research Institute.  

"It's always what people underestimate and this is a huge operation. We've seen that play out, the difficulty in running this program." 

Dr. Wilson said it won't be known whether the money being spent on this vaccination campaign is justified until after the virus passes. 

If rolling out the vaccine in October, instead of November as previously planned, helped protect a large segment of the population and did not hinder workplace productivity, then the cost is justified, he said. 

"We're sort of in the grey zone, is it worth it or not? We'll have to see how this plays out to determine that. If there is a potential third wave and the vaccine program has helped mitigate that in Canada ... then it still may be worth it," Dr. Wilson said.