H5N1

Coronavirus: How the lessons of SARS could save us today

Via The Observer: Coronavirus: how the lessons of Sars could save us today. After an excellent summary of the rise and spread of SARS, the story goes on:

The policy of containment and travel restriction advocated by the WHO ultimately proved successful. By the summer of 2003 the disease had all but run its course. 

It would transpire that, by happy chance, the virus was maximally infective only when patients were at their most unwell and usually already in hospital. This explained the huge risk to hospital staff but the relatively low rate of infection in the wider community. 

Deadly but unable to spread efficiently – and with Sars victims largely contained within hospitals – the virus burnt itself out in intensive care beds across the globe. 

It is for this reason that the newly reported coronavirus, principally observed in the Middle East, is of such interest. Laboratory investigations have been successful in characterising the nature of the virus. But the true lethality of the disease and the efficiency with which it might spread can only be determined by carefully monitoring its behaviour. 

For epidemiologists tracking these viruses and their rapidly evolving genomes, it is an onerous, nearly impossible task. Watching and waiting, monitoring fatalities and clusters of infection, trying to determine the right time to act. 

The coronavirus now circulating in the Middle East has some worrying features. It is capable of causing destructive pneumonias and, most recently, appears to have acquired the ability to spread from person to person. 

Nevertheless, the risk to the general public remains low. Thankfully, the cocktail of properties required to produce a dangerous pandemic have not yet arisen. It remains then for disease surveillance officials to keep up their watch. For them, knowing the right time to put public health measures in place is a difficult balancing act. 

But we should be thankful for their vigilance. This month marks 10 years since the identification of Sars, the announcement of the WHO's global health alert and the death of Carlo Urbani. It is an anniversary that deserves some recognition. These events set the template by which future outbreaks might be successfully contained. 

The experience of the 2003 Sars outbreak taught us very clearly that, for airborne viruses with pandemic potential, prevention is always far better than cure.

Australia: Drug-resistant pandemic H1N1 emerging

Via BBC News, a March 18 report: Drug-resistant pandemic swine flu 'community risk'. Excerpt:

Australian experts are concerned about the threat of a new type of drug-resistant pandemic flu that is circulating in the population at large. 

The swine flu strain has learned how to dodge the antiviral Tamiflu and, though rare, is emerging outside of hospitals. 

The team who have studied it say the virus is "fitter" than other drug-resistant strains and the world should be on alert for outbreaks.

UK experts say they have seen a handful of similar cases. 

The UK's Health Protection Agency said it would be closely monitoring the situation.

The Australian investigators presented their findings at a meeting on major infectious diseases. 

Experts at the Annual Scientific Meeting of the Australasian Society for Infectious Diseases heard how the 'H1N1pdm09' swine flu virus is still sensitive to another antiviral drug Relenza (zanamivir). 

But Tamiflu (oseltamivir) is now powerless against the strain that has been found in people in the community rather than sick patients with serious underlying conditions and weak immune systems. 

Vaccines can prevent infection occurring in the first place. 

Lead investigator Dr Aeron Hurt, from the World Health Organization Collaborating Centre for Reference and Research on Influenza in Melbourne, said: "The greatest concern is that these resistant viruses could spread globally, similar to that seen in 2008 when the former seasonal H1N1 virus developed oseltamivir resistance and spread worldwide in less than 12 months." 

The new strain that they have been examining is emerging among people who have never been treated with Tamiflu, suggesting it is very good at spreading from person to person. 

Dr Hurt says animal studies by his team confirm this. 

Although the Tamiflu-resistant strain is still relatively rare, affecting about 2% of people with swine flu in the Australian population that they studied, Dr Hurt is concerned that it has the potential to turn global. 

Similar resistant strains have been detected in Europe but at this stage only on an ad hoc basis, says Dr Hurt.

"The widespread transmission and circulation of oseltamivir-resistant H1N1pdm09 viruses remains a risk in the future. "Close monitoring of resistant viruses in both treated and community patients remains important."

CIDRAP: News scan for March 18

Via CIDRAP: NEWS SCAN: TB funding plea, Navy ship pandemic outbreak, ground beef outbreak called over. Click through for the full report and links. Excerpt:

Although a third of tested crew members aboard a US Navy ship became infected with the pandemic 2009 H1N1 (pH1N1) virus during a summer 2009 outbreak, 53% did not recall respiratory symptoms, just 35% met criteria for respiratory illness, and only 11% met criteria for influenza-like illness (ILI), according to a serologic study published yesterday. 

Writing in Influenza and Other Respiratory Viruses, researchers from the US Centers for Disease Control and Prevention (CDC) and the Navy reported results from 489 of a 2,000-member crew for whom pre- and post-outbreak serum samples were available.  Of the 489, 142 (32%) were shown to be pH1N1-infected by polymerase chain reaction testing; 78% had been vaccinated against flu the year before. 

The attack rate in the 57 women in the study was higher, 41%, compared with 31% in men. Marines had a higher attack rate compared with Navy personnel, 37% versus 25%. 

Of those infected, 74 (53%) were asymptomatic, 51 (35%) had acute respiratory symptoms, and 17 (11%) had ILI symptoms.

UK: Builders unearth Medieval plague victims in City of London square

Via The Guardian: Builders unearth Medieval plague victims in City of London square.

Seven centuries after their demise, the skeletons of 12 plague victims have been unearthed in the City of London, a find which archaeologists believe to be just the tip of a long-lost Black Death mass burial ground. 

Arranged in careful rows, the bodies were discovered 2.5 metres below the ground in Charterhouse Square in works for a Crossrail tunnel shaft beside the future ticketing hall for Farringdon station. 

Tests are needed to confirm the skeletons' provenance, but the discovery should shed more light on life and death in 14th-century Britain and help scientists to understand how the plague mutated. 

Crossrail's lead archaeologist, Jay Carver, said: "This is a highly significant discovery and at the moment we are left with many questions we hope to answer. However, at this stage, the depth of burials, the pottery found with the skeletons and the way the skeletons have been set out, all point towards this being part of the 14th-century emergency burial ground." 

Historical records contain references to a burial ground in what was then "no man's land", and archaeologists have long believed excavations would turn up bodies. 

But this is the first sign of what John Stow's 1598 Survey of London suggested could contain as many as 50,000 bodies. 

Experts now believe that is "something of an exaggeration", according to Nicholas Elsden ,of the Museum of London, who is working on the site. But he said there could be hundreds more buried under the gardens in Charterhouse Square. 

The first skeletons were laid out in neat rows, suggesting that they died in an early wave while the authorities – the then lord mayor – had made provision for the impending disaster coming from the continent. 

While the fast-train project promised to relieve congestion in the capital, work on Crossrail has now turned up so many bodies that archaeologists at the Museum of London admit that storage is becoming a problem. 

Despite the considerable scientific interest in the site, archaeologists are content to limit themselves to studying the skeletons discovered in the shaft. Crossrail works have already meant excavating 300 skeletons with up to 4,000 from the 17th-19th centuries expected from the Bethlem "Bedlam" hospital burial ground, now the site of Liverpool Street's new station. 

These bodies will be stored in the museum for up to two years before reburial. Elsden said specialist exhumation contractors have been called in to help. 

Most of the Bedlam dead will end up reburied, with a Christian memorial service, in Canvey Island in the Thames estuary. 

The rarer bones of the Black Death victims, lying untouched for seven centuries, are likely to kept overground a little longer for research. 

Don Walker, an osteologist examining one of the skeletons at the Crossrail site, said the bones belonged to a man, under 35, with decent teeth and, for a plague victim, in otherwise good shape. 

But the Black Death, which cut down almost two-thirds of London's population, had killed too quickly to leave a visible trace on the skeleton. 

"Something acute like plague, you don't get the marks on the bones," Walker said, but added that bacterial DNA could still be present and hold lessons for microbiologists studying the evolution of disease.

Pandemic H1N1 in Canada and the use of evidence in developing public health policies

Via Social Science & Medicine: Pandemic H1N1 in Canada and the use of evidence in developing public health policies – A policy analysis. The abstract:

When responding to a novel infectious disease outbreak, policies are set under time constraints and uncertainty which can limit the ability to control the outbreak and result in unintended consequences including lack of public confidence. 

The H1N1 pandemic highlighted challenges in public health decision-making during a public health emergency. Understanding this process to identify barriers and modifiable influences is important to improve the response to future emergencies. 

The purpose of this study is to examine the H1N1 pandemic decision-making process in Canada with an emphasis on the use of evidence for public health decisions. Using semi-structured key informant interviews conducted after the pandemic (July–November 2010) and a document analysis, we examined four highly debated pandemic policies: use of adjuvanted vaccine by pregnant women, vaccine priority groups and sequencing, school closures and personal protective equipment. 

Data were analysed for thematic content guided by Lomas' policy decision-making framework as well as indicative coding using iterative methods. We interviewed 40 public health officials and scientific advisors across Canada and reviewed 76 pandemic policy documents. 

Our analysis revealed that pandemic pre-planning resulted in strong beliefs, which defined the decision-making process. Existing ideological perspectives of evidence strongly influenced how information was used such that the same evidentiary sources were interpreted differently according to the ideological perspective. Participants recognized that current models for public health decision-making failed to make explicit the roles of scientific evidence in relation to contextual factors. 

Conflict avoidance theory explained policy decisions that went against the prevailing evidence. Clarification of roles and responsibilities within the public health system would reduce duplication and maintain credibility. 

A more transparent and iterative approach to incorporating evidence into public health decision-making that reflects the realities of the external pressures present during a public health emergency is needed.

Canada: Alberta government accused of interfering in independence of health-care probe

This has been a bad day for Canada's right wing, including the disgrace of one of its elder statesmen, who had some kind words last night for consumers of child pornography. Now, via The Globe and Mail: Alberta government accused of interfering in independence of health-care probe. Excerpt:

As Alberta’s controversial $10-million inquiry into queue jumping in the health-care system ended on Thursday after months of testimony – and a few revelations – the retired judge at the helm accused the Redford government of “interference” with the commission’s independence. 

Commissioner John Vertes said that with 3,000 pages of testimony from 68 witnesses to review as well as 158 exhibits, he can’t meet the government’s April 30 deadline to complete a “comprehensive and well-reasoned report.” Cabinet turned down his request to have an extension until Oct. 31. 

“Not only is such a rejection unprecedented, it borders on an interference with the independence of this commission, since it requires me to rush through a report that would not be as complete or thorough as I would want,” Mr. Vertes said during his closing statement. 

Writing to Progressive Conservative Health Minister Fred Horne this week, Mr. Vertes said he couldn’t rule out the possibility of more hearings and that he’ll work toward an Aug. 31 report. 

Mr. Horne said cabinet will consider the second request for an extension and rejected the notion of interference. 

“I don’t think there’s any basis to suggest that the government has in any way interfered with the inquiry,” he said in an interview. “In fact, I’ve really gone out of my way not to comment in the media on the proceedings or on the way the inquiry’s been conducted or on any aspect of it.” 

The opposition parties criticized the government for not promptly granting the extension. Heather Forsyth, health critic for the Official Opposition Wildrose Party, said constituents have complained about the inquiry’s costliness and ineffectiveness. 

“They’ve never heard so many ‘I don’t recall’s or ‘I can’t remember’s,” she said. “….I can’t argue with the comments that I’ve heard continually for weeks on this.” 

Commission lead counsel Michele Hollins said she believes the inquiry fulfilled its mandate to determine whether VIPs had – or continue to have – improper preferential access to the system, despite the inevitable criticisms of the process. She said new information is being investigated, and said the door isn’t closed to more testimony. 

But were there any smoking guns? “That’s ultimately for the public to say,” Ms. Hollins said. 

Witness offered some interesting testimony: 

H1N1: Public health nurses in Edmonton admitted inoculating friends and family after clinic hours and at home during the 2009 shortage of the influenza vaccine. The Calgary Flames and others connected to the hockey team were coached and paperwork doctored to make it look like they were vaccinated with the public, rather than a private facility set up for them.

CIDRAP: Flu news scan for February 27

Via CIDRAP: FLU NEWS SCAN: H5N1 in Cambodia, 2009 H1N1 in Australia. Excerpt:

Two thirds of early-pandemic cases in Victoria state, Australia—where the 2009 H1N1 (pH1N1) pandemic spread first in that country—were in school-aged children, and limited, short-term school closures appeared to have no impact, according to a study yesterday in PLoS One. 

Australian researchers studied records from the first 1,000 lab-confirmed pH1N1 cases reported in the state from May 20 to Jun 5, 2009. Two thirds of the patients were age 5 to 17 years old, with cases in 203 schools. One school accounted for nearly 8% of the 1,000 cases, but it was not closed until 9 days after the first identified patient had symptoms. Of all patients, 2% were hospitalized. 

The median time from illness onset to lab confirmation was 4 days, with only 10% of cases identified within 2 days of onset and therefore eligible for oseltamivir (Tamiflu) treatment. The authors conclude, 

"These scenarios and lessons learned from them need to be incorporated into revisions of pandemic plans."

Canada: Quebec prepares for zombie attack

Via The Tyee, a report from The Canadian Press: When zombies attack: Quebec public security ministry to prepare for scenario. Excerpt:

If zombies do eventually rise from the dead and take their long-awaited revenge against humanity, Quebec's public security department plans to be ready. 

Participants at an annual symposium on civil security next week will be discussing, among other topics, how they would handle a zombie attack in the province. 

The zombies, of course, are purely hypothetical. 

But a department spokesman says the exercise has a serious purpose: the living dead-themed drill is meant to simulate a real-life catastrophic event. 

"When we're talking about zombies, we're talking about a training concept," says Denis Landry, director of disaster recovery with the Quebec civil security department. 

Hypothetical zombie attacks are becoming a popular emergency preparedness teaching tool. Even the Centers for Disease Control in the United States has used the tactic. It has a graphic novel on its website dubbed, "Preparedness 101: Zombie Pandemic." 

The idea behind the exercise is that if you're ready to fend off the flesh-eating undead, then you're probably ready for any other disaster that may strike. 

"Just about every U.S. state has adopted this type of exercise, whether it be workshops or simulations," Landry said. "It's essentially designed to prepare authorities for any kind of disaster, right up to pandemics."

If all the exploiters of zombies actually paid royalties to the government of Haiti, it might have enough money to fund proper cholera reporting by the Ministry of Public Health and Population...with plenty left over for earthquake and hurricane relief. After all, zombies are Haitian intellectual property. And what's intellectual property theft if not brain-eating?

GSK vaccine ingredient scrutinized for narcolepsy clues

Via Reuters: GSK vaccine ingredient scrutinized for narcolepsy clues. Excerpt:

Mounting evidence of a link between GlaxoSmithKline's Pandemrix flu shot and a spike in narcolepsy cases among children in Europe is putting one of the vaccine's key ingredients, AS03, under intense scrutiny. 

The ingredient is one of a class of pharmaceuticals known as adjuvants, or boosters, designed to turbo charge the potency of a vaccine and the body's immune response to it. 

AS03 was widely used in Europe during the 2009-2010 H1N1 flu pandemic and is also contained in a GSK adjuvanted flu vaccine which in November last year became the first of its kind to be recommended for approval by the normally adjuvant-wary United States Food and Drug Administration (FDA). 

There's little doubt AS03 does its job well. 

Pandemrix, the flu vaccine under suspicion for the narcolepsy link, needs only a fraction of the antigen - the part that actually does the immunization - of other flu shots to give sufficient protection. 

This means the manufacturer - in this case GSK - can produce multiple times the number of vaccine doses without needing to spend valuable time making large amounts of the antigen. 

In a pandemic situation in which the lives of millions around the world are under threat, that could make the difference between having enough vaccines to protect entire populations, or having to decide how to ration them out. 

Yet some experts believe the turbo-charged immune response AS03 generates, or the ingredients that drive it, may also be the answer to why almost 800 cases of the incurable sleeping disorder narcolepsy have been linked to Pandemrix's use in Europe during the 2009/2010 H1N1 pandemic. 

"The adjuvant in the Pandemrix vaccine is very potent and we think it may have played a role," says Markku Partinen, a neurologist at the Helsinki Sleep Clinic in Finland who has spent the past few years investigating what might be behind the link between the vaccine and narcolepsy. 

If it is the reason for the spike in the disease, Partinen and other researchers think it may be because the adjuvant's strength boosted not just a good immune response but possibly an adverse one too. 

Partinen was one of the first scientists to pick up a signal that something might be going awry in children in Finland vaccinated with Pandemrix in a nationwide immunization campaign against the H1N1 flu. 

Since then studies in Sweden, Finland, Ireland and now Britain have found the risk of developing narcolepsy is between seven and 13 times higher in children who were immunized with Pandemrix than in those who were not.

Why we still need to think about H5N1

The Tyee has published my article Why We Still Need to Think About Bird Flu, which was inspired by the Cambodian outbreak. Excerpt:

Between Jan. 9 and 15, five people in Cambodia contracted bird flu, and four died of it within a few days -- four young girls and a 35-year-old man. Only the first case, an eight-month-old boy, survived. 

This might seem like a minor event, but the World Health Organization sent rapid response teams into the country to help the Cambodian ministry of health. They've been looking for more cases and educating local residents about how to avoid the disease -- even though it's one of the hardest diseases to catch. 

"Bird flu" is a vague term: all influenzas come from birds, especially domestic poultry, though they sometimes reach us through pigs and other mammals. The Cambodians had H5N1 flu, which first got our attention when it broke out among chickens and humans in Hong Kong in 1997. That outbreak was stopped by killing every chicken and duck in the region, and banning further imports from the mainland. 

Six years later human H5N1 returned, in Vietnam, and since then has sputtered away from Indonesia and South Korea to Egypt and Nigeria. 

Between 2003 and the end of 2012, the WHO confirmed no more than 610 human H5N1 cases, most of them in Vietnam, Indonesia and Egypt. This, out of a population of over seven billion, makes it one of the world's rarest diseases. 

Rare and dangerous 

Its rarity is precisely what makes it so dangerous. Because it evolved to infect birds, H5N1 isn't designed to infect mammals. Humans, therefore, are a "naive" population with almost no immunity to it. That was what scared the health authorities in Hong Kong, and it's what scares the WHO today. 

Out of those 610 cases, 360 people died. That means the "case fatality rate" (CFR) was 59 per cent. The CFR varies by country -- it's 35 per cent in Egypt, and 83 per cent in Indonesia. But globally, three out of five people who catch H5N1 will die of it within a very few days.