H5N1

Hospital stays for respiratory illnesses increase among Canadian children

A news release from the Canadian Institute for Health Information: Hospital stays for respiratory illnesses increase among Canadian children.

February 22, 2024 —  The data confirms the anecdotal evidence from across the country last year: in 2022–2023, Canada’s hospitals saw a significant increase in stays due to respiratory illnesses among people younger than 18.  

In particular, data from the Canadian Institute for Health Information (CIHI) shows a rebound in hospitalizations for seasonal flu among children age 0 to 4 — the number of stays jumped to 2,444, a return to pre-pandemic volumes. The most common respiratory illnesses among children age 0 to 4 accounted for 32% of all hospitalizations in this group, increasing from 20% the previous year.   

In addition to seasonal influenza, hospitalizations for pneumonia tripled for Canadians age 0 to 17 and almost doubled for asthma. Among children age 0 to 4, hospitalizations doubled for lower respiratory infections, and stays for COVID-19 rose by 43%.  

“Having a baby or young child in hospital for any reason is tremendously difficult on families, and this increase in hospitalizations for respiratory illnesses among Canada’s youngest patients presented additional challenges for hospitals,” said Juliana Wu, Director, Acute and Ambulatory Care Information Services, CIHI. “We will continue to monitor and report on these trends to equip health system planners and decision-makers with the data required to continue to meet the needs of Canada’s pediatric population.”  

“Last year was unprecedented for all pediatric hospitals in this country and highlighted key gaps in our system. We know from experience that viral seasons will continue to affect our young patients, and this is why it is so important that we invest in our pediatric health system and adopt public health measures to help reduce the risks,” said Dr. Lindy Samson, Chief of Staff and Chief Medical Officer, Children’s Hospital of Eastern Ontario (CHEO), and pediatric infectious disease specialist.  

Quick facts  

• The respiratory illnesses that are in the top 10 reasons for hospitalizations accounted for 32% of all hospitalizations for Canadians age 0 to 4 in 2022–2023.  

• Hospitalizations for seasonal influenza among children age 0 to 4 increased to 2,444 in 2022–2023, similar to 2019–2020 volumes.  

• Large increases were also observed in this age group for other respiratory illnesses:  

* Hospital stays for lower respiratory infections such as acute bronchitis increased from 9,501 to 19,909.  

* Hospitalizations for pneumonia almost tripled, rising from 3,447 to 9,871.  

* Asthma hospital stays increased by 61%, from 3,474 to 5,607.  

* COVID-19 accounted for 3,310 hospitalizations, up 43% from the previous year.  

* Acute upper respiratory infections saw a 32% increase in hospitalizations, going from 2,114 to 2,797.

Texas children’s hospitals are under siege from RSV and COVID-19

Via The Texas Tribune: Texas children’s hospitals are under siege from RSV and COVID-19. Excerpt:

Estefani López’s 11-month-old baby was struggling to breathe. The little girl, Ava Rivera, had contracted COVID-19 and began having seizures. Then her pulse weakened. Her mom couldn’t feel her taking breaths anymore. 

López rushed her to an emergency room where they began initial treatments, putting tubes down her throat to pump her lungs with oxygen. But the baby’s condition required care at a pediatric hospital and none of the ones in the Houston area could take her in. They were all full. 

Instead, López had to watch as hospital staff placed her baby in a helicopter to be airlifted 150 miles away to Temple for emergency care at the nearest children’s hospital with space. López spent the next three hours driving to the hospital, praying her baby would survive. 

“I felt like my heart fell out of my chest. I didn't know what was happening for three hours,” López said. “It felt like it was three days.” 

More children are being treated in Texas hospitals for COVID-19 than ever before. But there’s a second factor that is putting pediatric hospitals on the path to being overwhelmed: an unseasonable outbreak of respiratory syncytial virus or RSV, a highly contagious virus that can require hospitalization mostly among children five years and younger and especially infants. 

During the last year, RSV was largely dormant, which experts believe was due to people masking up during the pandemic. Now, in just the last several weeks, thousands of Texas children have tested positive for the virus. 

In addition, the delta variant of COVID-19 appears to affect unvaccinated children more often than previous variants. It’s unclear if children are also becoming sicker from it than from other variants of COVID-19. And with the regular flu season approaching, medical experts are concerned over how hospital capacity could be affected. 

Over 5,800 children in Texas were newly hospitalized with COVID-19 in the seven-day period ending on Aug. 8, according to the Centers for Disease Control and Prevention, a 37% increase from a week prior. Nationwide, nearly 94,000 children contracted COVID-19 last week, according to the American Academy of Pediatrics and the Children’s Hospital Association. 

López's daughter is doing OK now. Doctors replaced the intubation treatment with a nasal tube, her fever broke, and she was able to go home the next day. 

But the situation in children’s hospitals continues to worsen. In Texas, it’s getting harder and harder for those hospitals to meet the combined demand for beds for COVID-19 and RSV patients as well as children with other conditions or injuries. And physicians fear what will happen with the reopening of schools, with far fewer children masked and far more attending in person than last year.

Circulation of influenza, RSV, and SARS-CoV-2: an uncertain season ahead

Via The Lancet Respiratory Medicine: Circulation of influenza, RSV, and SARS-CoV-2: an uncertain season ahead.

A new report by the Academy of Medical Sciences has warned that the UK could face exceptionally large outbreaks of respiratory syncytial virus (RSV) and influenza during the autumn and winter of 2021–22. The surge in infections could overlap with the spike in cases of COVID-19 that is expected to follow the lifting of lockdown restrictions across the country. “It is clear that the health-care system must plan for a high burden of respiratory diseases”, wrote the authors of the new report. They urged the government to rollout point-of-care joint testing for influenza, SARS-CoV-2, and RSV, and to ensure that the influenza vaccine is widely taken-up by eligible populations. 

The warning partly reflects the success of the precautions that have been deployed against SARS-CoV-2. Mask-wearing, social distancing, and sharply constrained population movements have dramatically reduced transmission of respiratory pathogens such as RSV and influenza. Hospitals in Italy and France reported drops of more than 80% in the number of paediatric patients treated for acute bronchiolitis during the 2020–21 season, compared with previous years. Australia, Chile, and South Africa registered just 51 cases of influenza between them over the entire 2020 southern hemisphere winter. In the USA, the 2020–21 influenza season was the mildest since at least 1997, the earliest year for which records are available. 

 The vast majority of children contract RSV before the age of 2 years. “We now have a whole bunch of children who have not been exposed to the virus for 18 months to 2 years”, points out Charlotte Summers, reader in intensive care medicine at the University of Cambridge, UK, and member of the expert advisory group for the Academy of Medical Sciences report. The larger the susceptible population, the greater the risk of a sizeable outbreak once a virus starts circulating. 

England discontinued nearly all of its lockdown restrictions on July 19, 2021. Scotland and Wales are scheduled to do the same by mid-August. Even though there are several weeks of summer remaining, cases of RSV are on the rise (the USA is also seeing an out-of-season increase in RSV detections). Whether this will translate to increased hospitalisations remains to be seen. The Academy of Medical Sciences report recommended that children's wards and paediatric intensive care units should be ready for a potential influx of patients with RSV, otherwise they could find themselves overwhelmed. Modelling studies undertaken for the report suggested that a reasonable worst-case scenario for RSV would entail an outbreak somewhere in the region of 1·5–2 times greater than during a typical year, assuming the UK stays out of lockdown. 

The results for the modelling studies for influenza were similar. “There has probably been a waning of immunity to influenza, plus we have not had enough cases elsewhere in the world to offer a strong idea of what needs to go into the vaccine”, said Summers. The mildness of the 2019–20 influenza season in the UK might have further reduced population immunity. 

Much is uncertain. “We do not know what the influenza virus is going to look like when it returns”, said Rachel Baker, associate research scholar in the department of ecology and evolutionary biology at Princeton University, USA, “How much did the virus evolve during the period of low case numbers? Will we see a strain that people have been exposed to or vaccinated against in the past?” It is unclear how the British will respond to the easing of the lockdown restrictions. “Without national mandates for things like mask-wearing and distancing, a lot will come down to individual behaviour, and no-one really knows how people's behaviour will change”, said Summers. Baker suggested that vulnerable populations should continue wearing masks in crowded public places. 

Hospitals will have to quickly identify which patients have influenza and which ones have COVID-19, and ensure the two sets of patients are kept separate from each other and from vulnerable patients who do not have any respiratory symptoms. No small task, particularly if the viruses are surging at the same time.

However, risk for all-cause dementia was reduced for those who engaged in low (odds ratio [OR], 0.30; 95% CI, 0.25 – 0.36) and moderate to high (OR, 0.13; 95% CI, 0.10 – 0.16) levels of physical activity compared with their inactive peers.

Feter said it is particularly noteworthy that adults aged 80 and older who engaged in moderate to high levels of physical activity were at lower risk for dementia than inactive adults aged 50 to 69 years.

"In our opinion, this is the study's main finding," he said.

Although aging is the strongest risk factor for dementia, "we showed that moderate-intensity physical activity once per week can attenuate, or even eliminate, the risk of dementia associated with aging," Feter noted. "In fact, older adults engaging in regular physical activity have a lower risk of dementia than adults aged up to 30 years younger."

However, he noted several study limitations, including the way that physical activity and dementia were assessed and that reverse causality and residual confounding "might not be ruled out from our findings."

Hong Kong: Another seven isolated over Wuhan virus scare

Via RTHK: Another seven isolated over Wuhan virus scare. But bear in mind that the detailed list of cases shows most of them are dealing with known viruses.

Hong Kong health authorities have moved another seven people to isolation after they showed pneumonia related symptoms and reported that they had visited Wuhan in the past 14 days. 

The Hospital Authority said the patients, who are aged between three to 50, had not visited any wet markets in the mainland city. 

Wuhan health officials say the newly identified coronavirus spread from a well known fish market area, where live animals are also sold. They reported one death, linked to the virus on Saturday – a 65-year-old chronic liver patient. 

The authorities there are also revised down the number of suspected cases to 41 after initially saying 59 people were thought to be affected by the virus. 

In Hong Kong, 60 people who had visited Wuhan recently were referred for isolation after falling ill and 46 of them had been discharged. The rest of the patients staying in hospitals were in stable condition.  

Singapore, Taiwan and South Korea have reported such suspicious cases, but on the mainland only Wuhan has officially reported this virus.

Canada: Petition calls for all Inuit babies to receive drug to protect against respiratory syncytial virus

Via The Globe and Mail: Petition calls for all Inuit babies to receive drug to protect against respiratory virus. Excerpt:

A group of doctors is urging officials in Nunavut to offer an effective but costly drug to all Inuit babies living in remote communities in the territory to protect them against a respiratory virus that disproportionately leads to their hospitalization.  

A petition, started by members of the 1989 graduating class of University of Toronto’s faculty of medicine, says giving the prophylaxis palivizumab to Inuit infants would reduce their rates of serious complications from respiratory syncytial virus (RSV) and would also save the government money it currently spends on air-ambulance services and hospital stays.  

But Nunavut’s chief medical officer disagrees, saying there isn’t enough evidence to support such an approach.  

For most people, symptoms of RSV infection are indistinguishable from the common cold, although an estimated 1 per cent to 3 per cent of infants in developing countries experience complications requiring hospitalization.  

Inuit babies in Canada, however, have an exceptionally high rate of RSV complications. Among some Inuit communities on Baffin Island, as many as half to two-thirds of babies are hospitalized with lower respiratory lung infections, mostly owing to RSV, according to Anna Banerji, an expert on Indigenous and refugee health and associate professor of pediatrics at the University of Toronto who helped start the petition. 

Although it is not entirely understood why, experts believe Inuit infants are disproportionately affected because of a combination of genetic and environmental factors, including food insecurity and a lack of adequate housing arising from a history of forced settlement. 

Palivizumab, the only available prophylactic treatment for RSV, is currently given to infants in Canada who are considered at high risk of complications, such as those born prematurely or who have underlying heart or lung conditions. But it is not routinely administered in Nunavut to healthy Inuit infants who are born at full term. 

At the cost of roughly $6,500 a child for each season, the drug is expensive, Dr. Banerji says. Yet, according to her analyses, giving it to all Inuit babies in remote communities can cost less than the alternative. 

The petition had more than 21,600 signees as of late last week and has the support of the Ontario Medical Association.

Tuberculosis rate among Inuit is 290 times higher than for non-Indigenous people in Canada. Here's why

Via CBC News: Tuberculosis rate among Inuit is 290 times higher than for non-Indigenous people in Canada. Here's why. Excerpt:

The Public Health Agency of Canada (PHAC) says there were 1,796 active cases diagnosed in this country in 2017, up 2.6 per cent from 2016, when there were 1,750 active cases.  

The average annual rate of TB infection is 290 times higher among Inuit in Canada than among Canadian-born non-Indigenous people, PHAC says. 

In actual numbers, there were 1,684 cases diagnosed in all of southern Canada in 2017. There were 112 in the three far less populated territories, including 101 in Nunavut alone. 

According to data from PHAC, the average rate of infection in Canada's 10 provinces in 2017 was 4.46 per 100,000 people.  

In Nunavut, it was 265.8.  Inuit make up about 85 per cent of Nunavut's population, according to PHAC.   

The World Health Organization says the rate of infection in the world's poorer nations is between 150 and 400, so Nunavut falls squarely in that range.   

Why are people in the North more vulnerable? 

There are several factors that contribute to the much higher rates of infection in the North. 

"Many Inuit people live in overcrowded homes that are poorly ventilated ... they're very airtight," said Banerji, who has researched respiratory infections in babies in Canada's Arctic for many years. "Also, there is quite a bit of poverty, which can make tuberculosis worse. Malnutrition can exacerbate tuberculosis." 

Poor access to health care, or issues of not feeling safe going to an outpost nursing centre or a hospital, can also be factors.  

And there is another possible factor Banerji believes needs further study. 

She says Inuit babies have the highest rate of respiratory syncytial virus (RSV) in the world. Banerji says Nunavik, the northernmost region of Quebec, provides the RSV antibody to all babies, but the government of Nunavut does not; it provides the antibody to babies considered high-risk.  

She wonders if there is a connection between high RSV rates and TB.  

"It's just to say that a lot of respiratory disease is over-represented in Inuit populations," she said. "Babies or people who have scarring or damage to the lungs probably are more susceptible to active tuberculosis."

Acute myocardial infarction after laboratory-confirmed influenza infection

Via NEJM: Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. The abstract:

BACKGROUND Acute myocardial infarction can be triggered by acute respiratory infections. Previous studies have suggested an association between influenza and acute myocardial infarction, but those studies used nonspecific measures of influenza infection or study designs that were susceptible to bias. We evaluated the association between laboratory-confirmed influenza infection and acute myocardial infarction.  

METHODS We used the self-controlled case-series design to evaluate the association between laboratory-confirmed influenza infection and hospitalization for acute myocardial infarction. We used various high-specificity laboratory methods to confirm influenza infection in respiratory specimens, and we ascertained hospitalization for acute myocardial infarction from administrative data. We defined the “risk interval” as the first 7 days after respiratory specimen collection and the “control interval” as 1 year before and 1 year after the risk interval.  

RESULTS We identified 364 hospitalizations for acute myocardial infarction that occurred within 1 year before and 1 year after a positive test result for influenza. Of these, 20 (20.0 admissions per week) occurred during the risk interval and 344 (3.3 admissions per week) occurred during the control interval. The incidence ratio of an admission for acute myocardial infarction during the risk interval as compared with the control interval was 6.05 (95% confidence interval [CI], 3.86 to 9.50). No increased incidence was observed after day 7. Incidence ratios for acute myocardial infarction within 7 days after detection of influenza B, influenza A, respiratory syncytial virus, and other viruses were 10.11 (95% CI, 4.37 to 23.38), 5.17 (95% CI, 3.02 to 8.84), 3.51 (95% CI, 1.11 to 11.12), and 2.77 (95% CI, 1.23 to 6.24), respectively.  

CONCLUSIONS We found a significant association between respiratory infections, especially influenza, and acute myocardial infarction.

Finland: Health officials grapple with HRSV virus — 500 new infections in one week

Via Yle Uutiset: Health officials grapple with HRSV virus — 500 new infections in one week.

Health officials have seen an alarming increase in the number of cases involving HRSV[human respiratory syncytial virus] infections, according to the National Institute for Health and Welfare, THL. Specialist Niina Ikonen said that more than 500 cases were recorded in the infectious diseases register last week alone.  

The HRSV virus can cause respiratory tract infections in people of all ages. However in small children and the elderly, it can cause complications such as pneumonia. Older children and other adults may experience milder symptoms of infection, including a runny nose or throat pain.  

According to Harry Saxén, a professor of paediatric infectious diseases and medical chief of staff at Helsinki’s Children’s Hospital, the HRSV outbreak has so far been mainly confined to Helsinki. 

Saxén told Yle that there are currently just over a dozen children under the age of 12 months with HRSV infections at the hospital.  

“At the moment we are treating about 15 children. In my view that’s a lot. In worse years we have had 30 patients at a time,” he added. 

Biennial peak in infections  

The physician said that it is difficult to estimate whether the contagion has peaked or if more cases will emerge. He noted that it is typical for infections to decrease every other year and for the disease to occasionally rear its head.  

“We have seen annual cases of HRSV but the epidemic is greater every other year. So this would be a time for a bigger outbreak so to speak. We have to assume that this winter will produce more infections that the same time last year,” added the THL’s Ikonen. 

The viral infection is especially intransigent among children under the age of 12 months. The first symptoms usually include difficulty eating, so children cannot breast feed and they wheeze, Saxén explained.  

There is no known treatment for the disease. Patients are treated at hospital with oxygen and by aspirating any phlegm that accumulates. Saxén urged the parents of young infants to reconsider visiting homes or other locations where others have flu-like symptoms. 

“The disease is generally transmitted by family members. I would not deliberately go to places where a lot of people have the flu, but that may be difficult in practice. After all, you can’t bottle up children,” he remarked. 

The THL said that health centres across the country have also reported a significant rise in patients of all ages coming in with the flu.

China: Serious flu and other outbreaks in Yangzhou

Via FluTrackers, Sharon Sanders posts an unedited Google translation from a long report in the Yangzhou Times: China - "This year's flu is the fiercest in recent years, with a long duration and a wide area of ​​infection.." Excerpt and then a comment:

It is reported that currently there are five major virus rampant, namely, influenza virus, Norovirus, rotavirus, adenovirus, syncytial virus, influenza virus most likely to cause respiratory infections; Norovirus and rotavirus can cause vomiting in children And diarrhea, while adenovirus can cause diarrhea in children. Syncytial virus, it will cause children fever, bronchitis, pneumonia, myocarditis and so on.

Q: Why are so many children more recently?

A: The flu season, and the weather 　　

Chen Xiao analysis, on the one hand, this and the recent weather changes. Dry weather in winter, will stimulate the respiratory tract, leading to the human body to the outside world the resistance of the virus decreased, some time ago the weather is colder, the temperature has picked up these days, a cold and heat, weak immune children are particularly vulnerable to cold; the other It is also the popular season for influenza virus. Both have caused the current peak. 　　

"This year's flu is the fiercest in recent years, with a long duration and a wide area of ​​infection, which have not been experienced in recent years." The reporter interviewed pediatric experts from other hospitals and learned that with the opening of the second child policy, It is also a factor that has dramatically increased the number of outpatient and emergency department visits in pediatrics.

Despite the inevitable garbling of a Google translation from Chinese to English, the full report indicates that Yangzhou hospitals are swamped with sick kids. I'll try to find out if other Chinese cities are reporting similar problems.

Dr. Oxford on Ebola as an aerosol virus

Thanks to Irene L for tweeting the link to this important post at International SOS Ebola: comments on Ebola as an aerosol virus by Professor John Oxford. Excerpt:

A key virological fact to remember here is that we are dealing with vast populations of Ebola as much as 10 million viruses per micro drop of diarrhoea. These early observations have been well confirmed in the current outbreak. Of necessity with this way of spreading then the number of cases in the community will remain very low and the chain of infection will be easily broken by quarantine of suspects, training of medical staff in Personal Protective Equipment (PPE), good hygiene and a ‘no touch’ technique at funerals of victims and in the community. Evidence from most outbreaks as well as the present one amply confirms this. 

As regards the numerical issue, we have to date around 21,000 cases in 12 months in a population of 30 million or so in the countries involved. These are relatively low numbers indeed and do not speak to us of aerosol or air droplet spread. 

To give a contrary example of droplets and aerosol spread, in the last week a cornucopia of respiratory viruses have struck in the UK such as influenza, RSV and adenovirus, all spread mainly in the airborne manner and 100,000 persons have been infected over those few days. 

I also want to widen the context to other viruses to illustrate that under very special circumstances these minute viruses can take advantage of a unique or unexpected opportunity to spread. We all know that hepatitis B is at a relatively high level in Africa and is spread by sex, blood and birth. 

But in an overcrowded family household with lots sharing of towels, toothbrushes and shaving kits, even in the observed absence of blood, the virus can spread. This happens in the UK as well. The reason? The virus, like Ebola, is present in the victim in exceedingly high numbers of greater than 10 million viruses per micro drop of blood. 

We never begin to speculate with hepatitis B that it could be spread by coughing, although I have little doubt that amongst the 200 million or so carriers in the world such a transmission has occurred! The virus would certainly be present in mouths with poor tooth hygiene. 

Even more relevant is polio. The spread here is faecal/oral via sewage contaminated rivers, swimming pools or, in the family, by poor hand hygiene. But many of the early studies with the live attenuated polio vaccines described the presence of polio virus in saliva from the throat. So again we have well established and documented manner of spreading of a virus by the faecal/oral route, but it is never thought that polio could be spread by coughs and sneezes. 

As a final illustration of the ‘just possible’ is rotavirus. This important diarrhoea virus, which incidentally would be expected to have killed more children in West Africa during the last year, compared to Ebola, is again present in stools in exceedingly high quantities. So should a mother casually throw a diarrhoea nappy [diaper] onto the table a few virus particles could spray out as droplets and it is possible that these could be breathed in. 

As regards the ‘catch all’ that RNA viruses can mutate, most they do not and the exceptions are influenza and HIV. Polio, rubella, measles, mumps to name a few have not changed in 60 years and Ebola is the same. 

Post peak infection curves of the virus always carry a danger 

The curve of acquisition of new cases of Ebola, along with figures of death, had peaked in Liberia and Guinea  before Christmas: shortly before the arrival of many international groups. This does not mean that their help was unneeded. The contrary is definitely the case. The withdrawal of these trained medical and nursing staff at this precise moment would not be helpful. 

The downward running curve of Ebola cases is exceedingly dangerous for two reasons. Firstly the medical staff will be refocused on the other infections in West Africa, malaria, Lassa fever, cholera and enteric pathogens and TB. The declining Ebola cases will make them more easy to miss. 

Even more important, these communities themselves will begin to relax and touching and kissing, and funeral habits will start up again. 

It took one year to go from one case to 21,000 but now we are not at ground zero with the number of persons currently infected and so outbreaks could start up again from figures way above one! West Africa needs our scientific and medical help for at least the next 6 months and thereafter to train staff for the next outbreak.

Dr. Oxford concludes by writing: "...what these three West African countries really need is international help to build safe water system, sewage, and a health service with well trained doctors and nurses fit for the 21st century. Is this beyond the pale in a world where 500 young people in Europe have volunteered in the last few days to go to Mars on a one way ticket?"