No one knows what the
future will bring but these resources might assist the reader in their
continuing education to better
understanding the possibilities. The accuracy of any information listed directly
or indirectly is not guaranteed. The reader is encouraged to download this page
if they find it useful as it may not remain hosted for a long time.
"Any state, any community,
or for that matter any citizen that failed to prepare -- assuming that the
federal government could take care of them during a pandemic -- would be
tragically wrong," - Health and Human Services Secretary Mike Leavitt
on
Minnesota Public Radio,
December 14, 2005. Flu pandemic could kill 30,000 in
Minnesota, by Tom Scheck,
http://news.minnesota.publicradio.org/features/2005/12/14_scheckt_flusummit/
Collection of resources about H1N1
(revised 8/30/2009)
The media
theme "but it is mild" is in part true, but it is
clearly misleading the public
1. A modern reference point for pandemics is
1918 and this is from a paper on the CDC website from the Dr. who sequenced the
1918 virus. Notice how the 1918 virus descriptions echo the current pandemic
descriptions in severity.
1918 Influenza: the Mother of All Pandemics
Dr. Jeffery K. Taubenberger, M.D. & Ph.D., and Dr. David M. Morens, M.D.
Emerging Infectious Diseases •
www.cdc.gov/eid • Vol. 12, No. 1, January 2006
http://www.cdc.gov/ncidod/eid/vol12no01/pdfs/05-0979.pdf
a. “An estimated one third of the world’s
population (or ≈500 million persons) were infected and had clinically
apparent illnesses during the 1918–1919 influenza pandemic.”
b. “Total deaths were estimated at ≈50 million and were arguably as high as
100 million.”
c. “Despite the extraordinary number of global deaths, most influenza cases
in 1918 (>95% in most locales in industrialized nations) were mild and
essentially indistinguishable from influenza cases today.”
d. “nearly half of the influenza-related deaths in the 1918 pandemic were in
young adults 20–40 years of age, a phenomenon unique to that pandemic year.”
2. In 2009, this “mild”
theme has been repeated over and over but does not jibe with the
information below. In June they changed the theme from “mild” to their new theme
"mild to moderate" but the USA public may be fixated on the “mild” message. When
connecting the pieces of information that follow throughout this document one
can clearly see that those with knowledge are very concerned about this fall of
2009 and beyond. Using the data below on might speculate USA 307 million * 30%
CAR * 2% hospitalized * 1/3 hospitalized on vents = 600,000 needing vents.
a. Weekly epidemiological record
No. 21, 2009, 84, 185–196
World Health Organization, 22 may 2009, 84th year
http://www.who.int/wer/2009/wer8421.pdf
i. 51% of the deaths in Mexico were in the age
group 20-39 as of May 20, 2009
ii. 81% of the deaths in Mexico were in the age group 20-59 as of May
20, 2009 and had a 3.6 % Case Fatality Rate (CFR
iii. 2.0 % Case Fatality rate (CFR) for all confirmed cases in Mexico as
of May 20, 2009
iv. 54% of the Mexican fatalities were previously healthy people
v. Approximately 2–5% of confirmed cases in the United States and
Canada, as well as 6% in Mexico, have been admitted to hospital.
vi. One-third of those hospitalized required mechanical ventilation.
vii. Fever has been absent in some outpatients and in up to 1 in 6
surviving hospitalized patients.
viii. Gastrointestinal symptoms (nausea, vomiting and/or diarrhoea) have
occurred in up to 38% of outpatients in the United States.
b. Situación actual de la epidemia
Secretaria de Salud, Mexico, May 19, 2009
http://portal.salud.gob.mx/descargas/pdf/influenza/situacion_actual_epidemia_190509.pdf
i. 77% of deaths are in the 20-54 year age bracket
ii. 88% of the cases had fever
c. Situação epidemiológica da nova influenza A (H1N1) no Brasil, 2009
Secretaria de Vigilância em Saúde, Brazil, August 1, 2009
http://portal.saude.gov.br/portal/arquivos/pdf/informe_influenza_se30_03_08_2009.pdf
Entre os 844 casos de SRAG confirmados para Influenza A(H1N1), 11,4% (96)
evoluíram para óbito
d. A preliminary analysis of the epidemiology of influenza A(H1N1) virus
infection in Thailand from early outbreak data, June-July 2009
Eurosurveillance, Volume 14, Issue 31, 06 August 2009
e. Swine flu leaves victims flattened as they stay in intensive care for
longer
Grant McArthur, Herald Sun, July 17, 2009
http://www.news.com.au/heraldsun/story/0,21985,25791755-2862,00.html
i. “SWINE flu patients at Victoria's intensive care units are becoming
far sicker and taking four times longer to recover than other seriously
ill patients.”
ii. “While the average length of stay for intensive care patients is 4.5
days, some of those with swine flu are in ICU for a month.”
iii. "Some of them have been very sick and certainly here, and at The
Alfred, some patients have had to go on a heart-lung machine because the
mechanical ventilation was insufficient to maintain oxygen levels in the
blood.”
iv. “the northern hemisphere will enter winter before a vaccine is
available.”
f. Swine flu danger for pregnant women
Janelle Miles, Courier Mail, July 17, 2009
http://www.news.com.au/couriermail/story/0,23739,25794324-3102,00.html
“Pregnant women should quarantine themselves as much as possible during the
swine flu outbreak to avoid getting the potentially deadly disease,
obstetricians say.”- the Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
g. Up to 79 per cent of NZers expected to catch swine flu - study
Martin Johnston, New Zealand Herald, July 24, 2009
http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10586395
“And this suggests nearly 79 per cent of an affected population will catch
the virus, although not all will become ill.”
h. Swine flu could hit up to 40 percent in US
Mike Stobbe, Associated Press, July 25, 2009
http://abcnews.go.com/Health/wireStory?id=8171069
“In a disturbing new projection, health officials say up to 40 percent of
Americans could get swine flu this year and next and several hundred
thousand could die without a successful vaccine campaign and other
measures.” (n.b. compare this with the notion that 36000 die from seasonal
flu)
i. Neurologic Complications Associated with Novel Influenza A (H1N1) Virus
Infection in Children --- Dallas, Texas, May 2009
CDC (Center for Disease Control), July 23, 2009
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5828a2.htm?s_cid=mm5828a2_e
j. Pregnant Women and Novel Influenza A (H1N1)
Virus: Considerations for Clinicians
CDC, 6/30/09
http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
"Early treatment with influenza antiviral medications is recommended for
pregnant women with suspected influenza illness. Clinicians should not wait
for test results to initiate treatment since these medications work best if
started as early as possible after illness onset."
k. Seeking Lessons in Swine Flu Fight
Lawrence K. Altman, The New York Times, August 10, 2009
http://www.nytimes.com/2009/08/11/health/11docs.html
"But an odd feature of the new virus is the lack of fever in a significant
proportion of documented cases, even after some patients become seriously
ill. In Chile, it was about half, in Mexico City about a third and
elsewhere, less, Dr. Wenzel said. Lack of fever has been noted by other
observers in several Canadian cases."
l. Boro prepares for
fall’s swine flu cases
Anna Gustafson, Astoria Times, August 13, 2009
http://www.yournabe.com/articles/2009/08/13/astoria_times/news/astoria_times_newsmizhiqz08122009.txt
i. "The Centers for Disease Control has
predicted a 2.1 percent to 3.3 percent death rate among those who come
down with swine flu this fall, which translates into an additional
52,000 to 86,000 deaths in the city over a three-month period, Kasdan
said." (comment: working backwards these numbers
also imply a 30% infection rate or CAR)
ii. “It’s mind-boggling,” Kasdan said of the possible death rate.
“Is the CDC right? Who knows — hopefully not. But you need to be
prepared.” ([NY] Metropolitan Funeral
Directors Association Director Martin Kasdan)
36000 debunked
-
Trends in Pneumonia and Influenza Morbidity and Mortality
American Ling Association, Research and Scientific Affairs, Epidemiology and
Statistics Unit, August 2004
Table 1 data based on;
CDC,
National Center for Health Statistics, Report of Final Mortality Statistics,
1979-2001
a.
http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/PI1.PDF
or
b.
http://74.125.113.132/search?q=cache:EtdmX7GePuQJ:www.lungusa.org/atf/cf/%257B7a8d42c2-fcca-4604-8ade-7f5d5e762256%257D/PNEUMONIA%2520%26%2520INFLUENZA%2520SEPT%25202008.PDF+TRENDS+IN+PNEUMONIA+AND+INFLUENZA+MORBIDITY+AND+MORTALITY&cd=2&hl=en&ct=clnk&gl=us
| Year |
US Influenza Fatalities |
| 1979 |
604 |
| 1981 |
3006 |
| 1983 |
1431 |
| 1985 |
2054 |
| 1987 |
632 |
| 1989 |
1593 |
| 1991 |
1137 |
| 1993 |
1044 |
| 1995 |
606 |
| 1996 |
745 |
| 1997 |
720 |
| 1998 |
1724 |
| 1999 |
1665 |
| 2000 |
1765 |
| 2001 |
257 |
| total |
18983 |
| average |
1266 |
-
Are U.S. Flu
Death Figures More PR Than Science?
ScienceDaily, December 10, 2005
http://www.sciencedaily.com/releases/2005/12/051210120020.htm
"The CDC uses indirect modelling methods to estimate the number of deaths
associated with influenza. Thus the much publicised figure of 36,000 is not
an estimate of yearly flu deaths, as widely reported in both the lay and
scientific press, but an estimate - generated by a model"
-
A Pandemic of Confusion
About Flu's Death Rates
The Numbers Guy, Wall Street
Journal, May 13, 2009
http://online.wsj.com/article/SB124217724145913411.html
"According to the CDC's own
numbers, influenza was listed as the underlying cause on just 849 death
certificates in 2006, the most recent year available -- half as many as
hernias and a quarter the number killed by peptic ulcers. This number has
been flat in recent decades even as the CDC's much larger estimates of
annual flu deaths have been increasing."
- Swine flu could hit up to 40 percent in US
Mike Stobbe, Associated Press, July 25, 2009
http://abcnews.go.com/Health/wireStory?id=8171069
a. In a disturbing new projection, health
officials say up to 40 percent of Americans could get swine flu this year
and next and several hundred thousand could die without a successful vaccine
campaign and other measures.
b. Health officials say flu cases may explode in the fall, when schools
open and become germ factories, and the new estimates dramatize the need to
have vaccines and other measures in place.
c. The CDC came up with the new projections for the virus' spread last
month, but it was first disclosed in an interview this week with The
Associated Press. The estimates are based on a flu pandemic from 1957, which
killed nearly 70,000 in the United States but was not as severe as the
infamous Spanish flu pandemic of 1918-19. The number of deaths and illnesses
from the new swine flu virus would drop if the pandemic peters out or if
efforts to slow its spread are successful, said CDC spokesman Tom Skinner.
"Hopefully, mitigation efforts will have a big impact on future cases," he
said. Besides pushing flu shots, health officials might urge measures such
as avoiding crowded places, handwashing, cough covering and timely use of
medicines like Tamiflu.
- Boro prepares for
fall’s swine flu cases
Anna Gustafson, Astoria Times, August 13, 2009
http://www.yournabe.com/articles/2009/08/13/astoria_times/news/astoria_times_newsmizhiqz08122009.txt
i. "The Centers for Disease Control has
predicted a 2.1 percent to 3.3 percent death rate among those who come
down with swine flu this fall, which translates into an additional
52,000 to 86,000 deaths in the city over a three-month period, Kasdan
said." (comment: working backwards these numbers
also imply a 30% infection rate or CAR)
ii. “It’s mind-boggling,” Kasdan said of the possible death rate.
“Is the CDC right? Who knows — hopefully not. But you need to be
prepared.” ([NY] Metropolitan Funeral
Directors Association Director Martin Kasdan)
- read more of the
"But it is mild", but not really
Countries are now openly speaking of severe disease
1. Forty people a day could die from swine flu
by next month
Shan Ross, Scotsman.com, July 4, 2009
http://news.scotsman.com/latestnews/Forty-people-a-day-could.5429067.jp
England is projecting potentially 40 deaths per day in late August.
2. Argentina
a. Swine Flu Death Toll in Argentina Climbs
Alexei Barrionuevo, The New York Times, July 3, 2009
http://www.nytimes.com/2009/07/04/world/americas/04argentina.html?ref=global-home
"Swine flu has killed more people in Argentina than in any other country in
South America, where the winter flu season is just beginning. The death rate
of 1.6 percent is more than three times the world average, Claudio Zin, the
health minister of Buenos Aires Province, said Friday."
b. Ministerio de Salud de la Nacion pone en funcionamiento 28 unidaded
moviles hospitalarias para atencion de Gripe A
Ministerio de Salud, Argentina, July 9, 2009
http://www.msal.gov.ar/htm/Site/noticias_plantilla.asp?Id=1476
Argentina’s CFR (case fatality rate) is changing and may now be at 3% using
their official numbers (83 per 2677 as of July 9, 2009)
3. USA
a.
Boro prepares for fall’s swine flu cases
Anna Gustafson, Astoria Times, August 13, 2009
http://www.yournabe.com/articles/2009/08/13/astoria_times/news/astoria_times_newsmizhiqz08122009.txt
i. "The Centers for Disease Control has
predicted a 2.1 percent to 3.3 percent death rate among those who come
down with swine flu this fall, which translates into an additional
52,000 to 86,000 deaths in the city over a three-month period, Kasdan
said." (comment: working backwards these numbers
also imply a 30% infection rate or CAR)
ii. “It’s mind-boggling,” Kasdan said of the possible death rate.
“Is the CDC right? Who knows — hopefully not. But you need to be
prepared.” ([NY] Metropolitan Funeral
Directors Association Director Martin Kasdan)
Schools and other focal points
-
Swine flu could hit up to 40 percent in US
Mike Stobbe, Associated Press, July 25, 2009
http://abcnews.go.com/Health/wireStory?id=8171069
"Health officials say flu cases may explode in the fall, when schools open
and become germ factories, and the new estimates dramatize the need to have
vaccines and other measures in place."
- Widespread Pandemic H1N1 School Outbreaks
in Southern US
Henry Niman, Recombinomics, August 20, 2009
http://www.recombinomics.com/News/08200901/H1N1_South_School.html
a. Large
outbreaks are expected nationwide, as students return to the school in the
next few weeks.
b. Most schools are following CDC
recommendations and remaining open, while offering guidance centered on
keeping ill students at home. However, these guidelines are tightly linked
to a fever, which is in the CDC H1N1 swine flu case definition. The
association of fever with swine flu infections is tenuous, and some
countries like Chile, are reporting 50% of patients without fever, even in
more severe cases. Similarly, initial data from Mexico also noted that 30%
of confirmed cases did not have a fever, raising concerns that these figures
are low, and most infections have no or low fever.
c. Thus, the policy of keeping schools
open, and using fever as one of the key symptoms, may lead to extensive
spread by patients who have low or no fever. Moreover, most of the students
have mild illnesses, so they are not tested, which may allow important
genetic changes to silently spread. One such change is H274Y, which confers
Tamiflu resistance. Many of the
confirmed cases have
quickly developed
resistance, raising concerns the H274Y is
widespread, but present as a minor species which is largely
undetected in samples collected prior to Tamiflu treatment.
- Study of infections per age group
http://cdc.gov/h1n1flu/images/graphs/qa_graphA.gif
-
Raise Your Flu IQ
Daniel J. DeNoon, WebMD Health News,
December 5, 2003
http://www.webmd.com/cold-and-flu/news/20031205/raise-your-flu-iq
Question: How long are you contagious?
Dr. Clements: Most adults are contagious for about five to seven days.
With young children, it's longer. The youngest kids (1 to 2 year olds)
can be contagious for 10-14 days. And they can also have diarrheal
illness when they get the flu. They get more symptoms that we adults
typically have. Note: According to the CDC, people with lowered
immune systems -- such as people with AIDS or people taking drugs to
prevent transplant rejection -- can shed flu virus for weeks or months
after infection.
High risk groups
- Study of fatalities by age group
a. CDC
http://cdc.gov/h1n1flu/images/graphs/qa_graphC.gif
b. Thailand
http://www.eurosurveillance.org/images/dynamic/EE/V14N30/Thailand_Fig2.jpg
- Pregnancy
a.
Swine flu danger for pregnant women
Janelle Miles, Courier Mail, July 17, 2009
http://www.news.com.au/couriermail/story/0,23739,25794324-3102,00.html
“Pregnant women should quarantine themselves as much as possible during the
swine flu outbreak to avoid getting the potentially deadly disease,
obstetricians say.”- the Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
b. Pregnant Women and Novel Influenza A (H1N1)
Virus: Considerations for Clinicians
CDC, 6/30/09
http://www.cdc.gov/h1n1flu/clinician_pregnant.htm
"Early treatment with influenza antiviral medications is recommended for
pregnant women with suspected influenza illness. Clinicians should not wait
for test results to initiate treatment since these medications work best if
started as early as possible after illness onset."
c. Situação epidemiológica da nova influenza A (H1N1) no Brasil, 2009
Secretaria de Vigilância em Saúde, Brazil, August 1, 2009
http://portal.saude.gov.br/portal/arquivos/pdf/informe_influenza_se30_03_08_2009.pdf
39.5% of the fatal respiratory cases caused by H1N1 were pregnant.
Attack
rate, Testing, and Data Reporting
1. Attack Rate:
a. “Novel” A(H1N1) influenza situation, New York,
USA
EpiSouth, 5/1/09
http://www.episouth.org/download.php?&id=7806
33% Symptomatic
b. CDC Briefing on Investigation of Human Cases of H1N1 Flu (transcript)
Centers for Disease Control and Prevention (CDC), July 24, 2009
http://www.cdc.gov/media/transcripts/2009/t090724.htm
i. Anne Schuchat: Okay. The 40% figure that I gave was not about
illness. what I was trying to say was our planning assumptions for a
severe pandemic were that at a certain period up to 40% of the workforce
might be affected and not able to work either because they were ill or
because they needed to stay home to care for an ill family member. So a
lot of that is the ill family member, not the worker themselves. The
second question that you asked -- I'm just forgetting what it was. I'm
sorry.
ii. Joanne Silberner: How does the 6% to 8% attack rate compare with
seasonal flu?
iii. Anne Schuchat: It's difficult to compare that. One reason that it's
difficult is that 6% to 8% attack rate occurs in the May to June period
when there was zero cases of seasonal influenza. To some some extent we
were seeing a lot of transmission when the circumstances weren't that
great for transmission. During seasonal influenza, the winter months, we
might see rates of 10% to 15% of people developing influenza-like
illness. And so what we saw in that sort of three to four-week period
with the 6% to 8% was probably just a glimpse of what might happen over
the longer winter season when transmission circumstances like
temperature are different. So it's really an apples and oranges
comparison.
2.
Data Reporting:
a. Pandemic (H1N1) 2009 briefing note 3 (revised)
World Health Organization, July 16 2009
http://www.who.int/csr/disease/swineflu/notes/h1n1_surveillance_20090710/en/index.html
i. The WHO will no longer issue the global
tables showing the number of confirmed cases for all countries.
ii. For countries already experiencing community-wide transmission, the
focus of surveillance activities will shift to reporting against the
established indicators for the monitoring of seasonal influenza
activity. Those countries are no longer required to submit regular
reports of individual laboratory-confirmed cases to the WHO.
b. Why did the CDC stop reporting individual
confirmed and probable novel H1N1 Flu cases?
Pandemicflu.gov
http://www.pandemicflu.gov/faq/swineflu/sf039.html
i. Thus, on July 24, 2009 CDC transitioned
from reporting probable and confirmed case counts to only reporting
regional disease activity levels using its seasonal surveillance systems
to track the progress of the novel H1N1 flu outbreak. (see also
http://www.cdc.gov/media/transcripts/2009/t090724.htm) This form of
reporting disease activity levels is the method CDC uses to report on
routine seasonal flu activity, which does not count individual cases,
but instead monitors activity levels and virus characteristics through
nine nationwide surveillance systems. Results from these systems are
updated weekly and are posted on the CDC website on Fridays at
www.cdc.gov/flu.
ii. We have been saying for some time that this change would eventually
happen. We recognize that individual case counts are easy to understand
and desirable, but these indicators represent a significant
underestimate of overall disease burden and spread in the United States.
CDC will continue report the total number of novel H1N1 flu
hospitalizations and deaths each week.
3.
Testing:
a. Political/economic influences: If you don’t
test, you don’t confirm the disease or a high death rate. The data can be
skewed.
b. Health Alert #27, 2009
New York City Department of Health and Mental Hygiene, July 8, 2009
http://www.nyc.gov/html/doh/downloads/pdf/cd/2009/09md27.pdf
Preliminary data from an outpatient ILI surveillance project being conducted
by DOHMH in collaboration with the Institute for Family Health and Columbia
University show that among 114 patients presenting with febrile or
respiratory illness since the end of May 2009 who had results available, 61
(54%) were positive for pandemic H1N1 by PCR testing at Columbia University,
with declining incidence of pandemic H1N1 in recent weeks. Rapid test (EIA)
had low sensitivity, only detecting 17 (28%) of these cases.
c. Swine flu tests must be repeated, medics told
Ella Lee, South China Morning Post, Jul 25, 2009
http://www.scmp.com
i. Dr Tsang, convenor of the public hospital laboratories network,
said a review of severe cases showed that the virus load in the upper
respiratory tracts would drop by half three to four days after the onset
of the illness.
ii. "The virus load is almost zero on the seventh
or eighth day after the onset, meaning that a test of their nasal fluid
after that period could turn out to be a false negative," he said. "In
that situation, a specimen from the lower respiratory tract should be
taken for tests."
iii. Another rapid test, the antigen test, which takes only one hour to
complete, is not being used. Dr Tsang said the test could only tell
whether a patient had contracted influenza A, of which swine flu is a
form, and was only 60 to 70 per cent accurate. "We don't use this test
in swine flu because of its high false-negative rate."
d. Quick Tests for the Flu Found Often Inaccurate
Andrew Pollack, The New York Times, August 6, 2009
http://www.nytimes.com/2009/08/06/health/06flu.html?_r=2&ref=business&pagewanted=print
i. In a study published recently in The
Journal of Clinical Virology, Dr. Ginocchio found that one rapid test
detected only 10 percent of the swine flu infections that could be
picked up by a more sophisticated laboratory culture. A different rapid
test detected 40 percent. (Dr. Ginocchio is a consultant to Luminex
Corporation, a company that makes a more accurate but slower test.)
ii. The federal Centers for Disease Control and Prevention is expected
to publish its own study of the rapid tests soon. Last week, it updated
guidance urging doctors to be cautious in relying on the tests.
iii. “We’re saying you need to understand the limitations of these
tests,” Dr. Timothy M. Uyeki, an author of the C.D.C. guidance, said in
an interview. “The clinician should not base a decision to treat or not
treat on the basis of a negative result.”
e. Interim Guidance for the Detection of Novel
Influenza A Virus Using Rapid Influenza Diagnostic Tests
Centers for Disease Control and Prevention (CDC), July 29, 2009
http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm
i. Rapid Influenza Diagnostic Tests:
Compared to RT-PCR, the sensitivity of RIDTs for detecting novel
influenza A (H1N1) virus infections ranged from 10-70%. Therefore, a
negative RIDT result does not rule out novel influenza A (H1N1) virus
infection.
ii. The Role of RIDT for Detecting Novel H1N1: Clinical Considerations:
A RIDT may provide useful information that might impact on patient care
(Figure). However, understanding the limitations of RIDTs is very
important to appropriately interpret results for clinical management.
When influenza viruses are circulating in a community, a positive test
result indicates that influenza virus infection is likely present in the
specimen. Knowledge of the presence of influenza A or B virus infection
can help to inform influenza treatment decisions. However, a negative
rapid test result does not rule out influenza virus infection. Since
false negative results can occur, if clinical suspicion of influenza is
high in a patient who tests negative by RIDT (or if RIDT is not
offered), empiric antiviral therapy should be administered, if
appropriate, and infection control measures implemented. Guidance on the
use of influenza antiviral agents is available at:
http://www.cdc.gov/h1n1flu/recommendations.htm. In settings where
policies indicate exclusion of patients who may have influenza (e.g.,
schools, camps, day care centers), a negative RIDT, performed on a
patient with clinically compatible illness, should not be used as
justification for early return to that setting. Finally, a negative RIDT
result can not exclude influenza as a cause of an outbreak in a facility
with ill residents or patients with clinically compatible illness.
http://www.cdc.gov/h1n1flu/images/rid_tests01.gif (flowchart below
but, N.B. Fever present in only 50% cases in Chile, 70% Mexico...
http://www.nytimes.com/2009/08/11/health/11docs.html)
Antiviral drug resistance (drug becomes
ineffective)
Asymptomatic Traveler With Tamiflu Resistant Pandemic H1N1
Recombinomics, July 4, 2009
http://www.recombinomics.com/News/07040901/H274Y_Asymptomatic.html
Anti-viral drug supply (Tamiflu and Relenza)
is very limited
1. Sales of Flu Drug Improve
Results at Roche
Andrew Pollack, New York
Times, July 23, 2009
http://www.nytimes.com/2009/07/24/business/24roche.html
a. “Still, Mr. Schwan [Roche CEO] said that Roche,
in cooperation with outside contractors, would increase its manufacturing
capacity to 400 million packs a year by the beginning of 2010, about four
times the current capacity.”
b. “He said that should be an ample volume, given that the company sold a
total of only 300 million packs during the last five years — a period that
encompassed a bird flu scare as well as the current swine flu outbreak.”
c. “Glaxo said it planned to triple its manufacturing capacity for Relenza
by the end of the year to 190 million treatments annually.”
2. notes:
a. One Tamiflu “pack” = one
treatment course = 10 doses (2 per day for 5 days), so Roche is probably
speaking about 400 million courses in production per year in 2010.
b. One course of treatment may not be enough
to treat infection
c. People may receive multiple infections in a year
due to flu mutation
d. Hundreds of thousands of courses are being used
globally to avoid infection. There may be much less antiviral medication
available in reality.
3. 100 million antiviral treatment courses will be
available this fall
CIDRAP, August 14, 2009
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/aug1409vaccine.html
"In an update on the nation's antiviral stockpiles, Robin said that 84 million
treatment courses are currently in federal and state stockpiles and that 3
million more doses are expected soon. He projected that a total of 100 million
antiviral treatment courses will be available this fall, but he added that only
a small amount will be available commercially."
4. older news
Obama
Admin. Releases Stockpile of Antiflu Virus Drug
John Hendren, ABC News, April 26, 2009
http://abcnews.go.com/Health/ColdandFluNews/story?id=7434061&page=1
50,000,000 treatment courses in the USA Government anti-viral stockpile, but
much may have been used.
Pandemics
strike in waves
http://www.cdc.gov/ncidod/eid/vol12no01/05-0979-G1.htm
Vaccine
1. Vaccines for the new Influenza A (H1N1)
World Health Organization, Up-to-date as of 27-May-2009
http://www.who.int/csr/disease/swineflu/frequently_asked_questions/vaccine_preparedness/en/index.html
“a global survey made by WHO on May 15, 2009, a
maximum 4.9 billion could be produced in 12 months. This would only be
the case if a number of conditions are met— notably that production yields for
influenza A (H1N1) vaccine are equivalent to those usually obtained for seasonal
vaccines, and that manufacturers use the vaccine formulation which has been
shown for H5N1 influenza as being the most "dose-sparing" (i.e. those which use
the smaller quantity of active principle). A more conservative estimate of
global capacity is at least 1 to 2 billion doses per year. This does not
translate automatically into numbers of persons vaccinated, as we do not yet
know how many doses of the vaccine will be needed to achieve protection.”
2. Swine flu vaccine production hits a snag: yield so far is 'less than optimal'
Helen Branswell, The Canadian Press, July 12, 2009
http://www.google.com/hostednews/canadianpress/article/ALeqM5hJMZ2o0rf1lyVv_1ZIxwdlZOqJuQ
"The World Health Organization says so far the
yield for egg-based production is half or less what manufacturers get when they
make vaccine to protect against seasonal H1N1 viruses."
3.
Flu Vaccine Production Hits Snag
Jeanne Whalen, The Wall Street Journal, July 17, 2009
http://online.wsj.com/article/SB124778234560554209.html
a. “But the H1N1 virus being used for swine-flu
vaccine is so far yielding a "low" level of antigen, Swiss drug maker
Novartis AG said Thursday. It said the yield so far is about 30% to 50% of
what the company normally gets for seasonal flu vaccines.”
b. Robert Parkinson, chief executive of Baxter International Inc. of
Deerfield, Ill., also described "yield optimization" Thursday as a
challenge.
4. WHO: Full Pandemic Flu Vaccine Production To Start In 2 Weeks
Anita Greil, Dow Jones Newswires, June 11, 2009
http://online.wsj.com/article/BT-CO-20090611-711589.html
Vaccine production is
starting in July 2009 more or less
5. Officials lower expectations for size of first
novel flu vaccine deliveries
CIDRAP, August 14, 2009
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/aug1409vaccine.html
"Federal officials today during a pandemic H1N1 planning update dialed back the
number of novel flu vaccine doses they expect in October from 120 million to 45
million, listing several reasons for the smaller projection.
a. During a late July meeting of a federal
immunization advisory panel, which targeted 159 million people to receive
the first doses, authorities projected that 120 million doses would be
available in October, with another 80 million per month in the following
months.
b. However, during a National Biodefense Safety Board (NBSB) teleconference
today, Dr. Robin Robinson, director of the Biological Advanced Research and
Development Authority (BARDA) at the US Department of Health and Human
Services (HHS), said the latest expectation is 45 million doses by mid
October, with manufacturers delivering 20 million doses per week after that.
c. He said the revised estimate is based on several factors expected to slow
vaccine delivery from manufacturers. Health officials have already
acknowledged that yields of the novel H1N1 antigen are less than for the
seasonal flu vaccine. Robinson also said vaccine makers have a limited
number of fill-and-finish sites, which are just completing seasonal flu
vaccine production, but that federal officials are looking for ways to
maximize the current capacity."
6. UK swine flu cases third worst in the world
Stephanie Busari, CNN, July 10, 2009
http://edition.cnn.com/2009/HEALTH/07/10/swine.flu.uk/index.html?iref=mpstoryview
They don’t know yet how many doses each person needs but The UK NHS is planning to use double doses.
7. Legacy of 1976 swine flu outbreak led to Canada's pandemic vaccine contract
Helen Branswell, The Canadian Press, July 17, 2009
http://www.google.com/hostednews/canadianpress/article/ALeqM5gHmjskDrW9P8WGnQ2XHa64Zs56CA
“Canada had the first national pandemic plan
and the first pandemic vaccine contract. And when GSK's production line starts
pumping out pandemic vaccine, the plant will be producing more than what Canada
needs.”
8. Vaccine Allocation Tiers in USA (as of
July 18, 2009)
http://www.pandemicflu.gov/vaccine/allocationguidance.pdf
Severity,
Calculations, and Response
1.
Graphics from the Department of Homeland Security
a.
http://www.pandemicflu.gov/plan/community/community_mitigation.pdf
b.
http://www.pandemicflu.gov/images/clip_image002_com.jpg
c.
http://www.pandemicflu.gov/images/clip_image004_com.jpg
2. The National Influenza Vaccine Summit 2009 Meeting
a.
http://www.ccldhe.org/resources/2009_InfluenzaSummitUpdate.pdf
b.
http://www.preventinfluenza.org/nivs_summ_2009.asp
3. Calculations:
Some links
- Great Flu presentations
a. Pandemic Influenza: What we all need to know
Kathy M. Williams RN, BS
http://www.studentsprepamerica.org/docs/Pandemic_Influenza_H1N1_&_H5N1_V2.ppt
b. Good summary post as of August 2009
http://www.singtomeohmuse.com/viewtopic.php?t=3577&postdays=0&postorder=asc&start=0
c. Influenza A (H1 N1) Master Update Ver 30.3 July 3 2009
Michael Fraser, RN
Irish First Point Responder Unit
http://www.slideshare.net/Bilogical/influenza-a-h1-n1-master-update-ver-303-july-3-2009
2. Flu cases data
a. N.B. Expect much less clear data after July 16,
2009
“The WHO will no longer issue the global table showing the numbers of
confirmed cases for all cases,”
http://www.who.int/csr/disease/swineflu/notes/h1n1_surveillance_20090710/en/index.html
b.
http://en.wikipedia.org/wiki/2009_H1N1_influenza_outbreak
c.
http://www.peterosborn.com/pandemic.htm
d.
http://spreadsheets.google.com/ccc?key=rZIWyvI97h892s2bmCVlm6A
e.
http://homepage.mac.com/monotreme1/Outbreak%20folder/H1N1Outbreaks.html
f.
http://www.cdc.gov/h1n1flu/update.htm
g.
http://wonder.cdc.gov/mmwr/mmwrmort.asp
3. Flu discussion forums
and blogs
http://pfiforum.com
http://monotreme1000.wordpress.com
http://www.flutrackers.com/forum/index.php
http://www.fluwiki.info
http://www.curevents.com/vb/forumdisplay.php?f=40
4. Flu news - current
a. aggregator (streaming)
http://www.newsnow.co.uk/h/?JavaScript=1&search=H1N1
http://www.newsnow.co.uk/h/?JavaScript=1&search=gripe
http://www.newsnow.co.uk/h/Business+%26+Finance/Industry+Sectors/Agriculture/Bird+Flu
b. School closings
http://news.google.com/news?pz=1&ned=us&hl=en&as_maxm=4&q=school+shut+OR+closed&as_qdr=d&as_drrb=q&as_mind=27&as_minm=3&cf=all&as_maxd=26&scoring=n
5. Flu researchers
a.
http://www.recombinomics.com/whats_new.html
6. Flu infections maps
(currently have frequent updates during each day)
a. Niman and Rhiza Map
http://flutracker.rhizalabs.com/
b. A Google map
http://maps.google.com/maps/ms?ie=UTF8&hl=en&source=embed&msa=0&msid=109496610648025582911.0004686892fbefe515012&ll=43.580391,-53.085937&spn=90.39,228.515625&t=h&z=3
7. Emergency preparedness
http://www.singtomeohmuse.com/viewtopic.php?t=3235
http://www.curevents.com/vb/forumdisplay.php?f=23
http://www.planforpandemic.com/
http://getpandemicready.org/
http://www.youtube.com/user/NHPandemicPlanner#play/uploads/10/fcCfzvYBo2c
http://www.singtomeohmuse.com/parent/wiki%20files/Becoming_Self-Sufficient%5B1%5D.pdf
8. Official government
sites
a. Argentina- Health Department notices
http://www.msal.gov.ar/htm/site/default.asp
b. Mexico, Secretaria de Salud
http://portal.salud.gob.mx/
c. UK- National Health Service
http://www.nhs.uk/Pages/HomePage.aspx
d. United Nations- WHO (World Health Organization)
http://www.who.int/en/
e. USA
i. CDC news (Center for Disease Control)
http://www.cdc.gov/swineflu/whatsnew.htm
ii. Department of HHS and CDC
http://www.pandemicflu.gov/
iii. Los Alamos National Laboratory flu wave simulation
http://www.lanl.gov/news/images/bird4x3red.mov
iv. CIDRAP
http://www.cidrap.umn.edu/
