Journal

Dengue Fever confirmed in Greater Orlando area, Ocala

2010-07-16T17:21:03Z

According to Fox News Orlando, Dengue fever is confirmed in Orlando, and the Obama Administration is to blame!

OK, the first part of that sentence is true. Dengue fever has been confirmed in Orange County, which includes Orlando and all your world-renowned theme parks. The Fox affiliate is reporting that three Orange residents are stricken with dengue. Here's the link, and the text:

LAKE MARY, Fla. (AP) - A health department official from Orange County has told FOX 35 that there are three cases of dengue fever in Orange County.

Late Thursday, health officials in Miami and Ocala were reporting the first suspected cases of dengue fever, a potentially serious mosquito-borne illness that had once disappeared from the United States.

Dengue fever is a flulike illness spread by the bite of an infected Aedes aegypti mosquito (ay-EE-deez ee-JIP-ty), a common urban mosquito in the U.S. and Caribbean. It's known as breakbone fever because of the intense joint pain suffered in extreme cases.

Health officials say the Miami Beach man who is suspected of contracting the disease has fully recovered. No further information was released Thursday about the case in Ocala.

A recent study revealed five percent of Key West residents show evidence they have been exposed to the virus, but few became ill.

Orange County Health Department spokesperson Dan Weister said the cases in Orange County involve residents who have traveled to Puerto Rico and the Caribbean.

As we know, you can get a lot more than a sunburn by traveling to Puerto Rico, trinidad, and just about anywhere wlse in the Caribbean these days. Anyone who goes to these areas without a) sunscreen and b) a ton of DEET-laden repellent, is crazy!

About an hour north of Orlando is Ocala, where horsemen and -women breed champion thoroughbreds. It is equidistant between Orlando and Gainesville, where Gators breed national championships! Anyway, Ocala has also reported its first case of dengue since Johnson was president. Here is that story, from the Ocala Star-Banner:

Dengue fever identified in county

The Marion County Health Department has requested the Marion County Commission conduct a mosquito spray in the northeast area of Citra after receiving confirmation of a case of Dengue fever in the county.

More Information:

CDC page on Dengue fever

“We have requested the mosquito spray as a precautionary measure,” said Dr. Nathan Grossman, director of the Marion County Health Department, in a news release. “The risk of transmission from this mosquito-borne disease is very low, but as part of our mission to protect the health of Marion County citizens we are taking additional steps to further reduce possible transmission.”

Dengue fever is a mosquito-borne virus that is transmitted to humans by the bite of an infected mosquito. It is usually seen in subtropical and tropical land regions. Symptoms are headache, fever, exhaustion, severe joint and muscle pain, swollen glands, mild bleeding and rash. There is no specific treatment.

Because the fever can be transmitted to another human from a mosquito that has bitten a person with the disease, citizens should take precautions to protect themselves from mosquito bites.

The Health Department advises following the “5 Ds:

* Dusk and Dawn – Avoid being outdoors when mosquitoes are most active.

* Dress – Wear clothing that covers most of the skin.

* DEET – Use repellents containing DEET (N,N-diethyl-meta-toluamide, or N,N-diethyl-3-methylbenzamide). Picaridin and oil of lemon eucalyptus are options.

* Drainage – Check around homes and rid areas of standing water where mosquitoes can lay eggs.

For more information, call 629-0137.

So dengue has gone from "What it that?" to "OMG!" Stay tuned, for i am sure there will be plenty more to read about. And follow Avian Flu Diary and H5N1 for more details. Their links are in the column to the left.

Dengue fever alert posted for South Florida

2010-07-16T15:49:40Z

Things are moving very quickly on the dengue fever front in South Florida. Just this morning, the Ft. Lauderdale Sun-Sentinel reported that the Centers for Disease Control and Prevention (CDC) have issued an unprecedented dengue fever warning for South Florida. Here's the article:

Advisories were in effect in Broward and Palm Beach counties Thursday after health department officials announced that a Miami Beach man had come down with a suspected case of locally-acquired dengue fever.

The announcement from the Miami-Dade Health Department follows word earlier this week of what was described as a small outbreak of the exotic, mosquito-borne disease in Key West.

That prompted a warning from the federal Centers for Disease Control and Prevention that the disease, which can be serious and even fatal on rare occasions, could spread.

Candy Sims, a spokeswoman for the Broward County Health Department, said no suspected cases have been reported locally. "But we are on high alert and monitoring the situation," she said.

Earlier this week, Harold Margolis, chief of CDC's dengue branch, issued a report in which he said, "We're concerned that if dengue gains a foothold in Key West, it will travel to other southern cities where the mosquito that transmits dengue is present, like Miami.''

Health officials urged people to keep covered up and use insect repellent as precautions.

A viral disease common to the southeastern United States and the tropics, dengue fever is not spread from person to person and is seldom fatal except to the very young and elderly with other health conditions, according to health department experts.

But this outbreak is serious enough that a specialist from the CDC recently gave classes in South Florida teaching doctors and hospital officials how to recognize the disease.

Symptoms include a high fever, severe headache, a rash, and pain in bones and joints, according to the CDC. More than 100 million cases of dengue occur every year worldwide.

The Miami Beach man who is suspected of contracting the disease has fully recovered, said Miami-Dade Health Department Director Lillian Rivera. "He is doing well," she said.

A blood sample from the Miami Beach man is being tested by the state. If dengue is confirmed, it would be the first locally contracted case of the disease in Miami-Dade Countyin at least 45 years, said Rivera.

"This is not a cause for alarm; it is a cause for creating awareness that we live with mosquitoes and we need to protect ourselves," she said.

In Palm Beach County, Health Department Director Alina Alonso sent a memo to county physicians and infection control specialists on June 30, urging "enhanced surveillance" for dengue after the Key West cases had been identified.

"It is of utmost importance that suspected cases of dengue are accurately and promptly diagnosed," she wrote in the memo. "Recent travel history to the Caribbean, Central and South American countries, or Key West in a patient with the above symptoms may suggest a consideration of dengue in the differential diagnosis."

In Key West, doctors have recorded 14 cases of dengue since April, following an outbreak of 27 cases last fall. Those cases were the first recorded in the continental United States since 1945.

More recently, epidemic dengue has become more common in the tropics and subtropics, including Puerto Rico.

But the Key West cases, said the CDC's Margolis, "represent the re-emergence of dengue fever in Florida and elsewhere in the United States after 75 years."

"These people had not travelled outside of Florida," said Margolis is a statement, "so we need to determine if these cases are an isolated occurrence or if dengue has once again become endemic in the continental United States."

For the first time in five decades, dengue fever is gaining a foothold in the United States. The authorities are moving swiftly and decisively to set up the means to detect this virus and monitor its progress. This is yet another value-add from the swine flu pandemic and bird flu preparedness drills. The monitoring mechanisms to diagnose, detect and track the spread of dengue would not be so easily set into motion, had it not been for pandemic exercises and the actual swine flu pandemic itself. People should remember this, especially residents of South Florida.

Miami gets first Dengue fever case

2010-07-15T19:14:49Z

The Miami New Times is a groundbreaking alternative publication. Published weekly, it has been a (free!) source of reporting and commentary since the 1970s. It occasionally crosses over into the mainstream, and it has won numerous awards. One look at its building, a high-rise office complex on Biscayne Boulevard, is a metaphor for both its profitability and its transition from a small scraggy operation to a Pillar Of The Community.

The New Times is reporting Miami-Dade County's first confirmed case of Dengue fever. the link is here:

http://blogs.miaminewtimes.com/riptide/2010/07/first_case_of_dengue_fever_rep.php

This makes three stories about Dengue in South Florida in as many days. Stay tuned.

Dengue fever gains beachhead in US

2010-07-14T14:08:56Z

Several news articles are circulating today regarding the apparent re-establishment of a permanent dengue fever colony in the United States. This should not come as a surprise; I and others have been warning of the eventual and guaranteed establishment of dengue in the US for years. Nor should the location come as a surprise. Key West is a mere 90 miles from the northern coast of Cuba, and Key West (as everyone knows) sticks out into that intersection of the Gulf of Mexico and the western Caribbean Sea, via the Straits of Florida.

Two articles illustrate the re-established dengue colony in Key West.

More than 1,000 exposed to dengue in Florida: CDC

Tue, Jul 13 2010

WASHINGTON (Reuters) - Five percent of the population of Key West, Florida -- more than 1,000 people -- have been infected at some point with the dengue virus, government researchers reported on Tuesday.

Most probably did not even know it, but the findings show the sometimes deadly infection is making its way north into the United States, the researchers said.

"We're concerned that if dengue gains a foothold in Key West, it will travel to other southern cities where the mosquito that transmits dengue is present, like Miami," said Harold Margolis, chief of the dengue branch at the U.S. Centers for Disease Control and Prevention.

"These cases represent the reemergence of dengue fever in Florida and elsewhere in the United States after 75 years," Margolis said in a statement.

"These people had not traveled outside of Florida, so we need to determine if these cases are an isolated occurrence or if dengue has once again become endemic in the continental United States."

Dengue is the most common virus transmitted by mosquitoes, infecting 50 million to 100 million people every year and killing 25,000 of them.

It can cause classic flu-like symptoms but can also take on a hemorrhagic form that causes internal and external bleeding and sudden death. Companies are working on a vaccine but there is not any effective drug to treat it.

Dengue was eradicated in the United States in the 1940s but a few locally acquired U.S. cases have been confirmed along the Texas-Mexico border since the 1980s. More cases have been reported recently in Mexico and the Caribbean.

After 27 cases of dengue were reported in Florida in 2009, scientists from the CDC and the Florida Department of Health took blood samples from 240 randomly chosen Key West residents.

Of these, 5 percent had active dengue infections or antibodies to the virus, showing they had been infected, the researchers told the International Conference on Emerging Infectious Diseases being held in Atlanta.

The second article is from the Sun-Sentinel, one of Florida's largest daily newspapers, headquartered on Ft. Lauderdale:

Officials warn again about dengue fever in Key West

Bob LaMendola, Sun Sentinel

11:02 p.m. EDT, July 13, 2010

As South Floridians motor to the Keys for summer vacation, health officials on Tuesday urged caution about the persistent presence of mosquito-borne dengue fever in Key West.

Doctors have logged 14 cases in the old town since April — two last week — after an outbreak of 27 cases last fall marked the first time since 1945 that someone got the virus in the continental United States.

No one has died, and most people don't even get sick when infected with dengue, officials said in Tuesday's report from the federal Centers for Disease Control and Prevention. But it's the first time the virus has returned for a second U.S. outbreak in the same place.

"Most experts thought it would not be back, but here it is. It has come back," said Carina Blackmore, a Florida Department of Health expert on mosquito diseases who helped write the CDC report. "We all need to be careful."

That includes the 3.3 million tourists who visit the Keys each year, 35 percent of whom are from Florida and a large share of whom come from South Florida.

Officials said tourists have little to worry about as long as they take basic precautions against bug bites: Stay indoors from dusk to dawn, wear long sleeves and pants if outside at those times, use repellent with the chemical DEET and eliminate even small pools of standing water where the bugs breed.

"I don't think people have to worry about coming to Key West. They should be aware of the outbreak, but if they stay in a hotel with air conditioning and take simple steps, their risk should be absolutely minimal," said Dr. Mark Whiteside, medical director at the Monroe County Health Department.

Aside from dengue, three horses in South Florida have died from mosquito-borne encephalitis, and a few chickens have tested positive for West Nile virus. All three diseases are carried by different mosquitoes, but officials said the need for caution is clear.

Dengue fever infects about 50 million people worldwide and kills 25,000. The symptoms can include fever, aches, pains, rash, upset stomach and vomiting. Two of those infected in the Keys were hospitalized.

Last fall, health officials took blood samples from 240 Key West residents and reported Tuesday that 5 percent had been exposed to dengue. Blackmore said the number probably has gone up.

There's little risk of the carrier mosquito — Aegus aegypti — venturing off the island. Blackmore said the species generally stays close to home. But a risk is that a visitor could get infected and then be bitten by mosquitoes at home, spreading dengue to a new locale.

"We're concerned that if dengue gains a foothold in Key West, it will travel to other southern cities where the mosquito that transmits dengue is present, like Miami" and the rest of South Florida, said Harold Margolis, dengue chief at the CDC.

For more information, see http://www.cdc.gov/dengue or call 800-232-4636.

We once had a powerful weapon to fight mosquitoes, and it was a doozy: DDT. But the advent of Silent Spring, the '60s Rachel Carson book, pretty much killed DDT like Ralph Nader killed Corvairs. Now, however, we are learning more and more about DDT. And it appears Ms. Carson took extreme liberties when it came to the effects of DDT on the environment. I am stopping short of saying Ms. Carson lied, but the effect on DDT was the same as if she had.

I head a story on the radio, and I heard a similar story from another source, and the stories prompted me to remember riding my bicycle behind the ol' fogger truck as it made its way through my old Lighthouse Point, Florida neighborhood. It was so cool to ride in the "fog" created by that machine as it lumbered through our streets! Sometimes it would back up and hit a backyard, a vacant lot, a wooded area or a construction site with more fog, upon request.

I am certain that some readers are recoiling in abject horror at that statement! But I am also confident that there are several of you out there who recall those days with fondness. Despite the recoil, let me assure you that I have no visible nor invisible scars to show for those days.

How many African children could have been saved with the re-establishment of DDT? Perhaps the million per year that die from mosquito-borne viruses? Sadly, our only answer to malaria, dengue and chickungunya (all mosquito-borne) is to buy a lot of DEET-enriched repellent and to ship mosquito nets to Africa. I shake my head at that.

Even the WHO has issued entreaties to restore the development and production of DDT. It's the only thing that reliably works on mosquitoes. And I do not believe (someone will correct me, I am sure) that mosquitoes develop a resistance to DDT.

As mosquito-borne diseases continue to grow and expand, there is a knee-jerk reaction from governments, courtesy of the Friends of the Mosquitoes, to do little to nothing to combat the winged vector of diseases. Here in the Peoples' Republic of Tallahassee, the Leon County Commission bowed to the wild-eyed lunatic fringe, and imposed one of the most ludicrous acts in recent memory. If one single homeowner objected to the spraying for mosquitoes, then spraying would be abandoned for every parcel within a quarter-mile -- a quarter-mile! -- of that home. The effect was that 100 homeowners would effectively shut down mosquito spraying for almost all Leon County, Florida residents.

Former Leon Commissioner Ed DeDuy, a very good friend of mine, once said that few things arose as much passion as messing with mosquito spraying. And we was proven right again, as the silent majority of homeowners went apoplectic and raised such a ruckus that the commission flip-flopped and reversed the ban.

Those who oppose spraying for mosquito control strike me as in the same league as those who oppose vaccines because they (mistakenly) think they cause autism. Mosquito control is as much of a public health issue as vaccinating the population.

With West Nile Virus, Eastern Equine Encephalitis and Dengue fever, Florida is a contender for the Triple Crown of mosquito-borne diseases. Throw in some other diseases that hypothetically might be controlled by such spraying -- Lyme disease, for example -- and it is an imperative that we deal with these dangerous pests quickly and decisively. To paraphrase: Spray, baby, spray!

And bring back DDT. Let's abandon the junk science and save some lives.

Songbirds, not just fowl, represent avian flu threat to US

2010-06-25T18:56:06Z

Over at Flutrackers, there is a thread regarding the prevalence of avian influenza in American birds.

Avian influenza virus (AIV) is an important public health issue because pandemic influenza viruses in people have contained genes from viruses that infect birds. The H5 and H7 AIV subtypes have periodically mutated from low pathogenicity to high pathogenicity form. Analysis of the geographic distribution of AIV can identify areas where reassortment events might occur and how high pathogenicity influenza might travel if it enters wild bird populations in the US. Modelling the number of AIV cases is important because the rate of co-infection with multiple AIV subtypes increases with the number of cases and co-infection is the source of reassortment events that give rise to new strains of influenza, which occurred before the 1968 pandemic. Aquatic birds in the orders Anseriformes and Charadriiformes have been recognized as reservoirs of AIV since the 1970s. However, little is known about influenza prevalence in terrestrial birds in the order Passeriformes. Since passerines share the same habitat as poultry, they may be more effective transmitters of the disease to humans than aquatic birds. We analyze 152 passerine species including the American Robin (Turdus migratorius) and Swainson's Thrush (Catharus ustulatus).
Methods

We formulate a regression model to predict AIV cases throughout the US at the county scale as a function of 12 environmental variables, sampling effort, and proximity to other counties with influenza outbreaks. Our analysis did not distinguish between types of influenza, including low or highly pathogenic forms.

Results

Analysis of 13,046 cloacal samples collected from 225 bird species in 41 US states between 2005 and 2008 indicates that the average prevalence of influenza in passerines is greater than the prevalence in eight other avian orders. Our regression model identifies the Great Plains and the Pacific Northwest as high-risk areas for AIV. Highly significant predictors of AIV include the amount of harvested cropland and the first day of the year when a county is snow free.
Conclusions

Although the prevalence of influenza in waterfowl has long been appreciated, we show that 22 species of song birds and perching birds (order Passeriformes) are influenza reservoirs in the contiguous US.

OK, insightful analysis time. We always associate bird flu with ducks, or chickens, or turkeys or geese, but rarely do we associate it with songbirds and other smaller birds. This study makes a clear association between those birds (called "passerines") and bird flu.

The distribution of those avian flu cases is seen in this map (thanks Laidback Al!):

Now let us look at a map of the principal migratory bird routes over North America:

There is a veritable swarm of migratory bird routes over the Great Plains and Mississippi River delta, and a very strong west coast migratory route. So it is no coincidence, in my mind, that these migratory superhighways also contain the areas where avian flu has been most strongly detected since 2005.

Now you also notice those "down arrows" leading South of the Border. This map helps illustrate what happens south of us:

We've got birds encroaching from the south as well as from the north. This does not just figure into the avian flu equation: There is this little thing called a major dengue fever epidemic that is raging in many, if not most, South American nations. And as I mentioned recently, Key West, Florida has enough dengue in it to sicken a man this year.

This all leads into the current status of H5N1 sentinel activity. With massive budget cuts, waning interest, and competition for attention from swine flu and other diseases, do we have as good a handle on things as we did in 2006 and 2007? I would like to think so, but I doubt it.

Imagine the encounter: A researcher goes into his/her supervisor's office, requesting additional funds for H5N1 monitoring. What, the supervisor says? You want me to divert $$ from certain necessary projects over to bird flu monitoring? All while my departmental budget is being cut to ribbons?! No stinking way!

Or words to that effect. I wish it were not so, but I am pretty certain I am right.

In the midst of all this, the Mexican government recently issued an alert to be watchful for an H5/H1 hybrid virus. My first impulse was to say, What do they know? What have they heard? But is may have been nothing more than speculation. Nonetheless, vigilance is important, now more than ever. For H1N1v may not have been the pandemic everyone feared, but it was substantial in terms of its effect on the young; far worse than, say, 1977. Yet H1N1v, being 1/3 avian, can still hang out with avian flu viruses and reassort. It is precisely this scenario that should cause us to view this latest report with concern.

Trust Fineberg's committee to deliver accurate, relevant, honest WHO appraisal

2010-06-22T17:38:37Z

Wow. It has been more than two months since my last blog entry. that must mean that H1N1v, or swine flu, is gone, right?

No. It means I am incredibly busy these days, and have not had much to say about pandemics nor about infectious disease. Well, that is not entirely true. For example, dengue fever has established a beachhold in Key West, Florida, where a Navy person recently was confirmed to have contracted dengue from within Key West's city walls.

Also, and as most of us surmised, swine flu is still worming its way through the developing world. India seems to be under the gun with outbreaks of H1N1v, and I am not sure what the genetic makeup of this new virus might be.

Additionally, recent reports regarding testing of the H1N1 vaccine on mice and subsequent attempts at infection with 1918 Spanish flu are encouraging. It appears that there is some conferred immunity from the 1918 pandemic virus with the H1N1 swine flu vaccine. This is important, because if you recall from reading this Blog, the 1977 recurrence of H1N1 was believed to be the result of a Soviet lab accident. So this pandemic may have been serendipitous in that it is helping immunize the planet against another Spanish Flu.

Anyway, the article that prompted me to write this blog actually deals with the WHO analysis of itself. The WHO has been the subject of much scrutiny as the result of what has been to date, a very mild pandemic. Some are inferring that Big Pharma actually orchestrated this pandemic in order to make a lot of money on vaccine and antivirals.

Believe me, Big Pharma has more and bigger things to make money on than vaccines. Anyone who really believes Big Pharma would drop everything it was doing to go and make vaccine just does not understand how drug companies make their money today. Druf companies see vaccine production as a necessary evil; a component of what they do, but not nearly as profitable as making and selling drugs dealing with everything from erectile dysfunction to hair loss.

In fact, accusing drug makers of profiting unnecessarily from vaccine production may actually cause drug makers to forego vaccine production in the future. Now some, including those misguided but WRONG individuals who think vaccines cause autism, might rejoice in that thought. But the simple truth is that drug companies see vaccine production as an important public health duty. And accusing them of orchestrating an overly aggressive response to a flu pandemic is placing blame in the wrong place.

Is there a right place to place blame? In my opinion, no. There is no blame. The WHO acted correctly. Now there are protocol adjustments to make, and my previous blogs have covered the principal problems, dealing with severity. The WHO needs to adopt the US "Saffir-Simpson" standard for pandemic severity. I am sure that concept will get an airing and eventual adoption.

But the absolute best news I gleaned from today's article about the WHO oversight committee deals with the committee itself. First, the AP story of today:

2 experts resign from WHO swine flu review panel

(AP) – 1 hour ago

GENEVA — The World Health Organization said Tuesday that two members of an expert panel reviewing the global body's response to the swine flu outbreak have resigned over concerns about perceived conflict of interest.

John MacKenzie and Tony Evans stepped down because their close association with the UN health organization during the outbreak could be seen as conflicting with the panel's ability to remain independent, WHO said.

"Both have been closely engaged in deliberations at WHO which our committee is charged to review," said panel chairman Harvey Fineberg. "They each concluded it would be better to avoid the position as reviewer of their own earlier actions."

Mackenzie, a professor of tropical infectious diseases at Curtin University in Australia, and Evans, medical chief of the Montreal-based International Civil Aviation Organization, were on the emergency committee that advised WHO's Director-General Margaret Chan before she declared swine flu a pandemic.

WHO convened the panel in April to conduct a "credible and independent review" of how it and national authorities handled the outbreak. Concerns were raised at the time that several panel members were trusted WHO advisers and government employees who could end up whitewashing any failures.

The review panel will present a final report next year.

Harvey Fineberg is Dr. Harvey Fineberg, head of the Institute of Medicine in Washington, DC. He also is the former head of the Harvard school of public health, and former Harvard provost. But to flubies, Harvey is best-known as the co-author of the seminal study of the 1976 swine flu debacle, along with the late historian Richard Neustadt. Harvey is also a pen pal of mine, and I engage him occasionally as a sounding board for ideas that, depending on his thoughts, eventually appear here as blogs.

Harvey may be the most-qualified person in the world to assess the WHO's handling of the 2009-10 swine flu pandemic. His 1976 study should be required reading for anyone who is interested in public policy when it comes to public health and infectious disease policy. I am equally certain his committee's analysis of the WHO's conduct during this latest pandemic will also be compelling reading.

Why Na Tao matters, despite apparent lack of human bird flu transmission

2010-04-19T13:16:15Z

A reader of this Blogsite, Jonathan Singleton, asked me to comment on the recent proMED report regarding Na Tao, Vietnam. As you may know, Na Tao is at the heart of a possible cluster of human cases of bird flu. My previous two blogs have covered this developing situation.

The proMED report in question is below.

Influenza A (H5N1) is not transmitted from human to human

---------------------------------------------------------------------------

Yesterday afternoon [14 Apr 2010], at a meeting of the National Steering Committee for pandemic influenza control and prevention, Dr Tran Nhu Duong, Deputy Director of the National Institute of Hygiene and Epidemiology confirmed that influenza A (H5N1) has not been transmitted from human to human.

The investigation of the Institute on 2 cases of influenza A (H5N1) in Na Tao village, Nhu Co commune, Cho Moi District, Bac Kan province did not detect human to human virus transmission.

Reports of two investigation teams of the Institute in Bac Kan showed that the two patients were living about 100 meters apart, and they had never been in direct contact with each other.

All 33 people who had contact with the patients, including relatives, visitors, neighbors, nurses, and physicians, were tested and monitored for 16 days. There has been no case with symptoms of the disease. All the test results were negative.

Communicated by:

PRO/MBDS

<promed-mbds@promedmail.org>

As we now know, there are three suspected human cases, not two. But that is not material to our discussion. What is material is that two persons, living about a little more than a football field's distance apart, contracted H5N1 bird flu.

The report seems to conclude that distance alone, coupled with a lack of direct contact of one with another, eliminates the possibility of human-to-human (H2H) transmission. That sounds logical enough.

But the larger issue -- the proverbial elephant in the room -- is this: Has the virus itself changed enough in Na Tao, Vietnam, to allow for an easier method of transmission from avian to human respiratory cells? If so, that disclosure would prove to be almost as big (and ultimately more potentially troublesome) than another H2H cluster.

That is a question that the Vietnamese report does not answer.

Let's consider the facts. Three persons in one district contract bird flu. Apparently they all contracted it via contact with diseased poultry. That tells me that either the virus in that area of Vietnam is more potent, and/or the ability of the virus to favor human epithelial cells as much as it favors chicken epithelial cells.

We all know from reading the research papers that this proclivity toward one species or another is primarily driven by temperature. The fact that both diseased poultry and diseased villagers have been detected in a cluster bears investigating by the WHO. For a cluster is a cluster whenever you get multiple persons in a close area, H2H or no H2H. Three B2H bird flu cases in one hamlet should be significant enough to want to gather many samples and look at them very, very carefully.

Vietnam's Na Tao hamlet: Ground Zero for latest bird flu cluster

2010-04-13T19:48:00Z

The world press is beginning to focus on the province of Bak Kan (or Bac Can), Vietnam. Bak Kan is in the extreme north of Vietnam, near the Chinese border. Last week, I blogged on the potential H5N1 bird flu cluster that was threatening to emerge within that province. Just scroll down to read my previous blog.

Following my blog, a second story appeared regarding a second human infection. It was dated at 6:01 PM, 04/09/2010. It appears below, and the link to the VOV story is in the headline:

Another A/H5N1 infection case reported in Bac Kan

Bac Kan province has confirmed a second A/H5N1-infection case in Na Tao hamlet, Nhu Co commune, Cho Moi district. The patient, Nguyen Thi Thanh Thu, 27, visited a bird flu-infected area four or five days before being diagnosed with the deadly virus.

The healthcare centre in Cho Moi district has reported nine suspected cases, eight of them from Na Tao hamlet. (bold mine) All nine showed symptoms of high fever, breathing difficulty and coughing.

The first A/H5N1 case was detected in Bac Kan on April 5. The patient, Trung Van Hoa, 22, was also from Na Tao hamlet.

At present, local authorities and health agencies are intensifying emergency measures to sterilise infected areas and strictly monitor new outbreaks of the disease.

Cho Moi district has been given 700 doses of Tamiflu vaccine(bold mine) and enough medical equipment to ensure that necessary checkups and treatment can be provided to local patients.

Now today, a copyrighted story has appeared via the Canadian Press. It has also been picked up by AP and has gone worldwide. Here is that story:

Bird flu sickens 2 in Vietnam; 11 others quarantined, recovering from flulike symptoms

By Tran Van Minh (CP) – 5 hours ago

HANOI, Vietnam — Two Vietnamese from a poor, mountainous area have been infected with bird flu, and 11 others were quarantined with flulike symptoms, health officials said Tuesday.

A 22-year-old man and a 27-month-old girl remain hospitalized after testing positive for the H5N1 virus, said Hoang Van Linh, deputy director of northern Bac Kan province's health department. He said the 11 others, some of whom were relatives of the confirmed cases, had fallen ill with fever, coughing and shortness of breath.

They were given the antiviral Tamiflu and have since recovered. He said they were tested for bird flu, but the results have not come back.

Dead chickens were reported at the homes of the two patients, and the toddler's family is believed to have slaughtered and eaten some of the infected poultry, according to the Ministry of Health's Web site. Ly Quoc Khach, an infectious disease official from the provincial health department, said all 11 people, members of the Tay and Nung ethnic minorities, had contact with the sick birds, and he said he did not believe there would be any reason to fear possible human-to-human transmission if they did test positive.

The 22-year-old man remains on a respirator after being hospitalized April 2, while the toddler, who was admitted two days later, is in stable condition, Hoang said. All of the sick people's homes in Ma Tao commune have since been disinfected, and the infected poultry have been slaughtered, Ly said.

Vietnam has been hit with a spate of fresh H5N1 outbreaks among poultry, and two people have died from the disease this year, according to the World health Organization, which confirms 59 deaths since late 2003.

The disease remains rare among people, with most cases linked to direct contact with infected poultry. But experts have long feared the virulent virus could mutate into a form that allows it to spread easily among people, possibly igniting a pandemic.

OK, time for award-winning commentary again. Note that the Vietnamese press is listing three -- NOT two -- confirmed H5n1 cases. Note also that the VoV article speaks of a Tamiflu blanket that has been applied over the entire district of Cho Moi, which includes the hamlet (and apparent epicenter of this bird flu outbreak), Na Tao.

Note that the total of suspected human bird flu patients is up to 11. If we include the three previous cases, we have as many as 14 possibles. This would make this the largest bird flu human cluster since 2008.

Bird flu is cropping up all over Asia again. China is seeing a re-emergence, no doubt facilitated by illegal trade in smuggled birds (Google my blog of, oh, I dunno, maybe 2007 on that topic). A veritable Ho Chi Minh trail of smuggling activity exists between China and Vietnam, the irony of which is not lost on Americans.

But I digress. The Vietnamese government has acted quickly and decisively on the issue of Bak Kan. They have applied a Tamiflu blanket over an area comprising 700 villagers. They have eleven villagers in quarantine with clear symptoms of influenza, and three confirmed human cases.

The next thing to look at is the timeline. The first human case in Bak Kan was March 30th of this year. The toddler was admitted two days after the first case. The third confirmed case was "four or five days before being diagnosed with the virus," meaning some time possibly between the 30th of March and the 5th of April (the story was written on the 9th).

The epicenter of the epicenter appears to be a commune within the hamlet. Now I suppose it is possible that people would have eaten diseased poultry at the same time. But the onset of symptoms is staggered by several day between the first and third cases. This would cause me to speculate that you cannot exclude human-to-human contact. And the simple fact that 700 surrounding villagers are currently on Tamiflu as a preventative would seem to support that hypothesis.

Hopefully, the reasonably transparent Vietnamese government will be very forthcoming with samples of this virus. In light of the fact that H1N1v, aka swine flu, is still traversing those same remote hamlets of Asia, and in light of the jarring re-emergence of H5N1 bird flu across eastern Europe and Asia, we need to know: Has bird flu mutated?

All eyes on Vietnam for potential human bird flu cluster

2010-04-06T19:40:02Z

Yesterday, Vietnam confirmed yet another human bird flu case. This time, however, this case bears watching, because it could signal something far more disconcerting than just a single human case.

From the proMED report:

The Director of the Bac Kan provincial Health Department, Nong Quoc Chi, confirmed an A (H5N1)-infected case on [5 Apr 2010]. The patient, [male], 22, from Na Tao hamlet, Nhu Co commune, Cho Moi district, is currently in critical condition. He is being treated at the [National Institute of Tropical and Infectious Diseases]. The patient got sick on [30 Mar 2010] with symptoms of high fever and cough. He was admitted to Bac Kan provincial hospital, and then sent to the [National Institute of Tropical and Infectious Diseases] on [3 Apr 2010] where he tested positive for the lethal strain of A (H5N1) virus.

At present, 4 other people in Nhu Co commune show similar symptoms of high fever and cough. They are under quarantine and being treated at Bac Kan provincial hospital.

The patient in question was taken ill on the 30th of March, and then sent to Hanoi when his condition worsened. The four suspected human bird flu cases are currently in quarantine at the provincial hospital in the provincial capital of Bak Kan. (Or Bac Can, as shown on map at left).

There are many unanswered questions. The most obvious of these is whether these four suspected cases are bird flu, or swine flu?

If these cases are indeed bird flu, has there been human-to-human chain transmission, or were these people all infected during the same timeframe by a single vector? Were they all infected by sick poultry, or were they sickened by a human infection?

OK, let's assume these four people were all H1N1/swine flu infections. That is not good news! That would mean that, once again, bird flu and swine flu had "rubbed elbows" in rural Vietnam. Search my Blogsite for the earlier known case, back in 2009.

According to the Vietnamese Department of Preventive Medicine and the Environment, there are no outbreaks of H1N1 anywhere in Vietnam. From VOA News:

No more A/H1N1 outbreaks in Vietnam

There have been no more A/H1N1 outbreaks in the country, except some isolated cases, said a health official.

At a meeting reviewing the flu epidemic situation in Hanoi on March 31, the Deputy Director of the Department of Preventive Medicine and the Environment, Tran Khac Phu, confirmed that 11,208 people in the country had been infected with the virus as of March 31 and 58 of them had died.

Regarding the A/H5N1 flu, Phu said that there were no more confirmed cases last week, and the total number of such cases so far this year stands at five, including two deaths.

The A/H1N1 virus epidemic appears to have subsided and the country has not detected any mutations in the virus, said Associate Professor Dr. Nguyen Tran Hien, Director of the Central Institute of Hygiene and Epidemiology.

However, Hien urged localities to closely monitor for the A/H5N1 virus as it is still being found on poultry in several areas.

According to the World Health Organisation (WHO), by March 30, there had been 492 confirmed cases of A/H5N1 infection in 15 countries, resulting in 291 deaths.

Vietnam is actively looking for bird flu cases, so perhaps this is why they feel so confident that no H1N1 outbreaks have occurred. But this may be at odds with the WHO Vietnam report of February 10, 2010. that WHO report stated, matter-of-factly:

Pandemic (H1N1) 2009 is continuing to spread throughout Viet Nam. The spread of the virus to all countries, worldwide, is considered inevitable.

As of 10 February 2010, Viet Nam's Ministry of Health has received reports of 11,186 laboratory confirmed cases, including 58 deaths. (Bold WHO's)

It is important to note that this pandemic is currently referred to as of “moderate” severity based upon the global situation. The overwhelming majority of patients are recovering without the need for hospitalization or even medical care, the levels of severe cases are similar to the levels we expect for seasonal influenza, and the health care systems are able to cope with the number of people seeking care.

With the increasing spread of H1N1 in Viet Nam, we expect that there will be a number of people who have serious complications and some will die.

All-righty then! Is Vietnam's swine flu rate climbing or falling? This is not an unimportant question, because it is becoming apparent that Vietnam, more than any other nation save Egypt, may have the potential to be that flashpoint where H5 and H1 reassort. Vietnam has had, to date, prior to this report, 5 bird flu cases with 2 deaths. Egypt, in contrast, has had 18 human bird flu cases with 6 deaths. Both areas are of huge concern.

Let's all keep our eyes on this developing situation.

CIDRAP report reminds us that H1N1 was/is worse than we thought

2010-04-05T15:17:02Z

Over at Computerworld, I have just delivered my first blog in over six months! And you thought I blogged slowly over here!

Anyway, I want you to go over there and read it, because I am not supposed to post their blog over here, and vice versa. Here's the link: http://blogs.computerworld.com/15879/dont_write_off_h1n1_pandemic_yet

The CIDRAP study I mention in the blog was authored by Cecile Viboud, a research scientist at the National Institutes of Health's Fogarty International Center, and Lone Simonsen, research professor at the Department of Global Health, George Washington University, School of Public Health and Health Services, Washington, D.C. Another co-author is Michael T. Osterholm, PhD, MPH, director of the University of Minnesota Center for Infectious Disease Research and Policy, and publisher of CIDRAP News. Mike is also a good friend and I am danged glad to know him. I have also mentioned Dr. Viboud's work on this Blogsite, particularly on the 1951 "Liverpool Flu" and her discovery of how deadly that epidemic was in the UK.

The recent CIDRAP study "sought to devise an 'apples to apples' way to compare pandemic and seasonal flu mortality. To estimate the age distribution of pandemic deaths, they relied mainly on a European study of 468 laboratory-confirmed pandemic deaths, published in August 2009. It showed that more than 85% of the deaths were in people younger than 60, with an overall mean age of 37.4, as compared with an estimated mean age of 76 in those who die of seasonal flu. (bold mine)

"The team then developed an estimate of pandemic deaths, given that only a fraction of cases and deaths are laboratory tested and that final statistics will not be available for another 2 to 3 years. This task involved comparing preliminary mortality data from the CDC's 122 Cities mortality surveillance system with final mortality data from the National Center for Health Statistics for 1999 through 2006. The team also used data on deaths in non-flu-season months to estimate the number of monthly deaths that would occur in the absence of flu.

"Using these variables and the 122 Cities data for April through December 2009, the researchers estimated the (US) pandemic death toll to be between 7,500 and 44,100. The lower number is based on deaths classified as due to pneumonia and influenza (P & I). The higher number, Viboud told CIDRAP News by e-mail, is an estimate of "excess all-cause mortality, which is more inclusive as it also takes into account excess deaths from all respiratory and cardiovascular diseases that are associated with influenza infection, but may not be reported as such."

"(Dr. Viboud) added that the 'excess all-cause mortality' approach has traditionally been used to measure the impact of seasonal epidemics and for the 1957 and 1968 pandemics, while the P&I approach has been used in assessing the 1918 pandemic. The team used both approaches to allow fair comparisons with past flu seasons, she said."

The study's results were revelatory.

More than 85% of the H1N1(2009) deaths were in people younger than 60, with an overall mean age of 37.4, as compared with an estimated mean age of 76 in those who die of seasonal flu.
the H1N1 (2009) pandemic, so far, has taken a toll of between 334,000 and 1,973,000 years of life lost (YLL) in the United States.
The 1968 pandemic, with 86,000 deaths and victims averaging 62.2 years old, caused 1,693,000 Years of Life Lost (YLL).
The 1957 pandemic, with 150,600 deaths and a mean age of 64.6,caused 2,698,000 YLL.
The 1918 pandemic, with an estimated 1,272,300 deaths and a mean age of only 27.2, exacted a toll of 63,718,000 YLL.
An average flu season dominated by influenza A/H3N2-which generally causes more severe epidemics than other strains-causes 47,800 deaths and 594,000 YLL, with a mean age of 75.7. (bold mine)

From the CIDRAP press release:

"Thus, the authors say, the lower end of their YLL estimate for the H1N1 pandemic is comparable to the estimate for an H3N2-dominated flu season, while the upper end is greater than that for the 1968 pandemic. Those impacts, of course, are dwarfed by that of the catastrophic 1918 pandemic.

"Based on US mortality surveillance data, we conclude that the YLL burden of the 2009 pandemic may in fact be as high as for the 1968 pandemic-but that at this time the assessment is still tentative," the report states. More waves of H1N1 cases are likely to come over the next few flu seasons, and later waves could be worse, it says."

Now for the commentary you have come to expect from this Blogsite:

H1N1 is not done infecting people, not by a long shot. And as the CIDRAP study amply demonstrates, the impact of even this "light" pandemic on the future is significant.

Need context? In the US, losing even 300,000 years if life in younger, productive stages will affect future payments to Social Security. Medicare. Federal, state and local taxes. Billions lost. Try factoring that into the budget deficit equations! Not to mention the lost buying power of those persons due to the pandemic.

And of course, it goes without saying that the emotional burden of people having lost youthful loved ones to this disease is tremendous. Watching someone get cut down in the prime of life -- especially someone previously described as healthy -- is a trauma no one would wish on anyone except Osama Bin Laden.

Note something that not even I knew: The 1957 and 1968 pandemics had a much older average age at death than has (so far) the 2009 H1N1 pandemic. No doubt this is because we have the perspective of history and the separation of decades to view the cumulative effects of 1957 and 1968. Since this H1N1 pandemic is far from over, its ultimate average age at death is yet to be determined. But at a shade over 37 years of age, the current age at death is second only to 1918's 27 years in terms of youthful mortality.

I believe it was my buddy John Barry (what a shameless name-dropper I am!) that said in his superior book The Great Influenza, that the average age at death in the United States from 1918-1919 dropped by ten full years as a direct result of both WWI and the 1918 Spanish Flu.

And let us not forget the lingering by-product of 1918's pandemic: Encephalitis Lethargica. That scourge stayed with America (and the world) until it mysteriously dropped from sight around 1930. (Re)Watch "Awakenings" to recall that terrible ordeal.

I also want to crosswalk to a recent study that shows just how antigenically similar the 1918 and 2009 H1N1 viruses are. From Reuters, via ChinaDaily.com:

WASHINGTON - The H1N1 swine flu virus may have been new to humanity in many ways but in one key feature its closest relative was the 1918 pandemic virus, researchers reported on Wednesday.

Their findings could point to better ways to design vaccines and help explain why the swine flu pandemic largely spared the elderly.

"This study defines an unexpected similarity between two pandemic-causing strains of influenza," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), said in a statement.

Two studies show an important structure called hemagglutinin is very similar in both the swine flu H1N1 and its distant cousin, the H1N1 virus that caused the 1918 pandemic. Hemagglutinin is used by viruses to infect cells and gives influenza viruses the "H" in their designations.

For one study, published in Science Translational Medicine, Chih-Jen Wei, Gary Nabel and colleagues at NIAID injected mice with a vaccine made using the 1918 influenza virus - which killed an estimated 40 million to 100 million people.

When they infected the mice with H1N1 swine flu, the vaccinated mice survived, while many unprotected mice died.

The reverse also worked - when they immunized mice using the 2009 H1N1 virus, and then infected them with the 1918 strain, the mice were protected.

"This is a surprising result," Nabel said. "We wouldn't have expected that cross-reactive antibodies would be generated against viruses separated by so many years."

The team also showed that as flu viruses circulate, they develop a kind of shield called a glycan that protects them from the body's immune system. That may allow them to become regular, seasonal visitors.

"It gives us a new understanding of how pandemic viruses evolve into seasonal strains, and, importantly, provides direction for developing vaccines to slow or prevent that transformation," Fauci said.

This type of experiment was performed in 2009, with similar results. I believe Kawaoka did this type of work. Webster may have done it also. It reinforces the concern that one or two teeny little changes might really turn this virus into a nasty, nasty bug.

Policy makers, or persons who still labor under the false assumption that H1N1(2009) was a "false pandemic," would do well to examine the CIDRAP report. Examine, and pray this virus does not mutate or evolve into anything more closely resembling its ancestor. Because it's uncomfortably close already.