Pandemic Update – November 1, 2009

There have been over 6,500 reported deaths due the new H1N1 virus.

There have been over 1,400 reported deaths in the United States. President Obama has declared a National Emergency with respect to the 2009 H1N1 influenza pandemic. The federal government has released the last of its stockpiled supplies of the children’s version of Tamiflu to the States. Some vaccine has been delivered and administered, but the number of people who wish to be vaccinated greatly exceeds the available supply. This is likely to continue to be true for weeks, if not months. Flu activity continues to be erratic, but appears to be increasing in the densely populated Northeast. New Mexico, Utah and Arizona have the highest incidences of death. Approximately 1 in every 100,000 citizens in those States have already died of pandemic flu.

In Europe, Ukraine has taken draconian steps to stop the rapid spread of influenza in the western oblasts (provinces). Although the number dead is relatively small as compared to the total population, there are reports of thousands in the hospitals. Since deaths lag hospitalisations by several weeks, there may be many more dead soon. In the United Kingdom, ICUs are once again filling up. In Ireland, some patients have been sent to the ECMO Center at Karolinska in Sweden. ECMO is an advanced technology for people with severe respiratory disorders.

In Asia, few cases are being reported in most countries. This is more likely attributable to a desire to hide the extent of the disease, than a true decrease in its spread. The pace of deaths has slowed dramatically in India. However, concern about a more lethal version of the virus has again been expressed due to a new and more severe pathology. South Korea will raise its alert to the highest level next week due to the rapidly increasing numbers of infections and deaths.

There are reports people who exhibit all the symptoms of the new H1N1 but who test negative for it in many countries, including the US, India and Ukraine. Many of these patients have died. Either the reagents developed to detect the H1N1 virus are starting to fail, perhaps due to mutations, or there is an unknown, highly infectious disease capable of causing severe symptoms and death circulating throughout the world.


Pandemic Update – October 17, 2009

There have been over 5,342 reported deaths due to the new H1N1 virus. Many countries have ceased reporting their deaths, so the actual figure is likely much higher.

In the United States, some cities and states have stopped reporting their H1N1 deaths, but others continue to provide this information. There have been over 1,000 lab-confirmed H1N1 deaths in the United States, thus far. Since the schools opened, the number of children who have died of pandemic flu has skyrocketed, to well over 100. There are anecdotal reports suggesting that more adults are starting to become infected. Outbreaks are unevenly distributed across the US. Regions where schools opened early are particularly hit hard. In some cities, ICUs are already full. Except in a few cases, most of the US stockpile of Tamiflu has not been released to the general public. People are having increasing difficulty in obtaining this medication, especially the children’s liquid.

Deaths continue to be reported in some South American countries: 153  in Peru; 111 in Colombia and 91 in Venezuela.

In Europe, deaths have started to increase in numbers in the United Kingdom. There are now at least 106 dead in the UK. 45 are reported dead in Spain. Some reports suggest a cover up of some deaths at the local level. 32 have reportedly died in France, although most of these deaths are in its Overseas Departments. There is controversy over whether or not there have been deaths in Russia. One prominent virologist suggests that a cover up of the severity of the pandemic in Russia is ongoing.

In Asia, some countries have simply stopped reporting their deaths: these include Indonesia, Malaysia and the Phillipines. China has reported two deaths on the Mainland, one in Tibet and the other in Xinjiang. The lack of reports of any deaths in the populous cities on the Eastern Seaboard is not credible. India now reports at least 405 deaths.

There is increasingly good evidence that the new H1N1 virus is far more lethal than seasonal flu. The lung pathology of patients reminds investigators of H5N1. There have been a number of suggestions that there may be multiple strains of the new H1N1, some of which are more severe than others.

Pandemic Update – September 20, 2009

There have been over 4,370 deaths reported due to the new H1N1 virus. Brazil has the most reported deaths in the world with 1,024. The United States has altered its reporting system which makes it more difficult to discern how many deaths have occurred, but the number appears to be 687 lab-confirmed deaths. Argentina has reported 596 deaths. Thus, the greatest number of reported deaths remains in the Americas.

In Asia, the greatest number of reported deaths continues to be in India where at least 240 people have died. The absence of reported deaths in adjacent Pakistan strains credibility. Similarly, although 70 deaths have been reported in Malaysia, only 10 have been reported in adjacent Indonesia. Mainland China still has not reported a single death despite reporting over 11,000 cases. Adjacent Hong Kong has reported 22,000 cases and 12 deaths. Failure to acknowledge cases and deaths in Pakistan, Indonesia and Mainland China is dangerous to the health of their citizens. The rest of the world is also put at risk as all three countries have experienced lethal cases of H5N1 influenza. These three countries are at elevated risk for being ground zero for the production of a H1N1/H5N1 hybrid virus which may have the most damaging characteristics of its parent strains.

In Australia and New Zealand, the number of infected appears to be decreasing. How much respite these countries will have is not clear. The Spanish influenza caused the most death in these countries during their summers.

In Europe, the UK continues to be the worst affected country in terms of deaths: at least 80. There are some suggestions that the resumption of school is leading to a new increase in cases. The health care system continues to show signs of severe strain which appears to have resulted in deaths of individuals who did not have the new H1N1 virus but who did not receive adequate care due to misdiagnosis over the phone.Germany continues to report large numbers of cases, over 19,000, but no deaths.

There have been anecdotal reports of very rapid progression of disease, onset of symptoms to death within 72 hours, both in India and the United States. Whether this represents a different, more severe strain of H1N1 is unknown at this time. But, given the significance of such an event, this possibility should be given careful consideration.

India – Situation Report 2 – September 15, 2009

In the first Situation report on India, on August 13, 2009, I wrote that there had been 20 deaths due to the new H1N1 virus. Today, about a month later, there are now over 200 deaths in India due to the new H1N1 virus. 6,588 people have been reported to be infected. Thus, the case fatality rate for India is 3%, worse than the 1918 pandemic. It is likely that not all cases of H1N1 have been identified. However, it is equally likely that not all deaths have been identified. Thus, as in most countries, we do not know the true CFR. However, there is reason to believe that it is significant.

Today, this startling claim by Indian public health authorities [hat-tip, treyfish]:

From the Deccan Herald, September 16, 2009

Health experts believe the A(H1N1) virus has been mutating with local variants to become more virulent, with low temperatures and wet weather providing an ideal breeding ground.

As a way of substantiating their claims, they say that patients are dying within 24 to 48 hours after being infected by the virus. “The virus is not giving any chance to the doctors to treat the patient. That’s why even patients with good immunity are dying,” said Dr E A Ashok Kumar, superintendent of the government-run Gandhi hospital here.

Dr S V Prasad, superintendent of the government-run Chest Hospital—the nodal agency for swine flu treatment—believed the virus must have undergone change in its genetic make-up as it seem to affect patients faster than before.  Given its virulence, Dr Prasad said the present virus must have emerged from the one imported from abroad, which has mutated with local variants.

It is not clear that there is any sequence data to support the claim that the virus in India differs from the virus present in other areas of the world. However, the alarming nature of the sudden deaths observed after infection is real.

As the number of serious cases mount, the strain on the Indian health care system is becoming dangerously high.

Also from the Deccan Herald:

Meanwhile, authorities at government-run hospitals are forced to turn away the increasing number of patients with A(H1N1) symptoms due to lack of equipment and space.

Corporate hospitals are also closing their doors for Flu patients, fearing that they would spread the virus inside their campuses.

The case of 20-year-old Ashish Raj was an unfortunate one as he had been turned away by no less than three hospitals. Raj was sent away on Saturday by a corporate hospital and two government ones, including Chest Hospital.

Osmania Government Hospital finally admitted him after considerable begging and pleading from Raj’s relatives, before death had put an end to his plight.

Many H1N1 patients in the countries with access to advanced medical care have survived only because they received expensive, state-of-the-art treatment. India has some capacity to provide this level of care, but it is limited to only a small fraction of its population. As more and more people become ill, more and more hospitals will become overwhelmed and more and more people will die for lack of care.

If the chain of infections in India is not interrupted by school and business closures, the strain on the Indian health care system will become unbearable and access to hospitals will cease, not just for H1N1 patients, but for everyone.

Pandemic Update – September 14, 2009

There have been over 3,590 deaths reported due to the new H1N1 virus. However, several countries appear to have stopped reporting their deaths. Brazil has not offiically reported any deaths since last week, when the total was 657. The United States has officially announced that it will no longer count H1N1 deaths. Thus, the true total number of deaths due to the pandemic virus is becoming increasingly difficult to discover.

In North America, the number of new cases appear to be exploding in the United States and Mexico. It is less clear what is happening in Canada. The vast majority of the new cases in the US are associated with the opening of school. At least 15 children, and likely more, have already died as result of going to school and getting infected with the new H1N1. At least two university students have already died. Emergency rooms are starting to be overwhelmed in some hospitals, especially in the South. Increasing concern is being expressed regarding the capacity of ICUs to handle the influx of new cases.

In the Southern Hemisphere, fewer new cases have been reported, although new deaths continue to occur. It is worth noting that during the 1918 pandemic, countries in the Southern Hemisphere experienced their biggest impact during their summer, at the same time that countries in the Northern Hemisphere were experiencing their Fall/Winter.

In Europe, deaths have been reported in more countries. However, countries that had reported large numbers of deaths, the UK and Spain, are reporting few or no additional deaths.

In Asia, India now has reported the greatest numbers of deaths: at least 188. The number of cases and deaths continue to increase rapidly there. Other countries in Asia that had been reporting large numbers of cases, such as Malaysia and Thailand, no longer appear to report all of their deaths. The Indonesian government has apparently decided not to report more than a fraction of their deaths. The Chinese government still does not report any deaths on the mainland, but acknowledges that the situation is “grim”.

Some vaccine is likely to become available in the next few weeks, although it is not clear how much. It is likely that only a small percent of the world’s population will receive vaccine before they are infected with the new H1N1 virus.

Pandemic Update – September 6, 2009

There have been over 3,300 deaths due to the new H1N1 virus.

Brazil has reported the most deaths, at least 657. Although the WHO has suggested that the number of infections in the South America is declining, the number of deaths continues to increase. For example, Ecuador now reports 44 deaths, many of them recent.

In the United States, 593 deaths have been reported. A noticeable increase in deaths among children whose schools started a few weeks ago has occurred. As most schools have just opened or will open this week in the US, there may be a large wave of deaths among children starting within the next few weeks. In Mexico, there has been a recent increase in the number of cases reported on a daily basis. There have been at least 207 officially confirmed deaths in this country.

In Australia and New Zealand, the number of new cases have been reported to be in decline, although the number of deaths continue to increase. There have been reports of a large numbers of deaths in Papua New Guinea. The reported causes of death have included cholera, dysentery and influenza. How many people have been killed by flu and what subtype is causing the deaths is not clear. The infections and deaths continue to increase. The WHO is investigating.

In Europe, Germany continues to report large numbers of new infections, but no deaths. The UK has reported many fewer cases of infections than Germany, but has reported at least 70 deaths. Spain has reported 25 deaths.

In Asia, India has reported at least 140 deaths, now the most in the region. Thailand has reported 130 deaths. Malaysia has reported 73 deaths. Vietnam has only reported 3 deaths, but news stories indicate a sudden increase in cases among children. Hospitals are now overcrowded with children who must share mats on the floor. In China, there are 12 reported deaths, none on the mainland. The disproportionate number of cases in Hong Kong and Macao as compared to the mainland is not credible. This raises concern of a cover-up within mainland China as to their true situation, as occurred with SARS and early H5N1 cases.

The situation in Africa is unclear. South Africa has now reported 27 deaths. Mauritius has reported 8 deaths and Ghana 1 death. However, given the state of the public health infrastructure in many countries in Africa, it is likely that there have been many cases that have not been reported.

There are increasing numbers of deaths in the Middle East. 26 deaths have been reported in Saudi Arabia. 21 deaths have occurred in Israel. 5 deaths have been reported in Kuwait and 4 in the United Arab Emirates.

There are an increasing number of  reports of Tamiflu-resistant strains of the new H1N1. There are anecdotal reports of patients being treated with Relenza, in some cases in combination with Tamiflu. Efforts are underway to identify alternative therapies to treat patients if Tamiflu- and Relenza-resistant strains become dominant.

Pandemic Update – August 30, 2009

There have been over 3,000 deaths due to the new H1N1 virus.

Brazil has now overtaken the US in the number of deaths. 602 deaths have been reported in Brazil, while 555 have been reported in the US. There are reports that the number of cases have been decreasing in South America. With schools opening in North America, it is likely there will be a surge in cases there, soon. There have already been anecdotal reports of severe pneumonia and deaths among children in the US. Some have been verified as due to the new H1N1 virus and some are still being tested.

In Australia and New Zealand, it is still not clear what has been happening in ICUs. Has care been rationed? How many people have died as a result of insufficient resources? We still don’t know. There have been reports of an unusual number of very severe flu cases in both countries.

In Asia, the focus continues to be on India. There are now at least 100 deaths. More and more cities are reporting cases and deaths. Bangladesh has just reported its first death. Japan now reports seven deaths. Mainland China and Indonesia are likely under-reporting their cases and deaths.

In the African region, Mauritius has been the hardest hit with 40 deaths. South Africa now reports 2o cases. Ghana reports two deaths.

The number of deaths reported in the Middle East have been increasing recently. Israel now reports 18 deaths, a large number given the size of the country. Saudi Arabia reports 19 deaths.  Syria and the United Arab Emirates each report two deaths.

12 countries now report Tamiflu-resistant strains of the new H1N1 virus.