H5N1 in the US

From NBC News, January 22, 2015:

A green-winged teal shot by a hunter in northern Washington state has tested positive for H5N1 bird flu — a relative of the virus that’s infected nearly 700 people globally and killed 400 of them.

[snip]

To make matters more complicated, this strain of H5N1 found in the teal appears to be a mix of H5N1 and the H5N8 found in Washington state and elsewhere in the U.S. as well as in Europe, South Korea, Japan and Taiwan.

The pandemic potential of this version of H5N1 is unknown.

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Vaccine shortages and price gouging

From news-journal.com, December 24, 2013

Holbert said the pharmacy at Louis Morgan has vaccinated between 75 and 100 people each day for the past two weeks and is running low on flu shots. The pharmacy has been buying flu vaccines from southeastern states that haven’t had as many cases of influenza-like illness, including Georgia and Mississippi, he said

“We have 150 flu vaccines left right now,” he said. “We are paying double in certain situations but we are still buying them. We’re just trying to make sure everybody’s covered.”

It is understandable why Texas pharmacies would want to obtain flu vaccines from wherever they can under current circumstances. But public health and government officials in other states should consider what is likely to happen when stories about severe illness and death start to appear in their States.

I don’t like the report that pharmacies are “paying double” for vaccines in “certain situations”. Price gouging for vaccines during a medical emergency should be illegal – if it isn’t already. Government authorities better get on top of this quickly or black market vaccines may be coming next.

Tamiflu in short supply in Texas

From The Victoria Advocate, December 22, 2013

“I’ve seen almost 200 confirmed cases in the last three days,” McNeill said. “We have to call around to different pharmacies because Tamiflu is in short supply.”

[snip]

“We prescribe Tamiflu if it’s caught in the first 48 hours,” Barrett-Garcia said. “But it’s very expensive, and most of our patients don’t have insurance.”

The flu can last for two weeks, and Tamiflu knocks the symptoms down more quickly, she said.

Without Tamiflu, McNeill suggests patients stay well-hydrated, take Tylenol or Motrin to control fever and body aches and see a doctor if symptoms worsen.

“One patient with the flu went by ambulance to the hospital today,” McNeill said.

[snip]

Dr. John McNeill is “owner and physician of Twin Fountains Walk-In Health Clinics”.

Shana Barrett-Garcia is “a medical assistant.”

Is Tamiflu in such short supply that at least some people, the ones without health insurance, are being advised to take Tylenol instead? Further clarification is requested.

The return of H1N1

pH1N1 has been quiet the past few years. But now its back. And its killing people.

From KHOU, December 19, 2013

Health officials say there have been six confirmed deaths from H1N1 in the Houston area recently, KHOU 11 News confirmed Thursday afternoon. That includes the four deaths at Conroe Regional Medical Center.

At least 14 people have become critically ill in Harris, Montgomery and Jefferson counties, including the four patients at Conroe Regional Medical Center.

Although public health officials are saying that this is the same strain that caused the pandemic of 2008/2009, we won’t really know that until the sequences from Conroe Texas have been made publicly accessible. In the meantime, it would be wise not to assume that either previous exposure or vaccine status is protective. They may be. But I woudn’t bet my life on it.

Given demonstrated problems with detection of the virus and its ability to kill, public health authorities are recommending prescription of Tamiflu based on symptoms alone. This is a wise policy.

Two pandemics? SARS 2 and H7N9

There are currently two viruses with apparent pandemic potential circulating in the world today – SARS 2 (nCoV) and H7N9.

Although many details are being suppressed, SARS 2 appears to be spreading human to human:

From Gulf News, May 6, 2013

The 13 cases linked to one Saudi hospital suggest the spread of nCoV may have reached a dangerous new stage in which it is spreading from one human to another, rather than infecting humans from another source such as an infected animal, according to infectious disease experts.

The virus has spread quickly: 13 people were infected between April 14 and May 1, nearly half of the 30 total cases that have been reported to the World Health Organisation. Of those 30 cases, 18 have died, giving the disease a case fatality rate similar to that of the feared H5N1 avian flu.

[snip]

Two terse emails posted on Promed over the past few days by the Saudi government suggest the virus spread multiple times from one person to another.

“It has to be person to person — I can’t imagine any other way,” said Michael Osterholm, director of the Centre for Infectious Disease Research and Policy at the University of Minnesota.

“Animal contact doesn’t appear to play a role at all” in the latest cases, he said. Moreover, he said, the length of time between the dates of onset of disease in the 13 people-from April 14 to May 1 — suggests “multiple chains of transmission”.

From the Wall Street Journal, May 6, 2013

“People are sending messages, SMSs, saying, ‘stay home.’ That all the hospitals have the virus. All,” said one man, a cousin to one of the men who died and to two other men who have been sickened in the current outbreak and are still being treated.

The man confirmed an account from a hospital official in Hofuf that his three relatives had gone to three different hospitals in Eastern Province.

“The Ministry of Health just wants to close the books” by saying the latest outbreak is limited to one hospital, the man said, speaking on a Hofuf street lined with medical centers and pharmacies.

It is possible that the virus has infected a number of people in hospitals. This is primarily how the original SARS spread. If so, the virus can likely be contained with aggressive testing and infection control. However, if the virus is spreading easily in community settings, containment will be more difficult. We won’t know which of these possibilies to expect until the Saudi government stops hiding information.

There are now 129 reported infections and 31 deaths from H7N9 in China. The official story is that all of these cases are due to bird to human infection. This is almost certainly false because a number of clusters have been reported. Further, there are adaptive changes in the virus isolated in humans that have not been seen in birds. Release of all sequences from human cases would provide a better indication of what is going on in China, but this information has been suppressed by the government.

Both SARS 2 and H7N9 have the potential to cause pandemics. However, unless the relevant governments change their policy of data suppression, we may not know a pandemic has started until large numbers of cases have been observed in multiple countries.

And that is too late.

How to stop a H9N7 pandemic – containment

Although officially all cases of H7N9 have resulted from bird to human contact, there are strong indications that this assertion is false:

1. There is no virological link between between birds and affected humans.
2. Mutations have been found in humans but not birds which indicate that the virus is adapting to a human host rather than an avian host.
3. The rapid spread of cases in China is consistent with human to human dissemination but not bird to human transmission.

At the least, the precautionary principle should be invoked given the available evidence and the apparent lethality of the virus. Insisting on a high bar before considering the possibility that this virus could cause a pandemic would be foolhardy.

Is it still possible to prevent a pandemic from starting? Maybe. Viruses vary in their infection efficiency. Models suggest that viruses with lower R0’s, say under 1.6, would be relatively easy to stop from causing pandemics. I am somewhat dubious of these models. But it does make sense to intervene at the earliest possible timepoint in viral spread. H7N9 may still be in the process of adapting to the human host. Hence, it may transmit at a slow rate now. However, once it is fully adapted, the spread may accelerate. The only way to prevent adaptation is to stop the spread among humans. With each passage from one human to another, selective pressures will force the virus to adapt more completely to humans increasing the efficiency with which it is spread.

What can be done? Increase surveillance: we need a massive effort to test large numbers of people wherever cases have been reported as soon as possible; Social distancing: closing schools, theaters, shopping centers and other venues where people meet; Tamiflu blanket: give this antiviral to all contacts of infected patients; Travel restrictions: limit travel from and to affected areas.

The Chinese government and its hand-picked Director of the WHO may hesitate to take these actions for fear of the economic costs. But the consequences of not acting now, when there may still be time, could be far higher.

Reference

Longini et al. 2005 Containing Pandemic Influenza at the Source. Science. 309: 1083-1087