Wednesday, February 29, 2012

Bangladesh: Reporting Their 4th H5N1 Case

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# 6186

 

Although Bangladesh has seen a great deal of H5N1 in poultry over the past 4 years, they have – until now – only reported 3 human infections with the avian flu virus. The first case was detected in 2008, while two additional cases were found in 2011.


All of these cases involved young toddlers (ages 15 to 39 months), and were detected via their influenza sentinel surveillance system. All three recovered.

 

Today an eagle-eyed Ronan Kelly on FluTrackers has picked up a report from Bangladesh’s IEDCR (Institute of Epidemiology, Disease Control & Research) – dated February 28th – that describes that country’s 4th known H5N1 detection.

 

Unlike the three earlier cases, this one involves an adult male. But as with the others, this patient has fully recovered.

 

 

Fourth H5N1 human case in Bangladesh


A 40 year old male has been diagnosed as fourth case of Human Avian Influenza (H5N1) in Bangladesh. This case has been reported from live bird market surveillance system in Dhaka City on 26 February 2012. This was confirmed by rRT-PCR. The patient is a live bird market worker.

The case presented with cough. Throat and nasal swabs were collected and found positive for H5N1. Presently he is free from symptom. IEDCR & ICDDR,B jointly investigating the case and monitoring the situation. 


In Bangladesh the first case was detected in 2008, second and third cases were found in 2011. 

 

Presumably the IEDCR has notified the World Health Organization, and we’ll get a confirmation in due time.

 

Bangladesh is somewhat unique in that all of their known H5N1 cases have recovered, while apparently experiencing only mild to moderate illness (Myanmar, with only 1 reported case, also has a 100% recovery rate).

 

Contrast this with Indonesia, where more than 80% of the known cases have died, or Egypt, where nearly 40% have succumbed, and it certainly begs the question; why the huge disparity?

 

  • Is this just some sort of statistical, reporting, or surveillance fluke?
  • Or is the virus circulating in Bangladesh less pathogenic to humans than the one in Indonesia? 
  • Or is it perhaps, the people of some regions carry higher levels of community immunity to the H5 virus?

 

Fascinating questions, but for now, answers remain elusive.

ECDC Risk Assessment On H5N1 Transmissibility Studies

 

 

# 6185

 

 

Today the ECDC  released a Risk Assessment on the H5N1 transmissibility studies conducted by Fouchier and Kawaoka that illustrates the difficulty that all of us are having in assessing this story.

 

Outside of a closed circle of scientists, none of us have access to all the facts

 

And apparently, some of the details that have been reported –  according to Ron Fouchier at this morning’s ASM Biodefense webcast – have not been completely accurate.

 

All of which makes it very difficult to sit back and make any sort of informed judgment from the sidelines. The ECDC’s executive summary acknowledges these limitations by stating:

 

This document’s starting point is that without sight of data and analyses it is very difficult to undertake risk assessments. It is not even clear at present how pathogenic these viruses are in animal models. The
document also puts forward the ECDC position on some of these issues according to ECDC’s limited mandate, recognising the value of the research but also the potential risks.

 

ECDC stresses the need to consider mechanisms
for a robust biorisk-management approach along the lines of international standards and  EU-wide guidance on laboratory biosafety/biosecurity for any future emerging threats.

 

ECDC indicates that it would advocate open publication of the findings and emphasises the importance of sustaining and enacting the pandemic influenza preparedness framework with its underpinning global virological surveillance and sharing of information and benefits in order to enhance global health security.

 

It is ECDC’s intention to support the European Commission and Member States, to monitor these developments closely and with its stakeholders and collaborators to revisit its risk assessment for A(H5N1) viruses as the research findings emerge. 

 

 

Nonetheless, this ECDC risk assessment does a good job in defining many of the complex issues at hand, even if definitive answers are elusive. 

 

 

Risk assessment: Laboratory-created A(H5N1) viruses transmissible between ferrets

Technical reports - 29 Feb 2012

Available as PDF 

ABSTRACT

The results of two, as yet unpublished, investigations of laboratory-induced genetic changes in avian influenza A(H5N1) viruses have been reported to have found that a surprisingly few number of changes make the viruses transmissible between ferrets, the most commonly used model for the way influenza behaves in humans. The possibility that this could have resulted in the development in laboratories of A(H5N1) influenza viruses transmissible between humans has caused concern for public safety and generated unusually high levels of debate in the scientific community.

 

This report summarises and explains the complex public health and scientific issues around these developments including the positive and negative aspects of some of the responses that have been proposed internationally.

CIDRAP News: NSABB May Revisit H5N1 Research

 

 


# 6184

 

Robert Roos, News editor for CIDRAP News, has a detailed report on today’s ASM Biodefense panel discussion (see ASM BioDefense Meeting Video Now Online).

 

With new data presented by Ron Fouchier at this meeting, the NSABB may take another look at these studies.

 

 

With new data, NSABB may revisit H5N1 studies

Robert Roos * News Editor

Feb 29, 2012 (CIDRAP News) – The mutant H5N1 virus generated in one of two controversial studies was less lethal and contagious than has been generally understood, and the US government's biosecurity advisory committee will be asked to examine new and clarified data from the study, scientists and government officials revealed today.

(Continue . . . )

 

The Tracks Of Our Fears

 

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Severe Weather Tracks Feb 28th, 2012 Source NOAA 



# 6183


Yesterday morning, in It Happens Every Spring, I wrote about the inevitability of severe weather during this time of year, particularly from tornadoes in the mid-west and deep south.

 

As it turned out, overnight a number of severe tornado producing storms swept across Kansas, Arkansas, and Missouri.

 

The remarkable image above comes from NOAA’s Environmental Visualization Laboratory (h/t @JustinNOAA)

 

Feb 29, 2012

NOAA Radar Tracks Tornadoes in Midwest

NOAA's NEXRAD system of radars deployed throughout the United States provide meteorologists the most up-to-date information on the ground regarding severe weather, especially when it comes to identifying potential tornado outbreaks. By analyzing both the rotational velocity of the storm systems (the spinning of tornadoes has high rotational velocity compared to the surrounding storms) and presence of hail, scientists at the NOAA National Severe Storms Laboratory have developed a product that approximates the track of tornadoes, shown here for the February 29, 2012 storms in Kansas, Missouri, and Arkansas.

At least four people have been killed and many others injured as these storms swept through the Midwest early in the morning. The NOAA Storm Prediction Center has issued advisories for Tennessee and the surrounding areas for the remainder of the day. Although the tracks shown in this image are not actual confirmed ground tracks, they are helpful in identifying features associated with tornadoes, preparing communities for such potentially deadly outbreaks, and emergency response once a severe weather outbreak has passed.

 

More storms (and fatalities) have been reported today in Illinois, and as the graphic below from the Storm Prediction Center in Norman, Oklahoma shows, the bad weather is moving eastwards.

 

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While early in the storm season, these tornadoes should serve as a wake up call to prepare, and Ready.gov has the tools to help you do so.

 

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If you haven’t created, practiced, and updated your family’s emergency plan, now is the time to do so.

ASM BioDefense Meeting Video Now Online

 

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# 6182

 

This morning’s ASM BioDefense panel discussion of the NSABB’s call to redact portions of two H5N1 research papers is now online, and available to all.

 

In a bit of a surprise, Erasmus University researcher Ron Fouchier characterized the results of his experiments somewhat differently than we’ve seen in the past.

 

While the mutated virus could be spread via the aerosol route between ferrets, Fouchier reassured, "Our data suggests this virus spreads very poorly."

 

Fouchier also downplayed the pathogenicity of virus, stating that ferrets infected this way only suffered mild illness (it required direct deep-lung inoculation to produce death/severe illness).

 

It is not highly lethal if ferrets start coughing and sneezing to one another”, he said.


One must note that when the news was `all bad’ about the transmission and pathogenicity of this mutated virus, many scientists were quick to caution us that ferrets aren’t a perfect model for how the virus will act in humans’.

 

Which means that the reduced pathogenicity and transmissibility in ferrets described by Fouchier today may not necessarily translate to how the virus would act in a human host.

 

 

The 70 minute video may now be viewed at THIS LINK.

 

Very much worth watching.

 

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Featuring: 

Michael T. Osterholm, Ph.D., MPH  NSABB/CIDRAP

Anthony S. Fauci, M.D  (NIAID)

Bruce Alberts, Ph.D. Editor-in-Chief of Science

Ron A.M. Fouchier, Ph.D.    H5N1 Researcher

Tuesday, February 28, 2012

Webcast: Discussion Of NSABB’s H5N1 Recommendations

 

 

# 6181

 

My thanks to Helen Branswell for tweeting this event.

 

Set you alarm clocks accordingly, as tomorrow morning (Wednesday, February 29th) the ASM Biodefense and Emerging Diseases Research Meeting will provide a live webcast of an hour-long discussion over the NSABB’s recommendations to redact portions of two H5N1 research papers.

 

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Featuring: 

Michael T. Osterholm, Ph.D., MPH  NSABB/CIDRAP 

Anthony S. Fauci, M.D  (NIAID)

Bruce Alberts, Ph.D. Editor-in-Chief of Science

Ron A.M. Fouchier, Ph.D.    H5N1 Researcher

Live Stream Details
Date: Wednesday, February 29, 2012
Time: 7:15 a.m. - 8:15 a.m. EST
Link:

If you are unable to watch the live feed, a video should be posted by 1:00pm.

WHO: Egypt Announces Two New Bird Flu Cases

 

 

# 6180

 

The World Health Organization has posted a new update in their GAR (Global Alert & Response) system regarding two new H5N1 human infections in Egypt, both of which proved fatal.



These are the 4th and 5th H5N1 infections reported in Egypt this year and the first fatalities. A hat tip to Françoise Ramona on FluTrackers for posting this in the French forum.

 

 

Avian influenza – situation in Egypt – update

28 February 2012 - The Ministry of Health and Population of Egypt has notified WHO of two new cases of human infection with avian influenza A (H5N1) virus.

 

The first case is a thirty-two year old male from Behira governorate, in the Abo Elmatameer District. He developed symptoms on 16 February 2012 and was admitted to hospital on 21 February 2012 where he received oseltamivir treatment upon admission. He died on 28 February 2012.

 

The second case was a thirty seven year-old female from Kafr Elshihk governorate in the Kelleen District. She developed symptoms on 18 February 2012 and was admitted to hospital on 23 February 2012 where she received oseltamivir treatment upon admission. She died on 26 February 2012.

 

Preliminary investigations into both cases with regard to the source of infection indicate close contact with sick or deceased backyard poultry at the cases' respective residences.

 

Both cases were confirmed by the Central Public Health Laboratories, a National Influenza Center of the WHO Global Influenza Surveillance Network.

 

Of the 163 cases confirmed to date in Egypt 57 have been fatal.

 

CDC Webinar: Antiviral Medication Recommendations For Influenza

 

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Credit – CDC COCA


# 6179

 

Primarily of interest to clinicians - including physicians, nurses, physician’s assistants, pharmacists, paramedics, veterinarians, epidemiologists, public health practitioners, and state and local health department officials -  the CDC will hold a webinar later today on the use of antiviral medications for influenza.

 

These COCA (Clinician Outreach Communication Activity) calls are designed to ensure that clinicians have the up-to-date information for their practices, and also provide Continuing Education Credits.

 

The details of today’s COCA call follows, along with links to some recent calls that are archived and available for viewing.

 

 

2011-2012 Influenza Season: Antiviral Medication Recommendations 

Continuing Education = Continuing Education Credits

Date: Tuesday, February 28, 2012

Time: 2:00 - 3:00 pm (Eastern Time)

Participate by Phone:

Dial:800-779-7163
Passcode: 7319016

Participate by Webinar:

https://www.mymeetings.com/nc/join.php?i=PW6062720&p=7319016&t=c

Presenter(s):

 

Timothy Uyeki, MD, MPH, MPP
CAPT, U.S. Public Health Service
Deputy Chief for Science
Epidemiology and Prevention Branch
Influenza Division
National Center for Immunization and Respiratory Diseases
CDC

Overview:

CDC estimates that influenza virus infections in the United States result in an average of more than 200,000 related hospitalizations, and between 3,300 to 49,000 deaths each year, depending upon the severity of the influenza season. Annual influenza vaccination is recommended for all persons aged 6 months and older, and is the best way to prevent influenza. However, available evidence consistently indicates that antiviral treatment, when initiated as early as possible in patients with confirmed or suspected influenza, can reduce severe outcomes of influenza.  During this COCA conference call, a subject matter expert will review current Advisory Committee on Immunization Practices (ACIP) and CDC guidance on the use of antiviral medications in the prevention and treatment of influenza.

 

 

For a list of recent (and upcoming) conference calls, visit this link.

It Happens Every Spring

 

 

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Credit NOAANWS Storm Prediction Center

 

# 6178

 

For very good reasons, during the months of February and March many states across the nation – particularly in the mid-west and the deep south – promote a Severe Weather Awareness Week.

 

Last year’s record breaking tornado season, which claimed the highest number of lives in a half century, serves as a stark reminder of just how vulnerable we are to these violent weather events.

 

NOAA provides a State by State listing of Weather Awareness Events, and some states publish severe weather preparedness guides.  A few examples follow, but you can Google `Severe Weather Awareness’ and your State’s name, to see if one is available for your area.

 

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Some states have Severe Weather Guides online, such as this website maintained by the Texas Department of Public Safety.

 

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While it is impossible to predict just what kind of spring and summer storm season we will see, when warm moist air to the south and east does battle with cooler or drier air masses to the north and west, you have the basic ingredients for severe weather.  

 

And outbreaks of tornadoes can frequently result. 

 

But it isn’t just tornadoes that we watch out for. Straight line winds, downbursts, hail, lightning, and torrential rains are also hazards carried by these storms, and all can be deadly.

 

 

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March, April, May and June generally see the strongest, and most frequent tornadoes, but in truth - these violent windstorms can occur any time of the year - particularly in the south

 

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In an average year, more than 1,000 tornadoes are reported in the United States.   It is likely that the actual number is considerably higher, as not all tornadoes occur in areas where they can be seen or confirmed.

 

All but a small part of the United States is vulnerable to these storms, but the strongest of these storms generally occur in an area we call Tornado Alley (below Left), which runs from middle Texas north though Oklahoma, Kansas, Nebraska and South Dakota.

 

This is the area where you will generally find the largest and most powerful tornadoes; the F5 wedge type

 

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TORNADO ALLEY                       DIXIE ALLEY

 

Fortunately, much of the mid-west is sparsely populated, and so the number of tornado deaths that occur here are actually less than in other areas of the country.   

 

DIXIE ALLEY (above right) sees more frequent, albeit usually less severe tornadoes.  Due to a higher population density, more deaths occur in Dixie Alley than in Tornado Alley most years.

 

To keep abreast of severe storm forecasts, you can visit NOAA’s Storm Prediction Center online.  There you’ll find interactive maps showing current and anticipated severe weather threats all across the nation.

 

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Another resource is NOAA WEATHER RADIO.

 

Once thought of as mainly a source of local weather information, it has now become an `All-Hazards' alert system as well.

 

In order to receive these broadcasts, you need a special receiver.  Many of these radios have a special `Tone Alert', and will begin playing once they receive a special alert signal from the broadcaster.

 

Like having an emergency kit, a first aid kit, and a portable AM/FM radio - having a weather radio is an important part of being prepared. 

 

Most Americans are woefully unprepared to deal with emergencies.  This despite dozens of major disasters (often weather related) that occur every year in this country. 

 

Agencies like FEMA, READY.GOV and the HHS are constantly trying to get the preparedness message out, so that when (not `if') a disaster does occur, human losses can be minimized.

 

For more information on how to prepare for emergencies, up to and including a pandemic, the following sites should be of assistance.

 

FEMA http://www.fema.gov/index.shtm

READY.GOV http://www.ready.gov/

AMERICAN RED CROSS http://www.redcross.org/

Monday, February 27, 2012

A New Flu Comes Up To Bat

 

UPDATED:  Helen Branswell has a report on this story HERE, and you’ll find another report by Virginia Gewin  on Nature.com HERE.

 

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Photo Credit- Wikipedia

 

# 6177

 

A fascinating story today coming from the journal PNAS, that is eerily reminiscent of fictional MEV-1 virus from the movie Contagion

 

Researchers report the discovery of never before seen influenza virus, that surprisingly, was detected in bats. Specifically, from little yellow-shouldered bats (Sturnira lilium) captured at two locations in Guatemala.

 

Scientists have previously identified 16 different hemagglutinin (HA) proteins, and 9 different neuraminidase proteins.

 

And while birds are the natural host for influenza viruses, they’ve never been isolated in bats before.

 

This new influenza is described as deviating from the 16 known HAs and is designated as H17. The neuraminidase (NA), and internal genes, are also highly divergent from previously known influenzas.

 

Despite all of these differences, the authors state this bat virus appears to be genetically compatible with human and avian influenza viruses, and the potential for reassortment exists.

 

Unfortunately, the entire report is behind a pay wall, but according to an AP report by Mike Stobbe, there remains some questions over exactly what these researchers have uncovered.

 

One scientist - Richard Fulton of Michigan State University - pointed out that the authors have not been able to grow the virus in cell cultures or egg embryos, and that they only have isolated fragments of the virus.

 

More research will be needed to determine what, if any, implications this new found pathogen will have to public health. Meanwhile, researchers are already looking for it, and similar viruses, in other hosts and bat colonies.

 

 

A distinct lineage of influenza A virus from bats

Suxiang Tong, Yan Li, Pierre Rivailler, Christina Conrardy, Danilo A. Alvarez Castillo, Li-Mei Chen,Sergio Recuenco, James A. Ellison, Charles T. Davis, Ian A. York, Amy S. Turmelle, David Moran, Shannon Rogers, Mang Shi, Ying Tao, Michael R. Weil, Kevin Tang, Lori A. Rowe, Scott Sammons, Xiyan Xu, Michael Frace, Kim A. Lindblade, Nancy J. Cox, Larry J. Anderson, Charles E. Rupprecht, and Ruben O. Donis

Abstract

Influenza A virus reservoirs in animals have provided novel genetic elements leading to the emergence of global pandemics in humans. Most influenza A viruses circulate in waterfowl, but those that infect mammalian hosts are thought to pose the greatest risk for zoonotic spread to humans and the generation of pandemic or panzootic viruses.

 

We have identified an influenza A virus from little yellow-shouldered bats captured at two locations in Guatemala. It is significantly divergent from known influenza A viruses. The HA of the bat virus was estimated to have diverged at roughly the same time as the known subtypes of HA and was designated as H17. The neuraminidase (NA) gene is highly divergent from all known influenza NAs, and the internal genes from the bat virus diverged from those of known influenza A viruses before the estimated divergence of the known influenza A internal gene lineages.

 

Attempts to propagate this virus in cell cultures and chicken embryos were unsuccessful, suggesting distinct requirements compared with known influenza viruses. Despite its divergence from known influenza A viruses, the bat virus is compatible for genetic exchange with human influenza viruses in human cells, suggesting the potential capability for reassortment and contributions to new pandemic or panzootic influenza A viruses.

Preparing For An Unwanted Arrival

 

 

 


# 6177

 

 

PAHO, the Pan American Health Organization, in partnership with the CDC, have put together a 161-page guide for preparing for the arrival of Chikungunya to the Americas.

 

Chikungunya is a mosquito borne alphavirus (similar to Australia’s Ross River Virus, and EEE), of East African origin, that typically produces a fever, severe muscle and joint pain, and headaches.

 

They symptoms usually go away after a few weeks, but some patients can retain permanent disability.

 

First described in the early 1950s in Tanganyika, it was only sporadically seen over the years in eastern and central Africa. That is, until 2005, when Chikungunya made a jump to the Indian Ocean island of Réunion.

 

In the seven years since that time, Chik has migrated to India, Indonesia, and much of south-east Asia.   It has even been imported into Italy.

 

I told the story several years ago in It's A Smaller World After All, but the short version is that a traveler, returning from India, brought the virus to Italy in 2007 which led to more than 290 cases reported in the province of Ravenna, which is in northeast Italy.

 

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Many infectious disease specialists have expressed concerns that Florida – which has recently seen a return of Dengue fever after more than 5 decades – could one day face the establishment of chikungunya as well.

 

The two primary mosquito vectors of Chikungunya are the Aedes aegypti and Aedes albopictus, both of which can be found across many regions of the Americas.

 

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Aedes albopictus (Asian Tiger) Mosquito

Dark blue: Native range
Dark green: introduced (as of December 2007)

 

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Credit – PAHO

 

For more on all of this, excerpts from the press release from PAHO, and a link to the PDF.

 

PAHO, CDC publish guide on preparing for chikungunya virus Introduction in the Americas

 

The Pan American Health Organization/World Health Organization (PAHO/WHO), in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), has published new guidelines on chikungunya, a mosquito-transmitted virus transmitted that causes fever and severe joint pain.  The Guidelines for Preparedness and Response for Chikungunya Virus Introduction in the Americas aims to help countries throughout the Americas improve their ability to detect the virus and be prepared to monitor, prevent, and control the disease, should it appear.

 

Hundreds of people who have traveled from the Americas to Asia and Africa in the past five years have become infected with the chikungunya virus. While the virus has not spread locally in the Western Hemisphere, experts say there is a clear risk of its introduction into local mosquito populations. Local transmission could occur if mosquito populations in the United States or elsewhere in the Americas became infected with the virus and began spreading it to people in that area.

(Continue . . . )

 

To download the guide, Preparedness and Response for Chikungunya Virus Introduction in the Americas select this link.

CDC Telebriefing On Influenza

 

 


# 6176

 

On Friday, Feb. 23rd, the CDC held a briefing on this year’s influenza season by Dr. Joseph Bresee.  Today they’ve posted the transcript, and an mp3 audio file from the briefing.

 

As Dr. Bresee points out, this is the slowest start to an influenza season that we’ve seen in 29 years.

 

And with this slow start has come a much lower incidence of hospitalization, pneumonia, and pediatric flu-related fatalities.


There are signs that the season is starting to pick up, and it is not unheard of for the flu season to peak in March or even April.

 

Dr. Bresee talks about the new WHO vaccine recommendations, and then takes questions from the press, primarily about reasons why the flu season is late this year.

 

 

 

CDC Telebriefing: Influenza Activity Update

Friday, February 23, 2012 at 1PM ET

ECDC: Flu Starting To Peak In Parts Of Europe

 

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Credit- ECDC

 

# 6175

 

Just as we’ve been seeing in North America, Europe’s flu season has been slow to get going this winter.  Of 28 EU countries reporting this week, 10 continue to report low levels of influenza activity. 

 

Only Austria and Greece are reporting high levels of influenza intensity. However, 19 countries are reporting that flu cases are still increasing, while nations 6 report cases as being stable, and three appear to be post-peak, and on the decline.

 

As is noted in the abstract, some of the H3 and B strains now circulating have moved antigenically away from those in the current flu vaccine, prompting a change in next season’s flu vaccine (see WHO: Northern Hemisphere 2012-2013 Flu Vaccine Composition).

 

Here is the ECDC’s latest surveillance report.

 

 

Weekly influenza surveillance overview, 24 February 2012 - week 7

Surveillance reports - 24 Feb 2012

 

 

 ABSTRACT

The 2011-2012 influenza season started later than in recent seasons and has been without any clear geographic progression.

 

Medium or high intensity was reported by 18 countries and increasing trends by 19 countries.

 

Of 1 873 sentinel specimens tested, 927 (49.5%) were positive for influenza virus, which is a similar percentage to that observed during the two previous weeks.

 

Of the 2 901 influenza viruses detected from sentinel and non-sentinel sources during week 7/2012, 96.1% were type A and 3.9% were type B. Of the 1 085 influenza A viruses subtyped, 98.2% were A(H3) and 1.8% were A(H1)pdm09.

 

No resistance to the neuraminidase inhibitors (oseltamivir and zanamivir) has been reported so far this season.

 

The influenza A(H3) and B viruses circulating this season have moved genetically and antigenically away from 2011–2012 seasonal vaccine viruses. This prompted WHO to recommend different vaccine viruses for the 2012-2013 seasonal vaccine.

 

The national influenza season epidemics in Europe may be approaching their peak in the first affected countries and remain dominated by A(H3) viruses.

Saturday, February 25, 2012

His Bags Are Packed, He’s Ready To Go

 

 

Note: I don’t usually write about family or personal events in this blog, but today I  hope you’ll forgive me if I make an exception.

 

 

# 6174

 

 

In a couple of hours I’ll be making a 50 mile drive to see my Dad, possibly for the last time. He is 87, in failing health, and (thankfully) receiving almost daily home hospice care. 

 

Dad, who hates the idea of being in the hospital, has stated his last goal is to die in his own bed. Something that my sister and I are trying to make happen.

 

To that end, we’ve prepared for this day for well over a year. In fact, I discussed some of our pre-planning a year ago in On Having `The Conversation’, a brief excerpt from which follows:

We’ve discussed, in detail, exactly what Dad would want us to do if he were unable to make medical decisions for himself.

 

In fact, a few months ago Dad asked if I would get for him a legally binding Do Not Resuscitate (DNR) order, so that if something happened to him, and an ambulance were called, no heroics would be performed.

 

Verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.

 

Dad now proudly has the bright yellow DNR order posted over his bed, and carries another credit-card sized one in his wallet.

 

In Florida, the form must be printed on yellow paper. Different states have different requirements.  You should check with your doctor, or the local department of health to determine what the law is in your location.

 

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We’ve also had (for many years) a living will and a Health Care Proxy drawn up for Dad, so either my sister or I can make decisions regarding Dad’s health care should he no longer be able to.

 

 

Sensing his time was growing short last fall, Dad insisted on going down to the local funeral home to make his own prepaid funeral arrangements.

 

He didn’t want anyone else to have to make those decisions when the time came.

 

When his health really began to decline over the Christmas holiday, we discussed several matters, including bringing in home hospice care.

 

Dad, who has always been fiercely independent, balked at first, but it soon became apparent to him that my sister could no longer physically provide all of the care he would need.

 

Although they’ve been coming only for a few weeks, the hospice nurses and doctor have done a great deal to relieve Dad’s pain, to make him more comfortable, and relieve my sister of some of her care giving duties.

 

Having home healthcare visits mean he no longer must make the monumental efforts to bathe, dress, and be driven by my sister to see his doctor. 


In other words, it’s been an absolute Godsend.

 

In retrospect, I wish we’d have brought them in a little earlier, but I doubt that until after Christmas, Dad would have agreed.

 

The end appears to be coming quickly now.

 

His nurse believes his kidneys are failing and he’s in and out of consciousness a lot. The morphine, which at long last is controlling his intractable pain, blurs reality for him as well. Lucid moments are becoming rarer.

 

When awake he’s mostly `travelling’ now; talking to friends long departed, revisiting the adventures of his youth (he was in the Navy in WWII, and a private pilot in civilian life), and earlier this week proudly announced he’d been hired to build one last skyscraper in Tampa.

 

Not a bad thing, considering. He’s not afraid, and he’s not in pain. I’ll settle for that.

 

Over the past dozen years my sister and I have seen Dad through 3 cancer surgeries, two major eye operations, Mom’s passing 6 years ago, a car wreck followed by 5 weeks in rehab, and a couple other health crises.

 

It isn’t easy to accept that we’ve done what we can, that we’ve reached the end of a long road, and now it’s time to day goodbye.

 

But that’s where things stand. And while you can hate it, there’s no changing it.

 

The fact that we’ve taken the steps to ensure that Dad gets to go out of this world on his own terms - at peace, without being poked and prodded, and in his own bed - help immensely.  It was literally his last wish.

 

That, and his hope that we not make a big fuss over his passing. “It’s time,” he said when we last spoke, “and I’ve had a damned good ride.”

 

I talk about preparedness a lot in this blog.

 

Most of the time, it is on preparing to survive a disaster or some kind of emergency, but there are other types of preparedness as well. And preparing for the end that must come to each of us, is one of them.

 

As a medic, I’ve seen the anguish that relatives suffer when trying to make life or death decisions on behalf of a loved one.

 

These are deeply emotional issues, and can create life-long rifts in the fabric of families.

 

While nothing can eliminate the emotional trauma that comes with a medical crisis or the impending loss of a loved one, making rational decisions in advance – and making them known and binding – can greatly reduce the strain later.

 

While I know it hasn’t always been pleasant or easy for Dad to consider the practicalities of his final days, I think he considers that to be his parting gift to my sister and myself.

 

Something that, I can assure you, both of us appreciate.

Friday, February 24, 2012

The Great CFR Divide

 

 

 

# 6173

 

 

Over the past two days we’ve seen two highly divergent papers come out on the probable spread, and Case Fatality Rate, of the H5N1 virus in the human population.

 

The lead author of the first one was Peter Palese and the second Michael Osterholm. Both are scientists of considerable reputation in the world of infectious diseases.

 

You can access them via my blogs below:

 

Science: Peter Palese On The CFR of H5N1
mBio: Mammalian-Transmissible H5N1 Influenza: Facts and Perspective

 

In 25 words or less, though:

 

Professor Palese maintains that seroprevalence studies suggest `millions’ of uncounted H5N1 infections, and would indicate the virus is nowhere near as deadly as has been proclaimed.

 

Osterholm cites flaws in some of those studies, and using WHO guidelines for testing, finds scant evidence to support the idea that many cases go uncounted, and the CFR is low.

 

Shamefully simplistic summaries on my part, but we’ve covered this territory many times in the past few days. I would encourage everyone to read both papers in their entirety.

 

In the wake of their publication, we are starting to see some media coverage and comparison of the two papers, and reactions from other scientists on this issue.

 

First stop, Reuters, which has a long report on this controversy, which was published before the mBio  paper was released this morning.

 

Bird flu may not be so deadly after all, new analysis claims

By Sharon Begley

NEW YORK | Fri Feb 24, 2012 6:38am EST

 

Despite the title, this report does quote the World Health Organization as standing behind their numbers, and has comments by Arturo Casadevall and Michael Osterholm disputing Palese’s results.

 

Next, New Scientist has a report by Debora MacKenzie that looks at the debate, and along the way she posits a theory of her own.

 

New doubt over H5N1 death rate – but risks still high

16:50 24 February 2012

 

 

And lastly, Lisa Schnirring of CIDRAP News has undertaken a difficult task and (skillfully, I think) has put together a comparison of the two papers.

 

She includes reactions from several leading scientists (including Gaun Yi and Marc Lipsitch) who have read the papers.

 

 

Debate on H5N1 death rate and missed cases continues

Lisa Schnirring * Staff Writer

Feb 24, 2012 (CIDRAP News) – Two leading voices on the potential threat of lab-modified H5N1 viruses laid out their arguments about the human H5N1 fatality rate and undetected cases today and yesterday, with one group claiming "millions" likely have been infected and the other group saying current World Health Organization (WHO) fatality-rate estimates are about right.

 

(Continue . . . )

 

 

While this is a fascinating debate, and I know just about everyone would like to know the true CFR of the H5N1 virus (myself included), I’m not sure how much value (or comfort) that we would derive if we had that knowledge.

 

First, we tend to talk about the H5N1 virus as if it were a single, monolithic virus.

 

It isn’t.

 

There are more than 20 identified clades (and growing), with many minor variations within each clade.

 

image 

 

If we could figure out the CFR for the clades commonly found in Indonesia (2.1.1, 2.1.2. and 2.1.3), it probably wouldn’t tell us much about those circulating in Egypt (2.2.1 and 2.2).

 

And it might tell us even less about the CFR of some future human-adapted H5N1 virus that may one day appear.

 

As any prospectus will warn you, Past performance is no guarantee of future results.

 

So even if we were accept that Professor Palese is correct, and the CFR of currently circulating H5N1 strains are somewhat less than 1%, I’m not exactly comforted by that knowledge.

 

I think what is important here is that this virus has been shown to provoke severe, often devastating illness in nearly all of the humans cases we’ve confirmed so far. It also seems to have a preference for younger victims.

 

Admittedly, that could change as the virus evolves.

 

But it is enough to convince me that we need to regard this virus as a dangerous and formidable pathogen, regardless of whether its CFR right now turns out to be 30%  or .3% or somewhere in between.

 

Because if a new and improved version of the virus ever emerges, all of the old arguments (and datasets) will quickly become academic.

mBio: Mammalian-Transmissible H5N1 Influenza: Facts and Perspective

image

Photo Credit – CDC PHIL

 

 

# 6172

 

As I mentioned yesterday in Science: Peter Palese On The CFR of H5N1, not everyone agrees with his analysis of H5N1 seroprevalence studies, which he believes supports the idea that `millions’ of people have already been infected by the virus, and that the true fatality rate (CFR) is far lower than advertised.

 

Today, a counter argument (an added bonus, this is an open access paper) appears in mBio, authored by CIDRAP director Michael T. Osterholm and Nick Kelley.

 

(Fair disclosure: I’m acquainted with both Mike and Nick, and was invited to be presenter at a CIDRAP pandemic conference back in 2009).

 

The paper is called:

 

Mammalian-Transmissible H5N1 Influenza: Facts and Perspective

Michael T. Osterholm Nicholas S. Kelley

Abstract

Two recently submitted (but as yet unpublished) studies describe success in creating mutant isolates of H5N1 influenza A virus that can be transmitted via the respiratory route between ferrets; concern has been raised regarding human-to-human transmissibility of these or similar laboratory-generated influenza viruses.

 

Furthermore, the potential release of methods used in these studies has engendered a great deal of controversy around publishing potential dual-use data and also has served as a catalyst for debates around the true case-fatality rate of H5N1 influenza and the capability of influenza vaccines and antivirals to impact any future unintentional or intentional release of H5N1 virus.

 

In this report, we review available seroepidemiology data for H5N1 infection and discuss how case-finding strategies may influence the overall case-fatality rate reported by the WHO.

We also provide information supporting the position that if an H5N1 influenza pandemic occurred, available medical countermeasures would have limited impact on the associated morbidity and mortality.

 

I would encourage you to read the entire article, where the authors dissect some of the methods used in existing seroprevalence studies.

 

It is quite a detailed analysis, and worthy of your full consideration.

 

After excluding some of the seroprevalence studies that utilized an extremely low antibody titer threshold (in some studies, set as low as ≥1:10), the author’s conclude that:

 

The available seroepidemiologic data for human H5N1 infection support the current WHO-reported case-fatality rates of 30% to 80%

 

The go on to say that:

 

In fact, if H5N1 virus does become a pandemic virus, the virulence (as measured by the case-fatality rate) could decrease 10- to 20-fold from what is currently documented and the virus would still generate a more severe pandemic than the 1918 pandemic, where the overall case-fatality rate was probably about 2%.

 

Given the global population and the current dynamics of population movement around the world, an H5N1 pandemic, even with a relatively low case-fatality rate, would be a truly catastrophic event.

 

I’ve reproduced their summary below.

 

SUMMARY

In summary, we believe that the debate about the case-fatality rate of H5N1 influenza in humans and the suggested important role of currently available antivirals and vaccines in mitigating an H5N1 pandemic are without merit.

 

Furthermore, we do not believe that continued focus on these issues helps to address how best to manage research involving influenza viruses, such as H5N1, that are transmissible between mammals and have the potential to be highly virulent in humans.

 

Future discussions specific to the current controversy need to resolve critical questions such as how we safely conduct H5N1 virus transmission studies in mammals, how we share critical methods and results with those who have a need to know, and how we ensure that laboratory-generated H5N1 viruses do not escape controlled environments.

 

Resolution of these issues with regard to H5N1 influenza viruses has the potential to serve as a template for similar situations involved existing or emergent pathogens. It is our belief that the current controversy provides a valuable opportunity for scientists and public policy experts to work together in creating this road map for the future.

 

Notes

Dr. Osterholm is a member of the National Science Advisory Board for Biosecurity. His views expressed here do not represent the official policy or scientific conclusions of the NSABB.

 

 

NOTE: Since this was an open access paper I was able to incorporate more of it into today’s blog than I could with yesterday’s Palese paper.

 

 

I suspect this debate will rage, unresolved, until we get more and better data.

 

Hopefully, we’ll get that data from well mounted and standardized seroprevalence studies, and not from the butcher’s bill from the next pandemic.

China: Hebei Outbreak Identified As Adenovirus 55

 

 

image

Adenovirus- Credit CDC

 

 

# 6171

 

 

Yesterday the Internet was abuzz with rumors of `SARS’, or at least something that looked like SARS, sending scores of people to hospitals in Hebei, China (see China Denies Internet Rumor Of SARS Outbreak).

 

While SARS seemed unlikely (we haven’t seen an outbreak in 9 years), news reports out of Hebei over the past week have suggested some kind of respiratory outbreak was in progress.

 

Today, Taiwan’s CDC is reporting that China has notified them that the outbreak is due to the Adenovirus type 55, not to SARS.

 

A hat tip to Shiloh on FluTrackers for picking up this story and adding it to their thread.

 

China confirms suspected adenovirus infection outbreak: CDC


2012/02/24 19:54:00

Taipei, Feb. 24 (CNA) An outbreak of disease that is causing a stir in the Chinese online community is not SARS but adenovirus infection, the Centers for Disease Control (CDC) confirmed Friday after checking with the Chinese health authorities.

 

China told the CDC that the suspected outbreak in Hebei Province was in fact adenovirus type 55 infection, CDC Deputy Director-General Chou Chih-hau said.

 

China, however, did not reveal the scale of the epidemic to Taiwan.

(Continue . . . )

 

 

Adenoviruses are one of the most common causes of respiratory illness in the world, and to date, more than 50 different types have been isolated.

 

The CDC’s Adenovirus Information page describes the virus this way:

 

Adenoviruses most commonly cause respiratory illness. The symptoms can range from the common cold to pneumonia, croup, and bronchitis. Depending on the type, adenoviruses can cause other illnesses such as gastroenteritis, conjunctivitis, cystitis, and less commonly, neurological disease.

 

Infants and people with weakened immune systems are at high risk for severe complications of adenovirus infection. Also, adenoviruses commonly cause acute respiratory illness in military recruits.

 

Some people infected with adenoviruses can have ongoing infections in their tonsils, adenoids, and intestines that do not cause symptoms. They can shed the virus for months or years.

 

We have seen rare outbreaks of emerging strains of adenovirus that have caused more serious illness, including one serotype (Ad14) that has been associated with a number of deaths during the past decade (see 2007 MMWR Acute Respiratory Disease Associated with Adenovirus Serotype 14 --- Four States, 2006—2007).

 

Like all viruses, adenoviruses are capable of evolving and mutating, and new strains are likely to crop up from time to time, with varying degrees of severity.

 

While not influenza (or worse, SARS), we’ll keep an eye on this outbreak, and see how it progresses.

Egypt & Indonesia Confirm New H5N1 Cases

 

# 6170

 

 

This morning we’ve two reports of human infection from the H5N1 virus, one of which has proved fatal.

 

First stop, is Egypt, where the World Health Organization has announced their 3rd case of 2012, a 1 year-old girl from Gharbeia governorate who is recovering.

 

Avian influenza – situation in Egypt – update

24 February 2012 - The Ministry of Health and Population of Egypt has notified WHO of a new case of human infection with avian influenza A (H5N1) virus.‪

 

The case is a one year-old female from Gharbeia governorate. She developed symptoms on 14 February 2012 and was admitted to a hospital on 15 February 2012, where she received oseltamivir treatment upon admission. She is in good medical condition.

 

Epidemiological investigation into the source of infection is ongoing. Preliminary investigations indicate presence of backyard poultry in her area of residence.

 

The case was confirmed by the Central Public Health Laboratories; a National Influenza Center of the WHO Global Influenza Surveillance Network.

 

Of the 160 cases confirmed to date in Egypt, 55 have been fatal.

Meanwhile, the Indonesian Ministry of Health has posted a notice regarding the bird flu infection, and death, of a 12-year-old boy from Bali.


A hat tip to Gert van der Hoek on FluTrackers for the following link.

 

Development of Bird Flu Cases

February 24, 2012 | 1:33 pm

Ministry of Health through the Directorate General of Disease Control and Environmental Health, announced a new case of H5N1 have been confirmed by the Center for Basic Biomedical and Health Technology, Balitbangkes.

 

Case on behalf of DWM (male, 12 years) resident of Badung, Bali. Dated February 11, 2012 fever symptoms develop, see a doctor in private clinics and hospitals. On February 16, 2012 the case was being treated RS. Because of increased shortness, on February 20, 2012 the case was referred to the Referral Hospital Bird Flu, but eventually the case died on February 21, 2012.

 

Epidemiological investigations have been conducted in the home and neighborhood environment cases by the local Health Department with the results of risk factors is unclear.

 

With the increase of these cases, the cumulative number of bird flu in Indonesia since 2005 until this news was broadcast on 186 cases with 154 deaths.

 

Director General of Disease Control and Environmental Health Yoga Aditama Prof.dr.Tjandra as the focal point of the International Health Regulations (IHR) has been informed about the case to the WHO.

 

This is the time of the year when we expect the greatest number of human infections from the H5N1 virus, and so the announcement of four cases this week is hardly unexpected or alarming.

 

The extremely high fatality rate in Indonesia continues (100% in 2012, 83% in 2011), while in Egypt this year, all known cases have survived. 

 

Last year, Egypt’s fatality rate was 38%.

 

The H5N1 virus remains poorly adapted to human physiology, and so far remains primarily a threat to poultry and wild birds.


That could change of course, as the dozens of strains and clades around the world continue to mutate and evolve. So we watch these cases with great interest, looking for any signs that the threat has changed.

Thursday, February 23, 2012

Science: Peter Palese On The CFR of H5N1

 

 



# 6169

 

 

One of the livelier `sideshows’ in the vigorous debate over the safety and wisdom of H5N1 lab research has been the argument over just how deadly the H5N1 virus really is.

 

Although the virus first appeared 15 years ago in Hong Kong that question remains difficult (perhaps, impossible) to answer.

 

The media has reported, ad nauseum, that the virus kills 6 out of 10 people it infects. Which would give it a CFR (Case Fatality Ratio) about 60%.

 

But then it gets complicated.

 

We literally have no good read on how many people the virus has actually infected.  If `mild’ or asymptomatic infections occur, then they are unlikely to be noticed.

 

A large part of the reason is that surveillance is less than robust in many of the regions where the virus is endemic. Testing – when it is done (and often it isn’t) – has long suffered from sensitivity problems. 

 

Beyond that, many people who get sick (and even die) in places like Cambodia, Vietnam, or China may do so without ever seeking medical care.

 

Intuitively we can say that these cases almost certainly exist, but we have no way to accurately measure them. In truth, even the CDC can’t tell you exactly how many people are sickened or die from the flu (or any other cause) each year.

 

Most scientists would grant that what we see with the H5N1 virus is probably the tip of the iceberg. It is the size of what lies beneath that visible tip that is heavily disputed.

 

Today we’ve a paper, authored by Professor Peter Palese  et. al., that argues that we are likely missing a great many uncounted H5N1 infections, and that the virus is far less lethal than has been assumed in the past.

 

This is similar to the argument that Vincent Racaniello  used last month in his blog Should we fear avian H5N1 influenza?

 

The reason behind this debate – beyond the obvious need to quantify an important aspect of this virus – is the debate over whether this virus is too dangerous to work with in a BSL-3 laboratory environment. 

 

Relegating it to the highest containment labs (BSL-4), it has been argued, would severely restrict the number of scientists (and countries) who could work on this pathogen

 

 

One way to get an idea of the uncounted number of people infected by a virus in a population is to conduct regional seroprevalence studies.

 

You essentially check antibody levels against a specific virus in a representative group of the population.

 

Unfortunately, you don’t end up with a clear cut Infected/Not Infected reading from these tests. You get an antibody titer level, and that requires a subjective decision as to what level constitutes proof of a `previous infection’.

 

Set the bar too high, and you rule out possible cases whose antibodies have declined over time (or who were exposed to an antigenically different H5N1 strain).

 

Make it too low, and you may count people who were exposed to a non-H5 virus or who received such a low viral load as to not develop illness or immunity. 

 

Over the years we’ve seen a number of seroprevalence studies on the H5N1 virus, and the results (and methods) have varied considerably.

 

Palese’s paper appears today in the journal Science (the embargo lifts at 2pm EST), and here he makes his case:

 

Seroevidence for H5N1 Influenza Infections in Humans: Meta-analysis


Taia T. Wang,  Michael K. Parides,  Peter Palese

ABSTRACT

The prevalence of avian H5N1 influenza A infections in humans has not been definitively determined. Cases of H5N1 infection in humans confirmed by the World Health Organization (WHO) are fewer than 600 in number with an overall case fatality rate of >50%.

We hypothesize that the stringent criteria for confirmation of a human case of H5N1 by WHO does not account for a majority of infections, but rather, the select few hospitalized cases that are more likely to be severe and result in poor clinical outcome.

Meta-analysis shows that 1-2% of more than 12,500 study participants from 20 studies had seroevidence for prior H5N1 infection.

 

While stating that we don’t have definitive numbers, Palese writes that if one assumes a 1-2% infection rate among exposed populations, there would likely be millions of people who have been infected by the H5N1 virus.

 

Palese grants that deaths from the virus may also be undercounted, and calls for better studies (something that I think everyone, regardless of where they stand on this issue, would agree with).

 

If we assume that Professor Palese is correct in his assumptions, then the H5N1 would seem to be not much more dangerous than some strains of seasonal flu.

 

A comforting thought.

 

But one that seems at odds with the argument proffered by many scientists calling for aggressive research into the H5N1 virus because of its serious `pandemic potential’.

 

Of course not everyone views the available data in quite the same way as does Professor Palese.

 

We’ll be getting a counter-argument either later today or tomorrow from Michael Osterholm and Nick Kelley of CIDRAP, who have their own analysis coming out in mBio this week (see press release).

 

Stay tuned.

China Denies Internet Rumor Of SARS Outbreak

 

UPDATED :   China: Hebei Outbreak Identified As Adenovirus 55

 

# 6168

 

 

Between text messaging, emails, and the twitterverse, unsubstantiated rumors can quickly spread – and take on a life of their own - even across China.

 

Today, some Chinese newspapers, traffic on Twitter, and even Hong Kong’s government have taken note of a story suggesting that a SARS outbreak has erupted in China.

 

Normally I’d wait on a story like this, but since it is already lighting up twitter, and Hong Kong has posted an official response, I decided to mention it.

 

At this time I’ve seen no credible evidence to support this rumor. 

 

Hong Kong’s government has posted the following statement on their website.

 

CHP actively follows up with Ministry of Health on SARS rumour

A spokesman for the Centre for Health Protection (CHP) of the Department of Health today (February 23) said that the CHP had successfully contacted the Ministry of Health (MOH) to ascertain a rumour concerning an incident of Severe Acute Respiratory Syndrome (SARS) in Hebei province and was initially confirmed by MOH that there was no SARS outbreak. The Mainland authority concerned will announce relevant information later.

 

The spokesman said that there are well-established communication channels, including the SARS notification mechanism, between Hong Kong and the Mainland to enable timely exchange of important information about infectious disease incidents and outbreaks.

 

The CHP will continue to follow up actively with the MOH and monitor the latest development.

Ends/Thursday, February 23, 2012
Issued at HKT 18:39

 

Obviously, it is not beyond the realm of possibility that SARS, or some other type of pneumonia, has caused an outbreak of illness in Hebei Province. 

 

FluTrackers is following this story on this thread, and I’ll report back if this turns out to be anything more than a rumor.

WHO: Northern Hemisphere 2012-2013 Flu Vaccine Composition

 

image

Photo Credit PHIL

# 6167

 

 

After consultations this week with public health officials, researchers, and pharmaceutical companies the World Health Organization has released their recommendation for the antigen composition of this fall’s trivalent flu vaccine.

 

 

Recommended composition of influenza virus vaccines for use in the 2012-2013 northern hemisphere influenza season

It is recommended that vaccines for use in the 2012-2013 influenza season (northern hemisphere winter) contain the following:

  • an A/California/7/2009 (H1N1)pdm09-like virus;
  • an A/Victoria/361/2011 (H3N2)-like virus;
  • a B/Wisconsin/1/2010-like virus.
For more information
                                   

                                        Due to the continual antigenic drift of flu viruses, flu vaccine formulations are frequently adjusted. After 3 years with essentially no changes in the flu vaccine, this new formulation makes changes to both the H3N2 and B virus strains.

                                         

                                        The H1N1 component remains essentially unchanged, with the A/California/7/2009 (H1N1)pdm09-like  still recommended.

                                         

                                        • The old A/Perth/16/2009 (H3N2)-like virus now gives way to the A/Victoria/361/2011 (H3N2)-like virus.
                                        • And the Victoria lineage B/Brisbane/60/2008-like virus will be replaced by a Yamagata strain; the B/Wisconsin/1/2010-like virus. 

                                         

                                        While the World Health Organization makes vaccine recommendations twice each year (Recommendations  are made in September for the Southern Hemisphere), national and regional public health organizations are responsible for deciding what formulation to use locally.