# 3736
Researchers tell us that the CFR (Case Fatality Ratio) during the 1918 pandemic varied widely around the world, with some countries seeing relatively low fatality rates, and others much greater ones.
In a 2006 paper , "Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis" Christopher J.L. Murray, Alan D. Lopez, Brian Chin, Dennis Feehan, Kenneth H. Hill (Lancet 2006; 368:2211-2218) estimated that the CFR in central India may have been 39 times higher than that of northern Europe.
It comes as little surprise then that developing countries with less advanced and available health care, higher population densities, and more pre-existing health problems would see greater impacts from the novel H1N1 virus than would some more developed nations.
Essentially, what might be a CAT 1 pandemic in the North America or Europe, could easily be a CATEGORY 2 pandemic in India, Africa, or other developing regions.
This is a scenario I’ve written about before, including A Tale of Two Pandemics.
In the past 48 hours we’ve been seeing some news reports out of India that suggest they may be seeing a higher mortality rate with this pandemic virus than we’ve seen in other parts of the world.
I stress the world `suggest’ because the Indian press has been known to indulge in hyperbole on occasion, particularly when it comes to reporting on disease and illness.
We are also seeing a fair bit of speculation in these reports about the possibility of a viral mutation; something which I would caution my readers to regard with a certain degree of skepticism.
While mutations are always possible, for now, regional socio-economic factors seem a far more likely explanation for a higher CFR.
With those caveats in place, a pair of news reports dug up by the hard working newshounds on the flu forums.
First, from Commonground on Flutrackers, we get this report from The Times of India.
Evidence-based policy needed to combat H1N1
TNN 15 September 2009, 03:44am IST
PUNE: City-based Jan Arogya Abhiyan (JAA), a forum of health professionals and NGOs, has called for an evidence-based policy to control the spread of the H1N1 influenza.
"Health authorities and experts should consolidate the evidence, the data about the current swine flu epidemic in the city so that a realistic, scientific assessment can be done to combat the epidemic. Number of deaths is not the only criterion to monitor the progress of the epidemic," Anant Phadke, coordinator, JAA, said.
In the city, deaths as a result of the swine flu is being reported everyday, and it's not at all clear whether the epidemic is on the decline or not. Dismissing the swine flu threat by saying that it's a minor ailment or creating scare about it are both equally wrong, Phadke said.
Though it is true that around 90 per cent of the swine flu-infected patients recover, it is also true that the swine flu mortality rates have been very high compared to the ordinary seasonal flu, said Phadke. "The mortality rate in ordinary seasonal flu epidemics in the US is usually less than 0.1%. (No figures are available for India). However, the swine flu mortality rate in the US is 0.7%, that is, seven times as much high," Abhay Shukla, co-conveynor of JAA, said.
There have been 43 deaths out of 985 confirmed cases in the city till now. This means a mortality of 4.3 per cent, said Shukla. Assuming that only half the cases are getting tested and therefore assuming that mortality rate is half of what has been recorded, still a swine flu case fatality rate' of more than 2 per cent is very high, he added.
I’m always a bit wary of attempts to calculate CFRs based on `confirmed cases’ of this virus, since there are probably a lot of mild, undetected cases in the community.
Of course, there could be undetected deaths from the virus as well. So as regards these numbers, Caveat Lector.
This next report, also on FluTrackers from Treyfish is one of several that have appeared in the past 24 hours suggesting a `mutation’ may have occurred in the virus.
I am unaware of any genetic testing that has been done to support that claim. This speculation appears to be based entirely on the clinical presentation of patients in Hyderabad, India.
HYDERABAD: The A(H1N1) virus is showing signs of getting ‘mutated’ into a more virulent form.
Clinical observation of experts in the State capital indicate that the genetic make up of A(H1N1) virus has ‘changed’ and is now more ‘potent’ after coming into contact with the local existing viral forms.
‘Second wave’
This is the ‘second wave’ of swine flu virus, coinciding with the rainy season, which is still active. There is a possibility of onset of a third and more virulent form in the upcoming winter season. The virus is getting more ‘time’ to stay in the atmosphere because of low temperatures, experts opine.
A pattern, among the swine flu fatalities in twin cities, has been detected. “Patients are dying within 24 to 48 hours after getting infected with A(H1N1). The virus is not giving any chance to the doctors to treat the patient. The virus has become virulent and that’s why we are losing patients who have good immunity,” said Gandhi Hospital Superintendent E.A. Ashok Kumar.
Between May and August, when A(H1N1) virus was imported from other countries, it did not cause severe illness to patients. “These days, the patient’s condition is deteriorating within 24 hours. There is a definite shift in the genetic make up of the virus. It might have genetically changed after coming into contact with local influenza virus,” Superintendent of Chest Hospital S.V. Prasad.
Experts assert that authorities and the public should be prepared for the onset of a third wave of swine flu in winter.
Obviously, the newshounds on the flu forums are going to be keeping a close eye on this situation, as I’m sure are public health officials around the world.
If the clinical presentation has changed, no doubt virus samples will be analyzed for genetic mutations. If anything untoward is detected, we’ll hear about it.
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Now is a good time to remind my readers that agencies like the Red Cross, Red Crescent, CARE, Save The Children, The H2P Project, UNICEF, and others are working around the world every day to combat poverty and disease, and are going to be on the front lines during any pandemic.
They could use your support.
These NGO’s do a great deal with very little, and even small donations can help make a difference.
