Monday, January 31, 2011

Waiting For Snowmageddon

 

 

# 5273

 


It’s being billed as a practically a Snowpocalypse by weather forecasters, and referenced on twitter with the humorous hashtag #snOMG!. 

 

But whatever you call it, conditions are setting up for what may turn out to be a record breaking blizzard for large parts of the mid-west and the northeastern United States over the next 72 hours.

 

Here is a graphic from the Kansas City, Mo National Weather Service depicting local conditions expected tomorrow.

 

 image

By Wednesday, snowfalls in excess of 18 inches are possible in some places.

 

As bad as heavy snow can be, anyone who has lived through one will vouch for the fact that heavy icing can be much, much worse. 

 

Power lines, even entire power poles, can snap under the heavy load of ice.  And in some places it may take days or even weeks to restore electrical service.

 

And heavy icing may be on the way.

 

Here is the HPC Experimental Probabilistic Winter Precipitation Guidance for .5 inches of ice or more over the next 48 hours.

 

 image

 image

And here is the Wednesday-Thurs snow > 12 inches forecast.

  image

 

 

Craig Fugate, director of FEMA, is tweeting preparedness information  practically every hour (follow him at @CraigatFema and @FEMA). 

 

A few recent tweets include:

 

NWS mobile weather page is fast and works good on smart phones http://mobile.weather.gov/ #snomg #icestorm #blizzard #snow #winter #wx

 

NWS Kansas City, MO: Winter Wx Briefing http://go.usa.gov/YRB "a crippling #snow storm expected to hit the region" #snomg www.ready.gov

 

@allhazardsblog SPC http://www.spc.noaa.gov/ and HPC http://www.hpc.ncep.noaa.gov/ are working better than weather.gov checking with NWS

 

"@RCham220: Don't forget your hydrants." when you start to dig out, help out your local fire department by clearing around fire hydrants.

 

#snomg #icestorm #blizzard #winter #storm #freeze #sleet #cold #wx don't forget to check on your neighbours www.ready.gov www/listo.gov 

 

Meanwhile, the American Red Cross has issued this statement:

 

American Red Cross Urges Preparedness As Damaging Winter Storm Threatens About 100 Million People

Blood donors needed as winter weather continues to affect supply

National Headquarters
2025 E Street, N.W.
Washington, DC 20006
www.redcross.org

Contact: Public Affairs Desk
FOR MEDIA ONLY
media@usa.redcross.org
Phone: (202) 303-5551

WASHINGTON, Monday, January 31, 2011 — The American Red Cross is preparing to respond to the destructive winter storm that is bearing down on the country from just east of the Rocky Mountains to the coast of New England. The storm could impact a third of the population of the United States, and it threatens to bring blizzard conditions and heavy ice and snow.

Winter driving ERV

Winter storm safety checklist [PDF]

This latest winter blast could further impact the Red Cross blood supply which has already seen more than 18,000 expected blood donations go uncollected over the last several weeks due to bad winter weather. People are asked to make an appointment to give blood by calling 1-800-RED CROSS or visiting www.redcrossblood.org. Those who live in the path of the storm are asked to schedule a donation time when it is safe to travel. All blood types are needed, but there is a special need for donors with O-Negative, A-Negative and B-Negative blood.

(Continue . . . )

 

 

 

But if you live in the path of this massive blizzard, I’m sure you aren’t particularly worried.

 

After all, you’re already prepared to go several days, or longer, in sub-freezing temperatures without power.

 

Right?

 

The governor of Oklahoma has declared a state of emergency for all 77 counties, and others states will likely follow.

 

State and local officials are taking this storm very seriously, and so should the residents in its path.

 

To be on the safe side, today would be an excellent day to review your family’s cold weather emergency plans, and make any last minute adjustments.

 

And to help you along, you may want to review some of the winter preparedness information I’ve posted recently in the following blogs:

 

Hypothermia, Frostbite & The Big Chill
Cold Weather Car Bag
Preparedness: How To Chill When It’s Cold Outside

Haiti: Charting The Cholera Epidemic

 

 


# 5272

 

 

I’ve not done a lot on the Cholera outbreak in Haiti over the past few weeks, simply because Crofsblog has been extraordinarily dedicated to the story since it began.  And for daily coverage of Haiti, that’s the site to visit.

 

But from time to time - when I’ve thought I could add some value - I’ve posted on the outbreak, including:

 

MMWR: Haiti Cholera Update
Haiti: The Progression Of An Epidemic
Haiti: Updated Cholera Outbreak Map
 

Sixty days ago I posted some graphics showing the progression of the Cholera Epidemic through the end of November.  At the time, the mortality rate was listed at 2.2%.

 

image

These are just reported numbers, of course. The real numbers are likely much higher.   Also, a great many more people are assumed to be asymptomatic carriers of the bacteria.

 

Today OCHA has posted a freshly updated map, and chart of the epidemic’s progress, hosted by Reliefweb.  You can download the map in its entirety at the link below, but I’ve excerpted a couple of interesting segments to highlight.

 

Haiti: Cholera Cumulative Cases since October 2010 (as of 24 Jan 2011)

Map of 'Haiti%3A%20Cholera%20Cumulative%20Cases%20since%20October%202010%20(as%20of%2024%20Jan%202011)'

  • Date: 27 Jan 2011
  • Type: Natural Disaster
  • Keyword(s): Epidemic; Health; Natural Disaster; Affected Population
  • Format:

    map.pdfPDF *, 1218 Kb

 

 

In addition to depicting the spread of the epidemic in a series of maps, this release also charts the number of cases and fatalities. 

 

While 4000+ deaths is obviously a tragedy, the CFR (case fatality ratio) has dropped considerably over what was first reported back in October (roughly 8%).  

 

image

image

 

A goodly portion of this drop can no doubt be attributed to better surveillance and the counting of less severe cases, which may not have been included in the earliest numbers. 

 

Some of it, however, is undoubtedly due to the ramped up response by numerous relief agencies to the crisis.

 

 

Even assuming the vagaries of surveillance and reporting out of Haiti, and the likely undercounting of fatalities (and total cases), these numbers indicate that progress is being made.

 

That earthquake ravaged Port-au-Prince is running under a 1% mortality rate is actually quite remarkable.

 

And the (roughly) 2% CFR outside of the capital is noteworthy as well, given the pre-existing disease burdens and poor health care infrastructure that exists in rural Haiti.

 

While the cholera situation in Haiti can hardly be described as good, thankfully, it does appear that some progress is being made.

 

For some background on other diseases plaguing Haiti, you may be interested an a blog I wrote last November:

 

Haiti: Three Non-Cholera Health Threats

Sunday, January 30, 2011

What Goes Around, Comes Around

 

 


# 5271

 

 


With bird flu outbreaks among poultry and wild birds increasing across South Korea and Japan (North Korea and possibly China are unknown factors), other Asian countries that see migratory bird visitations over the winter are understandably on the alert.

 

Today, a news release form the National News Bureau of Thailand, Public Relations office that reflects their concern. 

 

Bird flu fear sparks warning across the country

BANGKOK, 30 January 2011 (NNT)-Public Health Minister Jurin Laksanawisut has instructed public health services across Thailand to warn people of a possible outbreak of bird flu in human, although there has been no report on any one contracting the disease so far.

 

Following an unidentified cause of death of 100 chickens in Sam-Chuk district, Suphan Buri province, local residents fear H5N1 or commonly known as bird flu was the reason. However, an autopsy on dead chickens are still underway. Mr. Jurin has taken a precautionary step and instructed health services to coordinate with officers from the Department of Livestock and the Department of Agriculture for help.

 

According to the Health Minister, it is important that people are aware of risks and know how to protect themselves against the flu. People have also been warned not to come in contact with dead poultry. Mr. Jurin said even though Thailand has been free of the flu since 2006 ,the Ministry of Public Health will continue to monitor the disease to safeguard the health of the Thai people

 

We’ll have to wait to hear if this turns out to be anything, but it gives you an idea of how seriously officials are taking these latest outbreaks.

 

Japan, Korea, and Thailand are part of the great East Asian - Australasian Flyway. All three countries are the winter home for many species of migrating birds, many of which spend their summers in Siberia, China, and Mongolia. 

 

There are, however - overlaps between these flyways - enabling pathogens to be carried from one to another.

 

image

 

In what may turn out to be a related story, yesterday in an EID dispatch (see EID Journal: H5N1 Branching Out) we saw a report out of Qinghai, China indicating that a new (for them) clade 2.3.2  of H5N1 bird flu was reported in wild birds near major migratory nesting grounds back in 2009 (admittedly, news travels slow out of China).

 

Clade 2.3.2 isn’t new, of course. 

 

It’s been circulating - primarily among poultry in Vietnam and parts of China - since the middle of the last decade, and started showing up in wild bird surveillance a couple of years later.

 

In March of 2009, the CDC’s EID Journal published the following report.

 

Characterization of Avian Influenza Viruses A (H5N1) from Wild Birds, Hong Kong, 2004–2008


Gavin J.D. Smith,1 Dhanasekaran Vijaykrishna,1 Trevor M. Ellis, Kitman C. Dyrting, Y.H. Connie Leung, Justin Bahl, Chun W. Wong, Huang Kai, Mary K.W. Chow, Lian Duan, Allen S.L. Chan, Li Juan Zhang, Honglin Chen, Geraldine S.M. Luk, J.S. Malik Peiris, and Yi Guan

(EXCERPT)

Genetic and antigenic characterization of 47 HPAI (H5N1) viruses isolated from dead wild birds in Hong Kong showed that these isolates belonged to 2 antigenically distinct virus groups: clades 2.3.4 and 2.3.2.

 

Although research has shown that clade 2.3.4 viruses are established in poultry in Asia, the emergence of clade 2.3.2 viruses in nonpasserine birds from Hong Kong, Japan, and Russia raises the possibility that this virus lineage may have become established in wild birds.

 

 

Passerine birds encompass `perching birds’ & songbirds, while nonpasserine birds include ducks, swans, storks, ostriches, aquatic water fowl, quail, turkeys, and gulls . . . among many others.

 

In Late November of 2010, after 2 and 1/2 years without an outbreak, the H5N1 virus was detected at a poultry farm in Japan (see Japan: Bird Flu Investigation At Poultry Farm).  

 

Subsequently, the OIE WAHID follow up report # 1 identified the strain as being clade 2.3.2.  A hat tip to Ironorehopper for archiving the following information on his website:

 

Highly pathogenic avian influenza, Japan (WAHID Interface - OIE World Animal Health Information Database, Dec. 09 2010, edited

Epidemiological comments

  • It is considered that the virus was carried to the surroundings of the farm by migratory birds because the outbreak occurred in a season when migratory birds came flying from the north to Lake Nakaumi nearby the farm.

  • The virus might have invaded the affected henhouse through wild birds, wild animals or others.

  • The National Institute of Animal Health affirmed by comparison of gene sequence that the isolate is classified into clade 2.3.2 and a closely-related strain with the virus isolated from faeces of migratory wild ducks in Hokkaido in October 2010.

  • The homology between these viruses is 99.6%.

 

We’ll have to await further phylogenetic analysis from other farms in Japan, Korea, and elsewhere to know for certain .  .  .  but it certainly appears that the  2.3.2 clade has become well established in migratory birds.

 

While that in itself may not be a game changer, it is a reminder that the bird flu virus isn’t just a moving target.

 

It is actually a half dozen (or more) moving targets.  And that just counts the H5N1 clades.

 

With myriad influenza A viruses comingling, swapping genetic material, and continually trying out new genetic combinations in order to make a better, more `fit’ virus – it is imperative that we do what we can to improve global pathogenic surveillance and reporting.

 

Because experience has shown us, diseases that go around in one part of the world, have a nasty habit of eventually coming around to the rest of the planet.

Finland To Release Interim Pandemrix – Narcolepsy Study On Feb 1st.

 

 

RECENT UPDATES TO THIS STORY:

National Institute for Health and Welfare Statement – Feb 1st

WHO Statement

GSK Statement

 

 

# 5270

 

An update to a story that first emerged last August (see Finland Suspends Use of Pandemrix Vaccine),we learn today that Finland will soon release an interim report on the potential link between the Pandemrix vaccine and an unusual spike in narcolepsy which was reported in Finland, Iceland, and Sweden.

 

While we don’t have the results at hand, we do have a report from YLE.fi where the head of Finland's National Public Health Institute has conceded that administering the shot to children may possibly have been a mistake.

 

Exactly why these countries should experience a rise in narcolepsy, while other countries using the same vaccine have not reported similar problems, is unknown. 

 

Since I’ve not seen this Interim report, there is little I can say about today’s report. You can read it at the link below.

 

Health Official: Swine Flu Vaccinations for Children Possibly a Mistake

published today 04:40 PM, updated today 04:45 PM

 

While stating that further research is warranted (and will take months), earlier reports from regulatory agencies in Europe stated that no link has been found between the Pandemrix vaccine and recent reports of narcolepsy.

 

On September 9th, I ran a story called Sweden: No Link Between Pandemrix And Narcolepsy, which linked to a CIDRAP report on the findings of Sweden’s Medical Products Agency’s investigation into the matter.

 

And two weeks later, the European Medicines Agency (EMA) said its Committee for Medicinal Products for Human Use had reviewed all available data and found insufficient evidence to confirm a causal link between cases of narcolepsy and the vaccine.

 


We’ll simply have to wait to see if this interim report has credible evidence to the contrary.

 

The CDC published a statement on these concerns last September, part of which states:

 

Pandemrix is not licensed for use in the United States. No adjuvanted influenza vaccines are licensed in the United States. The European Medicines Agency has launched a review of Pandemrix to investigate whether there is a link between cases of narcolepsy and vaccination with Pandemrix. This vaccine has been used in at least 30.8 million Europeans.

AFD Editorial Policies

 

Note: My apologies for this lengthy post in advance.

 

In response to several queries over the past few months as to why I do or don’t do specific things on this blog, I’ve decided to post my rationale for how I manage this blog.

 

Over five years, this blog (and blogger) have undergone a number of changes. Hopefully for the better - but that is for you, the reader - to judge. I’ve learned a great deal about infectious diseases of course, but perhaps even more about science blogging in general.

 

So today, if you’ll indulge me, an outline of the editorial policies I use when writing this blog, including  the sticky issue of`fair use’ of other people’s work.

 

These policies are specific to me, and and geared to address my personal strengths, sensitivities and foibles, and are not intended to be a guide for any other blogger but myself.

 

We each have our own style, strengths, and weaknesses. It would be a boring Internet indeed if we all wrote by the same rules.

 

# 5269

 

 

I have, admittedly, some fairly stringent self-imposed rules for writing this blog.  Since I serve as both author, and editor of AFD, they are the only safeguards I have to keep this 5-year endeavor from `jumping the shark’ (1).

 

Primarily, I try not to speculate, rant, or make this blog all about me. I also avoid, as much as possible, lifting more than a paragraph or two (with a link back) from any newspaper article.

 

Of course, from time-to-time, bits of these elements do sneak in. So it isn’t a complete ban.

 

But it is a goal.

 

And then there’s the tricky minefield of what to do with conflicting science, pseudoscience, politics and individual belief systems. 

 

 

A day doesn’t pass when I don’t find some idiotic news item, blog post, or nutty idea worthy of an acidic rant. The internet is, as they say, a target rich environment. And the strong, sometimes overwhelming temptation is to go after these nutbars with devilish delight.


But I’m pretty sure my small but erudite band of loyal readers don’t need me to tell them when some idea, or policy, is inane.

 

I’d be preaching to the choir. In the end, a rant would only serve to vent my own spleen.  So while I sometimes write them (it’s therapeutic!), I rarely post them.

 

Besides, if I succumbed to the temptation often, this blog would start to sound like a broken record. So I try to resist.

 

 

As far as personal speculation or bias goes, I work constantly to remove it from my writing.

 

Why?

 

Because no one should give a flip what cockamamie ideas this aging ex-paramedic might have on avian flu, virology, or any other subject for that matter.

 

When on rare occasions I do speculate, I try to clearly label it as such.  And I must feel I have at least some credible evidence to back it up.

 

Otherwise, it’s nothing more than biased dreck, and I know it.

 

My goal is to provide context and scientific evidence, not my opinion. I figure my readers are smart enough make up their own minds, without me insultingly trying to do it for them.

 

 

I also try to avoid assuming facts which are not yet in evidence.  Even if they seem `reasonable’, I side with caution.

 

Which is why, when we see suspected cases of H5N1 in Indonesia or Egypt, I don’t automatically assume them to be positive.

 

Or assume that negative results are always`false-negatives’.

 

When we see more than one infection in the same vicinity, and at the same time, I don’t instantly assume them to be the result of human-to-human transmission.

 

Yes, I know.

 

Someone else will likely be the first to declare that an outbreak has begun somewhere in the world. But since I know of no prize for being first to shout `Pandemic’ on the internet, I can live with that.

 

I’d rather be a day late and sure of the facts, than a day sooner and dead wrong.

 

Yes . . .you can always print a retraction, but Google never forgets. 

 

 

You’ve probably noticed I use colored text to segregate what I’m writing from excerpts or quotes by others (always in blue text).

 

Just another way to clarify who is saying what.

 

The subject of `fair use’ has come up a lot over the last year, and while I’ve always limited the amount of text I would lift from a news item (usually a linked headline, and a few paragraphs, followed by a second link), I’m taking even less today.

 

Over the past year I’ve tried to go with just the linked headline and no more than 1 or 2 paragraphs, along with my own summary of the news report.

 

Exceptions are generally press releases, state or official news releases, and of course, open access journal articles.

 

For other journal articles, I’ll give the citation, and some excerpts from the abstract, and then my own summary. 

 

Everything gets linked back to the source, of course.

 

My reasons are simple.

 

It’s no secret that newspapers, and journalists, are in financial trouble. And at least part of the problem is the wholesale `borrowing’ of their work, and reposting it all over the web.

 

I believe I can help them by enticing people to follow the link I provide and to read the original article with a well placed snippet or two, but I would be hurting them if I took much more than that.

 

I’ve too much respect for the talent and hard work of Maggie Fox, Helen Branswell, David Brown, Jason Gale, Lisa Schnirring, Robert Roos, David Dobbs, Maryn McKenna, and many others to ever want to scuttle their ships in order to pad my blog.

 

You’ll find that I use the very same standards when referring to another blogger’s work. And whenever I use a news item dug up by a newshound, I try to give them credit (note: I don’t use items unless linked to the original source), as well.

 

Now, I must confess that I have a personal bias when it comes to this blog.

 

I believe in promoting evidence based public health policies.

 

Unfortunately, sometimes scientific evidence is weak, anecdotal, or conflicting.  And as we all know, today’s `accepted truth’ has a bad habit of becoming tomorrow’s rejected fallacy.

 

Which is why you’ll sometimes find I write blogs like The Temporary Immunity Hypothesis and When Studies Collide (Revisited), that look at conflicting reputable scientific studies.  

 

When I do, I try not to take sides (at least not in print).

 

But when scientific evidence favoring one side is strong enough (notice I used the word `evidence’, not `proof), I’ll side with the preponderance of evidence. Even though I know there is a chance it may be proven wrong later.

 

Why?  

 

Because the best we can do on any given day is to base our decisions on what the best evidence indicates right now, even if absolute proof is lacking.

 

As I’ve said before, if you want a guarantee. . . buy a Craftsman.

 

Which explains why I am pro-vaccination, even though I’m aware of the (minor) risks involved and the fact that they aren’t 100% effective.  And why I don’t use this blog to actively push unproven protective regimens, like Vitamin D (a frequent question, btw), even though there is some evidence that it may be effective.

 

(Personal admission: Being a `belt and suspenders’ type of guy, every flu season I use both).

 

 

Beyond that, I try not to attack anyone personally, even if I vehemently disagree with them (their ideas are always fair game, however). I also avoid dragging politics or religion into this blog like the plague, simply because I believe they polarize the audience, and distract from the science. 

 

I’ll leave that to others, better equipped and better suited, to joust with those windmills.

 

But most importantly, I try my very best not to sensationalize, or use unnecessary hyperbole when reporting on emerging threats. I believe that to do so is both irresponsible, and unprofessional.

 

And that, I think, harkens back to my years as a paramedic (yes, I’m violating the `about me’ rule here, but this whole blog post teeters on that precipice), where maintaining calm while in the midst of chaos was ingrained into us.

 

It’s why we walked (albeit briskly) at the scene of an emergency, never ran. And its how we `handled’ dealing with a dozen horrible events every day.

 

So if you detect the hint of a detached or dispassionate voice when I report on what are admittedly terrible events around the world, you now know why.  

 

There you have it.  The basic rationale I use when writing this blog.  These are my rules, for my blog, and are not meant to apply to anyone else.

 

I’ll post this on my sidebar, so that it remains available on the front page.

 

Hopefully it will have answered any questions you may have had, and now that I’ve written it down, will make it easier for me to stick to.

 

          *             *           *           *            *

 

(1)  `Jumping the Shark’ is an American idiom that goes back to the late 1970s.  It refers to an episode of the sitcom Happy Days, where Fonzie on water skis, jumps over a shark.  It was seen as a low point in the series, and a sign that the show was running out of good ideas, and on the decline.


To `jump the shark’ now means that something that was once great, has lost its way, and is on the downhill path.

Saturday, January 29, 2011

EID Journal: H5N1 Branching Out

 

 

 

# 5268

 

 

From the CDC’s EID journal we’ve a dispatch describing a new clade of the H5N1 virus discovered among wild birds at Gengahai Lake in Qinghai, China.

 

Gengahai Lake is located some 90 Km from Qinghai Lake, the scene of the massive die-off of birds from H5N1 in May of 2005.

 

 Qinghai Lake

First the link and abstract, then a little discussion.

 

New Avian Influenza Virus (H5N1) in Wild Birds, Qinghai, China

Yanbing Li, Liling Liu, Yi Zhang, Zhenhua Duan, Guobin Tian, Xianying Zeng, Jianzhong Shi, Licheng Zhang, and Hualan Chen 

Abstract


Highly pathogenic avian influenza virus (H5N1) (QH09) was isolated from dead wild birds (3 species) in Qinghai, China, during May–June 2009. Phylogenetic and antigenic analyses showed that QH09 was clearly distinguishable from classical clade 2.2 viruses and belonged to clade 2.3.2.

 

 

In the relatively short history of the H5N1 bird flu virus, the huge bird die off in 2005 at Qinghai lake was a watershed moment. Up until then, the H5N1 virus had been pretty much limited to southeast Asia; Hong Kong, Vietnam, Thailand, Laos, and China.

 

But suddenly, and unexpectedly, we learned that waterfowl (brown headed gulls, cormorants, ducks, geese, etc.) – species that normally carry avian flu viruses with little ill effect – had died by the thousands at Qinghai lake.

 

Something had obviously changed with the virus.

 

As flu viruses mutate, new strains are continually produced that are either `biologically competitive’ and go on to spread, or are not, and quickly fade away.

 

When one of these competitive strains diverges enough genetically from its ancestors, it is designated as being a new `clade’ of the virus.

 

Essentially a new branch on the virus’s phylogenetic tree.

 

What emerged at Qinghai Lake was clade 2.2 of the H5N1 virus.

 

And over the next 18 months, this new clade managed to spread widely – likely on the wings of migratory birds -  across Asia, and into Europe and Africa.

 

Other clades have appeared, and have staked out claims on their own territories across the globe.

 

Clades 2.1.1, 2.1.2. and 2.1.3 for instance, are very common in Indonesia while 2.2.1 and 2.2 are often to be found in Egypt.

 

There are now more than a dozen identified clades, although some of them were temporarily blips, and are no longer seen in the wild.  You can see the evolution of the virus over the years in the graphic below.

 

image

For more on this evolution see Variations On A Bird Flu Theme.

 

What researchers have discovered at Gengahai Lake, 4 years after the original outbreak of clade 2.2, is a new clade (2.3.2) – not seen before in migratory birds in Qinghai.

 

Some excerpts from the discussion (but follow the link to read the whole paper):

 

Our results indicated that QH09 virus is a reassortant containing 7 gene segments of clade 2.3.2 viruses detected in wild birds and the PA gene of CK/Yamaguchi/7/04-like virus, which contributed the PA gene to 1 QH05 virus

 

<SNIP>

 

Similar genotypes of QH09-like clade 2.3.2 viruses were also detected in great-crested grebes and black-headed gulls in Russia in 2009 (12). Bar-headed geese, whooper swans, and other anseriforme birds in Mongolia were infected with QH09-like clade 2.3.2 viruses (13).

 

Therefore, QH09-like clade 2.3.2 virus is likely adapted to wild birds and is similar to clade 2.2 viruses, and its presence in Qinghai suggests that wild birds have spread this virus to other regions.

<SNIP>

 

Qinghai Lake is located near multiple avian flyways. Although there are no reports of detection of clade 2.3.2 virus in wild birds near Qinghai Lake, the finding of clade 2.3.2 virus in the Gengahai wetlands of Qinghai increases concerns about a potential pandemic and the likelihood that avian influenza virus (H5N1) will again spread and increase its genetic diversity.

 

Therefore, determining movements of wild migratory waterfowl from Qinghai Lake and their virologic status is needed to assess potential avian vectors of HPAI virus (H5N1).

Referral: McKenna On Farm Vectors Of Resistant Bacteria

 

 


# 5267

 

 

Maryn McKenna has an important and illuminating post on gaps in our surveillance systems and the surprising ways that antibiotic resistant bacteria may be moving around, and off of, farms.

 

Go read it, and I’ll be back with a brief note.

 

 

Farm antibiotics, human illness and what connects them. (It has legs.)

 

 

As an interesting aside, from time-to-time over the past 5 years, flies have also been mentioned as possible vectors of bird flu as well.   You’ll find a few of my blogs on the subject listed below.

 

Indonesian Updates And Vector Concerns
Houseflies Revisited
Cats and Dogs and Flies, Oh My!

 

All of which shows that the interconnections between man, other species, pathogens, and possible vectors are complex.

 

And our understanding of how they fit together remains limited.

North America: Flu Surveillance Week 3

 

 

 

# 5266

 

 

The weekly surveillance numbers from Canada and the United States were released yesterday and some interesting trends are beginning to emerge.

 

In Canada, the peak of the flu season may have been reached, although some indicators are up while others are down – while in the United States influenza activity is picking up pretty much across the board.

 

Interestingly, while the H3N2 virus remains the dominant influenza A strain detected in the United States, after several months of low activity, levels of H1N1 have risen 3 weeks in a row.

 

We’ll start with Canada’s weekly FluWatch report.

 

January 16 to January 22, 2011 (Week 03)

Summary of FluWatch Findings for the Week ending January 22, 2011

  • Overall influenza detections appear to have peaked, with most regions across the country now showing a decline in the percentage of positive influenza detections, except BC and the Atlantic provinces. Paediatric and adult hospitalizations have decreased this week, however, some indicators have increased including the number of regions reporting widespread and localized influenza/ILI activity, the number of outbreaks, and the ILI consultation rate.  
  • Since the beginning of the season, 89.5% of the subtyped positive influenza A specimens were influenza A/H3N2.In week 03, detections of pandemic H1N1 2009 increased slightly to 16.9% of all subtyped influenza A specimens, compared to 15.5% in week 02. The overall proportion of positive tests for RSV has increased from 9.6% to 12.5% in week 03.

image

image

Percent positive influenza tests, compared to other respiratory viruses, Canada, by reporting week, 2010-2011

Percent positive influenza tests, compared to other respiratory viruses, Canada, 
by reporting week, 2010-2011

 

Moving south, the CDC’s  FluView system paints a picture of a flu season still gaining speed.  While it varies from year-to-year, February is usually the the height of the influenza season in the United States.

 

 

2010-2011 Influenza Season Week 3 ending January 22, 2011

All data are preliminary and may change as more reports are received.

Synopsis:

During week 3 (January 16-22, 2011), influenza activity in the United States increased.

  • Of the 5,823 specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division, 1,754 (30.1%) were positive for influenza.
  • The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
  • Three influenza-associated pediatric deaths were reported. Two of these deaths were associated with influenza A (H3) virus infection and one was associated with an influenza B virus.
  • The proportion of outpatient visits for influenza-like illness (ILI) was 3.6%, which is above the national baseline of 2.5%. Six of the 10 regions (Regions 2, 3, 4, 5, 6, and 7) reported ILI above region-specific baseline levels. Nine states experienced high ILI activity, eight states experienced moderate ILI activity, New York City and nine states experienced low ILI activity, 24 states experienced minimal ILI activity, and data were insufficient from the District of Columbia.
  • The geographic spread of influenza in 25 states was reported as widespread; 16 states reported regional influenza activity; the District of Columbia and four states reported local influenza activity, Puerto Rico, the U.S. Virgin Islands, and four states reported sporadic influenza activity, Guam reported no influenza activity, and one state did not report.

U.S. Virologic Surveillance:

WHO and NREVSS collaborating laboratories located in all 50 states and Washington D.C. report to CDC the number of respiratory specimens tested for influenza and the number positive by influenza type and subtype. The results of tests performed during the current week are summarized in the table below.

All 50 states and the District of Columbia have reported laboratory-confirmed influenza this season.

image

INFLUENZA Virus Isolated

Pneumonia and Influenza (P&I) Mortality Surveillance

During week 3, 7.5% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage was below the epidemic threshold of 7.9% for week 3.

Pneumonia And Influenza Mortality

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(click for interactive map)

 

 

 

For more on all of this, Lisa Schnirring at CIDRAP news has an excellent summary of this week’s flu reports.

 

US flu picking up pace; global activity mixed

Friday, January 28, 2011

IOM: PPEs For HCWs 2010 Update

 

 

 

# 5265

 

 

Regular readers will no doubt recall the controversy that surrounded the substitution of surgical masks for N95 respirators for some HCWs dealing with the 2009 H1N1 pandemic.

 

Nurses Protest Lack Of PPE’s
Report: Nurses File Complaint Over Lack Of PPE
California Nurses Association Statement On Lack Of PPE

 

For decades, the assumption was that only properly fitted N95 masks protected the wearer, and that surgical masks were only worn by HCWs to protect the patient during invasive procedures.

 

image image

N-95 Respirator         Surgical Facemask

 

But over the past two years we’ve seen dueling studies that alternately show surgical masks to be an effective barrier against respiratory viruses  . . . or pretty much useless.

 

Take your pick.

 

In October of 2009 the NEJM published a perspective article (see NEJM Perspective: Respiratory Protection For HCWs) based on a 2009 IOM evaluation of surgical masks vs. respirators, and came out in favor of the N95.

 

A few days later JAMA (Journal of the American Medical Association) published a study which reported that HCWs using surgical masks experienced `noninferior rates of laboratory-confirmed influenza.

 

In March of 2010, we saw the following study (see Study: Efficacy of Facemasks Vs. Respirators) in Clinical Infectious Diseases, that suggested that surgical masks are just as effective as respirators in protecting HCWs.

 

In guidance, updated as late as March of 2010, the CDC continued to recommend N95 respirators for HCWs who came in close contact with suspected or confirmed influenza patients.

 

But in June of last year, the CDC proposed new guidance that relaxed those recommendations to using surgical masks for routine care, and reserving N95 masks for aerosol producing procedures (intubation, suctioning, etc).

 

Still, the controversy remains. 

 

Adding to the confusion, we’ve seen recent studies that give more credence to the notion that influenza may be spread in aerosolized form (see Study: Aerosolized Transmission Of Influenza), as opposed to primarily by large droplets. 

 

But the truth is, our knowledge of how influenza spreads, and what barriers work to protect HCWs, is severely limited. 
 

 

I’ve mentioned the National Academies Press a number of times before as a terrific source  for scientific reports, and books that may be purchased, viewed online - or in many cases - downloaded for free.

 

If you have a scientific bent at all, you owe it to yourself to visit http://www.nap.edu/ to peruse the more than 3,000 titles available.

 

The IOM (Institute of Medicine) has just released, through the National Academies Press,  an extensive, 200+ page update on the use of PPEs (personal protective equipment) for healthcare workers when facing pandemic influenza and other viral respiratory illnesses.

 

The short version is, we need better science upon which to make decisions regarding the right kind of protection for HCWs. 

 

While the entire 200 page pre-publication pdf can be downloaded for free, you can also view an executive summary and an abbreviated list of recommendations.

 

Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel Update 2010
Released: January 27, 2011
Type: Consensus Report

In 2009, the H1N1 influenza pandemic brought to the forefront the many unknowns about the virulence, spread, and nature of the virus, as well as questions regarding personal protective equipment (PPE) for healthcare personnel. Researchers still have much to learn about how influenza is transmitted from person to person, and one major question that arose during the H1N1 influenza pandemic was determining what types of PPE—particularly face masks or respirators—are needed to protect healthcare personnel from disease transmission. Because the focus of research efforts often shifts to other health concerns between pandemics, continuing the research momentum is critical to ensure that the nation is prepared for the next influenza pandemic.

 

In light of the unanswered research questions following the 2009 H1N1 influenza pandemic, the National Personal Protective Technology Laboratory at the National Institute for Occupational Safety and Health (NIOSH) asked the IOM to assess the progress of PPE research and to identify future directions for PPE for healthcare personnel. While the IOM finds that there are gaps and deficiencies in the research about PPE use in health care, there is sufficient knowledge to recommend a four-pronged strategy for effective PPE use:

  1. Deliberate planning and preparation at the leadership and organizational levels
  2. Comprehensive training for all personnel, including supervisors and managers
  3. Widespread and convenient availability of appropriate PPE devices
  4. Accountability at all levels of the organization

The IOM also offers several recommendations for continuing the momentum of PPE research that are detailed in the report and the report brief. The more scientists and researchers know about how to maximize the effectiveness of PPE and its use, the more prepared we will be for the next influenza pandemic.

Report at a Glance

Recommendations (HTML)

Report Brief (PDF, HTML)

Lancet: Progress Towards A Dengue Vaccine

 

 

 

# 5264

 

 

2010 was the year that Dengue Fever finally began to receive the public attention here in the United States (and in the rest of the developed world) that it truly deserves. 

 

As is too often the case, our newfound concern has been largely spurred – not by concerns over the huge burden the disease has placed in poorer tropical regions for decades – but by the recent influx of cases into more developed countries. 

 

The return of dengue fever to Florida after an absence of 60 years, and the worst epidemic of Dengue fever in Puerto Rico in decades, have both raised awareness.

 

Similarly, locally acquired dengue has been showing up in Australia and Hong Kong, and in travelers returning from areas where the virus is endemic.

 

As Maryn McKenna wrote yesterday in her blog (see Spreading cholera, maybe polio: Now will we care about Haiti?) - “infectious diseases do not respect borders”.

 

Unlike even a few decades ago, we cannot depend upon vast oceans and prolonged travel times to protect us against the encroachment of exotic diseases into previously immunologically naive regions.

 

Simply put, we neglect them at our own peril.

 

While our dengue awareness may be relatively new, the explosion in cases has been accelerating for decades. The World Health Organization now estimates there may be as many as 50 million dengue infections each year. 

 

Dengue Trends

 

Since the 1950s a rare, but far more serious form of the disease – DHF or (Dengue Hemorrhagic Fever) –  has emerged.  

 

PAHO recently released new numbers on dengue in the Americas for 2010, in this pdf file, dated December 10th.    So far, more than 1.5 million cases have been reported (many more are likely undiagnosed).

 

image

 

Over the past few months we’ve seen a number of reports on novel attempts to prevent dengue by controlling the mosquito vector, including:

 
The Cayman Island Mosquito Trials
Malaysia: `Terminator’ Mosquito Field Test On Hold

 

The introduction of GM (genetically modified) mosquitoes have exciting possibilities, but their effectiveness in the wild remains unproven.

 

The other big hope is to come up with a safe, effective, and affordable vaccine.  And a number of vaccine candidates have been under study for several years.

 

I’ve written in the past about the race to produce a safe and effective dengue vaccine by number of different companies and entities, including Sanofi, the NIAID vaccine trials, GlaxoSmithKline , Hawaii Biotech Inc (HBI), and an entry created by Inviragen and the CDC.

 

One of the major obstacles in developing a vaccine is that there are four strains of dengue; DEN1DEN4. Single strain live attenuated Dengue vaccines have been developed and tested, and seem effective.

 

They aren’t considered a good solution, however, because having antibodies to one strain of dengue can make an individual more likely to develop the more dangerous hemorrhagic form of dengue when exposed to a different strain.

 

Today, a correspondence appears in The Lancet (free registration required for access), outlining progress being made towards a viable dengue vaccine.

 

The Lancet, Volume 377, Issue 9763, Pages 381 - 382, 29 January 2011

doi:10.1016/S0140-6736(11)60128-

Dengue vaccine prospects: a step forward

 

Bruno Guy a, Jeffrey Almond a, Jean Lang a

PREVIEW

The worldwide expansion of dengue fever is a growing health problem. Crucial issues surround this global expansion and some of them present some challenges for vaccine development. Nevertheless, several promising approaches are being investigated in both academic and industrial laboratories.1 Vaccine candidates include live, attenuated vaccines obtained via cell passages or by recombinant DNA technology (such as those being developed by the US National Institutes of Allergy and Infectious Diseases, InViragen, Walter Reed Army Institute of Research/GlaxoSmithKline, and Sanofi Pasteur), and subunit vaccines (such as those developed by Merck/Hawaii Biotech).

 

 

While the authors state that - `a dengue vaccine is now within reach’  and `we can reasonably expect to address the crucial and urgent medical need for this vaccine in the near future’ -  human clinical trials are just starting, and a safe, effective, and available vaccine is still several years away.

 

But it is progress.

 

Thursday, January 27, 2011

Eurosurveillance: Debating The D222G/N Mutation In H1N1

 

 

 

# 5263

 

 

For well over a year there has been considerable debate among virologists, and other researchers, over the impact of an amino acid substitution seen in a small percentage of 2009 H1N1 samples.

 

The `Norway’ or D222G/N (D225G/N in influenza H3 Numbering) mutation was first linked to more severe disease by Norwegian Scientists in November 2009, although patients carrying these strains can have mild illness as well. 

 

While we’ve covered this territory a number of times over the past year, a brief (and hopefully simple) review is in order. If you are up to speed on receptor binding, and the history of the D222G/N variant, feel free to skip the next section.

 

 

This mutation involves a single amino acid change in the HA1 gene at position 222 from aspartic acid (D) to glycine (G) (or asparagine (N)).

 

The pdmH1N1 virus carrying this mutation appears to bind more readily to receptor cells (α2-3) found deeper in the lungs, whereas unmutated seasonal flu strains bind preferentially to the (α2-6) receptor cells found in the upper airway.

 

A virus’s ability to bind to specific cells is controlled by its RBD or Receptor Binding Domain; an area of its genetic code that allows it to attach to, and infect, specific types of host cells.

image

(A Very Simplified Illustration of RBDs)

Like a key into a padlock, the RBD must `fit’ in order to open the cell to infection.

 

 

The evidence for the D222G/N  amino acid substitution driving increased virulence has been mixed, with the World Health Organization, the CDC, and the HPA continuing to investigate. 

 

During the first week of January, Eurosurveillance  printed a study looking at fatal and non-fatal cases of influenza in the UK (see Eurosurveillance: Analysis Of Fatal H1N1 Cases In The UK).

 

Ellis et al. reported that almost all of the virus samples tested in fatal and non-fatal cases during the early wave of the 2010/11 influenza season showed aspartic acid (D) at position 222.

 

In other words, no `Norway’ mutation.

Today, Eurosurveillance published a letter from an Italian researcher who has found a high percentage of D222G/N mutations in severely ill patients (43%)  – particularly when taking virus samples from the lower respiratory tract (lungs).

 

You can read the entire letter at the link below.

 

Eurosurveillance, Volume 16, Issue 4, 27 January 2011

Letters

Letter to the editor. Virological analysis of fatal influenza cases in the United Kingdom during the early wave of influenza in winter 2010/11

F Baldanti

 

 

The point being, that if the UK researchers were only taking nasal (or upper respiratory) swabs, they might be missing some D222G/N mutations.

 

In a reply, the authors of the original study concede that in many cases, only upper respiratory swabs were available for this analysis, and that when possible, samples from the lower respiratory system would be useful.

 

 

Eurosurveillance, Volume 16, Issue 4, 27 January 2011

Letters

Authors’ reply. Virological analysis of fatal influenza cases in the United Kingdom during the early wave of influenza in winter 2010/11

J Ellis , M Galiano, R Pebody, A Lackenby, CI Thompson, A Bermingham, E McLean, H Zhao, S Bolotin, O Dar, J M Watson, M Zambon

 

 

This scholarly debate isn’t over, of course. As Ellis et al. state in their reply:

 

The selection and emergence of the D222G mutation as a cause or consequence of more severe lower respiratory tract infection is still to be resolved.

 

Emergence of this mutant is likely to exacerbate severity of disease, but by itself, may be neither necessary nor sufficient to account for a severe disease outcome, which is invariably a balance between virus virulence factors and host immune response capability.

 

It will take more samples, more research, and more time to determine the truth in the matter. 

 

And even if this mutation should eventually be linked to higher virulence, its ultimate impact on public health will ride on how just prevalent this D222G/N is among the H1N1 viruses in circulation.

 

Stay tuned.   There’s a lot left for us to discover.

UK: HPA Week 3 Influenza Report

 

 


# 5262

 

 

The level of new consults for flu-like illnesses in the UK continued to drop dramatically in the latest reporting period, sparking hopes that the worst of Britain’s influenza season is behind them.

 

The number of deaths (a trailing indicator that can lag several weeks) continues to rise, of course.  And even then, the numbers we get are likely to only represent a fraction of the true number of flu-related deaths.

 

Today’s HPA summary, along with a graph or two, and then a couple of parting comments.

 

Weekly flu report, 27 January 2011

27 January 2011

Latest figures from the Health Protection Agency (HPA) indicate that flu activity in the UK is continuing to decline.  The predominant strain in circulation is now influenza B which has overtaken influenza A H1N1 2009 'swine flu'.  This drop in activity is consistent across all the surveillance systems that are used to look at levels of flu.

 

In the past week, the number of number of GP consultations in England has fallen to 40.7 per 100,000, down from 66.5 per 100,000 the previous week.  The baseline level is 30 per 100,000 and the peak level was 124.4 per 100,000 in the flu report dated 30 December.

 

The total number of people who are reported to have died from flu in the UK since the season began in October has reached 338. The vast majority of the new deaths reported today (84) did not occur in the past week - a substantial number will have occurred over the past six weeks, but due the verification process they have only been confirmed this week.

 

Of the 306 cases with information on age, ten have been aged less than five years; 14 were aged between 5-14; 217 aged between 15-64 and 65 were older than 64 years of age.

 

Where information is available on the fatal cases, 184 out of 252 (73 per cent) were in a clinical 'at risk' group for vaccination. Where information on vaccine status was available for this season's trivalent vaccine, 82 out of 108 (76 per cent) had not received their jab this season.

 

Professor John Watson, head of the respiratory diseases department at the HPA, said: "Our latest flu report suggests levels of flu are continuing to decline across the UK and we appear to be over the peak of activity.

 

"However flu is still circulating and it is important that people remember to practice good cough and hand hygiene such as covering your nose and mouth with a tissue when you cough and sneeze, and then disposing of these as soon as possible to stop it spreading in the community."

 

 

You can view the full list of HPA influenza graphs and charts at this link. 

 

image

image

 

The slide in new consults for influenza is obviously a good sign, although the H3N2 virus is still circulating (at low levels) in the UK.  While perhaps not likely, a second wave is not out of the realm of possibility.

 

Among the fatalities (where age data is available),  70% were aged between 15 and 64.  A legacy of the 2009 H1N1 virus, which – as often happens with a pandemic virus – demonstrates an age shift to younger patients.

 

As the numbers decline in the UK and western Europe, we look more for influenza to move to the Eastern European stage.

 

With 2 or 3 months remaining in this year’s flu season, it is too early for anyone to let down their guard. 

 

In Europe, in North America, and around the world.

Home Is Where The (fatal) Heart Attack Is

 

 

# 5262

 

telemetrympc__4_

Yep, that’s me - circa 1976 with my (now museum piece) LifePak 5 (and an almost full head of hair).

 

While I try not to tell paramedic `war stories’, or go out of my way to make this blog about me, every once in awhile I can’t resist throwing in a personal anecdote.

 

In August of 1974 I was among the first 36 D.O.T. paramedic graduates in the state of Florida. With portable defibrillators, IVs, Cardiac meds, and radio telemetry on board - everyone expected us to start saving lives left and right.

 

And while our `saves’ went up, they didn’t go up as dramatically as many hoped.

 

Sure, we had some great saves - particularly among younger patients, drowning victims, and trauma.   

 

But overall, our cardiac arrest success rate was dismal.   Perhaps now, after all these years, we may have a better clue why.

 

First, a quickie lesson in heart attacks and EKGs (the readout of the electrical activity of the heart). 

 

In a cardiac arrest, the patient is pulseless, usually non-breathing, and unable to circulate oxygenated blood to the brain and other organs. Death follows generally in 4 to 10 minutes.

 

But not all pulseless arrests are created equal.


This is bad.

(Ventricular Tachycardia)

 

This is very bad

(Ventricular Fibrillation)

 

And this is worst of all.

(Asystole)

 

 

The first two rhythms strips are considered `shockable’ arrhythmias. The heart may not be beating, but there is still some (albeit, chaotic) electrical activity going on. 

 

Applying an electrical shock promptly enough can often restore NSR (normal sinus rhythm) to a stopped heart. 

 

But despite what you may have seen in the movies, and on television, you can shock an asystolic (flatlined) heart all day long without much hope of success.   

 

There are some cardiac meds that can (rarely) convert asystole to fibrillation, but defibrillation alone is generally futile.

 

 

Yesterday the NIH announced  a study comparing the type of cardiac arrests experienced by people at home verses people who collapsed in public.

 

And the results are fascinating.   At least to an old EMT-II like myself.

 

First, some excerpts from the press release, then a link to the NEJM study, after which I’ll be back with a little more.

 

 

Shockable cardiac arrests are more common in public than home

Comprehensive NIH study helps explain discrepancy in survival rates between cardiac arrests in public and at home

Cardiac arrests that can be treated by electric stimulation, also known as shockable arrests, were found at a higher frequency in public settings than in the home, according to a National Institutes of Health-funded study appearing in the Jan. 27 issue of the New England Journal of Medicine.

 

The study compared home and public cardiac arrests under various scenarios. For example, the study considered whether bystanders or emergency medical services (EMS) personnel witnessed the cardiac arrest, and whether the person experiencing the arrest received treatment with an automatic external defibrillator (AED).

 

In every scenario, a higher percentage of public cardiac arrests were classified as ventricular tachycardia (VT) or ventricular fibrillation (VF), the types of abnormal heart rhythms that can be treated by electric shock.

 

More than one-third of the people who had a cardiac arrest in public and were treated with an AED survived. This is a significant improvement over the roughly 8 percent national average of cardiac arrest survival. In comparison, the overall survival for home-occurring cardiac arrests treated with an AED was 12 percent.

(Continue . . .)

 

Ventricular Tachyarrhythmias after Cardiac Arrest in Public versus at Home

 

Myron L. Weisfeldt, M.D., Siobhan Everson-Stewart, Ph.D., Colleen Sitlani, M.S., Thomas Rea, M.D., Tom P. Aufderheide, M.D., Dianne L. Atkins, M.D., Blair Bigham, M.Sc., Steven C. Brooks, M.D., M.H.Sc., Christopher Foerster, M.Sc., Randal Gray, M.A.Ed., Joseph P. Ornato, M.D., Judy Powell, B.S.N., Peter J. Kudenchuk, M.D., and Laurie J. Morrison, M.D. for the Resuscitation Outcomes Consortium (ROC) Investigators

N Engl J Med 2011; 364:313-321January 27, 2011

(Read Full Report . . . )

 

 

Like all studies, there are limitations to this one.

 

Some assumptions regarding the arrhythmias of successfully cardioverted arrest victims using AEDs (which only shock when they detect VT or VF) had to be made in lieu of actual EKG strips.

 

Likewise, home heart attacks (where AEDs are less likely to be found, or the patient’s collapse witnessed) may have started with VT or VF and progressed to asystole by the time rescuers with their EKGs arrived.

 

But even when you take these items into account, it appears that cardiac arrests that occur in public are far more likely to be a `shockable’ (VT or VF) rhythm than those that occur in the home.

 

This likely has more to do with the age, and physical condition of the patient, than the actual location.  Those who are able to be out and about are probably in somewhat better overall health than those who are house bound.

 

All of which points out the benefits of putting more AEDs in public places, and promoting lay person CPR and AED training. 

 

The authors of this NEJM report conclude:

 

Conclusions

Regardless of whether out-of-hospital cardiac arrests are witnessed by EMS personnel or bystanders and whether AEDs are applied by bystanders, the proportion of arrests with initial ventricular fibrillation or pulseless ventricular tachycardia is much greater in public settings than at home. The incremental value of resuscitation strategies, such as the ready availability of an AED, may be related to the place where the arrest occurs. (Funded by the National Heart, Lung, and Blood Institute and others.)

 

 

For more on the recent changes to bystander CPR, you may wish to visit these recent blogs.

 

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CPR As A Requirement For High School Graduation

AHA Unveils 2010 CPR Guidelines

JAMA: Compression Only CPR

MMWR: Sudden Cardiac Arrest Awareness Month