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PED-EM-L  July 2009

PED-EM-L July 2009

Subject:

H1N1 Observations in the Southern Hemisphere Temperate Zone Winter

From:

James Wilson <[log in to unmask]>

Reply-To:

James Wilson <[log in to unmask]>

Date:

Sun, 5 Jul 2009 11:28:42 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (532 lines)

Dear PED-EM-L Listserv Members,

Thank you for allowing me the opportunity to share our observations of H1N1
activity.  You will note below the snapshots are focused on Argentina,
Chile, Australia, and New Zealand- basically, developed and developing
countries with a medical infrastructure somewhat analogous to the US who are
currently experiencing H1N1 during a temperate zone winter- it is the
intensity of transmission and the environmental conditions seen to promote
greater transmission during the winter that is of interest.  Please note the
date range of this snapshot-  there is an update in regards to Argentina,
where we believe their ICU capacity is about to collapse (they have
requested 200 additional ventilators).  Compare this to the current
situation in Winnipeg, Canada- direct quote from one of the PICU chiefs up
there:

³75% of our PICU bed capacity has been occupied with ventilated kids aged 6
months to 16 years. They all had a severe ARDS and have been ventilated for
1- 3 weeks so far. The implications for staffing and for managing the usual
patient load that does not stop are apparent.
It has been a graphic illustration of what might transpire in the fall.²

We are quite concerned about the functionality of our hospitals if the ICU
becomes overwhelmed.  We certainly saw the effect in Hong Kong and Toronto
during SARS.  The concern relates to what happens to a hospital¹s ability to
admit patients if the ICU is overwhelmed, and the ripple effect throughout
the community if the ambulance diversions result in a Œcascade failure¹ of
the hospital network.  Bottom line, the ICU-ED axis is the infrastructure
component we are most focused on protecting (or at least anticipating
scenarios that would impact the axis).

Regarding H1N1 genetic drift, we have no evidence to suggest it has happened
yet, however we just received report this morning that the Argentinean
authorities have not shared their isolates with Canada and the US CDC.  We
still need to verify that with CDC and/or WHO.

We are monitoring the entire planet in near-real time with dozens of
languages with two operations centers of analysts whose professional
discipline it is to detect, track, and verify indications of infectious
disease events, crises, and disasters.  Please note our observations are not
absolute, particularly during a rapidly evolving crisis, and feedback is
welcome and encouraged.

Thanks again for allowing me the opportunity to share this with the group.

Cheers,
Jim Wilson, MD
CTO & Chief Scientist, Veratect Corporation
Kirkland, WA, USA
[log in to unmask]

The Winter Experience of the Southern Hemisphere With A/H1N1 (Swine-Origin
Influenza Virus): Part I, Argentina and Chile

 

Abstract 
 

Monitoring the winter experience of the Southern Hemisphere with A/H1N1
(Swine-Origin Influenza Virus) may provide healthcare practitioners in the
United States with insight into what we may expect for the Northern
Hemisphere winter season.  Currently, we have no indication of a verified
A/H1N1 genetic drift that would imply a different clinical presentation.
The experience of Argentina and Chile to-date has not reflected a
substantive departure from information presented by either the U.S. Centers
for Disease Control and Prevention or the World Health Organization.
Reported inundation of the medical infrastructure in Argentina and Chile has
focused primarily on population dense urban areas and has followed several
stages of strain.  The first level of strain has been reported to be
inundation of outpatient services due to phone consultations and visits by
both the anxious well and truly ill.  Near-simultaneous documentation of
inundation of emergency departments was observed.  The second level of
strain, inundation of ward level hospital care, was recently documented.
This was observed two weeks after the first level of strain was reported in
Argentina.  We did not observe this transition in Chilean reporting, however
it can be assumed to have probably occurred based on hospitals reporting
³collapse²- we continue to monitor the situation there.  We have not
observed the final level of strain where intensive care units and critical
care capacity has been exceeded.  We do expect to see at least focal
reporting of this in July. We have not seen much reporting of healthcare
worker infection and subsequent compromise of the medical infrastructure due
to absenteeism, however this has been documented elsewhere in the world.
Detailed aspects by country are noted below.

 

 

Targeted Information:  Points of interest associated with
influenza/respiratory disease in Argentina and Chile

Targeted Time Period:  15 May ­ 24 June 2009

 

 

Argentina 

 

Country Summary.  We are now observing an increase in presumptive A/H1N1
reported, reflective of the expected peak in the influenza season.  The
actual peak has not occurred yet.  Medical infrastructure strain has
transitioned from a combination of anxious well and low morbidity disease
severely impacting the outpatient clinics and emergency departments to
inpatient ward admissions exceeding capacity and overflow requiring
reallocation of hospital facilities to influenza-dedicated treatment.
Military medical services have been asked to support the civilian sector. We
have not observed the ICU level of the medical infrastructure to be
overwhelmed at present but expect to see this later as we approach the true
peak of the season.

 

Primary Affected Age Group:  75% of cases < 17 years old

 

Unique Population(s) Affected

·     Participant in equine sporting event reported to have contracted
influenza A (H1N1) virus through close contact with a Peruvian national also
participating in the event

·     24 June: First report of infected health care worker (Posadas,
Misiones Province)

 

Transmission/Hospitalization Data

·     Record absentee rates documented at schools in the greater Buenos
Aires region 

·     Three cases currently receiving treatment in ICU

 

Social Anxiety/Disruption:

·     Civil unrest reported:  Residents of Godoy Cruz attacked a bus
transporting a suspected influenza A (H1N1) case to a local medical
facility.  Seven individuals were injured.  Police responded to the scene.

·     Health Ministry expresses ³concern² over rapid spread of influenza A
(H1N1) virus 

·     Public ³fearful² of visiting hospital treating influenza A (H1N1)
patients

·     Panic buying of facemasks from pharmacies in San Salvador de Jujuy

 

Impact:

·     Educational Sector:  School closure/class suspension

·     Healthcare Sector:

o  10 June: First report of emergency medical services ³overwhelmed²; case
count at 235 at that time.  Steady increase of suspected and confirmed cases
recorded starting on 30 April and leading up to this date.

o  11 June:  Report of ³collapsed private health care infrastructure² due to
influx of individuals seeking medical attention triggered by ³fear² of
infection. Ministry of Health acknowledges demand for medical services is
³overwhelming.²  No report of response to the situation.

o  24 June: Healthcare system in the greater Buenos Aires area described as
³overwhelmed.²  Health officials have asked for the evacuation of the
Federico Abete Hospital in Malvinas, so that the facility can be used to
treat only influenza A (H1N1) and seasonal influenza patients.  Health
officials also coordinating with Ministry of Defense to utilize local
military hospital for treatment of influenza cases.   All non-urgent
surgeries in Buenos Aires have been postponed.

 

Normal Influenza Season:  Currently underway, peak in July

Optimal Influenza Transmission:  <51 degrees Fahrenheit (F)

Current Temperature Range:

·     25 June, Buenos Aires: 60 degrees F high ­ 35 degrees F low

 

 

Chile 

 

Country Summary.  We are now observing an increase in presumptive A/H1N1
reported, reflective of the expected peak in the influenza season.  The
actual peak has not occurred yet.  Medical infrastructure strain has
transitioned from a combination of anxious well and low morbidity disease
severely impacting the outpatient clinics and emergency departments to
inpatient ward admissions exceeding capacity.  Military medical services
have not been asked yet to support the civilian sector, however this would
be an expected next step by the Chileans.  We have not observed the ICU
level of the medical infrastructure to be overwhelmed at present but expect
to see this later as we approach the true peak of the season.

 

Primary Affected Age Group:  5 ­ 19 years old (61% of cases)

 

Transmission Data

·     A total of 5,186 confirmed influenza A (H1N1) cases registered
nationwide as of 24 June

·     Two fatal cases and ³a high frequency of cases² under investigation

·     Health Ministry reports new respiratory disease entities (adenovirus,
para-influenza, respiratory syncytial viruses) circulating among population
that have decreased the percentage of novel influenza A (H1N1) virus present
from 90% to 65% out of all respiratory disease cases recorded in Chile

·     Increase of cases in critical condition; Health Ministry deploys
public health specialists and unspecified ³reinforcements² to health centers

·     First fatal influenza A (H1N1) case reported in South America,
identified in Puerto Montt

·     Novel influenza A (H1N1) virus reported to be ³delaying or replacing
the presence of seasonal influenza² viruses based on overall declining
influenza infection rates

·     No reports of health care worker infections to date

 

Social Anxiety/Disruption

·     Family members of hospitalized patients concerned over suspension of
visiting hours; convey they do not want relatives hospitalized at facility
treating H1N1 infected patients

 

Impact:

·     Educational Sector:  Schools ordered closed/classes suspended

·     Healthcare Sector:

o  18 June: First report of healthcare infrastructure strain.  Description
in media of ³collapsed² hospitals; further details not provided.  Ministry
of Health evoked authority allowing for the recruitment of medical students
to support response efforts as health care staff.

o  24 June: Unspecified Chilean health officials reporting ³collapsed²
emergency services at public hospitals due to influenza A (H1N1).
Significant increase in new cases noted.

 

Normal Influenza Season:  Currently underway

Optimal Influenza Transmission:  <51 degrees Fahrenheit (F)

Current Temperature Range:

·     25 June, Curico:  46 degrees F high ­ 42 degrees F low

 

The Winter Experience of the Southern Hemisphere With A/H1N1 (Swine-Origin
Influenza Virus): Part II, Australia and New Zealand

 

Abstract 
 

Monitoring the winter experience of the Southern Hemisphere with A/H1N1
(Swine-Origin Influenza Virus) may provide healthcare practitioners in the
United States with insight into what we may expect for the Northern
Hemisphere winter season.  Currently, we have no indication of a verified
A/H1N1 genetic drift that would imply a different clinical presentation.
The experience of Australia and New Zealand to-date has not reflected a
substantive departure from information presented by either the U.S. Centers
for Disease Control and Prevention or the World Health Organization.

 

Reported inundation of the medical infrastructure in Australia and New
Zealand, like that described in Argentina and Chile, has focused primarily
on population dense urban areas and has followed several stages of strain.
The first level of strain has been reported to be inundation of outpatient
services due to phone consultations and visits by both the anxious well and
truly ill. Near-simultaneous documentation of inundation of emergency
departments was observed.  The second level of strain, inundation of ward
level hospital care, has been documented.  We have not observed the final
level of strain where intensive care units and critical care capacity has
been exceeded.  We do expect to see at least focal reporting of this in
July. We have documented reporting of healthcare worker infection and
subsequent compromise of the medical infrastructure due to absenteeism in
New Zealand.  Detailed aspects by country are noted below.

 

 

Targeted Information:  Points of interest associated with
influenza/respiratory disease in Australia and New Zealand

Targeted Time Period:  15 May ­ 24 June 2009

 

 

Australia 

 

Primary Affected Age Group:  15 ­ 39 years old

 

Unique Population(s) Affected

·     Patient at Nambour Hospital in Queensland reported to have contracted
influenza A (H1N1) infection from infected nurse.  Testing of patient and
staff populations at the facility implemented in response.

·     Single influenza A (H1N1) case reported in the remote, aboriginal
community of Nguiu on Bathurst Island (no travel history reported)

·     Influenza A (H1N1) confirmed in multiple remote Aboriginal communities
in Northern Territory (Kintore, Warlpiri, Yuendumu) and Western Australia
(Kiwirrkurra), including Australia¹s first death from Kiwirrkurra Community;
approximately half of Northern Territory¹s 96 Novel Influenza A (H1N1) cases
are Indigenous Australians

·     An inmate at the Capricornia Correction Centre in Rockhampton,
Queensland has tested positive for influenza A (H1N1)

Transmission/Hospitalization Data

·     8 June:  Report of early start to influenza season by 2-3 months due
to novel influenza A (H1N1) virus

·     Concern over inaccuracy of influenza A (H1N1) testing method,
real-time reverse transcriptase polymerase chain reaction (RRT-PCR)

·     High worker absentee rates reported in Victoria

·     Total of 168 cases hospitalized since outbreak began; 6 are currently
hospitalized, 13 of whom are in ICUs

·     New guidelines established for Indigenous Australians due to increased
susceptibility to influenza-related complications; any Indigenous Australian
with influenza-like symptoms can be treated with Tamiflu

·     Reports of increased confirmed case counts compared to same time last
year; spokespeople attribute increase to changes in surveillance, different
start times of the influenza seasons, and increased testing

Social Anxiety/Disruption

·     "Widespread fear" and "significant confusion" among remote communities
about the seriousness of the influenza A (H1N1) situation; indigenous people
³concern[ed]" that the virus will spread quickly among the communities due
to travel and gathering patterns (22 June)

·      ³Widespread panic² reported in response to increase in case counts
(Melbourne, 26 May, case count reaches 24)

·     Australian Medical Association receiving reports of practitioners not
being able to access personal protective equipment and antiviral medication

·     Family placed under quarantine reported to have ³run out of food;²
health officials responded by arranging supply delivery via Australian Red
Cross

 

Impact

·     Tourism Sector:

o  Cruise ships report infected passengers and crewmembers; divert from
scheduled ports, companies offer compensation to affected passengers

o  School groups cancel ski trips to influenza A (H1N1) infected Victoria
state

o  Influenza A (H1N1) cases evicted from Sydney hotels

·     Educational Sector:  School closures

·     Health care Sector:

o  25 June: Hospitals in Alice Springs, Northern Territory, cancel overnight
stay elective surgeries in anticipation of "surge" in novel influenza A
(H1N1) cases

o  24 June: Fewer blood donations in Perth, Western Australia attributed to
common cold and influenza

o  27 May:  Doctors ³inundated² with members of the public displaying
influenza-like illness in multiple states; multiple new medical clinics
established at hospitals in response

§  Point of Interest:  Case count in the state of Victoria was only at 24
when inundation of medical facilities was triggered along with the
previously noted ³widespread panic²

o  Doctors report limited supplies of anti-viral medication and personal
protective equipment, consider turning away new patients with suspected
influenza A (H1N1) infections

·     Commercial Sector:

o  Businesses attribute concerns of influenza A (H1N1) transmission with
decrease in sales at local establishments in Melbourne

o  McDonalds and Domino¹s in Sunshine Coast implement home isolation and
employee body temperature monitoring, respectively, after employee (s) test
positive

 

Normal Influenza Season:  June ­ September, peak in August

Optimal Influenza Transmission:  <51 degrees Fahrenheit (F)

Current Temperature Range:

·     25 June, Melbourne: 58 degrees F high ­ 45 degrees F low

 

 

New Zealand 

 

Primary Affected Age Group:  Not reported

 

Unique Populations Affected

·     Nurses 

 

Transmission/Hospitalization Data

·     A total of 417 influenza A (H1N1) cases have been confirmed as of 24
June 

·     Single Influenza A (H1N1) case admitted to ICU in Wellington;
individual described as morbidly obese with chronic respiratory problems

 

Impact

·     Commercial/Tourism Sector:

o  Seafood processing plant ordered closed by Ministry of Health due to
infected staff member

o  22 June:  Thousands of tourists from Asia cancelling travel to Rotorua
resulting in staff layoffs

o  Pharmacies sold out of Oseltamivir and facemasks

·      Education Sector:

o  School closure 

o  High-level absentee rates at high schools

o   International students cancelling planned attendance at New Zealand
schools 

·     Health care Sector:

o  Patients awaiting medical attention asked to remain in their cars instead
of utilizing office waiting rooms

o  Health Ministry authorizes the legal power for local officials to force
individuals exposed to influenza A (H1N1) virus into quarantine

o  4 June: Hospital emergency departments reported to be ³struggling² with
the number of seasonal influenza cases; number of seasonal influenza cases
reported two days prior to the report was relatively low (17 unsubtyped, 15
seasonal H1N1, 12 H3N2, 9 novel H1N1, 2 influenza A/Brisbane/59/2007
(H1N1)-like virus and two influenza B)

o  19 June:  Health officials restrict access to Tamiflu to severe cases
only

o  19 June:  Additional doctors recruited in Wellington to support treatment
of influenza A (H1N1) cases; local medical officer noted they have not
received adequate training

o  23 June:  Significant worker absenteeism at Wellington Hospital leaves
facility ³struggling² to function

Normal Influenza Season:  May ­ September

Optimal Influenza Transmission:  <51 degrees Fahrenheit (F)

Current Temperature Range:

·     25 June, Auckland: 57 degrees F high ­ 51 degrees F low

 






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