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A-H1N1 Pandemic Sounding
More Like 1918 Flu
 Inflamed, Flooded Lungs Trigger Death By Swine Flu

By Jason Gale Bloomberg.com
Swine flu [influenza pandemic (H1N1) 2009 virus infection] is most  dangerous when it causes the lungs to become inflamed, flood with fluid,  and fail to function, doctors in Australia and New Zealand have found.  While a majority of people infected with the virus have a mild illness, a  small number develop life-threatening disease, intensive care specialists  Steven Webb and Ian Seppelt said. They described the most common of 3 main  complications from the pandemic 2009 strain as "flu A-associated acute  respiratory disease syndrome", or "FLAARDS."
"FLAARDS -- sometimes with associated multiple organ failure -- is the most  common syndrome and has the highest attributable mortality," Webb and  Seppelt wrote in an editorial in the September [2009] issue of the medical  journal Critical Care and Resuscitation [text and abstract not yet  available. - Mod.CP]
The new pandemic (H1N1) 2009 influenza strain has killed at least 3917  people and spread to 191 countries and territories since its discovery in  Mexico and the US in April 2009. Hospitals in the Northern Hemisphere are  bracing for a surge in flu cases in coming weeks, spurred by colder weather  that promotes its spread. In Australia, flu patients occupied a quarter of  beds in intensive care units last winter [2009] and 178 died.
Cases may be peaking in Hong Kong. Average daily attendance at the city's  accident and emergency departments rose from 6354 in the last week of  August [2009] to 7086 last week [week of 21 Sep 2009], according to a  government statement on 25 Sep 2009. The virus has killed at least 23  people in Hong Kong.
Intensive care doctors in Australia and New Zealand are pooling data on  more than 400 swine flu cases to describe disease patterns and treatment  strategies, and inform the Northern Hemisphere countries about what to  expect this winter [2009-10]. "ICUs [intensive care units] are the 'canary  in the coal mine'," Webb and Seppelt wrote in the editorial. "It is only by  documenting the severe cases requiring intensive care that it is possible  to get an idea of the overall impact of this new disease."
In Victoria, Australia's 2nd most-populous state, the pandemic virus  sickened about 5 per cent of the population, with 0.3 per cent of infected  patients being hospitalized, health officials said in a study yesterday [28  Sep 2009] in the Medical Journal of Australia. One in 5 people admitted to  the hospital were transferred to an ICU, mostly because of severe  respiratory failure. 85 per cent of critically ill patients survived after  staying an average of 9 days in ICU. Almost 3/4 of these patients required  mechanical ventilation to breathe and 7 per cent needed to have their blood  pumped through an artificial lung in a procedure known as extracorporeal  membrane oxygenation, or ECMO.
In most cases, flu remains in the nose, throat and bronchi, where it causes  a runny nose, sore throat, and cough until the body's immune systems  eliminates it, usually within a week. The new pandemic (H1N1) 2009 strain  may be at least 1000 times more adept than seasonal flu at infiltrating the  lower branches of the airway, said Yoshihiro Kawaoka, a virologist at the  University of Tokyo, who has studied the viruses in non-human primates.
In severe cases, influenza can damage the capillaries surrounding the tiny  grape-like sacs, known as alveoli, where gas is exchanged through the  blood. Damaged alveoli can bleed, causing pulmonary hemorrhage and blood  clots. Inflammatory substances are produced by the immune system to fight  the infection and repair the damage. An over-exuberant response can worsen  the effect by filling the lungs with fluid and cause permanent scarring  that restricts lung function.
Besides FLAARDS, the other predominant disease patterns associated with the  pandemic flu virus are community-acquired bacterial pneumonia and an  exacerbation by the virus of airflow limitation, Webb and Seppelt said.  Life-threatening infection may be more common in people with underlying  health conditions, including morbid obesity, type-2 diabetes, cancer, a  weakened immune system, and chronic lung disease, they said. Pregnant women  and those who recently gave birth also appear at higher risk.
Still, "many patients with FLAARDS are young and previously well," they  said. In Australia, the median age of people dying from seasonal flu is 83.  In the case of the novel pandemic (H1N1) 2009 virus, it is 51 years, the  health department said in a report last week [week of 21 Sep 2009].
Communicated by ProMED-mail rapporteur Mary Marshall
These observations reinforce those described in the preceding ProMED-mail  report [Influenza pandemic (H1N1) 2009 (60): bacterial coinfection  20090930.3410] that bacterial coinfection was observed frequently in lung  tissue specimens from fatal cases of influenza pandemic (H1N1) virus  infection in the USA. - Mod.CP
Date: 1 Oct 2009 Source: Taiwan Epidemiology Bulletin, Taiwan Centers for Disease Control 
Early release: the first 100 hospitalized severe complicated influenza  cases caused by 2009 pandemic influenza A (H1N1) in Taiwan 2009/09/25
To understand the features of the severe complicated influenza patients  caused by 2009 pandemic influenza A (H1N1), we retrospectively reviewed the  medical records of the 1st 100 laboratory-confirmed cases (by date of  onset), analyzed all clinical variables and described their clinical and  epidemiologic characteristics.
The cases had onset dates from [2 Jul 2009 to 29 Aug 2009];
half of them were adults and the other half were children.  The median age was 16.5 years. 38 had preexisting medical conditions; 6 of  the 50 adults were morbidly obese; 8 of the 50 children were obese, and 2  women were pregnant. The most common initial presentations were fever (99  per cent) and cough (93 per cent). 89 patients had viral pneumonia; 23 were  complicated with respiratory failure requiring mechanical ventilation, and  9 were treated with concomitant support by extra-corporeal membrane  oxygenation.
By [18 Sep 2009], 82 patients recovered and were discharged  from the hospitals; 9 were still hospitalized, and the remaining 9 patients  (including 2 obese patients and one pregnant woman) died. The median time  between onset of symptoms and 1st doctor visit was one day, and the median  hospital stay for those who had been discharged was 6 days. The average  duration from onset of symptoms to the date of rapid testing, admission, or  prescription of oseltamivir for patients with onset after [15 Aug 2009] was  shorter than those with onset before [15 Aug 2009].
In conclusion, most of the severe complicated influenza patients caused by
2009 pandemic influenza A (H1N1) were children and young to middle-aged adults; overweight and  pregnancy posed higher risk to these patients. The preventive and control  measures conducted by the public health sector have effectively accelerated  diagnosis and treatment. However, quality of medical care remains to be  improved to further reduce the number of severe complicated influenza cases  and mortality.
Centers for Disease Control, Department of Health, Executive Yuan, Taiwan,  R.O.C. Copyright: All rights reserved. 2007 No. 6, Linshen South Road,  Taipei, Taiwan 10050, R.O.C. Communicable Disease Reporting and  Consultation Hotline: 1922
The full article is presently only available in Chinese and can be found at  http://teb.cdc.gov.tw/upload/doc/23452_
An English translation of the full article should be available by about 25  Oct 2009.
Communicated by Angela Song-En Huang, MD MPH Field Epidemiology Training Program Taiwan Centers for Disease Control <mailto:huang.songen@gmail.com>huang.songen@gmail.com
Jen-Hsiang Chuang, MD MS PhD Epidemic Intelligence Center Taiwan Centers for Disease Control <mailto:jhchuang@cdc.gov.tw>jhchuang@cdc.gov.tw
ProMED-mail would like to thank Dr Angela Song-En Huang and Dr Jen-Hsiang  Chuang for alerting us to this document. As with other reports on  hospitalized/severe cases of influenza pandemic (H1N1) 2009 virus  infection, the high risk groups appear to include younger ages, pregnant  women, and obese individuals (see ProMED-mail postings below). Of concern  is the stated figure that 89 (89 per cent) of the severe cases had viral  pneumonia, a significantly higher percentage than reported elsewhere (see  ProMED-mail postings below).
The recent ProMED-mail posting on FLAARDS [flu A-associated acute respiratory
disease syndrome] described in Australia and New Zealand mentions that
20 per cent of hospitalized patients had severe respiratory disease with FLAARDS
requiring intensive care unit management of the cases [Influenza pandemic (H1N1)
2009 (61): FLAARDS 20091001.3419]. 
Of note is the recent description of 29 per cent of severe cases in the USA  with secondary bacterial pneumonia Influenza pandemic (H1N1) 2009 (60):  bacterial coinfection 20090930.3410.
For a map of Taiwan, see  http://www.lib.utexas.edu/maps/middle_east_and_asia/taiwan_pol92.jpg.
For the interactive HealthMap/ProMED map of Taiwan, see  <http://healthmap.org/r/00DX>http://healthmap.org/r/00DX. - Mod.MPP
Patricia A. Doyle DVM, PhD Bus Admin, Tropical Agricultural Economics Univ of West Indies Please visit my "Emerging Diseases" message board at: http://www.emergingdisease.org/phpbb/index.php Also my new website: http://drpdoyle.tripod.com/ Zhan le Devlesa tai sastimasa Go with God and in Good Health

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