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Clusters of Hemorrhagic H1N1 Pneumonia in Ukraine
Recombinomics Commentary 11:54
November 4, 2009

Ivano-Frankivsk Oblast

All the six dead young people had symptoms of severe hemmorhagic pneumonia. The disease starts slowly, with temperature rising to 37.2 - 37.3 degrees, slight cough and pain in joints. Nasal catarrh developed at the end of the second or third day. Autopsy revealed that the lungs were soaked with blood, the oblast chief specialist said.

The above comments are from an early story describing cases in Ukraine.  The clustering of hemorrhagic cases raised concerns.  The concern was increased by anecdotal reports citing a high frequency of such cases in Lviv (see map).  The recent WHO announcement that they were initially focusing of severe acute respiratory illness in Lviv also increased concerns.

Hemorrhagic pneumonia was also observed in the 1918 pandemic and was thought to be linked to cytokine storm. Consequently, those with robust immune systems (previously health young adults) disproportionately died, which has also been seen in the current outbreak (Mexico, US, and worldwide).  However, the cases in Ukraine appear to be clustered, raising concerns that the virus has changed.

However, the change may be minor, since the current H1N1 has produced the above symptoms in earlier cases.  More severe cases may be linked to a higher viral load, which could be linked to minor genetic changes, or simply due to concentration of virus in schools.  In the US the spread of the virus has been linked to school openings, which lead to an explosion of cases and subsequent student deaths.  However, now there are increases in fatalities in teachers and administrators, increasing concerns worldwide.

In Ukraine, weather changes and heating issues may have led to a surge in cases, and increased concentrations of virus could have produced conditions favoring high viral loads and increased cytokine storms.

Samples have been sent to Mill Hill, and sequence data should be released shortly.  Similarly, investigations on hemorrhagic pneumonia in lviv should help resolve the mechanism for the high concentration of such cases in western Ukraine.

However, H1N1 spread in Kiev has been noted, and other countries such as Belarus have announced additional H1N1 suspect or confirmed fatalities

Sequence analysis of these cases and an update on the frequency of hemorrhagic pneumonia in Ukraine and worldwide would be useful.

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