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Paradigm Shift Intervention Monitoring
HPA is receiving reports of fatal
influenza cases from various sources (clinicians, laboratory reports
and death certificates). These reports have been reconciled and
verified with clinicians. These will not represent all
Twenty-three of the 38 fatal cases with available information (61%) were in one of the CMO-defined clinical risk groups for vaccination.
The above data is from the latest report by the HPA and indicate that 39% of reported H1N1 fatalities had no broadly defined underlying condition. Although this level is slightly lower than the more than 50% reported last week, the reported cases will be heavily biased towards those with underlying conditions, who are the focus of almost every agency statement coming out of the UK. As noted above, the 38 fatal cases do not represent all H1N1 deaths. Many have not been confirmed and many will not be reported because of a lack of testing.
The high percentage of fatal and severe cases with no underlying conditions is severely straining health care delivery in the UK. The latest spike in severe cases to 738 is well above the peak of 180 cases reported last season, and well above the 460 reported last week. Many of these severe cases will need ECMO machines, which are already stretched to the limit. There are only 20 such machines in the entire country, and on average only two become free each day, so the demand far outstrips the supply leading to needless deaths.
However, the severe pressure on ICU beds and staff will exacerbate the crisis, as more patients are denied care and become more critically ill and/or die.
The latest report also describes an increase in Tamiflu resistance, which will also increase the number of severe cases and deaths, which will create additional concerns.
These problems can be traced to poor planning linked to misguided statements on the end of the pandemic and an associated relaxation of preparedness, which is compound by agency comments attempting to downplay the significance of the crisis, which is spreading to Europe and will soon impact the entire northern hemisphere.
The signal began to appear in Australian and New Zealand where a new sub-clade emerged which was drifting away from last years strain. Ferret antibodies against the new sub-clade had significantly low antibody titers against last year’s vaccine target, California/7, and the sequences in the UK show additional drift driven by recombination, as seen in the first four sets of sequences released by the Health Protection Agency. Additional sequences from Iran and Asia demonstrate additional recombination, which will create additional problems.
Such changes are not unexpected. The pandemic H1N1 initial spread because of a lack of immunity, particularly in those under 65. As the population developed immunity, the levels fell and the WHO made its declaration on the end of the pandemic phase, even though H1N1 was killing young adults in India and Australia.
However, pandemic always show such a decline as new variants emerge, and there are no assurances that the new variants will produce a milder disease.
Pandemic H1N1 is a swine influenza which jumped species, as happened in 1918, and excessive deaths in the following year, as seen in 1919, was not unexpected. Indeed, increased travel and population density set the stage for an aggressive re-emergence, as is being seen in the UK, where the proportion of severe and fatal cases in previously healthy young adults is on the rise, and the current vaccine targets the H1N1 isolates in the spring of 2009.
Aggressive actions in the UK and on the vaccine front are long overdue, as are additional sequences from fatal and severe cases in the UK as well as other countries like Egypt and Sri Lanka.