Asking this because in my country H5N1 testing is virtually non-existent. Even though many people coming by plane straight from endemic areas. How much is there H5N1 screening nowadays?
Well, maybe not NON-existant, but quite close to it…
Thinlina, which country are you in?
Why do you ask?
Is there routine screening or even testing from time to time in your country, BroncoBill? Do you know? In what situations?
I ask because you stated that testing “in your country” is virtually non-existent. As far as I know, there is no human testing here in the US; however, there is testing of wild birds in Alaska, and soon to begin testing of wild birds in the lower 48 states…
I wonder if our hospitals even have the capability of testing for H5N1. Anybody know?
I posted this a couple of days ago in the Canadian Preppers II thread.
I hope to hear about other North American jurisdictions.
I found this on the Canadian Pandemic Plan a quote about surveillance;
“Acquire (when available) and disseminate any laboratory testing materials (i.e., reagents)”
Guess what. This does not START until WHO announces phase 4.
Does the Government of Canada expect to be able to place an order, receive the material, distribute across the country to each locale, and be ready to test before the pandemic hits our shores?
I meant testing in hospitals. So human testing is in question. Yes, we have some bird testing here, too. It’s hard to know excactly how much, because it’s not discussed in media. But what we knoew is that at least those many hundred dead Jurmo birds were not tested properly. Or if they finally were, it wasn’t told about in media.
But the point beig: almost no human testing even though straight air plane routes non-stop to the endemic areas.
I think this was posted somewhere else earlier, but there was testing in North Texas…. Is this the kind of thing you are looking for?
There was one case reported about two weeks ago in a Texas, Arizona, or New Mexico newspaper about a woman who had just returned from visiting family in vietnam going to hospital emergency with severe flu-like symptoms.
The hospital was proud to report that as soon as they identified flu, she wasplaced in isolation and tested for Avian flu. About four hours later she was released with ‘regular’ flu. They were pleased that their handling of the situation was correct according to their recent guidelines. I looked for the reference but could not find it. It’s the only case I know of.
See also page 7 Planned Surveillance. You may notice that everything is “Future Steps/In Progress” meaning we are working on it. This is the latest updated plan as of March 1, 2006.
I also read somewhere (I couldn’t find it just now) that one of the AND criteria for sentinel reporting at hospitals was “72 hours after admission of unexplained ARDS” (don’t remember the exact phrase, but it was invented after SARS outbreak).
Well, good luck. 72 hours would be too late to administer Tamiflu.
We’ll find out when there are too many dying, unfortunately.
No test kit will be ordered until WHO Phase 4.
Rille – at 15:47 Yes something like that. But do you know why they didn’t say when this story of given link happened?
ANON-YYZ – at 16:02 “No test kit will be ordered until WHO Phase 4.”
And lets repeat the big question again…: What are the criteria for WHO phase 4?
Great… : /
Thinlina – at 16:10
Phase 6
ANON-YYZ – at 16:12 “Phase 6″
; D Shouldn’t be laughing, but…
According to WHO site, their chart says 25 human to human transmissions or more. By that time…..
But we will find out in Toronto before WHO announces Phase 4, in a hospital with patients dying of unexplained ARDS more than 72 hours after admission. Test kit is for post mortem only.
You can tell I am trying to stay calm.
25 h2h or more? In that time the h5n1 travels around the world for at least 12 times via the migrating people of business classes. Doesn’t sound good!
ANON-YYZ – at 16:17: “Test kit is for post mortem only.”
Test kit is for post festum only…hmmm.
Any one knows the U.S. plan for surveillance?
No one?
Thinlina - looks like the article was dated July 25, 2006, and the event happened the previous Friday - being July 21.
Rille – at 16:58
The story is all good. But if the patient visited Thailand recently, instead of Vietnam, a positive seasonal flu test may not be enough to let the guard down.
http://tinyurl.com/gtuea here is the URL for the number of cases as noted at 16:15. It’s a pdf report says 25 to 50 human to human transmission locally in a period of 2 to 4 weeks.
Rille – at 16:58
“Thinlina - looks like the article was dated July 25, 2006, and the event happened the previous Friday - being July 21″.
Where in the article is said that it happened previous Friday? I didn’t find. I’m asking this because the article sounds somehow too good… But if it’s true, then grreat!
Our small comunity hospital can test for A or B but that is all the futher that they can identify them. Kelly
I think in my country the hospitals can also test whetrher A or B, but the tests are still scarce.
Any one knows the U.S. plan for surveillance?
Just trying to assess how likely it’s going to be caught quickly the moment pandemic arrives in North America.
Thanks.
Most clinics, every hospital has Influenza A/B rapid screening. It’s been around for awhile; like a strep culture. State Offices of Epidemiology routinely track influenza cases and have for a long time. That’s how they determine what flu strains are in circulation and for vaccine development.
An ‘A’ result gets reported and usually nothing more. Since H5N1, an ‘A’ result gets packaged and shipped to a local or state lab for H5 identification. If it’s H5, it gets sent on to a high-containment Biosafety Level 3 lab.
A diagnostic protocal. http://ceid.med.cuhk.edu.hk/docs/Day2(PChan).pdf
In our Hosptal Lab we recently received information about h5n1 testing being offered by our reference lab (Quest Labs) I’m pretty sure it was an antibody test, I’ll check it out again next week.
bump
In NJ,USA, the state had added H5N1 testing to their other tests of sentinel poultry flocks, which are in Cape May County, the southern part of the state. This is along the east coast migration routes.
Grace RN – at 08:55
What about human testing, any plans?
I am trying to assess whether the arrival of a pandemic strain can be detected early enough to be useful.
I guess in most Western countries if the pandemic strain arrived now it wouldn’t be searched nor found before it had killed maso many previously healthy people that the doctors started to wonder why are these people dying.
I mean die-is it dieing?
I haven’t read every single comment in this thread as I’m in a hurry. Sorry if this is redundant.
There is human testing being done in the US. I don’t think it is being done routinely, but I distinctly remember reading at least two separate articles that humans have been tested for H5N1 in the US. One was Massachusetts-based. The other was out of Texas. If I could provide links, I would, but I don’t even remember the exact timeframe in which I read these. I know it was around the time of/shortly after Karo.
Human testing for H5N1 begins with an index of suspicion. That index is raised when there are indications that The Bug is going pandemic, as indicated by sustained chains of H2H transmission (the cusp of which we are all sitting on right now). Case definitions help, but the need for suspicion needs to be hammered relentlessly in hospitals and doctors’ offices.
Hospitals and local labs cannot conduct confirmatory tests for H5N1. There is no approved rapid test for H5N1 at this time. It is critical that clinical specimens are collected and immediately forwarded to the state’s LRN lab. Early identification of the index case is the best chance for controlling or at least slowing down the outbreak. LRN facilities have to be involved because H5N1 is a select agent and requires specialized containment and testing procedures.
H5N1 is a tough customer to ID. It is a moving target. It exhibits multi-tissue tropism and may not be found in the usual sites (e.g. nasopharyngeal swabs) or move around during the clinical course.
Few hospitals or local health departments are completely on board with this. The LRN directors are out spreading the word, but understanding is uneven, at best.
The Sarge – at 10:46 And if that’s what the situation is in western developed countries, what might it be in developing countries around the world…
Thinlina – at 12:23 I mean die-is it dieing?
You were correct in your first 12:23 post, it is “dying.”
Thinlina -
I shudder to think…
Dennis in Colorado – at 11:53 Thanks! (:
The Sarge – at 12:18 What would make people out there think that this might be a case of bird flu? Too many dead of seasonal influenza, perhaps…
Thinlina -
The problem of detection of a novel pathogen, whether it be pandemic flu, SARS or some bioweapon, is a difficult one. Mostly this is because of the lack of specificity in the early symptoms, or prodrome. Nobody gives it a second thought when they get fever, chills, cough, a slight rash, what have you. Most don’t even go to a doctor (if they even have one to go to). They treat themselves with OTC medicine, home remedies or WFWJ. They go home to bed, or worse, try to go into the office. Hours or days later, fulminant symptoms erupt - acute respiratory distress and cyanosis (anthrax), an exquisitely painful centripetal rash and raging fever (smallpox), multi-organ failure, hemmorhaging, altered mental state, death.
Doctors aren’t necessarily good at finding evidence of bad bugs in the early chief complaints either. Remember the poor unfortunate postal worker who presented at the hospital with a non-specific prodrome and got sent home with Tylenol? He worked at a postal facility where the anthrax letters were processed in 2001. Hours later, he’s back in the hospital, where he dies shortly thereafter. If I’m not mistaken, (and I may be), he told the docs about his employment and the fact that anthrax was traced to the facility was known at the time. This is an example of what can happen when the index of suspicion is too low.
The index of suspicion, and therefore the scope of testing, are ideally functions of the warnings given by epidemiologists. When cases of respiratory illness present, the history should be taken, and if the patient has traveled in, or had contact with persons from, an epidemic area, then testing needs to be done and isolation implemented until the result comes back. Likewise a case definition needs to be developed and kept in mind: “If the patient has symptoms X, Y and Z, suspect pandemic flu”. The warning indicators have to be sent out and continuously reinforced wherever the patient may present, be that at a hospital ED, urgent care clinic or private doctor’s office.
The problem gets really acute when respiratory disease cases are already prevalent, i.e. during ‘normal’ flu season. In this case, the ‘signal to noise’ ratio is low - it is more difficult to discern the potential panflu case against the background of the seasonal bug. Not that the pandemic bug won’t or can’t get detected, it is just that finding that first case is really critical in knowing that The Bug is present in the community and; acting to contain it and its impact.
Which is one reason to recommend wide application of seasonal flu vaccinations - to help lower the background noise of all of the seasonal flu cases.
Thank you for the excellent explanation, Sarge. A couple of questions:
First, (and I’ll try to track down the stories I referred to in my earlier post), am I understanding correctly that the hospitals in Mass. and Texas to which the articles I read referred are not equipped to test for H5N1? Does that necessarily mean that those states’ state-level labs are equipped to test for H5N1?
Second, on another thread you referred to the fact that the govt agencies you’ve been working with are taking pandemic prep “deadly serious.” I posted a question over there that I think may have gotten lost in the Request from China phishing debate. If I may pose it here again… Are the agencies with which you are working talking in terms of a pandemic outbreak timeframe? I’m wondering if they are using a range of dates for planning purposes.
Thanks!
Edna Mode -
First question - Since H5N1 is a select agent (a legal definition imposed by presidential order), the manipulation of The Bug needs to occur within specified labs. The Laboratory Response Network (LRN) is a collection of (mostly) state and federal agency labs affiliated with the CDC. There are three levels of labs: sentinel, reference and the CDC itself. The state pandemic plans that I have examined all call for clinical specimens to be collected according to a specific protocol and fowarded by most expeditious means to the state-level LRN facility, where the initial testing will be done. Confirmatory tests will be done at the CDC. When I say expeditious, I mean flying it in police helicopters if necessary - they want it there in a couple of hours.
As Dr. Niman has illustrated many times, The Bug is tough to ID, especially if the specimens are allowed to deteriorate. Also, it is a dangerous pathogen that requires biosafety level III or better, which most hospital labs cannot accomodate. So there is a plan and a procedure. The problem lies in identifying and getting everyone who may be involved on board with it.
Second question - They aren’t working on any specific timeline. No (reputable) one can or will try to issue a prediction for when, or even if, there will be an H5N1 pandemic. However, there are many signs of a bug behaving badly in H5N1. There is a general recognition that our public health infrastructure (and for that matter, our clinical health infrastructure) is inadequate to deal with the impact of a highly virulent disease pandemic. This is not a new problem or issue, but the existential threat of H5N1 has served to concentrate the collective mind, so to speak, and thus the conversation is started. None of what is being discussed is secret - the same subjects are all over this Wikie - how do we deal with medical surge, mass fatalities, absenteeism, supporting quarantined or sheltering populations, folks with special needs, keep the lights on, all of that. It means expanding and engaging the universe of people who might normally be involved in the management of an infectious disease outbreak to include public safety agencies, volunteer organizations and businesses.
Thank you for an enjoyably great posts, Sarge! I guess if the testing is expeditious - as you reasonably say - we won’t have a big chance to contain an outbreak in it’s early phases. The test should be so cheap that every doctor could take it from patients that the doctor thinks might probably be cases. And the test should be so quick that those seasonal flu patients would not have to make a queue that grows twice around the block in the meantime the test results come. I don’t see realistic that all suspect h5n1 patients’ tests could be delivered by like police helicopters. Even though it would be nice!
--- could take it from every patient that the doctor thinks might probably be cases. ---
Thanks, Sarge. Appreciate your thorough answers tremendously.
That was me. Darn cookies!
The Sarge – at 10:46
“Human testing for H5N1 begins with an index of suspicion. That index is raised when there are indications that The Bug is going pandemic, as indicated by sustained chains of H2H transmission (the cusp of which we are all sitting on right now). Case definitions help, but the need for suspicion needs to be hammered relentlessly in hospitals and doctors’ offices. “
First of all, thank you very much for a thorough explanation of testing.
Secondly, how dependable is the sentinel as described in the bold face text? How does it work on the ground?
I don’t feel that hammering very well, if there’s some…
Just came back from a treatment for bursitus with my Physical Therapist. Asked him what he thought of Avian Flu, though he is not a physician. He seems to think they’ll be warning by the CDC or WHO. That might be the way a lot in the the medical field think. I mentioned Africa, people in Indonisia who don’t trust doctors or the government. He agreed that possibly it would be impossible to chart accuratly. Perhaps lay people constantly pulling apart reports as is done on this and other sites will be the best we can expect.
ANON-YYZ - at 1830 As far as trying to assess how likely it’s going to be caught quickly the moment pandemic arrives in North America, I’d say no matter how hard people might try, it’s going to be impossible to catch it quickly enough to give us all the warning that we would like to have.
I’ve gone from hoping for a week’s warning to a day or two . . . and now, I suspect we will only know when pandemic has arrived in retrospect - which, in this case, would be just a fancy word for “too late”. With the exception of a last trip for fresh produce and things, we’re as well prepped as we’re likely to get.
It’s the only way I can figure to deal with the fact that we probably won’t know it’s here until people begin to die. Get ready now, and then sit back and watch - which can be more difficult than it sounds, because I know I for one do much better psychologically as long as I think I can do something about whatever the problem might be. Sitting and waiting may be harder than prepping.
Lily - at 1729 I too just returned from a medical appt., with our family doctor. He asked me if I were still “scared” of the bird flu. I said no, not scared - but very attentive. He’s labeled me OCD in relation to H5N1. He then said the most stupid thing I’ve heard in a long time . . . he said, “Well, they’ve made great strides with it in the past year” (almost a year now since he wrote my Tamiflu/Relenza scripts). I gave him a look so blank that he stopped and said, “haven’t they?” to which I replied - uh, no. If anything, things are worse than a year ago, not better.
I expect ignorance if I should stop a store clerk and ask what they think of H5N1 - I am dismayed to find this degree of ignorance in my own doctor. Actually, it’s just about enough to make me consider changing doctors - but we’ve spent almost two years with him as our doc, and he was fresh out of residency when we began to see him, so we sort of feel we’ve contributed to his education. I don’t know. I’ve already got the meds stashed that I wanted, and I suspect I’ll stick with the young doctor a while longer - it’s not as though I think he’d be able to do anything for us in a pandemic situation, anyway - and if he could, we know where he lives.
The chances of a clinician recognizing a suspect case is, IMHO, uneven, and is highly variable depending on what the clinician has been told by the recognized authorities (CDC, public health departments, etc.) The threat seems remote at this time, when one is dealing with present ‘routine’ threats. Part of the public conversation is aimed at getting that awareness level up to where it needs to be.
I don’t think we can count on weeks of warning coming from overseas, where the ever-vigilant WHO finds the index outbreak in some remote village and flashes the warning to the world community. It would be nice, but that is nothing to hang our collective hat on. The scenario could just as easily come to be like that cheesy ABC movie - a business person gets infected while on an overseas trip and incubates into the index case while on a 23 hour airline trip home.
Right now, I don’t give us two cents’ chance that an index case arriving unexpectedly on our shores is going to get detected in time. After that, it all depends on the kinetics of the outbreak - the vulnerable contacts of the index case, the reproductive rate, all of those lovely mathematical and epidemiological factors.
As far as testing is concerned, the first one to market with a reliable rapid test is going to be rich. Once the disease is manifest in the population, we won’t be flying specimens around in ‘copters. That is only in the very beginning, when we still have a glimmer of hope of containing the outbreak. After a short while, comparitively little testing is going to be done, because a good case definition will have been developed, and state and federal labs will move into a monitoring mode, looking for changes in the bug like novel genetic sequences, anti-viral resistance and decreasing susceptibility to any vaccines that are in use.
Clawdia – at 17:31 “I’ve gone from hoping for a week’s warning to a day or two . . . and now, I suspect we will only know when pandemic has arrived in retrospect - which, in this case, would be just a fancy word for “too late”. With the exception of a last trip for fresh produce and things, we’re as well prepped as we’re likely to get.”
Watching and reading about the public/media/authorities reaction to the Michigan Swans, I really hope that Mr Dow Jones et al. won’t decide to give us the “don’t worry, be happy” information for too long.
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