Ukraine Hemorrhagic Pneumonia Deaths! Belarus H1N1 Deaths Raise Concerns!

• It looks like hemorrhagic pneumonia plague is the correct description of this disease spreading in Ukraine. It sounds like the 1918 Spanish flu, well, at least the symptoms are the same! Henry L Niman reports:
   
  Ivano-Frankivsk Oblast 
  All the six dead young people had symptoms of severe hemorrhagic 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. 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. 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 current 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.  
    
  Belarus H1N1 Deaths Raise Concerns
  Recombinomics Commentary 16:43
  November 3, 2009
  The first Belarusian death from swine flu was registered by health officials on Tuesday. The victim, a 37-year-old female resident of the town of Drogichin, died on Friday, but results of blood tests confirming the presence of the H1N1 virus only became available Tuesday, said Oleg Arnautov, chief doctor of the western Brest province.
   
  The woman reportedly had visited Ukraine’s western Kovel region, currently near the centre of Ukraine’s flu outbreak, in early October.
  In recent weeks, the Belarusian capital Minsk has seen an estimated 10 deaths of persons suffering from pneumonia preceded by flu-like symptoms. Public health workers were working to identify the virus causing the illnesses.
   
  The above translation describes the first confirmed H1N1 fatality in Belarus, as well as ten more likely swine flu deaths in Minsk.  These deaths are not surprising. Although Belarus has acknowledged 59 confirmed pandemic H1N1 cases, the flu activity is characterized as widespread, and over 99% of influenza A in Europe is swine flu.
   
  The outbreak in western Ukraine (see map) has raised concerns that transmission and virulence has increased.  The number of cases may be related to seasonal weather changes.  Flu Trends shows that the Ukraine has historically had a jump in cases at this time of year, presumably linked to colder weather and availability or lack thereof of heat for homes.  Since virtually all flu in Europe at this time is swine flu, this jump in flu cases would create a jump in swine flu cases.  Moreover, the spike this year is markedly higher than prior years, which could explain the increases in hospitalizations and deaths. 
   
  However, the hospitalization of more than 15,000 raises concerns that the death toll could increase dramatically.  Today’s government update has been delayed, but a local media report on Lviv described a sharp increase in cases to 104,019 and an increase in fatalities from 30 to 37.
   
  The above reports of fatalities in neighboring Belarus raises concerns that there are also significant numbers of hospitalized and fatal cases there.  There have been some efforts of limiting border crossings out of Ukraine, but it seems likely that the H1N1 associated with these fatal cases has already spread throughout the region.
   
  Sequence data on isolates from fatal cases in the Ukraine and Belarus would be useful. 

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