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Biosurveillance
April 24, 2009
Swine Flu in Mexico- Timeline of Events
*Introduction*
At Veratect, we operate two operations centers based in the United
States (one in the Washington, DC area and one in Seattle, WA) that
provide animal and human infectious disease event detection and tracking
globally. Both operations centers are organizationally modeled after
our National Weather Service using a distinct methodology inspired by
the natural disaster and meteorology communities. Our analysts handle
information in the native vernacular language and have been thoroughly
trained in their discipline, which include cultural-specific
interpretation of the information. We are currently partnered with 14
organizations that provide us with direct ground observations in 238
countries. We are a multi-source, near-real time event detection and
tracking organization with years of experience in this discipline.
*March 30*
Veratect reported that a 47-year-old city attorney for Cornwall was
hospitalized in a coma at Ottawa General Hospital following a recent
trip to Mexico. Family members reported the individual voluntarily
reported to the hospital after gradually feeling ill upon returning from
his trip on 22 March. The source stated that the hospital did not know
the cause of illness. The case was reportedly on a respirator and
awaiting a blood transfusion, but sources did not provide symptoms or a
suggested cause of illness. This information was available in our web
portal to all clients, including CDC and multiple US state and local
public health authorities, however no one had connected this man’s
illness with a potential crisis in Mexico.
We have learned this case tested negative according to Canadian
officials. The only value this event would have had would have been to
tip someone to take a closer look at where this individual traveled in
Mexico, possibly stumbling on reports of 'unusual respiratory disease-
we have absolutely no indication anyone did this, or if they did they
found anything to prompt closer scrutiny. We certainly didn't.
*April 2*
Local media source Imagen del Golfo reported that state health officials
recorded a 15% increase in disease over an unspecified period in the
highland areas of Veracruz, which includes La Gloria. The increase was
primarily due to higher levels of upper respiratory disease and
gastroenteritis. Specifically, officials noted an increase in pneumonia
and bronchial pneumonia cases. Health officials attributed the increase
to seasonal climate changes.
I would like to be clear here- we are aware local media sources
apparently reported this on April 2nd, but we ourselves did not nor
posted it on April 2nd.
*April 6*
Veratect reported local health officials declared a health alert due to
a respiratory disease outbreak in La Gloria, Perote Municipality,
Veracruz State, Mexico. Sources characterized the event as a "strange"
outbreak of acute respiratory infection, which led to bronchial
pneumonia in some pediatric cases. According to a local resident,
symptoms included fever, severe cough, and large amounts of phlegm.
Health officials recorded 400 cases that sought medical treatment in the
last week in La Gloria, which has a population of 3,000; officials
indicated that 60% of the town’s population (approximately 1,800 cases)
has been affected. No precise timeframe was provided, but sources
reported that a local official had been seeking health assistance for
the town since February.
Residents claimed that three pediatric cases, all under two years of
age, died from the outbreak. However, health officials stated that there
was no direct link between the pediatric deaths and the outbreak; they
stated the three fatal cases were "isolated" and "not related" to each
other.
Residents believed the outbreak had been caused by contamination from
pig breeding farms located in the area. They believed that the farms,
operated by Granjas Carroll, polluted the atmosphere and local water
bodies, which in turn led to the disease outbreak. According to
residents, the company denied responsibility for the outbreak and
attributed the cases to "flu." However, a municipal health official
stated that preliminary investigations indicated that the disease vector
was a type of fly that reproduces in pig waste and that the outbreak was
linked to the pig farms. It was unclear whether health officials had
identified a suspected pathogen responsible for this outbreak.
And to be crystal clear, the way we used this information was to simply
flag an event as worthy of closer scrutiny and higher awareness, as
there was absolutely no proof of true involvement of this company in the
outbreak- a proper epidemiological investigation is required to prove
such links.
Local health officials had implemented several control measures in
response to the outbreak. A health cordon was established around La
Gloria. Officials launched a spraying and cleaning operation that
targeted the fly suspected to be the disease vector. State health
officials also implemented a vaccination campaign against influenza,
although sources noted physicians ruled out influenza as the cause of
the outbreak. Finally, officials announced an epidemiological
investigation that focused on any cases exhibiting symptoms since 10 March.
This information was available in our web portal to all clients,
including CDC and multiple US state and local public health authorities.
We do know, after checking our web site logs, that the Pan American
Health Organization, the WHO Regional Office of the Americas, accessed
this specific report in our system on April 10th and again on April 11th.
*April 16*
Veratect reported the Oaxaca Health Department (SSO) indicated that an
unspecified number of atypical pneumonia cases were detected at the
Hospital Civil Aurelio Valdivieso in Reforma, Oaxaca State, Mexico. No
information was provided about symptoms or treatment for the cases. NSS
Oaxaca reported that rumors were circulating that human coronavirus was
spreading at the hospital; sources did not provide any response to these
statements from the hospital or health officials.
Laboratory samples were sent to Mexico City for analysis; results were
expected to be released sometime next week. According to NSS Oaxaca,
health officials had intensified preventive measures aimed at mitigating
further spread of the disease. Sources reported that the SSO also
implemented a sanitary cordon around the hospital.
This information was pushed to CDC in an email alert notification
provided by Veratect on April 16 and April 17:
"16 Apr 2009 4:14 PM GMT Respiratory Disease Detailed Mexico
(Reforma, Oaxaca) Reforma: Atypical Pneumonia Cases Reported at
Hospital", sent at "April 16, 2009 10:08:06 AM PDT" and again at "April
17, 2009 10:08:06 AM PDT" to CDC and at "April 16, 2009 10:27:13 AM PDT"
to the California State Department of Health.
*April 20*
Veratect was urgently asked to provide access to the VeraSight Global
platform on 20 April by a client in the US public health community, and
indicated they had received word from their counterparts in Canada that
Mexican authorities had requested support. This client speculated
whether notification of all southern U.S. border states’ public health
authorities should be done and were confused as to why the CDC had not
issued an advisory. Veratect contacted the CDC Emergency Operations
Center to sensitize them about the situation in Mexico. CDC indicated
they were already dealing with the crisis of recently detected H1N1
swine influenza in California and possibly Texas.
*April 21*
Veratect reported the Oaxaca Health Department (SSO) confirmed two
adults died from atypical pneumonia at the Hospital Civil Aurelio
Valdivieso in Oaxaca, Oaxaca State, Mexico. One of the cases was a
39-year-old female; the other case was an adult male of unspecified
age. After the deaths, the hospital established a quarantine in the
emergency room due to initial concerns that avian influenza was
responsible for the cases. However, the SSO subsequently stated that
neither avian influenza nor coronaviruses, including that which causes
severe acute respiratory syndrome (SARS), were the source of infection.
Additionally, the SSO denied the cases represented an epidemic.
According to local sources, the SSO indicated that the atypical
pneumonia cases were caused by an unspecified bacterial pathogen and
were treatable with antibiotics. Sources indicated a total of 16
additional patients exhibited signs of respiratory infection; none of
these patients exhibited complications.
Veratect sources indicated the 39-year-old female was treated at the
hospital for five days before dying on 13 April. This case was
reportedly immunocompromised; in addition to acute respiratory symptoms,
she also had diabetes and diarrhea. The SSO contacted 300 people that
had been in contact with the woman; sources stated that between 33-61
contacts exhibited symptoms of respiratory disease, but none showed
severe complications. The SSO characterized the incident as an
"isolated case;" they noted that over 5,000 cases of pneumonia occur
annually in Oaxaca.
Another local source reported the SSO launched surveillance measures in
the former residential areas of the two fatal cases and in other
targeted geographic areas. No additional information was provided
regarding the second fatal case at the hospital.
Veratect reported that the Oaxaca State Congress Permanent Committee on
Health had undertaken an investigation into the cases. The committee
inspected the Hospital Civil Aurelio Valdivieso on 20 April. The
director of the medical school at the University Autónoma "Benito
Juárez" de Oaxaca (UABJO), along with other medical academics, publicly
requested that national health authorities investigate the cases of
atypical pneumonia. No information was provided indicating that
national health authorities plan to investigate the matter. The
director of the medical school also requested the SSO furnish evidence
showing that the cases were negative for avian influenza, SARS, and
other severe pathogens; his request was echoed by readers commenting on
an online user forum.
Veratect also reported the National Ministry of Health issued a health
alert due to a significant increase in influenza cases during the spring
season in Mexico. Officials indicated that there have been 14 influenza
outbreaks throughout the country. The most heavily affected states are
Baja California, Chihuahua, Distrito Federal (Mexico City), Hidalgo,
Tlaxcala, and Veracruz. Local case counts were not provided.
Officials stated that 4,167 probable cases of influenza, 313 of which
were confirmed, have been reported throughout the country in 2009. Case
counts for suspected and confirmed influenza cases have tripled in 2009
as compared to the equivalent time period in 2008. The National
Institute of Respiratory Diseases recorded two fatal cases of influenza
in 2009, but specific dates and locations were not provided.
Health officials stated they were unsure precisely why the incidence of
influenza had increased. However, they believed the increased presence
of influenza B, in combination with influenza A, was a contributing
factor. In response, officials advised anyone exhibiting influenza
symptoms to avoid self-medication and seek medical care immediately.
Officials had also enhanced epidemiological surveillance for influenza.
Lastly, health officials had focused efforts on providing antiviral
medications and influenza vaccinations to the most vulnerable segments
of the population. According to the Mexican Ministry of Health, 44.3%
of the national population was vaccinated against influenza in 2005-2006.
Veratect sensitized the International Federation of Red Cross who in
turn requested broader access be provided to the Pan-American Disaster
Response Unit (PADRU). Veratect moved to notify several US state and
local public health authorities, providing the caveat the situation in
Mexico remained unclear due to pending laboratory results. Veratect
reached out to World Health Organization (WHO) operations, informing
them the Veratect team was on an alert posture and available for
situational awareness support. They indicated they and their
subordinate, the Pan American Health Organization (PAHO) were now aware
of the situation but had no further information. Veratect also extended
contact to the British Columbia Center for Disease Control and offered
assistance in tracking the events in Mexico. All contacts indicated
laboratory results were pending.
*April 22*
Veratect reported the Oaxaca Health Department (SSO) indicated 16
employees at the Hospital Civil Aurelio Valdivieso in Oaxaca, Oaxaca
State, Mexico had contracted respiratory disease. However, the SSO
denied these cases were connected to the recently identified cases of
atypical pneumonia at the hospital. No information was provided
indicating how many employees work at the hospital or whether the number
of respiratory disease cases was higher than average. The source
reported that "fear" persisted among hospital physicians concerning the
possible presence of a deadly bacteria or virus circulating in the
hospital. One anonymous hospital employee criticized hospital
management as "unfair" for not providing clear information regarding the
first fatal atypical pneumonia case.
An additional source reported the cause of the atypical pneumonia cases
remained unknown; it stated that bacteria or virus could have caused the
cases. In contrast, according to an 18 April report, the SSO indicated
that the atypical pneumonia cases were caused by an unspecified
bacterial pathogen and were treatable with antibiotics. The reason for
this discrepancy was unclear at this time.
The Instituto Mexicano del Seguro Social (IMSS), a national health
entity, had now joined the SSO in responding to the cases; reports did
not indicate the Mexican National Ministry of Health had joined in the
response efforts. The IMSS extended the sanitary cordon surrounding the
hospital. Patients exhibiting flu-like symptoms would be sent to the
hospital’s epidemiology department for further study. IMSS instructed
physicians to hospitalize respiratory disease patients immediately if
they meet certain standards for severity of symptoms. Lastly, the
hospital’s emergency room would remain closed for an additional 15 days
so that cleaning and preventive disinfection could be carried out.
Veratect also reported the Mexican Ministry of Health indicated that an
"unusual" outbreak of laboratory-confirmed influenza caused five deaths
from 17-19 April 2009 in Mexico City, Mexico. The deaths occurred at
the following three hospitals: el Hospital de la Secretaría de Salud
(2), el Institute Nacional de Enfermedades Respiratorias (2), and el
Hospital Ángeles del Pedregal (1). According to unofficial sources, the
fatal case count was higher than that provided by officials. There were
currently 120 influenza cases hospitalized throughout Mexico City.
National health officials indicated that influenza vaccines were sold
out in Mexico City and that they were attempting to acquire additional
supplies of the vaccine.
At this point, the Mexican Health Secretary reportedly stated there was
an influenza epidemic in Mexico City and throughout the rest of the
county. In response to the cases, the official stated health
authorities would launch a public awareness and vaccination campaigns.
He stated that 400,000 vaccines would be administered, primarily to
medical staff; it was unclear whether these efforts would be focused on
Mexico City or any other geographic area. Health officials also ordered
the provision of special masks, gloves, and gowns for medical personnel
that were in contact with influenza cases.
A total of 13 fatal cases of influenza were reported in Mexico City in
the past three weeks. However, several other media sources reported
that the 13 deaths were recorded since 18 March 2009; the reason for
this discrepancy was unclear. Sources reported a total of 20 fatal
cases of influenza throughout Mexico over the disputed timeframe. The
other cases were located in San Luis Potosí (4), Baja California (2),
and Oaxaca (1). The Director of Epidemiology at the National Center for
Epidemiological Surveillance and Disease Control characterized the
outbreak as "quite unusual."
No information was provided indicating that the strain of influenza
itself was unusual. Rather, several sources indicated that it was
"unusual" to record this many fatal influenza cases during this time of
year. Influenza cases normally peak from October to February, while
these cases had occurred during Mexico’s spring season.
Canada announced a national alert for travelers returning from Mexico
with respiratory disease, beginning a campaign of public media
announcements. Potentially ill contacts were identified returning from
Mexico and isolated in Canada. Internet blogs begin to spin up. CDC
indicates concern about the events unfolding in Mexico. Veratect
sensitizes the US community physician social network managed by Ozmosis.
*April 23*
Veratect reported the Secretary General of the Oaxaca Ministry of Health
Workers Union confirmed that a doctor and a nurse from the Hospital
Civil Aurelio Valdivieso in Oaxaca, Oaxaca State, Mexico were under
observation for suspected "atypical" pneumonia. This contradicted
statements made by the Oaxaca Health Department (SSO) on 22 April that
16 hospital employees contracted respiratory disease, but none of the
cases exhibited atypical pneumonia.
The union official stated that a review by the Oaxaca State Board of
Medical Arbitration indicated that the hospital faced serious
difficulties caused by overcrowding; he stated that overcrowded
conditions created a "breeding ground" for the spread of various
epidemics. According to the official, the hospital has 120 beds but the
number of patients hospitalized had at times surpassed 240.
Other sources reported that the Department of Livestock, Fisheries,
Rural Development, and Feed (SAGARPA) declared on 20 April that Oaxaca,
Mexico was free of avian influenza. SAGARPA stated that authorities
should remain vigilant in monitoring for the disease among birds.
Canadian local health officials stated that a Rouge Valley resident with
influenza-like illness was being monitored at Scarborough Centenary
Hospital in Scarborough, Ontario. The precaution was being taken in
accordance with an alert issued by the Ministry of Health asking
hospitals to watch for severe respiratory illnesses in travelers
returning from Mexico. Despite the warning, the Ministry had indicated
that evidence is not suggestive of a novel pathogen or influenza strain,
according to the source. A representative for the Rouge Valley Health
System stated that this case is being monitored related to the alert.
The source did not specifically indicate symptoms or that the person had
traveled to Mexico. No additional information regarding the case,
including age or health status, was reported.
The source stated that hospital employees were asking any patients
admitted to the hospital if they had recently traveled to Mexico, which
according to the source was a popular tourist destination for
Durham-region residents.
Additional Canadian sources indicated Southlake Regional Health Centre
officials treated a patient with influenza-like illness (ILI) who
recently returned from Mexico. The Ministry of Health recently notified
Southlake, in addition to health units across the country, that an
outbreak of severe respiratory disease was affecting areas of Mexico;
ill travelers returning from that region with ILI symptoms were
encouraged to be monitored. Sources did not provide any specific
information about the case, including age or current treatment status.
Information regarding the individual’s travel to Mexico was also not
provided, including destinations and duration of time in country.
The Public Health Agency of Canada (PHAC) noted that an Ontario resident
who returned from Mexico on 22 March experienced severe respiratory
illness, but has fully recovered and was not considered connected to the
current situation. Veratect recently reported on 30 March that a public
official from Cornwall, Ontario was hospitalized with an unknown illness
following a trip to Mexico; however, it is unclear if the cases are
related, or if this was the case referenced by PHAC officials.
Veratect assesses the situation and notes the following:
/Affected areas: /
Oaxaca, Distrito Federal, San Luis Potosí, Baja California
/Distance to nearest international airport: /
• Oaxaca airport, located approximately 150 miles from Reforma, is
connected via non-stop air traffic to Houston
• Mexico City (Distrito Federal) airport is connected via non-stop
air traffic to many cities in the US, Canada, Europe and Latin America,
with the most outbound traffic to Los Angeles, Frankfurt, Houston,
Dallas, and Amsterdam
• San Luis Potosí airport is connected via non-stop air traffic to
Dallas and Houston
• Mexicali airport in Baja California is connected via non-stop
traffic to Los Angeles
• Veracruz airport is connected via non-stop air traffic to Houston
/
Large mass gatherings: /
Semana Santa (April ~April 3 – 12, Palm Sunday to Easter Sunday), which
is Mexico’s second largest holiday. Mexico’s population is
approximately 90% Catholic, which results in substantial population
migration patterns during this time period. For instance, in Ixtapalapa
(in Mexico City), one million people visit for Semana Santa. Other
well-known sites for the holiday include Pátzcuaro, San Cristobal de las
Casas (Chiapas), and Taxco. Veratect notes substantial population
migration has just occurred that could facilitate the spread of
respiratory disease.
/Civil Unrest: /
The recent surge in organized crime and drug-related violence in Mexico,
including homicides, kidnappings, extortion, and theft, has
disproportionately impacted Mexican states along the Pacific Coast and
U.S.-Mexico border. This factor may confound situational awareness of
respiratory disease in Mexico and contribute to problems in
epidemiological investigation and response measures. Baja California is
one of five states within this region that currently accounts for more
than 75 percent of Mexico's drug-related homicides, and has recorded
high levels of drug seizures and police corruption cases. Veracruz, a
state with high drug cartel activity in the Gulf of Mexico, has recorded
little violence, while the state of Oaxaca to the southwest, recently
recorded the assassination of a political party leader. Mexico City, in
the center of the country, recently arrested a major drug cartel leader,
and recorded few homicides this month. The levels of unrest in Hidalgo,
San Luis Potosi, and Tlaxcala, however, are very low, and have not
reported a single homicide related to organized crime in the past month.
Veratect issues notification to additional public health authorities in
two states. Veratect reaches out to the Pan American Health
Organization emergency operations team but is unable to establish
contact. Veratect notes no publicly available English language
reporting from ProMED, HealthMap, FluNET, CDC, ECDC, or WHO about the
unfolding events in Mexico. Many of Veratect’s clients, including
Canadian, ask why an alert has not been issued by the US to sensitize
their healthcare community.
*April 24*
Veratect continues to process a dramatic increase in reporting on the
situation in Mexico.
WHO requests access to the Veratect system. Veratect is aware of
laboratory samples from Mexico are positive for “swine flu” H1N1, a
novel virus. World media are now aware of the situation in Mexico. CDC
issues a press statement, as does WHO.
Veratect notifies the private US clinical laboratory community and
activates a Twitter feed (twitter.com/veratect) to enable more rapid
updating of information.
Posted at 09:37 PM | Permalink