Commentary
Fatal
H1N1 Infection In Healthy Child In Texas
Recombinomics Commentary
11:45
December 11, 2008
Two days later, she was taken to the local emergency room, where she
was found to be hypotensive. Despite intensive resuscitative efforts, she died 12 hours later; the postmortem examination showed necrotizing pneumonia and extensive alveolar hemorrhage. A viral culture confirmed an influenza A (H1N1) infection, and methicillin-resistant Staphylococcus aureus was isolated from a tracheal aspirate.
The major influenza virus that was prevalent during that season was
influenza A/New Caledonia (H1N1), a strain that was included in the available vaccine.
This girl was one of 12 children who were reported to have died in Texas during the 2006–2007 influenza season.
The above comments are from a paper in today’s New England Journal of Medicine entitled “Prevention and Treatment if Seasonal Influenza.” It details the fatal H1N1 infection of the 15F described above and discusses oseltamivir resistance in general terms, with a reference to the current recommendations for anti-virals which cite the level of 7.6% overall and 10.9% for H1N1 in the United States last season, which keeps the prior recommendations which discourage treatment with adamantidines and recommend treatment with oseltamivir. The recommendations also include the reminder to check for changes in recommendations for the 2008/2009 season, but at this time the recommendations are unchanged even though they represent a mismatch with the influenza circulation in the United States this season.
During the 2006/2007 it was still assumed that oseltamivir resistance would be limited to treated patients and H274Y would be associated with a fitness penalty. However, last season the widespread levels of H274Y, including frequencies of 67% in Norway clearly indicated that there was no fitness penalty. Moreover, it was also clear that H274Y had been identified on a number of seasonal flu backgrounds, including New Caledonia isolates from the 2006/2007 and in fact one isolate, collected on March 28, 2007 was in Texas. The sequence from the isolate, A/Texas/31/2007(H1N1), was public, and the lack of treatment in the host was also published.
The author of the paper disclosed “receiving consulting fees from Sanofi Pasteur, GlaxoSmithKline, Roche, Novartis, MedImmune, and Merck and research support from MedImmune” so he should have been familiar with recent developments, including levels of 100% resistance in H1N1 in multiple countries in the summer hemisphere this year.
In the United States and Europe this season H274Y has become fixed in H1N1 and in the United States 85-90% of influenza A tested to date has H274Y, yet the current antiviral recommendations remain mismatched with the influenza in circulation and the paper in today’s NEJM on treating seasonal flu glaringly avoids the current situation, which was quite predictable when the paper was written and reviewed.
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