March 24, 2010
Twelve HCPs reported influenza symptoms during the study period; none were tested for pH1N1. Five reported working while ill; one of these received oseltamivir. Viral isolates from the four patients had complete genomic homology and the H275Y mutation for oseltamivir resistance, which was not identified in other pH1N1 specimens obtained from the hospital or throughout the state.
The above comments describe potential sources for the death cluster at Duke University Medical Center. Four patients were infected with Tamiflu resistant (H274Y) H1N1 which had the rare HA marker, Y233H, leaving little doubt that the virus was transmitting among the patients. However, the source remains unclear. The index case had completed a 5 day prophylactic regime of oseltamivir (Tamiflu) but did not develop symptoms until 8 days post-treatment. Thus, the minimum of 13 days between exposure and symptoms suggests the source of infection was another contact in the hospital, and the above comments describe multiple potential sources who had symptoms, but were not tested.
The cluster of three fatalities, who died within a few days of each other, signaled transmission of D225G, which had been associated with fatal cases worldwide, although the WHO/CDC working hypothesis was that the D225G/D225N cases were sporadic and due to random copy errors. However, 27/37 autopsy lung samples in Ukraine had D225G, D225N, or both, indicating the RBD changes were transmitting, which was also supported by the detection of D225G in two family members in Italy.
The transmission was also supported by the HA sequences from isolates from the index case (42F) samples collected on Oct 15, A/North Carolina/39/2009 and 16, A/North Carolina/49/2009 had D225G. D225N was also found in the isolate from a second fatal case indicating both markers were transmitting, but the sequencing failed to identify D225G or D225N in the other two patients.
However, these detection failures may have been due to ratios in the mixtures, D225G can bind to gal 2,3 receptors which are in human lung, so the detection in the index case may have been linked to the sample source. Oct 16 is the last data point for Gantt chart of the index case, suggesting the Oct 16 sample may have been collected at autopsy and D225G would be more easily detected in lung samples. In contrast, samples from the other two fatalities were collected on Oct 14, one or four days prior to death, and were likely samples from the upper respiratory tract, where D225G samples could have been lower, since wild type H1N1 RBD was present in all four patients.
Thus, three of the four samples from the three fatal cases had D225G or D225N, as expected from a death cluster, but these changes were not mentioned in any of the three reports on the outbreak. Moreover, it is unclear if the cases were included in the tally of 7-8 D225G cases cited by the CDC.
The failure of the CDC or WHO to address this transmission in a fatal cluster is cause for concern, as is the failure to collect/release sequence data from autopsy material. The transmission of Tamiflu resistant H1N1 is rarely reported and the transmission of D225G has been denied directly or indirectly by the CDC and WHO. Since two of the three fatalities were treated on the day of death, BAL or autopsy collections should have been convenient and routine.
The failure to release sequence data from autopsy samples is cause for concern. Detection of D225G would destroy the WHO and CDC working hypothesis which has no real scientific basis. It is dependent on false negatives and lack of testing as highlighted in the Duke death cluster. Although both isolates from the index case had D225G, the direct sequencing of the first collection failed to detect D225G. Moreover, the direct sequencing of the second collection was not reported/released. Similarly, direct sequencing of the sample that yielded the D225N positive isolate also failed to detect D225G or D225N. Like the index case, no direct sequencing or isolates from samples closer to the date of death have been reported/released for either of the other fatal cases.
The WHO/CDC working hypothesis can only survive through the withholding of data or the failure to test, as demonstrated by the investigation of the Duke death cluster which failed to identify the origin of the cluster, in spite of two rare markers in the HA and NA sequence.
The testing failures and the reliance on false negatives by the CDC and WHO to prop up their outdated and false hypothesis of genetic drift and acquisitions via random mutations continues to be hazardous to the world’s health.
Recombinomics Paper at Nature Precedings