@dreamy_run:
… Timeline:
Day 1 (Nov. 2)
-Conjunctivitis
Day 2
-Fever
Day 3
-1st trip to ER
–No PPE
–No testing, sent home
Then cough, vomiting, & diarrhea
Day 6
-2nd trip to ER; admitted for respiratory distress & hemodynamic instability
-Tested + for H5N1
Day 7
-Transferred to PICU @BCChildrensHosp with respiratory failure, pneumonia, kidney injury, thrombocytopenia, leukopenia
–Tamiflu FINALLY administered
–Airborne PPE (N95s) FINALLY implemented
Day 8:
-Progression to ARDS; placed on ECMO (near death)
What is left of the girl’s brain?
Day 7 X-ray of lungs. Some opacities.
Day 8 X-ray of lungs. Lungs are almost completely white
Day 21
-Removed from ECMO
Day 27
-Extubated
Day 28
-Deemed no longer infectious
Day 33
-Moved from ICU to regular ward
Day 38
-Dialysis stopped
Day 47
-Supplemental oxygen stopped
Day 60 (today)
-No mention the child has been discharged, so she’s probably still very sick …
HCWs did not wear N95s until the child was admitted to the ICU, which was the day after she tested positive for H5N1. No one in the ER, including any IC patients, was told to wear an N95 during either of her infectious visits — no protection vs. airborne HAI & coinfections.
The citation given for “no secondary cases of transmission of H5N1 in the patient’s home or hospital have been identified at this time” is Dr. Bonnie Henry’s presser over a month ago. No mention is made of whether anyone actually looked for secondary cases.
The first thing the paper reports about this 13-year-old child is that she’s overweight & has a pre-existing condition (asthma).
Authors include Urgency of Normal’s Jennifer Grant. “On consultation with our Research Ethics Board, review was not deemed to be required.”
Good luck, world. With people like these in charge, we’re going to need it.
Best wishes for a quick and complete recovery for this 13-year-old BC girl.
***
@kasza_leslie:
Management of this young teen was screwed up BADLY. NOW they broadcast their mistakes in the New England Journal of Medicine for ALL TO SEE??? The hubris and unwillingness to learn from mistakes STUNNING. Beyond awful. No use of the precautionary principle. Gobsmacked.:((
Like you, I really hope and pray that this young lady recovers fully. Her poor parents and family.:((
To be clear, diagnoses can be missed quite easily. But the lack of humility in recognizing this and the complete recklessness of not recognizing that H5N1 was in the area – prompt use of the precautionary principle, which means immediate airborne precautions is disgusting.
@beansprouts_mom:
And pediatric testing continues to be discouraged.
@ScaryHealthcare:
This happens when there were no consequences in SARS1 (2003) and an individual Social murderer her royal self, Dr. Bonnie Henry — make sure to give her another honourary degree and more expensive gifts like EV bicycleswho messed up in SARS1 is promoted to the PHO in BC- fails upwards.
Sadly, nothing from SARS1 was implemented (Precautionary Principle) in SARS2 as a result the Commission was a waste of time and [money].
***
DrJames @YorkU (he/him/il) @jasmith_yorku:
That kid in BC with bird flu?
The details are awful.
“plasma exchange was performed daily from November 14 through November 16.”
Three plasma exchanges. To fight off bird flu?!
What are plasma exchanges? Looks like you have to hook up the patient to a blood exchange machine… and replace their blood. For bird flu. Think about it.
Now think about why it’s important to stop bird flu from transmitting in people.
https://rheumatology.org/patients/plasm
One co-author is Dr. Jennifer Grant, who has co-authored work with Dr. Martha Fulford.
Note how Dr. Grant has previously poo-pooed the use of masks against COVID:
“For example, masks are identified as highly effective, yet the data are weak at best.”
https://www.cmaj.ca/content/re-no-more-waves-strategy
Dr. Martha Fulford minimized the risk of COVID to children from very early on in the pandemic.
***
Dr Richard Hirschson @richardhirschs1:
… First description of a CRITICALLY ILL PAEDIATRIC PATIENT with H5N1 BirdFlu in North America.
The D1.1 virus circulating in BC birds almost KILLED this 13 yr old in less than 96 hours. She presented in multi-organ failure 3 days after mild conjunctivitis.
Her lungs were WHITE-OUTS.
Only modern day organ support (ECMO/CVVHDF) saved her.
Christine Guenter @ChristineGuent8:
The HC team neglected to test the child on her initial visit to ER & sent her home. They missed window of time to give her antivirals. The child returned to ER six days later on death’s doorstep. The HC team does not deserve accolades. This child suffered due to their inaction.
Gordon Anderson @a14286983:
after waiting hours in Emergency with conjunctivitis she was sent home without treatment. this is a scandal.
Patti Forrington @peppermintpatti.bsky.social:
Nice to finally get some info on how the BC teen is doing.
@erohealthcomms.bsky.social:
“Survived” but what are the life long complications going to look like?
Amir Attaran @amirattaran.bsky.social Dec 31, 2024:
H5N1 case report of the BC teenager. **Barely survivable** respiratory failure even with state-of-the-art antiviral, immunological, and critical care (needed plasma exchange and ECMO).
This looks more dangerous than COVID-19. Terrifying.
We are as little as one mutation away from something more infectious to humans, and therefore, the opening salvo of a human-to-human pandemic. Gotta say, I hope Brain Worm Kennedy is being well briefed.
Jelmer Visser @dietukkerfries.bsky.social:
Hebben jullie enig idee hoe gigantisch fucked we zijn als die H5N1-vogelgriepvariant besmettelijker wordt bij interpersoonlijk contact?
Jan Kirsch, M.D., email hidden; JavaScript is required:
WE NEED A RESPONSE TO H5N1 NOW
Antiimperialist_empathy @intpaexplorer.bsky.social:
RFK is trying to figure out how to blame H5N1 on chem trails as I write this.
Jan Kirsch, M.D., M.P.H. @drjanicekirsch.bsky.social
Right.
He’s fucking championing raw milk!
We have to be ready with enough vaccine should cases become more widespread or, God forbid, we see person-to-person spread.
David Rosenberg @davebeerguy.bsky.social:
Pray to God that RFK Jr isn’t confirmed, or if he follows through with saying there should be a halt on infectious disease research and elimination of the FDA.
Yep, I’ve sent letters to my two GA senators. Racist, 5G, anti-vax, AIDs denying, FDA conspiracy grifter who has actual blood on his hands….should not be near actual science.
Nietzsche Nomad @godless2.bsky.social:
No efforts will happen until they figure out how to blame it on China.
Jan Kirsch, M.D., M.P.H. @drjanicekirsch.bsky.social
Maybe they’ll use it to invade Canada.
Those damned geese!
Cultural Revolution USA 2025 @littleredmagahat.bsky.social:
What do these results mean?
Jan Kirsch, M.D., M.P.H. @drjanicekirsch.bsky.social:
We knew about the child since 11/24.
The virus isolated had characteristics which MIGHT (not inevitably) make it more easily transmitted to humans.
This poor kid required ECMO (lung failure was so severe, the oxygenation was done outside the body).
It’s a heads-up, not for panic, but preparedness.
@seentoomuch.bsky.social:
I’m a pharmacist and even I can read that X-ray. Which means it’s really bad.
Jennifer Grant, M.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Andrew Sparling @awsparling.bsky.social:
Nothing ironic about it. It’s completely in keeping with B.C.’s disastrous response to COVID and the province’s antiscientific approach to infection control.
@gina.bzky.team:
Geebus. ECMO??!!
@wishda.bsky.social:
We do not have the capacity for this on a large scale.
@harlickjen.bsky.social:
Judging by those numbers we also do not have capacity for this on a small scale. Or any scale > ~ 5 people per major urban centre. Lol. We’re so screwed.
Mike Sasges @uvmike.bsky.social:
There is no way this level of intervention could be done if/when this becomes widespread.
writerartisteh.bsky.social @writerartisteh.bsky.social:
Nope, anyone over a certain age probably would be triaged out, plus anyone with any pre-existing condition, any disabled people, anyone with autism, dev’l delays etc. Because, at least in Canada, we practice open medical eugenics. Any human life does ≠ any human life.
@bige65.bsky.social:
Very scary. Being put on a vent, ECMO & dialysis to make it out on the other side could mean a lot of people die is the virus goes H2H. There won’t be enough beds/resources to treat everyone. N95s and avoiding close contact with other people is going to need to be a thing.
Tom Owens @tomowens67.bsky.social:
The fatality rate for H5N1 infections is 51%. She got lucky.
Jeff Lacroix@jtlesq.bsky.social:
Wow. Heart/lung machine, ventilator and dialysis! God bless her. Terrifying.
Steph @observingangel.bsky.social:
Absolutely terrible. Wondering whether or not they detected any neurological symptoms given the prevalence of neurological symptoms in other mammals. Glad she recovered
@manuel-herrick.bsky.social:
As a layperson, ECMO is something I really hoped to never hear about ever again. So. Bummer.
@madphysiologist.bsky.social:
Wow, very scary. Amazing she survived.
Xtine Irandokht Milrod, PhD @xtinemilrod.bsky.social:
ECMO?!? OMG!!!!
@fishiejs.bsky.social:
Oh wow, poor kiddo. That is really terrible and does not bode well.
Jessica Rousseau @jessrousseau.bsky.social:
Yikes. Ecmo and crrt? They need to show that to anti-vaxers. That child has a long road to recovery ahead.
Amelie @amfu.bsky.social:
She will have a degree of cognitive impairment following that ordeal
Critical Illness in an Adolescent with Influenza A(H5N1) Virus Infection
Published December 31, 2024, The New England Journal of Medicine
To the Editor:
Highly pathogenic avian influenza A(H5N1) viruses are circulating among wild birds and poultry in British Columbia, Canada.1 These viruses are also recognized to cause illness in humans. Here, we report a case of critical illness caused by influenza A(H5N1) virus infection in British Columbia.
On November 4, 2024, a 13-year-old girl with a history of mild asthma and an elevated body-mass index (the weight in kilograms divided by the square of the height in meters) of greater than 35 presented to an emergency department in British Columbia with a 2-day history of conjunctivitis in both eyes and a 1-day history of fever. She was discharged home without treatment, but cough, vomiting, and diarrhea then developed, and she returned to the emergency department on November 7 in respiratory distress with hemodynamic instability. On November 8, she was transferred, while receiving bilevel positive airway pressure, to the pediatric intensive care unit at British Columbia Children’s Hospital with respiratory failure, pneumonia in the left lower lobe, acute kidney injury, thrombocytopenia, and leukopenia (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). A nasopharyngeal swab obtained at admission was positive for influenza A but negative for A(H1) and A(H3) by the BioFire Respiratory Panel 2.1 assay (BioFire Diagnostics). Reflex testing of the specimen with the Xpert Xpress CoV-2/Flu/RSV plus assay (Cepheid) revealed an influenza A cycle threshold (Ct) value of 27.1. This finding indicates a relatively high viral load for which subtyping would be expected; the lack of subtype identification suggested infection with a novel influenza A virus. Oseltamivir treatment was started on November 8 (Table S2), and the use of eye protection, N95 respirators, and other precautions against droplet, contact, and airborne transmission were implemented.
A reverse-transcriptase–polymerase-chain-reaction (RT-PCR) test specific for influenza A(H5)2 was positive on the day of admission. The patient had signs of respiratory deterioration — chest radiographs were consistent with progression to acute respiratory distress syndrome (Fig. S1) — which prompted tracheal intubation and initiation of venovenous extracorporeal membrane oxygenation (ECMO) on November 9. Continuous renal replacement therapy was initiated on November 10. Combination antiviral treatment with amantadine (initiated on November 9) and baloxavir (initiated on November 11) was added to ongoing treatment with oseltamivir. Bacterial cultures of blood (samples obtained at admission) and endotracheal aspirate (obtained after intubation) yielded no growth.
Because of concern for cytokine-mediated hemodynamic instability, plasma exchange was performed daily from November 14 through November 16. Serial influenza A–specific RT-PCR tests showed increasing Ct values, which suggested a decline in the viral RNA load in serum and a decline in viral RNA in upper- and lower-respiratory specimens shortly after the initiation of antiviral treatment, with the first negative RT-PCR result for serum obtained on November 16 (Table 1). It is notable that lower-respiratory specimens consistently yielded lower Ct values than upper-respiratory specimens, a finding that suggested higher viral levels in the lower-respiratory tract (Table S3).
Influenza A(H5N1) virus was cultured from respiratory specimens obtained between November 8 and November 12 but not from subsequent respiratory specimens or from any serum specimens (Table 1). No evidence of reduced susceptibility to any of the three antiviral agents used in treatment was observed in serial respiratory specimens by either genomic analysis or phenotypic testing with the NA-Star influenza neuraminidase inhibitor resistance detection kit (ThermoFisher Scientific) (Table 1). The patient’s respiratory status improved, ECMO was discontinued on November 22, and the patient’s trachea was extubated on November 28.
The viral genome sequence obtained from a tracheal-aspirate specimen collected on November 9 (8 days after the onset of symptoms) was reconstructed as described previously.3 The virus was typed as clade 2.3.4.4b, genotype D1.1,4 most closely related to viruses detected in wild birds in British Columbia around the same time (Fig. S2). Markers of adaptation to humans were detected in the tracheal-aspirate specimen collected on November 9: the E627K mutation was detected (52% allele frequency) in the polymerase basic 2 (PB2) gene product, and analysis of the H5 hemagglutinin (HA) gene yielded ambiguous calls in the codons for amino acid residues E186 (E190 according to H3 mature HA numbering) — 28% allele frequency for E186D — and Q222 (Q226 according to H3 mature HA numbering) — 35% allele frequency for Q222H. The mutations in the H5 HA gene have previously been shown to increase binding to α2-6–linked sialic acids, which act as receptors that facilitate viral entry into cells in the human respiratory tract and enable viral replication.5
Highly pathogenic avian influenza A(H5N1) virus infection acquired in North America can cause severe human illness. Evidence for changes to HA that may increase binding to human airway receptors is worrisome.
Agatha N. Jassem, Ph.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Ashley Roberts, M.D. British Columbia Children’s Hospital, Vancouver, BC, Canada
John Tyson, Ph.D.
James E. A. Zlosnik, Ph.D.
Shannon L. Russell, Ph.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Jessica M. Caleta, M.Sc. Public Health Agency of Canada, Winnipeg, MB, Canada
Eric J. Eckbo, M.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Ruimin Gao, Ph.D.
Taeyo Chestley, Ph.D. Public Health Agency of Canada, Winnipeg, MB, Canada
Jennifer Grant, M.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Timothy M. Uyeki, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA
Natalie A. Prystajecky, Ph.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Chelsea G. Himsworth, D.V.M., Ph.D. British Columbia Ministry of Agriculture and Food, Abbotsford, BC, Canada
Elspeth MacBain, M.D. British Columbia Children’s Hospital, Vancouver, BC, Canada
Charlene Ranadheera, Ph.D. Public Health Agency of Canada, Winnipeg, MB, Canada
LynneLi, M.D. British Columbia Children’s Hospital, Vancouver, BC, Canada
Linda M. N. Hoang, M.D. British Columbia Centre for Disease Control, Vancouver, BC, Canada
Nathalie Bastien, Ph.D. Public Health Agency of Canada, Winnipeg, MB, Canada
David M. Goldfarb, M.D. British Columbia Children’s Hospital, Vancouver, BC, Canada email hidden; JavaScript is required
Notes
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
This letter was published on December 31, 2024, at NEJM.org.
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
Supplementary Material
Supplementary Appendix (nejmc2415890_appendix.pdf)
- Download 527.86 KB
Additional case and content information
The patient was deemed to be no longer infectious on November 29th after two upper
respiratory specimens collected >24 hours apart were negative by influenza A RT-PCR and on the same day she was transitioned from CRRT to intermittent hemodialysis. On December
4th the patient was transferred to the pediatric ward and intermittent hemodialysis was
discontinued December 9th and by December 18th she was no longer requiring supplemental oxygen. To date, no source of H5N1 virus exposure for the patient has been identified1. The patient and family consented to this report and on consultation with our Research Ethics Board, review was not deemed to be required. No secondary cases of transmission of H5N1 in the patient’s home or hospital have been identified at this time1.
Genotyping is performed as part of a public health response. The D1.1 genotype detected in
this case reflects the predominant HPAI A(H5N1) genotype that has been circulating among poultry and wild birds in British Columbia, Canada (results supporting this analysis are currently under review, Himsworth et al., submitted Dec. 4, 2024), and Washington State, USA since October 2024, and is the same genotype recently detected in a severe human infection in Louisiana2. In 2024, HPAI A(H5N1) viruses associated with B3.13 and D1.1 genotypes have been responsible for spillover events in dairy cattle and poultry in North America, respectively, causing associated infections in exposed humans.
This is the first report of a critically ill pediatric patient with HPAI A(H5N1) virus infection in North America. Use of commercial multiplex respiratory testing in this patient allowed for rapid detection of an influenza A non-subtypeable result for further subtyping and diagnosis by A(H5)-specific RT-PCR testing and prompt initiation of oseltamivir treatment. No evidence of reduced antiviral susceptibility was detected in genotypic or phenotypic assays of virus isolates and respiratory specimens before or after initiation of triple combination antiviral therapy. This case highlights the importance of a robust hospital laboratory surveillance system in the background of ongoing HPAI A(H5N1) virus circulation in animals and close collaboration with public health laboratories.
Disclosure Forms (nejmc2415890_disclosures.pdf)
- Download 1.28 MB
***
LizW @cave-malum.bsky.social:
No mention of discharge. Extubation on 28 Nov. is the last event? Wonder what kind of shape she’s in. Glad the docs caught it
doxy-cycling.bsky.social @doxy-cycling.bsky.social:
first two pages of the supplement has more info on course of illness.
Eric email hidden; JavaScript is required:
3 new @nejm.org papers on H5N1 today “highlight the urgent need for vigilant surveillance of emerging mutations and assessment of the threat of human-to-human transmission” …
Grambo @grambo1.bsky.social:
we’re doomed.
John email hidden; JavaScript is required:
köchelt auch weiter vor sich hin.
Kommt dann nach H5N1.
SARS‑CoV‑2 (COVID-19) @covid19disease.bsky.social:
The H5N1 outbreak on dairy farms could have been stopped months ago with quick action.
But USDA officials worried about the impact on business.
Now, we are one mutation away from a serious disaster.
LA Legault (NATO) @lalegault.bsky.social:
Good thing the entire cdnmedia is obsessed with making Trudeau resign before fhe best pandemic manager we had is able to deal with H5N1. Madness. Please start thinking about what it is you are doing. Poilievre will be a terrible pandemic manager.
Aurora Julja of the email hidden; JavaScript is required:
He will work with Danielle using the AB model across the country to wreak havoc on us all
@vfxpapa.bsky.social:
It’s brutal that we may have to live through a second “once in 100 years” pandemic, all cuz the price of eggs or whatever the fuck.
Eniko Kitsune Tails out now! @eniko.bsky.social:
I dont know what happened in the last 25 years that made humanity pathologically incapable of preventing crises. Covid, climate change, H5N1, antivax attitudes, even rewriting history to make preventative victories like Y2K out like an overreaction. Where did things go so wrong? Makes me feel insane
…
I get why America is so fucked up, but what I don’t get is why this is such a pervasive global phenomenon
@profolus.com:
Cats, both large felines and their domestic counterparts, are at risk as H5N1 avian influenza ravages across the U.S. Reported cases appear to have death rates ranging from 50 to 90 percent.
Refer also to: