Discussion: What are the risks involved with co-infection between H1N1pdm09 and the novel coronavirus?

[alert]

The United Kingdom has recently reported a co-infection between H1N1pdm09 and the novel coronavirus:

http://www.flutrackers.com/forum/sho...d.php?t=200042

My question at this point is, what precisely are the risks this poses?

The first thing that comes to mind is the risk of reassortment or recombination. H1N1 is, for most people, a mild virus that transmits easily H2H. The novel coronavirus is a severe virus (5 of the 10 cases so far have died, with 2 more still in the ICU) that does not appear to transmit H2H efficiently. One could imagine that a hybrid virus might be as severe as the novel coronavirus, but transmit with the efficiency of H1N1. That would potentially be as severe as a H5N1 pandemic. Fortunately, the risk of such mutation between such different viruses is probably very low. We discussed this a bit at:

http://www.flutrackers.com/forum/sho...d.php?t=169731

in which we decided the risk of a flu and rabies combination was low for precisely that reason.

There are at least two other risks I can think of from this co-infection. The first is misdiagnosis. If a co-infected patient presents as a SARI case and tests positive for H1N1pdm09, further testing is likely to stop. The coronavirus infection will not be diagnosed. I wonder if H1N1 patients are still be isolated. It is conceivable that the misdiagnosis of such a case as due solely to H1N1 might produce more spread of the coronavirus.

The second issue is ease of transmission. Even if genetic material from the H1N1 virus does not transfer to the coronvairus, could the coronavirus transmit more efficiently from a co-infected case, perhaps due to increased coughing or the presence of both viruses in the upper respiratory tract instead of just the lower one?

This seems like a very odd coincidence that one of the only 10 known novel coronavirus infections happens to be co-infected with H1N1. Might this co-infection actually have made this case more likely to be detected than simply a coronavirus case? Might this co-infection actually argue that the coronavirus could be more widespread (and thus milder) than previously thought and that we are missing large numbers of coronavirus infections?

Any thoughts on this?

[Giuseppe Michieli]

It is really unlikely that two viruses belonging to different families could exchange genetic material (ie sub-units) between us.

For the clinical pattern, it could be possible that a viral pneumonia may be misdiagnosed as caused by H1 alone but I think that the multiple organ failures caused by nCoV could help clinicians toward additional microbiological tests on respiratory samples of a patient.

Another reason for a less likely misdiagnosis is the age-related illness of H1pdm09, much more common in young and healthy adults than aged people.

The main reason to not suspect secondary spread of nCoV is the current lack of contacts infections.

But the quest remains open.

[Treyfish]

The way I see it, if you can cough it, you can spread it. So little is known or been revealed about it, how can anyone tell what the deal is. I am amazed they even admitted he had both infections. I see no good from this case, as it shows people can and do get infected with both. Since he has been coughing around town and on the plane, we may see a few more cases pop up soon.

Don't try to tell me it can't re assort with flu unless there is a new scientific study, saying this new coronavirus 2012 cannot do it.

[Giuseppe Michieli]

Influenza A and Coronavirus cannot reassort.

They belong not only to a different species but also distinct orders.

Order: Nidovirales->
Family: Coronaviridae->
SubFamily: Coronavirinae->
Genus: Betacoronavirus->
Species: Betacoronavirus

Order: Not Assigned->
Family: Orthomyxoviridae->
Genus: Influenzavirus A->
Species: ...

[Treyfish]

If dude had both diseases at the same time, and you can't readily tell them apart, then mild cases may be present. Since we don't know which one he caught first, or where, or exactly when, we don't know much. IMO, A new coronavirus may be able to re-assort with camel flu or pig flu or dog flu or maybe a human flu. Either way, get a bunch of people with H1N1, and try to guess which one has the new "SAUDI SARS" Can't do it, or tell how far and fast it is spreading by cough or touch..not to say it won't mutate by itself. Sars #1 did a fine job. We already saw that it can go h2h in Jordan.
They are saying it is hard to spread h2h this week. In 10 days they may be telling us something completely different..

If dude has both, and coughing up some crony in your face, he may give it to you.
Since it is so new and shiny, I wouldn't put anything past it. IF not Swine flu, then what disease will/can mutate with it?? Tell ya what, drop it off in Cambodia or Nam and see what jumps up.

[Treyfish]

On a molecular level, this new coronovirus more closely resembles the SARS virus which sickened 8,000 people and killed 774 between 2002 and 2003, than a cold virus.

But it doesn't seem to behave like SARS did, says WHO spokesman Gregory Hartl. These two men not only suffered from severe respiratory illness, they also had kidney failure, something that wasn't seen in SARS patients. Also, none of the close contacts or health personnel caring for the patients has become infected yet, says Hartl, but they are still being watched.

"There is reason to be interested and even concerned" about this new coronavirus, says Dr. William Schaffner, chairman of the Department of Preventive Medicine at Vanderbilt University Medical Center.

But he notes that when the SARS epidemic was going on, many of those caring for patients were infected too. The fact that this hasn't been seen with these cases so far is a good sign. "There's no evidence yet that these viruses are readily transmissible," says Schaffner, who is also the past president of the National Foundation for Infectious Diseases.

There are still many unknowns for researchers to uncover. Have there been other serious cases that haven't been reported yet?

"We don't know if this virus causes mild diseases also," says Hartl. "We don't know if this is two out of two cases or two out of 2 million (which might include a lot of mild cases)." http://thechart.blogs.cnn.com/2012/0...dical-mystery/

[alert]

Could the H1N1 infection have been picked up in the ICU from anthoer patient after he was already critically ill with the coronavirus? That would remove the coincidental factor from the equation as any respiratory illness in that ICU might have contracted H1N1.

[Giuseppe Michieli]

Originally Posted by Giuseppe Michieli

Influenza A and Coronavirus cannot reassort.

They belong not only to a different species but also distinct orders.

Order: Nidovirales->
Family: Coronaviridae->
SubFamily: Coronavirinae->
Genus: Betacoronavirus->
Species: Betacoronavirus

Order: Not Assigned->
Family: Orthomyxoviridae->
Genus: Influenzavirus A->
Species: ...

Systematics and taxonomy aren't pure speculative sciences.

When one talks about Fishes, this Class of animals includes - for example - salmons and sharks.

Both are fishes but they belong to orders, families, genera and finally distinct species.

Is it possible for a couple of mating salmon and shark to generate an hybrid?

Clearly in nature, they can't.

For viruses, organism infinitely less complex than fishes or other animals - or bacteria (that have indeed a system to exchange DNA fragments through plasmids), the mating of so distant in evolutionary scale members should be also almost impossible, in nature.

[curiosity]

Originally Posted by alert

Could the H1N1 infection have been picked up in the ICU from anthoer patient after he was already critically ill with the coronavirus? That would remove the coincidental factor from the equation as any respiratory illness in that ICU might have contracted H1N1.

That would make sense.

If they had tested for H1N1 originally - it seems likely they would not have continued searching for something else.

However, if they were looking for the causative organism causing severe respiratory disease, and the initial test was negative for influenza, they would have sent away for a series of r/o type tests - including the novel coronavirus.
While waiting for the results, the patient's condition could have worsened, or a series of H1N1 infections in other patients on same floor could have indicated a need to test all at risk patients for influenza.

Conversely, it might be routine testing for all severe respiratory illness associated with recent Middle East travel, and the test results were positive for both simultaneously.

I think the hybrid idealogy is far fetched-

I am more concerned about the viruses working together to potentiate their virulence.

It happens all the time - influenza viruses create the perfect conditions for deadly bacterial infections. Take for instance last spring's Maryland triple fatality secondary to community influenza and staph co-infections.

The fact that the two viruses were isolated in one patient during a random event is either a needle in a haystack find - or the first piece of hay.

If the two began potentiating eachother, I imagine the event would unfold with increasing severity in flu patients (most of them not tested for coronavirus if rapid flu test positive) in areas of the Middle East. More in - depth testing would then reveal the coronavirus co-habitation and a plausible explanation for the severity.

Makes one wonder if they tested the Argentina group for Coronavirus, too...

[alert]

Originally Posted by curiosity

Makes one wonder if they tested the Argentina group for Coronavirus, too...

The cluster in Argentina (http://www.flutrackers.com/forum/sho...d.php?p=484157) scares me a bit. It really does sound a bit like what happened in April 2012 in Jordan, and that is why when the outbreak was completely undiagnosed, I put a "Breaking" sign on the thread. It appears that 4 samples have come back (weakly?) positive for some kind of influenza A, after a bunch of other samples came back negative. But they have been unable to subtype it so far, a nurse has died and a second is critically ill, and the timing is not consistent with the "imported from US" flu story as the time from travel to onset is over 3 weeks. The presence of several undiagnosed respiratory fatalities in that hospital in November and December might be indicative of Legionella contamination within the ICU itself; those tests are apparently still pending. If they haven't tested for coronavirus yet there, they really should.

I believe WHO guidelines do say that clusters of SARI with no known cause anywhere in the world should be tested for the novel coronavirus.

It is also worth remembering that during the 2003 SARS outbreak, the WHO definition said that a suspected SARS case should be excluded if an alternative diagnosis is found only after discarding the possiblity of coinfection.

[curiosity]

WHO guidelines do say that clusters of SARI with no known cause anywhere in the world should be tested for the novel coronavirus

They would have to admit it is a cluster.

Given Mexico's economic drop in tourism and pork sales immediately after H1N1pdm09 broke - I don't think many countries want to be the first to find unsual events.

I have always been under the impression that Argentina's health care system is pretty good. It really does seem odd that they haven't identified distinctively the culprit.

Legionella would have grown in culture by now - or if for some strange reason that test was still pending, why would they open the hospital without knowing which hospital system to treat?

[gsgs]

They are even from different groups, positive stranded
vs. negative stranded - so they have entirely
different methods of replication.

But I assume they could maybe create such hybrids in the lab.
Just do an insertion of a foreign gene (or a replacement) into the flu-genome,
some hundred nucleotides into some of the 8 segments.
Or even adding a new segment - maybe another HA.
And then see how/whether it replicates and evolves
in cell-cultures.
Had it been done ? When will it be done ? Would they tell us ?

Maybe they can create viruses that have the normal functions
but additionally emit some light so they can better see them and
experiment with them ...
Make them less virulent and then let them outcompete existing
viruses in the wild
Of course, they could as well make them more virulent, if they wanted.
Virulence-change looks like an easy mutation for flu.
(e.g. just insert some amino acids at the HA-cleavage site of H5,H7 -
they must be able to do that in a lab already)

[gsgs]

here we had a recombination of entirely different, unrelated
RNA strains : http://www.ncbi.nlm.nih.gov/pubmed/15200862

but only 30 nucleotides

but this is rare

3 cases:

69. Orlich M, Gottwald H, Rott R. Nonhomologous recombination between the hemagglutinin
gene and the nucleoprotein gene of an influenza virus. Virology. 1994;204:462–465. [PubMed]
70. Khatchikian D, Orlich M, Rott R. Increased viral pathogenicity after insertion of a 28S
ribosomal RNA sequence into the haemagglutinin gene of an influenza virus. Nature.
1989;340:156–157. [PubMed]
71. Suarez DL, Senne DA, Banks J, Brown IH, Essen SC, Lee CW, Manvell RJ,
Mathieu-Benson C, Moreno V, Pedersen JC, et al. Recombination resulting in
virulence shift in avian influenza outbreak, Chile. Emerg Infect Dis. 2004;
10:693–699. [PMC free article] [PubMed]

Non-homologous recombination involving influenza A viruses has been
reported rarely in the literature (Fields & Winter, 1982; Bergman et al., 1992;
Khatchikian et al., 1989; Orlich et al., 1990, 1994; Suarez et al., 2004).
http://vir.sgmjournals.org/content/86/3/727.full

[Treyfish]

Looks like one popped up. As usually stated, he may have had a pre-existing condition.
Now I ask, did the relative give him the H1N1?
What was the new guy getting treated for that makes him susceptable to SS?
Who else was in the house?
How many licks to the center of a tootsie roll pop?

[Treyfish]

...Michael Osterholm, an infectious diseases expert at the University of Minnesota, warned the virus could be adapting into a more transmissible form. "At any moment the fire hydrant of human-to-human transmission cases could open," he said. "This is definitely a 'stay tuned' moment." He noted that before SARS sparked a worldwide epidemic, there were a handful of human-to-human cases, until something happened, like a virus mutation, which triggered an explosion of cases...

http://www.usatoday.com/story/news/w...virus/1909415/

[Giuseppe Michieli]

The paucity of available information about these patients should induce a much more cautious approach about commentators in mainstream media.

We don't know:

--- demographics of patients (except for age, we haven't info about job, travel, citizenship (a part the 'resident' status in a country or another), reason for the movement abroad, people they've seen, socioeconomic status); these people could be as wealthier enough to be treated and medvac from Arabic Paeninsula to high skill institution abroad).

--- clinical course: very few data were released about timing of infection, symptoms, treatment regimes, diagnostic tests, chest objectivity etc.

--- anatomo-pathological findings during necroscopic examinations, useful to distinguish between tissues damages from nCoV and other possible co-factors;

--- serosurveys in contacts;

--- possible link between patients (are they part of a group of people of 'interest', politicians, diplomacies, businessmen?).

Before starting to say that - as Mr Osterholm - the epidemic valve is opening, I would suggest authorities to disclose more on these patients and the reason behind their prompt diagnosis.

[Treyfish]

He may know for sure, way more than we do. It is pretty obvious to them and us, that a new infection was confirmed in the UK. Apparently h2h. I think he is just stating the obvious in comparison to the first SARS outbreak. That it started slowly, but surely. You got 1 thing right though, they aren't saying very much. We should see this as a wake up call at the very least.
I am glad we have such a good network of hound dogs on the trail

[jeffrey]

WHO says the virus is probably more widespread than just the Middle East and has advised countries to test any people with unexplained pneumonia.

Is it possible this is in the US?

[Giuseppe Michieli]

It could be eveywhere.

The problem is to understand why does it cause illness in a such strange manner?

Too little is known to draw any conclusion at the time.

[gsgs]

http://www.who.int/csr/don/2013_02_11b/en/index.html

http://www.who.int/csr/don/2012_09_29/en/index.html
no evidence so far of person to person transmission of the novel coronavirus.

http://www.who.int/csr/disease/coron.../en/index.html
Based on current information, it does not appear to transmit easily between people,
unlike the SARS virus.

----------------------------------------------------
der spiegel : http://www.spiegel.de/gesundheit/dia...-a-882908.html

(in German. apparently h2h now)
The latest case but now for the first time it differs: infected British
itself not in the Middle East had traveled according to the health
authorities in London. He was in Birmingham in medical treatment.
Although there first is a strong reference to the possibility of human
to human transmission with the current case in the United Kingdom,
the danger to the public was on very small, British experts.
Also the German Robert Koch-Institut (RKI) speaks of a "limited
human to human transmission" and classified the risk of disease
in Germany recently as low.
----------------------------------------------------

[Treyfish]

Originally Posted by Treyfish

If dude had both diseases at the same time, and you can't readily tell them apart, then mild cases may be present. Since we don't know which one he caught first, or where, or exactly when, we don't know much. IMO, A new coronavirus may be able to re-assort with camel flu or pig flu or dog flu or maybe a human flu. Either way, get a bunch of people with H1N1, and try to guess which one has the new "SAUDI SARS" Can't do it, or tell how far and fast it is spreading by cough or touch..not to say it won't mutate by itself. Sars #1 did a fine job. We already saw that it can go h2h in Jordan.
They are saying it is hard to spread h2h this week. In 10 days they may be telling us something completely different..

If dude has both, and coughing up some crony in your face, he may give it to you.
Since it is so new and shiny, I wouldn't put anything past it. IF not Swine flu, then what disease will/can mutate with it?? Tell ya what, drop it off in Cambodia or Nam and see what jumps up.

Although authorities still aren't how this particular virus is spread, they believe that, like other coronaviruses, it could be spread through the air in droplets that are produced when a person coughs or sneezes. Like the flu, it could be highly contagious.http://www.scienceworldreport.com/ar...ly-british.htm