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Sudden deaths and influenza

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  • NS1
    Re: Sudden deaths and influenza

    FT 216332

    Death Of City Worker Investigated As Possibly Flu-Related
    January 10, 2014 6:25 PM
    Joel Thomas

    TARRANT COUNTY (CBS 11 NEWS) ? Fort Worth health workers are looking into what may be another flu-related death.

    Co-workers and acquaintances say Diana Ruelas was in her mid to late 30′s. According to a CBS 11 News source, Ruelas left her job, as a City of Fort Worth Code Compliance Officer, early with flu-like symptoms. She died Thursday night...

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  • tetano
    Re: Sudden deaths and influenza

    "He was healthy the night before, running around, laughing," Prymych said.

    When she went to wake him up the next morning, her son was unresponsive. "He was face down and when I turned him over he was blue."

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  • tetano
    Re: Sudden deaths and influenza

    Gimli boy who died had H1N1 flu virus in lungs, says mom

    A mother from Gimli, Man., is urging parents to ensure their children have the flu shot, after an autopsy on her young son revealed the H1N1 influenza virus was in his lungs.

    Michelle Prymych's 19-month-old son, Kylan Lux, was found dead in his crib on the morning of Dec. 12.

    Prymych said her son's death was swift and unexpected. Video footage she captured of Kylan the night before showed a robust and playful toddler.
    Michelle Prymych

    Michelle Prymych looks at a picture of her son, Kylan Lux, on Thursday. She says in the weeks following Kylan's death, her friends have arranged to get flu shots for their children. (Katie Nicholson/CBC)

    After weeks of wondering how her toddler died, Prymych said provincial health officials called her on Wednesday with a potential clue: the autopsy on Kylan indicated the H1N1 virus was present in his lungs.

    A Manitoba mother is urging parents to ensure their children have the flu shot, after an autopsy on her young son revealed the H1N1 influenza virus was in his lungs.

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  • tetano
    Re: Sudden deaths and influenza

    Inquest to be held into Mary?s tragic death

    Mr Jim Fergus Park Avenue Dundalk has persuaded county Louth coroner Ronan Maguire to sanction an inquest into his daughter?s death after a four-year campaign.

    Mr Fergus lost his pregnant daughter Mary after she contracted swine flu in November 2009 and has been campaigning for an inquest so that the family can finally have some measure of closure.


    She explained that she had a temperature with aches and pains and was told she probably had a seven-day virus and to drink plenty of water and rest.

    ?Swine flu was rampant at the time but Mary had refused to take the vaccine as the doctor couldn?t guarantee it wouldn?t harm the baby.?

    Jim says that he did not know Mary was pregnant at the time as she hadn?t told anyone apart from her partner and her doctor.

    ?If I had of known she was pregnant I would have taken her to the hospital myself straight away.?

    Instead Jim took Mary?s son, who was 18 months at the time, out of the house so that Mary could be alone and get the rest her doctor had advised.

    Mary made another call to the doctor?s surgery on Tuesday but a few hours later when Jim called to her home on the Avenue Road he found her dead in her bedroom.

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  • tetano
    Re: Sudden deaths and influenza

    Influenza-Associated Pediatric Deaths in the United States, 2004?2012

    Karen K. Wong, MD, MPHa,
    Seema Jain, MDb,
    Lenee Blanton, MPHb,
    Rosaline Dhara, MPHb,
    Lynnette Brammer, MPHb,
    Alicia M. Fry, MD, MPHb, and
    Lyn Finelli, DrPHb

    aEpidemic Intelligence Service assigned to Influenza Division, and
    bInfluenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia


    BACKGROUND: Influenza-associated deaths in children occur annually. We describe the epidemiology of influenza-associated pediatric deaths from the 2004?2005 through the 2011?2012 influenza seasons.

    METHODS: Deaths in children <18 years of age with laboratory-confirmed influenza virus infection were reported to the Centers for Disease Control and Prevention by using a standard case report form to collect data on demographic characteristics, medical conditions, clinical course, and laboratory results. Characteristics of children with no high-risk medical conditions were compared with those of children with high-risk medical conditions.

    RESULTS: From October 2004 through September 2012, 830 pediatric influenza?associated deaths were reported. The median age was 7 years (interquartile range: 1?12 years). Thirty-five percent of children died before hospital admission. Of 794 children with a known medical history, 43% had no high-risk medical conditions, 33% had neurologic disorders, and 12% had genetic or chromosomal disorders. Children without high-risk medical conditions were more likely to die before hospital admission (relative risk: 1.9; 95% confidence interval: 1.6?2.4) and within 3 days of symptom onset (relative risk: 1.6; 95% confidence interval: 1.3?2.0) than those with high-risk medical conditions.

    CONCLUSIONS: Influenza can be fatal in children with and without high-risk medical conditions. These findings highlight the importance of recommendations that all children should receive annual influenza vaccination to prevent influenza, and children who are hospitalized, who have severe illness, or who are at high risk of complications (age <2 years or with medical conditions) should receive antiviral treatment as early as possible.

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  • tetano
    Re: Sudden deaths and influenza

    Coroner pays tribute to girl,4, who died at Milton Keynes Hospital

    City coroner, Tom Osbourne, paid tribute to a ‘courageous and brave’ four-year-old girl who died at Milton Keynes Hospital.

    Leshaylia Ebanks, of Coffee Hall, died on April 6 after being admitted to A&E with flu symptoms.

    An inquest on Tuesday heard the toddler had already been suffering with Emanuel Syndrome, a chromosomal disorder that affects development, and had contracted the H1N1 flu virus.
    The corner was told Leshaylia became ill after coming down with what her mother thought was a cold. She was given some Calpol and put to bed, but at at 10.44pm her mother couldn’t wake her up and called an ambulance. She was taken to A&E at Milton Keynes Hospital but died hours later.


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  • tetano
    Re: Sudden deaths and influenza

    During the last three seasons I implemented a monitoring of sudden deaths of people under the age of 65 years for 'malore' ( sudden illness), with no reports of pathologies and/or past predisposition and not related to physical activity. The research is based on the Google search engine, for the months of December, January, February and March, using the key words 'morte'(death) and 'malore' ( sudden illness), in chronological order from the first to the last day of each month. The goal of this survey is to use the Internet to gather news related to cases of unexplained sudden deaths among otherwise healthy adults during the 2010-11, 2011-12 and 2012-13 seasons, while taking account of the different epidemiological development, with the first and the last seasons being characterized by the A(H1N1)-pdm09 virus and the second by the A(H3N2) virus.
    In the winter months there is a spike in mortality from respiratory and circulatory causes and various explanations of this phenomenon may be found.
    Among the most credited there are climatic factors (low temperatures). Research suggests that EWM ( excess winter mortality) may be higher in countries with a warmer winter climate because people there tend to take fewer precautions against the cold. These countries tend to have homes with poorer thermal efficiency (for example, fewer homes have cavity wall insulation and double glazing), which makes it harder to keep homes warm during the winter. It has been shown that low indoor temperature is associated with higher EWM from cardiovascular disease in England. The Eurowinter group (1997) reported that compared with people living in countries with cold winters, those from warmer countries were less likely to wear warm protective clothing in cold weather.
    Although EWM is associated with low temperatures, conditions directly relating to cold, such as hypothermia, are not the main cause of excess winter mortality. The majority of additional winter deaths are caused by cerebrovascular diseases, ischaemic heart disease and respiratory diseases (The Eurowinter group, 1997 and ONS, 2010). Although cancer causes more than a quarter of all deaths annually, previous research found that there was no clear seasonal pattern for these deaths.
    The cold can have various physiological effects, which may lead to death in vulnerable people.
    Woodhouse et al found that colder home temperature was associated with increased blood pressure in older people. The Eurowinter group (1997) noted that cold causes haemoconcentration, which leads to thrombosis, and that cold can also lower the immune system?s resistance to respiratory infections.
    Another major cause of EWM can be linked to environmental factors: evidence of association between exposure to air pollution and overall cardiovascular morbidity and mortality is increasingly found in the literature. Exposure to higher than usual levels of air-borne air pollutants over a few hours to several days has been reported to contribute to increased risk of myocardial infarction, arrhythmia, stroke and heart failure in susceptible patients. In particular, the focus has been on fine particulate matter (PM) <2.5 ?m in aerodynamic diameter (PM2.5). More recently, ultrafine particles <0.1?m, nitrogen oxides, ozone, elemental carbon, organic carbon and other sources of air pollutants (eg traffic and accidental fires) have also been studied.
    In recent years increasing evidence show a correlation between winter mortality and circulation of infectious agents, in particular of influenza virus.
    The level of influenza circulating in the population increases in winter and in vulnerable groups, such as the elderly or those with pre-existing health problems influenza can lead to life-threatening complications, such as bronchitis or secondary bacterial pneumonia.Indeed most influenza related deaths are not due directly to the primary viral infection but are from complications such as secondary bacterial pneumonia or worsening of chronic health conditions such as congestive heart failure or pulmonary disease. As a result, most persons for whom influenza initiated the chain of events leading to death will not be tested for influenza at the time of death or even at the time of hospitalization and will no longer be shedding virus by the time they are brought to medical attention.
    Most measures of influenza-related mortality are estimates based on calculating the number of deaths occurring above, or in excess of, the number expected for that time of year if influenza viruses were not circulating. Data are typically collected from death certificates and the outcomes most frequently used are pneumonia and influenza deaths, respiratory and circulatory deaths, or all cause deaths. Counting only pneumonia and influenza deaths produces a very conservative estimate of influenza associated mortality that likely underestimates the true impact of influenza, while using increases in deaths due to all causes attributes any seasonal increase in the number of deaths to influenza and likely overestimates the impact of influenza.

    Influenza (and other upper respiratory infections) may trigger cardiovascular events by causing an acute and severe inflammatory state in the body which can lead to destabilization and rupture of atherosclerotic plaques.
    The influenza attack rate in a typical year is 10?20% and, given the high burden of symptomatic and asymptomatic coronary artery disease, many of these cases occur in subjects with coronary heart disease (CHD). This attack rate (and in many cases, the severity of the subsequent disease) will be even higher during epidemics and pandemics. Accordingly, it has been noted that during influenza epidemics and pandemics (except for 1918 Spanish flu pandemic), roughly twice as many subjects die of cardiac causes rather than from influenza pneumonia.

    Over the last three seasons in Italy, two years were marked by prevailing circulation of pandemic H1N1-09 virus (in 2010-11 and in 2012-13) and a year in which the seasonal H3N2 virus prevailed (2011-12). My working hypothesis is that the pandemic virus, targetting the population under 65 years, may have resulted in an excess of mortality from cardiovascular causes, including sudden deaths for ' malore ', in this population, unlike the seasonal virus, which mostly affects the elderly.
    An unconventional research method has been adopted, one based on an examination of news found online using Google Search. Internet can be an innovative tool of great potential used along side, if not replacing, traditional monitoring systems in order to increase detection capabilities, particularly in countries where the monitoring tools have proven inadequate in documenting the true impact of epidemics related to traditional or emerging viruses.

    At other times of the year, outside of the winter , the fatal sudden events with features that I have indicated range around 30 per month. Only in the last 15 days of August 2011, under a heatwave, the incidence was double.
    During the last season (2012-2013) I recorded the following data:

    December 39
    January 65
    February 65
    March 51

    By comparison, in the 2011-12 season, dominated by H3N2 virus and that has been characterized by very high levels of mortality in the elderly, the number of deaths recorded in January was 38 and in February 43 (coinciding with a wave of very low temperatures that hit Italy in the first half of the month). In December and March were 34 and 29 respectively.

    In the period between mid-January and mid-February of the 2011 during the period of maximum circulation of the H1N1 flu virus, in the second year of circulation in Italy and without abnormal cold waves, such deaths were 125.

    from 01/01 to 01/14 31
    from 01/15 to 02/15 125
    from 02/16 to 02/28 24
    March 56

    My survey did not pretend to prove a certain role of pandemic influenza in determining more of these events in individuals younger than 65 years, but wants to be a starting point for methodologically sound investigations to shed light on the association between influenza and cardiovascular diseases, expecially in a country like Italy which lacks rapid mortality indicators adopted by many western countries.

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  • tetano
    Re: Sudden deaths and influenza

    Healthy Birmingham schoolgirl dies of swine flu day after 16th birthday

    A healthy Birmingham schoolgirl died of swine flu the day after celebrating her 16th birthday.

    Amie Prosser collapsed at the family home in Short Heath after complaining of stomach pains.

    Her mum Julie Cooper broke down as she told an inquest of the moment she knew her daughter had died.

    ?I screamed for her brother Anthony and said something had happened to Amie,? she said.

    ?He phoned the ambulance while I tried to get her to breathe again. I knew straight away she was dead ? I knew it.?

    Mrs Cooper said Amie had earlier been violently sick and had been sent home early from school.

    She said the teenager?s lips turned blue as she collapsed in the lounge.

    Amie died on December 10, 2009 ? the day after her birthday ? as a second wave of the deadly H1N1 virus swept the country.

    An inquest at Sutton Coldfield Town Hall heard tests on her body returned positive results for swine flu.

    The precise cause of death was given acute myocarditis ? an inflammation of the heart ? caused by H1N1 influenza.

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  • tetano
    Re: Sudden deaths and influenza

    Pediatric studies show the flu's deadly danger, the benefits of school vaccinations

    Findings among the research featured at first IDWeek conference

    San Diego, CA (October 19, 2012) – New data being presented at IDWeek 2012TM shows the fatal risk that influenza poses even for children without underlying health conditions and the effectiveness of school-based vaccination programs in protecting student populations. Together, these findings support the crucial public health message that families should take the flu virus seriously every year.

    One study viewed influenza from an epidemiological perspective, analyzing U.S. pediatric influenza-associated deaths over an eight-year period and finding that 43 percent of the deaths occurred in children with no health conditions, such as asthma or diabetes, that would have predisposed them to being at high risk of serious flu complications. Moreover, the study found that those young, previously healthy patients succumbed faster. The median duration of illness from onset of initial symptoms to death was four days in children with no underlying high-risk health conditions compared with seven days in children with at least one such condition.

    "During the 2004-2012 influenza seasons, almost half the children who died had been previously healthy," said Karen K. Wong, MD, an Epidemic Intelligence Service officer with the Centers for Disease Control and Prevention (CDC) and the study's lead researcher. "The numbers demonstrate how important it is for all children, even children who are otherwise healthy, to get a flu vaccine every year, and underscore why all children with severe illness should get treated early with influenza antiviral medications."

    The other study looked at influenza from a proactive perspective, assessing the impact of immunization programs in elementary schools in the Los Angeles area and finding lower rates of flu and higher rates of attendance. At one school where nearly half of the students received either a flu shot or the nasal spray, a "herd immunity" seemed to even safeguard the unvaccinated children.

    "It's the school-aged children who spread the flu. They generally are contagious even when active, so they tend to be around other children, giving it to them and spreading it for longer periods of time," said lead researcher Pia Pannaraj, MD, an assistant professor of pediatrics at the University of Southern California and Children's Hospital Los Angeles. "It seems like the best place to prevent community spread of influenza is actually to go and prevent it at the school level."

    This work is among the significant research being discussed at the inaugural IDWeek meeting, taking place through Sunday in San Diego. With the theme Advancing Science, Improving Care, IDWeek features the latest science and bench-to-bedside approaches in prevention, diagnosis, treatment, and epidemiology of infectious diseases, including HIV, across the lifespan. More than 1,500 abstracts from scientists in this country and internationally will be highlighted over the conference's five days.


    New data being presented at IDWeek 2012TM shows the fatal risk that influenza poses even for children without underlying health conditions and the effectiveness of school-based vaccination programs in protecting student populations. Together, these findings support the crucial public health message that families should take the flu virus seriously every year.

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  • tetano
    Re: Sudden deaths and influenza

    Sudden and fulminant deaths of healthy children in Italy during the 2010-11 and 2011-12 seasons: results of an online study
    Stefano Prandoni

    Published: 2012-07-31 15:11:31 | DOI: 10.4081/jphr.2012.e29 | Abstract views: 37
    Search for citations in Google Scholar
    Related articles: Google Scholar


    The 2009 pandemic in Italy has been viewed as a false alarm, and it has not been properly understood based on historical precedents and more in-depth studies that have been conducted in other countries. Some of these studies have pointed to a phenomenon of sudden and fulminant death among healthy children, which is not the sole prerogative of pandemic influenza, but was, in 2009, a more frequent occurrence than in previous years. The purpose of this study is to gather such cases occurring during the 2010-11 and 2011-12 seasons. Google Search was used in order to find cases of children and teens with no reported preexisting conditions of relevance and who died suddenly and unexpectedly after exhibiting flu-like symptoms during the two seasons. During the 2010-11 season, 29 deaths were found to meet the above conditions, 18 of which were fulminant and 11 sudden. For the 2011-12 season, there were ten such cases: five fulminant and five sudden. Most of these cases occurred during the period of maximum circulation of the flu virus. Fulminant deaths were three times more frequent during the first of these seasons and involved children of a higher average age than the more recent season. It is not possible to come to any definite conclusions, but there is reason to suspect that the driver of this significant increase may be the A(H1N1)pdm09 virus. Regardless of how one wishes to interpret these results, it is advisable that the surveillance systems be strengthened and more recent study techniques be adopted in order to determine the causes of similar deaths in the future.

    full article Stefano Prandoni | family pediatrician, Italy. ABSTRACT The 2009 pandemic in Italy has been viewed as a false alarm, and it has not been properly understood based on historical precedents and more in-depth studies that have been conducted in other countries. Some of these studies have pointed to a phenomenon of sudden and fulminant death ... Read more

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  • tetano
    Re: Sudden deaths and influenza

    Vomiting toddler sent home from hospital with ibruprofen... and dies just 22 hours later

    A two-year-old girl died just 22 hours after doctors sent her home from hospital with ibuprofen, an inquest heard.

    Michelle Fernando began displaying flu-like symptoms one week after her mother Uthpala, 27, fell ill swine flu.

    Her concerned father Rashid, 30, took her to Bristol Children?s Hospital but doctors sent her home with the painkiller and advised her parents to give her plenty of water.

    Michelle suddenly stopped breathing the following day and she was rushed back to hospital by ambulance but pronounced dead on arrival.

    Traces of the deadly swine flu virus were found in her nose and throat but a pathologist ruled that she died of pneumonia and septicaemia.
    The inquest at Flax Bourton Coroner?s Court, near Bristol, heard how doctors examined the toddler but sent her home after diagnosing a viral infection on November 17, 2009. But the next night she started having difficulty breathing.


    Read more:

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  • tetano
    Re: Sudden deaths and influenza

    In the course of the season just passed I renewed the work of monitoring deaths that have the characteristics of sudden deaths ( without previous symptoms) and fulminant (shorty after influenza like illnesses) as well as I did during the season 2010/11.

    The interest of the comparison between the two seasons is given by the different epidemiological characteristics , since the first season was dominated by the virus H1N1 ( with a 26% of virus B) and the second by the virus H3N2.

    In the period between mid December and the end of March, which coincides with the prevalent circulation of the influenza virus, I counted a total of 35 deaths, of which 23 in the period between 14/01 and 15/02.

    Over the same periods last season the total deaths were 85 and 44 respectively.

    Many of the deaths occurred in the period in which the circulation of the influenza virus is higher so it is reasonable to suspect that the virus is implicated, at least in a part of the cases, .

    The number of deaths registered during the season 2010/11 is considerably higher ( more than double ) than those of the last season, indicating a possible greater impact linked to the pandemic virus.

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  • Tonka
    Re: Sudden deaths and influenza

    Teen boy dies after collapsing during a hockey game

    Tyler Kerr died after suffering a cardiac arrest at an Ottawa-area hockey arena on Feb. 6, 2012.

    A 15-year-old boy is dead after collapsing at an arena in Carp during a hockey game Sunday, Feb. 5, 2012.
    Updated: Mon Feb. 06 2012 5:43:40 PM

    The family of 15-year-old Tyler Kerr is at a loss as they question how a healthy teen could have suffered a cardiac arrest and die unexpectedly.

    His uncle, Curtis Kerr, told CTV his nephew did not have any known health issues and that they have no idea why his heart suddenly stopped....

    ...CTV has confirmed Kerr was not hurt during the game and that he did not complain about feeling sick leading up to the collapse.

    Autopsy results are pending.

    more from the source.

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  • tetano
    Re: Sudden deaths and influenza

    Myocardial Injury and Bacterial Pneumonia Contribute to the Pathogenesis of Fatal Influenza B Virus Infection
    J Infect Dis. (2012) doi: 10.1093/infdis/jir861

    An autopsy study involving influenza B infections revealed how histologically similar the disease is to fatal influenza A and how quickly it can kill, challenging the notion that it is milder than influenza A.

    Influenza B is more fatal in children, though the disease can cause a substantial number of seasonal flu infections in adults, including some deaths, according to the researchers.

    Of 35 patients with available information, 24 (69&#37 died within 4 days of illness onset.

    The group said the rapid progression from illness onset to death was a notable finding, with durations that were shorter than several other flu viruses, including the 1918 pandemic H1N1, 2009 H1N1, and seasonal H3N2. They added that reasons for the variations, which could relate to the disease itself or various biases, still need to be determined.

    Myocardial injury was seen in 20 (69%) of 29 case-patients for whom samples were available. Investigators found that 17 patients had evidence of myocyte damage, including 10 with myocarditis. They didn't find viral antigens in any of the myocardial samples, though rRT-PCR testing found evidence of influenza B from one patient's myocardial tissue.

    Regarding the cardiac findings, the authors said they were surprised about how frequent evidence of cardiac damage was found, even when tests didn't reveal myocarditis.

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  • tetano
    Re: Sudden deaths and influenza

    In the northern hemisphere winter of 2003–04 antigenic variant strains (A/Fujian/411/02 –like and A/Korea/770/2002-like) of influenza A H3N2 emerged and had drifted antigenically from the A/Panama/2007/99 virus, the H3N2 component of the 2003–2004 influenza vaccine.
    Circulation of these strains in the UK and in USA was accompanied by an unusually high number of laboratory confirmed influenza associated fatalities in children. Several indicators suggest that this season was more severe than the previous three seasons. These indicators included estimates of outpatient visits, pediatric hospitalizations, and influenza-related mortality.

    One hundred fifty-three influenza-associated deaths among children from October 11, 2003, through April 13, 2004, were reported to the CDC by 40 state health departments.

    Seventeen fatal cases of laboratory-confirmed influenza A in children under eighteen years were reported to HPA between September and December 2003.

    The median age of the american children was 3 years (range, 2 weeks to 17 years).

    The median age of british cases was two years, with a range from four months to seventeen years.

    Among the 149 american children for whom information on underlying health status was available, 70 (47 percent) had previously been healthy.

    Among the sixteen british cases for whom underlying health status information was available none was recorded as having a known risk factor for severe influenza.

    Forty-five american children (29 percent) died within three days after the onset of illness, and eight (5 percent) died within one day. Sepsis or shock were diagnosed in 50 (34 percent). 47 (31 percent) died at home or in transit to a health care facility. 31 of the 47 children who died outside a hospital (66 percent) had a temperature of 38&#176;C or higher, 35 (74 percent) had respiratory symptoms, and 18 (38 percent) had gastrointestinal symptoms. 6 died of myocarditis or pericarditis and 2 of myocardial infarction.
    Among the causes of death there was fulminant progression to death after an initially mild illness. The mechanisms of these sudden deaths are unknown but could include an exaggerated inflammatory response to influenza-virus infection or complications of an unrecognized metabolic disorder.

    Four (24&#37 british deaths were sudden with either no recognized antecedent illness or illness of less than 6 hours duration. A further four (24%) occurred within forty-eight hours of onset of symptoms.
    Eight (47%) children died following hospitalization and nine (53%) died in the community. In the cases with recognized antecedent illness, eight (57%) had fever, eleven (79%) had respiratory symptoms (cough/chest infection/croup), three (21%) had vomiting and/or diarrhea, two (14%) had clinically recognized sepsis. Two (14%) children were markedly confused prior to collapse. Myocarditis was detected in two cases (12%).
    The range of clinical complications in UK fatal cases can be grouped into categories including fulminant progression to death after an initially mild illness.

    In the british case series over 40% of death certificates had no mention of influenza as a direct or indirect cause of death, and in over 70% of cases the diagnosis of influenza was not made until post mortem tissue was examined. The burden of influenza in young children is therefore under recognized, precisely because few influenza infections are recognized clinically.The number of deaths is not comprehensive and is likely to underestimate the number of fatal cases that occurred.

    Influenza-Associated Deaths among Children in the United States, 2003–2004
    Niranjan Bhat, M.D., Jennifer G. Wright,et al.
    N Engl J Med 2005; 353:2559-2567December 15, 2005

    Fatal Cases of Influenza A in Childhood.
    Johnson BF, Wilson LE, Ellis J, Elliot AJ, Barclay WS, et al. (2009)
    PLoS ONE 4(10): e7671. doi:10.1371/journal.pone.0007671

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