Manitoba Keewatinowi Okimakanak (MKO) Grand Chief David Harper said at a press conference in Winnipeg Dec. 3 that more than 20 people are being treated for influenza on the Garden Hill First Nation -- including a three-year-old and five-year-old -- and the reserve and surrounding Island Lake First Nations face a "potential pandemic," Brennan Manoakeesick, assistant to the grand chief and special projects co-ordinator, said a day earlier.

Manoakeesick is from the Garden Hill First Nation.

"(Provincial officials) are saying this is just a common flu, but when people are coughing up blood, this is not a regular flu," Harper said.

Two confirmed cases of Influenza A have resulted in death in the Island Lake region, says Manoakeesick. "The MKO leadership is urgently appealing for emergency medical care within their remote and isolated First Nations," he said.

Harper said a 35-year-old woman was the first victim about a week ago, while a man, also about 35, died Dec. 2.

Both people from Garden Hill who died with Influenza A also had underlying medical problems and health officials are trying to determine what role the virus played in their deaths, Dr. Joel Kettner, Manitoba's chief provincial public health officer, said Dec. 3. In a normal year anywhere from 50 to 100 Manitoba residents will die of influenza-related illness, Kettner said, with many in poor health to begin with, including the elderly or those with chronic health problems.

Kettner said additional physician services, provided through the Northern Medical Unit, have been sent to the community, but he didn't give specifics. "They're watching the situation very closely and will do everything they can to provide appropriate additional services as needed."

Kettner said the province believes that Garden Hill is experiencing a seasonal outbreak of A/H3N2 influenza.

The Public Health Agency of Canada says "circulation of the H1N1 flu virus in Canada is very low at this time." The World Health Organization (WHO) in Geneva says H1N1 is now in the "post-pandemic period" and influenza disease activity will have returned to levels normally seen for seasonal influenza. "It is expected that the pandemic virus will behave as a seasonal influenza A virus."

The novel H1N1 influenza pandemic, which started in Mexico in March 2009, albeit with relatively mild symptoms in most cases, was the first pandemic since the Hong Kong Flu of 1968. It originated in Guangdong Province in southeast China, but the first record of the outbreak was in Hong Kong on July 13, 1968.

By the end of July, extensive outbreaks were reported in Vietnam and Singapore. By September 1968, Hong Kong Flu reached India, Philippines, northern Australia and Europe. That same month, the virus entered California via returning Vietnam War troops but did not become widespread in the North American until December 1968.

A vaccine became available in 1969 one month after the Hong Kong flu pandemic peaked in North America. About a million people died worldwide in what are described as "excess" death beyond what be expected in a normal flu season, but still only half the mortality rate of the Asian flu a decade earlier. H1N1 swine flu is the first worldwide influenza pandemic since the Hong Flu of 1968-69.

A decade earlier, the The Asian Flu pandemic of 1957 was an outbreak of avian-origin H2N2 influenza that originated in China in early 1956 and lasted until 1958. It originated from mutation in wild ducks combining with a pre-existing human strain. The virus was first identified in Guizhou and spread to Singapore in February 1957, reaching Hong Kong by April and the United States and Canada by June 1957. Estimates of worldwide deaths caused by the Asian Flu pandemic vary, but the World Health Organization believes it is about two million.

The Asian Flu strain later mutated through antigenic drift into H3N2, resulting in the milder Hong Kong Flu pandemic of 1968 and 1969.

Influenza A viruses are classified into subtypes on the basis of two surface proteins: hemagglutinin (H) and neuraminidase (N).

Three subtypes of hemagglutinin (H1, H2 and H3) and two subtypes of neuraminidase (N1 and N2) are recognized among influenza A viruses that have caused widespread human disease, says the Public Health Agency of Canada. "Since 1977 the human H3N2 and human H1N1 influenza A subtypes have contributed to influenza illness to varying degrees each year. It is not yet known if this pattern will be altered by the emergence of the 2009 pandemic virus [A/California/7/2009 (H1N1)]. Immunity to the H and N antigens reduces the likelihood of infection and lessens the severity of disease if infection occurs."

Influenza B viruses have evolved into two antigenically distinct lineages since the mid-1980s, represented by B/Yamagata/16/88-like and B/Victoria/2/87-like viruses. Viruses of the B/Yamagata lineage accounted for the majority of isolates in most countries between 1990 and 2001. Viruses belonging to the B/Victoria lineage were not identified outside of Asia between 1991 and 2001, but in March 2001 they re-emerged for the first time in a decade in North America. Since then, viruses from both the B/Yamagata and B/Victoria lineages have variously contributed to influenza illness each year.

The antigenic characteristics of current and emerging influenza virus strains include A/California/7/2009 (H1N1)-like, A/Perth/16/2009 (H3N2)-like and B/Brisbane/60/2008 (Victoria lineage)-like antigens.

Garden Hill First Nation is situated on Island Lake and adheres to Treaty No. 5. The reserve covers about 18,180 acres and is only accessible by winter road or air. The language in the community is Oji-Cree, often referred to as the Island Lake dialect. Garden Hill has more than 4,000 band members. Harper said the reserve has only one doctor for its 4,000 residents and its ongoing problems with overcrowded housing and lack of running water are making a bad situation worse.

Manitoba Keewatinowi Okimakanak Inc. is a non-profit, political advocacy organization that has represented 30 First Nation communities in Northern Manitoba since 1981.

Northern Manitoba's St. Theresa Point First Nation and Island Lake First Nations were hit very hard in May 2009 by the H1N1 human swine flu pandemic, which began in Mexico two months earlier, during the first flu wave, especially between mid-May and mid-June of last year, when cases swept through isolated First Nations communities in the southernmost part of the Burntwood Regional Health Authority's (BRHA) catchment area.

The BRHA, however, has no jurisdiction over delivering health care services to First Nations Inuit Health (FNIH) communities with federal nursing stations and where the federal government has primary health care responsibility.

Manitoba Health Public Health Epidemiology and Surveillance, in their most recent statistics available for cases reported up to Nov. 27, says there had been 37 laboratory-confirmed cases of Influenza A identified at the Cadham Provincial Laboratory in Winnipeg.

Since Sept. 1, the National Microbiology Laboratory (NML) reported that it had antigenically typed 10 influenza virus samples received from Cadham Provincial Laboratory as A/H3N2 and the other 27 cases were A unsubtyped, but were negative for Pandemic H1N, for a total of 37 influenza cases in Manitoba.

"The Influenza A/H3N2 virus characterized by National Microbiology Laboratory was antigenically related to A/Perth/16/2009-like. The isolate was found to be resistant to Amantadine [but] sensitive to Oseltamivir and Zanamivir antiviral agents," Manitoba Health Public Health Epidemiology and Surveillance reported.

The National Microbiology Laboratory (NML), also in Winnipeg, is responsible for the identification, control and prevention of infectious diseases and is located at the Canadian Science Centre for Human and Animal Health.

It is the only Canadian facility to have high containment laboratories for human and animal health in one location. It is equipped with laboratories ranging from Biological Safety Level 2 (BSL 2) to Biological Safety Level 4 (BSL 4), which means it is designed to accommodate the most basic to the most deadly infectious organisms.

The National Microbiology Laboratory is Canada's only operational Biological Safety Level (BSL 4) containment laboratory and one of just 15 such laboratories in the world.