MBayFluWatchMonterey Bay's Pandemic Flu Watch...keeping Monterey Bay communities informed about influenza |
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MBayFluWatchMonterey Bay's Pandemic Flu Watch...keeping Monterey Bay communities informed about influenza |
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Andrea Gerlin, a writer for Bloomberg, reports that the European Centre for Disease Prevention and Control (ECDC) registered 84 deaths resulting from influenza A(H1N1) in 31 European Union and European Free Trade Association (EFTA) member states during the week of November 2, compared with 43 the previous week. According to the ECDC, 414 people in Europe (including countries that do not belong to the EU or EFTA, such as Russia) have died from influenza A(H1N1) since the outbreak began in Mexico and the U.S. in April of this year. Almost 80 percent of all influenza A(H1N1) cases in Europe have occurred in people under 30 years of age. The influenza A(H1N1) outbreak has been most severe in northern European countries such as Ireland, Iceland, and the Ural region of Russia. Norway, Sweden, England, and the Netherlands have also experienced significant numbers of the illness. The article quotes Denis Coulombier, head of the ECDC's unit of preparedness and response, as stating: "We are globally entering the acceleration phase. We are heading toward the peak for sure."
Edward Wong, a writer for New York Times, reports on China's aggressive measures to slow the transmission of influenza A(H1N1). The measures that have proven effective in preventing the spread of flu include isolating entire plane loads of people entering the country if anyone on the flight exhibits flu-like symptoms and cancelling classes if anyone in a school appears sick. As a result, China has not had to cope with an overwhelming number of influenza A(H1N1) cases. China was also the first country in the world to begin administering the influenza A(H1N1) vaccine, already in early September of this year. As of November 10, the Chinese Center for Disease Control Prevention has registered more than 59,000 influenza A(H1N1) cases, of whom at least 30 died.
According to foreign officials, China has demonstrated an unusual openness in information sharing about influenza A(H1N1) with its citizens and other governments, which contrast significantly to the secretive approach it took when affected by severe acute respiratory syndrome (SARS) during 2002-2003. The article quotes Dr. Michael O'Leary, the director of WHO's Beijing office, as stating: "I think there were a variety of measures put in place by different countries, and it's difficult to say what worked best and what didn't, but China's has worked very well."
A report by Radio Free Europe/Radio Liberty' Russian Service from Ulan-Ude states that the president of Buryatia (a region in south-central Russia) Vyacheslav Nagovitsin signed a regulation banning all mass gatherings and events in the region due to the influenza A(H1N1) emergency. It also instructs inhabitants to wear a surgical mask when in public. As of November 5, Buryatia's health officials have confirmed 72 influenza A(H1N1) cases. In the Baikal region of Zabaikalye health officials have introduced a similar regulation, where violators may be subject to a 500 ruble ($17) fine. Health officials in the Far Eastern Khabarovsk Krai (province) ordered all theatre- and movie-goers to wear surgical masks. All those who work behind a counter and public transportation workers also must wear surgical masks. Khabarovsk's health officials have confirmed a three times higher rate of influenza and respiratory diseases in 2009 as compared to recent years.
A team of Radio Free Europe/Radio Liberty reporters have written a review of the influenza A(H1N1) situation in Central Asian and Caucasus regions – see below. They raise the question about how many of the reported flu cases may be influenza A(H1N1) rather than ordinary flu. The symptoms of both diseases are easily confused and in many countries health providers have limited experience with diagnosing the new A(H1N1) strain.
News agencies report that the influenza A(H1N1) pandemic has become especially severe in Ukraine, where nearly 70 people have died from this disease. On November 4, the Ukrainian Health Ministry asserted that the number of flu patients in the country has risen to 450,000, although health officials are not certain as to how many of those people actually have contracted influenza A(H1N1). Only two days previously, the ministry claimed that 255,000 Ukrainians, including 83,000 children, have been registered by public health authorities as having contracted swine flu. Authorities closed all schools for three weeks to avoid the spread of flu and banned large public gatherings.
Iran's health officials are warning the public of the need for additional precautions amid reports of a worsening flu situation. The Mehr news agency quotes Majlis Health Commission spokesman Mohammadreza Rezaei Kuchi as claiming that 3,000 Iranian citizens have been infected with influenza A(H1N1), of whom 28 died. Authorities have closed approximately 70 schools in Tehran, as well as many other schools throughout the country.
Afghanistan has declared a nationwide public health emergency and closed all educational institutes for three weeks. Afghanistan's Health Minister Said Mohammad Amin Fatami has reported approximately 700 confirmed influenza A(H1N1) cases, with 273 of those being foreign soldiers stationed in the country. Eight Afghans reportedly have died to date.
Jonathan Lynn, a writer for Reuters, reports on an WHO announcement stating that influenza A(H1N1) vaccine recipients need only one dose of the vaccine. WHO recommends that adults and adolescents over age 10 should receive a single dose of influenza A(H1N1) vaccine, whereas the vaccines' effectiveness in children younger than 10 years remains unclear. WHO's guidance on influenza A(H1N1) vaccination is important for vaccine producers' investment decisions, as well as on government policies on purchasing and distributing vaccines.
The article also reassures influenza A(H1N1) vaccine recipients world-wide that the vaccine is safe to use. It quotes Marie-Paule Kieny, the director of WHO's vaccine research, as saying: "All the reports received to date following vaccination -- either in clinical trials or in mass vaccination campaigns -- have shown that the safety profile of these pandemic vaccines is good and is very similar to the one which is known for seasonal influenza vaccine. Nothing special in terms of adverse events has been noted." WHO's Strategic Advisory Group of Experts on Immunisation (SAGE) advises that influenza A(H1N1) vaccines do not cause any severe complications, such as illness or death. As a result, SAGE recommends that pregnant women, a population particularly vulnerable to influenza A(H1N1), should receive the vaccine.
Avelar Martinez, a writer for La Prensa Grafica Loida, reports that Salvadoran health officials have identified four cases of simultaneous influenza A(H1N1) and dengue virus infections. El Salvador's Vice Minister of Health, Violeta Menjivar excluded the probability that the intersection of these viruses will occur at the national level, because local health officials have reinforced the necessary preventive sanitary measures. As of 24 October, El Salvador has reported six deaths from dengue fever and 22 from influenza A(H1N1).
A report by Radio Free Europe/Radio Liberty (RFE/RL) states that authorities in the far northern Russian city of Murmansk have closed all schools in the region due to an outbreak of influenza. Secondary schools in the region were closed on October 20 as the number of students hit by the flu virus increased drastically. On October 22, it was decided to send all students in the region on fall break early as the flu continued to spread. Murmansk Oblast Education and Science Minister Vasily Kostukevich told RFE/RL it is the first time such precautions have been taken. Currently, all the schools in the region are under the control of health officials. This outbreak is due to seasonal flu; no cases of influenza A(H1N1) have been reported.
Influenza has also prompted school closings in Iraq, but in that country the cause is fear of influenza A(H1N1), not seasonal flu. John Leland, a writer for New York Times reports that school authorities have closed 2,500 schools throughout the country. Since only 121 influenza A(H1N1) cases have so far been confirmed in Iraq, many health officials have called the action an overreaction due to a panic. While Iraq's schools provide a fertile environment for the spread of influenza A(H1N1) due to overcrowding, government health officials' inability to inform parents about the disease spread, a shortage of doctors and nurses, and poor sanitary conditions, an epidemic has not yet occurred.
Robert Roos, a writer for Center for Infectious Disease Research & Policy, University of Minnesota (CIDRAP), reports on a WHO announcement listing population groups that face the greatest risk of becoming severely infected with influenza A(H1N1); pregnant women, children younger than two years, and people with chronic lung disease. Disadvantaged populations, such as minority groups and indigenous people, as well as groups that lack access to healthcare are also disproportionately susceptible to severe influenza A(H1N1) infection. In addition, the announcement highlights asthma, diabetes, and obesity as preconditions for a higher than normal probability of becoming infected with influenza A(H1N1).
According to CIDRAP, WHO currently is most concerned about "small subsets of patients who rapidly develop very severe progressive pneumonia" because in these patients, "severe pneumonia is often associated with failure of other organs, or marked worsening of underlying asthma or chronic obstructive airway disease." WHO predicts that treating these patients will deplete the majority of emergency rooms' and intensive care units' capacity during the ongoing pandemic; a prediction that is in agreement with similar reports that have been recently published in several medical journals.
BBC reports on a WHO announcement to the effect that pharmaceutical companies and a group of wealthy nations will donate millions of doses of influenza A(H1N1) vaccine to about 100 poorer countries. The article quotes WHO's head of vaccine research, Dr. Marie-Paule Kieny as saying that: "We are trying to have a first [influenza A(H1N1)] vaccine delivery [to poorer countries] starting in November. The idea is to start with northern hemisphere countries first since winter is approaching in this hemisphere." According to Dr. Kieny, the priority group for receiving the vaccine in poorer countries is health workers.
Sanofi-Aventis and GlaxoSmithKline will donate about 150 million doses of influenza A(H1N1) vaccine, whereas another pharmaceutical company, Medimmune, will donate an unspecified amount of vaccine. Besides vaccination, WHO recommends school closures, avoidance of large gatherings, antibiotic treatment for secondary infections, and the maintenance of high levels of personal hygiene as other measures to counter the spread of influenza A(H1N1).
AFP reports that Google added Japan, Russia, and several European countries to Google Flu Trends, a flu-tracking web site that provides information about 20 countries in 37 languages. Google launched this site in November 2008 and it is available at: google.org/flutrends/
Health analysts may apply Google Flu Trends to count number of flu-related queries on Google's internet search engine and use that data to make estimates on influenza outbreaks in respective regions. AFP quotes Google engineers Matt Mohebbi and Dan Vanderkam as claiming that "By tracking the popularity of certain Google search queries, we are able to estimate the level of flu, in near real-time." Google claims that Internet users tend to search for influenza-related terms when they, or people they know, exhibit symptoms of influenza.
Alexander G. Higgins, a writer for Associated Press, reports on an WHO announcement claiming that besides a few minor side effects, vaccine remains the best protection against influenza A(H1N1). WHO has based this claim on the initial results of the influenza A(H1N1) vaccination campaign in China, where four out of 39,000 vaccine recipients have reported on side effects such as muscle cramps and headache. The article quotes WHO spokesman Gregory Hartl as saying: "Adverse events are fully to be expected, especially these mild types. The vaccine is the single most important tool that we have against influenza."
In the U.S., mass vaccination against influenza A(H1N1) is scheduled to begin in late October. U.S. health authorities hope to quickly detect any detrimental side-effects, regardless of how rare, that may be caused by the vaccine and not pure coincidence. In 1976, a very small number of American influenza vaccine recipients were diagnosed with Guillain-Barre syndrome, a rare paralyzing condition that is sometimes fatal, months after having received the vaccine. Scientists, however have never been able to conclusively demonstrate the alleged link between the 1976 influenza and the syndrome. But no one wishes to repeat the 1976 experience, so the heightened level of monitoring efforts are therefore being instituted.
Helen Branswell, a writer for Canadian Press, reports that WHO influenza vaccine experts were unable to reach a consensus upon whether seasonal flu vaccine leads to and increased probability of its recipients being susceptible to influenza A(H1N1) infection, as found by a recent Canadian study. The article quotes David Wood, co-ordinator of the quality, safety and standards team of WHO's department of immunization, vaccines and biologicals, as stating that: "It didn't seem very likely that we're going to be able to . . . suddenly come up with the magic explanation as to why the Canadian data are different to others. In the short term, this is really probably as far as we're going to get. The fact that it's just been seen in Canada at the moment, I don't think that that's going to force global policy changes."
WHO's strategic Advisory Group of Experts on Immunization, a group that makes recommendations for the WHO on vaccination policy, will analyze the Canadian case in late October. According to Wood, WHO will probably not change its vaccination protocol this fall.
So far, American, British, and Australian scientists have not detected a similar link between seasonal flu vaccine and influenza A(H1N1) infection s did the Canadians. Furthermore, scientists from these countries have speculated that the Canadian data may include factors that can lead to false results. For instance, if people who receive seasonal flu vaccination are also more likely to seek a diagnosis of influenza A(H1N1) if they become infected, it might appear that more of them developed the illness, when in actuality; it is more probable that a higher number of their illnesses were recorded.
Jason Gale, a writer for Bloomberg, reports on a recent study where doctors in Australia and New Zealand have found that A(H1N1) flu is most dangerous when it causes the lungs to become inflamed, flooded with fluid, and then fail to function. In severe cases influenza viruses can damage the capillaries surrounding the tiny grape-like sacs, known as alveoli, which are the primary sites for gas exchange with blood. Damaged alveoli can bleed, causing pulmonary hemorrhage and blood clots. The invading viruses stimulate the immune system to produce a multitude of chemicals whose purposes are to fight the infection and repair damages to tissues. However, if there is an over-exuberant response that results in too much of these chemical being produced, it will have negative effects by filling the lungs with fluid and causing permanent scarring that restricts the ability of lungs to affect efficient gas exchange.
The doctors described the most common of three main complications from the pandemic strain as flu A-associated acute respiratory disease syndrome, or "flaards." According to the authors, besides flaards, two other disease patterns are associated with the pandemic flu virus, namely community-acquired bacterial pneumonia and an exacerbation of problems that limit airflow within lungs.
Katie Derosa, a writer for Vancouver Sun, reports that British Colombia may suspend seasonal flu shots for the younger population. This possible decision is based on the results of a recent Canadian study suggesting that people who receive normal flu vaccine are twice as likely to contract the A(H1N1) virus. Even though this study is still under peer review, health officials in several Canadian provinces other than British Columbia have suspended seasonal flu shots for anyone younger than 65.
Xinhua reports on an announcement by Mexican Health Minister Jose Angel Cordova stating that the country's public hospitals are instituting new measures to deal with a renewed outbreak of the A(H1N1) influenza virus including delaying non-essential surgeries and reserving 12 percent of their available beds for A(H1N1) flu patients. Furthermore, Mexican hospitals have established special zones to quarantine patients infected with the A(H1N1) flu.
According to most recent estimates, A(H1N1) flu patients could fill 8,000 to 10,000 hospital beds in the coming winter, i.e. between 9.4 percent and 11.8 percent of hospital beds available in the whole country. The article also quotes Victor Hugo Borja, a Mexican Social Security Institute (MSSI) contingence coordinator, as saying that MSSI is prepared to assist up to 900,000 A(H1N1) patients.
Bob Grant, a writer for Scientist's blog, reports that the biopharmaceutical companies (Novartis, GlaxoSmithKline, MedImmune, Australian drug maker CSL, and Sanofi-Pasteur) that have been contracted by the U.S. Department of Health and Human Services (HHS) for development and production of more than 195 million doses of A(H1N1) flu vaccine will make hundreds of millions of dollars in profits. For instance, CSL's profits from supplying A(H1N1) vaccine to Australian and U.S. governments will likely fall between $218 and $262 million. Normally, drug companies do not announce these types of figures because most of the time their profits can only be estimated.
The US government recently tasked MedImmune, a Maryland-based subsidiary of the drug maker AstraZeneca, to supply an additional 29 million doses of its live attenuated nasal spray A(H1N1) vaccine, bringing the company's total contract to 40 million doses worth more than $450 million. No financial details have been announced for Sanofi-Pasteur's latest contract, where the US government ordered an additional 27 million doses of bulk antigen on top of the more than 75 million doses of monovalent A(H1N1) vaccine the company has already agreed to provide. Meanwhile Novartis has received $690 million from the US government for A(H1N1) vaccine production.
CBC News Canada reports that Dr. Don Low, microbiologist-in-chief at Mount Sinai Hospital in Toronto, claims the seasonal flu shot may put people at greater risk for getting A(H1N1) flu. "This is some evidence that has been floated. It hasn't been validated yet, it's very preliminary. This is obviously important data to help guide policy decisions. How can we best protect people against influenza?" the article quotes Dr. Low as saying. His statement is based on four Canadian studies that involved about 2,000 people, where researchers found that people who had received the seasonal flu vaccine in the past were more likely to get sick with the A(H1N1) virus.
In view of these findings, Canadian public health authorities are debating the idea of shortening, delaying, or scrapping their seasonal flu vaccination campaign in favor of mass inoculations against A(H1N1). They argue that the A(H1N1) may be the dominant strain of influenza circulating this flu season, so the seasonal flu vaccine campaign could be a waste of time and resources.
Yahoo News writer Marianne Marriaux reports that China will become the first country in the world to start vaccinating their population against A(H1N1) flu. The vaccination campaign will start on October 1 when health officials will seek to immunize around 100,000 students who were expected to participate in National Day activities. The A(H1N1) flu shots for students will be free and be administered on a voluntary basis. Medical workers, border inspection, transportation workers, military and police, other kindergarten, elementary and middle school students and teachers, and those with chronic heart and lung diseases have priority for early vaccinations. Shipments of vaccines have been distributed to eight provinces including Guangdong, Shandong, Sichuan and Hunan, where A(H1N1) outbreaks have been the most severe.
In 2009, China's health ministry plans to vaccinate 65 million people, or five percent of the country's total population of 1.3 billion. So far, the Chinese government has approved five companies to produce the vaccine.
The A(H1N1) virus has spread to all of China's 31 provinces and regions and 95 percent of the cases are being transmitted domestically, rather than via travellers from abroad. As of September 21st, China had recorded 13,262 cases of A(H1N1) flu. No deaths have yet been reported.
Stephanie Nebehay, a writer for Reuters, reports that the weekly production of A(H1N1) vaccine over the next year will be less than the previously expected amount of 94 million doses a week, making it difficult to reach 4.9 billion doses for the year 2010, as previously estimated by the World Health Organization (WHO). WHO's estimate of 4.9 billion doses had been based on two assumptions: drug makers switching all their production of seasonal flu vaccine to the production of A(H1N1) vaccine, and obtaining good yields and using an immune booster known as an adjuvant to stretch supplies.
WHO estimates that about every third person on the planet could be affected by the A(H1N1) pandemic. Despite its concerns that the current global A(H1N1) vaccine supply is not adequate for the world's needs, the organization sees a positive turn in this issue after the United States, Australia, Brazil, Britain, France, Italy, New Zealand, Norway, and Switzerland pledged to donate 10 percent of their A(H1N1) vaccine supplies to less developed countries. WHO reiterated its recommendation that people be inoculated against both seasonal and A(H1N1) flu.
Michelle Fay Cortez, a writer for Bloomberg News, reports that WHO believes that Tamiflu resistant A(H1N1) influenza virus strains are less contagious than normal strains. "It's a very specific genetic mutation that causes resistance and reduces the transmissibility of the virus, so it's not infectious," David Mercer, acting head of the communicable diseases unit of the WHO's European region explains in the article. Mercer recommends that healthy seasonal flu patients with "uncomplicated illness" should not get Tamiflu, because the virus is "almost entirely resistant" to it. "Overuse of Tamiflu could result in the same thing for A(H1N1) flu" Mercer warned. According to Mercer, in Europe there have been 23 cases of persons having become ill with Tamiflu-resistant A(H1N1) flu strains.
In the United Kingdom, where about 90 percent of Europe's deaths caused by the A(H1N1) have occurred, health officials in April started providing Tamiflu on request to people who had come into contact with pandemic flu patients, in an attempt to slow the spread of the disease. For patients with seasonal influenza that do not respond to Tamiflu, the only treatment option is an inhaled drug called Relenza.
Last week, Chinese manufacturer Sinovac Biotech Ltd. announced that it has developed an A(H1N1) flu vaccine that requires a single standard dose to be effective. Previously, it was thought that it would take two doses to achieve the same result. Now, CBS News reports that Australian vaccine maker CSL Ltd. and the U.S. National Institutes of Health have confirmed the effectiveness of a single dose flu shot.
The CSL study concluded that one shot prompted the same kind of immune response indicating protection that is achieved with regular flu vaccines. Vaccine recipients will be protected eight to 10 days after the inoculation. Vaccine studies on children have not yet been completed.
AP reports that top health officials from Canada, the United States, Japan, Germany, France, Italy, and Great Britain attended the meeting held in Brussels and agreed that the highest priority for first doses of A(H1N1) influenza vaccines should be accorded to pregnant women, health workers, and those presenting with risky health conditions. Representatives of Mexico, Sweden (which holds the rotating EU presidency), and Spain, (which will be the next holder of EU presidency), were also present.
AFP reports that the World Health Organization (WHO) has urged Asian countries to prepare for a surge in A(H1N1) flu cases because winter in the northern hemisphere is approaching. WHO specialists are especially concerned about the spread of A(H1N1) in Asia because so far, the region has been relatively lightly affected.
"A winter surge is a real possibility in the Southeast Asia region. It is important to allocate appropriate resources and maintain the overall pandemic preparedness," Samlee Plianbangchang, WHO director for Southeast Asia, is quoted as saying. WHO considers Southeast Asia to include Bangladesh, Bhutan, North Korea, India, Indonesia, the Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and East Timor.
WHO has said it has given technological and financial assistance to three major vaccine manufacturers in the region, but that the new vaccines may not be available before winter starts. In addition, it has urged more public information, such as reminders about the importance of washing hands, respiratory hygiene, and cough etiquette, to slow the spread of the disease.
The PigProgress.com new service reports that Joel Haggard, senior vice president of the U.S. Meat Export Federation (USMEF), spoke at the Fifth International Meat Secretariat (IMS) World Conference in Qingdao, China, on Thursday, September 3, which was attended by more than 600 global pork industry executives. He stated "In the early stages of the outbreak, 64 percent of Chinese consumers refrained from pork consumption. The research suggests that the initial Chinese consumer reaction to A(H1N1) was sharp, and that a significant number of consumers may still associate the virus with pork and hogs." Haggard was citing findings from a survey 200 consumers in each of six Chinese cities: Beijing, Shanghai, Chongqing, Guangzhou, Nanjing and Shenyang.
Even months after the initial outbreak in April, 21.2 percent of those surveyed still believe that eating pork can lead to catching the A(H1N1) virus. Despite efforts by the Chinese government to educate consumers regarding the safety of pork, 54.7 percent of those who fear the connection between pork and the flu virus say that it is because the virus has been labeled "swine flu. It is feared that China — both the world's largest pork producer and consumer — has been more affected by the A(H1N1) virus outbreak than previously suspected.
Commenting on this survey, ProMED noted that the international agencies Food and Agriculture Organization, International Office of Epizootics (OIE), and World Health Organization (WHO) in May 2009 published a common statement pertaining to pork safety, which included the following:
"Influenza viruses are not known to be transmissible to people through eating processed pork or other food products derived from pigs. Heat treatments commonly used in cooking meat (such as 70 deg C/160 deg F core temperature) will readily inactivate any viruses potentially present in raw meat products. Pork and pork products, handled in accordance with good hygienic practices recommended by the WHO, Codex Alimentarius Commission, and the OIE, will not be a source of infection."
Betsy McKay and Gordon Fairlough, writers for the Wall Street Journal, report that the Chinese vaccine maker Sinovac Biotech Ltd. won approval from China's drug regulator for the commercial production of that country's first A(H1N1) flu vaccine, and said it is effective with a single standard injection. China predicts that by the end of the year its vaccine manufacturers will produce enough vaccine for about 65 million people, or about 5 percent of its population. That would exceed China's usual seasonal flu-vaccination rate.
U.S. officials are hoping for similar results from American clinical trials. The Chinese vaccine is similar to the shots that are being tested in the U.S., according to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Initial results are expected sometime within the next two weeks.
Furthermore, Novartis AG, a Swiss pharmaceuticals company, reported that its A(H1N1) flu vaccine also prompted a strong immune response after a single dose in a pilot trial. The company said that two doses provided better protection, but that its study suggested one dose could be enough to protect adults against A(H1N1) flu.
The WHO has warned that there is not enough production capacity to produce shots for the world's entire population. About 25 companies are making A(H1N1) pandemic vaccines. The U.S. has ordered 195 million doses from five companies, and is expected to receive the first 45 million to 52 million doses in mid-October.
Ting Kheng Siong and Hoe Yeen Nie, writers for Channel News Asia, report that the pork sales in Singapore dropped by 40 percent a day after some live pigs infected with the A(H1N1) flu virus were imported from Indonesia. Even though authorities have assured that there is no risk of catching the virus from eating pork, if cooked properly, consumers prefer not to take any risks.
Tan Hoo Leong, a pork seller, is quoted as saying "Usually by this time of the day, most of us would have sold everything. But today, there is still some left. Business has gone down 30, 40 percent." At this time of the year Chinese usually eat large amounts of pork because of the seventh lunar month, when people traditionally offer pork to the hungry ghosts.
On 28 August, the World Health Organization (WHO) published its Briefing Note 9. The following are excerpts from that Note. The entire note can be accessed at:
http://www.who.int/csr/disease/swineflu/notes/h1n1_second_wave_20090828/en/index.html
"Monitoring of outbreaks from different parts of the world provides sufficient information to make some tentative conclusions about how the influenza pandemic might evolve in the coming months. Thus, WHO is advising countries in the northern hemisphere to prepare for a second wave of pandemic spread. Evidence from multiple outbreak sites demonstrates that the H1N1 pandemic virus has rapidly established itself and is now the dominant influenza strain in most parts of the world. The pandemic will persist in the coming months as the virus continues to move through susceptible populations.
"Monitoring of viruses by a WHO network of laboratories shows that viruses from all outbreaks remain virtually identical. Studies have detected no signs that the virus has mutated to a more virulent or lethal form. Likewise, the clinical picture of pandemic influenza is largely consistent across all countries. The overwhelming majority of patients continue to experience mild illness. Although the virus can cause very severe and fatal illness, also in young and healthy people, the number of such cases remains small.
"Large numbers of people in all countries remain susceptible to infection. Even if the current pattern of usually mild illness continues, the impact of the pandemic during the second wave could worsen as larger numbers of people become infected. Larger numbers of severely ill patients requiring intensive care are likely to be the most urgent burden on health services, creating pressures that could overwhelm intensive care units and possibly disrupt the provision of care for other diseases.
"Current evidence points to some important differences between patterns of illness reported during the pandemic and those seen during seasonal epidemics of influenza. The age groups affected by the pandemic are generally younger. This is true for those most frequently infected, and especially so for those experiencing severe or fatal illness. To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in stark contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older.
"Perhaps most significantly, clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays. Preparedness measures need to anticipate this increased demand on intensive care units, which could be overwhelmed by a sudden surge in the number of severe cases.
"An increased risk during pregnancy is now consistently well-documented across countries. This risk takes on added significance for a virus, like this one, that preferentially infects younger people. Data continue to show that certain medical conditions increase the risk of severe and fatal illness. These include respiratory disease, notably asthma, cardiovascular disease, diabetes, and immunosuppression. When anticipating the impact of the pandemic as more people become infected, health officials need to be aware that many of these predisposing conditions have become much more widespread in recent decades, thus increasing the pool of vulnerable people. Obesity, which is frequently present in severe and fatal cases, is now a global epidemic. WHO estimates that, worldwide, more than 230 million people suffer from asthma, and more than 220 million people have diabetes. Moreover, conditions such as asthma and diabetes are not usually considered killer diseases, especially in children and young adults. Young deaths from such conditions, precipitated by infection with the H1N1 virus, can be another dimension of the pandemic's impact.
"Several early studies show a higher risk of hospitalization and death among certain subgroups, including minority groups and indigenous populations. In some studies, the risk in these groups is four to five times higher than in the general population. Although the reasons are not fully understood, possible explanations include lower standards of living and poor overall health status, including a high prevalence of conditions such as asthma, diabetes and hypertension. Such findings are likely to have growing relevance as the pandemic gains ground in the developing world, where many millions of people live under deprived conditions and have multiple health problems, with little access to basic health care. As much current data about the pandemic come from wealthy and middle-income countries, the situation in developing countries will need to be very closely watched. The same virus that causes manageable disruption in affluent countries could have a devastating impact in many parts of the developing world.
"The 2009 influenza pandemic is the first to occur since the emergence of HIV/AIDS. Early data from two countries suggest that people co-infected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided these patients are receiving antiretroviral therapy. In most of these patients, illness caused by H1N1 has been mild, with full recovery. If these preliminary findings are confirmed, this will be reassuring news for countries where infection with HIV is prevalent and treatment coverage with antiretroviral drugs is good. On current estimates, around 33 million people are living with HIV/AIDS worldwide. Of these, WHO estimates that around 4 million were receiving antiretroviral therapy at the end of 2008.
"Only a handful of pandemic viruses resistant to oseltamivir have been detected worldwide, despite the administration of many millions of treatment courses of antiviral drugs. All of these cases have been extensively investigated, and no instances of onward transmission of drug-resistant virus have been documented to date. Intense monitoring continues, also through the WHO network of laboratories."
Maria Cheng, a medical writer for Associate Press, reports that a poll taken of 2,255 Hong Kong health workers, approximately half stated that they would refuse the swine flu vaccine. Most of those who said they would pass on the swine flu shot gave as reasons that they were afraid of side effects and doubted how safe and effective it would be. The poll results were published online in the BMJ, formerly known as the British Medical Journal, on 26 July.
The WHO recommends countries vaccinate their health workers. Officials of several Western countries including Great Britain, Spain, and the U.S. have said doctors and nurses will be among the first to get swine flu shots. The reason is that doctors and nurses are on the public health front lines — and if they become infected, they may not only spread the disease to patients, but their absence from work could cripple health systems. Paul Chan of the Chinese University of Hong Kong, one of the study authors, thought the results would be similar elsewhere. Fewer than 60 percent of health workers in most countries get vaccinated against regular flu, thought to be a reliable indicator of whether they will chose to receive the swine flu vaccine. In the U.S., about 35 percent of health workers get a regular flu shot, while in Great Britain, only about 17 percent do.
George Annas, a bioethics expert at Boston University, is quoted as saying "A good argument can be made that health workers have an ethical obligation to be vaccinated, not to protect themselves, but to protect their patients. But if they don't believe that vaccine to be safe and effective, it will be a hard sell."
Several drug makers are testing their swine flu vaccines. So far, officials say that among the few thousand people who have been injected, no one has reported anything more serious than a sore or swollen arm. However, it is unlikely any rare side effects will be detected until the vaccine has been given to millions of persons. For example, the Guillain-Barre syndrome, a temporary paralyzing disorder, affected fewer than 1 in a million vaccine recipients during and after the 1976 swine flu vaccination campaign in the U.S.
The BMJ article can be accessed at: http://www.bmj.com/cgi/content/abstract/339/aug25_2/b3391
According the new service Swedish Wire, Health Minister Maria Larsson said in a statement that "The government will earmark one billion crown [$142 million] for the costs incurred by county councils linked to the pandemic." County councils are in charge of health care in Sweden and will be tasked with carrying out and paying for the mass vaccination. Sweden has signed an agreement with the British pharmaceutical company GlaxoSmithKline for the delivery of 18 million doses of the vaccine as soon as it ready, which is enough to cover its population even if two doses are necessary for each person.
According to an estimate made by the Swedish National Board of Health and Welfare (Socialstyrelsen) and the Institute for Infectious Disease Control (Smittskyddsinstitutet) published in July, more than 436,000 Swedes might get infected by the swine flue during the autumn even if a vaccination program starts quickly after the vaccine becomes available . In the agencies' worst-case scenario, up to 5 million people, more than half of the population of 9.3 million people, will get infected if the disease spreads quickly.
Medical News Today reports that the World Health Organization (WHO) has announced that children with severe or deteriorating illness, and those at risk of more severe complications from swine flu (H1N1) infection, should receive prompt antiviral treatment, including all children under the age of 5 years. However, otherwise healthy children over 5 who have mild symptoms need not be given antiviral treatment, unless their condition deteriorates.
WHO said that following recent publications of two clinical reviews, some concerns have emerged about the advisability of giving antivirals to some children. The following should be considered as general danger signs and symptoms:
In children, the following are also danger signs:
Federico Quilodran, an Associated Press writer reporting from Santiago, Chile, writes that tests showed that the A(H1N1) flu has jumped to turkeys, opening a new chapter in the global epidemic. Top flu and animal-health experts with the Food and Agriculture Organization (FAO) in Rome and the CDC were said to be monitoring the situation closely. So far, the infected turkeys have suffered only mild effects, easing concern about a potentially dangerous development such as dangerous mutation. Further, Chile's turkey meat remains safe to eat.
Chile's health ministry has ordered quarantine for two turkey farms where the infected birds were found, which are owned by Sopraval SA and are located outside the port city of Valparaiso. Is also reported the problem to the World Health Organization and the FAO. After initial tests on four samples, further genetic testing confirmed a match with the subtype A/H1N1 2009. Deputy Health Minister Jeannette Vega is quoted as stating "What the turkeys have is the human virus -- there is no mutation at all." The Health Ministry is working closely with Chilean government scientists and the FAO to contain the outbreak.
In a commentary for ProMED, Dr. Julio Garcia Moreno, Head of the Biomedical Department at the Instituto de Salud Publica de Chile, writes: "Our point is that for the first time, it has been proven that transmission of the new virus from humans to birds has occurred. This is a concern vis-a-vis the possibility that this may happen in Asia or Africa under conditions of co-infection with H5N1 virus."
Sweden's major newspaper Dagens Nyheter (The Day's News) reports that the Swedish Association of Local Authorities and Regions (SALAR) has recommended to the government that all persons living in Sweden should be given free A(H1N1) vaccine. (SALAR's mission is "to safeguard the interests of Swedish local and regional authorities.") In SALAR's view, providing free vaccine will ensure that most inhabitants will indeed seek to be vaccinated. This recommendation is almost certain to be accepted by the Swedish government. The Swedish government has already announced that it has purchased sufficient vaccine to immunize everyone in Sweden, and has developed priorities for which risk groups will be the first to be vaccinated. Thus, the risk groups that will be vaccinated within one to two weeks after vaccines are delivered towards the end of September will be persons suffering from chronic illnesses, pregnant women, and health and medical workers. The remainder of inhabitants in Sweden will be vaccinated within two to three weeks of vaccine delivery. The vaccine campaign to vaccinate all 9 million Swedish inhabitants will cost an estimated 2 - 3 billion crowns (approximately $286 - 429 million), of which the cost of the vaccine will be 1.3 billion crowns ($186 million). A decision for distributing the vaccine at no cost would be different than decisions taken by Denmark and Great Britain, both of which have announced that those who wish to be vaccinated will have to pay an as yet undetermined amount at the site of vaccination.
Annika Linde, state epidemiologist at the Swedish Institute for Contagious Disease Control, stated that as of this date, Sweden has not yet been affected by the first wave of A(H1N1) influenza. Nevertheless, it is important to at least protect the risk groups by vaccination since a major lesson from past vaccination campaign is that they are very difficult to reach once a pandemic is raging and everyone demands vaccine. Further, if the majority Swedish inhabitants are protected by the vaccine, the probability of full scale pandemic occurring in Sweden is substantially lowered.
Agence France-Presse reporter Marlowe Hood writes that according to the World Health Organization, northern hemisphere countries have so far ordered more than one billion doses of swine flu vaccine, causing concerns over shortages. Some countries, such as Greece, The Netherlands, Canada and Israel, have ordered enough double doses to inoculate their entire populations, while others, such as Germany, the U.S., Great Britain, and France, have ordered sufficient vaccine to cover between 30 and 78 percent of their populations.
WHO spokeswoman Melinda Henry is quoted as stating that "In the early days, there will be a very limited supply of vaccine. There won't be sufficient supply to vaccinate whole populations, or even huge proportions of populations."
Radio Free Europe/Radio Liberty reports that a Kazakh fashion studio is producing what it calls "glamour surgical masks" as the fear of contracting swine flu spreads across the country. Gulnara Zhunusova, the owner of the fashion studio Inkar Sezimi in the eastern city of Semey (formerly known as Semipalatinsk), said that the idea to create the designer surgical masks came after more and more people in the country began wearing the masks to prevent flu infections. Zhunusova's masks - which are decorated with rhinestones and other costume jewelry - cost between 150-200 tenges ($1-$1.33) each. Zhunusova is quoted as stating that many people are uneasy about wearing surgical masks in public and suggests the decorated masks might help them feel more comfortable. Her collection of designer masks has thus far been popular with women in Semey, but Inkar Sezimi now working to design decorated surgical masks for men.
Kazakhstan was the first Central Asian country to report an outbreak of swine flu, and thus far has 17 confirmed cases.
Simeon Bennett, a reporter for Bloomberg news service, writes that a swine flu vaccine made in China by Sinovac Biotech Company is, according to its developer, safe and protects people against the pandemic virus after a single shot. Clinical studies have demonstrated that the vaccine met "international criteria for vaccines" and caused no severe adverse reactions in any of the 1,614 volunteers who received it. Sinovac claims that these results are the first reported anywhere in the world on a vaccine to fight A(H1N1). The company is compiling data on the flu shot as soon as possible before seeking regulatory approval for it in China. Sinovac did not give details about the efficacy of differing doses or vaccination methods used.
Lorena Brown, professor of microbiology and immunology at the University of Melbourne, is quoted as stating "The reported results of the Sinovac trial of H1N1 vaccine hinting at good efficacy after a single inoculation are encouraging. These will be of particular interest when the data are analyzed in terms of age-group, vaccine dose, vaccine form, and the requirement for adjuvant, all of which can affect the practicality of vaccine manufacture and use."
On June 19, Sinovac announced that it received an initial order for 4 million doses from the Chinese government and expects to make delivery by the end of September. It anticipated additional orders in October for a total of 10 million doses.
Hugh Pennington, a reporter for the English newspaper Guardian, has written a poignant article that is worth quoting in full: "A giant experiment started in England on Thursday 23 July. The algorithm-driven free "prescription" of Tamiflu through the National Pandemic Flu Service is without precedent. Never before has an antimicrobial agent been used on such a vast scale without medical control. However, there is a growing worry among public health professionals that the government's exuberant use of Tamiflu will hasten the appearance and spread of resistant mutants.
"There is no doubt that Tamiflu brings benefits. The earlier it is given the greater they are. The ideal is to take it before the onset of symptoms. Even after a couple of days it shortens the illness by a day or so. It is less certain how effective it is in preventing the development of severe complications, although it is reasonable to assume that it may reduce their frequency. Its effect in reducing the transmission of the virus from person to person is probably not very great. Influenza virus sufferers are excreting virus before the onset of symptoms so taking Tamiflu a day or so later means that they will already have had plenty of opportunities to infect their close contacts.
"So the benefits to be expected from giving Tamiflu - even on a grand scale - are real, but limited. And there are downsides. Some will experience side effects. These are well known. Nausea and vomiting has been taken up by the tabloids. In most of the anecdotes it is impossible to know whether the symptoms have been caused by the drug, or by the influenza for which the complainant was being treated. The big worry is that the exuberant and poorly controlled use of Tamiflu will hasten the appearance and spread of resistant mutants.
"It used to be thought that these were feeble viruses that spread poorly. No longer. H1N1 seasonal viruses that are highly resistant and effective spreaders suddenly appeared throughout Europe in the 2007-2008 winter flu season. Only time will tell whether swine flu will go down the same road. As a general principle the use of a single antimicrobial agent sooner (if poorly controlled) or later (when under medical control) selects for resistance. Exceptions are few and far between. So the operations of the National Pandemic Influenza Service carry a big risk. The race is between resistance and the vaccine."
The European Union Health Security Committee and the Early Warning and Response authorities (HSC/EWRS) unanimously adopted for the first time two policy statements proposed by the European Commission on public health measures for pandemic influenza A (H1N1). The statements set out a coordinated European approach on what kind of school closures may be most appropriate to protect public health, and how to balance freedom of movement and public health protection for travelers with flu symptoms. The Commission proposed the statements for adoption by the HSC/EWRS as part of the broader strategic planning and preparedness for coordinated efforts in Europe on pandemic influenza A (H1N1). The two statements provide a basis for implementing shared public health measures among Member States and the European Commission to ensure an efficient coordinated response at the EU level in the current pandemic situation. The statements may be revised taking into account developments in the situation.
Statement on school closures
The EU Health Security Committee states that Member States do not presently see the need to enact pre-emptive mass school closures. However, the Member States recommend at present the approach to locally close schools reactively upon infection being found among students as beneficial to delay the transmission of the virus. The benefit of such an approach clearly depends on timely action. Furthermore, to ensure that school closures are efficient, they should be accompanied by other measures, in particular to ensure that alternative gatherings of children do not happen.
Statement on symptomatic individuals travelling
The statement by the EU Health Security Committee provides a set of options on what to do in a situation where a traveler falls ill before or during travel. As an increasing number of individuals may develop symptoms just before planned travel or while travelling, the EU Member States may have to face the need to handle and manage cases among travelers. In this context, the overriding public health recommendation to symptomatic individuals remains to delay travel and stay at home. However, this public health recommendation in the pandemic situation should not lead to restriction of movement at the EU borders and travel restrictions between EU Member States.
For more information on EU reactions to A(H1N1), access: http://ec.europa.eu/health/ph_threats/com/Influenza/novelflu_en.htm
Building on strong trilateral cooperation this past spring, and, in anticipation of a possible fall wave of flu due to the 2009 A(H1N1) virus, President Barack Obama, Mexican President Felipe Calderón, and Canadian Prime Minister Stephen Harper issued a joint statement at the North American Leaders Summit, held August 9-10 in Guadalajara, Mexico. Following is the complete statement:
The White House
Building on the strong record of our trilateral cooperation during the spring of this year, we will remain vigilant and pledge to continue our close collaboration in addressing the H1N1 pandemic. We agree to work together to ensure that we have effective strategies, grounded in the best available science.
Our governments have worked closely together since the very beginning of this outbreak to protect the health of our citizens. During the onset of the H1N1 outbreak, we worked to implement science and evidence-based measures in our countries and on our borders. These measures were geared to provide an appropriate public health response. Movement across our shared borders is essential to the economic health of our countries. We recognize that highly restrictive measures such as general border closures would be unlikely to prevent the spread of this virus and could aggravate the economic and social consequences of an influenza pandemic.
We continue to study the severity and progression of the virus both here and in other parts of the world to help inform future public health decisions, including the use of vaccine, antiviral, and non-pharmaceutical interventions. Through regular communications; exchange of scientific knowledge, expert personnel, and clinical data; and shared access to laboratory facilities, we have been working to promote the health of the people of our three nations. In anticipation of a possible fall wave of flu due to the 2009 H1N1 virus, we will look to enhance our exchange of information, ensure common understanding on the effectiveness of public health measures, and share expertise through technical assistance and capacity building. We will continue to do everything we can to ensure that our people have timely and accurate information, and that our citizens are as prepared as they can be. In this regard, we will focus our attention on mitigating the effects of the outbreak in our communities. We encourage all families in North America to learn more about the simple steps they can take to prevent the spread of the flu, including frequent hand washing with soap and water, coughing into your sleeve, and staying home when sick to help prevent illness and the spread of the virus to others.
We know that cooperation and communication between nations, governments, citizens, and domestic and international organizations are the most effective ways to ensure that we are all protected. The strong collaboration between our countries allowed us to have a more secure North America region. We are proud that our countries have collaborated so effectively to this point, and we are firmly committed to continuing to work together in the months ahead. We will continue to work collaboratively with the World Health Organization and the Pan American Health Organization and support their leadership in facilitating international and regional collaboration in addressing this global issue."
New York Times reporter Rod Nordland writes that on 9 July, Iraqi officials expressed concern that more than 100 American soldiers in Iraq may be infected with swine flu and could spread the disease throughout the country. Members of Parliament have expressed alarm that U.S. troops could be introducing the disease into Iraq, particularly among members of the Iraqi military with whom they patrol.
Ever since the virus began to spread, Iraqi officials have been greeting visitors to the country with health teams, who take the temperatures of passengers as they leave airplanes. So far, seven foreign visitors have been registered as having swine flu since the screening started, said Dr. Ihsan Jafar, director general for communicable disease in Iraq's Ministry of Health. United States soldiers, however, are not subject to screening by Iraqi officials. "We expect more cases among American soldiers," Dr. Jafar said.
A U.S. spokesperson stated that the military conducts its own screening of service members before they enter Iraq, and that once in Iraq those who develop flu symptoms are put in isolation for seven days. According to the military, by far most of those turn out not to have swine flu. However, as of 9 July, swine flu had been diagnosed in 51 American troops in Iraq and an additional 71 are suspected of carrying the virus. The U.S. government has said it reports any cases of the virus to the Iraqi government under an agreement between the two countries.
A medical research team at Oxford University Department of Primary Health Care on 10 August published the findings of a research project called "Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials" in the British Journal of Medicine (BJM). Its major conclusions were: "Neuraminidase inhibitors [oseltamivir and zanamivir] provide a small benefit by shortening the duration of illness in children with seasonal influenza and reducing household transmission. They have little effect on asthma exacerbations or the use of antibiotics. Their effects on the incidence of serious complications, and on the current A/H1N1 influenza strain remain to be determined."
These conclusions have been publicized widely in the mass media under headlines such as "Flu drugs 'unhelpful' in children" (BBC) and "No Tamiflu for children, doctors told" (The Independent). These kinds of commentaries seem extreme, but they do bring up the question: Is it time to rethink the guidelines for tamiflu?
The BJM article can be accessed at: http://www.bmj.com/cgi/content/abstract/339/aug10_1/b3172
Reuters new service reports from Quito, Ecuador, that 12 South American governments have pledged to respect regional vaccine price ceilings to prevent businesses from exploiting fear of the A(H1N1) flu pandemic. The governments making the pledge are members of the South American National Union (UNASUR), which include Brazil, Ecuador, Colombia, Surinam, Guyana, Argentina, Uruguay, Paraguay, Chile, Peru, Bolivia, and Venezuela. Ecuador's Health Minister Caroline Chang is quoted as stating: "(We) establish a commitment to not buy individually, above the prices set by the Pan-American Health Organization (PAHO), to prevent commercial interests from taking advantage of pandemic panic. The region needs 200 million flu vaccine doses."
South American governments back what Chang said was the World Health Organization's negotiations with pharmaceutical companies and rich "First World" countries to ensure those most vulnerable have access to the vaccine under development. Leading flu vaccine makers include Sanofi-Aventis, GlaxoSmithKline, Novartis, Baxter, CSL, and Solvay.
SciDev.Net reports that the World Health Organization (WHO) Regional Office for Africa and the U.S. President's Emergency Plan for AIDS Relief have initiated a program to improve the diagnostic capabilities of laboratories in13 African countries (Botswana, Cameroon, Côte d'Ivoire, Ethiopia, Ghana, Kenya, Malawi, Nigeria, Rwanda, Senegal, Tanzania, Uganda, and Zambia). Currently, only a handful of African laboratories are accredited and even so most lack equipment, proper funding, adequate training for laboratory workers, and systematic management of work, all of which detrimentally affect their ability to diagnose disease. Laboratories first will be assessed, based on a five-step objective process, where they are well placed to be able to institute improvements required to gain full accreditation as reference laboratories. This method will replace that currently yes/no process used in many developed countries that depends on self-administered questionnaires. At least 30 laboratories will be assessed in the first phase.
This initiative should help the involved countries to improve diagnosis and monitoring of emerging diseases, a deficiency that has been highlighted by the A (H1N1). Deborah Birx, director of the Global AIDS program at the U.S. Centers for Disease Control and Prevention (CDC), which will be implementing the program, stated "Of most concern of this move is to enable African laboratories to rapidly detect and diagnose swine flu. One of the reasons why there are very few A(H1N1) cases on the continent could be because of the lack of capacity of African laboratories to carry out diagnosis." However, Odette Mukabayire, director-general of the Rwanda National Reference Laboratory, told SciDev.Net that the A(H1N1) virus should not be the main focus of African laboratories. "The African continent is not the main target of the pandemic," she says, claiming that existing diagnostic measures are adequate.
Agence France Presse reports that Canadian health officials have announced that the government is purchasing 50.4 million doses of swine flu vaccine. Canada's Chief Public Health Officer David Butler-Jones is quoted as stating that "the vaccine will be made available for everyone who needs and wants it, and extra doses would also be available in case some need multiple doses. We encourage everyone to be immunized but we know that not everyone will choose to do so." Health Minister Leona Aglukkaq added that the vaccine would be available in November.
Reuters new service reports that authorities in Vietnam's capital, Hanoi, have closed schools in the city to try to prevent the spread of H1N1 flu, which has infected more than 1,000 people in Vietnam and killed one so far. A circular by the Hanoi education department states that effective 7 July, schools must "immediately stop every activity that involves gathering students." The new school year is scheduled to begin as planned on Aug. 17, but some schools had started early and summer classes were in session at many others. Three schools in Hanoi had reported students infected with the A(H1N1) virus, although cases have been reported in all of the country's regions.
Radio Free Europe/Radio Liberty reports that more than 14 cases of the swine flu virus have been confirmed in Kazakhstan since the first such case was detected in Astana last week. It is the first time swine flu cases have been officially registered in Central Asia. Most of the patients are Kazakh students who have returned home from European countries. The news has caused panic among some Astana and Almaty residents. Many people have stopped buying pork, thinking it might cause the disease, and travel agencies say they have received many phone calls from clients who are considering canceling or postponing their planned trips to Europe.
Health officials have been trying to calm people, saying they have enough stockpiles of anti-viral drugs and that all necessary measures have been taken to prevent the spread of the disease. Quarantine regimes are in place in Astana and Almaty, and special working groups have been set up to contain any domestic outbreak of swine flu. Scanners have been installed at airports and main railway stations where medical teams check arriving passengers' body temperatures. Anyone with fever or flu-like symptoms is sent for further tests. Some Kazakh health officials have even suggested categorizing the threat of a swine flu epidemic as a national security issue.
In other Central Asian nations, officials have taken measures to prevent the spread of the disease. Special teams have been stationed at the Tashkent international airport in Uzbekistan to conduct medical inspections to determine whether any passengers arriving from abroad are infected with the A(H1N1) virus. Kyrgyz flight attendants were told to report any passenger showing symptoms of influenza to public health authorities. Tajikistan has introduced a national program to contain the outbreak of new influenza strains, including swine flu and bird flu. Turkmen President Gurbanguly Berdimukhamedov has called on the country to take the risk of the disease seriously.
Medical scientists Ying-Chun Li and Chi-Mei Liu at the Institute of Health Care Management, National Sun Yat-Sen University, Taiwan, reported on the findings of a project aiming to discover why persons living in a country where the universal health care coverage provides free influenza vaccinations for people 65 years or older has low vaccination rates. Specifically, among the sample of 23,023 older adults, the overall yearly vaccination rates were 38.6%, 44.3% and 39.3% for 2002, 2003, and 2004, respectively.
The project's major findings were that free vaccination coverage does not guarantee high vaccination rates. Continual ongoing public health interventions are necessary in order to generate optimal vaccination rates. While increased access to vaccinations may improve vaccination rates and reduce infections during epidemics of infectious disease, so may individual responses to disease threats. Project results show that prior influenza vaccination, frequency of prior outpatient visits for flu-like respiratory conditions, particularly during the interim season (closer to the following epidemic season) significantly predict the vaccination status of an older adult. Further, perceived threat is a significant predictor of vaccination status among the older adults. These findings can be used to help design public health policies and campaigns to increase the vaccination rate of this vulnerable group of citizens. In particular, older adults who never had influenza vaccinations should be identified, educated, and encouraged to participate in these types of important public health programs.
The entire report can be accessed at BMC Public Health; http://www.biomedcentral.com/content/pdf/1471-2458-9-275.pdf
Anthony L. Kimery of HSToday writes that Hong Kong researchers have found that wearing a face mask along with regular hand washing tended to help reduce transmission rates for seasonal flu among members of the same household. However, the study was unable to conclude the degree of protection provided by face masks over the proven benefit of regular hand washing, which authorities have long stressed. Additionally, the use of a face mask in conjunction with regular hand washing only showed benefit when it was performed within 36 hours of a person developing influenza contamination symptoms.
The study's author Dr. Benjamin Cowling, assistant professor at the School of Public Health, University of Hong Kong, is quoted as stating: "Our study shows that face masks are useful in households when one person has influenza, to prevent transmission to other household members. We did not study the use of face masks in other circumstances, for example for individuals trying to protect themselves against infection in other community settings."
Public health authorities have repeatedly told HSToday that surgical masks, dust masks and the like do not provide any protection against influenza viruses, and that even N-95 masks — the only masks rated for use in contaminated environments — do not provide absolute protection and must be properly fitted.
A CDC spokesperson said that it does not intend to change its guidelines for the use of respirators like the N-95 face mask. CDC's guidance on the use and effectiveness of N-95 respirators, especially with regard to the new H1N1 flu virus, states at the outset that "information on the effectiveness of facemasks and respirators for the control of influenza in community settings is extremely limited."
The Center for Infectious Disease Research & Policy (CIDRAP) at the University of Minnesota reports that the World Health Organization (WHO) has issued a list of warning signs of possible severe disease in A(H1N1) flu patients, and added to the recent warnings about the virus's threat to pregnant women. WHO listed signs that can signal a progression to severe disease as including shortness of breath, difficulty breathing, turning blue, bloody or colored sputum, chest pain, altered mental status, high fever lasting more than 3 days, and low blood pressure. In addition, particular danger signs in children include fast or difficult breathing, lack of alertness, difficulty in waking up, and little or no desire to play. Because a patient's condition can worsen very quickly, medical attention should be sought when any of the warning signs appear, WHO advised.
WHO noted that most patients will have mild symptoms and recover fully within a week, but a few people, usually younger than 50, rapidly progress to severe and often fatal illness. "No factors that can predict this pattern of severe disease have yet been identified, though studies are under way," WHO stated.
Regarding pregnant women, the WHO pointed to a U.S. study published in The Lancet that found an increased risk of severe or fatal A(H1N1) disease in this group. Further, several other countries also have noted an increased risk for pregnant women and a higher risk of fetal death or spontaneous abortion. "WHO strongly recommends that, in areas where infection with the H1N1 virus is widespread, pregnant women, and the clinicians treating them, be alert to symptoms of influenza-like illness," the statement reads. WHO recommends that pregnant women should be treated with oseltamivir as soon as possible after symptom onset and should be a priority group for immunization.
Two studies conducted by the United Kingdom's Health Protection Agency (HPA) showed a "high proportion" of British schoolchildren reporting problems after taking the anti-viral drug. Data was collected from children at three schools in London and one in south west England who were given Tamiflu earlier this year after classmates became infected with A(H1N1). The studies by HPA experts were carried out in the early stages of the epidemic between April and May, when everyone sharing a classroom with a child who developed swine flu was given the drug, even if they showed no symptoms.
Their research, published in Eurosurveillance scientific journal, studied side-effects reported by 11 and 12-year-old pupils in one school year in a secondary school in south west England. 248 pupils took part in the study after their school was closed for 10 days. 77 percent of these children took the full course of Tamiflu. Of these, the report stated that "51 percent experienced symptoms such as feeling sick (31.2 percent), headaches (24.3 percent) and stomach ache (21.1 percent)." The second study, also published by Eurosurveillance, involved 103 children. Of these, 53 percent of children at three London schools had one or more side effects. The most common side effect was nausea, with 29 percent of the pupils complaining of this. Another 20 percent complained of stomach pain or cramps, while 12 percent had problems sleeping. Almost one in five (18 percent) of the children reported a "neuropsychiatric side effect, such as poor concentration, inability to think clearly, problems sleeping, feeling dazed or confused, bad dreams or nightmares, and behaving strangely."
The UK's Department of Health said in a statement: "The European Union regulatory position remains that no causal association between Tamiflu (or Relenza) and an increase in neuropsychiatric events has been established."
Reports from Japan, where Tamiflu has in the past been widely-used against seasonal flu, has linked the drug in rare instances with unusual neurological and psychiatric disturbances in children, according to media reports. Japan is now advising against prescribing Tamiflu to youngsters aged 10 to 19 after its own studies revealed that people reported psychiatric symptoms.
The Xinhua News Agency reports that Hong Kong's health authorities announced that a new variant of the H3N2 seasonal influenza virus has been found in the city. Thomas Tsang, controller of Hong Kong's Center for Health Protection (CHP), stated "The Brisbane strain has been the prevalent circulator of H3N2 in the past year, and the new variant is its direct descendent. However, it has some genetic changes distinguishing it from the old Brisbane strain. It is normal for viruses to go through genetic changes," adding that overseas health authorities, including those in Canada, Britain and Australia, had also found the new variant.
Tsang said although vaccines provided for the northern hemisphere may not be a direct match for this new flu virus variant, they will still provide some protection against it. Noting that vaccines will be widely available in Hong Kong in a month, Tsang appealed to high-risk groups, such as those with chronic diseases, the elderly and children, to get flu shots. According to the CHP, H3N2 accounts for 43 percent of flu viruses circulating in Hong Kong, while A/H1N1 accounts for 49 percent.
Inside News24 reports that the region most severely affected by A(H1N1) is Latin America, which has accounted for approximately two-thirds of the deaths from the disease. The outlook is especially unsettling for the estimated 380 million people grappling with winter in South America, where the A(H1N1) virus is rapidly spreading.
Argentina already has at least 165 deaths, making it the country with the highest H1N1 flu fatality count in the world after the United States, where 302 people have died. Mexico, where the pandemic first came to light in April, follows, with 138 deaths. Chile has recorded 79 deaths. Brazil, Latin America's most populous nation with 190 million inhabitants, is concerned that its confirmed fatalities, which rose by six on Tuesday to 56, so far presage a national emergency, especially as it appears infections are now happening without any contact with travelers. On a per-capita basis, it is Uruguay that is suffering most. Its small population of 3.5 million has yielded 23 fatalities. In Mexico, officials acknowledge the situation is out of control in the poor southeast Chiapas state, which features popular tourist sites, and heavy traffic of Central American immigrants heading to the United States.
Conscious of the dangers, South American leaders and officials from Argentina, Bolivia, Brazil, Chile, Ecuador, Paraguay, Uruguay and Venezuela met last week and decided to demand that their countries be exempt from patent restrictions in producing the A(H1N1) flu vaccine. Brazilian President Luiz Inacio Lula da Silva suggested the region's health ministers hold an August 9 meeting in Ecuador to negotiate a strategy with the WHO and drug laboratories. The leaders were also informed that that all initial stocks of A(H1N1) vaccine due to be available at the end of September have already been purchased by European countries, United States, and other wealthy nations.
For the short term, some precautions have been imposed. Several Latin American governments or regional authorities have extended school vacations to prevent classroom contamination. Stocks of Tamiflu, one of two drugs shown to act on swine flu infections, have been built up. In Brazil, penitentiary officials in the south of the country, close to the border with Argentina, are reportedly requesting permission to allow non-dangerous prisoners to go into home detention for two weeks to stop the spread of flu in overcrowded cells.
The Agence France-Presse reports from Geneva that the World Health Organisation issued a statement on 28 July that it will consult experts on the way anti-viral drugs such as Tamiflu are used to tackle the A(H1N1) flu pandemic, and possible drug resistance. WHO spokeswoman Aphaluck Bhatiasevi is quoted as stating that "In the coming days we're having technical consultations by teleconference regarding antivirals. They will be looking at specifics related to antiviral resistance and use of oseltamivir. But as of now WHO's recommendations for use of antivirals has not changed. WHO's recommendation for use of oseltamivir is for treatment." Oseltamivir is the active ingredient of Tamiflu, one of two drugs the WHO recommends to treat influenza A(H1N1).
According to Agence France-Presse, different countries have gradually evolved different approaches on the use of Tamiflu - normally a prescription drug - and some have been distributing it more widely to fearful populations than others. But some doctors have expressed fears that excessive use, especially for preventive purposes or to tackle mild symptoms, could lead to the development of wider drug resistance and reduce the effectiveness of Tamiflu. Health officials in Canada recently identified a case of drug resistance, adding to cases in Denmark, Hong Kong and Japan. Roche, the manufacturers of Tamiflu, has said it expects a 0.5 per cent rate of case resistance based on clinical trials.
ScienceInsider reported that a six-month-old Mexican girl is now thought to be the first person to have contracted influenza A(H1N1). Celia Alpuche, head of the Institute of Epidemiological Diagnosis and Reference in Mexico City, stated that a baby girl from San Luis Potosí, north-central Mexico, was probably infected on 24 February, making her the earliest case yet detected.
The World Health Organization (WHO) issued a statement on 16 July telling national health departments that they should change the way they track the spread of swine flu. WHO noted that it no longer serves any useful purpose to count individual confirmed cases. That type of resource-intensive surveillance is not needed in places where outbreaks are already established and the work required for case-by-case counting is not sustainable. Instead the WHO asked that countries look for signs of "unusual events" — indicators that might suggest alterations in patterns of disease severity or spread that might be signs of changes in the pandemic virus. WHO stated "The increasing number of cases in many countries with sustained community transmission is making it extremely difficult, if not impossible, for countries to try and confirm them through laboratory testing. Moreover, the counting of individual cases is now no longer essential in such countries for monitoring either the level or nature of the risk posed by the pandemic virus or to guide implementation of the most appropriate response measures."
Case counts have never provided a full picture of the degree to which the infection is spreading. That is because influenza is a tip- of-the-iceberg type of illness, with only a relative small proportion of cases coming to the attention of medical authorities. As with seasonal flu, most people who contract H1N1 virus recuperate without the need to seek medical care and therefore are not reflected in national or global case counts.
In response to the new WHO statement, the U.S. Centers for Disease Control and Prevention (CDC) reacted positively. Tom Skinner, a CDC spokesman, said the change in the WHO's case-reporting policy was expected because the WHO and the CDC have been emphasizing over the past several weeks that the number of laboratory confirmed cases is just the tip of the iceberg of the true number of people who are or were sick with the novel H1N1 virus. Specific case counts were once needed to help characterize the early spread of the disease, he said. Now that the virus is widespread and poised for a potential surge in the fall, "specific case counts are no longer needed, and since they don't represent the true picture of the situation, they are not necessary," Skinner said. The CDC will likely make a similar move to downplay the number of confirmed cases, but it will maintain, if not expand, surveillance to gauge the health impact of the pandemic and the severity of the illness, he said.
YahooNews reports that number of swine flu cases in Australia has reached 10,387, more than 10 percent of the global total as confirmed by the World Health Organization. Health Minister Nicola Roxon said the real number could be much higher, adding that 123 people were in hospital, with 58 in intensive care. Roxon said "There isn't testing for every person who might have a mild case of A(H1N1)."
Bangkok has closed 435 schools for five days to prevent the spread of the H1N1 flu virus, a senior official said on 13 July. As he announced the closures, Ponksak Semsan, permanent secretary-general of the Bangkok Metropolitan Administration, said "We will conduct a thorough cleaning of the schools during the closure to prevent further outbreaks here." Thailand has reported 4,057 cases of H1N1 since mid-May, including 24 deaths; 10 of them from Bangkok.
Breffni O'Rourke, a writer for Radio Free Europe/Radio Liberty, writes that even as the swine flu continues to spread, one could be lulled into a belief that things are not too disturbing since its mortality rate is low. After all, "normal" seasonal flu accounts for tens of thousands of deaths per year worldwide, while the new H1N1 strain would seem to be adding only slightly to that statistic. O'Rourke quotes medical historian John Barry of the Tulane/Xavier Center for Bioenvironmental Research in New Orleans as stating "People say, 'Oh, well that's nothing to worry about then.' That's not exactly true, because people are protected against seasonal influenza. Whether they are vaccinated or not, their immune system has seen that virus before and it gives them significant protection. This new virus is something nobody has ever seen before. So even if it is mild, it is going to infect so many more people if it becomes fully adapted that there will still be a significant death toll." Therefore, the import of what we are facing is the possibility of a much more dangerous pandemic than presently seems the case.
O'Rourke asserts that one of the most troubling aspects of the current situation is that no specific vaccine against H1N1 has yet been developed, and even when it is, distributing it around the world will be a massive and slow undertaking. She quotes Marie-Paule Kieny, head of WHO's Initiative for Vaccine Research, as having said in London on July 12 that a fully licensed swine-flu vaccine might not be available until the end of the year. Further, Kieny said that production of the virus required in the vaccine has been "poor." Yields from growing the new virus has been less than 50 percent of that obtained with normal seasonal flu strains. She said the big drugs research companies are now studying alternative strains that will hopefully increase output.
Kieny also said that doctors, nurses, and other healthcare workers should get priority doses, so that they are fit to cope with an outbreak in the general population. In Italy, the government has already said it will give priority to "essential" personnel, such as police officers, firefighters, and health workers. Also in that category would be people with a prior illness. Business groups in Belgium expect one in four workers to be hit by illness.
AFP news service reports that health ministers from six South American countries were to meet on Wednesday to seek a coordinated response to the swine flu pandemic. Argentina was to host the meeting of ministers from Bolivia, Brazil, Chile, Paraguay and Uruguay.
Argentina's new death toll made it the worst-hit nation in terms of fatalities after the United States. Argentina dramatically upped its death toll from 94 to 137 in just three days. Chile has 33 deaths, Uruguay has 15, Paraguay has six, Brazil has four, and Bolivia has two. In terms of confirmed infections, Chile has the most with 10,491, though some uncertainty exists since tallying methodology vary across the region. (Central America has suffered 10 deaths, with seven of them in Costa Rica.)
Some 15,000 doctors in Peru called for a nationwide protest on Wednesday to demand better prevention against swine flu, which has claimed at least five lives and infected around 2,000 people in the South American nation. "We demand addressing adequately the needs of hospitals in order to prevent further mistakes in the treatment of swine flu and to avoid more deaths," Leoncio Diaz, president of the Peruvian Medical Federation, told AFP.
Maria Cheng, a medical writer for Associated Press, writes from London that there is an ugly scramble is brewing over the swine flu vaccine. It appears that when it will become available, Great Britain, United States, and other nations could find that the contracts they have signed with pharmaceutical companies are easily broken. The reason is that during a global epidemic, which the world is in now, governments may be under tremendous pressure to protect their own citizens first before allowing companies to ship doses of vaccine out of the country. That does not bode well for many countries, including the United States, which makes only 20 percent of the flu vaccines it uses, or Great Britain, where all of its flu vaccines are produced abroad.
Cheng quotes Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota, as stating "This isn't rocket science. If there is severe disease, countries will want to hang onto the vaccine for their own citizens." That being the case, politicians would not be able to withstand the pressure from their constituencies to keep vaccines at home. "The consequences of shipping vaccine to another country when your own people don't have it would be devastating," added David Fedson, a retired vaccine industry executive.
About 70 percent of the world's flu vaccines are made in Europe, and only a handful of countries are self-sufficient in vaccines. The U.S. has limited flu vaccine facilities, and because factories can't be built overnight, there is no quick fix to boost its vaccine supplies except to purchase from foreign suppliers.
Jon Ungoed-Thomas, a reporter for the London Sunday Times, writes that the National Health Service (NHS) is preparing to vaccinate the entire population against swine flu after the disease claimed the life of its first healthy British patient. A man from Essex was confirmed on 10 July as the first person without underlying health problems to have died from the virus. The NHS stated that most people ill with the virus had only mild symptoms.
A new vaccine is expected to arrive in Great Britain in the next few weeks and could be fast-tracked through regulatory approval in five days. As many as 20 million people could be inoculated this year. The NHS has secured up to 90 million doses, and the rest of the population is likely to be offered vaccinations next year. The vaccine is being supplied to the United Kingdom by GlaxoSmithKline Plc and Baxter Healthcare.
According to Ungoed-Thomas, the first patients in the queue for vaccination may understandably be a little nervous at any possible side effects. A mass vaccination campaign against swine flu in America was halted in the 1970s after some people contracted Guillain-Barré syndrome, a disorder of the nervous system. However, regulators have promised that fast-tracking would not be at the expense of patient safety. A spokesperson from the European Medicines Agency claims that "The vaccines are authorized with a detailed risk management plan. There is quite a body of evidence regarding safety on the trials of the mock-up, and the actual vaccine could be assessed in five days."
An article in the current issue of the British science journal Nature reports on a meeting between influenza scientists and policymakers that was held in Italy last week (2-3 July) to discuss the influenza A(H1N1). It was a shock to many attendees to hear that many developing-country governments are unconvinced that influenza is a major health problem relative to the other health challenges that their countries face. However, Abdullah Brooks of the International Centre for Diarrhoeal Disease Research in Bangladesh noted that a third of pneumonia deaths in under-two children are due to influenza and said that according to the UN agency UNICEF, pneumonia kills more than two million under-five children annually.
As the meeting ended, flu experts called on developing countries to set up seasonal influenza vaccine program, mainly to increase the health status of their children. As well as improving public health, such program would create a more sustainable market for influenza vaccines. This point was emphasized by Rino Rappuoli, head of vaccine research at Novartis, who said that before the current influenza A(H1N1) pandemic arose the company had been discussing the need to close vaccine-manufacturing plants because of financial losses.
The authors of an article named "Department of Defense Global Laboratory-Based Influenza Surveillance: 1998-2005," which is being published in the American Journal of Preventive Medicine (Vol. 37, Issue 3, September 2009), note that national concerns about emerging infectious diseases led the Department of Defense (DoD) to establish a Global Emerging Infections Surveillance and Response System (DoD-GEIS) in 1997. This program has 6 objectives relevant to influenza: (1) To isolate and identify circulating influenza viruses, (2) To detect new virus variants or subtypes for possible vaccine modification, (3) To identify influenza outbreaks, (4) To determine the incidence of influenza-like illness among sentinel military populations at high risk, such as basic training populations, (5) To prevent or control endemic and pandemic influenza outbreaks, and (6) To conduct global, operationally relevant, laboratory-based influenza surveillance.
Writing in the article, Colonel James Neville of the US Air Force School of Aerospace Medicine, Brooks City-Base, Texas, and colleagues state, "During seven complete influenza seasons, the DoD Global Laboratory-Based Influenza Surveillance Program...coordinated and expanded influenza surveillance efforts among the uniformed services and with DoD partner nations overseas, and operated in concert with WHO and CDC programs. As a result, the DoD and other global communities benefited from improved surveillance and expanded influenza laboratory and epidemiologic capability. The generated data and information supported timely, informed decision making in response to threats, expanded the data set used to select the components for seasonal influenza vaccines, and provided candidate seed viruses for possible use in influenza vaccines used worldwide."
In a commentary in the same issue of the journal, Dr. Patrick W. Kelley of the Institute of Medicine, observes that, "The somewhat unexpected emergence of novel H1N1 in Mexico, rather than in the anticipated Asian setting, highlights a lesson learned about the need for comprehensive global influenza surveillance. This is a lesson that geographically diverse foreign military health systems may be well-positioned to help address."
Today's e!ScienceNews reports on a research project that is published in the current Journal of General Virology. In particular, Dr Thomas Vahlenkamp and a team of virologists from the Friedrich-Loeffler-Institut in Greifswald-Insel Riems, Germany, have demonstrated that the A/H1N1 strain has been shown to be infectious to pigs and to spread rapidly in a trial pig population. The team experimentally infected five pigs with the strain of swine flu that is causing the current human pandemic and found that within four days the virus had spread to three un-infected pigs housed with the infected ones and all pigs were showing clinical signs of swine flu. Dr. Vahlenkamp is quoted as stating "Although in the early stages of the swine flu pandemic there were worries that humans would catch the virus from pigs, this has so far not been documented and pigs and other animals have not been involved in the current spread of A/H1N1 influenza in humans. However, with the increasing numbers of human infections, a spill over of this human virus to pigs is becoming more likely. The prevention of human-to-pig transmissions should have a high priority in order to avoid involvement of pigs in the epidemiology of this pandemic."
The study found that although the virus spread quickly to the non-infected pigs, it did not spread to five chickens that were housed together with the pigs. This may imply that while the virus can pass from human to pig it does not pass from pig to chicken. Based on these research findings, the scientists recommend that persons who are suspected of having swine flu should not be allowed to have contact with pigs and that regulatory bodies should agree on appropriate restriction measures for swine holdings where A/H1N1 infection is detected. Experiments are underway to determine whether currently available vaccines may be able to provide pigs with a certain immunity to stop a potential spread of the virus.
Jason Gale, a reporter for the Bloomberg news service, writes that spurred by a surge in cases of swine flu, which is supplanting the winter strains, New Zealand is suffering the worst influenza season in more than a decade. Doctors reported 183.7 cases of flu-like illness per 100,000 people across the country in the week ended July 5, the Institute of Environmental Science and Research and National Influenza Centre said in a report today. The rate is about double last year's peak. Sue Huang, Director of the National Influenza Centre, is quoted as stating "Flu activity has reached the point of being the highest in 12 years. It keeps going up, and the season hasn't really peaked yet." Also, Fran McGrath, New Zealand's deputy-director of public health, on 8 July announced the country's fifth fatality from the pandemic virus.
That Associated Press reports that a 16-year-old is San Francisco resident who was diagnosed with swine flu in June while on travel in Hong Kong, but who has since recovered is the third person in the world to be diagnosed with a strain resistant to Tamiflu. Hong Kong health officials, known as aggressive about trying to detect and isolate swine flu cases, detected the resistant strain in the girl. The other two resistant cases, in Denmark and Japan, had been taking Tamiflu as a preventive measure after coming into contact with someone with swine flu, but the Californian girl had not taken Tamiflu. This means that she was infected by an already-circulating resistant strain before she traveled to Hong Kong.
CDC health officials say they are not alarmed, and have been expecting to see some swine flu cases shrug off Tamiflu treatment. However, they believe resistance is not a widespread problem. No resistance was seen in the CDC's analysis of about 200 U.S. swine flu samples. California officials have found no resistance in their tests of about 30 other samples in that state. But no one should be complacent about the future because such resistance has been seen in other flu strains. In 2008, CDC officials reported that the most common flu bug circulating at the time was overwhelmingly resistant to the drug.
The Associated Press reports that a group of 20 students studying in Japan through the University of California Davis have been quarantined after two of their Japanese tutors were diagnosed with swine flu. AP quotes UC Davis summer abroad coordinator Kathy Cunningham as stating on 8 July the student group arrived in Kyoto, Japan, on 27 June 27 and were quarantined to a dormitory on 3 July. She says Japanese health officials are monitoring the group for symptoms and that no students have shown any sign of the disease so far. She also says the quarantine is set to end Friday 10 July.
While attending a series of high-level meetings for health ministers from American states in Cancun, Mexico, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced that the U.S. will provide 420,000 treatment courses of Tamiflu (Oseltamavir) to the Pan-American Health Organization (PAHO) to fight the novel H1N1 influenza in Latin America and the Caribbean. "The U.S is committed to supporting and enhancing the health security in the region by reducing transmission and severity of illness," Sebelius told officials in Cancun. "Viruses know no borders. The U.S. recognizes that a novel virus such as the H1N1 is a burden borne by all nations, and all of us have a responsibility to help support one another in the face of this challenge." Transmission of the virus throughout the Americas is a significant U.S. health security concern because of the vast amount of travel and commerce in the hemisphere.
HHS holds approximately 50 million courses of antiviral medications in the Strategic National Stockpile (SNS). In April, HHS deployed 11 million treatment courses from the SNS to the states across the country to fight the H1N1 influenza. Since then, HHS has purchased antiviral drugs to replenish the SNS along with an additional 2 million treatment courses.
The U.S. supports the goal of improving access to vaccines and antiviral drugs for developing countries, particularly in the context of public-health emergencies as part of its broader commitment to protect global public health. The U.S. has provided significant support to the World Health Organization's vaccine programs and has promised to work to support international partners and developing nations around the world.
While visiting the World Health Organization in Geneva, United Nations Secretary General Ban Ki-moon said that developing countries could need "a little over one billion dollars" by the end of the year to fund measures against the swine flu pandemic, especially vaccines. Funding had "not been flowing as expected," following appeals in recent weeks, he added. "This pandemic flu is also a sort of a global crisis which needs global response through global partnership and solidarity," said Ban.
Table: Antiviral resistance detected in influenza viruses from European countries during the season 2008/2009, by virus subtype and drug class (updated 12/06/2009)[1,2]
| Virus type and subtype |
Resistance to neuraminidase inhibitors | Resistance to M2 inhibitors | ||||
| Oseltamavir | Zanamivir | |||||
| Isolates tested | Number Resistant (%) | Isolates tested | Number Resistant (%) | Isolates tested | Number Resistant (%) | |
| A(H3N2) | 653 | 0 | 612 | 0 | 644 | 644 (100) |
| A(H1N1) | 259 | 255 (98) | 259 | 0 | 124 | 1(0) |
| A(H1N1)v | 26 | 0 | 26 | 0 | 28 | 28(100) |
| B | 117 | 0 | 113 | 0 | NA | NA |
[1] The analysis of resistance against neuraminidase inhibitors (oseltamivir and zanamivir) and M2-ion channel inhibitors (amantadine and rimantadine) is done by measuring IC50 values and/or by genotyping of viruses for detection of known drug resistance mutations. As influenza A viruses are fully cross resistant for amantadine and rimantadine these are not shown separately in the table.
[2] Source: European Centre of Disease Control and Prevention
Reuters news service today published an article about the first case in the world of a patient with H1N1 influenza in Denmark showing resistance to Tamiflu, which is marketed by Roche. "While receiving the drug, the patient appeared to develop resistance to it," said David Reddy, Roche's pandemic taskforce leader. "This is the first report we have of it in H1N1." Common seasonal flu can resist Tamiflu and Reddy said a case of resistance in H1N1 was not unexpected, adding Roche has been working on strategies to counter such a development.
The Australian news agency WA Today reports that Indonesia's Health Minister Siti Fadilah Supari has stated that his government will ask all persons arriving from Australia and other swine flu-affected countries to wear face masks for at least three days. The presence of the H1N1 virus was confirmed in Indonesia only last week and so far four of the eight known cases have been foreigners. "Visitors from infected countries should wear masks. It's a precautionary measure we're taking to avoid human-to-human transmission of the virus," said Supari. "We'll give them the masks when they arrive at the airports and tell them to wear them for three days."
However, so as not to discourage tourism, mask wearing will not be mandatory. "There'll be no penalty if people don't wear them. You can't expect people to wear masks when they're swimming," Supari said, adding the masks would be handed out to visitors as soon as possible depending on funding.
Australia is the Asia-Pacific country worst-hit by swine flu with more than 4,000 cases, while Indonesia has been the country hit hardest by avian influenza with 141 deaths since 2003.
Olivia Rondonuwu, a reporter for the Reuters new service, writes that Indonesia's first cases of the new H1N1 flu have raised concerns that if the virus spreads it could combine with the entrenched and deadly H5N1 avian influenza to create a more lethal strain of flu. Influenza viruses not only mutate quickly and unpredictably, but they can swap genes, especially if a person or animal becomes infected with two strains at once. The new H1N1 strain is itself a mixture of various strains, genetic tests show. It also is worth remembering that should the two strains combine, the new strain is just as likely to be less virulent, or no more virulent, as more virulent than either of the two original strains.
H5N1 bird flu has been circulating in Asia for years and has hit Indonesia harder than any other country. Although it only rarely infects people, it has killed 262 out of 433 infected globally since 2003, with 141 of those cases in Indonesia. But Kamaruddin Zarkasie of Indonesia's Bogor Agriculture University said he felt the risk the two viruses might combine was only a random possibility. Even if they do not, H1N1 may be a serious threat, other experts said. Ben Cowling, public health expert at the University of Hong Kong, said people with serious infections who would be admitted to hospitals in developed countries and survive might die in poorer countries.
Fergus Walsh, a BBC News medical correspondent, writes that the first doses of an H1N1 swine flu vaccine have been produced in Europe - but it will be around two months before any is distributed. The doses were produced by Novartis at a plant in Marburg, Germany. The vaccine was made in cell culture, a much faster method than the traditional way of growing it in eggs. But Novartis said although the vaccine is ready, the first batch will not be used, as it was created using the wild type strain of H1N1.
All large scale vaccine production around the world will use a slightly modified "reassortant seed" virus. This was provided by health officials in the US and is optimized to grow rapidly in hens eggs, which is the traditional means of creating flu vaccine. So although Novartis is claiming to have created the first swine flu vaccine, it will not be until clinical trials are completed on a vaccine made from the seed virus and the first doses are delivered, that the race to get a vaccine will truly have been won.
The company said it had orders from 35 governments for its H1N1 pandemic flu vaccine. None of the vaccine manufacturers has begun clinical trials of the H1N1 vaccine. These will test whether the vaccine is safe and efficacious. Once these parameters have been satisfied, the manufacturer will work out what dose is required and whether people will need one or two injections. The current working assumption is that two jabs will be needed, probably spaced three or so weeks apart.
Agus Maryono writing in today's Jakarta Post reports that at least 20 villages in the Purbalingga province, Central Java, have been affected by bird flu, forcing local authorities to cull more than 1,000 infected chickens and incinerate their bodies. To curb the virus from spreading further in Purbalingga, local authorities have set up a special team to combat bird flu. "The team is already working 24 hours a day. Any time we receive a report on a dead chicken we will go to the location immediately," said local health official Hartono.
The World Health Organization has provided 240,000 doses of vaccine to the region to help it control the spread of bird flu. Hartono said that "Around 30 percent of the vaccines have already been used." WHO has also provided Purbalingga with anti-bird flu disinfectants.
Commenting on this outbreak, ProMED-mail Rapporteur Mary Marshall writes that "More Indonesians have died from avian influenza than anywhere else in the world, with 31 of 33 provinces known to have been infected by highly pathogenic H5N1, which has become endemic. The country's 240 million people are spread over 6,000 inhabited islands. Since 2006, the Food and Agriculture Organization has helped to train teams of local veterinarians and paraveterinarians in participatory disease surveillance and response (PDS/R) techniques. Veterinarians and paravets are engaging community members, tapping into their local knowledge and involving them in control efforts. Villagers are also trained to detect and report bird flu cases in poultry and be responsible for their own safety and that of their families."
A team of Mexican scientists reported in today's New England Journal of Medicine on the results of an extensive study performed March 24-April 29, 2009, during which 2,155 cases of severe pneumonia, involving 821 hospitalizations and 100 deaths, were reported to the Mexican Ministry of Health. 8,817 nasopharyngeal specimens that were submitted to the National Epidemiological Reference Laboratory, of which 2,582 were positive for H1N1 virus. The team compared the age distribution of patients who were reported to have severe pneumonia with that during recent influenza epidemics to document an age shift in rates of death and illness. During the study period, 87% of deaths and 71% of cases of severe pneumonia involved patients between the ages of 5 and 59 years, as compared with average rates of 17% and 32%, respectively, in that age group during the referent periods. These findings means that "features of this epidemic were similar to those of past influenza pandemics in that circulation of the new influenza virus was associated with an off-season wave of disease affecting a younger population."
The Bloomberg News Service reported today that Sanofi-Aventis SA will be donating 100 million doses of swine-flu vaccine to the World Health Organization. Once production of a vaccine begins, Sanofi will reserve 10 percent of output for the donations, the Paris-based company promised. The donation will help ensure that the poorest countries have access to the shots, a Sanofi representative said. "It's a call for collective action," Sanofi Chief Executive Officer Chris Viehbacher said. "We all have to play our part. It can't be only the rich countries having access to the vaccines, in case of a pandemic." GlaxoSmithKline Plc. also plans to donate 50 million doses to WHO, spokesman Stephen Rea said in an interview today. The decisions by Sanofi and Glaxo contrast with that of Novartis AG, which said this week that it would not donate any of its vaccine.
Medical News Today reports on a study conducted by researchers from the Motherisk Program at The Hospital for Sick Children (SickKids) in Toronto and the Japan Drug Information Institute in Pregnancy in Tokyo, Japan, on the special risks posed to pregnant women by the H1N1 influenza strain. Pregnant women, especially those in the third trimester, were found to be at high risk of serious complications from the H1N1 influenza virus.
For treatment or prevention during the current pandemic, "oseltamivir appears to be the drug of choice because there are more data on its safety in pregnancy," writes Dr. Shinya, Head of the Division of Clinical Pharmacology and Toxicology at SickKids. Zanamivir can be used, although there is less data available about its safety in pregnant women. Neither drug appears to affect the growth and development of the fetus, although ongoing data collection is important. The groups at high risk of flu-related complications from the novel H1N1 influenza are the same as those for seasonal flu – pregnant women, children under 5 years, the elderly and others such as those with chronic lung conditions. (Tamiflu is the proprietary name for oseltamivir; Relenza is the proprietary name for zanamivir and is inhaled.)
In a communication to the New England Journal of Medicine (11 June 2009), Chinese scientists from the Guangzhou Center for Disease Control and Prevention reported on a survey done to detect H5 and H9 influenza virus strains in the region. Human infection with the H5N1 or H9N2 avian influenza virus has been reported in the city of Guangzhou in southern China. To assess the risk of avian influenza virus infection among humans, the scientists conducted a serologic surveillance study in Guangzhou. A total of 2,191 healthy persons were recruited from 230 workplaces and seven types of occupations from March 2007 through July 2008.
Their results show that the positive rate of anti-H5 antibodies was much lower than that of anti-H9 antibodies among poultry retailers (0.8% vs. 15.5%, P<0.001) and among wholesalers (0.8% vs. 6.6%, P=0.001). This difference may be attributed to the wide use of H5 vaccine in poultry, whereas vaccination against H9 is not available. In addition, H9 avian influenza virus infection in poultry is usually asymptomatic and associated with virus shedding. Given that reassortant of H9N2 with other subtypes of avian influenza virus has been reported to occur in southern China, the finding of the Guangzhou scientists highlights the potential risk of H9 avian influenza virus to public health.
Dr Margaret Chan, Director-General of the World Health Organization, raised the pandemic level from 5 to 6 on 11 June. This is the first time in 41 years that a virus has reached this level. The following statements were included in Dr. Chan's announcement:
"In late April [2009], WHO announced the emergence of a novel influenza A virus. This particular H1N1 strain has not circulated previously in humans. The virus is entirely new. The virus is contagious, spreading easily from one person to another, and from one country to another. As of today [11 Jun 2009], nearly 30 000 confirmed cases have been reported in 74 countries... This is only part of the picture. With few exceptions, countries with large numbers of cases are those with good surveillance and testing procedures in place. Spread in several countries can no longer be traced to clearly-defined chains of human-to-human transmission. Further spread is considered inevitable... I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose. On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. I have, therefore, decided to raise the level of influenza pandemic alert from phase 5 to phase 6.
"The world is now at the start of the 2009 influenza pandemic. We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch. No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the last 5 years, in pandemic preparedness.
"We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years. In some of these countries, around 2 percent of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia. Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years. This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail, elderly people.
"Many, though not all, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include respiratory diseases, notably asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity. At the same time, it is important to note that around 1/3rd to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people. Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.
"Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries. Let me underscore 2 of many reasons for this concern. 1st, more than 99 percent of maternal deaths, which are a marker of poor quality care during pregnancy and childbirth, occur in the developing world. 2nd, around 85 percent of the burden of chronic diseases is concentrated in low- and middle-income countries.
"A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail. Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a 2nd wave of infection. WHO continues to recommend no restrictions on travel and no border closures."
According to the article, the World Bank has released substantial funds to prepare these regions. Many people in poorer countries suffer from HIV/AIDS and malnutrition making them more vulnerable to A(H1N1). "In addition, they are likely to be left out of the global scramble for a vaccine, which has already started as nations such as the United States and Britain rush to tie up vaccine contracts," states Hayden.
The UK reported its first death to H1N1 swine flu on Sunday after a 38-year old mother from Glasgow died in a Scottish hospital days after she gave birth to her baby prematurely. The patient, named locally as Jacqui Fleming, had underlying health problems and is thought to have died while receiving treatment at the at the Royal Alexandra Hospital in Paisley. She had been in intensive care there since last month, reported The Herald. Fleming was one of 10 patients being treated for swine flu in greater Glasgow, reported the BBC.
Professor Hugh Pennington, a bacteriologist at Aberdeen University, said in the case of Fleming, underlying health problems were most likely a "significant factor" in her death, and while it is "very sad", because of the numbers, it was to be expected that a death would occur sooner or later. The "underlying health problems" were not identified.
As of 17:00 GMT, 15 June, 76 countries have officially reported 35, 928 cases of influenza A(H1N1) infection, including 163 deaths. As before, the U.S. has had the most cases with 17,855, followed by Mexico (6,241), Canada (2,978), and Australia (1,823). The largest change from a week ago is the rapidly growing number of new cases in South and Central America, with Chile leading with 1,694 cases.
New Orleans Mayor Ray Nagin is being held in quarantine in a Shanghai hotel, after a passenger on his flight from the US fell ill with suspected swine flu. Mr Nagin's office confirmed the quarantine of the mayor, his wife Seletha, and a security guard. They were on a 10-day trip to China and Australia aimed at promoting business to his city.
The World Health Organization reports that as of 06:00 GMT on 8 June, 73 countries have officially reported 25,288 cases of influenza A(H1N1) infection, including 139 deaths. The four most affected countries are the United States (13,217), Mexico (5,717), Canada (2,115), and United Kingdom (557). As for California, as of 4 June it had 796 confirmed and 218 probable cases. Monterey County has had 13 confirmed and 3 probable cases. On 4 June, a Contra Costa County child died of the A(H1N1) infection, the first pediatric death in California. This elementary school aged child also suffered from a bacterial infection. This brings the total number of deaths due to this cause to three.
In an article published in the British science journal New Scientist there is a report about a scheme to help poor countries meet requirements of the UN's Convention on Civil Aviation, which requires nations to "prevent the spread of communicable diseases by means of air navigation". The scheme aims to assist airports in developing nations to prepare for a pandemic. Existing measures include managing infected passengers but also in the pipeline is software to enable airport authorities to detect someone with a sickly cough by analysing patterns in their coughing frequency using networks of microphones installed in airports. Coughers can be identified and then checked for infection, says the article.
The global spread of the swine flu - influenza virus A(H1N1) - virus shows no sign of slowing as Africa reported its first confirmed case, in Egypt, this week. In addition, there are eight suspected cases; one each from Namibia, Cape Verde, Eritrea, Gambia and South Africa, as well as 3 from Congo Democratic Republic. Keiji Fukuda, WHO assistant director-general for health security and environment, said the agency was close to declaring a 'phase 6' pandemic alert - a fully-fledged pandemic where community spread is established outside the first region where the disease was reported. Phase 6, the WHO's highest pandemic alert system, described as a global pandemic, is the stage that the global community has long feared due to its implication for possible economic disaster. The designation does not necessarily reflect the severity of the disease but only its spread.
The number of confirmed swine flu cases in Australia rose to more than 1,000 today, as federal Health Minister Nicola Roxon said the government expects the virus to spread across the country. Victoria, the worst-hit state, confirmed a further 122 cases overnight, taking its tally to 874, its health department said. Authorities believe H1N1 influenza will advance "in all jurisdictions," Roxon told reporters earlier in Canberra. The cases are proving to be "mild" and the outbreak isn't severe enough to restrict interstate travel, she added.
An article in the British science journal Nature published 3 June questioned how much vaccine developing countries would receive. "The picture here isn't bright ... The WHO is trying to negotiate for ten per cent of global production to be set aside for developing countries. If, for example, 860 million doses are available by Christmas, that would mean just 86 million doses; if two doses were needed per person, it will be only enough for 43 million people," reporter Declan Butler wrote.
In a telephone press conference on 28 May, Anne Schuchat, the interim deputy director for the US Centers for Disease Control and Prevention's Science and Public Health Program, confirmed the CDC had shipped candidate virus strains to several different manufacturers for the production of a vaccine. "Manufacturers involved in developing and producing the novel H1N1 vaccine will start the process by producing candidate lots in the coming weeks," Schuchat said. But she warned that a vaccine was likely to be ready only by October because clinical trials would need to be completed first. Further, BBC Online reported on 28 May that British scientists have produced a viral strain that can be used to make a vaccine against swine flu. Stephen Inglis, director of the UK-based National Institute for Biological Standards and Control, said their scientists had been "working around the clock" since they received the first isolate of swine flu from colleagues in the United States at the beginning of May. "The strain is now available for supply to vaccine manufacturers so that they can begin the first steps in the vaccine production process, and to other flu laboratories around the world for research."
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