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The Oita Prefecture government culled 13,000 chickens at a poultry farm and a meat processing center on February 3rd. Oita is the fifth Japanese prefecture to have confirmed cases caused by the H5N1 virus. The prefecture imposed a ban on the transport of chickens and eggs within a 10-km radius of the farm and conducted on-site inspections at 10 poultry farms within the area. Based on visual examinations, officials did not observe any additional infections, but will wait for the results of blood tests and other exams before deciding if the outbreak has stopped.
Source: Japan Today: http://www.japantoday.com/category/national/view/oita-completes-cull-of-8100-chickens-as-5th-bird-flu-hit-prefecture
At an emergency meeting in Tokyo, the Japanese farm ministry urged prefectural officials to make more efforts to control the spread of bird flu. The first outbreak of the H5N1 influenza this season occurred at a Japanese poultry farm in November in the Shimane Prefecture. Since then, further infections have been confirmed at five other farms and a meat processing center, as well as, among wild birds.
There have been five outbreaks of H5N1 influenza this season in the Miyazaki Prefecture in Japan, which has resulted in 96,000 chickens being culled in this prefecture. The highly lethal virus has also been confirmed in chickens at farms in the Aichi and Kagoshima prefectures.
Source: Hindustan Times: http://www.hindustantimes.com/Japan-holds-emergency-meeting-on-bird-flu-epidemic/Article1-656419.aspx
According to the latest World Health Organization (WHO) update, flu activity is increasing in many of the temperate-zone countries of the Northern Hemisphere.
Morocco, Algeria and Tunisia are mostly reporting influenza B. In the Middle East, Iran and Pakistan are mostly reporting 2009 influenza A (H1N1) virus. Flu activity in Mongolia and Northern China has predominantly been H3N2 virus, while South Korea and Japan are reporting that the 2009 H1N1 virus has become the dominant strain. In Western Europe, flu activity has been high, especially in the United Kingdom, France, Portugal, the Netherlands and Denmark, where there have been reports of hospitalizations and deaths from the H1N1 virus and influenza B. The European Centre for Disease Prevention and Control (ECDC) issued a flu surveillance report on January 14, which provided more details on the influenza in the region (See link below).
Further, in the United Kingdom, two patients with the 2009 H1N1 virus have been reported to carry the H275Y substitution, a mutation known to confer resistance to oseltamivir (Tamiflu). Another development is that the Hong Kong's Center for Health Protection has reported that a 3-year-old boy was infected with a "European avian-like H1N1" swine influenza reassortant, which means that this strain has a genetic construct derived from an avian flu virus strain.
Source:
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/jan1811global.html
ECDC Flu Surveillance:
http://www.ecdc.europa.eu/en/publications/Publications/110114_SUR_Weekly_Influenza_Surveillance_Overview.pdf
In the context of the high cost of surveys to measure public perceptions in emergencies and the new "infoveillance" methods such as mining, aggregating and analyzing online textual data in real-time, this study evaluated Twitter as a complementary approach for understanding and measuring public attitudes during the 2009 H1N1 pandemic. The study aimed to 1) monitor the use of terms "H1N1" versus "swine flu" over time, 2) conduct a context analysis of "tweets", and 3) validate Twitter as a real-time tracking tool for trends in content, sentiment, and public attention.
The 2009 H1N1 influenza-related tweets were primarily used to disseminate information from reliable sources; thus, 52.6% of tweeted H1N1-related material were from news media. 90.2% of tweets provided references to information that they were providing, allowing others to confirm the trustworthiness of the material. Tweets also provide a source of opinions and experiences. This study demonstrates the potential of using social media to conduct "infodemiology" studies for public health. Tweets can be used for real-time content analysis and knowledge translation research, whose findings could be used by health authorities to respond to public concerns.
Source: Cynthia Chew and Gunther Eysenbach PLoS ONE; 5:11:
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0014118
An outbreak of the influenza A (H1N1) virus early in the influenza season in the UK could spread to the rest of the European continent. Similar to the 2009 pandemic, this influenza virus primarily affects people under 65 who have previously been healthy with no underlying problems. According to the Great Britain's Royal College of General Practitioners, there were about 99 cases per 100,000 people in the first week of January, a decrease in comparison to December when there were 124 cases per 100,000 people. Swine flu symptoms include fever, muscle aches, a sore throat and diarrhea.
50 people with flu have died, the majority of whom were not vaccinated. Blame is being placed on the British Government for having discontinued its annual flu vaccination campaign. Presently, a vaccine shortage is forcing British authorities to use leftover vaccines from the 2009 swine flu pandemic. European countries such as France and Germany are being encouraged to step up their vaccination programs given that H1N1 appears to be the main virus spreading in Europe.
In the U.S. and Canada, the influenza virus appearing in most cases is H3N2, with H1N1 accounting for only 10 percent of cases.
Source: Associated Press, Maria Chang, January 7, 2011
http://www.washingtonpost.com/wp-dyn/content/article/2011/01/07/AR2011010701809.html?referrer=emailarticle
The winter influenza season has begun in the Northern Hemisphere. Parts of the United States and Canada are experiencing increases in influenza-like illness associated primarily with influenza A (H3N2) and type B viruses. In the US, influenza type A viruses account for about 56 percent of virus detections and influenza type B, 44 percent. In contrast, 99 percent of influenza viruses in Canada are type A. The United Kingdom has seen a pronounced increase in both mild and severe cases primarily associated with influenza A (H1N1) virus, which is the 2009 pandemic virus. On the European continent, the Middle East and in northern Asia, rates of influenza-like illness are low, but recent increases have been noted in France, Ireland the Russian Federation, Ukraine, Iran and Mongolia. In the Southern Hemisphere, no significant influenza transmission has been reported.
The majority of the influenza viruses that have been reported throughout the Northern Hemisphere have been antigenically similar to those that constitute the current trivalent influenza vaccine.
Source: World Health Organization (WHO), CSSR Disease Outbreak News
http://www.who.int/csr/disease/influenza/2010_12_30_GIP_surveillance/en/index.html
In the mail-report of December 8, 2010, ProMed reported cases of H5N1 influenza (Avian influenza) in Indonesia, Nepal, South Korea and Egypt.
In Indonesia, a confirmed human case of H5N1 influenza is being treated in hospital. This case marks the 171st human case of H5N1 virus infection since an outbreak in the country in 2005, and the ninth in 2010.
In Nepal, a commercial poultry farm was identified as being affected with the H5N1 virus but outbreak's etiology so far in unknown. The outbreak began on October 25 and was resolved by October 30.
In South Korea, there is a confirmed case of H5N1 influenza in a wild bird, but at the moment, there are no reports of the virus having spread to the 219 chicken farms and 13 duck farms in the area.
In Egypt, a 30-year-old man who died on December 6 was a suspected case of H5N1 influenza. He was one of five suspected cases of H5N1 influenza undergoing treatment. If confirmed, he will be the 114th human H5N1 influenza case since the first one was recorded in 2006, and is the 24th case in 2010.
Source: ProMED Digest, December 8 2010, vol. 2010, #580.
On November 17, 2010, the Centre for Health Protection (CHP) confirmed a case of human influenza A (H5N1) infection in a 59-year old woman in Hong Kong. This is the first confirmed case of H5N1 infection since 2003 in Hong Kong. Her symptoms included a runny nose, fever and cough with blood streak sputum. She was placed in intensive care and treated with Tamiflu. Her close contacts had not developed any symptoms at the time of reporting. The source of the infection is not confirmed, but it is possible that it is from either Hong Kong or Mainland China. Before her incubation period, she had traveled to Shanghai, Nanging and Hangzhou in Mainland China; poultry farms and markets are being inspected currently in those locations.
Precautionary measures are in effect in Hong Kong public hospitals, including tests on patients with symptoms of influenza, those have recently returned to Hong Kong from Shanghai, Nanjing and Hangzhou and who have visited markets or had close contact to poultry.
According to the latest update from the World Health Organization, as of October 18, 2010, there were a total of 507 confirmed cases (including 302 deaths) of human infection with the H5N1 virus.
The full articles can be found at:
http://www.chp.gov.hk/files/pdf/cdw_v7_24.pdf
http://www.news.gov.hk/en/categories/health/html/2010/11/20101118_134024.shtml
Carol Campbell and Yojana Sharma have written an article for the SciDev.Net on some of the effects of the A(H1N1) pandemic on African countries. In particular, they wonder whether the high financial cost incurred in preparing defenses against the disease might have been better spent, given that it did not spread as widely as feared, nor cause as much damage as originally planned for.
Campbell and Sharma quote Frew Benson, South Africa's chief director of communicable diseases, as claiming that the country spent 115 million rand ($15.6 million) on vaccine but ended up using only about $3.4 million worth. South Africa also retains a huge stockpile of antivirals; 100,000 treatment courses were imported, but only 25,000 were used so far. However, Lucille Blumberg, head of epidemiology at South Africa's National Institute for Communicable Diseases, said it was not all wasted — laboratories had been upgraded and skills improved across Africa to cope with the epidemic. She told SciDev.Net: "Yes, there was excessive use of resources in South Africa during the epidemic. But this was inevitable. There was a time, at the height of the epidemic, when laboratories couldn't cope. In hindsight we didn't need to test and treat every case, but at that stage we didn't know what we were dealing with — or how dangerous it was."
Rick Bright, scientific director of the global vaccine development program at Seattle-based nongovernmental organization PATH, said that "a network of influenza centers around the world had been strengthened and regional labs expanded, including in Africa where there are now major laboratories in Madagascar, Senegal and South Africa. This is particularly important for flu, which does not display specific external symptoms and can be diagnosed only through laboratory testing."
Bright also noted that "H1N1 taught us a lot by intensifying attention without the occurrence of fatalities. It was a dry-run for a larger more lethal flu pandemic. The pandemic scare highlighted the global shortage of vaccine, and the need for governments to be able to manufacture antivirals and vaccines within their own countries. Stockpiling is not a solution, because no one knows what the next mutation of the influenza virus will be."
Kathleen Neuzil, Senior Advisor for Immunizations at PATH, added: "In terms of preparedness, we are in much better shape than ten, five, or even two years ago, especially in terms of the degree of surveillance, and the number of countries involved in surveillance."
The SciDev.Net article can be accessed at: http://www.scidev.net/en/news/swine-flu-yielded-valuable-lessons-for-future-say-experts.html.
Anders Forsström writing in the Swedish newspaper Dagens Nyheter reports that Finland on August 23 stopped vaccinating children against swine influenza because of an increased number of narcolepsy among recipients. Finish doctors have identified 14 cases of narcolepsy among children who received the flu vaccine Pandemrix.
So far, approximately five million children in Europe have been vaccinated with Pandemrix. Cases of narcolepsy among recipients have been identified in Germany and Sweden. However, the incidence of narcolepsy is very low; for example, in Sweden more than one million children have been vaccinated with Pandermrix but only six cases of narcolepsy have been reported to the Swedish Medical Products Agency. Nevetheless, according to a spokesperson from the National Board on Health and Welfare, the Swedish government will meet on August 24 to discuss whether vaccinations with Pandemrix should be discontinued.
The Dagens Nyheter article can be accessed at: http://www.dn.se/nyheter/varlden/finland-stoppar-svininfluensavaccinationerna-pa-grund-av-risker-1.1158774
A Hong Kong research team examined community psychological and behavioral responses at the beginning of the influenza A(H1N1/2009) pandemic in Hong Kong and published its findings in the August 2 issue of the Journal of Infectious Diseases. The research team surveyed 12,965 Hong Kong residents between April and November 2009 by telephone. Survey data examined trends in anxiety, risk perception, knowledge about methods of A(H1N1/2009) virus transmission, and preventive behaviors. The team reported that:
Perceived susceptibility to infection and perceived severity of A(H1N1/2009) were initially high but declined early in the epidemic and remained stable thereafter. As the epidemic grew, knowledge on modes of transmission did not improve, the adoption of hygiene measures and use of face masks did not change, and social distancing declined. Greater anxiety was associated with lower reported use of hygiene measures but greater social distancing. Knowledge that H1N1 [virus] could be spread by indirect contact was associated with greater use of hygiene measures and social distancing.
Based on the insignificant change in preventive measures and the general population's lack of knowledge about the modes of A(H1N1/2009) virus transmission, the research team concluded that public health measures instituted by the community played a small role in mitigating the impact of influenza A(H1N1/2009) pandemic.
The full article can be accessed at:
http://www.journals.uchicago.edu/doi/full/10.1086/655811
WHO Director General Margaret Chan announced at a press conference on August 10 that the A(H1N1) pandemic has largely run its course. Chan made the announcement after the WHO Emergency Committee's declaration that the A(H1N1) virus is now in the post-pandemic period. According to Chan's statement, current levels and patterns of A(H1N1) virus transmission differ significantly than they were during the pandemic; out-of-season outbreaks are no longer being reported in either the northern or southern hemisphere; and influenza outbreaks, including those primarily caused by the A(H1N1) virus, show an intensity similar to that seen during seasonal epidemics. However, Chan stated, just because the post-pandemic period has been declared, it does not mean that the A (H1N1) virus has disappeared. She said that, "Based on experience with past pandemics, we expect the H1N1 virus to take on the behavior of a seasonal influenza virus and continue to circulate for some years to come... it is likely that the virus will continue to cause serious disease in younger age groups, at least in the immediate post-pandemic period."
The WHO press statement can be accessed at: http://www.who.int/mediacentre/news/statements/2010/h1n1_vpc_20100810/en/index.html
The WHO recommendations for the post-pandemic period can be accessed at: http://www.who.int/csr/disease/swineflu/notes/briefing_20100810/en/index.html
A Belgium research team studied the affects of adjuvanted A(H1N1/2009) vaccines on adults up to 85 years of age, and published its findings in the August 2 issue of Clinical Infectious Diseases. It found that a single dose of adjuvanted A(H1N1/2009) vaccine was effective and well tolerated in adults up to 85 years of age including those who had earlier received the trivalent seasonal vaccine.
The researchers administered a monovalent A(H1N1/2009) vaccine containing 3.75 micrograms of antigen and the oil-in-water adjuvant AS03A to healthy adults in two age-groups, 18–60 and 60–85. After one dose, researchers measured antibody response against A(H1N1/2009) virus in the recipients, and then gave half the patients another dose of the vaccine. The team found that the immune response levels were in 97.5% and 87.4% of patients in the younger and older age-groups, respectively, which meets European licensure criteria. These levels persisted whether or not patients received the second dose. Researchers found that post-vaccination antibody titers in the 18–60 group were lower in those who had previously received seasonal influenza vaccination when compared with those who had not. That was not the case with the 60-85 group.
The full article can be accessed at: http://www.journals.uchicago.edu/doi/abs/10.1086/655830
A Harvard School of Public Health research team published a study in the September 2010 issue of Emerging Infectious Diseases that describes how mobile messaging was used as a surveillance tool during the A(H1N1/2009) influenza pandemic. Researchers evaluated cell phone technology for influenza outbreak surveillance during the outbreak of pandemic A(H1N1/2009) influenza in Mexico through a text message survey sent on May 12, 2009 to a random sample of 982,708 telephones that belonged to a 18 million nationwide telephone network.
The team found that 17% of respondents reported influenza-like illness (ILI) symptoms, of which 49% were severe. Severe ILI was defined as inability to work, study, or maintain responsibilities at home. Researchers compared these findings with a nationwide clinic-based surveillance system, which showed the percent of severe cases increasing from 36% on April 1 to a peak of 58% on April 26. Researchers said the data comparison from the text-message survey with clinic-based epidemic curves for pandemic A(H1N1/2009) influenza, "showed less variability than expected...no geographic variation was detected."
The team concluded that, when carefully deployed, unstructured supplementary service data surveys may be a practical, low-cost, and timely complement to traditional surveillance methods. However, further refinements of this tool are required to improve its validity. Further, conducting repeated surveys at short intervals may improve the response rate.
The full article can be accessed at: http://www.cdc.gov/eid/content/16/9/PDFs/10-0671.pdf
An international research team published a study in the July 29 issue of PLoS Pathogens whose major finding is that oseltamivir-resistant A(H1N1/2009) viruses possess lower transmissibility and fitness than influenza A(H1N1/2009) virus strains that are susceptible to oseltamivir. The team noted, however, that while only a small proportion of A(H1N1/2009) viruses are oseltamivir-resistant, were these strains to become readily transmittable, the proportion of resistance may increase among all A(H1NI/2009) viruses.
The team evaluated the transmissibility and fitness of A(H1N1/2009) viruses by co-infecting ferrets with oseltamivir-sensitive and resistant strains. It found that resistant A(H1N1/2009) virus was most efficiently transmitted by direct contact, while the sensitive A(H1N1/2009) virus was efficiently transmitted by both direct contact and respiration.
The team concluded that considering the extensive use of oseltamivir during the A(H1N1/2009) pandemic, its findings could be used to assess the clinical relevance of contemporary pandemic viruses. The study states, "...the fact that the oseltamivir-resistant H1N1/2009 virus retained efficient transmission through direct contact underlines the necessity of continuous monitoring of drug resistance and characterization of possible evolving viral proteins during the pandemic."
The team also noted that as its study continued, additional A(H1N1/2009) virus mutations emerged even in the absence of oseltamivir use. It warned that "The emergence of these viruses should raise concerns as to whether resistant A(H1N1/2009) viruses will acquire significantly greater fitness and spread worldwide as did the naturally resistant H1N1 viruses during the 2007-2008 season." The team observed that because "oseltamivir-resistant H1N1/2009 virus retained efficient transmission through direct contact," it is necessary for the public health community to conduct "continuous monitoring of drug resistance and characterization of possible evolving viral proteins" during future pandemics.
The full report can be accessed at: http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1001022?rss
A team of Korean researchers conducted a cross-sectional survey on hand washing among Korean university students between December 1 and 8, 2009, in order to better assess Koreans' perceptions, motivational factors, and behaviors associated with hand washing to prevent A(H1N1) virus transmission. The team administered the survey to 942 students at the university campus in Suwon. Results published in the July 28 issue of BMC Infectious Diseases showed that 30.3% of interviewees reported increased hand washing when compared to one year prior to the Korean A(H1N1) flu pandemic. When compared to male students, female students were found to wash their hands more frequently than males; perceive the effectiveness of hand washing to be lower; and perceive illness severity and personal susceptibility to A(H1N1) virus infection to be higher.
The team concluded that Korean students increased their frequency of hand hygiene practices during the pandemic, suggesting that the public campaigns through mass media and public education regarding A(H1N1) infection prevention were successful in terms of increased public awareness. The article states, "Here, the factors that affected hand washing behavior were similar to those identified at the beginning of the H1N1 or SARS pandemics, suggesting that public education campaigns regarding hand hygiene are effective in altering individual hand hygiene habits during the peak periods of influenza transmission." Findings also show that significant gender differences exist in the attitudes and behaviors related to the use of hand washing as a means of disease prevention. Specifically, men are more likely to perceive hand washing as an effective means of disease prevention while women exhibit a higher frequency of hand washing.
The full report can be accessed at: http://www.biomedcentral.com/content/pdf/1471-2334-10-222.pdf
U.S. Secretary of State Hillary Clinton announced that the United States has pledged $14 million in aid for a pandemic control program that will target Emerging Pandemic Threats in Cambodia, Thailand, Laos and Vietnam as part of the U.S. - Lower Mekong Initiative. Secretary of State Clinton made the announcement at the 43rd Association of Southeast Asian Nations (ASEAN) Ministerial Meetings in Hanoi on July 23. According to a VOV News report, the Emerging Pandemic Threats program will, "improve the identification of and response to new public health threats that originate in animals and strengthen animal and human health systems to combat outbreaks of infectious diseases."
The U.S. Department of State press release can be accessed at: http://www.state.gov/r/pa/prs/ps/2010/07/145066.htm
The Epidemic Intelligence team at the International and Tropical Department, Institut de Veille Sanitaire, Saint-Maurice, France studied the trends of A(H5N1) influenza since November 2003, and published its findings in Eurosurveillance on July 22. The team stated that despite the decrease in A(H5N1) influenza cases reported worldwide, data shows that A(H5N1) virus continues to circulate intensely in some countries, particularly Egypt and Indonesia.
Between November 1, 2003 and July 1, 2010, 15 countries notified the WHO of a total of 500 confirmed human A(H5N1) influenza cases including 296 deaths (case fatality rate 59%). The majority of cases occurred between November and April. This variation is due to seasonal patterns in the countries that A(H5N1) influenza affects in the northern hemisphere, especially Egypt, Thailand and Vietnam. In Indonesia, however, cases tend to occur throughout the year. Most A(H5N1) influenza cases in humans occur after exposure to sick or dead poultry or wild birds.
According to the article, some countries, such as Thailand and Turkey, successfully control A(H5N1) influenza outbreaks in birds and thus reduced the risk of exposure to A(H5N1) virus by humans. The A(H5N1) virus, however, continues to circulate in poultry elsewhere, especially in Bangladesh, Egypt and Indonesia. The article states, "The A(H5N1) influenza virus is one of several which could hypothetically give rise to a pandemic in the future." Recent poultry outbreaks and human cases occur in densely populated urban and suburban areas, increasing the risk of human transmission. Due to an increasing number of A(H5N1) virus outbreaks in highly populated areas, applying the current control measures intended for rural communities is ineffective. The report concludes that, "Human cases continue and will continue to occur as long as the situation in animals is not brought under control."
The full article can be accessed at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19619
Agence France-Presse (AFP) reported that the WHO 15-scientist emergency influenza committee will delay holding a meeting on whether to end the year-old A(H1N1) influenza pandemic alert until August 2010. WHO Director-General, Margaret Chan told AFP that the committee, originally scheduled to meet mid-July, will obtain more information during the southern hemisphere's winter influenza season before making a decision. Chan said that, "In the northern hemisphere, the situation is OK, but we have to look at the situation in the southern hemisphere....The president of the committee said that we have to wait and see what is going on in Australia and New Zealand where, traditionally, the peak for influenza is in August."
CIDRAP News reported on the 2010 International Conference on Emerging Infectious Diseases (ICEID) held in Atlanta, Georgia during July 11-14. Keynote speaker, Keiji Fukuda, special influenza adviser to WHO Director-General Margaret Chan, spoke on lessons learned from the A(H1N1/2009) pandemic and stressed the vital role of preparedness, from diagnostic testing to stockpiling of antiviral medications. Guidelines on pandemic influenza developed under the 2004 International Health Regulations, which came into effect about the time that the 2009 A(H1N1/2009) outbreaks in Mexico and California began, stimulated countries to adopt new methods of prevention and response to acute public health risks, and think of influenza as not just a healthcare, but a social issue.
In addition, Fukuda noted that despite strong political will and private-sector support, efforts to rapidly distribute influenza vaccine were inadequate. Fukuda said that 99 countries asked for vaccines early in the pandemic, but currently only 61 countries have received some of the amount they requested. Countries have received a total of 45 million vaccine doses and 22 million are scheduled for delivery by the end of July.
Fukuda mentioned another lesson is that, "During the H1N1 response, public health officials learned that they will need to shift their communication strategies to keep up with social networking sites and other forms of citizen journalism such as blogging." He added that information no longer filters top-down from the experts and major news media. Fukuda concluded that, "The new media have the capacity to shape global perceptions and understanding and have the advantages of being innovative, direct, interactive, and personal... However, without the voice of authority and a filter, the marketplace decides what is good or bad, which can lead to misinformation, confusion, and speculation."
The full CIDRAP report can be accessed at: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/jul1210keynote.html
The ICEID home page can be accessed at: http://www.iceid.org/
A research team at Hannam University in South Korea led by E.K. Jeong has published an article in the American Journal of Infection Control titled, "Inactivation of influenza A virus H1N1 by disinfection process." Jeong et al. write:
Because any patient, health care worker, or visitor is capable of transmitting influenza to susceptible persons within hospitals, hospital-acquired influenza has been a clinical concern. Disinfection and cleaning of medical equipment, surgical instruments, and hospital environment are important measures to prevent transmission of influenza virus from hospitals to individuals. This study was conducted to evaluate the efficacy of disinfection processes, which can be easily operated at hospitals, in inactivating influenza A virus H1N1 (H1N1).
Jeong et al. tested the disinfection properties of diluted (0.1 mol/L) sodium hydroxide, 70% ethanol, 70% 1-propanol, solvent/detergent using 0.3% tri (n-butyl)-phosphate and 1.0% Triton X-100, heat, and ethylene oxide by adding each chemical to virus suspended in solutions. Also, a surface test method was used that involved drying virus on a surface and then applying the chemical onto it for 1 minute of contact time. The test results were that A(H1N1) virus was completely inactivated to undetectable levels in 1 minute by 70% ethanol, 70% 1-propanol, and solvent/detergent treatments in both the surface tests and solution tests. The virus was completely inactivated in 1 minute by diluted sodium hydroxide in the solution tests and also in surface tests. The virus in solutions was inactivated to undetectable levels within 5 minutes, 2.5 minutes, and 1 minute of heat treatment at 70, 80, and 90 degrees Celsius respectively. Also, A(H1N1) virus was completely inactivated by ethylene oxide treatment in the surface tests. Jeong et al. concluded: "These results would be helpful in implementing effective disinfecting measures to prevent hospital-acquired infections."
The article can be accessed at: http://www.ajicjournal.org/article/S0196-6553(10)00187-2/abstract
A research team from BMC (BioMedCentral) Medical Informatics and Decision Making in Victoria, Australia has developed a new method to prospectively detect the start of an influenza outbreak. The team proposed using an exponentially weighted moving average (EWMA) control chart (which attributes more importance to recent data observations while not discarding older observations) of laboratory confirmed influenza cases to detect the start and end of influenza outbreaks. This has been difficult to do in the past because the model of an influenza outbreak has phases that are difficult to present mathematically.
Since "quick and reliable detection of the start of an outbreak is needed to promote public health measures," researchers consider the EWMA control chart a useful tool in aiding medical/health workers during influenza outbreaks. Specifically, the researchers identified a number of ways that the EWMA control chart/tool could assist public health workers to prepare for influenza outbreaks:
Reminders can be made for eligible persons to be vaccinated. Once the influenza season has commenced, hospitals may wish to change admission procedures, depending on the anticipated number of patients with an influenza-like illness (ILI) requiring hospitalization. For instance, hospitals might decide to reduce bookings for elective surgery in anticipation of increased acute admissions for influenza and its complications. Also, at relatively higher levels of ILI activity, wards admitting patients who are immunosuppressed may elect to roster [list] only staff who have been vaccinated against influenza in order to protect those highly susceptible patients.
In order to test the EWMA control chart, team members tabulated the recorded weekly level of influenza activities in Victoria over seven years. They utilized weekly laboratory confirmed influenza notification data that, in Victoria, health care providers must submit within five days of influenza diagnosis to the Victorian Government Department of Health. The polymerase chain reaction (PCR) assay was utilized for diagnosis of the influenza cases. Using this historic data, they set a threshold/baseline influenza activity, which when exceeded would indicate the beginning of an outbreak. They then compared the predictive ability of the EWMA control chart to determine the beginning of a seasonal influenza outbreak by comparing it to historic and new laboratory notification data. They found that the EWMA control chart data tracked well with the increase in number of laboratory confirmed influenza notifications, thus giving clear and visible notice of seasonal influenza outbreaks. This suggests that the start of an influenza outbreak should be easier to detect prospectively using EWMA.
The team also proposes using EWMA for detecting "out of season" influenza outbreaks, especially in tropical climates where seasonality of disease may not be apparent. According to researchers, EWMA can also be used to ascertain the start and endpoints outbreaks of diseases other than influenza.
The full article can be accessed at: http://www.biomedcentral.com/content/pdf/1472-6947-10-37.pdf
The World Health Organization (WHO) reported on 30 June that, with the exception of providing A(H1N1) vaccine, the level of support by donor countries and organizations for response efforts in developing countries is inadequate. Specifically, donations that aim to assist nations to improve health system planning, healthcare worker training, strengthening communications, humanitarian readiness, and public-health decision-making has been well below what was estimated to be needed in a September 2009 WHO report. That report focused on interventions that can largely be delivered within a six month time-frame, with follow up support for a further six months.
WHO estimated in September 2009 that 64 "least-resourced countries" needed a total of $1.48 billion in aid for vaccine, medicines and supplies, laboratory and surveillance services, improving communication capacity, and other activities to respond adequately to the challenges posed by a pandemic. The 2010 final WHO report identified areas of weak financial response support, such as general preparedness, which was estimated to require $237.8 million, but only received $102.2 million. According to the report, lab capacity was the only item for which estimated needed resources were met, at $25.4 million. The WHO estimated that donors have provided a total of $536.2 million in cash and resources, instead of the needed $1.48 billion, to assist developing countries in overall pandemic response. Of this amount, vaccine and related supplies received the largest proportion of $335.7 million and WHO's Public Health Emergency Fund received $137.1 million for vaccine deployment and global response.
WHO acknowledged that the need estimated in September 2009 was based on predictions for a severe pandemic. The 2010 report stated, "Since the virus has proven to be generally mild, it is likely that, in practice, the financial resources needed to respond to the A(H1N1) pandemic are less than the amount originally requested."
The full report can be accessed at: http://un-influenza.org/files/June2010UNIPReport_0.pdf
The Journal of Infectious Diseases published findings of a study that suggests southern China is a common source of multiple clusters of A(H5N1) influenza virus. A team of researchers from China and the United States used hemagglutinin gene sequences from 215 human A(H5N1) viruses to trace their source and dispersal pattern on a global scale. The study found that each virus can be identified as belonging to one of four geographic clusters: southern China, Indonesia, Indo-China, and Middle Asia-north Africa. By combining genetic analyses with geographic information system data analyses, the team's findings indicate that southern China was the source of the A(H5N1) virus, which then spread to Southeast Asia, then western and northern China, and finally across Eurasia and into the Middle East and Africa. The article can be accessed at: http://www.journals.uchicago.edu/doi/abs/10.1086/653709?journalCode=jid
The Hindu reported that A(H1N1) influenza deaths rose significantly with the onset of monsoon season in Kerala, India this year. A(H1N1) influenza virus spread increases with a dip in temperature, thus monsoon season is the most favorable time for a rise in the incidence of influenza, the report states. Since the beginning of the 2010 monsoon season in late May, the number of A(H1N1) influenza-related deaths in India rose to 32, the majority of which were from Kerala and Maharashtra. Between 15 May and 15 June Kerala reported 16 deaths, prompting the Central Government to send a team of health professionals to Kerala to assess the situation. The Kerala State government has also requested that the Union Health Ministry facilitate distribution of H1N1 vaccine to ensure its availability to the public.
The International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) released a statement 24 June on lessons learned from the 2009-2010 A(H1N1) influenza pandemic. Vaccine manufacturers noted several effective elements of the pandemic response. Response efforts showed a high level of preparedness among public health authorities, regulatory agencies and vaccine producers, and the World Health Organization (WHO) network and industry scientists, who collaborated on improving vaccine development, testing and availability and in other ways demonstrated global cooperation and flexibility. Nevertheless, IFPMA suggests improvements to strengthen preparedness in several areas of pandemic response, including the need for technical advancements to increase vaccine manufacturing and supply, countries to negotiate in advance vaccine supply agreements, enhanced regulatory processes to accelerate vaccine availability, and strengthening public communications.
The full report can be accessed at:
http://www.ifpma.org/fileadmin/webnews/2010/pdfs/20100624_Statement_H1N1_Lessons_24Jun2010.pdf
In the 25 June issue of PloS ONE, an international team of scientists, lead by virologist, Mauro Delogu, reported having discovered a new mechanism whereby avian A(H5N1) influenza virus circulates and is transmitted in nature. The team found that preen oil gland secretions (by which all aquatic birds waterproof their feathers through the process of preening) support a natural mechanism that concentrates water-borne A(H5N1) influenza virus onto birds' bodies. The process of preening therefore appears to facilitate transmission of the virus from bird to bird. Delogu stated:
Our discovery really opens a door to explain the highly pathogenic H5N1 circulation and persistence in Eurasia, as well as the only recorded human case of fatal infection passed from wild birds in February 2006. All infected humans were involved in defeathering of dead wild swans after a massive die-off of these aquatic birds occurred in Azerbaijan.
Delogu added that it may be necessary to develop new sampling methods for detecting avian influenza virus on birds' bodies. Current detection methods may not detect influenza virus on feathers, which could complicate future surveillance and rapid responses to the emergence and spread of new viruses.
The full article can be accessed at:
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0011315
BMC Infectious Diseases published the "Central European Vaccination Advisory Group (CEVAG) guidance statement on recommendation for influenza vaccination in children" on 14 June. The CEVAG guidance statement recommends universal influenza vaccination for all children over the age of 6 months. Vaccination is especially important for children up to 60 months of age, who are considered at a higher risk for influenza and its adverse affects. Since children are considered to be the main transmitters of the influenza virus during local outbreaks, CEVAC stated that "universal vaccination of infants and children could result in decreased morbidity and morality in other high-risk groups in the community." CEVAG strongly encourages continued education for health-care professionals and the public on the benefits of immunization in order to increase vaccination rates among children. The statement can be accessed at: http://www.biomedcentral.com/content/pdf/1471-2334-10-168.pdf
Bird Flu Information Corner reported the death of a patient on 9 June with a suspected diagnosis of avian A(H5N1) virus infection at the Dr. Murwadi Hospital in Solo, Indonesia. According to the report, this is the third case of A(H5N1) influenza-related human death in the Wonogiri area. An epidemiological investigation conducted by the Kabupaten Wonogiri Health Services near the victim's residence in Dusun Pakelan, discovered several fatal cases of A(H5N1) influenza in chickens. The head of Health Services, Aug Jarot Budiharso, MKes, told reporters, "by observing clinical signs, the cause of death indicates bird flu infection. But, we're still waiting for blood test result from Jakarta laboratory."
Options for the Control of Influenza recently announced that its seventh international influenza conference will be held in Hong Kong during 3 – 7 September 2010. The conference will provide opportunities for scientists and officials to present papers related to guidance for influenza prevention, influenza control and treatment, approaches for improving A(H1N1) vaccines, and planning for seasonal and pandemic outbreaks.
Organizations that will send representatives to the conference include the U.S. Centers for Disease Control and Prevention, the World Health Organization and the National Institutes of Health. Conference chair Marlik Peiris told VaccineNewsDaily that "flu planning has never been more vital." In view of the recent A(H1N1/2009) influenza outbreak Peiris said that "a multi-disciplinary and international approach is required to mitigate its impact and this is what the Options meeting tries to foster. Being the first meeting of the Options series to occur in the aftermath of a pandemic, with over 800 scientific abstracts already submitted, this meeting promises to be a landmark event."
The first report to summarize the epidemiology of A(H1N1/2009) in Greece was released by the Centers for Disease Control and Prevention (CDC) on 11 June. The CDC reported on findings of a study conducted in Greece by the Hellenic Centre for Diseases Control and Prevention (HCDCP), in collaboration with the National Health Operations Centre (AaHOC) of the Ministry of Health and Social Solidarity. Between May 18, 2009 and February 28, 2010, researchers collected and analyzed data regarding 1) laboratory-confirmed A(H1N1/2009) influenza cases, 2) influenza-like illness (ILI) visits to hospital emergency departments, 3) ILI hospitalizations, 4) confirmed A(H1N1/2009) influenza case admissions to intensive-care units (ICU), and 5) confirmed A(H1N1/2009) influenza related deaths in hospitals.
During the time of the study, a total of 18,075 laboratory-confirmed A(H1N1) influenza cases were reported, of which there were 294 ICU admissions and 140 deaths. Of the 140 fatalities, 82.1% had at least one underlying medical condition, with the most common conditions being obesity, diabetes, and cardiovascular disease. 63.5% of patients who died were under 60 years old and 5.7% were under 19 years old. The rate for ICU admission was estimated at 2.6 cases per 100,000 population, and the death rate was estimated at 1.2 deaths per 100,000 population.
Study findings also showed limited vaccination coverage in Greece due to limitations in vaccine availability. Therefore, much of the population in Greece is likely to be susceptible to influenza, the report says. Study findings suggest that continued surveillance and effective vaccination programs will be needed for the 2010-2011 winter influenza season. The full report can be accessed at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5922a2.htm?s_cid=mm5922a2_x
CSA Standards released a comprehensive white paper reporting the results of the national Roundtable on Healthcare and Emergency Service Sector Pandemic Preparedness, held in December 2009. The white paper, Voices From the H1N1 Pandemic Front Lines: A White Paper on How Canada Could Do Better Next Time, was released on 8 June at the World Conference on Disaster Management. The white paper provides constructive recommendations on how to address the challenges facing Canada's healthcare and emergency services, specifically through collaboration between governments at the federal and provincial levels to improve influenza preparedness plans for the future. Among the recommended steps to achieving preparedness goals were: 1) harmonization of federal and provincial frameworks to create a single standard approach for pandemic preparedness planning, 2) scalability improvement through a severity index for infections and implementation triggers, 3) implementation of a multi-faceted approach to protection through personal protective equipment and antivirals, 4) clear identification of "priority" groups' access to vaccines, and 5) communication improvement among all levels of government, healthcare organizations, and the general public. The white paper can be accessed at: http://www.csa.ca/cm?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1241708779869&ssbinary=true
An article in Pediatric Infectious Disease Journal published findings of a study to evaluate the safety and efficacy of oseltamivir (Tamiflu) in infants. Researchers accessed medical records (from 2003 to 2007) from a hospital in Germany to conduct a retrospective analysis of clinical characteristics and response to seasonal influenza infection treatment in 157 younger than one-year old infants. "This is the largest reported series of children <1-year-old treated with oseltamivir for influenza," the article states. Infants within the study group were those who presented with sudden onset influenza-like symptoms, had a positive rapid influenza test, and received parental consent for study participation. Oseltamivir was administered at a dose of 2 mg/kg of body weight twice a day to study group infants within 48 hours of influenza symptom onset, and they continued to receive the drug oseltamivir for 5 days. Only one infant did not complete the 5-day treatment course due to repeated vomiting.
Treatment efficacy was evaluated by how long fever remained after the time treatment started. Approximately 90% of infants received oseltamivir within 24 hours of symptom onset. 82% of infants in the study group showed a decrease in body temperature to 100.4 degrees F or below within 36 hours of treatment having commenced, while 5% showed decrease in body temperature within 48 hours.
Tolerability to oseltamivir was evaluated from the frequency of side-effects after it was administered. Approximately 50% of the infants presented symptoms including vomiting and mild diarrhea, while 7% of infants suffered from gastrointestinal infections.
According to the report's authors, their findings were comparable to previously published data of oseltamivir use in over one-year old children. A comparison of these findings suggests that oseltamivir is safe and effective for the treatment of influenza in infants younger than one-year, an age group that is particularly vulnerable to influenza. Researchers caution, however, that "this hypothesis warrants further testing in prospective, controlled studies." The full article can be accessed at: http://journals.lww.com/pidj/Fulltext/2010/06000/Oseltamivir_for_Treatment_of_Influenza_in_Infants.4.aspx#.
BMC Public Health published a study to evaluate influenza preparedness program and health systems of six Asian countries (Cambodia, Indonesia, Lao PDR, Taiwan, Thailand, and Viet Nam). In evaluating each country's program, the study took into account its general health system and wider socio-cultural and political qualities. Results show that the health systems of the six countries varied in regard to epidemiological context, health care financing, and health service provision patterns. Although the nature of plans differed between countries, the study found that each country had developed national governance and plans on national pandemic preparedness, including plans for responding to both avian and human influenza.
The study found that investment in pandemic preparation has contributed to improvement in the health system surveillance, laboratory capacity, monitoring and evaluation, and public communications of all six countries. The study also presented suggestions on how each country can strengthen pandemic preparedness and overcome basic health system constraints. The study identifies a need for additional research, which may include "implications of pandemic preparedness on health systems e.g. financial trend, health workforce burden, the economic analyses of resource needed to fill the capacity gaps, and so on." The full article can be accessed at: http://www.biomedcentral.com/1471-2458/10/322/abstract
The New England Journal of Medicine published two studies on the spread of the A (H1N1) virus during the early phase of the 2009 pandemic and implications for the control of influenza outbreaks. One study tested the efficacy of ring chemoprophylaxis with oseltamivir to control pandemic A (H1N1) outbreaks among military personnel in Singapore. The second study generated findings on the comparative epidemiology and virology of the pandemic A (H1N1/2009) virus and co-circulating seasonal influenza A viruses in Hong Kong.
The Singapore study reported on efforts to control four separate outbreaks of A(H1N1) influenza between June 22 and June 25, 2009. Oseltamivir was administered to all confirmed infected military personnel (a total of 82 confirmed cases) followed by clinical isolation to contain the spread of the virus. 3 of 4 outbreaks showed a significant reduction in the rate of infection after the intervention. Thus, oseltamivir ring chemoprophylaxis, coupled with prompt identification and isolation of infected military personnel, proved to be effective in reducing the impact of the A (H1N1/2009) outbreak in a semi-closed setting.
The Hong Kong study compared the spread of A (H1N1) virus with seasonal influenza A viruses among 284 persons in 99 households in Hong Kong. Findings showed similar characteristics between the pandemic A (H1N1) virus and seasonal influenza A viruses in terms of household transmission, viral-load dynamics, and severity of clinical illness. Considering the similarity in transmission and other characteristics of A(H1N1) influenza and seasonal influenza, the study suggest that interventions for controlling seasonal influenza are also likely to be effective in controlling pandemic A(H1N1) influenza.
Outcomes of both studies show that maximum benefit of intervention is achieved through early case detection and the prompt, simultaneous implementation of multiple measures to control influenza outbreaks. In addition, measures to control influenza outbreaks among populations in semi-closed or institutional settings should be distinguished from broader community efforts. The full articles can be accessed at: http://content.nejm.org/cgi/content/full/362/23/2175; http://content.nejm.org/cgi/content/full/362/23/2166
Two reports released on 4 June, accuse the World Health Organization (WHO) of having exaggerated the threat posed by pandemic A(H1N1/2009) influenza virus. One report was co-authored by the British Medical Journal (BMJ) and the Bureau of Investigative Journalism of London and the second by the Social, Health and Family Affairs Committee of the Parliamentary Assembly of the Council of Europe (PACE) in Paris. Both allege that WHO failed to disclose possible influence on it by pharmaceutical companies producing antiviral drugs and vaccines, and for misleading the public as to the seriousness of the A(H1N1/2009) influenza pandemic. According to the BMJ report, millions of dollars were wasted by countries as a result of having responded to the unnecessary fear caused by WHO reporting, including widespread unnecessary vaccination and stockpiling of antiviral drugs.
Several defensive responses have been issued by WHO, including a statement issued on 8 June by WHO Director General Dr. Margaret Chan in reference to the BMJ's "article on conflicts of interest at the WHO." The statement disputed claims that commercial interests played any role in WHO decision making on the pandemic. "Accusations that WHO changed its definition of a pandemic in order to accommodate a less severe event (and thus benefit industry) are not supported by the facts," Director General Chan stated. And according to a Washington Post report, several independent experts publicly disputed the reported accusations, calling the two reports misrepresentative of the seriousness of the pandemic, and asserting that WHO's response was carefully formulated and necessary, given the potential threat.
WHO has launched two investigations since the European reports were released, one of which being led by the Institute of Medicine's president, Harvey Fineberg. Fineberg told the Washington Post that accusations made against WHO will be fully considered by the institute's review committee. "These reports raise questions about potential, inappropriate influences on WHO decision-making in the assessment and response to the 2009 H1N1 pandemic and, more generally, question practices employed by WHO to guard against conflict of interest among its expert advisers," Fineberg said in an email interview. The original articles discussed in this report can be accessed at:
British Medical Journal http://www.bmj.com/cgi/content/full/340/jun03_4/c2912;
Parliamentary Assembly of the Council of Europe http://assembly.coe.int/CommitteeDocs/2010/20100604_H1N1pandemic_e.pdf;
World Health Organization http://www.who.int/mediacentre/news/statements/2010/letter_bmj_20100608/en/index.html
A recent study, published in Nature Biotechnology, generated findings that may lead to production of a new drug to treat the flu. A University of Hong Kong research team has identified a highly potent chemical compound, nulceozin, that targets the influenza A nucleoprotein responsible for virus replication. According to study findings, the compound has proven to be effective against influenza A (H1N1), influenza A (H3N2), and influenza A (H5N1) viruses, and therefore can be further developed into a drug to treat influenza.
The Wall Street Journal reported that CSL Ltd., a leading vaccine manufacturer in Australia, voluntarily withdrew its Fluvax influenza vaccine on 1 June. The withdrawal came after Australia's Health Department investigation found an unacceptable rate of vaccine side effects such as convulsions, vomiting, and fever in children. Specifically, the vaccine induced seizures in children at nine times the expected level, with the rate of febrile convulsion at approximately 9 per 1,000 in infants younger than age 5, while the expected rate is less than 1 per 1,000. CSL was subsequently directed by the Health Department to issue new warnings on the vaccine, alerting medical professionals about the risks associated with vaccine use in young children. CSL has agreed to comply fully with the directive and continues cooperating with government investigations to identify the reason for adverse vaccine side effects.
Australia's chief medical officer, Jim Bishop, told the Wall Street Journal, "influenza itself often causes fever in young children which can lead to convulsions, and flu vaccine can also produce these side effects... but there is a clear signal that the rate of fever with convulsions is higher with this year's vaccine across all jurisdictions." Bishop advises medical professionals to exercise caution when using other vaccines on children as well, including the Solvay SA's Influvac vaccine and the Sanofi-Pasteur SA Vaxigrip. According to the report, the audits and lab testing conducted as part of the Health Department investigation has yet to identify any abnormalities that would explain the vaccine side effects.
ProMED reported on a human case of highly pathogenic avian influenza A (H5N1) virus infection in Hubei Province, which caused the death of a 22 year old pregnant woman on 3 June. Samples from the patient's respiratory tract tested positive for the A (H5N1) virus. The death was reported by China's Ministry of Health on 4 June, followed by the launch of an investigation and laboratory tests on poultry. Initial epidemiological investigations by local health agencies found that the patient had been in contact with sick and dead poultry before the onset of illness. China's Ministry of Agriculture reports that no outbreaks of avian influenza have been found in poultry thus far.
The Singapore Straits Times reported that the epidemic season in Singapore is especially severe this year, as the number of persons reporting flu-like symptoms have reached epidemic, or near-epidemic levels, for the past six weeks. A high of 18,420 people sought treatment for the flu at government health polyclinics during the week of 17 May, which is 4,000 more patients a week than the norm for this time of the year. Many of the flu cases involve the pandemic A (H1N1) strain. According to the Singapore Ministry of Health, 29 percent of patients with flu-like symptoms were infected with the A(H1N1) virus. According to the Singapore Straits Times, it is especially worrying that a high number of patients are turning out to be sick with pneumonia, a severe form of upper respiratory tract infection. Pneumonia is the third largest killer in Singapore, after cancer and heart disease, accounting for more than 2,000 deaths in 2008.
(According to the WHO Pandemic (H1N1) 2009 update #101 of 21 May, the most active areas of pandemic influenza virus transmission in South and Southeast Asia are Bangladesh, Malaysia, and Singapore.)
Times of India reported that the National Institute of Virology (NIV) recently detected three new variants of A(H1N1) virus. The viruses were first detected in India in May 2009, and have caused both recovered and fatal cases in many parts of the country. NIV now reports that all of the three new variants are responsive to treatment with the antiviral drug oseltamivir (Tamiflu). But, according to the NIV, the viruses are actively acquiring new properties so scientists are closely monitoring them for any genetic change that might lead to antiviral resistance.
Reuters reported on a study that was published in the 21 May issue of the British Medical Journal, which found stronger immune responses in children receiving vaccines containing a booster than vaccines without the adjuvant. The study tested the immune response of 900 children, ages 6 months to 12 years, to the vaccines Celvapan and Pandemrix, of which Pandemrix contained the adjuvant AS03. Comparing results of the two vaccines showed 98.2 percent immune response to Pandemrix against 80.1 percent for Celvapan, in children under three, and 99.1 percent for Pandemrix against 95.9 percent for Celvapan, in children over three.
Researcher Dr. Mathew Snape of the Oxford Vaccine Group told Reuters that both vaccines were well tolerated by participating children and provided good protection, but he considered the strong response to Pandemrix in children under three as the most important outcome. Snape stated that the data generated by this study will be "reassuring for countries such as the US, which haven't approved the use of adjuvants for influenza vaccines."
A study published in the Archives of Internal Medicine shows a lower incidence of fever and dyspnea in hospital patients in Singapore infected with novel influenza A(H1N1) virus than in those with the seasonal flu virus. The study, which was conducted within a 12 week surveillance period, showed that patient symptoms, including fever, cough, sore throat, rhinorrhea, and dyspnea, were significantly different between A(H1N1) influenza, A(H3N2) influenza, A(H1N1/2009) influenza, and influenza B cases. Patients infected with the A(H1N1) virus tended to be younger and present symptoms such as a cough, sore throat, and muscle aches, while those infected with seasonal flu showed a higher incidence of fever and dyspnea.
Reuters reported that South Korea is offering free A(H1N1) vaccinations to soccer fans traveling to South Africa for the World Cup, which begins next month. South Korea's Center for Disease Control and Prevention (KCDC) told Reuters that it was administering the vaccinations at health clinics around the country.
ProMED-mail translated a Marker article that reported that H5N1 infection has appeared in poultry in the Palestinian Authority (PA). The Laboratories of the Veterinary Services at Beit Dagan examined dead birds from Tulkarm and found them infected with H5N1 virus. Israel's Ministry of Agriculture Inspection Unit for Fauna and Flora, which has responsibility for controlling animal and plant movements, has intensified its efforts to prevent smuggling of infected poultry at border crossings, gateways, and passages between the West Bank and Israel. Moshe Haimovich, the Director of Israel's Veterinary Services, has urged the public to buy poultry and eggs only in regulated stores and enterprises.
Last week, highly pathogenic H5N1 influenza virus were discovered in animals at the small children's zoo of Kibbutz Ein Gedi. The inspectors of the Services destroyed all birds at the zoo to prevent the spread of the epidemic.
According to a report from Germany published 6 May in Eurosurveillance, an adjuvanted vaccine against the pandemic A(H1N1) virus was found to be highly effective in adolescents and younger adults and moderately effective in older people. (An adjuvant is a substance that boosts the recipient's immunity response to the vaccine, thus allowing a smaller dose of vaccine to be administered.) Using data on vaccinated and unvaccinated people who had confirmed cases of A(H1N1) influenza and survey data on vaccination coverage, a team from the Robert Koch Institute in Berlin estimated vaccine effectiveness (VE) in people aged 14 through 59 years at almost 97%, while VE in those 60 and older was estimated at about 83%. By comparison, seasonal flu vaccines well-matched to circulating strains are generally estimated to be about 70% to 90% effective in healthy young adults, but their effectiveness in the elderly is probably substantially lower. The researchers wrote that their findings may overestimate VE to some degree because vaccinated people might have been less likely to be tested for A(H1N1) virus if they got sick. Nevertheless, the results still suggest excellent effectiveness for the vaccine.
In an email exchange with CIDRAP News, Lisa Jackson, an immunization researcher and senior investigator at the Group Health Research Institute in Seattle, called the study's findings interesting but is skeptical of the VE estimates. A major strength of the study is its use of lab-confirmed flu cases, but its limitations include uncertainty about the timing of disease onset after vaccination. She believes there is "likely inaccuracy in estimating population vaccine coverage, which is critical to this type of analysis. Estimating vaccine coverage was inherently difficult given the fast pace of the vaccination campaign and further limited by the use of a relatively small sample (N=1,000) to estimate coverage."
D.A. Janies and colleagues at the Medical Department, Ohio State University, have published an article titled "Selection for resistance to oseltamivir in seasonal and pandemic H1N1 influenza and widespread co-circulation of the lineages." (International Journal of Health Geographics 9:13, May 2010). Their major findings are that (1) there currently are two main strain types of the A(H1N1) virus circulating in humans, a seasonal strain and a pandemic strain; (2) the primary treatment method for both strains is the antiviral drug Tamiflu (oseltamivir); and (3) the level of resistance to Tamiflu among both strains is rising.
The researchers hypothesize that the evolution of resistance to oseltamivir in pandemic H1N1 could be due to point mutations in the neuraminidase or a reassortment event between seasonal H1N1 and pandemic H1N1 viruses that provide a neuraminidase carrying an oseltamivir-resistant genotype to pandemic H1N1. By combining phylogenetic and geographic data the Ohio researchers have so far identified 53 areas of co-circulation where reassortment can occur. (At their POINTMAP website, these areas and information about can be visualized: http://pointmap.osu.edu.) The major conclusion of the researchers is: "Reassortment and, more likely, point mutation have the potential to create a strain of pandemic H1N1 against which we have a reduced number of treatment options."
The article can be accessed at: http://www.ij-healthgeographics.com/content/9/1/13
New research conducted by Taiwanese scientists has found that influenza viruses may be carried in the air for long distances, even across continents, by dust storms. The concentration of influenza viruses in the air was found to be 20 to 30 times higher during dust storms than at other times. This finding by researchers, led by Pei-Shih Chen of Kaohsiung Medical University in Taiwan, might explain why not all outbreaks of bird flu in animals have been linked to movement of poultry or wild birds. They wrote, "H5N1 outbreaks in South Korea and Japan were not consistent with either reported poultry trade or the timing and direction of migratory bird travel during the month of outbreak, suggesting that other factors led to these introduction events. Avian influenza outbreaks in downwind areas of Asian dust storms suggest that viruses might be transported by dust storms."
However, Don Beezhold and John Noti of the U.S. Centers for Disease Control and Prevention, in an email to Emerging Health Threats Forum noted, "The amount of detected virus during Asian dust storm days was only 21 or 31 times higher. At best, this is only a modest increase in viral count." Beezhold and Noti agreed that viruses could be carried by air over very long distances, observing, "But the real question is whether the virus remains active. There are studies, including our own unpublished data, that indicate small amounts of aerosolized virus [are] infectious. The question is for how long and how far in the outdoor environment can viable virus travel?"
The World Health Organization's Disease Outbreak News of May 6 reported that Indonesia's Ministry of Health has announced two new laboratory confirmed cases of human infection with the H5N1 avian influenza virus. A 45 year old woman from the city of Malang in East Java province developed symptoms on February 22, but recovered fully. She had disposed of dead chickens four days before onset of symptoms. The second case was a four year old girl from Pekanbaru city who presented with symptoms on April 19, was hospitalized on April 22, and died on April 28. It is not known as yet how she contracted the virus. The alarming statistics from Indonesia are that of the 165 laboratory confirmed infections with the H5N1 avian influenza virus in that country, 136 (82%) have been fatal. This is a much higher mortality rate than, for example, anthrax and smallpox and about the same as Ebola and Marburg virus fever disease.
The Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza published an article in the New England Journal of Medicine stating that the A(H1N1) flu disproportionately affected children and young adults instead of the older adults normally affected by the traditional flu. The article provides a comprehensive overview of the A(H1N1) virus' affects and characteristics and responses to infection, including epidemiology, pathogenesis, clinical features, diagnosis, and clinical management.
The committee noted that the uncertain evolution of this virus among humans and potentially other species highlights the need for continued virologic surveillance for antigenic changes, viral reassortment, antiviral resistance, and altered virulence. The authors concluded that the gaps in knowledge and the experience to date underline the urgent need for better international collaboration in clinical research, particularly in the case of diseases with pandemic potential, for which rapid detection, investigation, and characterization of clinical syndromes are prerequisites for improved mitigation of their public health consequences.
According to WHO, the pandemic influenza H1N1 situation during the week of April 25 was largely unchanged since the previous week. The most active areas of transmission of this virus continued to be parts of West and Central Africa with some focal areas of activity in South and Southeast Asia, but activity remained low in much of the temperate areas of both the northern and southern hemispheres. As of April 25, more than 214 countries and overseas territories have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 17,919 deaths.
Of the seasonal influenzas, the type B virus predominates, though t low levels of circulation, across East Asia, Northern and Eastern Europe. Influenza type B viruses have also been detected in Central Africa and this week in West Africa. Seasonal influenza H3N2 viruses have continued to be detected in South and Southeast Asia, as well as sporadically in some countries of West and Central Africa, and Eastern Europe.
The United States Agency for International Development (USAID) released a press statement that it has helped Indonesia reduce the risks associated with the transmission of H5N1 virus. With USAID assistance, the risk of contracting H5N1 influenza has been reduced in tens of thousands of villages in Indonesia since the launch of its Community-Based Avian Influenza Control Project (USAID-CBAIC) in 2006. USAID's press release also stated that the project had worked with the commercial poultry private sector to increase biosecurity and management practices to improve disease control and productivity among commercial birds. While the CBAIC project has ended, USAID is still supporting a robust Avian and Pandemic Influenza prevention and control program. This year USAID will build upon the CBAIC project by providing US$14 million of assistance to reduce the impact of H5N1 on humans and animals and to minimize the risk of a greater pandemic.
The Malaysian National News Agency reported that on 28 April, a conference entitled "Sustaining Efforts to Reduce Risk of AI [H5N1] through Partnerships" was held to mark the end of the four-year USAID-CBAIC program to reduce H5N1 risk at the village level and throughout the commercial poultry supply chain. The conference also encouraged and reinforced local, district, provincial, and national commitment to sustain H5N1 control and risk reduction efforts in the future. Walter North, USAID Mission Director, said that in particular, partnerships with existing community-based networks and with large industrial poultry firms can facilitate risk reduction efforts at the village level and expand biosecurity in the commercial poultry sector.
The Sidney Morning Herald reported that New Zealand children have suffered convulsions after having been administered influenza vaccine produced by Australian company CSL. On 28 Apr 2010, Pat Tuohy, New Zealand's Health Ministry chief adviser for child and youth health, told politicians that 5 children had been reported to have suffered febrile convulsions in New Zealand since 23 Apr 2010. These reactions follow reports of similar reactions in Australia. Last week, the NZ Ministry of Health advised doctors against using CSL's vaccine, called Fluvax, on children.
Australia, New Zealand, and Singapore were the only countries to have used the Fluvax vaccine so far this year. Over 260,000 Fluvax doses were administered in New Zealand, and the NZ Ministry of Health said supplies were now likely to be low. More supplies of an alternative vaccine, called Vaxigrip, were expected to arrive from Europe this week.
CIDRAP News reported that a multi-national meeting whose aim was to generate an agreement for eradicating H5N1 avian flu in Southeast Asia within 10 years concluded deliberations on 27 April with a call for cooperation to keep animal diseases from crossing national borders. The First Technical Working Group Meeting on Highly Pathogenic Avian Influenza (HPAI) Roadmap, a project of the Association of Southeast Asian Nations (ASEAN), met for 2 days in Jakarta to work out mutually agreed plans—the "roadmap"—that will be submitted to the 10 member countries (Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam) later this year.
The draft agreement produced by the meeting calls on member countries to establish a single regional economic market in livestock and animal products by 2015 and eradicate H5N1 avian influenza from the region by 2020. It pays particular attention to instituting a "One World, One Health" approach (a concept backed by 38 national and international health organizations) of treating animal and human diseases as a continuum that requires consistent policy responses across government and development agencies.
The Wall Street Journal reported that Australian Chief Medical Officer Jim Bishop suspended influenza vaccinations for all children under five years old. Dr. Bishop said the action was a precaution "due to a spike in the number of young children in Western Australia experiencing fever and convulsions following seasonal flu vaccinations." He said health authorities are seeking more information from CSL Ltd., including which batches of vaccine were used in Western Australia. CSL Ltd., the only commercial manufacturer of influenza vaccines in the Southern Hemisphere, halted the distribution of its pediatric influenza vaccine on April 23 after Australian authorities linked severe adverse reactions (seizures and high fevers) in young children with the vaccine. A company spokeswoman said the center of concern is a seasonal vaccine that immunizes children against three influenza strains, including A(H1N1). CSL stated that it was working with health authorities to investigate the problem.
IRIN News reported that attendees at the International Ministerial Conference on Animal and Pandemic Influenza in Hanoi this week discussed the lessons learned from SARS, H5N1, and A(H1N1). After the outbreak of SARS in 2003, Vietnam dramatically stepped up its disease surveillance. To assist Vietnam build up its capacity to undertake disease surveillance, the WHO and U.S. government have provided money for new laboratory equipment and training. This has enabled Vietnam to set up 15 new sentinel surveillance sites that collect and test samples of sputum collected from patients suspected of being infected with influenza, and provide with results that allow health officials to detect and track the disease much earlier than was previously possible. Vietnam now possesses one of the most advanced surveillance systems in the world. Nguyen Tran Hien, director of Vietnam's National Institute of Hygiene and Epidemiology said, "'It's different now... We have a better understanding of these diseases and we are in an active position to cope. If something new emerges, we can send our teams to get a specimen and conduct an investigation. A quick response means early containment."
Officials attending the conference warned that countries need to remain alert against emerging diseases in order to prevent a pandemic. David Nabarro, senior UN system influenza coordinator, told the conference in a video message, "The need to contain existing diseases and prevent new pathogens from jumping between species is set to increase as our environment changes and human and animal populations continue to grow."
Research findings presented at the national Kidney Foundation's Spring Clinical Meetings reported that people who were critically ill with A(H1N1) infection often suffered kidney damage as well as respiratory illness. Dr. Manish M. Sood, an assistant professor of medicine at the University of Manitoba in Winnipeg and director of hemodialysis at St. Boniface General Hospital said: "It's concerning that so many people got some form of kidney injury, although it was reversible in the majority of them. Patients who come to the ICU with critical illness who also have kidney injury stay longer, take up more resources and have a much higher chance of dying."
Dr. Sood also noted that because the study included relatively few patients from a single Canadian province, the results may not be applicable to all patients with serious A(H1N1) infections. However, these results indicate that doctors treating these patients should be aware of the possibility of kidney damage and avoid it, if possible, by making sure patients do not become dehydrated and by not giving them substances that could harm kidneys, such as contrast agents used in imaging.
A new United Nations-World Bank study reports that sustaining defenses against new infectious diseases will require a 21st century skill set: well-synchronized coordination among public and private sector institutions; a global network of laboratories and surveillance systems; a collaborative international outlook; clear communication with the public; and steady political commitment even as other events dominate headlines. Further, with an estimated 75 percent of new human diseases originating in animals, and an annual average of two new animal diseases with cross-over capability emerging each year, the crowding of three major epidemiological events into the first decade of the new century -– SARS, H5N1 avian influenza, and A(H1N1) pandemic influenza –- is an indication of the rate at which threats may continue to arise.
Critical factors for responding to new infectious diseases include in-country institutional frameworks to tackle the root causes of disease emergence; use of the World Health Organization's 2005 set of International Health Regulations and the World Animal Health Information System of the World Organization for Animal Health; improved biosecurity in poultry production systems; more public awareness and participation in basic hygiene practices; advance planning to maintain businesses and public services during periods of potential duress due to pandemic; and sharpened surveillance systems.
The World Health Organization (WHO) has recommended vaccine strains for the 2010-2011 Northern Hemisphere trivalent influenza vaccine, and the U.S. Food and Drug Administration has made the same recommendations for influenza vaccine composition for the United States. Both agencies recommend that vaccines contain A/California/7/2009-like (2009 H1N1), A/Perth/16/2009-like (H3N2), and B/Brisbane/60/2008-like (B/Victoria lineage) viruses. The recommendation by WHO was based on surveillance data related to epidemiology and antigenic characteristics, serologic responses to 2009-2010 trivalent seasonal and 2009 H1N1 monovalent vaccines, and the availability of candidate strains and reagents.
A seasonal influenza A(H1N1) component is not included in the 2010-2011 formulation, and the A(H3N2) component has been changed from A/Brisbane/59/2007 in the 2009-2010 Northern Hemisphere vaccine formulation.
According to the World Health Organization (WHO), Chile has reported new detections of the A(H1N1) virus in at least three regions in advance of the start of its flu season. The WHO's weekly flu report noted that the significance of the rise in pandemic flu in parts of Chile to the rest of Chile's flu season is unknown.
Other infection hot spots are occurring in Bangladesh and parts of Africa. Localized pandemic flu transmission persisted in the Eastern African areas of Tanzania and Rwanda. Cuba, Guatemala, Peru, and Bolivia have reported localized flu activity as well. Several states in Mexico, particularly in the Federal district, an area that has experienced recent increases in severe and fatal pandemic A(H1N1) infections, reported localized activity throughout March. Brazil, which had increased levels of influenza-like illnesses over the past month, reported that most of the severe and fatal pandemic A(H1N1) infections occurred in the country's northern regions. However, A(H1N1) viral activity remained stable in most other parts of the world.
Winter outbreaks of H5N1 avian influenza in Europe tend to occur at the leading edge of cold fronts, according to a study published in Public Library of Science (PLoS) Pathogens. Researchers determined that disease outbreaks during winter of 2005-2006 were driven by movements of large flocks of wild waterfowl away from areas of frozen surface water toward areas of higher temperatures (32°F to 36°F). Such areas tended to occur on the leading edge of cold fronts, where lakes and streams remained unfrozen. The resulting congregation of varied bird species created ideal conditions for H5N1 viral transmission and many European countries confirmed outbreaks in wild birds in 2006. The researchers wrote, "Movements of cold weather fronts, and in particular the 0°C isotherm of maximum surface air temperature, can readily be anticipated by operational weather forecasts." Such forecasts, they recommend, should trigger increased H5N1 surveillance in such regions, especially in poultry-dense areas.
Vietnamese doctors have, for the first time, saved a patient with a life-threatening case of H5N1, said a spokesperson for the Bach Mai Hospital in Hanoi, Vietnam. Dr. Nguyen Gia Binh, head of the Intensive Care Department, said the patient, 25-year old Nguyen Thu Thuy, was taken to the hospital in serious condition, suffering from primary viral pneumonia and multi-organ failure.
Vietnamese doctors consulted with Japanese counterparts to create a comprehensive treatment plan that included continuous renal replacement therapy to remove toxins in the patient's blood and reduce inflammation and organ damage. After seven days of this treatment, Thuy began to improve and no longer required assisted breathing. After 10 days of intensive treatment, Thuy's organs had returned to functioning normally.
Dr. Binh said this treatment method was first used in Japan, but is not widely implemented because it is very expensive. The Disease Control and Prevention Center of the International Medical Center of Japan, which has a partnership with Bach Mai Hospital, sponsored the US $10,500 treatment process.
All Headline News reported that according to the World Bank, the H5N1 situation in Bangladesh has remained stable with significantly fewer outbreaks reported during 2009 and 2010 than 2008. However, risks for further outbreaks persist because 50 percent of the national poultry flock is backyard poultry. Further, Bangladesh also has a large duck population (about 39 million) and is visited annually by about 21 species of migratory birds that can carry the virus. These risk factors, coupled with a high population density, mean that the country remains in danger of possible H5N1 outbreaks.
The Malaysian National News Agency reports that, in Malaysia, the A(H1N1) pandemic has shown signs of a resurgence. Malaysian Health Minister Datuk Seri Liow Tiong Lai announced an increase in the number of cases over the past three weeks (50 cases per week compared to 20 cases per week in January and February). "Throughout the week, 10 ILI [Influenza-Like Illness] clusters have been reported in Kelantan, Perak, Kedah, Selangor and Melaka," he said.
Because clusters of infection were located mostly at schools, Liow advised school workers, students, and their parents to practice preventive measures and seek early treatment should they experience ILI symptoms. Liow said A(H1N1) vaccinations were available for those individuals representing high-risk groups such as pregnant women, patients with kidney problems, and patients with chronic illnesses.
The Public Health Agency of Canada will award a $176,000 (Canadian dollars) contract to a Toronto-based team of researchers to study international air traffic patterns during the A(H1N1) pandemic. The study's goal will be to determine whether governmental warnings directed at Canadians influenced the way the disease spread throughout Canada and around the world. Researchers will also collect data on flight patterns during the Vancouver 2010 Winter Olympics to study whether mass gatherings could be instruments for accelerating disease spread.
Project leader Dr. Kamran Khan, an infectious disease specialist at St. Michael's Hospital said, "There is a science behind how we interact as a global community and...if we can understand how we move, indirectly we understand how infectious diseases move, because essentially we're the ones that are transporting the disease around the world primarily through commercial air travel." Khan expects the study to find that travel advisories had little bearing on the behavior of travelers because anecdotal evidence suggests passengers base travel decisions on economic factors, such as the inability to refund a trip if cancelled, or their own personal perceptions of risk.
Safaa Abdoun of Daily News Egypt reported that the Egyptian Minister of Health Hatem El-Gabaly said that the government plan for combating bird flu has proven successful. The death rate from the H5N1 virus has substantially decreased, and citizen awareness has increased. In the Egyptian parliament on Tuesday, El-Gabaly responded to several requests for investigation into the effectiveness of the precautionary measures taken against H5N1, which included the culling of poultry suspected of infection. One hundred eight H5N1 cases in humans have been reported in Egypt, of which 75 recovered and 33 died, the Minister said.
A WHO representative stated on Wednesday that the H5N1 virus remains a threat to humans: "The newly confirmed human and poultry cases of avian influenza this year are a reminder that the virus poses a real and continuous threat to human health. So far this year, authorities monitored 21 human cases of bird flu from Egypt, Vietnam and Indonesia, including seven deaths." The fatality rate for humans infected with H5N1 is 59%.
The Irish Independent reported today that 40,000 babies born in Ireland during 2009 did not receive the BCG vaccine routinely administered to newborns because public health workers were ordered by the Health Service Executive to give top priority to A(H1N1) influenza. While sufficient A(H1N1) vaccine has by the end of March 2009 been administered to Irish children to allow public health workers to catch up with their other duties, there is concern that parents of children who should have received the BCG vaccine will not bother about bringing them back to clinics. The difficult public health situation is compounded by a moratorium imposed by the Health Service Executive that prevents the hiring of new public health workers.
A new study to be published in the April 2010 issue of Radiology found that x-rays can help physicians better identify high-risk A(H1N1) patients requiring close monitoring. Lead author Galit Aviram, head of cardiothoracic imaging in the Department of Radiology at Tel Aviv Sourasky Medical Center, said: "Working in the emergency room is very stressful and physicians need information fast. Our study provides significant findings that will help clinicians triage patients presenting with clinically suspected H1N1 influenza."
Aviram and colleagues analyzed the chest x-rays of 97 patients over a five month period, between May and September 2009, with flu-like symptoms and laboratory-confirmed diagnosis of A(H1N1) infection. The mean age of patients in the study, which included 53 men and 44 women, was 40.4 years. The scientists then correlated the x-ray findings with adverse patient outcomes. The chest x-rays revealed abnormal findings for 39 of the patients—five of whom experienced adverse outcomes such as death or the need for mechanical ventilation. For the other 58 patients chest x-ray findings were normal, and of this group only two experienced adverse outcomes. Aviram said, "To our knowledge, this is the largest series describing the presentation of chest x-ray findings in patients diagnosed with H1N1 influenza. Abnormal findings in the periphery of both lungs and in multiple zones of the lungs were associated with poor clinical outcomes. In H1N1, as in various types of community-acquired pneumonia, initial chest x-rays may not show abnormalities that develop later in the course of the disease. Further x-rays should be performed according to the patient's clinical course."
Aviram noted that though a normal chest x-ray did not exclude the possibility of an adverse outcome, the study's findings may help physicians better identify high-risk A(H1N1) patients who require close monitoring.
Rita Uplend of Vaccine News Daily reported on a study that found pregnant women in Australia and New Zealand infected with A(H1N1) virus were 13 times more likely to become critically ill and require admission to a hospital than non-pregnant women of childbearing age. The findings confirm earlier research that pregnant women are at higher risk of serious complications if they get the flu. The study, published in the British Medical Journal, analyzed data collected during the southern hemisphere's 2009 winter and found that seven of the mothers (11 percent) and seven of the babies (12 percent) died after the mothers were admitted to intensive care with A(H1N1) infection.
Ian Seppelt, member of the Australian and New Zealand Intensive Care Influenza Investigators and lead author of the BMJ study, noted that none of the studied women had been immunized against regular seasonal flu, despite recommendations issued nation-wide that pregnant women should be immunized. During the study period from June 1 to August 31, 2009, 209 women ages 15 to 44 were admitted to intensive care units with confirmed A(H1N1) infection. Sixty-four of them were either pregnant or had recently given birth.
The study found that women who were more than 20 weeks pregnant were 13 times more likely to be admitted to intensive care than non-pregnant women who had A(H1N1) flu. Approximately 69 percent of the women required ventilators to help them breathe, and of these, 14 percent required extracorporeal membrane oxygenation. Seppelt concluded that "Although a mortality of 11 percent seems low when compared to usual outcomes of respiratory failure in intensive care ... a maternal mortality of 11 percent is high when compared with any other obstetric condition."
The FAO Media Centre reports that an international team of experts established by the Food and Agriculture Organization (FAO) in Rome has warned that while more is known today about the role of wild birds in the spread of the highly pathogenic avian influenza (HPAI) H5N1 virus than ever before, significant information gaps remain unfilled as government and public attention is shifting elsewhere. The Scientific Task Force on Avian Influenza and Wild Birds asserted that "Waning attention to HPAI H5N1 is reducing surveillance and research opportunities, negatively affecting capacity building and coordination between environmental and agricultural authorities, and impacting efforts to further refine understanding of the epidemiology and the ecology of the virus."
According to Juan Lubroth, FAO's Chief Veterinary Office, "Unfortunately, H5N1 may have slipped off the radar screen for some people, but it continues to be a major problem, especially in Egypt and parts of Asia, where it is having a huge impact on food security and the livelihoods of farmers and local communities. H5N1 HPAI is has not been restricted to Asia alone, having also occurred in Europe, Central Asia and parts of Africa."
FAO reports that in the past six months, there have been outbreaks of the virus in domestic poultry in Bangladesh, Cambodia, Romania, Israel, Myanmar, Nepal, Egypt, Indonesia, India, and Viet Nam and in wild birds in China, Mongolia, and the Russian Federation. Just this week, Bhutan reported outbreaks for the first time and the virus was detected after a three year absence in Romania in domestic poultry.
The task force was established in 2005 and is comprised of 15 international organizations, including several UN agencies, other intergovernmental groups, and specialist non-governmental organizations (see: http://www.aiweb.info/).
Reuters reported that the World Health Organization (WHO) announced today it delivered the first doses of A(H1N1) vaccine to Cuba. According to the U.N. agency, of Caribbean countries Cuba has reported the largest number of fatalities (54 deaths) from A(H1N1) flu. 1.1 million doses of A(H1N1) vaccine arrived in Cuba on March 17. Shipments to Honduras and El Salvador are also en route. Further, a dozen countries in Africa will receive millions of doses in coming weeks. Gregory Hartl, WHO spokesperson for Epidemic and Pandemic Diseases, said that Nigeria, Africa's most populous country, as well as Kenya and South Africa are among those countries scheduled to receive vaccine doses by May. Hartl stated that "In the next weeks, 10-15 countries will receive vaccine. We are doing what we can to limit the effects of H1N1 on the African continent." The shipment for Nigeria will contain approximately 2.8 million doses of vaccine.
More generally, WHO reported in its latest weekly update that "limited data suggests that pandemic influenza activity may be increasing across parts of Central America and the Caribbean." The A(H1N1) virus also continues to spread across much of West Africa, including in Ghana and Nigeria.
In the wake of the A(H1N1) influenza outbreak in late April 2009, China closed its market to U.S. pork products. However, the National Pork Producers Council stated that the United States and China have reached an agreement to reopen the Chinese market to the import of U.S. pork products. Pork trade between the two countries will resume upon the finalization of export documentation.
The National Pork Producers Council is working with officials in the U.S. government to resolve outstanding trade issues related to pork with China. Some of these issues include China's ban on U.S. pork produced with ractopamine (an FDA-approved feed additive that promotes leanness in pork), subsidies that China provides its domestic pork producers, and a value-added tax China imposes on imports.
The U.S. pork industry shipped nearly 400,000 metric tons of pork, worth nearly $690 million, to China/Hong Kong in 2008, making it the third largest importer of U.S. pork. Last year, U.S. pork exports to China/Hong Kong were down by 38 percent, falling to just under $427 million.
An international team comprised of Chinese and U.S. researchers have published the most complete molecular and genetic analysis to date of the 2009 A(H1N1) virus. We abstract here some information from the highly technical article that appeared in the electronic journal PLoS ONE. Briefly, the article states that 2009 A(H1N1) influenza virus proved to be a novel swine-origin pandemic influenza A(H1N1) virus (H1N1pdm, also referred to as S-OIV). Its hemagglutinin (HA), nucleoprotein (NP), and nonstructural (NS) protein genes belong to the classical swine lineage, while its neuraminidase (NA) and matrix (M) protein genes derive from a Eurasian swine influenza lineage that entered pigs from avian hosts around 1979, and its polymerase gene segments, PA, PB1 and PB2, descended from the North American triple reassortant swine lineage. During the short period of time when the WHO pandemic alert level was raised from phase 4 to phase 6, one signature residue at the position of NP-100 mutated from valine to isoleucine. A total of 4 non-signature residues, at positions NA-91, NA-233, HA-206, and NS1-123, also changed during the epidemic in 2009. All these mutant residues, except that at NA-91, are located in the viral functional domains, suggesting that they may play roles in the human adaption and virulence of 2009 H1N1pdm.
The report makes several points of high importance to public health. Specifically, it notes that the unique genetic combination described above may contribute to the improved fitness of the H1N1pdm in humans and its human-to-human transmissibility, although none of the molecular features previously shown to confer increased human-to-human transmissibility has so far been identified in the 2009 H1N1pdm. Since there is a serious concern that the virus may further mutate into a more dangerous form, it is critical to monitor the evolutionary trends of the 2009 H1N1pdm virus.
The article may be accessed at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0009549
The Indo-Asia News Service (IANS) reports that India plans to administer imported A(H1N1) vaccine to population groups at high risk of A(H1N1) infection starting next week. High-risk groups include doctors and paramedics. V.M. Katoch, the first secretary of the Department of Health Research, government of India, and the director general of the Indian Council of Medical Research, stated: "Most likely, we will start the vaccination next week. The last set of data from Sanofi Pasteur's bridge study in India came to us Feb 28. The data is now with a government committee, which is analyzing it. We expect the analysis to end in a few days and vaccination most likely to start the coming week."
India has procured 1.5 million doses of A(H1N1) vaccine from Sanofi Pasteur. Prior to administration of the vaccine, authorities asked the company to conduct a human trial in India to test the vaccine's suitability for the Indian population.
Xinhua reports that the A(H1N1) influenza outbreak, which has killed nearly 800 people on the Chinese mainland, passed its peak in the autumn-winter flu season. The Ministry of Health reported this information on its website and, also, that the proportion of A(H1N1) infections in all flu cases had decreased sharply, from 36.6% in January to 11.1% in February of 2010.
The ministry report quoted expert estimations that no mutation has occurred in the A(H1N1) virus, and that 30 percent of the population has developed immunity against the strain . The ministry, however, warned that though a pandemic was unlikely to reoccur in the near future, localized spreading of the disease could not yet be ruled out, especially in crowded public venues such as schools. Therefore, flu prevention measures should remain in effect as the population still has limited access to A(H1N1) vaccines.
Reuters reports that Australian researchers confirm that the A(HIN1) flu affects pregnant women particularly severely, especially if they also suffer from asthma, obesity, and/or diabetes. Dr. Michelle L. Giles of Monash Medical Center in Clayton, Victoria, writes that "This finding underscores the importance of education regarding recommendations for vaccination in pregnancy and the need for rapid testing and earlier use of antivirals in suspected influenza." Giles et al. note that past studies found that pregnant women who contract influenza may face a greater risk of complications like pneumonia. However, the effects of influenza on the fetuses they carried are less well understood.
Giles et al. add that while more than three-quarters of the women in the study had been treated with oseltamivir (Tamiflu), two-thirds had been sick for at least 48 hours before receiving the drug. Flu medication should be started as soon as possible after symptoms appear in order to be maximally effective.
To investigate the effects of A(H1N1) influenza on pregnancy, the researchers studied 43 pregnant women with lab-confirmed A(H1N1) virus admitted to six different Victoria hospitals during the 2009 outbreak. Two women were admitted during their first trimester, 13 during their second trimester, and 28 in their third trimester. Of the 43, 25 had been hospitalized due to flu-like illness while 11 were admitted for pneumonia. Of the first group; all but one were hospitalized for less than one week. But among the pneumonia group, seven were hospitalized for more than one week. Half of the 43 women studied had at least one other health problem, such as asthma, obesity, or diabetes mellitus, but they did not seem to be at an increased risk of pneumonia or pregnancy complications compared to women without other health problems.
Of the 15 women who delivered during hospitalization, six did so before 37 weeks' gestation while nine were at 37 weeks or later. The researchers had further information on 24 of the 43infants at the end of July 2009. Twenty-one infants were alive, two had died in the womb (at 26 and 31 weeks' gestation), and one died 26 days after delivery due to prematurity-related complications. Seven of the infants, including the infant who died, were tested for A(H1N1) virus, but none was infected. Giles et al. noted that 40 percent of the women went into preterm labor, compared to the normal rate for the hospitals included in the study of about 10 percent. All of the women who delivered before 37 weeks were confirmed to have pneumonia.
Giles et al. write "The mechanism by which pregnancy, particularly late pregnancy, increases disease severity is unknown." Immune system changes could be a factor. A woman's expanding uterus can reduce her lung capacity; this as well as the increased demands pregnancy places on the heart and lungs could also be factors.
Some experts assert that many women are reluctant to receive immunizations or take drugs during pregnancy. For this reasons, although flu shots are recommended for pregnant women, many chose not obtain them. However, Giles et al. note that there is evidence doctors' lack of awareness of how important it is that pregnant women receive the vaccine may be "a major contributor, with good acceptance by mothers when the risks and benefits are explained."
Reuters reports that the Keiji Fukuda, Special Adviser on Pandemic Influenza to the Director-General of the World Health Organization (WHO), stated, "This pandemic appears to be on the less severe side of the spectrum of pandemics that we have seen in the 20th century." He spoke the day after the WHO's emergency committee decided it was premature to declare that the current pandemic has peaked. The committee plans to reconvene in a few weeks.
As of February 14, 2010, more than 212 countries and communities have reported cases of A(H1N1) 2009 influenza to WHO, with at least 15,921 related deaths. North Africa, Eastern Europe, and East Asia continue to show active transmissions of the virus among humans.
New-Fields announced on February 24 that over a dozen experts from Great Britain and the United States are confirmed to speak at the International Swine [A(H1N1)] Flu Conference (ISFC), which will take place during March 10-12, 2010, in London, United Kingdom. The ISFC will focus on pandemic prevention, preparedness, response, and recovery strategies designed by international bodies to end human-to-human transmission of A(H1N1) virus. Speakers will discuss strategies for creating solid continuity plans in order to prepare for, respond to, and survive a pandemic. Sessions will address the following topics:
Registration information can be found at:
http://new-fields.us/em/link.php?M=27621391&N=172&L=203&F=T [PDF format].
UPI reports that South Korea is donating $863,000 worth of hand sanitizer to North Korea in order to help it fight the spread of A(H1N1) virus. The 200,000 liters of sanitizer are to be delivered next week. Twenty South Korean trucks are to be used to transport the hand sanitizer across the military demarcation line and deliver it at the North Korean border town of Kaesong, Unification Ministry spokesman Chun Hae-sung said.
North Korea acknowledged its first cases of A(H1N1) infection early in December, but has yet to report any flu-related deaths. Also in December, South Korea gave North Korea about $15 million worth of the anti-viral medication Tamiflu.
Early each year, representatives of the WHO Collaborating Centres on Influenza meet to analyze epidemiological data and then make a recommendation for the composition of the coming flu season's vaccine. Seasonal influenza vaccines typically are trivalent, being comprised of two influenza A strains and one influenza B strain. The recommendation, which is always accepted by WHO, is used by pharmaceutical manufacturers to produce a vaccine that matches the influenza virus strains that are expected to circulate in the coming flu season. WHO also provides the manufacturers with prototype strains for the manufacture of the seasonal vaccine.
ProMED reports that on this date, WHO published recommendations for the composition of influenza virus vaccines for the forthcoming season (November 2010 to April 2011) in the northern hemisphere. According to the report, the Collaborating Centres' representatives recommended that the next seasonal trivalent vaccine be comprised of an A/California/7/2009 (H1N1)-like virus, an A/Perth/16/2009 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus.
Science Daily reports social interaction between neighbors, work colleagues and other communities and social groups makes voluntary vaccination programs for epidemics such as A(H1N1), SARS or the Avian Flu virus a surprisingly effective method of disease control. New research published in New Journal of Physics shows that contact with others can positively influence individuals to choose voluntary vaccination when considering the pros and cons.
The group of Chinese researchers found that in scale-free networks -- social networks with an uneven distribution of connectedness such as neighborhoods, work places or gyms -- the so-called hub nodes, people with multiple social connections, tend to choose to vaccinate themselves as they are at higher risk of infection from others, thus containing the spread of epidemics. Based on their studies, the researchers have observed that at the beginning of an epidemic, when levels of infection are high, a large number of people will gradually get vaccinated. As the effects of the temporary vaccination wear off, a second wave of an infection outbreak will occur, however on a less severe level due to the number of individuals who still are effectively immunized.
Thus, outbreaks of disease and voluntary vaccination occur periodically, eventually settling to a stable state. Individuals with a large social network play a crucial role in this cycle as, given information on the spread of the disease is freely available, the majority of them will choose voluntary vaccination.
In order to create an effective vaccination strategy, the researchers noted that it is crucial to affect the hub nodes' willingness to become vaccinated, which may be negatively influenced by factors such as the risk of infection, the coverage of disease and the cost of vaccination. The researchers reported, "Sometimes the high costs of vaccination or misunderstanding the side effect of vaccinations can reduce the enthusiasm for taking vaccination. In this case the external incentives such as subsidy of vaccination cost would be helpful in enhancing the vaccination inclination of the hub nodes."
Radio Netherland reports on the Senegalese Minister of Health and Preventive Medicine Modou Diagne Fada's confirmation that the country had been hit by the pandemic A(H1N1) virus. According to earlier reports, the first cases were detected in the religious city of Touba and nearby Diourbel. As hundreds of thousands of followers of the Mouride Muslim Brotherhood gathered in Touba to celebrate religious festivities, Health Minister Diagne confirmed the outbreak of the disease during a press conference. He noted that the country was equipped to contain the situation.
According to the Health Minister, 14 cases of A(H1N1) virus were recorded between the three districts of Dagana, Diourbel and Touba. According to health experts, Senegal does not yet have a preventive vaccine. But the Senegalese Health Minister is already calling for patients suspected of infection to be isolated until examination confirms their cases. "We have enough resources to deal with influenza AH1N1," Dr Diagn said. "We will deal with all cases and we have the means." The minister noted that among those infected none had died, and that all had in fact "been taken care of, treated and returned home."
The Straits Times reports on a British announcement made yesterday regarding closure of the crisis unit which has handled the A(H1N1) flu pandemic this past year. The unit is closing due to dwindling numbers of new A(H1N1) infections.
Britain, which was the hardest hit country in Europe by the A(H1N1) virus, will "stand down" the National Pandemic Flu Service (NPFS) beginning next Thursday, February 11, said Health Minister Gillian Merron. "This is being done in response to the steady reduction in the estimated number of H1N1 flu cases in the community," she said in a written statement to lawmakers. Merron further stated the move "is in line with our overall aim of ensuring the operational response is appropriate to the level of threat posed by the virus." Merron also added that, if necessary, the NPFS could be re-activated within seven days.
Britain was among the first countries hit by the A(H1N1) virus after it emerged in Mexico early last year, and at one point recorded more than 100,000 new cases a week as the virus was officially declared a pandemic.
The spread of the virus slowed over the summer, then briefly accelerated again in autumn as children returned to school in September. It then dropped off again during the colder winter months when vaccine usage increased.
Last month Britain recorded less than 5,000 new cases of A(H1N1) infection for each of the last three weeks.
Donald G. McNeil, Jr., of New York Times reports that wealthy nations, including the United States currently have a large excess of unused A(H1N1) vaccine, which has prompted them to find uses for their surpluses. In contrast, the world's poorest countries — a few still facing the brunt of the pandemic — are receiving very little A(H1N1) vaccine.
Of the 95 countries that told the World Health Organization (WHO) last year they had no means of getting flu vaccine, only two, Azerbaijan and Mongolia, have so far received any. Afghanistan is the next country expected to receive vaccine.
Early last month, WHO officials said they had hoped to have shipped vaccine to 14 countries by now. Even if this were accomplished it would have only been enough to protect 2 percent of the countries' populations. A(H1N1) infection rates have waned in North America, however, it is still prevalent in North Africa, Central Asia and parts of Eastern Europe.
Countries that can afford vaccines use them for themselves first and, when infection rates have diminished, transfer their leftovers to the poor, using the WHO as a clearinghouse. That transfer "turns out to be an incredibly difficult logistical action," said Dr. Keiji Fukuda, the WHO's chief of pandemic influenza. "It's a mammoth effort by an awful lot of people and organizations and countries but holy moly, it's a very complex operation."
Each country must submit a plan proving it can store refrigerated vaccine, give it to those who need it most, inject it safely and perform medical follow-up post vaccination. It must also sign letters exempting donors from legal liability. Additionally, the WHO must certify the vaccine as safe for use if the country has no regulatory agency that can certify the vaccine itself. These tasks, combined with shipping, add significant delays in the process. For instance, Dr. Fukuda said, only five countries had even received syringes by last December.
Bill Gates, who just pledged the largest charitable donation in history to getting other vaccines to the poor ($10 billion), dismissed flu vaccine shipments as "a pipe dream." "It's not practical; they have no infrastructure to deliver it," he said. "And you don't want to distract them away from measles vaccine, for example. That could cost lives."
Although 190 million doses have been pledged to the WHO, they are not ready for use. As a result, wealthy countries are frantically trying to cancel orders. These surpluses resulted from orders made under the assumption that two doses of vaccine would be needed to provide protection. However, it was determined that for most people, only one dose was necessary. Also, as the virus proved less lethal than originally thought, many countries lost interest in acquiring the vaccine.
Reuters reports on the World Health Organization (WHO) announcement that the A(H1N1) flu is still spreading in North Africa, parts of eastern and southeastern Europe and areas of Asia, but is generally declining. The WHO reported that A(H1N1) is still the predominant influenza virus circulating worldwide, posing an increased risk to pregnant women and people with underlying medical conditions such as asthma.
Much of the temperate northern hemisphere passed a peak of influenza transmission between late October and late November, the WHO reported in a weekly update. But the A(H1N1) virus continues to transmit actively in North Africa, including Egypt, limited areas of eastern and southern Europe, and in parts of South and East Asia, including western India. In China, the WHO reports that the A(H1N1) virus has declined substantially since peaking last November, but other influenza viruses have been increasingly detected in recent weeks.
Staff at the New England Journal of Medicine report that results from three studies conducted in the United States, China, and Hungary demonstrate the safety and efficacy of the A(H1N1) flu vaccine. An estimated 100 million doses of A(H1N1) flu vaccines have been administered worldwide since September 2009. The three new studies, containing data previously available to regulators only, provide important information on the safety and efficacy of these vaccines. All vaccines used in these studies were inactivated injected vaccines, produced from a single A(H1N1) strain recommended by the World Health Organization.
In a randomized U.S. study, 1,300 healthy people received one of three formulations of A(H1N1) vaccine or placebo. Prior to vaccination, 20% to 30% of adults and relatively few children had protective levels of A(H1N1) antibody; 21 days after vaccination, 92% to 100% of adults and 45% to 69% of children had protective levels of A(H1N1) antibody.
Chinese investigators randomized nearly 13,000 people to receive one of eight A(H1N1) vaccine formulations or placebo. The vaccine formulations (or placebo) were given in two doses, 21 days apart. Prior to vaccination, few participants had protective A(H1N1) antibody levels; 21 days after first vaccination, 56% to 88% of children younger than 12 and 54% to 98% of older people had protective antibody levels. After the second vaccination, those rates rose to 93% to 99% and 83% to 100%, respectively.
In Hungary, researchers randomized 355 adults with no detectable A(H1N1) antibodies to receive single injections of a low-dose A(H1N1) vaccine, with or without simultaneous trivalent seasonal flu vaccination. After 21 days, 70% of both groups had protective levels of A(H1N1) antibody.
In the two placebo-controlled studies, protective antibody levels were essentially unchanged in placebo recipients, and low-dose immunizations generally were as effective as higher doses in all but the oldest adults. In all three studies, adverse effects were mild and consisted primarily of injection-site tenderness and low-grade fevers.
OneIndia reports that at the executive board meeting of the World Health Organization (WHO) in Geneva, India's Union Health Secretary K. Sujatha Rao discussed recent media reports calling the A(H1N1) infections a "false pandemic". He requested that the WHO clarify this issue. Rao noted that these media reports have adversely affected public health care measures.
The WHO replied with an official statement: "In response to this intervention by India, it was agreed that WHO would formally write to National Focal Points in all countries clarifying the factual position about the H1N1 pandemic to quell all doubts that have been created."
Rao also demanded transparency on the terms and conditions vaccine manufacturers are requiring for supplying their vaccines to various countries.
The Pan American Health Organization released its regional update on A(H1N1) today. According to the report, deaths in Canada associated with the A(H1N1) virus have remained lower than the levels seen in October and November 2009. In Mexico, the rate of A(H1N1) infections decreased for 10 consecutive weeks; in the United States, the proportion of deaths attributed to pneumonia and influenza remained below the epidemic threshold.
Costa Rica and Panama reported widespread influenza activity, but decreased trends in acute respiratory disease. Influenza activity was also reported as widespread in Ecuador and Venezuela, however there was no reported activity in Bolivia.
Brazil and Chile reported regional influenza activity, and Paraguay reported localized activity. In Argentina, the incidence of influenza-like illness has remained under the epidemic threshold for twelve consecutive weeks.
Voice of America reports that the British Medical Journal's (BMJ) staff is examining why the A(H1N1) virus did not cause the huge epidemic many feared.
BMJ deputy editor Tony Delamothe says, "I think you're right to say everybody was concerned about the potential for H1N1, but from the vantage point of early January 2010, at least in the U.K., it doesn't look as if it's any worse than an average bout of flu."
Over 360 deaths from the disease have been reported in the United Kingdom, but Delamothe says, "Really, flu kills people every year. And it's really hard to know whether that's more than an average year for flu mortality." Delamothe added that data collected by BMJ staff "suggest that week on week the number of flu cases is going down.... It was here and now it's going. And it's going pretty fast."
The World Health Organization's latest estimate is that A(H1N1) flu has killed 13,000 people throughout the world. It expects that number to be much larger after the final estimate is calculated in the coming months. In comparison, seasonal flu kills about 36,000 people annually in the United States.
Laura MacInnis of Reuters writes that the WHO reported today that the A(H1N1) flu virus is spreading most actively in North Africa, South Asia and parts of Europe. Raising its official global death toll from the pandemic to nearly 14,000, the WHO also reported that while India's A(H1N1) infections may have peaked in December, neighboring Nepal and Sri Lanka were still experiencing widespread transmission.
According to WHO, Morocco, Algeria and Egypt are continuing to see the active spread of the A(H1N1) virus and some countries in Europe, including Romania, Ukraine, Turkey and Switzerland, are also reporting moderately intense rates of respiratory disease. "Pandemic H1N1 2009 virus continues to be the predominant circulating influenza virus in the European region with only sporadic detections of seasonal influenza viruses," the WHO reported, noting the same for northern Africa and swathes of Asia, including China. Flu activity in Japan, China and Mongolia has been declining since November. In North Korea, "geographically regional influenza activity with increasing respiratory diseases trend was reported during early January 2010." In the Americas, where the virus was first identified in April 2009, infection rates have declined since October 2009, although small areas of increased flu activity may be occurring in central and northern Mexico."
Stefanie McIntyre, a Reuters reporter, writes that Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases in China's southern Guangdong province, urges that the influenza A(H1N1) and avian influenza (H5N1) virus strains currently present in the country be carefully monitored for mutations. According to the article, the two virus strains "could mix and become a monstrous hybrid -- a bug packed with strong killing power that can transmit efficiently among people." Therefore, Zhong suggests that the "reporting of the death rate must be really transparent" in all influenza cases. A week earlier, Zhong claimed that China may have had more influenza A(H1N1) flu deaths than its government has reported because local governments might be concealing suspected cases.
On 24 November, WHO warned that A(H5N1) influenza was affecting poultry in Egypt, Indonesia, Thailand, and Vietnam. Similarly to Zhong, the WHO also hypothesized that the A(H5N1) virus "could undergo a process of "reassortment" with another influenza virus strain and thus produce a completely new strain "that is as deadly as the former (i.e. H5N1) and as contagious as the latter (influenza A(H1N1))."
Xinhua reports that health officials in Canada's western province Manitoba have withdrawn about 170,000 doses of GlaxoSmithKline's (a British pharmaceutical company) influenza A(H1N1) vaccine due to an unusually high number of allergic reactions. Health officials in Manitoba have registered six cases presenting with severe allergic reactions, whereas only one or two allergic reactions would be expected from a batch of that size. GlaxoSmithKline has issued a statement claiming that the withdrawal was a precaution and that the company would investigate to determine whether there was something wrong with the batch.
According to Dr. David Butler-Jones, Canada's Chief Public Health Officer, 6.6 million Canadians have received vaccination against influenza A(H1N1), of whom just 36 have presented with serious adverse reactions. Dr. Butler-Jones also stated that Canadian health officials have registered one death that may have resulted from a serious reaction to the influenza A(H1N1) vaccine, but this has not been verified.
Fergus Walsh, a health correspondent for BBC News, reports that physicians at the University Hospital of Wales have diagnosed five patients infected with a Tamiflu-resistant strain of influenza A(H1N1) virus. The patients were treated at an intensive care unit for people with severe underlying health conditions. Of the five patients, three appear to have acquired the infection while in the hospital. Two of these patients have recovered and have been discharged from the hospital, one remains in critical care, and two are being treated in a general ward.
The article quotes Dr Roland Salmon, director of the National Public Health Service for Wales Communicable Disease Surveillance Centre, as stating: "The emergence of influenza A viruses that are resistant to Tamiflu is not unexpected in patients with serious underlying conditions and suppressed immune systems, who still test positive for the virus despite treatment. In this case, the resistant strain of swine flu does not appear to be any more severe than the swine flu virus that has been circulating since April."
Health officials world-wide have previously reported that influenza A(H1N1) virus have developed resistance to Tamiflu, but so far there has been no confirmation that patients have passed on a resistant strain to others. U.S. health officials have identified one possible person-to-person transmission of a Tamiflu-resistant influenza A(H1N1) virus strain between two participants at the same summer camp, but this case has not been confirmed.
Rob Stein, a Washington Post reporter, writes that Norwegian scientists have detected a mutated form of the influenza A(H1N1) virus in two patients who died from influenza A(H1N1) and a third who became severely ill. The two patients were the first influenza A(H1N1) fatalities in Norway. A Norwegian Institute of Public Health statement warns that the mutation "could possibly make the virus more prone to infect deeper in the airways and thus cause more severe disease," such as pneumonia. The Institute claims, however, that there is no indication that this mutation would hinder the ability of the current influenza A(H1N1) vaccine to protect people from becoming infected or impair the effectiveness of antiviral drugs. It also states that "it seems that the mutated virus does not circulate in the population, but might be a result of spontaneous changes which have occurred in these three patients."
According to WHO, influenza A(H1N1) viruses with a similar mutation possessed by the one detected in Norway have also been detected in China, Japan, Mexico, Ukraine, and the United States. Accordingly, WHO concludes that "No links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread." The article also quotes Arnold S. Monto of the University of Michigan, whose explanation is that "Influenza is a mutable virus, and changes are to be expected. This is typical early in the spread of a pandemic virus."
Associated Press reporters comment on a WHO announcement claiming that the extraordinary measures adopted by China to contain the spread of influenza A(H1N1) (including mass school closures and isolation of entire planeloads of passengers, even if only one individual in each situation exhibits symptoms of influenza A(H1N1)) have proven to be ineffective. According to Dr. Michael O'Leary, WHO's top representative in China, WHO expected the spread of a contagious disease such as influenza A(H1N1) to occur regardless of the preventive measures imposed because people often spread influenza viruses before developing any symptoms. Other countries that have adopted strict influenza A(H1N1) policies, such as Ukraine, Mongolia, Argentina, Singapore, Malaysia, and Egypt, also indicate that these policies have had little effect in containing the disease.
In addition, Feng Zijian, head of China's Center for Disease Control and Prevention, acknowledged that his government has presented influenza A(H1N1) statistics representing only "a very small portion" of the total number of influenza A(H1N1) cases. China has so far reported nearly 70,000 influenza A(H1N1) cases with 53 deaths. The article also quotes Sandra Mounier-Jack, an influenza expert at the London School of Hygiene and Tropical Medicine, as stating: "The issue in China has to do with surveillance." According to Mounier-Jack, influenza A(H1N1) symptoms are vague, and therefore health officials in China (and elsewhere in the world) are often unable to identify all cases with certainty.
Andy Heil, a reporter for Radio Free Europe/Radio Liberty, writes that authorities in Moldova are taking some interesting precautions against influenza A(H1N1) (which is spreading there just as its borders are opening to the outside world). Moldova's army is feeding its soldiers onions and garlic to help them ward off influenza A(H1N1). Defence Ministry chief doctor Colonel Sergiu Vasislita claims that about 25 grams (0.9 ounces) of onions and 15 grams (0.5 ounces) of garlic will be added to each soldier's daily diet. That roughly corresponds to a small onion and a couple of garlic cloves. Onion and garlic are traditional remedies in Moldova where they are widely believed to boost the immune system.
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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