300 Schools in the US shut

From the Washington Post:

"Nearly 300 schools nationwide were closed yesterday to avoid the spread of swine flu, and education and health officials in the Washington area and elsewhere were working in tandem to reassure worried parents and weigh whether more campuses should be shuttered.

The bulk of the closures were in Texas, where the 147-school Fort Worth system closed for 10 days after confirmation of one case of swine flu at one campus and probable cases at three others."

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/30/AR2009043001734.html?hpid=topnews

First case of H1N1/swine flu in the U.S. State of Georgia

From the Atlanta Journal Constitution -

"A Kentucky woman who came to Georgia for a wedding and shopped in Atlanta remained in the intensive care unit of a LaGrange hospital Thursday — the state’s first confirmed victim of the swine flu outbreak.

The 30-year-old woman, who officials declined to identify, has been isolated and remains in stable condition in the West Georgia Medical System Hospital, officials said.

She is beginning to show modest signs of improvement,” hospital chief Jerry Fulks said. “But she is still very seriously ill.”

Unlike many of the cases reported in the United States, this case seems to have required hospitalization

http://www.ajc.com/news/content/health/stories/2009/04/30/swine_flu_georgia.html

Lao PDR - Preparedness on track

Although there are as yet no suspected or confirmed cases of H1N1 in Laos or indeed its many south east asian neighbours, the government and international agencies have activated their pandemic preparedness plans.

Laos etsblished a multi sectoral coordination office, NAHICO, responsible for avian and human influenza and pandemic preparedness in 2006, and this office is taking the lead in ensuring the country is well prepared.

CARE alongside NAHICO have been managing a national AI hotline and this freecall hotline has now been converted to the national hotline about H1N1. The hotline is able to provide information about the disease and prevention measures the public is able to to take at this stage.

Daily travel advisory for CARE staff about affected areas

As of 7.30pm EST on April 30th, there were suspected and confirmed cases of H1N1/swine flu in the following countries,

Confirmed: Austria, Canada, Costa Rica, Germany, Israel, Mexico, New Zealand, United States, Spain, Peru, United Kingdom

Suspected: Australia, Argentina, Bolivia, Brazil, Belgium, Chile, Columbia, France, Guatemala, Greece, Honduras, Hong Kong, Italy, Ireland, Norway, Poland, Russia, Slovakia, South Korea, Sweden, Switzerland, Uruguay, Venezuela.

CARE is not restricting or advising against travel and is following WHO and CDC guidelines. Staff living in or traveling to affected areas should be aware of the guidance (http://wwwn.cdc.gov/travel/contentSwineFluMexico.aspx) and monitor the situation.

Pandemic preparedness website for humanitarian actors launched!

Many of you may have heard me speak or blog about the H2P Initiative, of which CARE is a partner through the CORE Group. H2P is a USAID funded initiative to bring humanitarian actors together for pandemic preparedness, including IFRC, CORE Group, Interaction, AED and UN Agencies.

As a group we were planning a launch of our website soon and populating the website with materials.

Due to the current situation, We've now launched the site: http://pandemicpreparedness.org

The Initiative will be working rapidly to populate the site with further information and relevant materials.

H1N1 is NOT Transmitted Through Pork-Products

Joint FAO/WHO/OIE Statement on influenza A(H1N1) and the safety of pork:

"In the on-going spread of influenza A/H1N1, concerns about the possibility of this virus being found in pigs and the safety of pork and pork products has been raised.

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 (e.g. 70°C/160°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 will not be a source of infection

Authorities and consumers should ensure that meat from sick pigs or pigs found dead are not processed or used for human consumption under any circumstances."

WHO: http://www.who.int/mediacentre/news/statements/2009/h1n1_20090430/en/index.html

In particular, the virus currently circulating, H1N1, is transmitted from human to human. Contact with pigs or any other animals is not necessary to contract this virus. To avoid contracting the virus, people should:

1. Avoid crowded areas or people who are ill
2. Cover their cough or sneeze with a tissue/arm/sleeve (not hands)
3. Wash their hands frequently with soap and water or use alcohol-based hand sanitizer
4. Wipe down commonly used or shared surfaces with sanitizer or soap
5. Seek medical treatment if you have severe symptoms (there are antivirals - oseltamivir and zanamivir - that seem to be useful in treating H1N1)
6. Stay away from home or work if you become ill to avoid spreading the virus to others

Webcasts from HHS

The US Department of Health and Human Services (HHS) is going to be doing live webcasts about the current outbreak of H1N1/swine flu and also on pandemic preparedness. Today's webcast is posted below, for future webcasts check http://www.hhs.gov

First H1N1 Case in Switzerland; US Cases Rise

"Switzerland confirmed on Thursday its first case of swine flu, saying a young man returning from Mexico had tested positive for the virus" He tested positive at a hospital in Baden, near Zurich.

http://www.reuters.com/article/middleeastCrisis/idUSLU680898

168 Lab-confirmed Cases (8 deaths) Total in 11 Countries:

The following countries have reported laboratory confirmed cases - Austria (1), Canada (13), Germany (3), Israel (2), Mexico (26; 7 deaths), New Zealand (3), Peru (1), Spain (4), Switzerland (1), the United Kingdom (5), and the United States (109; 1 death).

US Cases: 109 in 11 States

Arizona: 1
California: 14
Indiana: 1
Kansas: 2
Massachusetts: 2
Michigan: 1
Nevada: 1
New York: 50
Ohio: 1
South Carolina: 10
Texas: 26 (1 death)

CDC: http://www.cdc.gov/swineflu/index.htm

First case of H1N1/swine flu confirmed in Peru

From FOCUS Information Agency

"Peruvian Health Minister Oscar Ugarte Wednesday confirmed that an Argentine woman was the first case of swine flu in Peru. The woman had been hospitalized after sickening and showing flu-like symptoms, he added. Argentina meanwhile has said that it still has four suspected cases of swine flu, after ruling out another 21 patients as having been infected with the deadly disease."


http://www.focus-fen.net/?id=n179420

The last official update on case count world wide was posted by WHO on the 29th

"The United States Government has reported 91 laboratory confirmed human cases, with one death. Mexico has reported 26 confirmed human cases of infection including seven deaths.

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (13), Germany (3), Israel (2), New Zealand (3), Spain (4) and the United Kingdom (5)"

http://www.who.int/csr/don/2009_04_29/en/index.html

WHO Raises Pandemic Threat Level to Phase 5

In a statement today, Director General Chan of the WHO decided, on expert advice from a Committee convened for this purpose, to raise the current level of influenza pandemic alert from phase 4 to phase 5.

This move has been expected the past 24 hours as evidence of community-level transmission begins to surface in NYC. While the definition notes that Phase 5 is only a signal that a pandemic is imminent, Director General Chan made it clear in her statement that she expects a declaration of "pandemic" to be forthcoming as more information is gathered.

What remains to be seen however is how severe this virus, and a pandemic, may be. Investigations continue. In the meantime this declaration signals to governments, multilateral institutions, and manufacturers in the health sector to begin preparing for a pandemic now.

WHO's definition of a pandemic:
"Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region (Figure 4). While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short."

WHO:
http://www.who.int/en/
http://www.who.int/mediacentre/news/statements/2009/h1n1_20090429/en/index.html

CDC: US Cases - 91 in 10 States

US: 91 in 10 States:

Arizona: 1
California: 14
Indiana: 1
Kansas: 2
Massachusetts: 2
Michigan: 2
Nevada: 1
New York City: 51
Ohio: 1
Texas: 16 with 1 death

"The outbreak of disease in people caused by a new influenza virus of swine origins continues to grow in the United States and internationally. Today, CDC reports additional confirmed human infections, hospitalizations, and the nation's first fatality from this outbreak. The more recnet illnesses and teh reported eath suggest that pattern of more severe illness associated with this virus may be emerging in the US. Most people will not have immunity to this new virus, and, as it continues to spread, more cases, more hospitilizations, and more deaths are expected in the coming days and weeks." -- CDC

CDC: http://www.cdc.gov/swineflu/

Egypt: No cases, but culling pigs en masse

"Egypt started slaughtering some 300,000 pigs in the country Wednesday as a precaution against swine flu even though no cases have been reported there, infuriating farmers who objected the measure and demanded compensation.

'It has been decided to immediately start slaughtering all the pigs in Egypt using the full capacity of the country's slaughterhouses,' Egypt's Health Minister Hatem el-Gabaly told reporters after a Cabinet meeting presided over by President Hosni Mubarak. "

In Jordan, five farms were shut down for health violations. Some of the pigs will be culled, while others will be moved away from the population.

****We want to reiterate that WHO and CDC are stating that you cannot get the current strain of swine influenza from consuming pork products. This current strain of swine influenza A/H1N1 is being transmitted human-to-human and no contact with swine is necessary to contract the virus.****

News Story:
http://www.albawaba.com/en/news/244716

CDC: New Guidance for Identifying Ill Passengers on Flights

Guidance released today regarding identifying ill passengers on planes and quarantine procedures upon landing:

"During the swine influenza outbreak, extra vigilance is required to identify and reportpassengers with respiratory symptoms or fever. Any passenger who appears ill, or who reportsnot feeling well, should be observed or queried for the following signs or symptoms:

• Feeling feverish or temperature greater than 100°F (37.8°C) if measured. For children,feeling warm by parent’s report.
  
• Sore throat
  
• Cough
  
• Stuffy or runny nose
  

Any passengers observed to have or who report having two or more of these symptoms should be reported immediately to the CDC Quarantine Station of jurisdiction where the plane is expected to land.

Flight and cabin crew should follow airline guidelines for preventing spread of infection wheninteracting with these travelers."

CDC: http://www.cdc.gov/swineflu/aircrew.htm

Further Travel Guidance:
In CDC's supplemental MMWR this morning, CDC noted, they are:

"Continuing to conduct routine illness detection at ports of entry with heightened awareness for travelers who might be infected with S-OIV.

In addition, CDC in collaboration with the U.S. Department of Homeland Security, is distributing travelers health alert notices to all persons traveling to countries with confirmed cases of S-OIV infection. CDC has recommended that U.S. travelers avoid nonessential travel to Mexico (http://wwwn.cdc.gov/travel/contentswineflumexico.aspx). Travelers who cannot delay travel to Mexico should visit http://www.cdc.gov/travel and follow the posted recommendations to reduce their risk for infection."

MMWR: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0428a2.htm?s_cid=mm58d0428a2_e

CDC Public Service Announcements on Preparing for Swine Flu

Early this morning, CDC released a series of short public service announcements about protecting yourself form the swine flu and preparing for a possible pandemic.

The major messages:

"Officials are acting to combat this threat, but the outbreak might grow. So be prepared."

1) To help fight swine flu, cover your nose and mouth with a tissue when you cough or sneeze, then throw the tissue away. Wash your hands often with soap and water, especially after coughing or sneezing. Stay home if you’re sick and limit contact with others to keep from infecting them.

2) Get involved and stay in touch with local leaders, community organizations, and your health authorities.

3) Store a two-week supply of food and water. Have two weeks of your regular prescription drugs at home. Keep health supplies on hand, including pain relievers and cold medicines.


CDC: http://www.cdc.gov/swineflu/psa/

Update: Global Confirmed Human Swine Flu Cases

Nine countries have reported lab-confirmed cases of swine flu. Thus far, the majority of confirmed cases have recently traveled to Mexico.

United States: 64 with 1 confirmed death in Texas

Mexico: 26 with 7 deaths

Canada: 6 with no deaths

UK: 5 with no deaths

New Zealand: 3 with no deaths

Germany: 3 with no deaths

Spain: 2 with no deaths

Israel: 2 with no deaths

Austria: 1 with no deaths

Germany confirms 3 cases of H1N1/swine flu

From Yahoo News:

"BERLIN – Germany's national disease control center says it has confirmed three swine flu cases — making it the third country in Europe where the disease has surfaced.

The Robert Koch Institute says Wednesday the cases include a 22-year-old woman being treated for flu-like symptoms in a Hamburg hospital after returning from a visit to Mexico.

The other two cases are a man in his 30s being treated at a university in the southern city of Regensburg; and a 37-year-old woman from another southern town who recently traveled to Mexico.

Britain and Spain already have already confirmed cases of the disease, which was first detected in Mexico and has now been found in several other countries worldwide."

http://news.yahoo.com/s/ap/20090429/ap_on_re_eu/swine_flu_world

First US fatality from H1N1/swine flu

From CNN:

"A two-year-old child in Texas has become the first fatality from swine flu in the United States, officials said Wednesday.

"A child has died from the H1N1 virus," the acting director of the Centers for Disease Control Dr. Richard Besser told CNN's "American Morning" on Wednesday. "As a parent and a pediatrician, my heart goes out to the family."

The child is the first person to die of swine flu outside of Mexico where the virus has caused more than 159 deaths and roughly 2,500 illnesses.

So far, the World Health Organization (WHO) says at least 112 cases have been confirmed worldwide -- 64 in the United States; 26 in Mexico (including seven deaths); six in Canada; three in New Zealand; and two each in Spain, the United Kingdom and Israel.

The WHO list does not include 11 additional cases reported by New Zealand health officials, five by British officials, three in Germany or one confirmed by Costa Rica's health ministry."

http://edition.cnn.com/2009/HEALTH/04/29/swine.flu.international/index.html

CDC Daily Briefing: 5 Confirmed US Hospitilizations Related to Swine Flu

Dr. Besser reported that cases continue to be confirmed at the state level but that CDC will only be updated their case counts once a day. CDC's lab-confirmed case count for the US stands at 64. The median age of those infected in the US is 16 years, with a range from 7 to 54. Symptoms seem to be lasting between 2 to 5 days and most remain mild. However, CDC is are confirming that there are 5 US hospitlizations related to the Swine Flu:

California: 3
Texas: 2

(Note: unofficially, earlier cases identified in these states were all reported to have recovered, so these are assumedly new cases)

CDC did not release any information about the 5 individuals, when they became symptomatic, their age, co-infections, or chronic medical conditions. They told media to contact State Health Department officials who are investigating those cases.

Besser also noted that we still dont know why Mexico is seeing more severe cases. That's still the most critical epidemiological question that will help determine outbreak response and preparedness for further outbreaks. He noted many possibilities for the variation, but said concrete answers are still forthcoming.

Given the continued rise in case counts, CDC may be moving in the following days to describing state-level situations and disease clusters instead of individual case counts.

Please see the CDC website for more information (the transcript from today's briefing should be available shortly): http://www.cdc.gov/swineflu/press/

CDC: Interim Guidance on Antiviral Use

Early this morning, CDC released guidance on the use of antivirals for treating suspected and confirmed cases of swine flu in additon to pre- and post-exposure chemoprophylaxis for certain high-risk populations.

Antiviral Sensitivity:
This swine influenza A (H1N1) virus is sensitive (susceptible) to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir.

It is resistant to the adamantane antiviral medications, amantadine and rimantadine.

Treatment
Antiviral treatment should be considered for

• Confirmed,
• Probable, and
• Suspected cases of swine influenza A (H1N1) virus infection

Treatment is prioritized for hospitalized patients and patients at higher risk for influenza complications.

Antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of symptoms; studies have shown benefits from treatment from seasonal influenza are strongest in the first 48 hours after onset. However, treatment for priority populations should be started even after this 48 hour window as it may reduce mortality and duration of hospitalization.

Recommended duration of treatment is five days.

Chemoprophylaxis Recommendations:
Antiviral chemoprophylaxis (pre-exposure or post-exposure) with either oseltamivir or zanamivir is recommended for the following individuals:

• Household close contacts of confirmed, probable or suspected cases who are at high-risk for complications of influenza (e.g., persons with certain chronic medical conditions, persons 65 or older, children younger than 5 years old, and pregnant women)
• School-age children with chronic medical conditions who had close contact with a confirmed, probable, or suspected case.
• Travelers to Mexico who are at high-risk for complications of influenza (e.g., persons with certain chronic medical conditions, persons 65 or older, children younger than 5 years old, and pregnant women).
• Health care workers or public health workers who were not using appropriate personal protective equipment during close contact with an ill confirmed, probable, or suspect case of swine influenza A (H1N1) virus infection during the case’s infectious period (1 day prior and 7 days after illness onset).

For the full interim guidance, please refer to CDC: http://www.cdc.gov/swineflu/recommendations.htm

HealthMap: Keeping Abreast of News Reports on Swine Flu

HealthMap (http://healthmap.org/en) is pulling together all open-source and official reports on swine flu outbreaks and cases as they occur.

You can follow many different disease events, but this is particularly helpful with the evolving swine flu situation. By selecting only swine flu (H1N1) and the surveillance or news reports you'd like to pull from, the map will pinpoint case and news reports by country/region.

Please keep in mind these are not always official, lab-confirmed cases of H1N1, but often pulled from open-source and media data.

Update: Confirmed Human Swine Flu Cases Around the World: 103 Total Cases

Below is an updated tally of laboratory-confirmed human cases around the world:

United States: 64 Total Cases with no deaths

California: 10
Kansas: 2
New York City: 45
Ohio: 1
Texas: 6

Mexico: 26 Total Confirmed Cases, with 7 Confirmed Deaths

Canada: 6 Total Confirmed Cases with no deaths

New Zealand: 3 Total Cases with no deaths

Scotland: 2 Total Cases with no deaths

Spain: 1 Total Case with no deaths

Israel: 1 Total Case with no deaths

WHO: http://www.who.int/csr/don/2009_04_27/en/index.html

CDC: http://www.cdc.gov/swineflu/index.htm

Public Health Agency of Canada: http://www.phac-aspc.gc.ca/alert-alerte/swine_200904-eng.php

Israel confirms 1 case of swine flu

Israeli health authorities confirmed today that a 26-year-old Israeli man who had recently returned from a trip to Mexico has the H1N1 swine flu virus. He has been hospitalized, but for observation purposes only, and has only mild symptoms.

According to AFP, a 49-year-old Israeli is also under quarantine and being tested for H1N1 after a recent visit to Mexico.

News story from Reuters:
http://www.alertnet.org/thenews/newsdesk/N27476506.htm

From AFP:
http://www.google.com/hostednews/afp/article/ALeqM5gObfuFgD_J6_JOcvGzMTHAlPagWA

New Zealand confirms 3 cases of swine flu

New Zealand's Health Minister confirmed at least 3 of the students with suspected swine flu had the virus. More confirmed cases are expected. So far, however, the illnesses have been mild.

From Reuters:

"New Zealand said on Tuesday it had at least three confirmed cases of swine flu among a school group that had recently visited Mexico and was expecting more.

Minister of Health Tony Ryall said a World Health Organisation laboratory in Australia had tested three samples out of 11 and confirmed they had the H1N1 flu strain.

"Officials have informed me that is sufficient to indicate that swine flu is the cause of the illness experienced by the group," Ryall told a news conference.

Tests on a fourth sample were under way, but the three positive tests were being taken as an indication the others had also contracted swine flu.

Ryall said all those affected appeared to have only mild symptoms and had been responding to treatment.

"All 11 are recovering at home," he said."

http://www.reuters.com/article/latestCrisis/idUSSP465504

CDC advises against non-essential travel to Mexico

"At this time, CDC recommends that U.S. travelers avoid all nonessential travel to Mexico. Changes to this recommendation will be posted at http://wwwn.cdc.gov/travel/"

http://wwwn.cdc.gov/travel/contentSwineFluMexico.aspx?s_cid=tw_epr_78

Currently, WHO has not issued any travel warnings. However, they are asking that travelers stay home if they are feeling sick and postpone travel plans. Also, if you do travel and become ill, seek care and check in with your health care provider.

CDC's Daily Briefing: Emphasizes Need for Community Mitigation Measures & Individual Responsibility

In the daily briefing today, CDC's Acting Director, Dr. Richard Besser, emphasized the evolving nature of the H1N1 swine flu situation and that communities and individuals should look to their pandemic preparedness plans and think about what they would do if this situation escalates to a pandemic. He further emphasize the refined guidelines on community mitigation measures and that everyone should understand what is recommended and expected of individuals to protect themselves and their families from getting sick.

"I don't know the odds of somebody in Atlanta has this infection. But it's important that people in Atlanta, and people in Dallas, and people in Philadelphia, and people in small towns know about this, that they pay attention. That they understand that they have a responsibility here in terms of protecting themselves and also knowing what the signs and symptoms are and what they should do if they're ill," Besser said.

Besser said that the key, critical epidemiological question at this point is why cases are more severe in Mexico and less so everywhere else. "As we continue to look I expect we will see additional cases and that the spectrum of disease (severity) will expand" Besser said. He also noted that while the origins of this virus are in swine, the virus has mutated at this point and people are susceptible to the virus even if they have no contact with pigs. Further, you cannot get this virus by eating well-cooked pork products.

Travel advisory change:
CDC also noted that they will be issuing a revised travel advisory later this evening (still not posted as of 5:30pm EDT) asking individuals to post-pone non-essential travel to Mexico at this time, out of an an abundance of caution.

Declaration of Public Health Emergency (PHE) and CDC Public Health Response:
The declaration of a PHE has allowed CDC to forward deploy antivirals and diagnostic testing equipment from the strategic national stockpile to select, high-risk states (primarily those currently experiencing outbreaks). So far, about 25% of the materials in the SNS earmarked for pandemic response have been forward deployed for possible use if necessary.

CDC is also gathering "seed stock" of the current strain of H1N1 causing illness for possibly using to begin manufacturing a vaccine if considered necessary in the following weeks.


CDC's information for individuals about signs, symptoms, and protective measures for swine flu:
http://www.cdc.gov/swineflu/swineflu_you.htm

CDC's Community Mitigation Measures Guidance:
http://www.cdc.gov/swineflu/mitigation.htm

CDC's April 27 Briefing Transcript:
http://www.cdc.gov/media/transcripts/2009/t090427.htm

WHO Upgrades Pandemic Alert to Phase 4

The Emergency Committee, established in compliance with the International Health Regulations (2005), held its second meeting today to consider whether or not to raise the pandemic threat level.

After considering available epidemiological data on confirmed outbreaks of H1N1 swine influenza in the United States, Mexico, and Canada and reports of possible spread to additional countries, the Committee and Director General decided to change the pandemic alert to Phase 4. As further information becomes available, WHO may decide to either revert to phase 3 or raise the level of alert to another phase.

WHO also said that given the widespread nature of the virus, containment is not possible and health authorities should focus on mitigation efforts. No travel or trade restrictions have been imposed at this time, though ill individuals should delay travel and those feeling ill after traveling should seek medical care.

WHO's explanation of Phase 4:
"Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted.

Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion."


See the Statement by WHO Director-General, Dr Margaret Chan: http://www.who.int/mediacentre/news/statements/2009/h1n1_20090427/en/index.html

See the WHO Pandemic Alert Site:
http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

See the WHO site:
http://www.who.int/en/

Update: Confirmed Human H1N1 Cases

As of 6:00 a.m. (EDT) this morning, the US CDC confirmed 40 nonfatal, human cases of swine flu in the U.S.:

California: 7
Kansas: 2
New York City 28
Ohio: 1
Texas: 2

Investigations are ongoing to determine the source of the infection andwhether additional people have been infected with swine influenzaviruses.

CDC Swine Flu Investigation Website: http://www.cdc.gov/swineflu/index.htm

Interim Guidance for Nonpharmaceutical Community Mitigation

Late last night, the CDC posted interim guidance for nonpharmaceutical community mitigation in response to human infections with swine influenza (H1N1) virus. The CDC stresses that these recommendations are based on current information and are subject to change based on ongoing surveillance and continuous risk assessment.

The following are scenario-related recommendations:

When Human Infection with Swine Influenza A (H1N1) Virus is Confirmed in a Community Strongly Recommend Home Isolation of Cases:
• Persons who develop influenza-like-illness (ILI) (fever with either cough or sore throat) should be strongly encouraged to self-isolate in their home for 7 days after the onset of illness or at least 24 hours after symptoms have resolved, whichever is longer. Persons who experience ILI and wish to seek medical care should contact their health care providers to report illness (by telephone or other remote means) before seeking care at a clinic, physician’s office, or hospital. Persons who have difficulty breathing or shortness of breath or are believed to be severely ill should seek immediate medical attention.
• If ill persons must go into the community (e.g., to seek medical care) they should wear a face mask to reduce the risk of spreading the virus in the community when they cough, sneeze, talk or breathe. If a face mask is unavailable, ill persons needing to go into the community should use a handkerchief or tissues to cover any coughing.
• Persons in home isolation and their household members should be given infection control instructions: including frequent hand washing with soap and water. Use alcohol-based hand gels (containing at least 60% alcohol) when soap and water are not available and hands are not visibly dirty. When the ill person is within 6 feet of others at home, the ill person should wear a face mask if one is available and the ill person is able to tolerate wearing it.

Regarding Household Contacts:
• Household contacts who are well should:
1. remain home at the earliest sign of illness;
2. minimize contact in the community to the extent possible;
3. designate a single household family member as the ill person’s caregiver to minimize interactions with asymptomatic persons.

School Dismissal and Childcare Facility*Closure:
• Dismissal of students should be strongly considered in schools with a confirmed or a suspected case epidemiologically linked to a confirmed case.
• Decisions regarding broader school dismissal within these communities should be left to local authorities, taking into account the extent of ILI in the community.
• If the school dismisses students or a childcare facility closes, they should also cancel all school or childcare related gatherings and encourage parents and students to avoid congregating outside of the school.
• Schools and childcare facilities should dismiss students for a time period to be evaluated on an ongoing basis depending upon epidemiological findings.
• Schools and childcare facilities should consult with their local or state health departments for guidance on reopening. If no additional confirmed or suspected cases are identified among students (or school-based personnel) for a period of 7 days, schools may consider reopening.
• Schools and childcare facilities in unaffected areas should begin to prepare for the possibility of school dismissal or childcare facility closure. This includes asking teachers, parents and officials in charge of critical school-associated programs (such as meal services) to make contingency plans.

Other Social Distancing Interventions:
• Large gatherings linked to settings or institutions with laboratory-confirmed cases should be cancelled, for example a school event linked to a school with cases; other large gatherings in the community may not need to be cancelled at this time.
• Additional social distancing measures are currently not recommended.
• Persons with underlying medical conditions who are at high risk for complications of influenza may wish to consider avoiding large gatherings.

These recommendations are subject to change as additional epidemiological and clinical data become available.

*Childcare facility: centers and facilities that provide care to any number of children in a nonresidential setting, large family childcare homes that provide care for seven or more children in the home of the provider and small family childcare homes that provide care to six or fewer children in the home of the provider.

To read the entire posting, including background information, please visit CDC’s swine flu website by clicking on the following link: http://www.cdc.gov/swineflu/mitigation.htm

6 cases of swine flu confirmed in Canada

The Public Health Agency of Canada website does not seem to be updated yet, but many news outlets are covering the news conference were Federal Health Minister Aglukkaq announced 6 confirmed cases of swine flu.

"Federal health officials have confirmed six cases of human swine influenza in British Columbia and Nova Scotia and are warning more cases are likely in the near future as medical personnel around the world test for the virus linked to a serious outbreak in Mexico.

Federal Health Minister Leona Aglukkaq said at a news conference in Ottawa on Sunday that two people from B.C. and four from Nova Scotia had "relatively mild" symptoms of H1N1 swine flu and have since recovered.

"But these cases are likely not the last we'll see in Canada," she said."

http://www.vancouversun.com/Health/high+alert+after+cases+swine+confirmed/1536056/story.html

Media interviews with Mexico's Health Minister - Mexico death toll increased to 103

Media outlets are reporting on updates and statments made today by Mexico's Minister of Health, Jose Angel Cordova. I'm going to have to rely on information from the Vancouver Sun since I don't speak Spanish and can't referrence the actual interveiw or the ministry's web page.

"MEXICO CITY - The death toll in Mexico from an outbreak of a new type of swine flu has risen to 103 people, Health Minister Jose Angel Cordova said Sunday.

Cordova told Mexican television that around 400 people were in hospital out of a total of around 1,600 suspected cases.

The outbreak of a new strain of flu in Mexico in the last few days has stoked fears of a global epidemic as new cases cropped up in the United States and Canada. Possible infections are also being checked in Europe, Israel and New Zealand

...

“The most recent reports we have are of 1,614 cases, with 103 deaths, and we still have around 400 patients in hospital,” Cordova told the Televisa network, explaining that around two-thirds of the sick patients had recovered."

http://www.vancouversun.com/Health/Swine+death+toll+Mexico+rises/1536635/story.html

For any of our Spanish speaking staff, if you have a chance to check PAHO and MoH websites and keep us updated, that would be great.

Case classifications: What are suspected, probable, and confirmed cases?

There is a lot of information circulating about the swine flu and its pandemic potential. Some of this information may be confusing and difficult to interpret. Additionally, rumors, inflated or sensational reporting, and the use of jargon serve to further complicate the picture. As you read updates on the swine flu situation, you may come across the terms suspected case, probable case, and confirmed case. Understanding what these terms mean and when they are used may help you interpret the information presented in the media.

A case classification system is something epidemiologists and other members of the public health community use for tracking cases. Cases are typically classified as one of the following: suspected, probable, or confirmed.

A suspected case is a case that meets clinical case definition; meaning the signs and symptoms a person has or presents with are consistent or compatible with a particular disease. The suspected case definition is often used for reporting purposes, so a case is reported to public health authorities for further investigation. For instance, a San Diego resident presenting to a health clinic with fever, cough, sore throat, muscle aches, tiredness, and headache may be reported by the clinic staff to public health authorities as a suspected case of swine flu. Health authorities may then require the clinic to obtain a clinical specimen from the patient in order to determine whether the suspected case meets probable or confirmed case definition.

A probable case is a case that meets clinical case definition and has supportive or presumptive laboratory results that are consistent with the diagnosis, yet do not meet the criteria for laboratory confirmation. For instance, with regard to swine flu, a probable case may be a case that meets clinical case definition (fever, cough, sore throat, muscle aches, tiredness, and headache) and provided a clinical specimen that tested positive for influenza A, but was untypable at a certain laboratory. While this patient has supportive laboratory results, as evidenced by a positive influenza A result, the specimen likely has not been strain typed; therefore, the case cannot be considered confirmed.

A confirmed case can either be laboratory confirmed or epidemiologically linked.

Laboratory confirmed: A confirmed case is laboratory confirmed if the patient’s clinical specimen meets the diagnostic criteria of a specified laboratory method. Clinical specimens are often forwarded to a reference laboratory for ascertainment or confirmation of laboratory results. National laboratories such as those at the Centers for Disease Control and Prevention and the Public Health Agency of Canada have been testing samples for the swine flu strain causing recent epidemic levels of human infection.

Epidemiologically linked: A confirmed case is a case in which:
a) the patient has had contact with one or more persons who either have/had the disease or have been exposed to a point source of infection
b) transmission of the disease-causing pathogen (in this case influenza virus) by the usual modes of transmission are plausible
A case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed. This means, for instance, if a child in a household is a laboratory confirmed case of swine flu and the child’s parent becomes ill with symptoms consistent with swine flu within a time period consistent with the amount of time it would take to develop symptoms after being infected by the child, the parent would be considered an epidemiologically linked confirmed case.

As you read media releases, please keep in mind that the numbers of suspected cases will be higher than the numbers of probable and confirmed cases. This makes sense because the criteria for meeting a suspected case classification are broader or more sensitive than probable and confirmed case classifications. Often times, information sources may use suspected case counts to sensationalize the situation; other times, suspected case counts are used because it takes time and resources to confirm cases and demand for instantaneous information is high.

The White House Press Briefing on Swine Flu: US Department of Health and Human Services declares a public health emergency in the US

Just after 12:30 pm EDT, the White House Office of the Press Secretary hosted a press briefing on swine flu. During the briefing, representatives from the Departments of Homeland Security and Health and Human Services provided an update on the swine flu situation in the US and Mexico.

The following is a list of key points highlighted during the briefing:

1. The Department of Health and Human Services (the equivalent of the US Ministry of Health) declared a public health emergency in the US
   - This is a standard operating procedure and may sound more severe than it actually is
   - This declaration allows the government to free up federal, state, and local agencies and resources for prevention and mitigation efforts


2. The public health community is enhancing disease surveillance to better understand the scope and magnitude of the outbreak


3. Top officials emphasized early identification as a vitally important component in the overall response effort. Early identification is important for:
   - recognizing additional cases and sites of infection quickly;
   - responding rapidly with guidance for the public health community and the general public in the infected area; and
   - triggering an assessment of capabilities to mitigate the effects of a broader outbreak.

Key Actions:
"...there is a role for everyone to play when there's an outbreak going on. There are things that individuals do, there [are] things that families do, and [there are things] communities do to try to reduce the impact." --Dr. Richard Besser, Acting Director, Centers for Disease Control and Prevention

These officials stressed that influenza is unpredictable and outbreaks of infectious diseases are extremely unpredictable and variable, so guidelines and recommendations will remain fluid and likely will change based on the information at hand. Individuals should follow hand hygiene and respiratory etiquette:
- Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
- Wash your hands with soap and water regularly, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
- Try to avoid close contact with sick people.
- If you get sick with influenza, stay home from work or school, limit contact with others to keep from infecting them, and do not take public transportation. Avoid touching your eyes, nose or mouth. Germs spread this way.
- Practice forward thinking with regard to being prepared for a pandemic or localized outbreak. Visit PandemicFlu.gov for more information on how to prepare yourself and your family: http://www.pandemicflu.gov/

To read the entire press briefing transcript, please click on the link below:
http://www.whitehouse.gov/the_press_office/Press-Briefing-On-Swine-Influenza-4/26/09/

CDC confirms 8 cases of swine flu in New York and 1 case in Ohio

CDC has confirmed the cases of swine flu from a preparatory high school in Queens. At 11:30am today the CDC website was updated with 8 confirmed cases in New York and 1 additional case listed in Ohio. At this time, I cannot find any additional information about the case in Ohio


U.S. Human Cases of Swine Flu Infection

State # of laboratory confirmed cases
California 7 cases
Kansas 2 cases
New York City 8 cases
Ohio 1 case
Texas 2 cases
TOTAL COUNT 20 cases


As of April 26, 2009 9:00 AM ET

http://www.cdc.gov/swineflu/investigation.htm?s_cid=swineFlu_outbreak_002

CDC video and podcast on swine flu

Take a look at this video update from CDC

CDC releases interim guidance on face masks in swine flu

CDC has posted guidance on the use of face masks for the current swine flu epidemic.


"Information on the effectiveness of facemasks and respirators for the control of influenza in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in controlling swine influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment and the historical use of facemasks and respirators in other settings.

In areas with confirmed human cases of swine influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of simple actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings.

When it is absolutely necessary to enter a crowded setting or to have close contact3 with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators can help prevent some exposures, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. When crowded settings or close contact with others cannot be avoided, the use of facemasks1 or respirators2 in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:

1. Whenever possible, rather than relying on the use of facemasks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.

2. Facemasks should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people's coughs and to reduce the wearers' likelihood of coughing on others; the time spent in crowded settings should be as short as possible.

3. Respirators should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (e.g., family member with a respiratory infection) at home.

These interim recommendations will be revised as new information about the use of facemasks and respirators in the current setting becomes available.

For more information about human infection with swine influenza virus, visit the CDC Swine Flu website."


http://www.cdc.gov/swineflu/masks.htm

WHO updates the definitions of pandemic phases (but does not raise the alert level)

My current information sources tell me that the WHO expert panel will convene again on Monday, though some media reports cite Tuesday. They have not yet raised the pandemic alert level, but in the meantime have posted revisions to the definitions of each phase. The text is below, visit the website to see the new graphic.

http://www.who.int/csr/disease/avian_influenza/phase/en/index.html


"Current WHO phase of pandemic alert
Current phase of alert in the WHO global influenza preparedness plan
Pandemic preparedness

In the 2009 revision of the phase descriptions, WHO has retained the use of a six-phased approach for easy incorporation of new recommendations and approaches into existing national preparedness and response plans. The grouping and description of pandemic phases have been revised to make them easier to understand, more precise, and based upon observable phenomena. Phases 1–3 correlate with preparedness, including capacity development and response planning activities, while Phases 4–6 clearly signal the need for response and mitigation efforts. Furthermore, periods after the first pandemic wave are elaborated to facilitate post pandemic recovery activities.

The current WHO phase of pandemic alert is 3.

In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans.

In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat.

In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region (Figure 4). While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.

Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.

In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required."




http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

Press Release on 2 cases of confirmed swine flu from Kansas

The report below is from a pdf linked to the Kansas department of Health website

http://www.kdheks.gov/


"KDHE Reports 2 Cases of Swine Flu in Kansas

The Kansas Department of Health and Environment (KDHE) announced today that two cases
swine flu have been confirmed in Kansas involving two adults residing in the same household in Dickinson County. Neither of the patients was hospitalized – one is still ill and being treated,
and one is recovering.

One of the patients had recently traveled to Mexico, flying in and out of Wichita. Both persons work in Saline County and became ill with the same unique (H1N1) strain of swine flu that has been identified in Mexico, California and Texas.

“It’s not yet known whether this will become the next flu pandemic,” stated Dr. Jason Eberhart-Phillips, State Health Officer and Director of the KDHE Division of Health.

“We are working closely with health agencies at all levels and are continuing to monitor these cases. We are taking this situation very seriously.”

KDHE and the Dickinson County Health Department are investigating the sources of exposure, and efforts are being coordinated with the Centers for Disease Control and Prevention (CDC). Individuals who have been in contact with the patients are being interviewed and tested. Local health departments and hospitals in Kansas are being continuously updated and provided with information about the swine flu virus.

In accordance with the Kansas Response Plan, KDHE is also monitoring and instituting
recommendations from CDC for any additional influenza disease surveillance activities,
reviewing plans to further enhance those activities, and advising health care providers to use rapid detection tests for persons who have symptoms consistent with swine flu, especially if they have recently been in Mexico, and taking other steps under the plan.

The symptoms of swine flu in humans are similar to the symptoms of seasonal flu and include:
• Fever greater than 100 degrees
• Body aches
• Coughing
• Sore throat
• Respiratory congestion
• In some cases, diarrhea and vomiting"

NYC holds press briefing, 8 "probable" cases of swine flu. Specimens en route to CDC in Atlanta

New York Health Commissioner briefs the press. 8 of 9 specimens tested from a school in Queens are probable cases of wine flu according to testing done in New York. A good explanation of testing methods is covered

WHO declares "public health emergency of international concern"

From AP


"GENEVA – The World Health Organization warned countries around the world Saturday to be on alert for any unusual flu outbreaks after a unique new swine flu virus was implicated in possibly dozens of human deaths in North America.

WHO Director-General Margaret Chan said the outbreak in Mexico and the United States constituted a "public health emergency of international concern."

The decision means countries around the world will be asked to step up reporting and surveillance of the disease, which she said had "pandemic potential" because it is an animal virus strain infecting people. But the agency cannot at this stage say "whether or not it will indeed cause a pandemic," she added.

Chan made the decision to declare public health emergency of international concern after consulting with influenza experts from around the world. The emergency committee was called together Saturday for the first time since it was created in 2007.

In theory, WHO could now recommend travel advisories, trade restrictions or border closures, none of which would be binding. So far it has refrained from doing so.

The agency also held off raising its pandemic alert level, citing the need for more information.
Earlier, Chan told reporters that "it would be prudent for health officials within countries to be alert to outbreaks of influenza-like illness or pneumonia, especially if these occur in months outside the usual peak influenza season."

"Another important signal is excess cases of severe or fatal flu-like illness in groups other than young children and the elderly, who are usually at highest risk during normal seasonal flu," she said.

Several Latin American and Asian countries have already started surveillance or screening at airports and other points of entry.

At least 62 people have died from severe pneumonia caused by a flu-like illness in Mexico, WHO says. Some of those who died are confirmed to have a unique flu type that is a combination of bird, pig and human viruses. The virus is genetically identical to one found in California.
U.S. authorities said eight people were infected with swine flu in California and Texas, and all recovered.

So far, no other countries have reported suspicious cases, according to WHO.
But the French government said suspected cases are likely to occur in the coming days because of global air travel. A French government crisis group began operating Saturday. The government has already closed the French school in Mexico City and provided French citizens there with detailed instructions on precautions.

Chilean authorities ordered a sanitary alert that included airport screening of passengers arriving from Mexico. No cases of the disease have been reported so far in the country, Deputy Health Minister Jeanette Vega said, but those showing symptoms will be sent to a hospital for tests.

In Peru, authorities will monitor travelers arriving from Mexico and the U.S. and people with flu-like symptoms will be evaluated by health teams, Peru's Health Ministry said.

Brazil will "intensify its health surveillance in all points of entry into the country," the Health Ministry's National Health Surveillance Agency said in a statement. Measures will also be put in place to inspect cargo and luggage, and to clean and disinfect aircraft and ships at ports of entry.
Some Asian nations enforced checks Saturday on passengers from Mexico.

Japan's biggest international airport stepped up health surveillance, while the Philippines said it may quarantine passengers with fevers who have been to Mexico. Health authorities in Thailand and Hong Kong said they were closely monitoring the situation.

Asia has fresh memories of an outbreak of severe acute respiratory syndrome, or SARS, which hit countries across the region and severely crippled global air travel.

Indonesia, China, Thailand, Vietnam and other countries have also seen a number of human deaths from H5N1 bird flu, the virus that researchers have until now fingered as the most likely cause of a future pandemic.

The Dutch government's Institute for Public Health and Environment has advised any traveler who returned from Mexico since April 17 and develops a fever over 101.3 degrees Fahrenheit (38.5 Celsius) within four days of arriving in the Netherlands to stay at home.

The Polish Foreign Ministry has issued a statement that recommends that Poles postpone any travel plans to regions where the outbreak has occurred until it is totally contained.

The Stockholm-based European Center for Disease Prevention and Control said earlier Saturday it shared the concerns about the swine flu cases and stood ready to lend support in any way possible. "

http://news.yahoo.com/s/ap/20090425/ap_on_re_eu/un_un_mexico_swine_flu

New WHO page for swine flu

WHO has set up a new page for swine flu

http://www.who.int/csr/disease/swineflu/en/index.html

There is an audio briefing from Director- General Margret Chan and this brief below:


"In response to cases of swine influenza A(H1N1), reported in Mexico and the United States of America, the Director-General convened a meeting of the Emergency Committee to assess the situation and advise her on appropriate responses.

The establishment of the Committee, which is composed of international experts in a variety of disciplines, is in compliance with the International Health Regulations (2005).

The first meeting of the Emergency Committee was held on Saturday 25 April 2009.
After reviewing available data on the current situation, Committee members identified a number of gaps in knowledge about the clinical features, epidemiology, and virology of reported cases and the appropriate responses.

The Committee advised that answers to several specific questions were needed to facilitate its work.

The Committee nevertheless agreed that the current situation constitutes a public health emergency of international concern.

Based on this advice, the Director-General has determined that the current events constitute a public health emergency of international concern, under the Regulations.

Concerning public health measures, in line with the Regulations the Director-General is recommending, on the advice of the Committee, that all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia.

The Committee further agreed that more information is needed before a decision could be made concerning the appropriateness of the current phase 3. "

WHO is expected to post on their decision regarding the current pandemic alert phase any minute so stay tuned to the WHO page...

CDC Swine Flu Briefing

Our AI Coordinator Maryann Delea was able to attend the CDC briefing in person today. She wrote up these notes below:

Friday, April 24, 2009 CDC media briefing: Human cases of swine influenza infection

Dr. Besser, Acting Director of the CDC, held a media briefing regarding human cases of swine influenza infection among persons in California, Texas, and Mexico. The following is a list of relevant points presented during the briefing:

• Concern has grown since yesterday, in light of new information from Mexico:
• One additional case was reported and laboratory confirmed in a child from San Diego, bringing the total number of confirmed US cases to 8
• 6 CA residents, 2 TX residents
• Nine-54 years of age
• All recovered from infection, one hospitalized
• One San Diego case had a history of travel to Mexico
• CDC tested 14 untypable influenza A specimens from Mexico; 7 tested positive for swine influenza and all were similar to the US specimens – per analyzed genetic component (the entire viral genomes were not sequenced), and 7 were negative for swine influenza
• Illness presentations among Mexican cases are reportedly more severe
• CDC does not have case information on the 7 positive specimens, so they were unable to comment on the validity of these reports
• There have been reported deaths, but CDC did not have information on case fatality rate and would not comment on the number of attributable deaths
• At this point in time, this particular strain is believed to have undergone several cycles of person-to-person transmission, as evidenced by the broad geographic distribution of cases in the absence of any identified linkages
• This hypothesis may change as new epidemiologic information becomes available
• There has been no change in the WHO global pandemic alert level (which remains at level 3), but WHO is obtaining more information about the situation in Mexico and convening an expert panel to determine whether evidence necessitates an increase in alert level
• WHO is not at the point of declaring a pandemic, but they are looking to learn more about the virus
• WHO will assess virulence and spectrum of disease when considering changes in the pandemic alert phase
• CDC has sent an EpiAid to southern CA, is working on sending a team to TX, and will possibly send a team to Mexico
• The teams will focus on conducting contact investigations and assisting laboratories
• There have been no travel advisories or restrictions implemented at this time, but as per standard operating procedures, CDC posted an outbreak notification for southern and central Mexico
• CDC defers to Mexican authorities and WHO for case counts as well as information regarding sources of exposure and virulence
• CDC recommends that people begin to think about what they would do in the event of a pandemic à visit pandemic preparedness website for information

Updated: you can see the unedited transcript at

http://www.cdc.gov/media/transcripts/2009/t090424.htm

WHO update on swine flu cases

So far, WHO has posted the most comprehensive list of suspected vs. confirmed cases in the US and Mexico. Below is their latest update.

"24 April 2009 -- The United States Government has reported seven confirmed human cases of Swine Influenza A/H1N1 in the USA (five in California and two in Texas) and nine suspect cases. All seven confirmed cases had mild Influenza-Like Illness (ILI), with only one requiring brief hospitalization. No deaths have been reported.

The Government of Mexico has reported three separate events. In the Federal District of Mexico, surveillance began picking up cases of ILI starting 18 March. The number of cases has risen steadily through April and as of 23 April there are now more than 854 cases of pneumonia from the capital. Of those, 59 have died. In San Luis Potosi, in central Mexico, 24 cases of ILI, with three deaths, have been reported. And from Mexicali, near the border with the United States, four cases of ILI, with no deaths, have been reported.

Of the Mexican cases, 18 have been laboratory confirmed in Canada as Swine Influenza A/H1N1, while 12 of those are genetically identical to the Swine Influenza A/H1N1 viruses from California.

The majority of these cases have occurred in otherwise healthy young adults. Influenza normally affects the very young and the very old, but these age groups have not been heavily affected in Mexico.

Because there are human cases associated with an animal influenza virus, and because of the geographical spread of multiple community outbreaks, plus the somewhat unusual age groups affected, these events are of high concern.

The Swine Influenza A/H1N1 viruses characterized in this outbreak have not been previously detected in pigs or humans. The viruses so far characterized have been sensitive to oseltamivir, but resistant to both amantadine and rimantadine.

The World Health Organization has been in constant contact with the health authorities in the United States, Mexico and Canada in order to better understand the risk which these ILI events pose. WHO (and PAHO) is sending missions of experts to Mexico to work with health authorities there. It is helping its Member States to increase field epidemiology activities, laboratory diagnosis and clinical management. Moreover, WHO's partners in the Global Alert and Response Network have been alerted and are ready to assist as requested by the Member States.

WHO acknowledges the United States and Mexico for their proactive reporting and their collaboration with WHO and will continue to work with Member States to further characterize the outbreak."

http://www.who.int/csr/don/2009_04_24/en/index.html

Update: Swine Flu Situation in US and Mexico

Over the past week, there have been confirmed human cases of a new influenza virus - swine influenza (H1N1) - in the Southwest United States (8 confirmed cases) and Mexico (19 confirmed cases). The CDC and WHO have stated that the strains circulating in the US and Mexico are identical H1N1 strains.

The H1N1 strain is NOT related to H5N1 avian influenza. H5N1 avian influenza is circulating primarily in Southeast Asia and has caused concern over its potential to cause a pandemic. This unusual strain of H1N1 virus is primarily a swine influenza, including genes from North American swine and avian influenza, human flu, and a European/Asian strain of swine flu.

WHO, PAHO, CDC, and Mexican and Canadian health authorities are collaborating in the ongoing investigation to determine the extent of the virus' spread, transmissibility, and severity. Thus far there is evidence of human-to-human transmission of the virus.

While the situation is concerning and world health agencies continue to monitor the situation carefully, there is no reason to believe this is the start of a pandemic. In fact, there are currently no travel restrictions to the Southwest US (California and Texas) or Mexico at this time. WHO has not raised the pandemic threat level. However, CDC and WHO are encouraging all nations to consult their pandemic preparedness plans and remain alert. CDC will be holding daily briefings on the situation over the next few days.

Below is some more detailed information concerning the outbreaks and the public health response to the situation.

UNITED STATES:

US CASES: 8 non-fatal cases of H1N1 have been confirmed by the CDC in California and Texas. At least one of these cases, a young boy from California, had traveled to Mexico recently.

CLINICAL TREATMENT GUIDELINES: Thus far, CDC clinical guidelines suggest treating the illness with oseltamivir (Tamiflu) and zanamavir (Relenza). All US cases have been successfully treated using this course. Thus far all cases have been resistant to adamantanes.

MEXICO:

LAB-CONFIRMED CASES: Mexican health officials sent 32 samples to the Canadian Public Health Agency and CDC; together they have confirmed the same strain of H1N1 circulating in the US in 19 of the 32 samples. All agencies continue to gather samples and test for H1N1 to get a better understanding of the severity, transmissibility, and spread of the virus.

PANDEMIC THREAT LEVEL:
· The world is currently at level 3 of the WHO's six-rung pandemic alert ladder.
o Phase 3 means there are occasional human cases with a novel flu virus.
· WHO plans to convene a panel to determine whether to raise the pandemic threat level. WHO would need the advice of an expert panel to move to Phase 4 or beyond.
· Phase 6 is a pandemic.

FOR MORE INFORMATION:
From WHO:
http://www.who.int/csr/don/2009_04_24/en/index.html
From CDC:
http://www.cdc.gov/flu/swine/http://www.cdc.gov/flu/swine/investigation.htm

From open source media (further information about the situation in Mexico):
http://www.theglobeandmail.com/servlet/story/RTGAM.20090424.wflumain0424/BNStory/International/home
http://www.cbc.ca/health/story/2009/04/24/health-flu-mexico090424.html?ref=rss
http://www.alertnet.org/thenews/newsdesk/LO332728.htm
http://www.bloomberg.com/apps/news?pid=20601124&sid=azAqR4.k2qEY&refer=home
http://online.wsj.com/article/SB124058255179552887.html

WHO Considers Raising Pandemic Threat Level: Swine Flu Outbreaks in Southwest US and Mexico

Following the detection of 7 cases of swine flu in Texas and California last week, Mexico City officials requested the help of the WHO yesterday in investigating 130 suspected cases of swine flu. Reports vary on confirmed cases - but between 16 and 20 deaths from severe respiratory illness have been reported in Mexico in the last four weeks. Estimates of suspected cases spiked on Friday to between 800 and 900 in south and central Mexico and near Baja California Norte (which borders California). At least three of the US cases have been linked to the Mexican cases.

Though no numberes have been released, Mexican officials confirmed today that at least some of the deaths and other suspected cases are in fact the same strain of H1N1 found in Texas and California.

The unsusual strain of H1N1 virus includes genes from North American swine and avian influenza, human flu, and a European/Asian strain of swine flu. This strain is NOT related to H5N1 avian influenza, the strain that's circulating primarily in Southeast Asia and has caused concern about its pandemic potential over the past five years. Because human H1N1 viruses continually circulate among the human population, there may be some immunity to this strain by those previously infected with human flu. However, it's unclear how much immunity one could expect because this new H1N1 strain is made up primarily of swine flu genes.

"Reports suggest the majority of the cases are occurring in young, previously healthy adults in their mid 20s to mid 40s. There are said to have been over 800 cases so far, but it remains unclear if all of those people are sick with this virus or if other flu or respiratory viruses are also circulating and muddling the picture.

Mr. Hartl said the WHO is sending staff to Mexico to help authorities there get a better handle on the scope of the problem. “We're extremely concerned because we're looking at five different influenza events which may or may not be connected,” he said, referring to California, Texas and three possibly linked outbreaks in Mexico.""The world is currently at level 3 of the WHO's six-rung pandemic alert ladder, because of ongoing sporadic cases of human infection with the H5N1 avian flu virus. Phase 3 means there are occasional human cases with a novel flu virus. WHO would need the advice of an expert panel to move up to Phase 4 or beyond. Phase 6 is a pandemic."

Mexican health officials, the WHO, the US Centers for Disease Control and Prevention, and Canadian health ministries are working in collaboration to get a handle on the confirmed/suspected cases in Mexico.

CDC is holding a press briefing on the outbreak at 2:30 pm. We will provide updates as appropriate throughout the day.

For more from CDC:
http://www.cdc.gov/flu/swine/investigation.htm
http://www.cdc.gov/flu/swine/

For the full story see these related articles:
http://www.theglobeandmail.com/servlet/story/RTGAM.20090424.wflumain0424/BNStory/International/home
http://www.thestar.com/News/Canada/article/623074
http://www.bloomberg.com/apps/news?pid=20601124&sid=azAqR4.k2qEY&refer=home
http://online.wsj.com/article/SB124058255179552887.html

Drug Resistance Prompts Diversification of Pandemic Stockpiles

There's growing evidence of H5N1 genetic diversification and resistance to the front-line flu antiviral, Tamiflu. Pairing fears of H5N1 resistance with near universal resistance to the drug from this year's seasonal flu has led to increasing calls for diversifying pandemic drug stockpiles .

Tamiflu comprises the majority of antiviral drugs in Canadian (90%) and American (80%)stockpiles. Waning efficacy in these drugs against seasonal and H5N1 are causing concern among scientists and government officials about the usefulness of such stockpiles in a pandemic.

While older flu drugs, such as Relenza and amantadine were previously considered less effective than Tamiflu for use in a pandemic, the scientific perspective seems to be shifting.

"'I think the general view is that from a scientific perspective, greater diversification (of stockpiles) would be desirable,' says King, director general of the (Canadian) public health agency's centre for immunization and respiratory infectious diseases."

British and American officials are now considering or preparing for diversification of such stockpiles.

For the full story, see: http://cnews.canoe.ca/CNEWS/Politics/2009/04/19/9166586-cp.html

New study show surprising diversity of H5N1 virus

CIDRAP has posted a summary of a new study of H5N1 in Vietnam.

"H5N1 influenza viruses found in chickens seized at Vietnam's border with China in 2008 show a surprising level of genetic diversity, suggesting that the viruses are evolving rapidly and raising questions about disease surveillance and the effectiveness of prepandemic H5N1 vaccines, according to a team of Vietnamese and US scientists.

The findings suggest that the subgroup of viruses identified in the study has been circulating in the region either undetected or unreported for a "considerable amount of time," the report says. The viruses are in clade 7, a group that has not been found in an outbreak since one in China's Shanxi province in 2006. "

As a background for those of you who may not know much about the H5N1 viruses and what a clade is, I suggest the wikipedia entry on H5N1 http://en.wikipedia.org/wiki/H5N1

To read the whole entry from CIDRAP, go to:

http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/apr1409vietnam.html

New materials from the Asian Disaster Preparedness Center

The Asian Disaster Preparedness Center (ADPC) partnered with CARE and others this past year to bring together the major organizations working on preparedness and prevention of Avian and Human Influenza (AHI) in the region. The goal of this partnership was to highlight the best practices and lessons learned from organizations developing and testing new approaches to managing AHI at the community level. These organizations agreed on best practices and approaches to develop into a comprehensive resource package and week-long workshop to train community practitioners in these approaches. The workshop was developed by ADPC, CARE, AED, IRC, IFRC, Kyema Foundation, among others, and piloted in November of last year. The materials were evaluated by participants and facilitators, revised, and then finalized at a second workshop this past February.

CARE was specifically asked highlight our new approach to community-based surveillance, in addition to helping identify other important organizations and approaches. The materials produced from this workshop represent the first comprehensive compilation of best practices, lessons learned, and new approaches for community-management of AHI from a broad-based partnership. As a follow-up to these workshops, ADPC has now made available online all the background resources and materials: http://adpcahi.hostrator.com/.

These resources can be incredibly useful in developing, informing, or refining AHI programs, taking particular note of the lessons learned and best practices from the different approaches.

The website (http://adpcahi.hostrator.com/) includes links to organization websites, training guides and manuals, some IEC materials, and case studies for the 5 major topics covered at the workshop:
1) using research to inform program practice;
2) communication for mobilizing individual and social change for AI prevention;
3) biosecurity;
4) community-based surveillance; and
5) community preparedness and response.

We'll be updating CARE's website soon with our training materials on Community-based surveillance, including facilitator guides!

. . . And in Malaysia, An Answer for Resistance to Culling?

The new Agriculture Minister in Malaysia, Datuk Noh Omar, announced a pilot project to insure poultry and padi fields in Johor and Kedah to protect farmers (and the nation's economy) from economic losses due to floods and H5N1.

“I have seen chicken breeders and padi farmers suffering huge losses when their animals died from bird flu and padi fields are destroyed by floods.

“I believe the insurance scheme is the best solution to prevent them from incurring further losses,” he told reporters after launching the ministry’s Cultivation Month Programme yesterday.

For more on the story, see The Star: http://thestar.com.my/news/story.asp?file=/2009/4/13/nation/3683137&sec=nation

Resistance to Culling Aiding Spread of H5N1 in Indonesia

Over the weekend, Indonesian officials announced that H5N1 has spread to poultry in at least three villages in Sungai Apit district in Siak regency, Riau. The outbreak was first detected following the death of a young child at the end of March, but die-offs of poultry in the boy's village were occurring for at least a week before he became ill. Lab tests have confirmed H5N1 is present in these villages, and may have spread throughout the subdistrict.

Reluctance among poultry farmers and residents to report suspected H5N1 and continued resistance by farmers to cull their sick poultry are aiding the spread of the infection, health officials said. The main factor behind such resistance is lack of compensation for farmers and residents that cull their poultry.

"It's not that we don't want to, but the district office has no such budget for the purpose (culling compensation). For now, we can only remind the residents, including through sermons at mosques, of the risks of bird flu. We cannot force the residents to cull their poultry if they don't want to," he (District chief Indra Atmaja) said.

For more on this story see the Jakarta Post: http://www.thejakartapost.com/news/2009/04/11/bird-flu-virus-spreads-riau-after-boy039s-death.html

Silent/Subclinical H5N1 Infections in Egypt?

CIDRAP published an interesting article Wednesday about the possiblity of subclinical infections in Egypt, sparking fears that untreated subclinical infections could allow the virus more time to mutate and reassort to form a strain with pandemic potential. The Egyptian government, in partnership with the WHO, will soon start a study to investigate whether subclinical cases have been occurring. The study will include "testing the blood of people who were potentially exposed to infected birds but had not gotten sick."

"The recent series of H5N1 avian influenza cases in Egyptian children yet very few in adults has raised concern that some Egyptians may be getting infected without getting sick, according to a Reuters news report published today. If there is any subclinical case in Egypt, the aim is to treat immediately to stop the reproduction of the virus," he told Reuters. "Because whether [through] mutation or reassortment, this will lead to the pandemic strain."

The Reuters story said that all but two of the 11 Egyptians infected with H5N1 this year have been children under age 3 , as opposed to the cases last year which all occurred in adults and older children. When this many cases occur in children without similar cases in adults, it raises the question of whether adults were being infected without falling ill.

"Tim Uyeki, MD, a medical epidemiologist in the Influenza Division at the Centers for Disease Control and Prevention, told CIDRAP News that limited studies in several countries over the past few years have found little serologic evidence of asymptomatic or unrecognized cases of H5N1 virus infection. "

For the full story see:
http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/apr0809asymp.html

Community mobilization against avian flu in Tangerang

Just a little clip of our CARE Indonesia team leading a community event with local women's groups. This is a march through the neighborhoods designed to attract attention so the women's groups can handout information about avian flu. Also, they have the best avian flu inspired hats!

FDA Approves Rapid Diagnostic Test for H5N1 in Humans

On Tuesday, the FDA approved a rapid diagnostic test developed by Arbor Vita Corporation to diagnose H5N1 in humans in about 40 minutes.

"'The test, called AVantage A/H5N1 Flu Test, detects influenza A/H5N1 in throat or nose swabs collected from patients who have flu-like symptoms,' the FDA said in a statement."

This test was hailed by the FDA as a major step forward, particularly as the AVantage test is the fastest test (compared to 4 hours for the next fastest) to accurately diagnose the particular H5N1 influenza strain. It's also apparently easier to use.

Thus far, Arbor Vita has only announced plans to use the rapid diagnostic test for the US population (if necessary) and forward-deployed US military personnel. No information regarding per-test cost was readily available from news sources or Arbor Vita's site.

For more information:
http://www.flutrackers.com/forum/showthread.php?p=217880

http://www.arborvita.com/news_PR13.html

http://crofsblogs.typepad.com/h5n1/

CARE Vietnam featured by The Communications Initiative

The Communications Initiative will feature CARE Vietnam's approaches to AI community mobilization and surveillance in the next installment of its e-magazine The Drum Beat, which has more than 40,000 monthly subscribers.

From The Drum Beat:
"This report describes and evaluates the strategies shaping a community-based
surveillance initiative developed by CARE Vietnam in an effort to improve the
detection and reporting of avian influenza (AI). Mobilising and building the
capacity of volunteers are hallmarks of this public health approach. As part of
Targeting the Risk of Avian Influenza Now (TRAIN), local partners at the
administrative levels closest to communities - village, commune, and district -
take the lead in implementing surveillance activities."

The Communications Initiative is a network of wide-ranging partnerships to foster information sharing "between the people and organisations engaged in or supporting communication as a fundamental strategy for economic and social development and change"


You can read The Communications Initiative coverage of the CARE Vietnam program here:
http://www.comminit.com/en/node/273362/293

You can access the full report on CARE Vietnam's Community-Based Surveillance model here: http://www.comminit.com/redirect.cgi?m=d3dd6c72b7130140b7fce7e32d8bdb3a

Indonesia: Cluster of 6 Suspected Human H5N1 Cases Under Control

In Bandung, West Java over the weekend, six people, ranging in age from 14 months to 65 years, were admitted to the Hasan Sadikin Hospital after presenting with flu-like symptoms three days after contact with poultry confirmed to have H5N1.

A family of five reportedly cooked and consumed the sick poultry, which was owned by their neighbor. Animal health officials noted that the sick poultry was "dead around the neighborhood" and confirmed to have H5N1.

All six patients are recovering. Four patients are receiving Tamiflu treatment at home. The remaining two patients (25-year old father and 14-month-old child) are still being treated and held for observation at the hospital. They reportedly had the most severe symptoms and closest interaction with the sick poultry.

While cultures and blood samples were collected from all suspected H5N1 cases yesterday, no results have been released by officials.

For more information see:
http://birdflucorner.wordpress.com/2009/04/05/bandung-west-java-more-bird-flu-suspects/

http://birdflucorner.wordpress.com/2009/04/06/bandung-west-java-patients-recover/

http://crofsblogs.typepad.com/h5n1/

Egypt: Upswing in Human H5N1 Cases

With 61 reported human H5N1 cases and 23 fatalities, Egypt has the highest number of reported cases of any country outside of Asia. Six new human H5N1 infections in the past month, mostly in young children in northern rural areas, have spurred WHO to request an investigation into the seeming susceptibility of young children to contracting the virus in rural areas. This susceptibility seems to be explained by greater involvement of young girls and women in poultry raising activities in rural areas, a practice similar to other countries experiencing ongoing spread of H5N1.

Despite a rising number of new infections, the case-fatality rate remains relatively low compared to other countries with reported human H5N1 cases. Quicker treatment of possible cases and the use of oseltamivir have been credited for the lower rate.

For more information, see:
http://www.ennaharonline.com/en/international/744.html
http://crofsblogs.typepad.com/h5n1/