Vaccine news for H1N1 & H5N1

Much of our attention is focused on H1N1 these days, but scientist and vaccine producers have not forgotten H5N1 as a potential pandemic virus. Reuters is reporting on new strains from Egypt being utilized:

"Scientists have used bird flu virus samples from Egypt to develop a new basis for a vaccine against the toxic H5N1 strain that continues to circulate, the World Health Organisation said on Thursday.

Avian influenza kills about half the people it infects, but unlike the quickly circulating H1N1 flu virus has not been shown to pass easily between humans to date.

The WHO said the candidate virus was developed at the U.S. Centres for Disease Control and Prevention in Atlanta "thanks to the ministry of health and population of Egypt, for providing virus specimens,"

"This recombinant vaccine virus is available for distribution," it said in a statement on its website.

"Institutions, companies and others interested in pandemic vaccine development who wish to receive these candidate vaccine viruses should contact either the WHO Global Influenza Programme ... or the Centers for Disease Control and Prevention."

Pharmaceutical companies including Novartis are already working on vaccines against H5N1 bird flu, which has killed or forced the culling of more than 300 million birds since 2003 as it spread to 61 countries in Asia, the Middle East and Africa."

http://uk.reuters.com/article/worldNews/idUKTRE54R2S720090528?rpc=401&&pageNumber=1&virtualBrandChannel=0

Meanwhile, the Sanofi Pasteur Institute, a leading manufacturer of influenza vaccine announced they had recieved the seed virus for H1N1 vaccine production. According to their press release:

"Receipt of the seed virus means that Sanofi Pasteur will begin the development process, called
“passaging”, that will yield a “working seed.” Passaging is the process for acclimating virus to grow in a production environment at optimum yield. The passaging process is expected to take approximately two weeks. Following quality controls, Sanofi Pasteur will be prepared to begin industrial production as soon as directed by public health agencies."

http://198.73.159.214/sanofi-pasteur2/ImageServlet?imageCode=25915&siteCode=SP_CORP

WHO has said they will make decisions about vaccine production this summer.

Daily case count from WHO

As of 06:00 GMT, 29 May 2009, 53 countries have officially reported 15,510 cases of influenza A(H1N1) infection, including 99 deaths. That's an increase of 2,112 cases since yesterday, the majority of new cases being reported in the US, followed my Mexico, Canada & Australia.

Check here for the full list of countries reporting cases:

http://www.who.int/csr/don/2009_05_29/en/index.html

Crisis and Emergency Risk Communication Resources

CDC developed several crisis and emergency risk communication resources. These resources are useful for people, such as our country office focal points, who will be required to develop and disseminate risk communication messages.

Below, we have posted two podcasts on this topic.

Crisis and Emergency Risk Communications: Best Practices
In this podcast, CDC's Dr. Barbara Reynolds discusses best practices in crisis and emergency risk communication. She characterizes the initial phase of the crisis communication lifecycle and describes the five most common mistakes made in emergency communication to the public and how to counter them.

Running time: 7:10
Author: Centers for Disease Control and Prevention, Office of the Director
Series Name: CDC Featured Podcasts

A direct link can be found on CDC’s website at: http://www2a.cdc.gov/podcasts/player.asp?f=11509


Crisis and Emergency Risk Communications: Countering Stigmatization
In this podcast, CDC's Dr. Barbara Reynolds defines stigmatization, describes how stigmatization can occur in a community, and discusses activities that response officials and communication professionals can do to prevent or confront stigmatization.

Running time: 10:29
Author: Centers for Disease Control and Prevention, Office of the Director
Series Name: CDC Featured Podcasts

A direct links can be found on CDC’s website at: http://www2a.cdc.gov/podcasts/player.asp?f=11376

Daily Influenza A(H1N1) Updates

WHO

41 countries have officially reported 11,034 cases of novel influenza A(H1N1) infection, including 85 deaths. The map below, created by WHO, indicates the number of laboratory confirmed cases and deaths reported to WHO.

For more information, visit: http://www.who.int/csr/disease/swineflu/en/index.html

CDC

As of Wednesday, 27 May 2009 (CDC is providing updated case reports on Mondays, Wednesdays, and Fridays), CDC reported 7,927 confirmed and probable cases of novel influenza A(H1N1) in 48 states in the US, including 11 deaths. The map below illustrates geographic spread of the novel influenza A(H1N1) virus in the US.

For more information, visit: http://www.cdc.gov/h1n1flu/

Daily Updates, 11,034 cases in 41 countries

WHO: 41 countries have officially reported 11 034 cases of influenza A(H1N1) infection, including 85 deaths (not including additional US death confirmed by CDC today).
http://www.who.int/csr/don/2009_05_21/en/index.html

CDC: 5764 cases (9 deaths) in 48 states (including DC)
Newly reported death from Utah.
Deaths now in Arizona, Missouri, Texas, Utah, and Washington State.

http://www.cdc.gov/h1n1flu/update.htm

New Web Technology for H1N1 Surveillance?

An excerpt from the NEJM regarding the uses of technology for surveillance, monitoring, and mobilizing global response for outbreaks, such as the current H1N1 epidemics.

"Data about diseases and outbreaks are disseminated not only through online announcements by government agencies but also through informal channels, ranging from press reports to blogs to chat rooms to analyses of Web searches (see Digital Resources for Disease Detection) ... The Internet is also providing new opportunities for connecting experts who identify and report outbreaks. Information technologies such as wikis, social networks, and Web-based portals can facilitate communication and collaboration to accelerate the dissemination of reports of infectious diseases and aid in mobilizing a response ..."

Some scientific societies are leveraging technologies for data exchange, analysis, and visualization:
Distributed Surveillance Taskforce for Real-Time Influenza Burden Tracking and Evaluation (DiSTRIBuTE): a group of state and local health departments that use the Web to share, integrate, and analyze health data across large regions.

GeoSentinel project (CDC & International Society of Travel Medicine): brings together travel and tropical-medicine clinics in an electronic network for surveillance of travel-related illnesses.

Emerging Infections Network (CDC & Infectious Diseases Society of America): a Web-based network of more than 1000 infectious disease specialists that is geared toward finding cases during outbreaks and detecting new or unusual clinical events.

Electronic Health Records, Cell Phones & Texting: Useful for Surveillance?
Broader Web-based networks are also proving useful for surveillance. Social-networking sites for clinicians, patients, and the general public hold potential for harnessing the collective wisdom of the masses for disease detection. Given the continued deployment of personally controlled electronic health records, we expect that patients' contributions to disease surveillance will increase. Eventually, mobile-phone technology, enabled by global positioning systems and coupled with short-message-service messaging (texting) and "microblogging" (with Twitter), might also come into play. For instance, an organization called Innovative Support to Emergencies, Diseases, and Disasters (InSTEDD) has developed open-source technology to permit seamless cross-border communication between mobile devices for early warning and response in resource-constrained settings."

Potential Drawbacks that may limit the realization of their potential for public health practice and clinical decision making.

• Information overload
• false reports
• lack of specificity of signals
• sensitivity to external forces such as media interest
• difficulties with verification and follow-up.

Sample Web-based data sources:
Global Public Health Intelligence Network (GPHIN), www.phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk-eng.php
DiSTRIBuTE, www.syndromic.org/projects/DiSTRIBuTE.htm
GeoSentinel, www.istm.org/geosentinel/main.html
Emerging Infections Network, http://ein.idsociety.org

Full article: http://content.nejm.org/cgi/content/full/360/21/2153

New Cases in Japan, China, South Korea

Japan
WHO reported today that Japan has a total of 210 H1N1 cases, 51 of which were newly confirmed since yesterday. There was also report of the first two cases in Japan's denseley populated capital city, Tokyo. These two cases were high-school aged girls recently returned from New York City. The newly confirmed cases prompted officials to close even more Japanese schools (more below).

China & South Korea
There were also reports of a new quarantined H1N1 case in South Korea, a new case in Beijing (for a total of 2 in the capital city), and one in Taiwan (an Australian cruise ship doctor).

Quarantine & School Closings:
"About 4,500 schools, mostly in the western prefectures of Osaka and Hyogo about 400 km (250 miles) from Tokyo, have closed their doors until the end of the week. The local government in neighbouring Shiga prefecture, which also confirmed its first case on Wednesday, was also urging its schools to follow suit. A university campus in Shiga was also closed, affecting 18,000 students, after one of them was infected with the virus.

A hospital in the port city of Kobe, where a member of staff had been infected, was to ban visits to flu patients, Kyodo news agency said."

Shifts in Preparedness and Response (from H5N1 to H1N1)
"The (Japenese) government is considering drawing up a new plan by Friday to deal with the virus, which is not as deadly as the avian influenza for which existing plans had been created. It is also considering winding down strict health checks at international airports at the end of the week, which had been imposed to try to buy time before an outbreak in Japan."

http://www.who.int/csr/don/2009_05_20/en/index.html
http://www.alertnet.org/thenews/newsdesk/SP441009.htm
http://crofsblogs.typepad.com/h5n1/

Pandemic Alert Phase Change???

**It seems that the sharp increase of Japanese cases reflects the presence of community-level transmission of the A/H1N1 virus. Unless WHO changes their definitions of pandemic phases, this would certainly prompt an uptick in the Pandemic Alert from Phase 5 to Phase 6 (Pandemic). This change has not occurred, however, and there are no reports that WHO has convened the advisory council to discuss such a change. They have been considering development of a pandemic severity scale along with possible revisions of the pandemic phase definitions. More to come**

WHO & CDC Daily Case Update

WHO reports: 41 countries have officially reported 10,243 cases of influenza A(H1N1) infection, including 80 deaths (which does not include updated CDC counts, including two additional deaths).

CDC reports: 5710 cases (8 deaths) in 48 states.

Deaths:
Arizona: 2; Missouri: 1; New York: 1; Texas: 3; Washington: 1

http://www.cdc.gov/h1n1flu/update.htm
http://www.who.int/csr/don/2009_05_20/en/index.html

Director-General's Address to WHA

Director-General Chan addressed the World Health Assembly at the opening of the 62nd meeting. She emphasized overall health disparities and the role of global health authorities in alleviating these disparities. She also spoke at length about the impact of an influenza pandemic and the disproportionate burden placed on low- and middle-income countries and vulnerable populations in such a situation. Some select excerpts are below:

"As I said, equity in health matters in life-and-death ways. It matters most especially in times of crisis. The world of today is more vulnerable to the adverse effects of an influenza pandemic than it was in 1968, when the last pandemic of the previous century began."

Because:
1) The speed and volume of international travel have increased

2) "The radically increased interdependence of countries amplifies the potential for economic disruption."

3) Just-in-time production and supply chains: "Apart from an absolute moral imperative, trends such as outsourcing and just-in-time production compel the international community to make sure that no part of the world suffers disproportionately. We have to care about equity."

"Unfortunately, other (additional) vulnerabilities are overwhelmingly concentrated in the developing world."

Underlying Medical Conditions & Vulnerable Populations
"On current evidence, most cases of severe and fatal infections with the H1N1 virus, outside the outbreak in Mexico, are occurring in people with underlying chronic conditions. In recent years, the burden of chronic diseases has increased dramatically, and shifted dramatically, from rich countries to poorer ones.

Today, around 85% of the burden of chronic diseases is concentrated in low- and middle-income countries. The implications are obvious. The developing world has, by far, the largest pool of people at risk for severe and fatal H1N1 infections."

The Necessary Health Sector Response
"The health sector cannot be blamed for lack of foresight. We have long known what is needed.
An effective public health response depends on strong health systems that are inclusive, offering universal coverage right down to the community level. It depends on adequate numbers of appropriately trained, motivated, and compensated staff.

It depends on fair access to affordable medical products and other interventions. All of these items are on your agenda. I urge you, in particular, to complete work under the item on public health, innovation and intellectual property. We are so very close."

Read the full speech: http://www.who.int/dg/speeches/2009/62nd_assembly_address_20090518/en/index.html

CDC Press Briefing

Spread of the virus continues in the US and more people continue to be hospitilized. Thus far 22 states have regional spread of H1N1 and there are cases in 48 states.

SCHOOL CLOSURES & PROTECTING CHILDREN FROM H1N1
Given the differences in spread and clustering of cases, responses need to be localized, particularly in the school setting. It's appropriate to close schools if a lot of children or staff are ill and there's too much disruption to function properly. However, school closures are not appropriate to stop the spread of illness.

Aside from closing schools for a very long period of time, there are no interventions that will stop the spread of the virus in school environments. Even if schools are closed long-term, children will still interact with other children/adolescents, and are still at risk of getting the illness. Further, they can shed the virus a full day before becoming ill. Once they are ill, parents need to keep children home for at least 7 days.

Chronic Conditions = Higher Risk of Complications
Seasonal flu rates are highest in children and adolescents, and this seems to be similar for H1N1. Children with chronic health problems, like asthma and diabetes, are at increased risk for developing complications. The largest number of H1N1 cases thus far have been in people between the ages 5-24 (no deaths reported in this age group at this time); CDC wouldn't be surprised for rates of hospitalization and death to increase for children with underlying medical conditions.

HOSPITILIZED CASES (MMWR):
CDC released an MMWR today reviewing 30 hospitlized cases. There is a wide range in severity in disease from these cases from short-term uncomplicated hospitilizations to long-term very complex cases. No one has died of these 30 cases, though some remain in the hospital.

About 2/3 of the patients in the series had underlying medical conditions:

• chronic lung disease
• conditions associated with immuno-suppression
• pregnancy
• obesity
• heart disease

Clinical symptoms:

• Seasonal flu symptoms
• All (but 1) had fever
• Vomitting was present in nearly all the cases

Treatment:

All hospitlized cases should be treated with antivirals, even if they come in more than 48 hours after onset of illness.

CDC: http://www.cdc.gov/h1n1flu/
MMWR: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0518a1.htm

Daily Update: ~10,000 cases worldwide

WHO: No new countries reported H1N1 cases since yesterday. Current tally: 40 countries, 9830 cases (79 deaths)

http://www.who.int/csr/don/2009_05_19/en/index.html

CDC: United States: 5469 cases(6 deaths) in 48 States

http://www.cdc.gov/h1n1flu/update.htm

As of 06:00 GMT, 18 May 2009, 40 countries have officially reported 8829 cases of influenza A(H1N1) infection, including 74 deaths. WHO is now reporting these cases in table format, so click here to see the affected countries. The only new country, as of this weekend, to join is Chile, which now has one case.

http://www.who.int/csr/don/2009_05_18/en/index.html

The United states is now reporting 5,123 cases and 5 deaths

http://www.cdc.gov/h1n1flu/update.htm

Japan shuts schools over H1N1 cases

Japan has shut 3,200 schools in response to dozens of students in Kobe and Osaka contracting the virus. So far, there aren't any reports that the illness is any more severe than what's been seen elswhere. Widespread community-level transmission in Japan would cause us to meet the current definition of Phase 6, so WHO will be watching this one closely.

http://www.abc.net.au/news/stories/2009/05/19/2574219.htm?section=justin

CDC removes travel warning for Mexico

CDC downgraded it's travel warning for Mexico, but still recommends that travelers at high risk for complications be cautious. It's important to remember that the in cases of severe illness caused by H1N1 (so far) have been in people with pre-existing health conditions (we think).

"CDC recommends that travelers at high risk for complications from any form of influenza discuss with their physicians the risks and benefits of travel in the context of their planned itinerary to Mexico, and may want to consider postponing travel. Travelers at high risk for complications include:

*Children less than 5 years old
*Persons aged 65 years or older
*Children and adolescents (less than 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection
*Pregnant women
*Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders
*Adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV)
*Residents of nursing homes and other chronic-care facilities"

http://wwwn.cdc.gov/travel/content/travel-health-precaution/novel-h1n1-flu-mexico.aspx

Nations urge WHO to revise the pandemic alert system

The World Health Assembly begins today and continues through this week. H1N1 is expected to dominate the discussion and the headlines coming out of the week long meeting.

Countries are urging WHO to revise the pandemic alert system. Currently, the system only takes into account how the virus is spreading, not the severity of illness it causes. Taking into account severity could help depoliticize the move to Phase 6, which might cause panic and undue concern.

It sounds like a good idea, and CDC even has it's own severity index for the United States. Unfortunately, it's not easy to quantify severity at a global scale:

"Severity and the broader impact on society is something that we really can't set globally, because of the unique conditions in every community," WHO spokesman Dick Thompson told The Associated Press. "Severity is going to be different in different countries. And within a country, it will be different in different populations."

http://hosted.ap.org/dynamic/stories/M/MED_SWINE_FLU?SITE=AP

FluView and Surveillance Data

On CDC's surveillance site, FluView, there is clear indication of a massive spike in flu cases, including seasonal flu as well as H1N1 (about a 50/50 breakdown). This is mostly an artifact of massive amounts of specimen testing. CDC tracks flu cases nationwide through two systems:

1. One system is completely dependent on lab-based specimen testing. The FluView graph (below) represents this system. The late spike in 'cases' shown in week 17 is due to massive amounts of testing for all ILI in any clinical setting. This activity is affected acutely by media coverage and H1N1 concerns among the population.
   
2. The second system uses an ILI network of 4500 providers nationwide providing information on how many people seek care at clinics for all causes and how many of those are presenting with ILI symptoms. This system is much less affected by public health messages or media coverage. Information on clusters of H1N1 in the SW and NW are based on this system. This information is also consistent with the number of school closures and other reports on H1N1 in those areas.

http://www.cdc.gov/flu/weekly/

CDC Press Briefing

Case Update: Geographic Clustering in SW and Pacific NW
The fourth death was reported today in Arizona; the individual reportedly had an underlying health/respiratory condition.

• Most H1N1 cases among people aged 5 to 25 years.
• Hospitalizations (~1.4% of cases) are among vulnerable persons with underlying medical conditions.
• Particular clustering of cases in the Pacific NW and in the SW; >10 states have continued transmission and increased influenza activity.
• The proximate cause of death in people that are dying 'from' H1N1 seems to be viral pneumonia, a direct infection of the lower respiratory tract caused by the flu virus. (Note: still very few tissue samples and specimens from fatalities and this may change)

Virus Mutations and A Second Wave?
CDC has not seen any mutations of the virus toward more virulence at this point. CDC urged the community to be prepared for the return of the seasonal flu season in the fall and to continue using appropriate hygiene. CDC and WHO are monitoring the southern hemisphere's seasonal flu season for:

• Severity (and changes in virulence) and spread of infection (clusters & contagiousness)
• Characterizing genetic markers of the H1N1 virus and looking for antiviral resistance or mutations
• Tracking number and location of people hospitilized for severe acute respiratory infection (SARI) & estimates of ILI prevalence (differences from normal flu seasons, etc.)

TRAVEL PRECAUTIONS DOWNGRADED
Downgrading travel precautions for Mexico: No longer asking people to delay travel to Mexico, but for those at-risk individuals (with underlying medical conditions, >65, pregnant women) to take additional precautions while traveling.

WHO & CDC Daily Update

7936 cases of influenza A(H1N1) infection (66 deaths) in 34 countries. All below are laboratory-confirmed A(H1N1) cases and deaths.

Mexico: 2446 (60 deaths).
United States: 4714 (4 deaths), 47 States.
Canada: 449 (1 death).
Costa Rica: 8 (1 death).

The following 30 countries have H1N1 cases with no deaths - Argentina (1), Australia (1), Austria (1), Belgium (1), Brazil (8), China (4), Colombia (10), Cuba (3), Denmark (1), El Salvador (4), Finland (2), France (14), Germany (12), Guatemala (3), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (40), Poland (1), Portugal (1), Republic of Korea (3), Spain (100), Sweden (2), Switzerland (1), Thailand (2), and the United Kingdom (71).

WHO Map: http://www.who.int/csr/don/GlobalSubnationalMaster_20090515_0800.jpg
WHO H1N1 Site: http://www.who.int/csr/disease/swineflu/en/index.html
CDC: http://www.cdc.gov/h1n1flu/
CDC Map: http://www.cdc.gov/h1n1flu/update.htm

Not to be Outdone: NEJM's H1N1 Resource Center

Similar to the Lancet, the New England Journal of Medicine has recently greenlighted a website pulling together and making available free articles, editorials, and scientific perspectives from NEJM authors - including recent and archived published material.

Similar to the Lancet site, this site offers background materials on influenza and scholarly articles on pandemic preparedness. Unlike the Lancet site, however, the NEJM site offers advice for practitioners and news and surveillance data updates.

Both sites are worthwhile and offer great resources and information for those involved in program and research.

Check out NEJM's site: http://h1n1.nejm.org/

FREE: Lancet Resource Library for H1N1 and Pandemic Influenza

Lancet has made available a wealth of resources on all things flu (from H1N1 and H5N1 to general pandemic preparedness and response).

Their H1N1 Resource Center has brought together not only articles from The Lancet, but also other well-known journals, such as Trends in Microbiology, American Journal of Medicine, Health Policy, Public Health and many others.

The materials are broken down by subject matter, from Diagnosis and treatment to epidemiology, pathogensis, and pandemic preparedness. The materials do not only cover the current H1N1 situation, but past research and debate on H5N1 and emergency/pandemic preparedness in general.

The resource library also features links, podcasts, webcasts, and audio from scientists and researchers on the current situation.

Great resource, check it out: http://www.thelancet.com/H1N1-flu

CDC& WHO Daily Update

Combining CDC & WHO case reports as of 14 May, 33 countries have officially reported 7443 cases (65 deaths) of influenza H1N1

Mexico: 2446 (60 deaths)
The United States: 4,298 cases (3 deaths), 47 States (including DC)
Canada: 389 (1 death)
Costa Rica: 8 (1 death)

The following countries have reported laboratory confirmed cases with no deaths - Argentina (1), Australia (1), Austria (1), Brazil (8), China (4, comprising 2 in China, Hong Kong Special Administrative Region, and 2 in mainland China), Colombia (7), Cuba (1), Denmark (1), El Salvador (4), Finland (2), France (14), Germany (12), Guatemala (3), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (29), Poland (1), Portugal (1), Republic of Korea (3), Spain (100), Sweden (2), Switzerland (1), Thailand (2), and the United Kingdom (71).

http://www.who.int/csr/don/2009_05_14/en/index.html
http://www.cdc.gov/h1n1flu/

H1N1 in Thailand: Concerns for Mixing of H5N1 & H1N1?

The US CDC confirmed two cases of H1N1 after testing two specimens in the US lab sent from Thailand yesterday. These are the first cases in Southeast Asia. (In the Asian region, there was one case in Hong Kong, and 3 in the Republic of Korea). There are suspected cases (awaiting lab-confirmation) of H1N1 in Indonesia as well.

"There were two confirmed cases of type A (H1N1), both of them contracted in Mexico," the Thai Public Health Minister said. "These persons are now well, not sick, without fever. They are now in a normal condition after undergoing a five-day antiviral regimen. The patients have fully recovered and returned home."

As CDC and WHO officials said this week, there is concern that with H1N1 circulating alongside seasonal flu strains and H5N1 (avian influenza) there is a greater risk that the H1N1 (or other viruses) will combine, reassort, and mutate into a different virus strain.

It's certainly too early to tell whether this will happen or not, but world health officials are urging vigilance. Dr. Schuchat, during a CDC press briefing over the weekend, noted that surveillance at the animal-human interface and in regions where multiple influenza type-A viruses are circulating will provide timely information about any reassortment or genetic shifts in the viruses.

Thailand has already alerted its vast village health volunteer network, which has been used for surveillance for H5N1 (avian influenza), to be on the lookout for severe influenza-like illness and inform the health ministry of any suspected cases.

http://www.nationmultimedia.com/2009/05/13/national/national_30102538.php
http://birdflucorner.wordpress.com/2009/05/13/bandung-west-java-more-on-h1n1-suspected-patient/

Daily CDC+WHO Case Count Update

Also, follow the case count via PAHO's interactive map, noting all cases by state/province in the Americas (note ~24 hour lag in updates): http://ais.paho.org/flu/sm/en/atlas.html

*******
WHO reports: 33 countries have officially reported 5728 lab-confirmed cases of H1N1 (61 deaths). The WHO tally does not include additional lab-confirmed cases released by the CDC this morning, which would bring the overall toll to 6071 (case counts below reflect CDC updates).

Mexico: 2059 of infection(56 deaths).
United States: 3352 cases (3 deaths), 45 states (including DC).
Canada: 358 cases (1 death).
Costa Rica: 8 cases, (1 death).

Countries with confirmed cases (no deaths):
Argentina (1), Australia (1), Austria (1), Brazil (8), China (3, comprising 1 in China, Hong Kong Special Administrative Region, and 2 in mainland China), Colombia (6), Cuba (1), Denmark (1), El Salvador (4), Finland (2), France (13), Germany (12), Guatemala (3), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (29), Poland (1), Portugal (1), Republic of Korea (3), Spain (98), Sweden (2), Switzerland (1), Thailand (2), and the United Kingdom (68).

http://www.who.int/csr/don/2009_05_13/en/index.html
http://www.cdc.gov/h1n1flu/

CDC Updates US Case Count: 3009

CDC released updated numbers today, raising the total H1N1 case count to 3009 (3 deaths) in 45 states, including the District of Columbia (DC).

Two deaths were confirmed in Texas over the past few weeks. A third was recently confirmed in Washington, DC.

http://www.cdc.gov/h1n1flu/
map: http://www.cdc.gov/h1n1flu/update.htm

WHO &CDC: Influenza Training Materials Online!

In 2006 the WHO Global Influenza Programme started a clearing house of Influenza Training materials. This material has been recently updated and new material has been added, including training material from CDC.

"The Influenza Training Digital Library" is now accessible through www.influenzatraining.org

Topics range from animal issues, case investigation, communications, ethical considerations, infection control, public health measures to mitigate the effect of a pandemic to pandemic exercises.

This is a great resource from which to find general information about these topics (e.g. case studies, guidance, background information), in addition to training modules and example plans, forms, and training materials.

The public health measures and pandemic preparedness sections are particularly noteworthy.

http://www.influenzatraining.org/

CDC: Interim Guidance for Public Gatherings (H1N1)

Decisions should be made based on local influenza activity, evolving information about severity of illness from this virus, and identification of high risk groups, and other local considerations.

CDC generally recommends that:

1. Persons with influenza-like illness (ILI) (i.e. fever with cough or sore throat) should stay home for 7 days after illness onset or 24 hours after symptoms cease, whichever is longer. See additional guidance for persons with ILI.
   
2. Persons at high risk of complications H1N1 (e.g. persons with chronic medical conditions, children <5,>65, and pregnant women) should consider avoiding public gatherings in communities with reported cases of H1N1.
   
3. All persons should use appropriate respiratory and hand hygiene precautions.
   
4. Large public gatherings offer an opportunity for public health officials and event organizers to deliver key educational messages about measures attendees can take to help reduce the spread of H1N1 (e.g. the need to remain home if ill, use good hygiene practices while at the event).

Additional Measures

1. Make widely available at the event hand washing facilities with soap and running water, hand sanitizer, and tissues.
   
2. Provide on-site medical assessment and care for persons with ILI.
   
3. Provide alternative options and venues for participation (e.g., remote Web-based viewing sites) and reduce crowding.

http://www.cdc.gov/h1n1flu/guidance/public_gatherings.htm

WHO: Developing a Pandemic Severity Scale to Use with Alert Phases

WHO is developing a revised pandemic severity scale to accompany the pandemic alert phases for the current H1N1 virus (which is not considered a pandemic yet). There are many different considerations for determining the severity of a pandemic. WHO's initial comments on these considerations are noted below:

A. Properties of Virus Spread and Severity:

• The virus is new or hasn't circulated among humans in recent memory - meaning the population has little or no immunity to the illness
• Contagiousness of the virus will determine how many fall ill and how quickly it spreads
• Large numbers of people will fall ill (see above), causing economic and social disruption even if the virus isn't severe
• The virulence of the virus will determine the severity of symptoms and the proportion of people who are hospitalized or die from the virus
• The population most at risk (very young and very old, similar to seasonal flu, or young, healthy adults) [it's concerning when young, healty adults become ill and not only the most vulnerable young and old]

All these properties combine in different ways to determine the ultimate severity of a pandemic caused by some new virus.

B. Pandemic "Waves"
Past pandemics have often started at the end of a seasonal flu season, taper off during the warm summer months, and re-emerge at the beginning of the next seasonal flu season, sweeping the globe in two or three waves. Wave severity differs, sometimes dramatically, because the influenza virus mutates and shifts between waves, meaning that the characteristics of the virus can also change. While one wave may be mild, subsequent waves may be much more virulent and less contagious (or any combination thereof).

C. Response Capacity
"The same virus that causes only mild symptoms in countries with strong health systems can be devastating in other countries where health systems are weak" (e.g. lack of medicine, human resources, equipment).

Current Situation Assessment
A. Characteristics of H1N1

• H1N1 is an entirely new virus
• The virus apperas to very contagious - at twice the attack rate of seasonal influenza, 15 - 33% of those people that come in contact with someone ill with H1N1 will contract the virus
• The virus appears to be very mild (similar to seasonal flu) EXCEPT in Mexico (the difference in virulence is not understood at this time)
• While the ill range in age from newborn to elderly, many have been young, healthy adults

B. Possibility of Mutations & Genetic Shifts:
"In these early days of the outbreaks, some scientists speculate that the full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread ... Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses as the normal influenza season in that hemisphere begins."

C. Response Capacity
The world is better prepared now than ever before to deal with a pandemic - see previous blog posts about WHO statement to this effect.

http://www.who.int/csr/disease/swineflu/assess/disease_swineflu_assess_20090511/en/index.html

Daily Updates: WHO & CDC

30 countries have officially reported 5251 cases of influenza A(H1N1) infection and 61 deaths. All case counts below have been laboratory-confirmed.

Mexico: 2059 cases, including 56 deaths.
United States: 2600 cases, including 3 deaths.
Canada: 330 cases, including 1 death.
Costa Rica: 8 cases, including one death.

Countries w/ cases and no deaths: Argentina (1), Australia (1), Austria (1), Brazil (8), China (2, comprising 1 in China, Hong Kong Special Administrative Region, and 1 in mainland China), Colombia (3), Denmark (1), El Salvador (4), France (13), Germany (12), Guatemala (1), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (16), Poland (1), Portugal (1), Republic of Korea (3), Spain (95), Sweden (2), Switzerland (1) and the United Kingdom (55).

Travel:
WHO is not recommending travel restrictions related to the outbreak of the influenza A(H1N1) virus. Individuals who are ill should delay travel plans and returning travelers who fall ill should seek appropriate medical care. These recommendations are prudent measures which can limit the spread of many communicable diseases, including influenza.

http://www.cdc.gov/h1n1flu/
http://www.who.int/csr/don/2009_05_12/en/index.html

Daily Updates from WHO and CDC

WHO is reporting 4694 cases today:

"11 May 2009 -- As of 06:00 GMT, 11 May 2009, 30 countries have officially reported 4694 cases of influenza A(H1N1) infection.

Mexico has reported 1626 laboratory confirmed human cases of infection, including 48 deaths. The United States has reported 2532 laboratory confirmed human cases, including three deaths. Canada has reported 284 laboratory confirmed human cases, including one death. Costa Rica has reported eight laboratory confirmed human cases, including one death.

The following countries have reported laboratory confirmed cases with no deaths - Argentina (1), Australia (1), Austria (1), Brazil (8), China (2, comprising 1 in China, Hong Kong Special Administrative Region, and 1 in mainland China), Colombia (3), Denmark (1), El Salvador (4), France (13), Germany (11), Guatemala (1), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (15), Poland (1), Portugal (1), Republic of Korea (3), Spain (95), Sweden (2), Switzerland (1) and the United Kingdom (47). "

http://www.who.int/csr/don/2009_05_11/en/index.html

CDC reported a slighlty higher number today than the one WHO reported for the US - 2600 cases and 3 deaths

http://cdc.gov/h1n1flu/?s_cid=tw_epr_130

World is Better Prepared for an Influenza Pandemic

In an address during the ASEAN+3 Health Ministers’ Special Meeting on Influenza A(H1N1) in Bangkok on 8 May, WHO Director-General Dr. Margaret Chan applauded health ministers for their diligence over the past five years in tracking, reporting, and treating the H5N1 influenza virus in humans and animals. Dr. Chan went on to mention that H5N1 “taught the world to expect a pandemic, and to plan for this event,” and because of those efforts, "[t]he world is better prepared for an influenza pandemic than at any time in history….” Due to pandemic preparedness initiatives, over the past five years, nations across the world have worked to develop preparedness plans and cultivate vaccine manufacturing capacity.

Dr. Chan did urge health ministers to use science to inform public health action in dealing with the current influenza A(H1N1) virus:

“Countries will, quite rightly, want to do everything possible to prevent the arrival of the [H1N1] virus or, once in a country, to delay its further spread and thus flatten the epidemiological peak. At the same time, it is important for countries to refrain from introducing economically and socially disruptive measures that lack solid scientific backing and bring no clear public health benefit.”

After making these statements, Dr. Chan made two additional requests for responding to influenza A(H1N1):
1. Do not drop the ball on monitoring H5N1. This virus is endemic in poultry in parts of the region. We have no idea how H5N1 will behave under the pressure of a pandemic.
2. Battle misperceptions with the facts, and respond to the disease with facts.

Read the transcript of the address at: http://www.who.int/dg/speeches/2009/asean_influenza_ah1n1_20090508/en/index.html

WHO Update: Influenza A(H1N1)

10 May 2009 -- As of 07:30 GMT, 10 May 2009, 29 countries have officially reported 4379 cases of influenza A(H1N1) infection.
Mexico has reported 1626 laboratory confirmed human cases of infection, including 45 deaths. The United States has reported 2254 laboratory confirmed human cases, including two deaths. Canada has reported 280 laboratory confirmed human cases, including one death. Costa Rica has reported eight laboratory confirmed human cases, including one death.

The following countries have reported laboratory confirmed cases with no deaths - Argentina (1), Australia (1), Austria (1), Brazil (6), China, Hong Kong Special Administrative Region (1), Colombia (1), Denmark (1), El Salvador (2), France (12), Germany (11), Guatemala (1), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Panama (3), Poland (1), Portugal (1), Republic of Korea (3), Spain (93), Sweden (1), Switzerland (1) and the United Kingdom (39).
WHO is not recommending travel restrictions related to the outbreak of the influenza A(H1N1) virus.

Individuals who are ill should delay travel plans and returning travelers who fall ill should seek appropriate medical care. These recommendations are prudent measures which can limit the spread of many communicable diseases, including influenza.
Further information on the situation will be available on the WHO web site on a regular basis.

http://www.who.int/en/

CDC Weekend Briefing

Dr. Anne Schuchat: "We expected more cases, and we continue to find them." Despite reports about a decline in cases, the US is still seeing an increase in cases and it does not seem as though the US has hit its peak.

Cases Confirmed: 2254 cases
Hospitalized: 154 (many have underlying conditions)
Deaths: 2 (Texas)

Extended Q&A:
Is this an Epidemic?
A: CDC compares seasonal flu and hospitalizations to surveillance data to determine if there are enough cases to consider it an epidemic of seasonal flu. The ILI diagnoses are going above the threshold we would normally see at this time of the season, but it is still not above the "epidemic threshold". In particular, there has not been an increase in mortality data.

Antiviral Therapy & CDC Guidance:
Antiviral therapy needs to be reserved for those with the most severe illness or underlying medical conditions. Most people have a self-limited infection, spending a few days at home and self-treating is sufficient. Antivirals should be used for treatment (of specific cases) not prevention, as resistance to the antivirals is a concern given the fact that seasonal influenza rapidly developed resistance to these antivirals. Though CDC is not yet seeing H1N1 resistance to antivirals.

Virulence
Virulence markers characterized in the 1918 strain, the 1957 strain, and the H5N1 (bird flu) strains which cause concern about severity of illness and high mortality have not yet been found in the H1N1 strain. "But remember the first strain in 1918 was fairly mild, and it was the second and third waves that were so devastating," Dr. Schuchat.

Circulating Strains of Influenza and Risk of Virus Reassortment
**There are continued seasonal influenza cases which do account for many of the people seeking treatment for ILI. Having both strains circulating at the same time does increase the risk of reassortment and mutation of the H1N1 strain.

"One of the biggest problems with influenza is it's ability to reassort and recombine. So because of that, it is problematic that we're seeing circulation of seasonal flu, H1N1, and, in some countries, H5N1 (avian influenza) at the same time" ... That is why it is so important for countries to have "strong capacities to deal with influenza and have systems in place to look at what happens at the interface between people and animals", Dr. Schuchat**

****
CDC is encouraging trackers of seasonal and H1N1 flu to begin referring to the seasonal flu surveillance database: http://www.cdc.gov/flu/weekly/fluactivity.htm
****

Update: H1N1 Cases Worldwide

WHO reports that 29 countries have officially reported 3440 cases of influenza A(H1N1) infection (with 48 deaths). This total does not reflect an additional 615 cases confirmed by CDC today as well, which brings the total to 4055.

Mexico has reported 1364 laboratory confirmed human cases of infection, including 45 deaths. The United States has reported 2254 laboratory confirmed human cases in 44 states, including two deaths. Canada has reported 242 laboratory confirmed human cases, including one death.

The following countries have reported laboratory confirmed cases with no deaths - Argentina (1), Australia (1), Austria (1), Brazil (6), China, Hong Kong Special Administrative Region (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (12), Germany (11), Guatemala (1), Ireland (1), Israel (7), Italy (6), Japan (3), Netherlands (3), New Zealand (5), Panama (2), Poland (1), Portugal (1), Republic of Korea (3), Spain (88), Sweden (1), Switzerland (1) and the United Kingdom (34).


http://www.cdc.gov/h1n1flu/
http://www.who.int/csr/don/2009_05_09/en/index.html
http://www.who.int/csr/don/GlobalSubnationalMaster_20090509_0805.jpg

Harvard Polling Data on H1N1 Awareness Among Americans

Harvard School of Public Health Polling Data

Dr. Robert Blendon of Harvard School of Public Health joined the CDC briefing today to speak about Harvard's on the spot polling about people's perceptions of public health messages on H1N1 and what issues need to be clarified.

• 67% of Americans are washing their hands or using sanitizers more often
• 77% of people are continuing to follow the news on H1N1
• While 61% are not concerned that they or a family member will get sick from H1N1 in the next year
• People with children in school are substantially more concerned than those without. Half the parents didn't know what schools are doing to protect kids from H1N1.
• School officials need to clarify their plans and explicitly address parents' concerns.
• 83% are satisfied with district, local, and federal public health actions.
• 88% satisfied with information they are receiving regarding H1N1.
  

CDC's Dr. Besser and Dr. Blendon agreed this indicates that public health officials have communicated the risks appropriately; people are concerned and watchful but not fearful of H1N1. They are also taking general hygiene precautions (increased handwashing). Both noted that this may help reduce spread of other respiratory infections through better cough/sneeze etiquette and handwashing behaviors.

Also interesting is that individuals with family members in higher risk groups (young children in school) understand the heightened risk and are appropriately seeking information from school officials.

http://www.hsph.harvard.edu/

CDC Daily Briefing

Case count: 2500 probable and confirmed cases in 43 states; 1639 confirmed cases:

• 3.5% of cases (57) have been hospitalized (up form 13 reported yesterday)
• Detailed info on 26 hospitalized cases: 58% had underlying conditions: most had asthma.
• Respiratory infections can be a trigger for asthma attacks, so asthma sufferers should be in touch with health professionals if they believe htey have any flu or respiratory infection
• Transmission continues around the country. Most people experience symptoms and severity similar to seasonal flu. Illness lasts less than a week. Unlike seasonal flu, a higher percentage seem to have vomiting and diarrhea.
• In addition, younger adults represent a larger proportion of cases than we see with seasonal flu (which usually affects very young and old individuals). It's still unclear why this is the case - either greater contact through travel of younger individuals, elder immunity, or something else.

While transmission continues, the virus is expected to dissipate in the coming weeks. However, CDC expects a possible second wave in the fall.

What's being done to prepare for a potential second wave:
CDC:

• monitoring H1N1 as it circulates in the southern hemisphere during their seasonal flu season (monitoring for resistance to medications or mutations into a severe/milder form)
• monitoring antigenic/genetic shifts
• planning for containment and treatment protocols and guidance

Individuals:

• make sure you have a communication plan for your faimliy
• know what you will do if school/work is closed for an extended period of time
• know what to do/how to handle social services disruption for a few weeks

See: http://www.panflu.gov/ for preparedness checklists for families, individuals, schools, and others.

No WHO Pandemic Alert Change:
Because we still have not seen sustained community level transmission outside of the US and Mexico, WHO will remain at a Phase 5 Pandemic Alert for now.

********
CDC will no longer be doing formal press briefings; as of tomorrow they will be doing telebriefings.

Update: H1N1 Cases

WHO's reported today that 24 countries have officially reported 2384 cases of influenza A (H1N1) infection. The WHO tally did not include CDC's updated case count (+743 CDC newly confirmed cases).

CDC today confirmed 1639 confirmed cases (2 deaths) in 43 US States [up from 896 yesterday] (picture below). Mexico has reported 1112 laboratory confirmed cases (42 deaths).

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (214), China, Hong Kong Special Administrative Region (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (5), Germany (10), Guatemala (1), Ireland (1), Israel (6), Italy (5), Netherlands (2), New Zealand (5), Poland (1), Portugal (1), Republic of Korea (3), Spain (81), Sweden (1), Switzerland (1) and the United Kingdom (32).

WHO's map of global cases:
http://www.who.int/csr/don/h1n1map_20090508_8AM.jpg

CDC's map of US cases by state:
http://www.cdc.gov/h1n1flu/update.htm

Avian influenza cases continue during H1N1/swine flu

Just so we don't forget - avian influenza has not gone away and still remains a threat. Two cases were reported this week, an Egyptian woman who is currently in stable condition and a Vietnamsese woman who passed away

http://www.who.int/csr/don/2009_05_06b/en/index.html

http://www.who.int/csr/don/2009_05_06c/en/index.html

What's different about H1N1 so far?

An article in the MMWR yesterday (www.cdc.gov/mmwr) made note of two unusual characteristics of the current H1N1 outbreaks -

"Several characteristics of this outbreak appear unusual compared with a typical influenza seasonal outbreak. First, the percentage of patients requiring hospitalization appears to be higher than would be expected during a typical influenza season. Second, the age distribution of hospitalizations for novel influenza A (H1N1) virus infection is different than that of hospitalizations for seasonal influenza, which typically occur among children aged <2>65 years, and persons with chronic health conditions. In Mexico and the United States, the percentage of patients requiring hospitalization has been particularly high among persons aged 30–44 years. "

Why do these characteristics matter? Even if the virus continues to cause mostly mild illness, a higher hospitalization rate could make a big impact on health facilities everywhere if this virus continued to spread globally as pandemic influenza and we entered phase 6.

CDC Daily Briefing

During today’s CDC daily press briefing, Acting CDC Director Dr. Richard Besser presented new USA-specific probable and confirmed case counts of novel influenza A(H1N1). Although this is a dynamic situation and case counts are constantly changing with on-going confirmation at state public health laboratories, as of 11 am EDT, there were 896 confirmed cases in 41 states and 925 probable cases across the nation; a total of 2 deaths have been reported.

Dr. Besser stressed that the CDC is working to learn more about various aspects of the virus. A series of studies is being conducted to explore the following topics:
- Viral shedding in respiratory secretions and stool among various age groups of infected persons
- The impact of antiviral medications on viral shedding
- Household transmission of the virus
- Healthcare setting transmission of the virus
- Background levels of influenza-like-illness in communities
The results of these studies will be used to inform future CDC guidance and recommendations.

Dr. Besser also announced the release of three publications today:

The New England Journal of Medicine published two articles related to novel influenza A(H1N1); the first article describes the first 241 US cases, and the second article discusses 10 cases of swine-associated H1N1 infection. I did not see either of these articles in the electronic version of the Journal today, but I have put a request into CDC to obtain these articles.

CDC’s Morbidity and Mortality Weekly Report (MMWR) published an article that presents the global picture of the current influenza A(H1N1) situation. View the article here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5817a1.htm

CDC has developed a PCR diagnostic test kit to detect novel influenza A(H1N1) virus; 131 countries have requested test kits, and CDC has shipped kits to 78 countries so far. The provision of these test kits will increase testing capacity, and there likely will be an increase in the number of reported confirmed cases we see worldwide as a result.

CDC has yet to post the transcript of today’s press briefing; but when they do so, you can view the transcript and listen to the audio at: http://www.cdc.gov/h1n1flu/press/ .

Why are we still in Phase 5? Why so much attention?

Here's some notes that we gleaned from the latest WHO conference call that can help answer some common questions people have at this stage

Why are we still in Phase 5?

We are still seeing human-to-human, community-level transmission in North America only, not anywhere else. We would need to see community-level transmission (which means it's spreading easily within the community) rather than sporadic cases from people returning from travel. Since we haven't seen that, we are still in phase 5.

Why are we paying so much attention to this virus, especially when so many cases are mild?

From the beginning of this situation a few weeks ago, WHO has said the situation was evolving and didn’t know where it was going to go. Virus has gone to a number of countries, and is established in just 2. We still don’t know why or have a full picture of the situation. Two critical questions remaining are:

• Most of the activity is in the northern hemisphere. Will it spread in the Southern hemispehere? What will happen when it does?
• Will the virus change, and become more dangerous later this year or in the next few years?

If we move into a pandemic, we will see a large number of people to be infected worldwide, maybe up to 1/3 of the world’s population. When you look at a world of 6 billion people, that’s a lot of people to be infected. Even if not a big deal on the individual level, we’re talking about big numbers, so there could be a lot of people with pneumonia and complications.

When the southern hemisphere goes to winter, that’s when we see more influenza virus. The population in the southern hemisphere is different – younger populations in developing countries, often more vulnerable (because malnourished, war, HIV…). Have seen that when seasonal influenza hits, what is mild in the developed could be quite severe in developing world.

Pandemics don’t occur in a couple of days – this could happen over a 2-year period. WHO sees that this is the time to work with countries so that there are more prepared for the increase in people getting sick.

Thanks to colleagues from American Red Cross for notes on WHO briefings!

Map of confirmed cases from WHO

WHO update - 2099 cases in 23 countries

Today's official update from WHO

"7 May 2009 -- As of 06:00 GMT, 7 May 2009, 23 countries have officially reported 2099 cases of influenza A(H1N1) infection.

Mexico has reported 1112 laboratory confirmed human cases of infection, including 42 deaths. The United States has reported 642 laboratory confirmed human cases, including two deaths.

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (201), China, Hong Kong Special Administrative Region (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (5), Germany (9), Guatemala (1), Ireland (1), Israel (4), Italy (5), Netherlands (1), New Zealand (5), Portugal (1), Republic of Korea (2), Spain (73), Sweden (1), Switzerland (1) and the United Kingdom (28)."

http://www.who.int/csr/don/2009_05_07/en/index.html

CDC Daily Briefing

Dr. Richard Besser, Acting Director, CDC: "As of 11 a.m. today, we are reporting 1487 probable and confirmed cases in 44 states ... In terms of the age range the median age for cases is 16 years with a range of 3 months to 81 years."

Of these cases, there have been 2 deaths, and 35 confirmed hospitalizations and 17 probable hospitalizations. Besser also noted that, of those hospitalized, "seven of them had known conditions that would put them at risk for more severe infection".

"We are continuing to see virus spread in the United States and around the globe. The majority of the confirmed cases in this country are in younger people. And it's important that people have respect for this virus, because it does cause severe disease, hospitalization and death ... Everything we've seen to date leaves us with the understanding that we need to remain vigilant."

He noted that it is unclear what kind of underlying conditions put people at greater risk (they are gathering additional information on this now) and why younger people have been most affected thus far - whether this is a result of the virus OR if it is due to the fact that many of the initial US case were on spring break in Mexico (younger people are by default more likely to travel).

Risk to Health Care Workers?
"We are working with Texas and California (to assist the) investigation team there to look in particular at the issue of health care worker transmission. We want to see what are the dynamics of transmission, are there certain practices putting people at risk and if so, what can be done to tailor the guidance that we currently are providing in that area."

Increased Risk for Pregnant Women:
"I want to put a little focus today on the issue of pregnancy and disease risk. So far, we are aware of six confirmed and five probable cases of H1N1 infection involving pregnant women. However, pregnancy is a risk factor, a known risk factor for known disease."

See Guidance for Clinicians and Pregnant Women on the CDC Website:
Pregnant Women Educators: http://www.cdc.gov/h1n1flu/guidance/pregnant-hcw-educators.htm
Pregnant Women Info: http://www.cdc.gov/h1n1flu/guidance/pregnant.htm
Info for Clinicians: http://www.cdc.gov/h1n1flu/clinician_pregnant.htm

Q&A:
Q: The officials at WHO announced today they would be convening experts to consider wholesale production of a new implemented [H1N1] virus [vaccine] as well as halting production of seasonal flu vaccine.

A (Dr. Besser): "That's the body that helps inform them whether it's time to move phases of a pandemic. And that's body that will help inform them as well in terms of the global position on vaccination. And the U.S. government has participation on that committee ... Here in the United States, we are pushing forward with production of seasonal flu vaccine and that's moving forward very aggressively."

Further, US health officials will determine later whether to move from seasonal to H1N1 vaccine production, but are first trying to "clear the decks" of seasonal flu vaccine that needs to be manufactured before possibly moving to H1N1, given the fact that 36,000 US citizens die each year from seasonal flu and we already know that vaccine will definitely be needed.

CDC Briefing Transcript: http://www.cdc.gov/media/transcripts/2009/t090506.htm

Update: H1N1 Cases Worldwide

As of 6 May 2009, 22 countries have officially reported 1755 cases* of influenza A (H1N1) infection and 31 deaths.

Mexico has reported 822 laboratory confirmed human cases of infection, including 29 deaths. The United States has reported 642 laboratory confirmed human cases, including two deaths.

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (165), China, Hong Kong Special Administrative Region (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (4), Germany (9), Guatemala (1), Ireland (1), Israel (4), Italy (5), Netherlands (1), New Zealand (6), Portugal (1), Republic of Korea (2), Spain (57), Switzerland (1) and the United Kingdom (27).

WHO: http://www.who.int/csr/don/2009_05_06/en/index.html
CDC: http://www.cdc.gov/h1n1flu/

The United States: 642 Confirmed Cases in 41 States (2 deaths). CDC notes an additional 845 probable cases have been reported from 42 states nationwide. This is a total of 1,487 confirmed and probable cases in 44 states in the United States.

Note from CDC:
CDC-developed PCR diagnostic test kits to detect this virus have been distributed to all states in the U.S. and Puerto Rico. This increase in testing capacity in the United States likely will result in a rapid jump in the number of confirmed cases in this country once states start doing their own testing. This will be an artifact of testing, but will actually present a more accurate picture of the true scope of novel H1N1 disease in the United States.

US: 642 Cases (2 deaths) in 41 States (new states: Hawaii, Oklahoma, Washington)

Alabama: 4; Arizona: 48; California: 67; Colorado: 17; Connecticut: 4; Delaware: 33; Florida: 5; Georgia: 3; Hawaii: 3; Idaho: 1; Illinois: 122; Indiana: 15; Iowa: 1; Kansas: 2; Kentucky: 2; Louisiana: 7; Maine: 1; Maryland: 4; Massachusetts: 45; Michigan: 8; Minnesota: 1; Missouri: 2; Nebraska: 4; Nevada: 5; New Hampshire: 2; New Jersey: 7; New Mexico: 3; New York: 97; North Carolina: 7; Ohio: 5; Oklahoma: 1; Oregon: 15; Pennsylvania: 1; Rhode Island: 2; South Carolina: 16; Tennessee: 2 Texas: 61 (2 deaths); Utah: 1; Virginia: 3; Washington: 9; Wisconsin: 6

*Case numbers compiled from WHO and CDC daily reports

CDC Daily Briefing

Secretary Sebelius was at CDC today and presided over the daily briefing. CDC Acting Director Dr. Besser updated the case count (previous posting) and noted that the Mexican cases are beginning to plateau, but that a second wave should be expected in the fall. The rest of the briefing focused on easing public health guidance, discussions about what's to come, and specifically addressing school closure guidance changes and the work on a flu vaccine.

Secretary Sebelius noted that now there are "more than 400 confirmed, more than 700 probable (cases) in 44 states." She emphasized that we should expect the virus to continue to spread, and for possible deaths from the H1N1 virus.

Good news is that the "virus doesnt apear as severe as we thought during the initial studies based on the mexican outbreak." However, she also noted that the virus is very easily transmitted. Very much like seasonal flu, the virus is transmitted easily (especially between children) and causes mostly mild/moderate illness. "36,000 people die (in the US) a year from seasonal flu, so we are likely to see deaths with this virus," the Secretary said.

"We are now recommending that schools cease closing when they have suspected cases - it makes it even more imporatnt that parents and teachers pay attention to sickness if it breaks out. Parents: if your child is sick, do not send your child to school because your child will transmit the virus to other children."

Vaccine Manufacturing Decisions: (No H1N1 vaccine to be manufactured yet)

CDC is not, at this time, pushing for the development of an H1N1 vaccine, instead they are accelerating production of seasonal flu vaccine to "clear the decks" so that if the decision is made to manufacture an H1N1 vaccine, the manufacturing capacity is freed up to turn to H1N1. The virus is expected to mutate over the next few months, and a second wave is expected in the fall when the seasonal flu season starts again. To better be able to manufacture an appropriate vaccine, a seed strain would need to mirror the circulating strain as closely as possible.

Importantly, the southern hemisphere is about to enter its flu season. The CDC and WHO will be watching to see how H1N1 affects their seasonal flu season and will inform decisions for public health preparedness, vaccine manufacturing, and other public health guidances.

CDC: http://www.cdc.gov/h1n1flu/index.htm

CDC: H1N1 Cases in the US

US: 403 Cases, 1 Death in 38 States

Alabama: 4
Arizona: 17
California: 49
Colorado: 6
Connecticut: 2
Delaware: 20
Florida: 5
Georgia: 1
Idaho: 1
Illinois: 82
Indiana: 3
Iowa: 1
Kansas: 2
Kentucky: 1
Louisiana: 7
Maine: 1
Maryland: 4
Massachusetts: 6
Michigan: 2
Minnesota: 1
Missouri: 1
Nebraska: 1
Nevada: 1
New Hampshire: 1
New Jersey: 6
New Mexico: 1
New York: 90
North Carolina: 1
Ohio: 3
Oregon: 15
Pennsylvania: 1
Rhode Island: 1
South Carolina: 16
Tennessee: 2
Texas: 41 (1 death)
Utah: 1
Virginia: 3
Wisconsin: 3

CDC: http://www.cdc.gov/h1n1flu/index.htm

Do you twitter?

Twitter has gotten a bad reputation in the past few days from other media when it comes to H1n1/swine flu, but I've found it extremely helpful for staying informed. It all depends on who you "follow". If you are on twitter, I suggest following these organizations for updates on influenza:



BirdFluGov ;healthmap ;CDCemergency ;CDCFlu; whonews ;Veratect; pahowho; eqpaho; sanjayguptaCNN; AIDigest



What about you? Do you twitter? Who are you following?

CDC Eases Guidance for School Closures

"Closing schools once a student falls ill with swine flu may no longer be worth the toll on students and families, because the illness will soon be present almost everywhere in the country and few cases have been severe, federal health authorities said Monday.

“Closing schools is not effective” in halting the spread of the virus, said Dr. Richard E. Besser, acting director of the Centers for Disease Control and Prevention.

The new advice is part of a gradual easing of concerns over swine flu. While the disease continues to spread around the world, it is far less deadly than initially feared. And in Mexico, where the outbreak apparently had its origins, new cases have begun to ebb.

The closings were intended not only to protect students but also to slow the spread of the virus, because schools can serve as viral transport hubs. But on Monday, the disease centers reported 279 confirmed cases of swine flu in 36 states — up from 226 in 30 states on Sunday — and more than 700 probable cases in 44 states.

With the virus almost everywhere, school closings will no longer have much effect. Only 35 people have been hospitalized with the virus."

********
In New York, A school reopens after 10 days closed:

Mayor Michael Bloomberg attended the reopening at Saint Francis, a Catholic Church-run school in the Queens neighborhood that saw the biggest single outbreak of the virus outside of Mexico.
"It is good to see you. Things are back to normal. Let's go back to work," said the headmaster.

The city believes as many as 1,000 people in New York have been infected, the bulk at Saint Francis, but that more testing is unnecessary.

City Health Commissioner Thomas Frieden said that it was too early to let down the guard, particularly since a second A(H1N1) wave is expected to strike in autumn, along with the usual seasonal flu.

Updated CDC Guidance: http://www.cdc.gov/h1n1flu/K12_dismissal.htm

• School closure is not advised for a suspected or confirmed case of novel influenza A (H1N1) and, in general, is not advised unless there is a magnitude of faculty or student absenteeism that interferes with the school’s ability to function.
• Schools that were closed based on previous interim CDC guidance related to this outbreak may reopen.

NYTimes:
http://www.nytimes.com/2009/05/05/health/05flu.html?_r=1&ref=americas
http://www.nytimes.com/interactive/2009/04/27/us/20090427-flu-update-graphic.html

AFP:http://www.google.com/hostednews/afp/article/ALeqM5hbUvgb0FQ9NSNehamF3ZUV5lFBjA

CDC: http://www.cdc.gov/h1n1flu/index.htm

New article from Laurie Garrett on swine flu, avian flu and pandemics

Laurie Garrett, a highly respected reporter and author of 2 books and many articles on public health and influenza has a new article in newsweek. It's a great description of why some of the the flu viruses currently circulating in humans and animal (H1N1 seasonal flu, H1N1 swine-origin flu, H5N1 avian flu) should remain a concern. I especially like how Garrett describes science in a vivid lanague that helps people understand these concepts.

An excerpt -

"At the viral level, influenza is an awfully sloppy microbe that is in a constant state of mutation and evolution. Its genetic material is in the form of RNA (not DNA, as in humans), loosely collected into chromosomes. When a virus infects a cell, its chromosomes essentially fall apart into a mess, which is copied to make more viruses that then enter the bloodstream to spread throughout the body. Along the way in this copying process any other genetic material that may be lying about the cell is also stuffed into the thousands of viral copies that are made. If the virus happens to be reproducing this way inside a human cell, it picks up Homo sapiensgenetic material; from a chicken cell it absorbs avian genes; and from a pig cell it garners swine RNA. The jackpot events in influenza evolution occur when two different types of flu viruses happen to get into an animal cell at the same time, swapping entire chromosomes to create "reassorted" viruses."

I highly reccomend the whole article at:

http://www.newsweek.com/id/195692

New CARE website for influenza

We are pleased to launch a new flu site that will compile information on the current H1N1 influenza (swine flu outbreaks) and tools that your country office can use for staff safety and security and pandemic preparedness.

The new site is: www.flu.care.org

We are still maintaining our blog (www.avianflunetwork.blogspot.com) for breaking news.

We will be continually updating this website, particularly for guidance and tools that are in draft format, so we encourage you to check the website regularly. As with any new website that is being updated, there may be technical difficulties from time to time. We urge you to be patient and simply check back later.

Another website that I highly recommend for NGOs is www.pandemicpreparedness.org This website is part of the H2P Initiative and a highly credible source.

Posting your country office documents to the website:

We would love to receive updates from your country office. If you have translations, tools or preparedness plans that you’ve developed, please email them to: care.flu@sharepoint.care.org - Your document will be automatically uploaded to the website. Our team will approve it and it will be available for everyone to see.

Daily update from WHO

WHO updated it's number just a short while ago. However, they have the United States at 286. This morning, according to CDC, the total cases of novel H1N1 flu in US = 403, states affected = 38

"As of 06:00 GMT, 5 May 2009, 21 countries have officially reported 1124 cases of influenza A (H1N1) infection.

Mexico has reported 590 laboratory confirmed human cases of infection, including 25 deaths. The United States has reported 286 laboratory confirmed human cases, including one death.
Related links

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (140), China, Hong Kong Special Administrative Region (1), Costa Rica (1), Colombia (1), Denmark (1), El Salvador (2), France (4), Germany (8), Ireland (1), Israel (4), Italy (2), Netherlands (1), New Zealand (6), Portugal (1), Republic of Korea (1), Spain (54), Switzerland (1) and the United Kingdom (18). "

http://www.who.int/csr/don/2009_05_05/en/index.html

Mexico Says H1N1 Outbreak on Decline

Mexico's Health Minister Jose Angel Cordova said the swine flu epidemic in his country "is now in its declining phase," even as the U.S. and five other countries in Europe and Latin America reported new cases Sunday. But WHO and CDC officials suggest that this is a premature declaration, and that there is still much to learn about the virus and how transmission is occurring.

The death toll in Mexico was changed late Sunday night to 22, while the tally of infected cases had increased to 568 from 506.

"[Cordova] said data suggest the epidemic peaked sometime between April 23 and April 28, and that drastic measures — closing the nation's schools, shuttering most of its businesses and banning mass public gatherings — apparently have helped curb the flu's spread." He also said that antivirals wre effective against the flu, and that paried with the public's use of facemasks and hand-washing had limited the spread of the virus.

"But he warned the assessment was preliminary and that it was important 'not to lower one's guard.' Nevertheless, the prospect of the national flu emergency ending soon was viewed with relief across Mexico."

"Scientists warn that the virus could mutate into a deadlier form." And that this could be simply the first, mild wave of an evolving virus.

"'Influenza is unpredictable,' said Dr. Tim Uyeki, an epidemiologist at the U.S. Centers for Disease Control and Prevention who has worked on SARS and H5N1 bird flu outbreaks. 'There are so many unanswered questions. This is a brand new virus. There's so much we don't know about the human infectious with this virus.'"

"Right now, one of the biggest hurdles is a lack of information from Mexico. A team of international and Mexican virus sleuths is trying to piece together an epidemiological picture of who's dying and where transmission began, while also uncovering just how it's attacking people with severe illness. But details are emerging slowly."

http://www.google.com/hostednews/afp/article/ALeqM5hw7j2BynQwqpfvc-iKY8IYTA4j9Q
http://www.google.com/hostednews/ap/article/ALeqM5gzz357patY4-QaJFvo9O95zMM_EQD97UVR280

CDC & WHO daily updated numbers and comments

WHO is reporting 1003 confirmed cases of H1N1 influenza from 20 countries on four continents.

CDC is reporting 286 cases and 1 death in 36 states. Starting today, CDC will also begin to report on probably cases. Thus far, 99% of probable cases have been confirmed H1N1 (swine flu) infections, so reporting on probable cases for the United States will give a more accurate picture of the outbreak.

Dr. Chan gave some excellent remarks today again explaining how the global community is neither underestimating or overestimating the risk. Rather, we are just keeping in mind the unpredictable nature of influenza viruses. See her communications below:


"We do not know how long we have until we move to phase 6, which indicates we are in a pandemic. We are not there yet. The criteria will be met when we see, in one region outside North America, clear evidence of community-level transmission.

Although we face many uncertainties, we do know some things, which I want to share with you now.

Some of this knowledge comes from the behaviour of past pandemics. Other knowledge is specific to the new H1N1 virus and comes from the cases we are seeing in different countries and a look at the virus in the laboratory.

This helps us understand the situation, right now. However, experience during past pandemics warns us that the initial situation can change in many ways, with many, many surprises.

Historically, influenza pandemics have encircled the globe in two, sometimes three, waves. During the previous century, the 1918 pandemic, the most deadly of them all, began in a mild wave and then returned in a far more deadly one. In fact, the first wave was so mild that its significance as a warning signal was missed.

As we are seeing, the world today is much more alert to such warning signals and much better prepared to respond.

The pandemic of 1957 began with a mild phase followed, in several countries, by a second wave with higher fatality. The pandemic of 1968 remained, in most countries, comparatively mild in both its first and second waves.

At this point, we have no indication that we are facing a situation similar to that seen in 1918. As I must stress repeatedly, this situation can change, not because we are overestimating or underestimating the situation, but simply because influenza viruses are constantly changing in unpredictable ways."

http://www.who.int/dg/speeches/2009/influenza_a_h1n1_situation_20090504/en/index.html

May 3 WHO Briefing on H1N1

The WHO briefing opened with a discussion by Peter Ben Embarek, a scientist with the food safety program, about the current report from Canada that swine have been infected with the H1N1 virus.

Embarek noted that Canada announced H1N1 in a swine herd; these swine were not carriers of the virus, but were infected by a farm worker who recently traveled to Mexico. The herd was infected between 12-14 April, and it took nearly 10 days before the swine began showing symptoms, which were mild.

Embarek clarified that swine are not a reservoir for the currently circulating H1N1 disease, which is a mutated form of swine flu, and that these swine contracted the disease from a human. He also reiterated that you cannot get H1N1 from eating cooked pork. The focus now in Canada is monitoring swine near the infected farm and preventing spread of the virus in additon to preventing humans who are in regular contact with these infected swine (who were previously infected by a farm worker) from getting the new H1N1 virus.

WHO still does not recommend an embargo on meat, because the virus isn't present in swine herds en masse and the virus is sensitive to heat - so cooking the meat would render any potentially infected meat safe.

Questions:
Q: When was WHO notified that H1N1 was found in Canadian pigs? Given that the virus went from human to pig then back to human, does this show anything?
A: WHO was informed just before Canadian authorties made a formal announcement about the situation late last night. 10% of herd was affected and it was not very serious. He also clarified that there is no information at this time that other people have been infected by the pigs. Following good, general biosecurity guidelines, the farm is under quarantine and no animals have left the premises.

Q: Does the mixing back and forth (between swine and humans of H1N1) cause risk of a more severe disease?
A: There is no sign that this is happening; however, that could happen. As influenza viruses change, they could become stronger, milder, or stay the same.

Q: Given the current mixing, is there a risk of H5N1 and H1N1 mixing into a cocktail?
A: That is a concern, but we have no way of knowing if that could happen. That's why WHO is encouraging national authorities to actively monitor animals and keep the viruses from spreading geographically.

Q: When are we likely to go to Phase 6?
A: This is of course not easy to predict, because transmission of influenza virus doesn’t always move at the same speed. Since we have not seen sustained human-to-human transmission outside the Americas, it wouldn't "be prudent to predict" or set a timeline.

WHO Virtual Press Briefing Center: http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html

Update: H1N1 Cases Worldwide

Total Cases: 898 cases in 18 countries (20 deaths)

The following countries have reported laboratory confirmed cases with no deaths - Austria (1), Canada (85), China, Hong Kong Special Administrative Region (1), Costa Rica (1), Denmark (1), France (2), Germany (8), Ireland (1), Israel (3), Italy (1), Netherlands (1), New Zealand (4), Republic of Korea (1), Spain (40), Switzerland (1) and the United Kingdom (15).

Total Mexico cases: 506 confirmed (19 deaths)

Total US Cases: 226 cases (1 death) in 30 states

Alabama: 1
Arizona: 18
California: 26
Colorado: 4
Connecticut: 2
Delaware: 10
Florida: 3
Illinois: 3
Indiana: 3
Iowa: 1
Kansas: 2
Kentucky: 1
Massachusetts: 7
Michigan: 2
Minnesota: 1
Missouri: 1
Nebraska: 1
Nevada: 1
New Hampshire: 1
New Jersey: 7
New Mexico: 1
New York: 63
Ohio: 3
Rhode Island: 1
South Carolina: 15
Tennessee: 1
Texas: 40 (1 death)
Utah: 1
Virginia: 3
Wisconsin: 3

WHO: http://www.who.int/csr/don/2009_05_03/en/index.html
CDC: http://www.cdc.gov/h1n1flu/index.htm