Mutated influenza A(H1N1) 2009 detected in Norway

The Norwegian Institute of Public Health reported today that it detected an unusual mutation in three individuals; two of whom were the first fatal cases of influenza A (H1N1) 2009 in the country, and one of whom has severe illness.

The Norwegian Institute of Public Health reported on these detections, as did WHO (also see links to reports below). The Norwegian public health agency subsequently analyzed isolates from more than 70 patients infected with influenza A (H1N1) 2009 who manifested clinical illness, and no further instances of mutation were detected. These findings suggest that the mutation is not widespread in the country.

WHO reports that worldwide, laboratory monitoring of influenza viruses has detected a similar mutation in viruses from several other countries (with the earliest detection occurring in April), including Brazil, China, Japan, Mexico, Ukraine, and the US. No evidence currently suggests these mutations are leading to an unusual increase in the number of H1N1 2009 infections or a greater number of severe or fatal cases.

Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention mentioned in a media briefing today that while this mutated virus is unusual, it sporadically has been detected in the US, though typically associated with more mild disease.

What are the implications of viral mutation?

• Viral mutations are normal; this specific mutation detected by the Norwegian Institute of Public Health probably will be of little or no importance (per Norwegian Institute of Public Health).
• This specific viral mutation is associated with the virus's virulence and ability to live deeper in respiratory tissue.
• Current data suggest this viral mutation has no implications for pandemic influenza A (H1N1) vaccine match or antiviral efficacy.
• The public health implications of this mutation are unclear, and may be difficult to assess (per WHO and Dr. Schuchat). It is important to note, however, that WHO reports there is no current evidence suggesting this mutation is leading to an unusual increase in the number of H1N1 2009 infections or a greater number of severe or fatal cases.
• To date, no links between the small number of patients infected with the mutated virus have been found, and the mutation doesn't appear to be spreading.

Sources:

Norwegian Institute of Public Health: http://www.fhi.no/eway/default.aspx?pid=233&trg=MainLeft_5669&MainLeft_5669=5544:81363::0:5667:1:::0:0

WHO: http://www.who.int/csr/disease/swineflu/notes/briefing_20091120/en/index.html

CDC media briefing: http://www.cdc.gov/media/transcripts/2009/t091112.htm

H1N1 and the 2009 Hajj

The Ministry of Health of Saudi Arabia has recently issued a set of health requirements and recommendations for entry visas for Saudi Arabia for the Hajj and Umra season, with special focus on reducing the transmission of pandemic (H1N1) 2009 influenza among pilgrims.

These health requirements and recommendations call for those population groups who are considered to be at high risk for complications from influenza to refrain voluntarily from this year’s Hajj. The requirements issued by the Kingdom also request the health authorities in pilgrims’ countries of origin to educate and advise pilgrims on basic public health measures (personal hygiene measures, cough etiquette, use of antiseptic hand gel, etc.) to be followed during Hajj and Umra to prevent the spread of pandemic (H1N1) 2009 during the upcoming Hajj season.

There are some concerns about transmission in the Middle Eastern region because despite the preferred WHO/CDC nomenclature of 'influenza pandemic (H1N1) 2009 virus', the misleading name 'swine flu' is used more often than not. Joining the Arabic word for swine (transliterated 'alkhanaazeer') leaves an impression in a subset of the population that, there being no local swine population, the risk of transmission to animals is nil.

By some estimates, the Hajj is the single largest, annual gathering in the world; the pilgrimage of Muslims to Mecca attracts between 2 and 3 million visitors from all over the globe. In Saudi Arabia, health officers have been stationed at all points of entry, and some airports have even been equipped with heat sensors to detect people with high fevers. Officials have also recommended that travelers get vaccinated, but not all countries are going to be able to inoculate all pilgrims before they leave for Mecca. With low vaccine supplies globally, it's a problem that is likely to be repeated at other world events.

WHO posts a briefing note on the safety of pandemic vaccines

From WHO:

"To date, WHO has received vaccination information from 16 of around 40 countries conducting national H1N1 pandemic vaccine campaigns. Based on information in these 16 countries, WHO estimates that around 80 million doses of pandemic vaccine have been distributed and around 65 million people have been vaccinated. National immunization campaigns began in Australia and the People’s Republic of China in late September.

Vaccination campaigns currently under way to protect populations from pandemic influenza are among the largest in the history of several countries, and numbers are growing daily. Given this scale of vaccine administration, at least some rare adverse reactions, not detectable during even large clinical trials, could occur, underscoring the need for rigorous monitoring of safety. Results to date are encouraging.

Common side effects
As anticipated, side effects commonly reported include swelling, redness, or pain at the injection site, which usually resolves spontaneously a short time after vaccination.
Fever, headache, fatigue, and muscle aches, occurring shortly after vaccine administration, have also been reported, though with less frequency. These symptoms also resolve spontaneously, usually within 48 hours. In addition, a variety of allergic reactions has been observed. The frequency of these reactions is well within the expected range.

Guillain-Barre syndrome
To date, fewer than ten suspected cases of Guillain-Barre syndrome have been reported in people who have received vaccine. These numbers are in line with normal background rates of this illness, as reported in a recent study. Nonetheless, all such cases are being investigated to determine whether these are randomly occurring events or if they might be associated with vaccination.

WHO has received no reports of fatal outcomes among suspected or confirmed cases of Guillain-Barre syndrome detected since vaccination campaigns began. All cases have recovered. WHO recommends continued active monitoring for Guillain-Barre syndrome.

Investigations of deaths
A small number of deaths have occurred in people who have been vaccinated. All such deaths, reported to WHO, have been promptly investigated. Although some investigations are ongoing, results of completed investigations reported to WHO have ruled out a direct link to pandemic vaccine as the cause of death.

In China, for example, where more than 11 million doses of pandemic vaccine have been administered, health authorities have informed WHO of 15 cases of severe side effects and two deaths that occurred following vaccination. Thorough investigation of these deaths, including a review of autopsy results, determined that underlying medical conditions were the cause of death, and not the vaccine.

Safety profile of different vaccines
Campaigns are using nonadjuvanted inactivated vaccines, adjuvanted inactivated vaccines, and live attenuated vaccines. No differences in the safety profile of severe adverse events among different vaccines have been detected to date.

Although intense monitoring of vaccine safety continues, all data compiled to date indicate that pandemic vaccines match the excellent safety profile of seasonal influenza vaccines, which have been used for more than 60 years. "

Source: http://www.who.int/csr/disease/swineflu/notes/briefing_20091119/en/index.html

WHO releases revised interim planning considerations for mass gatherings

WHO released an 8-page document outlining revised guidance for event planners.

In the document, entitled Interim planning considerations for mass gatherings in the context of pandemic (H1N1) 2009 influenza, authors recommend that event planners conduct a thorough risk assessment, in partnership with local and national public health authorities, prior to the event.

Highlighted considerations include:

• Level of influenza activity
• Period of time over which the gathering will take place - this has implications for when event-based cases would begin experiencing signs and symptoms of the flu (e.g., during the event if the event lasts longer than 2-3 days [the typical incubation period for flu] vs. afterward for events with shorter durations), and the type of resources (e.g., health care professionals, essential medical supplies/equipment, etc.) planners should have on hand during the event
• Age of participants
• Occurrence of severe disease and health care capacity

The guidance document can be downloaded free of charge at: http://www.who.int/csr/resources/publications/swineflu/h1n1_mass_gatherings/en/index.html

WHO 2009 H1N1 Weekly Update

13 November 2009 -- As of 8 November 2009, worldwide more than 206 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 6250 deaths.

For additional information related to geographic spread of influenza activity, qualitative indicators, and virological surveillance data, view the weekly report in its entirety at: http://www.who.int/csr/don/2009_11_13/en/index.html

WHO Rushes Drugs to Nations Hit by 2009 H1N1

Via Pam Belluck of The New York Times - excerpts:

“Emergency supplies of antiviral drugs are being sent to Ukraine, Afghanistan and other countries in Eastern Europe and Central Asia, where hospitals report that they are being overwhelmed by patients with swine flu, the World Health Organization said Thursday….

The new guidelines say that anyone with flu-like symptoms for three days, along with people in several high-risk groups — pregnant women, children under 2 and people with underlying respiratory problems — should not wait for laboratory tests to confirm the diagnosis but should be treated right away with drugs like Tamiflu.

‘The pandemic virus can cause severe pneumonia even in healthy young people,’ Dr. [Nikki] Shindo [a medical officer with the organization’s global influenza program] said, adding that “the virus can take life within a week….’ ‘The window of opportunity is very narrow to reverse the progression of the disease,’ she said. ‘The medicine needs to be administered before the virus destroys the lungs.’

Although antiviral medications are most effective when used within 48 hours after symptoms start, Dr. Shindo said the drugs should be given even after that if a person is very sick.

Dr. Shindo said the guidelines, similar to those in use in the United States, had not been adopted sooner because the agency was not yet confident, as it is now, about the safety and efficacy of the antivirals, Tamiflu and Relenza. Doctors there were also worried about shortages.

The agency said the countries most affected were Afghanistan, Mongolia, Belarus, Ukraine, Azerbaijan and Kyrgyzstan. The first four have already been sent supplies; the other two are to receive them soon.

‘Doctors involved in caring for very sick patients in intensive care units regretted that the patients arrived too late and even the most sophisticated medical procedures could not save their lives,’ she said. ‘We asked what could have been done differently to avoid the tragic outcomes. All of them answered, without exception, that things may have been very different if they had been treated with an antiviral drug earlier.’

Although Tamiflu had been stockpiled, protocol required doctors to prove a patient had H1N1 with laboratory testing before prescribing the medicine, said Nadezhda Rudnitskaya, the chief of pulmonology at Lviv Medical University.”

View the entire article at: http://www.nytimes.com/2009/11/13/world/13flu.html?_r=2

WHO - Clinical management of human infection with new influenza A (H1N1) virus: revised guidance

WHO released revised guidance for clinical management of persons infected with 2009 H1N1. The 15-page document provides information on an array of topics; including guidance for clinical management in resource-poor settings, and examples of clinical triage algorithms for ILI and pneumonia.

The document provides information/guidance on the following:

• Risk factors for severe disease


• Case descriptions (uncomplicated influenza, complicated influenza, signs and symptoms of progressive disease)


• Infection control


• Diagnosis


• General treatment considerations


• Antiviral therapy


• Care of severely ill patients (initial evaluation, antiviral therapy, supportive care, adjunctive pharmacologic therapy, secondary bacterial pneumonia)


• Resource poor settings


• Examples of clinical triage algorithms for ILI and pneumonia

The guide can be viewed in its entirety at: http://www.who.int/csr/resources/publications/swineflu/clinical_management/en/index.html