Case count update from WHO

As of June 29th, WHO is reporting 70,893 cases and 311 deaths. It looks like the latest countries to find their first cases are Nepal, Monaco, and Lithuania.

http://www.who.int/csr/don/2009_06_29/en/index.html

While we're still reporting on WHO cases counts, it's important to keep in mind that these will be severe underestimates. CDC is estimating that there are probably one million Americans infected with swine flu (but have not been tested)

http://www.nytimes.com/2009/06/27/health/27flu.html

1st case of H1N1 resistance to tamiflu found in Denmark

From Reuters: "Scientists have established the first case of the new H1N1 influenza strain showing resistance to Tamiflu, the main antiviral flu drug, Danish officials and the manufacturer said on Monday.

"While receiving the drug, the patient appeared to develop resistance to it," David Reddy, Roche Holding AG's (ROG.VX) pandemic taskforce leader, told reporters on a conference call on a case observed in Denmark. "This is the first report we have of it in H1N1."

Common seasonal flu can resist Tamiflu and Reddy said a case of resistance in H1N1 -- also know as swine flu -- was not unexpected. Roche had been working on strategies to counter such a development."

http://www.reuters.com/article/swineFlu/idUSLT265113?feedType=RSS&feedName=swineFlu&virtualBrandChannel=10521

CDC updates guidace on antivirals (slightly)

From CIDRAP:

"Jun 25, 2009 (CIDRAP News) – The US Centers for Disease Control and Prevention (CDC) today at the Advisory Committee on Immunization Practices meeting in Atlanta issued updated guidelines for treatment of influenza, including novel H1N1, suggesting basing antiviral selection on laboratory test results when possible.

The new guidance appears to be aimed at preventing the inadvertent prescription of oseltamivir (Tamiflu) for seasonal H1N1 infections, which have shown extensive resistance to oseltamivir in the United States and other parts of the world. The update was provided by CDC spokesman Tom Skinner.

According to the CDC update, only patients who test positive for influenza A/H3N2, pandemic H1N1, or B should receive oseltamivir. Zanamivir (Relenza) is preferred for patients who test positive for seasonal H1N1 influenza.

If a laboratory test is not performed or the test is negative but clinical suspicion remains, the preferred treatment is zanamivir or a combination of oseltamivir and rimantadine, which is an older drug of the adamantine class of antivirals. If testing indicates influenza A or unspecified influenza, the preferred treatment is also zanamivir or a combination of oseltamivir and rimantadine.

As with its earlier recommendation for novel H1N1 treatment, the CDC emphasized in today's updated guidance that treatment should be started as soon as possible after illness onset.

The CDC added a few more specifics to the list of people for whom antiviral treatment should be considered to include those who are hospitalized with influenza, have influenza with viral or bacterial pneumonia, or have influenza with a higher risk for complications, regardless or illness severity."

http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/jun2509tamiflu-brjw.html

Is "Mild" the right word for H1N1?

There's really no such thing as a "mild" pandemic. Even with a virus that causes mostly mild illness, roughly 30% of the world's population will become ill with the virus. That means increased deaths, even if the case fatality rates are low, and increased burden on health systems. That's most likely why WHO has characterized the pandemic as "moderate"

Yet we keep seeing the word mild pop up a lot and Helen Branswell, an imminently respected influenza reporter wrote about some of the inherent problems with using the word mild.

"Officialdom's mantra about swine flu - "it is overwhelmingly mild" - might seem incongruous if we knew the number of children, teens and young adults in ICU beds right now alive only because a breathing machine has taken over for their ravaged lungs.

The heavy reliance on the word "mild " could be creating a false impression of what is actually going on and what the world may face in coming months, some experts worry."

....

"When we're told that swine flu is mild, we don't think, 'It will infect a half to a third of the world population and kill a few million people, mostly young people, before it's over,"' says Sandman. "We think, 'It's like having a bad cold."'

Well, swine flu isn't over. And it's not like a bad cold sweeping the globe.

But officials and experts are having a hard time striking the balance in messages to the public, unclear what they are dealing with now and what it might become.

"I think the problem is we don't know how to paint this picture properly," says Dr. Allison McGeer, a flu expert at Toronto's Mount Sinai Hospital.

"Because it's perfectly true that most cases are mild. But it doesn't mean that you shouldn't worry about it."

Regular flu, as anyone who has had it know, is no walk in the park.

And with this new flu, a small subset of people gets very, very sick. Their lungs are overwhelmed by an aggressive viral pneumonia one doctor described as looking like a "white out" on an X-ray. A number of hospitals are struggling to keep these people alive.

Generally much younger than the typical hospitalized flu patient, many of these people have been on ventilators for weeks. And every day, officials in some part of the globe announce that a 15-year-old boy, a 24-year-old woman or an otherwise healthy pregnant woman in her third trimester has lost the battle.

"When you look at those things then you begin to say 'Well, is it really accurate, is it really fair to say that this is a mild phenomenon?"' says Dr. Keiji Fukuda, the World Health Organization's top flu expert.

Fukuda and his team have been warning for some time that the unusual age pattern of severe cases, the odd out-of-season spread and the fact that the virus is killing some previously healthy young adults makes the term moderate a more appropriate severity assessment.

That pattern, seen in previous pandemics, makes flu watchers sit up and take notice. "What it really leads you to conclude is that boy, we'd better watch this pretty carefully," Fukuda says.

There still isn't a good estimate of the percentage of total swine flu cases that becomes gravely ill, or the percentage that succumbs to the virus's onslaught. Currently the numbers may seem small; 25 deaths in Canada, 127 in the U.S., 263 worldwide. (Swine flu has already beat bird flu in terms of death tolls.)

But as a human pathogen this virus is still a baby, despite its rapid global spread. No one knows what it is going to be when it grows up.

Catch the whole article here at:

http://chealth.canoe.ca/channel_health_news_details.asp?news_id=28382& news_channel_id=145&channel_id=145

Reports from Southern Hemisphere

CDC indicates today that there are reports of co-circulation of pandemic H1N1, seasonal H3N2, and some seasonal H1N1 viruses in the southern hemisphere at this time.

Additionally, CDC indicates reports of increasing outbreaks of pandemic H1N1 in certain countries in the southern hemisphere.


Source: CDC Joint Information Center

CDC Estimates at Least 1 Million Cases of Pandemic H1N1 in the US, to Date

"At the June 25, 2009 Advisory Committee on Immunization Practice Meeting, CDC estimated that there have been at least 1 million cases of pandemic H1N1 in the United States to date. This estimate is derived from population-based surveys in areas with focal outbreaks of pandemic H1N1 that have reported the incidence of influenza-like-illness to be approximately 6%.

On June 10, 2009, the New York City Health Department released preliminary findings from a household survey suggesting that 6.9% of New Yorkers may have experienced flu-like illness between May 1 and May 20, 2009.

Several other local population-based surveys produced similar estimates of ILI incidence/pandemic H1N1 incidence.

Given the occurrence of pandemic H1N1 outbreaks in cities with large populations and the results of these surveys, CDC estimates that there have been at least 1 million cases of pandemic H1N1 in the United States."

Source: CDC Joint Information Center

WHO Update

As of Friday, 26 June, WHO is reporting 59,814 laboratory-confirmed cases of influenza A(H1N1), including 263 associated deaths in 112 countries/territories/areas. Since Wednesday (WHO is providing reports on Mondays, Wednesdays, and Fridays), 4 new countries/territories/areas are reporting laboratory confirmed cases of influenza A(H1N1). The following list includes the number of lab-confirmed cases and associated deaths, by country/territory/area for these 4 countries/territories/areas:

Reporting site (Cases, Deaths)
- Indonesia (2,0)
- Iran (1,0)
- Serbia (2,0)
- UK: Guernsey, Crown Dependency (1,0)

It is difficult to interpret this information, as it may be a sign of enhanced surveillance and/or improved reporting rather than a true indication of increasing distribution and spread of the virus.

While we think it is important to provide a situation update as well as an update on the distribution and spread of reported disease in countries/territories/areas reporting to WHO, we would like to emphasize that certainly not all cases are detected and/or appropriately reported. Therefore, the figures presented in these updates likely are a substantial underestimate of the actual amount of disease and the numbers of affected countries/territories/areas.

Source site: http://www.who.int/csr/don/2009_06_26/en/index.html

WHO says H1N1 Virus is Stable, Not Yet Mutating

By Guy Faulconbridge

"MOSCOW (Reuters) - The World Health Organization said on Thursday that the H1N1 virus was stable and there was no sign yet of it mixing with other influenza viruses.

Some health officials have raised concerns that if H1N1, known by many as swine flu, combined with the much deadlier H5N1 bird flu virus then the pandemic could claim many more lives.

'The virus is still very stable,' WHO Director-General Dr Margaret Chan told reporters at a news briefing in Moscow when asked if there were any signs of the virus mixing with other strains such as avian flu.

'But as we all know the influenza virus is highly unpredictable and has great potential for mutation,' Chan said after meeting Russian Health Minister Tatyana Golikova.

Chan's remarks are some of the first comments by the WHO leadership since the United Nations agency declared an influenza pandemic on June 11. Chan said the viruses needed to be closely monitored to make sure there was no mutation.

'We would need to look at how they are behaving in southern hemisphere countries to see whether the H1N1 and the usual seasonal influenza virus would reassort. So far we have not detected any signal,' she said.

'Another important thing we need to monitor is H1N1 and H5N1, which is endemic in some countries in Asia and the Middle East. We would like to see whether there will be any change,' she said. "Again, we did not detect any signal that there is any reassortment.'

Chan, a straight-talking native of Hong Kong, said that while much effort was being expended on seeking vaccines, common sense measures could still reduce risks of being infected.

'In prevention and reducing the risk of this infection there is of course a lot of attention given to antivirals and vaccines. But we must not forget there are what we call non pharmaceutical measures which are very effective,' she said.

'These are simple measures that each individual can take to protect themselves: don't smoke, get enough rest, eat a balanced diet to support a high level of immunity and frequent washing hands with water and soap.'

'If you do unfortunately get infected, please do go to see a doctor.'"

Source site: http://thestar.com.my/news/story.asp?file=/2009/6/26/worldupdates/2009-06-25T223820Z_01_NOOTR_RTRMDNC_0_-406071-3&sec=Worldupdates

H1N1 Detected in Pigs in Argentina

Dow Jones Newswires
June 26, 2009

"The first sign of swine flu has been detected in the Argentine pig population.

At least five hogs in Argentina's populous Buenos Aires Province have tested positive for the H1N1 flu, according to the animal health and sanitation service, or Senasa. A 15-kilometer quarantine area has been imposed, with hogs from surrounding farms being tested, Senasa spokesman Carlos Chichizola said.

Chichizola noted that the presence of the disease in the pig population did not increase the risk to humans, adding that there is no danger from consuming pork. The infected pigs all recovered.

In fact, it's the pigs that are at greater risk from human contact, with Senasa working based on the hypothesis that the pig was made sick through contact with an infected human.

Argentina has been the most seriously affected country in South America by the so-called swine flu. On Wednesday, four more swine flu deaths were reported, raising to 21 the number of people who have died from the flu strain.

According to the Health Ministry, the number of confirmed swine flu cases rose by nearly 100 on Wednesday, to 1,391. Another 967 people are being tested due to suspicion that they may be infected.

The government is currently considering taking sweeping measures to control the disease, which is running rampant in the midst of the southern hemisphere's winter.

With mid-term elections slated for Sunday, any measures that would hinder the vote are unlikely. However, following the vote, the government could take such measures as closing areas where large numbers of people gather, local daily La Nacion reported Thursday, citing government sources. The closing of shopping centers, schools, cinemas and concerts is being considered, La Nacion said.

For now, health minister Graciela Ocana is recommending voters keep at least one-meter distance between themselves and others as they wait in line to vote and to stay in open, well-ventilated areas as much as possible.

According to the World Health Organization, swine flu has spread to 109 countries, infected 55,000 and killed 238 people since March. The WHO declared a global swine flu pandemic on June 11. Canada has also reported cases of the disease in pigs."

Source site: http://www.weeklytimesnow.com.au/article/2009/06/26/89381_latest-news.html

World Bank on Potential Economic Impacts of Flu Pandemic

Jason Gale, Bloomberg contributor, summarizes a World Bank report on the potential economic implications of the current influenza pandemic.

"June 23 (Bloomberg) -- The pandemic sparked by swine flu may be as severe as the Hong Kong flu of 1968-69 that cost an estimated 0.7 percent of global gross domestic product, according to the World Bank.

The new H1N1 flu strain might reduce second-quarter GDP by as much as 2.2 percent in Mexico if disruptions to businesses, including those in the restaurant, hotel and transportation industries, persist in the Mexico City region, the Washington- based lender said.

Transmission of the bug is likely to accelerate as the flu season begins in the Southern Hemisphere and again when it returns in the Northern Hemisphere, the bank said in a report released yesterday. As many as 1.5 million people die in a normal flu season worldwide, and even a mild new flu might add another 1.4 million deaths, the report said.

'Even if it does not mutate into a more deadly form, a second wave of the flu in low-income countries could have serious consequences -- given poor countries’ limited capacity to monitor and treat an outbreak and the higher incidence of chronic disease within their populations,' the bank said.

More than 52,000 cases of swine flu have been reported by at least 90 countries, the World Health Organization said yesterday. In most cases the virus causes little more than a fever and cough. Still, governments have ordered millions of doses of vaccine to protect against the scourge.

Bird Flu

WHO is watching for any sign the disease is worsening as the germ circulates during the Southern Hemisphere’s flu season, creating opportunities for its genes to mutate or combine with those of other viruses, including the H5N1 bird flu strain that’s lethal in three of every five reported cases.

The new virus, which has genes from strains that have sickened humans, pigs and birds, has caused 231 deaths, Geneva- based WHO said. Almost half of them were in Mexico, where the economic costs of the epidemic have been concentrated, particularly in the nation’s transport industry, according to the World Bank report.

The bank, formed after World War II to fund health and development projects in poor countries, said that air travel to and from Mexico has declined 80 percent since the outbreak, and hotels in popular resorts have reported vacancy rates as high as 80 percent.

Overall, tourism revenue is down about 43 percent, increasing Mexico’s external financing gap because tourism is an important source of foreign currency.

4.8% of GDP

Unlike seasonal flu, from which the elderly suffer the most death and disease, the new bug is preferentially targeting the young and causing potentially fatal complications in otherwise healthy people aged 30 to 50, pregnant women and those with asthma, diabetes and obesity.
Simulations of the potential economic and human costs of a pandemic based on avian flu that was undertaken for a 2006 report suggested that the costs of a global outbreak could range from 0.7 percent to 4.8 percent of global GDP, depending on the severity of the outbreak, the lender said.
The lower estimate was based on the Hong Kong influenza pandemic of 1968-69, while the upper bound was benchmarked on the 1918-19 Spanish flu. In the case of a serious flu, 70 percent of the overall economic cost would come from absenteeism and efforts to avoid infection, according to yesterday’s report.

'Developing countries would be hardest hit because higher population densities, relatively weak health care systems and poverty accentuate the economic impacts in some countries,' it said. "

Source: Bloomberg.com - http://www.bloomberg.com/apps/news?pid=20601087&sid=ah0aeqRTBdLI

WHO Update

As of Wednesday, 24 June, WHO is reporting 55,867 laboratory-confirmed cases of influenza A(H1N1), including 238 associated deaths in 108 countries/territories/areas. Since Monday (WHO is providing reports on Mondays, Wednesdays, and Fridays), 9 new countries/territories/areas are reporting laboratory confirmed cases of influenza A(H1N1). The following list includes the number of lab-confirmed cases and associated deaths, by country/territory/area for these 9 countries/territories/areas:

Reporting site (Cases, Deaths)
- Antigua and Barbuda (2, 0)
- Cambodia (1 , 0)
- Cape Verde (3 , 0)
- Cote d’Ivoire (2 , 0)
- Ethiopia (2 , 0)
- Latvia (1 , 0)
- Montenegro (1 , 0)
- Tunisia (2 , 0)
- Vanuatu (1, 1 )

It is difficult to interpret this information, as it may be a sign of enhanced surveillance and/or improved reporting rather than a true indication of increasing distribution and spread of the virus.

While we think it is important to provide a situation update as well as an update on the distribution and spread of reported disease in countries/territories/areas reporting to WHO, we would like to emphasize that certainly not all cases are detected and/or appropriately reported. Therefore, the figures presented in these updates likely are a substantial underestimate of the actual amount of disease and the numbers of affected countries/territories/areas.

Source site: http://www.who.int/csr/don/2009_06_24/en/index.html

HHS Announces Advanced Development Contract for New Way to Make Flu Vaccine

HHS Secretary Kathleen Sebelius announced today that the department will pursue advanced development of new way to make influenza vaccine. The work will be done by Protein Sciences Corporation, Inc., of Meriden, Conn., under a new $35 million contract. The contract could be extended up to five years at a total cost of approximately $147 million.

“The technology has advanced in recent years to a point that we believe it could help meet a surge in demand for U.S.-based vaccine for seasonal and pandemic flu,” Secretary Sebelius said. “We want to use the technology to help our nation respond to emerging infectious diseases.”

With this new technology, known as recombinant influenza vaccine, a gene would be extracted from a flu virus and placed into an insect virus called baculovirus, which does not affect people and can multiply quickly to high levels in insect cells. The cells are purified to become a basic part of a human vaccine.

Using this method, vaccine candidates, clinical investigational lots, and commercial-scale vaccine production may be available faster than by using traditional vaccine production methods. Because the basic cells can be frozen and stored indefinitely, manufacturing large quantities of a vaccine is also faster using this recombinant technology.

The new contract will be administered by the Office of Biomedical Advanced Research and Development Authority (BARDA) within HHS and will support Protein Sciences Corporation, Inc., in advanced development activities needed for potential Food and Drug Administration (FDA) approval to use this new technology for producing flu vaccines.

If this new technology is demonstrated to be safe and effective and the FDA licenses the new technology for flu vaccines, the contract requires the company to establish domestic manufacturing capability to provide a finished vaccine within 12 weeks of pandemic onset and to produce at least 50 million doses of pandemic flu vaccine within six months of pandemic onset.

Today’s award aligns with the National Strategy for Pandemic Influenza Implementation Plan, which calls on HHS to develop and procure medical countermeasures for pandemic influenza or for potentially pandemic strains, such as the recent novel H1N1 flu virus.

To learn more about the HHS Assistant Secretary for Preparedness and Response and BARDA, visit http://www.hhs.gov/aspr/barda. The National Strategy for Pandemic Influenza Implementation Plan can be found at http://www.pandemicflu.gov/plan/federal/.

http://www.hhs.gov/news/press/2009pres/06/20090623c.html

Congress approves $7.65 billon in pandemic response funds

From CIDRAP:

"Most of the pandemic money is for activities by the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC), but the bill includes $350 million to boost state and local capacity for responding to the novel H1N1 flu pandemic.

According to a House Appropriations Committee summary of the legislation, it provides $1.5 billion in fiscal year 2009 money and $5.8 billion in "contingent emergency appropriations" for HHS and the CDC.

The funds are to be used for expanding surveillance, increasing federal stockpiles of drugs and medical supplies, and developing, buying, and administering vaccines.

The $350 million in state and local money, according to the House summary, is intended to help public health departments hire and train staff members, buy equipment to improve diagnostic capabilities, distribute antivirals and personal protective equipment from federal and state stockpiles, improve communication and maintain disease-reporting hotlines, and address other challenges, such as hospital surge capacity.

The bill also includes $50 million for distribution by the US Agency for International Development to help countries respond to pandemic flu."

http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/jun2209funding.html

Signature features of Influenza Pandemics – Implications for Policy

In a recent Perspective article in the New England Journal of Medicine (N Engl J Med 360; 25 NEJM.org June 18, 2009), Mark A. Miller et al. enumerate the signature features of influenza pandemics and discuss their implications for policy.

“Past pandemics were characterized by [I’ve numbered these for ease of reading]
1. a shift in virus subtype
2. shifts of the highest death rates to younger populations
3. successive pandemic waves
4. higher transmissibility than seasonal influenza
5. differences in impact in different geographic regions.”

The authors go on to outline how knowledge of the signature features of pandemics can be used to inform and prioritize national strategies and aid in addressing initial and successive pandemic waves:

1. “Although influenza pandemics are classically defined by the first of these features, the other four characteristics are frequently not considered in response plans.…
2. Advance knowledge of which subpopulations are most likely to be at increased risk for death can shape the optimization of control strategies.…
3. The occurrence of multiple waves potentially provides time for health authorities to implement control strategies for successive waves. …
4. Since models of containment and pandemic control assumed lower reproductive numbers for the current epidemic than those that have been historically observed, they are likely to be overly optimistic regarding the success of containment strategies.…
5. This variability is probably explained by the complex heterogeneity in the degree of immunity in local populations to the circulating influenza strains, as well as by transmission factors such as geographic conditions, social mixing, degree of viral infectiousness, and ‘seasonal forcing’ (small seasonal changes in the effective transmission rate). The benefits of sharing data on all these variables provide major incentives for international collaboration."

Of interest to those following our blog, the authors also provide their perspective on other subtypes which may pose a pandemic threat:

“Although the A/H5N1 influenza subtype has spread to avian populations in more than 30 countries and infected nearly 400 persons, with a case fatality rate above 50%, scientists disagree about its pandemic potential. Such a highly pathogenic virus does not usually adapt well to its host, since it tends to kill faster than it can be transmitted. Other avian subtypes are also considered to be pandemic threats. Although avian viruses have a different tropism for respiratory cellular receptors in birds than for those in humans, gradual viral mutations or gene-segment reassortments in a mammal “mixing vessel” could result in a novel viral clade or subtype that spreads rapidly in a population that has largely not previously been exposed to it. Such changes may have occurred in the current swine H1N1 circulating strain.

The death toll of a future pandemic depends not only on the virulence of the virus in question but also on the rapidity with which we are able to introduce effective preventive and therapeutic measures. Although A/H5N1 has been associated with a “cytokine-storm” phenomenon reminiscent of that observed in 1918 and 1919, new methods for the timely manufacture and administration of antiviral agents and influenza and pneumococcal vaccines could mitigate the effects of a pandemic.

The evidence of multiple waves in the 20th-century pandemics underlines the importance of active real-time viral surveillance on a global scale. Transnational collaborations are crucial for the effective exchange of genomic, clinical, and epidemiologic data that will make possible the development of vaccines and treatment protocols and the identification of the best population-based strategies….

Though the rapidity of transmission of influenza virus during pandemics necessitates immediate action, it can be hoped that close collaborations and lessons drawn from previous pandemics will contribute to reducing national and global mortality. The documented relevant signature features can help health authorities prioritize national strategies and aid international collaborators in addressing the initial and successive waves of illnesses and deaths.”

This article can be viewed in its entirety (be sure to scroll down to the second half of the first page that displays on the site) at: http://content.nejm.org/cgi/reprint/360/25/2595.pdf

WHO update

As of Monday, 22 June, WHO is reporting 52,160 laboratory-confirmed cases of influenza A(H1N1), including 231 associated deaths in 99 countries/territories/areas.

Since Friday, 5 new countries/territories/areas are reporting one case of influenza A(H1N1), and no associated deaths:
- Algeria
- Bangladesh
- Brunei Darussalam
- Fiji
- Slovenia

It is difficult to interpret this information, as it may be a sign of enhanced surveillance and/or improved reporting rather than a true indication of increasing distribution and spread of the virus.

While we think it is important to provide a situation update as well as an update on the distribution and spread of reported disease in countries/territories/areas reporting to WHO, we would like to emphasize that certainly not all cases are detected and/or appropriately reported. Therefore, the figures presented in these updates likely are a substantial underestimate of the actual amount of disease and the numbers of affected countries/territories/areas.

http://www.who.int/csr/don/2009_06_22/en/index.html

WHO update

WHO case count: 39,620 cases and 167 deaths. That's only 3692 additional cases and 4 additional deaths since the the last update, almost 48 hours ago. Most likely, countries are beginning to report cases more slowly as the numbers go up. CDC had moved from reporting cases daily, to reporting Monday, Wednesday and Friday, and is now reporting cases on a weekly basis. Now that CDC reports cases on Fridays, we'll like see jumps in WHO's numbers on Mondays.

Canada and Chile posted the biggest increase in numbers, with Yemen, Jordan, Sri Lanka, and several Caribbean and Pacific Island nations confirming their first cases.


http://www.who.int/csr/don/2009_06_17/en/index.html

Sanofi-Pasteur to donate 100 million doses of pandemic H1N1 vaccine to WHO

"We welcome this very generous gesture by Sanofi-Pasteur. One hundred million doses of vaccine against the pandemic H1N1 2009 virus is a sizeable and generous gesture to and on behalf of the world's less-developed countries. WHO will now work to ensure that this vaccine gets to groups who otherwise would have no access to pandemic vaccines.

"It is gratifying that vaccine manufacturers are demonstrating their solidarity with WHO in protecting the health of the world's poorer people: influenza knows no boundaries and so to protect people in one country is to protect us all."

Sanofi-Pasteur made its announcement of the donation of 100 million doses of vaccine at the Pacific Health Summit in Seattle, USA. WHO Director-General Dr Margaret Chan will be speaking there tomorrow.

http://www.who.int/mediacentre/news/statements/2009/vaccine_donation_20090617/en/index.html

H1N1 strain in Brazil is not different after all

Media reports about a new mutation in Brazil are apparently incorrect, according to BirdFluGov on Twitter (the US Goverment's twitter feed to the www.pandemicflu.gov website. That's great news!

I'm removing the post on the article from yesterday and will post more if I find out how the mistake was made.

Studies suggest antiviral drugs are safe for pregnant women

An important update! We know that pregnant women are at increased risk for severe illness for both seasonal and pandemic influenza. We haven't had clear data before about the safety of antivirals for pregnant women. This new study looks at previously unpublished evidence and the data suggests that antiviral use is relatively safe. I've posted the article here and it's a must read for those concerned with staff safety and security and as a consideration for vulnerable populations:

"The antiviral drugs Tamiflu and Relenza are relatively safe for use in pregnant and breastfeeding women, say the authors of review of data that includes previously unpublished evidence.

The analysis, published electronically on Monday by the Canadian Medical Association Journal, suggested Tamiflu is the best bet for pregnant women, but either drug can be used safely by breastfeeding women who come down with influenza.

The review may assuage concerns of women who contract swine flu and are worried about whether or not to use antiviral drugs. Pregnant women are at higher risk of complications than their non-pregnant peers when they catch seasonal flu. Evidence from some previous pandemics suggests they can be hit disproportionately hard by a strain of pandemic influenza.

“During the current pandemic, we shouldn’t hesitate to treat those patients at increased risk,” said senior author Dr. Shinya Ito, head of the division of clinical pharmacology and toxicology at Toronto’s Hospital for Sick Children.

“In terms of risk-benefit ratio I think it’s very clear that the benefit is much more significant to use the drug for pregnant women, even in the first trimester.”

The authors, from the Motherisk Program at Sick Kids and the Japan Drug Information Institute in Pregnancy, examined the available data on antiviral drug use in pregnant and breastfeeding women.

They admitted the evidence is limited and said it will be important to monitor what happens
with antiviral drug usage by pregnant women during the pandemic.

In addition to looking at reports of use filed to the drugmakers after the fact, they found unpublished Japanese data that followed 90 pregnant women who took Tamiflu during the first trimester of their pregnancies. The first trimester is the period when concern is greatest that chemicals or drugs a mother is exposed to or takes could have a detrimental effect on the developing fetus.

Of those women, only one gave birth to a child with a birth defect. The rate of birth defects in the general population is between one to three per cent. Given that the rate among Tamiflu users isn’t higher, it suggests the single case occurred by chance, not as a result of exposure to the drug.

In another study, scientists used a human placenta to see if Tamiflu introduced to the placenta would flow to the fetus. Ito said it took a high concentration of Tamiflu to see even small concentrations of drugs coming out the other end.

The authors suggested Tamiflu is probably the better choice of the two flu drugs to give pregnant women infected with this new strain of H1N1 flu, because there is more safety data on its use in pregnancy.

But they said for women who are breastfeeding, either Tamiflu or Relenza could be used because only small amounts are excreted in breast milk.

The paper said neither drug appears to affect the growth or development of fetuses exposed to them in the womb.

The U.S. Centers for Disease Control said last week that it’s receiving reports that some pregnant women who catch swine flu are refusing to take antiviral drugs out of fear it might put their fetuses at risk."
http://www.edmontonsun.com/news/canada/2009/06/15/9806136.html

First case of H1N1 announced in Lao PDR

The first case of H1N1 in Lao PDR was announced in a media release today by the Ministry of Health.

Below is an except.

'Lao PDR's first case of new influenza A (H1N1) was confirmed on Tuesday, 16 June 2009 by the National Center for Laboratory and Epidemiology (NCLE).
The infected person does not require hospitalisation and is currently isolated at home. He is recovering well with a mild illness that did not require treatment with Tamiflu medication. While the identity of the person cannot be made public, it can be shared that the person recently travelled from a country with confirmed cases of Influenza A H1N1. All close contacts of this person are being contacted and monitored for symptoms of infection in order to minimize the spread of infection in the community.
A sample was collected from the patient on the afternoon of June 15th, and was sent to NCLE for testing. The positive result was confirmed on June 16th using Real-Time RT-PCR testing with materials specifically designed to detect the new A/H1N1 influenza, provided by USCDC. An emergency meeting was convened hours later by the Health Minister and key health officials.'

World case count from WHO

"15 June 2009 -- As of 17:00 GMT, 15 June 2009, 76 countries have officially reported 35, 928 cases of influenza A(H1N1) infection, including 163 deaths."

The latest country to join the list of affected countries is West Bank/Gaza Strip

http://www.who.int/csr/don/2009_06_15/en/index.html

Poorer countries health services could be overwhelmed by pandemic influenza

Many experts have been discussing the impact of a "moderate" pandemic on already fragile health services and poorer countries.

"World Health Organization (WHO) chief Margaret Chan warned Monday that the current swine flu pandemic could cripple fragile health services in poor countries.

"Developing countries have the greatest vulnerability and the least resilience. They will be hit the hardest and take the longest to recover," she told a UN forum on global health. . .

The pressures of a pandemic, on top of the rise in chronic diseases, could alone cripple fragile health services" in the developing world, Chan said.

While noting that the world's preparedness for the pandemic was unprecedented, she stressed that "the level of preparedness, and the capacity to cope, are strongly biased toward wealthy countries."

"In terms of measures to mitigate the health impact, many poor countries are virtually empty-handed," the WHO director general said. "Even the use of non-pharmaceutical measures has limited relevance to poor countries, especially in sub-Saharan Africa."

http://news.yahoo.com/s/afp/20090615/hl_afp/healthfluworldun_20090615223225

Swine flu is hitting First Nations in Manitoba harder

Since WHO has called the pandemic "moderate" (so far) experts are increasingly looking at how this pandemic will affect vulnerable populations. From previous pandemics we know that some demographics are hit harder by pandemics and we don't always know why.

Currently, Canada is monitoring the situation in Manitoba where First Nations people seem to be more severely affected, though the numbers are small so it's hard to draw hard conclusions.

"It appears from our information that . . . (among) our most severe cases, there's an over-representation from a population and demographic perspective, of First Nations and aboriginal people," Kettner, the chief medical officer of health, said Monday in an interview from Winnipeg... two-thirds of 24 Manitobans in intensive care units fighting swine flu last week were First Nations people. Given that aboriginal peoples make up only 10 to 15 per cent of the population of the province, that seems an unduly large proportion"

http://www.pddnet.com/news-ap-hl-swine-flu-is-hitting-first-nations-in-manitoba--061509/

CDC Urges Review and Revision of Pandemic Business Continuity Plans

A staff writer for The Center for Infectious Disease Research and Policy (CIDRP) wrote a piece yesterday about a teleconference CDC convened, during which the agency urged businesses to review their pandemic plans and modify them, as needed, to ensure there is enough flexibility to respond to a moderate or severe influenza pandemic.

As CARE continues to urge its country offices to do the same, there are some key points that can be taken from this article. Although it is a bit domestic in focus, I have pasted excerpts below which may be meaningful to many in the field. The article can be viewed in its entirety at: http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/jun1209business-br.html

Lisa Schnirring Staff Writer

"Jun 12, 2009 (CIDRAP News) – On the heels of yesterday's pandemic declaration by the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC) today urged businesses to review their pandemic plans to make sure they're flexible enough to respond to a moderate or severe pandemic.

...Anthony Fiore, MD, MPH, a medical epidemiologist in the CDC's influenza division, said the novel flu cases and hospitalizations are hitting younger people and children the hardest. "This is much of the workforce, as well as their children," he said.

... Fiore advised businesses to plan on using basic preventive measures as a fallback, such as encouraging employees to stay home when they're sick, cover their coughs, and wash their hands frequently.

Employees who have risk factors for flu complications, such as asthma, cardiac conditions, or pregnancy, should be advised to seek medical care quickly if they have flu symptoms, he said. Those who don't have risk factors and experience severe symptoms should also seek care.

[Lisa Koonin, MN, MPH, a senior adviser with the CDC's influenza coordination unit] reminded companies that the WHO's pandemic declaration wasn't based on severity, but on sustained transmission levels in different parts of the world. However, she advised groups to be alert for new flu developments by seeking out situation updates from public health agencies, which will help businesses align their practices with public health recommendations. She warned that the novel virus will affect different locations in different ways.

"There will be different pictures all around the world," Koonin said. "We need to be nimble and tailor our response based on that picture."

Employers should review their leave, pay, and benefits policies to determine if any adjustments are needed to allow employees to stay home for 7 to 10 days if they are sick with the novel flu or need to stay home to care for a sick family member, she said.

She advised the group to address business continuity concerns by identifying essential business functions and critical employees, planning for staffing redundancy for key positions, and assessing supply-chain and critical input issues. Koonin added that it's a good idea for businesses to ask suppliers to provide details about their pandemic plans.

…Some businesses also asked the CDC for clearer guidance on how long people with novel flu infections should stay home before returning to work. Fiore said the current guidance, issued out of an abundance of caution but without much scientific data, is 7 days or 24 hours after symptoms resolve, whichever is longer.

He said the CDC is actively examining its recommendation on how long to stay home and hopes to update its guidance within the next few weeks.”

WHO - Assessing Severity of an Influenza Pandemic

"The major determinant of the severity of an influenza pandemic, as measured by the number of cases of severe illness and deaths it causes, is the inherent virulence of the virus. However, many other factors influence the overall severity of a pandemic’s impact.

Even a pandemic virus that initially causes mild symptoms in otherwise healthy people can be disruptive, especially under the conditions of today’s highly mobile and closely interdependent societies. Moreover, the same virus that causes mild illness in one country can result in much higher morbidity and mortality in another. In addition, the inherent virulence of the virus can change over time as the pandemic goes through subsequent waves of national and international spread. "

WHO considered the following factors before characterizing the severity of the current pandemic influenza as "moderate":

• properties of the virus;
• population vulnerability;
• subsequent waves of spread;
• capacity to respond; and
• an assessment of the current situation

Detailed information and a breakdown of these factors can be viewed on WHO's website: http://www.who.int/csr/disease/swineflu/assess/disease_swineflu_assess_20090511/en/index.html


Additionally, this week's WHO Weekly Epidemiological Record is entitled Considerations for Assessing the Severity of an Influenza Pandemic. The information in this document is presented in both English and French. http://www.who.int/entity/wer/2009/wer8422.pdf

WHO and CDC Updates

WHO Influenza A(H1N1) Update:
12 June 2009 -- As of 07:00 GMT, 12 June 2009, 74 countries have officially reported 29,669 cases of influenza A(H1N1) infection, including 145 deaths.

For further information on the breakdown of the number of laboratory-confirmed cases, visit: http://www.who.int/csr/don/2009_06_12/en/index.html


CDC H1N1 Flu Infection Case Counts:
As of June 12, CDC is reporting 17,855 probable and confirmed cases of novel H1N1 flu infection, including 45 deaths in all 50 states, the District of Columbia, and the territory of Puerto Rico.

For more information, visit CDC's H1N1 flu website: http://www.cdc.gov/h1n1flu/

Statements by HHS and DHS Secretaries on WHO Decision to Declare a Pandemic

U.S. Department of Health and Human Services Secretary Kathleen Sebelius and U.S. Department of Homeland Security Secretary Janet Napolitano issued the following statements yesterday in response to WHO's decision to raise the pandemic alert phase to phase 6, signaling a pandemic influenza.

“Today’s decision by the WHO was expected and doesn’t change what we have been doing here in the United States to prepare for and respond to this public health challenge. Once we saw how fast this virus was spreading, we activated our pandemic plans and started doing all the things we needed to do to keep the public as safe and secure as possible,” said Secretary Sebelius. “What this declaration does do is remind the world that flu viruses like H1N1 need to be taken seriously. Although we have not seen large numbers of severe cases in this country so far, things could possibly be very different in the fall, especially if things change in the Southern Hemisphere, and we need to start preparing now in order to be ready for a possible H1N1 immunization campaign starting in late September.”

“We responded to the H1N1 outbreak from the outset with the presumption that a pandemic was likely, so this decision comes as no surprise. We acted aggressively to stay ahead of the virus as it spread across the country. Now our challenge is to prepare for a possible return in the fall,” said Secretary Napolitano. “The Obama Administration has been working together across the government and will continue to do so over the weeks and months ahead to keep the American people safe. We are reaching out to our partners in state and local government, in school districts and the private sector to urge them to modify and update their pandemic plans. We are working with our scientists to test and prepare a possible vaccine. And we are working with governments around the world to share what we know and learn from what is happening in their countries.”

For more information, please visit the U.S. Department of Health and Human Services website: http://www.hhs.gov/news/press/2009pres/06/20090611a.html

"A Pandemic is Declared"

From CDC:

"On June 11, 2009, the World Health Organization (WHO) raised the worldwide pandemic alert level to Phase 6 in response to the ongoing global spread of the novel influenza A (H1N1) virus. A Phase 6 designation indicates that a global pandemic is underway.

More than 70 countries are now reporting cases of human infection with novel H1N1 flu. This number has been increasing over the past few weeks, but many of the cases reportedly had links to travel or were localized outbreaks without community spread. The WHO designation of a pandemic alert Phase 6 reflects the fact that there are now ongoing community level outbreaks in multiple parts of world.

WHO’s decision to raise the pandemic alert level to Phase 6 is a reflection of the spread of the virus, not the severity of illness caused by the virus."

More information, guidelines and recommendations can be found on CDC's H1N1 flu website: http://www.cdc.gov/h1n1flu/

WHO Director-General Declares Phase 6: An Influenza Pandemic

Today, Director-General of WHO, Dr. Margaret Chan, declared an influenza pandemic by raising the pandemic phase from phase 5 to phase 6 (the final of 6 phases, which designates a pandemic). “On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6. The world is now at the start of the 2009 influenza pandemic. We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch."

On the topic of preparedness and response in the face of uncertainty, Dr. Chan stated:

“No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the last five years, in pandemic preparedness.

We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.”

On the topic of severity, Dr. Chan noted:

“Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity. As we know from experience, severity can vary, depending on many factors, from one country to another.” …

Many, though not all, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include respiratory diseases, notably asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity.

At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people.

Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.”

A transcript of the entire WHO press briefing can be viewed at: http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html

Daily update of cases from WHO

"As of 06:00 GMT, 10 June 2009, 74 countries have officially reported 27,737 cases of influenza A(H1N1) infection, including 141 deaths."

Click here to see affected countries:

http://www.who.int/csr/don/2009_06_10a/en/index.html

Looks like Ukraine is the newest country added to the list

WHO announces emergency committee meeting tomorrow

WHO is convening and emergency committee meeting tomorrow and many believe they'll move to phase 6 after this meeting.

"GENEVA, June 10 (Reuters) - The World Health Organisation has called an emergency meeting of experts on Thursday to discuss the spreading H1N1 flu outbreak, a spokesman said.
"The emergency committee has been called for tomorrow noon," WHO spokesman Gregory Hartl told Reuters. "They will be consulting on the state of the outbreak."
The United Nations agency said on Tuesday that it was on the verge of declaring the first influenza pandemic in more than 40 years, but wanted to ensure that countries are well prepared to prevent a panic over the disease, widely known as swine flu."

http://www.alertnet.org/thenews/newsdesk/WLA6370.htm

We'll be watching the news closely!

WHO daily update

As of 06:00 GMT, 8 June 2009, 73 countries have officially reported 25,288 cases of influenza A(H1N1) infection, including 139 deaths (http://www.who.int/csr/don/2009_06_08/en/index.html)

In today's WHO briefing, Dr. Fukuda repeated that WHO is getting closer to declaring a pandemic.

WHO has been focusing preparing countries for the announcement. Declaring a pandemic is not simply a matter of just saying we’re in phase 6; it means countries are as prepared as possible, have the right tools and guidance and are able to address concerns of the population. It's critical people and goverments do not over react and that they understand that the current assessment is that the pandemic is moderate, so countries have a variety of options to responding to a pandemic in a moderate situation.

Another situation that WHO and flu experts are watching closely - The Canadian Province of Manitoba has a surge in the number of people requiring intensive care for influenza-like illnesses.

Many thanks to our colleagues at the H2P Initiative (www.pandemicpreparedness.org) for putting together notes on the press briefings.

For an audio of the meeting, visit: www.who.int/mediacentre

Watch the probable sequence of re-assortments for H1N1!

Are you confused as to how the current H1N1 virus that everyone's worried about came to have genes human, avian and swine viruses? FAO has produced a great animation of how they think it happened



"Many laboratories and institutions around the world have been working on various aspects of swine and human influenza, for many years. Classical H1 swine influenza viruses (SIVs) were first detected in North America in the 1930s. Reassortment of genes from swine, avian, and human viruses have occurred periodically. Triple swine, avian, and human H1N1, H1N2, and H3N2 reassortant viruses have been circulating in swine since 1998, especially in North America. These viruses have also been detected in some Asian swine populations. There have been sporadic incidents (2-3 per year) of transmission of triple reassortant swine viruses and other SIVs to humans (e.g. H1N1, H1N2), but no previously reported sustained human to human transmission.


The novel H1N1 virus in humans appears to be a further reassortant of the triple reassortant swine viruses mentioned before, that now carries two genes most likely originating from Eurasian swine. Today, it is unclear why this particular virus is so transmissible among humans. Scientists around the world are working hard to answer this and other questions to gain insight and understand better how this virus might evolve."



Watch here:



http://www.fao.org/ag/againfo/programmes/en/empres/AH1N1/Background.html#

Daily update from WHO & CDC

As of 06:00 GMT, 8 June 2009, WHO is reporting 73 countries have officially reported 25,288 cases of influenza A(H1N1) infection, including 139 deaths. (For countries affected go here: http://www.who.int/csr/don/2009_06_08/en/index.html)


Also, on Friday CDC updated it's talking points, interesting additions include:



1.During week 21 (May 24 - 30, 2009), the May 29 FluView Report shows that influenza activity decreased in the United States overall; however, there are still higher levels of influenza-like illness than is normal for this time of year and novel H1N1 outbreaks are ongoing in parts of the United States, in some cases with intense activity.



2. It is a good sign that nation-wide influenza-like-illness surveillance is trending downward. However, it is possible that localized outbreaks will continue to occur over the summer. The real uncertainty is the fall and how the novel H1N1 virus will affect the 2009-2010 influenza season in the United States.



3. So far, the largest number of novel H1N1 confirmed and probable cases (57% of cases) have been in people between the ages of 5 years and 24 years old.

Third Meeting of the IHR Emergency Committee

"The WHO Director-General convened a third meeting of the International Health Regulations (IHR) Committee on 5th June 2009. The purpose of the meeting was to update the Committee on the global situation and seek advice on proposals to introduce severity assessments in any future announcements of pandemic phase changes by WHO.

There was a broad consensus on the importance of including information on severity in future announcements. The committee gave further advice regarding a number of parameters, the monitoring of which will provide information for the assessment of the severity of the epidemic.
In discussion with the Committee, the Director-General noted that with the world remains in Pandemic Influenza Phase 5 and reaffirmed that WHO will continue to monitor the situation closely in all countries reporting cases of new Influenza A (H1N1).
Based on the advice of the Committee, the Director-General determined that it was appropriate to continue the existing Temporary Recommendations, namely:

• That all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia.
• Not to close borders and not to restrict international travel. It is considered prudent for people who are ill to delay international travel and for people developing symptoms following travel to seek medical attention.
• That the production of seasonal influenza vaccine should continue at this time, subject to re-evaluation as the situation evolves. "

http://www.who.int/csr/disease/swineflu/3rd_meeting_ihr/en/index.html

WHO and CDC Updates

WHO Influenza A(H1N1) - update 44

5 June 2009 -- As of 06:00 GMT, 5 June 2009, 69 countries have officially reported 21,940 cases of influenza A(H1N1) infection, including 125 deaths.

Visit the WHO Influenza A(H1N1) website for further details: http://www.who.int/csr/don/2009_06_05/en/index.html


CDC Update

As of 11 am June 5, CDC is reporting 13,217 confirmed and probable cases of novel influenza A(H1N1), and 27 deaths in all 50 states, the District of Columbia, and the territory of Puerto Rico.

Visit the CDC H1N1 flu website for further details: http://www.cdc.gov/h1n1flu/

World bank fast tracks $500 million for H1N1

"WASHINGTON (Dow Jones)--The World Bank approved Tuesday a $500 million fast-track facility to help countries control the fast-spreading swine flu, known as influenza A/H1N1.

The money will top up the World Bank's existing $500 million credit line set up in 2006 for countries coping with the avian flu.

Low- and middle-income countries can access the financing to pay for drugs, medical equipment, hospital care, human and livestock health surveillance, and offset the economic and social costs associated with pandemic flu, the bank said in a release.

"This is a particularly bad time for a pandemic to occur given that developing countries are more vulnerable now because of the compounded effects of the food, fuel and financial crises," said Jeff Gutman, the World Bank's vice president for operations, in a statement.

Sixty-two countries had reported 17,410 cases of swine flu, including 115 deaths, as of Monday, according to the World Health Organization. Dr. Keiji Fukuda, the WHO's acting assistant director-general for health security and environment, said Tuesday the agency is moving closer to setting the highest level of pandemic alert, Phase 6."

http://online.wsj.com/article/BT-CO-20090602-714268.html

Daily case count from WHO

3 June 2009 -- As of 06:00 GMT, 3 June 2009, 66 countries have officially reported 19,273 cases of influenza A(H1N1) infection, including 117 deaths.

http://www.who.int/csr/don/2009_06_03/en/index.html

As we mentioned, CDC has switched to updates on Mondays, Wednesdays and Fridays

Managing and Reducing Uncertainty in an Emerging Influenza Pandemic

In a recent Perspective article in the New England Journal of Medicine, Dr. Marc Lipsitch et al. addressed several relevant issues related to decision-making in an environment of uncertainty in their article entitled Managing and Reducing Uncertainty in an Emerging Influenza Pandemic.

While the article touches on several important considerations, the authors' last statement about disproportionate implications for developing countries resonated with me:

"As we adjust our mitigation policies, there will be a continuing need to make decisions without definitive estimates of severity. For example, the decision to move from production of vaccine for seasonal influenza to that for pandemic influenza will need to be made in the next month or two. Similarly, the United States will need to decide soon whether to use adjuvanted vaccines to protect more people with a given amount of antigen, although such vaccines are not currently licensed in the United States. As always, however, the main losers from delays in such decisions are likely to be developing countries, which will have less access to vaccine while probably suffering the greatest clinical impact from this new pandemic virus. "

While the article is a bit domestic in focus, I think many of the key points can be translated into the international setting. The entire article is worth reading, and can be viewed at: http://content.nejm.org/cgi/content/full/NEJMp0904380

WHO & CDC Updates

3 June, 2009 -- As of 06:00 GMT, 3 June 2009, 66 countries have officially reported 19,273 cases of influenza A(H1N1) infection to WHO, including 117 deaths.

More details on cases counts by affected country can be viewed at: http://www.who.int/csr/don/2009_06_03/en/index.html


CDC is reporting 11,054 confirmed and probable cases of novel influenza A/H1N1 in 50 states, the District of Columbia, and the territory of Puerto Rico, including 17 deaths.

More details on the summary of the situation in the U.S. can be viewed at: http://www.cdc.gov/h1n1flu/update.htm

Bloomberg reports that WHO will declare phase in the next 10 days, according to anonymous source

An article on bloomberg.com is reporting that WHO will declare phase in the next 10 days, according to anonymous source.

"The Geneva-based agency, sometime in the next 10 days, will declare the first flu pandemic in 41 years, said the people, who spoke on condition of anonymity because the WHO’s deliberations are private. WHO is using the time before the announcement to help member states prepare.
“We held a series of consultations with public health officials and academics around the world to understand their concerns and get their advice about moving to level 6,” said Dick Thompson, a WHO spokesman in Geneva. “We are not at phase 6. We’re just exploring the issues associated with announcing a pandemic.” "

The article also discussed WHO using a scale to define severity, with the current H1N1 flu outbreak being characterized as less severe in order to provide clear guidance to countries and not cause panic or economic consequences

"Following yesterday’s discussion, the WHO is considering a three-point scale to denote different levels of severity once phase 6 has been declared, Keiji Fukuda, the agency’s assistant director-general of health security and environment, said on a conference call with reporters today. The experts said that besides assessing severity, the agency should offer tailored guidance to countries on how to respond to a pandemic, he said."

For the full article, see:
http://www.bloomberg.com/apps/news?pid=20601087&sid=aT9sIzRoUnNo&refer=home

WHO getting closer to Phase 6

The WHO Briefing today provided some important updates summarized here. The audio should be up soon at www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html

1. We are now "closer" to Phase 6, with UK, Spain, Japan, & Australia in transition to widespread community transmission.

2. WHO is characterizing current outbreak as “moderate” not mild, with most severe illness in the 20 – 40 yr age group. It appears that the number of serious illnesses is limited, but we don’t really know the numerator or denominator. Also, those who die are both what we might expect to see in influenza deaths (underlying illnesses, pregnant) but also those who are otherwise healthy and we don't know why.

3. *It sounds like the Phase 6 definition, based on geography of spread, will be more or less retained but may modify the "movement" to phase six with degree of severity. WHO should then provide guidance to countries based on level of severity. WHO is working on guidance for assessments of severity. They have not decided what indicators will be used for severity.

4. Novel-H1N1 (rather than seasonal flu strains) seems to be predominating so far at the start of the southern hemisphere season in Chile.

Many thanks to our colleagues at the H2P Initiative (http://www.pandemicpreparedness.org/) who are keeping us updated on briefings and articles.

Researchers identify a new highly pathogenic arenavirus

Scientists have discovered a new virus in Africa, named Lujo (LUJV) after the two the two cities Lusaka, Zambia and Johannesburg, South Africa where it originated. The virus, which causes hemorrhagic fever (symptoms include bleeding gums and bleeding around injection sites, fever, shock, coma, and organ failure) infected 5 people in Zambia and South Africa in September and October of last year. Consequently, 4 of the cases died as a result of the infection.

While it is not know how the first patient became infected, scientists were able to analyze tissue and blood specimens from the case patients, which did provide some insight into likely modes of transmission. Through these analyses, scientists determined the Lujo virus was a new member of the arenavirus family. Documented modes of transmission of arenavirsues include inhalation of small aerosols of rodent waste which contain the virus or from particles such as dust that have become infected with the rodent waste and are then disbursed into the air (often by mechanical harvesters used for farming and grain processing). Arenaviruses that are deposited in the environment may also be infective when ingested or when they come in contact with cuts or skin abrasions. Person-to-person transmission of arenaviruses has also been documented, but this type of transmission typically occurs through contact with infected body fluids and in family or health care settings, as was the case with this particular outbreak.

Researchers have developed specific reagents which will enable them to further investigate the virus's reservoir, geographic distribution, and high pathogenicity (ability of the virus to cause disease). Like most emerging and re-emerging infectious diseases, evidence seems to suggest the agent-host-environment triad played an important role in the emergence of Lujo virus.

The full journal article detailing the epidemiology of the Lujo virus can be viewed at: http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1000455

CDC posts "General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers"

CDC has published "General Business and Workplace Guidance for the Prevention of Novel Influenza A (H1N1) Flu in Workers" on its website

This is actually a great starting point for NGOs to develop appropriate workplace guidance and HR policies.

An excerpt from the site:

"What can employers do to protect employees?

1. Encourage sick workers to stay home and away from the workplace, and provide flexible leave policies.

2. Encourage infection control practices in the workplace by displaying posters that address and remind workers about proper handwashing, respiratory hygiene, and cough etiquette. These posters can be found on the Germ Stopper: Posters and Other Materials page.

3.Provide written guidance (email, etc.) on novel influenza A (H1N1) flu appropriate for the language and literacy levels of everyone in the workplace. Employers should work closely with local and state public health officials to ensure they are providing the most appropriate and up-to-date information (e.g., the CDC H1N1 Flu website).

4. Provide sufficient facilities for hand washing and alcohol-based (at least 60%) hand sanitizers (or wipes) in common workplace areas such as lobbies, corridors, and restrooms.

5. Provide tissues, disinfectants, and disposable towels for employees to clean their work surfaces, as well as appropriate disposal receptacles for use by employees.

One study showed that influenza virus can survive on environmental surfaces and can infect a person for up to 2-8 hours after being deposited on the surface. To reduce the chance of spread of the novel influenza A (H1N1) virus, disinfect commonly touched hard surfaces in the workplace, such as work stations, counter tops, door knobs, and bathroom surfaces by wiping them down with a household disinfectant according to directions on the product label."

To review the whole site visit: http://www.cdc.gov/h1n1flu/guidance/workplace.htm

Daily update from WHO & CDC

1 June 2009 -- As of 06:00 GMT, 1 June 2009, 62 countries have officially reported 17,410 cases of influenza A(H1N1) infection, including 115 deaths. To see countries affected, go here:

http://www.who.int/csr/don/2009_06_01a/en/index.html

CDC is reporting 10,053 cases and 17 deaths in the United States. All 50 states have been affected.

http://www.cdc.gov/h1n1flu/update.htm?s_cid=tw_epr_143

Rising number of H1N1 cases worldwide, why no declaration of a pandemic?

We continue to see a rising number of cases in Japan, Australia and the EU, so why has WHO not declared a pandemic?

The current WHO phase alert system for pandemics does not take into account severity. WHO is concerned about raising the alert to phase 6 when severity of the current virus seems limited. WHO has expressed concern that it may cause unnecessary alarm and action on the part of the public and national governments. Additionally, since there is no higher level alert, WHO would have no additional tools to convey the seriousness of the situation should the current H1N1 situation become more severe or another virus (such as H5N1) begins spreading around the globe through human to human transmission.

Dr. Keiji Fukuda,the WHO's assistant director-general, said:
"If you go and declare Phase 6 without very clear evidence that
there is a sort of change in the global situation, it can lead
to extra work for countries without much gain,"

So, the WHO is looking to rewrite the pandemic phases. According to the Washington Post, "Dr. Keiji Fukuda, the deputy director general making the W.H.O. announcement, said that he could not predict exactly what the new rules would be but that criteria would include a
"substantial risk of harm to people," not just the geographic spread of a relatively benign virus."

For more on rewriting the definition of a pandemic: http://www.washingtonpost.com/wp-dyn/content/article/2009/05/30/AR2009053001766.html?hpid=topnews