Posted on 06/24/2009 8:04:24 AM PDT by metmom
Just a note of thanks again for compiling all these articles into one thread. You’ve saved me a tremendous amount of surfing to find articles that prick my interest about new and developing H1N1 issues. Bless you. - OB1
http://www.who.int/csr/disease/swineflu/notes/h1n1_clinical_features_20091016/en/index.html
Clinical features of severe cases of pandemic influenza
Pandemic (H1N1) 2009 briefing note 13
16 OCTOBER 2009 | GENEVA — To gather information about the clinical features and management of pandemic influenza, WHO hosted a three-day meeting at the headquarters of the Pan American Health Organization in Washington, DC on 14–16 October. Findings and experiences were presented by around 100 clinicians, scientists, and public health professionals from the Americas, Europe, Asia, Africa, the Middle East and Oceania.
The meeting confirmed that the overwhelming majority of persons worldwide infected with the new H1N1 virus continue to experience uncomplicated influenza-like illness, with full recovery within a week, even without medical treatment.
Need for intensive care
However, concern is now focused on the clinical course and management of small subsets of patients who rapidly develop very severe progressive pneumonia. In these patients, severe pneumonia is often associated with failure of other organs, or marked worsening of underlying asthma or chronic obstructive airway disease.
Treatment of these patients is difficult and demanding, strongly suggesting that emergency rooms and intensive care units will experience the heaviest burden of patient care during the pandemic.
Primary viral pneumonia is the most common finding in severe cases and a frequent cause of death. Secondary bacterial infections have been found in approximately 30% of fatal cases. Respiratory failure and refractory shock have been the most common causes of death.
Presentations during the meeting explored the pathology of severe disease in detail, with findings supported by work in experimental animals. These findings confirm the ability of the new H1N1 virus to directly cause severe pneumonia.
Clinical picture different from seasonal influenza
Participants who have managed such cases agreed that the clinical picture in severe cases is strikingly different from the disease pattern seen during epidemics of seasonal influenza. While people with certain underlying medical conditions, including pregnancy, are known to be at increased risk, many severe cases occur in previously healthy young people. In these patients, predisposing factors that increase the risk of severe illness are not presently understood, though research is under way.
In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset. Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive care unit. Upon admission, most patients need immediate respiratory support with mechanical ventilation. However, some patients do not respond well to conventional ventilatory support, further complicating the treatment.
On the positive side, findings presented during the meeting add to a growing body of evidence that prompt treatment with the antiviral drugs, oseltamivir or zanamivir, reduces the severity of illness and improves the chances of survival. These findings strengthen previous WHO recommendations for early treatment with these drugs for patients who meet treatment criteria, even in the absence of a positive confirmatory test.
In addition to pneumonia directly caused by replication of the virus, evidence shows that pneumonia caused by co-infection with bacteria can also contribute to a severe, rapidly progressive illness. Bacteria frequently reported include Streptococcus pneumoniae and Staphylococcus aureus, including methicillin-resistant strains in some cases. As these bacterial co-infections are more frequent than initially recognized, clinicians stressed the need to consider empiric antimicrobial therapy for community acquired pneumonia as an early treatment.
Groups at greatest risk
Participants agreed that the risk of severe or fatal illness is highest in three groups: pregnant women, especially during the third trimester of pregnancy, children younger than 2 years of age, and people with chronic lung disease, including asthma. Neurological disorders can increase the risk of severe disease in children.
Evidence presented during the meeting further shows that disadvantaged populations, such as minority groups and indigenous populations, are disproportionately affected by severe disease. Although the reasons for this heightened risk are not yet fully understood, theories being explored include the greater frequency of co-morbidities, such as diabetes and asthma, often seen in these groups, and lack of access to care.
Although the exact role of obesity is poorly understood at present, obesity and especially morbid obesity have been present in a large portion of severe and fatal cases. Obesity has not been recognized as a risk factor in either past pandemics or seasonal influenza.
WHO and its partners are providing technical guidance and practical support to help developing countries better detect and treat illness caused by the pandemic virus. Patient care advice that can be applied in resource-limited settings is being rapidly compiled.
_________________
4-year-old may be latest swine flu victim in Fort Worth
http://www.dallasnews.com/sharedcontent/dws/news/healthscience/stories/101709dnmetswine.2209fa416.html
October 16, 2009 By CHRIS DELL
The swine flu virus may have claimed a second victim in the Fort Worth school district.
The Fort Worth ISD reported this week that a student became ill and last attended school on Oct. 9. The district did not identify the school or the student.
KDFW-TV reported the girl was 4-year-old Yeimi Sierra Reyes. The Tarrant County medical examiner’s office said the girl died Wednesday but did not list a cause of death.
The school district said in a statement that it had no information regarding the cause of death but that custodial staff was sanitizing the school. “This step was taken strictly as a measure of assuring our parents, staff and students that we are mindful of their safety in all situations,” the school district said.
KDFW-TV reported that Yeimi began experiencing flu-like symptoms Monday, including fever, chills and difficulty breathing. The girl’s family told the television station that she had no underlying medical conditions.
In September, a Fort Worth ISD student died of swine flu. The family of Chloe Lindsey, a 14-year-old at Leonard Middle School, said the girl had no underlying medical conditions.
On Wednesday, Tarrant County health officials reported the death of another swine flu victim – a man in his 50s.
Youth Coach Dies Of Flu Symptoms (Idaho)
http://www.spokesman.com/blogs/hbo/2009/oct/16/youth-coach-dies-flu-symptoms/
October 16 Brian Walker
“Coach Spud,” as he was known in Post Falls youth sports, expected more from his players than to be just good athletes. Kerrie Scott wanted his teams to respect their parents, teachers, themselves and their teammates. “We preached that daily,” said Roy McKenzie, Scott’s brother-in-law who was coaching with Scott on the eighth-grade Broncos team in Junior Tackle this fall. … Scott, 39, died unexpectedly on Tuesday morning after he collapsed at a friend’s home. Police said an autopsy revealed he had flu-like symptoms.
Comment
The comment at the end of this story will be interesting to people who report being infected twice.
Escambia (Ala.) Man Dies From H1N1
http://www.northescambia.com/?p=11636
October 16, 2009
An Escambia County (Ala.) man has died from the H1N1 flu.
Health department officials said today that a man in his 40’s from Escambia County (Ala.) man dead after testing positive for H1N1. Health officials did not release the man’s location within the county.
The area man’s death brings the total number of deaths in Alabama to 18 from H1N1, commonly referred to as the swine flu.
Other H1N1 deaths in Alabama have occurred in Bullock, Calhoun, Cherokee, Dale, Houston, Jackson, Jefferson, Macon, Madison, Mobile, Montgomery, Russell and Talladega counties.
Alabama Public Health officials said they would announce when and where the H1N1 vaccine would be available in Escambia County on their website, www.adph.org.
18th swine flu fatality in Alabama
http://www.waff.com/Global/story.asp?S=11326992
October 16, 2009 By Stephen Gallien
The State Health Department confirms an 18th fatality in Alabama H1N1 Influenza.
The victim is a man in his 40’s from Escambia County.
The latest death is being reported as the first doses of swine flu vaccine arrive in Huntsville.
WAFF 48 News has learned at least two private health care providers have now received the vaccine.
The vaccine is only being given to people most at risk for the H1N1 Influenza. It is a group that includes pregnant women.
The Alabama Health Department has now been notified that it has received over 100,000 doses of the vaccine. Health care providers in the state have requested over one million doses. The State Health Department anticipates getting two million doses of vaccine by January.
Tracking Flu In The Schools (Oklahoma)
http://www.fox23.com/mostpopular/story/Tracking-Flu-In-The-Schools/zw8R1YgQXECSC74a0geoZA.cspx
Rebecca Smith 10/15
Fear of the flu has taken a hold on schools across Green Country and the Tulsa Public Schools district is no exception.
“Yes, it does concern me,” said Maria Scerenil, the mother of a student at Cooper Elementary. “I certainly have them wash their hands and stuff like that.”
Some parents we talked to at Cooper want to do everything in their power to keep their kids flu-free, especially after a four year old who attended Cooper died over the weekend from H1N1.
Parents received a letter from the principal of that school on Monday notifying them of the student’s death.
“It said that a little pre-kindergartner had passed away,” said Scerenil. “They didn’t say it was from the swine flu or anything like that. We were kind of concerned about that.”
The Superintendent of Tulsa Public Schools, Dr. Keith Ballard, says when parents should be notified of the death of a student if the cause is suspected H1N1 isn’t always so clear-cut.
“We must take into consideration the needs of the family and the sympathies for the family when something might be reported,” said Dr. Ballard.
The district’s Director of Health Services, Dr. Pam Butler, tells me she’s “not always privy to death notices” and wouldn’t comment whether or not she knew of the death when she spoke with us Tuesday.
That was days after the student had died from what we now know to be H1N1.
Then, Dr. Butler told us there had only been one H1N1 case in the district- that of East Central High School student, Latowyn Gaston, who also died from the virus.
She says she can only tell us what is confirmed and not what is suspected.
Meanwhile, Dr. Ballard says low attendance at particular schools is being watched.
“We are assuming that the high rate of absenteeism is flu-related and we’re taking our action according to those reports,” he said.
According to reports provided to us by Tulsa Public Schools, attendance at schools across the district dipped the first week of October. It’s since leveled out. But, keep in mind, the flu season hasn’t officially started. It does, typically, in late November.
Students staying home over flu fears (Canada)
http://www.nugget.ca/ArticleDisplay.aspx?e=2133074
THOMAS PERRY
The death of a 15-year-old O’Gorman High School student who had been suffering from the H1N1 virus Wednesday has increased the concerns of some Timmins parents.
An anonymous fax sent to The Daily Press Wednesday evening suggested the author was going to keep his two daughters home from school.
Northeastern Catholic District School Board director of education Glenn Sheculski acknowledged the absentee rate at the school is higher than normal,” but he said there is no indication that figure is higher because of parents keeping their children home from school.
He would not divulge the level of absenteeism, nor comment on how it would compare to a normal mid-October rate.
I am sure there might be some panic out there,” he said.
But H1N1 is not specific to the school, I would hope parents would make informed decisions.”
Sheculski pointed out that students kept home from class could still come into contact with the virus almost anywhere they go.
He said the board has sent home information on the H1N1 virus for parents of students at all of its schools to read and also met with officials from the Porcupine Health Unit.
We have hand sanitizers in all of the classrooms and have been doing everything possible to keep the transfer of germs from occurring,” Sheculski said.
He added parents should not be any more concerned about their children attending classes than they would be going to the mall, or any other public facility.
There would be no point in closing down the school and having it professionally disinfected,” Sheculski said, noting any benefits would be lost as soon as students and staff — who could have potentially been exposed to the virus in the community — returned to classrooms.
Sheculski could not comment on whether or not the second teenager infected with the H1N1 virus — recovering at home — is also an O’Gorman student, citing board policy regarding the release of information on any of its students.
2009 H1N1 Influenza Vaccine Supply Status
October 16, 2009, 12:00 PM ET
http://www.cdc.gov/h1n1flu/vaccination/vaccinesupply.htm
Gov’t: Swine Flu Linked to 11 More Child Deaths
Gov’t: Swine flu causing unprecedented amount of illnesses; 11 more children died in past week
By LAURAN NEERGAARD AP Medical Writer
WASHINGTON October 16, 2009 (AP) The Associated Press
The swine flu is causing an unprecedented amount of illness for so early in the fall — and federal health officials said Friday that 11 more children have died in the past week.
The Centers for Disease Control and Prevention says about half of the child deaths since September have been among teenagers.
And overall for the country, deaths from pneumonia and flu-like illnesses have passed what CDC considers an epidemic level. About 6 percent of all doctor visits are for flu-like illnesses, levels not normally seen until later in the fall.
The CDC’s Dr. Anne Schuchat (SHU’-kit) says, “These are very sobering statistics.”
http://abcnews.go.com/Health/wireStory?id=8845792
Medical condition, swine flu combine to claim 40-year-old woman
JOURNAL AND COURIER • October 16, 2009
LAFAYETTE, Ind. — Health officials say a 40-year-old woman has died of complications from swine flu in central Indiana’s Tippecanoe County.
County health officer Dr. Michael Bohlin says the woman had a previous medical condition that caused severe complications that led to respiratory failure. The woman died Thursday at a Lafayette hospital.
The State Department of Health has confirmed five other deaths in Indiana from swine flu since July.
Widespread flu illness prompted the Clinton Prairie School Corp. in neighboring Clinton County to cancel Friday’s classes and all weekend sports events.
Athletic director Bobby Smith says more than a quarter of the junior-senior high school’s some 430 students were absent Thursday.
http://www.pal-item.com/article/20091016/UPDATES/91016014/1008/rss
CT:
Health officials hold H1N1 informational session
By David Hennessey
Updated: 10/16/2009 12:20:05 PM EDT
http://www.connpost.com/brooks/ci_13576067
NORWALK - Jack Kleis, 84, of Norwalk, made his way with his wife Jean to an informational meeting at Norwalk City Hall last Wednesday night to try and separate fact from fiction in regard to the so-dubbed swine flu or H1N1 virus.
Kleis said after the meeting he found much of the information useful, as he was able to glean important facts about swine flu vaccines and risk factors. State Sen. Bob Duff headed the session, alongside Terry Rabatsky-Ehr, field epidemiologist for the State Department of Public Health, Tim Callahan, director of Norwalk’s Health Department, David Knauf, director of health for Darien, and Dr. Eliot Husarsky, Internist and Infectious Diseases physician at Norwalk Hospital.
Both Kleis and his wife have health problems - he suffers from diabetes and she has health difficulties that compromise her immune system - that can heighten the severity of swine flu in some patients. They were relieved, however, when they saw that, according to recent statistics from the Center for Disease Control, the 2009 H1N1 virus has largely avoided the elderly since its first appearance in California early this spring.
H1N1 so far has attacked young children most frequently, according to Callahan.
The Kleises and two dozen other people who attended the session learned vaccines will be arriving in Connecticut before the end of the month.According to information from Gov. M. Jodi Rell’s office, 20,000 doses of intranasal swine flu vaccine will arrive in the state sometime over the next week.
“It’s one of those things where, if you want, you’ll be able to get it,” Jack Kleis said. “But no one is forcing you to get it.”
Both Kleises said they would probably get vaccinated when it becomes available.
Swine flu vaccines were a hot topic last Wednesday evening, as some members of the public questioned the safety of such precautions - particularly since some of the forthcoming vaccines contain traces of the live virus - but Callahan and Rabatsky-Ehr were adamant any vaccines administered through licensed health clinics and doctors would be safe.
Tamiflu and Zanamivir, they said, are still the preferred methods of treatment once a patient has contracted the virus.
“As a dad and someone in the community, I hear a lot about H1N1,” Duff said. “Maybe it’s an information overload, but maybe we do need to learn a little bit more about it.”
Symptoms of the virus can be similar to the seasonal flu and can include fever, cough, weakness and difficulty breathing, Rabatsky-Ehr said. “If you’ve ever had the flu, you probably felt like you had been run over by a truck,” she said.
The virus is spread through respiratory droplets, she said.
People infected with seasonal and the 2009 H1N1 flu virus may be able to infect others from one day before getting sick to five to seven days after, according to the CDC. This time period can be longer in some people, especially in children and people with weakened immune systems and in people infected with the new H1N1 virus.
The CDC recommends covering your nose and mouth with a tissue when coughing or sneezing and throwing the tissue in the trash after you use it.
You should also wash your hands often with soap and water and use an alcohol-based hand rub if soap is not available. Avoid touching your eyes, nose or mouth. Try to avoid close contact with sick people. If you are sick with a flu-like illness, the CDC recommends you stay home - except to get medical care or for other necessities - for at least 24 hours after your fever is gone. Your fever should dissipate without the use of a fever-reducing medicine. Keep away from others as much as possible, the CDC says.
“I don’t want to say it’s not a big deal - and we are planning for the worst, but we haven’t had many hospitalizations in the state,” Knauf said.
Using the metaphor of a smoking kitchen to describe H1N1, he said: “The house is not on fire.” { give it five minutes...}
Canada:
Tamiflu-resistant H1N1 in Hamilton
Young man is first in Ontario with swine flu that doesn’t respond to drug
October 16, 2009
Joanna Frketich
The Hamilton Spectator
(Oct 16, 2009)
A young Hamilton man was infected with Ontario’s first case of Tamiflu-resistant H1N1.
Only a few dozen people worldwide have been reported to have pandemic influenza resistant to the antiviral treatment. They include a 60-year-old Quebec man and an Alberta woman. Both recovered without being hospitalized.
The Hamilton man is in his 20s. Public health officials don’t believe he spread it because no one he had contact with has become sick.
“People should take this seriously, but not panic,” said Dr. Chris Mackie, Hamilton’s associate medical officer of health.
The emergence of Tamiflu-resistant H1N1 comes at the same time local doctors have reported to the public health department that at least one company tried to pay for its staff to get prescriptions for the antiviral to prevent the flu.
“It sent a letter with all of their employees out to doctors saying we’ll pay you $60 to give a 60-day prescription to prophylactics,” Mackie said.
“This is exactly the sort of thing that generates resistance.”
Tamiflu is only to be used as a treatment for high-risk patients with symptoms and not for prevention.
The H1N1 flu shot is the best way to protect against the pandemic and Mackie says he’s hoping to announce today when it will be available and where.
He refused to provide any details about the young man who caught the Tamiflu-resistant strain. He wouldn’t even say whether the man is dead or alive.
Normally, public health provides details about whether the person is in hospital or at home and how ill.
“For reasons of confidentiality, I’m afraid we can’t say anything more about this individual case and I really apologize about that,” said Mackie.
The Ministry of Health is confident it’s an isolated case.
“At the moment there is no evidence of widespread resistance to Tamiflu anywhere,” said ministry spokesperson David Jensen.
There are other antiviral treatments available when H1N1 is resistant to Tamiflu. However, it can take weeks to determine the strain is resistant. Often, the patient’s illness gets worse and that’s what prompts doctors to try other antiviral treatments.
So far, it hasn’t been a big concern because there have been so few cases.
“This virus has been remarkably stable,” said Dr. Michael Gardam, director of infectious disease prevention and control at Ontario’s Agency for Health Protection and Promotion. “It hasn’t shown any propensity at this point to easily develop resistance and then for those resistant strains to spread.”
http://www.thespec.com/article/654504
Houston, TX:
Student Dies From Swine Flu
POSTED: Friday, October 16, 2009
UPDATED: 11:44 am CDT October 16, 2009
http://www.click2houston.com/news/21316607/detail.html
HOUSTON — A Pasadena high school student has died after catching the H1N1 virus, also known as the swine flu, KPRC Local 2 reported Friday.
A school district spokesman said the Dobie High School junior had not been in class recently.
The student, who was not identified, passed away on Wednesday.
Pasadena ISD officials said it is a difficult time because earlier this month, another student passed away from cancer.
“The loss is tremendous and we want to support the family and the students who have suffered that loss,” said Candace Ahlfinger with the Pasadena ISD.
Officials said the student had been out of school since September, and he also had the pre-existing condition of asthma.
So far this year, there have been six swine flu deaths in Harris County. Four of the deaths occurred in September and two in October.
In Houston, there have been three swine flu deaths, including the Dobie High School student.
Fort Bend County has had three swine flu deaths and Brazoria County has had one.
Houston Health Department spokeswoman Kathy Barton encouraged everyone to practice good hygiene to prevent the spread of the disease.
“Maintain good, interpersonal space between themselves and other people. Wash your hands frequently. Avoid touching your face during the day. Cover your cough. If you’re sick, stay home. If your kids are sick, do not send them to school,” Barton said.
The Houston Health Department said it always tracks pediatric deaths, but more so nowadays in regards to influenza deaths. Health officials said it’s a better way to protect the community.
“So that we may make recommendations in regards to immunizations or potential actions that people in the community need to do to protect themselves,” Barton said.
School officials said additional cleaning of the school is not necessary since the student has not been in class since September.
School custodians are using a special disinfectant on all the doorknobs to prevent the spread of any disease.
nice.
thx.
5 More Swine Flu Hospitalizations In Illinois
Posted: 11:10 AM Oct 16, 2009
http://www.wifr.com/news/headlines/64500847.html
SPRINGFIELD, Ill. (AP) — Five people were hospitalized for swine flu in Illinois this week.
Font Size: The Illinois Department of Public Health released the updated statistics on Friday. The department cited no swine flu deaths in the past week, but did not include the death of a 14-year-old suburban Chicago high school student that was related to swine flu.
Michelle Fahle, a Naperville North High School student, died last week, bringing the state’s total swine flu deaths to 20.
DuPage County Health Department spokesman Dave Hass said the county coroner is conducting tests to see if other medical problems contributed to the girl’s death. He said the results would not be available until later this month.
_________________
India:
119 new swine flu cases, no deaths
http://www.newkerala.com/nkfullnews-1-132547.html
New Delhi, Oct 16 : There were no fresh deaths in the country due to swine flu Friday but 119 new cases of infections were reported, the health ministry said here.
Among the new infections, 40 cases were reported from Kerala followed by 27 in Maharashtra and 22 in Delhi. Other states which reported fresh cases of influenza A (H1N1) were Andhra Pradesh (9), Karnataka and Haryana (6 each), Tamil Nadu (4), Uttarakhand and Uttar Pradesh (2 each) and West Bengal (1).
With these cases Maharashtra remains the most infected state with 3,444 cases closely followed by Delhi, which has 3228 cases of swine flu so far. With 405 cases, the casualty figure remains unchanged across the country.
Among the states, Maharashtra has lost 171 people due to the pandemic followed by 112 in Karnataka, 42 in Andhra Pradesh and 38 in Gujarat.
India reported its first swine flu case in Hyderabad early May and registered its first H1N1 casualty in August first week.
CDC: H1N1 vaccine production slower than expected
Friday, October 16, 2009 12:57 PM
By Misti Crane
The Columbus Dispatch
Slower-than-expected production of vaccine against the H1N1 virus, or swine flu will mean fewer Americans will be able to seek protection in the next few weeks, federal health officials said today.
Meanwhile, flu - almost all of it blamed on the new virus - is hitting every part of the country at levels unprecedented for October and crowding doctors’ offices and emergency departments.
The Centers for Disease Control and Prevention has emphasized the importance of vaccine to quell the spread and expected about 40 million doses available by month’s end.
The real number will probably be closer to 30 million or less, said the CDC’s Dr. Anne Schuchat.
“The next couple weeks will continue to be a slow start,”’ she said.
“The delays will have a substantial impact for the states in their prevention efforts.”
http://www.dispatch.com/live/content/local_news/stories/2009/10/16/fluupdate.html?type=rss&cat=&sid=101
UK:
Swine flu briefing - 16 October 2009, 4.00pm
Current situation
Rates of influenza-like illness continue to increase, but steadily rather than explosively. There were an estimated 27,000 new swine flu cases in the past week, up from 18,000 the week before. The Health Protection Agency has said this indicates a doubling of the numbers every fortnight. An increase was seen in most age groups except those over 65 years. The main age groups affected continue to be the 5 to 14 and 15 to 24 year olds. There has been an increase in deaths related to swine flu. To date, there have been 106 deaths in the UK, with 83 in England, 15 in Scotland, 4 in Northern Ireland and 4 in Wales. There has been a further rise in hospitalisations, with 364 patients with swine flu in hospital in England (as of 8am on 14 October). The proportion of hospitalised patients in critical care is at its highest level yet, at 74 patients. The disease is mild in most people so far, but is proving severe in a small minority of cases. Globally, 4,703 people with swine flu have died. In the past seven days, the total number of deaths reported globally has increased by 4% - the same increase as reported last week.
H1N1 vaccination:
Swine flu vaccination will begin next week, it was announced today. Priority groups will receive the vaccine first, including those with long-term health conditions, pregnant women, people who are in close contact with someone whose immune system is compromised, and frontline health care staff. The first batches of licensed vaccine are now in the NHS distribution network. The first supplies will reach NHS acute hospitals from 21 October. The earliest possible delivery date for the first supplies of vaccine to general practices is from the week beginning Monday 26 October 2009. On 15 October 2009, Roy Taylor, National Director for Social Care Flu Resilience, issued a letter to all Directors of Adult Social Services (DASS) to update them on the vaccination programme. Financial support for vaccination of frontline social care workers: The Department of Health has agreed to make financial support available to councils for the vaccination of independent sector workers, personal assistants and the council’s directly managed social care workers. The Department will send more information on the funding and payment arrangements in a separate letter.
Other key areas covered include: Roles and responsibilities, Data collection & Communications Involvement of local staff side / Trade Unions representatives The full letter can be found attached and at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_107196 Also on 15 October 2009, Ian Dalton, National Director of the NHS Flu Resilience at DH, issued a letter to all NHS Chief Executives in England to update them on logistical arrangements for the vaccination programme. This letter can be found at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_107086 Download the full LGA Swine flu briefing, 16 October 2009 (PDF, 3 pages, 78KB)
Link is http://www.lga.gov.uk/lga/core/page.do?pageId=4787526
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