HHS Individual Planning.
Updated federal guidelines offer state and local public health and school officials a range of options for responding to 2009 H1N1 influenza.
http://www.pandemicflu.gov/plan/individual/index.html
FEMA:
Get pandemic ready:
http://www.getpandemicready.org/
Save the Children:
http://www.savethechildren.org/publications/technical-resources/avian-flu/
Thanks for the continued pings guys & gals , I’m away on holidays this week, gonna catch up when I’m back.
FALL FLU SEASON MAY HIT HARDER WITH SWINE FLU
Officials have a plan ready if Minnesota’s health care system is swamped by 1.5 million cases.
Aug. 11, 2009
By MAURA LERNER, Star Tribune
Last update: August 10, 2009 - 11:35 PM
http://www.startribune.com/lifestyle/health/52921842.html?elr=KArks:DCiU1OiP:DiiUiD3aPc:_Yyc:aUU
State health officials warned Monday that 1.5 million Minnesotans may get the flu in coming months, straiining the ability of hospitals and clinics to care for them.
Dr. Ruth Lynfield, the state epidemiologist, said that number is based on national estimates that about 30 percent of Americans will be infected with either the new swine flu virus or the traditional seasonal flu next fall and winter.
“This is going to impact our society in many, many ways, even if this strain (of swine flu) does not become more virulent,” Lynfield told a legislative health care committee in St. Paul. So far, 253 Minnesotans have been hospitalized since May with the swine flu, also known as H1N1, and thousands more have been sickened. Two children and one older adult died. But experts are bracing for a much tougher wave this fall, the traditional start of the flu season.
According to Lynfield’s projections, some 772,000 people could flood Minnesota doctor’s offices and clinics for help if rougly half of those infected seek medical care.
Depending on the severity of the illness, she said, anywhere from 15,000 to 172,000 people may be hospitalized, and 3,600 to 32,900 could die of influenza—including those with seasonal flu.
Lynfield and her colleagues at the Minnesota Department of Health are working with hospitals and clinics to help them prepare. “We think the health care system is going to be overburdened,” she said.
In an interview, Lynfield said that if hospitals are swamped, a statewide emergency plan would kick in. “We’ve been working on this for years,” she said.
The plan calls for the creation of free-standing flu centers for people seeking treatment. Hospitals already have plans in place to delay or cancel elective procedures to free up beds if necessary. If that’s not enough, health officials would set up alternate sites to take the overflow of patients who need round-the-clock care, she said.
Even the best case scenario predicts that clinics wil be swamped. Lynfield advised people to get routine doctors appointments out of the way now, if possible. “They are going to be very busy in the fall,” she said.
At the same time, officials are putting their hopes on a new swine-flu vaccine, still in development, which could soften the blow and save lives. “A vaccine is really our best tool in the toolbox,” Lynfield said. The first doses are expected to be available by October, although there won’t be enough for everyone who wants to be vaccinated. Lynfield said priority would be given to those considered at highest risk, including children, pregnan women and health-care workers.
If the virus does turn more deadly, the state could turn to more drastic measures, such as closing schools and cancelling public gatherings.
Michael Osterholm, a pandemic flu expert at the University of Minnesota, also warned legislators that the swine flu will ripple through the economy.
“It’s going to be extremely disruptive,” he said, causing absenteeism at work and schools and interrupting supply chains of key materials, such as medications and syringes, made overseas. “Trust me, the systems are going to be severely challenged,” he said.
Dr. Greg Poland, an influenza expert at the Mayo Clinic, said it’s still too early to know how the second wave of swine flu will play out.
“I think the best guess, if what we’re seeing in the Southern Hemisphere right now holds true this fall, is that there’ll be widespread transmission,” he said. At the moment, it’s acting like a “moderate” seasonal flu in terms of its severity, but that could change, if the fatality rate increases, he said. “I think it’s fair to say it’s going to be disruptive. But it’s so hard to know.”
The federal Centers for Disease Control and Prevention (CDC) is now testing a swine flu vaccine on about 2,800 volunteers. Health officials expect to have about 160 million doses available this fall.
Officials say people may need three shots this year—one for season flu, and two doses for the swine-flu vaccine. But Lynfield warned that seasonal flu could be a bigger problem than usual, because this year’s shot is not a perfect match for the strain in circulation. “Whether we are going to be in dire straits, I don’t now,” she said. “I think that having the tools of a seasonal flu vaccine and a swine flu vaccine may have a significant impact.”
Also at Monday’s hearing, several natural-health advocates voiced concern about the risks of the swine flu vaccine, and appealed to legislators to ensure that the vaccines are voluntary. State health officials have said the vaccine would not be mandatory.
http://content.nejm.org/cgi/content/full/361/7/680
Volume 361:680-689 August 13, 2009 Number 7
Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico
Rogelio Perez-Padilla, M.D., Daniela de la Rosa-Zamboni, M.D., Samuel Ponce de Leon, M.D., Mauricio Hernandez, M.D., Francisco Quiñones-Falconi, M.D., Edgar Bautista, M.D., Alejandra Ramirez-Venegas, M.D., Jorge Rojas-Serrano, M.D., Christopher E. Ormsby, M.Sc., Ariel Corrales, M.D., Anjarath Higuera, M.D., Edgar Mondragon, M.D., Jose Angel Cordova-Villalobos, M.D., for the INER Working Group on Influenza
PubMed Citation
ABSTRACT
Background In late March 2009, an outbreak of a respiratory illness later proved to be caused by novel swine-origin influenza A (H1N1) virus (S-OIV) was identified in Mexico. We describe the clinical and epidemiologic characteristics of persons hospitalized for pneumonia at the national tertiary hospital for respiratory illnesses in Mexico City who had laboratory-confirmed S-OIV infection, also known as swine flu.
Methods We used retrospective medical chart reviews to collect data on the hospitalized patients. S-OIV infection was confirmed in specimens with the use of a real-time reverse-transcriptase–polymerase-chain-reaction assay.
Results From March 24 through April 24, 2009, a total of 18 cases of pneumonia and confirmed S-OIV infection were identified among 98 patients hospitalized for acute respiratory illness at the National Institute of Respiratory Diseases in Mexico City. More than half of the 18 case patients were between 13 and 47 years of age, and only 8 had preexisting medical conditions. For 16 of the 18 patients, this was the first hospitalization for their illness; the other 2 patients were referred from other hospitals. All patients had fever, cough, dyspnea or respiratory distress, increased serum lactate dehydrogenase levels, and bilateral patchy pneumonia. Other common findings were an increased creatine kinase level (in 62% of patients) and lymphopenia (in 61%). Twelve patients required mechanical ventilation, and seven died. Within 7 days after contact with the initial case patients, a mild or moderate influenza-like illness developed in 22 health care workers; they were treated with oseltamivir, and none were hospitalized.
Conclusions S-OIV infection can cause severe illness, the acute respiratory distress syndrome, and death in previously healthy persons who are young to middle-aged. None of the secondary infections among health care workers were severe.
This case series describes the clinical and epidemiologic characteristics of the first 18 persons with pneumonia and laboratory-confirmed S-OIV infection (also known as swine flu) hospitalized at the National Institute of Respiratory Diseases (INER) in Mexico. We also describe apparent transmission of this infection to health care workers during the initial days of the outbreak.
Methods
INER is the Mexican national tertiary care and research center devoted to respiratory diseases. The 178-bed facility provides clinical services primarily for the uninsured population of Mexico City and neighboring states. We retrospectively reviewed medical charts and radiologic and laboratory findings. This study was determined to be exempt from the requirement of institutional review, because it was conducted as part of a public health investigation into retrospective data. All tests and procedures were performed at the request of the physicians in charge of the patients. All study patients had influenza-like illness with opacities found on the chest radiograph (revealing pneumonia) and had laboratory-confirmed S-OIV infection. We also reviewed clinical data from a group of 21 hospitalized patients with influenza-like illness and pneumonia but with a negative result on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) testing for influenza A (H1N1).
Microbiologic Studies
Nasopharyngeal-swab specimens were collected at admission, and bronchial-aspirate samples were obtained after tracheal intubation. Specimens were placed in transport medium and kept at a temperature from 2 to 4°C. RT-PCR testing was done in accordance with published guidelines from the U.S. Centers for Disease Control and Prevention (CDC).7 Primers and probes for S-OIV were recently developed and distributed to the Mexican Secretariat of Health and its affiliated national institutions by the CDC. In addition, respiratory specimens from all patients were tested with the use of a multiplex PCR assay for respiratory viral and atypical bacterial panels (Seagene) for the detection of influenza A, influenza B, adenovirus, respiratory syncytial virus, parainfluenza (types 1, 2, and 3), human metapneumovirus, rhinovirus, Legionella pneumophila, Chlamydophila pneumoniae, and Mycoplasma pneumoniae.
Statistical Analysis
Data analysis was conducted using STATA statistical software.8 We compared clinical characteristics on admission between patients positive for S-OIV who died and those who survived and between patients who were positive for S-OIV and those who were negative for S-OIV. The risk of death was analyzed by means of a univariate Cox proportional-hazards model; odds ratios were calculated and Fisher’s exact test was performed for dichotomous categorical variables. Continuous data were tested by means of the Wilcoxon rank-sum test. All reported P values are two-sided and were not adjusted for multiple testing.
Results
Study Patients
The number of emergency room visits for pneumonia or influenza-like illness increased considerably at the INER in Mexico City during the last week of March 2009, peaking in late April and decreasing during the first week of May (Figure 1). From March 24 through April 24, 2009, a total of 214 emergency room consultations for cases of pneumonia or influenza-like illness were registered, 98 of which required hospitalization. Of these cases, 18 confirmed cases of S-OIV infection, with pneumonia and influenza-like illness, are the focus of this report.
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Figure 1. Emergency Room Consultations for Pneumonia or Respiratory Infection, Including Influenza-like Illness, at the National Institute of Respiratory Diseases of Mexico.
Patients with the reported cases were admitted between March 24 and April 24 (gray vertical lines). The Ministry of Health issued an epidemiologic alert on April 17 and a full sanitary alert, with closing of schools and cancellation of many public activities on April 23, after it was confirmed that the patients were infected with the novel influenza A (H1N1) virus.
Characteristics of the 18 study patients with confirmed S-OIV infection are listed in Table 1, and Table S1 in the Supplementary Appendix (available with the full text of this article at NEJM.org). The ages of the patients ranged from 9 months to 61 years (median, 38 years). More than half the patients were between 13 and 47 years of age, and 90% were less than 52 years of age. Nine patients (50%) were male.
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Table 1. Characteristics of the 18 Study Patients Who Had Confirmed Infection with Novel Swine-Origin Influenza A (H1N1) Virus.
All patients resided in the Mexico City greater metropolitan area. Eight patients had preexisting medical conditions: arterial hypertension (in three patients), non–type 1 diabetes mellitus (in three, one of whom also had hypertension), asthma (in two), and obstructive sleep apnea (in one). Only three of the patients had undergone seasonal influenza vaccination in 2008–2009; all three survived without requiring mechanical ventilation. None of the patients had a history of pneumococcal vaccination. Among the 14 patients whose occupation was recorded, 6 were students, 2 were taxi drivers, 3 were housekeepers, 1 was a locksmith, 1 was an employee of a billiards parlor, and 1 was a physician who did not have clinical duties and was not an INER employee.
The time between onset of symptoms and admission to the hospital ranged from 4 to 25 days (median, 6) (Figure 2). All patients had fever, with temperatures higher than 38°C, cough, and dyspnea or respiratory distress. Four of the five children (all under 14 years of age) had diarrhea, and only two patients (11%) reported wheezing. The median Acute Physiology and Chronic Health Evaluation II score9 was 14 (range, 4 to 32), and the median Sequential Organ Failure Assessment score10 was 6 (range, 1 to 13); both were higher, indicating more severe abnormalities among the patients who died than among those who lived (Table 2).
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Figure 2. Clinical Courses of the Study Patients.
The median time of presentation to the hospital was 6 days after the onset of symptoms. Most deaths occurred in patients who required mechanical ventilation on admission. Patient 15 was discharged from the hospital on June 8, 2009.
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Table 2. Survival and Death among the 18 Study Patients Who Had Confirmed Infection with Novel Swine-Origin Influenza A (H1N1) Virus.
Twelve patients sought medical care at other institutions as outpatients before hospitalization at INER and were treated with one or more antibiotics: ceftriaxone (five patients), amikacin (three), azithromycin (one), amoxicillin–clavulanate (two) or other macrolides (three), or another agent (two). Except for two patients transferred from other health centers, the reported hospitalization was the first hospitalization related to the disease.
Laboratory Results
At the time of admission, all 16 tested patients had elevated lactate dehydrogenase levels; levels in 10 patients exceeded 1000 IU per liter (range, 1086 to 6309). Ten of the 16 patients had increased creatine kinase levels, which were above 1000 IU per liter (range, 1099 to 5122) in 5 patients. Eleven of all 18 patients (61%) had lymphopenia (<1000 lymphocytes per cubic millimeter), 2 patients had more than 10,000 leukocytes per cubic millimeter, and 2 patients had mild thrombocytopenia at admission. Patient 3 had myocardial ischemia, as revealed on electrocardiography, with myocardial infarction documented on autopsy. Three patients had elevated creatinine levels (1.8 to 4.6 mg per deciliter [159 to 407 µmol per liter]) at admission. Four patients had d-dimer levels greater than 1000 IU per liter, and 11 patients had elevated aminotransferase levels (aspartate aminotransferase, 50 to 65 U per liter; alanine aminotransferase, 43 to 147 U per liter). Results of other routine tests were within normal limits.
The following bacterial cultures obtained within 24 hours after admission were negative: cultures of blood specimens from six patients, of bronchial aspirate samples from two patients, and of pleural-fluid specimens from one patient. Three of these patients had received antibiotics within 24 to 48 hours before admission. No other respiratory viruses or atypical bacteria were identified by means of PCR assay in any patient tested.
All 18 patients had radiologically confirmed pneumonia (Figure 3A, and Figure S2 and S3 in the Supplementary Appendix) with bilateral patchy alveolar opacities (predominantly basal), affecting three or four lung quadrants in 11 patients. Also common were linear, reticular, or nodular shadows (interstitial opacities). Findings on chest radiographs were consistent with the acute respiratory distress syndrome in all patients requiring mechanical ventilation.11
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Figure 3. Initial Radiograph of the Lung and Lung-Tissue Sample from Patient 3.
The radiograph (Panel A) shows bilateral alveolar opacities in the base of both lungs that progressed and became confluent. The specimen (Panel B, hematoxylin and eosin) shows necrosis of bronchiolar walls (top arrow), a neutrophilic infiltrate (middle arrow), and diffuse alveolar damage with prominent hyaline membranes (bottom arrow). Bacterial cultures were negative on admission, and no evidence of bacterial infection of the lungs was found. The patient ultimately died.
Treatment
None of the patients had received oseltamivir before admission; 14 received it in the hospital, at a dose of 75 mg twice a day for a minimum of 5 days; 11 began receiving it at admission (a mean of 8 days after the onset of symptoms) and 3 between 2 and 10 days after admission. Four patients who survived did not receive oseltamivir. After admission, 17 patients received ceftriaxone and 10 received clarithromycin. Additional antibiotics were prescribed in several patients, on the basis of their clinical course: three were given levofloxacin; seven, vancomycin; five, cefepime; five, imipenem; and two, dicloxacillin.
Clinical Course during Hospital Stay
Respiratory distress requiring intubation and mechanical ventilation developed in 10 patients within the first 24 hours after admission. These patients had a median oxygen saturation of 71% (interquartile range, 64 to 77) in the absence of supplementary oxygen (2240 m above sea level), and treatment of eight patients involved positive end-expiratory pressure at or above 16 cm of water. Two additional patients required mechanical ventilation during their stay in the hospital (Table S2 in the Supplementary Appendix). Duration of mechanical ventilation ranged from 7 to 30 days in patients who survived and from 4 to 17 days in patients who died. Norepinephrine infusion was begun in 9 of 18 patients (50%) during the period of hospitalization, and 5 patients received corticosteroids (hydrocortisone at a dose of 300 mg per day or methylprednisolone at a dose of 60 mg per day). Of the six patients in whom renal failure developed, five died. Seven patients had multiorgan system failure. None of the patients had disseminated intravascular coagulation or neurologic complications. Four patients had ventilator-associated pneumonia, each case with a different cause: Acinetobacter baumannii, Achromobacter xylosoxidans, methicillin-resistant Staphylococcus aureus, or Escherichia coli.
Of the 18 patients, 7 died, and 11 recovered and were discharged from the hospital. Patients died within 10 to 23 days (mean, 14) after the onset of illness and between 4 and 18 days (mean, 9 days) after admission. Figure 3B shows a lung-tissue specimen from the autopsy of Patient 3, a 43-year-old patient who died after a 14-day illness complicated by acute renal failure and myocardial infarction. Pathological evaluation of the lung showed diffuse alveolar damage, thick hyaline membranes, and prominent fibroblast proliferation.
Patients with confirmed S-OIV infection had more severe disease, including a higher death rate (Table S2 in the Supplementary Appendix), than did hospitalized patients with negative test results. The median time from illness onset to collection of samples for viral testing was 9 days (range, 3 to 46) among the 18 patients who were positive for S-OIV infection and 10 days (range, 3 to 27) among those with negative test results (P=0.50).
Clinical Infection in Contacts and Health Care Workers
Patients identified a total of 82 family contacts, 20 of whom had respiratory symptoms within a week after the patient was hospitalized. Of the 20, 4 required hospitalization, including 3 contacts of Patient 6; 1 contact who had Down’s syndrome died in another hospital from respiratory failure. Patient 2, in whom severe respiratory failure developed, is the mother of Patient 9, who had milder disease and received early treatment with oseltamivir.
Influenza-like illness or respiratory symptoms developed in 22 of 190 health care workers caring for the first three patients with confirmed S-OIV infection in the emergency room and the intensive care unit, including 19 of 104 workers who were within 2 m of a patient or had direct contact. These 22 workers received oseltamivir for 5 days and were sent home for 3 to 7 days. They had mild-to-moderate disease, and none required hospitalization. Three of the 22 workers, who were nurses in the emergency room, had nasopharyngeal-aspirate samples that were positive for S-OIV. After infection-control measures were strictly enforced — with patients confined and isolated in three hospital areas and N95 respirators used in addition to goggles, gowns, and gloves, as well as liberal use of gel-alcohol hand sanitizer — no more health care workers had influenza-like illness, although 26 additional workers received oseltamivir for 5 days because of varied respiratory symptoms.
Discussion
This case series of the first 18 patients hospitalized in Mexico City with S-OIV infection documents the clinical findings of severe illness or death associated with S-OIV infection that were seen during the beginning of the S-OIV pandemic. The patients, most of them previously healthy, had an influenza-like illness that progressed during a period of 5 to 7 days, had pneumonia, and had findings during the first day of hospital admission that fulfilled the criteria of acute lung injury or the acute respiratory distress syndrome.12 Seven patients died, all from multiorgan system failure. The most consistent laboratory characteristics were increased lactate dehydrogenase level, a total leukocyte count within normal limits, lymphopenia,13 and increased creatine kinase level, most likely due to myositis (or myocardial ischemia, in one patient).
The patients described were part of an epidemic of influenza-like illness with pneumonia seen at our institution and other Mexican hospitals, and only a fraction of them tested positive for S-OIV. A false negative test in patients who had infection with S-OIV would be more likely if the test were delayed or if patients had limited viral shedding. In general, patients who tested negative for S-OIV had a milder clinical course than those who tested positive but were as much a part of the burden of the epidemic as those who were not tested.
Risk factors for severe S-OIV illness are still unknown, but most of our patients were young to middle-aged and had previously been healthy. The majority of the S-OIV infections reported in other countries have been mild, influenza-like illnesses.2 Mexico has also reported a large number of persons with mild disease, through the national surveillance system for influenza, but the full spectrum of clinical illness has not been determined. Other countries will probably report more severe infections as the pandemic spreads and the number of infected persons increases. One contributing factor for death in our patients may have been delayed admission and delayed initiation of oseltamivir. For seasonal influenza, the elderly and young children are at higher risk for severe disease; however, more than half of our patients were between 13 and 47 years of age, which was similar to the age distribution reported in national data of H1N1 infections in Mexico.6 During the 1918 pandemic, a large number of deaths were associated with bacterial infection,14 but concurrent bacterial infection does not appear to be a major contributing factor to the severity of illness in our patients, possibly in part because most received antibiotics before hospitalization.
Mortality among the patients requiring mechanical ventilation was 58%, and although four patients had nosocomial pneumonia, in most of our patients, lung damage was most likely due to the primary effect of infection with influenza virus. Possible mechanisms of damage include direct injury to the respiratory epithelium15 with a secondary cytokine storm. We do not currently know whether our patients, especially those who died, had viremia, as was reported in association with H5N1 infection, a very aggressive variety of influenza.13,16,17,18 Coinfection with other respiratory viruses could also explain the increased pathogenicity among our patients19,20; however, no other common respiratory viruses were found in our patients. Only three of the patients had received influenza vaccine in fall 2009, since most patients were within the age groups for which vaccine was not recommended in Mexico. It is currently unknown whether seasonal vaccination offered any protection against S-OIV infection, however. We did not find a factor that, before the onset of illness, predicted a worse outcome or death among our patients.
Since 2000, the WHO has prompted countries to prepare for a potential influenza pandemic. In Mexico, pandemic influenza planning began in 2001. Activities included the introduction of yearly influenza vaccination and a program to develop the country’s national vaccine production. In 2006, a strategic reserve of oseltamivir, antibiotics, and protective items for health care personnel was established. This reserve is the source of the oseltamivir prescribed to our patients and to most hospitalized patients in Mexico. The experience in our institution highlights the need to reinforce precautions and use of personal protective equipment to prevent the infection of health care workers.
In conclusion, S-OIV infection can cause serious illness and death in young, previously healthy persons. Future studies should identify predictive factors for severe disease and, especially, the effectiveness of early oseltamivir treatment and protection offered by having undergone seasonal influenza vaccination.
No potential conflict of interest relevant to this article was reported.
We thank Celia Alpuche, M.D., from the Mexican national reference laboratory (Instituto Nacional de Referencia Epidemiologica); the CDC for providing training and primers for the real-time RT-PCR assay for the swine influenza; the Canadian National Microbiology Laboratory; Michelle Weinberg for careful review of a draft of the manuscript; and all the patients and the personnel of INER who cared for them.
* Members of the INER Working Group on Influenza are listed in the Appendix.
Canada FluWatch updated for August 2-8:
1,366-1,315 = 51 new hospitalizations.
240-227 = 13 new ICU admissions.
August 2, 2009 to August 8, 2009 (Week 31)
http://www.phac-aspc.gc.ca/fluwatch/08-09/w31_09/index-eng.php
Summary of FluWatch Findings for the
Week ending August 8, 2009
The overall influenza activity remains similar to the previous week; the reported activity level (4 regions reported localized activity) and the national ILI consultation rate (15 consultations per 1,000 visits) are comparable to last week. While the proportion of influenza positive tests decreased this week (5.5% vs. 9.9%), the overall number of influenza outbreaks increased (4 vs. 0).
* As of 8 August, 2009, a total of 1,366 hospitalized cases and 240 cases admitted to an intensive care unit (ICU) had been reported to the Public Health Agency of Canada. This week, six deaths were reported for a total of 66 deaths since the beginning of the pandemic. More than 90% of the hospitalized cases and approximately 85% of the deaths have been reported by only 4 provinces (Alberta, Manitoba, Ontario and Quebec).
* The overall Pandemic (H1N1) 2009 influenza activity is decreasing across Canada. The peak period of laboratory-confirmed hospitalizations and deaths occurred between weeks 24 to 29 (June 14, 2009 to July 25, 2009) while the peak period of symptom onset date or specimen collection date due to Pandemic (H1N1) 2009 occurred two weeks before, from June 1, 2009 to June 18, 2009.
* The proportion of females affected, the median age and the proportion of cases with underlying medical conditions increase with increasing severity of illness (on a gradient from all cases, to hospitalized cases, to ICU-admitted cases, to deaths).
* While cases under 15 years of age have the highest hospitalization rate, they have a comparatively low mortality rate except for children under 1 year of age. Adults over 65 years of age have a low hospitalization rate, but a comparatively higher mortality rate.
Updated VACCINE INFO
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/aug1409vaccine.html
Officials lower expectations for size of first novel flu vaccine deliveries
Comment: Looks like they’ll be vaccinating using Plan B (smaller group) first. From ACIP for the USA population:
Quote:
further prioritization only if supply limited: (total 47M):
pregnant women (4M)
Household contacts and caregivers for children younger than 6 months of age (5M)
Healthcare personnel and emergency medical services (14M)
Children aged 6m through 4y (18M)
Children aged 5y through 18 y with chronic medical conditions (6M)
Greece: 1,500 A H1N1 cases registered
http://www.emportal.rs/en/news/region/96471.html
16. August 2009
A 28-year-old man was admitted to the intensive-care unit of the Navy Hospital in Athens yesterday suffering from breathing problems caused by swine flu.
The unnamed man had been on vacation on an unspecified Aegean island when he began to feel unwell. Doctors said that he was in a critical condition.
Meanwhile, a 29-year-old German woman who is a member of the crew of the Aida Vita cruise ship was in stable condition at the Metropolitan Hospital in Athens after also contracting the disease.
NY:
Back-to-flu season: Schools plan for expected rise in swine flu infections
by James T. Mulder / The Post-Standard
Sunday August 16, 2009, 8:12 AM
http://www.syracuse.com/news/index.ssf/2009/08/backtoflu_season_schools_plan.html
Central New York students might get vaccinations in school in the fall to protect them from a resurgence of the H1N1 virus, or swine flu.
That’s one scenario public health and school officials are considering as they plan for an expected spike in H1N1 when schools reopen next month. The novel virus is expected to infect even more people in the fall than it did when it appeared in the spring. Youngsters are particularly vulnerable.
“It’s going to be difficult to get kids who don’t even have insurance immunized,” said Dr. Richard Kulak, director of health services for the Syracuse City School District. “So the schools are very likely going to be a source to try to make sure that occurs.”
No decision has been made to use schools as vaccination sites, according to Dr. Cynthia Morrow, Onondaga County’s health commissioner. But the county is preparing for that possibility, said Morrow, who met Monday with school superintendents to discuss H1N1 planning.
There have been no school-based mass vaccination campaigns since the 1950s, when children lined up to get the polio vaccine.
No one knows when the H1N1 vaccine, which is still being tested, will be ready or how much will be available. The latest estimate is mid- to late-October.
The federal government has been racing to get it ready because novel viruses like H1N1 historically sicken more people during the fall than during the spring. The government’s goal is to have 120 million to 130 million doses available.
Flu normally disappears during the summer. This year, however, low levels of H1N1 have continued to circulate. Once the fall arrives, temperatures drop and people spend more time indoors, making it easier for the virus to spread.
Since the spring, H1N1 has killed more than 430 Americans and resulted in treatment of more than 6,500 in hospitals. In Onondaga County, three people died and 31 were treated in a hospital.
So far, H1N1 has been a mild illness, similar to the seasonal flu. But because influenza is so unpredictable, it could become more severe.
“The greatest challenge is the uncertainty we face,” Morrow said.
Even if H1N1 remains mild, a more widespread outbreak this fall would result in more people being treated in hospitals and more deaths, Morrow said.
The resurgence could come at the same time as the regular seasonal flu.
To further complicate matters, people will probably have to get three shots: two for H1N1 and a separate one for the seasonal flu. The first and second H1N1 shots might have to be spaced three to four weeks apart, according to the federal Centers for Disease Control and Prevention.
The H1N1 and seasonal flu vaccines cannot be combined into one shot because production of the seasonal flu vaccine was well under way when H1N1 appeared in the spring.
Making sure people get all those shots might prove tricky.
Morrow is advising people to get their seasonal flu shots as soon as possible. Most primary-care providers get that seasonal vaccine in September.
The county plans to conduct its seasonal flu shot clinics beginning in October, as usual. If the H1N1 vaccine is available in time, the county will offer it at the same clinics, Morrow said.
The H1N1 vaccine will be distributed by the federal government to state health departments. States, in turn, are expected to dole it out to local health departments and hospitals.
Initially, some of the H1N1 vaccine is expected to flow to pediatricians and obstetrician-gynecologists, because they treat children and pregnant women, two of the groups considered most at risk, Morrow said.
“It’s going to take months to get people vaccinated. We need the public to be patient,” Morrow said. “They need to understand everyone won’t be vaccinated in one or two weeks.”
The federal government is expected to spend about $1 billion on the H1N1 vaccine. While vaccinators will not be able to charge for the vaccine, they will be able to charge an administrative fee that can be billed to insurers. The vaccine will be provided free to people who cannot afford the fee, Morrow said.
Morrow said she expects some people may refuse to get the H1N1 vaccine because of problems associated with the 1976 swine flu vaccine.
The federal government ordered a nationwide vaccination program that year after an outbreak of swine flu struck Fort Dix Army base, in New Jersey, killing a 19-year-old private and infecting hundreds of soldiers.
Some people who were vaccinated developed Guillain-Barre syndrome, a paralyzing nerve disease. More than 30 people died of the condition. Facing protests, federal officials canceled the vaccination program at the end of 1976.
Since that episode, annual flu vaccines have been produced without serious side effects.
“My job will be to tell people this (H1N1) vaccine is being produced the same way the seasonal flu vaccine is produced,” Morrow said.
H1N1 attacks infants, children and young adults much more aggressively than it does older people, she said. Regular seasonal flu tends to target older people.
“The most important thing for parents to do is get your child vaccinated when the vaccine becomes available,” Morrow said.
When H1N1 appeared earlier this year, some Central New York schools closed if the virus was confirmed in just a single student. That will not happen in the fall because the federal Centers for Disease Control and Prevention has changed its guidelines.
Now, schools are discouraged from closing unless there is not enough staff available to teach and care for students.
Another major change involves the amount of time students with flu-like symptoms should be kept out of school. Schools had been telling students to stay home for seven days, regardless of when they started feeling better.
Now, the CDC says they can return to school 24 hours after their fever breaks.
Parents should plan to keep sick children home for about three to five days, Morrow said.
If H1N1 comes back strong in the fall, employers will need to be liberal with their sick-leave policies, according to Morrow.
“A lot of employers are concerned about potential misuse of sick leave,” she said. “But the worst thing you can do is put pressure on people who are sick to come into work. Not only do you have a sick employee, but you have many more employees who will get sick.”
Dr. Jessica Cohen, superintendent of Onondaga-Cortland-Madison BOCES, said school districts will send letters explaining H1N1 planning to parents and employees before school opens.
Working parents should form alternate child-care arrangements just in case, according to Cohen.
“It can be inconvenient and difficult for parents,” she said.
James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com
SAfrica swine flu fatalities ‘double in two weeks’
http://www.google.com/hostednews/afp/article/ALeqM5gjPAMSvGov2bDswBwjWj7HueBVqw
South Africa’s swine flu death toll has increased to six in two weeks making the country the worst affected by the epidemic on the continent, health officials said Sunday.
Three people died last week, two pregnant women aged 23 and 27 and a man in his 60s.
“Swine flu fatalities in the country now stand at six, this makes us the leading country in Africa with the most A(H1N1) case load and fatalities,” national health spokesman Fidel Hadebe, told AFP.
He said fatalities were reported from different provinces.
South Africa reported its first infection in June and the country is dealing with some 2800 cases so far, according to the health department.
Commentary
WHO Failure to See Spread of Tamiflu Resistant Pandemic H1N1
Recombinomics Commentary 15:19
August 16, 2009
http://www.recombinomics.com/News/08160901/H274Y_WHO_See_NOT.html
China and Singapore have found Tamiflu-resistant pandemic viruses, Charles Penn, a scientist with the Geneva-based agency, said in an interview with The Canadian Press.
He revealed that the WHO has also been alerted informally to the discovery of a small number of other Tamiflu-resistant viruses. He would not say where they were found or how many there were in total.
“It’s a small number. It certainly doesn’t change the scale of what we’re seeing,” Penn said.
The above comments were issued in response to queries about osletamivir resistance in Singapore and Hunan, China, as indicated by sequences made public at GISAID and Genbank. Those two instances were acknowledged, but the rationale behind the withholding of additional cases remains unclear. At the time Thailand had already acknowledged at least one case, and additional reports from Hong Kong and an MMWR Dispatch describing two immuno-compromised patients in Washington State were made public on Friday. Cases in Texas along the border with Mexico area till being denied, although the initial report included detail on two of the cases, suggesting the denials were largely based on semantics.
The cases in Texas would change the inferred scale, because the cases were at opposite ends of the border and had much in common with the initial H1N1 described in southern California. Those cases were unlinked to each other or swine, yet the sequences were virtually identical, indicating the virus was widespread. The same conclusion could be made from the cases in Texas, which may be related to the withholding of the information associated with these cases.
However, the detail that has come out in the past few days has left little doubt that the WHO’s “scale of what we are seeing” is false. The failure to see the true scale of the H274Y spread is due to the limited testing, which is largely focused on samples collected prior to Tamiflu treatment, which can be “seen” in results from patients on prophylactic Tamiflu treatment or in samples collected a few days after the start of Tamiflu treatment in symptomatic patients.
The Hong Kong case described Friday was another patient who became symptomatic while on prophylactic Tamiflu. Earlier detail on patients in Denmark and Japan indicated they became symptomatic on day 5 of prophylactic treatment. Since the incubation period of influenza is in the range of 2-4 days, the slightly longer time period indicated the H274Y was already present when Tamiflu treatment began, but because it was a minor component, disease onset was delayed by 1-2 days. The recent patient in Hong Kong developed symptoms on day 6.
However, the confirmatory data on silent spread of H274Y came from Singapore, where additional data on first confirmed case was disclosed. The sequence was from a May 30 sample from a 28F, but the detailed reports at the MOH indicated the patient (American working in Singapore who arrived late on May 26 after becoming symptomatic during flight, but passed fever scans, but was hospitalized on May 27 and confirmed on May 28. The recent comments indicated the patient was initially Tamiflu sensitive (May 28 test), and resistance was discovered after patient improved (she was discharged May 31). Thus, the resistance in the May 30 sample was present only a few days after the start of treatment and the sequences (on HA, NA. MP) had no evidence of a mixture, indicating the resistant sequence quickly replaced the wild type sequence, signaling silently spread of H274Y.
Thus, the WHO failure to see the resistance was linked to limited and delayed testing of samples collected a few days after the start of treatment, and the standard testing / sequencing failed to detect the H274Y transmitting as a minor population. The HA Singapore sequence has a polymorphism that was found in isolates in the US, Sweden, China, and Argentina, raising concerns that the H274Y was creating additional problems in Tamiflu treated patients as seen in the two immune-compromised patients in Washington State as well as rising fatalities being reported worldwide.