CDC: 2009-2010 Influenza Season Week 45 ending November 14, 2009

Synopsis:

During week 45 (November 8-14, 2009), influenza activity decreased slightly in the U.S.

• 3,106 (28.8%) specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division were positive for influenza.
• Over 99% of all subtyped influenza A viruses being reported to CDC were 2009 influenza A (H1N1) viruses.
• The proportion of deaths attributed to pneumonia and influenza (P&I) was above the epidemic threshold for the seventh consecutive week.
• Twenty-one influenza-associated pediatric deaths were reported. Fifteen of these deaths were associated with 2009 influenza A (H1N1) virus infection, and six were associated with an influenza A virus for which the subtype was undetermined.
• The proportion of outpatient visits for influenza-like illness (ILI) was 5.5% which is above the national baseline of 2.3%. All 10 regions reported ILI above region-specific baseline levels.
• Forty-three states reported geographically widespread influenza activity, Puerto Rico and seven states reported regional influenza activity, the District of Columbia reported local influenza activity, and Guam and the U.S. Virgin Islands reported sporadic influenza activity.

-snip-

Antiviral Resistance:

Since September 1, 2009, four influenza A (H3N2), one influenza B, and 353 2009 influenza A (H1N1) virus isolates have been tested for resistance to the neuraminidase inhibitors (oseltamivir and zanamivir), and 856 2009 influenza A (H1N1) original clinical samples were tested for a single known mutation in the virus that confers oseltamivir resistance. In addition, one influenza A (H3N2) and 182 2009 influenza A (H1N1) virus isolates have been tested for resistance to the adamantanes (amantadine and rimantadine). Additional laboratories perform antiviral testing and report their results to CDC. The results of antiviral resistance testing performed on these viruses are summarized in the table below.

Click on box:

*The adamantanes (amantadine and rimantadine) are not effective against influenza B viruses.
†Two screening tools were used to determine oseltamivir resistance: sequence analysis of viral genes or a neuraminidase inhibition assay.
‡Additional laboratories perform antiviral resistance testing and report their results to CDC. One additional oseltamivir resistant 2009 influenza A (H1N1) virus has been identified by these laboratories since September 1, 2009, bringing the total number to 11.

Over 99% of all of the subtyped influenza A viruses reported during week 45 were 2009 influenza A (H1N1) viruses, and the majority of 2009 H1N1 viruses tested since April 2009 have been resistant to the adamantanes (amantadine and rimantadine).

Antiviral treatment with oseltamivir or zanamivir is recommended for all patients with confirmed or suspected influenza virus infection who are hospitalized or who are at higher risk for influenza complications. Additional information on antiviral recommendations for treatment and chemoprophylaxis of influenza virus infection is available at http://www.cdc.gov/h1n1flu/recommendations.htm.

2009 influenza A (H1N1) viruses were tested for oseltamivir resistance by a neuraminidase inhibition assay and/or detection of genetic sequence mutation, depending on the type of specimen tested. Original clinical samples were examined for a single known mutation in the virus that confers oseltamivir resistance in currently circulating seasonal influenza A (H1N1) viruses, while influenza virus isolates were tested using a neuraminidase inhibition assay that determines the presence or absence of neuraminidase inhibitor resistance, followed by the neuraminidase gene sequence analysis of resistant viruses.

The majority of 2009 influenza A (H1N1) viruses are susceptible to the neuraminidase inhibitor antiviral medication oseltamivir; however, rare sporadic cases of oseltamivir resistant 2009 influenza A (H1N1) viruses have been detected worldwide. A total of 21 cases of oseltamivir resistant 2009 influenza A (H1N1) viruses have been identified in the United States since April 2009. In specimens collected since September 1, 2009, 11 cases have been identified in the United States, including seven newly identified cases since last week and one case reported during a previous week that was reclassified. All tested viruses retain their sensitivity to the neuraminidase inhibitor zanamivir. Of the 21 cases, 12 patients had documented exposure to oseltamivir through either treatment or chemoprophylaxis, eight patients are under investigation to determine exposure to oseltamivir, and one patient had no documented oseltamivir exposure. Occasional development of oseltamivir resistance during treatment or prophylaxis is not unexpected. Enhanced surveillance and increased availability of testing performed at CDC are expected to detect additional cases of oseltamivir resistant 2009 influenza A (H1N1) viruses, and such cases will be investigated to assess the spread of resistant strains in the community.
-snip-

Pneumonia and Influenza (P&I) Mortality Surveillance

During week 45, 7.5% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage was above the epidemic threshold of 6.9% for week 45. Including week 45, P&I mortality has been above threshold for seven consecutive weeks



Influenza-Associated Pediatric Mortality

Twenty-one influenza-associated pediatric deaths were reported to CDC during week 45 (Arizona [2], Colorado [3], Georgia [2], Louisiana [2], Minnesota, Mississippi, New York, New York City, Ohio, Oklahoma, Oregon [2], Texas, Virginia, Washington, and Wisconsin). Fifteen of these deaths were associated with 2009 influenza A (H1N1) virus infection, and six were associated with an influenza A virus for which the subtype is undetermined. The deaths reported during week 45 occurred between September 20 and November 14, 2009.

Since August 30, 2009, CDC has received 138 reports of influenza-associated pediatric deaths that occurred during the current influenza season (24 deaths in children less than 2 years old, 16 deaths in children 2-4 years old, 50 deaths in children 5-11 years old, and 48 deaths in children 12-17 years old). One hundred thirteen (82%) of the138 deaths were due to 2009 influenza A (H1N1) virus infections, and the remaining 25 were associated with influenza A virus for which the subtype is undetermined. A total of 171 deaths in children associated with 2009 influenza A (H1N1) virus infection have been reported to CDC.

Among the 138 deaths in children, 74 children had specimens collected for bacterial culture from normally sterile sites and 23 (31.1%) of the 74 were positive; Staphylococcus aureus was identified in eight (34.8%) of the 23 children. One S. aureus isolate was sensitive to methicillin, six were methicillin resistant, and one did not have sensitivity testing performed. Fifteen (65.2%) of the 23 children with bacterial coinfections were five years of age or older, and six (26.1%) of the 23 children were 12 years of age or older.

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Swine Flu surge: 18 more die in Ontario, 22 in Alberta, two in B.C.

OTTAWA – 52 more Canadians have died from Swine Flu to take the national fatalities from the novel pandemic virus H1N1 to 250 from the 198 deaths that were being reported just two days ago.

The Public Health Agency of Canada reported the new tally on Thursday, indicating that between Nov. 17 and 11 a.m. EST on Nov. 19, Ontario reported an additional 18 deaths while Alberta reported 22.

B.C.’s death toll climbed to 32 with two additional deaths since the last B.C. government report which indicated on Tuesday that there had been 30 deaths across the province.

The starling jump in a reporting period of less than three days is the highest national death toll reported since the Swine Flu pandemic hit Canada in a second, more lethal wave.

Seven additional deaths were reported in Quebec to take that provinces total fatalities to 65. Quebec’s death toll has jumped significantly in one week.
-snip-
hat-tip 6180
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Drug resistant swine flu found in N.C. hospital

Drug resistant swine flu found in N.C. hospital

Posted 29m ago
By Steve Sternberg, USA TODAY
Epidemic experts have launched an investigation of four Tamiflu-resistant swine flu cases at Duke University Medical Center to see whether the resistant virus has begun spreading person-to-person at the Durham, N.C. hospital and beyond.


If so, the cluster appears to be the first instance in which Tamiflu-resistant virus has been transmitted from person to person.



"The four patients involved in this situation had the same resistance pattern," says Daniel Sexton, the hospital epidemiologist leading the investigation, adding that the Centers for Disease Control and Prevention are now testing virus samples to see whether they're identical.



"The resistance pattern suggests that might be the case," he says.
All of the patients were located in a ward for people with cancer or severe blood disorders. All were severely ill and were highly susceptible to infections, Sexton says.


The patients became ill with flu in October. When they didn't respond to Tamiflu, the hospital sent specimens of their virus to see whether the virus might be resistant to antiviral treatment. The results didn't come back until two weeks ago, prompting Duke to launch an investigation.

Sexton says three epidemiologists from the CDC as well as experts from the state health department are now at Duke assisting in the investigation. The investigation has now been extended outside Duke to determine whether Tamiflu-resistant flu is circulating elsewhere in North Carolina.
CDC spokesman Dave Daige says the agency did confirm the cases and has sent three Epidemic Intelligence Service "disease detectives" to assist in the investigation.


Three of the four Duke patients have died; the fourth is extremely ill but is being treated with another antiviral called Relenza and appears to be recovering. In addition, the Reuters wire service has reported a cluster of nine Tamiflu resistant cases of swine flu, also called H1N1 flu, in Wales.


Ann Schuchat, director of CDC's national center for immunization and respiratory diseases, said Friday that she had not heard of the Wales cluster, but acknowledged that CDC has been tracking other instances of Tamiflu resistance. "We've seen a dozen or so at this point, but the cluster issue will be an important thing to track and understand because that would be a sign of transmission," she says.



If resistant strains start spreading in the midst of a pandemic, Sexton says, they could represent a global threat and potentially increase the number of flu deaths.
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Wales: Tamiflu-resistant swine flu spreads 'between patients'

hat-tip Boneset

By Fergus Walsh
Health correspondent, BBC News

Health officials say a Tamiflu-resistant strain of swine flu has spread between hospital patients.

Five patients on a unit treating people with severe underlying health conditions at the University Hospital of Wales, Cardiff were infected.
Three appear to have acquired the infection in hospital.



They are thought to be the first confirmed cases of person-to-person transmission of a Tamiflu-resistant strain in the world.
There have been several dozen reports around the world of people developing resistance to Tamiflu while taking the drug - but they have not passed on the strain to others.


Just one possible cases of person-to-person transmission of a resistant strain has been recorded - between two people at a US summer camp - and this has never been confirmed.



Two of the University Hospital Wales patients have recovered and have been discharged from hospital, one is in critical care and two are being treated on the ward.


The health officials stressed there was no risk to anyone else.



They said tests were being carried out to confirm exactly what happened.
The UK has bought enough doses of Tamiflu, which can shorten the duration of swine flu and reduce the risk of complications, for half the population.



Serious concern
So any spread of a Tamiflu-resistant strain of the illness is a serious public health concern.
The H1N1 virus has been remarkably stable since it emerged in April, but virologists had been half expecting new resistant strains to emerge.



Dr Roland Salmon, director of the National Public Health Service for Wale's Communicable Disease Surveillance Centre, said: "The emergence of influenza A viruses that are resistant to Tamiflu is not unexpected in patients with serious underlying conditions and suppressed immune systems, who still test positive for the virus despite treatment.



"In this case, the resistant strain of swine flu does not appear to be any more severe than the swine flu virus that has been circulating since April."
Dr Tony Jewell, Chief Medical Officer for Wales, said: "We know that people with suppressed immune systems are more susceptible to the swine flu virus, which is why they are a priority group under the first phase of the vaccination programme in Wales which is progressing at pace.



"We have stringent processes in place for monitoring for antiviral resistance in the UK so that we can spot resistance early and the causes can be investigated and the cases managed.



"Identifying these cases shows that our systems are working so patients should be reassured.



"Treatment with Tamiflu is still appropriate for swine flu and people should continue to take Tamiflu when they are prescribed it.
"It's also important that good hygiene practices are followed to further prevent the spread of the virus."



On Thursday it was announced that more than three million healthy children under five across the UK will be offered the swine flu jab.
Figures released on Thursday showed an estimated 53,000 new cases of swine flu in England in the last week, down from 64,000 in the week before.
In Scotland, the figure was 21,200, down from about 21,500 in the previous seven days.
The rate of flu-like illnesses diagnosed by GPs in Wales dropped to 36 cases for every 100,000 people from 65.8 the previous week.
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Flu vaccine batch pulled in Manitoba Higher rates of allergic reaction,

More than 900 unused doses of H1N1 vaccine have been pulled out of circulation in Manitoba after health authorities received word other vaccines from the same batch have been causing higher rates of allergic reactions than expected.

Dr. Joel Kettner, Manitoba's chief public health officer, said the Public Health Agency of Canada's monitoring of the H1N1 immunization program identified about 1 in 20,000 people in Manitoba were suffering severe allergic reactions to one particular lot of the vaccine, which is about five times the usual rate in other flu vaccines and what had been expected for the H1N1 shot.

"We've been asked by the manufacturer, GlaxoSmithKline, to not use this vaccine at this time," Kettner said. "Nobody knows if anything's wrong with it at all. All we've observed so far is a somewhat higher rate of anaphylactic reaction."

Kettner said the batch of vaccine in question was distributed across the country and other provinces are also being asked to hold whatever they have left of that lot.

In Manitoba, 63,000 doses from the lot arrived during the week of Oct. 19. It was distributed to clinics in Winnipeg, Brandon, and the Parkland and Northeastman health regions, as well as to a third-party organization. It was made available as of the first week of immunization, and the vast majority has been used up. Only 930 doses remain unused: 630 in Northeastman and 300 with the organization.

Kettner stressed anyone who would have suffered a reaction to the shot would have done so within 15 to 20 minutes of getting it, and there is no lasting danger to anyone who received a shot from the lot.

Three people in Manitoba suffered a severe anaphylactic reaction to the shot from that batch, all of whom were properly diagnosed and treated at their injection clinics, with none suffering any lasting effect, he said.

Meanwhile, Manitoba Health provided its weekly statistical update on the H1N1 flu yesterday, revealing 251 more cases have been confirmed in the past week, while another person with a confirmed case has died. It is the second death from H1N1 in Manitoba this fall and the ninth since the virus appeared in the spring.

The WRHA is advising its H1N1 immunization clinics will only be open to pregnant women and healthy people age 10 to 65 until it receives more adjuvanted vaccine. Its supply of adjuvanted vaccine will likely all be used up by early this morning, leaving it only with the unadjuvanted variety to use in its clinics today and tomorrow.

The unadjuvanted version is not recommended for children younger than 10, adults older than 65, or anyone with a weakened immune system.

The WRHA's 12 mass clinics will be open 9:30 a.m. to 4 p.m. today, while two special Saturday clinics will operate during those same hours tomorrow at the University of Manitoba and at the Holy Eucharist Parish Centre on Munroe Avenue.

More adjuvanted vaccine is expected to arrive in Manitoba early next week.
hat-tip Tonka
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Gripes about swine flu vaccine abound

[All I could think of when I read this article was the Obama Health Care Reform Bill. Please write your Senators/Congressman or e-mail, or call. This coming Saturday, the Senate will "debate" the Bill. They need to hear from you].

By MIKE STOBBE (AP) – 3 hours ago

ATLANTA — When the nation's swine flu vaccination program began in early October, health officials predicted it was going to be "messy." They were right. The program has been plagued with problems and information gaps:

_Health officials have been terrible at predicting when and how much vaccine would be available. Only about 44 million doses have been shipped so far. Initially, officials said more than three times that would be out by now.

_At times vaccine shipments have been inexplicably lopsided. For example, smaller counties in Illinois and California have received the same amount delivered to counties with seven times as many people.

_Health officials have stressed that people most at risk for swine flu complications should go to the head of the line, but they haven't tried to make sure that actually happened.

_And despite pledges that they would be transparent about the vaccine program, some health officials have refused to disclose where all the doses are going, and they have held back on public service announcements telling people who should be coming in for shots. Also, many states were slow to establish Web sites that give vaccination locations.

To be fair, health officials say, the government deserves credit for a herculean effort to develop and distribute a safe and effective vaccine against a deadly virus that was first identified only seven months ago.

"You have a brand-new disease that gets identified in April. By October, you have a vaccine for it. By any standards, it's a miracle," said Dr. Diane Helentjaris, director of the Virginia Department of Health office handling swine flu response.

But complaints have been mounting, with lawmakers this week holding hearings in Washington and elsewhere, pressing for explanations.

"Calls are still coming in to me about, 'Why can't I get the vaccine?'" said Andrea Stillman, a Connecticut state senator speaking at a Wednesday hearing in Hartford.

She noted reports of uneven distribution within her state, and of places where vulnerable patients can't get the vaccine. "Obviously we're very frustrated in southeastern Connecticut," she said.

People are frustrated everywhere, said Sen. Susan Collins, R-Maine. At a hearing in Washington on Tuesday, she complained of "layers of misinformation and miscommunication."

Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics, said health officials should have done more to make sure limited doses get to the people most at danger from the virus. And he said they should have been tougher on nurses and other health-care workers who are putting their patients at risk because they declined to get a shot.

"It is not working right at all," Caplan said.

In their defense, officials at the U.S. Centers for Disease Control and Prevention have said that the main issue is insufficient vaccine from manufacturers — something CDC can't control — and that health authorities are doing the best they can.

"A lot of this is a function of not having as much vaccine as we would like to have," said Dr. Anne Schuchat, who heads the agency's immunization section.

The new swine flu, also called 2009 H1N1, has not turned out to be the deadly global disaster that experts have long feared. But it has sickened an estimated 22 million Americans, hospitalized about 98,000 and killed 4,000. It has proved to be similar to seasonal flu but a much bigger threat to children and young adults.

There was no vaccine to protect against the new virus, so manufacturers had to create a new one. In July, a government health official estimated 120 million vaccine doses would be available by late October. Later, the government backed away from that estimate when manufacturers couldn't crank out vaccine so rapidly.

The CDC has been coordinating the vaccine campaign, but it is not fully in charge. As a matter of tradition and law, states have had more public health authority than the federal government. Each state health department has made decisions about which clinics, doctor's offices and other sites get vaccine from a federally contracted distributor.

"It's a little bit of a messy process and we expect it to be somewhat bumpy in the first few weeks," CDC Director Dr. Tom Frieden said in early October.

The bumps lasted more than a few weeks.

Health officials seem to have a poor idea of how many doses to expect. Two weeks ago, they predicted 8 million doses in the following seven days; it turned out to be 5 million — largely because a tropical storm nearly derailed some deliveries.

Blown delivery promises have had ripple effects at the state and local level. In Alaska, deliveries have lagged significantly, and other states report similar experiences. "We've learned to not put too much faith" in any extended vaccine supply estimates, said South Dakota Health Secretary Doneen Hollingsworth.

Demand has far exceeded supply in many places, and hundreds and even thousands people have waited hours in line. Many have been turned away when the vaccine ran out or the clinic hours ended.

One Delaware pediatrician, Dr. David Epstein, said patients were "banging on the door" for swine flu vaccine, and at some moments he felt like a United Nations relief worker in a refugee camp. "Everybody is desperate for it," said Epstein, who ordered 2,300 doses but had received only 300 as of last week.

Supply problems have forced states to make hard decisions about where to send the doses and which patients should get it.

Tennessee kicked off its campaign by targeting health-care workers, and many rejected the offer. Georgia emphasized getting initial doses to pediatricians and clinics that serve children. Minnesota randomly sent vaccine to clinics across the state as it became available, and then let the providers decide which patients should get it first.

"We haven't tried to micromanage the administration of the vaccine," said Buddy Ferguson, a spokesman for the Minnesota Department of Health.

Authorities made few attempts to police the crowds to make sure priority groups — like pregnant women, young people and those with certain health problems — got vaccine first.

There were inequities, too.

According to Illinois newspaper reports, tiny Kendall County got enough doses to cover nearly 20 percent of its residents, while Will County — with nearly seven times as many people — got just enough for 2 percent.

In California, Santa Cruz County at one point got nearly 30,000 doses, while Santa Clara County — again, with nearly seven times as many people — got less than half as much, local media reported.

In New York, Buffalo schools wanted to start vaccine clinics but hadn't received a single dose. School officials there were irate to learn New York City schools had begun vaccinating hundreds of thousands of students.

"How could the city of Buffalo, which contains the second-largest school district in New York State, not have been designated by your office to receive a proportional share of vaccine supply?" Buffalo schools Associate Superintendent Will Keresztes wrote Nov. 5 to the state health department.

Some inequities were corrected as more vaccine became available. But suspicions that money or politics played a role in some places were fed by news two weeks ago that Wall Street giants Goldman Sachs and Citigroup received swine flu vaccine for some employees.

Also contributing to public mistrust are health officials themselves. CDC officials have stressed repeatedly that they are striving to be transparent. They have held frequent news conferences and given updates on vaccine availability and the disease's toll.

But the CDC has refused to release information about where all the publicly financed vaccine has been going. The agency punted the question to states, but some states have been tightlipped, too.

If swine flu had turned out to be deadlier, the delays and communication problems might have been catastrophic. Now, cases are declining across much of the country.

Indeed, health officials are now beginning to worry that demand for the vaccine may wane, just as vaccine is becoming more plentiful, just as states are perfecting Web sites that help people locate providers, just as new efforts are under way to encourage more health workers to get vaccinated.

Federal health officials say they expect to start running a public service campaign about the shots shortly.

Associated Press writers Carla K. Johnson in Chicago; Zinie Chen Sampson in Richmond, Va.; Kristin Hill in Nashville, Tenn.; Susan Haigh in Hartford, Conn.; Carolyn Thompson in Buffalo, N.Y.; Randall Chase in Dover, Del.; Wayne Ortman in Sioux Falls, S.D.; Rachel D'Oro in Anchorage, Alaska; and Steve Karnowski in Minneapolis contributed to this report.

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H5N1 reminds us it's still here, despite swine flu pandemic

Scott McPhearson's blog:

Posted on Thursday, November 19, 2009 at 10:07AM by Scott McPherson in Politics and government, influenza and infectious diseases | Post a Comment

Recent reports confirm the return of H5N1 bird flu in poultry in Thailand and Vietnam. And in today's proMED report, a 21-year old Egyptian college student has a case of confirmed H5N1 bird flu.

The reports of the return of bird flu should not be surprising. Just because we're in the (so far, mild) grip of the first pandemic of the information age (I coined that term, as everyone knows) does not mean other flu strains cannot also continue infecting animals.

What is interesting is the case of the Egyptian college student. He reportedly had slaughtered poultry just days before his onset of symptoms, and it is to the Egyptian doctors' credit that they had the presence of mind to test the lad for H5N1 as well as H1N1.

There is no word if a co-infection was present, but this does confirm the concern that Egyptian authorities have expressed ever since they ordered the slaughter of every pig in the nation (overkill, to be sure). Namely, they were worried about Egypt becoming the mixing vessel for an H1/H5 mutant virus.

This makes the third time and third locale that H5 and H1 have rubbed elbows. In Vietnam and in Indonesia, the two viruses were in extremely close physical proximity to one another. Now, in the midst of the current (first?) wave of swine flu in Egypt, a young adult acquired bird flu.

I don't have the stats on seasonal flu in Egypt currently, but here in the US, of some 5,400 suspected flu samples submitted to the CDC for testing, only four -- FOUR! -- were seasonal flu. The remaining positive samples were confirmed H1N1v, influenza B, or the nefarious "untyped" influenza A.

Is it possible, then, that there are more diagnosed and undiagnosed H5N1 human cases in Egypt currently than there are cases of human seasonal flu? Interesting speculation. I leave it to you.

As winter approaches, we know we will get more H5N1 cases in birds and in people. And we know this H1N1v pandemic has a long way to go. So settle in for the long haul.

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INFLUENZA PANDEMIC (H1N1) 2009 (108): PAHO UPDATE

A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases


Date: Mon 16 Nov 2009
Source: Pan American Health Organization (PAHO), Epidemiological
Alerts [edited]



Regional update: pandemic (H1N1) 2009
-------------------------------------
The information contained within this update is obtained from data
provided by Ministries of Health of Member States and National
Influenza Centers through reports sent to the Pan American Health
Organization (PAHO) or updates on their web pages.


Evolution of the pandemic
-------------------------
North America
-------------
In Canada, the national influenza-like illness (ILI) consultation
rate slightly decreased compared to last week but remained above
average for the 6th consecutive week. The number of influenza
outbreaks remained high and these outbreaks were mostly reported in
the school setting. The proportion of tests positive for influenza
again increased this week to 38.1 percent from 36.3 percent (EW 43).
The total number of hospitalizations of persons with pandemic
influenza increased again this week; and hospitalization rates were
highest among those less than 20 years of age.

In Mexico, trends of acute respiratory disease remained unchanged,
with high intensity of acute respiratory disease, and moderate impact
of acute respiratory disease on health care services. Of note is that
the number of ILI [influenza-like illnesses] and severe acute
respiratory illness (SARI) cases, in EW 39 [27 Oct-3 Nov 2009],
surpassed what was observed in the 1st wave of the pandemic.

In the United States, the proportion of outpatient consultations for
ILI decreased for the 2nd consecutive week. Laboratory-confirmed
influenza hospitalization rates remained high, especially in children
0 to 17 years of age. The proportion of deaths attributed to
pneumonia and influenza remained above the epidemic threshold for the
6th consecutive week. 9 of 10 sub-national surveillance regions
reported decreases in proportion of outpatient visits for ILI as
compared to the previous week, but all 10 reported a the ILI
proportion to be above their region-specific baseline. A total of 35
influenza-associated pediatric deaths were reported this week, of
which 26 were associated with the pandemic virus. In total, since 30
Aug 2009, 98 pediatric deaths associated with the pandemic virus have occurred.

Caribbean
---------
These countries are reporting mostly unchanged trends in acute
respiratory disease and high intensity of acute respiratory disease.
Impact of acute respiratory disease on health care services was
reported as moderate. In countries providing these data, severe acute
respiratory infection (SARI) hospitalization rates decreased this
week, after 4 consecutive weeks of increases.

Central America
---------------
This week, among the countries that provided information, trends of
acute respiratory disease decreased. Intensity of acute respiratory
disease remained low/moderate and impact of acute respiratory disease
on health care services was low.

South America
-------------
Andean:
These countries continued to report widespread influenza activity.
Acute respiratory disease trends were reported as decreasing or
unchanged in most countries of the region, except Colombia and Peru,
which reported an increasing trend in acute respiratory disease. In
Peru, in the last week, the greatest increase in the number of
confirmed cases was observed in parts of the northeast jungle region.
In Ecuador, nationally, trends of acute respiratory disease were
reported as unchanged, but 3 of 24 provinces reported increases in
the number of SARI cases as compared to the prior week.

Venezuela's Ministry of Health reported that the outbreak of acute
respiratory infection in indigenous Yanomami communities has ended.
[For details, see ProMED-mail Influenza pandemic (H1N1) 2009 (90):
Venezuela, Yanomami 20091105.3820].

Southern cone:
Most of these countries reported decreasing or unchanged trends of
acute respiratory disease. This week, Paraguay reported 2 of 17
departments with an increasing trend of acute respiratory disease, as
compared to 8 departments last week; its overall national trend was
decreasing. All of these countries are reporting a low or moderate
impact of acute respiratory disease on health care services.

Weekly summary
--------------
- influenza-like illness activity remained above what is expected for
this time of year in Canada and the United States; in Mexico, it
surpassed the level that was observed during the 1st wave of the pandemic
- Caribbean countries reported mostly unchanged trends but high
intensity of acute respiratory disease this week
- Central America continues to report overall decreasing trends in
acute respiratory disease
- Most of South America had stable or decreasing trends of acute
respiratory disease, with the exception of Colombia and Peru, which
reported an increasing trend
- Venezuela reported that the outbreak of acute respiratory illness
in the Yanomami communities has ended
- a median of 99.9 percent of subtyped influenza A viruses were
pandemic (H1N1) 2009
- 294 new confirmed deaths in 8 countries were reported; in total
there have been 4806 cumulative confirmed deaths.

Descriptions of hospitalizations and deaths among confirmed cases of
pandemic (H1N1) 2009
----------------------------------------------------------------------
A table containing case counts reported to PAHO can be accessed via
the source URL above.

Approximately half of hospitalized cases were among women. Children
continued to be the age group with highest hospitalization rates.
Underlying co-morbidities were present in approximately half of
hospitalized cases.

Overall, approximately half of deceased cases were among women. In
the Dominican Republic, however, 82 percent of their 22 deaths were
among women and approximately 67 percent of deaths among women were
in pregnant women. The percentage of cases with underlying
co-morbidities varied from 58.3 percent to 76.1 percent.

Viral circulation
-----------------
For the purpose of this analysis, only countries, which reported data
on influenza A subtypes were considered. We excluded from the
calculations of the percentages, results from samples of influenza A
that were not subtyped or were unsubtypeable. Pandemic (H1N1) 2009
continues to predominate among circulating subtyped influenza A viruses.

Antiviral resistance
--------------------
The Centers for Disease Control and Prevention (CDC) complete
antiviral susceptibility testing on isolates submitted by various
countries in the Region. To date, 277 samples submitted from 18
countries were found to be sensitive to neuraminidase inhibitors
(oseltamivir and zanamivir). In the United States, a total of 15
cases of oseltamivir-resistance have been identified. Of the 15
oseltamivir-resistant cases, 13 had documented exposure to
oseltamivir, one case had no documented oseltamivir-exposure, and one
case is under investigation.

As of 13 Nov 2009, a total of 4806 deaths have been reported among
the confirmed cases in 27 countries of the Region.

In addition to the figures displayed in the table available at the
URL above, the following overseas territories have confirmed deaths
of pandemic (H1N1) 2009: United Kingdom Overseas Territories; Cayman
Islands (1 death); French Overseas Communities: Martinique (1 death);
Guadeloupe (1 death).

The distribution of cases and deaths at the 1st sub-national level
can be found in the interactive map available through the following
link: .

--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
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Commonground Comments

In Vietnam, China, Taiwan and South Korea, we get disclosure on the age, location, when they were put on antiviral medication, we get the onset of their illness, and date of death.

The U.S. does not report on names, locations, or ages of it’s victims of A/H1N1. We do not usually get a date of death. We do not get a duration of their illness. Because of the laws that the health officials are beholden to, they also do not report any specifics on their medical protocol for any given victim.

Therefore, we can not track any human-to-human transmission, nor can we track geographic spread. We also can not track any Tamiflu or Relenza resistance.

Some of this is not important for this particular pandemic. It is mild. Some of it is still important...like resistance to antivirals.

We have to wait for the authorities to hand us an update on the situation.

That goes against the grain of my driving force to investigate this pandemic. I have been tracking H5N1 for almost 4 years....because I needed to know myself. Not wait for an update from the “authorities”, with whatever it is they choose to tell me.

I can’t begin to tell you how frustrated and cynical I have become.
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