Macau, the first new variant of influenza virus infection of the deceased to determine

NEW YORK, Macao from the Influenza A H1N1 influenza has been recorded a total of two deaths, respectively in early September to early October this year, the first a wave of influenza was recorded during peak periods, including one called the 40-year-old daily healthy women, Another was 72-year-old male suffering from multiple chronic diseases.

Sample of the woman by the Hong Kong Department of Health laboratory analysis, identified as the recently discovered around the world D222G variant. The woman at the August 18 transfer from the Kiang Wu Hospital Conde General Hospital intensive care, rescued by the medical personnel is invalid, at noon on September 2 died. The incidence of middle-aged women with symptoms of fever and sore throat over and over again about eight days, initially in the emergency treatment fails, then deteriorated again attendance at the Kiang Wu Hospital and later diagnosed as influenza A H1N1 influenza, with bilateral pneumonia and respiratory failure, transferred to a general hospital intensive care unit Conde. The woman sustained critical condition after admission, consciousness almost lost their senses, blood pressure instability, severe respiratory failure has been required mechanical ventilation continued to use high concentrations of oxygen therapy, high concentrations of boost drugs and cardiac stimulant to maintain blood pressure, clinical worsening respiratory failure and the emergence of sepsis. Until the morning of September 2, his condition worsened again, after the medical staff once again to impose a CPR rescue measures proved ineffectual, at 12:05 where he died.

In late November of this year, the Norwegian public health research in two deaths and one cases of severe cases, found that the kinds of mutant viruses. According to WHO data, the first such mutation was detected in April this year. In addition to outside of Norway, in Brazil, China, Japan, Mexico, Ukraine and the United States and other countries have found that mutation of the virus. According to information provided by the Hong Kong Department of Health in Hong Kong found five cases of variant strains of virus infection cases, 2 cases were 37-year-old and 40-year-old woman died and another three cases have already been recovered.

Health Bureau is to maintain close contact with WHO, will arrange for more samples associated tests, are closely monitoring the spread of the virus variant and public health significance, and to be vigilant, pay attention to the possibility of viruses of great significance for public health More changes.

Health Bureau said that at present the World Health Organization has not been established whether the mutation to make it easier for the patient's condition serious, but it certainly is the current vaccine in use around the mutant virus as well as the variability of Tamiflu-resistant strains of the virus is still effective.

At present the Australian Influenza A H1N1 influenza virus activity of the signs of a slight increase in the first two waves of influenza occur at any time in Macau. 6 months to 9 years of age children were inoculated three weeks apart the first two, only a half months before and after the required protection, the health bureau urged the public to be vaccinated as soon as possible as soon as possible to be protected.

There are individual members of the public misunderstanding Influenza A H1N1 influenza vaccination screening form signed before the "life and death", the health bureau, said the main purpose of the screening form is to enable members of the public to fully understand the role of vaccines, side effects and contraindications, to facilitate the a large number of medical personnel to determine the suitability of the proposed by the kinds of persons vaccinated. Screening form signed by the kinds of persons does not exclude the authorities should bear any responsibility.

December 6, due to flu-like symptoms to the Conde hospital emergency room for treatment of children accounted for 70% of the number of pediatric patients, adults accounted for 31% of adults in attendance. December 7, there are two classes of local influenza-like symptoms due to the cluster events to be closed. Health authorities are continuing to closely monitor the schools, homes and other institutions, the prevalence of influenza.

As the afternoon of December 7, the local continued not recorded new Influenza A H1N1 confirmed patients were hospitalized; the current number of patients the hospital is zero.

December 7, there are 1044 passengers accepted the H1N1 influenza vaccinations. From November 23 to now, total of more than 15109 times have attended the H1N1 influenza vaccinations.

hat tip Treyfish

FEMA And The FCC Announce Adoption Of Standards For Wireless Carriers To Receive And Deliver Emergency Alerts Via Mobile Devices

[Nothing to do with infectious diseases, but thought I should pass this on....]

Release Date: December 7, 2009
Release Number: HQ-09-148

WASHINGTON D.C. -- As part of the Integrated Public Alert and Warning System (IPAWS), the nation’s next generation of emergency alert and warning networks, the Department of Homeland Security’s Federal Emergency Management Agency (FEMA) and the Federal Communications Commission (FCC) today announced the adoption of the design specifications for the development of a gateway interface that will enable wireless carriers to provide its customers with timely and accurate emergency alerts and warnings via their cell phones and other mobile devices.

The Commercial Mobile Alert System (CMAS) is one of many projects within IPAWS intended to provide emergency mangers and the President of the United States a means to send alerts and warnings to the public. Specifically, CMAS provides Federal, state, territorial, tribal and local government officials the ability to send 90 character geographically targeted text messages to the public regarding emergency alert and warning of imminent threats to life and property, Amber alerts, and Presidential emergency messages. The CMAS is a combined effort of the federal government and cellular providers to define a common standard for cellular alerts.

Today’s announcement marks the beginning of the 28-month period, mandated by the FCC in August 2008, for commercial mobile service providers who have elected to participate in the design specifications known as CMAS to develop, test and deploy the system and deliver mobile alerts to the public by 2012.

“Working as a team with our partners in the public and private sectors, the adoption of the CMAS standard brings us even closer to making the nation’s next-generation of emergency alerts and warnings – Integrated Public Alert and Warning System (IPAWS) – a reality,” said FEMA Administrator Craig Fugate. “Our goal is simple, to give one message over more devices to more people for maximum safety.”

“Today’s announcement brings us one step closer to ensuring that Americans receive critical emergency alerts and warnings to protect themselves on the go, anywhere, anytime,” said FCC Chairman Julius Genachowski. “I applaud FEMA for its leadership and look forward to working with both FEMA and the wireless industry to expedite the delivery of this important public safety service to consumers.”

Wireless carriers who choose to participate in the CMAS will relay authorized text-based alerts to their subscribers. To ensure that persons with disabilities who subscribe to wireless services receive these emergency alerts, the FCC adopted rules in 2008 that will require participating wireless carriers to transmit messages with both vibration cadence and audio attention signals.

The adoption of CMAS culminates the collaborative specification development work between FEMA, the Department of Homeland Security Science and Technology Directorate (DHS S&T), the Alliance of Telecommunications Industry Solutions (ATIS), and the Telecommunications Industry Association (TIA) and begins the next phase of CMAS collaboration with industry in which FEMA will build the Federal Alert Aggregator/Gateway. This collaboration with industry is a key component of the Integrated Public Alert and Warning System (IPAWS) Programs’ ability to provide alerts and warnings to the public through as many means as possible, including commercial mobile services.

FEMA’s mission is to support our citizens and first responders to ensure that as a nation we work together to build, sustain, and improve our capability to prepare for, protect against, respond to, recover from, and mitigate all hazards.

A New Way To Treat H1N1 At UNC Hospitals

[I am not sure if this person is the 4th case or not.]
Previous Post:
Excerpt:

Both clusters, detected in Wales, UK and North Carolina, USA, occurred in a single ward in a hospital, and both involved patients whose immune systems were severely compromised or suppressed. Transmission of resistant virus from one patient to another is suspected in both outbreaks.

In the USA outbreak, which involved four severely immunocompromised patients, cases occurred in a two-week period between mid-October and early November. Three of the four cases were fatal, but the role of H1N1 infection in contributing to these deaths is uncertain.
http://pandemicinformationnews.blogspot.com/2009/12/who-oseltamivir-resistance-in.html

12/06/09 02:45PM

Dr. Charles van der Horst, professor of medicine and infectious diseases at UNC, says Lillian Chason, the UNC student in critical condition with swine flu, has been receiving a new form of treatment. Relenza, or properly known as Zanamivir, is usually inhaled for treating and preventing influenza. Dr. van der Horst and colleague Christopher Hurt, from UNC’s Center for Infectious Diseases, are each leading the first studies of medications for IV treatment of influenza.

Dr. van der Horst says Chason’s case is a good example for why IV treatment for the flu, whether seasonal or H1N1, is over due. The UNC freshman is on a ventilator and cannot be orally administered Tamiflu and can’t inhale the aerosolized Relenza.

To receive the treatment intravenously, a patient has to be hospitalized with the flu for at least five days. Dr. van der Horst’s study is open to pregnant women and patients on ventilators, like Chason.

Novel H1N1 hasn’t shown the resistance to Relenza as it has with Tamiflu. Last month, three people infected with a mutation of H1N1 that is resistant to Tamiflu died at Duke University Hospital.

Gaza Strip: After the emergence of 5 cases .. Fears of the arrival of influenza to Gaza

Dominated by concern for the people of border areas in North Sinai, for fear of leakage of swine flu to them from the Gaza Strip after it published a number of Palestinian media that there were 10 cases of the disease and death in the Gaza Strip, where she said that at least ten children have died from the injury of swine flu in the Gaza Strip .

The sources said that Hamas, which controls the Gaza Strip hospitals prevented a permit or leaked the pretext of maintaining calm and not to create confusion in the sector.

The sources pointed out that the departments of hospitals in the Gaza Strip, which Hamas-appointed associates pretend to have citizens who lose their parents and their children that the death was natural or due to illness and a regular secret of the fact epidemic infected pigs, where she died of citizenship Nevin Jesus in their twenties with the disease.

The medical sources and media in Gaza, noted a few days ago a wave of severe flu, widespread and sweeping the Gaza Strip, and are different from previous years in terms of severity of patients and length of stay in condition, although dealing with treatment of her, but was quick to deny Hamas the health of the news and the assertion that the sector Gaza free of swine flu on Sunday, however, Hamas declared the emergence of 5 cases of the sector effectively.

On the other hand demanded that the opposition leaders in northern Sinai, raising the level of preparedness on the border to prevent infiltration by Palestinians, with emphasis on detection of cases that pass through the Rafah crossing to Egypt.

Ashraf said the Secretary-Hefny party rally that was noted by the Palestinian media was genuine, it is extremely dangerous and should prepare ourselves for lack of transmission to the Sinai and to prepare a full and careful at the same time through the border and the Rafah crossing.

According to Mustafa, the leading singer in the People's Committee for Civil Rights that there should be follow-up all come from the Rafah crossing to Egypt in anticipation to be the carrier of the disease, also called for the need to verify the accuracy of the published sites, especially as a Fatah are the ones that published the story, but not the sites by the Hamas, and perhaps be political differences behind this serious matter but he added that Hamas on Sunday confirmed the emergence of 5 cases of a serious matter indeed.

The Ala Reagent Information Secretary that they will start soon in a campaign to educate the residents especially the inhabitants of the border to take caution, because - God forbid - if go to the Sinai will be a major disaster, especially as the Sinai clean of any epidemic, not only bird flu or pigs.

Egypt: Girl with bird flu infection in Matrouh

Sunday, December 6th, 2009 - 18:58
Girl hit by bird flu in Matrouh Governorate

Department of Health confirmed the city Dabaa 140 km east of Matrouh Saturday of bird flu, a girl from the village of Nag Sawyery olive detained University Hospital in Alexandria.

The symptoms of the disease have appeared on the Q. P. M (17 years) Vtm samples and send them to the laboratories of the Ministry of Health, was transferred last Friday to the affected University Hospital in Alexandria for treatment.

Have been received on Saturday positive test results Faqamt Department of Health immediately sent a team of doctors to examine the contacts of the girl and clean her home.
hat-tip Twall

At death's door with H1N1 for three weeks

By JOSEPHINE MARCOTTY, Star Tribune

Last update: December 6, 2009 - 8:02 AM

Kim Lange's son was still coherent when the doctor said it was time to put him on a ventilator. He was as stoic as he could be -- a 23-year-old who had never been sick. But the look of terror in his eyes as he looked up from the hospital bed tore her heart.

"He said, 'Worst- case scenario, huh, Mom?' '' Lange recalled. "And I fell apart.''

Her son, Brad, just had the flu. The same H1N1 virus that has infected an estimated 22 million people in the United States -- and left most of them largely unscathed.

But in a small fraction of children and young adults the virus is unexpectedly deadly. For unknown reasons some perfectly healthy patients, like Brad Lange, end up in the intensive care unit, drowning in their own fluids.

It's a mystery that health officials badly want to solve, because H1N1 will most likely be back, maybe sooner than later.

As the New England Journal of Medicine put it recently: "No one should be complacent about an unpredictable virus capable of killing children and young adults in their prime."

Kim Lange certainly isn't.

Not anymore.

"Brad was always so proud that he never got sick," she said. "That's why this is so unusual that it would happen to him of all people." Brad Lange, of Hugo, started feeling lousy on a Saturday in mid-October. He was at a furniture store with his fiance, and he remembers looking longingly at the couches, keeping his eye out for the one he could fall into if he passed out.

On Monday he went to the doctor, who told him he had pneumonia and sent him home with pills. On Tuesday, when his temperature hit 104 degrees, his mom took him to the emergency room, where he got intravenous fluids and more pills. On Wednesday he went back to the doctor, who called an ambulance to take him from the clinic in Forest Lake to United Hospital in St. Paul. An ambulance? Kim Lange was shocked.

"Pneumonia. That was all. That's what I had," Brad Lange recalled. "I didn't know how serious pneumonia can get."

-snip-

Spain reports mutant swine flu death

05/12/2009

Madrid - A patient infected by a mutant strain of the swine flu A(H1N1) virus has died in Spain, the health ministry said Friday.

"We have registered three cases of mutation, including one which was fatal. These are three isolated cases, there has been no transmission to any other person," a ministry spokesman told AFP.

It is the sixth fatal case of mutated A(H1N1) virus in Europe, after one in the Netherlands and two each in France and Norway.

Last month the World Health Organisation said that mutations had been observed in Brazil, China, Japan, Mexico --, where the swine flu pandemic began -- Ukraine and the United States as early as April.

Italy also reported a non-fatal case on Monday.

"The mutations appear to occur sporadically and spontaneously. To date, no links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread," a WHO statement said on November 20.

The WHO also underlined that there was no evidence of more infections or more deaths as a result, while the mutated virus detected up to that point remained sensitive to antiviral drugs used to treat severe flu, oseltamivir (Tamiflu) and zanamivir (Relenza).

Scientists fear that mutations in flu viruses could cause a more virulent and deadly pandemic flu. The global health watchdog reiterated a call for close monitoring.

One of the three patients infected in Spain had a mutation which made the virus resistant to Tamiflu but was successfully treated with another medication, the health ministry spokesman said.

The two other patients, including the one who died, were infected with another type of mutation which was identical to the one detected for the first time in November in Norway, he added.

The patient who survived with this mutation had a "light form" of the disease, he said.

Spain has so far recorded 169 deaths related to the swine flu virus, according to the latest toll issued by the health ministry. It was the first European country to confirm a case of the virus.

Japan: H1N1 pandemic continues

Health officials across the globe continue to report cases of new influenza A (H1N1) but the World Health Organisation says the pandemic may be peaking in some countries.

The Japanese government says that the number of deaths from new influenza A (H1N1) has hit 100. The latest fatality was a 74-year-old man from Kyoto. Health authorities say the man had an underlying illness.

The Chinese government says its A (H1N1) death toll has now risen to 200; the vast majority of fatalities, 194 of them, were reported in November. According to the health ministry, the cold weather is behind the rapid rise in the number of deaths.

Beijing plans to immunise almost 65 million people by the end of the year; almost 27 million people have been vaccinated so far. The health authorities have reported 92,904 cases of A (H1N1).

Almost 10 million people across the European Union have now been vaccinated against pandemic influenza. On Thursday the Dutch authorities reported the first fatality due to infection by a mutant strain of the A (H1N1) virus. Health officials say the man, who died in the northern city of Groningen, is the third person in the country carrying a mutant strain resistant to Tamiflu, an anti-viral medication used to treat influenza.

A non-fatal case of mutant AH1N1 was reported by the Italian authorities on Monday. So far five people have died of mutated A (H1N1) in Europe.

Although the World Health Organisation says new influenza appears to have peaked in some countries, the WHO's top flu expert says a third wave of infections may be ahead. The global health organisation says more than 207 countries have reported laboratory confirmed cases of pandemic influenza H1N1 2009. The global death toll now stands at 8,768.

Norway: Two more with the mutated virus

Previous posts:

Excerpt:
Variant of swine influenza specifically attack the lung with young children
2009-12-05
Visit to the United States is Hong Kong's Research Hospital in St. Zhu De, Department of infectious diseases, virologists Weishi Bo (Webster), Professor said that the U.S. is now the second wave of swine influenza in the fall period,....

Weishi Bo also said that Norway discovered variant of swine flu, the global Nianer 200 cases have been found, because of its viral proteins, the regional variations in the H22, so that variants of swine influenza on children under ten or highly lethal, the virus can penetrate the lungs in patients with , resulting in two deaths in Norway, the deceased black lung, such as coke.
http://pandemicinformationnews.blogspot.com/2009/12/variant-of-swine-influenza-specifically.html

Excerpt:
Monday, November 23, 2009
Health Authorities Examine Reports Of Mutated H1N1
Samples of the H1N1 virus obtained by two patients who had died from the disease in Norway contained a mutated form of the virus, the WHO said Friday, Agence France-Presse reports. Health authorities also detected the mutated form of the virus in a third Norwegian patient with severe symptoms of the flu. "However, [the WHO] stressed that the mutation did not appear to cause a more contagious or more dangerous form of A(H1N1) influenza and that some similar cases observed elsewhere had been mild," the news service writes (11/21).
http://pandemicinformationnews.blogspot.com/2009/11/h1n1-spreading-eastward-who-says.html

05.12.09

Health authorities have found two more cases of mutated swine influenza virus in Norway. Now it turns out that up to six - not three - of the dead were outside the risk groups.

Thus, it found a total of five cases of what is internationally referred to as the Norwegian mutation. The last two people who have developed the mutation, have not had any contact with each other and not with the other three.

Preliminary test.
"It suggests that there is more sporadic cases, and that the mutated virus has not spread, but that the mutation has occurred at the individual," says physician Bjørn Iversen at the NIPH.

He points out that the last two mutations are not finally confirmed, but preliminary tests indicate that it is the same mutation. The mutated virus has the ability to attach themselves very far into the lungs and cause pneumonia. Because pneumonia is caused by viruses, not bacteria, it can not be treated with antibiotics.
At the mutated virus attaches itself so far down, probably reduces the risk that it infects others.

Health authorities do not know why the virus has mutated in just these five people.
-There is probably a pure coincidence, but in general we can say that the longer a person is influensasyk, the greater risk is that the virus muterer, explains Iversen.
hat-tip Treyfish

Statement By The Welsh Assembly Government On Latest Developments In Respect Of The Influenza A (H1N1) Swine Flu Pandemic

Previous post here:
http://pandemicinformationnews.blogspot.com/2009/11/news-update-on-person-to-person-spread.html
25 November 2009

One additional patient has tested positive for swine flu resistant to Tamiflu at a Cardiff hospital unit.

The patient – who was linked with the previous group of five people found to be resistant to Tamiflu last week – was tested as part of the routine screening arrangements introduced at the University Hospital of Wales.

Test results are still awaited on one other direct contact of the six patients with swine flu resistant to Tamiflu.

Date: 06 Dec 2009
Excerpt:

Eight patients on a unit treating patients with severe underlying health conditions at the University Hospital of Wales, Cardiff, have been diagnosed with swine flu resistant to Tamiflu. Three appear to have acquired the infection in hospital. All patients diagnosed with Tamiflu-resistant swine flu on the unit have been treated with an alternative antiviral. All other patients on the unit have been tested for swine flu. Three of the patients remain in hospital, with one in critical care and the others being treated in isolation on the unit. All patients are responding well to treatment. There is no evidence of spread of the Tamiflu-resistant strain of swine flu outside the unit.

Patients have been isolated or are being cared for in a designated area for influenza cases, and Cardiff and Vale University Health Board has ensured that all appropriate infection control measures are in place on the unit. Patients and staff at the unit have been offered swine flu vaccination, while patients due to come into the unit for treatment are being advised to have the vaccination from their GP in advance of coming to the hospital.

The discovery of new cases of bird flu Menoufia

Sunday, December 6th, 2009 - 11:55


Evidence of new positive case of bird flu Menoufia
Menoufia - Ayman Hassanein


Dr. Ahmed Fouad Ghoneim, General Manager of Veterinary Medicine Menoufia proved positive new cases of bird flu, a woman named Samia Abdel-Latif El-Bassiouni (35 years) and a resident Bazbp Rashid read out the center, pointing out that she was detained Fever Hospital El Kom.

Ghoneim said that the cause of injury to the situation in contact with dead birds and breeding birds live inside her house and was immediately given proper treatment and culling of birds in a home and which amounted to 140 chickens in addition to cleansing the house and neighboring houses chlorination and sampling of the rest of the family to make sure they are free from disease and sent to laboratories in Cairo, the ministry for analysis.
hat-tip Twall

The Ministry of Health confirms that the arrival of the swine flu virus resistant to Tamiflu, to Egypt

Saturday, December 5th, 2009

The announcement of WHO on the transmission of swine influenza virus resistant to treatment with Altammivloa for the first time since the discovery of the virus, to open the door to a new wave of evolution of the virus, which experts said was a new virus that no one knows the nature of the prevalence or Thorath and resistance to treatment.
-snip-
The Ministry of Health formed a committee to examine the death of the tenth case, due to the injury of swine flu, which was suspected of resistance to treatment Baltammivloa, but it has not yet been proved.

The WHO has indicated in published urgent this morning, it had registered for the first time two cases of infection caused by H1N1 viruses resistant to oseltamivir, the scientific name of the property wizard to swine influenza virus to "Altammivloa."

The first group launched by [snip] "and Wales" which was recorded in England, which was unveiled in late October last eight patients, was the introduction of all these patients to the hospital because of bloody unrest and tent. Has not been recorded any deaths among them so far, note that being treated and one of them in the intensive care ward.

The second group is a United States of America, which included four patients with a general shortage of Immunology, The cases occurred over two weeks in the period between mid-October and early November of last November, has resulted in three cases of a total of four cases of death, but that uncertainty does not continues to control the extent to which the H1N1 virus in the occurrence of such deaths.

Included all viruses H275Y resistance mutation itself, which refers to the resistance to the drug oseltamivir treatment of influenza first mutated and sensitivity about zanamivir, a drug the second anti-virus software.

The World Health Organization, once receiving reports, to organize a telephone conference with officials of the hospitals and their staff and experts in the fields of clinical medicine, epidemiology and virology to discuss the outbreaks mentioned, calling attention therapeutic options that can be made available to the immunocompromised patients who are infected with HIV pandemic.

UK: Change in swine flu virus is my biggest fear: Liam Donaldson

By Rebecca Smith, Medical Editor
Published: 6:17PM GMT 03 Dec 2009

Sir Liam Donaldson, the Chief Medical Officer: "My biggest fear is swine flu mutation." Photo: GEOFF PUGH

Cases of the H1N1 pandemic virus are dropping but the risk remains that the strain could change into something more virulent, he said.

Sir Liam revealed so-called 'drift' of the virus, where it changes slightly over time, was his biggest worry.

Experts have warned that although the virus is causing only mild illness in the majority of people currently, it could still change into a more dangerous disease.

Flu viruses have shown they can mutate easily and they can also mix with other strains raising the concern that swine flu could mix with the more deadly bird flu.

It comes after Tamiflu-resistant swine flu emerged in Wales and spread between very sick patients in a hospital ward. The strain does not appear to have escaped from the hospital and there have been no further cases.

Resistant forms have been found in other countries around the world.

Sir Liam revealed his 'worry list' for the first time, and said: "The biggest worry of all is the fear of mutation. We hear people saying something funny has happened (to the virus) in Norway or France but fortunately we have not seen any change in the virus so far.

"We are not claiming victory, there are still too many things to worry about, particularly at the severe end of the disease spectrum and it is still early days as far as the NHS winter is concerned."

Prof David Salisbury, head of immunisation at the Department of Health, said the vaccines with adjuvants, substances which boost the immune system and allow less active ingredient to be used in each dose, offer good protection even if the virus does change.

The GlaxoSmithKline vaccine, Pandemrix, which forms the bulk of the government programme, contains an adjuvant.

Prof Salisbury said: "One of the advantages with adjuvanted vaccines is their ability to protect against drifted strains. It opens the door for a whole new strategy in dealing with flu."

Sir Liam said his other major concerns were that the NHS could still face severe pressure this winter with ordinary seasonal flu coming after waves of swine flu, other respiratory infections and bad weather combining to stretch the service to it's limits.

And he is worried that there is a 'continuing stream' of children under five in hospital with severe swine flu and complications and that people are still dying from it.

Overall it is estimated there were just 22,000 new cases of swine flu last week, the lowest since the last week of September - near the start of wave two.

There have been 178 deaths in England linked to swine flu and 270 in the UK as a whole, Sir Liam said.

However, despite the drop in new cases, there are still high numbers in hospital, with over 700 patients in wards on Wednesday and 161 of them in critical care, which is only a slight drop on the previous week.

There are now more children under five with swine flu in hospital and in critical care that at any time and they remain the age group hardest hit by the virus.

Sir Liam said the numbers of children in hospital were for suspected swine flu and another virus called respiratory syncytial virus (RSV) which affects children at this time of year annually and has very similar symptoms.

A spokesman for the Health Protection Agency said their data was showing that RSV rates were 'in-line with previous years'.

The vaccination programme is due to be rolled out to children between six months and five years-old once the risk groups have been completed.

So far 11.2 million doses of Pandemrix, the GlaxoSmithKline vaccine, have been sent out to health services, along with 500,000 doses of Celvapan, made by Baxter.

It is estimated 1.6 million doses have been administered to people in the risk groups, including people with long-term conditions and pregnant women.

So far 275,000 doses have been administered to front line health workers in England, more than twice the number of doses of ordinary seasonal flu that were given in the whole of last year.

The figures suggest that front line health workers are not shunning the vaccine as some had feared.

2 Drug-Resistant H1N1 Cases Reported In Pa.

Dec 4, 2009 8:21 pm US/Eastern

PITTSBURGH (KDKA) -The standard treatment for H1N1 is anti-flu drug Tamiflu, so when cases of Tamiflu-resistant H1N1 turn up, it is concerning.

There are two cases in our state. Public health officials and hospitals have a plan, if they're faced with a local case.

"Tamiflu has been our mainstay of therapy. And yes, as we get more and more resistance, we do have some concerns about that," says Dr. Bruce Dixon, of the Allegheny County Health Department.

The state lab has been testing whether the virus samples it receives would respond to this drug.

"They've detected two cases in the state, in the eastern part of the state, and I don't think that's unexpected. We're seeing growing numbers in the country of resistant viruses showing up, and we know flu mutates quite readily," Dr. Dixon continues.

A series of steps would be taken should there be a local patient with drug-resistant virus.

In the hospital, some aspects would be the same as if they were dealing with a regular strain.

"The isolation we would use for any influenza case would be the same, people wearing gloves, and surgical masks when they're seeing the patients, everybody would already be in a private room," explains Dr. Amesh Adalja, a critical care medicine fellow at UPMC.

The treatment, though, would be different with an alternate anti-flu drug -- Relenza. It is typically inhaled, but when a patient is very ill, it has to be given by vein and that requires special permission from the hospital and the drug company.

"There's no evidence that this virus causes any more damage than the regular one. The prognosis may be a little worse because it's harder to get effective antiviral treatment to this patient," says Dr Adalja.

The health department would also take action.

"We look carefully to see if there are other family members that are ill, if there are other friends in their immediate circle of acquaintances who have gotten infected," Dixon said. "We do that regularly with the severe cases of H1N1."

The health department is reminding people that they will be holding an H1N1 vaccine clinic again this weekend. The vaccine will help prevent Tamiflu resistant cases in general, by cutting down on the number of people with H1N1 all together.

Variant of swine influenza specifically attack the lung with young children

Variant of swine influenza specifically attack the lung with young children
2009-12-05

Has emerged the world's 40 drug-resistant swine influenza viruses, University of Hong Kong Li Ka-shing (related) such as Harvard University School of Medicine in conjunction with the United States to conduct the study.

(Roundup) (Sing Tao Daily reported) the number of pick-up in swine influenza infection, there are visits to Hong Kong virus, experts believe that Hong Kong may have entered the swine flu, the second wave, although the epidemic is expected to moderate, but found the world's emerging 200 Nianer were variants of swine influenza virus, lethal for children under ten or stronger, the virus will go into the lungs; Experts urge people to fight swine influenza vaccine as soon as possible, but also proposes that the Government will be free for children vaccination of swine influenza vaccine policy and consists of six extended to the age of ten or below for children.

Visit to the United States is Hong Kong's Research Hospital in St. Zhu De, Department of infectious diseases, virologists Weishi Bo (Webster), Professor said that the U.S. is now the second wave of swine influenza in the fall period, but since the outbreak of swine influenza throughout the country since there are eight million 16 children under the age of infection, 36000 were hospitalized, 540 children died from swine flu, compared with an annual average of only 80 children die from seasonal influenza, a difference of nearly seven times the number of deaths.

Weishi Bo also said that Norway discovered variant of swine flu, the global Nianer 200 cases have been found, because of its viral proteins, the regional variations in the H22, so that variants of swine influenza on children under ten or highly lethal, the virus can penetrate the lungs in patients with , resulting in two deaths in Norway, the deceased black lung, such as coke.

He was worried that the United States when the third wave of swine flu, would be led by a variant of swine influenza virus, when more children will be subject to attack, but also worried that swine influenza virus and up to five percent of the deadly H5N1 bird flu virus reshuffle, will be more lethal severe.

Weishi Bo added that the U.S. is now a trial drug Peramivir, intensive care for children with severe swine influenza treatment, the drug directly into the blood vessels, a considerable effect, but each time you use are subject to prior approval of the U.S. Centers for Disease Control and Prevention (CDC) approval.

Hong Kong people infected with swine flu, the number rebounded Wei Shibo that, there are likely to have entered the second wave of swine flu, it is estimated that the overall epidemic in other countries or regions are similar, are considered moderate.

As concerns the virus variants influence, he worried that children under ten or infections as severe as with the United States, so that Hong Kong free of charge for children under six plan to fight flu shot, might consider extending to the old, "even if the virus mutates, the vaccine and drugs are still effective. "

In addition, the global drug resistance has emerged 40 of swine influenza virus, in conjunction with the University of Hong Kong Li Ka Shing School of Medicine at Harvard University and other mathematical model of the relevant research shows that in an influenza pandemic, the early use of a single antiviral drugs, such as Tamiflu, infection rates of up to Qi Cheng.

However, if at an early stage (community population, lower than the percentage rate of infection 1:00), restraint and medication, only the use of Relenza or amantadine, or mix them and Tamiflu can reduce the resistance, and also would reduce the transmission rate less than 5 into 7.

Participated in the study of Hong Kong School of Public Health assistant professor of beard-kei said: "This response is the nature of the insurance, but the Government has implemented, is still considering a number of factors, it is necessary to see the public would accept."
hat-tip Treyfish

CDC MMWR: Safety of Influenza A (H1N1) 2009 Monovalent Vaccines --- United States, October 1--November 24, 2009

December 4, 2009 / 58(Early Release);1-6
Excerpt:

CDC and FDA staff members searched the VAERS database to identify all U.S. reports of adverse events after vaccination with H1N1 vaccines and 2009--10 seasonal influenza vaccines during July 1--November 24. The first doses of H1N1 LAMV became available to the public in the United States on October 5, and H1N1 MIV became available the following week. VAERS reports were coded as fatal or nonfatal serious adverse events (defined by federal regulation as those resulting in death, life-threatening illness, hospitalization, prolongation of hospitalization, persistent or significant disability, or congenital anomaly) or as nonserious,^† and reporting rates per 1 million doses distributed as of November 20 were calculated.^§

VAERS reports coded as serious adverse events are reviewed by medical officers and assigned to predetermined broad diagnostic categories. To verify the reported event, medical records are requested and reviewed for all serious adverse event reports and for any reports (both serious and nonserious) that describe patients with possible Guillain-Barré syndrome or anaphylaxis. Cause of death is determined as stated in medical or autopsy records. Reports to VAERS indicate only that health events occurred after vaccination; causality generally cannot be determined solely by reports to VAERS. Excluded were 62 reports with insufficient information.

Through November 24, VAERS received 3,783 reports of adverse events after receipt of H1N1 vaccine, of which 204 were categorized as serious, and 4,672 reports after receipt of seasonal influenza vaccines, of which 283 were serious. During October 5--November 20, a total of 46.2 million doses of H1N1 vaccines (11.3 million LAMV and 34.9 million MIV doses) and 98.9 million doses of seasonal influenza vaccines were distributed to U.S states and territories. The overall VAERS adverse event reporting rates were 82 per 1 million H1N1 vaccine doses distributed and 47 per 1 million seasonal influenza vaccine doses distributed. The serious adverse event reporting rates were 4.4 and 2.9 serious adverse events per 1 million doses distributed for H1N1 vaccines and seasonal influenza vaccines, respectively. However, the percentage of serious adverse events among all adverse events reported after receipt of seasonal influenza vaccines was slightly higher (6.1%), compared with the percentage of serious adverse events after receipt of H1N1 vaccines (5.4%), and this finding was consistent for inactivated (5.8% versus 5.5%) and live attenuated (7.3% versus 4.7%) vaccines (Table 1).

VAERS received 13 reports of deaths occurring after receipt of H1N1 vaccine; three deaths occurred after receipt of LAMV and 10 after receipt of MIV (Table 2). In nine of these deaths, significant underlying illness (including illness that might be indication for vaccination) was present; one death resulted from a motor vehicle crash, and the remaining three deaths await review of final autopsy results or death certificates by CDC.

As of November 24, VAERS had received 10 reports of Guillain-Barré syndrome, and two additional reports of possible Guillain-Barré syndrome were identified by medical officers reviewing other reports to VAERS describing neurologic events. After chart review, four of these 12 reports (all after receipt of MIV) met Brighton Collaboration criteria^¶ for Guillain-Barré syndrome, four did not meet the criteria, and four are under review. VAERS also received 11 reports of anaphylaxis, and an additional eight reports of possible anaphylaxis were identified by medical officers reviewing reports to VAERS of serious allergic events. Of these 19 cases, 13 met Brighton Collaboration criteria, five had an anaphylaxis diagnosis on medical record review, and one has not been confirmed. Three of the Guillain-Barré syndrome cases and 15 of the anaphylaxis cases were coded as serious adverse events, in accordance with federal regulation.

The remaining 173 nonfatal serious adverse events after vaccination with H1N1 vaccines are under chart review. These reports fall into the following diagnostic categories: neurologic or muscular condition other than Guillain-Barré syndrome (49 [28%]); pneumonia or influenza-like illness (27 [16%]); other noninfectious conditions, including multiple medical symptoms (19 [11%]); respiratory or ear, nose, and throat condition (17 [10%]); allergic conditions other than anaphylaxis (16 [9%]); pregnancy complications** (15 [9%]); other infectious symptoms (10 [6%]); gastrointestinal (eight [5%]); cardiovascular (six [3%]); and psychiatric (six [3%]). Each category includes a variety of diagnoses; no patterns were identified.

CDC FluView: 2009-2010 Influenza Season Week 47 ending November 28, 2009

Excerpts:

U.S. Virologic Surveillance:

WHO and NREVSS collaborating laboratories located in all 50 states and Washington D.C., report to CDC the number of respiratory specimens tested for influenza and the number positive by influenza type and subtype. The results of tests performed during the current week are summarized in the table below.
Click on image:

*Subtyping results for the majority of specimens in this category were inconclusive because of low virus titers.

During week 47, seasonal influenza A (H3N2) and influenza B viruses co-circulated at low levels with 2009 influenza A (H1N1) viruses. Over 99% of all subtyped influenza A viruses reported to CDC this week were 2009 influenza A (H1N1) viruses.

Click on image:

Maryland: Mutated swine flu in city raises concerns

By Kelly Brewington
December 3, 2009
A mutated strain resistant to the most commonly prescribed drug used to treat swine flu has surfaced in Baltimore, raising concern among experts that the virus could become harder to treat.

The cases of two cancer patients at Johns Hopkins Hospital who contracted the mutated strain are the first involving Tamiflu-resistant H1N1 in Maryland and are among 75 worldwide.

Health officials, noting that the Hopkins patients recovered, say there is no cause for alarm because the cases are isolated and have not spread. But the local cases, diagnosed in October and November, come on the heels of similar mutations found last week in four cancer patients at Duke University Medical Center in North Carolina - three of whom died - and in another cluster of patients at a hospital in Wales.

Dr. Trish Perl, a Hopkins epidemiologist, said hospitals need to be careful about hygiene and watch for new strains, that doctors should prescribe Tamiflu only when necessary, and that the public should get vaccinated against swine flu to avoid transmission.

"Probably, this mutation is out there, so what we want to do is to engage everyone in thinking about this more, particularly the medical community," Perl said. "This is a big wake up call for us. We are going to be more vigilant."

The Hopkins patients were two men who have since been discharged. One was admitted to the hospital after complaining of fever. Doctors tested him for influenza and the sample was sent to the state Department of Health and Mental Hygiene, which has been testing for virus mutations since summer. The other patient was being treated at the hospital and did not get better after taking Tamiflu. Samples sent to the state lab confirmed a mutated strain.

Officials at Hopkins and at the state health department would not disclose more information on the men's conditions, ages or hometowns. Officials said the patients were not likely to spread the virus. The men, who had weakened immune systems which made them more susceptible, were cared for in private rooms by medical staff wearing masks.

-snip-

British officials said they have found 24 swine flu viruses with a mutation associated with Tamiflu resistance

Britain: Swine flu cases fall by more than half, WHO says it's too soon to say it's peaked

By THE ASSOCIATED PRESS (CP) – 7 hours ago

LONDON — British officials say swine flu cases in England fell by more than half last week, with about 22,000 new cases.

The week before, the government guessed there were 46,000 new infections, though the numbers have a big margin of error. The number of cases has been falling for weeks, but World Health Organization officials say it's too soon to say whether this wave of swine flu has peaked.

In a statement Thursday, British officials said they have found 24 swine flu viruses with a mutation associated with Tamiflu resistance. Contrary to WHO guidance, Britain gives out Tamiflu liberally, and does not require a doctor's advice to get the antiviral. Critics warn that could speed up the development of resistant viruses.

Netherlands reports mutant swine flu death

THE HAGUE — Dutch authorities said Thursday a patient infected by a mutant strain of the swine flu virus had died, but added that this was not the cause of death.

Harald Wychgel, spokesman for the Dutch Institute for Health and the Environment, told AFP that there had been a "minor change in the virus to make it resistant to Tamiflu," a key treatment for influenza.

"He died not because the virus was resistant but because he was seriously ill and caught the Mexican (swine) flu," Wychgel said.

The man, whose age had not been given, died Sunday in the northern city of Groningen, local health official Hans Coenraads said.

"We have carried out tests on the patient's associates to see if the mutation had spread but we found no such indications", he said.

Reports said that two more patients in the Netherlands had shown resistance to Tamiflu.

It is the fifth fatal case of mutated A(H1N1) flu in Europe, after two in France and two in Norway.

The World Health Organisation said last month that mutations had been observed in Brazil, China, Japan, Mexico, where the swine flu pandemic began, Ukraine, and the United States, as early as April.

Italy also reported a non-fatal case on Monday.

"The mutations appear to occur sporadically and spontaneously. To date, no links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread," a WHO statement said on November 20.

The WHO also underlined that there was no evidence of more infections or more deaths as a result, while the mutated virus detected up to that point remained sensitive to antiviral drugs used to treat severe flu, oseltamivir (Tamiflu) and zanamivir (Relenza).

Scientists fear that mutations in flu viruses could cause more virulent and deadly pandemic flu. The global health watchdog reiterated a call for close monitoring.

"Although further investigation is under way, no evidence currently suggests that these mutations are leading to an unusual increase in the number of H1N1 infections or a greater number of severe or fatal cases," it added.

WHO: It's too early to say pandemic has peaked

Robert Roos News Editor

Dec 3, 2009 (CIDRAP News)

The World Health Organization's (WHO's) top influenza expert said today it's too soon to judge whether the H1N1 influenza pandemic has passed its peak, though he acknowledged that cases are dropping in the United States and Canada.

"It's too early to say whether activity is peaking in the Northern Hemisphere, and it's not possible to predict what will happen in the spring," said Dr. Keiji Fukuda, special adviser to the WHO director-general on pandemic flu.



In response to questions, Fukuda said it's premature for the WHO to start formal discussions on whether the pandemic has crested. "In some countries there are still increasing infections, even though there are some countries, such as the United States and Canada, where infections are going down," he said.

Formal discussions on whether the pandemic is waning won't come until "sometime in 2010," he said.

Recent reports indicate that that the second wave of pandemic is ebbing in the United States and Canada. The latest report from the US Centers for Disease Control and Prevention (CDC), covering the third week in November, said physician visits for flu-like illness dropped for the fourth straight week.



And the Public Health Agency of Canada said on Nov 27 that all provinces and territories had reached "a possible epidemic peak."



The evidence from Europe is less clear. Today's update from the European Centre for Disease Prevention and Control (ECDC) said H1N1 deaths increased by 6% last week, signaling a slower rise in mortality, as the toll had been nearly doubling every 2 weeks over the preceding 6 weeks.



In other comments today, Fukuda said the WHO has not calculated a case-fatality rate (CFR) for the pandemic, after a reporter noted that the CDC recently estimated the US CFR to be .018%.

Fukuda said CFR estimates depend today, as in past pandemics, mainly on gathering data on all deaths and then using modeling techniques to estimate how many were flu-related. "People don't count flu deaths on a one-to-one basis," he said.



"It's much too soon to have the kind of vital record health data that's typically used to model estimates of overall [flu] deaths," he added. "I think it'll take another 1 to 2 years after the pandemic to collect this kind of data and come up with estimates."

The WHO estimates that 150 million doses of H1N1 vaccine have been distributed in about 40 countries so far, Fukuda said.

Meanwhile, the WHO released a statement today to allay concerns it said have been voiced in the news media that experts on some of the agency's advisory committees have pharmaceutical industry ties that influence policy decisions related to the pandemic.



The statement says the WHO has historically collaborated with the pharmaceutical industry because efforts to improve health depend on access to effective and affordable medicines, vaccines, and diagnostics. The agency said it has many safeguards to identify and deal with potential conflicts of interest.



The statement also says public perceptions of the H1N1 pandemic have been strongly influenced by the 5-year history of worry about the deadly H5N1 avian influenza virus. "Adjusting public perceptions to suit a far less lethal virus has been problematic," the agency said. "Given the discrepancy between what was expected and what has happened, a search for ulterior motives on the part of WHO and its scientific advisers is understandable, though without justification."

In the briefing, Fukuda emphasized the necessity of WHO's collaboration with many partners, including private companies, though he didn't mention media criticisms.

"It's the private sector that makes vaccine," he said. "Most vaccine is not made by governments, but by companies in the private sector, both in developed and developing countries. It's this group which has unique knowledge of vaccines because they manufacture them. It's essential for public health to access this knowledge."
hat-tip Harfang

Transplant infectious disease experts provide pandemic guidance

Public release date: 3-Dec-2009

Swine flu has major implications for solid organ transplants

Surgeons and other healthcare professionals specialising in solid organ transplants have been issued with expert advice to guide them through the complex clinical issues posed by the global H1N1 (swine flu) pandemic.

The paper, published online by the American Journal of Transplantation, also urges them to stay alert to the significant concerns that swine flu could combine with seasonal flu, and possibly even bird flu (H5N1), to develop into a strain with unpredictable virulence.

"The current virus pandemic can cause severe disease in transplant patients and could be transmitted from donors" explains assistant professor Dr Deepali Kumar, an expert in transplant-related infectious diseases from the University of Alberta, Canada. "This has major implications for donor selection and transplant management and care."

Dr Kumar has teamed up with infectious disease experts from across Canada and the USA to discuss the solid organ transplant guidance issued as part of the wider H1N1 guidelines produced by the American Society of Transplantation (AST) and The Transplantation Society (TTS), which are updated online as new information emerges.

The article, fast-tracked for online publication, has been produced on behalf of both societies and carries the additional endorsement of the Canadian Society of Transplantation.

It includes discussions about clinical presentation, diagnosis, therapy and prevention, specifically addressing areas such as chemoprophylaxis, immunization and donor-derived infection.

"Reaction to this novel respiratory virus in the transplant community has been swift, as clinicians have real concerns about the prevention, diagnosis and treatment of the flu virus as public health data mounts and the course of the pandemic evolves" says Dr Kumar.

"The International Society for Heart and Lung Transplantation has already developed guidelines for heart and lung transplant recipients in the pandemic setting, raising concerns about transmission from donors to recipients.

"However, autopsy studies suggest that other organs, such as the brain, kidney, pancreas, spleen, liver and heart, can also become infected. This pandemic has important clinical implications for all stages of the solid organ transplant process."

Key points raised by the discussion document include:

• All patients with influenza-like illnesses, and milder symptoms such as a persistent runny nose, should be tested for the virus and empiric antiviral therapy considered.
• Some experts recommend continuing antiviral therapy until viral replication has ceased and clinicians should base their therapy decisions on current advice from the Centers for Disease Control (CDC) and individual patient assessments.
• Some experts also recommend that the oseltamivir (Tamiflu) dose may be doubled in critically ill patients and a significant reduction of immunosuppression is recommended in patients with significant disease.
• However it should be noted that a CDC study (August 2009) reported oseltamivir resistance in two immunocompromised patients.
• Transplant patients and donors should receive at least one dose of H1N1 vaccine. Recent studies show that in healthy adults a single dose of inactive split-virus 2009 H1N1 vaccine had a seroconversion (antibody production) rate of 96.7 per cent, while a single dose of a vaccine containing adjuvant MF59 achieved 76 per cent.
• People who receive a Live Attenuated Influenza Vaccine may shed the virus for up to 21 days after immunization.
• There is currently no data on the duration of antiviral therapy that donors with H1N1 must undergo before organs can be safely used. If the donor has not completed a course of treatment, the current recommendation is to give the recipient five to ten days of antiviral therapy, at therapeutic not prophylaxis doses.

"As new information emerges about novel H1N1, updates will be made to the electronic guidance document posted on the AST and TTS websites so regular visits are recommended" stresses Dr Kumar.

###

The paper is available free online at: http://www3.interscience.wiley.com/cgi-bin/fulltext/123198716/HTMLSTART

Notes to editors

Guidance on Novel Influenza A/H1N1 in Solid Organ Transplant Recipients. Kumar et al on behalf of the AST Infectious Diseases Community of Practice and Transplant Infections Diseases Section of TTS. American Journal of Transplantation. Online publication ahead of print (December 2009). doi: 10.1111/j.1600-6143.2009.02960.x Available free online at: http://www3.interscience.wiley.com/cgi-bin/fulltext/123198716/HTMLSTART

American Journal of Transplantation is the leading, most authoritative source for current clinical and research results on all aspects of transplantation. As the official publication of the American Society of Transplantation and the American Society of Transplant Surgeons, the American Journal of Transplantation serves as a forum for debate and reassessment, an agent of change, and a major new platform for promoting understanding, improving results, and advancing science in organ and tissue transplantation. For more information, please visit www.amjtrans.com.

Wiley-Blackwell is the international scientific, technical, medical, and scholarly publishing business of John Wiley & Sons, with strengths in every major academic and professional field and partnerships with many of the world's leading societies. Wiley-Blackwell publishes nearly 1,500 peer-reviewed journals and 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit www.wileyblackwell.com or www.interscience.wiley.com

WHO alert/update entitled "Oseltamivir resistance in immunocompromised hospital patients" Is Misleading

In the post below this one, entitled:

"WHO: Oseltamivir resistance in immunocompromised hospital patients"

The article clearly states that one third of all cases were immunocompromised. I believe they should have put "one third" in the title. It is misleading. All cases were not from immunocompromised patients.

Within the past two weeks, the number of documented cases of oseltamivir resistance in H1N1 viruses has risen from 57 to 96.

Around one third of these cases occurred in patients whose immune systems were severely suppressed by haematological malignancy, aggressive chemotherapy for cancer, or post-transplant treatment.

WHO: Oseltamivir resistance in immunocompromised hospital patients

2 DECEMBER 2009 | GENEVA --

WHO has been informed of two recent clusters of patients infected with oseltamivir-resistant H1N1 viruses. Both clusters, detected in Wales, UK and North Carolina, USA, occurred in a single ward in a hospital, and both involved patients whose immune systems were severely compromised or suppressed. Transmission of resistant virus from one patient to another is suspected in both outbreaks.

The emergence of drug-resistant influenza viruses in severely immunosuppressed or immunocompromised patients undergoing antiviral treatment is not unexpected and has been well documented during seasonal influenza. Virus replication can persist in such patients for prolonged periods of time despite antiviral treatment, creating an environment in which drug-resistant viruses can readily be selected. This phenomenon has also been observed for the pandemic (H1N1) 2009.

Upon receipt of the reports, WHO organized a telephone conference with officials and staff from the hospitals and experts in clinical medicine, epidemiology, and virology to discuss the two outbreaks. Particular attention is being given to the best treatment options for immunocompromised patients who become infected with the pandemic virus.

The outbreaks

The Wales outbreak, which was detected in late October, involved eight patients. All of these patients were hospitalized because of severe haematological disorders. No deaths occurred. Three of these patients remain in hospital, with one being treated in intensive care.

In the USA outbreak, which involved four severely immunocompromised patients, cases occurred in a two-week period between mid-October and early November. Three of the four cases were fatal, but the role of H1N1 infection in contributing to these deaths is uncertain.

All of the resistant viruses carried the same H275Y mutation, indicating resistance to oseltamivir but susceptibility to the second antiviral drug, zanamivir.

Ongoing investigation

The outbreaks are being further investigated to determine the mode of transmission within the wards and to ensure that resistant viruses have not spread to staff, other patients in the hospitals, or into the wider community. Results to date are reassuring.

No illness in staff caring for these patients has been detected, suggesting that the resistant virus does not spread easily to otherwise healthy people, especially when good measures for infection control are in place. Moreover, intensified surveillance has found no spread to other wards within the two hospitals or into the wider community.

Modified treatment recommendations

The experts agreed that severely immunocompromised patients need to be regarded as an especially vulnerable group. These patients are highly susceptible to infection, particularly difficult to treat, and especially likely to develop resistance.

As early signs of influenza may be masked by symptoms associated with underlying disorders or their treatment, the experts further agreed that doctors treating such patients should operate with a high level of suspicion for influenza virus infection and be especially vigilant for the rapid development of oseltamivir resistance.

In these patients, standard treatment doses and duration for treatment with oseltamivir are unlikely to be sufficient. Though clinical judgement is important, doses may need to be increased and continued, without interruption, for the duration of acute illness. Zanamivir should be considered as the treatment of choice for patients who develop prolonged influenza illness despite treatment with oseltamivir.

Once oseltamivir resistant virus has been detected in a ward treating severely immunocompromised patients, doctors should consider switching to zanamivir as the antiviral drug of first choice for treatment and when considering post exposure prophylactic treatment of other patients on the ward.

The experts were emphatic in their recommendation that health care staff, carers and family contacts of patients be vaccinated against pandemic influenza.

Vigilant monitoring needed

WHO recommends vigilant monitoring for the development of oseltamivir-resistant viruses and for any changes in the transmissibility or pathogenicity of these viruses. Experience with seasonal influenza viruses shows that resistant viruses can quickly spread within the general population and become established, rendering one or more antiviral drugs ineffective.

Experience acquired since the initial characterization of the H1N1 pandemic virus in March shows that the neuraminidase inhibitors, oseltamivir and zanamivir, when administered early, reduce the risk of complications and may also improve the clinical outcome in patients with severe disease. This experience underscores the need to protect the effectiveness of these drugs by minimizing the occurrence and impact of drug resistance.

WHO received the first report of an oseltamivir-resistant pandemic virus in July. In general, cases of oseltamivir resistance have been geographically dispersed, sporadic and not linked to one another. The number of these events has been steadily increasing, in line with recent increases in influenza activity in many parts of the world and a corresponding increase in the administration of antiviral drugs.

Within the past two weeks, the number of documented cases of oseltamivir resistance in H1N1 viruses has risen from 57 to 96.

Around one third of these cases occurred in patients whose immune systems were severely suppressed by haematological malignancy, aggressive chemotherapy for cancer, or post-transplant treatment. The clusters in the two hospital wards should be viewed in the context of these overall trends. Although all incidents of oseltamivir resistance merit investigation, no evidence suggests that events to date constitute a public health threat.

Patients in Md., Va. treated for Tamiflu-resistant swine flu

By Michael Laris

Washington Post Staff Writer
Wednesday, December 2, 2009; 3:55 PM

Two swine flu patients in Maryland and one in Virginia were hospitalized with a form of the virus resistant to a commonly used medicine, prompting infectious disease specialists to call for renewed caution even as the intensity of the pandemic nationwide has declined.

Tamiflu is one of the key drugs used on the sickest patients, and the number of cases where it can no longer kill the H1N1 virus is tiny. But epidemiologists say experience with other flu strains shows that resistance can take over quickly, making monitoring and prevention crucial.

"I don't want to scare the public, but I do want people to be responsible in what they need to be doing, not only for their patients but also for public health," said Trish Perl, a professor at Johns Hopkins University Hospital.

"It's been reported in Seattle, it's been reported at Duke, it's been reported in our place. All of the sudden we're starting to see . . . more resistance than we saw earlier this spring," she said. "What it calls for is increased vigilance."

Diane Helentjaris, head of Virginia's office of H1N1 response, said two state residents have been treated for Tamiflu-resistant swine flu, one at a hospital in Virginia and one in another state.

"It's not unexpected at all, when you have many, many people taking an antiviral medication," she said. Extended treatment for those with immune problems is another issue. "The longer you're on something the more likely you might develop some resistance," she said.

Both Hopkins patients had weakened immune systems and were being treated under protocols consistent with leukemia patients. Staff had been vaccinated and wore masks, hospital officials said. Perl said initial virus samples responded to Tamiflu, but that changed during the onslaught of the treatment itself, leading to a mutated, resistant form. "Under the pressure it can emerge," she said. Doctors can try a different drug in such cases. Both patients were eventually discharged.

Perl said Tamiflu should not be over-prescribed, because that can lead to more chances for mutations. And people should avoid complacency and get vaccinated, she said.

In the District, officials confirmed the city's first swine flu-related death, of an adult male with a preexisting medical condition, Health Department spokeswoman Dena Iverson said.

Cases Of Tamiflu Resistant Swine Flu In Md

Wednesday, December 02, 2009
Scott Wykoff

The Maryland Department of Health and Mental Hygiene has reported the first two cases of Tamiflu resistant Swine Flu in Maryland to the Centers for Disease Control and Prevention.

Molecular testing by the DHMH Laboratory confirmed that each case had the Tamiflu resistant virus strain.

Notification is underway to the state's acute-care hospitals, physicians and other health care providers to remain on the lookout for other possible cases.

The resistant strain is presumed preventable by the Swine Flu vaccine and can be treated by alternative antiviral medication. "This kind of mutation of the flu virus has been expected and that is why we've tested over 500 H1N1 samples from across the state for resistance to Tamiflu as a part of our flu monitoring and surveillance effort," said John M. Colmers, DHMH Secretary. "These two resistant cases are of concern because although infections such as this can be prevented with vaccine, we also want to retain all of our options for treating those with serious influenza complications."

Routine testing at the state Public Health Laboratory discovered the first Maryland case. Astute clinicians suspected and reported the second case after a patient continued to test positive for flu despite antiviral treatment.

Tamiflu (oseltamivir) is the most frequently prescribed flu medicine for flu treatment of adults and children aged 1 year and older. When properly prescribed, antivirals such as Tamiflu can slow the rate at which a flu virus infects cells in the body, thus reducing the spread and the severity of the illness. A Tamiflu resistant strain of Swine Flu makes it more difficult for physicians to treat patients. "There is no indication that any Tamiflu resistant strain of the Swine Flu virus has spread broadly through the general population," said Frances Phillips, DHMH Deputy Secretary for Public Health Services. "Both of these patients have recovered from influenza. However, DHMH is working closely with local hospitals and health departments to be sure the virus has not spread to others."

These cases were diagnosed with flu during October and November hospitalizations at The Johns Hopkins Hospital and both have recovered from influenza. While there does not appear to be any link between the two cases, both had immunosuppression, which is an identified risk factor for the development of antiviral resistance.

Worldwide, there have been a small number of Tamiflu resistant H1N1 influenza cases identified by public health authorities. The majority of these cases have occurred among immunosuppressed patients undergoing treatment for influenza. Nationally, there are several cases of these resistant viruses transmitted in the healthcare environment or in group settings. It is common for strains of seasonal influenza to become resistant to antiviral medications as well, which is another reason why seasonal influenza vaccination is highly recommended among those at high risk for influenza complications. "Vaccination remains the best protection against the flu," added Secretary Colmers. "While we continue to see flu activity on a downward slope in Maryland for now, more H1N1 vaccine arrives each day and we urge everyone, especially members of the five target populations, to contact their doctors, health care providers or local health departments to get vaccinated."
hat-tip Treyfish

China H1N1 (2 articles)

By THE ASSOCIATED PRESS (CP) – 2 hours ago
China death toll from swine flu triples in 2 weeks

BEIJING — The number of swine flu deaths in China has more than tripled in two weeks with the onset of winter, the Health Ministry said late Tuesday.

By Sunday, the Chinese mainland had recorded 178 deaths from the H1N1 virus - a threefold-plus jump from the 53 deaths announced Nov. 15, according to the ministry's Web site.

The ministry also said three of four recent deaths reported after people received swine flu vaccinations have been determined to have no link to the inoculations themselves, the official Xinhua News Agency said.

The three deaths were "coincidental," Liang Wannian, director of the ministry's emergency response office, was quoted as saying. Results for the fourth death are still pending.

Of the 26 million people inoculated so far nationwide, a tiny fraction - 2,867 - reported adverse reactions, Liang said. Most of those reactions were fever or swelling, he said.

"Clinical tests and practices in China and other countries have shown the A/H1N1 flu vaccines are safe," Liang said.

More than 90,000 people in China have been infected with swine flu and nearly 80 per cent have recovered, Xinhua reported.

By comparison, China's figures are much smaller than in the United States. Since it was first identified in April, swine flu has sickened an estimated 22 million Americans, hospitalized about 98,000 and killed 4,000.

The flu situation in China is still "severe" as the number of cases and fatalities grows with the onset of winter, Liang said.

Swine flu made up about 90 per cent of all flu cases in recent weeks. Schools are still the main venue for prevention, with nationwide vaccinations continuing.

Dec 1, 2009
In China, Real Statistics of H1N1 Infection Kept Secret

Hospitals told to diagnose ordinary flu, pneumonia

The official H1N1 death toll in China’s northwestern province of Jilin was two as of Nov. 15, according to the province’s Health Bureau. The real death toll far exceeds that number, according to information from staff workers at the local Center for Disease Control and Prevention (CDC).

One staff worker who did not wish to be identified told The Epoch Times that “estimates of the H1N1 death toll cannot possibly be very accurate.”

“As far as we are concerned, the statistics of H1N1 infection are a secret. We have an obligation to keep it secret. We cannot even tell our parents about it,” said the staff worker, who is based at the CDC in Jilin Province’s Changchun City.

The staff worker further explained that, "Hospitals only test for H1N1 on critically ill patients to monitor changes in the H1N1 virus. Routine testing for H1N1 on less severely ill patients is almost non-existent: Most cases were just treated like ordinary flu, as required by the government. When there is a cluster infection, tests are only run on a few patients, and we don’t do it based on individual requests."

The staff worker also admitted that some of the deaths due to H1N1 infection were not included in the H1N1 death toll since tests were only conducted on critically ill patients. Changchun City’s CDC has also reported cases like this to the Health Bureau, according to the staff worker, adding that, “Whether the Health Bureau will publish the true data or not, we don’t have the right to intervene.”

This staff member’s information corroborates evidence given to The Epoch Times by another CDC staff member a few days ago—that many students have recently contracted the H1N1 virus. Many schools were shut down because of the disease at the time, although some chose not to report the situation, and thus the CDC does not know the exact figure.

An official from the Jilin Province Health Bureau, when contacted by The Epoch Times, said that patients now have to spend their own money to be treated for the H1N1 infection, as the regime has stopped providing coverage since August or September. He refused to comment further.

Zhong Nansha, an academic of the Chinese Academy of Engineering and a noted Chinese medical expert expressed his doubt of the official estimate of the H1N1 death toll in a report published by Guangzhou Daily on Nov. 19.
Jilin Authorities’ Coverup Guarantees Report of Zero Fatalities

A Chinese blogger posted an article on China’s famous Baidu Tieba (the Chinese equivalent of Google), stating he suspected that some critically ill patients, including one of his own family members in the Intensive Care Unit (ICU) in Jilin City Hospital had H1N1 infection.

Although the official diagnosis for this blogger’s relative was severe pneumonia, judging from the medication prescribed by the hospital, he suspects his relative has H1N1 infection. The high medical cost, which ran over 10,000 yuan (US$1,500) per day for 12 days, was a huge financial burden for the blogger’s family. After treatment, the patient still did not show any signs of improvement.

The blogger also said that there were patients with similar symptoms who were admitted to the ICU, and five of them were in a coma. There were also patients with similar symptoms in the nearby Railroad Hospital.

“There were clearly cases of H1N1 infection, yet they do not confirm or explain the cases. They only stated that these were severe cases of pneumonia. Covering up and avoiding reporting H1N1 infection is now a fact of public health,” according to the blogger.

He also indicated that the Jilin provincial government had promised the State Council that there will not be any fatalities recorded due to H1N1 infection in Jilin Province, and the promise was kept at the cost of blocking reports on H1N1 infection and going so far as stopping testing for H1N1 in elementary/middle schools and various medical facilities.

A 25-year woman who was seven months pregnant was admitted to the ICU ward of the Jilin City Hospital for H1N1 infection. The woman had a normal delivery, but the baby was already stillborn, according to the blogger.

Although 80 percent of flu cases in Jilin City were H1N1 infections, hospitals were instructed to not to give an H1N1 diagnosis, but instead to diagnose suspected cases as regular flu or pneumonia, according to another blogger who said he was given this information by a relative who is a nurse.

Yet another blogger stated that although nearly 400 students in his school had developed fever, not a single H1N1 diagnosis was given, and nobody showed any concern.

Vaccine No Longer Reliable Due to H1N1 Mutation

Major foreign media have reported the H1N1 mutation in China, a fact that Chinese authorities can no longer deny. As a result, many Chinese have started questioning the efficacy of the H1N1 vaccine.

“It is not our time to give students the H1N1 vaccine shots yet. But I think [they will not necessarily] develop immunity even if they are given the shots, due to the mutation of the virus,” an employee of the Changchun University of Science and Technology said when contacted by The Epoch Times, adding that, “The school is under lockdown. Students have to show their student ID’s to go in and out. The weather is unstable and many people have come down with the flu.”

When The Epoch Times contacted Jilin University, the reporter was told that classes were suspended in September and many students were infected with H1N1 when they returned to school after the Oct. 1 National Day. “Now students basically just stay in the school and wear masks when they are in public places.”

http://www.theepochtimes.com/n2/content/view/25896/99999999/1/1/

No more drug-resistant H1N1 found at Duke

Updated: Today at 1:22 p.m.

Durham, N.C. — Extensive testing has found no more cases of drug-resistant H1N1 flu at Duke University Hospital, officials said Tuesday.

The hospital reported on Nov. 20 that two men and two women had contracted a strain of the virus that was resistant to the drug Tamiflu, one of two medicines used to fight H1N1. Both men and one woman died.

The patients had been treated in an isolated unit of the hospital in the six weeks prior to the Nov. 20 announcement, and all had underlying compromised immune systems and other complex medical conditions at the time, officials said.

The U.S. Centers for Disease Control and Prevention and the state Division of Public Health worked with Duke Hospital to test all other patients in the isolated unit several times in recent days. Other people being treated for H1N1 at the hospital also were tested.

"Much work is still being done to better understand the nature of the four cases that were reported previously," Dr. Daniel Sexton, an infectious disease specialist and director of the Duke Infection Control Outreach Network, said in a statement.

-snip-

Vietnam: Difficult to distinguish influenza A/H5N1 and influenza A/H1N1

January 12, 2009 [translates bad..means 12/1/2009]

Excerpt:

Due to the difficulty to distinguish between patients of these two influenza A, so Dr. Nguyen Huy Nga, Director of Department of Preventive Health and Environment (Ministry of Health), said, the medical establishments and establishments that treatment and the patient must clearly understand the patient's history.

Patients if exposed to eating meat and poultry at risk (infected birds, dead) before the disease or is considered the most basic elements to distinguish influenza A/H1N1 and H5N1 influenza A for patients / H5N1 mainly transmitted from infected poultry, influenza A/H1N1 spread from person to person.

Dr. Nguyen Huy Nga adds, Central Institute of Hygiene and Epidemiology has studied and showed that influenza A/H5N1 virus in Vietnam does not have the gene variation.

Indonesia: The Deadly mutation of the Virus of Pig Flu with Bird Flu [Infeksi.com]

The community was appealed to anticipate the new virus attack that was formed from the combination two genetic the virus namely pig flu (H1N1) and bird flu (H5N1) with the level of the spread and the death was very high.

That was revealed by the Section Head the Dan Pengamatan Prevention of the Illness, Dinas Kesehatan of the Regency Lampung Selatan Kristi Endarwati SKM, on Monday (30/11).

He said, be based on pengamataan and the Department's research of the Health, naturally the two viruses were enabled bermutasi in a short time. "We received intruksi to guard against and anticipate him in accordance with the procedure continue to (Protap) clearly from the centre to handle him if terjangkit to humankind," he said.

He said, uptil now the community only learned the existence of the bird flu virus and pig flu separately, in fact was based on results of the scientific research, the virus could have a mutation and spread to humankind simultaneously in the form of the very deadly new virus.

Further, he explained, the bird flu virus uptil now the characteristics of his spread tended slower but the mortality rate that was resulted in by him very high. Whereas the flu virus of the spread pig was very fast antarmanusia but the mortality rate was classified as low. After having a mutation, continued he, the two viruses had finally become a new virus that was perfect with the characteristics was faster fast between humans was increased by the mortality rate was very high. The indication of the spread even more dasyat because of the combination of the sign of the two viruses.

He added, the mutation of this virus by the Department of the Health was not yet given by the name because of not yet having the case that happened because of that the community diintruksikan was on the alert and menyosialisasikan to that did not yet know him.

The "mutation" of "this virus happened naturally started from the virus H5N1 spread to the pig body that has infected H1N1 afterwards spread between humans in accordance with the original characteristics" of the "virus H1N1," said he. He said, was based on the research, the bird flu virus was really enabled to spread to the pig that already infected flu or humankind because of the structure of the pig body had the similarity with the human body, or H5N1 spread direct to humankind that has infected H1N1.

"One of the viruses till at this time still was difficult to be prevented in fact immune with antivirus, moreover if until the two viruses has bermutasi became the crueller new virus," explained he. He explained, after the virus was combined bermutasi became the virus just had speed perfection of the spread and height perfection of the death for that tertular.

To melaukan the early detection of the case, the Kesehatan Service make an effort with empowerment of the health service, and memebentuk 40 people surveilans (the observer) to berkerja be the same as gave the edication to the community. The important matter that must be done by the community to anticipate him that is guarding the pattern of the healthy life by maintaining the cleanliness as washing the hands before eating, maintained ethics when sneezing and the cough. (Ant/MI)