Analysis: Egypt H5N1 Cases for 2009

Regarding the previous posted chart....I have posted all Avian Influenza H5N1 updates from WHO further down in this post.

From January 2009 until update #14 (May 6) they had 23 fatalities.
In update #15 (May 15th) the fatalities jump to 26.
Somewhere between May 6th and May 15th, 3 people died.

I have 3 people on my list confirmed in that time period.

Quote:

Gharbiyah Gov. #71 (5/15) Tanta - #68 May 6th (posted on 5/15) Ash Sharqiyah Gov. #70 (5/15)

I have case #72 as a fatality - 5/18.

So, I only had one fatality on my list for the year.
The one I just mentioned. The 3 others above would make a total of 4 fatalities - which is what the WHO chart says.

Here is the list of updates for H5N1 in Egypt, in 2009, from the WHO site:

27 November 2009
Avian influenza - situation in Egypt - update 25

20 November 2009
Avian influenza - situation in Egypt - update 24

24 September 2009
Avian influenza - situation in Egypt - update 23

31 August 2009
Avian influenza - situation in Egypt - update 22

11 August 2009
Avian influenza - situation in Egypt - update 21

1 July 2009
Avian influenza - situation in Egypt - update 20

2 June 2009
Avian influenza - situation in Egypt - update 19

1 June 2009
Avian influenza - situation in Egypt - update 18

28 May 2009
Avian influenza - situation in Egypt - update 17

22 May 2009
Avian influenza - situation in Egypt - update 16

15 May 2009
Avian influenza - situation in Egypt - update 15

6 May 2009
Avian influenza - situation in Egypt - update 14

23 April 2009
Avian influenza - situation in Egypt - update 13

21 April 2009
Avian influenza - situation in Egypt - update 12

17 April 2009
Avian influenza - situation in Egypt - update 11

8 April 2009
Avian influenza - situation in Egypt - update 10

30 March 2009
Avian influenza - situation in Egypt - update 9

23 March 2009
Avian influenza - situation in Egypt - update 8

11 March 2009
Avian influenza - situation in Egypt - update 7

10 March 2009
Avian influenza - situation in Egypt - update 6

2 March 2009
Avian influenza - situation in Egypt - update 5

9 February 2009
Avian influenza - situation in Egypt - update 4

5 February 2009
Avian influenza - situation in Egypt - update 3

26 January 2009
Avian influenza - situation in Egypt - update 2

14 January 2009
Avian influenza - situation in Egypt - update

http://www.who.int/csr/don/archive/country/egy/en/

Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO

11 December 2009
Click on chart:

Total number of cases includes number of deaths.
WHO reports only laboratory-confirmed cases.
All dates refer to onset of illness.

CDC sharply raises H1N1 case estimates; kids hit hard

Robert Roos News Editor

Dec 10, 2009 (CIDRAP News) – Another month's worth of data on H1N1 influenza has led federal officials to more than double their estimates of total cases, hospitalizations, and deaths and to assert that the impact on children and younger adults has been far greater than that of a typical flu season.

After analyzing data for the weeks from Oct 18 through Nov 14, the Centers for Disease Control and Prevention (CDC) estimated that 47 million people, or about 15% of the population, have been infected and 9,820 have died in the pandemic. That compares with estimates of 22 million cases and 3,900 deaths issued Nov 12 and covering the period from April through Oct 17.

The new estimate of hospitalizations is 213,000, compared with 98,000 a month ago.

"By Nov 14, many times more children and younger adults, unfortunately, have been hospitalized or killed by H1N1 influenza than happens in a usual flu season," CDC Director Dr. Thomas Frieden said in a news briefing today.

The additional weeks covered in the latest report spanned the peak period for the fall wave of H1N1. In terms of the number of states reporting widespread activity, the last 2 weeks in October marked the crest, with 48 states in that situation. The number dropped to 43 states by the second week in November and has declined further since.

16 million cases in children
In an online report, the CDC estimated there have been 16 million cases in children up through age 17, leading to 71,000 hospitalizations and 1,090 deaths. For adults age 18 through 64, the agency estimated 27 million cases, 121,000 hospitalizations, and 7,450 deaths.

For elderly people, who are believed to have some protection form the virus because of past flu exposures, the new estimates are 4 million cases, 21,000 hospitalizations, and 1,280 deaths.

Less than 5% of the increases in total cases, hospitalizations, and deaths are explained by late reporting of events that occurred before Oct 17, the CDC report says. Frieden commented, "There is some correction for late reporting. But there has been a lot more disease in the month that's reported than in the months before."

All the numbers represent the midpoints of ranges of estimates the CDC produced with a new estimation method, which was unveiled Nov 12. The numbers of confirmed cases and related hospitalizations and deaths are far lower, because most people infected, including some who get severely sick, are not tested.

Comparing H1N1 with seasonal flu
When he was asked to compare the H1N1 pandemic with seasonal flu, Frieden said, "We know that it's much milder for older people. It's much less likely to result in death because older people are much less likely to get infected. But it has been a much worse flu season for people under the age of 65, particularly younger adults and children."

According to CDC estimates that are often quoted, the nation has about 200,000 flu-related hospitalizations and 36,000 deaths in an average flu season, with about 90% of the deaths occurring in elderly people. Frieden noted today that the pandemic estimates are not derived in the same way as these seasonal flu estimates.

While the estimation methods are different, seasonal flu is believed to cause fewer than 1,000 deaths per year in people younger than 50, he added. He said the CDC doesn't have a specific estimate of H1N1 deaths among adults under age 50, but a "large share" of the adult deaths are in that group.

"So it is really many times more severe in terms of severe illness, and hospitalizations are several times higher for children and young adults than in a usual flu season," he said.

The CDC estimates that between 5% and 20% of the population get seasonal flu in an average year. If 15% of people have already been infected with H1N1, the nation, 8 months into the pandemic, is already approaching the upper end of the average attack rate for seasonal flu.

However, the estimated death toll so far, 9,820, remains well below the estimated seasonal flu toll of 36,000, though children and younger adults make up about 87% (8,540) of that total, the opposite of what is seen with seasonal flu. Meanwhile, the estimate of 213,000 H1N1 hospitalizations is slightly above the estimate of 200,000 hospital cases for a typical flu season.

In terms of case-fatality rate (CFR), the new CDC estimate of 9,820 deaths in 47 million cases translates into an overall rate of about 0.021%, or about 210 deaths per million people sickened by the virus. That's just slightly higher than the 0.018% CFR indicated by the previous CDC estimate of 3,900 deaths among 22 million cases.

But the CFRs differ considerably by age-group. The CFR for children, with an estimated 1,090 deaths in 16 million cases, comes to 0.007%, or about 70 deaths in a million cases. The CFR for adults between 18 and 64 comes out much higher, at 0.028%, or 280 deaths per million. And the rate for the elderly is higher yet, at 0.032%, or 320 deaths in a million cases—supporting the view that while seniors seem less likely to get sick, they are more likely to die if they do.

Time to get vaccinated
Frieden used the new estimates to stress the importance of getting vaccinated against the pandemic virus. If about 15% of the population has already been infected, he said, "That still leaves most people not having been infected and still remaining susceptible to H1N1 influenza."

He reported that another 12 million doses of vaccine became available in the past week, bringing the cumulative total to about 85 million doses. Many states now have met the vaccine demand from priority groups and have begun offering doses to everyone, he added.

The CDC in the past week began offering the vaccine to all employees, in line with state policy in Georgia, Frieden reported. He said he would get the nasal-spray vaccine himself in a few days.

Though cases have been declining recently, vaccination is prudent given the possibility of a third wave of cases this winter, he said. "Flu season lasts until May. And we don't know what the future will bring in terms of H1N1 influenza," he observed.

Netherlands - Tamiflu Resistant cases

Previously posted:

Thursday, December 3, 2009

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.

http://pandemicinformationnews.blogspot.com/2009/12/netherlands-reports-mutant-swine-flu.html

New Influenza A (H1N1)
Summary December 11, 2009, week 50

Summary
? In the last week the hospitalization rate for a laboratory confirmed
New infection with Influenza A (H1N1) decreased from last week, 104
patients have been reported this week against 227 last week. In addition, 8 new
deaths reported: a 14-year-old boy, a 39-year-old woman, a 50-year-old man, a 52 --
old woman, a 54-year-old man, a 58-year-old woman, a 63-year-old woman and a 63-year-old men, 7 of which have underlying disease. In the 14-year-old boy is no underlying disease demonstrated. 8 One of the deceased person was vaccinated against Influenza A New (H1N1) and 4 of deceased persons was unknown whether they were vaccinated against New Influenza A (H1N1).

-snip-

Until this week were 11 patients diagnosed in the Netherlands, including 5 this week, with a New Influenza A (H1N1) virus that is resistant to the antiviral agent Tamiflu (oseltamivir) that such patients are treated. Four of these patients are deceased.
Around the 11 patients have so far no laboratory confirmed cases of transmission of the resistant influenza virus found.

Comments on CDC's Ability to forecast deaths and hospitalizations in a pandemic

Commonground's Commentary

Last month CDC announced that we would be updated "monthly" in regards to their data. This is the first monthly report. They emphasize that the figures denote the "burden" of the pandemic. They also note that these figures can not be used to project future predictions of the pandemic. Wait. That is their job. They need to project the future of this pandemic, and all infectious disease situations. This statement from their site:

The CDC is one of the major operating components of the Department of Health and Human Services.

Excerpts from their Mission Statement....

..."The Centers for Disease Control and Prevention (CDC) serves as the national focus for
developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States."
..."CDC is responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities."

I also am not quite understanding why the figures cannot be used to forecast the future cases. Quote from article: "This methodology is notpredictive and cannot be used to forecast the number of cases, hospitalizations and deaths that will occur going forward over the course of the pandemic because they are based on actual surveillance data." If you can't forecast it based on surveillance data...what would you suggest to be more accurate? HUH???

If the CDC is not willing to step up to the plate, and project future cases down the road for this H1N1 pandemic....what would it look like if we had a more severe pandemic? A pandemic with a higher Case Fatality Rate? Many experts around the world are currently worried about a H5N1/H1N1 strain, with the deadly virulence of the H5, and the easy transmission of the H1, combining. What would the CDC do then? What data would they actually provide for us, to keep us informed? Or would be be hearing this, like we are today?:

The true number of cases, hospitalizations and deaths may lie within the ranges provided or it’s also possible that they may lie outside the ranges.

That just about covers it all, wouldn't you say? Their job is to provide disease prevention and control.....environment health...health promotion... Wouldn't part of that be to let the public know what to expect down the road in a pandemic?

2009 H1N1-Related Deaths, Hospitalizations and Cases: Details of Extrapolations and Ranges: United States, Emerging Infections Program (EIP) Data
December 10, 2009, 1:00 PM ET
In order to provide a fuller and more accurate picture of the burden of the 2009 H1N1 pandemic on the United States, CDC has developed a methodology to estimate ranges of 2009 H1N1 cases and related hospitalizations and deaths. This method uses raw data on 2009 H1N1 hospitalizations collected through CDC’s Emerging Infections Program (EIP), which conducts surveillance for laboratory-confirmed influenza-related hospitalizations in children and adults in 62 counties covering 13 metropolitan areas of 10 states. The estimated ranges generated by this methodology provide a sense of scale in terms of the burden of disease caused by 2009 H1N1. It may never be possible to validate the accuracy of these figures. The true number of cases, hospitalizations and deaths may lie within the ranges provided or it’s also possible that they may lie outside the ranges.

This methodology is notpredictive and cannot be used to forecast the number of cases, hospitalizations and deaths that will occur going forward over the course of the pandemic because they are based on actual surveillance data. More information about this methodology is contained in this document.

http://www.cdc.gov/h1n1flu/estimates/results_2009_h1n1.htm

CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April – November 14, 2009

December 10, 2009, 1:00 PM ET
Excerpt:

The Numbers

(Print table )

On Novebmer 12, 2009 CDC provided the first set of estimates on the numbers of 2009 H1N1 cases and related hospitalizations and deaths in the United States between April and October 17, 2009.

Estimates from April – October 17, 2009:

• CDC estimated that between 14 million and 34 million cases of 2009 H1N1 occurred between April and October 17, 2009. The mid-level in this range was about 22 million people infected with 2009 H1N1.
• CDC estimated that between about 63,000 and 153,000 2009 H1N1-related hospitalizations occurred between April and October 17, 2009. The mid-level in this range was about 98,000 H1N1-related hospitalizations.
• CDC estimated that between about 2,500 and 6,000 2009 H1N1-related deaths occurred between April and October 17, 2009. The mid-level in this range was about 3,900 2009 H1N1-related deaths.

Updated Estimates from April – November 14, 2009

Using the same methodology CDC has updated the estimates to include the time period from April through November 14, 2009.

• CDC estimates that between 34 million and 67 million cases of 2009 H1N1 occurred between April and November 14, 2009. The mid-level in this range is about 47 million people infected with 2009 H1N1.
• CDC estimates that between about 154,000 and 303,000 2009 H1N1-related hospitalizations occurred between April and November 14, 2009. The mid-level in this range is about 213,000 H1N1-related hospitalizations.
• CDC estimates that between about 7,070 and 13,930 2009 H1N1-related deaths occurred between April and November 14, 2009. The mid-level in this range is about 9,820 2009 H1N1-related deaths.

Note: More than 95% of the increases in the estimated numbers of 2009 H1N1 cases, hospitalizations and deaths between the November 12 and December 10 estimates occurred between October 17 and November 14, 2009. (Less than 5% of increases are the result of delayed reporting in cases, hospitalizations and deaths that occurred prior to October 17, 2009.)

CDC Estimates of 2009 H1N1 Cases and Related Hospitalizations and Deaths from April-November 14, 2009, By Age Group

* Deaths have been rounded to the nearest ten. Hospitalizations have been rounded to the nearest thousand and cases have been rounded to the nearest million. Exact numbers also are available.

The results of this method confirm previous epidemiological data indicating that this disease primarily affects people younger than 65 year old, with the number of cases, hospitalizations and deaths overwhelmingly occurring in people 64 years and younger. This is very different from seasonal influenza, where about 60 percent of seasonal flu-related hospitalizations and 90 percent of flu-related deaths occur in people 65 years and older. The proportion of younger people being impacted by 2009 H1N1 is much greater than what occurs during seasonal flu and people 65 and older are much less affected by this virus than what routinely occurs with seasonal influenza. The results generated by this method also underscore the continued importance of the 2009 H1N1 vaccination program and support the recommended target groups for vaccination.

This methodology and the resulting estimates also underscore the substantial under-reporting that occurs when laboratory-confirmed outcomes are the sole method used to capture hospitalizations and deaths. Since the outbreak began in April, states have reported 2009 H1N1 hospitalizations and deaths to CDC. Cumulative reports of laboratory-confirmed 2009 H1N1 hospitalizations and deaths for the same period used in this analysis (April through October 17, 2009), are 17,283 hospitalizations and 1,004 deaths. CDC has maintained since the beginning of this outbreak that laboratory-confirmed data on hospitalizations and deaths reported to CDC is an underestimation of the true number that have occurred because of incomplete testing, inaccurate test results, or diagnosis that attribute hospitalizations and deaths to other causes, for example, secondary complications to influenza. (Information about surveillance and reporting for 2009 H1N1 is available at Questions and Answers: Monitoring Influenza Activity, Including 2009 H1N1.)

The estimates derived from this methodology provide the public, public health officials and policy makers a sense of the health impact of the 2009 H1N1 pandemic. While these numbers are an estimate, CDC feels that they present a fuller picture of the burden of 2009 H1N1 disease on the United States.

CDC will continue to use weekly data from systems that comprise the National Influenza Surveillance System to monitor geographic, temporal and virologic trends in influenza in the nation.

CDC's One Month Update Statistics H1N1

2009 H1N1 Flu In The News

December 10, 2009 1:00 PM ET

How many 2009 H1N1 cases, hospitalizations and deaths are estimated to have occurred in the United States?

CDC developed a method to provide an estimated range of the total number of 2009 H1N1 cases, hospitalizations and deaths in the United States by age group using data on flu associated hospitalizations collected through CDC’s Emerging Infections Program. On November 12, 2009 CDC provided the first estimates for April through October 17, 2009 and committed to updating those estimates approximately monthly. On December 10, 2009, CDC issued updated estimates for the numbers of 2009 H1N1 cases, hospitalizations and deaths in the United States since the pandemic started in April 2009 through November 14, 2009.

• CDC estimates that between 34 million and 67 million cases of 2009 H1N1 occurred between April and November 14, 2009. The mid-level in this range is about 47 million people infected with 2009 H1N1.

• CDC estimates that between about 154,000 and 303,000 2009 H1N1-related hospitalizations occurred between April and November 14, 2009. The mid-level in this range is about 213,000 H1N1-related hospitalizations.

• CDC estimates that between about 7,070 and 13,930 2009 H1N1-related deaths occurred between April and November 14, 2009. The mid-level in this range is about 9,820 2009 H1N1-related deaths.

A table showing this data by age group is available. In addition, background information on these estimates and information about the methodology used to generate these estimates also is available on the CDC web site.

Study eyes bird flu cases in children

HA NOI — Viet Nam kicked off an avian influenza survey on 12,000 over seven-year-olds in Thua Thien Hue and Tien Giang provinces, and Ha Noi yesterday.

"Outbreaks of avian influenza have occurred in almost all provinces in Viet Nam, yet the frequency of human infection among exposed populations remains unknown," said the United States Ambassador to Viet Nam, Michael Michalak.

The 12-month survey falls under the framework of a project focused on "Population-based seroprevalence of human avian influenza infection" jointly funded by the US National Institute of Health, the Henry Jackson Foundation and the World Bank.

The US$1.76 million project aims to estimate the seroprevelence and risk factor in Viet Nam, build testing capacity in the health sector and establish a specimen bank at the National Institute of Hygiene and Epidemiology.

Viet Nam ranks second in the world for the highest number of Avian Influenza infections and deaths among humans following Indonesia.

As of yesterday, 444 cases have been reported world-wide, including 262 fatalities in 15 countries. Five people have died from the H5N1 virus in Viet Nam so far this year. — VNS

MMWR News Synopsis for December 10, 2009

1. Deaths Related to 2009 Pandemic Influenza A (H1N1) Among American Indians/Alaska Natives – 12 States, 2009
2. Fatal Poisoning Among Young Children from Diethylene Glycol-Contaminated Acetaminophen – Nigeria, 2008-2009
3. Outbreak of Erythema Nodosum of Unknown Cause – New Mexico, November 2007-January 2008
4. Safety of Influenza A (H1N1) 2009 Monovalent Vaccines – United States, October 1-November 24, 2009 (previously released)

Egypt: United Nations delegation to monitor the experience in the fight against influenza Menoufia

Thursday, December 10th, 2009 - 15:00

Engineer Sami Amara, Governor of Menoufia, it is to be undertaken by a United Nations team comprising WHO, FAO and UNICEF visited a hospital dietary shebin mound to assess the measures taken by the Egyptian government to control the bird flu, saying the team will follow-up preventive measures against bird flu and pig together.

The governor that WHO had already chosen Monofia system to combat bird flu to be applied at the level of the world. Adding that this visit is to see the update application experience on Avian Influenza and the system of Menoufiya in the fight against swine flu, as well as the efforts of the Department of Health and veterinary medicine and crisis management to maintain in the implementation of those instructions and the system on the ground.

China: Many pregnant women die from influenza A/H1N1

[article is out of Vietnam]

China also has over 4300 patients with influenza A/H1N1 in serious condition.
Health officials proved China is concerned about the situation influenza A/H1N1 service lives of many women during pregnancy in China. Latest statistics of China's Health Ministry said, up to seven twelfths past, China recorded 326 deaths due to influenza A/H1N1. In particular, more than 13% of the pregnant women.

Currently, China is still on 4300 patients with influenza A/H1N1 in serious condition. Chinese health officials said, the percentage of pregnant women dying from influenza A/H1N1 in China is equivalent to other countries in the world. /.

Vietnam: Brother of dying from H1N1 influenza A/H5N1 infection Read more: http://translate.googleusercontent.com/translate_c?hl=en&ie=UTF-8&sl=vi&tl

[Previous posts said it was a "Cousin", this post says "Brother".]

Family in Dien Bien, just someone dying from influenza A/H5N1 has more people infected with influenza A/H1N1 brother.

This information was announced at the meeting the National Steering prevent pandemic influenza A/H1N1 pm 9/12.

Others, such as PV News, Vietnam has an additional male patients residing in Dien Bien death from influenza A/H5N1 and a history of eating more soup duck a week before death. Worrying is the brother of the patient is currently infected influenza A/H1N1.

At the same time, the sample of poultry in the family was positive for influenza A/H5N1. Dr. Nguyen Tran Hien - Director of Institute of hygiene and epidemiology TW concerned if the combination of two types of H1N1 virus in humans with the H5N1 virus in poultry and in humans to a new strain rate as H1N1 spreads rapidly and pathogenic H5N1 is strong as the high risk of death, many are very unpredictable.

Because mortality is too high related to influenza A/H5N1, so Central Hygiene and Epidemiology Institute and the Fund Henry Jackson Foundation (USA) have started the project "Research rates antibodies circulating H5N1 virus in humans in Hanoi, Thua Thien - Hue Tien Giang and "the funding made more than 1.6 million. The project will extend to September 2010. This is a study of influenza A/H5N1 biggest scale ever in Vietnam.

Transmission of Tamiflu-resistant H1N1 on a Vietnamese train 'a concern': WHO

By: Helen Branswell, Medical Reporter, THE CANADIAN PRESS

9/12/2009 7:00 PM |

TORONTO - Seven healthy people on a train from Ho Chi Minh City to Hanoi in Vietnam caught Tamiflu-resistant H1N1 flu, researchers reported Wednesday in a prominent medical journal.

The transmission event, which occurred in July, is one of the largest clusters of cases of resistant H1N1 seen so far and the first time so many linked cases have been seen in previously healthy people who had not been on the drug.

Surveillance since the summer has only turned up three additional drug resistant viruses, the authors note in their letter to the New England Journal of Medicine. But they say they cannot rule out the possibility of ongoing transmission of resistant pandemic H1N1.

The event is a warning that resistant viruses can spread among healthy people and more such events may be in store, an antiviral expert with the World Health Organization said.

"What this looks to be is ... the sort of situation we have been alert for, because it's something that we certainly don't want to see happening but need to know about if it does," Charles Penn said in an interview from Geneva.

Penn said this event is different from two recent clusters, in which severely immunocompromised patients in hospitals in Wales and North Carolina developed and probably transmitted among themselves Tamiflu-resistant H1N1 virus. It's known that resistance develops easily in such patients.

This, however, is a case where healthy people, who weren't taking the drug and who had no known contacts with sick people in the week before they fell ill, were infected with resistant viruses - "which is an apparent transmission of the resistant virus in a more normal community setting," Penn said.

"This is different and it does raise the levels of concern. But it also I think reinforces the message that we do need to be constantly monitoring for this. And reporting it as quickly as it's observed."

The scientists, from Vietnam's National Institute of Hygiene and Epidemiology and Oxford University's clinical research unit in Vietnam, reported that the event first hit the radar in early September when routine screening of H1N1 viruses turned up three with the mutation known to confer resistance to Tamiflu.

The ensuing public health investigation uncovered a tale of a 42-hour train trip in which 10 students who didn't know each other prior to the journey socialized on the train.

Six of the 10 became sick a day or two after arriving at their destination. Two didn't develop symptoms and public health officials were not able to trace two others.

Interestingly, a seventh person who travelled in a different carriage on the same train and who doesn't appear to have been in contact with the students also contracted Tamiflu resistant H1N1 during the trip.

"Ongoing transmission from the cluster was not detected, but the tracing of all contacts was not possible, so ongoing transmission (of resistant virus) cannot be ruled out," the authors wrote, adding that careful use of flu antivirals should be stressed to minimize that risk.

Penn said to date there have been over 100 cases of Tamiflu-resistant H1N1 viruses spotted. About a third have been seen in immunocompromised patients. Of the remaining two-thirds, nearly all have been in people who took the drug to treat or prevent illness, or who had close contact with people who took the drug for one of those purposes.

Prior to this report, he said, there have only been four cases spotted in people who hadn't taken the drug and didn't have traceable exposure to someone who had.

The authors reported they were able to grow viruses from samples from three of the cases.

Penn said the WHO will want to know if the viruses have been checked for other mutations that might account for the seemingly easy spread of resistant viruses. "I think we'll be in touch with the authors."

It used to be thought that flu viruses that developed resistance to Tamiflu would be so weakened by the mutation that confers resistance that they would not be able to spread from person to person. But that belief was shattered in the winter of 2008 when Norway reported a startling rate of Tamiflu resistance in seasonal H1N1 viruses.

Over the next year, the resistant seasonal H1N1 viruses virtually crowded out the Tamiflu-susceptible versions of the virus - a precedent public health authorities don't want to see repeated with the pandemic virus.

"But we are expecting and we've said this, that as the pandemic spreads through this Northern Hemisphere winter and as the medicines continue to be used around the world, the number of sporadic cases is going to rise, as it has been at a steady by small rate," Penn said.

"And then the risk of this sort of event occurring is going to increase with more virus around and those infections being treated."
hat-tip Dutchy

Vietnam: A Community Cluster of Oseltamivir-Resistant Cases of 2009 H1N1 Influenza

Published at www.nejm.org December 9, 2009 (10.1056/NEJMc0910448)

To the Editor: Oseltamivir-resistant infection with the 2009 pandemic influenza A (H1N1) virus has so far been described only rarely and is conferred by the H275Y substitution in the neuraminidase enzyme.¹ Only 3 of the 32 patients with oseltamivir-resistant infection reported on as of this writing were not receiving oseltamivir when the resistant viruses were detected, and ongoing community transmission has not yet been shown.¹ However, the emergence of oseltamivir-resistant 2009 H1N1 influenza remains a grave concern, since widespread oseltamivir resistance has been observed in seasonal H1N1. This resistance was unrelated to selective drug pressure, and the H275Y substitution did not appear to reduce transmissibility or severity.^2,3 We report on a cluster of seven cases of oseltamivir-resistant 2009 H1N1 infection in Vietnam.

In July 2009, during a 42-hour journey, 10 students socialized together in the same train carriage. None of the students knew each other before the journey, none had contact with a person with suspected influenza in the week before the trip, none were symptomatic during the journey, and none were previously or currently receiving oseltamivir. Fever developed in four of the students within 12 hours after arrival and in two more students within 48 hours after arrival (Fig. 1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). An additional case was identified in a traveler in a different carriage (Patient G). Nasal swabs, throat swabs, or both from all seven persons were positive for 2009 H1N1 RNA when tested with reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assays, and viruses were successfully cultured from specimens obtained from three of the persons. The H275Y substitution was detected retrospectively in diagnostic specimens obtained from all seven subjects before any oseltamivir treatment. The concentrations of oseltamivir carboxylate required for a 50% inhibition of neuraminidase activity of the isolated viruses in a fluorometric neuraminidase-inhibition assay were 323.6, 429.5, and 889.2 nM; these concentrations confirmed resistance⁴ (see the Supplementary Appendix).

Six patients were admitted to a hospital for isolation, one patient was isolated at home, and all were treated with oseltamivir phosphate at a dose of 75 mg twice daily (Fig. 1 in the Supplementary Appendix), since resistance testing had not yet been performed. All patients recovered uneventfully, although one patient (Patient F), with the highest 50% inhibitory concentration, continued to test positive on RT-PCR until day 9, despite receiving oseltamivir from the day of the onset of illness (Fig. 1 in the Supplementary Appendix). An extensive public health investigation did not identify additional patients or the index patient.

In this cluster, infection developed in at least 6 of the 10 people who were probably exposed to the index patient; this shows that resistant 2009 H1N1 viruses are transmissible and can replicate and cause illness in healthy people in the absence of selective drug pressure. Ongoing transmission from the cluster was not detected, but the tracing of all contacts was not possible, so ongoing transmission cannot be ruled out.

However, only three other resistant cases have been detected in Vietnam as of this writing, and all were due to selection of resistant viruses during treatment rather than person-to-person transmission. Although data are limited, it is likely that the detected levels of oseltamivir resistance are clinically relevant.⁵ The loss of oseltamivir as a treatment option for severe 2009 H1N1 infection could have profound consequences. To minimize this risk, the use of oseltamivir should be restricted to prophylaxis and treatment in high-risk persons or the treatment of people with severe or deteriorating illness, antiviral stockpiles should be diversified, and optimal dosages and combination therapies should be urgently studied.

Close monitoring and reporting of resistance to neuraminidase inhibitors are essential.


Le Quynh Mai, M.D., Ph.D.
National Institute of Hygiene and Epidemiology
Hanoi, Vietnam

Heiman F.L. Wertheim, M.D., Ph.D.
Oxford University Clinical Research Unit
Hanoi, Vietnam

Tran Nhu Duong, M.D., Ph.D.
National Institute of Hygiene and Epidemiology
Hanoi, Vietnam

H. Rogier van Doorn, M.D., Ph.D.
Oxford University Clinical Research Unit
Ho Chi Minh City, Vietnam

Nguyen Tran Hien, M.D., Ph.D.
National Institute of Hygiene and Epidemiology
Hanoi, Vietnam

Peter Horby, M.B., B.S., F.F.P.H.
Oxford University Clinical Research Unit
Hanoi, Vietnam
peter.horby@gmail.com

for the Vietnam H1N1 Investigation Team
Supported by grants from the Wellcome Trust United Kingdom (081613/Z/06/Z and 077078/Z/05/Z, to Drs. Wertheim, van Doorn, and Horby) and the South East Asia Infectious Disease Clinical Research Network (N01-A0-50042, to Drs. Wertheim, van Doorn, and Horby).
Financial and other disclosures provided by the authors are available with the full text of this letter at NEJM.org. This letter (10.1056/NEJMc0910448) was published on December 9, 2009, at NEJM.org.
hat-tip Pathfinder

Drug resistant H1N1 virus found in Delaware

Wednesday, December 9th, 2009


By: Mark Eichmann
meichmann@whyy.org

While the overall number of H1N1 cases nationwide has been on the decline in recent weeks, health officials are concerned that the virus could mutate to resist anti-viral medication.

The Centers for Disease Control confirmed that a 52-year-old Kent County man who died from complications of H1N1 last month had a strain that showed resistance to antiviral medication. It's the first such case found in Delaware that didn't respond to Tamiflu treatment. State health officials say the victim had a number of underlying health problems that made his fight against H1N1 complicated even without the resistance to antiviral medication.

Director of the Delaware Division of Public Health Dr. Karyl Rattay says the resistance can cause a number of other complications which would require increased treatment efforts. "Someone might be more likely to become dehydrated, so they might need IV fluids. They might be more likely to get a bacterial infection, and if it became widespread, we would certainly expect more deaths."

After examining more than 15-hundred specimens nationwide, the CDC has identified just 15 cases that were resistant to antiviral medication. While the resistant cases represent just one percent of those that were tested, the CDC is asking states to continue sending samples. Their main concern is making sure the drug resistant version of the virus doesn't grow more widespread.
hat-tip RoRo

This case is also mentioned here:

Fourth swine flu death in Del. reported
Staff and wire reports • November 9, 2009

DOVER — Delaware public health officials today reported the state's fourth death from swine flu.

Officials said they were notified that a 52-year old Kent County man who was hospitalized Oct. 21 with flu-related complications died Saturday.

Officials said the man had a very serious underlying health condition before contracting swine flu.

Some people are at higher risk of complications from the swine -- or H1N1 -- flu, including people with chronic health conditions such as asthma, diabetes, heart disease, obesity and those who are immuno-suppressed. according to the Division of Public Health.

Nationwide, some 672 deaths from Aug. 30 to Oct. 31 have been attributed to both seasonal and swine flu.
[link no longer works]
hat-tip Shiloh

New Models for Powerful Flu Fighters From Existing Drugs

Posted: December 9, 2009

By Tina Hesman Saey, Science News

Computer compatibility tests might help flu-fighting drugs find their groove.

A pandemic of the H1N1 swine flu virus has health officials worried that the virus could develop resistance to drugs such as Tamiflu used to treat infected people. A new computerized screening method could help find new or already existing drugs that find a flu virus’ weak spot, researchers from the University of California, San Diego reported December 6 at the annual meeting of the American Society for Cell Biology.

Researchers Daniel Dadon, Jacob Durrant and J. Andrew McCammon, all of UCSD, made a computer movie of slight structural shifts occurring in the neuraminidase 1 enzyme (the N1 in H1N1 and H5N1), a protein found in the avian and swine influenza viruses. Those changes reveal possible target areas that could allow drugs to circumvent a virus’ usual means of becoming resistant.

All influenza viruses have a neuraminidase enzyme, but the protein comes in several subtypes. Previous work had shown that the N1 subtype contains a loop that makes it more flexible than other neuraminidase subtypes, says Rommie Amaro, a computational biologist at the University of California, Irvine. “It is particularly nimble,” she says. The enzyme’s flexibility could affect the way drugs bind to it.

Analyses of still frames from the simulation, which is called a relaxed complex scheme, revealed 27 different natural conformations that the N1 protein could take on under conditions it might encounter in a host cell. Some parts of the protein change shape readily and some stiffer portions are locked into place, the researchers discovered.

Drugs currently used against flu, — including oseltamivirbetter known as Tamiflu, peramivir and zanamivir — all insert themselves into neuraminidase at about the same location within that enzyme. When the drugs insert into that pocket, they block the enzyme’s ability to release newly made viral particles from the cell, and this blockage prevents the spread of the disease.

That location is prone to structural changes such as those revealed by the simulation, and to genetic changes that affect the amino acid building blocks that compose the protein. Many of those amino acid changes also alter the shape of the pocket, keeping the drugs from binding and thus making the flu virus resistant to the drugs.

To find drugs that could block the protein's active site in a different way — and knock out viruses resistant to the currently used drugs — the researchers mined a library of FDA-approved drugs. The team digitally sliced up the drugs and simulated how the drug fragments might bind to all of the enzyme’s forms.

Among those fragments, the team found 15 novel compounds that could wedge into the protein’s pocket and block its action better than Tamiflu or other antiviral drugs would. A closer examination revealed that those 15 compounds share a common structure. What's more, the compounds lodge into a part of the protein that doesn't allow changes easily, meaning that those areas are less likely to mutate and develop drug resistance than the parts of the protein that come into contact with Tamiflu and other current flu treatments, Dadon says.

But because the computer-generated fragment molecules don't exist in the real world, the researchers needed to see whether any existing, small molecules could work just as well. Searching four databases of drugs turned up six small molecules that had the same common structure as the digitally diced compounds. These real compounds are currently being tested by collaborators in Australia to determine whether they really do block the flu's action.

Both of the approaches Dadon’s team followed in the new drug design scheme — examining all forms of the protein and then screening a library of fragments from approved drugs — could be easily adapted for other molecules, Amaro says. The caveat is that researchers need to have prior knowledge of an enzyme’s structure in order to develop effective drugs, she says.

Influenza A/H1N1 and A/H5N1 risk interact with each other

[article on the situation in Vietnam]

Updated at 17h31, on September 12, 2009
(VnMedia) - At the meeting the National Steering Committee for prevention of influenza pandemic in humans pm 9/12, Assoc. TS. Nguyen Tran Hien - Director of Institute of hygiene and epidemiology said the Central Government, translated influenza A/H1N1 still complicated development, especially with multiple risk occurring interaction between influenza A/H1N1 and influenza A/H5N1 in community.

According to survey research institute of the Central Hygiene and Epidemiology, cases of death from influenza A/H5N1 in Dien Bien past have discovered a family of patients positive for influenza A/H1N1. Meanwhile, poultry was raised in the patients were infected avian influenza H5N1.

Assoc. TS. Shows that the two types of this virus live together in one area can lead to the risk of formation of new virus strains with pathogenic stronger. Therefore, the Institute is conducting close monitoring of the outbreak evolutions in time to cope with bad situations can occur.
-snip-

Egypt: Damietta declares state of emergency to cope with bird flu

Wednesday, December 9th, 2009 - 15:37

Damietta Governorate declared a state of emergency to cope with bird flu during the current period, and through the elimination of hotbeds of home education and private farms and unlicensed.

The appearance of Numan Director of Environment in Damietta Dr Barady Damietta Governor emphasized the prohibition of circulation of live birds within the province and between provinces, as well as prevent the sale of live poultry shops, public markets and to assign the Directorate of Veterinary Medicine, Agriculture and Environment to pass daily through the follow-up committees to monitor and control cases of suspected violation stores and monitoring of suspected cases.
hat-tip Twall

Vietnam: First H5N1 avian influenza and pandemic influenza A/H1N1 appeared together in a community population

[This is NOT a combination of H1N1 & H5N1 within one person. It is a relative of a confirmed H5N1 death, with H1N1 and his poultry have H5N1]


First H5N1 avian influenza and pandemic influenza A/H1N1 appeared together in a community population

Risk associated virus A/H1N1, A/H5N1 is very close to

Wednesday, September 12, 2009 [trans. 12/9/09]

In case of death due to influenza A/H5N1 after eating duck soup more of a young men at Dien Bien on November 30 experts has raised concerns about the ability to match the influenza A/H1N1 virus and influenza A/H5N1 virus are at risk are very close.

"The risk of a combination of influenza virus A/H1N1 and influenza A/H5N1 virus is very close to. Vietnam currently has sufficient condition for this risk becomes reality", Dr. Nguyen Tran Hien, Director of Institute of Hygiene and Epidemiology of central receiving.

Show his outlook given the Institute of Hygiene and Epidemiology Central announced the latest report on the epidemiological investigation in Dien Bien, which is just the latest case of deaths due to H5N1.

Epidemiological investigation showed that: In case of death by eating more duck soup at Dien Bien is positive for influenza A/H5N1 virus. After taking a random sample from their child's case to test the test, the results showed that young cousin's death was due to influenza A/H5N1 influenza A/H1N1 infection.

Continue to check poultry being raised by families of cases of death due to influenza A/H5N1, the results showed: Poultry is also infected with influenza A/H5N1.

"So, the first in Vietnam, the same time, the influenza A/H1N1 and influenza A/H5N1 occurred in a community population, in both human and poultry. Therefore, likely a new strain will come out, the recombinant virus from the second. If this happens, the virus would have spread faster than influenza A/H1N1 virus, while also having a higher pathogenic influenza A/H5N1 virus, "said the sage.

If this risk becomes reality, the health sector will face challenges more heavily. Actually shows that influenza A/H1N1 virus can spread easily in all conditions. Now with influenza A/H5N1, mortality rate in Vietnam as of this moment is 100%!

Currently, the health sector is being implemented to control and closely monitor the disease situation at Dien Bien province in particular, at the same time coordinate with ministries and departments concerned to implement measures to control the back of avian influenza in other localities in the country.

However, in the current situation, this control may not happen as easily as expected. According to a review of the Department of Animal Health (Ministry of Agriculture and Rural Development), now many places have not actively implementing measures to prevent disease, lead to bird flu outbreak started emitted.

Vietnam: Ability concerns associated virus H1N1 and H5N1

[I understand the article to state that in their investigation of the H5N1 confirmed case in Dien Bien, they discovered the Cousin of the confirmed, was infected with H1N1, and that he had poultry with H5N1]

Ca H5N1 investigate recent deaths in Dien Bien, the health professional concerned to discover the cousin of H1N1 infected patients, also in the forums he chickens positive for H5N1, that is, there is close contact the two virus risk.
> Male youth died of H5N1

Dr. Nguyen Tran Hien, Director of Institute of Hygiene and Epidemiology said central, this is a typical case, very worrying. Many experts around the world have expressed concern the combination of genes between two virus will create a new pathogenic virus such as H5N1 and strong as H1N1 spreads fast. Thus, the health sector are increasing surveillance at Dien Bien.

In addition, masters Nguyen Hong Ha, deputy director of the Central Hospital of Tropical warnings, the hospital case notes with pneumonia during the winter influenza H1N1 infection should be suspected, the test date for the treatment accordingly.

"However, difficulties in that, among hospitals in the North, the only hospital in tropical Central and Children's Hospital Central is likely to be tested. Therefore, the hospital must take Left sample and sending it, "Mr Ha said.

About vaccines, the World Health Organization (WHO) said, is expected to move 1.2 million doses of vaccine to Vietnam, during the period from September 12, 2009 to February 2010.

WHO has confirmed H1N1 vaccines safe vaccines as flu season normally. Cases of hypersensitivity after injection include: urticaria, angioedema and anaphylaxis, and can range from mild to severe levels.

Anaphylaxis can be life threatening if not timely medical care. Although this phenomenon is rare, but the WHO also requires government agencies to be ready to receive and carry out appropriate treatment for this reaction.

According to WHO, the risk of adverse reactions of vaccines was still much smaller than the risk of serious flu epidemic that infected the high-risk group suffered.

Roche’s Tamiflu Not Proven to Cut Flu Complications, Study Says

---

Dec. 9 (Bloomberg) -- Roche Holding AG’s antiviral drug Tamiflu may not prevent complications from influenza in healthy adults, according to a review by an independent research group that reversed its previous findings that the medicine warded off pneumonia and other deadly conditions linked to the disease.

The pill has been the mainstay of treatment for pandemic swine flu, which has killed nearly 9,000 people since it emerged in April, according to the World Health Organization. Roche, based in Basel, Switzerland, defended the benefits of the drug, which it expects to generate 2.7 billion francs ($2.64 billion) in sales this year.

An analysis of 20 studies by the Cochrane Collaboration showed Tamiflu offered mild benefits for healthy adults and found no clear evidence it prevented lower respiratory tract infections or complications of influenza, according to the group. The review, published in the British Medical Journal and broadcast yesterday on the U.K.’s Channel 4 News, showed the drug eased and shortened symptoms if taken quickly.

The report, an update of a 2005 analysis by Cochrane, excluded eight studies funded by Roche that haven’t been published and whose full data wasn’t given to the researchers. The exclusion reversed the nonprofit group’s earlier finding that Tamiflu protects against complications.

Insufficient Evidence

“We now conclude there is insufficient evidence to describe the effects of Tamiflu on complications of influenza or the drug’s toxicity,” Tom Jefferson, the lead researcher from the Cochrane Collaboration in Rome, said in a telephone interview. “We have multibillion-dollar public health policies in place that rely on evidence not available for independent analysis.”

The group, which reviews medical evidence, excluded the eight studies, involving 2,500 patients, because it couldn’t get satisfactory access to the data involving the healthy adults in the study, he said.

The report raises questions about how drugs are reviewed, approved and distributed, Fiona Godlee, the British journal’s editor in chief, wrote in an editorial. The studies originally used to establish the benefits of Tamiflu were written by Roche employees and paid consultants, under-reported serious side effects and failed to clearly identify all the authors, she wrote. In at least one case, a study was attributed to a researcher who disavowed any involvement to the journal, Godlee wrote.

‘Taken on Trust’

Governments relied on the studies to justify the widespread use of Tamiflu, known chemically as oseltamivir, she said. The reviewers were unable to find any independent studies of the drug in healthy adults, she said.

“This case exposes how much of the evidence on drug safety and effectiveness is taken on trust,” Godlee wrote. “Governments around the world have spent billions of pounds on a drug that the scientific community has found itself unable to judge.” She called for more independent research, greater access to raw data used to license and sell drugs and stricter regulations on the conduct, review and publication of medical research.

Roche defended the drug’s benefits and its research, saying confidentiality agreements with patients enrolled in the trials kept the company from giving the investigators unreserved access to the findings.

“We fully stand behind the robustness of the data and the integrity of that data, particularly the efficacy and safety of Tamiflu, the conduct of our studies and publication policies,” David Reddy, head of the company’s global pandemic task force, said on a conference call with reporters. “We believe this drug is playing a pivotal role in the management of the current pandemic.”

Data From Pandemic

Two published trials show Tamiflu reduces complications in patients with seasonal influenza, while an observational study suggests it may lower death rates, Reddy said. Data emerging from the swine flu pandemic shows giving the drug within two days of symptoms appearing is the only effective way to help patients, he said.

More than 8,768 people worldwide have died from swine flu since it was first identified in Mexico and the U.S. in April, according to the Geneva-based WHO. More than 68 million people have taken Tamiflu since it was approved a decade ago. Influenza kills as many as 500,000 people worldwide each year.

The WHO recommends giving Tamiflu to infected people with a high risk of developing complications, including pregnant women and people with underlying medical conditions. The researchers said there is little evidence now available to show that otherwise healthy people should be routinely given Tamiflu.

In the U.K., patients can get a Tamiflu prescription by calling a national hotline or filling out an online questionnaire about their symptoms.

“The evidence shows that if taken within 24 hours, Tamiflu reduces symptoms of influenza by about a day,” Jefferson said. “It may reduce transmission. But we could not verify the claims that Tamiflu reduces complications. Once you took out the eight unpublished studies, the data relating to healthy adults that weren’t published, what remained showed no effect.”
hat-tip AlaskaDenise

Egypt Confirmed H5N1 (Avian Flu) Cases

Listed by Age, Location, Onset Date and # confirmed by Min. of Health

• 34 yo Tanta, [Gharbiyah Gov.] April 21 #68
• 5 yo Tama [Sohag Gov.] May 7 #69
  
• 4.5 yo Kafr Saqr [Ash Sharqiyah Gov.] May 10 #70
  
• 4 yo Hashim, Mahalla [Gharbiyah Gov.] May 12 #71
• 4 yo Ghamr [Dakahlia Gov.] May 9 #72
• 4 yo Sherbin Dakahliy [Dakahlia Gov] May 18 #73
• 3 yo Sohag [Sohag Gov] May 17 #74
  
• 4 yo Hehia, [Ash Sharqiyah Gov.] May 24 #75
• 4 yo Abo Hammad (Ash Sharqiyah Gov] May 23 #76
• 14 mos. Dekerness [Dakahlia Gov.] May 25 #77
  
• 4 yo El Sheikh [Ash Sharquiyah Gov.] May 30 #78
• 1.5 yo Albesartp [Damietta Gov.] June 1 #79
• 4 yo Maniya [Dakahlia Gov] June 5 #80
• 1 yo Kulain [Ash Sharqiyah Gov.] June 16 #81
• No Age Sidi Ghazi [Ash Sharqiyah Gov.] July 24 #82
• 1.6 yo Shebin [Menoufia Gov.] July 28 #83
• 2 yo Berket al-Saba [Menoufia Gov.] August 23 #84
• 14 yo Damietta [Damietta Gov.] August 21 #85
• 13 yo Ascot Park [Alexandria Gov] Sept. 13 #86
  
• 14 mos. Tahrer District [Beheira Gov.] Sept. 23 #87
• 21 yo Sedy Beshir [Alexandria Gov.] Nov. 11 #88
• 3 yo Minia District [Minya Gov.] Nov. 21 #89
• child Nag Sawyery [Matrouh Gov.] Dec. 5*
• 35 yo Bazbp Rashid [Menoufia Gov.] Dec. 6 Reported*
• 21 yo Tanta [Gharbiyah Gov.] Dec. 13 #90
  
  

* Not Reported By The Ministry of Health
* links to articles:
http://pandemicinformationnews.blogspot.com/2009/12/egypt-girl-with-bird-flu-infection-in.html
http://pandemicinformationnews.blogspot.com/2009/12/discovery-of-new-cases-of-bird-flu.html

Skepticism on Swine Flu’s Danger Limits European Vaccine Demand

By Andrea Gerlin

Dec. 8 (Bloomberg) -- Fewer Europeans are getting pandemic flu vaccine than typically get seasonal flu shots, as safety concerns and lower-than-expected death rates have damped demand.

The U.K., Ireland, Italy, Germany and France have vaccinated less than 10 percent of their populations, compared with 20 percent in Europe in a typical flu season. As a result, a fraction of the European Union’s 500 million people will be protected against the pandemic virus by early next year.

Public concerns that the vaccines made by GlaxoSmithKline Plc, Novartis AG and Baxter International Inc. may cause serious side effects have kept some Europeans on the sidelines since governments began vaccinating residents for free in October. That means Europe may donate more doses to poorer countries or experience a surge in hospital admissions if the virus mutates.

“If it’s not in the news anymore and if people don’t experience a lot of severe cases, to them it’s just a flu and not a pandemic flu in a way,” said Christian Ruef, professor of infectious disease and director of infection control at University Hospital Zurich. “The term pandemic to them is probably associated with more serious disease.”

The number of deaths is lower than what was predicted in worst-case scenarios after the virus first struck, Ruef said. Perceptions that the virus is mild may be hampering vaccination, he said.

The European Society of Clinical Microbiology and Infectious Diseases said on Nov. 23 that it was concerned about “mixed levels of uptake” and opposition from anti-vaccine activists challenging the safety of and need for the shot. The vaccines made by London-based Glaxo, Basel, Switzerland-based Novartis and Deerfield, Illinois-based Baxter were approved for use by the European Medicines Agency.

Unpredictable Virus

“No one should reject a safe and effective vaccine when we are dealing with an unpredictable virus capable of killing children and young adults in their prime,” said Javier Garau, president of the Basel-based European Society of Clinical Microbiology and Infectious Diseases.

More than 8,768 people worldwide have died from swine flu since it was first identified in Mexico and the U.S. in April, the Geneva-based World Health Organization said on Dec. 4. More than 850 deaths have been reported in Europe since April, according to the Stockholm-based European Centre for Disease Prevention and Control. As many as 500,000 people globally die of seasonal flu each year, according to the WHO.

Officials expect the virus to be prevalent again in 2010. The WHO in September decided to include swine flu in the vaccine for seasonal influenza in the next Southern Hemisphere flu season, meaning the agency believes it’s the most likely H1N1 strain to be circulating.

Polish Negotiations

Poland hasn’t used any vaccine so far, the country’s health ministry said.

“We’ve been negotiating with producers for at least a month now because we want them to guarantee the vaccine’s safe and take responsibility for any unwanted side effects, and that’s something they don’t want to do,” said Piotr Olechno, a Polish Health Ministry spokesman. The government is in talks with five companies, Olechno said. He declined to name them.

The U.K. has shipped 10 million doses of swine flu vaccine to family doctors, who have inoculated about 1.6 million of the 9.3 million people in risk groups, England’s Chief Medical Officer Liam Donaldson said Dec. 3. That’s less than 2 percent of the country’s entire population of about 60 million.

Washing Hands

To reduce the risk of catching swine flu, Emma Murphy is washing her and her toddler’s hands more often, avoiding people with colds and stocking up on honey and lemon. She and her 17- month-old son won’t get immunized.

“They put the vaccine out so quickly that I wouldn’t feel secure in giving it to him,” said Murphy, 29, a human resources assistant and student in Manchester, England, in an interview. “We’re being scared into making the decision by people saying children are dying.”

Italy had immunized 494,915 people out of about 60 million who live there as of Nov. 22, according to a Dec. 2 Health Ministry press release. France, where two patients died from a mutated version of the H1N1 virus that causes swine flu, has given pandemic shots to about 1.3 million people since Oct. 20, Health Minister Roselyne Bachelot-Narquin said on Dec. 3. The French government has ordered 94 million doses of vaccine for the country’s 63 million people.

Hard Decision

Parisian Simone Cartier said she “agonized” over whether to have her daughters, ages 2 and 5, immunized against swine flu. She doesn’t know anyone who has had the illness. After reading about the vaccine, she became concerned that it was produced too quickly and contains an adjuvant, an ingredient that boosts the immune system’s response. She then spoke to her doctor and changed her mind. Two weeks ago, she waited three hours in a school gym to get Glaxo’s Pandemrix shot for herself and her daughters.

“The night before going I thought: Am I going to inject my children with this poison or in 20 years am I going to be in front of a judge with kids who are sick?” said Cartier, 35, who works in book production. “Five minutes before leaving, I wanted to turn around. I try not to think about it.”

In Ireland, more than 150,000 people in risk groups -- pregnant women and people with underlying illnesses -- had been vaccinated as of Nov. 25, Gerry Mulligan of the Health Service Executive said. The country has had lower-than-expected uptake among children under 5 since it began vaccinating them in mid- November, Mulligan said. Ireland started vaccinating schoolchildren on Nov. 30, he said.

In the German federal state of Thuringia, 150,000 of 2.3 million residents have been immunized since Nov. 9, according to Thuringia’s health department.

Bright Spot

Declining swine flu rates in some countries also may deter people from getting the vaccine. England reported the fourth consecutive weekly drop in new swine flu cases on Dec. 3. Visits to U.S. doctors for influenza-like illness fell to the lowest level in three months, the government said on Dec. 4.

One bright spot in Europe’s pandemic immunization effort is Scandinavia. A third of Sweden’s 9.2 million people are estimated to have gotten the swine flu shot as of Nov. 20, according to the Swedish Association of Local Authorities and Regions. About 3.3 million doses of vaccine had been delivered to Sweden as of Nov. 20 and demand has outpaced supply.

“Everybody in my family got the shot,” said Jenny Mattisson, 36, a mother of three who lives in a suburb of Stockholm and usually doesn’t get a seasonal flu shot. “Our daughter is in a risk group so we wanted to try to minimize the chance of her getting sick, but I would have taken it anyway. I think it’s a good idea to get the vaccine; it helps slow it from spreading.”

Norway, U.S. Demand

Norway, where mutations in the H1N1 virus have been detected among two patients who died of the flu and one who was severely ill, had vaccinated all 1.2 million people in its risk groups as of Nov. 24, almost 25 percent of its total population, said Bjoerne-Inge Larsen, director general of Norway’s Directorate of Health. Finland has immunized about 1 million people, or 19 percent of its population, the government said on Nov. 26.

In the U.S., demand for the vaccine has been strong, with quick uptake of doses as they become available and waiting times at many providers, said Joseph Quimby, a spokesman for the U.S. Centers for Disease Control and Prevention, in an interview on Dec. 4. Doctors had administered about 20 million shots by mid- November. Health officials plan to release updated estimates of inoculations in the next few weeks, Quimby said.

There were 73 million vaccine doses available for distribution by the end of last week and an additional 10 million doses arriving this week, CDC director Thomas Frieden said in a press conference Dec. 4. Some states are beginning to offer the shots to a wider audience, after initial supplies were focused on protecting pregnant women, children and adults with chronic health conditions.

To contact the reporter responsible for this story: Andrea Gerlin in London at agerlin@bloomberg.net

Last Updated: December 7, 2009 19:01 EST

Vaccine Shortage in Developing Nations May Pose Security Threat

By Simeon Bennett

Dec. 8 (Bloomberg) -- Flu vaccine shortages in developing nations may destabilize global security should the H1N1 virus become more deadly, said David Heymann, a former deputy head of the World Health Organization.

Inequitable access to immunization against a highly lethal virus could inflame international tensions, Heymann, 63, said in an interview in Singapore yesterday. While the H5N1 bird flu virus helped industrialized nations prepare for the swine flu pandemic that is sweeping across the globe, there aren’t adequate measures in place to ensure less developed countries have access to vaccines, he said.

“Globally I think we’re not probably as prepared as we need to be in more equitable access to vaccines,” Heymann said. “An acute pandemic with high mortality and no vaccine in developing nations, and vaccine in industrialized countries, could cause various scenarios, and one of those could be an extreme destabilization of global security.”

About 200 million doses of swine flu vaccine have been donated to WHO for distribution to 95 low- and middle-income nations, according to the Geneva-based agency’s Web site. The United Nations health agency plans to provide enough vaccine for developing nations to immunize 10 percent of their populations.

The WHO plans to start immunizing health-care workers in developing nations this month, Marie-Paule Kieny, director of the agency’s Initiative for Vaccine Research in Geneva, said in an e-mail today.

Potential Crisis

Almost 73 million doses were available in the U.S. as of Dec. 4, and the government is preparing to offer the shots to everyone who wants one, the Centers for Disease Control and Prevention said yesterday.

“Countries that had good national plans and the financial ability to get vaccines were able to get them, and those countries that didn’t have the financial resources have not been able,” Heymann said. “For this virus it may not be so important because of the lower mortality rate, but if this were an H5N1-based pandemic with high mortality, it would be a major crisis.”

The H5N1 bird flu strain, which isn’t easily transmitted among people, was deadly in more than half of all laboratory- confirmed cases between December 2003 and April 2006, according to WHO data.

Swine flu kills 1 in every 2,000 to 14,000 ill patients, depending on whether scientists relied on medically evaluated cases or included self-reported flu symptoms. The research was published yesterday by the journal PLOS Medicine and used data collected in Milwaukee and New York from April to July.

Distribution Pledge

Equitable vaccine distribution was among issues discussed by health ministers from the Group of Seven nations and Mexico last week, the group said in a Dec. 4 statement.

“We reaffirm our commitment to work in close partnership with the WHO and other international partners to support developing countries and other countries in need of assistance in responding to the pandemic,” the ministers said.

Access to vaccines is an issue of national and global security, said Heymann, who is head of global health security at Chatham House, a London-based independent research and policy center. “It’s not just a health issue. This may really cause some tensions.”

In his previous capacity as the WHO’s assistant director general for communicable diseases, Heymann negotiated with Siti Fadilah Supari, then the Indonesian health minister, on providing samples of the H5N1 virus. Supari had refused to share the samples unless the WHO guaranteed free supply of vaccines developed from them.

“Minister Supari raised a very important issue,” Heymann said. “The way she raised it put the rest of the world at risk.”

To contact the reporter on this story: Simeon Bennett in Singapore at sbennett9@bloomberg.net

Last Updated: December 8, 2009 05:50 EST

Severity Of H1N1 Flu In US During Current Flu Season May Be Less Than Feared

Article Date: 08 Dec 2009 - 6:00 PST

A new study from researchers at the UK Medical Research Council and the Harvard School of Public Health (HSPH) projects that the severity of the H1N1 flu during the autumn-winter flu season in the U.S. will likely be less than previously feared. The estimates of hospitalizations and life-threatening events in the study are the most accurate to date of the H1N1 pandemic's impact in the U.S. The study appears online on December 7, 2009 in the journal PLoS Medicine.

"As more detailed data have become available, we have been able to improve our estimates of how severe this disease is. Early on, it was difficult to measure the flu's impact and it was crucial to plan for the full range of possible outcomes. Fortunately, the virus now appears to be near the milder end," said Marc Lipsitch, professor of epidemiology at HSPH and the study's senior author. Lipsitch heads the Center for Communicable Disease Dynamics at HSPH, which focuses on mathematical modeling and analysis of data on pandemic influenza, drug resistant infections, seasonal infectious diseases, and intervention allocation. The Center is funded through the National Institutes of Health's Models of Infectious Disease Agent Study (MIDAS), which is aiming to increase capacity to model disease spread, evaluate different intervention strategies, and help inform public health officials and policymakers.

While the news is better than was thought at the start of the pandemic, Lipsitch emphasizes that it remains important to continue to vaccinate against pandemic H1N1 and to remain vigilant about disease in groups at risk of complications. "This is a serious disease," said Lipsitch. "The U.S. Centers for Disease Control (CDC) and others have shown that certain high-risk groups, including pregnant women, people with asthma, and people with compromised immune systems, should be vaccinated and should seek prompt treatment if they suspect they are sick with H1N1. Even for people outside these high-risk groups, vaccination is an important way to reduce the risk of what can be a serious illness."

Estimates of the H1N1 flu's severity are important because they help public health officials plan for the types of interventions that are needed to treat symptoms, including life-threatening respiratory situations, and help officials project the possible burden on the health care system.

"Providing unbiased estimates to gauge the severity of the flu pandemic is crucial in order for local health services to be able to plan their resources properly and deliver the best level of care possible. Our study was careful to account for uncertainty in the evidence and analyse the different ways severity of the illness is being measured," said first author Anne Presanis of the Medical Research Council Biostatistics Unit in Cambridge, UK.

Up until this point, the severity of H1N1 flu among the U.S. population had been hard to measure, partly due to the difficulties of counting the large numbers of cases that overwhelmed health authorities and of testing the large numbers of people that had symptoms. The World Health Organization counts 209,000 laboratory-confirmed cases and more than 3,205 deaths worldwide as of September 11, 2009, but health authorities worldwide believe that these are substantial underestimates.

The researchers, led by Presanis and Lipsitch, measured the severity of the pandemic by analyzing what fraction of people in the study population that were sick with H1N1 flu were (1) hospitalized, (2) in an intensive-care unit (ICU) or on a ventilator or (3) had died. They analyzed data from the CDC and from New York and Milwaukee, two cities where health officials collected particularly high-quality surveillance data during the wave of infections from April to July 2009. The researchers then combined all the evidence using a statistical approach called Bayesian evidence synthesis to estimate the probability of the three outcomes above for individuals who fell ill with H1N1 in the overall U.S. population and by age group.

The researchers used two different approaches to estimate these risks. One approach led to an estimate that approximately 1.44% of patients with symptoms of H1N1 flu during the April-July time period were hospitalized, 0.239% required intensive care or mechanical ventilation and 0.048% died. The other estimate found probabilities 7 to 9 times lower, due to the use of different data to estimate how many individuals were sick. Based on these findings and assuming that the virus doesn't change its characteristics, the researchers estimate that the severity of the autumn-winter pandemic wave of H1N1 flu could have a death toll in a range from considerably below the estimated 36,000 associated with an average flu season in the U.S. to slightly higher. Also, unlike seasonal flu, which kills mainly elderly adults, the H1N1 flu could have the greatest impact in children aged 0-4 and especially adults 18-64, a shift toward nonelderly persons that has been seen in prior flu pandemics.

"The good news is that, along with previous work by the CDC and others, our work shows that the severity of the H1N1 flu may be less than initially feared," said Lipsitch. However, he adds that between 1 in 70 and 1 in 600 people who are sick with the illness will be hospitalized, and a fraction of those will die.

A preliminary version of this article was posted on PLoS Currents (September 25th 2009), a new forum for rapid publication of results designed to aid timely dissemination of important information during the pandemic.

Support for the study was provided by the UK Medical Research Council, the UK Health Protection Agency, the U.S. National Institutes of Health and Department of Homeland Security.

"The Severity of Pandemic H1N1 Influenza in the United States from April to July 2009: A Bayesian Analysis," Anne M. Presanis, Daniela De Angelis, The New York City Swine Flu Investigation Team, Angela Hagy, Carrie Reed, Steven Riley, Ben S. Cooper, Lyn Finelli, Paul Biedrzycki, Marc Lipsitch, PLoS Medicine, online Dec. 7, 2009

Source:
Todd Datz
Harvard School of Public Health