ECDC DAILY UPDATE Pandemic (H1N1) 2009 Update 20 October 2009, 09:00 hours CEST

excerpt:

Updates from U.S.A. and Canada
United States
Update Data as of 16 October 2009, for week ending 10 October 2009 (Week 40)

Virology: 100% of all subtyped influenza A viruses reported to CDC were 2009 influenza A (H1N1) viruses. 99.6% of all specimens were type A and 0.4% were type B. 2009 influenza A (H1N1) viruses continue to be similar to the strain chosen for the vaccine. Since September 1, 2009, four infections with oseltamivir resistant 2009 influenza A (H1N1) viruses have been identified in the United States, and a total of 13 cases have been identified in the U.S. since April 2009 (10 viruses identified by CDC and three viruses identified by additional laboratories).

The 13 cases represent an increase of one case over the previous week. All tested viruses retain their sensitivity to the neuraminidase inhibitor zanamivir. Eleven patients (including nine of the viruses detected at CDC and two viruses identified by the additional laboratories) had documented exposure to oseltamivir treatment or chemoprophylaxis, and the remaining two patients are under investigation to determine exposure to oseltamivir.

Since the emergence of the 2009 influenza A (H1N1), all isolates tested have been resistant to the adamantanes (amantadine and rimantadine). Currently, adamantane antiviral susceptibility testing has been suspended at CDC to allow a focus on neuraminidase inhibitors. Because of the low level of circulation of seasonal influenza A (H1N1), A (H3N2), and influenza B viruses, no samples collected since September 1, 2009 were available for antiviral resistance testing.

Mortality Surveillance:
Pneumonia and Influenza Hospitalization and Deaths: From 30 August – 10 October 2009, 4,958 laboratory-confirmed influenza associated hospitalizations, 292 laboratory-confirmed influenza associated deaths, 15,696 pneumonia and influenza syndrome-based hospitalizations, and 2,029 pneumonia and influenza syndrome-based deaths, were reported to CDC.

Pneumonia and Influenza (P&I) Mortality Surveillance:
During week 40, 6.7% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage was above the epidemic threshold of 6.5% for week 40.

Influenza-associated Pediatric Deaths: Influenza-Associated Pediatric Mortality:
Eleven influenza-associated pediatric deaths were reported to CDC during week 40. Ten of these deaths were associated with 2009 influenza A (H1N1) virus infection and one was associated with an influenza A virus for which the subtype is undetermined. These deaths occurred between 30 August and 10 October 2009. Since 30 August 2009, CDC has received 43 reports of influenza-associated pediatric deaths that occurred during the current influenza season. (A total of 86 deaths in children associated with 2009 H1N1 virus have been reported to CDC.) Among the 43 deaths in children, 28 children had specimens collected for bacterial culture from normally sterile sites and seven (25.0%) of the 28 were positive; Staphylococcus aureus was identified in five (71.4%) of the seven children.

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http://www.nlm.nih.gov/medlineplus/staphylococcalinfections.html

Staphylococcal Infections

Also called: Staph

Staph is short for Staphylococcus, a type of bacteria. There are over 30 types, but Staphylococcus aureus causes most staph infections (pronounced “staff infections”), including

• Skin infections
• Pneumonia
• Food poisoning
• Toxic shock syndrome
• Blood poisoning (bacteremia)

Skin infections are the most common. They can look like pimples or boils. They may be red, swollen and painful, and sometimes have pus or other drainage. They can turn into impetigo, which turns into a crust on the skin, or cellulitis, a swollen, red area of skin that feels hot.

Anyone can get a staph skin infection. You are more likely to get one if you have a cut or scratch, or have contact with a person or surface that has staph bacteria. The best way to prevent staph is to keep hands and wounds clean. Most staph skin infections are easily treated with antibiotics or by draining the infection. Some staph bacteria are resistant to certain antibiotics, making infections harder to treat.

Nevada: More Than 2,000 Stand in Line for H1N1 Vaccine

Monday, October 19, 2009

More than 2,600 people stood in line — sometimes longer than two hours — to be among the first in southern Nevada to get the injectable swine flu vaccine.

Gwen Osburn, community health nurse at the Southern Nevada Health District, said more than 300 people were vaccinated in the first hour after opening on Saturday.

The health district has received more than 48,000 doses of the H1N1 vaccine, including an initial delivery of 20,000 FluMist doses, which are administered through the nose.

About 11,000 doses have been distributed to doctors' offices in Clark County that serve at-risk populations.

USDA Confirms H1N1 in Minnesota Pigs

Monday, October 19, 2009

The U.S. Department of Agriculture says at least one pig from the Minnesota State Fair has tested positive for the H1N1 virus, the first case of a pig contracting the virus in the United States.

Agriculture Secretary Tom Vilsack said in a statement Monday that USDA officials have begun to reach out to international organizations and are emphasizing that H1N1, also known as swine flu, cannot be contracted by eating pork products.

The USDA's National Veterinary Services Laboratories confirmed the presence of H1N1 after an initial test suggested that as many as three pigs may have had the virus.

USDA officials say the infection of a so-called show pig doesn't indicate an infection of commercial herds because show pigs are in separate segments of the swine industry.

U.S. Department of Education Issues Guidance On Swine Flu

October 19, 2009

The US Department of Education has issued guidance that discusses waivers from federal education requirements that may provide state or local educational institutions with the operational flexibility necessary to efficiently close schools and otherwise respond to the administrative challenges presented by a potential H1N1 outbreak such as: prolonged school closures, excessive absenteeism, or other disruptions in the regular delivery of educational services to students for a prolonged period of time.

The document, which is quite lengthly, contains advisory information on six sections: Elementary and Secondary education issues, adult education and career and technology issues, Federal Student Aid and other postsecondary education issues, grant administration requirements, Family Educational Rights and Privacy Act (FERPA) issues, and distribution of flu vaccines at school facilities. The document also addresses concerns for IEPs and Special Education student services which may be disrupted.

The Guidance is available here.

Mitchell H. Rubinstein

Links to Pneumonia, Rapid Effects on Young Noted

By Rob Stein
Washington Post Staff Writer
Saturday, October 17, 2009
http://www.washingtonpost.com/wp-dyn/content/article/2009/10/16/AR2009101601384.html

As swine flu continues to spread around the globe, a clearer and in some ways more unnerving picture of the most serious cases has started to emerge, indicating that the virus could pose a greater threat to some young, otherwise vibrant people.

The virus can cause life-threatening viral pneumonia much more commonly than the typical flu, prompting the World Health Organization on Friday to warn hospitals to prepare for a possible wave of very sick patients and to urge doctors to treat suspected cases quickly with antiviral drugs.

Experts stress that most people who get the H1N1 virus either never get sick or recover easily. But some young adults, possibly especially women, are falling seriously ill at an unexpectedly rapid pace and are showing up in intensive care units and dying in unusually high numbers, they say.

Although why a minority of patients become so sick remains a mystery, new research indicates that H1N1 is different from typical seasonal flu viruses in crucial ways -- most notably in its ability to penetrate deep into the lungs and cause viral pneumonia.

"It's not like seasonal influenza," Nikki Shindo of the World Health Organization said at the conclusion of a three-day meeting of more than 100 experts the WHO convened in Washington to review swine flu. "It can cause very severe disease in previously healthy young adults."

Meanwhile, the Centers for Disease Control and Prevention reported Friday that vaccine production was proceeding more slowly than hoped. Officials had predicted that about 40 million doses would be available by the end of October, but that projection will probably fall short by about 10 million to 12 million doses, said Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases.

"Eventually, anyone who wants to be vaccinated will be able to be, but the next couple of weeks will continue to be a slow start," she said. So far, 11.4 million doses have become available and states have ordered about 8 million doses, but the vaccine will not become available in large amounts until November, she said.

The WHO's warning came as U.S. health officials reported that the number of states reporting widespread flu activity was up to 41, including Maryland and Virginia, and that the death toll among children had climbed to 86. Maryland has reported 10 deaths and Virginia health officials say eight people, including one child, have died. There have been no reports of deaths among District residents.

So far, the virus does not seem to sicken or kill people more often than the typical flu. But the pattern of people getting seriously ill is far different than in typical flu seasons. The elderly, who are usually most vulnerable, are generally spared; children, teenagers, pregnant women and young adults are the most common victims.

Officials have been closely monitoring the virus for signs it has mutated into a more dangerous form, and they have also been testing animals for the virus because of fears that infected livestock could cause more-lethal mutations.

Federal agriculture officials said Friday that pigs from the Minnesota State Fair had tested positive for H1N1, which would make them the first documented pig infections in the United States, if follow-up tests confirm the results. But there are no signs that the pigs were sick or that the animals had infected any humans. Children staying near the fair had gotten the virus, but there was no sign they were infected by the pigs.

Seasonal flu viruses tend to infect primarily the upper respiratory system. But recent animal studies and autopsies on about 100 swine flu victims show that H1N1 infects both the upper respiratory tract, which makes it relatively easy to transmit, and also the lungs, which is more similar to the avian flu virus that has been circulating in Asia.

"It's like the avian flu on steroids," said Sherif Zaki, chief of Infectious Disease Pathology at the CDC. He noted that unusually large concentrations of the swine flu virus have been found in the lungs of victims: "It really is a new beast, so to speak."

About a third of patients who required intensive care had bacterial pneumonia, but H1N1's proclivity to infect lung cells makes it more likely than seasonal flu to cause viral pneumonia, which can lead to life-threatening lung damage.

"Remarkably different is this small subset of patients that presents very severe viral pneumonia," Shindo said.

One of those patients was Karen Ann Hays of Sacramento, Calif., an otherwise healthy nurse whose hobby was tackling grueling triathlons. Despite desperate measures to keep her alive, Hays, 51, died in July within days of coming down with swine flu.

"I have seen more cases like this in the last three months than I have in the last 30 years," said Peter Murphy, director of intensive care at the Mercy San Juan Medical Center in Carmichael, Calif., who tried to save Hays.

Although it remains unclear how frequently the virus makes people seriously ill, recent reports from Mexico, Canada, the United States, Australia and New Zealand indicate that perhaps 1 percent of patients who get infected require hospitalization. Between 12 to 30 percent of those hospitalized need intensive care, and 15 to 40 percent of those in intensive care die.

While about two-thirds of U.S. patients who were hospitalized in the spring had other medical conditions, the CDC reported this week that an analysis of more than 1,400 hospitalized victims found perhaps half had no serious health problems.

About one-third of those around the world who have died or became seriously ill from swine flu appear to have been vulnerable because they had heart or lung disease, chronic kidney problems, or other ailments that usually put people at risk. But others had conditions that many may not immediately associate with frailness, such as mild asthma, high blood pressure, high cholesterol and obesity.

"Many of these people look just like you or me," said Anand Kumar, an associate professor of critical care and infectious disease at the University of Manitoba in Winnipeg, Canada, which was hit hard by the pandemic's first wave last spring.

There appears to be no way to predict with certainty who may suffer serious, life-threatening complications, since some victims have had no other health problems.

For instance, Stacey Hernandez Speegle, 30, of Madison, Calif., who died in July, "was in great shape. She was on the softball team. She had two young children. She was renovating her house," said her mother, Tamara Brooks. "It's just so hard to believe."

Although it has been well publicized that pregnant women appear to be at increased risk, some evidence has started to suggest that being female may itself be a risk factor, for reasons that remain unclear.

"There's no question that women, and particularly young women, are getting hit disproportionately," said Kumar. He noted that women tend to have more fat tissue, which can help stimulate a dangerous inflammatory response to infections.

And some of those who develop serious illness deteriorate soon after starting to feel ill. They require oxygen masks, ventilator machines to pump oxygen into their lungs to keep them alive, and drastic, often rarely used measures to try to save them within days of the first fever, ache or cough.

"The rapidity of it is striking," said Andrew R. Davies, deputy director of intensive care at Alfred Hospital in Melbourne, Australia.

Some of the cases in Australia and New Zealand were so severe that doctors resorted to a much more aggressive, less commonly used treatment known as extracorporeal membrane oxygenation (ECMO). It involves siphoning patients' blood into a machine to remove carbon dioxide and then infuse it with oxygen before returning it to their bodies.

"It's quite an extreme form of treatment," said Steve Webb, a clinical associate professor at the Royal Perth Hospital in Australia.

Other doctors have tried administering nitric oxide and putting patients in a bed that turns them upside down to help their lungs work better. "Our back was against the wall," Murphy said, adding that after the deaths of patients such as Hays his hospital is working to make ECMO available.

"It's very difficult to get this double-barreled message out that: 'Yes, most cases are mild, but in a small percentage of cases these cases are disastrous,' " Vanderbilt University's William Schaffner said. "But the message is: Don't underestimate H1N1."

Of the at least 86 Americans younger than 18 who have died from H1N1, 11 deaths were reported in the past week. About half of the deaths in the past month were among teenagers, Schuchat said. Since Aug. 30, 43 pediatric deaths have been reported, including three in those younger than age 2, five among those ages 2 to 4, 16 in those ages 5 to 11, and 19 among those ages 12 to 17, she said.

"These are very sobering statistics," Schuchat said, noting that only about 40 or 50 children usually die during an entire flu season.

Virginia Health Commissioner Karen Remley said Friday that although the majority of H1N1 cases in the state are "mild and moderate," significant numbers have become seriously ill.

In Maryland, at least 257 people have been hospitalized with confirmed cases of H1N1 since June, health officials said.

At least 2,914 Americans have died from flu-related illnesses since the H1N1 began, the CDC said.

Staff researcher Madonna Lebling and staff writer Michael Laris contributed to this report.
hat-tip Pixie

Swine Flu Causes Unprecedented Amount Of Illness Early In Season

LAURAN NEERGAARD, AP Medical Writer
October 16, 2009

WASHINGTON -- The swine flu is causing an unprecedented amount of illness for this early in the fall, with the deaths of 11 more children reported in the past week. And less vaccine than expected will be ready by month's end, federal health officials said Friday.

Of the 86 children who have died since the new swine flu arose last spring, 43 deaths have been reported in September and early October alone, the Centers for Disease Control and Prevention reported. That's a startling number because in some past winters, the CDC has counted 40 or 50 child deaths for the entire flu season -- and no one knows how long this swine flu outbreak will last.

"These are very sobering statistics," said the CDC's Dr. Anne Schuchat.

Also surprising, about half of the child deaths reported since Sept. 1 have been teenagers. Until now, much of the attention has focused on younger children.

Overall, what CDC calls the 2009 H1N1 flu is causing widespread disease in 41 states, and about 6 percent of all doctor visits are for flu-like illnesses, levels not normally seen until much later in the fall.

There may be only 28 million to 30 million vaccine doses dispersed around the country by month's end, Schuchat said, short of the 40 million-plus the government had hoped. But more will continue to arrive weekly, and she urged patience as people await their turn.

As of Wednesday, states had ordered 8 million of the 11.4 million doses of swine flu vaccine the government has ready to ship.

Initial vaccine shipments were only of FluMist, the nasal spray version that can be used by only certain people -- those ages 2 to 49 who aren't pregnant and have no chronic illnesses such as asthma. But swine flu shots now are shipping, too, accounting for a bit more than half of the vaccine available today, Schuchat said.
hat-tip Pixie

Canada: Young man is first in Ontario with swine flu that doesn't respond to drug

Canada:

Tamiflu-resistant H1N1 in Hamilton


October 16, 2009

Joanna Frketich
The Hamilton Spectator
(Oct 16, 2009)

A young Hamilton man was infected with Ontario's first case of Tamiflu-resistant H1N1.

Only a few dozen people worldwide have been reported to have pandemic influenza resistant to the antiviral treatment. They include a 60-year-old Quebec man and an Alberta woman. Both recovered without being hospitalized.

The Hamilton man is in his 20s. Public health officials don't believe he spread it because no one he had contact with has become sick.

"People should take this seriously, but not panic," said Dr. Chris Mackie, Hamilton's associate medical officer of health.

The emergence of Tamiflu-resistant H1N1 comes at the same time local doctors have reported to the public health department that at least one company tried to pay for its staff to get prescriptions for the antiviral to prevent the flu.

"It sent a letter with all of their employees out to doctors saying we'll pay you $60 to give a 60-day prescription to prophylactics," Mackie said.
"This is exactly the sort of thing that generates resistance."

Tamiflu is only to be used as a treatment for high-risk patients with symptoms and not for prevention.

The H1N1 flu shot is the best way to protect against the pandemic and Mackie says he's hoping to announce today when it will be available and where.

He refused to provide any details about the young man who caught the Tamiflu-resistant strain. He wouldn't even say whether the man is dead or alive.

Normally, public health provides details about whether the person is in hospital or at home and how ill.

"For reasons of confidentiality, I'm afraid we can't say anything more about this individual case and I really apologize about that," said Mackie.

The Ministry of Health is confident it's an isolated case.

"At the moment there is no evidence of widespread resistance to Tamiflu anywhere," said ministry spokesperson David Jensen.

There are other antiviral treatments available when H1N1 is resistant to Tamiflu. However, it can take weeks to determine the strain is resistant. Often, the patient's illness gets worse and that's what prompts doctors to try other antiviral treatments.

So far, it hasn't been a big concern because there have been so few cases.

"This virus has been remarkably stable," said Dr. Michael Gardam, director of infectious disease prevention and control at Ontario's Agency for Health Protection and Promotion. "It hasn't shown any propensity at this point to easily develop resistance and then for those resistant strains to spread."
hat-tip Treyfish

Shortage of shots as more kids die of swine flu

Oct. 16, 2009

CDC: H1N1 virus causing unprecedented number of infections for early fall

WASHINGTON - Even as swine flu infections are causing an unprecedented amount of illness for this time of year — and a growing number of deaths, particularly among children — supplies of vaccine to protect against it will be delayed, government health officials said Friday.

In the past week, 11 more children have died from H1N1 influenza infections, an official from the Centers for Disease Control and Prevention said, bringing the total to 86 children since April. That's a startling number because in some past winters, the CDC has counted 40 or 50 child deaths for the entire flu season — and no one knows how long this swine flu outbreak will last.

"These are very sobering statistics," said Dr. Anne Schuchat, the CDC's director of immunization and respiratory diseases.

At the same time, drug manufacturers have told health officials to expect at least 25 percent less vaccine by the end of the month than anticipated. Instead of the 40 million doses projected by the end of October, only 28 million to 30 million doses may be available, said Schuchat.

"We aren't expecting widespread availability until the end of the month or until November," Schuchat said. "It will be pretty challenging to find vaccine."

She urged people anxious to get immunized to check back with their state and local health departments.

"Keep looking," Schuchat said.

Initial vaccine shipments were only of FluMist, the nasal spray version that can be used by only certain people — those ages 2 to 49 who aren't pregnant and have no chronic illnesses such as asthma. But swine flu shots now are shipping, too, accounting for a bit more than half of the vaccine available today, Schuchat said.

Vaccine manufacturers have told CDC that the yield of H1N1 antigen, the substance that produces infection-fighting antibodies, has been lower than expected.

Swine flu is now widespread in 41 states, CDC reported. And overall for the country, deaths from pneumonia and flu-like illnesses have passed what CDC considers an epidemic level. About 6 percent of all doctor visits are for flu-like illnesses, levels not normally seen until later in the fall. Half of the all the child deaths have been in teenagers.

Earlier this week, health officials said that almost half of the hospitalized adult swine flu patients had been healthy people who did not have asthma or any other chronic illnesses before they got sick.

Unpredictable nature
Separately, the World Health Organization said Friday although the H1N1 virus has killed fewer than 5,000 people so far this year worldwide, the influenza remains a cause for concern because of its unpredictable nature.

Most people who catch the H1N1 virus suffer mild symptoms.

But in contrast to seasonal flu strains which can be serious for elderly people, H1N1 can turn dangerous for some people with existing health conditions or otherwise healthy young adults.

"There is a small subset of cases that do and can progress quite rapidly to severe disease and this is sometimes in the space of less than 24 hours and it then becomes a big, big challenge to save the people," said WHO spokesman Gregory Hartl.

"This disease continues to cause concern because it doesn't act exactly like seasonal influenza and because it doesn't affect the same groups who are affected by seasonal influenza."
hat-tip Pixie

Australia: Piggery quarantined after swine flu outbreak

October 14, 2009

A PIGGERY near Toowoomba has been placed under quarantine after test results came back positive for swine flu.

Biosecurity Queensland chief veterinary officer Ron Glanville said given the widespread presence of H1N1 in the human population, the occasional case in piggeries was to be expected.

"Fortunately, influenza A H1N1 in piggeries can be managed relatively easily through routine biosecurity measures,'' Dr Glanville said.

Biosecurity officers are working with the owners in the latest case to implement on-site biosecurity measures to ensure the virus remains contained.

"This is not a human health issue and food authorities maintain that pork and pork products are safe to eat,'' he said.

"The infection should be self-limiting within the piggery and the response is designed to allow the disease to burn out as quickly as possible.''

Dr Glanville said this was only the second case of human pandemic (H1N1) 2009 influenza detected at a piggery in Queensland following the quarantine of a piggery near Dalby in August.

"That piggery has since been released from quarantine after the illness ran its course,'' he said.

"The pigs at this site are now all in good health.''

All pig owners should maintain strict biosecurity procedures on their properties and report anything unusual in their herds to the Emergency Disease Watch Hotline on 1800 675 888.

BAMC to Use CombiMatrix Influenza Array to Study Genetic Drift of H1N1 Swine Flu

October 13, 2009 6:00 AM ET

MUKILTEO, Wash., Oct. 13, 2009 (GLOBE NEWSWIRE) -- CombiMatrix Corporation (Nasdaq:CBMX) announced today that Brooke Army Medical Center ("BAMC") is using the CombiMatrix Influenza-Detection System to analyze influenza cases including those involving H1N1 Swine flu. BAMC is a military hospital that is investigating the feasibility of screening all patients presenting in its emergency room with symptoms of respiratory distress and consenting to nasal swabs, by both electrochemical array-based diagnostics and bead-based multiplex fluorescent methods.

While there are other flu tests including the fluorescent test used at BAMC that can identify the presence or absence of H1N1 Swine flu, they do not provide information on genetic drift of the virus. It is important to understand the genetic drift of rapidly mutating pathogens in general and of Swine flu in particular because of the potential for increased pathogenicity of a mutated virus.

Recent estimates by the President's Council of Advisors on Science and Technology indicate that millions of U.S. citizens might contract Swine flu, and nearly 1.8 million individuals might be hospitalized, with up to 90,000 deaths in the U.S. during this flu season. World-wide, there are already several hundred thousand confirmed cases, and the World Health Organization has declared a pandemic. Although some of these estimates might be high, the numbers clearly indicate that this viral disease is a major public health concern. Because Swine flu can be a rapidly mutating virus, concerns exist about mutations that might make it more pathogenic while maintaining its highly infectious nature.

"We are pleased to be working with BAMC to evaluate the genetic drift of the Swine flu virus," stated Dr. Amit Kumar, President and CEO of CombiMatrix. "Our influenza array has demonstrated its ability to provide tremendous genetic information regarding numerous infectious agents including Bird Flu, Swine flu, and other infectious agents. It is especially significant to note that our Influenza-Detection System was developed with funding from the U.S. Department of Defense, and it is now being used to evaluate infections in military, former-military, and government personnel. Also, we encourage interested parties to review information on the website of the U.S. Centers for Disease Control and Prevention to get an understanding of the limitations of currently available flu tests, especially what we feel is poor performance of many rapid flu tests," concluded Dr Kumar. The link for this information is as follows: http://www.cdc.gov/h1n1flu/guidance/diagnostic_tests.htm

According to Dr. Gerald Merrill, Laboratory Director for the Department of Clinical Investigation at BAMC, "We are already seeing a high percentage of novel H1N1 flu cases in the San Antonio military community this season. The CombiMatrix system allows us to screen for Swine flu versus seasonal influenza A and influenza B. Samples analyzed using the CombiMatrix system from last season allowed us to look at clustering of genotypes and to see patterns suggesting genetic drift in both the novel H1N1 Swine flu virus and the seasonal influenza A virus in San Antonio. This can be useful in spotting divergence of strains and possibly in identifying problems earlier than if we did not screen for such divergence," concluded Dr. Merrill.

ABOUT COMBIMATRIX CORPORATION

CombiMatrix Corporation is a diversified biotechnology business that develops proprietary technologies, including products and services in the areas of drug development, genetic analysis, molecular diagnostics, nanotechnology and defense and homeland security markets, as well as in other potential markets where our products and services could be utilized. The technologies we have developed include a platform technology to rapidly produce user-defined, in-situ synthesized, oligonucleotide arrays for use in identifying and determining the roles of genes, gene mutations and proteins. This technology has a wide range of potential applications in the areas of genomics, proteomics, biosensors, drug discovery, drug development, diagnostics, combinatorial chemistry, material sciences and nanotechnology.
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People at High Risk of Developing Flu-Related Complications

October 8, 2009, 12:45 AM ET

Most people who get the flu (either seasonal or 2009 H1N1) will have mild illness, will not need medical care or antiviral drugs, and will recover in less than two weeks. Some people, however, are more likely to get flu complications that result in being hospitalized and occasionally result in death. Pneumonia, bronchitis, sinus infections and ear infections are examples of flu-related complications. The flu can also make chronic health problems worse. For example, people with asthma may experience asthma attacks while they have the flu, and people with chronic congestive heart failure may have worsening of this condition that is triggered by the flu. The list below includes the groups of people more likely to get flu-related complications if they get sick from influenza.

People at High Risk for Flu Complications:

• Children younger than 5, but especially children younger than 2 years old
• Adults 65 years of age and older
• Pregnant women
• People who have:
  • Cancer
  • Blood disorders (including sickle cell disease)
  • Chronic lung disease [such as asthma or chronic obstructive pulmonary disease (COPD)]
  • Diabetes
  • Heart disease
  • Kidney disorders
  • Liver disorders
  • Neurological disorders (such as epilepsy, cerebral palsy, brain or spinal cord injuries, moderate to profound intellectual disability [mental retardation] or developmental delay)
  • Neuromuscular disorders (such as muscular dystrophy and multiple sclerosis)
  • Weakened immune systems (such as people with HIV or AIDS or who are on medications that weaken the immune system )

Antigenic Diversity Increases with 7 Novel H1 SNPs from Chengdu and Jiangyin

On 2009-10-06 China deposited 22 Hemagglutinin sequences and 23 matching partial Neuraminidase sequences from the areas of Chengdu and Jiangyin sampled respectively on 2009-07-26 and 2009-08-16. The Neuraminidase segments are far too limited in data for evaluation. The HA segments are remarkable due to the fact that 100% of the distinguishable SNPs are, on first inspection, novel introductions to ΣPF11. Changes directly upstream and downstream of the Receptor Binding Domain may affect Antigen match.

HA Protein Codings to 7 Novel Polymorphisms and 1 Mixed Signal
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Japan: Drug-resistant flu can spread

Oct 8, 2009

TOKYO - A GENETIC mutation of H1N1 swine flu that is resistant to the antiviral drug Tamiflu has been detected in a Japanese teenager who had not previously been treated with the drug, a Japanese health official said.
The case could mark Japan's first instance of person-to-person transmission of a Tamiflu-resistant strain of the H1N1 flu but Health Ministry official Takeshi Enami said there was still insufficient evidence to confirm that.



'We cannot deny that this could be person-to-person transmission, but we are not able to reach that conclusion,' Mr Enami said. Japan has had eight cases of new H1N1 patients who were resistant to Tamiflu, he added.
The mutation was detected by health officials in Sapporo, northern Japan, in a teenage girl who had developed a fever on Aug 22. She was given GlaxoSmithkline's Relenza and recovered a day later, the ministry said in a statement.



The detected mutation did not worsen the virus, nor were there signs of an unusual rise in new H1N1 cases nearby, it said.
The risk of resistance is higher in patients who suffer from weak immune systems and have already been treated with Tamiflu, manufactured by Roche Holding under license from Gilead Sciences. -- REUTERS

Seasonal Flu Vaccine & Pandemic H1N1A Vaccine Shots Taken Together

Additional Information, previous post:

Thursday, October 1, 2009

Seasonal Vaccine "FluMist" and Swine Flu "FluMist" Do Not take together

Excerpt:

Can seasonal vaccine and novel H1N1 vaccine be administered at the same time?

October 6, 2009, 6:30 PM ET

Can seasonal influenza vaccine and 2009 H1N1 vaccine be given at the same visit?

Both seasonal and 2009 H1N1 vaccines are available as inactivated and live attenuated (LAIV) formulations. The simultaneous and sequential administration of seasonal and 2009 H1N1 inactivated vaccines is currently being studied. However, existing recommendations are that two inactivated vaccines can be administered at any time before, after, or at the same visit as each other (General Recommendations on Immunization, MMWR 2006;55[RR-15]). Existing recommendations also state that an inactivated and live vaccine may be administered at any time before, after or at the same visit as each other. Consequently, providers can administer seasonal and 2009 H1N1 inactivated vaccines, seasonal inactivated vaccine and 2009 H1N1 LAIV, or seasonal LAIV and inactivated 2009 H1N1 at the same visit, or at any time before or after each other. Live attenuated seasonal and live 2009 H1N1 vaccines should NOT be administered at the same visit until further studies are done. If a person is eligible and prefers the LAIV formulation of seasonal and 2009 H1N1 vaccine, these vaccines should be separated by a minimum of four weeks.


Can 2009 H1N1 vaccine be administered at the same visit as other vaccines?

Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine.

Japan: Sapporo's new flu-infected patients or people with resistant virus

2009/10/08 01:29

Ministry of Health and Sapporo on June 7, and seek medical attention for the city's 10 new flu virus was detected in patients with the woman announced that a gene mutation was found resistant to Tamiflu treatment.

厚労省によると、タミフル耐性ウイルスの確認は国内８例目だが、今回の患者はタミフルを使用しておらず、初 めてほかの人から感染した可能性があるという。

According to the ministry, confirmed Tamiflu-resistant virus, but eight of the domestic cases, this patient was not using Tamiflu, that there is a possibility of infection from other people first.

タミフル耐性が確認されたこれまでの例では、服用した患者の体内でウイルスが変異し、耐性を持ったとみられ ていた。

This was confirmed in cases of resistance to Tamiflu, the virus mutated in patients taking the body, with a resistance was expected.

厚労省などによると、女性は８月２２日に発熱し、医療機関で別の治療薬リレンザを投与されて翌日に解熱した 。

According to the ministry, the woman developed fever on August 22 and Sun, the day after antipyretic drug Relenza is administered by medical institutions.

９月２５日になって札幌市衛生研究所での遺伝子検査でタミフルへの耐性が判明。

September 25 found that genetic testing of resistance to Tamiflu in Sapporo City Institute of Public Health is in the Sun.

今月６日に国立感染症研究所で確定した。

This month the final six days at the National Institute of Infectious Diseases.

札幌市は女性の家族や周辺地域でタミフルの服用後に症状が改善しなかったりしたケースは確認していないとし ている。

Sapporo is the case or does not improve after taking Tamiflu symptoms in women family and the surrounding area has not been confirmed.

厚労省は「タミフル耐性を持つウイルスの女性からの感染拡大は確認されていない。女性が人から感染した可能 性は否定できない」としている。

The ministry is "the spread of Tamiflu-resistant virus from women has not been confirmed. The possibility of infection from a woman who can not be denied" and that.

Jqpan: New Tamiflu-resistant flu, Sapporo or first person infected

2009年10月7日23時12分

October 7, 2009 23:12


Ministry of Health and Sapporo on June 7 from patients infected with swine flu in the new city, announced the discovery of resistant virus could be resistant to the antiviral drug Tamiflu.

新型インフルのタミフル耐性例は国内８例目だが、今回の患者自身はタミフルを使っておらず、初めて人から感 染した事例の可能性もある。

Tamiflu-resistant flu cases in the new country, but of eight cases, the patient's own Tamiflu does not use this, possibly the first cases of infected people.

これまでの例は、タミフルを服用するうちに患者の体内で変異して耐性を持ったと見られていた。

Previous cases had been seen as the resistant mutant in the body of the patient taking Tamiflu.

厚労省などによると、患者は１０代女性。

According to the ministry, the patient is 10 year-old women.

８月２２日、発熱して受診した札幌市内の医療機関で簡易検査が陽性で別の抗ウイルス薬のリレンザを投与、翌 日には熱が下がった。

August 22, administered the antiviral drug Relenza is another simple test positive at the Sapporo Medical examination in the heat, the heat went down the next day.

９月下旬になって、同市衛生研究所の遺伝子検査でタミフル耐性の結果が出た。

Is in late September, showed Tamiflu-resistant genetic testing laboratory in the city's health.

このため、改めて国立感染症研究所で調査、今月６日に耐性だと確定した。

Therefore, the National Research Institute of Infectious Diseases in again, this month confirmed it resistant to six days.

女性の家族は発症しておらず、周辺でタミフルを服用して症状が改善しない患者は増えていない。

Family of women has not developed symptoms, the symptoms do not improve patient taking Tamiflu has not increased around.

これまでの報告例では、耐性ウイルスは感染力が弱かった。

The cases reported so far, the weak force resistant virus infection.

今回、人から感染していた場合、感染力を持った可能性もあるが、厚労省は、感染拡大は起きていないとしてい る。

This time, when people were infected, could be infected with the power ministry, the spread has not happened.

同省は、「人から感染したのか、ウイルスが体内で変異したのかわからない」としている。

Ministry, "or from an infected person does not know how the virus mutated in the body" and that.

（野瀬輝彦、小林舞子）

(Nose Teruhiko, Maiko Kobayashi)

Indiana: Elkhart County doctors see swine flu spike (500% @ Elkhard General Hospital)

We only have 2 hosptials in Elkhart County. The bigger one is Elkhart General and the other one is Goshen General.
----------------------------------------------------------------------
Last Updated: 10/6/2009 12:00:58 AM

ELKHART -- Despite occasional cases and one death attributed to swine flu, the virus hadn't fully hit Elkhart County yet, said a local hospital official.

At least that's what he thought until a week ago, when H1N1 flu cases jumped, by Dr. David VanRyn's estimates, 500 percent at Elkhart General Hospital's emergency department, where he is medical director.

"Doctors' offices are being inundated with people who think they're sick with the virus," he said.

VanRyn said a meeting scheduled for 7 p.m. Wednesday at Jimtown High School should help answer the public's questions about how the virus is transmitted, what to expect from it this fall and concerns about the vaccine.

"One of our big concerns is as the wave of these infections hits, as people inundate doctors' offices and emergency departments, the whole system would be bogged down," VanRyn said.

"The volume of people you would be talking about would shut down these offices" if everyone who suspects they have H1N1go to doctors' offices and emergency rooms to be checked, he said.

Statewide, the virus is responsible for four deaths. The virus has attacked younger patients than the seasonal flu vaccine traditionally does.

VanRyn attributes the sharp jump in H1N1 flu cases to the change in weather and people passing the virus to others.

Dan Nafziger, Elkhart County Health Officer and infectious disease physician at Goshen General Hospital, said anecdotally he's seen swine flu activity increase in the last two weeks.

"We do seem to have more influenza in the area than we've had earlier in the fall and certainly a lot more than we normally see at this time of the year for influenza," he said.

A group of Indianapolis health care workers were among the first to receive doses of the nasal mist swine flu vaccine Monday, the Associated Press reported. The mist is recommended for healthy people ages 2-49 who are not pregnant.

The injectible vaccine will be available in a few weeks and will be distributed first to targed groups: pregnant women, children, adolescents and young people ages 6 months to 24 and those who care for them, and older people who have chronic medical conditions.

Nafziger said he expects Elkhart County to have some doses of the nasal spray later this week.

INFORMATIONAL MEETING ON SWINE FLU WEDNESDAY
Where: Jimtown High School Auditorium, 59021 C.R. 3, Elkhart
When: 7 p.m. Wednesday
Who: Elkhart General Hospital, Elkhart County Health Department, Elkhart Emergency Physicians
Why: To inform Elkhart County residents what to expect from the H1N1 flu this fall, vaccine recommendations and how H1N1 is transmitted. The meeting will include a question and answer period.
hat-tip mixin

India: 25 swine flu ‘suspects’ of same family kept in isolation

Punjab Newsline Network

Monday, 05 October 2009

LUDHIANA: Twenty-five persons of a joint family that resides in Sarabha Nagar have been identified as the suspects of swine flu, Rapid Response Team (RRT) formed to deal with the Swine Flu cases act rapidly and put each of the family members on preventive medication followed by complete isolation. The family members were constantly in touch with their NRI relative, who was tested positive for H1N1 virus on September 3 at the PGI in Chandigarh. The relative of the family had come from Canada for attending his cousin’s wedding but got sick soon after landing in the city. The NRI had attended a wedding at Kothari resorts on September 30, which had a gathering of almost 1,000 people. Going by the incubation period of Swine Flu, which is five to 10 days, those showing symptoms should go in for swab sample test. However, district epidemiologist, Dr GP Mangla, stated that they had made the lists of persons who came in direct contact with the person infected by H1N1 virus and added that things were under control. The file of all above details has been prepared and sent to the state nodal official for Integrated Disease Surveillance Programme Dr Deepak Bhatia in Chandigarh. The swab samples of two servants and three members of the family have been sent to the PGI for test. District epidemiologist Dr GP Mangla said: “Having identified the cluster of suspects, we in order to take precautionary measures have sent five samples for testing. The reports will be available by tomorrow evening,” Dr Mangla added.

CR Poll: Americans unsure about getting swine flu vaccine

September 30, 2009

News about the swine flu and the H1N1 vaccine permeates airwaves and news headlines all over the world, but Americans aren’t so sure about whether they’ll get the vaccine when it becomes available this fall. According to a new poll conducted by the Consumer Reports Health Ratings Center, the majority of U.S. adults say they are either reluctant or unsure about whether they or their children will get vaccinated for the swine flu.

Just 34 percent of Americans said they definitely planned to get the swine flu vaccine, while 21 percent said they would not. Forty-three percent said their decision would depend on how things go. And though children are among the groups given priority for swine flu immunization, many parents said they were unsure about what they would do when the vaccine becomes available.

And all the uncertainty about whether or not to get the swine flu vaccine appears to be linked to the confusion over risk. Of the adults we polled, more than half of the people at high risk for flu complications don't realize they are. Among people who classified themselves as high risk for swine flu complications, 60 percent in our survey said they would definitely get vaccinated, and 29 percent said it would depend on circumstances. But more than half (55 percent) of those who reported that they had medical problems such as diabetes, asthma, or heart disease didn't realize that their medical conditions put them at higher risk. Meanwhile, the Centers for Disease Control and Prevention specifically recommends it for about 160 million Americans, including health-care and emergency workers, pregnant women, people who live with or care for children under 6 months of age, young people from 6 months through 24 years old, and adults ages 25 to 65 who have an underlying health condition or compromised immune system.

Take a look at the results of our swine flu poll, and tell us if you’ll be getting the swine flu shot when it becomes available this fall. Why or why not?

CIDRAP: First H1N1 vaccine doses headed to states, cities

Robert Roos News Editor

Oct 1, 2009 (CIDRAP News) – The first 600,000 doses of pandemic H1N1 vaccine—all of them the nasal-spray formulation—are on their way to 25 states and major cities and should arrive by Tuesday, Oct 6, matching earlier predictions, federal health officials said today.

"We are transitioning from the planning to the implementation phase" of the H1N1 vaccination effort, Dr. Anne Schuchat of the Centers for Disease Control and Prevention (CDC) said at a news briefing.

States and large cities began placing orders for vaccine yesterday, said Schuchat, who is director of the CDC's National Center for Immunization and Respiratory Diseases. She didn't name the states or cities, but urban areas that work directly with the CDC program are Washington, New York, Chicago, and Los Angeles County.

"Vaccine ordered yesterday should be arriving out to the sites by Tuesday," she said. "We're really pleased that this is starting, and it's earlier than we were planning."

In response to a question about when the doses will become available, Schuchat said, "There's a good chance they'll be available later next week in a lot of the sites."

CDC officials have been predicting that the earliest doses would reach providers in early October. CDC Director Thomas Frieden said last week that the first doses could reach providers as early as Oct 6.

Schuchat said that—as predicted previously—all of the earliest doses will be the live-virus nasal-spray vaccine, which is made by MedImmune. Like the company's seasonal vaccine, FluMist, it is approved for healthy people aged 2 through 49 years, but not for pregnant women or people with chronic conditions that raise their risk for flu complications.

"We believe a lot of the states will be directing those early doses to healthcare workers," Schuchat said. "There's a bit of a myth out there that the workers shouldn't get the live vaccine, but that's a myth. Most healthcare workers who are under 50 and don't have those chronic conditions can receive the nasal spray."

She said the CDC plans to release information each Friday on how much vaccine was available for ordering and how much was shipped to each of the states and large cities, as of the preceding Wednesday.

The CDC has contracted with McKesson Corp. to distribute the vaccine doses to vaccination sites designated by state health departments. McKesson also distributes vaccines in the CDC's Vaccines for Children program.

Schuchat cautioned that the vaccination drive will face some bumps in the road. "At the beginning we'll have a bit of a slow start. But we've ordered enough [vaccine] so everyone who wants to be vaccinated can be."

HHS releases children's Tamiflu to states
In other comments, Schuchat said Health and Human Services Secretary Kathleen Sebelius has released 300,000 pediatric doses of the antiviral drug Tamiflu (oseltamivir) from the national stockpile for distribution to states that may need it.

"Basically each state that needs their proportion of that supply will receive this Tamiflu over the next week," she said.

The CDC said earlier this week that Tamiflu for children could run short as the flu spreads and advised that pharmacists may need to formulate the medication, sold as a liquid, on site by mixing the adult formulation with other ingredients.

"Some of the liquid formulation will have an expiration date that may have passed, but the FDA [Food and Drug Administration] has extended the expiration date of those courses after careful testing," Schuchat said today.

She reported that Texas and Colorado have already requested and received allocations of the liquid antiviral, getting 22,000 and 4,600 doses, respectively.

Death toll in pregnant women rises
On another topic, Schuchat updated the CDC's numbers on H1N1 complications in pregnant women. As of late August, 100 pregnant women in the United States had required intensive hospital care for H1N1 and 28 had died, she said.

On a conference call with clinicians earlier this week, CDC officials said that about 5% of H1N1 deaths have been in pregnant women, though they make up only about 1% of the population. As of Aug 20, 24 of the 484 deaths in the country involved pregnant women, officials said.

"The H1N1 influenza in pregnant women has really been striking," Schuchat said today. CDC obstetricians have been talking to "doctors around the country who have never seen this kind of thing before."

She added that the CDC has not previously tracked seasonal flu complications in pregnant women, so it's not entirely clear if complications are actually much more common with the new virus or if it just seems that way because of increased surveillance.

CIDRAP: Preparedness report spells out H1N1 challenges

Lisa Schnirring Staff Writer

Oct 1, 2009 (CIDRAP News) – Though the nation is going into its second wave of the H1N1 pandemic armed with crucial improvements such as better vaccine capacity, remaining challenges in medical surge and vaccine distribution could hamper response now and into a third wave, preparedness experts said today.

Hospitals across the nation vary in their ability to bear the burden of mounting H1N1 cases, the experts said at a press conference during which they unveiled a 38-page report from Trust for America's Health (TFAH), a nonprofit, health advocacy group based in Washington, DC.

Fifteen states, including Arizona, Connecticut, and Oregon, could run out of hospital beds by the fifth week of the second wave if 35% of the population gets sick with pandemic flu. Twelve states—among them New Mexico and North Carolina—could reach or exceed 80% of their capacity.

Jeff Levi, PhD, TFAH executive director, said some health facilities in big cities were overwhelmed during the early stages of the pandemic. "Our point is that how readily even a mild pandemic can overwhelm the system," he said. "We need a better system for addressing these issues, and some states are beginning."

TFAH authors based their projections on a 35% attack rate, which is a planning projection at the low end of the range of scenarios included in an Aug 24 report by the President's Council of Advisors on Science and Technology (PCAST). The TFAH authors used the Centers for Disease Control and Prevention's (CDC's) FluSurge modeling program to estimate the number of hospitalizations in each state.

However, they said erosion of the public health funding and workforce that has accelerated over the past few years will make it difficult to meet the challenges, unless steady federal funding streams, such as those that support police and fire services, are established for public health departments.

Robert M. Pestronk, MPH, executive director of the National Association of County and City Health Officials (NACCHO) said periodic funding infusions are important, but the approach isn't helping build a strong public health system. "There isn't any end point in preparedness. It requires sustained funding," he said.

According to a recent survey from NACCHO, budget cuts forced public health departments to eliminate 8,000 positions between January and June of this year, which reflects a larger loss than all of 2008.

Levi said a strong pandemic vaccine delivery performance from states might help blunt some of the impact on hospitals. However, a 2008 federal report on state pandemic plans revealed that 21 states had gaps in their preparations to handle mass vaccinations. "It's a complicated task, even in the best of circumstances," he said.

Adding to the vaccination challenge, public health officials may have a hard time reaching risk groups with vaccine messages, because some in the priority scheme, especially children, young adults, and members of minority groups, haven't routinely been targeted for seasonal flu immunization, Levi said.

He added that public health systems can also help reduce the burden on hospitals by getting higher-profile messages out about when to seek medical care for pandemic H1N1 infections,

• Some of the other pandemic challenges addressed in the TFAH report include:
• Antivirals: some states have limited stockpiles because of budget constraints and other obstacles
• Surveillance: current systems are outdated, don't track flu in real time, and aren't ideal for identifying clusters or monitoring severity
• Medical equipment: 25 million N-95 respirators were released from the federal stockpile at the beginning of the outbreak, with no action to replace the supply, which could be difficult because of limited availability.

Today's TFAH report included recommendations to improve response to the current and future pandemic waves. For example, the authors recommended that states and localities refine their plans for rapid vaccine distribution and that the federal government allocate more resources for vaccine delivery, especially if insurers don't provide adequate coverage.

The experts urged public health department to extend their vaccine campaigns beyond the flu season to help prepare for a potential third wave of the pandemic.

States should at least purchase enough antiviral supplies to cover their at-risk populations, and the federal government should consider making antiviral stockpiling solely its responsibility, the report advised.

Though federal officials have been working hard to improve surveillance to monitor the spread of the pandemic H1N1 virus, the TFAH authors said officials should consider funding and implementing detailed surveillance improvements outlined in the PCAST report.

Longer-term improvements should include the establishment of regional consortiums to organize and plan for health emergencies, as well as redoubled efforts, such as overtime incentives, to develop a medical surge workforce.

The most important improvement, though, would be a steady funding stream to support public health preparedness, Levi said. "We're trying to surge a public health system that has been critically hampered," he said.

Seasonal Vaccine "FluMist" and Swine Flu "FluMist" Do Not take together

Excerpt:

Can seasonal vaccine and novel H1N1 vaccine be administered at the same time?

Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine

http://www.cdc.gov/h1n1flu/vaccination/public/vaccination_qa_pub.htm



Key Facts About Seasonal Flu Vaccine
excerpt:

There are two types of vaccines:

* The "flu shot" — an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions.
* The nasal-spray flu vaccine — a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine" or FluMist®). LAIV (FluMist®) is approved for use in healthy* people 2-49 years of age who are not pregnant.

http://www.cdc.gov/flu/protect/keyfacts.htm


And this:

Influenza A (H1N1) 2009 Monovalent Vaccine (MedImmune LLC)

INDICATIONS AND USAGE---------------------------
Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal is indicated for the active immunization of individuals 2-49 years of age against influenza disease caused by pandemic (H1N1) 2009 virus. (1)

http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm181970.htm

CDC: 2009 H1N1 Influenza Vaccine

September 29, 2009, 11:30 AM ET

What are the plans for developing 2009 H1N1 vaccine?

Vaccines are the most powerful public health tool for control of influenza, and the U.S. government is working closely with manufacturers to take steps in the process to manufacture a 2009 H1N1 vaccine. Working together with scientists in the public and private sector, CDC has isolated the new H1N1 virus and modified the virus so that it can be used to make hundreds of millions of doses of vaccine. Vaccine manufacturers are now using these materials to begin vaccine production. Making vaccine is a multi-step process which takes several months to complete. Candidate vaccines will be tested in clinical trials over the few months.

When is it expected that the 2009 H1N1 vaccine will be available?

The 2009 H1N1 vaccine is expected to be available in the fall. More specific dates cannot be provided at this time as vaccine availability depends on several factors including manufacturing time and time needed to conduct clinical trials

Will the seasonal flu vaccine also protect against the 2009 H1N1 flu?

The seasonal flu vaccine is not expected to protect against the 2009 H1N1 flu.

Can the seasonal vaccine and the 2009 H1N1 vaccine be given at the same time?

It is anticipated that seasonal flu and 2009 H1N1 vaccines may be administered on the same day. However, we expect the seasonal vaccine to be available earlier than the H1N1 vaccine. The usual seasonal influenza viruses are still expected to cause illness this fall and winter. Individuals are encouraged to get their seasonal flu vaccine as soon as it is available.

Who will be recommended to receive the 2009 H1N1 vaccine?

CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended that certain groups of the population receive the 2009 H1N1 vaccine when it first becomes available. These target groups include pregnant women, people who live with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months and 24 years old, and people ages of 25 through 64 years of age who are at higher risk for 2009 H1N1 because of chronic health disorders or compromised immune systems.

We do not expect that there will be a shortage of 2009 H1N1 vaccine, but availability and demand can be unpredictable. There is some possibility that initially the vaccine will be available in limited quantities. In this setting, the committee recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children 5 through 18 years of age who have chronic medical conditions.

The committee recognized the need to assess supply and demand issues at the local level. The committee further recommended that once the demand for vaccine for these target groups has been met at the local level, programs and providers should begin vaccinating everyone from ages 25 through 64 years. Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over the age of 65.

Do those that have been previously vaccinated against the 1976 swine influenza need to get vaccinated against the 2009 H1N1 influenza?

The 1976 swine flu virus and the 2009 H1N1 virus are different enough that its unlikely a person vaccinated in 1976 will have full protection from the 2009 H1N1. People vaccinated in 1976 should still be given the 2009 H1N1 vaccine.

Where will the vaccine be available?

Every state is developing a vaccine delivery plan. Vaccine will be available in a combination of settings such as vaccination clinics organized by local health departments, healthcare provider offices, schools, and other private settings, such as pharmacies and workplaces. For more information, see State/Jurisdiction Contact Information for Health Care Providers Interested in Providing H1N1 Vaccine.

Will this vaccine be made differently than the seasonal influenza vaccine?

No. This vaccine will be made using the same processes and facilities that are used to make the currently licensed seasonal influenza vaccines.

Are there other ways to prevent the spread of illness?

Take everyday actions to stay healthy.

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. If soap and water are not available, use an alcohol-based hand rub.*
• Avoid touching your eyes, nose or mouth. Germs spread that way.
• Stay home if you get sick. CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
  

Follow public health advice regarding school closures, avoiding crowds and other social distancing measures. These measures will continue to be important after a 2009 H1N1 vaccine is available because they can prevent the spread of other viruses that cause respiratory infections.

What about the use of antivirals to treat 2009 H1N1 infection?

CDC has issued interim guidance for the use of antiviral drugs for this season. CDC also has published Questions & Answers related to the use of antiviral drugs for this season.

Will two doses of vaccine be required?

The U.S. Food and Drug Administration (FDA) has approved the use of one dose of 2009 H1N1 flu vaccine for persons 10 years of age and older. This is slightly different from CDC’s recommendations for seasonal influenza vaccination which states that children younger than 9 who are being vaccinated against influenza for the first time need to receive two doses. Infants younger than 6 months of age are too young to get the 2009 H1N1 and seasonal flu vaccines.

What will be the recommended interval between the first and second dose for children 9 years of age and under?

CDC recommends that the two doses of 2009 H1N1 vaccine be separated by 4 weeks. However, if the second dose is separated from the first dose by at least 21 days, the second dose can be considered valid.

Can seasonal vaccine and novel H1N1 vaccine be administered at the same time?

Inactivated 2009 H1N1 vaccine can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine. Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine

2009 H1N1 Influenza Vaccine and Seniors

September 30, 2009, 2:30 PM ET

Why aren't people 65 and older recommended to get early doses of 2009 H1N1 vaccine?

There are two main reasons why people age 65 and older are not included in the groups recommended to get the initial doses of 2009 H1N1 vaccine:

1. People age 65 and older are least likely to get sick with this virus, and,
2. There will be limited amounts of vaccine available at first, so the first doses are recommended to go to those who are most likely to get infected and become very ill.

There has been very little 2009 H1N1 illness in people 65 and older since the 2009 H1N1 virus emerged. This has been true both in the United States and in the Southern Hemisphere during their flu season. Studies of who is most likely to be infected with 2009 H1N1 show that people 65 and older are the least likely to get sick with this virus. (One analysis showed that only 1.3 people for every 100,000 people 65 and older are had been infected with 2009 H1N1. This is compared to 26.7 per 100,000 of those 5 years to 24 years of age and 22.9 per 100,000 in those younger than 5 years old. Rates among younger persons were 15 to 20 times higher. This has been true both in the United States and in the Southern Hemisphere during their flu season.) Laboratory tests on blood samples indicate that older people likely have some pre-existing immunity to the 2009 H1N1 flu virus.

Because there has been so little 2009 H1N1 illness in people 65 and older, the Advisory Committee on Immunization Practices (ACIP) recommended that CDC and immunization programs focus on getting the first doses of 2009 H1N1 vaccine to those people who are more likely to get infected with the 2009 H1N1 flu virus. This includes all children and young adults 6 months through 24 years old, pregnant women, and adults 25 through 64 years of age who have health conditions associated with higher risk of medical complications from flu. In addition, the 2009 H1N1 vaccine is prioritized for people who live with or care for children younger than 6 months of age, and health care and emergency medical services personnel with direct patient contact. Persons 65 and older are a high priority for seasonal vaccine, just as they have been in past years. Please visit http://www.cdc.gov/h1n1flu/vaccination/acip.htm to see a summary of ACIP’s 2009 H1N1 vaccine recommendations.

Will people age 65 years and older be able to get the 2009 H1N1 vaccine this season?

Yes. The U.S. government has purchased 250 million doses of 2009 H1N1 vaccine, so anyone who wants to get the vaccine will have the opportunity to do so. While people 65 and older are not included in the groups recommended to get the earliest doses of vaccine, they can get the 2009 H1N1 influenza vaccine as soon as the high risk groups have had the opportunity to be vaccinated. Some communities and providers will offer the 2009 H1N1 vaccine to people 65 and over sooner than others, depending on how quickly they meet the needs of the initial prioritized populations. While the early doses of 2009 H1N1 vaccine are being given to those in high risk groups, CDC's priority for people 65 and older is to have them get their seasonal flu vaccine first, and to seek medical advice quickly if they develop flu-like symptoms this season. This will determine whether they need medical evaluation and possible treatment with antiviral medications.

Should people age 65 and older get the regular flu vaccine this year?

Yes. CDC's priority for people 65 and older is to have them get their regular, or “seasonal,” flu vaccine as soon as possible while we are waiting for more doses of the 2009 H1N1 vaccine. Seasonal flu viruses are expected to circulate along with 2009 H1N1 viruses this season. People age 65 and older are at increased risk for complications from seasonal influenza compared to younger people and are recommended for annual seasonal flu vaccines. This year is no exception.

What should people age 65 and older do if they feel like they have the flu?

People age 65 and older should seek medical advice quickly if they develop flu symptoms this season to see whether they might need medical evaluation and possible treatment with antiviral medications. People 65 and older are prioritized to get antiviral drugs if they become sick with the flu according to CDC’s antiviral guidance this season.

Why are people 65 and older prioritized for antiviral treatment if they get sick with the flu, but they are not in one of the early groups prioritized to get 2009 H1N1 vaccine?

People 65 and older are the least likely to be infected with 2009 H1N1 flu, but, if they become infected, they are more likely than people in some other groups to develop serious complications from their illness. That is why people 65 years and older are prioritized for treatment with antiviral drugs this season if they do become sick.

Interim Recommendations for Clinical Use of Influenza Diagnostic Tests During the 2009-10 Influenza Season

September 29, 2009, 6:00 PM ET

Excerpt:

Summary Points

• Most patients with clinical illness consistent with uncomplicated influenza who reside in an area where influenza viruses are circulating do not require diagnostic influenza testing for clinical management.
• Patients who should be considered for influenza diagnostic testing include:
• Hospitalized patients with suspected influenza
• Patients for whom a diagnosis of influenza will inform decisions regarding clinical care, infection control, or management of close contacts.
• Patients who died of an acute illness in which influenza was suspected.
• When a decision is made to use antiviral treatment for influenza, treatment should be initiated as soon as possible without waiting for influenza test results. Antiviral treatment is most effective when administered as early as possible in the course of illness. (http://www.cdc.gov/h1n1flu/recommendations.htm)
• Clinicians should be aware that the sensitivities of rapid influenza diagnostic tests (RIDTs) and direct immunofluorescence assays (DFAs) are lower than real-time reverse transcriptase polymerase chain reaction (rRT-PCR) tests and viral culture. A negative RIDT or DFA result does not rule out influenza virus infection. (http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm). Further, these tests cannot distinguish between 2009 H1N1 and seasonal H1N1 or H3N2 influenza A viruses.
• If most circulating influenza viruses have similar antiviral susceptibilities (as is the case currently in the United States), information on the influenza A subtype may not be needed to inform clinical care.
• If identification of 2009 H1N1 influenza virus infection is required, testing with a rRT-PCR assay specific for 2009 H1N1 influenza or viral culture should be performed.
• Laboratory tests to diagnose 2009 H1N1 influenza, such as rRT-PCR, should be prioritized for hospitalized patients and immunocompromised persons with suspected influenza where RIDT or DFA testing is negative or to determine influenza A virus subtype in patients who have died from suspected or confirmed influenza A virus infection.
• Information on testing of pathology specimens for suspected 2009 H1N1 influenza virus infection can be found at (http://cdc.gov/h1n1flu/tissuesubmission.htm).

H1N1 FluMist will not be for everyone

04:53 PM CDT on Wednesday, September 30, 2009
By JANET ST. JAMES / WFAA-TV

The first H1N1 vaccines to arrive in North Texas will be the FluMist - that's the one that doctors spray up your nose.

The FluMist looks like a syringe but it's filled with liquid vaccine.

Half is squirted in one nostril, the other half in the other side, just like an ordinary nasal spray.

Many pediatricians prefer it for children who fear needles.

But it is not for everyone.

Unlike the flu shot, which is a dead virus, FluMist is a weakened, live virus - which means it cannot be given to everyone.

FluMist is recommended for healthy people, from two to 50 years old, which means most school aged children are eligible.

Those at highest risk from seasonal and swine flu cannot take it. That group includes patients who have underlying medical conditions, including asthma; those with a weak immune system; children over five with a history of wheezing; pregnant women; people with a history of Guillain-Barre syndrome, which has been linked to the previous swine flu vaccine; and anyone with an allergy to eggs.

If you are not eligible for or don't want the FluMist, the shots should arrive by mid-to-late October.
hat-tip Shiloh

Many swine flu deaths linked with second infection

Wed Sep 30, 2009 3:32pm EDT

WASHINGTON (Reuters) - Many people who have died of H1N1 swine flu in the United States have also had bacterial infections, health officials reported on Wednesday.

A study of 77 patients who died of the new pandemic H1N1 virus showed 29 percent of them had so called bacterial co-infections, the U.S. Centers for Disease Control and Prevention reported.

About half of these had Streptococcus pneumoniae, which can be prevented with a vaccine, the CDC said. It said doctors may be missing these infections in people severely ill with flu.

The CDC has already reported that H1N1, declared a pandemic in June, has become more active as weather cools and schools reopened after summer breaks. Cases are reported in all 50 states and it is still circulating globally.

H1N1 is not any more deadly than seasonal influenza so far but it attacks a younger age group than seasonal flu does and because virtually the entire population lacks immunity, it can infect far more people at once than seasonal flu usually does.

"The findings in this report indicate that, as during previous influenza pandemics, bacterial pneumonia is contributing to deaths associated with pandemic H1N1," the team of experts at the CDC and state health departments reported.

"Our influenza season is off to a fast start and unfortunately there will be more cases of bacterial infections in people suffering from influenza," CDC epidemiologist Dr. Matthew Moore, who helped organize the study, added in a statement.

The report noted in previous pandemics -- in 1968, 1957 and 1918 -- many of the patients who died were also infected with S. pneumoniae, Haemophilus influenzae, Staphylococcus aureus and group A Streptococcus, which causes rheumatic fever and "strep throat".

The CDC team noted that at first it did not appear that people who were seriously ill with swine flu or who died of it had secondary infections but doctors may have missed them.

"Routine clinical tests used to identify bacterial infections among patients with pneumonia do not detect many of these infections," the CDC team reported.

Five of the patients who died, including a 9-year-old and an 11-year-old, had infections with the so-called superbug methicillin-resistant S. aureus or MRSA. None of the seven children who died had reported medical conditions that should put them at special risk of flu complications, although one was obese and one had Down syndrome.

The researchers cautioned that the patients whose cases were studied may not represent the nation as a whole. But like most of the victims of swine flu, they were young, with a median age of 31 and ranging from 2 months to 56 years.

Moore said people getting flu vaccinations should also ask about getting a pneumococcal vaccine.

Wyeth's Prevnar is part of the routine series of immunizations that children should get, and Merck and Co. makes a vaccine against so-called pneumococcal bacteria that is available for adults, mostly those over 65. Merck also makes an Hib vaccine, although there is no vaccine to prevent group A streptococcal infections or MRSA.

(Editing by Bill Trott)
hat-tip hawkeye

Dutch researchers find mutation linked to greater virulence in swine flu virus

Published Wednesday September 30th, 2009

TORONTO - Dutch scientists have reported they have found what was thought to be a key mutation in some swine flu viruses from the Netherlands, a change many virologists feared would give the viruses the ability to cause more severe disease.

But so far the evidence seems to suggest this mutation does not make the new H1N1 virus more virulent, the researchers said Tuesday.

The change, at position 627 on the PB2 gene of the virus, is known to increase the ability of flu viruses to replicate; prolonged viral replication can lead to more serious illness. The mutation has been found in all known human flu viruses, including the three that caused the pandemics of the last century.

"Everybody predicted that this mutation is going to have a big impact on virus replication of the new H1N1," said Dr. Ron Fouchier, one of the authors of the report and a molecular virologist at Erasmus Medical Centre in Rotterdam.

"If you would have asked me three months ago, I would have bet my car on it. But nobody placed that bet because everybody was sure that it would increase (virulence)."

If they had, it seems they might have been able to claim the keys to Fouchier's SUV.

Three people either known or suspected of having been infected with the mutated H1N1 viruses suffered only mild disease. And ferrets infected with a laboratory synthesized H1N1 virus with this change also did not suffer more severe disease. Ferrets are the standard animal model for human flu.

"Given the information that we have at present, we have no indication for increased virulence," said Dr. Marion Koopmans, chief of virology in the infectious diseases laboratory of the National Institute of Public Health, The Netherlands.

"This is a mutation that is in the textbooks as something to look out for, but whether it really confers something to these (H1N1) viruses remains to be seen."

Koopmans, Fouchier and a number of colleagues disclosed the surprising findings through ProMed, a website and mailing list that serves as an early warning system for infectious diseases developments. It is closely scrutinized by scientists and public health officials in the infectious diseases sphere.

The Dutch scientists reported finding two viruses with this change that appear to have been transmitted between mid-July and mid-August in the West Frisian Islands in the north of The Netherlands. The area is a popular destination for Dutch and German campers.

One of the mutated viruses was recovered from a male who had been there and who started developing symptoms on Aug. 9. The second was found in a girl who hadn't been to the area, but whose sister had been camping there at the time. The sister was also sick, but there was no specimen from her to test. Koopmans said the working assumption is that the sister who went camping was also infected with this virus.

The first virus was only discovered in mid-September, when it made its way to Koopmans' lab. An investigation at that point showed the male and the sister had been part of a group of 24 who shared two tents on the island. Most of the members of the camping party reported having been ill.

Koopmans said officials have looked at specimens from the area and from the regions from whence the campers came, but haven't found more viruses with this change.

"There's no evidence yet that this virus has spread any further in Holland," Fouchier said. "Of course we're currently still looking for it. Every virus we get our hands on we check (position) 627. But we haven't found any more."

Labs have been looking for this mutation from the moment the new H1N1 virus was fully analyzed and it was seen it didn't have the same amino acid at position 627 as other human viruses have.

Some scientists even suggested the virus might not be fully adapted to spread among humans because it didn't have this change, but instead had an amino acid at position 627 that is normally seen in avian flu viruses. The pandemic virus, which is a never-before-seen hybrid of swine, avian and human genes, has an avian PB2 gene.

Dr. Richard Webby, head of the World Health Organization's influenza collaborating centre at St. Jude Children's Research Hospital in Memphis, Tenn., said there is good evidence this mutation is associated with adaptation of avian influenza viruses to humans, but the proof that it is linked to severity of disease is less clear.

Viruses with this change show increased virulence in mice and sometimes in ferrets, but not always, he said, suggesting the ferret data probably are more reliable. "I think this is one instance where mice are probably lying a little bit," Webby said.

In some flu viruses this change is known to allow the virus to replicate at cooler temperatures, meaning they can infect the upper airways, rather than the warmer deep lung area preferred by avian flu viruses.

That might actually be a good thing with this H1N1, Webby said, noting autopsies have shown that in severe cases the pandemic virus wreaks havoc deep in the lungs.

Dr. Nancy Cox, who heads the influenza division at the U.S. Centers for Disease Control, warns people should not take too much comfort from the fact this change doesn't seem to make the virus more virulent at this point.

"We just know that influenza can change in unpredictable ways through mutation and reassortment," she said, referring to the process by which flu viruses swap genes with each other.

"The unexpected can arise, and arise very quickly. So we shouldn't write this off. It is causing hospitalization. It is causing fatalities. And in every single case that you hear about, it's a tragedy."
hat-tip Dutchy

WHO Lowers Expectation Of H1N1 Vaccine Output, Appeals For Donations To Fight Pandemic

Article Date: 28 Sep 2009

International drug makers are expected to produce three billion doses of the H1N1 (swine flu) vaccine, "enough for just under half the world's population," a WHO official said Thursday, Canwest News Service/Ottawa Citizen reports. "The agency was hoping pharmaceutical companies would be able to make about five billion doses a year, but data collected over the summer led to the revised estimate," the news service writes (Fitzpatrick, 9/24).

"These supplies will still be inadequate to cover a world population of 6.8 billion people in which virtually everyone is susceptible to infection by a new and readily contagious virus," the WHO said in a written statement. "Global manufacturing capacity for influenza vaccines is limited, inadequate and not readily augmented" (9/24).

The organization hopes to acquire a total of 300 million doses of the H1N1 (swine flu) vaccine - 100 million doses more than total pledged donations - for countries having difficulty accessing the vaccine, a WHO official said Thursday, the Washington Post reports. The WHO's goal is to distribute a supply of H1N1 vaccines to 90 countries, who combined make up "about 3 billion of the world's 6.8 billion people," the newspaper writes. "They either can't afford vaccine or have been unable to find a manufacturer able to supply it to them over the next few months, when the swine flu pandemic is expected to peak."

"We hope that the whole world will have some access to the vaccine," said Marie-Paule Kieny, director of WHO's Initiative for Vaccine Research. "In some countries it will be possible to vaccinate the whole population and in some countries only 10 percent." So far, the vaccine makers Sanofi Aventis and GlaxoSmithKline have agreed to donate a total of 150 million doses of H1N1 vaccine, and, last week, nine developed countries pledged to give 10 percent of their stockpiles - which Kieny estimated at "about 50 million doses in all," the first of which will become available in late October.

"In the meantime, WHO officials are seeking to fill the projected 100 million-dose gap with donations from other countries and manufacturers, of which there are 36 worldwide," the newspaper writes (Brown, 9/24). Kyodo News/Japanese Times reports the Foreign Ministry of Japan on Thursday announced the country would offer about $12.2 million in emergency aid to the WHO to help purchase H1N1 vaccines for developing countries (9/25).

Kieny also said the H1N1 vaccine continues to appear safe, Bloomberg reports. "Side effects from the swine flu vaccine given to 44,000 people in China have so far been mild, with just 14 cases of adverse events reported," Kieny reported Thursday, according to the news service (Serafino, 9/24).

Critics Question U.N.'s $1.5 billion H1N1 Appeal

In a related story, the Associated Press examines a recent report by the U.N. that the organization needs nearly $1.5 billion to fight the H1N1 virus. According to the news service, WHO Director-General Margaret Chan on Thursday met with top health officials to discuss the report and the appeal on the sidelines of the U.N. General Assembly meeting.

Because "most people recover [from H1N1] without ever being treated, not all experts are convinced swine flu merits such attention - and some critics even suspect the U.N. is using the pandemic as a convenient way to raise money," the news service writes. The WHO has rejected this claim, arguing even if the H1N1 virus fails to mutate into a more deadly form it could devastate already weak health systems in developing countries.

"Globally, WHO estimates more than 3,500 people have died of swine flu - far fewer than those killed by diarrhea, pneumonia, or road accidents," leading some experts, in turn, "to contend that WHO's prediction the virus could lead to 'civil disruption' in poor countries may be overblown." The article includes comments by health experts who question the WHO's recent funding appeal and the organization's handling of the H1N1 pandemic (Cheng, 9/24).

U.S. Health Officials Anticipate 6M H1N1 Vaccine Doses By Early October

Also on Thursday, U.S. health officials announced "[m]ore than six million doses of swine flu vaccine will be available by the first week in October, more that twice as many as had been recently expected, federal health officials said," the New York Times reports. Most of that vaccine "will be the FluMist nasal spray, which is recommended only for people ages 2 to 49 and not for pregnant women or people with health problems" (McNeil, 9/25). HHS Secretary Kathleen Sebelius emphasized there would be "plenty of vaccine for everyone who wants it," CNN reports (9/24).

This information was reprinted from globalhealth.kff.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Global Health Policy Report, search the archives and sign up for email delivery at globalhealth.kff.org.