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Published Date: 2009-04-26 08:12:54
Subject: PRO/AH/EDR> Influenza A (H1N1) virus, swine, human - N America (03)
Archive Number: 20090426.1566

INFLUENZA A (H1N1) VIRUS, SWINE, HUMAN - NORTH AMERICA (03)
***********************************************************
A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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In this update:
[1] WHO - Public Health Emergency of International Concern
USA
[2] CDC update
[3] New York City
[4] Kansas
Mexico
[5] Mexico
Elsewhere in the news:
[6] UK - flight attendant ex Mexico, suspected

******
[1] WHO - Public Health Emergency of International Concern
Date: 25 Mar 2009
Source: WHO website [edited]
<http://www.who.int/mediacentre/news/statements/2009/h1n1_20090425/en/index.html>

Statement by WHO director-general, Dr Margaret Chan [25 Apr 2009]
Swine influenza
---------------
In response to cases of swine influenza A(H1N1), reported in Mexico and the
United States of America, the director-general convened a meeting of the
Emergency Committee to assess the situation and advise her on appropriate
responses. The establishment of the committee, which is composed of
international experts in a variety of disciplines, is in compliance with
the International Health Regulations (2005). The 1st meeting of the
Emergency Committee was held on Saturday [25 Apr 2009].

After reviewing available data on the current situation, committee members
identified a number of gaps in knowledge about the clinical features,
epidemiology, and virology of reported cases and the appropriate responses.
The committee advised that answers to several specific questions were
needed to facilitate its work. The committee nevertheless agreed that the
current situation constitutes a public health emergency of international
concern.

Based on this advice, the director-general has determined that the current
events constitute a public health emergency of international concern, under
the regulations. Concerning public health measures, in line with the
regulations the director-general is recommending, on the advice of the
committee, that all countries intensify surveillance for unusual outbreaks
of influenza-like illness and severe pneumonia. The committee further
agreed that more information is needed before a decision could be made
concerning the appropriateness of the current phase 3.

Related links:
Swine influenza: <http://www.who.int/csr/disease/swineflu/en/index.html>
Current WHO phase of pandemic alert:
<http://www.who.int/csr/disease/avian_influenza/phase/en/index.html>
International Health Regulations (IHR): <http://www.who.int/ihr/en/index.html>

--
communicated by:
Kunihiko Iizuka
<edcvfr3464@yahoo.co.jp>

******
[2] USA - CDC update
Date: 25 Apr 2009
Source: CDC website [edited]
<http://www.cdc.gov/swineflu/investigation.htm>

Human swine influenza investigation: [25 Apr 2009] 19:30 EDT
------------------------------------------------------------
Human cases of swine influenza A (H1N1) virus infection have been
identified in the US in San Diego County and Imperial County, California as
well as in San Antonio, Texas. Internationally, human cases of swine
influenza A (H1N1) virus infection have been identified in Mexico.

US human cases of swine flu infection
-------------------------------------
State: No. of laboratory confirmed cases
California: 7 cases
Texas: 2 cases
Kansas: 2 cases
Total count: 11 cases (as of April 25th, 2009 7:30 pm EDT)

Investigations are ongoing to determine the source of the infection and
whether additional people have been infected with similar swine influenza
viruses.

CDC is working very closely with state and local officials in California,
Texas, as well as with health officials in Mexico, Canada and the World
Health Organization. On [24 Apr 2009], CDC deployed 7 epidemiologists to
San Diego County, California and Imperial County, California and 1 senior
medical officer to Texas to provide guidance and technical support for the
ongoing epidemiologic field investigations. CDC has also deployed to Mexico
1 medical officer and 1 senior expert who are part of a global team that is
responding to the outbreak of respiratory illnesses in Mexico.

Influenza is thought to spread mainly person-to-person through coughing or
sneezing of infected people. There are many things you can to do preventing
getting and spreading influenza:

There are everyday actions people can take 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. Alcohol-based hands cleaners are also effective.
* Avoid touching your eyes, nose or mouth. Germs spread that way. Try to
avoid close contact with sick people.
* Influenza is thought to spread mainly person-to-person through coughing
or sneezing of infected people.
* If you get sick, CDC recommends that you stay home from work or school
and limit contact with others to keep from infecting them.

--
communicated by:
ProMED-mail <promed@promedmail.org>

******
[3] USA - New York City
Date: 25 Apr 2009
Source: New York City Department of Health Press Release [edited]
<http://www.nyc.gov/html/doh/html/pr2009/pr015-09.shtml>

Probable cases of swine influenza found in students at school in Queens
-----------------------------------------------------------------------
The Health Department is investigating a cluster of respiratory illness in
a non-public school in New York City and has determined that at least 8
students have probable human swine influenza. More than 100 of the schools
students were absent several days this week due to fever, sore throats, and
other flu-like symptoms. The Health Department has interviewed more than
100 students or their families, and all students have had mild symptoms;
none have been hospitalized. Some family members have developed similar
symptoms, suggesting spread in the family.

In response to confirmed cases of swine influenza (swine flu) in Mexico,
California and Texas, the New York City Health Department is working
closely with the Centers for Disease Control and Prevention (CDC) to assess
the possibility of the spread of swine flu. Swine flu is a respiratory
infection caused by influenza type A viruses that regularly cause outbreaks
of influenza in pigs. People do not normally get swine flu, but human
infections can occur. Human cases typically involve people who have had
direct contact with pigs, but person-to-person transmission is suspected
among recent cases in the south west.

The cases in Mexico have had a high fatality rate, but the 8 recently
confirmed cases from California and Texas have been mild. All of the
non-NYC patients have recovered.

The Health Departments Public Health Laboratory has completed preliminary
viral testing on nose and throat swabs from 9 affected students. Eight of
the 9 tests are positive for influenza A. Because they do not match H1 and
H3 human subtypes of influenza A by available testing methods, they are
considered probable cases of swine flu. The specimens have been sent to the
CDC in Atlanta for confirmatory testing. Results of those tests are
expected on Sunday [26 Apr 2009]. (The attached chart outlines the steps
required for confirmation.)

Patients experiencing severe symptoms, such as difficulty breathing, should
seek health care and treatment. Otherwise, the Health Department recommends
at-home care. If affected students at the school in question have household
contacts at high risk for complications from influenza -- young children,
the elderly, and people with chronic illness -- those at risk should
receive preventive treatment. The most effective way to lower the risk of
transmission is for people with symptoms to stay home. All New Yorkers
should cover their mouths when they cough.

Swine influenza cannot be transmitted from eating pork or pork products.
The symptoms of swine flu in people appear to be similar to the symptoms of
regular human flu and include fever, cough, sore throat, body aches,
headache, chills, and fatigue. Some people have reported diarrhea and
vomiting associated with swine flu. Like seasonal flu, swine flu may cause
a worsening of underlying chronic medical conditions.

For facts about influenza, and more information about swine flu, please
visit the Health Department and CDC websites. Some specific resources:
From New York City Health Department: Facts about flu
<http://www.nyc.gov/html/doh/html/cd/cdinflu.shtml>
From Centers for Disease Control and Prevention:
General information about swine flu
<http://www.cdc.gov/swineflu/general_info.htm>
Swine flu case definitions <http://www.cdc.gov/swineflu/casedef_swineflu.htm>
Swine flu infection control and patient care
<http://www.cdc.gov/swineflu/guidelines_infection_control.htm>
Preventing the flu <http://www.cdc.gov/flu/protect/habits.htm>
Chart: steps required to confirm suspected cases of swine flu
<http://www.nyc.gov/html/doh/html/pr2009/pr015-09.shtml>

Contact: (212) 788-5290
Jessica Scaperotti/Erin Brady: PressOffice@health.nyc.gov

--
communicated by:
ProMED-mail <promed@promedmail.org>

******
[4] USA - Kansas
Date: 25 Apr 2009
Source: Kansas Department of Health and Environment (KDHE) [edited]
<http://www.kdheks.gov/swineflu/09-060%20Swine%20Flu%20News%20Release.pdf>

KDHE reports 2 cases of swine flu in Kansas
-------------------------------------------
The Kansas Department of Health and Environment (KDHE) announced today that
2 cases of swine flu have been confirmed in Kansas involving 2 adults
residing in the same household in Dickinson County. Neither of the patients
was hospitalized - one is still ill and being treated, and one is recovering.

One of the patients had recently traveled to Mexico, flying in and out of
Wichita. Both persons work in Saline County and became ill with the same
unique (H1N1) strain of swine flu that has been identified in Mexico,
California, and Texas. "Its not yet known whether this will become the
next flu pandemic," stated Dr Jason Eberhart-Phillips, state health officer
and director of the KDHE Division of Health. "We are working closely with
health agencies at all levels and are continuing to monitor these cases. We
are taking this situation very seriously."

KDHE and the Dickinson County Health Department are investigating the
sources of exposure, and efforts are being coordinated with CDC.
Individuals who have been in contact with the patients are being
interviewed and tested. Local health departments and hospitals in Kansas
are being continuously updated and provided with information about the
swine flu virus.

In accordance with the Kansas Response Plan, KDHE is also monitoring and
instituting recommendations from CDC for any additional influenza disease
surveillance activities, reviewing plans to further enhance those
activities, and advising health care providers to use rapid detection tests
for persons who have symptoms consistent with swine flu, especially if they
have recently been in Mexico, and taking other steps under the plan.

The KDHE Office of Surveillance and Epidemiology received a report of
unusual flu-like illness from Dickinson County on Friday [24 Apr 2009]
afternoon. Respiratory specimens were collected from both patients and
received by KDHE later on Friday evening. At about 2 am Saturday, the
Kansas Health and Environmental Laboratories at KDHE reported preliminary
results that were positive for influenza A viruses. Between about 2:30 and
3 am, KDHE notified the Dickinson County Health Department of those
preliminary results, which notified the attending physician.

Around that same time, KDHE obtained the use of Governor Kathleen Sebelius
plane to safely and securely transport the samples as rapidly as possible
to the CDC labs in Atlanta for confirmatory analysis to determine if the
viruses were of the (H1N1) strain. A staff member with the KDHE Center for
Public Health Preparedness handed the samples to a CDC representative at
about 6:10 am on Saturday, and the samples reached the labs at about 6:30
am KDHE convened staff in its Department Operations Center at 10 am on
Saturday, and was notified by CDC of the confirmatory results at 2:30 pm.

Prior to the recent outbreak in Mexico and the US, since 2005 12 cases of
human infection with swine influenza had been reported to CDC. Swine flu
infections in humans are rare, but are related to close proximity to
infected pigs, such as in pig production barns and livestock exhibits at
fairs. Neither of the current patients in Kansas reported having contact
with pigs.

For more information and updates, please visit the KDHE website at
.
Office of Communications
Curtis State Office Building, 1000 SW Jackson
Street, Suite 540, Topeka, KS 66612-1368
Contact: Maggie Thompson
<mthompson@kdheks.gov>
<http://www.kdheks.gov>

--
communicated by:
Philip Henika <philiphe@yahoo.com>
ProMED-mail rapporteur Mary Marshall
ProMED-mail <promed@promedmail.org>

******
[5] Mexico
Date: 25 Apr 2009 [edited]
Source: Yahoo News / Associated Press
<http://news.yahoo.com/s/ap/20090426/ap_on_re_la_am_ca/med_swine_flu>

Mexico fights swine flu with "pandemic potential"
-------------------------------------------------
Mexico's president assumed new powers Saturday to isolate people infected
with a deadly swine flu strain as authorities struggled to contain an
outbreak that world health officials warned could become a global epidemic.

New cases of swine flu were confirmed in Kansas and California and
suspected in New York City. But officials said they didn't know whether the
New York cases were the strain that now has killed up to 81 people in
Mexico and likely sickened 1324 since [13 Apr 2009], according to figures
updated late Saturday [25 Apr 2009] by Mexico's health secretary. Tests
have confirmed swine flu as the cause of death in 20 of the cases.

Mexican soldiers and health workers patrolled airports and bus stations as
they tried to corral people who may be infected with the swine flu, as it
became clearer that the government may have been slow to respond to the
outbreak in March and early April [2009].

Now, even detaining the ill may not keep the strain -- a combination of
swine, bird and human influenza that people may have no natural immunity to
-- from spreading, epidemiologists say. The World Health Organization on
Saturday [25 Apr 2009] asked countries around the world to step up
reporting and surveillance of the disease and implement a coordinated
response to contain it.

Two dozen new suspected cases were reported in Mexico City alone, where
authorities suspended schools and all public events until further notice.
More than 500 events, including concerts and sports games, were canceled in
the metropolis of 20 million. Mexican authorities ordered schools closed in
the capital and the states of Mexico and San Luis Potosi until [6 May
2009], and the Roman Catholic Church announced the cancellation of Sunday
masses in the capital.

The Mexican government issued a decree authorizing President Felipe
Calderon to invoke special powers letting the Health Department isolate
patients and inspect homes, incoming travelers and baggage. But officials
said it was designed to free health workers from possible legal reprisals
and to speed disease control efforts.

A team from the Centers for Disease Control had arrived in Mexico to help
set up detection testing for the swine flu strain, something Mexico
previously lacked. The US Embassy said the US has not imposed travel
constraints to and from Mexico but is suspending the processing of visas
and other services through Wednesday [29 Apr 2009] to avoid creating
crowds. It issued an earlier message advising US citizens to avoid large
crowds, shaking hands, greeting people with a kiss or using the subway.

While suspected swine flu cases have been reported in about 16 Mexican
states, health secretary Jose Cordova said "it has not spread to the entire
country."

WHO director-general Margaret Chan said the outbreak of the
never-before-seen virus has "pandemic potential." But she said it is still
too early to tell if it would become a pandemic. WHO lays out 3 criteria
necessary for a global epidemic: The virus is able to infect people, can
readily spread person-to-person, and the global population has no immunity
to it.

Early detection and treatment are key to stopping any outbreak. WHO
guidance calls for isolating the sick and blanketing everyone around them
with anti-viral drugs such as Tamiflu [oseltamivir]. Now, with patients
showing up all across Mexico and its teeming capital, simple math suggests
that kind of response is impossible. Mexico appears to have lost valuable
days or weeks in detecting the new virus. Health authorities started
noticing a threefold spike in flu cases in late March and early April
[2009], but they thought it was a late rebound in the December-February flu
season. Testing at domestic labs did not alert doctors to the new strain,
and Cordova acknowledged Mexican labs lacked the necessary profiling data
to detect the previously unknown strain.

The 1st death occurred in southern Oaxaca state on [13 Apr 2009], but
Mexico didn't send the 1st of 14 mucous samples to CDC until [18 Apr 2009],
around the same time it dispatched health teams to hospitals looking for
patients with severe flu or pnuemonia-like symptoms. Those teams noticed
something strange: the flu was killing people aged 20 to 40. Flu victims
are usually either infants or the elderly. The Spanish flu pandemic, which
killed at least 40 million people worldwide in 1918-19, also 1st struck
otherwise healthy young adults.

Even though US labs detected the swine flu in California and Texas before
last weekend, Mexican authorities as recently as Wednesday [22 Apr 2009]
were referring to it as a late-season flu. But mid-afternoon Thursday [23
Apr 2009], Mexico City health secretary Dr Armando Ahued said, officials
got a call "from the United States and Canada, the most important
laboratories in the field, telling us this was a new virus."

"That was what led us to realize it wasn't a seasonal virus ... and take
more serious preventative measures," Cordova said. Asked why there were so
many deaths in Mexico, and none so far among the 11 cases in the United
States, Cordova noted that the US cases involved children -- who haven't
been among the fatal cases in Mexico, either. "There are immune factors
that are giving children some sort of defense, that is the only explanation
we have," he said. Another factor may be that some Mexican patients may
have delayed seeking medical help too long, Cordova said. Some Mexicans
suspected the government had been less than forthcoming. "They always make
a big deal about good things that happen, but they really try to hide
anything bad," [a Mexico City paralegal] said.

Airports around the world were screening travelers from Mexico for flu
symptoms. But containing the disease may not be an option. "Anything that
would be about containing it right now would purely be a political move,"
said Michael Osterholm, a University of Minnesota pandemic expert.
Scientists have warned for years about the potential for a pandemic from
viruses that mix genetic material from humans and animals. This swine flu
and regular flu can have similar symptoms -- mostly fever, cough and sore
throat, though some of the US victims who recovered also experienced
vomiting and diarrhea. But unlike with regular flu, humans don't have
natural immunity to a virus that includes animal genes -- and new vaccines
can take months to bring into use.

A "seed stock" genetically matched to the new swine flu virus has been
created by CDC, said Dr Richard Besser, the agency's acting director. If
the government decides vaccine production is necessary, manufacturers would
need that stock to get started.

Mexican authorities did lay to rest one persistent doubt, after Mexican
museum director Felipe Solis died this week, just days after accompanying
US President Barack Obama on a tour of National Anthropology Museum on [16
Apr 2009]. Cordova said Solis had a pre-existing illness and died of
pneumonia unrelated to influenza.

[bylines: Mark Stevenson. (David Koop in Mexico City; Frank Jordans in
Geneva; Mike Stobbe in Atlanta; Malcolm Ritter in New York; and Maria Cheng
in London contributed to this report.)]

--
communicated by:
Sara M Volk, PhD, <sara.m.volk@gmail.com>
Postdoctoral Fellow, Alphavirus Pathogenesis and Evolution
Department of Pathology
Center for Biodefense and Emerging Infectious Diseases:
<http://www.utmb.edu/CBEID/virology.shtml>
University of Texas Medical Branch
Galveston, Texas, USA

******
[6] UK - flight attendant ex Mexico, susp
Date: 26 Apr 2009
Source: BBC [edited]
<http://news.bbc.co.uk/2/hi/uk_news/8018887.stm>

UK monitoring swine flu outbreak
--------------------------------
Health officials in the UK say they are closely monitoring the deadly
outbreak of swine flu in Mexico and the US, amid fears of a potential
pandemic. The Health Protection Agency (HPA) said it was working with the
government to assess any threat posed to public health in the UK. It
described the outbreak as "unusual" and warranting "further investigation
and vigilance" by other countries. However, no cases have so far been
identified anywhere in Europe.

At least 81 people in Mexico are now thought to have died from pneumonia
after contracting swine flu. Swine flu is a respiratory disease that
infects pigs and does not normally infect humans. However, sporadic cases
do occur, usually in people who have had close contact with pigs.

Precautionary tests
-------------------
WHO said some of those affected in Mexico had tested positive for a strain
-- H1N1 -- that had infected at least 7 people in the south western US. The
concern is that because this strain appears to be passing easily from human
to human, it has the potential to spread rapidly. WHO director-general
Margaret Chan said the strain had "pandemic potential" but that it was too
early to say whether one would actually occur. The HPA and the NHS have
systems in place which will alert public health authorities of any unusual
strain circulating in the UK.

Health Protection Authority statement
-------------------------------------
The HPA said: "More investigation and testing is needed to determine the
severity of the disease and the ease with which it can spread. "The HPA is
monitoring this situation closely and is working with the UK government to
review the current incident and any threat it poses to UK public health."

Meanwhile, a male British Airways cabin crew member is undergoing
precautionary tests in a London hospital after falling ill with "flu-like"
symptoms on a flight from Mexico City. He was taken to Northwick Park
Hospital, in Harrow after landing at Heathrow airport at 1400 BST (1300
GMT) on Saturday [25 Apr 2009]. A hospital spokesman said: "He has flu-like
symptoms and is responding well to treatment."The patient was admitted
directly to a side room and the hospital is scrupulously following
infection-control procedures to ensure there is no risk to any other
individual in the hospital." [BBC Radio News at 0900 BST 26 Apr reported
that the tests were negative. - Mod.SH]

Antiviral drugs
---------------
The HPA said there was currently a "very low level" of flu activity in the
UK, adding that the H1N1 strain at the centre of the American alert was
treatable with antiviral drugs such as Tamiflu [oseltamivir] and Relenza
[zanamivir]. "The HPA and the NHS have systems in place which will alert
public health authorities of any unusual strain circulating in the UK," it
said. Britons are not currently being advised to avoid travelling to
affected areas of Mexico and the US.

However, the Foreign Office recommends that anyone visiting those
destinations -- or who has recently returned -- should consult a doctor if
they experience flu-like symptoms.

--
communicated by:
ProMED-mail <promed@promedmail.org>

[To summarize the latest findings since the last update:

WHO is now following the guidelines established in the new International
Health Regulations (IHR 2005), having convened a meeting of the Emergency
Committee, defining the H1N1 (also known as "swine flu") outbreak a "public
health emergency of international concern. The current pandemic alert phase
is still at level 3 (see the chart with pandemic alert phases available at
<http://www.who.int/csr/disease/avian_influenza/phase/en/index.html>, with
a suggestion that this will be watched closely and may be altered depending
upon how the situation progresses.

In the USA, there have been cases identified in 2 additional states, New
York City (in New York State) and in Kansas. In New York City, there has
been an outbreak in a non-public school, with 8 probable cases out of about
200 children with an influenza like illness (ILI) -- these cases had
influenza A viruses identified that did not match H1 and H3 human subtypes
of influenza A by available testing methods, so they are considered
probable cases of swine flu -- and in Kansas there have been 2 cases
confirmed, one of whom recently travelled to Mexico. According to the CDC,
as of 7 PM EDT (GMT -4), there have been 7 confirmed cases in California
and 2 confirmed cases in Texas. With the addition of the 2 cases from
Kansas, there have been 11 cases confirmed thus far by the CDC. All cases
in the USA have been self limited with full recovery.

In Mexico, the case count is now 1324 (from about 1000 less than 24 hours
ago), with 81 reported deaths (up from 60 reported deaths less than 24
hours ago). Newswires describing the situation in Mexico are communicating
panic with the addition of significant political overtones, and "spin
doctors" are casting stones, blaming cover-ups and slow responses as
responsible for the outbreak "escaping", and rumors of implicated swine
production farms as the foci where the outbreak allegedly began -- an
unfortunate situation that seems to repeat itself every time there is a
major outbreak with many unknowns.

From the information that is becoming available, it does appear as though
there is significant human to human transmission ongoing of a novel
influenza virus. That translates into a large pool of susceptibles for the
virus to potentially infect. In the absence of a vaccine that will protect
against this novel strain, it is unclear if any measures could have been
effectively implemented that would have interrupted transmission earlier. A
situation that appears to be a reminder that mother nature is still the
most skilled bioterrorist out there.

The suspected case in an airline cabin crew member in the UK, having just
returned from Mexico, has -- it seems -- been discounted by initial tests.
According to the Health Protection Agency (HPA) of the United Kingdom, as
of 25 Apr 2009 there have not been any confirmed cases of this novel H1N1
virus infection in the UK and Europe (see
<http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1240646410227>
for the HPA update.

That being said, there are still many unknowns -- will the transmission
chain "burn out" on its own? Are the more severe cases and fatalities
reported from Mexico an indication of a more pathogenic strain for young
otherwise healthy individuals or are the reported deaths in individuals
with underlying disease? - Mod.MPP]

See Also