ProMED-mail |

Published Date: 2009-04-29 17:00:05
Subject: PRO/AH/EDR> Influenza A (H1N1) "swine flu": worldwide (06)
Archive Number: 20090429.1614

INFLUENZA A (H1N1) "SWINE FLU": WORLDWIDE (06)
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
[1, [2] Sequence analysis
[3] Nomenclature
[4] WHO update 4
[5] MMWR dispatch
[6] USA: 1st fatality
[7] Germany: 3 confirmed cases

******
[1] Sequence analysis
Date: Tue 28 Apr 2009
From: Peter Petermann <PPeterman@aol.com>

Concerning the question of the origin of the "novel" H1N1 virus [see
ProMED-mail Influenza A (H1N1) "swine flu": worldwide (04)
20090428.1609], may I direct attention to an anonymous statement of
CDC on the GISAID [Global Initiative on Sharing Avian Influenza Data]
website ("Summary of laboratory sequence data for swine influenza
viruses from 2 human cases in CA"), which comes to the same
conclusion as Professor Rabadan:

"Nucleotide blast results for the virus A/California/04/2009 isolated
from case A (Table 1), show that the HA, PB2, PB1, PA, NP, NS genes
contain gene segments from influenza viruses isolated from swine in
North America [such as, A/swine/Indiana/P12439/00], while the NA and
M genes are most closely related to corresponding genes from
influenza viruses isolated in swine population in Eurasia."

However, the NA and M genes from 2 swine virus isolates from America
are also closely related to the novel H1N1 virus
(A/swine/Virginia/670/1987, A/swine/Virginia/67a/1987), if a
reasonable nucleotide substitution rate is accepted. Thus, H1N1 from
Mexico may be a swine flu virus strain of entirely American origin,
possibly even of relatively ancient origin.

--
Dr Peter Petermann
WAI
[Wissenschaftsforum Aviaere Influenza (Science Forum on Avian Influenza)]
<PPeterman@aol.com>

******
[2] Sequence analysis
Date: Tue 28 Apr 2009
From: Joe Rojas-Burke <joerojas@news.oregonian.com>

"The original source of the assertion that the A/H1N1 virus is a
reassortment of avian, human, and swine viruses is Dr Anne Schuchat
from the [US] Centers for Disease Control and Prevention, who told
reporters that very specifically during the [23 Apr 2009] briefing.

The CDC transcript reads: "Preliminary testing of viruses from the
1st 2 patients shows that they are very similar. Additional testing
is ongoing with the newer isolates. We know so far that the viruses
contain genetic pieces from 4 different virus sources. This is
unusual. The 1st is our North American swine influenza viruses. North
American avian influenza viruses, human influenza viruses, and swine
influenza viruses found in Asia and Europe. That particular genetic
combination of swine influenza virus segments has not been recognized
before in the US or elsewhere." [The full transcript is available at
<http://www.cdc.gov/media/transcripts/2009/t090423.htm>.

This information contradicts the description in [Morbidity and
Mortality Weekly Report] MMWR 21 Apr 2009 / 58 (dispatch) ; 1-3
(<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0421a1.htm>), which
states the following: "Preliminary genetic characterization of the
influenza viruses has identified them as swine influenza A (H1N1)
viruses. The viruses are similar to each other, and the majority of
their genes, including the hemagglutinin (HA) gene, are similar to
those of swine influenza viruses that have circulated among US pigs
since approximately 1999; however, 2 genes coding for the
neuraminidase (NA) and matrix (M) proteins are similar to
corresponding genes of swine influenza viruses of the Eurasian
lineage (1). This particular genetic combination of swine influenza
virus segments has not been recognized previously among swine or
human isolates in the United States, or elsewhere based on analyses
of influenza genomic sequences available on GenBank."

--
Joe Rojas-Burke
Staff science writer
The Oregonian
Portland, Oregon
USA
<joerojas@news.oregonian.com>

******
[3] Nomenclature
Date: 29 Apr 2009
Source: The New York Times [edited]
<http://www.nytimes.com/2009/04/29/world/asia/29swine.html?hp>

The naming of swine flu, a curious matter
-----------------------------------------
What to call the new strain of flu raising alarms around the world
has taken on political, economic and diplomatic overtones.

Pork producers question whether the term "swine flu" is appropriate,
given that the new virus has not yet been isolated in samples taken
from pigs in Mexico or elsewhere. While the new virus seems to be
most heavily composed of genetic sequences from swine influenza virus
material, it also has human and avian influenza genetic sequences as
well, according to the Centers for Disease Control and Prevention in
Atlanta.

Government officials in Thailand, one of the world's largest meat
exporters, have started referring to the disease as "Mexican flu." An
Israeli deputy health minister - an ultra-Orthodox Jew - said his
country would do the same, to keep Jews from having to say the word
"swine." However, his call seemed to have been largely ignored.

Janet Napolitano, the secretary for homeland security, and
Agriculture Secretary Tom Vilsack went out of their way at a press
conference in Washington on Tuesday to refer to the virus by its
scientific name, as the "H1N1 virus."

"This is not a food-borne illness, virus -- it is not correct to
refer to it as swine flu because really that's not what this is
about," Mr. Vilsack said.

The World Organization for Animal Health, which handles veterinary
issues around the world, issued a statement late Monday suggesting
that the new disease should be labeled "North American influenza," in
keeping with a long medical tradition of naming influenza pandemics
for the regions where they were first identified. This has included
the Spanish flu of 1918 to 1919, the Asian flu of 1957 to 1958 and
the Hong Kong flu of 1967 to 1968.

The debate is likely to continue as scientists and health authorities
try to trace the disease. While all signs now point to Mexico as the
epicenter, the genetic material in the virus there includes part of a
swine influenza virus of Eurasian origin. And influenza viruses tend
to emerge from Asia.

Prime Minister Wen Jiabao of China called for stepped up measures on
Tuesday to prevent and control any possible cases of swine flu that
might show up in the country.

Many medical historians believe that the Asian and Hong Kong flus
started in southeastern China near Hong Kong, where very high
densities of people live in close proximity to hogs and chickens in
rural areas and can share their viruses. Some historians also suggest
that the Spanish flu also started in southeastern China.

The Mexican ambassador to Beijing, Jorge Guajardo, has been outspoken
this week in suggesting that the disease did not originate in Mexico.
He said in a telephone interview on Tuesday that the disease was
brought to his country by an infected person from somewhere in
"Eurasia," the land mass of Europe and Asia.

Ambassador Guajardo said in a telephone interview that his government
had been told by American and Canadian experts that the genetic
sequence of the virus pointed to Eurasian origin.

"This did not happen in Mexico," he said, adding, "It was a human who
brought this to Mexico."

But flu specialists in Asia said that the new virus probably did not
make the jump from animals to people in Asia.

"If that is the case, you would see a lot of infections in Asia by
now," said Subash Morzaria, the regional manager for Asia and the
Pacific at the Emergency Center for Transboundary Diseases, which is
part of the United Nations' Food and Agriculture Organization.

The neuraminidase genetic segment of the virus, which gives the virus
its "N1" name and controls the ability of the virus to break out of
infected cells, comes from a Eurasian strain of swine flu, said Dr.
Yuen Kwok-yung, a microbiologist at Hong Kong University. But he
added that enough pigs are moved across national borders that it is
impossible to place the location more precisely.

There seems little indication of any outbreak of the new flu in
China. There have been no recent surges in illnesses among pigs or
pig farmers, according to Ben Boake, the executive vice president of
the Henan Zhongpin Food Company Ltd., one of China's largest pork
processors.

Millions of pigs died in China two years ago in an epidemic so severe
that it pushed pork prices up 90 percent. Veterinarians attributed
the deaths at the time mainly to blue-ear disease, which does not
affect humans, but also to swine flu. The Chinese government did not
issue a public report assessing the outbreak and provided very few
details to international organizations.

[Byline: Keith Bradsher]

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

******
[4] WHO update 4
Date: Tue 28 Apr 2009
Source: WHO Epidemic and Pandemic Alert and Response (EPR) Disease
Outbreak News [edited]
<http://www.who.int/csr/don/2009_04_28/en/index.html>

Swine influenza - WHO update 4
------------------------------
The situation continues to evolve rapidly. As of 19:15 GMT, 28 Apr
2009, 7 countries have officially reported cases of swine influenza
A/H1N1 infection. The United States Government has reported 64
laboratory confirmed human cases, with no deaths. [but see below. -
Mod.JW] Mexico has reported 26 confirmed human cases of infection
including 7 deaths.

The following countries have reported laboratory confirmed cases with
no deaths: Canada (6), New Zealand (3), the United Kingdom (2),
Israel (2) and Spain (2).
Further information on the situation will be available on the WHO
website on a regular basis.

WHO advises no restriction of regular travel or closure of borders.
It is considered prudent for people who are ill to delay
international travel and for people developing symptoms following
international travel to seek medical attention, in line with guidance
from national authorities.

There is also no risk of infection from this virus from consumption
of well-cooked pork and pork products. Individuals are advised to
wash hands thoroughly with soap and water on a regular basis and
should seek medical attention if they develop any symptoms of
influenza-like illness.

--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp

******
[5] MMWR dispatch
Date: Tue 28 Apr 2009
Source: CDC. MMWR Morb Mortal Wkly Rep 2009; 58 (dispatch) [edited]
<http://www.cdc.gov/mmwr/PDF/wk/mm58d0428a2.pdf>

Update: infections with a swine-origin influenza A (H1N1) virus - USA
and other countries, 28 Apr 2009
----------------------------------------------------------------------
Since 21 Apr 2009, CDC has reported cases of respiratory infection
with a swine-origin influenza A (H1N1) virus (S-OIV) transmitted
through human-to-human contact (1,2). This report updates cases
identified in US states and highlights certain control measures taken
by CDC. As of [28 Apr 2009], the total number of confirmed cases of
S-OIV infection in the United States had increased to 64, with cases
in California (10 cases), Kansas (2), New York (45), Ohio (one), and
Texas (6). CDC and state and local health departments are
investigating all reported US cases to ascertain the clinical
features and epidemiologic characteristics. On [27 Apr 2009], CDC
distributed an updated case definition for infection with S-OIV [see
original article at URL above for details].

Of the 47 patients reported to CDC with known ages, the median age
was 16 years (range: 3-81 years), and 38 (81 percent) were aged less
than 18 years; 51 percent of cases were in males. Of the 25 cases
with known dates of illness onset, onset ranged from 28 Mar to 25 Apr
[2009] (data presented as a figure in the original text). To date, no
deaths have been reported among US cases, but 5 patients are known to
have been hospitalized. Of 14 patients with known travel histories, 3
had traveled to Mexico; 40 of 47 patients (85 percent) have not been
linked to travel or to another confirmed case. Information is being
compiled regarding vaccination status of infected patients, but is
not yet available. According to the World Health Organization (WHO),
as of 27 Apr [2009], a total of 26 confirmed cases of S-OIV infection
had been reported by Mexican authorities. Canada has reported 6 cases
and Spain has reported one case (additional information is available
at <http://www.who.int/en/>).

Emergency use authorizations
----------------------------
If an emerging public health threat is identified for which no
licensed or approved product exists, the Project BioShield Act of
2004 authorizes the Food and Drug Administration (FDA) commissioner
to issue an Emergency Use Authorization (EUA) so that promising
countermeasures can be disseminated quickly for the protection and
safety of the U.S. population (3).

In response to the current public health emergency involving
swine-origin influenza, FDA issued 4 EUAs on 27 Apr [2009] to allow
emergency use of: oseltamivir (Tamiflu) and zanamivir (Relenza) for
the treatment and prophylaxis of influenza (2 EUAs); disposable N95
respirators for use by the general public; and the rRT-PCR Swine Flu
Panel for diagnosis.

Oseltamivir is FDA-approved for treatment and prevention of influenza
in adults and children 1 year and older. Zanamivir is FDA-approved
for treatment of influenza in adults and children 7 years and older
who have been symptomatic for less than 2 days, and for prevention of
influenza in adults and children aged 5 years and older. The EUA
allows the use of oseltamivir for treatment of influenza in children
aged less than 1 year and prevention of influenza in children aged 3
months-1 year. Additionally, traditional prescribing and dispensing
requirements might not be met. Under the scope and conditions of
current EUAs, mass dispensing of both antiviral medications will be
allowed per state and/or local public health authority.

FDA has authorized use of certain N95 respirators to help reduce
wearer exposure to pathogenic biological airborne particulates during
a public health emergency involving S-OIV. On 27 Apr [2009], CDC
published guidelines for the use of N95 respirators. For example,
respirators should be considered for use by persons for whom close
contact with an infectious person is unavoidable. This can include
selected individuals who must care for a sick person (such as, family
member with a respiratory infection) at home. Additional information
is available at <http://www.cdc.gov/swineflu/masks.htm>.

Currently, no FDA-cleared tests specifically for the S-OIV strain
exist in the United States or elsewhere. For this purpose and to meet
the significant increase in demand for influenza testing throughout
the country, CDC has developed the rRT-PCR Swine Flu Panel to expand
and maintain the operational capabilities of public health or other
qualified laboratories by providing a detection tool for the
presumptive presence of S-OIV.

Control measures at ports of entry and travel warning for Mexico
----------------------------------------------------------------
CDC, in collaboration with industry and federal partners, is
continuing to conduct routine illness detection at ports of entry
with heightened awareness for travelers who might be infected with
S-OIV. During 17-19 Apr [2009], 15 cases of illness in travelers
entering the United States from Mexico that were clinically
consistent with S-OIV infection were detected. Of these 15 cases, 2
were laboratory confirmed as swine-origin influenza A (H1N1). Nine
travelers remain in isolation pending completion of evaluation, and 4
travelers were released to complete travel after influenza virus
infection was ruled out.

WHO has declared a Public Health Emergency of International Concern.
As part of its responsibilities under the International Health
Regulations, CDC is prepared to implement additional screening
measures for international flights, if deemed necessary, to prevent
exportation of S-OIV. In addition, CDC in collaboration with the US
Department of Homeland Security, is distributing travelers health
alert notices to all persons traveling to countries with confirmed
cases of S-OIV infection.

CDC has recommended that US travelers avoid nonessential travel to
Mexico (<http://wwwn.cdc.gov/travel/contentswineflumexico.aspx>).
However, CDC might revise its travel guidance as the outbreak in
Mexico evolves and is characterized more completely. Travelers who
cannot delay travel to Mexico should visit
<http://www.cdc.gov/travel> and follow the posted recommendations to
reduce their risk for infection.

Non pharmaceutical community mitigation
---------------------------------------
CDC has issued interim guidance for non pharmaceutical community
mitigation efforts in response to human infections with S-OIV
(<http://www.cdc.gov/swineflu/mitigation.htm>). Current
recommendations for isolation of patients with cases of S-OIV,
household contacts, school dismissal, and other social distancing
interventions also are available at
<http://www.cdc.gov/swineflu/mitigation.htm> and will be updated as
the situation evolves.

[The original text is supplemented with a figure of the confirmed
human cases of swine-origin influenza A (H1N1) infection with known
(25 of 64 cases) dates of illness onset - United States, 27 Apr 2009]

[Reported by: Strategic Science and Program Unit, Coordinating Center
for Infectious Diseases; Div of Global Migration and Quarantine,
National Center for Preparedness, Detection, and Control of
Infectious Diseases; Influenza Div, National Center for Immunization
and Respiratory Diseases, CDC Influenza Emergency Response Team, CDC]

References
----------
1. CDC: Swine influenza A (H1N1) infection in two children - Southern
California, March-April 2009. MMWR 2009; 58: 400-2 [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0421a1.htm>].
2. CDC. Update: swine influenza A (H1N1) infections - California and
Texas, April 2009. MMWR; 58 (in press) [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0424a1.htm>].
3. Nightingale SL, Prasher JM, Simonson S: Emergency Use
Authorization (EUA) to enable use of needed products in civilian and
military emergencies, United States. Emerg Infect Dis 2007; 13(7):
1046-51 [available at
<http://www.cdc.gov/eid/content/13/7/1046.htm>].

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

******
[6] USA: 1st fatality
Date: Wed 29 Apr 2009
Source: Thomson Reuters Foundation AlertNet [edited]
<http://www.alertnet.org/thenews/newsdesk/N29383699.htm>

Texas child who died of flu recently in Mexico
----------------------------------------------
The Texas baby who became the 1st confirmed US death from the new
H1N1 swine flu had recently traveled to Mexico, a US government
source said on Wednesday [29 Apr 2009].

The US Centers for Disease Control and Prevention had earlier
confirmed the 23-month-old child as the 1st swine flu death reported
outside Mexico, the country hardest hit by the influenza outbreak. US
officials have confirmed 65 cases of swine flu, most of them mild but
with 5 hospitalizations in California and Texas.

[Byline: Maggie Fox]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

******
[7] Germany: 3 confirmed cases
Date: Wed 29 Apr 2009
From: Oliver Schmetzer <oliver.schmetzer@gmx.net>

Three confirmed imported cases of A/H1N1-influenza in Germany.
--------------------------------------------------------------
In the morning of 29 Apr 2009 the Bernhard-Nocht-Institute confirmed
in a press release a case of a 22-year-old woman in Hamburg. She came
back with flu-symptoms from Mexico.

A 2nd case, a 30-year-old man in Regensburg has been confirmed. He
also arrived from Mexico.

The 3rd confirmed case is a 37-year-old woman, confirmed in Kulmbach.
She again arrived from Mexico.

The last 2 cases have been confirmed by the laboratory of the
University Clinic of Regensburg. There are several suspected cases
from different states in Germany (the 1st appeared on 26 Apr 2009).
All cases have been isolated and there is no human-to-human
transmission [so far]. The confirmed cases reached their hometown via
planes from Frankfurt and Stuttgart.

The national pandemic plan was published in 2005 and updated in 2007.
The plan contains several measurements and guidelines. The most
important suggested measurements until now are: hand washing,
hygiene, and prevention of hand to face contact.

On German TV there are many reports now, mainly showing controls of
flight passengers by doctors at Frankfurt international airport.
According to the Government, Germany has stored large quantities of
anti-viral drugs (Tamiflu etc.), which are enough to treat 40 million
people (over 50 percent of the population). In case of an epidemic,
the drugs are given to the community without charge. They have been
shown highly effective against this influenza strain in the US.

The German airline Lufthansa reported that their air-filters remove
viral particles and air-quality in their planes is "as good as in a
surgery room."

The director of the Bernhard-Nocht-Institute confirmed that in the
case of a pandemic alert level 5/6 from the WHO, a vaccine would be
available in 3 months. However a virologist in German TV (Prof
Alexander Kekul) stated that it will take until January [2010] to
prepare a vaccine.

--
Oliver Schmetzer
<oliver.schmetzer@gmx.net>

See Also