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Published Date: 2009-05-15 16:00:04
Subject: PRO/AH/EDR> Influenza A (H1N1) - worldwide (28): case counts
Archive Number: 20090515.1822

INFLUENZA A (H1N1) - WORLDWIDE (28): CASE COUNTS
************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[Please note that there may be discrepancies between the various sources of
information due to different times of "closure" of daily figures reported.
Times of daily report closures where known are listed in the table of
contents below. Newswires may mention a confirmed case in a location that
has not been on the official reporting entity list as the confirmation
arrived after closure of the day's report. - Mod.MPP]

In this update:
[1] WHO - global update (06:00 GMT)
[2] PAHO - Americas regional update (17:00 GMT-4)
[3] CDC - USA update (11:00 GMT -4)
[4] Mexico - MOH update (08:40 GMT -5)
[5] Canada - Public Health Agency of Canada (17:00 GMT -4)
[6] Spain - Eurosurveillance
[7] UK - Eurosurveillance
[8] News briefs

******
[1] WHO - global update (06:00 GMT)
Date: Thu 14 May 2009
Source: WHO Epidemic and Pandemic Alert and Response (EPR) [edited]
<http://www.who.int/csr/don/2009_05_14/en/index.html>

Influenza A (H1N1) - update 28 -- 14 May 2009
---------------------------------------------
As of 06:00 GMT, 14 May 2009, 33 countries have officially reported 6497
cases of influenza A (H1N1) infection.

Mexico has reported 2446 laboratory confirmed human cases of infection,
including 60 deaths. The United States has reported 3352 laboratory
confirmed human cases, including 3 deaths. Canada has reported 389
laboratory confirmed human cases, including one death. Costa Rica has
reported 8 laboratory confirmed human cases, including one death.

The following countries have reported laboratory confirmed cases with no
deaths - Argentina (1), Australia (1), Austria (1), Brazil (8), China (4),
Colombia (7), Cuba (1), Denmark (1), El Salvador (4), Finland (2), France
(14), Germany (12), Guatemala (3), Ireland (1), Israel (7), Italy (9),
Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (29),
Poland (1), Portugal (1), Republic of Korea (3), Spain (100), Sweden (2),
Switzerland (1), Thailand (2), and the United Kingdom (71).

Summary table of cases reported to WHO 30 Apr -- 14 May 2009
------------------------------------------------------------
Country: No. cases (deaths) Apr 30 / May 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
/ 10 / 11 / 12 / 13 / 14
Argentina: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1
Australia: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1
Austria: 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Brazil: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 4 / 6 / 6 / 8 / 8 / 8 / 8
Canada: 19 / 34 / 51 / 85 / 101 / 140 / 165 / 201 / 214 / 242(1) / 280(1) /
284(1) / 330(1) / 358(1) / 389(1)
China, Hong Kong, SAR, mainland: 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
/ 2 / 2 / 3 / 4
Colombia: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 3 / 3 / 6 / 7
Costa Rica: 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 8(1) / 8(1) / 8(1) /
8(1) / 8(1)
Cuba: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1
Denmark: 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
El Salvador: 0 / 0 / 0 / 0 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 4 / 4 / 4 / 4
Finland: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2
France: 0 / 0 / 2 / 2 / 4 / 4 / 5 / 5 / 12 / 12 / 12 / 13 / 13 / 13 / 14
Germany: 3 / 4 / 6 / 8 / 8 / 9 / 9 / 10 / 11 / 11 / 11 / 11 / 12 / 12 / 12
Guatemala: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 3 / 3
Ireland: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Israel: 2 / 2 / 3 / 3 / 4 / 4 / 4 / 6 / 7 / 7 / 7 / 7 / 7 / 7 / 7
Italy: 0 / 0 / 0 / 1 / 2 / 5 / 5 / 5 / 6 / 6 / 9 / 9 / 9 / 9 / 9
Japan: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 3 / 4 / 4 / 4 / 4
Mexico: 97(7) / 156(9) / 397(16) / 506(19) / 590(25) / 822(29) / 942(29) /
1112(42) / 1204(44) / 1364(45) / 1626(45) / 1626(48) / 2059(56) / 2059(56)
/ 2446(60)
Netherlands: 1 / 1 / 1 / 1 / 1 / 1 / 1 / 2 / 3 / 3 / 3 / 3 / 3 / 3 / 3
New Zealand: 3 / 4 / 4 / 4 / 6 / 6 / 5 / 5 / 5 / 5 / 7 / 7 / 7 / 7 / 7
Norway: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2 / 2 / 2
Panama: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 3 / 15 / 16 / 29 / 29
Poland: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Portugal: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Republic of Korea: 0 / 0 / 1 / 1 / 1 / 2 / 2 / 3 / 3 / 3 / 3 / 2 / 3 / 3 / 3
Spain: 13 / 13 / 13 / 40 / 54 / 57 / 73 / 81 / 88 / 88 / 93 / 95 / 95 / 98
/ 100
Sweden: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 2 / 2 / 2 / 2
Switzerland: 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Thailand: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2
United Kingdom: 8 / 8 / 15 / 15 / 18 / 27 / 28 / 32 / 34 / 34 / 39 / 47 /
55 / 68 / 71
United States: 109(1) / 141(1) / 160(1) / 226(1) / 286(1) / 403(1) / 642(2)
/ 896(2) / 1639(2) / 2254(2) / 2532(3) / 2600(3) / 3009(3) / 3352(3)
Total No. countries reporting cases: 11 / 13 / 16 / 18 / 21 / 21 / 23 / 24
/ 25 / 29 / 30 / 30 / 33 / 33
Total cases reported: 257(8) / 367(10) / 658(17) / 898(20) / 1085(26) /
1490(30) / 1893(31) / 2371(44) / 2500(46) / 4379(49) / 4694(53) / 5251(56)
/ 5728(61) / 6497(65)

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******
[2] PAHO - Americas regional update (17:00 GMT-4)
Date: Thu 14 May 2009
Source: PAHO H1N1 flu website [edited]
<http://new.paho.org/hq/index.php?option=com_content&task=view&id=1365&Itemid=569>

Up to 14 May 2009, 7479 confirmed cases of the new virus influenza A (H1N1)
infection, including 69 deaths, have been notified in 11 countries of the
Americas: Argentina, Brazil, Canada, Colombia, Costa Rica, Cuba, El
Salvador, Guatemala, Mexico, Panama, and the United States. The date of the
onset of symptoms of the 1st confirmed case was 28 Mar 2009 in the United
States.

Confirmed cases from other Regions: 249
No. of countries affected: 22

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[See the source URL link for full report with figures of number of cases
and deaths by country in the Americas. - Mod.MPP]

******
[3] CDC - USA update (11:00 GMT -4)
Date: Thu 14 May 2009
Source: CDC H1N1 flu website [edited]
<http://www.cdc.gov/h1n1flu/>

H1N1 flu (swine flu)
--------------------
Cumulative total of laboratory confirmed cases (deaths), by state, 30 Apr
-- 14 May 2009
States: Cases (deaths) Apr 30 / May 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
/ 11 / 12 / 13 / 14
Alabama: 0 / 0 / 0 / 1 / 4 / 5 / 4 / 4 / 4 / 4 / 4 / 9 / 9 / 41
Arkansas: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1
Arizona: 1 / 4 / 4 /18 / 17 / 17 / 48 / 48 / 131 / 182 / 182 / 182 /187 /
187 / 431
California: 14 / 13 / 24 / 26 / 30 / 49 / 67 / 106 / 107 / 171 / 282 / 193
/ 221 / 473
Colorado: 0 / 2 / 2 / 4 / 7 / 6 / 17 / 17 / 25 / 41 / 39 / 44 / 44 / 47
Connecticut: 0 / 0 / 1 / 2 / 2 / 2 / 4 / 4 / 4 / 14 / 24 / 28 / 33 / 38
Delaware: 0 / 4 / 4 / 10 / 20 / 20 / 33 / 28 / 39 / 44 / 44 / 45 / 54 / 58
Florida: 0 / 0 / 2 / 3 / 5 / 5 / 5 / 5 / 6 / 43 / 53 / 55 / 58 / 65
Georgia: 0 / 0 / 0 / 0 / 0 / 1 / 3 / 3 / 3 / 3 / 3 / 4 / 8 / 36
Hawaii: 0 / 0 / 0 / 0 / 0 / 0 / 3 / 3 / 5 / 6 / 6 / 6 / 6 / 10
Idaho: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 2 / 3 / 5
Illinois: 0 / 3 / 3 / 3 / 8 / 82 / 122 / 204 / 392 / 421 / 466 / 554 / 592
/ 620
Indiana: 1 / 3 / 3 / 3 / 3 / 3 / 15 / 15 / 29 / 39 / 39 / 61 / 70 / 70
Iowa: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 5 / 5 / 43 / 43 / 55 / 55 / 58
Kansas: 2 / 2 / 2 / 2 / 2 / 2 / 2 / 7 / 12 / 12 / 36 / 22 / 23 / 28
Kentucky*: 0 / 1 / 1 / 1 / 1 / 1 / 2 / 2 / 3 / 3 / 3 / 10 / 10 / 13
Louisiana: 0 / 0 / 0 / 0 / 7 / 7 / 7 / 7 / 7 / 9 / 9 / 20 / 33 / 45
Maine: 0 / 0 / 0 / 0 / 0 / 1 / 1 / 4 / 4 / 4 / 4 / 6 / 6 / 13
Maryland: 0 / 0 / 0 / 0 / 4 / 4 / 4 / 4 / 4 / 23 / 23 / 23 / 23 / 28
Massachusetts: 2 / 2 / 8 / 7 / 6 / 6 / 45 / 71 / 83 / 89 / 88 / 107 / 107 /
109
Michigan: 1 / 2 / 2 / 2 / 2 / 2 / 8 / 9 / 49 / 103 / 114 / 133 / 134 / 141
Minnesota: 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 7 / 24 / 31 / 34
Missouri: 0 / 0 / 1 / 1 / 1 / 1 / 2 / 4 / 9 / 10 / 10 / 14 / 18 / 20
Montana: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 5
Nebraska: 0 / 1 / 0 / 1 / 1 / 1 / 4 / 4 / 4 / 13 / 13 / 19 / 21 / 23
Nevada: 1 / 1 / 1 / 1 / 1 / 1 / 5 / 5 / 8 / 9 / 9 / 12 / 21 / 25
New Hampshire: 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 3 / 4 / 4 / 16 / 17 / 18
New Jersey: 0 / 5 / 7 / 7 / 7 / 6 / 7 / 7 / 7 / 7 / 7 / 7 / 8 / 12
New Mexico: 0 / 0 / 0 / 1 / 1 / 1 / 3 / 8 / 8 / 30 / 30 / 30 / 44 / 51
New York: 50 / 50 / 50 / 63 / 73 / 90 / 97 / 98 / 174 / 190 / 190 / 192 /
211 / 224
North Carolina: 0 / 0 / 0 / 0 / 1 / 1 / 7 / 7 / 7 / 7 / 7 / 11 / 12 / 12
North Dakota: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1
Ohio: 1 / 1 / 1 / 3 / 3 / 3 / 5 / 5 / 6 / 12 / 6 / 7 / 11 / 12
Oklahoma: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 4 / 4 / 14 / 14 / 22 / 22
Oregon: 0 / 0 / 0 / 0 / 3 / 15 / 15 / 15 / 15 / 15 / 17 / 74 / 74 / 94
Pennsylvania: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 10 / 10 / 17 / 22 / 50
Rhode Island: 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 7 / 7 / 7 / 7 / 7 / 8
South Carolina: 10 / 16 / 13 / 15 / 15 / 16 / 16 / 17 / 29 / 42 / 32 / 32 /
32 / 34
South Dakota: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 3 / 3 / 5
Tennessee: 0 / 0 / 0 / 1 / 1 / 2 / 2 / 2 / 36 / 46 / 54 / 54 / 57 / 63
Texas: 26(1) / 28(1) / 28(1) / 40(1) / 41(1) / 41(1) / 61(2) / 91(2) /
93(2) / 110(2) / 108(2) / 206(2) / 293(2) / 439(2)
Utah: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 8 / 24 / 60 / 63 / 67 / 72 / 80
Vermont: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1
Virginia: 0 / 2 / 2 / 3 / 3 / 3 / 3 / 11 / 14 / 16 / 16 / 17 / 17 / 20
Washington: 0 / 0 / 0 / 0 / 0 / 0 / 9 / 23 / 33 / 83 / 102(1) / 176(1) /
176(1) / 195(1)
Washington, DC: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 4 / 4 / 7 / 9 / 10
Wisconsin: 0 / 0 / 0 / 3 / 3 / 3 / 6 / 26 / 240 / 317 / 357 / 437 / 496 / 510
Total number of states: 11 / 19 / 21 / 30 / 36 / 38 / 41 / 41 / 43 / 44 /
44 / 44 / 45 / 45 / 47
Total counts, cases (deaths): 109(1) / 141(1) / 160(1) / 226(1) / 279(1) /
403(1) / 642(2) / 896(2) / 1639(2) / 2254(2) / 2532(3) / 2600(3) / 3009(3)
/ 3352(3) / 4298(3)
*Case is resident of KY but currently hospitalized in GA.

[For a map of number of cases by state, see
<http://www.cdc.gov/h1n1flu/update.htm> - Mod.MPP]

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******
[4] Mexico - MOH update (08:40 GMT -5)
Date: Thu 14 May 2009 [in Spanish, trans. Mod.MPP, edited]
Source: Secretaria de Salud website (MOH) [edited]
<http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html>

Case counts: 2009: Apr 29 / May 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 11 / 12
/ 13 / 14
No. confirmed cases: 99 / 397 / 443 / 506 / 727 / 866 / 1112 / 1204 / 1364
/ 1626 / 2059 / 2282 / 2446 / 2656
No. deaths: 8 / 16 / 16 / 19 / 26 / 26 / 42 / 44 / 45 / 48 / 56 / 58 / 60 / 64

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******
[5] Canada - Public Health Agency of Canada (17:00 GMT -4)
Date: Thu 14 May 2009
Source: Public Health Agency of Canada [edited]
<http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/surveillance-eng.php>

Cumulative confirmed cases (deaths) of human swine influenza by province,
30 Apr -- 14 May 2009
Province: Cases (deaths) as of Apr 30 / May 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 /
9 / 10 / 11 / 12 / 13 / 14
Alberta: 6 / 8 / 15 / 18 / 24 / 26 / 30 / 33 / 42(1) / 46(1) / 48(1) /
52(1) / 53 / 61 / 67
British Columbia: 11 / 15 / 22 / 29 / 39 / 46 / 54 / 54 / 60 / 79 / 79 / 79
/ 83 / 92 / 96
Manitoba: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 2 / 4 / 4
Nova Scotia: 8 / 14 / 16 / 33 / 38 / 48 / 53 / 53 / 56 / 56 / 56 / 57 / 64
/ 65 / 66
New Brunswick: 0 / 1 / 1 / 1 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2
Ontario: 8 / 12 / 14 / 16 / 31 / 36 / 49 / 56 / 61 / 76 / 76 / 110 / 113 /
119 / 155
Prince Edward Island: 0 / 0 / 0 / 0 / 2 / 2 / 2 / 2 / 3 / 3 / 3 / 3 / 3 / 3
/ 3
Quebec: 1 / 1 / 2 / 3 / 3 / 4 / 10 / 11 / 15 / 15 / 15 / 16 / 25 / 26 / 38
Saskatchewan: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2 / 2 / 4 / 10 / 12 / 16 / 17
Yukon: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1
Total no. Provinces with cases: 5 / 6 / 6 / 7 / 8 / 8 / 8 / 9 / 9 / 9 / 9 /
9 / 10 / 10 / 10
Total: 34 / 51 / 70 / 101 / 140 / 165 / 201 / 214 / 242(1) / 280(1) /
284(1) / 330(1) / 358(1) / 389(1) / 449(1)

[An epidemic curve available at the URL link above illustrates the course
of the current H1N1 flu virus (human swine flu) outbreak in Canada. It
shows the date when symptoms of H1N1 flu virus (human swine flu) began for
each of the laboratory-confirmed cases. - Mod.MPP]

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[6] Spain - Eurosurveillance
Date: Thu 14 May 2009
Source: Eurosurveillance edition 2009; 14(19) [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19209>

New influenza A (H1N1) virus infections in Spain, April-May 2009
----------------------------------------------------------------
An outbreak of infections with a new influenza A (H1N1) virus that was
first detected in the United States and Mexico is currently ongoing
worldwide. This report describes the initial epidemiological actions and
outbreak investigation of the first 98 laboratory confirmed cases of
infection with this new virus in Spain.

Background
----------
On 25 Apr 2009, the World Health Organization (WHO) declared the outbreak
of swine-origin influenza A (H1N1) virus infections, first reported by the
United States (US) [1] and Mexico [2], as a "Public Health Event of
International Concern" (PHEIC) under the International Health Regulations
(2005) [3]. The pandemic alert level was raised from level 3 to level 4 on
27 Apr, and to level 5 on 29 Apr [2009], after verification of sustained
community-level outbreaks in at least two countries from the same WHO region.

On [26 Apr 2009], epidemiological and laboratory investigations on 3
persons returning from Mexico were initiated in Spain. On [27 Apr 2009],
Spain reported the 1st laboratory-confirmed case of the new influenza A
(H1N1) virus infection in Europe, in a traveller returning from Mexico.
Since then, the number of confirmed cases in Spain has risen continuously
and reached a total of 98 as of 11 May 2009. [As of 14 May 2009 Spain is
reporting 100.]

Enhanced surveillance
---------------------
On [24 Apr 2009], in response to alarming reports from the US of
swine-origin influenza A (H1N1) virus infection in several patients [1,4]
and media news of a possibly related outbreak of severe respiratory illness
in Mexico, the Coordinating Centre for Health Alerts and Emergencies
(CCAES) at the Spanish Ministry of Health and Social Policy, issued a
national epidemiologic alert. The alert asked public health authorities at
national and regional level to enhance surveillance and to report urgently
any case of fever and severe respiratory illness among people with history
of travel to Mexico or history of previous contact with a confirmed case of
influenza virus A (H1N1) infection (table 1: see URL link above).

On 25 Apr 2009, following WHO's declaration of a PHEIC, the National
Pandemic Influenza Preparedness and Response Plan was activated. A case
definition as well as protocols for case and contact management and for
infection control were developed and distributed to the National Health
Service through regional health authorities and other involved institutions
(table 2: see URL link above).

No increase in seasonal influenza activity has been reported so far.
Routine seasonal influenza surveillance will continue beyond week 20. Data
analysis of mortality for all causes since [1 May 2009] has not shown an
increase or change of patterns in mortality.

Since 24 Apr 2009, the outbreak of new influenza A (H1N1) has been
monitored by the Ministry of Health and Social Policy (Centro de
Coordinacion de Alertas y Emergencias Sanitarias, CCAES) jointly with the
National Centre for Epidemiology (Instituto de Salud Carlos III) and in
coordination with all the Regional Surveillance and Alert Teams from the
Autonomous Communities in Spain. This new influenza A (H1N1) investigation
and control group also discusses and recommends prevention and control
measures.

Confirmed cases of new influenza virus A (H1N1)
-----------------------------------------------
As of 11 May 2009], 98 laboratory-confirmed cases of infection with the new
influenza virus A (H1N1) have been reported in Spain out of 640 possible
cases investigated. The geographical distribution of reported cases by
region is shown in figure 1 (see URL link above).

76 confirmed cases (78 per cent) acquired the infection abroad; all these
cases had a history of travel to Mexico. Of the 45 cases for whom this
information was available, 16 (36 per cent) were symptomatic during the
inbound flight from Mexico. Dates of return from affected areas were
available for 70 confirmed cases and ranged from [20 to 29 Apr 2009]
(figure 2: see URL link above).

Information on disease onset was available for 93 cases. The 1st of the 93
cases reported onset of illness (any symptom) on 19 Apr 2009, and the most
recent case reported onset on 4 May 2009 (figure 3: see URL link above).

More than 2000 contacts have been traced and followed. Of these, 39 per
cent were household members of cases and 45 per cent friends of cases. 21
confirmed secondary cases and one tertiary case have been reported.
Secondary cases were family or close contacts of cases with history of
travel to Mexico. 5 secondary cases were infected by primary cases that did
not meet clinical criteria. The tertiary case was a family contact of a
secondary case. Analysis of secondary transmission is ongoing.

4 secondary cases had received prophylaxis with oseltamivir before being
diagnosed as cases.

From the analysis of disease onset for primary and secondary cases, the
median of the serial interval was estimated to be 3.5 days, ranging from
one to 6 days. The estimation for the maximum incubation period ranged from
one to 7 days, with a median of 3 days.

Demographic and clinical features
---------------------------------
Cases ranged in age from 14 to 55 years, with an average of 24 years
(standard deviation (SD) 6.3) and a median of 22; 50 (51 per cent) cases
were male.

The most frequently reported symptoms were fever (96 per cent) and cough
(95 per cent). 4 cases did not have fever. Among 41 cases for whom this
information was available, 17 (41 per cent) reported diarrhoea (table 3:
see URL link above).

No deaths have been reported. Disease presentation has been described as a
mild influenza-like illness with full recovery in all cases. Some cases
were hospitalised at the beginning of the outbreak for respiratory
isolation following the national pandemic preparedness plan, this procedure
having no association with illness severity.

No differences in disease presentation have been described for secondary
cases. No pregnancies among confirmed cases have been reported.

Information on seasonal influenza 2008-09 vaccine status is available for
52 cases (53 per cent); of these, only 5 cases had history of vaccination.

Laboratory confirmation
-----------------------
Nose and throat swabs from cases who met clinical and epidemiological
criteria were taken and referred to the national influenza reference
laboratory (WHO National Influenza Centre) at the Instituto de Salud Carlos
III for confirmation. 2 independent assays have been used for diagnosis; a
reverse transcription (RT)-nested PCR designed for typing the nucleoprotein
gene and another one for subtyping the haemagglutinin gene. An alternative
RT-PCR was done in case the 1st 2 PCR gave contradictory results. Amplified
products were sequenced and a phylogenetic analysis was done to identify
the new A (H1N1) virus. The strain identified in all cases was confirmed as
genetically similar to viruses previously isolated from cases in California
(A/California/04/2009).

Detailed information on co-infection with other respiratory viruses is
pending. Virological studies on antiviral sensitivity and on
molecular-level indicators of severity are ongoing.

Discussion
----------
Spain was the 1st country in Europe to report a laboratory-confirmed case
of new influenza A (H1N1) virus infection. Several factors may have
contributed: intense air traffic and contacts with Mexico [5] but also a
timely alert with high media coverage that raised early awareness among
public health and healthcare professionals, as well as among the public.

An extremely efficient surveillance system and a sensitive case definition
that was distributed early in the event made it possible to detect cases at
the very beginning of the outbreak and to trace more than 2000 close
contacts. Secondary cases have been identified among close contacts of the
1st reported cases. However, they are still only a minor percentage of all
reported cases and further spread of this new influenza virus into the
community has not been documented. The last imported case had disease onset
on 2 May 2009, but the change in the case definition on 7 May 2009
including the US as an affected area may lead to notification of new
imported cases.

The preliminary findings from the analysis of the 1st 98
laboratory-confirmed cases of the new influenza A (H1N1) virus infection in
Spain indicate that symptoms in these cases appear to be similar to those
of seasonal influenza. Cases observed are mainly distributed among young
adults, reflecting the age structure of returning travellers from Mexico.
This group has no risk factors for influenza complications and is difficult
at this stage to assess the potential severity of this virus. For the time
being, the impact of this outbreak on the healthcare services has been
negligible.

Conclusion
----------
The evolution of this outbreak of influenza A (H1N1) in Spain is difficult
to predict. Though notification of new confirmed cases has decreased and
the disease seems mild, we will continue monitoring changes in the
epidemiology and/or clinical severity of new influenza A (H1N1) virus
infections in Spain in order to implement appropriate prevention and
control measures.

References
----------
1. CDC. Swine Influenza A (H1N1) infections -- California and Texas, April
2009. MMWR Morb Mortal Wkly Rep 2009; 58(16): 435-7. Available from
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a7.htm>.
2. CDC. Outbreak of swine-origin influenza A (H1N1) virus infection-Mexico,
March-April 2009. MMWR Morb Mortal Wkly Rep. 2009; 58(Dispatch): 1-3.
Available from <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a2.htm>.
3. WHO. International health regulations (2005). 2nd ed. Geneva: World
Health Organization; 2008. Available from
<http://www.who.int/ihr/9789241596664/en/index.html>.
4. CDC. Swine influenza A (H1N1) infection in two children -- Southern
California, March-April 2009. MMWR Morb Mortal Wkly Rep 2009; 58(15):
400-2. Available from <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5815a5.htm>.
5. Fraser C, Donnelly CA, Cauchemez S, Hanage WP, Van Kerkhove MD, D'eirdre
Hollingsworth T, et al. Pandemic potential of a strain of influenza A
(H1N1): early findings. Science Express 11 May 2009. DOI:
10.1126/science.1176062. Available from
<http://www.sciencemag.org/cgi/content/abstract/1176062v1>.

[reported by: Surveillance Group for New Influenza A (H1N1) Virus
Investigation and Control in Spain1,2,3,4
1. Coordinating Centre for Health Alerts and Emergencies, Spanish Ministry
of Health and Social Policy, Madrid, Spain
2. National Centre for Epidemiology and National Centre for Microbiology,
Instituto de Salud Carlos III, Madrid, Spain
3. Regional Surveillance and Alert Teams from the Autonomous Communities in
Spain
4. National Influenza Laboratory Network, Spain]

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[For information on the geographic distribution of cases in Spain as of 14
May 2009, see
<http://www.msc.es/en/gabinetePrensa/notaPrensa/desarrolloNotaPrensa.jsp?id=1509>.
- Mod.MPP]

******
[7] UK - Eurosurveillance
Date: Thu 14 May 2009
Source: Eurosurveillance edition 2009; 14(19) [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19213>

Epidemiology of new influenza A (H1N1) in the United Kingdom, April -- May
2009
------------------------------------------------------------
Following importations of cases from Mexico and the United States, by [11
May 2009], United Kingdom surveillance activities had detected a total of
65 individuals with confirmed infections caused by the new influenza A
(H1N1) virus. The infections were mainly in young people and younger adults
and they spread within households and within schools. The illness in the
United Kingdom is similar in severity to seasonal influenza and to date,
besides one case of bacterial pneumonia, no clinically serious cases have
occurred.

On [23 Apr 2009], several cases of severe respiratory illness were
confirmed as a new swine-lineage influenza A (H1N1) virus infection in the
United States [1]. Genetic analysis of these viruses indicated that they
were novel viruses, not detected previously in either the swine or human
population in North America [2]. Coincidentally, in March and April 2009,
Mexico experienced outbreaks of respiratory illness in several parts of the
country. Analysis of viral isolates from affected cases in Mexico indicated
that illness was associated with a novel then called "swine virus" similar
to that identified in sporadic cases in the US [3]. This novel virus has
since been identified in humans in Canada, Europe and elsewhere [4].

On [27 Apr 2009], the 1st 2 confirmed United Kingdom cases of new influenza
A (H1N1) virus infection were reported in Scotland, in a couple returning
from travel to Mexico.

In response to the detection of confirmed cases of new influenza A (H1N1)
in the United Kingdom, the Health Protection Agency (HPA) and the Devolved
Administrations strengthened national surveillance of respiratory illness
amongst travellers returning from affected areas. As part of case finding,
a possible case was defined as any person with a history of acute
respiratory illness and recent travel to an affected area or contact with a
confirmed or probable case; a probable case was defined as a person who was
a possible case and had tested positive for influenza A which was
non-subtypeable and a confirmed case was an individual that tested positive
for the new influenza A (H1N1) virus by specific-RT-PCR confirmed by
sequence analysis.

During the period [27 Apr 2009 to 11 May 2009], a total of 65 confirmed
cases were detected. From the 1st reported cases on [27 Apr 2009], initial
cases were amongst travellers returning from Mexico, and then the United
States, with a peak on [1 May 2009]. The 1st indigenously acquired
infections in the United Kingdom were reported on [1 May 2009] and the
proportion and number that are indigenously acquired has been reasonably
stable since [7 May 2009] (figure 1: see URL link above).

Cases of new influenza A (H1N1) have been identified in England (60) and
Scotland (5). Of the English cases, 34 have been identified in London; 6 in
North West and South East England; 5 in East of England; 3 in each of South
West and West Midlands; 2 in East of Midlands and one each in North East
and South East.

Of the 65 confirmed cases, 29 (45 per cent) are female (figure 2: see URL
link above). Cases range in age from 5 to 73 years -- with 58 per cent of
patients falling into the age range 10-29 years. The age distribution of
indigenous cases is predominately in the 10-19 year age group.

Travel history
--------------
Of the 65 cases, 24 reported a history of recent travel from Mexico and 5
from the US (one from each of California, Florida, Texas, and 2 from New York).

The remaining 36 (56 per cent) cases report no recent overseas travel and
acquired their infection through secondary transmission in the United
Kingdom. All but one of these can be linked to cases who travelled from
affected areas. These indigenous cases are mainly affecting 10-19 year olds
at present (figure 2: see URL link above). Of these cases, a number of
secondary cases are linked to transmission in different household/close
contact settings. Transmission has also occurred in 2 school settings in
London. An in-depth field epidemiology investigation of the school cluster
is presently under way.

Clinical picture
----------------
The First Few Hundred (FF100 project) aims to collect information about a
limited number of the earliest laboratory confirmed cases of new influenza
A (H1N1) and their close contacts [5]. This is to gain an early
understanding of some of the key clinical, epidemiological, and virological
parameters of the new influenza A (H1N1) virus and to facilitate real-time
modelling efforts to make predictions of the future course of the United
Kingdom epidemic. By [11 May 2009], of the total of 65 confirmed cases, 53
had been reported and entered into the First Few-100 database. Cases
generally presented with the most common symptoms typical of influenza --
with fever (94 per cent), sore throat (82 per cent), headache (81 per
cent), chills (80 per cent), and malaise (80 per cent). Diarrhoea (28 per
cent) and arthralgia (56 per cent) were moderately frequently reported. 5
cases reported epistaxis and one a seizure. Children were more likely to
have dry cough (83 per cent vs. 55 per cent OR = 5.7 95 per cent CI:
0.97-34.2), malaise (89 per cent vs. 69 per cent OR = 8.1 95 per cent CI
0.78-85.0) and epistaxis (24 per cent vs. 6 per cent OR = 4.9 95 per cent
CI: 0.46-52.4) than adults. Females were more likely to vomit than males
(40 per cent vs. 11 per cent, OR=6.7; 95 per cent CI: 1.1-41.1) and have
diarrhoea (39 per cent vs. 14 per cent, OR = 4.0 95 per cent CI: 0.8-19.8).

No case in the United Kingdom, to date, has died. Amongst those patients
with detailed information, 3 have been [admitted to] hospital -- one with
secondary pneumonia and 2 for clinical investigation. None of the cases was
reported to have underlying risk factors for severe influenza or to have
been vaccinated with either seasonal influenza or pneumococcal vaccine.

All of the cases except one had been treated with oseltamivir once
diagnosed. Contacts are currently being actively followed up to provide
information to enable estimations of epidemiological parameters such as
secondary attack rate, serial interval, and reproductive rate.

Conclusions
-----------
In summary, the United Kingdom continues to observe sporadic importations
of new influenza A (H1N1) virus from affected areas predominately Mexico,
but also now from the United States. As sustained transmission becomes
established in other countries, importations from other parts of the globe
to the United Kingdom will be observed. At this stage, healthy young adults
and children are being proportionately more affected than other parts of
the population. Based on the limited United Kingdom case series to date;
the clinical presentation of cases continues to be relatively mild. Further
work is on-going to describe more fully the emerging epidemiological,
virological and clinical characteristics of this new influenza A (H1N1).

References
1. CDC. Swine influenza A (H1N1) infection in two children -- Southern
California, March-April 2009. MMWR Morb Mortal Wkly Rep 2009; 58(15): 400-2
[available from <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5815a5.htm>].
2. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team.
Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N
Engl J Med. 2009 May 7 [available from
<http://content.nejm.org/cgi/content/full/NEJMoa0903810>].
3. CDC. Outbreak of swine-origin influenza A (H1N1) virus infection -
Mexico, March - April 2009. MMWR Morb Mortal Wkly Rep 2009 Apr 30;
58(dispatch): 1-3 [available from
<http://cdc.gov/mmwr/preview/mmwrhtml/mm5817a5.htm>].
4. WHO. Situation updates - Influenza A (H1N1). Available from
<http://www.who.int/csr/disease/swineflu/updates/en/index.html>.
5. McMenamin J, Phin N, Smyth B, Couzens Z, Nguyen-Van-Tam JS. Minimum
dataset for confirmed human cases of influenza H5N1. Lancet 2008;
372(9640): 696-7.

[reported by: Health Protection Agency and Health Protection Scotland new
influenza A (H1N1) investigation teams*1,2
1. Health Protection Agency, London, United Kingdom
2. Health Protection Scotland, Glasgow, United Kingdom]

*List of contributors
Health Protection Agency: Richard Pebody, Carol Joseph, Estelle McLean,
Colin Hawkins, George Kafatos, Mike Catchpole, Jonathan Van Tam, Pauline
Kaye, Jonathan Green, Peter White, Nick Phin, Barry Evans, John Watson,
Joanna Ellis, Alison Bermingham, Angie Lackenby, Gillian Smith, Stephen
Palmer, Stephen Inglis, Isobel Oliver, Deborah Turbitt, Helen Maguire, Tim
Wreghitt, David Carrington, Malur Sudhanva, David Brown, Liz Miller, Maria
Zambon on behalf of all those in the HPA who are contributing to the
on-going investigation and management of the swine influenza incident
Health Protection Scotland: McMenamin J, Ramsay C, Blatchford O, Goldberg
D, Cowden J, Donaghy M, Eastaway A]

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

[For information on the geographic distribution of cases in the UK as of 14
May 2009, see
<http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1242285217935?p=1231252394302>
- Mod.MPP]

******
[8] News briefs
Date: Thu 14 May 2009

[Below are links to newswires with information on confirmed cases in
countries not yet included in official updates, and other events of
potential interest. The newswires are full of reports of suspected cases in
many countries. Reports have been filtered and discarded as more
information becomes available during the day. - Mod.MPP]

Americas:
Peru - 1st case confirmed, history of travel to USA
<http://www.reuters.com/article/marketsNews/idUSN1452260620090515>
USA - 4th death confirmed, (1st death in Arizona), female with history of
pulmonary disease
<http://www.google.com/hostednews/ap/article/ALeqM5jQKNFu9iBzX02vBfajrRQpO_m1bQD986CCAG0>

Europe:
Belgium - 2nd case confirmed (in French)
<http://www.lefigaro.fr/flash-actu/2009/05/14/01011-20090514FILWWW00486-2e-cas-de-grippe-a-en-belgique.php>

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

[To summarize the current situation, as of 6:00 AM GMT on 14 May 2009 there
have been a total of 6497 cases and 65 deaths of influenza A (H1N1)
infection officially reported to WHO coming from 33 countries, up from 5728
confirmed cases and 61 deaths from 30 countries yesterday (13 May 2009). As
of 17:00 GMT-4, there have been a total of 7479 cases and 69 deaths
reported worldwide, with 11 countries in the Americas reporting cases.
According to newswires, in the past 24 hours, Peru has confirmed its 1st
case of influenza A (H1N1) infection in an individual with a history of
travel to the USA prior to onset of illness, Belgium has confirmed a 2nd
case of influenza A (H1N1) (no information on epidemiologic link to other
geographic areas was available) and the USA has confirmed a 4th death due
to complications of infection with influenza A (H1N1) virus in a woman with
a history of pre-existing pulmonary disease.

The USA has officially reported 4298 laboratory confirmed cases coming from
47 states (compared with 3352 cases from 45 states on 13 May 2009), and 3
deaths (one in a Mexican child with pre-existing illness visiting in the
USA, a 2nd in a resident of Texas with known pre-existing illness and a 3rd
in Washington State with known pre-existing illness). Canada has reported
449 cases from 10 provinces with 1 death in an individual with pre-existing
illness, up from 389 cases and one death reported from 10 provinces on 13
May 2009. As of 8:40 AM GMT-5, Mexico has reported 2656 confirmed cases
with 64 deaths (compared with 2446 cases and 60 deaths on 9 May 2009).

From the Eurosurveillance reports presented in [6] and [7], both Spain and
the UK have experienced secondary transmission of the influenza A (H1N1)
virus related to importations from Mexico and the USA.

For a map of reported confirmed cases, worldwide, as of 06:00 GMT 13 May
2009, see <http://www.who.int/csr/don/h1n1_20090514_0800.jpg>. For an
interactive map of reported confirmed cases in the Americas, as of 13 May
2009 showing burden of disease by state/province, see
<http://ais.paho.org/flu/sm/en/atlas.html>. - Mod.MPP]

See Also