ProMED-mail |

Published Date: 2009-05-19 23:50:00
Subject: PRO/AH/EDR> Influenza A (H1N1) - worldwide (36): case counts, amended
Archive Number: 20090519.1882

INFLUENZA A (H1N1) - WORLDWIDE (36): CASE COUNTS, AMENDED
************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[ProMED-mail would like to apologize for the
repeat of this posting, but new information
available on a case in a new country was
inadvertently omitted from the original
posting. Please see the amended [5] news briefs section. - Mod.MPP]

[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.
Oftentimes a newswire will 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 updates (06:00 GMT)
[2] PAHO - Americas regional update (18:00 GMT-4)
[3] CDC - USA update (11:00 GMT -4); hospitalized cases
[4] Mexico - MOH update (09:00 GMT-4)
[5] News briefs

******
[1] WHO - global update
Date: 18 May 2009
Source: WHO Epidemic and Pandemic Alert and Response (EPR) [edited]
<http://www.who.int/csr/en/>

Influenza A(H1N1) - update 33 -- 19 May 2009
<http://www.who.int/csr/don/2009_05_19/en/index.html>

Summary table of cases reported to WHO 30 Apr -- 19 May 2009
------------------------------------------------------------
Country: No. cases (deaths) Apr 30 / May 1 / 2 /
3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19
Argentina: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1
/ 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Australia: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1
/ 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Austria: 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 /
1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Belgium: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 1 / 2 / 4 / 5 / 5
Brazil: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 4 / 6 / 6
/ 8 / 8 / 8 / 8 / 8 / 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) / 449(1) / 496(1) / 496(1) / 496(1) / 496(1)
Chile: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
/ 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 4
China, Hong Kong SAR, mainland: 0 / 1 / 1 / 1 / 1
/ 1 / 1 / 1 / 1 / 1 / 1 / 2 / 2 / 3 / 4 / 4 / 4 / 5 / 6 / 7
Colombia: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 /
1 / 3 / 3 / 6 / 7 / 10 / 11 / 11 / 11 / 11
Costa:Rica: 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
/ 8(1) / 8(1) / 8(1) / 8(1) / 8(1) / 8(1) / 9(1) / 9(1) / 9 (1) / 9 (1)
Cuba: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 1 / 1 / 3 / 3 / 3 / 3 / 3
Denmark: 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 /
1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Ecuador: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1
El Salvador: 0 / 0 / 0 / 0 / 2 / 2 / 2 / 2 / 2 /
2 / 2 / 4 / 4 / 4 / 4 / 4 / 4 / 4 / 4 / 6
Finland: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 2 / 2 / 2 / 2 / 2 / 2 / 2
France: 0 / 0 / 2 / 2 / 4 / 4 / 5 / 5 / 12 / 12 /
12 / 13 / 13 / 13 / 14 / 14 / 14 / 14 / 14 / 14
Germany: 3 / 4 / 6 / 8 / 8 / 9 / 9 / 10 / 11 / 11
/ 11 / 11 / 12 / 12 / 12 / 12 / 14 / 14 / 14 / 14
Guatemala: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1
/ 1 / 1 / 1 / 3 / 3 / 3 / 3 / 3 / 3 / 3
India: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
/ 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1
Ireland: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 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 / 7 / 7 / 7 / 7 / 7
Italy: 0 / 0 / 0 / 1 / 2 / 5 / 5 / 5 / 6 / 6 / 9
/ 9 / 9 / 9 / 9 / 9 / 9 / 9 / 9 / 9
Japan: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 3 / 4
/ 4 / 4 / 4 / 4 / 4 / 4 / 7 / 125 / 159
Korea, Republic of: 0 / 0 / 1 / 1 / 1 / 2 / 2 / 3
/ 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3
Malaysia: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
/ 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2 / 2 / 2
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) / 2446(60) / 2895 (66) / 2895(66) / 3103(68) / 3648(72)
Netherlands: 1 / 1 / 1 / 1 / 1 / 1 / 1 / 2 / 3 /
3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3 / 3
New Zealand: 3 / 4 / 4 / 4 / 6 / 6 / 5 / 5 / 5 /
5 / 7 / 7 / 7 / 7 / 7 / 7 / 9 / 9 / 9 / 9
Norway: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
/ 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2 / 2
Panama: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 2 / 3
/ 15 / 16 / 29 / 29 / 40 / 43 / 54 / 54 / 59
Peru: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 2
Poland: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1
/ 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Portugal: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 /
1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Spain: 13 / 13 / 13 / 40 / 54 / 57 / 73 / 81 / 88
/ 88 / 93 / 95 / 95 / 98 / 100 / 100 / 100 / 103 / 103 / 103
Sweden: 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1
/ 2 / 2 / 2 / 2 / 2 / 2 / 3 / 3 / 3
Switzerland: 1 / 1 / 1 / 1 / 1 / 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 / 2 / 2 / 2 / 2 / 2
Turkey: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 2 / 2
United Kingdom: 8 / 8 / 15 / 15 / 18 / 27 / 28 /
32 / 34 / 85 / 39 / 47 / 55 / 68 / 71 / 71 / 78 / 82 / 101 / 102
United States: 109(1) / 141(1) / 160(1) / 226(1)
/ 286(1) / 403(1) / 642(2) / 896(2) / 896(2) /
1639(2) / 2254(2) / 2532(3) / 2600(3) / 3009(3) /
3352(3) / 4298(3) / 4714(4) / 4714(4) / 4714(4) / 5123(5)

Total No. countries reporting cases: 11 / 13 / 16
/ 18 / 21 / 21 / 23 / 24 / 25 / 29 / 29 / 30 / 30
/ 33 / 33 / 34 / 36 / 39 / 40 / 40
Total cases reported: 257(8) / 367(10) / 658(17)
/ 898(20) / 1085(26) / 1490(30) / 1893(31) /
2371(44) / 2500(46) / 2440(48) / 4379(49) /
4694(53) / 5251(61) / 5728(61) / 6497(65) /
7520(65) / 8451(72) / 8480(72) / 8829(74) / 9830(79)

--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp

******
[2] PAHO - Americas regional update (18:00 GMT-4)
Date: 19 May 2009
Source: PAHO H1N1 flu website [edited]
<http://new.paho.org/hq/index.php?option=com_content&task=view&id=1394&Itemid=1167>

Up to 18 May 2009, 9723 confirmed cases of the
new virus influenza A (H1N1) infection, including
80 deaths, have been notified in 14 countries of
the Americas: Argentina, Brazil, Canada, Chile,
Colombia, Costa Rica, Cuba, Ecuador, El Salvador,
Guatemala, Mexico, Panama, Peru and the United
States. The date of the onset of symptoms of the
1st confirmed case was [28 Mar 2009] in the United States.

WHO is not recommending any travel restrictions
related to the outbreak of the influenza A(H1N1)
virus. Individuals who are ill should delay
travel plans and returning travelers who fall ill
should seek appropriate medical care. These
recommendations are prudent measures which can
limit the spread of many communicable diseases, including influenza.

As of 19 May 2009, 11:00 AM ET, 48 states of the
United States have reported a total of 5469
confirmed and probable cases and 6 deaths. The
most affected states are: Wisconsin (with 766
cases), Illinois (with 707), Texas (556 cases,
with 3 deaths), California (553 cases), Arizona
(488 cases, with 2 deaths), and Washington state (362 cases, with 1 death).

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

******
[3] CDC - USA update

a. updated case count
Date: 19 May 2009 (11:00 GMT-4)
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 -- 19 May 2009
States: Cases (deaths) Apr 30 / May 1 / 2 / 3 / 4
/ 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 18 / 19
Alabama: 0 / 0 / 0 / 1 / 4 / 4 / 4 / 4 / 4 / 4 /
4 / 4 / 9 / 9 / 41 / 55 / 61 / 61
Arkansas: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 2 / 3 / 3
Arizona: 1 / 4 / 4 / 18 / 17 / 17 / 48 / 48 / 131
/ 182 / 182 / 182 / 187 / 187 / 432 / 435(1) / 476(1) / 488(2)
California: 14 / 13 / 24 / 26 / 30 / 49 / 67 /
106 / 107 / 171 / 282 / 191 / 193 / 221 / 473 / 504 / 553 / 553
Colorado: 0 / 2 / 2 / 4 / 7 / 6 / 17 / 17 / 25 /
41 / 39 / 39 / 44 / 44 / 47 / 55 / 56 / 56
Connecticut: 0 / 0 / 1 / 2 / 2 / 2 / 4 / 4 / 4 /
14 / 24 / 24 / 28 / 33 / 38 / 47 / 53 / 56
Delaware: 0 / 4 / 4 / 10 / 20 / 20 / 33 / 38 / 39
/ 44 / 44 / 44 / 45 / 54 / 58 / 60 / 65 /69
Florida: 0 / 0 / 2 / 3 / 5 / 5 / 5 / 5 / 6 / 43 /
53 / 54 / 55 / 58 / 65 / 68 / 101 / 103
Georgia: 0 / 0 / 0 / 0 / 0 / 1 / 3 / 3 / 3 / 3 /
3 / 3 / 4 / 8 / 36 / 18 / 24 / 25
Hawaii: 0 / 0 / 0 / 0 / 0 / 0 / 3 / 3 / 5 / 6 / 6
/ 6 / 6 / 6 / 10 / 10 / 21 / 21
Idaho: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 2 / 3 / 5 / 5 / 8 / 8
Illinois: 0 / 3 / 3 / 3 / 8 / 82 / 122 / 204 /
392 / 421 / 466 / 487 / 554 / 592 / 620 / 638 / 696 / 707
Indiana: 1 / 3 / 3 / 3 / 3 / 3 / 15 / 15 / 29 /
39 / 39 / 39 / 61 / 70 / 70 / 71 / 81 / 96
Iowa: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 5 / 5 / 43 / 43
/ 43 / 55 / 55 / 58 / 66 / 66 / 71
Kansas: 2 / 2 / 2 / 2 / 2 / 2 / 2 / 7 / 12 / 12 /
36 / 18 / 22 / 23 / 28 / 30 / 34 / 34
Kentucky*: 0 / 1 / 1 / 1 / 1 / 1 / 2 / 2 / 3 / 3
/ 3 / 10 / 10 / 10 / 13 / 13 / 14 / 16
Louisiana: 0 / 0 / 0 / 0 / 7 / 7 / 7 / 7 / 7 / 9
/ 9 / 9 / 20 / 33 / 45 / 57 / 57 / 65
Maine: 0 / 0 / 0 / 0 / 0 / 4 / 1 / 4 / 4 / 4 / 4
/ 4 / 6 / 6 / 13 / 14 / 12 / 10
Maryland: 0 / 0 / 0 / 0 / 4 / 4 / 4 / 4 / 4 / 23
/ 23 / 23 / 23 / 23 / 28 / 28 / 34 / 39
Massachusetts: 2 / 2 / 6 / 7 / 6 / 6 / 45 / 71 /
83 / 89 / 88 / 88 / 107 / 107 / 109 / 135 / 143 / 156
Michigan: 2 / 2 / 2 / 2 / 2 / 2 / 8 / 9 / 49 /
103 / 114 / 130 / 133 / 134 / 141 / 142 / 158 / 165
Minnesota: 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
/ 7 / 7 / 24 / 31 / 34 / 36 / 38 / 38
Mississippi: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 0 / 0 / 3 / 4
Missouri: 0 / 0 / 1 / 1 / 1 / 1 / 2 / 4 / 9 / 10
/ 10 / 14 / 14 / 18 / 20 / 19 / 19 / 20
Montana: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 5 / 4 / 4 / 9
Nebraska: 0 / 0 / 0 / 1 / 1 / 1 / 4 / 4 / 4 / 13
/ 13 / 13 / 19 / 21 / 23 / 27 / 28 / 28
Nevada: 1 / 1 / 1 / 1 / 1 / 1 / 5 / 5 / 8 / 9 / 9
/ 9 / 12 / 21 / 25 / 26 / 30 / 31
New Hampshire: 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 3
/ 4 / 4 / 4 / 16 / 17 / 18 / 18 / 19 / 20
New Jersey: 0 / 5 / 7 / 7 / 7 / 6 / 7 / 7 / 7 / 7
/ 7 / 7 / 7 / 8 / 12 / 14 / 15 / 18
New Mexico: 0 / 0 / 0 / 1 / 1 / 1 / 3 / 8 / 8 /
30 / 30 / 30 / 30 / 44 / 51 / 68 / 68 / 68
New York: 51 / 50 / 51 / 63 / 73 / 90 / 97 / 98 /
174 / 190 / 190 / 190 / 192 / 211 / 224 / 242 / 254 / 267
North Carolina: 0 / 0 / 0 / 0 / 1 / 1 / 7 / 7 / 7
/ 7 / 7 / 11 / 11 / 12 / 12 / 12 / 12 / 12
North Dakota: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 /
0 / 0 / 0 / 0 / 0 / 1 / 2 / 3 / 3
Ohio: 1 / 1 / 1 / 3 / 3 / 3 / 5 / 5 / 6 / 12 / 6
/ 6 / 7 / 11 / 12 / 14 / 13 / 13
Oklahoma: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 11 / 4 / 4
/ 14 / 14 / 14 / 22 / 22 / 26 / 32 / 42
Oregon: 0 / 0 / 0 / 0 / 3 / 15 / 15 / 15 / 15 /
15 / 17 / 17 / 74 / 74 / 94 / 94 / 94 / 94
Pennsylvania: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 /
10 / 10 / 10 / 17 / 22 / 50 / 47 / 56 / 55
Rhode Island: 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 7 /
7 / 7 / 7 / 7 / 7 / 8 / 8 / 8 / 8
South Carolina: 0 / 16 / 13 / 15 / 15 / 16 / 16 /
17 / 29 / 42 / 32 / 32 / 32 / 32 / 34 / 36 / 36 / 36
South Dakota: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 /
1 / 1 / 1 / 3 / 3 / 5 / 4 / 4 / 4
Tennessee: 0 / 0 / 0 / 1 / 1 / 2 / 2 / 2 / 36 /
46 / 54 / 54 / 54 / 57 / 63 / 74 / 82 / 85
Texas: 16(1) / 28(1) / 28(1) / 40(1) / 41(1) /
41(1) / 61(2) / 91(2) / 93(2) / 110(2) / 108(2) /
179(2) / 206(2) / 293(2) / 439(2) / 506(2) / 556(3) / 556(3)
Utah: 0 / 0 / 0 / 1 / 1 / 3 / 1 / 8 / 24 / 60 /
63 / 63 / 67 / 72 / 80 / 91 / 91 / 91
Vermont: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1 / 1
Virginia: 0 / 2 / 2 / 3 / 3 / 3 / 3 / 11 / 14 /
16 / 16 / 16 / 17 / 17 / 20 / 21 / 21 / 23
Washington: 0 / 0 / 0 / 0 / 0 / 0 / 9 / 23 / 33 /
83 / 102(1) / 128(1) / 176(1) / 176(1) / 195(1) / 246(1) / 294(1) / 362(1)
Washington, DC: 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1
/ 4 / 4 / 4 / 7 / 9 / 10 / 12 / 13 / 13
Wisconsin: 0 / 0 / 0 / 3 / 3 / 3 / 6 / 26 / 240 /
317 / 357 / 384 / 437 / 496 / 510 / 613 / 613 / 766

Total number of states: 10 / 19 / 21 / 30 / 36 /
38 / 41 / 41 / 43 / 44 / 44 / 44 / 45 / 45 / 47 / 47 / 48 / 48
Total counts, cases (deaths): 91(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) / 4714(4) / 5123(5) / 5469(6)

*Case is resident of Kentucky but hospitalized in Georgia.

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

******
b. Hospitalized Patients
Date: 18 May 2009
Source: MMWR 18 May 2009 / 58(Early Release);1-5 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0518a1.htm?s_cid=rr58e0518a1_e>

Hospitalized Patients with Novel Influenza A
(H1N1) Virus Infection -- California, April-May, 2009
----------------
Since [15 and 17 Apr 2009], when the 1st 2 cases
of novel influenza A (H1N1) infection were
identified from 2 southern California counties,
novel influenza A (H1N1) cases have been
documented throughout the world, with most cases
occurring in the United States and Mexico (1-3).
In the United States, early reports of illnesses
associated with novel influenza A (H1N1)
infection indicated the disease might be similar
in severity to seasonal influenza, with the
majority of patients not requiring
hospitalization and only rare deaths reported,
generally in persons with underlying medical
conditions (2,3). As of [17 May 2009], 553 novel
influenza A (H1N1) cases, including 333 confirmed
and 220 probable cases, had been reported in 32
of 61 local health jurisdictions in California.
Of the 553 patients, 30 have been hospitalized.
No fatal cases associated with novel influenza A
(H1N1) infection had been reported in California.
This report summarizes the 30 hospitalized cases
as of [17 May 2009], including a detailed
description of 4 cases that illustrate the
spectrum of illness severity and underlying risk
factors. This preliminary overview indicates
that, although the majority of hospitalized
persons infected with novel influenza A (H1N1)
recovered without complications, certain patients
had severe and prolonged disease. All
hospitalized patients with novel influenza A
(H1N1) infection should be monitored carefully
and treated with antiviral therapy, including
patients who seek care greater than 48 hours after illness onset (4,5).

Summary of Hospitalized Cases
-----------------------------
Beginning on [20 Apr 2009], the California
Department of Public Health (CDPH) and local
health departments in Imperial and San Diego
counties worked with hospital infection-control
practitioners to initiate enhanced surveillance
for hospitalized cases of laboratory-confirmed or
probable novel influenza A (H1N1) infection at
all 25 hospitals in the 2 counties. Then, 3 days
later, on [23 Apr 2009], CDPH extended this
surveillance statewide. Cases are reported as
either probable (defined as detection of
influenza A by real-time reverse
transcription-polymerase chain reaction [rRT-PCR]
that is unsubtypable for human influenza virus
subtypes H1 or H3) or confirmed (defined as
positive by CDC protocol for rRT-PCR for novel
influenza A H1N1).* Approximately 96 percent of
unsubtypable California specimens subsequently
have been confirmed as novel influenza A (H1N1)
at CDC or at the CDPH Viral and Rickettsial Disease Laboratory (VRDL).

For this report, a hospitalized case was defined
as a confirmed or probable case of novel
influenza A (H1N1) infection in a patient who was
hospitalized for greater than or equal to 24
hours. Of the 30 hospitalized patients, 26 were
confirmed and 4 were probable (confirmatory
testing is in progress); symptom onset ranged
from [3 Apr 2009 to 9 May 2009]. The cases were
reported from 11 counties, most of which are
located in southern or central California. The
largest number of patients, (15 [50 percent])
resided in San Diego and Imperial counties. Of
the 26 patients for whom information on ethnicity
was available, 17 (65 percent) were Hispanic.
Ages of the 30 patients ranged from 27 days to 89
years, with a median age of 27.5 years; 21 (70
percent) were female. 4 (13 percent) patients had
traveled to Mexico in the 7 days before onset of
illness. None of the 30 patients reported
exposure to swine or a known confirmed case of
novel influenza A (H1N1) infection.

The most common admission diagnoses were
pneumonia and dehydration. 19 patients (64
percent) had underlying medical conditions; the
most common were chronic lung disease (e.g.,
asthma and chronic obstructive pulmonary
disease), conditions associated with
immunosuppression, chronic cardiac disease (e.g.,
congenital heart disease and coronary artery
disease), diabetes, and obesity. The most common
symptoms were fever, cough, vomiting, and
shortness of breath; diarrhea was uncommon. Of
the 25 patients who had chest radiographs, 15 (60
percent) had abnormalities suggestive of
pneumonia, including 10 with multilobar
infiltrates and 5 with unilobar infiltrates. 6
patients were admitted to the intensive care unit
(ICU), and 4 required mechanical ventilation. 5
patients were pregnant. 2 of these developed
complications, including spontaneous abortion and
premature rupture of the membranes; the fetuses
were at 13 and 35 weeks gestation, respectively.

Of the 24 patients tested for influenza A in the
hospital, the rapid antigen test was positive in
16 and negative in 5; 3 patients tested positive
by other methods (direct immunofluorescent
antibody [2 patients] and culture [one patient]).
None of the 30 patients had microbiologic
evidence of secondary bacterial infection by
blood, urine, or sputum cultures (or endotracheal
aspirate or bronchoalveolar lavage cultures in
the case of intubated patients). 15 (50 percent)
received antiviral treatment with oseltamivir;
for 5 patients, treatment was initiated within 48
hours of onset of symptoms. Among the 15 not
treated with antivirals, 6 sought care greater
than 48 hours after illness onset. Of the 22
patients with available history, 6 (27 percent)
had received seasonal influenza vaccination. As
of [17 May 2009], 23 patients had been discharged
to home, with a median length of hospital stay of
4 days (range: 1--10 days). Seven patients
remained in the hospital, with median lengths of
stay of 15 days (range: 4--167 days) (Tables 1
and 2) [see URL link for tables].

Case Reports
------------
Patient 3. An infant girl aged 5 months was born
prematurely at 27 weeks in early December 2008
with intrauterine growth retardation and
congenital heart disease with patent ductus
arteriosus and ventricular septal defect. The
infant had a complicated hospital course in the
neonatal ICU after birth, including development
of bronchopulmonary dysplasia and respiratory
distress syndrome requiring prolonged mechanical
ventilation and multiple courses of steroids,
several episodes of clinical sepsis and
pneumonia, and chronic anemia and
thrombocytopenia. By the 5th month, the infant
had been weaned from the ventilator and was doing
well on high-flow nasal cannula oxygen. However,
on hospital day number 150, she developed a new
nonproductive cough and fever, with a new
infiltrate of the right lung on chest radiograph
that progressed to complete opacification of both
lung fields. Multiple blood, urine, and sputum
cultures were unrevealing; rapid antigen test was
positive for influenza A, with subsequent
confirmation at the CDPH VRDL for novel influenza
A (H1). The source of the infant's infection is
still under investigation. The infant was
reintubated and started on broad spectrum
antibiotics and oseltamivir at a dose of 2 mg/kg
every 12 hours, 3 days after fever. As of [14 May
2009], the patient remained hospitalized in critical condition.

Patient 16. A previously healthy woman aged 29
years, who was 28 weeks pregnant, sought care at
an emergency department on [26 Apr 2009] with
complaints of subjective fever, productive cough,
and increasing shortness of breath during the
preceding 10 days. Upon initial evaluation, the
patient's vital signs were notable for low grade
fever (99.6 F [37.6 C]), a respiratory rate of 38
breaths per minute, blood pressure of 112/57
mmHg, heart rate of 104 beats per minute, and
oxygen saturation of 87 percent on room air. A
chest radiograph revealed bilateral perihilar
interstitial infiltrates with mediastinal
lymphadenopathy. Her complete blood count and
chemistries were normal except for an elevated
white blood cell count of 11.4 cells/mm3 with a
differential of 42 percent segmented neutrophils,
45 percent bands, and 9 percent lymphocytes. The
patient was admitted to the ICU and started on
broad spectrum antibiotics (azithromycin and
ceftriaxone). Serial fetal ultrasounds were
normal. Multiple blood, urine, and sputum
cultures were unrevealing; rapid antigen test was
positive for influenza A, with subsequent
confirmation of novel influenza A (H1N1) at the
CDPH VRDL. She was not treated with antiviral
medications. She gradually improved and was
discharged on amoxicillin after 9 days.

Patient 18. A man aged 32 years with a history of
obstructive sleep apnea sought care at an
emergency department on [5 May 2009] with a 3-day
history of fever, chills, and productive cough.
The patient reported he had been taking
amoxicillin for a diagnosis of sinusitis,
following complaints of vertigo and dizziness,
for the past 2 weeks. His vital signs showed a
temperature of 99.1 F (37.3 C), blood pressure of
89/58 mmHg, and heart rate of 84 beats per
minute. Physical exam of the chest showed good
air movement bilaterally, although chest
radiograph revealed bilateral infiltrates. His
complete blood count and chemistries were normal
except for an elevated white blood cell count of
13.8 cells/mm3 with a differential of 94 percent
segmented neutrophils and 4 percent lymphocytes.
An arterial blood gas showed respiratory acidosis
and hypoxemia with pO2 of 80 mm Hg on room air.
The patient was admitted to the ICU on empiric
broad spectrum antibiotics and required
intubation on the 2nd hospital day for worsening
hypoxemia. Initial microbiologic workup and
influenza rapid antigen tests were negative; the
patient was started on oseltamivir on hospital
day 2. A repeat rapid antigen test and
bronchoalveolar lavage viral culture were
positive for influenza A, with subsequent
confirmation of novel influenza A (H1N1). The
patient improved, was extubated on hospital day
5, and was discharged on hospital day 10.

Patient 29. A woman aged 87 years with multiple
medical problems, including recently diagnosed
breast cancer with possible abdominal metastasis,
hypertension, diabetes mellitus, coronary artery
disease, cerebrovascular disease, chronic renal
insufficiency, and obesity, was brought for care
at an emergency department on [21 Apr 2009] after
being found unconscious by her daughter. The
patient had reported onset of fever, cough, and
weakness 2 days before admission and also new
onset of orthopnea and bilateral leg swelling.
She was wheelchair bound and had no recent
history of travel or known contact with ill
persons. In the emergency room the patient was
afebrile, with a blood pressure of 57/39 mmHg,
pulse 57, respiratory rate of 14 breaths per
minute, and oxygen saturation of 87 percent on
room air. Electrocardiogram was suggestive of non
Q-wave myocardial infarction. Chest radiograph
showed bilateral pneumonia and congestive heart
failure with marked cardiomegaly. Her laboratory
abnormalities included an elevated white blood
cell count of 13.4 cells/mm3, mild anemia with a
hematocrit of 34 percent, a mildly elevated
creatinine at 1.8 mg/dL, alanine aminotransferase
of 36 units/L and aspartate aminotransferase of
160 units/L, and markedly elevated troponin and
creatinine kinase levels of 29.43 ng/mL and 653
IU/L, respectively. The patient went into
respiratory arrest and was subsequently intubated
and started on low dose dopamine, and admitted to
the ICU with a diagnosis of myocardial
infarction, congestive heart failure, pneumonia
and presumed sepsis. A chest computed tomography
(CT) scan showed complete atelectasis of the
right middle lobe, bilateral ground glass
opacities of the upper lobes, and bilateral
pleural effusions. A subsequent bronchoscopy
identified a large cauliflower-shaped mass in the
right lower lobe airway. Multiple blood, urine,
and sputum cultures were unrevealing; rapid
antigen test was positive for influenza A, with
subsequent confirmation of novel influenza A
(H1N1) at the CDPH VRDL. The patient remains
hospitalized in critical condition under intensive care.

Reported by: J Louie, MD, K Winter, MPH, K
Harriman, PhD, D Vugia, MD, C Glaser, MD, B
Matyas, MD, D Schnurr, PhD, H Guevara, MS, CY
Pan, E Saguar, R Berumen, E Hunley, S Messenger,
PhD, C Preas, D Hatch, MD, G Chavez, MD,
California Dept of Public Health. P Kriner, MPH,
K Lopez, MD, Imperial County Public Health Dept;
D Sunega, D Rexin, San Diego County Health and
Human Svcs; Los Angeles County Swine Flu
Surveillance Team, Los Angeles County Dept of
Public Health; S Roach, J Kempf, Tulare County
Health and Human Svcs Agency; R Gonzalez, L
Morgan, MPH, San Bernardino County Dept of Public
Health, California. N Barnes, MS, L Berman, MS, S
Emery, MPH, B Shu, MD, KH Wu, PhD, J Villanueva,
PhD, S Lindstrom, PhD, Influenza Div; D Sugarman,
MD, M Patel, MD, J Jaeger, MD, E Meites, MD, N Dharan, MD, EIS officers, CDC.

MMWR Editorial Note:
--------------------
Initial surveillance for hospitalized cases of
novel influenza A (H1N1) infection in California
indicates that the majority of patients were
discharged after short hospital stays. Previously
healthy patients without underlying chronic
medical conditions recovered with an
uncomplicated hospital course and a median length
of stay of 2.5 days (range: 1--7 days). Although
one 3rd of hospitalized patients had abnormal
chest radiographs with multilobar infiltrates,
only 9 percent were treated with oseltamivir;
nonetheless, most had favorable outcomes. Of 5
pregnant women, 2 developed serious sequelae;
however, the role that preceding infection with
novel influenza A (H1N1) played in these outcomes is unclear.

Certain hospitalized patients in California
experienced severe disease and prolonged hospital
courses. Of note, 3 of the 6 California patients
admitted to an ICU continue to require prolonged
intensive care. Extremes in age and multiple and
debilitating underlying medical conditions might
be contributing to the severity of illness in
these patients. Although chronic underlying
medical conditions and pregnancy classically are
associated with a greater risk for complications
for seasonal influenza (6), one patient (patient
18) who was relatively healthy with only mild
chronic pulmonary disease required intensive care
and mechanical ventilation. More data are needed
regarding which populations are at greatest risk
for hospitalization and severe sequelae after
infection with novel influenza A (H1N1).

As of [15 May 2009], 9 percent of approximately
11 600 clinical specimens submitted for testing
to California public health laboratories since
[27 Apr 2009], were positive by rRT-PCR for
influenza A; of those, 23 percent and 28 percent
were subtyped as seasonal influenza A/H1 and
A/H3, respectively. These results indicate that
seasonal influenza viruses continue to circulate
throughout California and might be a cause of
influenza-like illness and positive results from
rapid antigen tests. Although rapid antigen test
results were positive in 67 percent of tested
cases in this series, anecdotal reports from
other cases confirmed at CDPH VRDL, tested mostly
in the outpatient setting, suggest that false
positive and negative results are common.
Accordingly, CDPH has emphasized the importance
of testing influenza viruses in the state with
rRT-PCR. CDPH also has advised clinicians in
California to collect respiratory specimens for
rRT-PCR testing, subtyping, and further
characterization at public health laboratories
from patients who are hospitalized or who die with febrile respiratory illness.

Additional information regarding California
testing guidelines is available at
<http://ww2.cdph.ca.gov/programs/vrdl/pages/diagnostictestingforswineinfluenzaA(H1).aspx>.
Additional information regarding novel influenza
A (H1N1) treatment guidance and other CDC
recommendations is available at <http://www.cdc.gov/h1n1flu/guidance>.

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/mm5815a5.htm>
2. Dawood FS, Jain S, Finelli L, et al. Emergence
of a novel swine-origin influenza A (H1N1) virus
in humans. N Engl J Med 2009;361[online].
Available at <http://content.NEJM.org/cgi/content/full/nejmoa0903810>.
3. CDC. Outbreak of swine-origin influenza A
(H1N1) virus infection---Mexico, March--April
2009. MMWR 2009;58:467--70. [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5817a5.htm>]
4. CDC. Novel influenza A (H1N1) virus infections
in three pregnant women---United States,
April--May 2009. MMWR 2009;58:497--500.
[available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5818a3.htm>]
5. McGeer A, Green KA, Plevneshi A, et al;
Toronto Invasive Bacterial Diseases Network.
Antiviral therapy and outcomes of influenza
requiring hospitalization in Ontario, Canada.
Clin Infect Dis 2007;45:1568--75. [full article
available at: <http://www.journals.uchicago.edu/doi/pdf/10.1086/523584>
6. CDC. Prevention and control of influenza:
recommendations of the Advisory Committee on
Immunization Practices (ACIP), 2008. MMWR
2008;57(No. RR-7). [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm>]

* Additional information available at
<http://www.who.int/csr/resources/publications/swineflu/realtimeptpcr/en/index.html>.

Additional information available at
<http://ww2.cdph.ca.gov/programs/vrdl/pages/enhancedsurveillanceforinfluenzaa(h1).aspx>.

Table 1. Case characteristics for 30 hospitalized
patients with novel influenza A (H1N1) ---
California, April 15, 2009--May 17, 2009
[available at MMWR article
URL
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0518a1.htm?s_cid=rr58e0518a1_e>]

Table 2. Detailed clinical characteristics for 30
hospitalized patients with novel influenza A
(H1N1) --- California, April 15, 2009--May 17,
2009 [available at MMWR article
URL
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58e0518a1.htm?s_cid=rr58e0518a1_e>]

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

******
[4] Mexico - MOH update 09:00 GMT-4
Date: 15 May 2009
Source: Secretaria de Salud website (MOH) [Trans. by Mod.MPP, edited]
<http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html>

Case counts: 29 Apr 2009 / May 1 / 2 / 3 / 4 / 5
/ 6 / 7 / 8 / 9 / 11 / 12 / 13 / 14 / 15 / 19
Number of confirmed cases: 99 / 397 / 443 / 506 /
727 / 866 / 1112 / 1204 / 1364 / 1626 / 2059 / 2282 / 2446 / 2656 / 2895 / 3648
Number of deaths: 8 / 16 / 16 / 19 / 26 / 26 / 42
/ 44 / 45 / 48 / 56 / 58 / 60 / 64 / 66 / 72

******
Bulletin 19 May 2009 [edited]
<http://portal.salud.gob.mx/redirector?tipo=0&n_seccion=Boletines&seccion=2009-05-19_3980.html>

Mexico urges G-7 to eliminate restrictions on countries affected by influenza
--------------------
- In Mexico, the evolution of the epidemic indicates a downward trend.
- Up through last night [18 May 2009] there were
3734 confirmed cases [of influenza A(H1N1) infection] of which 74 died

The Head of the Mexican Ministry of Health said
more than trade restrictions, there must be
solidarity in a global pandemic alert as
currently lives, as an example for any similar scenario in the future.

In Mexico, the evolution of the epidemic up
through yesterday [18 May 2009] shows a
continuing downward trend. This is a disease that
if treated early is usually curable. It is worth
mentioning that the onset of symptoms most of the
deaths occurred before [23 Apr 2009] when we
still did not know what virus we were treating.

At this stage we are implementing targeted
actions in the regions and localities with outbreaks of new cases.

Up through yesterday night [18 May 2009] we had
3734 confirmed cases. New cases continue at a lower rate.

There are now 74 confirmed deaths, only 7 of them
with onset of symptoms after [23 Apr 2009]. 31
states have reported cases, with the highest
number reported in the Federal District, followed
by San Luis Potosi, Hidalgo, Estado de Mexico and Veracruz.

Oseltamivir has been distributed to all states
according to their needs and we still have sufficient reserves.

The country with the largest number of confirmed
cases is the United States with 5123 cases (over
50 percent of the world total).

The Ministry of Health recommends:
- Continue to wash hands frequently
- Sneezing etiquette
- Seek medical advice for any symptoms
- Avoid hand shakes and greeting kisses
- In sites of uncontrolled crowds, such as public
transportation, maintain the use of face masks.
- Continue with school closures until further notice
--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[For a detailed update on the epidemiologic
situation of the outbreak in Mexico as of 19 May 2009, see
<http://portal.salud.gob.mx/descargas/pdf/influenza/situacion_actual_epidemia_190509.pdf>.
The report contains graphs and charts detailing
the epidemic curve, variables related to age
specific morbidity and mortality, geographic
distribution, clinical presentation of fatal cases.

Updated age distribution of cases and case
fatality rates (CFRs) (as of 19 May 2009)
age group (years): no. cases / no. deaths / case fatality rate (percent)
0-9 : 1046 / 6 / 0.6
10-19: 943 / 4 / 0.4
20-29: 754 / 21 / 2.8
30-39: 413 / 17 / 4.1
40-49: 306 / 12 / 3.9
50-59: 183 / 10 / 5.5
60 and over: 68 / 4 / 5.9
not available: 21 / 0 / --
Totals: 3734 / 74 / 2.0

The over all case fatality rate continues to
fall, from earlier reports. On 6 May 2009 the
overall reported CFR was 3.8, with age specific
CFRs of 0-9 years: 0.5; 10-19 years: 0.5; 20-29
years: 38.1; 30-39 years: 21.4; 40-49 years:
11.9; 50-59 years: 9.5, 60-69 years: 9.5 and 70 and older: 0. - Mod.MPP]

******
[5] News brief
Date: 19 May 2009

[Below are links to newswires with information on
confirmed cases in countries not included in
official updates from 19 May 2009, 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:
USA - additional deaths confirmed:
Missouri - 44 year old male
<http://www.columbiamissourian.com/stories/2009/05/19/st-louis-county-man-swine-flu-dies/>

Asia:
Taiwan - 1st confirmed case, history of travel to
USA (NY), detected through airport fever
screening
<http://www.cdc.gov.tw/ct.asp?xItem=23662&ctNode=220&mp=1>
[in Chinese, trans. by Rapp. AH]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

[To summarize the current situation, as of 6:00
AM GMT on 19 May 2009 there have been a total of
9830 cases and 79 deaths of influenza A (H1N1)
infection officially reported to WHO coming from
40 countries, up from 8829 confirmed cases and 74
deaths from 40 countries yesterday (18 May 2009).
There are no new countries confirming cases to
WHO in the past 24 hours. According to newswires,
there has been another death attributable to
infection with influenza A (H1N1) in a 44 year
old male in the state of Missouri in the USA, and
there is the 1st case identified in Taiwan in an
individual travelling to Taiwan from New York in
the USA. The case in Taiwan was detected through airport fever screening.

The USA has officially reported 5469 laboratory
confirmed cases coming from 48 states (compared
with 5123 cases from 48 states on 18 May 2009),
and 6 deaths. A review of 30 hospitalized cases
in the state of California revealed the majority
(64 percent) had underlying medical conditions
known to be high risk for severe disease with
influenza. Further review of hospitalized cases
include another 10 percent otherwise healthy less
than 2 years of age, also felt to be at higher
risk of serious disease with influenza virus.

Age specific case fatality rates are dropping in
Mexico as more cases are identified and fewer deaths are identified.

For a map of reported confirmed cases, worldwide,
as of 06:00 GMT 19 May 2009, see
<http://www.who.int/csr/don/h1n1_20090519_0600.jpg> - Mod.MPP]

See Also