|
INFLUENZA A (H1N1) - WORLDWIDE (63): CASE COUNT, PANDEMIC
***********************************************
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. 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. As the number of reports has increased
markedly, the format of the tables will provide the cumulative number
of cases reported by each country by the weeks ending on Fridays (1
May 2009, 8 May 2009, 15 May 2009, 22 May 2009, 29 May 2009, 6 Jun
2009) and then for day of report in the current week of reporting.
The daily summaries for prior dates can be found in all "case count"
postings ending with Influenza A (H1N1) - worldwide (40): case counts
20090521.1906. - Mod.MPP]
In this update:
[1] Worldwide update - WHO 06:00 GMT+2
[2] Americas update - PAHO 16:00 GMT-4
[3] WHO declares Phase 6 Pandemic
[4] EU+3 review
[5] News briefs
******
[1] Worldwide - WHO 14:00 GMT+2
Date: 11 Jun 2009
Source: WHO [edited]
<http://www.who.int/csr/don/2009_06_11/en/index.html>
Influenza A(H1N1) - update 47; 11 Jun 2009
-----------------------------------------
As of 14:00 GMT, 11 Jun 2009, 74 countries have officially reported
28 774 cases of influenza A(H1N1) infection, including 144 deaths.
Map of the spread of influenza A(H1N1): number of laboratory
confirmed cases and deaths:
<http://www.who.int/csr/don/GlobalSubnationalMasterGradSym_20090611_1600.png>.
As of 6:00 GMT, 10 Jun 2009 Laboratory-confirmed cases of new
influenza A(H1N1) as officially reported to WHO by States Parties to
the International Health Regulations (2005)
Summary table of cumulative cases reported to WHO as of 1 May 2009-10 Jun 2009
---------------------------------------------
Country: No. cases (deaths) May 1 / 8 / 15 / 22 / 29 / Jun 5 / 10 /
11 // Newly confirmed since the last reporting period (10 Jun)
Argentina: 0 / 0 / 1 / 1 / 37/ 147 / 235 / 256 // 21
Australia: 0 / 0 / 1 / 7 / 147 / 876 / 1224 / 1307 // 83
Austria: 1 / 1 / 1 / 1 / 1 / 2 / 5 / 7 // 2
Bahamas: 0 / 0 / 0 / 0 / 0 / 1 / 2 / 1 // 0
Bahrain: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 1 // 0
Barbados: 0 / 0 / 0 / 0 / 0 / 1 / 2 / 3 // 1
Belgium: 0 / 0 / 1 / 5 / 8 / 13 / 14 / 14 // 0
Bolivia: 0 / 0 / 0 / 0 / 0 / 3 / 3 / 5 // 2
Brazil: 0 / 4 / 8 / 8 / 10 / 28 / 36 / 40 // 4
Bulgaria: 0 / 0 / 0 / 0 / 0 / 1 / 2 / 2 // 0
Canada: 34 / 214 / 449(1) / 719(1) / 1118(2) / 1795(3) / 2446(4)/ 2446(4) // 0
Cayman Islands, UKOT: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 2 // 1
Chile: 0 / 0 / 0 / 24 / 165 / 369(1) / 1694(2) / 1694(2) // 1283(1)
China, Hong Kong SAR, mainland: 0 / 1 / 1 / 11 / 30 / 89 / 142 / 174 // 32
Colombia: 0 / 1 / 10 / 12 / 17 / 24 / 35 / 35(1) // 0(1)
Costa Rica: 0 / 1 / 8(1) / 9(1) / 20(1) / 33(1) / 68(1) / 93(1) / 104(1) // 11
Cuba: 0 / 0 / 3 / 4 / 4 / 4 / 5 / 5 // 0
Cyprus: 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 // 0
Czech Republic: 0 / 0 / 0 / 0 / 1 / 2 / 2 / 4 // 2
Denmark: 1 / 1 / 1 / 1 / 1 / 4 / 8 / 10 // 2
Dominica: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 // 0
Dominican Republic: 0 / 0 / 0 / 0 / 2 / 33 / 91 (1) / 91(1) // 0
Ecuador: 0 / 0 / 0 / 8 / 2 / 43 / 60 / 67 // 7
Egypt: 0 / 0 / 0 / 0 / 0 / 1 / 8 / 10 // 2
El Salvador: 0 / 2 / 4 / 6 / 11 / 49 / 69 / 69 // 0
Estonia: 0 / 0 / 0 / 0 / 0 / 3 / 4 / 4 // 0
Finland: 0 / 0 / 2 / 2 / 3 / 4 / 4 / 4 // 0
France: 0 / 12 / 16 / 16 / 21 / 47 / 71/ 73 // 2
Germany: 4 / 11 / 12 / 14 / 19/ 43 / 78 / 95 // 17
Greece: 0 / 0 / 0 / 1 / 3 / 5 / 5 / 7 // 2
Guatemala: 0 / 1 / 3 / 4 / 5 / 23 / 60 / 60 // 0
Honduras: 0 / 0 / 0 / 0 / 1 / 34 / 89 / 89 // 0
Hungary: 0 / 0 / 0 / 0 / 0 / 3 / 3 / 4 // 1
Iceland: 0 / 0 / 0 / 0 / 1 / 1 / 2 / 3 // 1
India: 0 / 0 / 0 / 1 / 1 / 4 / 4 / 9 // 5
Ireland: 0 / 1 / 1 / 1 / 3 / 8 / 12 / 12 // 1
Israel: 2 / 7 / 7 / 7 / 11 / 39 / 63 / 68 // 5
Italy: 0 / 6 / 9 / 10 / 26 / 38 / 50 / 54 // 4
Jamaica: 0 / 0 / 0 / 0 / 0 / 2 / 7 / 10 // 3
Japan: 0 / 0 / 4 / 294 / 364 / 410 / 485 / 518 // 33
Korea, Republic of : 0 / 3 / 3 / 3 / 33 / 41 / 48 / 53 // 5
Kuwait: 0 / 0 / 0 / 0 / 18 / 18 / 18 / 18 // 0
Lebanon: 0 / 0 / 0 / 0 / 0 / 3 / 8 / 8 // 0
Luxembourg: 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 // 0
Malaysia: 0 / 0 / 0 / 2 / 2 / 2 / 5 / 5 // 0
Mexico: 156(9) / 1204(44) / 2446(60) / 3892(75) / 4910(85) /
5563(103) / 5717 (106) / 6241(108)// 524(2)
Netherlands: 1 / 3 / 3 / 3 / 3 / 4 / 22 / 30 // 8
New Zealand: 4 / 5 / 7 / 9 / 9 / 11 / 23 / 23 // 0
Nicaragua: 0 / 0 / 0 / 0 / 0 / 5 / 29 / 45 // 16
Norway: 0 / 0 / 2 / 3 / 4 / 9 / 9 / 13 // 4
Panama: 0 / 0 / 40 / 73 / 107 / 173 / 221 / 221 // 0
Paraguay: 0 / 0 / 0 / 0 / 0 / 5 / 16 / 25 // 9
Peru: 0 / 0 / 0 / 5 / 31 / 47 / 64 / 64 // 0
Philippines: 0 / 0 / 0 / 1 / 6 / 29 / 54 / 77 // 23
Poland: 0 / 1 / 1 / 2 / 4 / 4 / 6 / 7 // 1
Portugal: 0 / 1 / 1 / 1 / 1 / 2 / 2 / 2 // 0
Romania: 0 / 0 / 0 / 0 / 3 / 8 / 9 / 11 // 2
Russia: 0 / 0 / 0 / 0 / 2 / 3 / 3 / 3 // 0
Saudi Arabia: 0 / 0 / 0 / 0 / 0 / 1 / 1 / 1 // 0
Singapore: 0 / 0 / 0 / 0 / 4 / 12 / 18 / 18 // 0
Slovakia: 0 / 0 / 0 / 0 / 1 / 3 / 3 / 3 // 0
Spain: 13 / 88 / 100 / 113 / 143 / 218 / 331 / 357 // 26
Sweden: 0 / 1 / 2 / 3 / 4 / 13 / 16 / 19 // 3
Switzerland: 1 / 1 / 1 / 1 / 4 / 10 / 16 / 20 // 4
Thailand: 0 / 0 / 2 / 2 / 2 / 8 / 8 / 8 // 0
Trinidad and Tobago: 0 / 0 / 0 / 0 / 0 / 0 / 2 / 2 // 0
Turkey: 0 / 0 / 0 / 2 / 2 / 8 / 10 / 10 // 0
Ukraine: 0 / 0 / 0 / 0 / 0 / 0 / 1 / 1 // 0
United Arab Emirates: 0 / 0 / 0 / 0 / 0 / 0 1 / 1 // 0
United Kingdom: 8 / 34 / 71 / 112 / 203 / 428 / 666 / 822 // 156
United States of America: 141(1) / 896(2) / 4298(3) / 5764(9) /
7927(11) / 11 054(17) / 13 217 (27) / 13 217 // 0
Uruguay: 0 / 0 / 0 / 0 / 2 / 15 / 24 / 24 // 0
Venezuela: 0 / 0 / 0 / 0 / 0 / 4 / 12 / 13 // 1
Viet Nam: 0 / 0 / 0 / 0 / 0 / 3 / 15 / 16 // 1
Total No. countries reporting cases: 13 / 25 / 34 / 42 / 53 / 69 / 74 / 74 // 0
Total cases reported: 367(10) / 2500(46) / 7520(65) / 11 168(86) / 15
510(99) / 27 737(141) / 28 774(144) // 1037(3)
Chinese Taipei has reported 36 confirmed cases of influenza A (H1N1)
with 0 deaths. Cases from Chinese Taipei are included in the
cumulative totals provided in the table above.
--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
******
[2] PAHO Regional Report 16:00 GMT-4
Date: 10 Jun 2009
Source: PAHO [edited]
<http://new.paho.org/hq/index.php?option=com_content&task=view&id=1493&Itemid=1167>
As of 10 Jun 2009, 24 826 confirmed cases of the new virus influenza
A (H1N1) infection, including 144 deaths, have been notified in 26
countries of the Americas: Argentina [256], Bahamas [1], Barbados
[3], Bolivia [3], Brazil [40], Canada [2446(4)], Chile [1694(2)],
Colombia [35(1)], Costa Rica [104(1)], Cuba [5], Dominica [1],
Dominican Republic [91(1)], Ecuador [67], El Salvador [69], Guatemala
[60], Honduras [89], Jamaica [10], Mexico [6241(108)], Nicaragua
[45], Paraguay [25], Panama [221], Peru [64], United States [13
217(27)], Trinidad and Tobago [2], Uruguay [24] and Venezuela [13].
WHO is not recommending any travel restrictions related to the
outbreak of the influenza A (H1N1) virus.
In the Americas region, there were 1399 additional confirmed cases
compared to the previous day. Colombia notified its 1st death caused
by the new influenza A (H1N1) virus.
--
Communicated by:
ProMED-mail Rapporteur Marianne Hopp
[The full report is available for download at the above given URL and
contains the case count by country as well as a map showing the
number of confirmed cases by 1st sub-national level (state/province) - Mod.MPP]
******
[3] WHO declares Phase 6 Pandemic
Date: 11 Jun 2009
Source: Press statement by WHO Director-General Dr Margaret Chan [edited]
<http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html>
World now at the start of 2009 influenza pandemic - Dr Margaret Chan
Director-General of the World Health Organization
--------------------------------------
Ladies and gentlemen,
In late April [2009], WHO announced the emergence of a novel influenza A virus.
This particular H1N1 strain has not circulated previously in humans.
The virus is entirely new.
The virus is contagious, spreading easily from one person to another,
and from one country to another. As of today [11 Jun 2009], nearly 30
000 confirmed cases have been reported in 74 countries.
This is only part of the picture. With few exceptions, countries with
large numbers of cases are those with good surveillance and testing
procedures in place.
Spread in several countries can no longer be traced to
clearly-defined chains of human-to-human transmission. Further spread
is considered inevitable.
I have conferred with leading influenza experts, virologists, and
public health officials. In line with procedures set out in the
International Health Regulations, I have sought guidance and advice
from an Emergency Committee established for this purpose.
On the basis of available evidence, and these expert assessments of
the evidence, the scientific criteria for an influenza pandemic have been met.
I have, therefore, decided to raise the level of influenza pandemic
alert from phase 5 to phase 6.
The world is now at the start of the 2009 influenza pandemic.
We are in the earliest days of the pandemic. The virus is spreading
under a close and careful watch.
No previous pandemic has been detected so early or watched so
closely, in real-time, right at the very beginning. The world can now
reap the benefits of investments, over the last 5 years, in pandemic
preparedness.
We have a head start. This places us in a strong position. But it
also creates a demand for advice and reassurance in the midst of
limited data and considerable scientific uncertainty.
Thanks to close monitoring, thorough investigations, and frank
reporting from countries, we have some early snapshots depicting
spread of the virus and the range of illness it can cause.
We know, too, that this early, patchy picture can change very
quickly. The virus writes the rules, and this one, like all influenza
viruses, can change the rules, without rhyme or reason, at any time.
Globally, we have good reason to believe that this pandemic, at least
in its early days, will be of moderate severity. As we know from
experience, severity can vary, depending on many factors, from one
country to another.
On present evidence, the overwhelming majority of patients experience
mild symptoms and make a rapid and full recovery, often in the
absence of any form of medical treatment.
Worldwide, the number of deaths is small. Each and every one of these
deaths is tragic, and we have to brace ourselves to see more.
However, we do not expect to see a sudden and dramatic jump in the
number of severe or fatal infections.
We know that the novel H1N1 virus preferentially infects younger
people. In nearly all areas with large and sustained outbreaks, the
majority of cases have occurred in people under the age of 25 years.
In some of these countries, around 2 percent of cases have developed
severe illness, often with very rapid progression to life-threatening
pneumonia.
Most cases of severe and fatal infections have been in adults between
the ages of 30 and 50 years.
This pattern is significantly different from that seen during
epidemics of seasonal influenza, when most deaths occur in frail,
elderly people.
Many, though not all, severe cases have occurred in people with
underlying chronic conditions. Based on limited, preliminary data,
conditions most frequently seen include respiratory diseases, notably
asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity.
At the same time, it is important to note that around 1/3rd to half
of the severe and fatal infections are occurring in previously
healthy young and middle-aged people.
Without question, pregnant women are at increased risk of
complications. This heightened risk takes on added importance for a
virus, like this one, that preferentially infects younger age groups.
Finally, and perhaps of greatest concern, we do not know how this
virus will behave under conditions typically found in the developing
world. To date, the vast majority of cases have been detected and
investigated in comparatively well-off countries.
Let me underscore 2 of many reasons for this concern. 1st, more than
99 percent of maternal deaths, which are a marker of poor quality
care during pregnancy and childbirth, occur in the developing world.
2nd, around 85 percent of the burden of chronic diseases is
concentrated in low- and middle-income countries.
Although the pandemic appears to have moderate severity in
comparatively well-off countries, it is prudent to anticipate a
bleaker picture as the virus spreads to areas with limited resources,
poor health care, and a high prevalence of underlying medical problems.
A characteristic feature of pandemics is their rapid spread to all
parts of the world. In the previous century, this spread has
typically taken around 6 to 9 months, even during times when most
international travel was by ship or rail.
Countries should prepare to see cases, or the further spread of
cases, in the near future. Countries where outbreaks appear to have
peaked should prepare for a 2nd wave of infection.
Guidance on specific protective and precautionary measures has been
sent to ministries of health in all countries. Countries with no or
only a few cases should remain vigilant.
Countries with widespread transmission should focus on the
appropriate management of patients. The testing and investigation of
patients should be limited, as such measures are resource intensive
and can very quickly strain capacities.
WHO has been in close dialogue with influenza vaccine manufacturers.
I understand that production of vaccines for seasonal influenza will
be completed soon and that full capacity will be available to ensure
the largest possible supply of pandemic vaccine in the months to come.
Pending the availability of vaccines, several non-pharmaceutical
interventions can confer some protection.
WHO continues to recommend no restrictions on travel and no border closures.
Influenza pandemics, whether moderate or severe, are remarkable
events because of the almost universal susceptibility of the world's
population to infection.
We are all in this together, and we will all get through this, together.
Thank you.
--
Communicated by:
ProMED-mail <promed@promedmail.org>
******
[4] EU+3 review
Date: 11 Jun 2009
Source: Eurosurveillance 2009: Volume 14/ Issue 23 Article 1 [edited]
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19238>
Preliminary analysis of influenza A(H1N1)v individual and aggregated
case reports from EU and EFTA countries
--------------------
Since the 1st importation of influenza A(H1N1)v virus to Europe in
late April of this year [2009], surveillance data have been collected
in the Member States of the European Union and European Free Trade
Association. This is the 1st preliminary analysis of aggregated and
individual data available as of [8 Jun 2009] at the European level.
Introduction
On [21 Apr 2009], the United States Centers for Disease Control and
Prevention (US CDC) reported 2 cases of influenza due to a new virus
strain of mixed swine, avian and human origin, the so-called new
influenza A(H1N1) virus (hereafter named A(H1N1)v virus) [1]. On [25
Apr 2009], the European Centre for Disease Prevention and Control
(ECDC) published a risk assessment, started developing tools to
monitor the situation and support the countries of the European Union
(EU) and European Free Trade Association (EFTA), and initiated its
1st situation report distributed daily to more than 700 stakeholders
since then. After the World Health Organisation (WHO) raised its
pandemic alert level to phase 4 on [27 Apr 2009] and up-scaled again
to phase 5 on [29 Apr 2009], ECDC was monitoring the situation around
the clock and provided epidemiological updates on global case numbers
3 times a day. Subsequently, the European Commission published a case
definition for surveillance of the new d!
isease [2], ECDC published information for travellers, updated its
risk assessment on [8 May 2009], published several documents on case
and contact management, and coordinated the surveillance of influenza
A(H1N1)v at EU level.
The objective of this paper is to present the epidemiological
situation in the 27 EU and the 3 countries in the European Economic
Area (EEA) and EFTA, Iceland, Liechtenstein and Norway, hereafter
called the EU +3 countries, on the basis of the surveillance data
provided by the EU+3 countries through individual and aggregated case reports.
Methods
Data used in this analysis of the epidemiological situation in the
EU+3 countries, as of Monday [8 Jun 2009], 08:00 CEST, include
individual case reports posted by countries in the Early Warning and
Response System (EWRS) and aggregated case reports provided daily
through the EWRS or through other official communication channels.
Confirmed cases are defined as persons in whom the infection has been
confirmed by RT-PCR, or by viral culture or by a 4-fold rise in
influenza A(H1N1)v-specific neutralising antibodies. The latter
implies, according to the EU case definition, the need for paired
sera from the acute phase of illness and from the convalescent stage
10-14 days later [2].
While countries with fewer cases are uploading data on their cases
directly into the surveillance database at ECDC, Spain and the United
Kingdom (UK), who both have high number of cases, and Belgium are
providing extracts from their own national databases, which are then
entered into the ECDC database. Re-coding of some of the variables
was necessary for Spain and the UK, and data were subsequently
validated by the countries. The data from Belgium were imported
manually after re-coding the variables.
Cases which are not explicitly reported as having been exposed during
travel in an affected country (imported cases) are considered to have
been infected in their own country.
Results
As of [8 Jun 2009], 1128 laboratory-confirmed cases of influenza
A(H1N1)v have been reported from 25 of the EU+3 countries through
aggregated case reports. Spain (26 percent) and the UK (49 percent)
together account for 75 percent of confirmed cases. Of those 1128
cases, 498 (44 percent) were also reported through individual case
reports (Table 1). Latvia, Liechtenstein, Lithuania, Malta and
Slovenia have not reported confirmed cases so far.
Table 1. Distribution of confirmed cases of influenza A(H1N1)v
reported until [8 Jun 2009] by source of information, EU+3 countries
(n=1128) [available at above given URL link - Mod.MPP].
Epidemic curves
The 1st confirmed case in EU+3 countries was a traveler returning
from Mexico to the UK. He was identified on [27 Apr 2009] and
reported onset of symptoms on [16 Apr 2009]. Figure 1 [available at
above given URL link] compares the distribution of cases by date of
onset from the individual case reports (n=498) with the distribution
of cases by reporting date from the aggregated case reports (n=1024).
It shows a delay of one week between date of onset and date of
reporting in the 1st weeks of the outbreak, up to [20 May 2009],
followed by an increasing discrepancy in the number of cases reported
by the 2 systems.
Figure 1. Distribution of confirmed cases of A(H1N1)v infections by
date of onset (n=498) and date of reporting(n=1,024), as of 5 June
2009, EU+3 countries [available at above given URL link].
Figure 2 shows the distribution of imported and domestic cases in
EU+3 countries by date of onset. The 1st case reported as in-country
transmission had onset of symptoms 5 days after the 1st imported
case. During the 1st 2-week period, 65 percent of cases were reported
to have been imported, compared to 40 percent during the 2nd and 73
percent during the 3rd 2-week period. The majority of imported cases
in the 1st 2-week period were imported from Mexico and in the 3rd
2-week period from the United States (US).
Figure 2. Distribution of confirmed cases of influenza A(H1N1)v
infections by date of onset and type of transmission, as of 31 May
2009*, EU+3 countries (n=457) [available at above given URL link].
Demographic characteristics of cases
The male to female ratio was 1.1. The median age was 23 years (range:
8 months to 73 years). Seven cases were younger than 2 years. Of 494
cases with known age, 168 (34 percent) were under the age of 20
years. The most affected age group was the group of 20-29 year-olds
and accounted for 37 percent of cases.
The proportion of imported cases older than 20 years (78 percent) was
significantly higher than the proportion of over 20 year-old cases
who were infected in their own country (27 percent, p less than
0.0001). The median age of imported cases was 25 years compared to 13
years for non-imported cases (Figure 3).
Figure 3. Distribution of cases of influenza A(H1N1)v infection by
age group and type of transmission, as of [8 Jun 2009], EU+3
countries (n=493) [available at above given URL link].
Symptoms
In the analysis of symptoms, the data from Spain and Belgium were
excluded due to recoding issues, leaving 371 cases for analysis.
Asymptomatic cases constituted 8 percent of reported cases (28/371)
and were more common among cases under the age of 20 years (11
percent) when compared with older cases (5 percent, p=0.02).
The most commonly reported symptoms were respiratory symptoms (79
percent), followed by fever or history of fever (78 percent).
Gastro-intestinal symptoms were reported from 86 cases (23 percent).
Presence of gastro-intestinal symptoms was not significantly
associated with travel exposure but was significantly more common
among cases under the age of 20 years (32 percent) than among older
cases (18 percent, p=0.001). Table 2 shows the distribution of
symptoms by category of symptom.
Table 2. Distribution of symptoms among cases of influenza A(H1N1)v
infection, as of 8 Jun 2009, EU+3 countries (n=371) [available at
above given URL link].
Pre-existing conditions
Underlying disease was reported for 24 cases: lung disease for 12,
heart disease for 4, renal disease from 3, human immunodeficiency
virus (HIV) infection from 3, and seizures from 2 cases (one of these
2 also had a not further specified cancer). One 14-month-old child
was reported with combined heart, lung and renal disease. None of the
cases was reported to be pregnant. Several cases with other
underlying conditions such as hypertension, iodine sensitivity,
allergic rhinitis or facial paralysis were reported, which are not
considered classical risk groups for seasonal influenza [3].
Treatment and prophylaxis
Of 292 cases for whom information is available, 258 (88 percent)
received antiviral treatment. Oseltamivir was the most commonly used
drug (255); zanamivir was reported to have been used for treatment of
3 cases. Post-exposure prophylaxis was reported to have been
administered to 13 (7 percent) of 198 cases for whom information was
available. 12 received oseltamivir and one received zanamivir as
prophylaxis. Six of the cases who received prophylaxis were imported cases.
Complications
Seven (2 percent) of the 286 cases for whom information is available
were classified as having complications. Four patients were reported
with pneumonia, one with otitis, one with elevated liver enzymes and
one with the need for steroid treatment. 53 cases reported shortness
of breath, one of whom had underlying heart disease.
Previous influenza vaccination
Twenty (8 percent) of the 260 cases for whom information is available
were reported to have received seasonal influenza vaccination in the
past season. Vaccinated persons were aged between 8 months and 76
years. 80 percent of vaccinated persons were returning travelers. Two
were reported to have asthma, one with underlying heart disease, one
with chronic disease not further specified and one with myalgic encephalopathy.
Hospitalisation
Among 291 cases, 36 percent (105) were reported to have been
hospitalised. The rate of hospitalisation varies by country. In
several countries, e.g. France, Austria, Belgium and Romania, cases
were hospitalised for isolation purposes.
Discussion
On the basis of the aggregated case reporting, 2 EU Member States
account for 75 percent of the cases reported in the EU+3 countries.
It is unlikely that a difference in the sensitivity of surveillance
systems alone could explain such a difference. The one-week delay
between date of onset (individual case reports) and reporting date
(aggregated case-reports) observed in the 1st weeks of the epidemic
probably reflects the delay in seeking medical care after onset and
getting laboratory confirmation (see Figure 1). The discrepancy
observed since the 3rd week of May 2009 in the numbers reported
through aggregated case reports versus individual case reports
highlights the increasing difficulties of the Member States in
investigating and reporting individual cases as the number of case increases.
This preliminary analysis does not allow an accurate description of
the level of in-country transmission, as the data are still
incomplete. However, a recent Eurosurveillance article suggests that
in the UK, most of the recent cases are due to in-country
transmission, although sustained community transmission still has to
be confirmed [4].
The age distribution of cases is significantly different among
imported and domestic cases. Imported cases tend to be young adults,
exposed while traveling abroad, and their demographic characteristics
are more representative of travelers than of the population
susceptible to A(H1N1)v infection. Domestic cases tend to be younger
(median age 13 years) and reflect school children and teenagers among
whom transmission is amplified. Therefore, the demographic
characteristics of cases documented in the EU so far do not reflect
the overall population at risk of infection but rather the population
contributing to seeding events (travelers) and amplification of
transmission (school children and teenagers) in the early stage of
the spread of a new influenza virus strain.
The relatively high proportion of asymptomatic cases, especially
among under 20 year olds, is probably due to intensive contact
tracing during school outbreaks. The difference in the number of
cases with gastro-intestinal symptoms observed in under 20 year olds
compared to older cases has been previously described for seasonal
influenza and is not significantly associated with an exposure abroad
[3]. The hospitalisation rate cannot be considered as a factor of
severity because many of the cases were reported to be admitted to
hospital for isolation. There was great variation among countries in
this respect.
Information on the interval between exposure and the start of
prophylaxis is not available and, therefore, no conclusions can be
drawn regarding the effectiveness of antiviral prophylaxis.
Individual case reports for less than half of the cases (498/1128)
were available for this analysis, which may bias the results. The
bias will particularly affect conclusions drawn on cases from the
last 3 weeks of the dataset, for which information from the most
affected Member States were not available. Bias may have been
introduced in the age distributions and the frequencies of symptoms
and underlying conditions, since the missing data particularly
concern in-country transmission. Therefore, the comparisons between
cases affected in their own country and travel-associated cases
should still be considered preliminary, and a change in disease
patterns during the period for which data are missing cannot be ruled
out. Due to delay in reporting from the Member States to ECDC, the
Europe-wide picture presented here may not fully represent the
reality of what was known at country level on [8 Jun 2009].
With the currently available information, conclusions about the
severity of the infection are limited. In addition, if cases
deteriorate while they are ill, this information would probably not
be reported to the ECDC.
Conclusions
The preliminary analysis of the initial few hundred cases reported at
the European level shows that the epidemiological pattern in the EU+3
countries does not differ from what was documented in the Americas.
Currently, the disease seems to be relatively mild and comparable
with seasonal influenza. However, it is still too early to define, on
the basis of this analysis, the age groups most at risk of infection.
These data are important to guide appropriate policy decisions. In
2008, a working group on surveillance in a pandemic, including ECDC,
WHO, and experts from the Member States, identified 9 strategic
parameters which would need to be assessed early in an influenza
pandemic [5]. Out of these, 6 parameters (including disease severity,
incidence by age-group and known risk-factors,
confirmation/modification of case definition and modes of
transmission) can only be properly evaluated using individual case reports.
As the number of cases grows, it will become increasingly difficult
for the Member States to investigate and report individual cases. The
surveillance currently in place may soon reach its limits. It may
well be that targeted outbreak studies will provide better
information on risk factors for more severe disease. A switch to
sentinel surveillance and/or surveillance of severe cases, as
implemented by countries outside the EU, has to be considered.
However, the case-based reporting should be continued at least until
countries experience community spread or large-scale epidemics. ECDC
is currently working with the Member States to automate the upload of
data in their own national formats.
In the meantime, aggregated case reporting complementing individual
case reports has proven very useful in describing recent trends and
anticipating future developments. As recent trends suggest that
Europe may be entering the acceleration phase [6], it is important to
continue collecting aggregated case reports.
Acknowledgements
These data were provided by the national focal points for the Early
Warning and Response System and the contact points for influenza
surveillance of the EU and EFTA countries. ECDC wishes to acknowledge
the serious commitment and effort of all these individuals and their
teams in ensuring the timely reporting of case-based data from their
respective countries. The full list of names is indicated below. The
final preparation of the report was made by ECDC working group on
influenza A(H1N1)v, see below.
Reported by: ECDC working group on influenza A(H1N1)1,2
1. European Centre for Disease Prevention and Control, Stockholm, Sweden
2. The ECDC working group on influenza (A Ammon, B Ciancio, D
Coulombier, I Devaux, P Kreidl, F Plata, M Salminen, P Zucs)
[Contributing individuals are listed in the original report at the
above given URL link for the report. - Mod.MPP]
References
1. Centers for Disease Control and Prevention (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 at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5815a5.htm>].
2. Commission Decision of 30 Apr 2009 amending Decision 2002/253/EC
laying down case definitions for reporting communicable diseases to
the Community network under Decision n 21/19/98/EC. 2009/363/EC.
Official Journal L 110/58. 01.05.2009. Available from:
<http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:110:0058:0059:EN:PDF>.
3. Chin J. Control of Communicable Diseases Manual. 17th ed.
Washington, DC: American Public Health Association; 2000.
4. Health Protection Agency, Health Protection Scotland, National
Public Health Service for Wales, HPA Northern Ireland Swine influenza
investigation teams. Epidemiology of new influenza A (H1N1) virus
infection, United Kingdom, April - June 2009. Euro Surveill.
2009;14(22):pii=19232. Available from:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19232>.
5. World Health Organization (WHO). Global Surveillance during an
Influenza Pandemic. Version 1. Updated draft April 2009. Available from:
<http://www.who.int/csr/disease/swineflu/global_pandemic_influenza_surveilance_apr09.pdf>.
6. European Centre for Disease Prevention and Control. Likely
Evolution of the Pandemic of the new Influenza Virus A(H1N1) 2 Jun
2009. Available from:
<http://ecdc.europa.eu/en/Health_Topics/Pandemic_Influenza/Likely_evolution_of_epidemics_pandemic_new_A-H1N1_influenza_090602.ppt#294,11,Age-specific>
(clinical attack rate in previous pandemics).
--
Communicated by:
ProMED-mail <promed@promedmail.org>
******
[5] News briefs
Date: 10-11 Jun 2009
[Below are links to newswires with information on confirmed cases in
countries not included in official updates presented in the above
reports (WHO update 10 Jun 2009 and PAHO 10 Jun 2009), and other
events of potential interest. The newswires are full of reports of
suspected cases in many countries and many cities, states, provinces.
Reports have been filtered and discarded as more information becomes
available during the day. - Mod.MPP]
Americas:
Guatemala - 1st death reported, 12-year-old male, admitted 29 May
2009 with bronchopneumonia, discharged and re-admitted on 5 Jun 2009
with renal failure. Influenza A(H1N1) positive on 2nd admission.
Source of infection listed as from 1st hospitalization
<http://www.laprensagrafica.com/el-salvador/lodeldia/38684-guatemala-muere-paciente-con-gripe-h1n1.html>
USA/Canada - increased severity in pregnancy, 2 USA deaths, 6
Canadian women on respirators
<http://www.google.com/hostednews/canadianpress/article/ALeqM5jiEhxWUiH_XUQapgsZTTYelXFQKw>
Middle East:
Palestine - 1st case confirmed, 4 years old, history of travel to USA (Texas)
<http://www.imemc.org/article/60784>.
Asia:
Thailand - 21/90 hotel/discotheque workers tested positive for H1N1
infection in Pattaya. Results of investigation following 2 H1N1 cases
identified in Taiwanese returning to Taiwan from Pattaya
<http://www.nationmultimedia.com/breakingnews/30104898/Thailand-found-21-new-cases-of-Influenza-2009-in-P>
Africa:
No cases officially confirmed in Africa other than Egypt
<http://genevalunch.com/2009/06/11/sub-saharan-africa-has-no-reports-of-swine-flu/>.
--
Communicated by:
ProMED-mail <promed@promedmail.org>
ProMED-mail Rapporteur Mary Marshall
[As of 14:00 GMT+2 today [11 Jun 2009], there have been a total of 28
774 cases with 144 deaths attributable to influenza A(H1N1) infection
confirmed to WHO. Given the observation of community wide
transmission in more than one region (North America, South America,
Europe, Asia and Oceana - Australia), WHO has officially announced
that the influenza A (H1N1) strain is now at a pandemic level. The
significance of the declaration of a pandemic has potential economic
repercussions if countries implement trade and travel restrictions,
although as can be seen in the press release of Dr. Chan (see [3]
above), WHO specifically states: "WHO continues to recommend no
restrictions on travel and no border closures." The positive impact
may well be a more rapid development of a vaccine that will assist in
reducing morbidity and mortality due to this virus.
One cautionary reminder is the statement made by many in the field of
public health and influenza surveillance that the one thing one can
predict with certainty is that the influenza virus will not behave in
a predictable manner, hence, predictions of what may occur over the
coming months with the present pandemic strain should be viewed as
"best guess" predictions but subject to change.
One observation this moderator has when reviewing the reported cases
combined with the newswire discussions of confirmed cases in
countries reporting very few cases is that in many instances, the
reported cases are always "imported cases" from countries with known
influenza A(H1N1) circulation, suggesting that surveillance efforts
are targeting travelers and may well miss local transmission of the
virus. Two examples of this occurred in the Dominican Republic and
Thailand. A few weeks ago, while several countries confirmed
influenza A (H1N1) infection in individuals with travel histories to
the Dominican Republic, the Dominican Republic had not yet confirmed
any cases. In Thailand, the notification of 2 Taiwanese returning to
Taiwan from Pattaya, Thailand led to active surveillance among hotel
and discotheque employees, and 21 individuals with influenza A(H1N1)
infection were identified. This moderator's favorite expression comes
to mind: "Seek, and ye shall find." - Mod.MPP]
[see also:
Influenza A (H1N1) - worldwide (62): Egypt, Lebanon 20090611.2150
Influenza A (H1N1) - worldwide (60): Egypt (Cairo) 20090608.2117
Avian influenza, human (101): Egypt, 79th, 80th cases 20090609.2123
Influenza A (H1N1) - worldwide (59): Worldwide 20060608.2117
Influenza A (H1N1) - worldwide (58): USA, Africa 20090607.2109
Influenza A (H1N1) - worldwide (57): Brazil, USA 20090605.2090
Influenza A (H1N1) - worldwide (56): case counts 20090605.2089
Influenza A (H1N1) - worldwide (55) 20090603.2056
Influenza A (H1N1) - worldwide (54): dynamics 20090601.2038
Influenza A (H1N1) - worldwide (53): case counts 20090531.2025
Influenza A (H1N1) - worldwide (52): seasonal vaccine 20090530.2010
Influenza A (H1N1) - worldwide (51): dynamics 20090529.1999
Influenza A (H1N1) - worldwide (50): swine immunity 20090528.1987
Influenza A (H1N1) - worldwide (49): case counts 20090528.1984
Influenza A (H1N1) - worldwide (48): case counts 20090527.1972
Influenza A (H1N1) - worldwide (47): China, epidemiology 20090526.1962
Influenza A (H1N1) - worldwide (46): case counts 20090526.1960
Influenza A (H1N1) - worldwide (45) 20090525.1951
Influenza A (H1N1) - worldwide (44): case counts 20090525.1945
Influenza A (H1N1) - worldwide (43): case counts 20090523.1931
Influenza A (H1N1) - worldwide (42) 20090523.1929
Influenza A (H1N1) - worldwide (41): case counts 20090522.1921
Influenza A (H1N1) - worldwide (40): case counts 20090521.1906
Influenza A (H1N1) - worldwide (39) 20090521.1903
Influenza A (H1N1) - worldwide (38): case counts 20090520.1895
Influenza A (H1N1) - worldwide (37) 20090520.1893
Influenza A (H1N1) - worldwide (36): case counts, amended 20090519.1882
Influenza A (H1N1) - worldwide (35): case counts 20090518.1867
Influenza A (H1N1) - worldwide (34) 20090518.1863
Influenza A (H1N1) - worldwide (33): case counts 20090517.1848
Influenza A (H1N1) - worldwide (32): case counts 20090517.1845
Influenza A (H1N1) - worldwide (31) 20090516.1835
Influenza A (H1N1) - worldwide (30): case counts 20090516.1831
Influenza A (H1N1) - worldwide (29) 20090515.1824
Influenza A (H1N1) - worldwide (28): case counts 20090515.1822
Influenza A (H1N1) - worldwide (27): case counts 20090514.1800
Influenza A (H1N1) - worldwide (26) 20090514.1798
Influenza A (H1N1) - worldwide (25): case counts 20090513.1785
Influenza A (H1N1) - worldwide (24): case counts 20090512.1772
Influenza A (H1N1) - worldwide (23) 20090511.1764
Influenza A (H1N1) - worldwide (22): case counts 20090511.1759
Influenza A (H1N1) - worldwide (21) 20090510.1749
Influenza A (H1N1) - worldwide (20): case counts 20090510.1741
Influenza A (H1N1) - worldwide (19) 20090509.1733
Influenza A (H1N1) - worldwide (18): case counts 20090509.1728
Influenza A (H1N1) - worldwide (17) 20090508.1722
Influenza A (H1N1) - worldwide (16): case counts 20090507.1715
Influenza (H1N1) - worldwide (15) 20090507.1709
Influenza A (H1N1) - worldwide (14): case counts 20090507.1702
Influenza A (H1N1) - worldwide (13) 20090506.1695
Influenza A (H1N1) - worldwide (12): case counts 20090505.1681
Influenza A (H1N1) - worldwide (11): coincident H3N2 variation 20090505.1679
Influenza A (H1N1) - worldwide (10): case counts 20090504.1675
Influenza A (H1N1) - worldwide (09) 20090504.1673
Influenza A (H1N1) - worldwide (08): case counts 20090503.1660
Influenza A (H1N1) - worldwide (07) 20090503.1658
Influenza A (H1N1) - worldwide (06): case counts 20090502.1654
Influenza A (H1N1) - worldwide (05) 20090503.1657
Influenza A (H1N1) - worldwide (04): case counts 20090501.1648
Influenza A (H1N1) - worldwide (03) 20090501.1646
Influenza A (H1N1) - worldwide (02): case counts 20090430.1638
Influenza A (H1N1) - worldwide 20090430.1636
Influenza A (H1N1) "swine flu": worldwide (07), update, pandemic 5
20090429.1622
Influenza A (H1N1) "swine flu": worldwide (06) 20090429.1614
Influenza A (H1N1) "swine flu": worldwide (05) 20090428.1609
Influenza A (H1N1) "swine flu": worldwide (04) 20090428.1601
Influenza A (H1N1) "swine flu": worldwide (03) 20090428.1600
Influenza A (H1N1) "swine flu": Worldwide (02) 20090427.1586
Influenza A (H1N1) "swine flu": Worldwide 20090427.1583
Influenza A (H1N1) virus, human: worldwide 20090426.1577
Influenza A (H1N1) virus, human - New Zealand, susp 20090426.1574
Influenza A (H1N1) virus, human - N America (04) 20090426.1569
Influenza A (H1N1) virus, human - N America (03) 20090426.1566
Influenza A (H1N1) virus, human - N America (02) 20090425.1557
Influenza A (H1N1) virus, human - N America 20090425.1552
Acute respiratory disease - Mexico, swine virus susp 20090424.1546
Influenza A (H1N1) virus, swine, human - USA (02): (CA, TX) 20090424.1541
Influenza A (H1N1) virus, swine, human - USA: (CA) 20090422.1516
Influenza A (H1N1) virus, swine, human - Spain 20090220.0715
2008
----
Influenza A (H1N1) virus, swine, human - USA (TX) 20081125.3715
2007
----
Influenza A (H2N3) virus, swine - USA 20071219.4079
Influenza, swine, human - USA (IA): November 2006 20070108.0077]
............................................mpp/msp/dk
*##########################################################*
************************************************************
ProMED-mail makes every effort to verify the reports that
are posted, but the accuracy and completeness of the
information, and of any statements or opinions based
thereon, are not guaranteed. The reader assumes all risks in
using information posted or archived by ProMED-mail. ISID
and its associated service providers shall not be held
responsible for errors or omissions or held liable for any
damages incurred as a result of use or reliance upon posted
or archived material.
************************************************************
Become a ProMED-mail Premium Subscriber at
<http://www.isid.org/ProMEDMail_Premium.shtml>
************************************************************
Visit ProMED-mail's web site at <http://www.promedmail.org>.
Send all items for posting to: promed@promedmail.org
(NOT to an individual moderator). If you do not give your
full name and affiliation, it may not be posted. Send
commands to subscribe/unsubscribe, get archives, help,
etc. to: majordomo@promedmail.org. For assistance from a
human being send mail to: owner-promed@promedmail.org.
############################################################
############################################################
|