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Influenza A (H1N1) i april 2009 kaldet Svineinfluenza
BioNyt's engelsksprogede side om svineinfluenza SWINE FLU

Søg på internettet om svineinfluenza

Søg på internettet om svineinfluenza PÅ ENGELSK

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A/H1N1 A-influenza eller "Svineinfluenza"-udbrud i foråret 2009

Influenza A (H1N1)Sundhedsstyrelsen vurderer, at influenza A er et nyt virus, der aktuelt ikke er særlig smitsomt, og som ikke synes at fremkalde symptomer, der er alvorligere end almindelig sæsoninfluenza. Det har også vist sig, at Influenza A (H1N1) kan behandles med antiviral medicin, som vi har i beredskab i Danmark. [7028]

A/H1N1 influenzaen fra april-2009 er konstateret i bekræftet form i bl.a. USA, Argentina, Brasilien, Østrig, Canada, Colombia, Norge, Kina, Hong Kong, Costa Rica, Danmark, El Salvador, Frankrig, Tyskland, Irland, Israel, Italien, Holland, New Zealand, Panama, SydKorea, Spanien, Sverige, Schweiz og Storbritannien.

En dansker blev smittet på en ferierejse til New York, og bragte 7. maj 2009 infektionen med tilbage til Danmark. Hun havde kun milde symptomer.

Hvis du er et sted, hvor der er infektionsfare for denne nye sygdom: Undgå kys eller anden kontakt. Hold afstand til andre. Forbliv indendørs så vidt muligt. Bær maske. Hold hænderne væk fra alt i det offentlige rum. Vask hænder meget ofte. Undgå steder med risiko for tæt kontakt til andre mennesker, såsom busser, stormagasiner osv.

Brug ikke håndtørremaskiner på toiletter – de spreder virus. Ifølge en undersøgelse havde folk 3 gange flere bakterier på hænderne efter brugen end uden brugen. Og det hvirvler virus op.

Den svineinfluenza, som blev opdaget i 2009 i Mexico, er et hidtil uset genetisk kludetæppe, sammenstykket af gener fra svin-, fugle- og menneskevirus og fra typer, som findes i N-amerika, Europa og Asien. Dette kan måske gøre den mere ustabil, og jo mere den spredes verden over, jo større vil risikoen være for at den samles med resistensgener, smitsomhedsgener eller mere patogene gener.

Svineinfluenza er en åndedrætssygdom hos svin forårsaget af type A influenza. Denne virustype forårsager jævnligt udbrud af influenza blandt svin. Normalt inficerer svineinfluenza ikke mennesker. Men infektioner hos mennesker med svineinfluenza kan ske, og der er dokumenteret tilfælde af smitte fra menneske til menneske af den nye type svineinfluenza.

Siden marts 2009 har man påvist en række bekræftede tilfælde hos mennesker af den nye stamme af svineinfluenza A (H1N1-virus) i Mexico, Californien og Texas. Den 26. april 2009 havde sygdommen spredt sig til New York. Den blev 27. april 2009 konstateret hos en mand i Spanien og hos to personer i Skotland, alle havde lige været i Mexico. Siden har den spredt sig til mange lande. Den danske kvinde, som bragte smitten til Danmark 7. maj 2009, var den første europæer, som var blevet smittet i USA. Omkring dette tidspunkt overhalede USA Mexico i antallet af smittede.

Den nye stamme fra svineinfluenza blev i starten antaget at være årsag til ca. 150 menneskers død i Mexico, men dette tal blev kraftigt nedjusteret ved senere test; dog var mange døde, som man ikke havde prøver fra. Nogle dødsfald kunne altså ikke bekræftes som forårsagen af den nye influenza, fordi man manglede prøver fra de døde. Det var 20 bekræftede tilfælde af den nye svineinfluenza 26 apr. 2009. Alle dødsfald er sket i Mexico, bortset fra at et lille barn fra Mexico døde på et hospital i Houston og en kvinde med kronisk sygdom døde senere i USA.

Eksperter er især bekymret over, at de fleste omkomne var i alderen 25 til 45 år, da det normalt primært er ældre eller helt unge, der dør under influenzaepidemier. Gennemsnitsalderen af smittede er 17 år i Mexico og 15 år i USA.

Myndighederne i Mexico havde indtil 6. maj 2009 lukket skoler, museer, biblioteker og teatre, kirker og mange arrangementer.

Denne altså potentielt dødelige influenza for raske yngre mennesker og i hvert fald smitsomme influenza er ikke udryddet. Forholdsregler på steder, hvor der er risiko for smitte: Undgå kys eller anden kontakt. Hold afstand til andre. Forbliv indendørs så vidt muligt. Bær maske. Hold hænderne væk fra alt i det offentlige rum. Vask hænder meget ofte. Undgå steder med risiko for tæt kontakt til andre mennesker, såsom busser, stormagasiner osv.

Brug ikke håndtørremaskiner på toiletter – de spreder virus. Ifølge en undersøgelse havde folk 3 gange flere bakterier på hænderne efter brugen end uden brugen. Og det hvirvler virus op.

Den nye virus kombinerer genetisk materiale fra svin, fugle og mennesker på en måde, som forskerne ikke har set før.

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Symptomer på smitsom svineinfluenza

Symptomer på den nye stamme af smitsom svineinfluenza ligner almindelige influenzasymptomer: feber, hoste og ondt i halsen.

Den nye virusstamme give mere opkastning og diarré end almindelig influenza.

Man skal altså være opmærksom på følgende: Pludselig feber over 38 grader, hoste, hovedpine, ledsmerter, generel træthed og mangel på appetit. Nogle mennesker, der har været smittet med sygdommen, klager desuden over løbende næse, ondt i halsen, kvalme, opkastning og diarré. I tidligere sager har svineinfluenza forårsaget lungebetændelse og åndedrætsbesvær samt forværret kroniske medicinske tilstande.

Smittede mennesker får symptomer i løbet af 5-9 dage eller deromkring. De er smittebærer fra dagen før de første symptomer og frem til ca. 7 dage efter symptomernes fremkomst. Små børn kan være smittebærere i længere tid.

Dag 1 Infektion! – men ingen symptomer!
Dag 2 ingen symptomer!
Dag 3 ingen symptomer!
Dag 4 ingen symptomer!
Dag 5 ingen symptomer! Men smittebærer!! (eventuelt varer den symptomfri periode 9 dage)
Dag 6 influenzasymptomer – Smittebærer!!
Dag 7 influenzasymptomer – Smittebærer!!
Dag 8 influenzasymptomer – Smittebærer!!
Dag 9 influenzasymptomer – Smittebærer!!
Dag 10 influenzasymptomer – Smittebærer!!
Dag 11 influenzasymptomer – Smittebærer!!
Dag 12- influenzasymptomer – Smittebærer!!

Denne oversigt gælder voksne. Små børn kan være smittebærere i længere tid end voksne.

Ovenstående gælder for sygdommen i almindelighed – men kan variere. Typisk antages inkubationstiden at være 5-10 dage.

Denne virus ikke kan spredes ved at man spiser tilberedt svinekød, pølser osv.

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Behandling af smitsom svineinfluenza

Den nye smitsomme svineinfluenza har vist sig resistent over for virusmidlerne amantadine og rimantadine.

Men den er modtagelig for oseltamivir (= Tamiflu) og zanamivir (= Relenza), der er nyere viruslægemidler for influenza.

Hvis influenzasmitten H1N1 breder sig så meget, at verden rammes af en egentlig pandemi, er det rimeligt at antage, at en tredjedel af verdens befolkning på omkring seks milliarder mennesker får smitten. Det vurderer Verdenssundhedsorganisationen WHO. Det betyder 2 milliarder smittede, siger Keiji Fukuda – han er vicegeneraldirektør i WHO. Da WHO skulle håndtere situationen, var organisationen nødt til at tage risikoen for en pandemi med i beregningerne, selv om kun et lille antal mennesker udviklede alvorlig sygdom. Vurderingen af, at en tredjedel af verdens befolkning kan rammes af en pandemi, er baseret på tidligere pandemier. Men det er stadig "meget for tidligt" at vurdere, hvor mange der vil dø under en pandemi. Man ved endnu ikke, hvor mange der i givet fald bliver alvorligt syge. "Situationen udvikler sig fortsat," siger Fukuda.[7015]

På et centralt lager i København ligger 300.000 kapsler Tamiflu klar, så 30.000 danskere, som myndighederne frygter kan være smittet, kan få behandling med det samme. Og i en fryser ligger der derudover et helt ton pulver klar, som kan omdannes medicin til en million danskere.

[7025]

Influenza er en virussygdom, som giver ømhed i muskler og led, hovedpine og feber mellem 38 og 40 grader. [7025]

• Influenza varer normalt tre til fem dage, men man kan godt være træt efterfølgende. [7025]

• Influenza skyldes en virus, og kan derfor ikke helbredes med penicillin. [7025]

Influenzavirus spredes gennem luften ved menneskeligt samvær. Sygdommen smitter via næse, hals eller lunger. [7025]

• Sygdommen kan ofte udvikle sig til en epidemi, der kan spredes fra by til by og fra land til land. [7025]

• Et område kan have epidemiske tilstande i typisk fire til seks uger, inden det aftager. [7025]

Findes der forskellige typer influenza? Der findes tre slags influenza: [7025]

• Type A er den hyppigste og alvorligste med kraftige symptomer. Den dukker som regel op hvert andet eller tredje år. [7025]

• Type B har de samme symptomer, men ikke så kraftige. Dukker op hvert fjerde eller femte år. [7025]

• Type C er den milde udgave med symptomer tættere på forkølelse. [7025]

Influenza varer som regel tre til fem dage. Hvis den varer over en uge, eller symptomerne er særligt kraftige, bør man kontakte sin læge. Influenza, der varer over en uge, kan være et tegn på, at sygdommen kan udvikle sig til alvorligere sygdomme, såsom lungebetændelse, mellemørebetændelse eller bihulebetændelse. [7025]

Både forkølelse og influenza er udløst af virus, men influenza-symptomerne er sædvanligvis kraftigere. [7025]

Fugtig luft eller kulde kan ikke udløse influenza, som myten siger. Men pludselige temperaturændringer kan få symptomerne til at vise sig hurtigere. [7025]

Man får sjældent den samme influenza-variant to gange, fordi man to til fire uger efter sygdommen udvikler modstandsdygtighed mod den. [7025]

Men influenzaen udvikler sig hele tiden til nye varianter. Dette sker ved mutationer (springvise ændringer) i virus eller ved at influenzavirus fra fugle eller svin blandes med influenzavirus fra mennesker. I sådanne tilfælde er der ikke immunitet (modstandsdygtighed) i befolkningen mod det nye influenzavirus, hvorfor større epidemier kan opstå. [7025]

Hvert år søger man ved internationalt samarbejde (WHO) at fremstille vaccine mod nyopståede influenzavirus. [7025]

Siden slutningen af 1990’erne har en ny variant af influenza A (fugleinfluenzaen H5N1) forårsaget store epidemier blandt hønse- og andefugle især i Asien (Kina, Thailand, Vietnam, Indonesien), hvorfra mennesker i et mindre antal tilfælde er blevet smittet og nogle er døde. Smitten har spredt sig med trækfugle til lokale hønse- og andefugle i flere andre lande også i Europa og Afrika, hvorfor WHO har taget forholdsregler for at forebygge en ny verdensomspændende epidemi. Disse forholdsregler følges også i Danmark. [7025]

• Man kan bære smitten videre til andre allerede dagen før, man selv får symptomerne. [7025]

• Man viderefører smitten, indtil ens egen feber er forsvundet. [7025]

• Mindre børn kan smitte flere dage efter at de er blevet raske. [7025]

Hvad er tegnene på influenza? [7025]

• hovedpine [7025]

• feber omkring 38 til 40 grader [7025]

• ømme muskler og led, samt brystsmerter [7025]

• mangel på appetit [7025]

• træthed og svaghedsfølelse [7025]

• løbende næse og øm hals og svælg [7025]

• eventuelt tør hoste og urolig søvn [7025]

• man fryser og har kuldegysninger. [7025]

Hvad kan man selv gøre? [7025]

• Drik mest muligt, da man taber væske under feber. [7025]

• Hold dig i ro, gerne i sengen. [7025]

• Sov meget. [7025]

• Undgå at ryge og drikke alkohol, da dette kan forlænge sygdomsperioden. [7025]

• Tag eventuelt hostemedicin. Man sover bedst, hvis søvnen er uforstyrret af hoste. [7025]

• Tag eventuelt febernedsættende og smertestillende medicin. Husk dog at holde dig i ro, selvom du føler dig bedre tilpas. [7025]

• Bliv inden døre og forkæl dig selv, indtil sygdommen er overstået. [7025]

• Søg læge, hvis symptomerne ikke aftager efter en uge. [7025]

• Influenza kan udvikle sig til lungebetændelse og andre bakterielle infektioner, derfor skal man passe på sig selv, mens sygdommen står på. [7025]

Hvem er særligt udsatte? [7025]

• Influenza kan være farlig for ældre mennesker. [7025]

• Især ældre på plejehjem og folk med lunge- og kredsløbs-sygdomme bør lade sig vaccinere én gang årligt mod influenza for at undgå, at influenzaen kan blive starten på en ond cirkel af andre sygdomme. [7025]

• Personale på sygehuse og plejehjem, da de let kan blive smittet af influenzapatienter og så videreføre smitten til andre patienter inden de selv bliver sygemeldt. [7025]

• Da influenzatyperne hele tiden ændres, er det nødvendigt at gøre det til et fast årligt ritual at få vaccinen. Hvis man er i tvivl, kan man søge sin læge. [7025]

Skal man lade sig vaccinere?
Sundhedsstyrelsen anbefaler vaccination til grupper, som er særligt udsatte for at få alvorlige følgesygdomme til influenza: [7025]

• Alle personer over 65 år [7025]

• personer med kronisk sygdomme som lungesygdomme, hjerte- og kredsløbs-sygdomme eller diabetes. [7025]

• personer med medfødte eller erhvervede defekter af immunsystemet. [7025]

• personer der bor på plejehjem eller lignende institutioner [7025]

• personer med andre svækkelsestilstande, hvor lægen vurderer, at influenza udgør en alvorlig sundhedsrisiko [7025]

• ansatte i sundhedssektioren blandt andet hospitalspersonale. [7025]

• vaccinationen skal foretages hvert år i oktober eller november, da influenzatyperne hele tiden ændres sig. [7025]

Hvor godt beskytter vaccinen? [7025]

Beskyttelsen indtræder cirka en uge efter, at man er blevet vaccineret. Yngre raske mennesker kan regne med at være beskyttet i 70-90 procent af de tilfælde, hvor de bliver udsat for smitte. Ældre er kun beskyttet i cirka 60 procent af tilfældene, men beskyttelsen mod alvorlige følgesygdomme, hospitalsindlæggelse og dødsfald er noget højere. [7025]

Hvilken medicin kan man tage?
Type A og B kan behandles med lægemidlet Tamiflu (oseltamivir), som hæmmer influenzavirus. Det helbreder ikke influenza, men lindrer symptomerne og nedsætter sygdomstiden, hvis de tages inden for de to første døgn af sygdommen. [7025]

Om almindelig influenza:
Den syge kan smitte allerede før, symptomerne er begyndt og i de første 3-4 dage af sygdommen. Børn kan smitte i op til 10 dage. [7026]

Som regel varer en influenza i op til 5 dage, men influenza efterfølges ofte af 1-2 uger med hoste, træthed og nedsat fysisk formåen. [7026]

Influenzaepidemier af 4-6 ugers varighed optræder normalt i Danmark i perioden november til marts og forekommer 5-7 gange i løbet af en 10-års periode. [7026]

Under en almindelig epidemi rammes op til 20 procent af befolkningen, og man ser tydelige stigninger i antallet af hospitalsindlæggelser og i antallet af dødsfald. [7026]

Under en gennemsnitsepidemi i Danmark forekommer mellem 1000 og 3000 ekstra influenzabetingende dødsfald. Omkring 90 procent af disse dødsfald rammer personer over 65 år. [7026]

En influenzaepidemi er normalt domineret af influenza A virus.
Influenza A giver et mere kompliceret sygdomsforløb end influenza B. [7026]

Både influenza A og B kan bane vej for følgesygdomme som lungebetændelse, bronkitis, bihulebetændelse og mellemørebetændelse – især børn er plaget af mellemørebetændelse. [7026]

Inden for både influenza A og B findes der forskellige influenza typer, – og de ændrer sig en smule fra år til år. Ofte får typerne navne som "New Caledonia", "California" eller "Shanghai". Navnet kendetegner det første sted, influenzatypen opstår. [7026]

Influenza A inddeles i forskellige subtyper. Nogle få af disse influenza A subtyper smitter blandt mennesker og kan medføre epidemier. De resterende subtyper smitter blandt dyr herunder især fugle. En af disse subtyper H5N1 betegnes fugleinfluenza. [7026]

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Om smitsom svineinfluenza

Virussets spredning: I månederne på overgangen 2007-2008 er H1N1 en af de to almindelige influenzaformer, der rammer Europa i influenzasæsonen. Midt i 2008 optræder den "almindelige" H1N1 i den sydafrikanske influenzasæson. På overgangen 2008-2009 er den en af de mest udbredte influenzavirus i USA (den kan ikke vende tilbage til Europa, hvor befolkningen er immun fra forrige influenzasæson). I de første måneder af 2009 bliver formentlig en svineavler i Mexico syg af almindelig H1N1 og smitter en gris, som i forvejen har en almindelig svineinfluenza (der muligvis er blandet op med noget fugleinfluenza). De to virus mødes i en celle, formentlig i den maxikanske gris. Her bytter de gener. Den nye svineinfluenza kan smitte mennesker, og smittede mennesker kan smitte andre mennesker. Man har aldrig fundet en gris med smitten. [Politiken sønd. 3.maj2009 PS s.6]

Svineinfluenza henviser til influenza-tilfælde, der er forårsaget af orthomyxovira. Disse vira er endemiske for populationer af svin.

Virussygdommen betegnes svineinfluenzavirus, engelsk: Swine influenza viruses (SIV).

De isolerede SIV-virusstammer er blevet klassificeret som influenzavirus A; betegnet A(H1N1).

Svineinfluenzavirus udvikler sig først i svin og kan overføres til mennesker.

Genetisk er svineinfluenzavirusset en kombination af gener fra europæiske svin og nordamerikanske svin, men med komponenter fra fugle og mennesket. Den mangler de karakteristika, som kendetegnede Den Spanske Syge.

Den normale lokale influenzasæson i Mexico plejer at stoppe i februar-marts, og det skete ikke – hvilket var årsagen til, at man opdagede den nye svineinfluenza.

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En 5 cm chip til 100 kroner kan hurtigt afsløre hvilken virus-type en person er smittet med En influenzachip kaldet FluChip er udviklet af firmaet InDevR Inc. Og skelner mellem menneskeinfluenza og svineinfluenza, men kan også afgøre om der er tale om et miks. Samtidig kan chippen pege på, om sygdommen stammer fra eksempelvis svin i Europa eller Nordamerika, siger Gary Heil til Scientific American. Gary Heil er forsker på 'University of Iowa's Center for Emerging Infectious Diseases' og har testet InDevR's teknologi i det seneste år. InDevR kan afsløre den præcise type virus, fordi den kan give et fingeraftryk fra den nye måske ukendte virus, som den holder op mod fingeraftryk for kendte vira. Metoden kan genkende H1N1-virussen. I et forsøg fik forskerne udleveret seks prøver af H1N1 fra U.S. Centers for Disease Control and Prevention (CDC) som de afprøvede ved metoden InDevR. FluChip-metoden opdagede alle seks H1N1-vira, siger Erica Dawson, InDevR's førende forsker på projektet og medopfinder af FluChip teknologien. Metoden virker ved, at den lille chip på to gange fem centimeter på overfladen har nogle små brønde med stykker af influenza-genomer, altså influenza-arvemasse i. Forskerne drypper en dråbe RNA-opløsning fra det virus, som de studerer, ned på chippen. RNA bruger virusset til at lave proteiner med. Når brøndene reagerer med opløsningen, placeres chippen i en IntelliChip-læser, som scanner den og producerer et digitalt billede, så forskeren kan identificere virussen helt ned til undertype. Processen tager omkring syv timer, og er derved ikke hurtigere, end den metode som for eksempel Statens Serum Institut bruger til at diagnosticere H1N1 med, kaldet PCR. Denne metode tager kun et par timer, men kan derimod ikke vise præcis hvilken undertype der er tale om. Prisen per chip afhænger af hvor mange man bestiller, men vil i starten ligge på omkring $20, det vil sige små 100 kroner Det amerikanske firma vil producere 2000 chip i løbet af nogle måneder. [6. maj 2009; http://ing.dk/artikel/98442-chip-til-100-kroner-afsloerer-smittekilder-til-svineinfluenza?utm_medium=rss&utm_campaign=nyheder]

Indbygget ventilationssystem i hvert flysæde, der udsender frisk luft kan forhindre, at flypassagerer smitter hinanden: Et forskerteam på Aalborg Universitet med professor Peter V. Nielsen i spidsen har arbejdet med en særlig pude, som placeres øverst i flysædet, og udblæser en søjle af luft omkring hver passager, så hver person sidder i sin egen friske, tilførte luft og bliver ikke påvirket af de personer, der sidder tæt ved, Skrækeksemplet på udbredning af smitte var, da en passager med den berygtede sygdom SARS om bord på et et fly fra Beijing til Hong Kong nåede at smitte 19 medpassagerer. Forskerteamet har brugt avancerede computermodeller til at gennemskue luftstrømmene i et fly og mannequindukker med samme kropstemperatur som et menneske og kunstige lunger til at simulere menneskelig vejrtrækning. Systemet kan udvikles på 2-3 år, hvis nogen vil investere i det. Et universitet i Hong Kong samarbejder om at teste systemet. [7016: http://jp.dk/nyviden/article1684799.ece]

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Reference 7025: her

Reference 7026: her

Video-film om influenzavirus: her

Reference 7028 (Sundhedsstyrelsen): her
OVERSÆTTELSE AF DEN ENGELSKE TEKST:

BioNyt – Videnskabens Verden (Kommentarer: bionyt@gmail.com)
Svineinfluenza – mexicansk A/H1N1 influenza – nordamerikansk influenza A/H1N1 virus
Udbrud i foråret 2009
Epidemiens historie; vurdering af sværhedsgraden af en influenzapandemi; Bakteriefremkaldte co-infektioner? Information for laboratoriepersonale; baggrund for epidemien; Generelle informationer; Symptomer på svineinfluenza; Helbredelse for svineinfluenza; Litteratur og henvisninger; Nøgleord og forkortelser; Svineinfluenza-gener i Kina – og diagnostiske midler; Andre influenza-epidemier; Links; AVAAZ-initiativet mod de store uregulerede svinebedrifter.
Influenza A (H1N1) er det officielle navn på sygdommen, idet den breder sig fra menneske til menneske og ikke fra svin til menneske, som navnet "svineinfluenza" kunne få folk til at tro.
Influenza A (H1N1)-epidemien er ikke alarmerende, fordi:

• Det er ikke en god dræber (Dette vidste man ikke i begyndelsen af epidemien)
Influenza A (H1N1)-epidemien kan blive alarmerende, fordi:

• Virusset kan ændre sig til at blive en bedre dræber.
• Den kan blive en bedre dræber i næste virussæson (Det er ikke ualmindeligt, at den næste bølge af epidemien et halvt år senere er mere aggressiv)
• Den kan spredes i lande, som går ind i deres influenzasæson(Argentina mv, Sydafrika, New Zealand)
Influenza A (H1N1)-epidemien er alarmerende, fordi:

• Den kan dræbe unge, raske mennesker ligesom influenza i 1918 (den spanske syge").

• Det er en ny influenza-virus fra dyr – og derfor ukendt for det menneskelige immunsystem.

• Den spredes globalt

• Den kan inficere fra menneske til menneske

• Den inficerer unge og midaldrende mennesker

• Man kan ændre sig til en mere dødeligt type – spontant eller hvis et individ (svin eller menneske) får to forskellige virustyper samtidig i dets celler.

• Vi ved af erfaring, at influenzavirus – hvis den er dødelig og smitsom – kan dræbe millioner af mennesker. Den spanske syge i 1918-1919 dræbte flere mennesker end der døde under første verdenskrig.

• En vaccine vil det tage over 6 måneder at producere.

• Den nye influenza kom i begyndelsen af influenzasæsonen for lande med dårlige ressourcer.
• Jo flere mennesker, der smittes med den nye influenza, jo større er risikoen for, at virusset vil inficere en celle, som allerede er inficeret med en anden influenzavirus (måske et fugleinfluenza-virus). Derefter kan en ny rekombineret virus opstå, som kan være mere dødeligt, mere smitsom eller både mere dræbende og mere smitsom. (Imidlertid har det fugleinfluenza-virus, som har smittet en hel del mennesker i løbet af de sidste 13 år og som er meget dødeligt, endnu ikke rekombineret med en menneskeinfluenzavirus)

• To milliarder mennesker vil sandsynligvis blive smittet, hvis influenzaen bliver en pandemi (nemlig omkring en trediedel af verdens 6 milliarder mennesker – hvis man skal vurdere ud fra erfaringer fra tidligere pandemier). Man kan derimod ikke vide hvor mange, som vil dø. Heldigvis er det nye virus ikke meget dødeligt. Det ligner snarere almindelig influenza. Men dette kan ændre sig og selv en ikke særlig dødelig virus kan forårsage stor skade, hvis den er meget smitsom.

[7015]
Svineinfluenza har symptomer, der er næsten identiske med almindelig influenza – feber, hoste og ondt i halsen – og den spreder sig som almindelig influenza – gennem bittesmå partikler i luften, når folk hoster eller nyser, eller ved at man rører ved noget, som virus er blevet afsat på for nylig.
Grunden til, at nogle mennesker dør af denne nye influenza kunne måske tænkes at være et resultat af immunsystemets overreaktion, som medfører væskeudtrædning i lungerne og blokering af iltoptagelsen til blodet.
Det forhold, at nogle mennesker dør, giver hurtigt et ressourceproblem for sygehuse mv. – idet der meget hurtigt vil være for få åndedrætsapparater og for lidt personel til at håndtere mange syge mennesker.
Omkring 4. maj 2009 blev det klart, at den svine-relaterede H1N1-influenza fra april 2009 ikke var så farlig, hvis de blev behandlet. Grunden til, at mennesker døde i Mexico, men ikke i andre lande, var formentlig manglende behandling. De mennesker, der døde, var ofte for fattige til at bruge tid til at gå hen på hospitalet (de havde ikke råd til at være syge), eller de blev ikke behandlet, selv om de kom til læge.
På et tidspunkt i starten af maj 2009 fik folk opfattelsen "influenzaepidemi-faren er forsvundet". Men det kan være for tidligt at konkludere dette. De fattige lande på den sydlige halvkugle – lande uden lægemidler til rådighed og uden planer for at undgå sådanne epidemier – går i løbet af 2009 ind i influenzasæsonen (vinter). Den omstændighed, at denne influenza ikke vil kunne inddæmmes, og faktisk stadig er farlig for ellers raske mennesker, er en grund til bekymring.
Ved 1918-pandemien var der en 4-måneders afstand mellem den første, milde infektionsbølge, og det store angreb, der havde en dødelighed som – hvis det omsættes til i dag – ville betyde 170 millioner dødsfald på verdensplan [6978]. En pandemi i dag vil måske tage færre liv – eller måske flere liv. Kun få lande har egen vaccineproduktion, og vaccinefabrikkerne ligger især i europæiske lande. Man kan forestille sig, at disse lande i en kaotisk, livstruende situation vil være mere eller mindre villige til at eksportere deres produkter. Smitsomme sygdomme er trods alt den største fjende for menneskeheden, selv i forhold til krig, jordskælv og tsunamier [6978].
Risikoen for globale, dødelige virusinfektioner burde tages mere alvorligt. Forskning i svinerelateret H1N1-influenzavirus er blevet forsømt. Den nye virustype bygger på virus, som er opstået i svin i USA i 1998, og som der altså i 2009 havde været 11 år til at studere og bekæmpe.
Denne 1998-svineinfluenzavirus blev efterhånden endemisk på svinefarme i hele Nordamerika.
Den nye mexicanske A/H1N1 svinerelateret H1N1-influenzavirus er særlig bekymrende, fordi overfladeproteinerne ikke vil blive genkendt og nedkæmpet af det menneskelige immunsystem, idet alle virussets overfladeproteiner er fra svineinfluenzavirus.
Virusset indeholder to gener fra fugleinfluenza-virus, som menes at gøre det lettere for virusset at spredes [6978]. H1N1-influenzavirusset fra 2009 spredes ret let fra mennesker til mennesker. Virusset indeholder også et humant influenza-gen – og fem svineinfluenzagener.
Jo mere virussen spreder sig (f.eks. blev en person fra Sydkorea smittet i april 2009), jo større er risikoen for, at virusset vil blandes ("reassort"), med andre influenza-virus og blive mere dødelig. "Der er betydelig risiko for at der vil ske ændringer i virusset og dette er foruroligende," lyder en advarsel fra virologen Kennedy Shortridge, der er professor emeritus ved University of Hong Kong, hvor han var leder af efterforskningen under de indledende faser af H5N1-fugleinfluenza i 1997, som dræbte seks af de 18 smittede mennesker. Byen kvalte virusudbruddet ved at slagte alle 1,4 millioner høns og ænder i Hong Kong området. Der kom et nyt H5N1-udbrud i 2003 og dette har siden kostet 257 menneskeliv under dets ødelæggende spredning gennem fjerkræflokke over hele Asien og dele af Afrika. Kennedy Shortridge var også blandt de første til at foreslå, at svin kan fungere som blandeapparater for nye kombinationer af virus. Han har længe slået til lyd for et globalt samarbejde i forbindelse med overvågningen af cirkulerende influenzavirus for at opdage nye virusstammer, således at sundhedsmyndighederne bedre kan planlægge et forsvar og så lægemiddelproducenter kunne få et forspring til at fremstille vacciner [Science, 6971]
Kennedy Shortridge er bekymret over, at den nye sammenstykkede virus fra 2009 – med gener, som formodes at komme fra N-Amerika, Europa og Asien – måske er ustabil. Virusset kan let rekombinere (reassort) med andre vira, såsom H5N1-virus i Asien og humane H1N1-virusstammer, som er resistente over for Tamiflu – sådanne resistente stammer cirkulerer mange steder i verden. Han forestiller sig, at udveksling af et eller flere gener med almindeligt forekommende vira kan resultere i et virus, der er mere sygdomsfremkaldende, mere smittefarlig fra menneske til menneske, og mere modstandsdygtig mod virusmidler [Science, 6971]
Forholdsregler på steder, hvor der er risiko for smitte:
Undgå kys eller fysisk kontakt. (I visse lande, bl.a. i Mexico, er kys en almindelig hilsen). Hold afstand. Ophold dig indendørs. Bær en maske for næse og mund. (Maskerne gør kun lidt for at forhindre spredning af virus – men får dig til at holde hænderne væk fra dit ansigt – og husker dig på at beskytte dig selv). Hold dig så vidt muligt væk fra steder med mange mennesker, såsom busser, stormagasiner osv. Hold hænderne så vidt muligt væk fra alting på offentlige steder. Vask dine hænder meget ofte. (Håndvask er en af de nemmeste og mest vigtige ting, du kan gøre for at stoppe spredningen af viruspartikler).

Vask altid hænder efter hostning, nys eller når du har pudset næse,
Efter brug af toilet,
Før og efter at have haft med fødevarer at gøre
Før du spiser,
Før og efter du har skiftet en ble på et barn,
Efter at du har rørt et dyr eller dets efterladenskaber,
Efter at have håndteret affald eller lavet havearbejde,
Før og efter pleje af en person, der er syg.

Husk at vaske hænderne i mindst tyve sekunder. Hvis du har brug for at måle tiden, kan du forestille dig, at du synger "Happy Birthday to you" sangen to gange igennem. Hvis du ikke har sæbe og vand i nærheden, så brug i stedet en alkohol-baseret håndrens-gel (med mindst 60% alkohol i).
Det kan hjælpe med at holde overflader rene for smitte, hvis man desinficerer ting, der deles af flere, og desinficerer ting, mange berører på fællesrealer. For eksempel kan man holde rent på vandrette flader såsom borde, i vasken, på dørhåndtag, telefoner, elevatorknappen og andet, som folk ofte rører ved.
Undgå at deles om personlige ting, dom har været i nærheden af en persons mund, næse eller øjne, såsom:

tandbørster

drikkekrus eller sugerør

makeup

spiseredskaber

håndklæder og vaskeklude
Hold etikette vedrørende host og nys:

Forsøg at holde dig mindst 3 meter væk fra andre mennesker
Dæk din mund og næse med et papirslommetørklæde, som du straks smider væk
Host eller nys ned i dit ærme, hvis du har et papirslommetørklæde (host og nys ikke ned i din hånd).

Vask altid dine hænder straks efter, at du har hostet eller nyst.
Hold afstand fra familiemedlemmer og parteren, indtil du er rask igen. Hvis du har børn, der er syge, er det en god idé at holde dem hjemme fra skole.

Brug aldrig håndtørreren på toilettet. Den spreder virus. Ifølge en britisk undersøgelse har mennesker 3 gange flere bakterier på hænderne efter brug af håndtørrermaskinen, end hvis de anvender papir til at tørre deres hænder. Luftstrømningen får også viruspartikler til at flyve rundt omkring dig.

Svineinfluenza er en åndedrætssygdom hos svin forårsaget af type A-influenza. Denne virustype forårsager regelmæssigt udbrud af influenza blandt svin.
Normalt inficerer svineinfluenzavirus ikke mennesker, men infektioner med svineinfluenza kan forekomme hos mennesker.
Den nye type svineinfluenzavirus fra marts/april 2009 smitter fra menneske til menneske.
Den nye undertype af A/H1N1 fra 2009 var ikke tidligere påvist – hverken hos svin eller mennesker.
Siden marts 2009 har der været en række bekræftede tilfælde hos mennesker af en ny stamme af svineinfluenza A (H1N1). Virusset er blevet påvist hos mennesker i Mexico, og (oftest efter en udlandsrejse) i El Salvador, Costa Rica, USA, Canada, Spanien, Portugal, Østrig, Schweiz, England/Skotland, Danmark, Norge, Sverige, Tyskland, Frankrig, Holland, Belgien, Israel, Sydkorea, Peru, Brasilien, Argentina, Astralien, New Zealand m.fl.
2009-stammen af svineinfluenza blev indtil udgangen af april 2009 anset for at have slået 150 mennesker ihjel i Mexico, men ved en revision af disse data blev kun 20 af disse bekræftet at være blevet smittet med den nye virusstamme. En del var dog døde uden at smitteårsagen kunne hverken bekræftes eller afkræftes. Senere kom flere dødsfald efter bekræftede virusinfektioner til.
De fleste af de døde var kun 25-45 år gamle. Normalt er det kun svækkede ældre og meget unge, der dør under influenzaepidemier. Under den spanske syge i 1918 døde mennesker, der kun var 15-45 år gamle.
Myndighederne i Mexico lukkede skoler, museer, biblioteker, teatre mv. i hovedstaden og bad folk om ikke at gå i kirke og til andre forsamlinger.
Myndighederne i Mexico forsøgte at indeslutte udbruddet, blandt andet med anbefalinger om håndvask, at undgå kys og nærkontakt osv.
Blive hjemme, hvis du bliver syg. Bliv hjemme fra arbejde eller skole og begræns kontakten med andre for at undgå at inficere dem.
Hav en beredskabsplan klar for familien som en sikkerhedsforanstaltning. Dette bør omfatte et lager af mad, medicin, ansigtsmasker, alkoholbaseret håndgel og andre vigtige forsyninger.
Brug aldrig håndtørrermaskinen på toilettet. Den spreder virus. Ifølge en britisk undersøgelse har mennesker tre gange flere bakterier på hænderne efter brug af håndtørrermaskinen, end hvis de anvender papir til at tørre deres hænder. Faktisk øger håndtørrermaskinen antallet af bakterier på hænderne med 254%, mens brugen af papir til tørring af hænderne reducerer (!) bakterietallet med 77%. Luftstrømningen får viruspartiklerne til at flyve omkring dig. Noro-virus er f.eks. kendt for at kunne spredes af håndtørrermaskinen. Brug ikke disse maskiner.
Den nye 2009-virus kombinerer genetisk materiale fra svin, fugle og mennesker på en måde, som forskerne ikke har set før. En genetisk test har påvist, at den nye svinerelaterede influenza bl.a. er en kombination af europæiske svinegener og nordamerikanske svinegener.
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Symptomer på svineinfluenza
Symptomerne på den nye virusstamme ligner almindelige influenzasymptomer: feber, hoste, ondt i halsen, hovedpine, løbende næse, og muskelømhed.
Den nye stamme give mere opkastning og diarré end almindelig influenza.
Smittede mennesker får symptomer inden for ca. 5-9 dage eller deromkring, og kan være smittebærere fra en dag før symptomerne og op til 7 dage eller mere efter at symptomerne startede.
Dag 1 Infektion

Dag 2 ingen symptomer!

Dag 3 ingen symptomer!

Dag 4 ingen symptomer!

Dag 5 ingen symptomer! Men smitsom!! (inkubationstiden kan være op til 10 dage)

Dag 6 influenzasymptomer – og smittende!

Dag 7 influenzasymptomer – og smittende!

Dag 8 influenzasymptomer – og smittende!

Dag 9 influenzasymptomer – og smittende!

Dag 10 influenzasymptomer – og smittende!

Dag 11 influenzasymptomer – og smittende!

Dag 12-13-14-15 – influenzasymptomer – og smittende!
Små børn kan smitte i længere tid.
Ovenstående er sygdommen generelt for voksne.
Virusset kan ikke smitte ved at spise svinekød.

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Vurdering af hvor alvorlig en influenzapandemi er.
Den vigtigste faktor for sværhedsgraden af en influenzapandemi, målt som antallet af de tilfælde af alvorlig sygdom og dødsfald, som den forårsager, er virussets iboende farlighed (virulensen). Men mange andre faktorer har indflydelse på den overordnede sværhedsgrad af pandemiens virkninger [7036]
Selv en pandemisk virus, som oprindeligt kun forårsager milde symptomer hos i øvrigt raske mennesker, kan skabe store ødelæggelser, især i de meget mobile og indbyrdes tæt afhængige samfund, vi har i dag. Desuden kan et virus, som kun forårsager mild sygdom i ét land, medføre langt højere sygelighed og dødelighed i et andet land.
Hertil kommer, at den iboende virulens af virus kan ændre sig over tid efterhånden som pandemien går igennem efterfølgende bølger af national spredning og international spredning [7036]
Influenzavirussets egenskaber

En influenzapandemi er forårsaget af et virus, som enten er helt nyt eller som ikke har cirkuleret for nylig og ikke har udbredt sig i befolkningen. Dette medfører en næsten universel sårbarhed over for infektion. Selv om ikke alle mennesker bliver smittet under en pandemi, er næsten alle mennesker modtagelige for smitte [7036]
Det forhold, at et stort antal mennesker blive syge omkring samme tidspunkt under en pandemi, er en af grundene til, at pandemier er socialt og økonomisk ødelæggende. Meget hurtig spredning kan underminere kapacitetsevnen hos regeringer og deres sundhedstjenester [7036]
Smitsomheden af virusset påvirker også graden af en pandemis ødelæggende virkninger, da høj smitsomhed kan øge antallet af personer, som bliver syge, og som har behov for pleje inden for en kort tidsramme på et bestemt geografisk område. På den positive side er det ikke alle dele af verden, eller alle dele af et land, der berøres samtidigt [7036]
Pandemier har normalt en koncentreret påvirkning af bestemte aldersgrupper. Koncentreret forekomst af sygdomme og dødsfald i den unge, økonomisk produktive aldersgruppe vil være mere forstyrrende for et samfund end hvis det er de meget unge eller meget ældre som bliver hårdest ramt [7036]
Befolkningens sårbarhed

Befolkningens samlede sårbarhed kan spille en stor rolle. For eksempel er mennesker med kroniske tilstande, såsom hjerte/kar-sygdomme, forhøjet blodtryk, astma, diabetes, leddegigt, og flere andre kroniske tilstande mere tilbøjelige til at opleve alvorlige eller dødelige infektioner. Udbredelsen af disse tilstande, kombineret med andre faktorer såsom ernæringsmæssige status, kan have indflydelse på graden af en pandemi på væsentlig måde [7036]
Senere bølger af smittespredning

Det overordnede sværhedsgrad af en pandemi er desuden påvirket af tendensen hos pandemier til at cirkulere om kloden i mindst 2, sommetider 3, bølger. Af mange årsager kan sværhedsgraden af de efterfølgende bølger variere dramatisk i nogle eller endog i de fleste lande [7036]
Et særligt kendetegn ved influenza-vira er, at mutationer forekommer hyppigt og uforudsigeligt i 8 gen-segmenter, og især i hemagglutinin-genet. Fremkomsten af en mere virulent virus i løbet af en pandemi kan aldrig udelukkes [7036]
Forskellige mønstre for spredning kan også påvirke sværhedsgraden af de efterfølgende infektionsbølger. For eksempel, hvis hovedsageligt skolebørn er smittet i 1. runde, kan det være de ældre, som må bære byrden under 2. runde, med en højere dødelighed på grund af større sårbarhed hos de ældre [7036]
1918-pandemien "den spanske syge" begyndte mildt og returnerede inden for 6 måneder som en langt mere dødelig form. Pandemien, der begyndte i 1957, var i begyndelsen mild, og vendte tilbage i en noget mere alvorlig form, men betydeligt mindre ødelæggende end i 1918. 1968-pandemien begyndte relativt mild, med sporadiske tilfælde allerede forud for den 1. runde, og forblev mild i den 2. runde i de fleste lande, men ikke i alle lande [7036]
Kapacitet til at reagere

Endelig påvirker kvaliteten af sundhedsydelserne virkningen af enhver pandemi. Det samme virus, som kun giver milde symptomer i lande med stærke sundhedsvæsener, kan være ødelæggende i andre lande, hvor sundhedssystemerne er svage, hvor leverancer af medicin, herunder antibiotika, er begrænsede eller ofte afbrydes, og hvor hospitalerne er overfyldte, dårligt udstyrede og underbemandede [7036] .
Vurdering af den Aktuelle situation

Observationerne, som er specifikke for H1N1, er vil være foreløbige i en længere periode så længde der kun er begrænsede data fra nogle få lande. Den H1N1-virusstamme, der forårsager de aktuelle udbrud, er en ny virusstamme, der er ikke sat tidligere i hverken mennesker eller dyr. Selv om sikre konklusioner ikke kan opnås på nuværende tidspunkt, forudser forskerne, at den eksisterende immunitet for virusset vil være lav eller ikke-eksisterende, eller måske stort sæt begrænset til ældre befolkningsgrupper [7036]
H1N1 synes at være mere smitsom end sæsonbestemt influenza. Det sekundære angrebsomfang (attack rate) af sæsonbestemt influenza ligger fra 5 pct til 15 pct. Nuværende skøn over den sekundære angrebsomfang af H1N1 spænder fra 22 pct til 33 pct [7036]
Med undtagelse af udbruddet i Mexico, som stadig ikke er helt forstået, har H1N1-virus tilbøjelig til at forårsage meget mild sygdom hos i øvrigt raske mennesker. Uden for Mexico er næsten alle tilfælde af sygdom, og alle dødsfald, blevet påvist hos mennesker med underliggende kroniske lidelser [7036]
I de til største og bedst dokumenterede udbrud til dato, i Mexico og i USA, er en yngre aldersgruppe blevet smittet end det ses ved sæsonbetingede epidemier af influenza. Selv om der er påvist smittede i alle aldersgrupper, fra spædbørn til ældre, er unge patienter med alvorlige eller dødelige infektioner, et slående træk ved disse tidlige udbrud [7036]
Tendensen hos H1N1-virus til at forårsage mere alvorlige og dødelige infektioner hos mennesker med underliggende sygdomsmæssige betingelser er grund til særlig bekymring [7036]
Prævalensen af kroniske sygdomme er steget voldsomt siden 1968, hvor den sidste pandemi i det forrige århundrede opstod. Den geografiske fordeling af disse sygdomme, som tidligere blev anset for at være tætte følgesvende til velhavende samfund, har også skiftet dramatisk. I dag skønner WHO, at 85%af byrden af kroniske sygdomme er koncentreret i lav-og mellemindkomstlande. I disse lande opstår kroniske sygdomme ved en yngre gennemsnitsalder end det ses i mere velstående dele af verden [7036]
Nogle forskere spekulerer på om ikke det fulde kliniske spektrum af sygdom forårsaget af H1N1 først vil blive synlig, når virusset er mere udbredt. Også dette vil kunne ændre det nuværende sygdomsbillede, som endnu i maj 2009 var overvældende mild uden for Mexico [7036]
Bortset fra den iboende omskiftelighed hos influenzavirus kan andre faktorer ændre sværhedsgraden af nuværende sygdomsmønstre, men på helt ukendte måder, hvis virusset fortsætter med at sprede sig [7036]
Forskere er bekymret for eventuelle ændringer, der kunne finde sted, efterhånden som virusset spreder sig til den sydlige halvkugle og der møder de i øjeblikket cirkulerede menneske-vira, som forekommer når den almindelige influenzasæson på den sydlige halvkugle begynder [7036]
Den omstændighed, at H5N1 fugleinfluenza-virus er fast etableret i fjerkræ i visse dele af verden er en anden årsag til bekymring. Ingen kan forudsige, hvordan H5N1-fugleinfluenzavirus vil opføre sig under pres af en pandemi. På nuværende tidspunkt er H5N1 et dyrevirus, som ikke let spredes til mennesker, og kun meget sjældent overføres det direkte fra en person til en anden [7036] .

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Hvordan overvindes svineinfluenza?
Det nye svineinfluenzavirus har vist sig at være resistent overfor virusmidlerne amantadine og rimantadine.
Det nye virus er modtagelig (dag -1 til +2 dag med symptomer) overfor oseltamivir (= Tamiflu) og zanamivir (= Relenza), der begge er nyere antivirale midler mod influenza. De skal gives inden for 48 timer.

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Om svineassocieret H1N1-nfluenza
Svineinfluenza henviser til influenza-tilfælde, der er forårsaget af orthomyxovira. Disse vira er endemiske for populationer af svin.
Disse virus betegnes svineinfluenzavirus (SIV).
Sondringen er ikke baseret på slægtsskab (fylogeni). De isolerede SIV-stammer i svin er blevet klassificeret som enten influenzavirus C eller en af de forskellige undertyper af influenzavirus A.
Svineinfluenzavirus udvikles første i svin og kan derfra overføres til mennesker. I 2009-epidemien smittede mennesker derefter andre mennesker med virus.
Smittespredningen kan forsinkes ved at vaske hænder og tøj, annullere små og store offentlige arrangementer. Ved at hæmme spredningen af virusset, vinder man tid, men sådanne ting vil ikke stoppe virusset. Antivirusmidler findes kun i begrænse lagre, og virker kun efter hensigten, hvis der indtages tidligt nok og helst inden der er gået 2 døgn. Hvis diagnosticeringen ikke er korrekt eller tager for lang tid, er der risiko for, at antivirus-medicin vil blive spilt på de bekymrede, men som blot er inficeret med en uskyldig virus – eller omvendt at lagrene bliver kontrolleret så strengt, at antivirusmidlerne anvendes for sent [6978].
Vaccine er svaret på virusinfektioner. Men vaccinefremstilling dikteres af nogle få selskabers kommercielle interesser. Hvis et selskab stopper med at fremstille vaccine mod sæsoninfluenzaen og går over til at fremstille en vaccine mod den nye influenza, risikerer virksomheden at miste indtægter fra den normale sæsonvaccination, og på den nye vaccine aldrig bliver solgt, fordi den frygtede pandemi faktisk aldrig sker [6978].
Ifølge én undersøgelse vil man kunne have 340 millioner doser af vaccine i løbet af fire måneder, hvis vaccineproducenterne fokuserer på dette. Hvis det viser sig let at fremstille vaccinen kan vi kan få tre gange flere vaccinedoser – men stadig ikke nok til alle se næsten 7 milliarder mennesker i verden [6978]. På langt sigt (ved politisk engagement i virusforskning) vil vi kunne samle alle vores ressourcer – fremstille vacciner som fokuserer på de dele af virusset, der ikke ændrer sig (og som derfor ville være aktive mod nye virustyper) – og vi kunne udvikle nye antiinflammatoriske behandlinger (for at hindre den dødelige immun-overreaktion i kroppen) – vi kunne fremstille nye DNA-vacciner og protein-vacciner – eller vi kunne basere antistofbehandlingen på serum af de, der har overlevet virusinfektionen [6978].
Den globale beredskab for en pandemi er meget ujævnt. Mere fattige lande er de mindst forberedte, men selv i de rigere dele af verden er der alvorlige mangler: Ved en undersøgelse i 2007 af situationen i 30 europæiske nationer fandt man, at landene kun havde etableret halvdelen af de foranstaltninger, der forventes af WHO [6991]. Den største forskel var i beredskabet for at holde samfundet fungerende efter ud over dets sundhedssystem, – f.eks. at sikre fortsat levering af elektricitet, transportmuligheder, bankvæsen, fødevareproduktion og politisk arbejde. Kun 12 af 30 nationer havde etableret multisektor-planlægning. I Afrika kun 35 ud af 53 lande har pandemiplaner. Udviklingslandene kæmper allerede med malaria, hiv og tuberkulose, og en dødelig influenza under influenzasæsonen ville udgøre en stor udfordring [6991].
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Discussion: Levende eller inaktiveret vaccine?

Med de nuværende fremstillingskapaciteter, der vil kun være vaccine nok til en brøkdel af verdens befolkning, og ikke før efter seks måneder. Og det meste vil gå til rige lande. [7040, 12. maj 2009 (Natur)]
En kontroversiel idé er at bruge en levende, svækket vaccine, som ville kunne øge antallet af doserne, der er til rådighed, med 50 til 100 gange. Fabrikanterne er lunkne over for idéen. Men nogle eksperter siger, at ideen om levende virus bør overvejes. David Fedson, en ekspert om pandemivaccine og pensioneret medicinsk direktør for den franske vaccineproducent Aventis-Pasteur, nu kendt som Sanofi Pasteur, hævder, at anvendelsen af levende virus er den rigtige vej at gå nu med H1N1. [7040]
Inaktiveret virus i sæsonbestemt influenza

Den almindelige sæsonbestemte influenzavaccine bruger inaktiveret virus. Der er strenge regulatoriske hindringer for at anvende en levende virusvaccine. Det vil indebære "ganske betydelige vanskeligheder" at påvise effekten og få myndighedsgodkendelse i tide , siger George Kemble, næstformand for vaccineforskning og udvikling på MedImmune i Gaithersburg, Maryland, som fremstiller levende influenza-virusvaccine. [7040]
Hvor lang tid vil fremstilling af en ny vaccine tage?

To faktorer afgør i vid udstrækning, om en vaccine kan beskytte et stort antal mennesker under en pandemi. Dyrkning af vacciner i hønseæg er den vigtigste tidsforsinkelse i produktionen af en ny vaccine. Forsinkelsen før betydelige mængder af vaccine blevet tilgængelig er normalt omkring seks måneder på grund af den tid, der kræves for at dyrke virusset i hønseæg. (Cellekultur og andre teknologier ville kunne være hurtigere, men disse er endnu ikke klar til brug.) [7040]
Den anden begrænsende faktor er produktionskapaciteten, der i øjeblikket er på omkring 700 millioner til 900 millioner doser af sæsonbestemt influenzavaccine årligt. [7040]
Vaccineproduktionskapacitet

Selv om den stadig er begrænset, er produktionskapaciteten nu i 2009 langt bedre end fem år i 2004 (i øjeblikket er kapaciteten 700 – 900 millioner doser af sæsonbestemt influenzavaccine årligt – men omkring 2004 var det omkring 300 millioner). Kapacitetsforøgelsen skyldes hovedsagelig foranstaltninger truffet af regeringer til at forberede sig på en pandemitrussel. [7040]
Indholdet af den sæsonbestemte vaccine

Den sæsonprægede vaccine indeholder antigener mod tre cirkulerende influenzastammer. [7040]
Et skift til at producere en enkelt vaccine mod kun den nye H1N1-virus kan i princippet medføre, at de eksisterende vaccineproducenter ville kunne fremstille tre gange så mange doser. [7040]
Men selv om verdens vaccineproducenter skiftede helt til at producere en inaktiveret H1N1-vaccine, kan højst ca. 1 milliard doser forventes at foreligge ved udgangen af året 2009, omkring tidspunktet for den nordlige halvkugle influenzasæson. [7040]
Efterson befolkningen har meget lidt elle ingen eksisterende immunitet må vaccinen sandsynligvis gives i to doser – hvilket reducerer det faktiske antal af vacciner til 500 millioner [7040]
Levende virusvacciner vil reelt øge produktionskapaciteten – virus i en sådan vaccine er i stand til at formere sig i mennesker, så meget lavere doser kan gives. [7040]
Levende virusvacciner kræver heller ikke adjuvanser (hjælpestoffer) til at styrke deres effektivitet, kan administreres nasalt (ved forstøvning i næsen) – undgår behovet for sprøjter – og menes at fremprovokere et bredere og stærkere immunrespons end inaktiveret vaccine. [7040]
Ét æg kan give én dosis af inaktiv vaccine – men for en levende vaccine giver et æg et sted mellem 50 og 100 doser. [7040]
Produktionskapaciteten vil også afhænge af, hvor godt den nye H1N1 virus kan dyrkes. Nyhederne om dette synes at være gode. [7040]
Doris Bucher, en immunolog på New York Medical College, blev af US Centers for Disease Control and Prevention i Atlanta, Georgia, bedt om at hjælpe med at dyrke de første referencestammer, som kunne sendes til producenterne. "Vi har lavet 7 cyklusser, hver på 42 timer, og det går meget godt," siger hun. [7040]
Det immunrespons, der frembringes af den resulterende vacciner, skal så afprøves i kliniske forsøg. Hvis der for eksempel kræves tre gange så meget antigen som ved sæsonbestemt influenza til at frembringe et tilstrækkeligt immunrespons, vil det reducerede den teoretiske produktionskapacitet til en tredjedel. [7040]
For at dyrke levende, svækkede vacciner, vil forskere rekombinere (reassort) det nye influenza-stamme med en 25° C kulde-tilpasset stamme, som vil formere sig i næsen, men som ikke kan vokse ved de højere temperaturer i de nedre luftveje. [7040]
Kun to forskergrupper har teknologien til at producere levende, svækket influenzavaccine: MedImmune og Nobilon, et datterselskab af Schering-Plough, som har fået licens på en teknologi, som er udviklet på Institute of Experimental Medicine i St. Petersborg, Rusland. [7040]
MedImmune's FluMist er godkendt til brug i USA for aldersgruppen 2-49 år, idet ældre mennesker har været udsat for tidligere pandemisk virus, og deres immunforsvar dræber derfor den levende vaccine for de virusstammer, som i øjeblikket cirkulerer. [7040]
WHO har opnået en licens fra Nobilon til at give producenterne i udviklingslandene lov til at bruge den russiske teknologi. [7040]
Producenter af inaktiveret vaccine synes skeptiske over for at bruge levende, svækkede vacciner mere bredt, selv i en pandemisk situation. [7040]
At gå over til en levende vaccine ville betyde indførelse af nye produktionsmetoder og muligvis kræve at firmaet måtte købe licens på speciel teknologi, f.eks. MedImmune's teknologi. [7040]
Der er også spørgsmål om sikkerhed og ansvar, fordi det vil være svært at organisere kliniske forsøg med en uafprøvede vaccine hurtigt nok. [7040]
Jesse Goodman, der er ledende forsker i den amerikanske Food and Drug Administration, bemærker, at levende, svækket vaccine er godkendt i USA for børn og unge voksne, der "kan er særlig udsat for smitte" under det aktuelle H1N1 udbrud i 2009. Sikkerhed er imidlertid afgørende, tilføjer han: "Det er også vigtigt at huske på, selv i lyset af en pandemitrussel, at det var vigtigt at gøre alt, hvad der er hensigtsmæssigt og muligt for at sikre høj vaccinekvalitet og sikkerhed, især når det overvejes at tage nye metoder og produkter i brug " [7040]
Mange husker stadig levende fiaskoen med 1976 influenzavaccinationen. Det år dukkede en ny svineinfluenza op ved en militærkaserne i New Jersey, og dræbte en person, men virusset spredte sig ikke yderligere. En massevaccination blev anbefalet til præsident Gerald Ford, som godkendte den, men massevaccinationen forårsagede neurologiske bivirkninger i nogle mennesker og dræbte 25 personer. [7040]
Foreløbige oplysninger tyder på, at vaccineproducenterne er godt på vej med fremstillingen af de sæsonbestemte H1N1 og H3N2 stammer for den nordlige halvkugle, men har problemer med at dyrke den tredje influenza-B-stamme. [7040]
En mulighed kan derfor være at udelade influenza-B ved næste års vaccine. Den nordlige halvkugles vaccineproduktion ville derved være fri til hurtigere at arbejde på udvikling af en svineinfluenzavaccine. [7040]
Den sydlige halvkugles vaccinefremstilling begynder typisk omkring november og fortsætter til slutningen af marts. [7040]
Mængderne af vaccine, som indkøbes af lande på den sydlige halvkugle, er langt mindre end indkøbene af lande på den nordlige halvkugle, hvilket betyder, at fabrikanterne ville have ekstra tid til at arbejde på en svineinfluenzavaccine til de nordlige lande. [7040]
Et scenario er, at fuld-skala produktion af svineinfluenzavaccine tidligst kan begynde i juli 2009. [7040]
Den nye H1N1 stamme er stadig modtagelig for virusmidlerne oseltamivir (Tamiflu) og zanamivir (Relenza). Billigere og mere bredt tilgængelige antibiotika og anti-inflammatoriske midler, såsom statiner, kunne også tænkes at ville begrænse dødeligheden under en svær pandemi. [7040]

Baggrund

I mange år har forskere antaget, at nye influenzastamme kan opstå, når et fugleinfluenzavirus inficerer svin, der samtidig er inficeret med menneskeinfluenzavirus. Denne dobbeltinfektion i den samme vært, sammen med en eventuel 3. saminfektion af et svineinfluenza-virus giver mulighed for rekombination (reassortment) af virussets genetiske materiale hvorved der kan opstå et virus, som er nyt for mennesker, og som kan inficere mennesker og overføres mellem mennesker [6955]
Fugle og mennesker får sjældent influenza-vira, der er tilpasset til en anden værtsart. Men sådanne vira kan overføre influenza til svin. Svin har også deres egne virusstamme. Hvis et svin smittes af to typer af influenza samtidig kan svinet virke som et blandekar. Hybrid-vira kan opstå med gener fra begge virus. Det er formentlig, hvad der skete.

Svin er modtagelige for de samme influenza A virussubtyper som mennesker: nemlig H1N1, H3N2 og H1N2.
Mange svineinfluenzavirus er resultatet af rekombination (reassortment), idet deres gener er sammensat af menneske- og fuglevirusgener og / eller svinevirusgener.
Det er kendt, at både menneske- og fugleinfluenzavira undertiden smitter svin, og at svin kan fungere som "blandekar" for disse vira. Dermed kan vira udveksle genetisk materiale og fremstå som en ny "hybrid"-virus.
Pandemisk virus kan vise sig efter reassortment hos svin.
Influenza er en væsentlig årsag til akut luftvejssygdom hos svin. Subkliniske infektioner er også almindelige hos svin.
Symptomerne og sygdomsvirkningerne af influenza hos svin viser bemærkelsesværdige ligheder med de sæsonbetingede influenza hos mennesker. Men epidemiologien er anderledes på grund af den ekstremt hurtige omsætning af svinepopulationen med konstant indførelsen af immunologisk naive dyr i svinebesætninger.
Ved udgangen af den seks måneder lange opfedningsperiode har mange svin haft infektioner med to eller endda tre svineinfluenza-subtyper.
Virus i Europa afviger signifikant i deres antigene og genetiske opbygning fra de virus, der cirkulerer i Nordamerika, selv om de består af de samme H og N subtyper.
Mennesker, der er i kontakt med svin, bliver undertiden smittet med svineinfluenzavirus. Men menneske-til-menneske smitte af svineinfluenza synes at være sjælden.
Mennesker, der arbejder med svin i Europa og Nordamerika, er langt mere tilbøjelige end andre til at blive smittet med potentielt dødelige patogener, såsom MRSA (methicillin-resistente Staphylococcus aureus), resistente E. coli og Salmonella, og selvfølgelig infektion med svineinfluenza. Mange forskere antager også, at mennesker, der arbejder i store "svinefabrikker" (CAFOs) er mere udsatte for at kontakte og sprede disse og andre "zoonotiske" sygdomme, udgangen mennesker, der arbejder på mindre svinefarme, med udendørs folde eller græsarealer, hvor svinene går langt mindre tæt.
Eksempel: En midaldrende kvinde i Spanien fik en så mild influenza-lignende sygdom, som få læger ville have taget en virusprøve for. Men den alment praktiserende læge, som hun kontaktede, deltog tilfældigvis i et aktivt influenzaovervågningsprogram og en virusprøve blev taget og påvist at være influenza A (H1N1) fylogenetisk tæt paa europæiske H1N1 svineinfluenzavirus. Dette var før 2009-epidemien med svineassocieret influenza A/H1N1.
Indtil marts-april 2009 har mennesker, der arbejder med svin, sjældent inficeret andre mennesker med svineinfluenza, med undtagelse af nære familiemedlemmer. Og det er grunden til, at den nye 2009-stamme svinerelateret H1N1-influenzavirus er så forvirrende – og alarmerende. Den synes at spredes meget nemt ved tilfældig menneskelig kontakt.
Den fortsatte cirkulering af svineinfluenzavirus og andre infektioner i store dyrebesætninger eller dyreflokke giver øget mulighed for dannelse af nye virustyper ved mutationer eller rekombinationer, som kan resultere i mere vírus, der er mere effektive til at spredes mellem mennesker. Hertil kommer, at landarbejdere danner en bro mellem dyrene i kæmpestore dyrefarme og lokalsamfundet. Denne broeffekt øger risikoen for dannelse af nye virustyper ved at menneskevirus kan komme ind i dyrebesætningen og her tilpasse sig til forholdene i dyrene [6989, PEW Kommission for Industrielle husdyrgenetiske Produktion, http://ncifap.org/]

Rekombinerede influenzavirus (reassortant influenzavira) med humane komponenter har hærget den moderne svineindustri. Sådanne nye vira øger potentielt risikoen for zoonotisk sygdomsspredning i de lokalsamfund, hvor de ansatte på svinefarmene bor.
64% af 63 personer, der var tæt på mennesker, som var smittet med H7N7 fugleinfluenzavirus, udviste serologisk bevis på, at de havde haft en H7N7-infektion efter fugleinfluenzaudbruddet blandt fjerkræ i Holland i 2003. Ægtefællerne til arbejdere på svinefarme, der ikke havde nogen direkte kontakt med svin, indeholdt hyppigere antistoffer mod svineinfluenzavirus. I lokalsamfund, hvor der boede et stort antal mennesker, som arbejdede i industrielle dyrefarme, er der et stort potentiale for, at disse arbejdere øger smitte med pandemisk influenzavirus. Officielt betegnes de "confined animal feeding operations," eller "CAFOs" [udtalt KAY-fohs], medens de fleste mennesker kender dem "factory farms." (animalske fabrikker). I de sidste mange år, har amerikanske storfirmaer inden for svineavl kæmpestore industrifarme for svin i Mexico, herunder snesevis omkring Mexico City og i de mexicanske delstater Puebla og Veracruz [6989]
Gregory Gray, en professor i international epidemiologi ved University of Iowa og ekspert i zoonotiske infektioner, advarede om, at landbrugsmedhjælpere på industrifarme kunne tjene som bro for virus til lokalbefolkningen. Industrilandbrug kunne føre til en ny 1918-pandemi. Måske smittede fugle svin i USA med en ny tytpe fugle/svine-supervirus, som hurtigt smittede landbrugsarbejdere, måske i Iowa, som tog til militærlejre for at træne til 1. verdenskrig, og derfra spredte 1918-virusset verden over [6989]
Industrilandbrug er ikke hermetisk lukkede miljøer. Patogener kan komme ind og ud via arbejdere på svinefarme eller fluer, via gyllepøle og genbrugt vand i stalde (svindende grundvandreserver er et særlig problem i dele af Mexico). Vilde fugle lander i laguner og kan medbringe influenzavirus til vandet. Industrilandbrug har meget ventilation, idet et stort antal af dyrene ville dø af varmestress medmindre bygningen blev ventileret. Forskerne har målt bakterier og vira i miljøet omkring fjerkræ- og svineanlæg [6989]
Intensiv drift af kyllingeavl og svineavl i industrilandbrug bidrager til at fremskynde virusudviklingen [6989]. Under en igangværende epidemi er det ikke så vigtigt at vide, hvor virusset udviklede sig, som at lokalisere virusset, og standse dets spredning [6989]
• Sikre at fugle ikke kan få adgang – Alle døråbninger, vinduer og lugtventilationskanaler i svinebygninger bør være tilstrækkeligt forseglet for at forhindre indtrængen af fugle.
• Vandbehandlingsanlæg – Der bør ikke anvendes ubehandlet overfladevand som enten drikkevand eller vand til rengøring i svinefarme. Ligeledes kan det være fornuftigt at forsøge at minimere vandfugles brug af gårdens affaldslaguner.
• Adskillelse af svine-og fjerkræproduktion. Der bør ikke avles svin og høns på det samme landbrug.
• Sikkerhed vedrørende foderet. Svinefoderet bør opbevares i lukkede beholdere til at undgå forurening med ekstrementer fra overflyvende vandfugle.
• Arbejderes biosikkerhedspraksis. Der bør være støvler, som kun bruges inden for svineanlægget.
Svin flyver ikke, men hvert år flyver mere end to millioner vilde vandfugle op til 1.500 miles eller mere mod øst hele polarhavet fra Asien til Nordamerika og møder her nordamerikanske arter. I oktober 2008 offentliggjorde US Geological Survey en undersøgelse i Molecular Ecology, hvor de beskrev fund af genetiske beviser for (ikke-H5N1) influenzavirus i spidsænder i Alaska, hvis gener var mere tæt forbundet med asiatiske fugleinfluenzastammer end ved virusstammerne i Amerika. (Spidsand lever i moser og strandenge i Nordeuropa, Asien og Nordamerika) [6989]
Vilde fugle kan bære virus med svineviruskomponenter. Mange fugleinfluenzavira indeholder elementer fra svinevirus. En asiatisk fugleinfluenzavirus kan indeholde svineinfluenza-komponenter fra eurasiske svin. Et svin, der er inficeret med en fugleinfluenzavirus, kan komme i kontakt med svineinfluenzavirus, som derefter kunne rekombinere og smitte en fugl igen [6989]
Grise flyver ikke, men svinekød gør. Der er en aktiv international overførsel af alle former for animalske produkter – nogle af dem er importeret fra Asien eller Europa til Nordamerika. "[6989]
Og mennesker flyver. Menneskers rejse er den mest sandsynlige måde, hvorpå eurasiske svineinfluenzavirus-komponenter kom til Mexico. En turist fra Kina kunne have rejst til Mexico City, og den asiatiske virusstamme kan være blevet samlet op af en anden person, som arbejdede på en svinefarm [6989]
En bekymring er, at nye stammer af fugleinfluenza, der er rekombineret med svineinfluenza, kan gøre svineinfluenza mere dødelig, og fordi virus passerer så let mellem svin og mennesker, kan en sådan ny fugleinfluenzakomponent gøre svineinfluenza mere virulent [6989]
Når mennesker bliver syge af svineinfluenza ligner symptomerne sygdom forårsaget af infektioner med human influenzavirus. Lungebetændelse og død er undertiden blevet rapporteret i litteraturen hos i øvrigt raske voksne. Men infektioner hos mennesker med svineinfluenzavirus er normalt langt mildere end dem, der ses ved infektion med fugleinfluenza A (H5N1).

I 1976 blev et udbrud af svineinfluenzavirusinfektioner hos mennesker opdaget hos rekrutter i en militærlejr i Fort Dix, New Jersey i USA. Den formodede link til svin blev aldrig opdaget, men der var omfattende menneske til menneske smitte, med over 200 infektioner resulterende i 12 indlæggelser og et dødsfald. Det var mennesket til mennesker smitte af en ny influenza-virus, som kan beskrives som WHO Pandemi Fase 4.
Den sande incidens af svineinfluenza hos mennesker er ukendt. Dvs.: Det er ukendt hvor mange mennesker som smittes med svineinfluenza pr. år.
Det er kendt fra USA, at de få rapporterede tilfælde af svineinfluenza hos mennesker repræsenterer et større antal upåviste infektioner blandt mennesker, der har kontakt med svin. Men to faktorer begrænser sandsynligvis smitte af mennesker: Virusset har formentlig begrænset fitness i en anden værtsart, og måske beskytter immunitet for menneskets H1 eller H3 influenza-virus mod infektion med svineinfluenzavirus.
Nogle forskere har anbefalet sæsonbestemt influenzavaccination til personer, der arbejder med grise til at reducere deres risiko for at blive smittet. Men erfaringerne med mennesker, som arbejder med fjerkræ, opfordrer ikke til at man vaccinerer. I en vurdering af et sådant vaccinetilbud i Europa var konklusionen at vaccinen blev optaget dårligt, og at de, der blev tilbudt vaccination, var forvirret over, hvad de blev tilbudt beskyttelse imod.
I 1998 hybridiserede svine-H1N1 med menneskeinfluenzavirus og fugleinfluenzavirus, hvilket resulterede i svin-menneske-fugl triple-rekombinationer "reassortants". Virusset dukkede op i Minnesota, Iowa og Texas. Denne tredobbelte rekombination (reassortant) hos svin synes at være en forløber for den mexicanske influenza i 2009. Virusset havde oprindeligt menneskevirus-overfladeproteiner og indre svinevirusproteiner, med undtagelse af tre gener, der laver RNA-polymerase (enzymet for virusreplikation). To af disse tre afgørende gener var fra fugleinfluenza-virus, og en var fra menneskeinfluenzavirus. Forskere mener, at fuglepolymeraseenzymet tillader virus at kopiere sig selv hurtigere end virus med menneskevirus- eller svinevirus-versioner, – hvilket i så fald vil gøre virusset mere virulent [6978]
Svinevirus-versionerne med disse hurtigere kopierende fugleviruspolymerase-enzymer udkonkurrerer let de vira, som ikke har disse hurtige polymerase-enzymer, således at disse nye vira i 1999 udgjorde de dominerende influenzastammer i nordamerikanske svin. I modsætning til de svineinfluenzavirus, som de erstattede, udviklede de sig hurtigt, og i 2009 var der mange udgaver med forskellige svinevirus-overfladeproteiner eller menneskevirus-overfladeproteiner – herunder en med H1 og N1 fra den oprindelige svineinfluenzavirus. Dette er præcis som den mexicanske influenza fra marts-april 2009 [6978]
Alle disse vira indeholdt stadig samme "kassette" af interne gener, herunder fuglevirus- og menneskevirus-polymerasegenerne. Men virusserne havde udskiftet deres overfladeproteiner for derved at undgå svinenes immunsystem. Polymerasegensekvenserne var af fuglevirus- og menneskevirus-type, men alligevel blev disse virus i mange år kun rapporteret hos svin [6978]
Der var i 2009 så mange slags svineinfluenzatyper, at svineinfluenza ikke længere var sæsonbetinget. En ud af fem svineproducenter i USA producerede deres egne vacciner, fordi vaccineproducenterne ikke kunne holde trit med virusændringerne [6978]
Denne hurtige udvikling udgør et potentiale for pandemisk influenza. Forskere, der fokuserede på svineinfluenza, kunne se truslen udvikler sig, hvorimod de medicinske forskere, der fokuserer på menneskeinfluenzavirus, syntes at have været uvidende om denne trussel. [6978]
Omkring 2004 advarede flere forskere om, at svin i USA var blevet et stadig vigtigere reservoir af virus med human pandemisk potentiale. Hver femte svinearbejdere i USA har vist sig at have antistoffer mod svineinfluenza i kroppen, hvilket viser, at de er blevet smittet, men de fleste mennesker har ikke havde nogen immunitet over for disse vira. Også den amerikanske sygdomsvarslingsinstitution CDC advarede i 2008 om, at svine-H1N1 vil udgøre en pandemisk trussel, hvis virusset begyndte at cirkulere blandt mennesker [6978]
Immunresponset i kroppen gør hele forskellen mellem en mild sygdom og en dødelig sygdom. Vores immunrespons skyldes hovedsagelig virussets H-overfladeprotein. Den mexicanske virus fra 2009 bærer svinevirusversionens overfladeprotein. Derfor vil de antistoffer, som vi mennesker bærer mod menneskevirus-H1N1, ikke genkende virusset, der har svinevirustypen af H-proteiner på overfladen af viruspartiklen [6978].
Fuglevirus-polymerasegener er særligt bekymrende, da lignende gener er det, som gør H5N1-fugleinfluenza meget dødelig for pattedyr og altså mennesket, og som gjorde det pandemiske 1918-virus så dødeligt i mennesker [6978].
En russisk videnskabsmand forudsagde den dødelige svineinfluenzapandemi tilbage i 2004, da han forudsagde, at den dødelige fugleinfluenza ville kunne blande sig med menneskeinfluenzavirusset i kroppen af en gris. Professor Dmitry Lvov fra virusinstituttet på det russiske videnskabsakademi sagde på en konference, at op til en milliard mennesker kan blive dræbt inden for seks måneder, og at en sådan pandemi var muligt i 2005 eller senere. Pandemien ville kunne skyldes en mutation af H3N2-fugleinfluenzavirus, sagde han. Fugleinfluenzaen dræbte millioner af fugle i Sydasien. Ud af 45 mennesker, der blev smittet af fugleinfluenza, døde de 30. Det værste var, at virusset kom ind i en population af svin. Fugleinfluenzavirusset er ikke meget smitsomt for mennesker, men svin er ideelle "væksthuse" til at avle en ny stamme af virus, langt dødeligere end H5N1 eller H3N2 [6995]
The Veratect Corporation baseret i Kirkland, Washington, overvåger verdenspressen og regeringsrapporter for at give tidlige sygdomsadvarsler for deres klienter. Deres første fornemmelse af det mexicanske svineinfluenza A/H1N1 var en rapport fra 2. april 2009 om en stigning i luftvejssygdomme i byen La Gloria (Perote Kommune, Veracruz stat, Mexico), øst for Mexico City, som medførte dødsfald af tre småbørn [6978]. Omkring 3000 indbyggere, de fleste af indbyggerne i La Gloria, havde influenzasymptomer. 1300 blev undersøgt, og 450 af disse behandledes, skrev nyhedsmedierne senere. Svin blev dræbt som en forebyggelse, selv om influenza ikke blev fundet i svinene [7008, video fra La Gloria].
Først den 16. april 2009 – efter påskeugen, når millioner af mexicanere rejste for at besøge slægtninge – kom der rapporter om andre infektionssteder i Mexico [6978]
Lokale rapporter i La Gloria lagde skylden på svinebedrifternes ca. 8 km fra byen i det nærliggende Perote. Svinefarmene her ejes af Granjas Carroll, et datterselskab af den amerikanske gigantiske svineindustrikoncern Smithfield Foods. Bedrifterne producerer næsten en million svin om året. Smithfield Foods fastholder i en erklæring, at der var "ingen kliniske tegn eller symptomer" af svineinfluenza i deres svin eller i deres arbejdere i Mexico – men det var ikke overraskende, da selskabet også sagde, at det "rutinemæssigt vaccinerer svinebesætningerne mod influenzavirus". (Men selskabet ville ikke fortælle nærmere til New Scientist om de seneste test). Desuden forhindrer vaccination svin i at blive syge, men blokerer ikke for infektion eller smittespredning af virus [6978]
A "pandemi" er en epidemi, der bliver global. Teknisk er der en influenzapandemi hvert år, men udtrykket er normalt forbeholdt alvorlige udbrud. Influenzavirus udvikler sig konstant. Pandemier ske med nogle få årtiers mellemrum, når influenzavirusset får nye overfladeproteiner, som mennesker har meget lidt immunitet overfor, oftest fordi virusoverfladeproteinerne kommer fra en dyrevirusstamme [6978]
Den manglende immunitet betyder, at virusset påvirker flere mennesker mere alvorligt. H5N1-fugleinfluenza er meget farlig, fordi dens H5-overfladeprotein er helt nyt for mennesker – og fordi H5N1-fugleinfluenzavirus har dræbt mere end halvdelen af de mennesker, den har inficeret [6978]
Fugleinfluenzavirus fra H5, H7 eller H9 virusfamilier, som er ukendte for vores krop, behøver kun at blive meget smittefarlige for at medføre en pandemi [6978]
H1N1 har fået mindre opmærksomhed, tildels fordi en H1N1-stamme allerede cirkulerer i mennesker. Men den mexicanske stamme bærer forskellige versioner af H1-overfladeproteiner [6978]
Den nye stamme fra Mexico pakker en hurtigere virusmotor end tidligere H1N1-stammer. Med sit fugleinfluenzavirusgen er det blevet dominerende i svin – ingen ved, om dette vil gøre det farligt for mennesker [6978]

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Svineinfluenzagener i Kina – og diagnostiske midler.
HA-segmentet og 5 andre gen-segmenter er ifølge søgninger i gendatabanker fra det foregående h1.3.2 "klassiske" svineinfluenzavirus. De andre 2 gen-segmenter i virusset (NA og M) menes at være fra h1.1.3 ( "fugle-lignende") svineinfluenzavirus [6994].
De 3 klynger af H1 subtyper kan afsløres ved et RT-PCR-testsystem (ved hjælp af en øvre primer og 2 differentierede nedre primere med sekvenserne:
H1S-3: 5'-TAAGCAAAAGCAGGGGAAAATAAAA-3 '

H1R-1143: 5'-TGGTGATAACC (G / A) TACCATCCATCT-3 '

H1Rm-610: 5'-CACGAGGACTTCTTTCCCTTTATCAT-3 ' [6994].
Det er vigtigt at opdage det virale NA gen for at afklare, om virusset er magen til den nuværende A (H1N1) svineinfluenzavirus, som spreder sig i mennesker [6994].
Hvis mistænkelige prøver findes ved den ovennævnte påvisning af det virale HA-gen, kan følgende primer anvendes til at opformere og sekvensbestemme det virale NA gen [6994].
NAS-5A 5'-GCAAAAGCAGGAGTTTAAAATGAA-3 '

NAR-1108A 5'-GTTCTCCCTATCCAAACACCAT-3 '[6994].
Endnu et kit til påvisning af alle H1 subtype-svineinfluenzavirus er:
H1-762U: 5'-TATCAACAATAAGAA-3 '

H1-762L: 5'-CAAACATCCAGAAGA-3 '
Den øvre primer H1-762U er placeret på et meget variabelt område i målgenet, så specificiteten af primerne kan ikke garanteres [6994].
Endnu et kit til påvisning af det nuværende A (H1N1) svineinfluenzavirus, der er cirkulerer blandt mennesker, er [6994].
H1-292U: 5'-CATTAATGATAAAGG-3 '

H1-292 L: 5'-TCCAGCATTTCTTTC-3 '[6994].
Da primerne er for korte kan specificiteten af primerne og den effektive kombination af primerne til de tilsvarende regioner ikke garanteres [6994].
De fleste af de influenza-virus, der cirkulerer blandt svin i Kina, har været H1N1 (klynge: h1.3.2 "klassiske") og H3N2 (klynge: h3.1.5) svineinfluenzavirus [6994].
De pågældende virus inden for klynge h1.1.3 ( "fugle-lignende") blev isoleret udelukkende fra svin i 2007 i Kina [6994].
H9N2 subtype fugleinfluenzavira er blevet isoleret fra svin i Kina siden 2003 [6994].
H5N1 subtype fugleinfluenzavirus blev kun én gang isoleret fra svin i 2005 og (indtil 2009) aldrig efter, at Kina har gennemført obligatoriske H5-vaccinationer af fjerkræ [6994].
Et par humane H3N2 og H1N1 undertyper af influenzavirus er også blevet isoleret fra svin i Kina [6994]
Desuden så det ud til, at rekombination (reassortment) af gensegmenterne af influenzavirus fra forskellige oprindelser var temmelig hyppige hos svin i Kina [6994]
En rekombineret (reassortment) subtype af H1N2-svineinfluenzavirus er blevet påvist siden 2004 [6994].
I marts-april 2009-versionen af A (H1N1) svineinfluenzavirus, som spreder sig i mennesker, er aldrig blevet isoleret i Kina trods overvågning af flere forsknings-grupper igennem det sidste årti i Kina. Men med erfaringerne fra de seneste fremkomst af et farligt menneskeinfluenzavirus, formodentlig direkte fra svin i Nordamerika, er det af stor betydning at foretage grundig overvågning af influenza-virus, der i lang tid er cirkuleret blandt svin i Kina. Den A (H1N1) influenzavirus, som marts-april 2009 spredtes hos mennesker, er meget farlige for Kina, som har en meget stor befolkning og begrænsede hygiejneressourcer [6994].
Epidemiens sygelighed og dødelighed kan, hvis den udbredes i Kina, være lige så høj som i Mexico, da begge lande er udviklingslande, og dermed kan tusindvis af unge mennesker i Kina dø på grund af infektionen. Derfor er det rationelt for Kina til at træffe nogle strenge foranstaltninger til at forhindre sygdommen i at sprede sig til Kina, i overensstemmelse med forskrifterne af World Organisation for Animal Health (OIE) [6994].

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Bakterielle co-infektioner?
De dødsfald, der ses fra influenzaen i Mexico, kan skyldes en kombination af virus- og bakterieinfektioner. Tre observationer gør det meget sandsynligt, at den influenzadødsfaldene i virkeligheden skyldes tilstødende bakterieinfektioner.
1. I en undersøgelse (Ramilio m.fl.., Blood, 2007) af mennesker med influenza-symptomer konstaterede man, at mere end 30 procent af dødsfaldene var mennesker med bakterie/influenza co-infektioner. Da man ved, at der er utilstrækkelighed diagnosemuligheder kan antallet af co-infektioner være langt højere end 30 procent, måske endda 90 procent ved dødsfaldene [6994].
2. "Tilfælde nul" (the index case) i Mexico var en lille dreng, der blev alvorligt syg, men hans læge gav ham et antibiotikum (hvilket er normalt for bakterielle infektioner), og drengen overlevede. Den omstændighed, at han fik det bedre 2 dage efter at have fået antibiotikum kan indikere, at han havde en bakteriel infektion som supplement til influenza-infektionen [6994].
3. En af de tidligste mexicanske dødsfald var en kvinde i 40'erne, som var diabetiker. En lungebiopsi indeholdt influenzavirus. Adskillige mennesker omkring hende havde respiratoriske sygdomme, men ingen af dem var positive for influenzavirus! Det betyder, at det er muligt, at hun også havde både influenza og bakterielle infektioner, der førte til hendes død [6994].
Det er velkendt, at influenzavirus-infektioner kan medføre, at bakterielle infektioner i luftvejene lettere opretholdes – og omvendt at bakterieinfektioner gør personen mere følsom for virusangreb [6994].
For at sikre sig mod influenza-relaterede dødsfald kan læger ordinere mere antibiotika. Men da udgifterne til antibiotika er høj, og da over-ordinering af antibiotika er farligt på grund af resistensrisiko, bør der foretages diagnostik, der kan diskriminere mellem virale og bakterielle infektioner. Der er allerede en FDA-godkendt graviditet-test [produceret af Rapid Pathogen Screening (RPS), Inc.], der kan afgøre, om tårer fra en person med øjenbetændelse har en bakteriel eller en viral infektion (ved testen bruges antistoffer mod MxA- og C-reaktive proteiner, som er tidlige værtssvar mod enten virale eller bakterielle infektioner). Molekylærbiologer har fundet ændringer i cirkulerende H3N2-virus samt H1N1-virus, og da diagnosen er dårlig, kan meget af det, der blev beskyldt for H1N1-infektion, have været H3N2 (eller en anden virus eller bakterie eller en co-infektion). Langt mere burde sættes ind på udvikling af værtreaktion-diagnostik, da der er omkring 100 kendte værtsproteiner, der kan skelne mellem akutte bakterieinfektioner og akutte virusinfektioner. Ekspressionen af disse proteiner i plasma skulle gøre det muligt at forskelsbehandle de alvorlige tilfælde fra de milde tilfælde. Men antibiotika bør kun anvendes med sandsynlige bakterieinfektioner – og hvad der også er vigtigt er at benytte passende antibiotika, f.eks anti-stafylokok midler, hvis der mistænkes en stafylokok-lungebetændelse snarere end en pneumokok-lungebetændelse. Ved 1957-pandemien var S. aureus den næstvigtigste (efter pneumococcus) som en årsag til sekundær bakteriel lungebetændelse, men mange andre organismer kan forårsage sekundær bakteriel lungebetændelse. Et andet spørgsmål til diskussion er behovet for at have et tilstrækkeligt udbud af antibakterielle stoffer til rådighed samt antivirale midler ved tilstedeværelse af en pandemi. Den bekymring, som mange infektionssygdomeksperter i USA har, er at vi ikke har en sådan leveringssikkerhed, og at der er utilstrækkeligt med nye antibiotika i støbeskeen for at håndtere nye tilfælde af bakterieresistens [6994].

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Information til laboratoriepersonale:

CDC's vejledning til laboratoriepersonale: diagnostiske test for mistanke om svineinfluenza A (H1N1) bør udføres på et BSL2 laboratorie, prøvetagning bør ske inde i et biosafety-cabinet, og isolering af virus i et BSL2 laboratorium med BSL3-praksis (forøgede BSL2-betingelser) [6955, fredag den 24. april 2009]

Yderligere forholdsregler omfatter:

• Personlige værnemidler (baseret på stedspecifik risikovurdering)

• Åndedrætsværn – fit-testet N95-maske eller højere beskyttelsesniveau.

• Dække til sko

• Kittel (closed-front gown)

• Dobbelte handsker

• Øjenbeskyttelse (beskyttelsesbriller eller ansigtsskjold) [6955]

Passende desinfektionsmidler

• 70 procent ethanol

• 5 pct Lysol

• 10 pct blegemiddel [6955]

For personale, der har været udsat for ubeskyttet eksponering eller en kendt brist med hensyn til de personlige værnemidler til klinisk materiale eller levende virus fra et bekræftet tilfælde af svineinfluenza A (H1N1), skal antiviral forebyggende behandling med zanamivir (= Relenza) eller oseltamivir (= Tamiflu) i 7 dage efter eksponeringen overvejes [6955]
Oseltamivir (varenavn Tamiflu ®, fremstillet af Roche AG), er godkendt til både at behandle og forebygge influenza A- og B-virusinfektion hos mennesker fra 1 års alderen og ældre [6958]
Zanamivir (varenavn Relenza ® fra GlaxoSmithKline) er godkendt til behandling af influenza A-og B-virus-infektion hos mennesker fra 7-årsalderen eller ældre og til at forebygge influenza A og B virusinfektion hos mennesker fra 5-årsalderen og ældre [6958]
Oseltamivir (= Tamiflu, produceret af Roche AG)

reducerede sygdommen med en dag, fra omkring 5 dage til omkring 4 dage [TV DR1 27 Apr.2009 aften]
Oseltamivir (= Tamiflu, produceret af Roche AG) og Zanamivir (varenavn Relenza ® fra GlaxoSmithKline) er begge neuraminidasehæmmere.

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Påvisning af virus

Virus kan påvises med flere midler. InDevR (www.indevr.com) er en lille biotekvirksomhed i Boulder, Colorado, grundlagt 2003, som har købt licens til FluChip teknologien fra University of Colorado og CDC. M-gen versionen af FluChip kan afsløre svineoprindelig H1N1 influenza A virus og kan klart skelne dem fra sæsonbestemt influenza-vira (A/H1N1 og A/H3N2) samt dødelig A/H5N1 fuglevirus. M-gen udgave af FluChip er mere robust, fordi det diagnostiske mål er et stabilt, indre gen, som koder for virussets matrixproteiner. De nuværende qRT-PCR subtypebestemmelseprøver er målrettet mod et mere højtmuteret gen

, som koder for et protein, hemagglutinin (HA), som er underlagt antigen drift. Som det er sket i fortiden, hvis HA genet ændres i en kritisk retning, vil qRT-PCR mislykkes og forskeren ikke vil vide hvorfor, før genet er igen sekvensbestemmes [7020; http://www.eurekalert.org/pub_releases/2009-05/uoca-ifd050509.php]

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Fremstilling af vacciner

6 maj 2009: Efter at H1N1-virusset var blevet fundet i en canadisk svinebesætning udviklede en forsker fra Iowa State University en H1N1 influenzavaccine til svin.
Hank Harris, professor i veterinær diagnostik og produktion af medicinn til dyr har etableret en virksomhed på ISU Research Park, Harrisvaccines, Inc., hvor man bruger en teknologi, der er meget hurtigere til at producere vacciner end de traditionelle metoder.
Teknikken kaldes "RNA Backbone" og blev udviklet til mennesker med en North Carolina selskab kaldet Alphavax. Harrisvaccines har tilpasset metoden til svin. Teknikken bruger elektrisk strøm for at kombinere RNA Backbone materiale med de relevante genetiske oplysninger fra det aktive influenzavirus ved en proces, der kaldes elektroporation. Harris konstaterer, at hans nye vacciner, der bruger RNA Backbone metoden, i øjeblikket er på vej til godkendelse og kan måske forventes at have en godkendelse fra United States Department of Agriculture i 2011. For nylig blev Harris' nye, hurtigere metode til fremstilling af vacciner anvendt under et udbrud af sygdommen Porcine Reproductive Respiratory Syndrome virus. Harris' Backbone metode gjorde det muligt at have vaccinen klar til brug inden for to måneder efter udbruddet. Denne forskning er blevet støttet af USA's Department of Agriculture's Small Business Innovation Research Program. Traditionelle produktionsmetoder kræver fem til seks måneder for at udvikle vacciner til mennesker og 11 til 12 måneder for svinevacciner. "Lige nu må man, for at fremstille menneske- eller dyrevacciner anvende levende virus og dyrke dem i æg eller cellekultur og derefter inaktivere det," sagde Harris. "Vi behøver ikke at gøre det." "Det er det, der virkelig smart ved denne teknologi, – du behøver virkelig ikke det levende virus," siger han. "Vi skal bare have generne fra den oprindelige virus, som kan fremstilles syntetisk." Harris har kun behov for virussets genetiske information, som er let tilgængelig. Den nye H1N1-virus er for eksempel allerede blevet genetisk kortlagt og er allerede offentlig tilgængelig på internettet [7021; http://www.eurekalert.org/pub_releases/2009-05/isu-isu050609.php]
Tjek disse hjemmesider for yderligere oplysninger og opdateringer:

www.cdc.gov/swineflu og www.cdc.gov/swineflu/investigation.htm.

The Association of Public Health Laboratories (APHL)'s internetside om svineinfluenza kan findes www.aphl.org/aphlprograms/infectious/outbreak/ Pages/swineflu.aspx [6955]

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2009-svineinfluenzaens historie

Februar 2009 – til begyndelsen af marts 2009: I februar døde en syv måneder gammel baby af lungebetændelse i landsbyen La Gloria i Veracruz delstaten i det sydlige Mexico. I begyndelsen af marts 2009 døde en to-måneder gammel baby i La Gloria. Forældrene fik at vide, at begge børn var døde af bakteriel lungebetændelse [6964]
18 marts 2009: Federal District of Mexico begynder at konstatere tilfælde af svineinfluenza [6966]
21 Marts 2009: Omkring 21 marts 2009 begyndte snesevis af mennesker i La Gloria at få lidelser med høj feber, voldsomme smerter og ondt i halsen, der førte til problemer med vejrtrækningen [6964]
Bertha Crisostomo, en kvinde, som var en leder i lokalsamfundet, tilkaldte myndighederne i byen Perote. Læger blev sendt ind med antibiotika og smertestillende midler [6964]
I Veracruz delstaten i det sydlige Mexico er svineproduktion en vigtig industri i småbyer i bjergene. På hver side af den lange lige vej til La Gloria trækker skrøbelige heste plove gennem de flade, sandede marker, og sende skyer af støv i vejret. Disse steder er små klinikker den eneste sundhedspleje [6964,6963]
Indbyggerne i La Gloria siger, at den fremherskende vindretning altid blæser den ildelugtende luft i deres retning, hvor lugten bliver hængende i luften på grund af bakkerne, som rejser sig lige bag landsbyen [6964]
28 marts 2009: Den tidligste startdato for svineinfluenza i USA, i henhold til CDC [6965]
2 april 2009: Edgar Hernández Hernández, en kær fireårig drenjg med et genert smil, som bor i et lille hvidt hus i La Gloria, havde en sygdom, der holdt ham i sengen i en uge: "Mit hoved gør meget ondt… Jeg kunne ikke ånde", fortalte han senere journalister, da han var blevet rask igen [6964]
3 april 2009: Lokale sygeplejersker tog en prøve fra Edgar's hals den 3. april 2009 og to uger senere blev denne prøve sammen med et parti andre prøver sendt til Centres for Disease Control and Prevention in Atlanta, Georgia.
Prøven blev testet positiv for en ny stamme af svineinfluenza. Edgar's var den tidligste prøve. (Edgar Hernández Hernández var en af en gruppe beboere, der blev syg af, hvad der var på det tidspunkt blev betegnet som en særlig slem influenza. Det blev senere reporteret, at kun én prøve fra denne gruppe, – den som kom fra drengen, var blevet bevaret) [6964] [6988]
9 april 2009: En dør til dør-skattekontrollør, Maria Adela Gutierrez, blev indlagt den 9 april 2009 med akut åndedrætsbesvær i nabostaten Oaxaca, og smittede 16 hospitalsansatte, før hun blev Mexico's første bekræftede dødsfald. Hun havde sukkersyge, og hun døde den 13 april 2009, fire dage efter at være blevet indlagt på det lokale hospital. Hun følte sig syg efter et møde med en vikar fra Veracruz, som syntes at have en meget slem forkølelse. Hun var en 39-årig kvinde ansat i skattevæsenet i Oaxaca og kan have haft kontakt med mange mennesker. Hun boede i den sydlige by Oaxaca, hovedstaden i staten af samme navn. Martin Vazquez Villanueva, der er den regional sundhedsminister i Oaxaca, benægtede lokale mediereportager, der sagde, at hun havde smittet 20 mennesker, såvel som hendes mand og børn [6963] [6988]
"Efterhånden begyndte vi at få det bedre, men det var virkelig forfærdeligt, mens det varede," fortalte Bertha Crisostomo fra landsbyen La Gloria senere journalister. "Lægerne fortalte os, at det kun var en atypisk forkølelse og intet at bekymre sig om, – og at det sandsynligvis var forårsaget af fluer fra svinefarveme, så de sendte hold af desinfektører til området for at gasse fluerne". Bertha Crisostomo blev selv syg i over en uge [6964]
"Vi så, hvad der foregik i Mexico City, og vi sagde til hinanden, at det var præcis, hvad der skete for os," sagde Rosa Jimenez senere til journalister. Mange familier i La Gloria har slægtninge, der arbejder i Mexico City, men der kom tilbage til landsbyen for påskeugens festligheder omkring 3-5 april 2009. "Kunne det være på den måde, smitten spredte sig til hovedstaden i Mexico City?" spurgte hun [6964]. Også folk fra La Gloria blev ved med at gå på arbejde i Mexico City på trods af sygdom, og kan have smittet mennesker i hovedstaden [6963].
Beboerne i La Gloria mener, at de fik sygdommen, før den 4-5 årige dreng Edgar. De bebrejder de enorme svinefarme i området, der tilhører den multinationale koncern Smithfield Foods. Svinene bor i modulstalde omkring dalen – i lange metalbygninger med store rektangulære gylletanke ved. Den nærmeste til La Gloria er nogle få kilometer nede ad en asfalteret vej og et par mere finde nede ad et vejspor med kaktur langs siderne. Gylletankene står åbne, tilsyneladende uden opsyn, og en ram lugt udsendes fra dem. Virksomheden har på det kraftigste benægtet, at dens svin havde noget at gøre med udbruddet [6964]
Der er stor frygt i La Gloria for, at selskabet vil blive vred over antagelserne om, at de kan have haft noget at gøre med infektionen. Mange mennesker ville kun tale med journalister på betingelse af anonymitet, bl.a. en mand, der gik og ryddede op uden for sit hjem: "Jeg var syg, min kone blev syg, mine børn, min tante. Vi var alle i seng med nøjagtig de samme symptomer, som vi nu får fortalt er svineinfluenza, "sagde han. "Men jeg ønsker ikke at udtale sig, fordi jeg er bange for det. Dette er en virksomhed med masser af magt og masser af dollars. De har altid været beskyttet af regeringen, og der er ikke meget, vi kan gøre ved det". Den mexicanske sundhedsminister, José Ángel Cordova (Angel Cordoba Villalobos), insisterede på, at Edgar, den 4-5-årige dreng, var det eneste tilfælde af svineinfluenza i La Gloria – skønt byens indbyggere siger, at hans sygdom kom flere uger efter, at de fleste i landsbyen havde været syge [6964]

Lokale sundhedsmyndigheder i Mexico gav en anden forklareing på infektionskilden: Infektionen kan have startet med en vandrende landbrugarbejder, der vendte hjem fra arbejde i USA og gav sygdommen til sin kone, som så igen viderebragte den det videre til andre kvinder i lokalsamfundet [6988]
Mandag den 8. april 2009: En 2-års barn (23 måneder) fra Mexico fik den nye svineinfluenza. Han døde mandag den 27. april 2009 (på et hospital i Houston, Texas). Han havde underliggende helbredsproblemer.
3-12 April2009 Semana Santa (~ 3-12 april, Palmesøndag til Påskedag), som er Mexicos næststørste ferietidspunkt. Mexico's befolkning er ca 90% katolske, hvilket resulterer i at talrige mennesker rejser i denne periode. I Ixtapalapa (i Mexico City) kommer en million mennesker på besøg under Semana Santa festlighederne. Andre velkendte lokaliteter for ferie omfatter Pátzcuaro, San Cristobal de las Casas (Chiapas) og Taxco.
Søndag 12 april 2009 (Påskedag): Menneske smitter svin: En svinefarm i Canada med 2200 svin (220 søer og deres smågrise i 2 stalde og 1800 opfedningssvin i 4 stalde) blev smittet af et menneske med A/H1N1. 450 svin blev smittet (23%). De døde så vidt vides ikke, eller dødeligheden var ikke tydeligt hævet.
[6993]. En tømrer, der var lejet af en canadisk gårdejer i Alberta (ALB-001), rejste til Mexico og vendte tilbage til Canada den 12. april 2009. Tømreren, svineavleren og hans familie blev syge med influenza-lignende symptomer omkring 14 – 29 april 2009 [6983]
Et team fra Canadian Food Inspection Agency (CFIA) undersøgte senere stedet den 28. april 2009 og indsamlede prøver fra svin for influenzavirus på CFIA National Centre for Foreign Animal Diseases (NCFAD) i Winnipeg. Prøverne blev kørt igennem konventionel RT-PCR for Matrixgenet og H1-genet. Disse resultater viste, at 19 ud af 24 prøver var positive for M-genet og 15 ud af 24 prøver var positive for H1-genet [6983]
Dette blev straks fulgt op af sekvensbestemmelse af disse PCR-produkter (6 prøver for Matrix-genet og 5 for H1-genet). Sekvenserne af et segment på cirka 244 nukleotider i Matrix-genet fra 6 prøver viste, at denne sekvens var 100 procent identisk med sekvenser, der stammer fra den nye A/H1N1 influenzavirus fra USA og Mexico og lignende resultater (99-100 procent identitet) fandtes for omkring 500 nucleotider i H1 genet fra 5 prøver [6983]
Sekvenserne, der er udvundet fra svine-prøver, var identiske med hinanden og for M-genet var lignede de mest det eurasiske linie, hvorimod H1-genet mere mindede om den nordamerikanske linie, som man ville kunne forvente for denne nye virus [6983]
Yderligere sekvensbestemmelse af en del af N-genet viste klart, at dette var et N1 virus og sekvensen af det ca. 1400 nukleotider lange fragment var meget beslægtet til nye A/H1N1 influenzavirus [6983]
Det blev således bekræftet, at dette var den nye A/H1N1 influenza-virus at den var meget tæt beslægtet med de humane virusstammer af den nye mexicanske svineinfluenza baseret på de gener, der hidtil var blevet sekvesbestemt [6983]
Man kan forestille sig, at lignende situationer er opstået i andre lande, hvor H1N1-inficerede mennesker har haft kontakt med tamsvin. Dette er særlig relevant for Mexico, hvor udbredelsen af den nye virus hos mennesker kan være stor. "Overvågning i svinefarme i Mexico forventes snart iværksat", sagde FAO senere, den 4. maj 2009 [6983]
De, der er involveret i overvågning af svinefarme, samt personalet på svinebestande, der mistænkes for at være smittede, bør vaccineres mod sæsonbetinget influenzavirus for at undgå eventuelle blandingsinfektioner [6983]
Efter afsløringen af A/H1N1 virus i svin i Canada overført af et menneske, the opfordrede FN's Food and Agriculture Organization (FAO) de nationale myndigheder og landmænd til at holde nøje øje med, om svinene har influenza-lignende symptomer [6983]
Det er ikke overraskende, at influenza-virus er i stand til at overføre smitte fra mennesker til dyr, som det ses i Canada [6983]
Alle tilfælde af lungesymptomerne hos svin blev anbefalet straks at blive indberette til veterinærmyndighederne [6983]
Når A/H1N1 influenza bekræftes bør der indføres restriktioner i 7 dage efter, at det sidste dyr er blevet rask [6983]
Personer, der arbejder direkte med svin, bør tilskyndes til ikke at gå på arbejde, hvis de har nogen tegn på luftvejssygdom, feber eller en influenzalignende sygdom [6983]
Mennesker, der håndterer dyr, og dyrlæger bør bære beskyttelsestøj for at minimere risikoen for at blive smittet [6983]
FAO understregede ([6984] 4. maj 2009, www.fao.org/news/story/en/item/19365/icode/), at der absolut ikke er grund til at slagte dyr med henblik på at forhindre udbredelsen af det nye A/H1N1 virus [6983]
FAO understreger, at A/H1N1 virus ikke kan overføres til mennesker af svinekød og svinekødsprodukter [6983]
ProMED [6993] skrev om dette: Historien om menneske-inficerer-svin viser tydeligt, hvordan den zoonotiske bro mellem dyr og mennesker er en 2-sporet motorvej. Mennesker og dyr kan mødes og overfører sygdomssmitte via mange uforudsigelige scenarier, som illustreret ved denne historie. Historien fremhæver også behovet for overvågning af svinefarme – især dem, hvor usædvanlige, tilfældige kontakter mellem et sygt menneske og svin kan være sket i begyndelsen af dette udbrud, før man fik kendskab til denne virus. Det understreger også betydningen af at holde syge mennesker borte fra svinefarme – dette bør være klart for alle [6993]
Svinefarme i Mexico, Texas og Californien i nærheden af stedet for starten på af de tidlige tilfælde af smittede mennesker bør på intensiv måde vurdere alle luftvejssygdomme og inddrage den nye influenza A (H1N1) i overvejelserne[6993]
En omfattende overvågning af svinepopulationer bør være en klar prioritet på dette tidspunkt i smitteudbruddet [6993]
Beslutningen om ikke at slå svinene ned kan meget vel skyldes, at svinene allerede var kommet sig efter tegn på luftvejssygdomme [6993].
Det er muligt, at virusset stammer fra svinepopulationer et sted i Nordamerika. Det er også muligt, at virusset stadig findes i nogle svinepopulationer et eller andet sted i Nordamerika, ukendt nøjagtig hvor. Da variationen af H1 subtyperne af influenzavira er meget kompliceret i svin, er det meget vanskeligt at foretage en test for de faktisk forekommende H1-undertyper af A/H1N1 i svin [6994].
Der er 3 hovedgrupper af H1 subtyper af svineinfluenzavirus, som cirkulerer i svin i verden. De kaldes h1.3.2 "klassiske", h1.2.5 "human-lignende" og h1.1.3 "fugle-lignende" [= "eurasiske", fordi næsten alle vira inden for denne gruppe er blevet isoleret fra Europa og Asien]. En anden klynge, h1.3.1 "gammel klassisk", svarer til klassisk svineinfluenza-virus, der var i omløb i verden i 1930'erne og 1940'erne, men som stort set er forsvundet fra verden [6994].
Det A (H1N1) svineinfluenzavirus, der spredte sig blandt mennesker fra marts-april 2009, tilhører klyngen af h1.3.2 "klassiske". Det er meget homogent til nogle nordamerikanske stammer, der er blevet isoleret efter år 1999 [6994].
Der er 2 hovedgrupper af N1 subtype svineinfluenzavirus, som cirkulerer i svin i verden. De kaldes n1.3.2 "klassiske" og n1.1.7. "fugle-lignende" ("eurasiske") [6994].
A (H1N1) influenzaen fra 2009 hører til den klynge, der kaldes n1.1.7 ("fugle-lignende") – og er meget homogen med mange eurasiske stammer, og med mindst 2 nordamerikanske stammer, der er isoleret i det seneste årti [6994].
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Omkring 15 april 2009: Virus blev sekvensbestemt i fuldt omfang. Virussets genetik: 14 kilobaser langt, omfattede otte gener, som koder for overfladeproteinerne hemagglutinin (H) og neuraminidase (N), matrix'en, der omgiver kernen, nukleoproteinet selv, og tre polymerase-enzymer kaldet PA, PB1, og PB2. Det havde ligheder på omkring 94% af hemagglutinin [H] genet til nærmeste kendte stamme – og var næsten lige så langt fra svineinfluenzavirus fra USA og fra Eurasien. Neuraminidase-genet og matrix-genet var nære slægtninge til svineinfluenzavirus-gener fra Asien. PA (fugleinfluenza), PB1 (human-influenza), og PB2 (fugleinfluenza). Menneskevirus-influenzagenet har været kendt i svineinfluenzavirus siden 1998. Neuraminidase- og matrix-generne er ikke set i nordamerikanske svineinfluenzavira før.
De var to nye spillere fra Asien. Virus fra det amerikanske midtvesten blev eksporteret til Asien, da Korea og mange andre lande importerede svin fra USA Så i virkeligheden kunne virus komme fra Asien eller fra Europa – fra en person. Det kunne tyde på, at blandingen ikke skete i Mexico. Hemagglutinin-genet er specielt, og det er ukendt, hvor det har udviklet sig [6974]
Virusset vokser ikke særlig godt i æg. Forskerne håber, at virusset vil forbedre dets evne til at vokse i æg, så det bliver lettere at fremstille en vaccine meget hurtigt. Men nogle lande har næppe en så god overvågning, at de gøre korrekt brug af sådanne vacciner [6974]
Tirsdag den 21 april 2009: CDC laboratorier bekræftede to tilfælde i Californien [6965]
Onsdag den 22. april 2009: I sag efter sag har patienter i Mexico klaget over at blive fejldiagnosticeret, afvist af læger eller nægtet adgang til lægemidler.
En 32-årig lastbilchauffør, Alejandro, havde en svær hoste, da han vendte tilbage til Mexico City fra Veracruz og snart efter udviklede han feber og hævede mandler. Han blev sendt til en række læger og til sidst til et stort hospital. På det tidspunkt havde han havde feber på 102 Fahrenheit og kunne knap nok stå oprejst. De sendte ham væk og sagde, at det var bare halsbetændelse. Hans kone, Monica Gonzalez, tog ham til Mexico City's bedste hospital for lungesygdomme", og han var så syg, at det var som om han var ved at dø i taxaen." Lægerne diagnosticerede lungebetændelse hos ham, men det kan have været for sent: Han havde fået etn sammenklappet lunge og var bevidstløs. Dette var den 22 april 2009 – og på dette tidspunkt var det medicinske samfund i Mexico City klar over, at der var en foruroligende udvikling i lungeinfektioner og Veracruz var blevet udpeget som et sted for bekymring [6963]
Torsdag den 23. april 2009: Mexico bebudede epidemien 23 april 2009 [6967]. Dette tidspunkt af året var meget sent for sæsonbestemt influenza. (Det var faktisk en lille smule lettere, at epidemien først kom ved slutningen af influenzasæsonen, fordi der så ikke var så meget støj med baggrundsinfluenza at kigge igennem for de læger, som forsøgte at følge sygdommens spredning). I de kommende dage blev militært personel set på gaden, hvor de distribuerede millioner af masker til folk og ledte efter mennesker med tegn på influenza. Sundhedsmyndighederne fik bemyndigelse til at isolere folk og til at foretage eftersøgninger i deres huse efter syge mennesker. Via TV fik folk med influenza besked på at kontakte lokale læger og hospitaler, hvilket resulterede i lange køer uden for lægehuse og hospitaler.
Fredag den 24. april 2009: I Danmark blev Else Smith, direktør for Center for sygdomsforebyggelse under Sundhedsstyrelsen, underrettet første gang om den nye sygdom d. 24. apr. 2009. I løbet af den følgende uge måtte hun give omkring 50 interviews til journalister og informere sundhedsministeren fem gange.
Lørdag den 25 april 2009: WHO's Emergency Committee sammenkaldtes for første gang siden det blev oprettet i 2007. Udvalget trækker på eksperter fra hele verden. Udvalget var enige om, at situationen udgjorde en krisesituation af internationalt omfang på folkesundheden.
Lørdag den 25 april 2009: The Centers for Disease Control and Prevention (CDC) i USA: Der var nu 11 bekræftede tilfælde i USA med 7 i Californien, 2 i Texas og 2 i Kansas.
Lørdag den 25 april 2009: To 16-årige drenge i Texas nær San Antonio blev bekræftet smittet. Det var indlysende, at der nu skete smitte mellem mennesker, da der ikke havde været nogen kontakt med svin. Virusset indeholdt genetiske segmenter fra fire forskellige viruskilder: Nogle genetiske segmenter fra nordamerikanske svineinfluenzavirus, nogle gen-segmenter fra nordamerikanske fugleinfluenzavirus. Et gen-segment fra en menneskeinfluenzavirus og to gen-segmenter, der normalt findes i svineinfluenzavira i Asien og Europa. Genetiske rekombinationer (reassortment) af et svineinfluenzavirus fra Amerika med et svineinfluenzavirus fra Eurasien ikke var blevet opdaget tidligere. Genetisk sekvensbestemmelse af influenzavirus, der var isoleret fra et ti-årigt og et ni-årigt barn (San Diego County og Imperial County, begge Californien) viste, at virussene var meget ens, men ikke identiske med hinanden [6967]
Sekvensen af virus blev offentliggjort på internettet: http://www.gisaid.org.
Lørdag den 25 april 2009: Den amerikanske regering erklærede en "public health emergency", da antallet af identificerede tilfælde af svineinfluenza i USA steg til 20. I New York City blev otte studerende på St. Francis Preparatory School i Queens testet positive for svineinfluenza.
Lørdag den 25 april 2009: 81 døde i Mexico var på dette tidspunkt blevet anset for "sandsynligvis forbundet" til svineinfluenza. 20 af disse var den 25, april 2009 blevet bekræftet for at have været bærere af den nye virusstamme.
Lørdag den 25 april 2009: Canada bekræftede sit første tilfælde af svineinfluenza med fire mennesker i den østlige provins Nova Scotia. Detr var tale om studerende, der for nylig havde rejst til Mexico. Disse smittede personer blev kun mildt syge.
Lørdag den 25 april 2009: Alle 8 personer, der var smittet med svineinfluenza i Californien og Texas, var blevet raske.
Lørdag den 25 april 2009: I New Zealand mistænkte man, at 22 elever og tre lærere fra Auckland's Rangitoto College, der var hjemme efter en tre-uger lang sprogrejse til Mexico, var blevet smittet med svineinfluenzavirus. Fjorten af gruppen havde haft influenzalignende symptomer. 10 af de studerende blev testet positive for influenza A af en eller anden type. Prøverne blev efterfølgende sendt til WHO for at afgøre, om det var H1N1 svineinfluenza.
Lørdag den 25 april 2009: Gregory Hartl for Verdenssundhedsorganisationen WHO sagde, at virusstammen i Mexico er bekymrende, fordi det har muteret fra ældre stammer. "Hver gang, at der er et virus, som ændrer sig, betyder det, at den immunitet, der er opbygget i den menneskelige krop til at behandle influenza, ikke er justeret godt nok til at håndtere den nye virus", sagde Gregory Hartl.
Lørdag den 25 april 2009: Rusland forbød import af kød fra Mexico, visse stater i USA og 9 latinamerikanske lande.
Søndag den 26. april 2009: I alt var der nu i Canada seks bekræftede tilfælde, heraf fire i Nova Scotia, – alle kun med milde symptomer og ingen indlæggelser. Det var den samme type A, H1N1 svineinfluenzavirus, der tidligere havde optrådt i Californien og i Mexico.
Søndag den 26. april 2009: En speciallæge i luftvejssygdomme og intensiv pleje på Mexican National Institute of Health beskrev en alvorlig nødsituation i løbet af svineinfluenzaen der: "Flere og flere patienter bliver indlagt på intensivafdelingen. Trods den heroiske indsats, som læger, sygeplejersker, specialister mv gør, fortsætter patienterne uundgåeligt med at dø. Sandheden er, at de antivirale behandlinger ikke kan forventes at have nogen virkning, selv ved høje doser. Det er en stor frygt blandt de ansatte. Smitterisikoen er meget høj blandt læger og sundhedspersonale " [6954]
Søndag den 26. april 2009: USA havde nu rapporteret om 20 bekræftede tilfælde (8 i New York, 7 i Californien, 2 i Texas, 2 i Kansas og 1 i Ohio). Alle havde mild influenzalignende sygdom. Kun én krævede kortvarig hospitalsindlæggelse [6955]
Søndag den 26. april 2009: I Mexico var der nu over 1400 rapporterede tilfælde i 19 af 32 stater, med 81 (eller 86 afhængigt af kilden) rapporterede dødsfald [6954]
Søndag den 26. april 2009: En talsmand for WHO, Fukuda, sagde: "Lige nu har vi infektioner, der sker i forskellige lande og flere forskellige steder – men vi ved også, at i den moderne verden kan smittede personer simpelthen flytte rundt fra ét sted til et andet."
Søndag den 26. april 2009: Indtil dette tidspunkt havde WHO kun opfordret regeringerne til at optrappe deres overvågning af mistænkelige sygdomsudbrud. Men WHO's generaldirektør Margaret Chan kaldte udbruddet en krisesituation ("public health emergency") på folkesundhedsområdet af "pandemisk potentiale". WHO overvejede at udstede ikke-bindende anbefalinger om rejser og handelsbegrænsninger, og om man skulle anbefale at lukke landegrænser. Det ville i så fald være op til regeringerne selv til at beslutte, om de ville følge rådet fra WHO.
Søndag den 26. april 2009: Kina sagde, at enhver som fik influenzalignende symptomer inden for 2 uger efter ankomsten fra et berørt område, skulle rapportere det til de kinesiske myndigheder.
Søndag den 26. april 2009: En russisk sundhedmyndighed sagde, at passagerer fra Nordamerika, der havde feber, ville blive sat i karantæne indtil årsagen til feberen kunne bestemmes.
Søndag den 26. april 2009: Tokyos Narita lufthavn installerede et apparat til at teste kroopstemperaturen hos passagerer, der ankom fra Mexico.
Søndag den 26. april 2009: Janet Napolitano fra Department Homeland Security i USA erklærede en krisesituation (public health emergency) på folkesundhedsområdet i USA for at give mulighed for, at der kunne bruges økonomiske midler til forebyggelse af smittespredning.
Søndag den 26. april 2009: Et e-mail-kort om håndvask blev fremstillet i USA, så folk kunne sende kortet til hinanden.
Søndag den 26. april 2009: Fem mennesker døde af svineinfluenza i løbet af 24 timer i Mexico City, hvilket bringer det samlede antal af dræbte op på 15 i hovedstaden, sagde Mexico City's borgmester, Marcelo Ebrard.
Søndag den 26. april 2009: En skolegruppe fra New Zealands største by Auckland blev sat i karantæne, efter at være vendt hjem fra Mexico
Mandag den 27. april 2009: Første bekræftede tilfælde fundet i Europa: Spanien.
Mandag den 27. april 2009: Det første dødsfald som følge af udbruddet uden Mexico var et 2 års barn fra Mexico City, som var rejst til Texas med familien. Barnet døde mandag den 27. april 2009 på et hospital i Houston. Barnet havde været syg siden den 8. april 2009 og havde underliggende helbredsproblemer.
Mandag den 27. april 2009: To bekræftede tilfælde fundet i Storbritannien (Skotland). Begge patienter, en mand og en kvinde, var i god bedring. 7 andre mennesker, som havde været i kontakt med dem, fik milde symptomer. Begge skotske patienter var fra Forth Valley området i det centrale Skotland. Det par, som havde været på rejse sammen, vendte tilbage fra Mexico den 21. april 2009.
Mandag den 27. april 2009: WHO's advarselsniveau 3 af 6 bør sættes til 6 (maksimalt niveau), sagde Guan Yi, professoren i Hongkong, der fandt SARS-virus i et kattellignende dyr i 2003 og som startede initiativet, som medførte, at man forbød salg af sådanne dyr på markederne. Som altid er WHO for langsom og for tilbageholdende med at hæve sit advarselsniveau, sagde professor Guan Yi.
Mandag den 27. april 2009: Flyselskabers aktier faldt 5-17% på grund af svineinfluenza. Lægemiddelselskaber som Roche, som laver vacciner, steg.
Mandag den 27. april 2009: Myndighederne i Hongkong opfordrede indbyggerne til ikke at rejse til Mexico. De gav ordre om omgående tilbageholdelse på et hospital af enhver, der ankom med feber og symptomer på en luftvejssygdom efter rejser inden for de foregående syv dage gennem en by med et laboratorie-bekræftet udbrud af den nye influenza. Thomas Tsang, der er ansvarlig for Hongkong-regeringens Center for Sundhedsbeskyttelse, sagde, at indtil testen havde vist sig negativ, skulle en sådan person ikke have lov at komme ud af hospitalet. Grænsen for at have feber ville være 100,4 grader Fahrenheit. Det ville tage to eller tre dage at opnå testresultatet.
Mandag den 27. april 2009: Der var oplysninger i pressen om, at 145 mennesker måske er døde i Mexico efter sygdommen. De fleste tilfælde var ikke blevet bekræftet. Der var ikke rapporteret om dødelige tilfælde uden for Mexico [TV DR1 Danmark]
Mandag den 27. april 2009: Alle skoler i Mexico blev beordret lukket indtil den 6. maj. Dagplejecentre, universiteter, museer, pyramider og de 35.000 restauranter i Mexico City blev lukket for at udelukke, at forsamlinger af mennesker kunne sprede smitte. Kirker blev lukket – en stor ting i et katolsk land, hvilket fortalte folk, at situationen var alvorlig. Sociale og kulturelle aktiviteter blev suspenderet. Offentlige festligheder som Cinco de Mayo blev forbudt. For første gang i årtier annulerede Mexico den populære fest tikl fejring af 5. maj 1862 sejren over de invaderende franske tropper i den centrale delstat Puebla. Omkring 2.000 mennesker kan være blevet smittet. Folk på gaden fik uddelt masker. Enhver havde fyldt deres køkken med mad og blev hjemme.
Den hollandske regering's Institut for Folkesundhed og Miljø rådgav alle rejsende, der vendte tilbage fra Mexico efter april 17 og som udviklede feber over 101,3 grader Fahrenheit (38,5 Celsius) inden fire dage efter ankomsten til Holland om at blive hjemme.
Hongkong brugte infrarøde scannere i lufthavnen for at afsløre folk med feber: Lige siden 2003-udbruddet af SARS-infektionen har Hongkong brugt infrarøde scannere til at måle ansigtstemperaturen på alle ankommende i lufthavnen og ved grænseovergangene til det kinesiske fastland.
Hong Kong er måske bedre forberedt på en influenzapandemi end alle andre steder i verden. Frygten for, at SARS skal gentages, dukker op hver vinter, og byen har engageret sig i et byggeprogram for at udvide sin kapacitet til at isolere og behandle dem, der bliver inficeret med sådanne luftvejssygdomme.
Hong Kong har også udvidet sin influenzaforskning. Hongkongs viruslaboratorier var allerede blandt de bedste i verden og førende i at spore H5N1-fugleinfluenzavirusset, som dræber en usædvanlig stor andel af sine ofre. Dette har regelmæssigt udløst frygt for en eventuel pandemi, ligesom svineinfluenzaen gjorde i foråret 2009.
Mandag den 27. april 2009: Mindst 20 sager i USA var nu blevet bekræftet i New York, Ohio, Californien, Kansas og Texas.
Mandag den 27. april 2009: På nuværende tidspunkt var dødeligheden (case fatality rate , CFR) stadig usikker. Hvis antallet af smittede i Mexico var betydeligt højere end de rapporterede cirka 1.500 tilfælde på dette tidspunkt, ville det sænke den beregnede dødelighed af sygdommen (CFR-tallet) [6955]
Mandag den 27. april 2009: I USA var der nu 40 bekræftede tilfælde: New York City 28 tilfælde, Californien 7 sager, Kansas 2 tilfælde, Texas 2 sager og Ohio 1 tilfælde [http://bit.ly/KO5pA].
CDC's Division for Strategiske Nationale Lagre (Strategic National Stockpile, SNS) i USA frigav en fjerdedel af sine antivirale lægemidler, personlige værnemidler og åndedrætsværnsudstyr for at hjælpe staterne i USA til at kunne reagere på udbruddet.
Mandag den 27. april 2009: WHO øgede omfanget af influenzapandemi-alarmen fra fase 3 til fase 4, hvilket indikerer, at sandsynligheden for en pandemi var steget. WHO's fase 4 "er karakteriseret ved verificeret smitte fra menneske til menne af et dyrevirus eller menneske/dyr-influenza rekombinant (reassortant) virus, der er i stand til at forårsage udbrud på samfundsniveau. " … Fase 4 viser en betydelig stigning i risikoen for en pandemi, men betyder ikke nødvendigvis, at en pandemi vil ske med sikkerhed. "
I betragtning af den udbredte forekomst af virus, mente WHO nu, at indeslutningen af udbruddet ikke mere ville være mulig. Det nuværende fokus bør i stedet være på afbødningsforanstaltninger. WHO anbefalede ikke at lukke grænserne og ikke at begrænse den internationale rejsetrafik. Det blev anset fornuftigt for syge at udskyde deres internationale rejser.
Mandag den 27. april 2009: Mexico havde nu indberettet 26 bekræftede tilfælde af infektion af mennesker med samme virus, herunder 7 dødsfald (det samlede formodede antal dødsfald i Mexico var 149 mennesker blandt 1.995 mennesker, som var blevet indlagt med alvorlige tilfælde af lungebetændelse siden begyndelsen af epidemien). Kun 2 laboratorier i landet Mexico, en i Mexico City og én i delstaten Veracruz, var i stand til at bekræfte denne nye virusstamme. Denne dag skete i øvrigt et jordskælv i Mexico.
Mandag den 27. april 2009: Canada havde nu rapporteret om 6 sager. Stadig ingen dødsfald uden for Mexico.
Mandag den 27. april 2009: Israels sundhedsminister opdaterede en nervøs offentligheden om svineinfluenzaepidemien – og omdøbte den til den mexicanske influenza.
Mandag den 27. april 2009: Schweizisk politi sagde, at en beholder med animalske svineinfluenzaprøver eksploderede, da den blev sendt med et tog fra Zürich til Genève, og sårede en kvinde. Myndighederne sagde, at tøris, som holdt prøver kolde, forårsaget eksplosionen, men at hændelsen ikke udgjorde nogen trussel mod mennesker.
Tirsdag 28 april 2009: Det var nu klart, at infektionen ikke kunne indesluttes, sagde WHO's influenzaekspert Keiji Fukuda. "Indeslutning er ikke en anvendelig mulighed". Keiji Fukuda sagde dog, at det ikke var uundgåeligt, at udbruddet ville udvikle sig til en global epidemi – eller pandemi – men at landene skulle "benytte lejligheden til at forberede sig herpå". WHO-talsmanden Gregory Hartl sagde, at eksperter arbejdede på at udvikle en vaccine, men sagde, at det ville kunne tage fem eller seks måneder at udvikle en sådan vaccine.
Tirsdag 28 april 2009: Siden slutningen af marts 2009 havde Mexico observeret et usædvanligt mønster af akut respiratorisk infektion (SARI), som steg endnu mere i de første uger af april 2009. Fra den 17. til den 28. april 2009 blev der rapporteret om 1551 mistænkte tilfælde af influenza med svær lungebetændelse, herunder 84 dødsfald. Disse tal var mindre end de, der var blevet rapporteret dagen før – på grund af det igangværende undersøgelsesarbejde med at rense dataene for usikkerheder og fejl. De mistænkte tilfælde var blevet registreret i 31 af de 32 delstater i Mexico [6970]
Onsdag den 29. april 2009: World Health Organization rejste nu sin pandemialarm for svineinfluenza til det næsthøjeste niveau, "fase 5", hvilket betyder, at man mener, et et globalt udbrud af sygdommen er overhængende. Det var første gang, WHO havde erklæret et fase 5 udbrud. (Erklæringen af fase 4 var også første gang). En fase 5 alarm betyder, at der sker vedvarende spredning blandt mennesker i mindst to lande. Når virusset viser effektiv smitte i to forskellige regioner i verden, vil et fuldstændigt pandemiudbrud – fase 6 – blive erklæret, hvilket betyder en global epidemi af en ny sygdom, der er dødelig i et vist omfang [6963]

Onsdag den 29. april 2009: Der var nu 3 lande (USA, Canada og Mexico), der havde rapportering om spredning af virusset fra menneske til mennesker [6970]
Onsdag den 29. april 2009: I Canada havde der indtil denne dato været 13. humane tilfælde af svineinfluenza A/H1N1 i bekræftet form (2 i Alberta, 4 i provinsen New Scotland, 3 i British Columbia og 4 i Ontario), nogle af dem efter en nylig rejse til Cancun, Mexico. Ingen krævede hospitalsindlæggelse [6970]
Onsdag den 29. april 2009: Der var nu bekræftede tilfælde i følgende lande uden for Mexico og USA: Østrig (1), Canada (13), Tyskland (3), Israel (2), New Zealand (3), Spanien (4) og Storbritannien (5 ) [6970]
Onsdag den 29. april 2009: Den mexicanske sundhedsminister, José Ángel Córdova, reducerede pludselig det officielle antal bekræftede døde af infektionen fra 20 til 7 på et kaotisk pressemøde i Mexico City, hvor han modsagde sig selv flere gange. På pressemødet bar mange journalister og fotografer masker som beskyttelse mod sygdommen. Stemningen var til tider fjendtlig, og journalister råbte flere spørgsmål end embedsmændene syntes villige til at svare på. Men han indrømmede, at det mexicanske sundhedssystem ikke kunne håndtere situationen. Kun 10 af de 31 delstater i Mexico har et viruslaboratorium. Prøverne skal sendes til Mexico City, og det tager tid. Fra alle hjørner af landet er der beretninger om kaos og panik på hospitalerne, hvor patienterne venter i dagevis for medicinsk overvågning og ender med at gå hjem uden at have mødt en læge. Hygiejnen på hospitalet i Obregon i Mexico City er katastrofal, skrev en blogger. Sygehusene er på nippet til at give op. Statens Institut for luftvejssygdomme (The National Institute for Respiratory Diseases) har behov for masker, kirurgibriller og hvide kitler og advarer om, at de vil stoppe behandlingerne, hvis de ikke får sådanne leverancer. Den antivirale medicin er blevet en mangelvare, og mange hospitaler har ikke mere. Korruption er grunden til det – medicinen er blevet stjålet og sælges til højere priser, før det når frem til hospitalerne. 2009 er et valgår i Mexico. Den mexicanske sundhedsminister, Jose Angel Córdova, har sagt, at landets forsyning af medicin var tilstrækkelig [6963]
Onsdag den 29. april 2009: Tysklands største rejsearrangør suspenderede rejser til Mexico [6968]
Onsdag den 29. april 2009: USA's præsident Barack Obama bad Kongressen om 1.5 milliarder dollar for at hjælpe med at forberede landet på et eventuelt sygdomsudbrud. Han foreslog, at alle skoler burde være lukket, hvis eleverne havde nogen risiko for at blive smittet. USA har 132.000 skoler. USA havde nu 91 bekræftede smittede i 10 stater. Med 13 tilfælde i Californien erklærede guvernør Arnold Schwarzenegger Californien i undtagelsestilstand (state of emergency) på grund af truslen.
Onsdag den 29. april 2009: I det muslimske Egypten besluttede regeringen at dræbe alle svin i landet, ca. 300.000 – 350.000. Egypten beordrede svinene slagtet, selv om der ikke havde været et eneste tilfælde af svineinfluenza i Egypten – og selv om A/H1N1 "Svineinfluenza" infektion ikke breder sig fra svin til mennesker, men fra mennesker til mennesker (og derfor ikke burde bedde svineinfluenza, uanset at det oprindelig må stamme fra et ukendt svin). Svineejerne i Egyptne ikke er muslimske, men kristne. På grund af dårlig information tror folk i Egypten, at svinekød er inficeret – 98% af svinekødsalget i landet kollapsede. Det vil tage et halvt år til at dræbe alle svin i Egypten, men regeringen vil købe 3 maskiner med en kapacitet til at dræbe 3000 svin dagligt for at det kan ske hurtigere. Den 5. maj 2009 var omkring 1.821 svin blevet dræbt i svineaflivningskampagnen i landet. For at stille sagen i perspektiv er Egypten på dette tidspunkt smittet med fugleinfluenza (H5N1). 68 personer i Egypten er blevet smittet med dette influenzavirus og ikke mindre end 23 af disse 68 inficerede mennesker er døde af infektionen. Men ingen taler om at dræbe alt fjerkræ i landet (fjerkræ er en vigtig fødevare i Egypten) [6992]
Mens epidemiologer bliver ved med at understrege, at det er mennesker, ikke svin, der spreder sygdommen, faldt salget af svineproducenter i hele verden. WHO udtalte, at det er sikkert at spise svinekød, men f.eks. mexicanerne har endda skåret ned på forbruget af deres elskede svine-tacos. Svinekødproducenterne forsøgte at få folk til at holde op med at kalde sygdommen svineinfluenza, og den amerikanske præsident Barack Obama omtalte kun sygdommen ved dens videnskabelige navn, H1N1. En dyresundhedsekspert Juan Lubroth fra FN bemærkede, at nogle forskere kalder sygdommen den "mexicanske influenza", og at det ville være en mere præcis betegnelse – et forslag som optændte lidenskaberne i Mexico [6963]
Onsdag den 29. april 2009: Libanon anbefalede folk at undgå de traditionelle arabiske kindkyshilsener, selv om ingen på dette tidspunkt endnu var blevet smittet med virus i landet [6963]
Onsdag den 29. april 2009: Peru og Ecuador fulgte Cuba og Argentina i at forbyde rejser såvel til og fra Mexico.
Onsdag den 29. april 2009: I England bestilte sundhedsministeren 32 millioner ansigtsmasker.
Onsdag den 29. april 2009: Det Europæiske Center for Disease Control frarådede unødvendige rejser til Mexico. WHO ville stadig ikke fraråde rejser til Mexico.
Onsdag den 29. april 2009: Den danske sundhedsminister bestilte 40.000 doser af Relenza antivirus-medicin i tilfælde af, at virusset bliver resistent over for Tamiflu, som Danmark har på lager. På et centralt lager i København ligger 300.000 piller af Tamiflu klar til 30.000 danskere for straks-behandling. I en fryser ligger 1.000.000 kg pulver af Tamiflu, som kan laves til antiviral medicin for en million danskere [7014].
Onsdag den 29. april 2009: Bekræftede sager var indtil nu blevet fundet i Mexico, USA, Canada, Storbritannien, Israel, New Zealand, Spanien, Sydkorea, Peru, Tyskland og Østrig, hvilket bragte antallet af ramte lande op på 11 [6963]
Onsdag den 29. april 2009: Spanien rapporterede det første tilfælde i Europa af svineinfluenza i en person, som ikke havde været i Mexico, hvilket illustrerede faren for person-til-person smitte [6963]
Onsdag den 29. april 2009: mistænkte tilfælde blev rapporteret fra mange lande, herunder latinamerika (Argentina, Bolivia, Brasilien, Chile, Colombia, Costa Rica, Ecuador, Guatemala, Uruguay): Colombia – 42 tilfælde af mistanke efter rejse til Mexico; Chile – 24 mistænkte tilfælde, Brasilien – 11 mistænkte tilfælde, Bolivia – 2 mistænkte tilfælde efter rejse til Mexico, Uruguay – 2 mistænkte tilfælde, Costa Rica – et "bekræftet tilfælde" efter rejse til Mexico rapporteret i medierne den 28. april 2009, men ikke bekræftet ifølge WHO; Guatemala – et mistænkt tilfælde efter rejse til Mexico.

Europa: Slovakiet – et mistænkt tilfælde efter rejse til Mexico; Belgien – 7 mistænkte tilfælde efter rejse til Mexico eller USA, Frankrig – 32 mistænkte tilfælde, hvoraf 2 anses for sandsynlige (efter rejse til Mexico); Polen – 3 mistænkte tilfælde efter rejse til Mexico.

Australien – 91 mistænkte tilfælde
Onsdag den 29. april 2009: En dansk ung kvinde bragte denne dags morgen Influenza A H1N1 smitte med på et Continental Airlines fly CO122N, der fløj direkte fra Newark (New York) til Kastrup (København), og landede i Københavns Lufthavn om morgenen den 29 april kl. 7.35 efter en ferierejse. Hun kontaktede Hvidovre Hospital samme aften med influenzasymptomer i svælget og musklerne, men hun havde ikke feber. En prøve blev taget, og hun blev bedt om at blive hjemme. Hun boede alene og havde kun begrænset kontakt med andre mennesker. Infektionen blev bekræftet den 1. maj 2009. Alle passagerer på flyet blev derefter kontaktet. Passagerne, der havde siddet op til 2 rækker foran eller bag den inficerede kvinde modtog forebyggende antiviral behandling. Efter at infektionen var blevet bekræftet ved en hurtigtest blev kvinden behandlet i isolation på et hospital indtil den 6. maj 2009. Pressen kunne ikke få oplysninger om, hvilket hospital hun var indlagt på [7013]. Virusset var lig med den type, der findes i New York, bortset fra en mutation. Det var følsomt over for Tamiflu. Denne dansker var den første europæiske person, der var blevet smittet i USA [7012]
Et dansk hold universitetsforskere har vist, at et flysæde, som sender luft op omkring hver passager i flyet, kan hindre infektion. Systemet ville kunne være i produktion i løbet af 2-3 år, hvis nogen ville investere i det. Systemet ville også kunne anvendes til busser, koncertbygninger og endda hospitalssenge. Avancerede computermodeller og forsøg med dukker med kunstige lunger har vist, at systemet fungerer godt. Under SARS-epidemien blev 19 passagerer smittet i løbet af en enkelt flyrejse. Kontakt bionyt@gmail.com for adresse til de danske opfindere.
25-29 april 2009: BBC bad folk i de berørte områder med svineinfluenza om at sende deres beretninger til BBC, der derefter offentliggjorde dem på http://news.bbc.co.uk/2/hi/talking_point/8018428.stm. Her er nogle eksempler fra 25-29 april 2009:
"To fodboldskampe er blevet annulleret ved det olympiske stadion. En udsolgt forboldskamp med 70.000 tilskuere blev spillet for lukkede døre. En anden fodboldskamp på det berømte Azteca Stadion, der forventeligt ville have haft 50.000 tilskuere blev også spillet for lukkede døre." [Juan Carlos Leon Calderon, Mexico City]
"To af mine venner på arbejdspladsen blev syge i et par dage. De gik på hospitalet, som dog sendte dem tilbage på arbejde. Lægen fortalte dem, at det bare var en influenza – indtil fredag, hvor alarmen blev spredt, – derefter fik de lov til at gå hjem. Jeg arbejder i et call center, og jeg er bekymret, fordi der ikke er vinduer i bygningen, så der kan ikke luftes ud og der er omkring 400 mennesker, som arbejder der. – Vi har alle talt med vores vejleder, men ingen har gjort noget – ikke engang at sterilisere eller desinficere området." [Adriana, Mexico City]
"Jeg arbejder som turnuslæge i en af de største hospitaler i Mexico City og desværre er situationen langt fra "under kontrol". Som læge er jeg klar over, at medierne ikke beretter sandheden. Myndigheder distribuerede vacciner blandt alle sundhedspersonalet uden resultater, idet to af mine partnere, der arbejdede på dette hospital blev dræbt ved dette nye virus på mindre end seks dage, selv om de var blevet vaccineret [(?) – vaccine findes ikke], som vi alle var. Det officielle antal dræbte er 20, ikke desto mindre er det sande antal ofre mere end 200. Jeg kan forstå, at vi skal undgå at gå i panik, men at sige sandheden nu kan det være bedre til at forhindre flere dødsfald. " [Yeny Gregorio Dávila, Mexico City]
"De siger i nyhedsmedierne, at de tilfælde, der er mest kritiske, omfatter folk i alderen fra 20 til 50" [Nallely T, State of Mexico]
"I hovedstaden i min delstat, Oaxaca, er der et hospital, som er lukket på grund af et dødsfald i forbindelse med svineinfluenza. Mange af mine venner, der arbejder på hospitaler eller sundhedsområdet iøvrigt, siger, at situationen er virkelig dårlig, – de taler om 19 mennesker døde i Oaxaca, herunder en læge og en sygeplejerske. I aftes var det lokale baseball-stadion fuldt, primært med unge. Hvad foregår der egentlig? Jeg ved, at den økonomiske situation er ikke den bedste, og at det bliver værre med panik. Men panik stammer fra mangelfulde oplysninger. Mange mennesker rejser for deres fornøjelse eller uden reelt behov. Ved at stoppe disse unødvendige rejser kan man afhjælpe meget på situationen. Vi må gøre noget! " [Alvaro Ricardez, Oaxaca City, Oaxaca, Mexico]
"Jeg har forsøgt at købe ansigtsmasker til mig selv og min familie – min kone og to børn – men har ikke kunnet få en nogetsteds. Jeg har besøgt seks apoteker i området, og alle har udsolgt." [Jorge, Mexico City, Mexico]
"Jeg er en læge, der er ansvarlig for forvaltningen af vacciner i den nordlige mexicanske stat Nuevo León. I søndags havde vi vores første dødsfald i området. Det var en, der kom fra Mexico City. Men vi har ikke midlerne til at bekræfte, hvorvidt det faktisk var som resultat af svineinfluenza. Vi er nødt til at have midlerne til at diagnosticere mennesker. Mere end noget andet mangler vi udstyr og laboratoriekits. Det eneste, vi kan gøre, er at se på symptomerne og foretage en klinisk diagnose. I de apoteker er der ingen Tamiflu til rådighed. Folk her er ikke klar over, at dette influenzaudbrud kan dræbe mennesker. " [Dr Vicente Torres, Monterrey, Nuevo Leon, Mexico]
"Jeg bor i Mexico City … Jeg studerer faktisk her! Mexico City er ikke et af de reneste steder og folks holdning gør det værre. Næsten halvdelen af de 20 millioner mennesker bærer ikke deres masker og nogle handler, som om det er normalt at have denne influenza med deres »Jeg er ligeglad" attitude. " [Rachael, Mexico City]
Torsdag, den 30. april 2009: På et møde mellem EU's 27 medlemsstater foreslog den franske sundhedsminister, Roselyne Bachelot, at alle flyvninger til Mexico fra Europa stoppes. Der blev ikke vedtaget sådanne rejsebegrænsninger til Mexico. Et argument var, at det stadig vil være muligt at rejse til et andet land og derefter ind i Mexico.
USA, EU og andre lande har anbefalet, at man undlader unødvendige rejser til Mexico. Nogle lande har opfordret deres borgere til også at undgå USA og Canada. Sundhedsmyndigheder sagde, at sådanne forbud ikke vil gøre ret meget for at stoppe virusset. WHO anbefalede ikke totalt forbud mod at rejse til Mexico, idet virkningen var tvivlsom, fordi virusset allerede var temmelig udbredt. "WHO anbefaler ikke lukning af grænser og anbefaler ikke restriktioner for rejser," sagde Dr. Keiji Fukuda, som er WHO's influenzatalsmand. "Fra et internationalt perspektiv vil lukning af grænser eller begrænsning af rejser have meget ringe effekt, om nogen virkning overhovedet, for at standse spredningen af denne virus." [6963]
Torsdag, den 30. april 2009: Danske turister i Mexico evakueres frivilligt til Danmark.
Torsdag, den 30. april 2009: Bekræftede tilfælde blev fundet i Schweiz (19 årig mand), Portugal og Holland (3 årig dreng).
Torsdag, den 30. april 2009: På dette tidspunkt var der 109 bekræftede tilfælde i USA, 1 død (mexicansk dreng der behandledes i Texas): New York 50, Texas 26, California 14, South Carolina 10, Kansas 2, Massachusetts 2, Michigan 1, Indiana 1, Nevada 1, Ohio 1, Arizona 1.
Torsdag, den 30. april 2009: Antallet af laboratoriebekræftede tilfælde var denne dag kommet op på 236 – et spring fra 148 dagen før [6972]
Torsdag, den 30. april 2009: Et medlem af den amerikanske præsident Barack Obama's sikkerhedsteam var under mistanke for at være blevet smittet med svineinfluenza under et besøg for nylig i Mexico med præsidenten [6972]
Torsdag, den 30. april 2009: Takket være en række yderligere test, er antallet af konstaterede tilfælde i Mexico faldet fra 97 fra 26. Antallet af dødsfald er forblevet på 7 [6972]
Torsdag, den 30. april 2009: Senior-embedsmænd fra forskellige landes sundhedsmyndigheder forsøgte at koordinere sygdomsovervågningen og reaktionen på truslen med hinanden, og måtte bruge timer på tværnationale telefonkonferencer, selv om de skulle bruge tid til at gruble over detaljer, såsom rejserestriktioner (der på det tidspunkt betragtedes nytteløs af CDC og WHO, men anbefaledes af nogle lande), og betydningen af antivirale lægemidler. Identifikationen af hvert enkelt sygdomstilfælde var også en prioritet, såvel om spørgsmålet om, hvornår man skulle begrænse sociale sammenkomster af mange mennesker, som Mexico havde gjort det, og overveje, hvilke offentlige tjenester, som skulle stoppes midlertidigt, såsom domstole, og hvilke som fortsat skulle fungere, sådan transport og håndtering af fødevarer [6972]
Torsdag, den 30. april 2009: Den amerikanske vicepræsident Joseph Biden skabte opmærksomhed, da han sagde, at han ikke ønskede at rejse med fly eller metro, og dermed modsagde sin chef's rådgivning [6972]
Torsdag, den 30. april 2009: Eksperter og myndigheder diskuterede, om vaccinefabrikanterne burdee skifte til at fremstille en vaccine mod den svinerelaterede H1N1 i stedet for at producere den sæsonbetingede influenzavaccine [6972]
Torsdag, den 30. april 2009: På dette tidspunkt var der også drøftelser om nytten af fritter (Mustela furo) til influenzasforskning. I oktober 2008 rapporterede forskere fra Iowa State University om et udbrud af en tidligere H1N1-svineinfluenzastamme i en frittekoloni på en farm i Iowa 400 m fra en svinefarm. 8% af de omkring 1000 af minklignende dyr blev smittet. Denne fritte-infektion ikke var forbundet med den senere "Mexico-influenza" hos mennesker eftersom H1N1-stammen var anderledes.
Torsdag, den 30. april 2009: Indtil udbruddet i april 2009 var smitte med svineinfluenza fra mennesker til mennesker praktisk talt aldrig set. CDC's laboratorier i USA modtog 300 prøver fra Mexico for månederne februar, marts og april 2009. Alle disse prøve var med menneske-influenzavirus indtil udgangen af marts 2009. Der er to eller tre tilfælde inden for de sidste dage af marts 2009, der er svineinfluenza. Så i april 2009 eksploderede antallet. Svineinfluenzavirusset smittede virkelig meget effektivt hos mennesker [6974]
Torsdag, den 30. april 2009: Den epidemiske svineinfluenza vil måske dø ud på den nordlige halvkugle, såsom i USA, som på det tidspunkt var på vej ud af influenzasæsonen, men landene på den sydlige halvkugle var op tidspunkt på vej ind i vinteren og influenzasæsonen.
Fredag 1 maj 2009: Det første bekræftede tilfælde i Danmark. En dansker fra Sjælland blev smittet med influenza A H1N1 i USA og medbragte det på en fly CO122N fra New York i København.
Lørdag den 2. maj 2009: Canada rapporterede identifikationen af A (H1N1) virus i en svinebesætning i Alberta. Det er meget sandsynligt, at svinene blev udsat for virus fra en canadisk medhjælper, som kort forinden var vendt tilbage fra Mexico, hvor der florerede influenzalignende symptomer og han havde haft kontakt med svinene. (Se 12 april 2009 for en beskrivelse af denne begivenhed).
De mennesker, der bor på svinbedriften i Alberta, hvor svinene blev anset for at være blevet inficeret med svineinfluenza, blev senere testet negative for virus. En række mennesker, der boede på svinefarvemn, oplevede influenzalignende symptomer efter at svinene var blevet syge. Disse mennesker blev testet for at se, om de også var smittet, men testene tydede ikke på, at de var smittet med H1N1 svineinfluenzavirus. Men der blev blodprøver fra disse mennesker for at teste for antistoffer som definitivt svar på, om de var blevet smittet. Den pågældende tømrer blev også testet negativ for virus, men man mente, at det var fordi, at han var for langt fremme i sin helbredelse til, at han stadig indeholdt virus. Et næseskrab fra manden blev først indsamlet, efter at svinene var begyndt at blive syge, og det var mere end 10 dage efter hans hjemkomst fra Mexico. Man tog også en blodprøve fra ham for at lede efter antistoffer mod den nye H1N1 svineinfluenzavirus. Antistoftesten blev udviklet ved Canada's National Microbiology Laboratory, som spillede en central rolle i forbindelse med undersøgelsen i denne nye influenzavirus. Det var Winnipeg-laboratoriet, som fastslog, at der var et usædvanligt udbrud af alvorlig luftvejssygdom i Mexico forårsaget af en ny svineinfluenzavirus, som amerikanske forskere havde fundet inficerede mennesker i USA. Det var betryggende at erfare, at det virus, der forårsagede sygdom hos svinene på svinefarmen i Alberta sandsynligvis ikke er blevet videregivet til de mennesker, der bor på gården. Svineinfluenzavirussets manglende smitte tilbage til mennesker tyder på, at det nye H1N1 virus, der forårsager sygdom hos mennesker, ikke kom ind i menneskepopulationen direkte fra svin [7003]

[Rapport om denne sag; 6 maj 2009]:
I Canada blev en svinebestand i Alberta inficeret af et menneske. Kliniske tegn blev observeret i 450 af de over 2000 svin. 19 ud af 24 prøver var positive for influenza A's matrixgen og 15 ud af 24 prøver var positive for H1-genet. Delvis sekvensbestemmelse tydede på 100 pct lighed med matrixgenet, og 99-100 % lighed H1-genet hos virusisolater fra mennesker inficeret i USA og Mexico med den nye influenza fra april 2009. [7041]

Dette var et isoleret tilfælde af fra-menneske-til-svine-smitte fordi en medhjælper vendte hjem fra ferie i Mexico. [7041]

Arbejderen var vendt tilbage fra Mexico den 12. april 2009, hvorefter han udviklede influenzalignende symptomer. Han vendte tilbage til arbejdet den 14. april og mellem d. 14. og d. 29. april viste arbejderen, svineavleren og hans familie alle symptomer. [7041] Den 24. april 2009 havde arbejderen overvundet sygdommen, og han testede negativt for influenza-virus. Efter denne dato udviste svinene imidlertid tegn på appetitløshed, feber og åndedrætssymptomer. [7041]

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<td width="50%"><!–mstheme–><font face="Trebuchet MS, Arial, Helvetica"><A href="http://www.bionyt.dk"

target=mainframe><B>BioNyt – Videnskabens Verden</B></A> (Comments: <a href="mailto:&#098;&#105;&#111;&#110;&#121;&#116;&#064;&#103;&#109;&#097;&#105;&#108;&#046;&#099;&#111;&#109">bionyt@gmail.co&#109</a>)

<br><br>

<font size="5">Swine flu – Mexican A/H1N1 influenza – North American influenza A/H1N1 virus</font><br>
Outbreak in spring 2009

<br><br>
<a href="#Things to do if the risk is there">Things to do if the risk is there</A>;

<A href="#History of the epidemic">History of the epidemic</A>;

<A href="#Assessing the severity of an influenza pandemic">Assessing the severity of an influenza pandemic</A>;

<A href="#Bacterial co-infections?">Bacterial co-infections?</A>;

<A href="#Information for laboratory workers">Information for laboratory workers</A>;

<A href="#Background for the epidemic">Background for the epidemic</A>;

<A href="#General information">General information</A>;

<A href="#Symptoms of the Swine Flu">Symptoms of the Swine Flu</A>;

<A href="#Overcoming the Swine Flu">Overcoming the Swine Flu</A>;

<A href="#Live or inactivated vaccine?">Should vaccination be with live or inactivated virus?;

<A href="#Next generation of vaccines">Next generation of vaccines</A>;

<A href="#Litterature and references">Literature and references</A>;

<A href="#Key words and abbreviations">Key words and abbreviations</A>;

<A href="#Swine flu genes in China – and diagnostic means.">Swine flu genes in China – and diagnostic means</A>;

<A href="#Other flu infections.">Other flu infections</A>;

<A href="#Links.">Links</A>;

<A href="#The AVAAZ initiative against big unregulated pig farms">The AVAAZ initiative against big unregulated pig farms</a>.<br><br>
<A name="General information">

Influenza A(H1N1) is the official name of the disease since it spreads from humans and not pigs<br><br>
The Influenza A(H1N1) epidemic is not alarming because: <br>

• It is not a good killer (this was not known in the beginning of the epidemic)<br><br>
The Influenza A(H1N1) epidemic could be alarming because: <br>

• It might change to become a better killer <br><br>

• It might be a better killer next virus season (it is not uncommon that the next wave of a flu a half year later is more aggressive)<br><br>

• It might spread in countries entering their flu season (Argentina etc., South Africa, New Zealand) <br><br>

The Influenza A(H1N1) epidemic is alarming because: <br>

• It can kill young healthy people just like the influenza in 1918 ("Spanish flu"). <br>

• It is a new flu virus from animals – unknown for the human immune system.<br>

• It spreads globally<br>

• It can infect from people to people<br>

• It infects young and middle aged people<br>

• It might change to a more lethal type – spontaneous or if an individual (pig or human) get two different virus types simultaneous<br>

• We know by experience that flu – if lethal and infectious – can kill millions. The Spanish flu i 1918-1919 killed more people than World War I. <br>

• A vaccine would take more than 6 months to produce.<br>

• The new flu came at the beginning of the flu season for countries with poor

ressources. <br><br>

• The more people are infected with the new flu, the bigger is the risk that the virus will infect a cell which is already infected by another flu virus (may be a bird flu virus). Then a new, recombined virus can emerge, which might be more lethal, more infectious or both. (However the bird flu virus which has infected few people during the last 13 years and which is highly lethal has not yet recombined with a human flu virus)<br>

• Two billion people will likely be infected if the flu becomes a pandemic (1/3 of the world 6 billion people based on experiences from earlier pandemics). It is unknown how many would die.Luckily the new virus is not very lethal, but rather similar to ordinary flu. However it may change and even a not very lethal virus could make great damage if it is highly infectious. <br>

[7015]<br><br>

Swine flu has symptoms nearly identical to regular flu — fever, cough and sore throat — and spreads like regular flu — through tiny particles in the air — when people cough or sneeze. <br>

<br>
The reason some people die of this infection seems to be a result of the immune systems overreaction resulting in fluid in the lungs blocking oxygen uptake to the blood.

<br>

<br>
The fact that some people die means a resource problem for the hospitals – very soon there will be too few respirators and too little personel to handle all the sick people.

<br>

<br>
Around 4 May 2009 it became clear that the swine flu of April 2009 was not so dangerous if treated. The reason that people died in Mexico but not in other countries was lack of treatment. The people who died were often too poor to go to hospital (could not afford to be ill), or were not treated. This became known as "the influenza epidemic danger has disappeared". However, it might be too soon to make this conclusion. The poor countries of the world – with no treatment drugs available and no plans for such epidemics – are now going into the flu season (winter). The fact that this flu might not be containable, and still is dangerous for otherwise healthy people is a course for concern.
<br>

<br>
In the 1918 pandemic there were a four-month gap between the first, mild wave of illness and the big attack, which had a death rate that if translated into today would mean 170 million victims world wide. [6978] A pandemic today could take fewer lives – or it could take more lives. Only a few countries have vaccine plants, mainly in Europe. They may in a chaotic life-treatening situation be more or less willing to export their products. Afterall infectious diseases are the greatest enemy, even compared to war, earthquake or tsunamis. [6978]
<br>

<br>

The risk of global deadly virus infections should be taken more serious. Research in the swine flu virus has been neglected. This new type of virus emerged in USA in 1998, so we have had 11 years to study and fight it.
<br>

<br>

It became endemic on swine farms across North America. The new virus combination is so different from existing human flu virus that most people have no immunity to is and there is no existing vaccines. [6978] The new Mexican A/H1N1 swine flu virus are parcicularly worrying because the surface proteins will not be recognised and defeated by the human immune system since all surface proteins are from swine flu virus. It contains two genes from bird flu virus which are thought to make the virus spread more easily [6978]. The new virus flu spreads rather easy from human to human. The virus also containes one human flu gene – and five swine flu genes.

<br>

<br>

The further the virus spreads (one person from South Korea was infected in April 2009) the more chance it will mix, or reassort, with other flu viruses in circulation and turn into something more lethal. "The prospects for change in the virus are considerable and worrying," warns virologist Kennedy Shortridge, who is a professor emeritus at the University of Hong Kong, where he led investigations into the initial emergence of H5N1 bird influenza in 1997, when it killed six of the 18 people it infected. The city squelched that outbreak by slaughtering all 1.4 million chickens and ducks in the territory. H5N1 re-emerged in 2003 and since then has claimed 257 lives while devastating poultry flocks throughout much of Asia and parts of Africa. Kennedy Shortridge also was among the first to suggest that pigs might act as mixing vessels for new combinations of viruses. He has long advocated global cooperation in the surveillance of circulating flu viruses to spot emerging new strains so that public health officials could plan a response and drug companies could get a head start on making vaccines. [Science, 6971]
<br><br>
Kennedy Shortridge is concerned that this new patched-together virus – with genes likely to come from N-America, Europe and Asia – might not be stable. The virus could easily reassort with other viruses such as H5N1 virus i Asia and strains of human H1N1 resistant to Tamiflu – such resistant strains are in circulation in many areas. He speculates that swapping one or more genes among these viruses could result in a virus that is more pathogenic, more easily passed from person to person, more resistant. [Science, 6971]
<br>

<br>

<font color="red">If you are exhibiting flu-like symptoms prior to going abroad, it is highly recommended that you consider postponing international travel. If you are currently travelling and have become ill, seek medical attention immediately. [7038]

<br><br>

<hr><br>
<a name="Things to do if the risk is there">
<b>Things to do if the risk is there: </b><br>

Do not kiss or make physical contact. Keep a distance. Stay indoor. Wear a mask. Keep hands off everything in the public. Wash your hands very often. Stay away from gatherings, such as busses, warehouses etc. (The masks do little to prevent the spread of the virus – but keep your hands away from your face – and make you recall to protect yourself). Hand washing is one of the easiest and most important things you can do to stop the spread of germs. <br><br>
Always wash hands:

after coughing, sneezing or blowing your nose <br>

after using the restroom <br>

before and after preparing food<br>

before eating <br>

before and after changing diapers<br>

after touching an animal or its waste <br>

after doing chores, such as handling garbage or doing yardwork<br>

before and after caring for someone who is sick or hurt <br>

<br><br>

Remember to wash your hands for at least twenty seconds. If you need a timer, imagine singing "Happy Birthday" two times. If you do not have soap and water nearby, use an alcohol-based hand sanitizer (at least 60% alcohol based).<br><br>
Disinfecting shared objects and common areas can help kill germs on surfaces and keep people from getting infected. For example, clean countertops, sinks, doorknobs, tables, telephones and anything else that people touch often.

<br><br>
Don't share personal items <br>

These include anything that has been near a person's mouth, nose or eyes, such as: <br>

toothbrushes <br>

drinking cups or straws<br>

makeup <br>

eating utensils <br>

washcloths or towels<br>

<br><br>

Practice cough and sneeze etiquette <br>

try to stay at least 3 feet away from other people<br>

cover your mouth and nose with a tissue, then throw the tissue away<br>

cough or sneeze into your upper sleeve if you have no tissue (not your hand)<br>

always wash your hands immediately afterwards <br>

<br><br>
Keep your distance from family and loved ones until you are well again. If you have children who are sick, it is a good idea to keep them home from school.

<br><br>

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<br>

<br>

<img src="http://www.bionyt.dk/svineinfluenza/handdryer80ax.jpg" width="150"><br>

Never use the hand dryer on the toilet. They spread virus. According to a British study people have 3 times more bacteria on their hands after using the hand dryer machine than if they use paper to dry their hands. The air flow also make virus to fly around you. <br><br>

<br>

<br>

Swine Influenza (swine flu, pig flu) is a respiratory disease of pigs caused by type A influenza. This virus type regularly cause outbreaks of influenza among pigs. Normally, swine flu viruses do not infect humans. However, human infections with swine flu do occur. Cases of human-to-human spread of the new type of swine flu viruses have been documented. The new subtype of A/H1N1 of the spring 2009 had not previously been detected in swine or humans.
<br><br>

Since March 2009, a number of confirmed human cases of a new strain of swine influenza A (H1N1) virus infection have been identified in Mexico, USA (including New York and California), Canada, Portugal, Spain, Switzerland, Scotland & Britain, Germany, Austria, Holland, Israel, South Korea, Peru, and New Zealand.

<br><br>

The new strain of swine flu is <font color="red">the suspected killer of about 150 people in Mexico</font> (April 26, 2009). 20 of these have been confirmed to have been infected by the new virus strain. Most concerning the dead were 25-45 years old, while normally only old people and very young die during influenza epidemics. During the Spanish Disease in 1918 people from 15-45 years old died.
<br><br>

The authorities closed schools, museums, libraries and theaters in the capital of Mexico and asked people not to go to church and other gatherings.
<br><br>

The authorities tried to contain the outbreak that had spurred concerns of a global flu epidemic. <b><i><font color="red">Do not kiss or contact. Keep a distance. Stay indoor. Wear a mask. Keep hands off everything in the public. Wash your hands very often. Stay away from gatherings, such as busses, warehouses etc.</b></i></font>
<br><br>Stay home if you get sick: Stay home from work or school and limit contact with others to keep from infecting them.

<br><br>

Develop a family emergency plan as a precaution. This should include storing a supply of food, medicines, facemasks, alcohol-based hand rubs and other essential supplies.

<br><br>
<img src="http://www.bionyt.dk/svineinfluenza/handdryer80ax.jpg" width="150"><br>

Never use the hand dryer on the toilet. They spread virus. According to a British study people have 3 times more bacteria on their hands after using the hand dryer machine than if they use paper to dry their hands. Even more: The use of the hand dryer machine INCREASED the bacteria on the hands 254%, while use of the paper for drying hands REDUCED the bacteria 77%. The air flow also make virus to fly around you. Noro-virus is known to be spread by the hand dryer machine. Do not use it. <br><br>
<br>

<br>
The new virus combines genetic material from pigs, birds and humans in a way researchers have not seen before. A genetic test has shown that the new swine influenza is a combination of European swine genes and North American swine genes.
<br><hr><br><br>

<A name="Symptoms of the Swine Flu">

<b>Symptoms of Swine Flu </b>
<br><br>

Symptoms of the new strain are similar to regular flu symptoms: fever, cough, sore throat, headache, runny nose, and

muscle aches. <br><br>
The new strain give more vomiting and diarrhea than regular flu.
<br><br>

Those infected will show symptoms within 9 days or so, and be contagious from one day before symptoms and for up to 7 (or more) days after symptoms start.<br><br>

Day 1 <b><i><font color="red">Infection</b></i></font><br>

Day 2 <b><i><font color="blue">no symptoms!</b></i></font><br>

Day 3 <b><i><font color="blue">no symptoms!</b></i></font><br>

Day 4 <b><i><font color="blue">no symptoms!</b></i></font><br>

Day 5 <b><i><font color="blue">no symptoms! </font><font color="red">BUT CONTAGIOUS!! (the incubation time might be up to 10 days)</b></i></font><br>
Day 6 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 7 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 8 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 9 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 10 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 11 <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>

Day 12-13-14-15- <b><i><font color="red">influenza symptoms CONTAGIOUS!!</b></i></font><br>
<br>Small children can be contagious for longer time.<br><br>
The above is the disease in general for adults – not everyone show symptoms on day 9, of course.
<br>

<br>
The viruses cannot be spread through eating pork. <br><br>
<br><hr><br><br>

<A name="Assessing the severity of an influenza pandemic">
<b>Assessing the severity of an influenza pandemic</b><br>

The major determinant of the severity of an influenza pandemic, as measured by the number of cases of severe illness and deaths it causes, is the inherent virulence of the virus. However, many other factors influence the overall severity of a pandemic's impact. [7036]<br><br>
Even a pandemic virus that initially causes mild symptoms in otherwise healthy people can be disruptive, especially under the conditions of today's highly mobile and closely interdependent societies. Moreover, the same virus that causes mild illness in one country can result in much higher morbidity and mortality in another. In addition, the inherent virulence of the virus can change over time as the pandemic goes through subsequent waves of national and international spread. [7036]<br><br>
<b>Properties of the virus</b><br>

An influenza pandemic is caused by a virus that is either entirely new or has not circulated recently and widely in the human population. This creates an almost universal vulnerability to infection. While not all people ever become infected during a pandemic, nearly all people are susceptible to infection. [7036]<br><br>
The occurrence of large numbers of people falling ill at or around the same time is one reason why pandemics are socially and economically disruptive. Very rapid spread can undermine the capacity of governments and health services to cope. [7036]<br><br>
The contagiousness of the virus also influences the severity of a pandemic's impact, as it can increase the number of people falling ill and needing care within a short time frame in a given geographical area. On the positive side, not all parts of the world, or all parts of a country, are affected at the same time. [7036]<br><br>
Pandemics usually have a concentrated adverse impact in specific age groups. Concentrated illnesses and deaths in a young, economically productive age group will be more disruptive to societies and economies than when the very young or very old are most severely affected. [7036]<br><br>
<b>Population vulnerability</b><br>

The overall vulnerability of the population can play a major role. For example, people with underlying chronic conditions, such as cardiovascular disease, hypertension, asthma, diabetes, rheumatoid arthritis, and several others, are more likely to experience severe or lethal infections. The prevalence of these conditions, combined with other factors such as nutritional status, can influence the severity of a pandemic in a significant way. [7036]<br><br>
<b>Subsequent waves of spread</b>

The overall severity of a pandemic is further influenced by the tendency of pandemics to encircle the globe in at least 2, sometimes 3, waves. For many reasons, the severity of subsequent waves can differ dramatically in some or even in most countries. [7036]<br><br>
A distinctive feature of influenza viruses is that mutations occur frequently and unpredictably in the 8 gene segments, and especially in the hemagglutinin gene. The emergence of an inherently more virulent virus during the course of a pandemic can never be ruled out. [7036]<br><br>
Different patterns of spread can also influence the severity of subsequent waves. For example, if schoolchildren are mainly affected in the 1st wave, the elderly can bear the brunt of illness during the 2nd wave, with higher mortality seen because of the greater vulnerability of elderly people. [7036]<br><br>
The 1918 pandemic began mild and returned, within 6 months, in a much more lethal form. The pandemic that began in 1957 started mild, and returned in a somewhat more severe form, though significantly less devastating than seen in 1918. The 1968 pandemic began relatively mild, with sporadic cases prior to the 1st wave, and remained mild in its 2nd wave in most, but not all, countries. [7036]<br><br>
<b>Capacity to respond</b><br>

Finally, the quality of health services influences the impact of any pandemic. The same virus that causes only mild symptoms in countries with strong health systems can be devastating in other countries where health systems are weak, supplies of medicines, including antibiotics, are limited or frequently interrupted, and hospitals are crowded, poorly equipped, and understaffed. [7036]<br><br>
<b>Assessment of the current situation</b><br>

To date observations specific to H1N1 are preliminary, based on limited data in only a few countries. The H1N1 virus strain causing the current outbreaks is a new virus that has not been seen previously in either humans or animals. Although firm conclusions cannot be reached at present, scientists anticipate that pre-existing immunity to the virus will be low or non-existent, or largely confined to older population groups. [7036]<br><br>
H1N1 appears to be more contagious than seasonal influenza. The secondary attack rate of the common seasonal influenza ranges from 5 per cent to 15 per cent. Current estimates of the secondary attack rate of H1N1 range from 22 per cent to 33 per cent. [7036]<br><br>
With the exception of the outbreak in Mexico, which is still not fully understood, the H1N1 virus tends to cause very mild illness in otherwise healthy people. Outside Mexico, nearly all cases of illness, and all deaths, have been detected in people with underlying chronic conditions. [7036]<br><br>
In the two largest and best documented outbreaks to date, in Mexico and the United States of America, a younger age group has been affected than seen during seasonal epidemics of influenza. Though cases have been confirmed in all age groups, from infants to the elderly, the youth of patients with severe or lethal infections is a striking feature of these early outbreaks. [7036]<br><br>
The tendency of the H1N1 virus to cause more severe and lethal infections in people with underlying conditions is of particular concern. [7036]<br><br>
The prevalence of chronic diseases has risen dramatically since 1968, when the last pandemic of the previous century occurred. The geographical distribution of these diseases, once considered the close companions of wealthy societies, has likewise shifted dramatically. Today, WHO estimates that 85 per cent of the burden of chronic diseases is now concentrated in low- and middle-income countries. In these countries, chronic diseases show an earlier average age of onset than seen in more wealthy parts of the world. [7036]<br><br>
Some scientists speculate that the full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread. This, too, could alter the current disease picture, which is overwhelmingly mild outside Mexico. [7036]<br><br>
Apart from the intrinsic mutability of influenza viruses, other factors could alter the severity of current disease patterns, though in completely unknowable ways, if the virus continues to spread. [7036]<br><br>
Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses as the normal influenza season in that hemisphere begins. [7036]<br><br>
The fact that the H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a pandemic. At present, H5N1 is an animal virus that does not spread easily to humans and only very rarely transmits directly from one person to another. [7036]<br><br><hr><br>

<A name="Overcoming the Swine Flu">

<b>Overcoming the Swine Flu</b><br><br>
The new Swine Flu virus have proved resistant to amantadine and rimantadine anti-viral drugs.
<br><br>

However, it is susceptible (day 1 and 2 of symptoms) to

oseltamivir (= Tamiflu) and zanamivir (= Relenza), both are newer anti-viral drugs for flu. Must be given within 48 hours.
<br><hr><br><br>

<b>About Swine Influenza</b>
<br><br>

Swine influenza (Swine flu, pig flu) refers to influenza cases that are caused by Orthomyxoviruses. These viruses are endemic to populations of pigs.
<br><br>

The viruses are referred to as Swine influenza viruses (SIV). <br><br>

The distinction is not based on phylogeny. The SIV strains isolated have been classified either as Influenzavirus C or one of the various subtypes of the genus Influenzavirus A. <br><br>

Swine influenza virus developes first in pigs and can be carried to humans. In the 2009-epidemic humans then infected other humans with the virus.
<br><br>
Washing hands and clothes, and cancelling big and small public events can slow the spread of the virus, giving time, but such things will not stop the virus. Antivirus drugs are limited in stocks, and only work if taken early enough like within 2 days. If diagnose is not accurate or takes too long time, there is the risk that the antivirus drugs will be spoilt on the worried but just infected by an innocent virus – or that the stocks are controlled to strict so that drugs are administered too late. [6978]
Vaccine is the answer to virus infections. But vaccine production is dictated by a few companies commercial interests. If a company stop producing vaccine towards the season flu and switch to a vaccine towards the new flu, the company risk to loose the income from the standard season vaccination and that the new vaccine are not sold because the feared pandemic never actually happen. [6978]
According to one study we could have 340 million doses of vaccine in four months if the companies focus on this. If the actual vaccine production is easy we might have three times more vaccine doses – but still not for all nearly 7 billion people in the world. [6978]
On the long line (of political involvement in virus infection research) We could pool all our resources – making vaccines that focus on the parts of the virus that do not mutate (and therefore would be active against new virus types) – and we could made new antiinflammatory treatments (to hinder the deadly immune-overreaction of the body) – and we could make new DNA vaccines and protein vaccines – or we could base the antibody therapy on the serum of survivors. [6978]
<br><br>

The global preparedness for a pandemic is extremely patchy. Poorer countries are least prepared, but even in richer regions there are serious gaps: a survey in 2007 of 30 European nations found that countries had in place only half of the measures expected by the WHO [6991]. The biggest gap was in preparedness to keep society functioning beyond its health system, to ensure continued provision of electricity, transport, banking, food and policing. Only 12 of 30 nations had multisectoral planning. In Africa only 35 out of 53 countries have pandemic plans. In developing countries already struggling with malaria, HIV and TB a lethal flu during the flu season would represent a profound challenge [6991].

<br><br>

<hr><br>

<A name="Live or inactivated vaccine?">

<b>Discussion: Live or inactivated vaccine?</b><br>

With current manufacturing capabilities, there will be enough vaccine for only a fraction of the world's population, and not before six months from now. And most of that will go to rich countries. [7040, 12 May 2009 (Nature)]<br><br>
One controversial idea is to use a live attenuated vaccine, which could boost the number of doses available by 50- to 100-fold. Manufacturers are lukewarm to the idea. But some experts say the live-virus idea should be entertained. David Fedson, a pandemic-vaccine expert and retired former medical director of French vaccine development company Aventis-Pasteur, now known as Sanofi Pasteur, argues that the live-virus approach is the way to go now with H1N1. [7040]<br><br>
<b>Inactivated virus in seasonal flu</b><br>

The ordinary seasonal flu vaccine uses inactivated virus. Serious regulatory barriers exist to introducing a live-virus vaccine. Demonstrating efficacy and getting regulatory approval in time would pose "quite significant difficulties", says George Kemble, vice-president of vaccine research and development at MedImmune in Gaithersburg, Maryland, which makes live flu-virus vaccine. [7040]<br><br>
<b>Time to be used for making a new vaccine</b><br>

Two factors largely determine whether a vaccine can protect large numbers of people during a pandemic. Culturing vaccines in chicken eggs is the main time delay in production. The delay before substantial quantities of vaccine become available is usually around six months due to the time required to grow the virus in hens' eggs. (Cell culture and other technologies could be faster, but they are not yet ready for prime time.) [7040]<br><br>
The second limiting factor is production capacity, currently at around 700 million to 900 million doses of seasonal flu vaccine annually. [7040]<br><br>
<b>Vaccine production capacity</b><br>

Although still limited, production capacity is now in 2009 much better than five years ago (currently 700 – 900 million doses of seasonal flu vaccine annually – but around 2004 it was around 300 million — mainly because of measures taken by governments to prepare for a pandemic threat. [7040]<br><br>
<b>The content of the seasonal vaccine</b><br>

The seasonal vaccine contains antigens against three circulating flu strains. [7040]<br><br>
Switching to producing a single vaccine against just the new H1N1 virus could, in principle, mean that existing vaccine producers could make three times as many doses. [7040]<br><br>
But even if global facilities switched entirely to producing an inactivated H1N1 vaccine, only about 1 billion doses at most are expected to be available by the end of the year, around the time of the Northern Hemisphere flu season. [7040]<br><br>
Because the population has little to no pre-existing immunity, the vaccine will probably need to be given in two doses — reducing the actual number of vaccines to 500 million. [7040]<br><br>
Live-virus vaccine would effectively increase production capacity – the virus in such a vaccine is capable of reproducing in humans, so much lower doses can be given. [7040]<br><br>
Live-virus vaccines also don't require adjuvants to bolster their effectiveness, can be administered nasally — avoiding the need for syringes — and are thought to provoke a broader and stronger immune response than inactivated vaccine. [7040]<br><br>
One egg yields one dose of inactive vaccine, – but for a live vaccine one egg yields somewhere from 50 to 100 doses. [7040]<br><br>
Production capacity will also depend on how well the new H1N1 virus can be grown and cultivated. The news here seems to be good. [7040]<br><br>
Doris Bucher, an immunologist at New York Medical College, was asked by US Centers for Disease Control and Prevention in Atlanta, Georgia, to help grow the first reference strains to be sent to manufacturers. "We've done 7 cycles, 42 hours each, and it's going very well," she said. [7040]<br><br>
The immune response produced by the resultant seed vaccines will need to be tested in clinical trials; if it were, for example, to require three times as much antigen as seasonal flu to prompt an adequate immune response, that would cut theoretical production capacity to a third. [7040]<br><br>
To grow live attenuated vaccines, scientists would reassort (recombine) the new flu strain with a 25°C cold-adapted strain, which will multiply in the nose but not grow in the higher temperatures of the lower respiratory tract. [7040]<br><br>
Only two groups have the technology to produce live attenuated flu vaccines: MedImmune, and Nobilon, a subsidiary of Schering-Plough, which has licensed technology developed at the Institute of Experimental Medicine in St Petersburg, Russia. [7040]<br><br>
MedImmune's FluMist is approved for use in the United States for those aged 2-49 years old; older people have been exposed to past pandemic viruses, and their immune systems therefore kill the live vaccine for current circulating strains. [7040]<br><br>
The WHO has obtained a licence from Nobilon to allow manufacturers in developing countries to use the Russian technology. [7040]<br><br>
Producers of inactivated vaccine seem sceptical about using live attenuated vaccines more widely, even in a pandemic situation. [7040]<br><br>
Changing over to a live vaccine would mean introducing new production methods and possibly having to license outside technology, such as that from MedImmune. [7040]<br><br>
There are also safety and liability issues, because it would be difficult to organize clinical trials of an untested vaccine quickly enough. [7040]<br><br>
Jesse Goodman, acting chief scientist of the US Food and Drug Administration, notes that live attenuated vaccine is approved in the United States for children and young adults, who "may be at particular risk of infection" in the current H1N1 outbreak. Safety, however, is paramount, he adds: "It is also important to keep in mind, even in the face of a pandemic threat, the importance of doing all that is appropriate and possible to assure high vaccine quality and safety, particularly if and as new facilities, processes and products may be considered." [7040]<br><br>
Memories are still vivid of the 1976 flu-vaccine fiasco. That year, a new swine flu emerged at an army barracks in New Jersey, killing one person but failing to spread further. A mass vaccination campaign ordered by president Gerald Ford caused neurological side effects in some people, and killed 25. [7040]<br><br>
Initial information suggests that vaccine producers are well along in producing the seasonal H1N1 and H3N2 strains for the Northern Hemisphere, but are having difficulty growing the third influenza B strain. [7040]<br><br>
One option may be drop the influenza B from next year's vaccine. Northern Hemisphere production would then be freed up faster to work on a swine-flu vaccine. [7040]<br><br>
In the Southern Hemisphere vaccine production typically starts around November and continues through March. [7040]<br><br>
The amounts of vaccine ordered by Southern Hemisphere countries is much lower than that by the north, meaning that northern manufacturers might then have extra time to work on a swine-flu vaccine. [7040]<br><br>
One scenario, she says, is that full-scale manufacturing of swine-flu vaccine could start by July 2009 at the earliest. [7040]<br><br>
The new H1N1 strain remains susceptible to the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza). Cheaper and more widely available antibiotics and anti-inflammatories, such as statins, could also have a role in limiting mortality in a severe pandemic. [7040]<br><br>

<br><hr><br><br>

<A name="Background for the epidemic">

<b>Background</b><br>

For years the scientific community has been speculating that new

influenza strains might arise when an bird influenza virus infects swine

that are also coinfected with human influenza viruses. This coinfection in

the same host, along with a possible 3rd coinfection of a swine influenza

virus, has been felt to offer the potential for reassortment of the genetic

material of the viruses, that might ultimately produce a virus that is

novel to humans, and can infect humans and be transmitted between humans.[6955]

<br><br>
Birds and humans rarely catch flu viruses which are adapted to another host. But such viruses can pass flu to pigs. Pigs also have their own strains. If a pig catches two kinds of flu at once the pig can act as a mixing vessel. Hybrid viruses can emerge with genes from both viruses. – THis is what happened

<br>
Swine are susceptible to the same influenza A virus subtypes as humans are – that is: H1N1, H3N2 and H1N2.<br><br>

Many swine influenza viruses are the result of reassortment: Their genes are composed of human and bird and/or swine virus genes. <br><br>
It is known that both human and bird influenza viruses occasionally transmit to pigs, and that pigs can serve as “mixing vessels” for these viruses. Thereby viruses can exchange genetic material and lead to the production of a new “hybrid” virus.<br><br>
Pandemic viruses could emerge following reassortment in pigs. <br><br>

Influenza is a major cause of acute respiratory disease in pigs. Subclinical infections are also common in pigs.
<br><br>
The symptoms and pathogenesis of influenza in pigs show remarkable similarities with those of seasonal influenza in humans. However, the epidemiology is different because of the extremely rapid turnover of the swine population with constant introduction of immunologically naïve animals into swine herds. <br><br>
By the end of the six-month-long fattening period many pigs have had infections with two or even three swine influenza subtypes.
<br><br>
The viruses in Europe differ significantly in their antigenic and genetic make-up from those circulating in North America, even though they consist of the same H and N subtypes.
<br><br>
Humans in contact with pigs occasionally become infected by swine influenza viruses. But person to person transmission of pig flu appears to be rare.

<br><br>
Hog workers in Europe and North America are far more likely than others to be infected with potentially lethal pathogens such as MRSA (Methicillin-resistant Staphylococcus aureus), drug-resistant E. coli and Salmonella, and of course, swine influenza. Many scientists also believe that people who work inside CAFOs are more at risk of contracting and spreading these and other "zoonotic" diseases than those working in smaller-scale operations, with outdoor pens or pasture and far lower animal density.

<br><br>
Example: A middle-aged woman in Spain suffered a mild influenza-like illness for which few physicians would have taken a swab. However the general practitioner (GP) she consulted happened to be part of an active influenza surveillance scheme and a specimen was taken and recognised as being influenza A (H1N1) phylogenetically close to European H1N1 swine influenza viruses.
<br><br>

Until March-April 2009, hog workers with swine flu have rarely gone on to infect other people, save for close family members. And that is why the new strain A/H1N1 of swine influenza virus is so vexing – and alarming. It seems to spread quite easily through casual human contact.
<br><br>

The continual cycling of swine influenza viruses and other animal pathogens in large herds or flocks provides increased opportunity for the generation of novel viruses through mutation or recombinant events that could result in more efficient human-to-human transmission of these viruses. In addition, agricultural workers serve as a bridging population between their communities and the animals in large confinement facilities. This bridging increases the risk of novel virus generation in that human viruses may enter the herds or flocks and adapt to the animals. [6989, Pew Commission on Industrial Farm Animal Production, http://ncifap.org/]
<br><br>

Reassortant influenza viruses with human components have ravaged the modern swine industry. Such novel viruses potentially increase zoonotic disease transmission risk to the communities where the workers live. 64% of 63 persons exposed to humans infected with H7N7 bird influenza virus had serological evidence of H7N7 infection following the 2003 Netherlands bird influenza outbreak in poultry. The spouses of swine workers who had no direct contact with pigs had increased odds of antibodies against swine influenza virus. Among communities where a large number of workers in factory farms live, there is great potential for these workers to accelerate pandemic influenza virus transmission. Industry calls they "confined animal feeding operations," or CAFOs (KAY-fohs), though most people know them simply as "factory farms." In the last several years, U.S. hog conglomerates have opened giant swine CAFOs south of the border, including dozens around Mexico City in the neighboring states of Mexico and Puebla and in the State of Veracruz [6989]

<br><br>

Gregory Gray, a University of Iowa professor of international epidemiology and expert in zoonotic infections, warned that factory farm workers could serve as a "bridging population" to rural communities sharing viruses with the pigs, and vice-versa. Factory farm production could lead to another 1918-style global pandemic. May be waterfowl cross-infected pigs in USA with a new type of avian-swine super-virus that was quickly transmitted to farm workers, possibly in Iowa, who went off to military training camps for World War I, and then spread the pathogen worldwide, starting the "Spanish flu" (only called Spanish because Spain at that time was not at war – and therefore free to report about the flu). [6989]

<br><br>

Factory farms are not hermetically sealed environments. Pathogens can enter and exit via swine workers or flies, via waste lagoons and recycled water into the animal housing (dwindling groundwater supplies is a particular concern in parts of Mexico). Wildfowl land in the lagoons and can shed influenza virus into the water. Factory farms have high rates of ventilation – enormous number of animals that would die of heat stress unless the building was ventilated. Scientists have measured bacteria and viruses in the environment around poultry and swine houses. [6989]

<br><br>
Intensive operations of chickens and pigs in factory farms are contributing to speeding up viral evolution. [6989]
During an ongoing epidemic Where the virus evolved is not as important as locating the virus, and stopping its spread. [6989]
<br><br>

• Bird-proofing – All doorways, windows and air-flow vents in swine housing units should be adequately sealed or screened to prevent entrance of birds.

<br><br>
• Water treatment – Do not use untreated surface water as either drinking water or water for cleaning in swine facilities. Likewise, it may be prudent to attempt to minimize waterfowl use of farm lagoons.

<br><br>
• Separation of pig and bird production – Do not raise pigs and domestic fowl on the same premises.

<br><br>
• Feed security – Keep pig feed in closed containers to prevent contamination with feces from over-flying waterfowl.

<br><br>
• Worker biosecurity – Provide boots for workers that are worn only within the pig housing units, thus eliminating.

<br><br>

Pigs don't fly, but every year more than two million wild fowl fly up to 1,500 miles or more eastward across the Arctic Ocean from Asia to North America and intersect with North American species. In October 2008 U.S. Geological Survey published a study in Molecular Ecology that found genetic evidence of (non-H5N1) flu viruses in northern pintail ducks in Alaska whose genes were more closely related to Asian bird flu strains than those in the Americas. [6989]

<br><br>
Wild birds can carry virus with swine components in it. A lot of bird viruses contain elements from pigs. An Asian bird virus could contain swine flu components from Eurasian pigs. A pig infected by a bird virus can come into contact with swine virus, which then could combine and be picked up by a bird again. [6989]

<br><br>

Pig's don't fly, but pork does. There is an active international transfer of all kinds of animal products – some of it is imported from Asia or Europe to North America."

[6989]<br><br>
And people fly. The human travel is the most likely way that Eurasian swine viral components made their way to Mexico. A tourist from China could have gone to Mexico City, and that Asian strain was picked up by somebody else, who then went to a swine barn. [6989]
<br><br>

A concern is that new strains of bird flu combining with swine flu could make the swine flu more deadly, and because viruses pass so easily between pigs and people, such a new bird component could make swine flu more virulent. [6989]
<br><br>

The human disease from pig flu is usually clinically similar to disease caused by infections with human influenza viruses. Pneumonia and death have occasionally been reported in the literature in otherwise healthy adults. However, human infections with swine influenza virus is normally much milder than those seen with bird influenza A (H5N1).
<br><br>

<br><br>
In 1976 an outbreak of swine influenza virus infections in humans was detected in recruits in a military camp in Fort Dix, New Jersey in the United States. The presumed link to pigs was never discovered but there was extensive human to human transmission, with over 200 infections resulting in 12 hospitalisations and one death. This was human to human transmission of a novel influenza virus which might be described as WHO Pandemic Phase 4.
<br><br>
The true incidence of swine influenza in humans is unknown. It is known from USA that the few reported cases of swine influenza in humans represent a larger number of undetected infections among those in contact with pigs. However, two factors are probably restricting infection of humans: limited fitness of the virus in a different host species, and immunity to human H1 or H3 influenza viruses may protect against infection with swine viruses.
<br><br>
Some scientists have advocated seasonal influenza vaccination to persons working with pigs to reduce their risk of getting infected. However, experience with workers with domestic poultry on this point is not encouraging. In one audit attempt in Europe uptake of the vaccine was low and those offered immunisation were confused as to what they were being protected against.

<br><br>

In 1998 swine H1N1 hybridised with human and bird viruses, resulting in swine-human-bird triple "reassortants". The virus emerged in Minnesota, Iowa and Texas. <b><i>This triple reassortant in pigs seems to be the precursor for the Mexican flu.</b></i> The virus initially had human surface proteins and internal swine proteins, with the exception of three genes that make RNA polymerase (the enzyme for virus replication). Two of these three crucial genes were from bird flu virus and one was from human flu virus. Researchers believe that the bird polymerase allows the virus to replicate faster than virus with human or swine versions, – making the virus more virulent. [6978]
<br>

<br>

The swine versions with these faster replicating bird polymerase enzymes easily outcompeted those viruses that did not have these fast polymerase enzymes, so that by 1999 these new viruses comprised the dominant flu strains in North American pigs. Unlike the swine virus they replaced, they were actively evolving and in 2009 there were many versions with different pig surface proteins or human surface proteins, – including one with H1 and N1 from the original swine virus. <b><i>This is just like the Mexican flu from March-April 2009.</b></i> [6978]
<br>

<br>

All these viruses still contained the same "cassette" of internal genes, including the bird and human polymerase genes. But the viruses had been actively switching their surface proteins – thereby evading the pigs' immunity. The polymerase gene sequences were of the bird-virus and human-virus type, yet these viruses were for many years only reported in pigs. [6978]
<br>

<br>

There were in 2009 so many kinds of pig flu that pig flu was no longer seasonal. One in five pig producers in USA maked their own vaccines, because the vaccine industry could not keep up with the virus changes. [6978]
<br>

<br>

This rapid evolution posed a potential for pandemic influenza. Researchers who focused on swine flu could see the threat developing, while the medical researchers who focused on human flu viruses seemed not to have been aware of this threat. Around 2004 several scientists warned that pigs in USA were an increasingly important reservoir of viruses with human pandemic potential. One in five pig workers in USA had been found to have antibodies to swine flu, showing they had been infected, but most people had no immunity to these viruses. Also the American CDC warned in 2008 that swine H1N1 would represent a pandemic threat if it started circulating in humans. [6978]
<br>

<br>

The immune response in the body makes the whole difference between a mild disease and a lethal disease. Our immune respons is mainly due to the H surface protein of the virus. The Mexican virus carries the swine version of the surface protein. Therefore, the antibodies we humans carry to human H1N1 viruses will not recognise the virus with the swine-virus type of H-proteins on the surface of the virus particle. [6978]
<br>

<br>

The bird polymerase genes are especially worrying, as similar genes are what make H5N1 bird flu very lethal in mammals and what made the 1918 human pandemic virus so lethal in people. [6978]

A Russian scientist predicted the deadly swine flu pandemic back in 2004, when he said the deadly bird flu was likely to mix with the human flu virus in the organism of a pig.

Professor Dmitry Lvov of the Virology Institute at the Russian Academy of Sciences said at a conference that up to one billion people could be killed within six months, and that such a the pandemic was possible in 2005 or later.

The pandemic could be caused by a mutation of the H3N2 ‘bird flu’ virus, he said.

Bird flu killed millions of birds in South Asia. Among 45 cases of humans catching bird flu 30 of them died. The worst thing was that the virus got into a population of pigs.
The bird flu virus is not very contagious for humans, but pigs are ideal “incubators” to breed a new stem of the virus, far deadlier than H5N1 or H3N2. [6995]

<br>

<br>

The Veratect Corporation based in Kirkland, Washington, monitors world press and government reports to provide early disease warnings for clients. Their first inkling of the Mexican swine flu A/H1N1 was a 2 April 2009 report of a surge in respiratory disease in the town La Gloria (Perote Municipality, Veracruz State, Mexico), east of Mexico City, which resulted in the deaths of three young children [6978]. About 3000 inhabitants, most of the people in La Gloria, had flu symptoms. 1300 were investigated, and 450 of these treated, the news media later wrote. The swine were killed as a prevention, although the influenza was not found in the pigs. [7008, video from La Gloria].

<br>

<br>

Only on 16 April 2009 – after Easter week, when millions of Mexicans travel to visit relatives – did reports surface elsewhere in Mexico. [6978]
<br>

<br>

Local reports in La Gloria blamed pig farms about 8 km from the town in nearby Perote owned by Granjas Carroll, a subsidiary of US hog giant Smithfield Foods. The farms produce nearly a million pigs a year. Smithfield Foods, in a statement, insists there were "no clinical signs or symptoms" of swine flu in its pigs or in its workers in Mexico – but that was unsurprising since the company also said that it "routinely administers influenza virus vaccination to swine herds". (However the company would not tell New Scientist any more about recent tests). Furthermore, vaccination keeps pigs from getting sick,, but it does not block infection or shedding of the virus. [6978]
<br>

<br>

A "pandemic" is an epidemic that goes global. Technically there is a flu pandemic every year, but the term is usually reserved for bad outbreaks. The influenza virus constantly evolves. Pandemics happen every few decades when the flu virus gets new surface proteins that people have little immunity to, generally because they come from an animal strain. [6978]
<br>

<br>

The lack of immunity means the virus affects more people more severely. H5N1 bird flu is very dangerous because its H5 surface protein is totally new to humans – and because H5N1 bird flu virus has killed more than half of the people it has infected. [6978]
<br>

<br>

Bird flu virus from the H5, H7 or H9 families, which are unknown for our body, only needs to become readily contagious to go pandemic. [6978]
<br>

<br>

H1N1 has received less attention partly because a H1N1 strain already circulates in humans. However, the Mexican strain carries different versions of H1 surface proteins. [6978]
<br>

<br>

The new strain from Mexico is packing a faster virus engine than previous H1N1 strains. With its bird virus gene it has become dominant in pigs, – no one knows if this will make it dangerous in people. [6978]
<a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19124">Literature</a><br><br><br>

<hr><br>

<br><br>

<A name="Swine flu genes in China – and diagnostic means.">
<b>Swine flu genes in China – and diagnostic means.</b><br><br>
The HA-segment and 5 other gene segments should according to searches in gene data banks be from the previous h1.3.2 "classical" swine influenza viruses. The other 2 gene segments in the virus (NA and M) are believed to be from h1.1.3 (“bird-like”) swine influenza viruses. [6994]. <br><br>
The 3 clusters of H1 subtypes can be detected by a RT-PCR system (using one upper primer and 2 differentiation down primers with the sequences: <br><br>H1S-3: 5'-TAAGCAAAAGCAGGGGAAAATAAAA-3'<br>
H1R-1143: 5'-TGGTGATAACC(G/A)TACCATCCATCT-3'<br>
H1Rm-610: 5'-CACGAGGACTTCTTTCCCTTTATCAT-3' [6994]. <br><br>
It is important to detect the viral NA gene to clarify whether the virus is similar to the current A(H1N1) swine influenza virus spreading in humans. [6994]. <br><br>
If¤ suspicious samples through the aforementioned detection of the viral HA gene is found, the following primer to amplify and sequence the viral NA gene can be used. [6994]. <br><br>
NAS-5A 5'-GCAAAAGCAGGAGTTTAAAATGAA-3'¤
<br>

NAR-1108A 5'-GTTCTCCCTATCCAAACACCAT-3' [6994]. <br><br>

Another kit for detection of all H1 subtype swine influenza viruses: <br><br>

H1-762U: 5'-TATCAACAATAAGAA-3'¤

<br>

H1-762L: 5'-CAAACATCCAGAAGA-3'¤

<br><br>

The upper primer H1-762U is located at a highly variable region within the targeted gene, so that the specificity of the primers cannot be guaranteed. [6994]. <br><br>
Another kit for detection of the current A(H1N1) swine influenza virus circulating in humans. [6994].

<br><br>

H1-292U: 5'-CATTAATGATAAAGG-3'¤<br>

H1-292 L: 5'-TCCAGCATTTCTTTC-3' [6994]. <br><br>
Since the primers are too short the specificity of the primers and the effective combination of the primers to the corresponding regions cannot be guaranteed. [6994]. <br><br>
Most of the influenza viruses circulating in pigs in China have been H1N1 (cluster: h1.3.2 "classical") and H3N2 (cluster: h3.1.5) swine influenza viruses. [6994]. <br><br>
The viruses within cluster h1.1.3 (“bird-like”) were isolated from pigs only in 2007 in China. [6994]. <br><br>
H9N2 subtype bird influenza viruses have been isolated from pigs in China since 2003. [6994]. <br><br>
H5N1 subtype bird influenza viruses were isolated from pigs only once in 2005 and (until 2009) never after China has implemented compulsory H5 vaccination in poultry. [6994]. <br><br>
A few human H3N2 and H1N1 subtypes of influenza viruses have also been isolated from pigs in China. [6994]

<br><br>

Moreover, it seemed that re-assortment of the gene segments of influenza viruses from different origins was rather frequent in pigs in China. [6994]

<br><br>

A re-assortment subtype (H1N2) swine influenza virus has been isolated since 2004. [6994]. <br><br>
The March-April 2009¤A(H1N1) swine influenza virus spreading in humans has never been isolated in China despite surveillance by several research groups in the past decade in China. However, with the experience of the recent emergence of a dangerous human influenza virus, presumably directly from pigs in North America, it is of high significance to carry out rigid surveillance on the influenza viruses circulating in the pigs in China for a long time. The March-April 2009¤A(H1N1) influenza viruses spreading in humans are very dangerous for China, which has a very large population and limited hygiene resources. [6994]. <br><br>
The morbidity and mortality of the epidemic, if spreading in China, could be as high as in Mexico, since both are developing countries, and consequently, thousands of young people in China could die due to the infection. Therefore, it is rational for China to take some rigid measures to prevent the disease from spreading to China, according with International Health Regulations and the Code of the World Organisation for Animal Health (OIE). [6994]. <br><br>

<br><br>

<hr><br>

<A name="Bacterial co-infections?">

<b>Bacterial co-infections?</b><br><br>
The death seen from flu influenza in Mexico could be due to the combination of virus and bakteria infections. Three observations make it highly likely that the "flu" fatalities are due to such bacterial co-infections: <br><br>
1st, a study (Ramilio et al, Blood, 2007) of humans with flu-symptoms found that greater than 30 percent of the fatalities were in people with bacterial-influenza co-infections. Knowing the inadequacy of the diagnostics the number of co-infections could be much higher than 30 percent, possibly even 90 percent in fatalities. [6994]. <br><br>
2nd, the index case (“case zero”) in Mexico was a small boy who got severely sick, but his doctor gave him an antibiotic (usually for bacterial infections), and he survived. The fact that he got better 2 days after an antibiotic may indicate that he had a bacterial infection in addition to a flu infection. [6994]. <br><br>
3rd, one of the earliest Mexican deaths was a diabetic woman in her 40's. A lung biopsy contained influenza. Several people around her had respiratory diseases, but none of them were positive for influenza! This means that it is possible she too had both flu and bacterial infections that lead to her death. [6994]. <br><br>
¤It is well known that flu infections make it easier to maintain respiratory bacterial infections and visa versa. [6994]. <br><br>
To safeguard against flu-related deaths, doctors could prescribe more antibiotics. However, since the cost of antibiotics is high and since over-prescribing antibiotics is dangerous, diagnostics that discriminate between viral and bacterial infections should be used. There is already an FDA approved pregnancy-test-type device [produced by Rapid Pathogen Screening (RPS), Inc.] that determines whether teardrops from a person with conjunctivitis arise from bacterial or viral infection (it uses antibodies to MxA and C-reactive proteins, which are early host responses to either viral or bacterial infections). Molecular biologists have found¤changes in circulating H3N2 viruses as well as H1N1 and since the available diagnostics are poor, much of what was blamed on H1N1 could have been H3N2 (or another virus or bacteria or a co-infection). Much more funding should go to developing host-response diagnostics, since there are about 100 known host proteins that can discriminate acute bacterial infections from acute viral infections. Expression of those proteins in the plasma should allow to discriminate the serious cases from the light ones. However, antibiotics should be used only with probable bacterial infection. and what is also important is the use of appropriate antibiotics, e.g. anti-staphylococcal agents if staphylococcal rather than pneumococcal.pneumonia is suspected. For example in the 1957 pandemic, S. aureus was 2nd only to the pneumococcus as a cause of secondary bacterial pneumonia, but many other organisms also caused secondary bacterial pneumonia. Also an issue for discussion is the need to have an adequate supply of antibacterial agents available as well as antivirals in the presence of a pandemic. The concern of many infectious diseases experts in USA is that we do not have such a supply and that there are inadequate antibiotics in the pipeline to deal with emerging bacterial resistance. [6994]. <br><br>

<A name="Information for laboratory workers">

<br><hr><br><b>Information for laboratory workers: </b>

<br>

CDC guidance is for laboratory workers: Diagnostic laboratory og suspected swine influenza A (H1N1)

should be conducted in a BSL2 laboratory, sample manipulations done

inside a biosafety cabinet, and Viral isolation in a BSL2

laboratory with BSL3 practices (enhanced BSL2 conditions). [6955, Friday 24 April 2009]<br>

Additional precautions include:<br>

• recommended personal protective equipment (based on site specific risk

assessment)<br>

• respiratory protection — fit-tested N95 respirator or higher level of

protection.<br>

• shoe covers<br>

• closed-front gown<br>

• double gloves<br>

• eye protection (goggles or face shields) [6955]<br><br>

Appropriate disinfectants<br>

• 70 per cent ethanol<br>

• 5 per cent Lysol<br>

• 10 per cent bleach [6955]<br><br>

For personnel who had unprotected exposure or a known breach in personal

protective equipment to clinical material or live virus from a confirmed

case of swine influenza A (H1N1), antiviral chemoprophylaxis with zanamivir (= Relenza)

or oseltamivir (= Tamiflu) for 7 days after exposure can be considered. [6955]<br><br>
Oseltamivir (brand name Tamiflu®, made by Roche AG) is approved to both treat and prevent influenza A and B virus infection in people one year of age and older. [6958]<br><br>
Zanamivir (brand name Relenza® made by GlaxoSmithKline) is approved to treat influenza A and B virus infection in people 7 years and older and to prevent influenza A and B virus infection in people 5 years and older. [6958]<br><br>
Oseltamivir (= Tamiflu, made by Roche AG) antivirus-compound reduced the disease with one day, from about 5 days to about 4 days. [TV DR1 27 Apr.2009 evening]

<br><br>

Oseltamivir (= Tamiflu, made by Roche AG) and Zanamivir (brand name Relenza® made by GlaxoSmithKline) are both neuraminidase inhibitors.

<br><br>

<A name="Detection of the virus">

<br><hr><br><b>Detection of the virus</b>

<br>
The virus can be detected with several means. InDevR (www.indevr.com) is a small biotech company in Boulder, CO, founded 2003, which licensed the intellectual property to the FluChip technology from the University of Colorado and CDC.
The M gene version of the FluChip can detect swine-origin H1N1 influenza A viruses and clearly distinguish them from seasonal influenza viruses (A/H1N1 and A/H3N2) as well as the deadly avian A/H5N1 virus.

The M-gene version of the FluChip is more robust because the diagnostic target is a stable, internal gene which codes for the virus' matrix proteins. Current qRT-PCR subtyping assays target a more highly mutable gene that codes for a protein, hemagglutinin (HA), which is subject to antigenic drift. As has happened in the past, if the HA gene changes in a critical region, qRT-PCR will fail and the researcher won't know why until the gene is re-sequenced. [7020; http://www.eurekalert.org/pub_releases/2009-05/uoca-ifd050509.php

]

<br><br>

<A name="Production of vaccines">

<br><hr><br><b>Production of vaccines</b>

<br>
6 May 2009: After the H1N1 virus was found in a Canadian swine herd an Iowa State University researcher developed an H1N1 flu vaccine for pigs, said Hank Harris, professor in animal science and veterinary diagnostic and production animal medicine.
Harris' start-up company at the ISU Research Park, Harrisvaccines, Inc., uses a technology that is much faster for producing vaccines than traditional methods.
The technique, called "RNA Backbone", was developed for human use by a North Carolina company called Alphavax. Harrisvaccines has adapted it for pigs.
The technique uses electric current to combine the RNA Backbone material with the relevant genetic information from the active flu virus through a process called electro-poration.
Harris notes that his new vaccines using the Backbone method are currently in the pipeline for approval and may have approval from the United States Department of Agriculture by 2011.
Recently, Harris' new, faster method of producing vaccines was put to use during an outbreak of the disease Porcine Reproductive Respiratory Syndrome virus. Harris' Backbone method allowed vaccines to be ready within two months of the outbreak. That research was supported by the United States Department of Agriculture's Small Business Innovation Research Program.
Traditional production methods require five to six months for human vaccines and 11 to 12 months for swine vaccines.
"Right now, to make human or animal vaccines, you have to get the live virus and grow it in eggs or cell culture and then inactivate it," said Harris. "We don't have to do that."
"That is what is really neat about this technology, you do not really need the live virus," he said. "We just need the genes from the original virus which can be made synthetically."
Harris needs only the virus' genetic information, which is easily available. The new H1N1 virus, for instance, has already been genetically mapped and is already available on the Web and in the public domain.
[7021; http://www.eurekalert.org/pub_releases/2009-05/isu-isu050609.php]
<br><br>

Check these websites for further information and updates <br>

<a href="http://www.cdc.gov/swineflu" target="win12">www.cdc.gov/swineflu</A> and

<a href="http://www.cdc.gov/swineflu/investigation.htm" target="win11">www.cdc.gov/swineflu/investigation.htm</A>.<br>

The Association of Public Health Laboratories (APHL) swine influenza web

page can be found

<a href="http://www.aphl.org/aphlprograms/infectious/outbreak/Pages/swineflu.aspx" target="win10">www.aphl.org/aphlprograms/infectious/outbreak/Pages/swineflu.aspx</A>. [6955]<br><br>

<A name="History of the epidemic">

<br><hr><br><b>History of Swine influenza: </b>

<br>

<b>February 2009 – early March 2009</b>: In February a seven-month-old baby died of pneumonia in the village La Gloria in the Veracruz state of Southern Mexico. In early March a two-month-old died in La Gloria. The parents were told both children had died of bacterial pneumonia. [6964]

<br>

<br>
<b>18 March 2009</b> : Federal District of Mexico begins to pick up cases of swine flu.[6966]

<br>

<br>
<b>21 Marts 2009</b>: Around 21 March 2009, dozens of people in La Gloria started suffering high fevers, terrible aches and sore throats that led to trouble breathing.[6964]

<br>

<br>
Bertha Crisostomo, a woman who is a local community leader, called the authorities in the city of Perote. Doctors were sent in with antibiotics and painkillers. [6964]

<br>

<br>

In Veracruz state of Southern Mexico pig farming is a key industry in mountain hamlets.

On either side of the long straight road to La Gloria scrawny horses pull ploughs across flat sandy fields, sending up clouds of dust. These places small clinics provide the only health care. [6964,6963]
<br>

<br>

Residents in La Gloria say the prevailing wind invariably blows the fetid air their way, where it gets stuck because of the hills that rise just behind the village. [6964]

<br>

<br>
<b>28 March 2009:</b> Earliest onset date of swine flu reaching the United States, according to the CDC.[6965]
<br>

<br>
<b>2 April 2009</b>: Edgar Hernández Hernández, a neat four old with a shy smile living in a little white house in La Gloria, had an illness that laid him up in bed for a week: "My head hurt a lot … I couldn't breathe", he later told journalists, when he was well again. [6964]

<br>

<br>

<b>3 April 2009</b>: Local nurses took a swab from Edgar's throat on 3 April 2009 and two weeks later this was sent with a batch of other swabs to the Centres for Disease Control and Prevention in Atlanta, Georgia. The sample was testet positive for a new strain of swine flu. Edgar's was the earliest sample. (Edgar Hernández Hernández was one of a group of residents who came down with what was at the time labeled a particularly bad case of the flu. It was later reportet that only one sample from the group, that belonging to this boy, was preserved)[6964][6988]

<br>

<br>
<b>9 April 2009</b>: A door-to-door tax inspector, Maria Adela Gutierrez, was hospitalized 9 April 2009 with acute respiratory problems in the neighboring state of Oaxaca, infecting 16 hospital workers before she became Mexico’s first confirmed death. She also had diabetes, and she died 13 April 2009, four days after being hospitalized on the local hospital.
She fell ill after pairing up with a temporary worker from Veracruz who seemed to have a very bad cold. She was a 39-year-old woman from working as a door-to-door census-taker or the tax board in Oaxaca and may have had contact with scores of people. She lived in the southern city of Oaxaca, capital of the state of the same name. Martin Vazquez Villanueva, the regional health secretary in Oaxaca, denied local news reports that said she had infected 20 people, as well as her husband and children.

[6963][6988]
<br>

<br>
"Eventually we began to get better, but it was truly terrible while it lasted," Bertha Crisostomo from the village La Gloria later told journalists. "The doctors told us that it was just an atypical cold and nothing to worry about, – and that it was probably caused by the flies from the pig farms, so they sent in fumigation teams to get rid of the flies". Bertha Crisostomo got ill herself for more than a week.[6964]

<br>

<br>
"We watched what was going on in Mexico City and we said to each other that was exactly what happened to us," said Rosa Jimenez later to journalists. Many families in La Gloria have relatives who work in Mexico City but who came back to the village for the Easter week celebrations around 3-5 April 2009. "Could that be how it spread to the capital of Mexico City?" she asked [6964]. Also people from La Gloria kept going to jobs in Mexico City despite their illnesses, and could have infected people in the capital [6963].
<br>

<br>
The villagers of La Gloria believe they suffered the disease before Edgar, the 5 year old boy. They blame a huge pig farm in the area belonging to a multinational, Smithfield Foods. The pigs live in modules around the valley in long metal buildings with large rectangular tanks attached. The closest one to La Gloria is a few miles back down a paved road and then a couple more down a cactus-lined track. The tank lies open, apparently unattended, and a putrid odour is emanating from it. The company has vehemently denied that its pigs had anything to do with the outbreak. [6964]

<br>

<br>

There is much fear in La Gloria that the company will get angry at suggestions that it might have had something to do with the infection. Many people would only talk to journalists on condition of anonymity, like one man raking rubbish outside his home: "I was ill, my wife was ill, my children, my aunt. We were all in bed with exactly the same symptoms as we are now being told are swine flu," he said. "But I don't want to speak out, because I am afraid. This is a company with lots of power and lots of dollars. They have always been protected by the government and there is not much we can do about it". The Mexican health minister, José Ángel Córdova (Angel Cordoba Villalobos), insisted that Edgar, the 5 year old boy, was the only case of swine flu in La Gloria – although residents say his illness came after weeks during which most of the village fell ill.[6964]
<br>

<br>

Local health officials in Mexico gave a different account of the source of infection: The infection may have started with a migrant farmer who returned from work in the U.S. and gave the disease to his wife, who in turn passed it on to other women in the community. [6988]
<br>

<br>

<b>Monday 8 April 2009:</b> A 23 months old child from Mexico got the new swine flu infection. He died Monday 27 April 2009 (at a hospital in Houston, Texas). He had underlying health problems.
<br>

<br>

<b>3-12 April2009</b> Semana Santa (~April 3 – 12, Palm Sunday to Easter Sunday), which is Mexico’s second largest holiday. Mexico’s population is approximately 90% Catholic, which results in substantial population migration patterns during this time period. In Ixtapalapa (in Mexico City), one million people visit for Semana Santa. Other well-known sites for the holiday include Pátzcuaro, San Cristobal de las Casas (Chiapas), and Taxco.
<br>

<br>
<b> Sunday 12 April 2009 (Easter Sunday)</b>: Human infect pigs: A pig farm in Canada with 2200 pigs (220 sows and their

piglets in 2 barns and 1800 growers in 4 barns) was infected by a human with A/H1N1. 450 pigs were infected (23%). Morbidity not significantly rised. <br><br>

[6993].

A carpenter hired by a Canadian farm owner in Alberta (ALB-001) travelled to Mexico

and returned to Canada on 12 Apr 2009. The carpenter, the

producer and the producer's family became ill with influenza-like

symptoms between 14 – 29 Apr 2009. <http://www.oie.int/wahis/public.php?page=single_report&pop=1&reportid=8065> [6983]<br><br>
A Canadian Food Inspection Agency (CFIA) team later attended the premises

on 28 Apr 2009 and collected samples from swine for influenza virus testing at the CFIA National Centre

for Foreign Animal Diseases (NCFAD) in Winnipeg. The

samples were run in conventional RT-PCR for the Matrix and the H1

gene. These results showed that 19/24 samples were

positive for the M gene and 15/24 samples positive for the H1 gene. [6983]<br><br>
This was immediately followed up by sequencing of these PCR products

(6 samples for the Matrix and 5 for the H1 gene). The sequences of a

segment of approximately 244 nucleotides of the Matrix gene from 6

samples showed that this sequence was 100 percent identical to sequences derived from the novel

A/H1N1 influenza virus from the USA and Mexico and similar results

(99-100 percent identity) were found for around 500 nucleotides of

the H1 gene from 5 samples. [6983]<br><br>
The sequences derived from the pig

samples were identical to each other and for the M gene most similar

to the Eurasian lineage while the H1 gene was more reminiscent of the

North American lineage as would be expected for this novel virus. [6983]<br><br>
Additional sequencing of part of the N gene clearly showed that this

was an N1 virus and the sequence of the approximately 1400 nucleotide

fragment was highly related to the novel A/H1N1 influenza virus. [6983]<br><br>
It was thus confirmed that this was the novel A/H1N1 influenza virus and

being very closely related to the human strains of the new Mexican Swine Flu based on the genes

sequenced so far. [6983]<br><br>

One can speculate that similar

situations have ocurred in other countries where H1N1 infected humans

have had contacts with domestic pigs. This is particularly relevant to

Mexico, where the prevalence of the new virus in humans may have reached high dimensions.

"Surveillance in pig farms

in Mexico is thus anticipated the earliest", said FAO later, 4 May 2009. [6983]<br><br>
Those involved in the surveillance

activities on farms, as well as personnel of suspected pig herds, should be

vaccinated against seasonal influenza virus to prevent possible mixed

infections. [6983]<br><br>
After the detection of the A/H1N1 virus in pigs in Canada transmitted

by a human, the Food and Agriculture Organization of the United

Nations (FAO) urged national authorities and farmers to

carefully monitor pigs for

influenza-like symptoms. [6983]<br><br>
It is no surprise that influenza viruses are capable of transmitting

from humans to animals, as seen in Canada. [6983]<br><br>
All cases of porcine respiratory syndrome were recommended to be

immediately reported to veterinary authorities. [6983]<br><br>
Where A/H1N1 influenza is confirmed, movement restrictions should be

in force for 7 days after the last animal has recovered. [6983]<br><br>
Persons who

work directly with swine should be urged not to go to work if they

have any signs of respiratory disease, fever or any influenza-like

illness. [6983]<br><br>
Animal handlers and veterinarians should wear protective

clothing to minimize the risk of being infected. [6983]<br><br>
The FAO stressed (<a href="http://www.fao.org/news/story/en/item/19365/icode/">[6984] 4 May 2009, www.fao.org/news/story/en/item/19365/icode/</a>) that there is absolutely no need to slaughter

animals in view of preventing circulation of the A/H1N1 virus. [6983]<br><br>
The

agency emphasized that the A/H1N1 virus cannot be transmitted to

humans by pork and pork products. [6983]<br><br>

ProMED [6993] wrote about this: The human-infect-pigs story clearly indicates how

the zoonotic bridge between animals and humans is a 2-lane highway. Humans and

animals can interface and transmit disease through many unpredictable scenarios as illustrated by the events described here.

The story also highlights the need for surveillance on swine farms

particularly those where the unusual chance contacts between an ill

human and pigs would have occurred early in this outbreak, before

awareness of this virus got disseminated. It also highlights the importance of

keeping sick people off swine farms – this should be fully realized everywhere. [6993]
<br><br>Swine farms in Mexico, Texas, and California near the location of

early human cases should intensively evaluate any respiratory disease

and include the new, novel influenza A (H1N1). [6993]
<br><br>Broad efforts at surveillance in swine

populations should be a definite priority at this point in the

outbreak.[6993]
<br><br>The decision not to cull the pigs may very well be because they had

already recovered from the respiratory signs indicated but

clarification would be helpful. [6993]
<br><br>
It is possible

that the virus originated from pig populations somewhere in North

America. It is also possible that the virus remains in some pig

populations somewhere in North America, unknown exactly

where. Since the diversity of H1 subtype influenza viruses is very complicated in

pigs, it is very difficult to make a test for actual pig H1-subtypes of A/H1N1. [6994].
<br><br>

There are 3 main clusters of <b>H1 subtype swine influenza viruses</b>

circulating in pigs in the world. They are called h1.3.2 "classical",

h1.2.5 "human-like" and h1.1.3 "bird-like" [= "Eurasian" because almost all of the viruses within the cluster were isolated

from Europe and Asia].

Another cluster h1.3.1 "old classical", corresponds to

the classical swine influenza viruses circulating in the world in the

1930s and 1940s, but which largely has disappeared from the world.

[6994].
<br><br>
The A(H1N1) swine

influenza virus spreading in humans from March-April 2009 is in the cluster of h1.3.2 "classical". It is highly homogenous to some North American strains

isolated after the year 1999.

[6994].
<br><br>

There are 2 main clusters of <b>N1 subtype swine influenza viruses</b>

circulating in pigs in the world.

They are called n1.3.2 "classical" and n1.1.7.

"bird-like" ("Eurasian").

[6994].
<br><br>
The A(H1N1)

influenza of 2009 belong to the cluster n1.1.7 ("bird-like") – and highly homogenous to many Eurasian strains

and at least 2 North American strains isolated in the past decade.

[6994].
<br><br>

xxxxxxxxxxxxxxx

<b>About 15 April 2009:</b> The virus was sequenced in full. The genetics of the virus – 14 kilobases long – include eight genes, which code for surface proteins hemagglutinin (H) and neuraminidase (N), the matrix that surrounds the nucleus, the nucleoprotein itself, and three polymerase enzymes called PA, PB1, and PB2. It had similarities of about 94% in the hemaggluttinin [H] gene to the nearest strain known – and almost equidistant to swine viruses from the United States and Eurasia. The neuraminidase gene and the matrix gene were close relatives to swine virus genes from Asia. PA (bird flu), PB1 (human flu), and PB2 (bird flu). The human flu gene had been known in swine viruses since 1998. The neuraminidase and the matrix genes had not been seen in North America swine virus before. They were two new players from Asia. Virus from Midwestern of US were exported to Asia, since Korea and many countries import swine from the U.S. So in reality the virus could come from Asia or Europe – from a person. It suggested that the mixing didn’t happen in Mexico. The hemagglutinin gene is a lonely branch – and unknown where it evolved. [6974]
<br>

<br>

The virus do not grow very well in eggs. The scientists hope the virus will improve the ability to grow in eggs so that it will be easier to produce a vaccine very quickly. However, some countries might not have the good surveillance to make proper use of such vaccines. [6974]

<br>

<br>

<b>Tuesday day 21 April 2009</b>: CDC laboratories confirmed two cases in California. [6965]
<br>

<br>
<b>Wednesday 22 April 2009</b> In case after case, patients in Mexico have complained of being misdiagnosed, turned away by doctors and denied access to drugs.

<br>

<br>
A 32-year-old truck driver Alejandro had a bad cough when he returned to Mexico City from Veracruz and soon developed a fever and swollen tonsils. He was taken to a series of doctors and finally a large hospital. By then, he had a temperature of 102 Fahrenheit and could barely stand. They sent him away and said it was just tonsillitis. His wife, Monica Gonzalez, took him to Mexico City’s main respiratory hospital, “like dying in the taxi.” Doctors diagnosed pneumonia, but it may have been too late: He had suffered a collapsed lung and was unconscious. This was 22 April 2009 – and by that time the medical community in Mexico City was aware of a disturbing trend in respiratory infections, and Veracruz had been identified as a place of concern. [6963]

<br>

<br>

<b>Thursday 23 April 2009</b>: Mexico announced the epidemic 23 April 2009 [6967]. The time of the year was very late for seasonal influenza. (It was in fact a little bit easier that the epidemic was occurring in the end of the influenza season because then there was not so much noise with background influenza to look through for the investigation teams). In the coming days military personnel were seen in the streets distributing million of masks and looking for people with flu.

The health authorities got authority to isolate people and search their houses for sick people. Via TV people with flu were told to contact lokal doctors and hospitals resulting in long queues outside medical houses and hospitals.<br>

<br>
<b>Friday 24 April 2009</b>: In Denmark Else Smith, the director of the Center for Disease Prevention at The National Board of Health (the supreme health care authority in Denmark), was informed first time about the new disease. During the next week she was to give about 50 interviews to journalists and inform the Minister of Health five times.

<br>

<br>

<b>Saturday 25 April 2009</b>: WHO's Emergency Committee, called together for the first time

since it was created in 2007. The committee draws on experts from around the world.

The Committee agreed that the situation constituted a public health emergency of international concern. Based on this advice, the Director-General determined that the events constituted a public health emergency of international concern.

<br>

<br>

Saturday 25 April 2009: The Centers for Disease Control and Prevention (CDC) in USA: There were 11 confirmed cases in the USA with 7 in California, 2 in Texas and 2 in Kansas.

<br>

<br>

Saturday 25 April 2009: Two 16-year-old boys in Texas near San Antonio were confirmed infected. Human-to-human spread was obvious since there had been no contact with pigs. The virus contained genetic segments from four different virus sources: Some genetic segments from North American swine influenza viruses. Some gene segments from North American bird influenza viruses. One gene segment from a human influenza virus and two gene segments that are normally found from swine influenza viruses in Asia-Europe. Genetic

reassortment of a virus of swine influenza from the Americas with a

swine influenza virus from Eurasia had not been detected in the past.

Genetic sequencing of influenza viruses isolated from a ten-year-old and a nine-year-old child (San Diego County and Imperial County, both California) were very similar but not identical to each other. [6967]

<br><br>

The sequence of the virus was published on the Internet <a href="http://www.gisaid.org">http://www.gisaid.org</A>.

<br>

<br>

Saturday 25 April 2009: The United States government declared a public health emergency as the number of identified cases of swine flu in the nation rose to 20. In New York City eight students at St. Francis Preparatory School in Queens have tested positive for swine flu.

<br>

<br>
Saturday 25 April 2009: 81 deaths in Mexico had been deemed "likely linked" to swine flu. 20 of these had by 25th April 2009 been confirmed as infections with the new virus strain.
<br>

<br>

Saturday 25 April 2009: Canada confirmed its first cases of swine flu with four people said to have the virus in the eastern province of Nova Scotia. The cases were among students who had recently traveled to Mexico. The people affected were only "mildly ill."
<br>

<br>

Saturday 25 April 2009: All 8 people infected with swine flu in California and Texas had

recovered.

<br>

<br>
Saturday 25 April 2009: In New Zealand 22 students and three teachers from Auckland's Rangitoto College back home from a three-week-long language trip to Mexico may have been infected with the swine flu virus.

Fourteen have shown flu-like symptoms. 10 students tested positive for influenza A. The specimens will be sent to WHO to determine whether it is H1N1 swine influenza.
<br>

<br>

Saturday 25 April 2009: Gregory Hartl of the World Health Organization said the strain of the virus seen in Mexico is worrisome because it has mutated from older strains. "Any time that there is a virus which changes … it means perhaps the immunities the human body has built up to deal with influenza might not be adjusted well enough to deal with this new virus" Gregory Hartl said.

<br>

<br>

Saturday 25 April 2009: Russia forbid import of meat from Mexico, some states in USA and 9 Latin American countries.
<br>

<br>

<b>Sunday 26 April 2009</b>: A total of confirmed cases in Canada was now six, including four in Nova Scotia, all of whom presented only mild symptoms and were not hospitalized. It was the same type A, H1N1 swine flu virus that had earlier appeared in California and Mexico.

<br>

<br>

Sunday 26 April 2009: A specialist doctor in respiratory diseases and intensive care at the Mexican National Institute of Health described the severe emergency over the swine flu there: "More and more patients are being admitted to the intensive care unit. Despite the heroic efforts of doctors, nurses, specialists, etc. patients continue to inevitably die. The truth is that anti-viral treatments are not expected to have any effect, even at high doses. It is a great fear among the staff. The infection risk is very high among the doctors and health staff".[6954]
<br>

<br>

Sunday 26 April 2009: USA reported of 20 confirmed cases (8 in New York,

7 in California, 2 in Texas, 2 in Kansas, and 1 in Ohio). All had mild influenza-like illness with only one requiring brief hospitalization. [6955]
<br>

<br>

Sunday 26 April 2009: In Mexico there was now over 1400 reported cases in 19 of 32 States, with 81 (or 86 depending upon the source) reported fatalities. [6954]
<br>

<br>
Sunday 26 April 2009: A spokesman for WHO, Fukuda, said. "Right now we have cases occurring in a

couple of different countries and in multiple locations – but we

also know that in the modern world cases can simply move around from

single locations and not really become established."
<br>

<br>

Sunday 26 April 2009: So far, WHO had only urged governments to step up their surveillance of suspicious

outbreaks. However, WHO director-general Margaret Chan called the outbreak a public

health emergency of "pandemic potential". Her agency was considering whether to issue nonbinding

recommendations on travel and trade restrictions, and even border closures.

It would in that case be up to governments to decide whether to follow the advice.
<br>

<br>
Sunday 26 April 2009: China said anyone experiencing flu-like

symptoms within 2 weeks of arrival from an affected area had to report to

authorities.
<br>

<br>
Sunday 26 April 2009: A Russian health agency said any passenger from North America

running a fever would be quarantined until the cause of the fever is

determined.
<br>

<br>
Sunday 26 April 2009: Tokyo's Narita airport installed a device to test the temperatures of

passengers arriving from Mexico.
<br>

<br>

Sunday 26 April 2009: The Secretary of the Department Homeland Security in USA, Janet Napolitano, declared a public health emergency in the United States to allow funds to be released to support the public health response.

<br>

<br>
Sunday 26 April 2009: <a href="http://www2a.cdc.gov/eCards/browse.asp?act=brs&chkcategory=HandWashing&submit1=GO&s_cid=tw_eh_27">An e-mail card </a>about handwash for sending to friends was made in USA.
<br>

<br>
Sunday 26 April 2009: Five people died of swine flu in the last 24 hours in Mexico City, bringing the total of those killed to 15 in the capital, Mexico City's mayor, Marcelo Ebrard said.

<br>

<br>
Sunday 26 April 2009: A school group from New Zealand's largest city of Auckland was being quarantined at home after returning from Mexico
<br>

<br>

<b>Monday 27 April 2009</b>: First confirmed case found in Europe: Spain.

<br>

<br>

Monday 27 April 2009: The first death from the outbreak outside Mexico was a Mexico City 2 year old child from Mexico who traveled to Texas with family and died Monday 27 April 2009 at a Houston hospital. He was ill since 8 April 2009 and had underlying health problems.
<br>

<br>

Monday 27 April 2009: Two confirmed cases found in United Kingdom (Scotland). Both patients, a man and a

woman, recovered well. 7 other people who had been in

contact with them were displaying mild symptoms. Both the Scottish

patients were from the Forth Valley area of central Scotland. The

pair, who had been traveling together, returned from Mexico on 21 Apr

2009.
<br>

<br>

Monday 27 April 2009: WHO's warning level 3 of 6 should be 6 (maximum), said the Guan Yi, the professor in Hong Kong, who found SARS-virus in a catlike animal in 2003 and started the initiative which forbid selling such animals. WHO are always too slow and reluctant to highten the warnings, said professor Guan Yi.

<br>

<br>

Monday 27 April 2009: Airplane companies shares fell 5-17% because of the swine flu. Drug companies like Roche which make vaccines rised.

<br>

<br>
Monday 27 April 2009: Officials in Hong Kong urged residents not to travel to Mexico. They ordered immediate detention at a hospital of anyone who arrived with a fever and symptoms of a respiratory illness after traveling in the previous seven days through a city with a laboratory-confirmed outbreak. Thomas Tsang, the controller of the Hong Kong government’s Center for Health Protection, said that until the test was proven negative the person would not be allowed out of hospital. The cutoff for having a fever would be 100.4 degrees Fahrenheit. It would take two or three days to obtain test results.

<br>

<br>
Monday 27 April 2009: There were information in the press that 145 people might have died in Mexico from the disease. Most cases were not confirmed. No lethal cases outside Mexico had been reported. [TV DR1 Denmark, evening broadcasting]

<br>

<br>

Monday 27 April 2009: All schools in the country of Mexico were ordered closed until 6th of May. Day-care centers,

and universities, museums, pyramids, and the 35000 restaurants in Mexico City were closed to keep crowds from spreading contagion. Churches were closed – a big thing in a catholic country, and telling people that the situation was serious. Social

and cultural activities were suspended. Public celebrations of Cinco de Mayo were banned. For the first time in decades, Mexico canceled the popular re-enactment of its May 5, 1862, victory over invading French troops in the central state of Puebla. About 2000 people might be infected. People on street were given masks by officials. Everybody had filled their kitchen with food and stay at home. <br>

<br>

The Dutch government's Institute for Public Health and Environment had advised any traveler who returned from Mexico since April 17 and develops a fever over 101.3 degrees Fahrenheit (38.5 Celsius) within four days of

arriving in the Netherlands to stay at home.
<br>

<br>

Hong Kong use infrared scanners in airport to detect people with fever: Ever since the 2003 outbreak of SARS-infection Hong Kong has used infrared scanners to measure the facial temperatures of all arrivals at its airport and at its border crossings with mainland China.

<br>

<br>

Hong Kong may be better prepared for a flu pandemic than practically anywhere else in the world. Fearing that SARS might recur each winter, the city embarked on a building program to enlarge its capacity to isolate and treat those infected with such respiratory diseases.
<br>

<br>

Hong Kong has also expanded its flu research labs, already among the best in the world and leaders in tracking the H5N1 bird flu virus (bird flu virus), which kills an unusually high share of its victims. It has periodically triggered fears about a possible pandemic, just like swine flu did in spring 2009.
<br>

<br>
Monday 27 April 2009: At least 20 cases in USA had now been confirmed in New York, Ohio, California, Kansas and Texas.
<br>

<br>
Monday 27 April 2009: At this time the case fatality rate (CFR) was still uncertain. If the number of infected in Mexico was significantly higher than the

reported approximately 1500 cases by this time, it would lower the

calculated case fatality rate (CFR). [6955]

<br>

<br>

Monday 27 April 2009: In USA there were now 40 confirmed cases: New York City 28 cases, California 7 cases, Kansas 2 cases, Texas 2 cases and Ohio 1 case. [http://bit.ly/KO5pA].

<br><br>CDC's Division of the Strategic

National Stockpile (SNS) in USA released one-quarter of its antiviral

drugs, personal protective equipment, and respiratory protection

devices to help states of USA respond to the outbreak.

<br>

<br>

Monday 27 April 2009: WHO raised the level of influenza pandemic alert

from phase 3 to phase 4, indicating

that the likelihood of a pandemic had increased. WHO Phase 4 "is characterized by verified human-to-human transmission

of an animal or human-animal influenza reassortant virus able to cause

'community-level outbreaks.' … Phase 4 indicates a significant

increase in risk of a pandemic but does not necessarily mean that a

pandemic is a forgone conclusion."

<http://www.who.int/csr/disease/avian_influenza/phase/en/index.html>
<br>

<br>

Given the widespread presence of the virus WHO now considered that containment of the

outbreak would not be feasible. The current focus should be on

mitigation measures. WHO recommended NOT to close borders and

NOT to restrict international travel. It was considered

prudent for ill people to delay international

travel.

<br>

<br>

Monday 27 April 2009: Mexico had now reported 26 confirmed

human cases of infection with the same virus, including 7 deaths (the total suspected death in Mexico toll: 149 people among 1995 people, who had been

hospitalized with serious cases of pneumonia since the beginning of the epidemic). Just 2 laboratories in the

country of Mexico, one in Mexico City and one in the state of Veracruz, were able

to confirm this new strain. This day an earthquake happened in Mexico.

<br>

<br>

Monday 27 April 2009: Canada had reported 6 cases. Still no deaths outside Mexico.

<br>

<br>

Monday 27 April 2009: Israel's health minister updated a nervous public about the swine flu

epidemic – and renamed it Mexican flu.

<br>

<br>
Monday 27 April 2009: Swiss police said a container with animal swine flu samples exploded as it was being shipped on a train from Zürich to Geneva, injuring a woman. Authorities said dry ice keeping the samples cold caused the explosion, but the incident posed no threat to humans.

<br>

<br>

<b>Tuesday 28 April 2009:</b> It was now obvious: The infection could not be contained. WHO flu expert Dr Keiji Fukuda said "Containment is not a feasible operation". However, WHO chief Dr Keiji Fukuda said it was not inevitable that the outbreak would develop into a global epidemic – or pandemic – but countries should "take the opportunity to prepare". WHO spokesman Gregory Hartl said experts were working on a vaccine, but said it could take five or six months to develop.

<br>

<br>

Tuesday 28 April 2009: Since the end of March 2009, Mexico had observed an unusual

pattern of acute respiratory infection (SARI) cases, which increased

even more in the 1st weeks of April 2009. From 17 to 28 Apr 2009,

1551 suspected cases of influenza with severe pneumonia were

reported, including 84 deaths. These figures were smaller than those

reported yesterday earlier due to the investigation work and

clean-up of data that had being carried out in field. The suspected

cases were recorded in 31 of the 32 states of Mexico. [6970]
<br>

<br>

<b>Wednesday 29 April 2009:</b> World Health Organization raised its pandemic alert for swine flu to the second highest level "phase 5", meaning that it believed a global outbreak of the disease was imminent. It was the first time the WHO had declared a phase 5 outbreak (phase 4 was also first time). A phase 5 alert means there is sustained transmission among people in at least two countries. Once the virus shows effective transmission in two different regions of the world, a full pandemic outbreak — phase 6 — would be declared, meaning a global epidemic of a new and deadly disease.

[6963]

<br>

<br>

<br>

<br>
Wednesday 29 April 2009: There was now 3 countries

(USA, Canada and Mexico) that had reporting human to human spread of

the virus.[6970]

<br>

<br>
Wednesday 29 April 2009: In Canada to that date, 13 human cases of swine influenza A/H1N1 had been

confirmed (2 in Alberta, 4 in the province of New Scotland, 3 in

British Columbia and 4 in Ontario), some of them with recent trip

history to Cancun, Mexico. None required hospitalization.[6970]
<br>

<br>
Wednesday 29 April 2009: Confirmed cases in countries outside Mexico were now: Austria (1), Canada (13), Germany (3), Israel (2), New Zealand (3), Spain (4) and the United Kingdom (5). [6970]

<br>

<br>

Wednesday 29 April 2009: The Mexican health minister, José Ángel Córdova, suddenly reduced the official number of confirmed dead by the infection from 20 to 7. On a chaotic press conference in Mexico City he contradicted himself several times. At the news conference, numerous journalists and camera operators wore masks as protection against the disease. The meeting grew hostile at points, with journalists shouting more questions than the officials seemed willing to take. However he admitted that the Mexican health system could no way handle the situation. Only 10 of the 31 states of Mexico have even one laboratory for virus. The samples must be sent to Mexico City, taking time. From all corners of the country there are report of chaos and panic in hospitals where patients wait in days for medical supervision and end going home without meeting a doctor. The hygiene of the hospital in Obregón in Mexico City is catastrophic, a blogger wrote. The hospitals are on the point of giving up. The National Institute for Respiratory Diseases need masks, surgery glasses and white coats and warn that it will stop treatment unless they got such supplies. The antiviral medicine has been in short supply, and many hospitals have no more. Corruption is the reason, the medicine is stolen and sold to higher prices before it reach the hospitals. 2009 is election year in Mexico. The Mexican health secretary, Jose Angel Cordova, has said that the country’s supply of medicine was sufficient. [6963]

<br>

<br>
Wednesday 29 April 2009: Germany's biggest tour operator suspended trips to Mexico. [6968]

<br>

<br>
Wednesday 29 April 2009: US President Barack Obama asked Congress for $1.5bn (£1bn) to help prepare for a possible outbreak. He suggested that all schools ought to be closed if the pupils had any risk of being infected. The country has 132,000 schools. USA had now 91 confirmed infected in 10 states. With 13 cases in California governor Arnold Schwarzenegger declared a state of emergency over the threat.
<br>

<br>

Wednesday 29 April 2009: In the Muslim Egypt the government decided to kill all pigs in the country, about 300.000 – 350.000. Egypt ordered the pig slaughter even though there hadn’t been a single case of swine flu in Egypt – and even though the A/H1N1 "Swine flu" infection is not spreading from pigs to humans, but from human to human. The pig owners are not Muslim but Christians. Because of bad information people in Egypt believe that the pig meat is infected – 98% of the pig meat sale collapsed. It will take a half year to kill all pigs in Egypt but the government will buy 3 machines with a capacity of killing 3000 pigs dayly. By 5 May 2009 about 1821 pigs had been killed in the pig killing campaign. To set the case in perspective Egypt is at this time infected by bird flu (H5N1). 68 people in Egypt have been infected by this flu virus and 23 of these 68 infected people have died of the infection. However, nobody talks about killing all poultry in the country (poultry is an important food supply in Egypt). [6992]
<br>

<br>

While epidemiologists kept stressing that it is humans, not pigs, who are spreading the disease, sales plunged for pork producers around the world. WHO says eating pork is safe, but Mexicans have even cut back on their beloved greasy pork tacos. Pork producers were trying to get people to stop calling the disease swine flu, and Obama notably referred to it only by its scientific name, H1N1. United Nations animal health expert Juan Lubroth noted some scientists say “Mexican flu” indicating that it would be more accurate – a suggestion which inflamed passions in Mexico. [6963]
<br>

<br>
Wednesday 29 April 2009: Lebanon discouraged traditional Arab peck-on-the-cheek greetings, even though no one has come down with the virus there. [6963]
<br>

<br>

Wednesday 29 April 2009: Peru and Ecuador joined Cuba and Argentina in banning travel either to or from Mexico.
<br>

<br>

Wednesday 29 April 2009: In England the health minister has ordered 32 million face masks.

<br>

<br>
Wednesday 29 April 2009: The European Center for Disease Control advised against unnecessary travels to Mexico. WHO did still not advise against travels to Mexico.
<br>

<br>

Wednesday 29 April 2009: The Danish health minister has ordered 40.000 doses of Relenza antivirus medicine in case the virus becomes resistant to Tamiflu, which Denmark has on stock.
On a central storage in Copenhagen 300.000 pills of Tamiflu is ready for 30.000 danes for immeadiate treatment. I en freezer 1.000.000 kg pulver is stored, which can be made into antiviral medicine for one million Danes.

[7014].
<br>

<br>

Wednesday 29 April 2009: Confirmed cases were by now found in Mexico, USA, Canada, Britain, Israel, New Zealand, Spain, – and this date also South Korea, Peru, Germany and Austria, bringing the number of affected countries to 11. [6963]
<br>

<br>

Wednesday 29 April 2009: Spain reported the first case in Europe of swine flu in a person who had not been to Mexico, illustrating the danger of person-to-person transmission. [6963]

<br>

<br>

Wednesday 29 April 2009: Suspected cases were being reported from many countries including

Latin America (Argentina, Bolivia, Brazil, Chile, Colombia,

Costa Rica, Ecuador, Guatemala, Uruguay): <i>Colombia</i> – 42 suspected cases after travel to Mexico <http://www.prensa-latina.cu/index.php?option=com_content&task=view&id=77300&Itemid=1>; <i>Chile</i> – 24 suspected cases; <i>Brazil</i> – 11 suspected cases; <i>Bolivia</i> – 2 suspected cases after travel to Mexico; <i>Uruguay</i> – 2nd suspected case under investigation

<http://www.andaluciainformacion.es/portada/?a=48861&i=1>; Costa Rica – one "confirmed case" after travel to Mexico

reported by media on 28 Apr 2009 but not confirmed according to WHO data <http://www.laprensa.com.ni/archivo/2009/abril/28/noticias/ultimahora/324454.shtml>; Guatemala – one suspected case after travel to Mexico <http://insidecostarica.com/dailynews/2009/april/29/cam04.htm>. <br>Europe: <i>Slovakia</i> – one suspected case after travel to Mexico

<http://www.tasr.sk/30.axd?k=20090429TBB00544>; <i>Belgium</i> – 7 suspected cases after travel to Mexico or USA <http://www.easybourse.com/bourse-actualite/sanofi-aventis/belgian-doctors-investigating-7-suspected-cases-of-swine-flu-FR0000120578-659591>, <i>France</i> – 32 suspected cases, of which 2 are considered probable (the

2 probable had a history of travel to Mexico) <http://www.20minutes.fr/article/322865/France-Grippe-porcine-deux-cas-fortement-suspects-en-Ile-de-France.php>; <i>Poland</i> – 3 suspected cases after travel to Mexico <http://news.xinhuanet.com/english/2009-04/29/content_11276133.htm>. <br>

<i>Australia</i> – 91 suspected cases <http://www.reuters.com/article/healthNews/idUSTRE53S88X20090429>
<br>

<br>

Wednesday 29 April 2009: A Danish young woman brought this day's morning Influenza A H1N1 infection with her on a Continental Airlines flight CO122N flying directly Newark (New York) – Kastrup (Copenhagen) landing in Copenhagen Airport on the morning 29 April at 7.35 o'clock, where she had been on vacation. She contacted Hvidovre Hospital the same evening with influenza symptoms in the throat and muscles but no fever. A sample was taken and the person was asked to stay at home. She lived alone and had only limited contact with other people. The infection was confirmed 1 May 2009. All passengers on the flight was thereafter contacted. The passengers sitting up to 2 rows in front or back of the infected received antiviral treatment. After the case was confirmed by a quick-test the woman was treated in isolation until 6 May 2009. The press could not get information about in which hospital [7013]. The virus was similar to the type found in New York except for a mutation. It was sensitive to Tamiflu. This dane was the first European person to be infected in USA. [7012]
<br>

<br>

A Danish university team has shown that a flight seat which send out air around each passenger in an airplane can hinder infection. The system could be in production in 2-3 years if someone would invest in the system. The system could also be used to busses, concert buildings and even hospital beds. Advanced computermodels and dolls with artificial lungs have shown that the system works well. During the SARS epidemic 19 passengers were infected during a single flight. Contact <a href="mailto:&#098;&#105;&#111;&#110;&#121;&#116;&#064;&#103;&#109;&#097;&#105;&#108;&#046;&#099;&#111;&#109">bionyt@gmail.co&#109</a>

for address to the Danish inventors. <br>

<br>

25-29 April 2009: BBC ask people in the areas affected by the swine flu outbreak to send their accounts to the BBC to be published on http://news.bbc.co.uk/2/hi/talking_point/8018428.stm. Here are some examples from 25-29 April 2009:
<br>

<br>

"Two soccer games have been cancelled at the Olympic Stadium. A sold out game with 70,000 expected attendance will be played behind closed doors. Another game at the famous Azteca Stadium that would draw an attendance of 50,000 will also be played behind closed doors." [Juan Carlos Leon Calderon, Mexico City]
<br>

<br>

"Two of my friends at work are sick, they were sick for a couple of days, they went to the hospital and they sent them back to work. The doctor told them it was just a flu until Friday when the alarm was spread, then they were allowed to go home. I work in a call centre and I'm worried because there are no windows in the building so it cannot be ventilated and around 400 people work there. – We all have talked to our supervisor but no one has done anything not even sterilise or disinfect the area. We will be sick soon and, well, do the math – 400 can infect at least another two per day. "[Adriana, Mexico City]
<br>

<br>

"I work as a resident doctor in one of the biggest hospitals in Mexico City and sadly, the situation is far from "under control". As a doctor, I realise that the media does not report the truth. Authorities distributed vaccines among all the medical personnel with no results, because two of my partners who worked in this hospital (interns) were killed by this new virus in less than six days even though they were vaccinated as all of us were. The official number of deaths is 20, nevertheless, the true number of victims are more than 200. I understand that we must avoid to panic, but telling the truth it might be better now to prevent and avoid more deaths." [Yeny Gregorio Dávila, Mexico City]
<br>

<br>

"They say on the news that the cases that are most critical involve people aged 20 to 50." [Nallely T, State of Mexico]
<br>

<br>

"In the capital of my state, Oaxaca, there is a hospital closed because of a death related to the porcine influenza. Many friends working in hospitals or related fields say that the situation is really bad, they are talking about 19 people dead in Oaxaca, including a doctor and a nurse. Last night the local baseball stadium was full, mainly with young people. What's really happening? I know that the economic situation is not the best, and it will worsen with panic. But panic comes from a lack of information. Many people travel for pleasure or without any real need. Stopping those unjustified trips can help a lot to ease the situation. We must do something!" [Alvaro Ricardez, Oaxaca City, Oaxaca, Mexico]

<br>

<br>

"I have been trying to purchase face masks for myself and my family – my wife and two children – but haven't been able to get one anywhere. I have visited six pharmacies in the area and all are sold out." [Jorge, Mexico City, Mexico ]
<br>

<br>

"I'm a doctor responsible for managing vaccines in the northern Mexican state of Nuevo Leon. On Sunday we had our first death in the area. It was someone who came from Mexico City. But we don't have the means to confirm whether it was as a result of swine flu. We need to have the means to diagnose people. More than anything, we lack equipment and laboratory kits. All we can do is look at the symptoms and make a clinical diagnosis. In the pharmacies, there is no Tamiflu available. People here are not aware that this flu outbreak can kill people." [Dr Vicente Torres, Monterrey, Nuevo Leon, Mexico]
<br>

<br>

"I live in Mexico city…I am actually studying here! Mexico city isn't the cleanliest of places and people's attitude make it worse. Nearly half of the 20 million people are not wearing their masks and some are acting as if it's normal to have this flu with their 'I don't care' attitude." [Rachael, Mexico City ]
<br><br>

<b>Thursday 30 April 2009: </b>On a meeting between the 27 EU member states the health minister of France, Roselyne Bachelot, suggest that all flights to Mexico from Europe stop. Such travel restriction to Mexico was not adopted. One argument was, that it would still be possible to travel to another country and then to Mexico.
<br><br>The U.S., the European Union and other countries have discouraged nonessential travel to Mexico. Some countries have urged their citizens to avoid the United States and Canada as well. Health officials said such bans would do little to stop the virus. WHO said total bans on travel to Mexico were questionable because the virus is already fairly widespread. “WHO does not recommend closing of borders and does not recommend restrictions of travel,” said Dr. Keiji Fukuda, the Geneva-based organization’s flu chief. “From an international perspective, closing borders or restricting travel would have very little effect, if any effect at all, at stopping the movement of this virus.” [6963]

<br>

<br>

Thursday 30 April 2009: Danish tourists in Mexico were voluntarily evacuated to Denmark.
<br>

<br>

Thursday 30 April 2009: Confirmed cases were found in Switzerland (19 year old man), Portugal and Holland (3 year old boy).

<br>

<br>

Thursday 30 April 2009: At this time 109 confirmed cases in USA; 1 death (Mexican boy treated in Texas): New York 50, Texas 26 , California 14, South Carolina 10, Kansas 2, Massachusetts 2, Michigan 1, Indiana 1, Nevada 1, Ohio 1, Arizona 1.

<br>

<br>

Thursday 30 April 2009: Lab-confirmed cases this date were up to 236 – a jump from 148 the day before. [6972]
<br>

<br>

Thursday 30 April 2009: A member of US President Barack Obama’s security team was suspected of catching swine flu during a recent visit to Mexico with the president. [6972]
<br>

<br>

Thursday 30 April 2009: Thanks to some additional testing, the number of confirmed cases in Mexico jumped to 97 from 26. The number of deaths remained at 7. [6972]

<br>

<br>

Thursday 30 April 2009: Senior health officials from different countries were attempting to coordinate disease surveillance and response with one another, spending hours on transnational conference calls even while separately quibbling over details such as travel restrictions (considered useless by CDC and WHO, but recommended by some countries), and the importance of antiviral drugs. Identifying every case was also a priority, as was determining when to limit social gatherings, as Mexico had been doing, and considering what types of businesses or government operations could briefly be shut down, such as courts, and which ones must stay open, such as the shipping of food. [6972]

<br>

<br>

Thursday 30 April 2009: U.S. Vice President Joseph Biden caused a stir when he said he wouldn’t want to travel by plane or subway, contradicting his boss’s advice. [6972]

<br>

<br>

Thursday 30 April 2009: Experts and authorities discussed whether vaccine manufacturers should shift efforts to producing a vaccine against the swine H1N1 instead of producing the seasonal flu vaccine. [6972]

<br>

<br>

Thursday 30 April 2009: At this time there was also discussions about the usefulness of ferrets for influenza research. In October 2008, researchers from Iowa State University reported about an outbreak of H1N1 swine influenza in a ferret colony on an Iowa farm about 0.4 kilometers from a swine farm. 8% of about 1000 of the minklike animals were infected. The ferret infection was not connected with the later human infection since the H1N1 differed.

<br>

<br>Thursday 30 April 2009: Until the outbreak in April 2009, the transmission of swine flu from human to human was virtually unheard of. The CDC laboratories in US received 300 samples from Mexico covering February, March, and April. Those sample were human flu virus until the end of March. There are two or three cases up to the last days of March that are swine flu. Then in April they skyrocket. The swine virus really transmitted very efficiently in humans. [6974]
<br>

<br>Thursday 30 April 2009: The epidemic swine flu might die out in the Northern hemisphere like USA, which were going out of the flu season, but countries on the Southern hemisphere were entering winter and flu season at this time.

<br>

<br><b>Friday 1 May 2009</b>:
First confirmed case in Denmark. A dane from Sjælland was infected with Influenza A H1N1 in New York. She took the infection with her on a direct flight from New York to Copenhagen.
<br>
<br><b>Saturday 2 May 2009</b>: Canada reported the identification of the A(H1N1)

virus in a swine herd in Alberta. The pigs

must have been exposed to the virus from a Canadian farm worker recently

returned from Mexico, who had exhibited flu-like symptoms and had

contact with the pigs. (See 12 April 2009 for a description of this event).
<br>

<br>
The people who live on an

Alberta pig farm where the pigs were found to be infected with swine flu

were later tested negative for the virus.

[7003]

<br><br>
A number of people living on the pig farm experienced

flu-like symptoms after the pigs fell ill and were tested to see

whether they too were infected.

[7003]

<br><br>
But tests

suggested the people were not infected with the H1N1 swine virus. However, blood samples from the people were taken to test for

antibodies to look for a definitive answer on whether they were

infected.

[7003]

<br><br>
The

carpenter also tested negative for the virus, but it was

believed that that was because he was too far along in his recovery to

be still shedding virus.

[7003]

<br><br>
A nasal swab from the man was only collected

after the pigs started falling sick, and that was more than 10 days

after his return from Mexico.

[7003]

<br><br>
Officials intended to test his blood too,

looking for antibodies to the new H1N1 swine flu virus.

[7003]

<br><br>
The antibody test was developed at Canada's National Microbiology

Laboratory, which played a key role in the investigation into

this new flu virus.

[7003]

<br><br>
It was the Winnipeg lab that determined that an

unusual outbreak of severe respiratory illness in Mexico was being

caused by a new swine flu virus which U.S. researchers had found was

infecting people in the United States.

[7003]

<br><br>

It was reassuring to learn that the virus causing illness in pigs on

the Albertan farm has (probably) not been transmitted to people

living on the farm.

[7003]

<br><br>
The failure of the swine virus to transmit

back to people suggested that the novel H1N1 virus causing human

illness did not come into the human population directly from swine.

[7003]

<br><br>

[Report about this case; 6 May 2009]:<br><br>
In Canada a pig herd in Alberta was infected by a man. Clinical signs were observed in 450 out of over

2000 pigs. 19 out of 24 samples were positive for the influenza A matrix

gene and 15/24 for the H1 gene. Partial sequencing indicated 100 per cent

identity of the matrix gene and 99-100 per cent identity of the H1 gene

with sequences from virus isolates from humans in USA and Mexico. [7041]<br><br>
This was an isolated incident of

human to pig transmission by a farm worker returning from holiday in

Mexico. [7041]<br><br>
The worker returned from Mexico on 12 Apr 2009, and then

developed flu-like symptoms. He returned to work on 14 Apr and between

14-29 Apr the worker, pig producer, and producer's family all showed

symptoms. [7041]<br><br>
By 24 Apr 2009 the worker had recovered and he tested negative for the

flu virus. After this date, the pigs exhibited signs of inappetence, fever,

and respiratory signs. [7041]<br><br>
The affected animals have recovered and there was no

mortality that could be directly attributed to influenza infection. [7041]<br><br>
The

premises came under quarantine. [7041]<br><br>
Transmission of influenza in pigs is via

inhalation of aerosols. Some influenza viruses have

the capacity to enter the bloodstream and therefore meat and other tissues,

but this has not been seen following natural infection in swine with influenza

viruses. [7041]<br><br>
Infection in swine does not produce viraemia and the virus is not

found outside the respiratory tract and associated lymph nodes. Therefore, it would be highly unlikely that influenza viruses could

be transmitted in pork or pork products or pig semen. [7041]<br><br>
Surveillance for influenza in pig herds in GB and elsewhere in the EU has

been carried out since 1991. Results suggest that although swine influenza

of all strains remains a low level disease with occasional epizootics of

new strains, this new variant of H1N1 does not appear to be present in pigs

in the UK or EU. [7041]<br><br>
There would be a negligible likelihood of

introducing new variant influenza A (H1N1) to the UK by the legal import of

pigs or pig products from Canada. The current EU trade rules for live pigs

and pig products are considered appropriate to mitigate the risk of disease

introduction. [7041]<br><br>
EU Rules allow the export of live pigs and pig meat or pig products from

Canada to the EU. [7041]<br><br>
Another possible route for disease introduction into pig herds by workers on a pig farm. Livestock workers recently returning

from an affected country and/or showing symptoms of an infectious disease

should not have contact with pigs or pig farms. [7041]<br><br>
Swine

influenza virus does not produce viraemia. The virus is not found outside

the respiratory tract and associated lymph nodes. The virus has not

been recovered from semen. This virus could be present

in semen but the disease probably would not be transmitted through

artificial insemination. [7041]<br><br>
Though animal influenza viruses do occasionally cause viraemia (such as

HPAI H5N1 in cats, it appears that viraemia generally does

not occur in cases of (classical) swine influenza. [7041]<br><br>

Saturday 2 May 2009:
Food

and Agriculture Organization of the United Nations (FAO), the World

Organisation for Animal Health (OIE), the World Health Organization

(WHO) and the World Trade Organization.

Influenza viruses are not known to be transmissible to people through

eating processed pork or other food products derived from pigs.
Heat treatments commonly used in cooking meat (e.g. 70 C/160 F core

temperature) will readily inactivate any viruses potentially present

in raw meat products.

Africa remaining the only

continent where no such information has yet become available
There are still serious gaps in the knowledge

about the virus, its epidemiology and pathogenicity, communicating

clear, unanimously accepted and scientifically-based information and

advice to the public is complex.

[7002]

<br><br>
<b>Sunday 3 May 2009</b>: 18 countries have officially reported 787 + 103 ten hours later this day.

cases of influenza A(H1N1) infection. Mexico has reported 506 confirmed human cases of infection, including

19 deaths. Other confirmed cases: USA (160), Austria (1), Canada (85), Colombia (1), China, Hong Kong Special

Administrative Region (1), Costa Rica (1), Denmark (1), El Salvador (1), France (2),

Germany (8), Ireland (1), Israel (3), Italy (1), Netherlands (1), New Zealand

(4), Republic of Korea (1), Spain (40), Switzerland (1) and the

United Kingdom (15). [6977]

<br>

<br>
<br>Sunday 3 May 2009: USA had by this time confirmed a total of 226 human cases: New York (63),

Texas (40),

California (26),

Arizona (18),

Carolina del Sur (15),

Delaware (10),

Massachusetts (7),

New Jersey (7),

Colorado (4),

Florida (3),

Illinois (3),

Indiana (3),

Virginia (3),

Wisconsin (3).

Connecticut (2),

Kansas (2),

Michigan (2),

Alabama (1),

Iowa (1),

Kentucky (1),

Minnesota (1),

Missouri (1),

Nebraska (1),

Nevada (1),

New Hampshire (1),

New Mexico (1),

Ohio (1),

Rhode Island (1),

Tennessee (1),

Utah (1),

<br>

<br>Sunday 3 May 2009: Ongoing testing of previously collected specimens in Mexico gave higher number of confirmed cases: 30 Apr:

97 (7 deaths) / 1 May: 156 (9 deaths) / 2 May: 397 (16 deaths) / 3 May: 506 (19 deaths) [6977]. The 506 confirmed cases 3 May 2009 had this distribution in Mexico:

Federal District: 288 (death: 13),

Mexico State: 70 (death: 4),

San Luis Potosi: 42,

Hidalgo: 27,

Tlaxcala: 19 (death: 1),

Baja California: 11,

Colima: 9,

Chiapas: 6,

Aguascalientes: 5,

Chichuahua: 4,

Tabasco: 4,

Zacatecas: 4,

Guerrero: 3,

Puebla: 3,

Durango: 2,

Queretaro: 2,

Guanajuato: 1,

Michoacan: 1,

Oaxaca: 1,

Veracruz: 1,

Quintana Roo: 1,

Sonora: 1,

Tamaulipas: 1.
<br>

<br>Sunday 3 May 2009: Germany had now 8 confirmed cases, 4 of which have

human-to-human transmission. In Bavaria an infection of a couple in Frankfurt/Oder in Brandenburg had been infected on a flight from Mexico likely by the confirmed case in Hamburg.

<br>

<br>

Sunday 3 May 2009: In Mexico 1498 samples had now been tested, 1280 had been

tested twice, and 218 would have a second verification test. This had given 506 confirmed cases from 23 states: 272 women (53.8%) and 234 men (46.2%). 487 survivors, 19 deaths.
Age breakdown of 506 confirmed cases were (population

distribution according to 2005 census):<br>

Ages 0-9 122 cases (24.1 %) (20.6 %)<br>

Ages 10-19 120 cases (23.7 %) (20.9 %)<br>

Ages 20-29 98 cases (19.4 %) (16.9 %)<br>

Ages 30-39 69 cases (13.6 %) (14.9 %)<br>

Ages 40-49 51 cases (10.1 %) (10.8 %)<br>

Ages 50-59 34 cases (6.7 %) (7.8 %)<br>

Ages 60+ 3 cases (0.6 %) (8.3 %)<br>

unknown age 9 cases (1.8 %)<br><br>
48 percent of confirmed cases in Mexico are less than 20

years of age and 43 percent of cases are 20-49 years of age.

<br><br>
Comparing the age distribution of cases with the general age

distribution of the population in Mexico (based on 2005 census data),

it appeared as though the young 0-20 year population was

slightly over-represented proportionally and the 20-49 year

group was appropriately represented (43 percent of cases, and 43

percent of the population). The elderly in Mexico appeared to be underrepresented – in contrast to seasonal influenza. It was not clear if

there was an epidemiologic or immunologic explanation for this.

<br>

<br>

The 19 death in Mexico confirmed to be related with A/H1N1-virus were: <br>

11 Apr 2009 — 2 deaths<br>

<br>13 Apr 2009 — 1 death

<br>16 Apr 2009 — 1 death

<br>17 Apr 2009 — 2 deaths

<br>20 Apr 2009 — 3 deaths

<br>22 Apr 2009 — 1 death

<br>24 Apr 2009 — 1 death

<br>25 Apr 2009 — 1 death

<br>26 Apr 2009 — 5 deaths

<br>27 Apr 2009 — 1 death

<br>28 Apr 2009 — 1 death

<br><br>
<b>Monday 4 May 2009</b>: In Canada the 1st serious case, a young child, was admitted to a intensive care unit

<a href="http://www.theglobeandmail.com/servlet/story/RTGAM.20090504.wflustaffmain0504/BNStory/International/home" target="_blank"> (link)</a>

<br><br>

Monday 4 May 2009: Spain had now 54 infected. 50 of them had returned from a visit to Mexico. (New York Times). <br><br>

In Mexico the R0 (i.e. the virus reproduction number, or

number of contacts of infected people that results in transmission of

the virus), was estimated 1.4, with a

variability ranging from 1.3 to 1.8. In the case of seasonal

influenza, this rate is somewhat lower 1.3. [6986]

<br><br>

<br><br>
The

reproductive ratio (R0) of 1.4 with a range of 1.3 to 1.8 whereas the

observed R0 for seasonal influenza was 1.3 (the R0 refers to the

expected number of secondary infections seen in a population of

susceptibles from contact with a single individual during their

infectious period.) This slight increase in R0 suggests that the

A(H1N1) observed in Mexico is slightly more transmissible than

seasonal influenza. <a href="http://www.globalsecurity.org/security/ops/hsc-scen-3_flu-transmission.htm" taget="_blank"> (Global Security discussion on influenza

transmission and the R0 figure)</a>.

<br><br>

<b>Tuesday 5 May 2009</b>:

A Texas woman who lived near a popular border crossing was confirmed as the second outside Mexico and the first U.S. resident to die after contracting the virus. She had chronic medical conditions. The 33-year-old woman was pregnant and delivered a healthy baby while hospitalized. She was a teacher in the Mercedes Independent School District, which announced it would close its schools until May 11 2009.

[6990]
<br><br>
Tuesday 5 May 2009:

Many people in Mexico city shunned their surgical masks Tuesday 5 May 2009; a boy selling music CDs on a subway train planted a wet kiss on the unprotected cheek of a girl hawking tiny flashlights. A fruit salad vendor dished up slabs of freshly cut mango and coconut without mask and gloves. The government is requiring businesses to keep a distance of 2 meters (yards) between customers to prevent the disease from spreading. The rule seemed unlikely to survive in the overcrowded capital. "It's a little senseless, that people ride into town all jammed together on the subway, and the minute they enter a restaurant, they have to be 2 meters apart," said Nahum Navarette, manager of Yug, a vegetarian restaurant that was still serving only takeout on Tuesday, its dining room deserted. Across Mexico, people were now eagerly anticipating the reopening of businesses, restaurants, schools and parks, after a claustrophobic five-day furlough. Thousands of newspaper vendors, salesmen hawking trinkets and even panhandlers dropped their protective masks and joined the familiar din of traffic horns and blaring music on the streets of the capital with its 20 million residents. Denver's annual festival, which typically draws 400,000, was going to be held as planned next weekend. High schools and universities were being scrubbed down to reopen Tuesday 5 May 2009. Younger children were to return to school on Monday 11 MAy 2009. Only essential services like gas stations and supermarkets had been allowed to operate since April 27. Some officials were worried about a sudden rush toward normalcy. "The scientists are saying that we really need to evaluate more," said Dr. Ethel Palacios, the deputy director of the swine flu monitoring effort here. "In terms of how the virus is going to behave, we are keeping every possibility in mind. … We can't make a prediction of what's going to happen", a journalist was told. [6990].

<br>

<br>

Tuesday 5 May 2009:

The Mexican influenza epidemic might be caused by not one but two new virus types.

Influenza A detections done by a laboratory in Canada between 24 Apr 2009 and 3

May 2009 found equally of the H1 or H3 subtype.

During late March and early April 2009 the laboratory reported an unexpected

number of late-season outbreaks due to H3 influenza in Canada, and two new H3 mutations arose in early March 2009. They also found at

least one returning traveler to have likely acquired illness due to

this new H3 virus in Mexico. If two new influenza viruses emerged simultaneously in Marts 2009 it might explain some unusual features with the Mexican epidemic. [6982]
<br><br>

5 May 2009 There had by this time been a world total of 1490 cases and 31 deaths of influenza A (H1N1) infection from 21 countries (a rise from the day before [4 May 2009], where the total figures were 1085 confirmed cases and 26 deaths from 21 countries).

<br>

<br>
Guatemala notified its first confirmed case of influenza A (H1N1) in a person that has travelled to Mexico.

<br>

<br>A few countries reported a day-by-day increase; death in parenthesis:

<br>Canada: 19 / 34 / 51 / 85 / 101 / 140<br>

Mexico: 97(7) / 156 (9) / 397 (16) / 506 (19) / 590 (25) / 866 (29) <br>

United Kingdom: 8 / 8 / 15 / 15 / 18 / 27<br>

United States: 109 (1) / 141 (1) / 160 (1) / 226 (1) / 286 (1) / 403 (1); USA had confirmed influenza A (H1N1) in 38 States.

<br>

<br>

<br>Mexico had by this time reported 866 laboratory confirmed human cases of infection, including 29 deaths.

<br>

<br>

In Mexico the majority of infections occurred in previously healthy young adult people, and few cases in children under 5 years old (102/822).

<br>

<br>

The 866 confirmed cases in Mexico corresponded to 32.2 % of the cases on which specimens were obtained. 50.9 % were women. With respect to confirmation of suspected cases, 47.8 % of the specimens obtained from young people between 10 and 19 years of age were positive. Of suspected cases in people older than 60 years only 16.5 % were confirmed. 73.7 % of the cases older than 60 years were women.

<br>

<br>The graph of the 866 confirmed cases showed a downward trend by date having begun on 26 Apr and now substantially lower numbers of cases were reported on a daily basis. This trend of decreasing case reports is among confirmed cases but also among suspected cases.

<br>

<br>There were initially 214 reported deaths attributable to acute pneumonia in Mexico. Of these were 74 definitively discarded based on clinical studies. This left 140 possible deaths due to A (H1N1). Only 29 were confirmed through molecular biologic studies. 35 laboratory studies were still pending. For 77 deaths it was not possible to obtain specimens so confirmation was impossible – they remained as suspected cases.

<br>

<br>The mean age of the infected is 17 years. The majority of deaths in Mexico were between 20 and 39 years of age [18 of the 26 deaths were aged 20 – 39 years, whereas 273 of the confirmed cases were in this age group, with an age specific case fatality rate of 6.6 percent, when compared with an overall case fatality rate of 3.0]. So, the overall case fatality rate (CFR) for the confirmed cases in Mexico was at this time 3.0 percent, but the CFR for the 20-39 year old age group was 6.6 percent.

<br>

<br>

41.5 percent of the Mexican population in general is

less than 20 years of age. 51.6 percent of confirmed cases in Mexico were less than

20 years of age – suggesting a higher representation of this

age group among cases (or higher age specific attack rate). [6986]

<br><br>
Mexico had 810 000 antiviral treatments – each involving 10 doses. The World Health Organization said it was shipping 2.4 million treatments of antiflu drugs to 72 countries "most in need," and France sent 100,000 doses of antiflu drugs worth $1.7 million to Mexico. [6986]

[6990]
<br>

<br>

Mexican Finance Secretary Agustin Carstens said the outbreak cost Mexico's economy at least $2.2 billion, and he announced a $1.3 billion stimulus package, mostly for tourism and small businesses, the sectors hardest hit by the epidemic. Mexico will temporarily reduce taxes for airlines and cruise ships and cut health insurance payments for small businesses.

[6990]
<br>

<br>
About 20 Chinese businessmen and students, each wearing surgical masks, left Tijuana zon Tuesday on a Chinese government flight after being stranded when China canceled all direct flights to Mexico.

Mexico, meanwhile, was collecting more than 70 Mexican nationals quarantined in China with its own charter flight.

[6990]
<br>

<br>

Four U.S. citizens were quarantined in China, the U.S. Embassy in Beijing said Tuesday, and about 200 passengers who flew from the United Kingdom were under quarantine in a Brunei hospital after three of them arrived with fevers.

[6990]
<br>

<br>

<b>Wednesday 6 May 2009</b>: Sweden report its first confirmed infection – a woman in Stockholm after a visit to USA.
<br><br>

Wednesday 6 May 2009: Canadian officials announced the Winnipeg

lab had completed full virus sequencing of 3 sample viruses, 2 from

Canadian swine flu cases and one from Mexico. The viruses

were virtually identical.

The full genetic sequences of viruses

retrieved from the pigs have not yet been completed. That work is

being done at the National Centre for Foreign Animal Diseases, the

National Microbiology Laboratory's animal health counterpart. The 2

labs are co-located.
Experts will be keen to study the genetic sequences of the viruses

isolated from the pigs to determine whether there are any mutations

that arose when the virus went back into swine.

[7003]

<br><br>

<b>Thursday 7 May 2009</b>:

Two new countries have confirmed cases: Brazil and Argentina [6999]

<br><br>

Thursday 7 May 2009.

The New England Journal of Medicine

<http://content.nejm.org/cgi/content/full/NEJMoa0903812> bring an article about the flu:

Between the 1930s and

the 1990s, the most commonly circulating swine

influenza virus among pigs — classic swine

influenza A (H1N1) — underwent little change.

But by the late 1990s multiple strains and

subtypes (H1N1, H3N2, and H1N2) of

triple-reassortant swine influenza A (H1) viruses (whose genomes included combinations of avian,

human, and swine influenza virus gene segments) had became predominant among North American pig herds.

Worldwide, more than 50

cases of swine influenza virus infection in

humans, most due to classic swine influenza

virus, have been documented in the past 35 years. People with

occupational swine exposure are at highest risk for infection.

Until

April 2009, only limited, nonsustained

human-to-human transmission of swine influenza virus had been reported.

The CDC identified the 1st

human infection with triple-reassortant swine

influenza A (H1) viruses in the United States in

December 2005.

From December 2005 through

February 2009, the CDC received 11 notifications

of human infection with triple-reassortant swine

influenza A(H1) viruses, 8 of which occurred

after June 2007.

Triple-reassortant swine influenza A

(H1) viruses (with genes from avian,

human, and swine influenza viruses) emerged and

became enzootic among pig herds in North America during the late 1990s.

From December 2005 until just

before the current human epidemic of swine-origin

influenza viruses, there was sporadic infection

with triple-reassortant swine influenza A (H1)

viruses in persons with exposure to pigs in the

United States.
Although all the patients

recovered, severe illness of the lower

respiratory tract and unusual influenza signs

such as diarrhea were observed in some patients,

including those who had been previously healthy.
<br><br>

Thursday 7 May 2009: The New England Journal of Medicine <http://content.nejm.org/cgi/content/full/NEJMoa0903810> – wrote in another article:

Triple-reassortant swine influenza viruses, which

contain genes from human, swine, and avian

influenza A viruses, have been identified in

swine in the United States since 1998.
12

cases of human infection with such viruses were

identified in the United States from 2005 through

2009.
On 15 Apr 2009 and 17 Apr 2009, the Centers

for Disease Control and Prevention(CDC)

identified 2 cases of human infection with a

swine-origin influenza A (H1N1) virus (S-OIV)

characterized by a unique combination of gene

segments that had not been identified among human

or swine influenza A viruses.

Prevention (CDC) identified 2 cases of human

infection with a swine-origin influenza A (H1N1)

virus (S-OIV) characterized by a unique

combination of gene segments that had not been

identified among human or swine influenza A

viruses.

From 15 Apr 2009 through 5 May 2009, a

total of 642 confirmed cases of S-OIV infection

were identified. The ages of

patients ranged from 3 months to 81 years.
The most common presenting

symptoms were fever (94 percent of patients),

cough (92 percent), and sore throat (66 percent);

25 percent of patients had diarrhea, and 25

percent had vomiting.

Of the 399 patients for

whom hospitalization status was known, 36 (9

percent) required hospitalization.
Of 22

hospitalized patients with available data, 12 had

characteristics that conferred an increased risk

of severe seasonal influenza, 11 had pneumonia, 8

required admission to an intensive care unit, 4

had respiratory failure, and 2 died.

It is likely that

the number of confirmed cases underestimates the

number of cases that have occurred.

[7000]

<br><br>
Wednesday 7 May 2009: First cases in Brazil. Three persons were infected in Mexico, and one person was infected in USA. All were young adult persons. [7010]

<br><br>

Thursday 7 MAY 2009:
The case-fatality rate of the flu was

still difficult to ascertain in a rapidly evolving outbreak, because an

unknown proportion of currently infected patients might die;

there may be unreported cases, and

groups at high risk for death from seasonal influenza (e.g., older

adults and patients with chronic disease) might not yet have been

exposed to the novel influenza A (H1N1) virus.
Summertime influenza outbreaks in temperate climates have been

reported in closed communities such as prisons, nursing homes, cruise

ships, and other settings with close contact. Such

outbreaks typically do not result in community-wide transmission, but

they can be important indicators of viruses likely to circulate in

the upcoming influenza season.
The novel influenza A (H1N1) virus

has been circulating in North America largely after the peak

influenza transmission season.
The imminent onset

of the season for influenza virus transmission in the southern

hemisphere, coupled with detection of confirmed cases in several

countries in the southern zone, raise concern that spread of novel

influenza A (H1N1) virus might result in large-scale outbreaks during

upcoming months.
Influenza virus can circulate year round in

tropical regions.

<br><br>Assessments to be made include: <br>

Clinical progression of disease.<br>

Rates of complications for different age and risk groups;<br>

Types of complications for different age and risk groups. <br>

Information on virus transmissibility. <br>

[7003]

<br><br>

Thursday 7 May 2009: In the Netherlands, the 2nd laboratory confirmed human case of

influenza A (H1N1) virus infection was reported. A

53-year-old woman returned on the 30 Apr 2009 from Cancun, Mexico.
During the flight she developed an unproductive cough.
2 days

later, on 2 May 2009, she had a temperature of 38.6C and a sore throat

and consulted a general practitioner.
Samples were submitted for

diagnostic evaluation and both the patient and her husband were

treated with oseltamivir.
The patient recovered completely and

uneventfully.

Samples collected 4 days later tested negative.
The sequence data suggested that the virus was susceptible to both

oseltamivir and zanamivir.
The amino acid 627 in PB2 (glutamicacid)

was not human-host-adapted, similar to recent swine influenza A

(H1N1) viruses.
However, a glutamic acid to glycine amino acid

substitution was detected at position 677 in PB2.
This mutation was

not observed in any of the A (H1N1) sequences submitted since 27 Apr

2009.
Lam et al. (2008) [T.T. Lam et al., "Evolutionary and transmission dynamics of

reassortant H5N1 influenza virus in Indonesia", PLoS Pathog. 2008 Aug

22;4(8):e1000130] postulated that this substitution could

reflect adaptation to mammalian hosts of highly pathogenic avian

influenza A (H5N1) viruses, as it was found to be under positive

selection based on phylogenetics of Indonesian viruses.
Based on the

position of the mutation it might contribute to more efficient

human-to-human transmission by enhanced replicative efficiency of the

polymerase of the influenza A (H1N1) virus in humans [PB2 is a

polymerase component].

The identification of a single mutation in the PB2 gene (encoding

the major component of the viral polymerase) of the novel 2009 strain of influenza A (H1N1) virus is only previously reported in the case of avian

influenza A (H5N1) virus.
Such a mutation

might influence the transmissibility and the host range of the virus.
But it would be premature to draw such a conclusion since there

appears to have been no onward transmission of the virus to any other

person.

[7001]

<br>

<br>

<b>Friday 8 May 2009</b>:

25 countries have

officially reported 2500 cases of influenza A (H1N1) infection. [6999]
<br><br>

Friday 8 May 2009: Mexico has reported 1204 laboratory confirmed

human cases of infection, including 44 deaths.

The United States has reported 896 laboratory

confirmed human cases, including 2 deaths. [6999]
<br><br>

Friday 8 May 2009: The following countries have reported laboratory

confirmed cases with no deaths – Austria (1), Brazil (4), Canada (214), Hong Kong (1), Colombia (1), Costa Rica (1), Denmark (1), El Salvador (2), France (12), Germany (11), Guatemala (1), Ireland (1), Israel (7), Italy (6), Netherlands (3), New Zealand (5), Poland (1), Portugal (1), Republic of Korea (3), Spain (88), Sweden (1), Switzerland (1), United Kingdom (34). [6999]

<br><br>

Friday 8 May 2009: Number of cases 30 Apr

2009 / 1 May / 2 May / 3 May / 4 May / 5 May / 6 May / 7 May / 8 May in some countries: [6999]
<br>

Canada: 19 / 34 / 51 / 85 / 101 / 140 / 165 / 201 / 214
<br>

France: 0 / 0 / 2 / 2 / 4 / 4 / 5 / 5 / 12

<br>

Germany: 3 / 4 / 6 / 8 / 8 / 9 / 9 / 10 / 11
<br>

Mexico: 97(7) / 156 (9) / 397 (16) / 506 (19)

590 (25) / 822 (29) / 942 (29) / 1112 (42) / 1204 (44)
<br>

Spain: 13 / 13 / 13 / 40 / 54 / 57 / 73 / 81 / 88
<br>

United Kingdom: 8 / 8 / 15 / 15 / 18 / 27 / 28 / 32 / 34

<br>

United States: 109 (1) / 141 (1) / 160 (1) / 226

(1) / 286 (1) / 403 (1) / 642 (2) / 896 (2)
<br>

Total No. countries reporting cases: 11 / 13 / 16 / 18 / 21 / 21 / 23 / 24 / 25

<br>

Total cases reported (death in parenthesis): 257 (8) / 367 (10) / 658

(17) / 898 (20) / 1085 (26) / 1490 (30) / 1893 (31) / 2371 (44) / 2500 (46) [6999]

<br><br>

<b>Friday 8 May 2009: </b>

Novel influenza A (H1N1) activity is now being detected in 2 of CDC's routine influenza surveillance systems as reported in the [8 May 2009] FluView [see <http://www.cdc.gov/flu/weekly/>]. FluView is a weekly report that tracks US influenza activity through multiple systems across 5 categories. The 8 May 2009 FluView found that the number of people visiting their doctors with influenza-like-illness is higher than expected in the US for this time of year. Also, laboratory data shows that regular seasonal influenza A (H1N1), (H3N2) and influenza B viruses are still circulating in the US, but novel influenza A (H1N1) and "unsubtypable"* viruses now account for a significant number of the viruses detected in the US. CDC continues to take aggressive action to respond to the outbreak. [7036]

<br><br>
<b>Saturday 9 May 2009: </b>
There was now reported more cases from USA than Mexico (1364 confirmed human cases of <br>

infection in Mexico, 1639 in USA (and number of confirmed cases rapidly growing during this day). 45 deaths in Mexico, 2 deaths in USA, Canada one death.)<br>

<br>

There was a dramatic increase in the number of cases in USA day-by-day: 109 – 141 – 160 – 226 – 286 – 403 – 642 – 896 – 1639.<br>

<br>

Two new countries, Argentina and Panama, have confirmed cases of <br>

Influenza A(H1N1). <br>

<br>

The World Health Organization maintained pandemic alert of Phase 5. <br>

There was no evidence of sustained community level human to human <br>

transmission outside of the Americas.<br>

<br>

In Brazil a mother of a 29-year-old <br>

student infected by a 21-year-old student who returned to Rio de <br>

Janeiro from Cancun, Mexico, on 2 May, was hospitalized on Sat 9 May <br>

as a suspect case. Test results will be known on Tue 12 May. <br>

<br>

Arizona: 1 / 4 / 4 /18 / 17 / 17 / 48 / 48 / 131 / 182<br>

California: 14 / 13 / 24 / 26 / 30 / 49 / 67 / 106 / 107 / 171<br>

Colorado: 0 / 2 / 2 / 4 / 7 / 6 / 17 / 17 / 25 / 41<br>

Connecticut: 0 / 0 / 1 / 2 / 2 / 2 / 4 / 4 / 4 / 14<br>

Delaware: 0 / 4 / 4 / 10 / 20 / 20 / 33 / 28 / 39 / 44<br>

Florida: 0 / 0 / 2 / 3 / 5 / 5 / 5 / 5 / 6 / 43<br>

Illinois: 0 / 3 / 3 / 3 / 8 / 82 / 122 / 204 / 392 / 421<br>

Iowa: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 5 / 5 / 43<br>

Maryland: 0 / 0 / 0 / 0 / 4 / 4 / 4 / 4 / 4 / 23<br>

Massachusetts: 2 / 2 / 8 / 7 / 6 / 6 / 45 / 71 / 83 / 89<br>

Michigan: 1 / 2 / 2 / 2 / 2 / 2 / 8 / 9 / 49 / 103<br>

Missouri: 0 / 0 / 1 / 1 / 1 / 1 / 2 / 4 / 9 / 10<br>

Nebraska: 0 / 1 / 0 / 1 / 1 / 1 / 4 / 4 / 4 / 13<br>

New Mexico: 0 / 0 / 0 / 1 / 1 / 1 / 3 / 8 / 8 / 30<br>

New York: 50 / 50 / 50 / 63 / 73 / 90 / 97 / 98 / 174 / 190<br>

Ohio: 1 / 1 / 1 / 3 / 3 / 3 / 5 / 5 / 6 / 12<br>

Oregon: 0 / 0 / 0 / 0 / 3 / 15 / 15 / 15 / 15 / 15<br>

Pennsylvania: 0 / 0 / 0 / 0 / 1 / 1 / 1 / 2 / 2 / 10<br>

South Carolina: 10 / 16 / 13 / 15 / 15 / 16 / 16 / 17 / 29 / 42<br>

Tennessee: 0 / 0 / 0 / 1 / 1 / 2 / 2 / 2 / 36 / 46<br>

Texas: 26 (1) / 28 (1) / 28 (1) / 40 (1) / 41 (1) / 41 (1) / 61 (2) / <br>

91 (2) / 93 (2) / 110 (2)<br>

Utah: 0 / 0 / 0 / 1 / 1 / 1 / 1 / 8 / 24 / 60<br>

<br>

Virginia: 0 / 2 / 2 / 3 / 3 / 3 / 3 / 11 / 14 / 16<br>

Washington: 0 / 0 / 0 / 0 / 0 / 0 / 9 / 23 / 33 / 83<br>

<br>

Wisconsin: 0 / 0 / 0 / 3 / 3 / 3 / 6 / 26 / 240 / 317<br>

<br>

A fatality has been reported <br>

from Costa Rica: a 53 year old male with preexisting diabetes and <br>

chronic lung disease. <br>

<br>

A new <br>

fatality reported in the USA: a 30-year-old male with preexisting <br>

heart disease. <br>

<br>

A confirmed case in Norway and <br>

the 1st locally transmitted case in Italy.<br>

<br>

The USA has officially reported 2254 laboratory confirmed cases <br>

coming from 44 states (compared with 1639 cases from 43 states on 8 <br>

May 2009)<br>
[7007]<br>
<br>
<b>Sunday 10 May 2009: </b><br>
First confirmed cases in Norway: A man from Oslo and a woman from Skien, who both studied in Mexico, were ill Wednesday 7 May 2009 with the flu. [7009]

<br>

<br>

Sunday 10 May 2009 (morning), 29 countries have officially reported 4379

cases of influenza A (H1N1) infection. Confirmed human cases of infection (deaths): Mexico 1626 (45), USA 2254 (2), Canada 280 (1), Costa Rica 8 (1). All other countries no deaths: Spain 93, United Kingdom 39, France 12, Germany 11, Italy 9, Israel 7, New Zealand 7, Brazil 6, Japan 4, Netherlands 3, Panama 3, Republic of Korea 3, El Salvador 2, Argentina 1, Australia 1, Austria 1, Colombia 1, Denmark 1, Guatemala 1, Hong Kong 1, Ireland 1, Poland 1, Portugal 1, Sweden 1, Switzerland 1. [7023]<br><br>

Sunday 10 May 2009: Day-by-day: Country: number of cases (deaths in parenthesis) 2009 Apr: 30 / May: 1 / 2 / 3 / 4 / 5 / 6 / 7

8 / 9 / 10:<br>

Total cases reported: 257 (8) / 367 (10) / 658 (17) / 898 (20) / 1085 (26)

/ 1490 (30) / 1893 (31) / 2371 (44) / 2500 (46) / 4379 (49)

[7023]
<br><br>Sunday 10 May 2009: Mexico has reported 2062 confirmed cases

of influenza A (H1N1), including 48 deaths, in 30 of 32 states. The states

with the highest number of confirmed cases are the Federal District (Mexico

City), State of Mexico, San Luis Potosi, and Hidalgo.

[7023]

<br><br>Sunday 10 May 2009: In Canada: 284 human cases of influenza A (H1N1) have been confirmed,

including 1 death in Alberta, in 9 of 13 Provinces (48 in Alberta, 79 in

British Columbia, 2 in New Brunswick, 56 in Nova Scotia, 15 in Quebec, 1 in

Manitoba, 76 in Ontario, 3 in Prince Edward Island and 4 in Saskatchewan).

[7023]

<br><br>Sunday 10 May 2009: USA has confirmed a total of 2532 cases of influenza

A (H1N1), including 3 deaths (2 in Texas and one in the state of

Washington), in 44 States (including the District of Columbia): 4 in

Alabama, 182 in Arizona, 282 in California, 39 in Colorado, 24 in

Connecticut, 44 in Delaware, 53 in Florida, 3 in Georgia, 6 in Hawaii, 1 in

Idaho, 466 in Illinois, 39 in Indiana, 43 in Iowa, 36 in Kansas, 3 in

Kentucky, 9 in Louisiana, 4 in Maine, 23 in Maryland, 88 in Massachusetts,

114 in Michigan, 7 in Minnesota, 10 in Missouri, 13 in Nebraska, 9 in

Nevada, 4 in New Hampshire, 7 in New Jersey, 30 in New Mexico, 190 in New

York, 7 in North Carolina, 6 in Ohio, 14 in Oklahoma, 17 in Oregon, 10 in

Pennsylvania, 7 in Rhode Island, 32 in South Carolina, 1 in South Dakota,

54 in Tennessee, 108 in Texas, 63 in Utah, 1 in Vermont, 16 in Virginia,

102 in Washington, 4 in Washington DC, and 357 in Wisconsin.

[7023]<br>

<br>

Graphics on the status of the epidemic:

<http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html>. [7023]
<br>

<br>

Sunday 10 May 2009: China-mainland report its first confirmed case. (It is also the 1st confirmed case on mainland after history of travel to USA). [7023]

<br><br>
Sunday 10 May 2009: Brazil, Colombia, and El Salvador each notified 2 new confirmed cases of influenza A (H1N1).
<br><br>

<b>11 May 2009:</b>
Monday 11 May 2009 morning: 30 countries have officially reported 4694 cases of influenza A(H1N1) infection.

<br><br>

Mexico has reported 1626 laboratory confirmed human cases of infection, including 48 deaths. The United States 2532 with 3 deaths. Canada 284 with one death. Costa Rica 8 with 1 death. Other countries (with no deaths): Argentina (1), Australia (1), Austria (1), Brazil (8), China-mainland (2), Hong Kong Special Administrative Region, and 1 in mainland China), Colombia (3), Denmark (1), El Salvador (4), France (13), Germany (11), Guatemala (1), Ireland (1), Israel (7), Italy (9), Japan (4), Netherlands (3), New Zealand (7), Norway (2), Panama (15), Poland (1), Portugal (1), Republic of Korea (3), Spain (95), Sweden (2), Switzerland (1) and the United Kingdom (47). [7036]<br><br>
Monday 11 May 2009 afternoon: The total of confirmed cases of influenza A (H1N1) recorded is 5029 including 61 deaths, in 10 countries of the Americas (Argentina, Brazil, Canada, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Panama, and the United States). This figure could be higher, however, because some countries are still waiting for the laboratory confirmation of samples collected in previous weeks. [7036]<br><br>
To date, the United States has confirmed a total of 2600 human cases of influenza A (H1N1) including 3 deaths, in 44 states including the District of Columbia: 4 in Alabama, 182 in Arizona, 191 in California, 39 in Colorado, 24 in Connecticut, 44 in Delaware, 54 in Florida, 3 in Georgia, 6 in Hawaii, 1 in Idaho, 487 in Illinois, 39 in Indiana, 43 in Iowa, 18 in Kansas, 10 in Kentucky, 9 in Louisiana, 4 in Maine, 23 in Maryland, 88 in Massachusetts, 130 in Michigan, 7 in Minnesota, 14 in Missouri, 13 in Nebraska, 9 in Nevada, 4 in New Hampshire, 7 in New Jersey, 30 in New Mexico, 190 in New York, 11 in North Carolina, 6 in Ohio, 14 in Oklahoma, 17 in Oregon, 10 in Pennsylvania, 7 in Rhode Island, 32 in South Carolina, 1 in South Dakota, 54 in Tennessee, 179 in Texas, 63 in Utah, 1 in Vermont, 16 in Virginia, 128 in Washington, 4 in Washington, DC and 384 in Wisconsin. Other suspected cases are being investigated. [7036]<br><br>
From [1 Mar 2009 to 10 May 2009], Mexico has reported 2059 confirmed cases of influenza A (H1N1), including 56 deaths, in 30 of 32 states. The states with the highest number of confirmed cases are Distrito Federal, Estado de Mexico, San Luis Potosi and Hidalgo. [7036]<br><br>
In Canada, to date 330 human cases of influenza A (H1N1) have been confirmed, including a death, in 9 of 13 provinces: (52 in Alberta, 79 in British Columbia, 2 in New Brunswick, 57 in Nova Scotia, 16 in Quebec, 1 in Manitoba, 110 in Ontario, 3 in Prince Edward Island and 10 in Saskatchewan). [7036]<br><br>
To date, Argentina has confirmed 1 human case of influenza A (H1N1); Brazil, 8 cases; Colombia, 3 cases; Costa Rica, 8 cases including a death; El Salvador, 4 cases, Guatemala, 1 case; and Panama, 15 cases. [7036]<br><br>

Monday 11 May 2009:

Judging the pandemic potential of this new flu is difficult with limited data but nevertheless is essential to inform appropriate health responses. [7024 (Science report)].<br>

<br>

By analyzing the outbreak in Mexico estimates suggest that 23 000 (range 6000-32 000) individuals had been infected in Mexico by late April 2009, giving an estimated case fatality ratio (CFR) of 0.4 per cent (range 0.3 to 1.5 per cent) based on confirmed and suspect deaths reported up to that time. [7024 (Science report)].<br>

<br>

In a community outbreak in the small community of La Gloria, Veracruz, no deaths were attributed to infection, giving an upper 95 per cent bound on CFR of 0.6 per cent. [7024 (Science report)].<br>

<br>

Thus, while substantial uncertainty remains, clinical severity appears less than that seen in 1918 but comparable with that seen in 1957. [7024 (Science report)].<br>

<br>

Clinical attack rates in children in La Gloria were twice those in adults (less than 15 years of age: 61%, 15: 29%). [7024 (Science report)].<br>

<br>

Three different epidemiological analyses gave R0 estimates in the range 1.4-1.6, while a genetic analysis gave a central estimate of 1.2. [7024 (Science report)].<br>

<br>

This range of values is consistent with 14 to 73 generations of human-to-human transmission having occurred in Mexico to late April 2009. ¤ [7024 (Science report)].<br>

<br>

Transmissibility is therefore substantially higher than seasonal flu and comparable with lower estimates of R0 obtained from previous influenza pandemics. [7024; (Science)].<br>

<br>

A UK analysis reported in Science concludes that the World Health Organization was right to raise the alert over a potential global flu pandemic. [7024b].<br>

<br>

It says the outbreak is likely to be comparable to the pandemics of the 20th century. [7024b].<br>

<br>

The study, led by Professor Neil Ferguson, of Imperial College, London, is published in the leading journal Science [see preceding report]. It finds that — as suspected — the virus is more infectious than normal. [7024b].<br>

<br>

Seasonal flu normally infects one in 10 of the population. [7024b].<br>

<br>

So far, swine flu has infected 1/3rd of the people that have come into contact with it in Mexico. [7024b].<br>

<br>

Professor Fergusons study (admitting it was difficult to quantify the impact at this stage) suggests that swine flu could kill between 4 in every 1000 infected people and 14 in every 1000. [7024b].<br>

<br>

Professor Ferguson said: "The World Health Organization was correct in its judgment that this is a virus that should not be ignored, but these figures suggest at this stage it is not going to be catastrophic." [7024b].<br>

<br>
Four other schools in England have reopened after cases of infection. Hampton School in south west London was closed for a week starting Monday 11 May 2009 after a Year 7 pupil fell ill after traveling overseas. It is offering antiviral drugs to all children in Year 7, any staff who had close contact with the pupil, and any other children who shared school coach journeys with him. [7024b].<br>

<br>

All infections in the UK so far had been "mild" and thanks to early diagnosis and treatment with antivirals, the spread of the virus is being limited and symptoms reduced. [7024b].<br>

<br>

2 cases in London are both connected with Alleyn's School in Dulwich, which was closed on 4 May 2009 after 5 pupils were confirmed with the virus. The 2 latest cases were a 12 year old pupil and a parent. [7024b].<br>

<br>

NHS East of England said the 4 cases in its area included a man from North Weald, Essex, who had close contact with an already confirmed case and a child from Canvey Island, also in Essex, who recently visited Mexico. [7024b].<br>

<br>

Another case involved a man from Lowestoft, Suffolk, who recently visited Florida. [7024b].<br>

<br>

The 4th case was a woman from the Huntingdonshire district in Cambridgeshire. [7024b].<br>

<br>

Holiday companies Thomson and First Choice were cancelling all flights to the Mexican resorts of Cancun and Cozumel up to and including 18 May 2009. [7024b].<br>

<br>

Their last holiday makers still in Mexico would be returning home to England on Monday 11 May 2009. [7024]

<br><br>

<hr><br>

<b>Tuesday 12 May 2009</b>
<br>The new virus, which had now infected 5,251 people in 30 countries and killed 61, has displayed great efficiency in spreading among people<br><br>
This virus, which has only been around a few months, is very unstable – and we know that its presence is dramatically increasing in human population, so the chance of it meeting with H5N1 (bird flu virus) is actually increased.<br><br>
Both swineorigin-H1N1 and birdflu-H5N1 are unstable so the chances of them exchanging genetic material are higher, whereas a stable (seasonal flu) virus is less likely to take on genetic material.<br><br>
While swineorigin-H1N1 appears to be mild so far with many infected people recovering even without treatment, the birdflu-H5N1 has a mortality rate of between 60 to 70 percent. <br><br>
Experts are fearful about the emergence of a hybrid which combines the killing power of the H5N1 with the efficient transmissibility of swineorigin-H1N1. <br><br>
birdflu-H5N1 is believed to be endemic in countries like China, Indonesia, Vietnam and Egypt. <br><br>
There is a huge information gap due to a lack of regular surveillance on animal disease. <br><br>
Each one of the eight gene segments in the new virus has been seen in pigs in the past 10 years, but experts have no clue when this new swineorigin-H1N1 virus strain first appeared and in which animal species it had been incubating.<br><br>
We know when each gene segment appeared, but we don't know when this strain first appeared, there is an information gap of about five to 10 years, from 1999 to 2009. If there was regular surveillance, we would know when this virus came about.<br><br>
We don't know if this reassortment happened in pigs or human … It's likely to have come from pigs because all the segments have been found in pigs, but we can't be 100 percent sure.<br><br>
It appears to be more virulent than seasonal flu because it is killing younger people and it appears to have higher mortality than seasonal flu, so it doesn't make sense to treat this like seasonal flu.<br><br>
[7033; interview with Guan Yi, a leading microbiologist with the University of Hong Kong.]

<br><br>
<br><br>
Tuesday May 12, 2009: The new H1N1 virus shows no signs of sustained person-to-person spread outside of North America and so has not yet tipped over into a pandemic, a top World Health Organization official, Dr. Keiji Fukuda, acting WHO assistant director-general, said on Monday. Things change on an almost daily basis," Fukuda said. "We are evaluating the clinical features, we are evaluating the epidemiology and the spread. [7034]<br><br>
In Mexico, millions of children, many of them wearing surgical masks and clutching hand sanitizer, went back to classes for the first time in two weeks. Schools throughout Mexico were scrubbed from floor to ceiling last week and the 20 million students who returned on Monday were told to follow strict hygiene rules. Although there is no evidence to show masks protect people who have not been infected, many children wore them. [7034]<br><br>
Chinese authorities were searching for 150 people who took the same flights as mainland China's first confirmed case of the new flu. State television and the Xinhau news agency said the government had tracked down and quarantined about 150 people who flew with the 30-year-old man, first from Tokyo to Beijing and then from Beijing to the Sichuan provincial capital, Chengdu. But another 150 or so were unaccounted for. The patient himself, a Chinese student in the U.S. state of Missouri, was doing well. [7034]<br><br>
Thai scientists who infected piglets with the new virus said it caused flu-like symptoms in the animals before disappearing, just like many of the human cases. [7034]<br><br>
Cuba reported its first confirmed case of the new flu in a student from Mexico. [7034]<br><br>
In Italy 1 in 10 Italians is said to have stopped eating pork despite reassurances the virus is not food-borne – while 12 percent were actually buying more pork because prices had fallen since the outbreak. [7034]<br><br>

Tuesday 12 May 2009: <br>
During seasonal influenza epidemics and previous pandemics, pregnant women

have been at increased risk for complications related to influenza

infection. In addition, maternal influenza virus infection and

accompanying hyperthermia place fetuses at risk for complications such as

birth defects and preterm birth. [7042]<br><br>
CDC initiated surveillance for

pregnant women who were infected with the novel virus. As of 10 May 2009,

a total of 20 cases of novel influenza A (H1N1) virus infection had been

reported among pregnant women in the United States, including 15 confirmed

cases and 5 probable cases. [7042]<br><br>
The age was 15-39 years. 3 women

were hospitalized, one of whom died. [7042]<br><br>
Pregnant women with confirmed, probable, or suspected novel

influenza A (H1N1) virus infection should receive antiviral treatment for 5

days. Oseltamivir is the preferred treatment for pregnant women. The

drug regimen should be initiated within 48 hours of symptom onset, if

possible. [7042]<br><br>
Pregnant women who are in close contact with a person with

confirmed, probable, or suspected novel influenza A (H1N1) infection should

receive a 10 day course of chemoprophylaxis with zanamivir or oseltamivir. [7042]<br><br>

On 15 Apr 2009 a woman aged 33 years at 35 weeks' gestation

with a one day history of myalgias, dry cough, and low-grade fever was

examined by her obstetrician. She had been in relatively good health and

had been taking no medications other than prenatal vitamins, although she

had a history of psoriasis and mild asthma. The patient had not recently

traveled to Mexico. Rapid influenza diagnostic testing performed in the

physician's office was positive. [7042]<br><br>
On 19 Apr 2009, she was examined in a local emergency department, with

worsening shortness of breath, fever, and productive cough. She experienced

severe respiratory distress, with an oxygen saturation of about 80 per cent

on room air and a respiratory rate of about 30 breaths per minute. A chest

radiograph revealed bilateral nodular infiltrates. The patient required

intubation and was placed on mechanical ventilation. On 19 Apr 2009, an

emergency cesarean delivery was performed, resulting in a female infant

with Apgar scores of 4 at 1 minute after birth and of 6 at 5 minutes after

birth; the infant is healthy and has been discharged home. On 21 Apr

2009, the patient developed acute respiratory distress syndrome (ARDS).

The patient began receiving oseltamivir on 28 Apr 2009. She also received

broad spectrum antibiotics and remained on mechanical ventilation. The

patient died on 4 May 2009. [7042]<br><br>
On 30 Apr 2009, a

nasopharyngeal specimen was collected, which was positive by rRT-PCR for

novel influenza A (H1N1) virus at CDC. [7042]<br><br>
Patient B. A previously healthy woman aged 35 years at 32 weeks' gestation was febrile 20 Apr 2009 (101.6 deg F [38.7

deg C]), with a heart rate of 128 beats per minute, respiratory rate of 22

breaths per minute. The patient received a parenteral nonsteroidal

anti-inflammatory medication, acetaminophen, and inhaled albuterol and later antibiotics, antinausea medication,

acetaminophen, and an inhaled corticosteroid. The patient recovered fully,

and her pregnancy is proceeding normally. She had been in Mexico during the 3 days preceding her arrival at the

emergency department. [7042]<br><br>
Several family members in Mexico and the United

States had recently been ill with influenza-like illness, and her sister

had been hospitalized for pneumonia during the preceding week. [7042]<br><br>
She had a confirmed infection with novel influenza A (H1N1) virus. [7042]<br><br>
Patient C. On 29 Apr 2009, a woman aged 29 years at 23 weeks' gestation

was experiencing cough, sore throat, chills, subjective fever, and weakness

of 1 day's duration. The patient had a history of asthma but

was not taking any asthma medications. Her son, aged 10 years, reportedly

had similar symptoms the week before the onset of her symptoms. Another

son, aged 7 years, had become ill on the same day as his mother and

accompanied her to the clinic. At the clinic, the younger son was coughing

vigorously and was asked to put on a mask by office staff members. The woman was prescribed

oseltamivir, which she began taking later the same day. Her symptoms are

resolving without complications, and her pregnancy is proceeding normally.

She had a confirmed infection

with novel influenza A (H1N1) virus. [7042]<br><br>
The physician who evaluated patient C was also pregnant (13

weeks' gestation). The physician began chemoprophylaxis with oseltamivir

and remained asymptomatic. [7042]<br><br>

Previous influenza pandemics (4,5) have shown

that pregnant women generally are at higher risk for influenza-associated

morbidity and mortality compared with women who are not pregnant. The

increased risk of complications is thought to be related to several

physiologic changes that occur during pregnancy, including alterations in

the cardiovascular, respiratory, and immune systems. Pregnant women

with underlying medical conditions such as asthma are at particularly high

risk for influenza-related complications. Because pregnant women are at

increased risk for influenza complications, the Advisory Committee on

Immunization Practices and the American College of Obstetricians and

Gynecologists have recommended that women receive the trivalent inactivated

influenza vaccine. [7042]<br><br>
Limited

data from observational studies among hospitalized patients with seasonal

influenza indicate that oseltamivir can reduce mortality, even when started

more than 48 hours after illness onset. [7042]<br><br>
In addition, oseltamivir and

zanamivir have been highly effective in preventing seasonal influenza if

used shortly after exposure to the disease. [7042]<br><br>
Little information is

available on the safety or effectiveness of these medications when used

during pregnancy. However, considering the limited information

available and the known risks for influenza complications during pregnancy,

any potential risk to a fetus likely is outweighed by the expected benefits

of influenza antiviral treatment for this novel virus. Thus, CDC interim

guidance indicates that pregnant women with confirmed, probable, or

suspected novel influenza A (H1N1) virus infection should receive antiviral

treatment for 5 days. [7042]<br><br>
Although zanamivir can be used in pregnancy, oseltamivir is preferred for

treatment of pregnant women because of its systemic absorption. [7042]<br><br>
Theoretically, higher systemic absorption might suppress influenza viral

loads more effectively in sites other than the respiratory system (such as

placenta) and might provide better protection against mother-child

transmission. [7042]<br><br>
Any pregnant

woman hospitalized with confirmed, probable, or suspected novel influenza A

(H1N1) virus infection should receive oseltamivir, even if more than 48

hours have elapsed since illness onset. Beginning treatment as early as

possible is critical. In addition, treating fevers in pregnant women with

acetaminophen is important because maternal hyperthermia has been

associated with various adverse fetal and neonatal outcomes. [7042]<br><br>

Pregnant women who are in close contact with a

person who has a confirmed, probable, or suspected case should receive a 10

day course of chemoprophylaxis with zanamivir or oseltamivir. [7042]<br><br>

Tuesday 12 May 2009: A total of 5696 cases and 63 deaths have been reported worldwide. [7042]<br><br>

Tuesday 12 May 2009: Thailand and Finland have each confirmed 2 cases after travels to Mexico. [7042]<br><br>

Tuesday 12 May 2009: The USA has officially reported 3009 laboratory confirmed cases coming from

45 states and 4 deaths. Mexico has reported 2282 confirmed cases with 58 deaths

[7042]

<!–æææ–>

<hr><br>

<A name="Other flu infections.">
<b>Other flu infections</b><br><br>
The H1N1 swine flu of 2009 is seen as the biggest risk since H5N1 bird flu re-emerged in 2003, killing 257 people of 421 infected in 15 countries. [6963]

<br><br>

In 1968 a “Hong Kong” flu pandemic killed about 1 million people globally. [6963]

<br><br>
A 1957 pandemic killed about 2 million. [6963]

<br><br>

The ordinary seasonal flu severely affects 3-5 million people and causes 250,000 to 500,000 deaths in a normal year [7038]. Including healthy children in rich countries. In a country like Denmark 1000-3000 die of influenza in a year of an ordinary influenza type. In the U.S. alone, health officials say about 36,000 people die every year from flu-related causes. [6963]
<br>

<br>

Pandemics: [7011]

1918-1919: "The Great flu (The Spanish flu), den spanske syge", About 40-50 million dead (Denmark 14000). [7011]<br>

1957-58 "Asian flu; Den asiatiske influenza", 2 mill. dead (Denmark 1700). [7011]<br>

1968-70 "Hong Kong influenza", 1 mill. dead (Denmark 1300). [7011]<br>

1997- "Bird flu, Fugleinfluenzaen", 257 dead (Denmark 0). [7011]<br>

2003 "SARS", 774 dead (Denmark 0). [7011]<br>

<br><br>

The Spanish flu 1919 (90 years ago) compared with today: <br>

Antiviral drugs such as Tamiflu was not available.<br>

Today effective vaccines can be produced in 6 months. Experimental vaccines can be made in one month [7032]<br>

Antibacterial drugs against secondary bacteria infections was not available.<br>

The health system today is much better today.<br>

The hygiene today is much better today.<br>

The information technology is much better today.<br>

The nutrition standard is much better today.<br>

The housing standard is much better today.<br>

<br>
<br>

<A name="Links.">

<a href="http://twitter.com/CDCemergency" target="win3">Follow the development of the epidemic through CDC (USA)</a><br><br>
<a href="http://www.promedmail.org/pls/otn/f?p=2400:1000:2035422834041757:::::" target="win8">Follow the disease via ProMed</a> (The global electronic reporting system for outbreaks

of emerging infectious diseases).

<a href="http://www.isid.org/promedmail/subscribe.lasso" target="win9">Subscribe to its email</a><br><br>

<a href="http://www.who.int/csr/disease/swineflu/en/index.html" target="win17">Follow the daily updates on the WHO swine influenza website</a><br><br>

<br>

<a href="http://www.google.com/search?as_q=influenza+2009&hl=da&rls=com.microsoft%3Ada%3AIE-SearchBox&rlz=1I7ADBF&num=100&btnG=Google-s%C3%B8gning&as_epq=&as_oq=pig+swine+&as_eq=&lr=&cr=&as_ft=i&as_filetype=&as_qdr=y&as_occt=any&as_dt=i&as_sitesearch=&as_rights=&safe=images">Read more on Google</a>
<br><br>

<hr><br>

The flu that never came:
President Ford's decision for a national inoculation against swine flu in 1976 is still debated by experts today.
<br><br>

On the cold afternoon of February 5, 1976, an Army recruit told his drill instructor at Fort Dix that he felt tired and weak but not sick enough to see military medics or skip a big training hike.
<br><br>

Within 24 hours, 19-year-old Pvt. David Lewis of Ashley Falls, Mass., was dead, killed by an influenza not seen since the plague of 1918-19,
<br><br>

government doctors knew from tests hastily conducted at Dix after Lewis' death that 500 soldiers had caught swine flu without falling ill.
<br><br>

Any flu able to reach that many people so fast was capable of becoming another worldwide plague,
<br><br>

Does America mobilize for mass inoculations in time to have everybody ready for the next flu season? Or should the country wait to see if the new virus would, as they often do, get stronger to hit harder in the second year?
<br><br>

The Great Plague, as it came to be called, rivaled the horrid Black Death of medieval times in its ability to strike suddenly and take lives swiftly. In addition to the half million in America, it killed 20 million people around the world.
<br><br>

The post-WWI flu was brought to Europe by American troops who had been based in the South before they went to war.
<br><br>

Medical detectives, still working on the case in the 1990s, determined that a small group of our soldiers took swine flu to Europe and that it spread to the world from there.
<br><br>

How the swine flu got to Fort Dix in 1976 still hasn't been tracked down.
<br><br>

CDC had to make a fast decision to get the immunizations manufactured by the fall.
<br><br>

The doctors knew they faced complaints if the epidemic broke out and vaccines weren't ready, as well as criticism if they spent millions inoculating people for a plague that didn't happen.
<br><br>

By mid-March 1976, CDC Director Dr. David J. Sencer had lined up most of the medical establishment behind his plan to call on president Ford to support a $135 million program of mass inoculation.
<br><br>

On March 24 in 1976, one day after a surprise loss to Ronald Reagan in the North Carolina Republican presidential primary, president Ford decided to make the announcement to the American public.
<br><br>

Congress still had to appropriate the money, and that wasn't going to be easy. Even before official congressional consideration of the plan was taken up, there were forces arguing against it.
<br><br>

Another big hurdle was the drug makers, who were insisting the government take liability for any harmful side effects from the vaccine.
<br><br>

During congressional hearings in the spring and early summer, lawmakers heard some naysayers who noted that the swine flu of last winter never got beyond Dix and that only one death had been reported.
<br><br>

The president and his experts prevailed, however, and on Aug. 12 Congress put up the money to get the job done.
<br><br>

The mighty task was put into the hands of a charismatic 33-year-old physician for the Department of Health, Education and Welfare, Dr. W. Delano Meriwether. Meriwether was given until the end of the year to get all 220 million Americans inoculated against swine flu.
<br><br>

By Oct. 1, 1976, the makers had the serums ready and America's public health bureaucracy had lined up thousands of doctors, nurses and paramedics to give out the shots at medical centers, schools and firehouses across the nation.
<br><br>

Within days, however, several people who had taken the shot fell seriously ill. On Oct. 12, three elderly people in the Pittsburgh area suffered heart attacks and died within hours of getting the shot, which led to suspension of the program in Pennsylvania.
<br><br>

In other states of US inoculations went on.
<br><br>

On Dec. 16, 1976, increasingly concerned about reports of the vaccine touching off neurological problems, especially rare Guillain-Barre syndrome, the government suspended the program, having inoculated 40 million people. The flu never came.
<br><br>

Hundreds of Americans later filed suit against the government on behalf of children left without a parent due to fatal side effects from the swine flu vaccine. [7005]
<br><br>

Scientists including Dr. Edwin Kilbourne believed at that time that pandemic flu returned periodically – they thought it came back once every eleven years or so. When a young soldier at Fort Dix (who went on a long march carrying a heavy pack despite his illness) died of a strain of influenza that seemed to be related to the 1918, flu experts were very concerned. About 40 million people were vaccinated, and a few hundred were paralyzed. At least 25 people died. It was called the Swine Flu pandemic – a flu pandemic that didn't happen.

<br><br><hr><br>

Interview 17 October 2005 [7004] (during the [still on-going] bird flu situation) with

Science writer Wendy Orent, author of "Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease" (Free Press).

<br><br>
According to the CDC, 36,000 people die a year in the United States from flu or its complications.

<br><br>
Flu virus depend on mobile hosts to transmit them through coughing and sneezing. Flu just isn't that deadly a disease – the need for the virus to keep the host mobile (and not immobilised in bed) ensures that flu normally is not too dangerous.

<br><br>
In the 1957 pandemic, the virus killed about 70,000 in the US.

<br><br>
Flu is too explosive to be quarantinable. But for most bioweapons agents, smallpox and plague quarantine would work quite well.

<br><br>
Children may be the chief disseminators of flu according to a study in Japan.

<br><br>
There is about one case per million (or fewer) of paralysis from the live polio virus. Not a high number, but in the absence of wild polio, that's still too high a risk, – which is why now people in the US are given the killed virus instead.

<br><br>
The people who die from flu, under normal circumstances, are elderly, immuno-compromised, pregnant, people with cardiac conditions, or sometimes the very young. That's the worst-case "normal" pandemic scenario – as happened in 1957. Under non-pandemic conditions (every year) it's typically the elderly or very young.

<br><br>
Masks won't really help – the flu particles are too small. The mask gets charged with moisture and turns useless. Stay home as much as you can – and more important, don't go out if you get ill, pandemic or not. That's the best way to minimize transmission of even ordinary flu. If you're sick, stay home! Flu is mostly airborne. You're at the mercy of those people who think that working while they're ill is heroic. I repeat – if you're sick, stay home! Please!

<br><br>
Wash your hands when you get home. Soap is soap – stay away from the antibacterial stuff, which can help grow resistant strains. Alcohol-based sanitizers are useful.

<br><br>
Bird flu virus in autopsies of people who died because of a bird flu infection shows up only deep in lung tissues. It can't be coughed out that way. We're a long way from transmissibility!

<br><br>

Virulence is deadliness – how thoroughly a germ exploits a host's tissues, how likely it is to kill. Transmissibility is how it gets from one host to another. ,…it has to be shed in some way. Human flu is highly transmissible, but not very virulent. 1918 flu was both virulent and transmissible. Bird flu is virulent, at least sometimes (and very virulent for chickens) but not transmissible.

<br><br>

Bird flu ought really to be called "poultry flu" – the entire bird flu problem comes from the conditions in which chickens and other birds are raised. In SE Asia and China, some of the poultry farms are enormous – one farm have five million chickens packed together – that's a very good way to start growing a virulent disease. Really disease factories.

<br><br>

The 1918 flu virus was an extremely well-adapted virus. It was very good at spreading among people and killing them. It was a human virus, even though its genes apparently originally came from birds.

<br><br>
The fact remains that H5N1 is NOT spreading in long chains person to person – there have been very few instances of person-to-person infection of this bird flu. [7004]

<br><hr><br>

7022; http://www.eurekalert.org/pub_releases/2009-05/l-pia050809.php

<br><br>
8 May 2009: An Editorial published by The Lancet says that the flu crisis in 2009 can be seen as a timely exercise in preparing health authorities for a far more devastating pandemic.

[7022]<br><br>
The Editorial praises the overall coverage by the media, saying: "Our impression is that mass media coverage of the H1N1 outbreak has—barring some chequebook journalism and a few unnecessary superlatives—been balanced and rational. Perhaps the media could be criticised for failing to put the outbreak into context, in that the morbidity and mortality associated with H1N1 has, until now, been inconsequential compared with the thousands of lives taken every day by—for example—AIDS, tuberculosis, malaria, pneumonia, sepsis, and even seasonal influenza. The general public seems to have passed its own judgement on the dangers of H1N1 in that there have been no signs of panic on the streets, and the story has already started to slip down the news agenda."

[7022]<br><br>
The Editorial concludes: "We have been fortunate in that the virus that has brought the world closest to an influenza pandemic for more than 40 years seems to cause little serious illness. This episode can be seen as a timely exercise in preparing health authorities for a far more devastating pandemic. By and large…national and international health authorities have responded to H1N1 in a measured fashion."

[7022]<br><br>
Science explores the limits of uncertainty. When asked to speculate on what course the H1N1 outbreak might take.for example, on number of deaths, influenza specialists have given a range of possible scenarios.

[7022]<br><br>
When translated into headlines, it is hardly surprising that the upper end of the possible range is emphasised.

[7022]<br><br>
8 May 2009 WHO reported 2384 confirmed cases in 24 countries with 44 fatalities. Among these, 1112 cases and 42 deaths were reported from Mexico.

[7022]<br><br>
There were at this time early indications that the epidemic peak has passed in Mexico, but WHO has accepted that the outbreak will continue to spread internationally.

[7022]<br><br>
Although the illness caused by H1N1 appears to be mild, this is a new form of the virus to which most human beings have little pre-existing immunity. Therefore, the potential for a pandemic has not gone away.

[7022]<br><br>
The virus may yet cause illness in a sufficient proportion of the population to produce economic disruption.

[7022]<br><br>
Since community-spread-of-infection, rather than severity-of-disease, is the criterion for determining whether a full pandemic should be declared (phase six on the WHO scale), such a decision might not be far away.

[7022]<br><br>
If a pandemic is declared, WHO will have to decide whether to begin manufacture of a vaccine against the pandemic virus.

[7022]<br><br>
The H1N1 strain will not be incorporated into the next seasonal influenza vaccine.

[7022]<br><br>
Therefore, manufacture of pandemic vaccine will impinge upon the capacity to make seasonal vaccine.

[7022]<br><br>
In the absence of a vaccine, closure of schools with infected pupils has been used by some countries as a measure to prevent spread of the H1N1 virus.

[7022]<br><br>
In the USA, the CDC initially supported school closures, but has since backed away from this recommendation.

[7022]<br><br>
The Public Health Agency of Canada does not recommend closing schools because, given the generally mild illness, the resulting disruption would outweigh any potential benefits.

[7022]<br><br>
The official line of the UK Health Protection Agency is that consideration should be given to temporarily closing the school.

[7022]<br><br>
In practice, all five schools in England with confirmed cases have been closed for several days.

[7022]<br><br>
Experts at the various agencies have presumably considered the same evidence on the benefit of school closures – yet reached different conclusions. This is an area that needs more research and harmonisation of guidelines.

[7022]<br><br>
We have been fortunate in that the virus that has brought the world closest to an influenza pandemic for more than 40 years seems to cause little serious illness.

[7022]<br><br>
This episode can be seen as a timely exercise in preparing health authorities for a far more devastating pandemic.

[7022]<br><br>
Influenza A H1N1 (swine flu) has spread around the world with what has, at times, felt like horrifying speed.

[7022]<br><br>
Of the first 2384 laboratory-confirmed cases reported in 24 countries, there was 44 deaths, 42 of which were in Mexico.

[7022]<br><br>
These numbers are far lower than the annual toll from seasonal influenza, which kills hundreds of people every day in the peak season.

[7022]<br><br>
Epidemiologists are still largely in the dark about how the virus will continue to spread and, ultimately, how severe the disease it causes will be.

[7022]<br><br>
The threats of severe acute respiratory syndrome (SARS) and H5N1 a few years ago prompted the world to set up plans to deal with the possibility that these viruses would, by developing sustained human-to-human transmission, trigger a pandemic.

[7022]<br><br>
The chaos caused by the outbreaks revealed just how badly countries around the world – increasingly linked by frequent international travel and growing globalisation – were prepared to deal with a worldwide infectious disease pandemic.

[7022]<br><br>
Pandemic preparedness has come a long way since those two viruses caused worldwide alarm, says Sandra Mounier-Jack (London School of Hygiene and Tropical Medicine, London, UK) but there are holes in many countries' plans.

[7022]<br><br>
In 2006, with her colleague Richard Coker, Mounier-Jack compared the strategies of Asia-Pacific countries with those in Europe.

[7022]<br><br>
Many of the Asia-Pacific plans, had a stronger focus on early containment of disease and social distancing.

[7022]<br><br>
Developing countries are likely to need this strategy more than developed ones, Mounier-Jack told TLID, because of chronic shortages of antiviral drugs and vaccines.

[7022]<br><br>
But the problem with focusing on surveillance and monitoring, she says, is that poor countries, especially those in Asia, do not have a plan B if the virus becomes pandemic.

[7022]<br><br>
Developing countries are severely underprepared for a pandemic.

[7022]<br><br>
Many existing plans focus somewhat short-sightedly on avian influenza in poultry.

[7022]<br><br>
Countries, including those in Europe, did not adequately address organisational responsibility at the local level.

[7022]<br><br>
Even now, these plans have only really been tested through desk-based exercises, says Mounier-Jack.

[7022]<br><br>
Whether strategic plans are operational is the key question, says Coker.

[7022]<br><br>
In southeast Asia, for example, only Thailand has evaluated its preparedness.

[7022]<br><br>
Despite being a relatively affluent country in the region, it would have substantial resource shortages if a pandemic is anything but mild, he says.

[7022]<br><br>
Without this sort of analysis, Coker adds, policy makers risk making knee-jerk decisions in their allocation of resources that may be ineffective, inefficient, and inequitable.

[7022]<br><br>
European preparedness is patchy too.

[7022]<br><br>
Many plans included only half of the WHO recommendations for dealing with pandemics.

[7022]<br><br>
The challenges Mounier-Jack foresees are implementational – how responsibility is divided between primary and secondary care, for example – rather than in technical or medical problems.

[7022]<br><br>
She also advocates a cohesive multisectoral approach between the food industry, the health-care sector, and government.

[7022]<br><br>
Quarantine and travel bans might seem an intuitive way to curb the spread, but the reality is more complicated.

[7022]<br><br>
For one thing, health officials have been at odds over the advice the public should follow.

[7022]<br><br>
In late April, the European Unions health commissioner Androulla Vassiliou said Europeans should avoid travelling to Mexico or the USA unless it is very urgent.

[7022]<br><br>
Almost immediately, Richard Besser, the acting director for the US Centers for Disease Control and Prevention, and Michael Bloomberg, New York Citys mayor, disagreed.

[7022]<br><br>
Apart from the fact that travel restrictions would have very little effect on stopping the virus from spreading, says Alessandro Vespignani (Indiana University, Bloomington, IN, USA), it would be highly disruptive to the global community.

[7022]<br><br>
Vespignani is modelling the spread of H1N1 with travel data, high-definition geo-graphical population data, and disease dynamics, including the number of people each infected person passes it on to (reproductive rate). Estimates for H1N1's reproductive rates are 1 0.1E4, which is fairly low given that seasonal influenza has a rate of 1E5.3E0.

Vespignani's predictions for the rest of May point to a steady increase in the number of observed cases.

[7022]<br><br>
More worryingly, he told TLID that just in the USA, we could hit several thousand cases. He hopes, however, that he will soon see discrepancies between his

Preparation for a pandemic: influenza A H1N1

[7022]<br><br>
Although this is not a scenario scientists usually wish for, in this case it would mean that containment and mitigation measures had been successful.

[7022]<br><br>
H1N1fs seemingly low reproductive rate does not mean we should be complacent: a 2006 study of the rate of the 1918 pandemic influenza suggests that the rate of the first wave of the virus was about 1E5, but that of the second wave was 3E5.

[7022]<br><br>
Coker points out that H5N1 is still present in many countries and is endemic in southeast Asia. One concern at the back of many virologists minds is the prospect, however remote, that the H1N1 might recombine with the virulent H5N1 to form a so-called Armageddon virus.

[7022]<br><br>
If that happened, says Coker, antivirals would need to be rapidly distributed; the problem is that those drugs are currently being allocated to deal with the existing H1N1 virus.

[7022]<br><br>
For now, though, the northern hemisphere is out of its annual influenza season and there is a window for H1N1 vaccine production.

[7022]<br><br>
An initial idea to incorporate this strain into the vaccine against regular seasonal influenza has been dismissed, and WHO is due to talk with vaccine manufacturers about switching to production of a pandemic H1N1 vaccine.

[7022]<br><br>
On May 6, Marie-Paule Kieny, director of WHOs vaccine research initiative, said WHO estimated that the worlds vaccine production capacity could make 1 billion to 2 billion doses of H1N1 vaccine.

[7022]<br><br>
During the H5N1 outbreaks, tests indicated that, unlike seasonal influenza, people needed two doses for a vaccine to be effective.

[7022]<br><br>
Whether people would need two doses of H1N1 vaccine is too early to say, said Kieny.

[7022]<br><br>
For developing countries, these issues are less pressing than the question of whether they can get their hands on the vaccine at all.

[7022]<br><br>
So, on 19 May 2009, WHOs Director General Margaret Chan and UN Secretary General Ban Ki-Moon are meeting in Geneva with vaccine manufacturers to appeal to corporate responsibility and discuss avenues to ensure equitable access for developing countries to this vaccine.

[7022]<br><br>
If doomsayers are right, and H1N1 does become pandemic, the biggest guns in the drug arsenal are oseltamivir and zanamivir.

[7022]<br><br>
However, monotherapy is vulnerable to resistance. N1 genes are more prone to mutations, and oseltamivir-resistance occurrence in N1 genes is not uncommon, says Alan McNally (Nottingham Trent University, Nottingham, UK).

[7022]<br><br>
Indeed the vast majority of seasonal H1N1 isolates this past autumn and winter were oseltamivir resistant.

[7022]<br><br>
This undoubtedly poses a threat, and is something that reference labs will be monitoring extremely closely, says McNally.

[7022]<br><br>
WHO is at pains to stress that raising the alert to level six would not relate to the severity of the infection.

[7022]<br><br>
If anything, initial indications are that the virus is no more harmful than seasonal influenza.

[7022]<br><br>
H1N1 is a hybrid of virus genes originating in viruses of pigs, birds, and human beings. Wendy Barclay (Imperial College, London, UK) has analysed H1N1's genes and says that it has no genetic features of a highly pathogenic virus at all.

[7022]<br><br>
She told TLID that it looks as though this virus should target the upper respiratory tract and not the lung. This is important because viruses that bind in the lower respiratory tract, such as H5N1, cause more severe illness.

[7022]<br><br>
Barclay adds that the virus's NS1 protein looks normal, so we would not expect a cytokine storm.

[7022]<br><br>
Epidemiologists are also scrabbling to collect as much information as they can about which groups of people are the hardest hit, and to find out why some people develop more severe symptoms than others.

[7022]<br><br>
On 5 May 2009, WHO's assistant director-general for health security and environment, Keiji Fukuda, told reporters that the average age of infection was the mid-20s.

[7022]<br><br>
But he pointed out that the infections tend to be seen in travellers, so does the age reflect a characteristic of the virus or the fact that young people are most likely to travel?

[7022]<br><br>
Older people might have an immunity if they have been exposed to components of the virus before.

[7022]<br><br>
Countries worldwide will now be figuring out how to prepare for a relatively unknown quantity.

[7022]<br><br>
Did scientists and health officials take their eye off the ball after the initial fears of a bird flu or SARS pandemic faded?

[7022]<br><br>
It is understandable that pandemic fatigue set in, says Mounier-Jack, since countries have a range of health-care concerns to deal with.

[7022]<br><br>
But should scientists have seen this coming?

[7022]<br><br>
In 2004, Richard Webby and Robert Webster (St Jude Childrens Research Hospital, TN, USA) raised a note of concern that in 1998 swine H1N1 had recombined with human and bird viruses.

[7022]<br><br>
They warned that the growing complexity of influenza at this animal/human interface and the presence of viruses with a seemingly high affinity for reassortment makes the US swine population an increasingly important reservoir of viruses with human pandemic potential.

[7022]<br><br>
Knowing this potential is one thing, but it is not clear how one would prevent that from happening, says Barclay.

[7022]<br><br>
As Fukuda told reporters on 4 May 2009, there is no timetable for how the virus will spread.

[7022]<br><br>
For now, it is going to be a matter of watching and waiting to see what H1N1 does next.

[7022]<br><br>

<hr><br>

Despite some resemblance to the deadly 1918 flu, the swine-origin flu of 2009 may not be so bad as first feared. [7039]

<br><br>.
There are certain characteristics, molecular signatures, which this virus lacks, said Peter Palese in an interview. He is a microbiologist and influenza expert at Mt. Sinai Medical Center in New York. In particular, the swine flu lacks an amino acid that appears to increase the number of virus particles in the lungs and make the disease more deadly. [7039]

<br><br>.
Ralph Tripp, an influenza expert at the University of Georgia, said that his early analysis of the virus' protein-making instructions suggested that people exposed to the 1957 flu pandemic–which killed up to 2 million people worldwide–may have some immunity to the new strain. That could explain why older people have been spared in Mexico, where the swine flu has been most deadly. [7039]

<br><br>.
At a press conference today held by the Centers for Disease Control, acting director Richard Besser said that it's premature to say anything about the virulence compared with other strains of influenza based on genetic analysis. [7039]

<br><br>.
If this virus keeps going through our summer, I would be very concerned," said Peter Palese, influenza expert at Mt. Sinai Medical Center in New York. [7039]

<br><br>.
<br><br>

<hr><br>
<A name="Next generation of vaccines">
<b>Next generation of vaccines</b>
<br>
Flu shots have to be reformulated every year, thanks to the constantly mutated virus. And the annual vaccine won't protect against more deadly strains, like the H5N1 bird flu. But that may soon change: scientists have now developed antibody proteins that can neutralize different strains of the influenza virus, including the deadly H5N1 bird flu, the virus behind the 1918 epidemic, and common seasonal strains. These new antibodies target part of the virus that is shared between different strains and thus appears to be broadly effective. The research was published February 2009 in the journal Nature Structural & Molecular Biology. [7039]

<br><br>.
The antibodies also give researchers clues about how to develop new vaccines. "This opens up the avenue of thinking about universal influenza vaccines, which has not been realistic before", says Peter Palese, an influenza expert at Mount Sinai School of Medicine in New York who was not involved in the work. [7039]

<br><br>.
A vaccine using this technology could theoretically be used to protect against various types of flu, as well as to treat the virus once a person is infected. [7039]

<br><br>.
Scientists who developed the antibodies say that they hope to have a candidate vaccine to test in humans within the next three years. [7039]

<br><br>.
But not everyone is as optimistic about the possibilities. According to an article in the New York Times, Henry L. Niman, a biochemist who tracks flu mutations, was skeptical, arguing that human immune systems would have long ago eliminated flu were the virus as vulnerable in one spot as this discovery suggested. Also, he noted, protecting the mice in the study took huge doses of antibodies, which are expensive and cumbersome to infuse. [7039]

<br><br>.
The research began by screening a library of 27 billion antibodies, looking for some that take aim at the hemagglutinin "spikes" on the shells of flu viruses The flu virus uses the lollipop-shaped hemagglutinin spike to invade cells in the nose and lungs. There are 16 known types of spikes, H1 through H16. [7039]

<br><br>.
The spike's tip mutates constantly, which is why flu shots have to be reformulated each year. But the team found a way to expose the spike's neck, which apparently does not mutate, and picked antibodies that clamped onto it. Once its neck is clamped, a spike can still penetrate a human cell, but it cannot unfold to inject the genetic instructions that take over the cell's machinery to make more virus. The team then turned the antibodies into full-length immunoglobulins and tested them in mice [7039]

<br><br>.

<hr><br>.
<A name="Key words and abbreviations">
<b>Words and abbreviations </b>used in articles about swine influenza: <br>
ILI = influenza like illness (ILI) <br>

CFR = case fatality rate (CFR).<br>

BMBL = Biosafety in Microbiological and Biomedical Laboratories (BMBL) <br>

BSC = biosafety cabinet (BSC).<br>

ISID = International Society for Infectious Diseases (ISID)<br><br>

<b>Swine Flu Keywords</b><br>
The Swine Flu keywords observed on Google HotTrends include: <br>

swine flu symptoms<br> swine flu more condition symptoms<br> cdc.gov<br> pig flu<br> swine flu san diego<br> pandemic<br> swine virus<br> center for disease control<br> swine flu mexico<br> swine influenza virus<br> swine flu in mexico<br> pig influenza<br> schweinepest<br> pig flu mexico<br> Pig flu sparks epidemic fears.<br><br>

<A name="Litterature and references">

<h2>References: </h2>

6954: <a href="http://crofsblogs.typepad.com/h5n1/2009/04/mexicans-on-the-bbc.html" target="_blank">here</a><br>

6955: <a href="http://www.promedmail.org/pls/otn/f?p=2400:1001:2035422834041757:NO:F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,77215" target="_blank">here</a><br>

6958: <a href="http://www.cdc.gov/swineflu/antiviral_swine.htm" target="_blank">here</a><br>

6961: <a href="http://www.nature.com/news/2009/090429/full/4581082a.html" target="_blank">here</a><br>

6962: <a href="http://www.nature.com/news/specials/swineflu/index.html" target="_blank">here</a><br>

6963: <a href="http://www.msnbc.msn.com/id/30398682/" target="_blank">here</a><br>

6964: <a href="http://www.guardian.co.uk/world/2009/apr/29/swine-flu-outbreak-mexico" target="_blank">here</a><br>

6965: <a href="http://www.nature.com/news/2009/090429/full/news.2009.416.html">6965</a><br>

6966: <a href="http://www.who.int/csr/don/2009_04_24/en/index.html" target="_blank">here</a><br>

6967: <a href="http://www.cdc.gov/media/transcripts/2009/t090423.htm" target="_blank">here</a><br>

6968: <a href="http://news.bbc.co.uk/2/hi/americas/8022437.stm" target="_blank">here</a><br>

6969: <a href="http://news.xinhuanet.com/english/2009-04/27/content_11264412.htm" target="_blank">here</a><br>

6971: <a href="http://sciencenow.sciencemag.org/cgi/content/full/2009/429/1" target="_blank">here</a><br>

6972: <a href="http://blogs.sciencemag.org/scienceinsider/2009/04/flu-preparation.html#more" target="_blank">here</a><br>

6973: <a href="http://blogs.sciencemag.org/scienceinsider/2009/04/ferreting-out-t.html#more" target="_blank">here</a><br>

6974: <a href="http://blogs.sciencemag.org/scienceinsider/2009/04/exclusive-cdc-h.html" target="_blank">here</a><br>

6975: <a href="http://news.bbc.co.uk/2/hi/talking_point/8018428.stm" target="_blank">here</a><br>

6976: <a href="http://www.ipsnews.net/news.asp?idnews=46690" target="_blank">here</a><br>

6977: <a href="http://www.promedmail.org/pls/otn/pm?an=20090503.1660" target="_blank">here</a><br>

6978: New Scientist 2. maj 2009 bd.202 nr. 2706 side 3, 6-9. (<a href="http://www.newscientist.com/article/mg20227063.800-swine-flu-the-predictable-pandemic.html?full=true">here</a> and <a href="http://www.newscientist.com/article/mg20227062.800-we-need-a-flu-manhattan-project.html

)" target="_blank">here</a>)<br>

6980: <a href="http://investors.smithfieldfoods.com/releasedetail.cfm?ReleaseID=379761" target="_blank">here</a><br>

6982: <a href="http://www.promedmail.org/pls/otn/pm?an=20090505.1679" target="_blank">here</a><br>

6983: <a href="http://www.promedmail.org/pls/otn/pm?an=20090505.1680" target="_blank">here</a><br>

6984: <a href="http://www.fao.org/news/story/en/item/19365/icode/" target="_blank">here</a><br>

6985: <a href="http://www.promedmail.org/pls/otn/pm?an=20090505.1681" target="_blank">here</a><br>
6986: <a href="http://mail.google.com/mail/?hl=da&tab=wm#inbox/1210ef9b726d75e7" target="_blank">here</a><br>

6989: <a href="http://www.huffingtonpost.com/david-kirby/swine-flu-outbreak—-nat_b_191408.html" target="_blank">here</a><br>

6990: <a href="http://www.huffingtonpost.com/2009/05/05/mexico-swine-flu-stimulus_n_196920.html" target="_blank">here</a><br>

6991: <a href="http://www.newscientist.com/article/mg20227063.900-can-the-world-cope-if-swine-flu-goes-pandemic.html" target="_blank">here</a><br>

6992: Danish radio broadcasting: Horizont – DR1 radio 6. maj 2009 kl. 22.30<br>

6993: <a href="http://www.promedmail.org/pls/otn/pm?an=20090506.1691" target="_blank">here</a><br>

6994: <a href="http://www.promedmail.org/pls/otn/pm?an=20090506.1695" target="_blank">here</a><br>
6995: <a href="http://www.mosnews.com/world/2009/04/28/prediction/" target="_blank">here</a><br>

7000: <a href="http://www.promedmail.org/pls/otn/pm?an=20090509.1733" target="_blank">here</a><br>

7001: <a href="http://www.promedmail.org/pls/otn/pm?an=20090508.1722" target="_blank">here</a><br>

7002: <a href="http://www.promedmail.org/pls/otn/pm?an=20090507.1710" target="_blank">here</a><br>

7003: <a href="http://www.promedmail.org/pls/otn/pm?an=20090507.1709" target="_blank">here</a><br>

7004: <a href="http://www.washingtonpost.com/wp-dyn/content/discussion/2005/10/14/DI2005101401462.html" target="_blank">here</a><br>

7005: <a href="http://www.capitalcentury.com/1976.html" target="_blank">here</a><br>

7007: <a href="http://www.promedmail.org/pls/otn/pm?an=20090510.1741" target="_blank">here</a><br>

7008: <a href="http://jp.dk/jptv/udland/article1677935.ece" target="_blank">here</a><br>

7009: <a href="http://nyhederne.tv2.dk/article.php/id-22249459.html" target="_blank">here</a><br>

7010: <a href="http://nyhederne.tv2.dk/article.php/id-22219826.html" target="_blank">here</a><br>

7011: Politiken 3. maj 2009 PS s.6.<br>

7012: <a href="http://www.bt.dk/article/20090501/NYHEDER/90501055/" target="_blank">here</a><br>

7013: <a href="http://politiken.dk/indland/article702106.ece" target="_blank">here</a><br>

7014: <a href="http://www.berlingske.dk/article/20090501/danmark/90501098/" target="_blank">here</a><br>

7015: <a href="http://nyhederne.tv2.dk/article.php/id-22209815.html" target="_blank">here</a><br>

7020: <a href="http://www.eurekalert.org/pub_releases/2009-05/uoca-ifd050509.php" target="_blank">here</a><br>

7021: <a href="http://www.eurekalert.org/pub_releases/2009-05/isu-isu050609.php" target="_blank">here</a><br>

7022: <a href="http://www.eurekalert.org/pub_releases/2009-05/l-pia050809.php" target="_blank">here</a><br>

7023: <a href="http://www.promedmail.org/pls/otn/pm?an=20090511.1759" target="_blank">here</a><br>

7024: Science: <a href="http://www.sciencemag.org/cgi/content/abstract/1176062" target="_blank">here</a> [<a href="http://www.promedmail.org/pls/otn/pm?an=20090511.1764" target="_blank">here</a>]<br>

7024b: <a href="http://www.promedmail.org/pls/otn/pm?an=20090511.1764" target="_blank">here</a> (BBC-News: <a href="http://news.bbc.co.uk/1/hi/health/8044299.stm" target="_blank">here</a>)<br>
7025: <a href="http://www.netdoktor.dk/sygdomme/fakta/influenza.htm" target="_blank">here</a><br>
7032: <a href="http://www.reuters.com/article/pressRelease/idUS213520+12-May-2009+PRN20090512" target="_blank">here</a><br>

7033: <a href="http://www.welt.de/english-news/article3725648/New-virus-is-very-unstable.html#reqRSS" target="_blank">here</a><br>

7034: <a href="http://www.reuters.com/article/topNews/idUSTRE5480IR20090512" target="_blank">here</a><br>

7038: <a href="http://www.iamat.org/blog/index.cfm/2009/5/1/Influenza-AH1N1–Update-3
7039: <a href="http://www.technologyreview.com/blog/editors/tags/influenza/" target="_blank">here</a><br>

7040 (Nature): <a href="http://www.nature.com/news/2009/090513/full/459144a.html" target="_blank">here</a><br>
7041: <a href="http://www.promedmail.org/pls/otn/pm?an=20090513.1790" target="_blank">here</a><br>
7042: <a href="http://www.promedmail.org/pls/otn/pm?an=20090513.1785" target="_blank">here</a><br>

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<A name="The AVAAZ initiative against big unregulated pig farms">

The AVAAZ initiative against big unregulated pig farms:

<a href="http://www.avaaz.org/en/swine_flu_pandemic/?cl=225074825&v=3271" target="_blank"> (link avaaz.org)</a>

(1) Biosurveillance report tracing the disease to the Smithfields farm: <a href="http://biosurveillance.typepad.com/biosurveillance/2009/04/swine-flu-in-mexico-timeline-of-events.html" target="_blank"> (link biosurveillance.typepad.com)</a>

Reports on the link between the Mexican factory farm and the flu:

<a href="http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/for-la-gloria-the-stench-of-blame-is-from-pig-factories-1675809.html" target="_blank"> (link)</a>

<a href="http://www.latimes.com/features/health/la-fg-mexico-flu28-2009apr28,0,1701782.story" target="_blank"> (link independent.co.uk)</a>

<a href="http://www.scientificamerican.com/podcast/episode.cfm?id=can-swine-flu-be-blamed-on-industri-09-05-01" target="_blank"> (link scientificamerican.com)</a>

<a href="http://www.newscientist.com/article/mg20227063.800-swine-flu-the-predictable-pandemic.html?full=true" target="_blank"> (link newscientist.com)</a>

<a href="http://www.huffingtonpost.com/david-kirby/swine-flu-outbreak—-nat_b_191408.html" target="_blank"> (link huffingtonpost.com)</a>
(2) WHO pandemic information

<a href="http://www.euro.who.int/influenza/20080618_19" target="_blank"> (link euro.who.int)</a>
(3) FAO, EC and CDC reports on the risks of industrial farming on public health

FAO and CIWF and

<a href="http://www.cdc.gov/cafos/about.htm" target="_blank"> (link cdc.gov)</a>
(4) CIWF and PETA video reports of the disgusting conditions for animals in factory farms and the disease ridden manure swamps:

CIWF and PETA
(5) Reports on Smithfield's animal welfare and environmental damage

<a href="http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/for-la-gloria-the-stench-of-blame-is-from-pig-factories-1675809.html" target="_blank"> (link independent.co.uk)</a>
<a href="http://www.foodandwaterwatch.org/press/releases/new-report-highlights-the-trouble-with-smithfield-article03132008" target="_blank"> (link foodandwaterwatch.org)</a>
<a href="http://avaazimages.s3.amazonaws.com/SmithfieldJan08.pdf" target="_blank"> (link avaazimages)</a>
(6) Reports on UK tax payers subsidising factory farms <a href="http://www.telegraph.co.uk/earth/agriculture/farming/5225298/Taxpayers-forking-out-700-million-for-factory-farming-in-England.html" target="_blank"> (link telegraph.co)</a>

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