INFLUENZA UPDATE Tuesday 8/4/09

1. INFLUENZA UPDATE Tuesday 8/4/09 “Ms. Beverly Lawrence, former Administrative Assistant in the Respiratory Virus Infections Unit at the Centers for Disease Control and Prevention, was shown here in this 1968 photograph handling test tubes containing frozen throat swab specimens that were to be tested for influenza.” – CDC photo

2. World Updates W.H.O. Laboratory-confirmed cases of H1N1 as of July 31 *Given that countries are no longer required to test and report individual cases, the number of cases reported actually understates the real number of cases.

3. World Updates • European Centre for Disease Prevention and Control data: • 188,139 laboratory-confirmed cases worldwide with 1,265 confirmed deaths. • USA: 43,771 confirmed cases, 339 deaths • Argentina: 4,895 confirmed cases, 266 deaths • Mexico: 16,442 confirmed cases, 146 deaths • Chile: 11,860 confirmed cases, 96 deaths • Australia: 23,692 confirmed cases, 70 deaths

4. World Updates • WHO Update 8/4/09 • Most countries in North and South America experienced widespread activity. All North American countries reported decreasing respiratory diseases activity trend, while several South and Central American countries reported increasing respiratory diseases activity trend. • In Europe, only two countries, the United Kingdom and Portugal, experienced widespread activity, while several others experienced localized or regional activity. Among countries reporting in Europe, most countries reported an increasing or unchanged respiratory diseases activity trend during a period outside of the normal influenza season. • Among countries reporting from Asia, most experienced an increase in respiratory diseases activity trend.

5. World Updates • Antiviral resistance: • WHO: A total of six oseltamivir resistant pandemic H1N1 cases have now been detected from Denmark, Hong Kong, Japan and Canada. Of these three were from patients in Japan. All six patients had received oseltamivir with the exception of one and have recovered well. All resistant viruses had the characteristic mutation at position 274/275 associated with resistance. • Journal of Virology: Australian researchers have reported what they say is the first evidence of resistance to zanamivir (Relenza) in seasonal influenza A (H1N1) strains… researchers from the Melbourne-based WHO Collaborating Centre for Influenza say their analysis of 391 samples of H1N1 influenza virus from the region found that nine (2.3%) had a markedly reduced zanamivir susceptibility. The H1N1 samples were collected from patients who were not being treated with the drug, and the resistance appeared to be conferred by a previously undescribed neuraminidase mutation.

6. World Updates • Jamieson et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, published online July 29, 2009 • Background: Pandemic H1N1 2009 influenza virus has been identified as the cause of a widespread outbreak of febrile respiratory infection in the USA and worldwide. We summarised cases of infection with pandemic H1N1 virus in pregnant women identified in the USA during the fi rst month of the present outbreak, and deaths associated with this virus during the first 2 months of the outbreak. • Methods: After initial reports of infection in pregnant women, the US Centers for Disease Control and Prevention (CDC) began systematically collecting additional information about cases and deaths in pregnant women in the USA with pandemic H1N1 virus infection as part of enhanced surveillance. A confirmed case was defined as an acute respiratory illness with laboratory-confirmed pandemic H1N1 virus infection by real-time reverse-transcriptase PCR or viral culture; a probable case was defined as a person with an acute febrile respiratory illness who was positive for influenza A, but negative for H1 and H3. We used population estimates derived from the 2007 census data to calculate rates of admission to hospital and illness.

7. World Updates • Jamieson et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, published online July 29, 2009 • Findings: From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states. 11 (32%) women were admitted to hospital. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population (0·32 per 100 000 pregnant women, 95% CI 0·13–0·52 vs 0·076 per 100 000 population at risk, 95% CI 0·07–0·09). Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC; all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. • Interpretation: Pregnant women might be at increased risk for complications from pandemic H1N1 virus infection. These data lend support to the present recommendation to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs. • paper attached to email

8. World Activity by Outbreak Severity Influenza Deaths Confirmed Cases Probable Cases http://upload.wikimedia.org/wikipedia/commons/0/0c/H1N1_map.svg

9. World Activity by Outbreak Size http://en.wikipedia.org/wiki/File:H1N1_map_by_confirmed_cases.svg

10. World Activity by Number of H1N1-Confirmed Deaths

11. World Updates • Recent news headlines: • “H1N1 flu spreads to remote corners of world” – Seychelles, St. Kitts, Netherlands Antilles, Belize, Tonga, Solomon Islands • “Netherlands reports first death from H1N1 flu” • “Researchers discover A(H1N1) flu strain resistant to Relenza” • Argentina: “Capital’s lively theater district grows quiet with arrival of H1N1” • “Royal Carribean crew striken by H1N1; docked in France” • “India may have its own H1N1 vaccine by September” • “Vietnam has its first death from N1N1 flu virus” • “Israel prepares for H1N1 flu epidemic” • “Lebanon records first H1N1 death”

12. “Big Cleaning Day” in Bangkok

13. “Students of an Islamic school with a suspected case of the H1N1 influenza virus lie in a makeshift room at a hospital in Surabaya, July 27, 2009.

14. US Updates • CDC 7/31/09: 5,514 hospitalized cases in 47 states and US territories, with 353 deaths. • NM, OK, CO, UT ‘sporadic’ activity; TX, NV ‘local’; AZ ‘regional’; CA ‘widespread’ • Interim Guidance for the Detection of Novel Influenza A Virus Using Rapid Influenza Diagnostic Tests http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm • Isolates sequenced at WHO and CDC suggest that the internationally circulating H1N1virus strains are similar to A/California/07/2009 strain selected by WHO as a potential candidate for the H1N1 vaccine. • Dr. Shuchat, CDC: Pregnant women have a four-fold increase in the chance of being hospitalized. Early treatment and vaccination are, and will be, important. • The CDC and the US Department of Education have established a School Dismissal Monitoring System to report on H1N1-related school or school district dismissals in the US (ie, school closures). Reports may be made by online form, email, or fax. See http://www.cdc.gov/h1n1flu/schools/dismissal_form/index.htm

15. US Updates • CDC guideline, Preparing for Vaccination with Novel H1N1 Vaccine • Vaccine is being procured by the U.S. government from 5 manufacturers – inactivated subunit (4) and live, attenuated vaccines (1). Inactivated vaccine will be available in single-dose syringes, or in multi-dose vials. Live attenuated vaccine will be available in limited number in inhaler sprayers. Single-dose syringes and inhaler sprayer products will be thimerosal-free. • State and local public health planners have been asked to plan for vaccine becoming available mid-October under the following scenarios: 40, 80, or 160 million doses becoming available over approximately a one month period, followed by weekly amounts of 10, 20 or 30 million doses. At this point, the planning assumption is that the vaccine will require 15 µg of antigen for an immunizing dose, and that two doses spanning over 21 or more days will be needed for efficacy for most persons.

16. US Updates • CDC guideline, Preparing for Vaccination with Novel H1N1 Vaccine, continued • Clinical trials will be conducted to determine which age groups, if any, require only one dose. The majority of vaccine will be packaged in multidose vials but enough preloaded syringes will be manufactured for young children and pregnant women. • Prioritized populations include students and staff (all ages) associated with K-12 schools (K-12th grade) and child care centers; pregnant women, children 6 months – 4 years of age, new parents and household contacts of children <6 months of age, non-elderly adults with medical conditions that increase risk, and health care workers and emergency services personnel.

17. US Updates • CDC guideline, Preparing for Vaccination with Novel H1N1 Vaccine, continued • “…public health planners can make the assumption that health plans will provide reimbursement for the administration of a novel (A) H1N1 vaccine to their members by private sector providers in both traditional settings e.g., doctor’s office, ambulatory clinics, health care facilities, and in non-traditional settings, where contracts with insurers have been established.” • A Vaccine Adverse Event Reporting System (VAERS) will collect and analyze reports. • A seasonal vaccine will be available beginning August or September 2009. • The process for ordering seasonal vaccine is unchanged from previous years.

18. US Updates • CDC Guideline, Novel H1N1 Vaccination Recommendations • http://www.cdc.gov/h1n1flu/vaccination/acip.htm . As previously reviewed: • Pregnant women because of higher risk of complications and potential to provide protection to infants who cannot be vaccinated; • Household contacts and caregivers for children younger than 6 months because vaccination of those in close contact with infants less than 6 months old might help protect infants by “cocooning” them from the virus; • Healthcare and emergency medical services personnel because infections among healthcare workers have been reported and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity; • All people from 6 months through 24 years of age • Children from 6 months through 18 years of age because schools increase the likelihood of spread, and • Young adults 19 through 24 years of age because of high infection rates and frequent close proximity; • Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.

19. H1N1 in the USA by Outbreak Severity Influenza Deaths Confirmed Cases Probable Cases http://commons.wikimedia.org/wiki/File:H1N1_USA_Map.svg

20. Tuesday 4/28 Monday 5/4 Monday 5/11 Monday 5/18 Tuesday 5/26 Tuesday 6/2 Tuesday 6/9 Tuesday 6/16 Tuesday 7/14 Tuesday 7/7 Tuesday 6/23 Tuesday 6/30 Influenza Deaths Confirmed Cases Probable Cases Tuesday 8/4 Tuesday 7/21 & 7/28

21. H1N1 in the USA by outbreak size http://upload.wikimedia.org/wikipedia/commons/6/6c/H1N1_USA_Map_by_confirmed_cases.svg

22. H1N1 in the USA by number of deaths http://upload.wikimedia.org/wikipedia/commons/e/ef/H1N1_USA_deaths_-_CSS_map.svg

23. US Updates • Recent news headlines: • Kentucky: “Prison locked down after inmates test positive with H1N1 virus” • “US officials to put less emphasis on school closings” • “Half of US should get N1N1 vaccination: officials” • “MedImmune ramps up H1N1 vaccine” • “US begins H1N1 vaccine testing” • “Wal-Mart weighs role in US H1N1 vaccination plans” • “Six Flags posts deep Q2 loss” – impacted by H1N1 • “Six Senate pages come down with ‘flu-like symptoms’” • “Ark-La-Tex schools try to prevent H1N1” • Indiana: “Son and daughter die from H1N1 virus”

25. New Mexico and UNM updates • NM DOH “H1N1 Flu Resources” website link  “404 Object Not Found” • UNM activity highlights: • main campus autumn planning meeting, drafting of influenza plan • SOM Incident Management Team autumn planning meeting • continuation of supplies stockpiling, N95 fit testing • seasonal and H1N1 vaccination planning • consultation with ENMU, provided educational materials, signage • developing a database for vaccination programs • Tricore Labs 7/18-7/24: 75 requests, 10 positives (mostly 12-64 yo) • reminder: “Pandemic Influenza and Immunization for the Coming Influenza Season”, by Dr. Andrew Kroger of the CDC National Center for Immunization and Respiratory Diseases on Thursday 8/20/09, 1230-1330 in the Domenici Auditorium, UNM HSC.