Drugs and Medicine

Medications A-Z

2010-08-22T12:46:00.000-07:00

Medications A-Z List - A

Cancer Vaccines

2010-08-22T12:43:00.000-07:00

Vaccines are designed to stimulate the immune system to mount an immune response against the target in the vaccine. For instance, the flu vaccine contains pieces of the flu virus, and stimulates the immune system to make cells that fight the flu virus. The flu vaccine needs to be given at least two weeks before exposure to the flu. This is an example of a preventive vaccine. The flu vaccine can stimulate long-lasting immunity to the strain of flu used in the vaccine.
Cancer vaccines are different in that they are not preventive. Rather, cancer vaccines are therapeutic-they are used to treat the disease rather than prevent it. Like the flu vaccine, cancer vaccines are designed to stimulate the immune system to mount a response toward the target-in this case the cancer cells. Unlike flu virus which is foreign to the body, cancer cells are not foreign and generally do not stimulate a strong immune response on their own. So cancer vaccines use other substances or cells to help the immune response along.
Some of the substances in cancer vaccines are called cytokines, which act as “immune hormones.” Other substances are called heat shock proteins. Heat shock proteins and cytokines can help alert the immune system to the information about the cancer cells. This alert helps certain immune cells that are sensitive to the cancer cells to divide. This new “army” of cells will kill any cancer cell they come in contact with.
The cells that are most efficient at stimulating an immune response are called dendritic cells. Dendritic cells are a specialized immune cells found throughout the body. To make a vaccine, precursor cells are taken from a blood sample of the patient and grown in the laboratory. Information about the surface of the patient’s cancer cells is placed inside dendritic cells that are grown in the laboratory. When the cells are injected they can activate an immune response toward the cancer cells. As with cytokine and heat shock protein activation, the alerted cells divide and kill cancer cells they come in contact with.
Unlike chemotherapy cancer vaccines generally have few side effects. Here at the clinic we use all the types of cancer vaccines described above. The results achieved vary with tumor, type of tumor and stage of disease.
Cancer vaccines represent an innovative potential cancer therapy — a therapy that seeks to harness the body’s own defenses to fight the uncontrolled growth and spread of cancer cells.
The immune system has the ability to recognize the difference between “self” and “non self,” that which is and is not a naturally occurring molecule in the body. In the case of cancer, the difference between cancer cells and normal healthy cells is sometimes so slight that they go unnoticed by the immune system and no response occurs, or the immune system is overwhelmed. The body is “tolerant” of the cells allowing them to multiply in the body. Cancer vaccines seek to “break” this tolerance.
Cancer vaccines are designed to introduce molecules expressed on cancer cells into the body in a new way that awakens the immune system to respond and destroy the cancer cell. These vaccines attract immune cells such as dendritic cells that engulf the vaccine cells which include “antigens” or proteins on their cell surfaces, and then present (exhibit) fragments of these antigens. These immune cells, known as “antigen presenting cells” (APCs), then signal other immune cells to mature and attack the specific invading antigen. Lymphocytes, including helper T cells, killer T cells, and B cells, are called into action. Helper T cells release cytokines, chemical messages that recruit other immune cells, and killer T cells engulf the antigen (and the cell it is attached to) the APCs presented to it. In addition to awakening the cellular side of the immune system to the tumor cell, some cancer vaccines stimulate the humoral side of the immune system, which includes antibodies, into action as well.
Types of Cancer Vaccines
Research and development efforts are currently under way to develop therapeutic cancer vaccines for the treatment of multiple forms of cancers. Currently, there are two primary approaches being explored in the development of making cancer vaccines—the “antigen-specific” approach, and the “whole cell” approach.
Antigen-Specific Approach
The antigen-specific approach seeks to make a vaccine that stimulates an immune response to a specific antigen or antigens that are believed to be unique to a specific type of tumor. This approach may result in a highly specific antitumor response, however poses the challenge of successfully identifying the specific antigens that are most highly expressed on a given tumor. Failure to identify the appropriate antigens could result in lower or no efficacy.
One approach to developing an antigen-specific vaccine involves the removal and isolation of a patient’s dendritic cells, one type of APC. The dendritic cells are exposed to antigens that are believed to be associated with a specific tumor type, and are given time to ingest, process, and “present” the antigens. The cells are then reintroduced into the patient in vaccine form.
Whole Cell Approach
The whole cell approach uses whole cancer cells to make the vaccine, not just a specific antigen. Since whole cells express multiple—sometimes thousands of—antigens, there is potentially a greater chance of stimulating an immune response since this approach does not require choosing specific antigens which may or may not turn out to be appropriate for the patient. Cell Genesys is pursuing a whole cell vaccine approach with its GVAX® cancer vaccines.
Whole cell vaccines can be either patient-specific (made completely from the individual’s own tumor cells), non patient-specific (made from a “cell line”—tumor cells that are grown in a laboratory), or a mixture of the two. Patient-specific vaccines may offer some advantages over non patient-specific vaccines when treating cancers that involve many different cell types with few like characteristics (e.g. non small-cell lung cancer). Using the patient’s own tumor cells may increase the likelihood of creating an individualized vaccine that effectively stimulates an immune response against all cell types associated with specific form of cancer being treated.
Activating an Immune Response
While some cancer vaccines are designed to stimulate an immune response based solely on the presence of antigens, others are being developed that utilize antigens as well as cytokines to mount an attack against cancer cells. Cytokines are chemical messages that stimulate other immune cells to attack antigens. Some researchers are exploring the idea of creating vaccines comprised of cells that have been genetically modified to secrete a cytokine such as GM-CSF, interleukins, and interferons. The presence of these cytokines may potentially help “jump start” the immune system to launch a more robust and efficacious immune response.
Possible Benefits of Cancer Vaccines
In addition to providing a new treatment option for patients who have failed other therapies, clinical data suggest that cancer vaccines may offer therapeutic advantages over existing therapies:
1. Favorable Side Effect Profile: Unlike many traditional cancer treatments such as chemotherapy and radiation therapy, cancer vaccines have generally been associated with very few side effects. This favorable side effect profile may potentially enable patients to maintain a higher quality of life during the course of treatment.
2. Combination Therapy: Numerous clinical trials are being conducted evaluating the use of cancer vaccines in combination with other traditional therapies such as chemotherapy, radiation therapy, and stem cell transplantation. Combination therapies offer the potential of improving/enhancing the efficacy of these traditional treatments.
The Current State of Cancer Vaccines
Research and development efforts are currently under way at numerous organizations to thoroughly evaluate the safety and efficacy of different approaches to cancer vaccines. Currently, cancer vaccines are being evaluated in multiple human clinical trials for many types of cancer and are available only in the clinical trial setting.

How To Prevent The Occurrence Of Swine Flu?

2010-08-22T12:23:00.000-07:00

How To Prevent The Occurrence Of Swine Flu?

Prevention is always better and preferred than cure. Especially when it comes to the prevention of swine flu, there are many aspects to be considered. Firstly, keeping one self away from other person while traveling by maintaining a good distance while sitting or standing keeps away the bacteria. Secondly while sneezing or coughing, one must protect self by keeping a towel or a napkin against nose to prevent the inhale and spread of germs.

Shaking of hands should be avoided because of the fact that germs can easily spread from hands too. Otherwise wiping hands with a hand cleanser or a hand wash should be an immediate preference. The emphasis is, the more you care, the better for you always especially if you are a traveler or a tourist. Apart from this, food intake should always be monitored. While traveling in a cold temperature, always cover yourself completely and never allow any little space of your body to remain uncovered.

By taking much care, you can always prevent swine flu. Another important aspect is, try to keep yourself away from sick people because viruses are more active.

Pay lot of attention to your diet. What you are eating and what are the hygiene levels in which you are having your food. Almost every aspect of food should be given lot of attention and good care should be administered.

Apart from food, water should also be paid attention. Preferably mineral bottled water or filtered water should be considered while traveling. Because it is food and water that spreads swine flu. Therefore first care should be given in food and water and secondly, traveling care aspect which is discussed above should be followed.

No matter where you travel, you luggage, your belongings and yourself should be properly maintained in terms of hygiene. The point of emphasis is more hygiene because swine flu is a viral infection and virus spreads where there are unhygienic surroundings or premises.

All kind of remedies to prevent swine flu should be considered. The first remedy is to check the in take of diet and secondly, keep off from sick people and take more precautionary measures while traveling.

If you can consult a physician and consider a swine flu vaccine it is more preferable. This way, you are not only safeguarding your health but also preventing the entry of it. Therefore this is an excellent practice.

Once you gain good knowledge about swine flu how it affects, what are the remedies available and how it can be prevented, you will be more careful in your workplace, travel and in your public presence.

This way, you can not only enjoy good health but can even advise people about how to protect from swine flu. The more knowledge you gain about swine flu and take prevention, the better for you to stay healthy and fit.

2010-08-22T12:12:00.000-07:00

WHO Says

H1N1 in post-pandemic period

The world is no longer in phase 6 of influenza pandemic alert. We are now moving into the post-pandemic period. The new H1N1 virus has largely run its course.

These are the views of members of the Emergency Committee, which was convened earlier today by teleconference.

The Committee based its assessment on the global situation, as well as reports from several countries that are now experiencing influenza. I fully agree with the Committee’s advice.

As we enter the post-pandemic period, this does not mean that the H1N1 virus has gone away. Based on experience with past pandemics, we expect the H1N1 virus to take on the behaviour of a seasonal influenza virus and continue to circulate for some years to come.

In the post-pandemic period, localized outbreaks of different magnitude may show significant levels of H1N1 transmission. This is the situation we are observing right now in New Zealand, and may see elsewhere.

In fact, the actions of health authorities in New Zealand, and also in India, in terms of vigilance, quick detection and treatment, and recommended vaccination, provide a model of how other countries may need to respond in the immediate post-pandemic period.

Globally, the levels and patterns of H1N1 transmission now being seen differ significantly from what was observed during the pandemic. Out-of-season outbreaks are no longer being reported in either the northern or southern hemisphere. Influenza outbreaks, including those primarily caused by the H1N1 virus, show an intensity similar to that seen during seasonal epidemics.

During the pandemic, the H1N1 virus crowded out other influenza viruses to become the dominant virus. This is no longer the case. Many countries are reporting a mix of influenza viruses, again as is typically seen during seasonal epidemics.

Recently published studies indicate that 20–40% of populations in some areas have been infected by the H1N1 virus and thus have some level of protective immunity. Many countries report good vaccination coverage, especially in high-risk groups, and this coverage further increases community-wide immunity.

Pandemics, like the viruses that cause them, are unpredictable. So is the immediate post-pandemic period. There will be many questions, and we will have clear answers for only some. Continued vigilance is extremely important, and WHO has issued advice on recommended surveillance, vaccination, and clinical management during the post-pandemic period.

Based on available evidence and experience from past pandemics, it is likely that the virus will continue to cause serious disease in younger age groups, at least in the immediate post-pandemic period. Groups identified during the pandemic as at higher risk of severe or fatal illness will probably remain at heightened risk, though hopefully the number of such cases will diminish.

In addition, a small proportion of people infected during the pandemic, including young and healthy people, developed a severe form of primary viral pneumonia that is not typically seen during seasonal epidemics and is especially difficult and demanding to treat. It is not known whether this pattern will change during the post-pandemic period, further emphasizing the need for vigilance.

As I said, pandemics are unpredictable and prone to deliver surprises. No two pandemics are ever alike. This pandemic has turned out to be much more fortunate than what we feared a little over a year ago.

This time around, we have been aided by pure good luck. The virus did not mutate during the pandemic to a more lethal form. Widespread resistance to oseltamivir did not develop. The vaccine proved to be a good match with circulating viruses and showed an excellent safety profile.

Thanks to extensive preparedness and support from the international community, even countries with very weak health systems were able to detect cases and report them promptly.

Had things gone wrong in any of these areas, we would be in a very different situation today

Swine Flu death

2010-08-13T13:46:00.000-07:00

One more death due to Swine Flu in Orissa, death toll rises to 8

Bhubaneswar: The Swine Flu death in the state is increasing. On Friday one Abhijit Parida (19) has been expired in Apollo Hospital here in Swine Flu . Abhijit is a resident of Cuttack Sikharpur area.

Swab of total 67 persons were tested, out of which Swab of 25 persons identified positive. Now the death in Swine Flu in the state increased to 8.

First Swine flu patient of Orissa expired in Apollo Hospital

Bhubaneswar : First Swine flu patient ( A Doctor ) of Orissa expired on Thrusday morning in Apollo Hospital ,New Delhi.
Dr. A.K.Banwal of Kiriburu Hospital of Keonjhar District suffered from Swine flu and admitted to the Ispat General Hospital , Rourkela on 11 October and were underwent treatment in a separate room. But his condition were detrioting day by day. He was shifted to the Apollo Hospital of New Delhi on 18 October by a special flight and expired on Thrusday morning ( 6 am ) . The death of a Doctor by Swine flu is the first case in the Country.

Software Engineer dies of Swine Flu in Orissa

Bhubaneswar: Breaking News! There is no respite from Swine Flu in India. A young Software Engineer became the latest Swine Flu victim. He succumbed to H1N1 at the SCB Medical College & Hospital in Cuttack.

With this, the Swine Flu death toll in Orissa has gone up to four. The victim was identified as Biswanath Ekka from Rourkela. He was admitted to SCB Medical College this morning in a critical condition. He died in the afternoon.

Biswanath Ekka had come from Hyderabad recently. He was working with a Software Development company there. It is believed that he was infected with A H1N1 virus in Hyderabad.

Four people have died of Swine Flu in the state since August 1. Two persons died in Bhubaneswar, while another person died in Cuttack.

SWINE FLU

2010-08-13T13:35:00.000-07:00

The H1N1 “Swine Flu” Pandemic

The H1N1 or “swine flu” virus, which first appeared in April 2009, has gone on to become a worldwide "pandemic." This flu season, scientists expect both H1N1 flu and seasonal flu to cause more people to get sick than a regular flu season. More hospital stays and deaths may result, which makes vaccines that prevent influenza critical for optimal health of populations.

How Is 2009 H1N1 Flu Different From Regular (Seasonal) Flu?

Seasonal flu viruses change from year to year, but they are closely related to each other. People who have had flu infections in the past usually have some immunity to seasonal flu viruses (their bodies have built up some ability to fight off the viruses). The 2009 H1N1 flu virus is an entirely new virus strain. It is very different from seasonal flu viruses, and most people have little or no immunity to 2009 H1N1 flu. As a result, their bodies are not prepared to fight off the virus, possibly leading to serious complications.

The H1N1 “Swine Flu” Vaccine

This season, 2009 H1N1 vaccines are being made to protect against the H1N1 influenza virus. The U.S. government has purchased 250 million doses of 2009 H1N1 vaccine, so anyone who wants to get the vaccine will have the opportunity to do so. Vaccine will be made available as quickly as possible as it rolls off the production lines. Limited quantities of the vaccine began shipping in early October and availability will continue to increase through the end of the year and into 2010.

Why Are Swine Flu Vaccine Supplies Limited?

Federal officials had projected that 40 million doses would be on hand by Oct. 15, but not even 13 million doses had arrived by the third week in October. According to Dr. Ciro Sumaya, a professor at the Texas A&M Health Science Center School of Rural Public Health and a member of the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, the H1N1 virus did not grow as quickly as expected during the half-century old -- and often-criticized -- egg-based production technique. He went on to explain that there have also been delays in the many steps before you get a vaccine that's available -- the production, the testing, the packaging, the allocation, and distribution. A top CDC official acknowledged that production of the vaccine was lagging, with a revised goal now of 50 million doses by mid-November and 150 million by year's end.

What Types of Swine Flu Vaccines Are Being Produced?

There are two forms of 2009 H1N1 vaccines being produced: a 2009 H1N1 "flu shot" and the 2009 H1N1 nasal spray flu vaccine. The same manufacturers who produce seasonal flu vaccines are producing 2009 H1N1 vaccines for use in the United States, and the vaccines are being made in the same way that the seasonal vaccines are made.

2009 H1N1 Flu Shot

The H1N1 flu shot is an inactivated vaccine (containing “killed” virus) that is given with a needle, usually in the arm. The indications for who can get the 2009 H1N1 flu shot are the same as for seasonal flu shots. The flu shot is approved for use in people 6 months of age and older, including healthy people, people with chronic medical conditions, and pregnant women.

2009 H1N1 Nasal Spray Flu Vaccine

The H1N1 nasal spray, given via a nasal sprayer, is a vaccine made with live, weakened viruses that do not cause the flu (sometimes called LAIV for "live attenuated influenza vaccine"). The indications for who can get the 2009 H1N1 nasal spray vaccine are the same as for seasonal nasal spray vaccine. LAIV is approved for use in healthy people 2-49 years of age who are not pregnant. The nasal spray vaccine for use in the United States is being made by MedImmune, the same company that makes the seasonal nasal spray vaccine called FluMist.

Does the H1N1 Vaccine Require One or Two Shots?

Kids under 10 years of age will need two doses of the H1N1 swine flu vaccine, given three weeks apart. In kids over 10 years of age, the H1N1 swine flu vaccine works just as well as it does in adults requiring only one dose of the swine flu vaccine with protection expected in eight to 10 days following the shot. This is similar to seasonal flu vaccine.
It's likely that kids will be able to get their seasonal flu shots and their H1N1 swine flu shots on the same day, although clinical trials are still looking at the issue. The inhaled FluMist version of the swine flu vaccine cannot be given on the same day a kid gets the FluMist version of the seasonal vaccine. That's because FluMist contains a live, weakened flu virus and stimulates the immune system in a different way than flu shots, which contain inactivated virus particles.

If I Think I've Had Swine Flu, Do I Need the Vaccine?

It's important to realize that influenza vaccine cannot give you the flu. The injected flu shot contains inactivated (killed) viruses, and the nasal spray contains attenuated (weakened) viruses and cannot cause flu illness.
If you came down with a flu-like illness since April 2009, you may have had the H1N1 swine flu. But the only way to know for sure is if your doctor took a nasal or throat swab, sent it off to a lab, and had that lab confirm the infection.
If that didn't happen, it's not safe to assume you already had the H1N1 swine flu. Especially if you're at risk of severe flu illness, it's a very good idea to get your H1N1 swine flu shot AND your seasonal flu shot. The vaccine is perfectly safe for people who actually have already had swine flu.

When to Get Vaccinated?

Vaccination against 2009 H1N1 should begin as soon as vaccine is available and continue throughout the influenza season into December, January, and beyond. This is because the timing and duration of flu activity can vary. Flu seasons can last as late as April or May. By early October 2009, extensive 2009 H1N1 flu activity was being reported in the United States. It's possible that there may be waves of 2009 H1N1 activity during the 2009-2010 flu season that hit communities more than once over the course of the season. While 2009 H1N1 viruses are likely to be the most common cause of influenza this season, the CDC still expects that seasonal influenza viruses will circulate and continues to recommend that people get a seasonal flu vaccine to protect against seasonal flu viruses.

Who Should Get Vaccinated?

The CDC's Advisory Committee on Immunization Practices (ACIP), a panel made up of medical and public-health experts, recommends that programs and providers administer vaccine to people in the following five target groups (order of target groups does not indicate priority):

pregnant women;
people who live with or provide care for infants younger than 6 months of age (for example, parents, siblings, and day-care providers);
health-care and emergency medical services personnel;
people 6 months through 24 years of age; and
people 25-64 years of age who have certain medical conditions that put them at higher risk for influenza-related complications.

Why It Is Important to Get Vaccinated if You Are Pregnant?

Every pregnant woman knows that staying healthy is the best thing she can do to ensure her baby is healthy. Pregnant women are at an increased risk for swine flu and seasonal flu because expectant mothers have decreased lung capacity and changes in how their immune system works. These changes make pregnant women more susceptible to flu-related complications, including pneumonia and acute respiratory distress syndrome, endangering both mother and baby. Influenza's potential impact on the unborn child can be very serious as well, including spontaneous pregnancy loss, fetal death, preterm birth, and birth defects. Public-health and medical professionals are urging pregnant women to get vaccinated against both seasonal and H1N1 flu to protect themselves and their unborn babies. In fact, the CDC is urging pregnant women to be among those who get the first doses made available in their communities.
Pregnant women should get flu shots -- not the nasal spray vaccine -- since the nasal spray has not been approved for use in pregnant women. Women can receive the nasal spray vaccine after they have delivered, even if they are breastfeeding.

Who Should Not Be Vaccinated?

There are some people who should not get any flu vaccine without first consulting a physician. These include

people who have a severe allergy to chicken eggs,
people who have had a severe reaction to an influenza vaccination,
people who developed Guillain-Barré syndrome (GBS) within six weeks of getting an influenza vaccine previously,
children younger than 6 months of age (influenza vaccine is not approved for this age group),
people who have a moderate to severe illness with a fever (they should wait until they recover to get vaccinated) , and
people taking certain medications that suppress the immune system should not receive the “live” form of nasal spray vaccine.

H1N1 Swine Flu Vaccine Side Effects -- Flu Shot

The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shot. Some minor side effects that could occur are

soreness, redness, or swelling where the shot was given;
fever (low grade); and
aches.

If these problems occur, they begin soon after the shot, are usually mild, and usually last one to two days. Almost all people who receive influenza vaccine have no serious problems from it. However, on rare occasions, flu vaccination can cause serious problems, such as severe allergic reactions.

H1N1 Swine Flu Vaccine Side Effects -- Nasal Spray

The viruses in the nasal-spray vaccine are weakened and do not cause severe symptoms often associated with influenza illness. (In clinical studies, transmission of vaccine viruses to close contacts has occurred only rarely.)
In children, side effects from LAIV can include

runny nose,
wheezing,
headache,
vomiting,
muscle aches, and
fever.

In adults, side effects from LAIV can include

runny nose,
headache,
sore throat, and
cough.

Is the H1N1 Swine Flu Vaccine Safe?

The H1N1 swine flu vaccine, both the shots and the nasal spray, are made the same way as the seasonal flu vaccine. Every year or so, the seasonal vaccine -- which includes a component based on the seasonal H1N1 virus -- is altered to match a flu virus that has changed its genetic makeup. The same kind of alteration resulted in the H1N1 swine flu vaccine and that's why the FDA approved it; they considered it just a strain change and not a brand-new vaccine.
Even so, both long- and short-term clinical trials are under way. Results from the short-term studies already are here: Other than causing the usual soreness and perhaps redness at the site of injection, the H1N1 swine flu vaccine causes no major side effects. And like the seasonal flu vaccine, the H1N1 swine flu vaccine can't be taken by everybody. The vaccine is produced in hens' eggs, so people with egg allergies cannot take the vaccine.
Will there be long-term side effects? That's not likely, but the CDC is taking no chances. The CDC and vaccine manufacturers have beefed up their safety monitoring process to look for anything unusual in people who get vaccinated against the new flu.

Will the 2009 H1N1 Vaccines Contain Squalene or Adjuvants?

The 2009 H1N1 swine flu vaccine will NOT contain squalene or adjuvants in the United States. This may or may not be the case in other countries.
Squalene is an oil that's a natural part of many body processes. It's widely used in cosmetics because it penetrates the skin easily without leaving an oily feel. Squalene is also used in substances called adjuvants (a substance that helps and enhances the pharmacological effect of a drug or increases the ability of an antigen to stimulate the immune system).
According to current federal plans, only vaccines without adjuvants will be used in the United States during the 2009 flu season. This includes all of the 2009 H1N1 and seasonal influenza vaccines that will be available for children and adults in both the injectable and nasal spray formulations. None of these influenza vaccines will contain adjuvants.
The 2009 H1N1 vaccines with adjuvants are being studied to determine if they are safe and effective. Experts will review these data when they are available. There is no plan at this time to recommend a 2009 H1N1 influenza vaccine with an adjuvant.

Will the 2009 H1N1 Influenza Vaccine Contain Thimerosal?

The 2009 H1N1 influenza vaccines that the FDA is licensing (approving) will be manufactured in several formulations. Some will come in multi-dose vials and will contain thimerosal as a preservative. Thimerosal is a mercury-based preservative that has been used for decades in the United States in multi-dose vials of some vaccines to prevent the growth of microorganisms, such as bacteria and fungi, which may contaminate them after the vial is opened.
Some 2009 H1N1 influenza vaccines will be available in single-dose units, which will not require the use of thimerosal as a preservative. In addition, the live-attenuated version of the vaccine, which is administered intranasally (through the nose), is produced in single-units and will not contain thimerosal.

Is There a Link Between Guillain-Barré Syndrome (GBS) and Swine Flu Vaccines?

Guillain-Barré syndrome (GBS) is a rare disease in which the body damages its own nerve cells, causing muscle weakness and sometimes paralysis. It is not fully understood why some people develop GBS, but it is believed that stimulation of the body's immune system may play a role in its development. Infection with the bacterium Campylobacter jejuni, which can cause diarrhea, is one of the most common risk factors for GBS. People can also develop GBS after having the flu or other infections (such as cytomegalovirus and Epstein-Barr virus). On very rare occasions, people may develop GBS in the days or weeks following receiving a vaccination.

The 1976 Swine Flu Vaccine Wasn't Safe. Why Should I Trust This One?

The 1976 swine flu vaccine was linked to safety issues. Neal Halsey, MD, director of the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health, was at the CDC in those days. "We did identify an increased risk of GBS [Guillain-Barré syndrome] in the six weeks following immunization," says Halsey. No flu vaccine since then has been linked to this risk. Halsey thinks there is the potential for the H1N1 flu vaccine to carry a risk of causing one case of GBS per million people vaccinated. "The theoretical risk of that rare complication has to be balanced against the severity of the H1N1 flu," he says. "There already have been a lot of deaths, many in otherwise healthy, normal children. There is always a real risk from the flu, and a theoretical risk from the vaccines."
The 1976 H1N1 swine flu was a very different virus from the 2009 H1N1 swine flu, which combines elements from flu viruses that evolved in birds, humans, and pigs. And unlike the 1976 virus, the 2009 bug is causing a very real pandemic.

Are H1N1 Swine Flu Shots Mandatory?

Swine flu shots are voluntary for most Americans. For those not in the military, there is no federal requirement to get the H1N1 swine flu vaccine.
Active-duty military personnel, National Guard troops on active duty, and civilian Defense Department employees in critical jobs will be required to get the vaccine.
Healthcare workers may be required by their employers to get vaccinated. The state of New York, for example, has mandated both seasonal and H1N1 swine flu vaccinations for all healthcare workers.

How Much Will the H1N1 Swine Flu Vaccine Cost?

The U.S. government purchased the vaccine from manufacturers and is providing the vaccine at no cost. The CDC has asked providers NOT to charge for administering the vaccine. Even if they do, several large insurance companies have said the costs would be covered. On October 24, 2009, President Barack Obama declared the H1N1 swine flu a national emergency.

Where Can My Children and I Get the Swine Flu Vaccine?

Medical practices and clinics that want to offer the H1N1 swine flu vaccine have already registered with their state health departments. You can check with your doctor to see if she or he is offering the vaccine. Because children are especially vulnerable to H1N1 swine flu -- and are especially likely to spread the disease to others -- many states will be offering H1N1 swine flu vaccinations in schools. In some states, permission slips already have been sent to parents.
Some states are also planning vaccinations at public sites. These plans will be announced locally. Different state, territory, and tribal health authorities have different plans. There is no one-size-fits-all plan; the CDC advises local health departments to adapt their H1N1 vaccination plans to local needs. That goes for retail chains as well. National retail outlets, such as pharmacy chains, may offer H1N1 swine flu vaccine in some areas but not in others.

What is swine flu (novel H1N1 influenza A swine flu)?

2010-08-13T12:21:00.001-07:00

Swine flu (swine influenza) is a respiratory disease caused by viruses (influenza viruses) that infect the respiratory tract of pigs and result in nasal secretions, a barking-like cough, decreased appetite, and listless behavior. Swine flu produces most of the same symptoms in pigs as human flu produces in people. Swine flu can last about one to two weeks in pigs that survive. Swine influenza virus was first isolated from pigs in 1930 in the U.S. and has been recognized by pork producers and veterinarians to cause infections in pigs worldwide. In a number of instances, people have developed the swine flu infection when they are closely associated with pigs (for example, farmers, pork processors), and likewise, pig populations have occasionally been infected with the human flu infection. In most instances, the cross-species infections (swine virus to man; human flu virus to pigs) have remained in local areas and have not caused national or worldwide infections in either pigs or humans. Unfortunately, this cross-species situation with influenza viruses has had the potential to change. Investigators think the 2009 swine flu strain, first seen in Mexico, should be termed novel H1N1 flu since it is mainly found infecting people and exhibits two main surface antigens, H1 (hemagglutinin type 1) and N1 (neuraminidase type1). Recent investigations show the eight RNA strands from novel H1N1 flu have one strand derived from human flu strains, two from avian (bird) strains, and five from swine strains.

Why is swine flu (H1N1) now infecting humans?

Many researchers now consider that two main series of events can lead to swine flu (and also avian or bird flu) becoming a major cause for influenza illness in humans.
First, the influenza viruses (types A, B, C) are enveloped RNA viruses with a segmented genome; this means the viral RNA genetic code is not a single strand of RNA but exists as eight different RNA segments in the influenza viruses. A human (or bird) influenza virus can infect a pig respiratory cell at the same time as a swine influenza virus; some of the replicating RNA strands from the human virus can get mistakenly enclosed inside the enveloped swine influenza virus. For example, one cell could contain eight swine flu and eight human flu RNA segments. The total number of RNA types in one cell would be 16; four swine and four human flu RNA segments could be incorporated into one particle, making a viable eight RNA segmented flu virus from the 16 available segment types. Various combinations of RNA segments can result in a new subtype of virus (known as antigenic shift) that may have the ability to preferentially infect humans but still show characteristics unique to the swine influenza virus (see Figure 1). It is even possible to include RNA strands from birds, swine, and human influenza viruses into one virus if a cell becomes infected with all three types of influenza (for example, two bird flu, three swine flu, and three human flu RNA segments to produce a viable eight-segment new type of flu viral genome). Formation of a new viral type is considered to be antigenic shift; small changes in an individual RNA segment in flu viruses are termed antigenic drift and result in minor changes in the virus. However, these can accumulate over time to produce enough minor changes that cumulatively change the virus' antigenic makeup over time (usually years).
Second, pigs can play a unique role as an intermediary host to new flu types because pig respiratory cells can be infected directly with bird, human, and other mammalian flu viruses. Consequently, pig respiratory cells are able to be infected with many types of flu and can function as a "mixing pot" for flu RNA segments (see Figure 1). Bird flu viruses, which usually infect the gastrointestinal cells of many bird species, are shed in bird feces. Pigs can pick these viruses up from the environment and seem to be the major way that bird flu virus RNA segments enter the mammalian flu virus population.

Figure 1.

What are the symptoms of swine flu (H1N1)?

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Symptoms of swine flu are similar to most influenza infections: fever (100F or greater), cough, nasal secretions, fatigue, and headache, with fatigue being reported in most infected individuals. Some patients also get nausea, vomiting, and diarrhea. In Mexico, many of the patients are young adults, which made some investigators speculate that a strong immune response may cause some collateral tissue damage. Some patients develop severe respiratory symptoms and need respiratory support (such as a ventilator to breathe for the patient). Patients can get pneumonia (bacterial secondary infection) if the viral infection persists, and some can develop seizures. Death often occurs from secondary bacterial infection of the lungs; appropriate antibiotics need to be used in these patients. The usual mortality (death) rate for typical influenza A is about 0.1%, while the 1918 "Spanish flu" epidemic had an estimated mortality rate ranging from 2%-20%. Swine flu in Mexico (as of April 2009) has had about 160 deaths and about 2,500 confirmed cases, which would correspond to a mortality rate of about 6%, but these initial data have been revised and the mortality rate currently in Mexico is estimated to be much lower. By June 2009, the virus had reached 74 different countries on every continent except Antarctica, and by September 2009, the virus had been reported in most countries in the world. Fortunately, the mortality rate as of October 2009 has been low but higher than for the conventional flu (average conventional flu mortality rate is about 36,000 per year; projected novel H1N1 flu mortality rate is 90,000 per year in the U.S. as determined by the president's advisory committee).

How is swine flu (H1N1) diagnosed?

Swine flu is presumptively diagnosed clinically by the patient's history of association with people known to have the disease and their symptoms listed above. Usually, a quick test (for example, nasopharyngeal swab sample) is done to see if the patient is infected with influenza A or B virus. Most of the tests can distinguish between A and B types. The test can be negative (no flu infection) or positive for type A and B. If the test is positive for type B, the flu is not likely to be swine flu (H1N1). If it is positive for type A, the person could have a conventional flu strain or swine flu (H1N1). However, the accuracy of these tests has been challenged, and the U.S. Centers for Disease Control and Prevention (CDC) has not completed their comparative studies of these tests. However, a new test developed by the CDC and a commercial company reportedly can detect H1N1 reliably in about one hour; as of October 2009, the test is only available to the military.
Swine flu (H1N1) is definitively diagnosed by identifying the particular antigens associated with the virus type. In general, this test is done in a specialized laboratory and is not done by many doctors' offices or hospital laboratories. However, doctors' offices are able to send specimens to specialized laboratories if necessary. Because of the large number of novel H1N1 swine flu cases (as of October 2009, the vast majority of flu cases [about 99%] are due to novel H1N1 flu viruses), the CDC recommends only hospitalized patients' flu virus strains be sent to reference labs to be identified.

The CDC developed a PCR diagnostic test to detect novel H1N1 virus. Photo courtesy of the CDC

What treatment is available for swine flu (H1N1)?

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The best treatment for influenza infections in humans is prevention by vaccination. Work by several laboratories has recently produced vaccines. The first vaccine released in early October 2009 was a nasal spray vaccine. It is approved for use in healthy individuals ages 2 through 49. This vaccine consists of a live attenuated H1N1 virus and should not be used in anyone who is pregnant or immunocompromised. The injectable vaccine, made from killed H1N1, became available in the second week of October. This vaccine is approved for use in ages 6 months to the elderly, including pregnant females. Both of these vaccines have been approved by the CDC only after they had conducted clinical trials to prove that the vaccines were safe and effective. However, caregivers should be aware of the vaccine guidelines that come with the vaccines, as occasionally, the guidelines change. Please see the sections below titled "Can novel H1N1 swine flu be prevented with a vaccine?" and the timeline update for the current information on the vaccines.
Two antiviral agents have been reported to help prevent or reduce the effects of swine flu. They are zanamivir (Relenza) and oseltamivir (Tamiflu), both of which are also used to prevent or reduce influenza A and B symptoms. These drugs should not be used indiscriminately, because viral resistance to them can and has occurred. Also, they are not recommended if the flu symptoms already have been present for 48 hours or more, although hospitalized patients may still be treated past the 48-hour guideline. Severe infections in some patients may require additional supportive measures such as ventilation support and treatment of other infections like pneumonia that can occur in patients with a severe flu infection. The CDC has suggested in their interim guidelines that pregnant females can be treated with the two antiviral agents.

Oseltamivir (Tamiflu) is an antiviral agent that may prevent or reduce influenza A and B symptoms. Photo courtesy of the CDC

Zanamivir (Relenza) has been reported to help prevent or reduce the effects of swine flu. Photo courtesy of the CDC

Can novel H1N1 swine flu be prevented with a vaccine?

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The best way to prevent novel H1N1 swine flu would be the same best way to prevent other influenza infections, and that is vaccination. The CDC has multiple recommendations for vaccination based on who should obtain the first doses when the vaccine becomes available (to protect the most susceptible populations) and according to age groups. The CDC based the recommendations on data obtained from vaccine trials and infection reports gathered over the last few months. The current (October 2009) vaccine recommendations from the CDC say the following groups should get the vaccine as soon as it is available:

pregnant women,
people who live with or provide care for children younger than 6 months of age,
health-care and emergency medical services personnel,
people between 6 months and 24 years of age, and
people from the ages of 25 through 64 who are at higher risk because of chronic health disorders such as asthma, diabetes, or a weakened immune system.

Currently, the CDC is stating that people ages 10 and above are likely to need only one vaccine shot to provide protection against novel H1N1 swine flu and further suggest that these shots will be effective in about 76% of people who obtain the vaccine. New vaccine trial data showed that healthy adults produce protective antibodies in about 98% of people in 21 days. Unfortunately, the vaccine shot in children ages 6 months to 9 years of age is not as effective as it is in older children and adults. Consequently, the CDC currently recommends that for ages 6 months up to and including 9 years of age, the children obtain two shots of the novel H1N1 vaccine, the second shot 21 days after the first shot.
Pregnant women are strongly suggested to get vaccinated as stated above. Although some vaccine preparations (multidose vials) contain low levels of thimerosal preservative (a mercury-containing preservative), the CDC still considers the vaccine safe for the fetus and mother. However, some vaccine preparations that are in single-dose vials will not have thimerosal preservative, so those pregnant individuals who are concerned about thimerosal can get this vaccine preparation when it is available.
Another type of vaccine (currently named Influenza A [H1N1] 2009 Monovalent Vaccine Live, Intranasal) has been made available during the first week in October 2009. It is a live attenuated novel H1N1 flu vaccine that contains no thimerosal, is produced by MedImmune, LLC, and is sprayed into the nostrils. This vaccine is only for healthy people 2-49 years of age, and some data suggest that it is less effective in generating an immune response in adults than the vaccine injection. The dosing schedule is as follows:

Children 2-9 years of age should receive two doses (0.1 ml in each nostril; total equals 0.2 ml per dose) -- the second dose should be given the same way about one month after the first dose
Children, adolescents and adults, 10-49 years of age should receive one dose -- (0.1 ml in each nostril; total equals 0.2 ml per dose)

The CDC occasionally makes changes and updates its information on vaccines and other recommendations about the current flu pandemic. The CDC states, "for the most accurate health information, visit http://www.cdc.gov or call 1-800-CDC-INFO, 24/7." Caregivers should check the vaccine package inserts for more detailed information on the vaccines when they become available. This article has an updated timeline for novel H1N1 swine flu attached (see below) and provides the reader with current details about the pandemic. The following is a list of the CDC-approved H1N1 vaccines and the companies that name and manufacture them as of 10/29/09:

Influenza A (H1N1) 2009 Monovalent Vaccine by Sanofi Pasteur
Influenza A (H1N1) 2009 Monovalent Vaccine by Novartis
Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal by MedImmune, LLC
Influenza A (H1N1) 2009 Monovalent Vaccine by CSL Limited

The CDC says that a good way to prevent any flu disease is to avoid exposure to the virus; this is done by frequent hand washing, not touching your hands to your face (especially the nose and mouth), and avoiding any close proximity to or touching any person who may have flu symptoms. Since the virus can remain viable and infectious for about 48 hours on many surfaces, good hygiene and cleaning with soap and water or alcohol-based hand disinfectants are also recommended. Some physicians say face masks may help prevent getting airborne flu viruses (for example, from a cough or sneeze), but others think the better use for masks would be on those people who have symptoms and sneeze or cough. The use of Tamiflu or Relenza may help prevent the flu if taken before symptoms develop or reduce symptoms if taken within about 48 hours after symptoms develop. Some investigators say that administration of these drugs is still useful after 48 hours, especially in high-risk patient populations .However, taking these drugs is not routinely recommended for prevention for the healthy population because investigators suggest that as occurs with most drugs, flu strains will develop resistance to these medications. Recently, the CDC made further suggestions about the use of these antiviral medications. Dr. Schuchat, a CDC official, indicated that three modifications were being suggested (Sept. 8, 2009) to the interim guidelines for use of Tamiflu and Relenza:

1. Patients with high-risk factors should discuss flu symptoms and when to use antiviral medications; doctors should provide a prescription for the antiviral drug for the patient to use if the patient is exposed to flu or develops flu-like symptoms without having to go in to see the doctor. 2. "Watchful waiting" was added as a response to taking antiviral medications, with the emphasis on the fact that those people who develop fever and have a preexisting health condition should then begin the antiviral medication. 3. The antiviral medications are the first-line medicines for treatment of novel H1N1 swine flu, and most current cases of flu are novel H1N1 and are, to date, susceptible to Tamiflu and Relenza. Your doctor should be consulted before these drugs are prescribed.
In general, preventive measures to prevent the spread of flu are often undertaken by those people who have symptoms. Symptomatic people should stay at home, avoid crowds, and take off from work or school until the disease is no longer transmittable (about two to three weeks) or until medical help and advice is sought. Sneezing, coughing, and nasal secretions need to be kept away from other people; simply using tissues and disposing of them will help others. Quarantining patients is usually not warranted, but such measures depend on the severity of the disease. The CDC recommends that people who appear to have an influenza-like illness upon arrival at work or school or become ill during the day be promptly separated from other people and be advised to go home until at least 24 hours after they are free of fever (100 F [37.8 C] or greater), or signs of a fever, without the use of fever-reducing medications. The novel H1N1 swine flu disease takes about seven to 10 days before fevers stop, but new research data (Sept. 14, 2009) suggests waiting until the cough is gone since many people are still infectious about one week after fever is gone. The CDC has not yet extended their recommendations to stay home for that extra week.

What is the history of swine flu (H1N1) in humans?

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In 1976, there was an outbreak of swine flu at Fort Dix. This virus is not the same as the 2009 outbreak, but it was similar insofar as it was an influenza A virus that had similarities to the swine flu virus. There was one death at Fort Dix. The government decided to produce a vaccine against this virus, but the vaccine was associated with neurological complications (Guillain-Barré syndrome) and was discontinued. Some individuals speculate that formalin, used to inactivate the virus, may have played a role in the development of this complication in 1976. There is no evidence that anyone who obtained this vaccine would be protected against the 2009 swine flu. One of the reasons it takes a few months to develop a new vaccine is to test the vaccine for safety to avoid the complications seen in the 1976 vaccine. New vaccines against any flu virus type are usually made by growing virus particles in eggs. A serious side effect (allergic reaction such as swelling of the airway) to vaccines can occur in people who are allergic to eggs; these people should not get flu vaccines. Individuals with active infections or diseases of the nervous system are also not recommended to get flu vaccines.

Can H1N1 be prevented if the H1N1 flu vaccine is not readily available?

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Although vaccination is the best way to "prevent" H1N1, currently (November 2009), there is not enough available for everyone who wants or needs H1N1 vaccination. Until H1N1 vaccine supplies meet demand, there are some things people can do to try and prevent infection. Without vaccination, the best strategy is to not allow H1N1 virus to contact a person's mucus membranes because if the virus does not reach cells in which it can grow, it cannot cause infection. Quarantining H1N1-infected people is an extreme measure that may work in some instances (for example, China uses this method), but even with quarantining, the virus may still spread by people who have minimal or no symptoms.
The next step that is easier to be implemented by individuals is for people with the disease to self-quarantine until they become noninfectious (about seven to 10 days after flu symptoms abate). Infected people can wear surgical masks to reduce the amount of droplet spray from coughs and sneezes and throw away contaminated tissues. Unfortunately, these approaches depend on the compliance of many other people, and the likelihood that such methods will be highly successful in preventing H1N1 infections, at best, is only fair. Such methods have not stopped the current pandemic. Yet there are still some other methods available to individuals. Perhaps the best way for individuals to try to prevent H1N1 infection is a combination of methods that are aimed at fulfilling the very basic principle that if H1N1 doesn't reach an individual's mucus membrane cells, infection will be prevented. The methods are as follows:

1. Kill or inactivate the virus before it reaches a human cell by using soap and water to clean your hands; washing clothing and taking a shower will do the same for the rest of your body. 2. Use an alcohol-based hand sanitizer if soap and water are not readily available. 3. Use sanitizers on objects that many people may touch (for example, doorknobs, computer keyboards, handrails, phones). 4. Do not touch your mouth, eyes, nose, unless you first do items 1 or 2 above. 5. Avoid crowds, parties, and especially people who are coughing and sneezing (most virus-containing droplets do not travel more than 4 feet, so experts suggest 6 feet away is a good distance to stay). If you cannot avoid crowds (or parties), try to remain aware of people around you and use the 6-foot rule with anyone coughing or sneezing. Do not reach for or eat snacks out of canisters or other containers at parties. 6. Avoid touching anything within about 6 feet of an uncovered cough/sneeze, because the droplets that contain virus fall and land on anything usually within that range. 7. Studies show that individuals who wear surgical or N95 particle masks may prevent inhalation of some H1N1 virus, but the masks may prevent only about 50% of airborne exposures and offer no protection against surface droplets. However, masks on H1N1 infected people can markedly reduce the spread of infected droplets. These seven steps can help prevent individuals from getting H1N1 infection, but for many people, adherence to them may be difficult at best. However, there are some additional strategies that may also help prevent H1N1 infections in unvaccinated people according to some investigators. Saline nasal washes and gargling with saline (or a commercial product) as a way to reduce or eliminate H1N1 virus from mucus membranes has been suggested. Proponents of these methods base their rationale on the fact that flu viruses usually take about two to three days to proliferate in nasal/throat cells. While nasal washes and gargling may be soothing to some people, there are no studies that indicate H1N1 is killed, inactivated, or completely removed by these methods; conversely, there are no data suggesting these methods cannot have any effect on H1N1. However, with long-term nasal washes using Neti pots, sinus infection with other pathogens may be encouraged.
Other investigators and physicians have offered additional methods that may help reduce exposure to H1N1 virus. For example, Dr. Gerberding, a former CDC director, had several suggestions about how to avoid H1N1 infection on an airplane. She suggested the following:

HEPA

Variations of her suggestions may be applicable in many different social, work, or travel situations, but there are no data to prove these methods are effective. In addition, common-sense precautions such as not drinking or eating things touched by others, avoiding casual physical contacts (for example, handshakes, social hugs or kisses, public water fountains [these are OK if you touch nothing and lips only touch flowing water], banisters on stairways, and restroom door handles) will limit exposure to H1N1. Again, these common sense suggestions lack data substantiation.
Many investigators suggest that people stay well hydrated, take vitamins, and get plenty of rest, but these precautions will not prevent H1N1 infections although they may help reduce the effects of infection by strengthening the person's immune system to fight infection. Similarly, current antiviral medications (described in the preceding section) act on H1N1 viruses that have already infected cells; they work by preventing or reducing viral particles from aggregating and being released from infected cells. Timing is important; if only a few cells are infected and the antiviral medications are administered quickly (usually before flu symptoms develop or within 48 hours), the viruses are reduced in number (they cannot easily bud out from the cell surface), so few, if any, other respiratory or mucus membrane cells become infected. This can result in either no flu symptoms or, if a larger number of cells were initially infected, less severe symptoms. The overall effect for the person is that the H1N1 infection was prevented (it was not; the symptoms were prevented from developing) or that symptoms were reduced.
In the strictest sense of the word prevention, even effective vaccines do not "prevent" infections. What they do accomplish is to alert the immune system to be on guard for certain antigens that are associated with a pathogen (for example, H1N1 virus, pneumococcal bacteria). When the pathogen first infects the host, its antigens are recognized, and these cause a rapid immunoprotective response to occur that prevents the pathogen from proliferating and developing symptoms in the host. People, including physicians and researchers, often term this complex response to vaccination as "prevention of infection" but what actually occurs is the prevention of further infection so well that symptoms do not develop or are minimal in the host.
In summary, if H1N1 viruses fail to contact cells they can infect, the disease will be prevented. As stated above, this is difficult, but not impossible, to do in almost all societies. Prevention of H1N1 symptoms of infection is possible with antiviral medications if these are given very early in the infection. There are many other methods that may reduce the chance of getting the virus on a person's mucosal surface, but most methods have not been backed up with objective data. Most doctors and investigators suggest that items that help boost or allow the immune response to function well will help people resist H1N1 infections and reduce symptoms, but these also do not prevent infections. Consequently, while waiting for H1N1 vaccine, these are some ways individuals can improve their chances of preventing or reducing the symptoms of H1N1 infections.

Is swine flu (H1N1) a cause of an epidemic or pandemic in 2009?

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An epidemic is defined as an outbreak of a contagious disease that is rapid and widespread, affecting many individuals at the same time. The swine flu outbreak in Mexico fit this definition. A pandemic is an epidemic that becomes so widespread that it affects a region, continent, or the world. As of April 2009, the H1N1 swine flu outbreak did not meet this definition. However, as of June 11, 2009, WHO officials determined that H1N1 2009 influenza A swine flu reached WHO level 6 criteria (person-to-person transmission in two separate WHO-determined world regions) and declared the first flu pandemic in 41 years. To date, the flu has reached over 74 different countries on every continent except Antarctica in about three month's time; fortunately, the severity of the disease has not increased.

What is the prognosis (outlook) for patients who get swine flu (H1N1)?

The following is speculation on the prognosis for swine flu (H1N1) because this disease has only been recently diagnosed and the data is changing daily. This section is based on currently available information.
In general, the majority (about 90%-95%) of people who get the disease feel terrible (see symptoms) but recover with no problems, as seen in patients in both Mexico and the U.S. Caution must be taken as the swine flu (H1N1) is still spreading and has become a pandemic. So far, young adults have not done well, and in Mexico, this group currently has the highest mortality rate, but this data could quickly change.
People with depressed immune systems historically have worse outcomes than uncompromised individuals; investigators suspect that as swine flu (H1N1) spreads, the mortality rates may rise and be high in this population. Current data suggest that pregnant individuals, children under 2 years of age, young adults, and individuals with any immune compromise or debilitation are likely to have a worse prognosis. Unfortunately, the problem with the prognosis is still unclear. If the mortality is like the conventional flu that causes mortality rates of about 0.1%, the result would be about 36,000 deaths per year because of the huge number of people who get infected. If the Mexico swine flu (H1N1) ends up with a mortality rate of about 6% and infects the same number of millions of people as conventional flu viruses, the projected numbers could be as high as 2 million deaths in the U.S. alone. This is a bad prognosis for about 2 million people and their families; these potential deaths are major reasons that health officials are so concerned about the spread of this new virus. As of September 2009, the current estimates are that about 90,000 deaths will occur in the U.S. from novel H1N1 swine flu (estimated by the president's advisory committee). As of October, these estimates have not been revised by the advisory committee or the CDC.
Another confounding problem with the prognosis of swine flu (H1N1) is that the disease is occurring and spreading in high numbers at the usual end of the flu season. Most flu outbreaks happen between November to the following April, with peak activity between late December to March. This outbreak is not following the usual flu pattern since novel H1N1 began its outbreak in April and had spread throughout the world by September. Some scientists think that swine flu (H1N1) will die down but return with many more cases in the fall, and still others speculate the current pandemic will eventually resemble the outcomes similar to the 1918 influenza pandemic. Some suggest it may resemble the SARS (severe acute respiratory syndrome caused by a coronavirus strain) outbreak in 2002-2003 in which the disease spread to about 10 countries with over 7,000 cases, over 700 deaths, and had a 10% mortality rate. Effective isolation of patients was done in this case, and many investigators think the outbreak was stopped due to this measure. Because swine flu (H1N1) is a new virus and does not seem to be following the usual flu disease pattern, any prognosis is speculative, although as of October 2009, the numbers of people with flu-like illness are higher than usual and the illness is affecting a much younger population than the conventional flu. As the pandemic progresses, this article will be updated. The best news about this novel H1N1 swine flu is that the majority of people, as of October 2009, who have caught the flu recover without medical treatment and have an excellent prognosis.

Where can I find more information about swine flu (H1N1)?

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For additional information see the following:
http://www.cdc.gov/swineflu/ (Note: This site is updated frequently with ongoing information on swine flu [H1N1].)
http://www.cdc.gov/swineflu
/clinician_pregnant.htm
http://wwwn.cdc.gov/travel/
http://www.medicinenet.com/influenza
/article.htm
http://emedicine.medscape.com/article
/219557-overview
http://www.webmd.com/cold-and-flu
/swine-flu/default.htm

Updated timeline of H1N1 2009 swine flu news

This timeline is provided to keep readers updated on subjects, information, and data related to the flu outbreak first noted in Mexico in 2009 and to augment the information found in the article written above. Updates are written by Dr. Charles Davis.
5/28/10: The CDC announced today that they are ending the weekly updates as all flu activity is low and the 2010 flu season is ending. Unless there is unusual flu activity, the updates will not resume until the next seasonal flu season begins in October 2010. Unless circumstances change, this will be the last entry for the MedicineNet.com updates. I thank the readers for their diligence. - C.P. Davis, MD, PhD
5/27/10: Tests to determine the presence of H1N1 flu viruses have had mixed reviews. A positive review was given to the Simplexa Influenza H1N1 test by the FDA; the agency has approved the test for detection of H1N1 in nasal swabs and aspirates. However, another test, the Direct Immunofluorescence Assay (DFA), was termed "unreliable" in patients eventually diagnosed with severe H1N1 infections in a Stanford University study. The study, "Difficulty in Rapid Diagnosis of Novel Influenza A (H1N1) Virus Using Direct Fluorescent Antibody Testing (DFA) in Critically Versus Non-Critically Ill Patients," is available as abstract #2477 at the May 2010 meeting of the American Thoracic Society.
5/21/10: For the last few weeks, the CDC reports have remained similar with no widespread flu outbreaks, and visits to doctors offices for flu-like illnesses are low. H1N1 flu virus remains the predominant flu strain in the U.S.
5/16/10: A new article in the journal Vaccine (Peter Pushko, Thomas Kort, Margret Nathan, et al., "Recombinant H1N1 Virus-like Particle (VLP) Vaccine Elicits Protective Immunity in Ferrets Against the 2009 Pandemic H1N1 Influenza Virus, Vaccine," In Press, Uncorrected Proof, available online [purchase] 12 May, 2010) shows that a VLP vaccine is capable of producing protection against H1N1 flu in the ferret animal model. The authors report that a single 15 μg dose of H1N1 VLPs resulted in complete virus clearance in the ferret lung. The authors conclude that their data provides support for the use of recombinant influenza VLP vaccine as an effective strategy against pandemic H1N1 virus and may serve as a model for developing other quickly implementable vaccines.
5/12/10: The CDC and InDevR have partnered to develop a new influenza assay to allow easy worldwide screening of emerging flu virus strains. The investigators suggest it will take about two years to develop this new surveillance tool.
5/11/10: Revenues earned by pharmaceutical companies worldwide were estimated by several company reports to be about $3 billion. The reports tell investors that such incomes are unlikely in the future as the 2009-2010 flu season was unique. Reports did speculate that 2010-2011 seasonal flu vaccines are likely to have an increased demand.
5/9/10: Several news agencies have published editorials that indicate the NEJM articles listed below on the 4/5/10 update offer a good global overview and review of the past year's experience with the flu pandemic.
5/5/10: The May 6, 2010, issue of the New Eng. J of Med. (NEJM, 362(18), pp 1708 and 1731, 2010) has two articles devoted to the H1N1 influenza pandemic. The first article ("Medical Progress: Clinical Aspects of Pandemic 2009 Influenza A (H1N1) Virus Infection," p. 1708) is a review of the medical progress that has happened during the last year. The article details many clinical aspects of the pandemic and offers a section on future directions for influenza research. The second article (p. 1731) documents how information from the Internet and rapid communications among reporting agencies (WHO, CDC, international health officials) around the world has changed the way people and governments can detect, track, and respond to pandemics. It also points out the weaknesses in current methods and offers some suggestions for future improvements. Readers who want a documented review of the first flu pandemic reported since 1968 are encouraged to read these two articles.
A company in Australia, Marinova Ltd., reports extracting a polysaccharide from seaweed termed Maritech 926 that inhibits flu virus. The company plans to eventually market the substance in nasal products and hand wash solutions.
4/30/10: It has been one year (as of April 2010) since the H1N1 virus has been identified as a human pathogen. Although there are sporadic reports of H1N1 infections, the CDC reports all flu activity in the U.S. as low with no states reporting even high regional flu activity. Currently, the highest H1N1 flu activity is reported in parts of Western and Central Africa. However, influenza type B (seasonal flu) is predominant in East Asia, Central Africa, and Northern and Eastern Europe.
4/28/10: A publication by OB/GYN researchers suggest that no major problems occurred in pregnant women or their babies when treated with antiviral medications for influenza (Obstetrics & Gynecology 115.4 [2010]: 711-716). The retrospective study examined 239 women who were treated. The study showed no difference in the mothers' rates of preeclampsia, preterm birth, gestational diabetes, premature membrane rupture, and fever during labor or prolonged hospital stay when compared to a large population of pregnant women who were not treated. After birth, no differences were noted in birth weight, need for intensive care, or seizures or jaundice among the babies of mothers that were treated. The authors state that the use of antiviral drugs (Tamiflu, Relenza, Flumadine) appears to be safe in pregnancy.
4/23/10: Pregnant women had a disproportionately high number of deaths due to H1N1 infections according to published results in the Journal of the American Medical Association (JAMA 303.15 [2010]: 1517-1525). The data showed that "pregnant women represent approximately 1% of the U.S. population, yet they accounted for 5% of U.S. deaths from 2009 influenza A (H1N1) reported to the CDC..."
Western Australia officials have advised physicians to stop giving seasonal flu vaccine to children because of a rise in adverse affects. Reported adverse reactions include fever, vomiting, and febrile convulsions. The government is trying to determine if a vaccine batch was somehow tainted. Vaccine for the pandemic H1N1 flu is not involved in this recommendation.
4/19/10: The CDC released its newest estimated statistics on H1N1; the following table is provided by the CDC:

CDC Estimates of 2009 H1N1 Cases and Related Hospitalizations and Deaths from April 2009 - March 13, 2010, By Age Group

2009 H1N1	Mid-Level Range*	Estimated Range*
Cases
0-17 years	~19 million	~14 million to ~28 million
18-64 years	~35 million	~25 million to ~51 million
65 years and older	~6 million	~4 million to ~9 million
Cases Total	~60 million	~43 million to ~88 million
Hospitalizations
0-17 years	~86,000	~61,000 to ~127,000
18-64 years	~158,000	~112,000 to ~232,000
65 years and older	~26,000	~19,000 to ~39,000
Hospitalizations Total	~270,000	~192,000 to ~398,000
Deaths
0-17 years	~1,270	~900 to ~1,870
18-64 years	~9,420	~6,700 to ~13,860
65 years and older	~1,580	~1,120 to ~2,320
Deaths Total	~12,270	~8,720 to ~18,050

* Deaths have been rounded to the nearest ten. Hospitalizations have been rounded to the nearest thousand and cases have been rounded to the nearest million.
The CDC data estimates continue to show clearly that the 18-64 year age range group had more deaths and hospitalizations than the other age groups, which is not the usual pattern for influenza.
4/16/10: The WHO was advised to keep the pandemic designation for H1N1 by John Mackenzie. He is the head of the panel advising the WHO on flu and pandemic alerts. He indicated that the alert should not be "wound down" until experts had the opportunity to track the progression of H1N1 "…in the south's (southern hemisphere's) traditional autumn and winter flu seasons over the coming months."
4/14/10: In an analysis of the WHO response to H1N1 flu, Dr. Fukuda acknowledged the six-phase system the WHO uses to assess a pandemic, which is based on "the geographic spread of a virus but not its severity" may have led to confusion in many instances; WHO officials plan to address this problem.
Studies done on serum samples from people in Singapore showed that young people and the military had the highest incidence of infection with H1N1 during the early months of the flu outbreak (June to September 2009). This data came from examination of about 3,000 blood samples before, during, and after H1N1 was found in Singapore, and the study is published in the Journal of the American Medical Association 303.14 Apr. 14, 2010: 1383-1391. The authors suggest the study shows these groups would best benefit from early immunization.
4/13/10: As the flu season approaches in Australia, health officials suggest that people get vaccinated with the trivalent seasonal flu vaccine to have more complete flu vaccine coverage even though H1N1 is expected to be the prevalent virus in the upcoming season. Anyone who is eligible to get the H1N1 vaccine and has not yet been vaccinated is advised to get the vaccine.
4/9/10: Flu levels remain low according to the CDC. Regional activity is noted in Alabama, Georgia, and South Carolina, with no states reporting widespread activity.
4/2/10: The weekly CDC update of flu data suggests that influenza-like illness has dropped from last week, although region 9 (Arizona, California, Nevada, and Hawaii) still reports elevated levels. Deaths have risen slightly and are now above baseline. The majority of flu cases still are H1N1; the vast majority of H1N1 are still susceptible to Tamiflu and Relenza.
4/1/10: A free workshop designed to discuss all types of vaccine developments is being sponsored, in part, by the National Science Foundation (NSF) on May 5, 2010. Many of the findings and studies on the newest, rapid, and safe vaccine developments are likely to be discussed, especially those related to flu vaccine development.
3/30/10: Areas in Alabama, Georgia, and South Carolina have noted an increase in sustained flu activity while influenza-like illness has recently increased in most of the southeast states (Regions 4, 7, and 9) according to the CDC. About one week ago, only one region (4) had shown an increase. Region 4 is comprised of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee while region 7 is Iowa, Kansas, Missouri, and Nebraska and region 9 is Arizona, California, Hawaii, and Nevada. The CDC is still urging people to get the H1N1 vaccine.
3/26/10: The CDC reported that internationally H1N1 activity is highest in certain areas of Southeast Asia, West Africa, and tropical regions of the Americas. An increase in 2009 H1N1 activity has been reported in recent weeks in Central America and the tropical regions of South America while it remains high in West Africa.
3/25/10: Two research articles have strongly suggested that the 1918 and H1N1 flu viruses are very similar in their structures (Science Express, Mar. 25, 2010,10.1126/science.1186430 and Science Translational Medicine. DOI: 10.1126/scitranslmed.3000799 [2010]), so similar in fact that the immune response to one virus is capable of reacting to the other.
3/24/10: A new article (Radiology, Apr. 2010 255:252-259; doi:10.1148/radiol.10092240) suggests that chest X-rays may provide information about the sickest patients with H1N1flu. "Abnormal findings in the periphery of both lungs and in multiple zones of the lungs were associated with poor clinical outcomes," said the researchers.
3/19/10: The CDC's weekly report again indicates low flu activity. However, the CDC still recommends vaccination and emphasized that people 65 and older should be vaccinated, because if they get the disease, they are at high risk to develop flu-related complications.
3/17/10: A 40% reduction in risk for influenza among people in the same household occurred when the household members had a discussion about how to prevent spreading the infection according to researchers (J. Infectious Diseases, 201:984, 2010).
3/16/10: Applied Nanoscience Inc., claims it has produced a new mask, a NanoFence protective face mask, that virus types (H1N1 and rhinovirus) cannot penetrate, according to company data that has been "verified" by an independent testing agency.
3/14/10: The CDC reported that flu cases showed about the same low levels as the past few weeks. They did report a few more cases of seasonal flu due to influenza B strains.
3/13/10: A new journal article in PCCM (Pediatric Critical Care Medicine. 11.2 Mar. 2010: 185-198.doi: 10.1097/PCC.0b013e3181cbdd76) found that the vast majority (92%) of the children had an underlying chronic disease, usually a lung disease such as asthma, before contracting H1N1 infection. They also found that PICU was the place to treat for best outcomes, even though many PICUs were full. "We show that PICU surge capacity is likely to be adequate assuming that 'older children' [age > 7-8 years] can be rerouted to an adult ICU environment preserving adequate bed space for 'younger children,' that enough adult ICU resources are available and that safe provision of care to children can be guaranteed," said the authors.
3/5/10: The CDC reported a slight increase in pneumonia and influenza deaths, but overall these remain still low for this time in the flu season.
3/2/10: An article in the International Journal of Health Geographics (2010, 9:13) suggests that pandemic flu strains are likely to develop Tamiflu resistance over time. The authors base their findings on computer analysis of strains of flu mutations that have developed since 1918. However, as of Feb. 3, 2010, only 225 cases of pandemic H1N1 flu strains were reported to be resistant to Tamiflu out of the predicted millions of cases of illnesses in the world.
2/28/10: The CDC again reported no widespread outbreaks of H1N1 in the U.S. even though this should be near the peak of the flu season.
2/24/10: The WHO emergency committee decided it was too early to declare that H1N1 has peaked worldwide. The 15-member committee decided to reconvene in about one or two months to readdress the H1N1 flu season pandemic situation.
2/23/10: A recent report from the Proceedings of the National Academy of Sciences journal (DOI:10.1073/pnas.0912807107) suggests that "reassortment between an avian H5N1 virus with low pathogenicity in mice and a human virus could result in highly pathogenic viruses and that the human virus PB2 segment functions in the background of an avian H5N1 virus, enhancing its virulence...Our data suggests that it is possible there may be reassortment between H5 and pandemic H1N1 that can create a more pathogenic H5N1 virus." The authors generated 22 strains with more pathogenicity (disease-causing potential) than the original H5N1 and three strains that were classified as extremely pathogenic. Although H5N1 had spread worldwide among bird populations and caused 447 confirmed human cases and 263 deaths (a 58.8 % fatality rate), the virus is not easily transmitted from human to human. The authors used H3N2 as the combining virus, not H1N1 but drew the conclusions above about H1N1 because of similarities in the virus' ability to reassort genetic elements.
On Monday, the FDA recommended that H1N1 be one of the three strains that will comprise the trivalent seasonal vaccine for use in the 2010-2011 seasonal flu vaccine.
2/21/10: The CDC reported that no states reported widespread flu outbreaks. Visits to doctors for flu-like illness increased slightly but remain still low for this segment of the flu season. Again, the majority of all flu cases that are identified are caused by H1N1 viruses.
2/20/10: Advanced proprietary virus-like-particle (VLP) technology, developed by Novavax, may be the next step in improved flu vaccine development. Novavax presented positive data to the WHO about its ongoing clinical trials in Mexico with the vaccine. The VLP vaccine against H1N1 flu virus showed good immune responses with a single dose of 15 mcg with an excellent safety profile over a broad range of ages (18-64), according to the report. The stage B clinical trial involving about 3,000 people is now progressing, and the data from it will form the basis of the company's goal to get approval for human use and commercialization.
2/18/10: WHO officials recommended that H1N1 flu strain be included as one of the strains in the seasonal trivalent vaccine scheduled for the 2010-2011 flu season. The U.S. recommendation will address this next week.
Although WHO guidelines suggest that in patients that are critically ill with H1N1 flu be treated with higher doses of Tamiflu, Canadian researchers suggest that the 75 mg dose twice a day was well absorbed even in patients critically ill with H1N1. The authors conclude that high doses of Tamiflu are unnecessary in these patients.
2/15/10: WHO officials announced plans to reevaluate the H1N1 pandemic and decide if the flu is entering a transitional or a post-peak phase later this month. While the flu is still spreading in a few countries, worldwide it is declining.
2/14/10: The CDC provided update estimates on H1N1 flu statistics in the following table:

CDC Estimates of 2009 H1N1 Cases and Related Hospitalizations and Deaths From April 2009 - January 16, 2010, by Age Group

2009 H1N1	Mid-Level Range*	Estimated Range *
Cases
0-17 years	~19 million	~13 million to ~27 million
18-64 years	~33 million	~24 million to ~49 million
65 years and older	~5 million	~4 million to ~8 million
Cases Total	~57 million	~41 million to ~84 million
Hospitalizations
0-17 years	~82,000	~58,000 to ~120,000
18-64 years	~150,000	~107,000 to ~221,000
65 years and older	~25,000	~18,000 to ~37,000
Hospitalizations Total	~257,000	~183,000 to ~378,000
Deaths
0-17 years	~1,230	~880 to ~1,810
18-64 years	~8,980	~6,390 to ~13, 170
65 years and older	~1,480	~1,060 to ~2,180
Deaths Total	~11,690	~8,330 to ~17,160

* Deaths have been rounded to the nearest 10. Hospitalizations have been rounded to the nearest 1,000, and cases have been rounded to the nearest million.
In addition, the CDC reported no U.S. states with widespread flu and that the H1N1 strain is still the majority strain causing the flu.
2/10/10: The International Journal of Obstetrics and Gynecology (BJOG 2010; DOI: 10.1111/j.1471-0528.2010.02522.x) examines how the H1N1 flu virus affects pregnant women (211 confirmed H1N1 flu-infected). Most patients reported having fever at home but only 62.2% had a fever when they arrived at hospital. Cough was the most prevalent symptom, occurring in 90.5%. Other symptoms were as follows: runny nose (62.1%), sore throat (58.8%), muscle ache (32.2%), headache (18%), and breathlessness (13.3%). Other illnesses that these women had included asthma (12.8%), hypertension (0.5%), and gestational diabetes (1.9%).
2/9/10: A Harvard poll, done in late January, suggests that about half of the U.S. population believe the H1N1 flu outbreak is over.
2/8/10: Investigators have reported that Zadaxin treatment given with the H1N1 vaccine led to a statistically significant increase in the percentage of subjects who seroconverted (developed antibodies to the virus) with H1N1 vaccine, In addition, when evaluated 42 days after vaccination, compared to those who received the H1N1 vaccine alone, increased antibody titers were seen in Zadaxin-treated patients. Zadaxin (thymalfasin) acts to enhance the immune response to H1N1 influenza monovalent vaccine.
2/5/10: Today the CDC reported that flu activity is low and that H1N1 is still the major viral type causing the flu. No states report widespread flu activity. However, the CDC still recommended that people get vaccinated with seasonal and H1N1 vaccine because the flu season is not over and should last several more months.
2/2/10: Romark Laboratories announced that it has initiated enrollment of patients in a clinical trial of nitazoxanide (Alinia), a new antiviral drug that acts at a site different from Tamiflu and Relenza. Researchers say, "It targets the maturation and intracellular transport of the viral hemagglutinin protein (HA), while Tamiflu (oseltamivir) and Relenza (zanamivir) target the neuraminidase protein (NA), and older drugs target the M2 protein. This unique mechanism is potentially very important in the setting of resistance or the threat of resistance to existing drugs."
1/30/10: WHO officials suggest that areas in Europe, Asia, and Africa still show spread of H1N1. Elsewhere, H1N1 is declining. However, H1N1 remains the dominant strain of flu worldwide.
1/27/10: Researchers report they have successfully generated several fully human monoclonal antibodies against pandemic A (H1N1 and H3N2) type influenza virus. They used a special cell line termed SPYMEG that allows easy cell fusion and allows monoclonal antibodies to be produced. The researchers suggest these antibodies may be more effective in treating severe H1N1 infections than drugs.
1/26/10: The WHO is scheduled to meet Tuesday with the Parliamentary Assembly of the Council of Europe to discuss undue influence by pharmaceutical companies to classify H1N1 as a pandemic. WHO spokesperson Gregory Hartl on Monday rejected such accusations that the organization miscategorized H1N1 flu as a pandemic. He said such accusations were "irresponsible."
1/23/10: The Journal of Infectious Diseases 201 (2010): 491-498, reports that face masks and hand-washing reduced influenza-like-infections (ILI) significantly (about 35%-51%) in weeks four to six of their study using over 1,000 college students. Face masks alone showed some reduction but this was not statistically significant. Unfortunately, the authors also concluded, "Neither face mask use and hand hygiene nor face mask use alone was associated with a significant reduction in the rate of ILI cumulatively." However, they suggest that in shared rooms (for example, dorms) the use of both face masks and hand washing may mitigate the impact of pandemics like H1N1 flu.
1/22/10: The CDC reported that no states are reporting widespread flu activity. Visits to doctors' offices and hospitalizations have decreased or leveled off although the vast majority of flu viruses isolated are still H1N1. During this lull, the CDC suggests it is a good time to get vaccinated as most states now have adequate vaccine supplies and the CDC personnel do not know if the flu will have a resurgence.
1/21/10: A study published in The Lancet indicated the following about H1N1 infections in children in England: "Around one child in every three was infected with 2009 pandemic H1N1 in the first wave of infection in regions with a high incidence, 10 times more than estimated from clinical surveillance." The authors suggest that this high rate shows the susceptibility of children to the disease and how rapidly it spread, especially in school-aged children. They also say that the children are likely a major factor in the spread of the disease to other non-school-aged people.
1/20/10: Researchers have recently claimed (J. General Virology 91 [2010]: 339-342) that 1918 and 2009 H1N1 influenza viruses are not pathogenic in birds. The authors suggest that although chickens and ducks produced an immune response to the viruses, the absence of any gross pathological changes suggests that the birds were not susceptible to the viruses. The authors further state that the experiments suggest the viruses did not spread from birds to humans.
1/19/10: Bharat Biotech, a pharmaceutical company in India, today announced that it has started phase I clinical evaluation of HN-VAC, its cell culture-based H1N1 vaccine candidate. Cell culture-based flu vaccines remove the need for traditional egg-based vaccines and allow the rapid production of vaccine in large quantities. These represent one method that may replace the cumbersome and time-consuming egg-based vaccines.
1/18/10: WHO adviser Keiji Fukuda, in response to critics that claim WHO overstated the pandemic influenza threat, stated, "The world is going through a real pandemic. The description of it as a fake is both wrong and irresponsible. WHO has been balanced and truthful in the information it has provided to the public. It has not underplayed and not overplayed the risk it poses to the public." Dr. Wolfgang Wodarg, chairman of the Council of Europe's health committee, called the worldwide H1N1 flu a "false pandemic." Fukuda said the WHO welcomes constructive criticism but clearly rejects the notion that H1N1 infections comprised a false pandemic.
1/16/10: The FDA Commissioner Margaret Hamburg commented on the safety of the H1N1 vaccine as follows: "According to the Jan. 8, 2010, update of FDA and CDC vaccine safety monitoring activities, as of Dec. 30, 2009, the total number of doses of H1N1 vaccines distributed was 99.3 million and the vast majority (94%) of adverse events reported to VAERS (Vaccine Adverse Event Reporting System) were classified as 'non-serious' (for example, soreness at the vaccine injection site)."
1/15/10: The CDC announced that for the last week, flu-like illnesses and hospitalizations were down from the previous week and no states were reporting widespread flu activity.
1/14/10: WHO officials plan to review their actions on the H1N1 pandemic after being criticized by member countries for exaggerating the pandemic. "Criticism is part of an outbreak cycle," WHO spokeswoman Fadela Chaib said in response. Two major points of criticism are whether the WHO acted too quickly to encourage vaccine stockpiling and whether pharmaceutical companies influenced health officials to make decisions to purchase more vaccine than necessary. The WHO said it plans to have an independent review of this pandemic but does not yet have a timeline as the pandemic is ongoing.
One of the first large trials of a recombinant flu vaccine will enter clinical trials in India. The vaccine will be made from viral antigens synthesized in bacteria and will have receptor-mediated immune enhancement. VaxInnate officials say this methodology is capable of producing hundreds of millions of vaccine doses in weeks instead of months. However, it must be approved by the Indian government before the vaccine is used on large populations.
1/10/10: Today the CDC begins its National Flu Vaccination Week (Jan. 10-16) in which it encourages the population to get flu vaccinations. The CDC reports that hospitalizations for flu-like illness remain steady but also reports that doctors' visits and deaths have dropped. However, they reported that they have 293 lab-confirmed pediatric flu deaths with only two due to seasonal flu since April 2009. Unfortunately, the CDC considers these high numbers to represent an undercount of deaths and will update their estimates soon. The good news is that only one state (Alabama) is still reporting widespread H1N1 infections, down from four states reported last week.
1/8/10: NexBio, Inc., announced the initiation of a double-blind, placebo-controlled multi-center trial at 50 sites in the U.S. and Mexico of Fludase for the treatment of laboratory-confirmed influenza infection. Fludase is a receptor inactivator and works by preventing viral entry into cells. Unlike current antiviral drugs (Tamiflu, Relenza), the drug targets human host receptors, not virus components. The company claims its targeted site confers a low likelihood for the development of viral resistance.
1/7/10: Dr. Schuchat said today that most people who want the H1N1 vaccine should be able to get it as supplies in most of the U.S. are meeting or exceeding demand. Although the flu has seemingly decreased in occurrence, she showed that in the 1957 pandemic flu, it too showed a similar incidence decline in the early winter and then reoccurred at high levels in the late winter and early spring. She indicated that no one knows if H1N1 will follow this same pattern but that the CDC urges people not to be complacent and still urges vaccination. She said that the CDC estimates that about 60 million people in the U.S. have been vaccinated with H1N1, the bulk of whom are children; she urges adults, especially those at high risk, not to delay getting the vaccine.
1/5/10: The FDA authorized use of a new test that can confirm H1N1 flu infection within one hour. The test is termed the Xpert Flu A Panel test and is based on PCR technology. The test is part of Cepheid's GeneXpert System and is only approved to be run by government (CLIA) certified labs.
1/4/10: In an upcoming online article in the Journal of Public Health Management and Practice (Jan. 2010), researchers suggest, via computer modeling, that closing schools for eight weeks or more may be the only effective plan to slow the spread of the flu in schools. Closing schools for less than two weeks may actually increase infection rates and prolong an epidemic, according to the investigators.
Today, the CDC reported little or no change in the number of people hospitalized last week for flu-like illness; they did report four flu-related pediatric deaths last week, down from nine the previous week.
1/2/10: Researchers at the University of Wisconsin announced that they have developed rapid semi- and fully-automated multiplex real-time RT-PCR assays to detect influenza A, influenza B, and respiratory syncytial virus (RSV). These tests are not yet available but represent the ongoing attempts to accurately diagnose the flu quickly.
12/31/09: Flu cases continue to decline in the U.S.; the CDC indicated that only four states were still reporting widespread flu activity, down from seven reported last week. However, visits to doctors for flu-like illnesses increased this week, the first increase in eight weeks. The vast majority of flu viruses isolated are still the H1N1 strain.
In the New England Journal of Medicine (Dec. 31, 2009 361: pp 2619), researchers report, in families, that children under 18 years of age were twice as likely to catch the flu than older people (19-50 years of age), while people over 50 years of age were 80% less likely to get the flu than those 18 years of age or younger. The good news is that the flu was only transmitted to 13% of two-person families and only 9% of six-person families. It took about 2.6 days for the second family member to get infected.
12/28/09: Today the CDC reported that widespread flu (mainly H1N1) continues to decline from 11 to 7 states. Flu-like illnesses also continued to decline. The CDC suggests that now is a good time for getting H1N1 flu vaccination since the demand has declined and supplies of the vaccine are available. CDC officials warn that the flu decline may not be sustained and that vaccination is the best protection against the flu.
12/27/09: A Harris poll indicated that about 40% of people polled changed their holiday plans due to H1N1 with about 21% avoiding air travel. Another poll (Harvard School of Public Health) found that by about December 17, 3 of 4 parents that wanted their child vaccinated against H1N1 were able to do so. This shows that vaccine is much more available than in November when only 1 of 4 parents could get the vaccine. The poll also suggests that only about 22% of high-priority adults have obtained the vaccine; however, 44% of high-risk patients indicated they will not get the vaccine for three major reasons (vaccine safety concerns, believe the disease is not dangerous, or believe they are not at risk for a serious disease).
12/24/09: CDC officials estimate that about 60 million people in the U.S. have been vaccinated against H1N1. They also suggest that only 11 States are reporting widespread H1N1 flu activity. About 40% of the vaccine was given to children. In related reports, two surveys (from Harvard and the CDC) suggest that about one-half of adults do not want the H1N1 vaccine and about one-third of adults do not want their children to get the vaccine. The major reason people do not want the vaccine is that they are not sure it is safe. Convincing this segment of the population that the H1N1vaccine is safe is likely to be difficult, the survey designers concluded.
12/23/09: In the American Journal of Respiratory and Critical Care Medicine, 81: 72 – 7 DOI:10.1164/rccm.200909-1420OC, researchers found in an autopsy study of 21 patients that died from H1N1 infection, three distinct patterns of pathologic findings. One pattern was acute lung injury, a second was "necrotizing bronchiolitis (NB)" usually associated with bacterial infection, and the third was a "hemorrhagic pattern" that occurred most often in patients that had heart disease or cancer. The researchers suggested that underlying conditions play a significant role in causing deaths of patients infected with H1N1, but the mechanisms are not yet clear.
12/21/09: For the research- minded readers, Nature (21 December 2009 | doi:10.1038/nature08699) just published an in-depth manuscript that describes how influenza viruses take over the infected cell's biologic mechanisms and make the cell produce new viruses. The authors identify 295 cellular cofactors required for viral replication and identify genes required for viral cell entry, growth, and replication. This type of new information allows researchers to investigate new ways to disrupt and stop viral replication.
12/20/09: In a research finding published today (JAMA. 2010; 303[1]:doi:10.1001/JAMA.2009/1911), investigators show that a single dose of the H1N1 vaccine effectively produces protective antibody responses in 92.5% of children with a single dose. "Our findings suggest that a single dose 15-microgram dose vaccine regimen may be effective and well tolerated in children, and may have positive implications for disease protection and reduced transmission of pandemic H1N1 in the wider population," the authors concluded.
12/19/09: Quest diagnostics has indicated that a 75% decrease in H1N1 testing may be a signal that the current "second wave" of infections is ending in the U.S. However, they suggest caution as the Christmas season may begin a third wave.
12/16/09: Three articles published by The Lancet (DOI: 10.1016/S0140-6736(09)62026-2) report the conclusions of three vaccine studies from the USA, China, and Hungary. The vaccine studies show that one dose of H1N1 influenza vaccine should give adults protection from infection, while two doses could be required for children aged less than 9 years in the USA study or less than 12 years for the Chinese study.
12/15/09: CDC officials indicated that about 800,000 doses of Sandofi – Aventis H1N1 children's vaccine are being recalled because the amount of virus in the prepared doses was less than specified. "While the antigen content of these lots is now below the specification limit for the product, the CDC and FDA are in agreement that the small decrease in antigen content is unlikely to result in a clinically significant reduction in immune response among persons who have received the vaccine," the CDC said.
Researchers at the Department of Energy's Pacific Northwest National Laboratory have developed mathematical formulations to assist planners in predicting what happens to populations when pandemics occur. The "Pandemic Influenza Planning" models the spread of a disease through various age groups and geographic populations and allows planners to analyze potential outcomes for different scenarios in advance. In another research paper, the December issue of the Journal of Critical Care, researchers suggest that hyperproduction of interleukin 17 (TH17) is found in severe infections caused by H1N1 and not in patients with mild infections. They suggest TH17 contributes to H1N1 disease severity and suggest that "By targeting or blocking TH17 in the future, we could potentially reduce the amount of inflammation in the lungs and speed up recovery."
12/14/09: WHO officials report that over 208 countries and other entities (territories and communities) worldwide have reported H1N1 infections. Although only about 10,000 deaths have been documented, WHO acknowledges this is probably a low number as many cases are underreported, not reported or not documented as H1N1.
In Eurosurveillance, Volume 14, Issue 49, a case report said two patients (in France) with H1N1 flu continued to shed virus for 14 and 28 days after initial flu symptoms. This prolonged viral shedding occurred even though both patients were treated with antiviral medications, but was not associated with the mutation H275Y in the neuraminidase structure.
12/11/09: The New England Journal of Medicine published an article describing transfer of Tamiflu-resistant H1N1 flu among six individuals (http://content.nejm.org/cgi/content/full/NEJMc0910448v1 ). The individuals (in Vietnam) were unrelated but shared space on the same train car. None were taking Tamiflu and none had any known association with other people with Tamiflu-resistant H1N1 infection or H1N1 in the week before the train trip. When tested, all six patients showed the H275Y neuraminidase mutation that confers Tamiflu resistance in their H1N1 isolates. This is the first community transmission of Tamiflu-resistant H1N1 reported without selective drug pressure seen in hospitalized patients treated with Tamiflu. Fortunately, all of the individuals recovered. The investigators suggest monitoring strains for resistance may be useful and Tamiflu should be "…restricted to prophylaxis and treatment in high-risk persons or the treatment of people with severe or deteriorating illness…"
For the fifth sequential week, The CDC has reported a decrease in doctor's office visits for flu and flu-like symptoms. Confirmed (not estimated, see Dr. Frieden's statements on 12/10/09 below) pediatric deaths due to H1N1 are 224, and 2 are now confirmed for seasonal flu (data collected between Aug. 30 –Dec. 5, 2009).
12/10/09: Dr. Frieden, Director of the CDC, said the following today: "By November 14th, many times more children and younger adults, unfortunately, have been hospitalized or killed by H1N1 influenza than happens in a usual flu season. Specifically, there have been, we estimate, nearly 50 million cases, mostly in younger adults and children. More than 200,000 hospitalizations, which is about the same number that there is in a usual flu season for the entire year. And, sadly, nearly 10,000 deaths, including 1,100 among children and 7,500 among younger adults. That's much higher than in a usual flu season. So as we've seen for months, this is a flu that is much harder on younger people and fortunately has largely spared the elderly until now. What that means, if you calculate it, is that about 15% of the entire country has been infected with H1N1 influenza and that means about 1 in 6 people. That still leaves most people not having been infected and still remaining susceptible to H1N1 influenza." He said these calculations (based on data from April 15th to November 14th, 2009) are what the CDC promised to deliver on a monthly basis. He further indicated that in American Indians and Alaskan Natives the death rates were about four times the normal rates; the causes are being investigated and the CDC is trying to get H1N1 vaccine to these susceptible groups. In answers to questions, Dr. Frieden said vaccination is still recommended for the H1N1 and seasonal (conventional) flu, and we cannot predict accurately what will occur during this flu season (for example, will the conventional flu cases dramatically increase or will there be a another large wave of H1N1infections?). In a response to use of antiviral drugs, Dr Frieden stated "All of the evidence that we've seen about Tamiflu is consistent with our recommendations. We don't recommend it for routine cases of influenza in healthy people. In this season we do recommend that people who have underlying conditions or people who are severely ill get promptly treated with anti-virals because that will reduce the likelihood of severe illness and death."
12/9/09: Controversy between Roche and researchers about the effectiveness of Tamiflu in preventing pneumonia in healthy people who get H1N1 infections is ongoing. The publication in the British Medical Journal (BMJ 2009; 339:b5106 doi:10.1136/bmj.b51060) states findings that suggest Tamiflu has very little effect in reducing symptoms in healthy individuals; Roche (the producer of Tamiflu) disagrees and has decided to make all key data available on Tamiflu available to qualified researchers.
For those individuals who have an interest in molecular biology, genetics, and H1N1 infections, the article http://www.pnas.org/content/early/2009/12/
04/0911915106 from the Proceedings of the National Academy of Sciences details the molecular changes in the RNA strands that allowed H1N1 to become the rapidly transmissible and infective pathogen it is currently. The research centers on the mutational changes that modify the polymerase, an enzyme which, in turn, allows effective replication of H1N1 in human cells even though the virus contains a majority of genomic material that belongs to swine and avian strains that normally do not replicate well in human cells.
12/8/09: Development of a flu vaccine that is reportedly effective against all flu strains has completed its initial trial in Israel. The vaccine is based on developing an antibody and cellular immune response to epitopes (antigens) that are found in all strains of influenza viruses. Dr. Ron Babecoff, CEO of BiondVax, says, "We are very proud of the success of the phase I/II clinical trial for the Multimeric-001 Universal Flu Vaccine and of this initial proof of the immunogenicity and safety of our vaccine. The results obtained in this trial are an important indication of a significant milestone toward the realization of the company's vision of ensuring protection against all flu strains through the use of a single vaccine. Such a vaccine is expected to do away with the need for annual vaccinations every year as required by current existing vaccines." The first trial results are being presented at the World Influenza Congress today in Belgium.
A joint study from Harvard and the U.K. suggests H1N1 may not be any more lethal than the conventional flu. However, a younger, rather than older population may be impacted with children 0-4 years of age and adults 18-64 years of age suffering the most hospitalizations and deaths (PLoS Medicine, online Dec. 7, 2009).
12/7/09: WHO officials say it is too early to declare the end of the H1N1 pandemic. They do agree that even though there are some indications the flu may have peaked in the Americas, there is enough variation in reports and it is too early in the flu season in the northern hemisphere to make that decision.
A novel approach to antiviral medication termed "rational drug design" was presented at the American Society for Cell Biology (ASCB) 49th Annual Meeting. The method uses computer searches of algorithms by taking the known shapes of drugs and matches them, one after another, to the known shapes of disease-related proteins that occur on viruses (and potentially other pathogens). The authors suggest this approach will allow investigators to use current compounds to be mixed and matched to be effective antiviral medications. They claim they have found about six compounds that should inhibit flu virus neuraminidase better than Tamiflu and Relenza. However, these investigators indicate that studies are still ongoing but may yield additional, more effective antiviral drugs than those currently available.
12/6/09: The CDC published new safety data on the H1N1 vaccine at http://www.cdc.gov/h1n1flu/in_the_news/vaccine_safety_summary.htm; they conclude the vaccine continues to show a good safety profile. So far, after about 50 million doses, 204 serious events have been recorded (defined as life-threatening or resulting in death, major disability, and abnormal conditions at birth, hospitalization, or extension of an existing hospitalization). Included in this number are 13 deaths, 10 cases of Guillain-Barré syndrome, and 19 cases of anaphylaxis. The report does not indicate if vaccination with H1N1 vaccine caused these problems, but investigations by the CDC of each case are ongoing to further determine if these cases are simply concurrent and not related to the vaccine or if vaccine played any significant role in the serious events.
12/5/09: Reports from China stated that several H1N1 infections have been documented in domestic dogs. Chinese officials indicate that although it may be possible for dogs to transmit the virus, they deem this form of transfer unlikely and report no dog-to-human transmission of H1N1. In related Chinese news, officials have reported that only about 27 million Chinese people have been vaccinated with H1N1 as of last week.
12/4/09: Dr. Frieden, director of the CDC, stated today that the H1N1 still is very active in about 25 states but continues to decline in the other 25 states. He reiterated that ongoing monitoring for adverse reactions to the H1N1 vaccine showed the vaccine is safe and is unlikely to have any serious side effects such as Guillain-Barré disease associated with inoculations. He indicated there are 210 deaths in children from proven H1N1 infections, which already is about three times the average number in a conventional flu season. Dr. Frieden commented that he was pleased that in some areas of the U.S. a high percentage (about 80%) of children were being vaccinated, which he hopes will limit H1N1 deaths in children.
One questioner stated that the fatality rate was estimated to be only 0.018% of H1N1 cases, which is lower than conventional (seasonal) flu fatality rates and wanted Dr. Frieden to comment. Dr. Frieden said that H1N1 was sparing the older population (>64yrs) but was hitting the younger population (<50 years and especially children). Antiviral medications, resiliency of youth, quick access to critical-care facilities, and immunizations all contribute to reducing the fatality rate; however, he indicated this flu season is far from being over, so what may occur from now to May 2010 remains to be experienced. In addition, he answered another question about potential genetic recombination between avian H5N1 and H1N1 by saying that the current H1N1 vaccine should offer protection as the vaccine targets the H1N1 virus infectivity sites which would likely be similar if such a recombinant virus developed. In response to a comment about minority groups not getting vaccinated, Dr. Frieden said the CDC is trying to reach all groups to provide vaccine, especially those in the high-risk groups and is encouraging state agencies to help do this.
12/3/09: Health and Human Services officials, as per Secretary Kathleen Sebelius, plan to do a major review of the government's efforts to respond and protect people from pandemics. This review plans to address "antiquated technologies" and vaccine shortages and will streamline regulations to speed approval of new technologies developed in response to health threats and bioterrorism.
In a technology-related article, Novavax, Inc., announced favorable outcomes in Mexico with its initial trial (stage A) of VLP H1N1 vaccine in about 1,000 people. VLP vaccines are made from the viral coat antigens but contain no live genetic material (viral genome). VLPs can be designed to match individual viral strains and are produced quickly with portable cell-culture technology instead of egg-based cultures that require significant time and materials to produce vaccine. The trials will go to stage B (about 3,000 people inoculated), because stage A indicated the new vaccine type was safe and effective in generating a protective level of antibody response.
In world news, the WHO has approved GlaxoSmithKline's H1N1 vaccine for purchase and use in developing countries. Several news services have reported a sharp increase in H1N1 deaths (from 53 to 178 in one week reported by China); the Chinese officials deny any "cover-up" of numbers of deaths but say that the H1N1 situation is "grim."
12/1/09: Dr. Frieden of the CDC described the current H1N1 flu situation as one of decreasing disease and increasing vaccine supply (about 70 million doses to date). After questioning a number of flu experts, their conclusion that this wave will be followed by another wave of increased cases is about a fifty-fifty chance. Unfortunately, other flu pandemics similar to the current H1N1 had a second high wave beginning in December, but no one knows what will occur with the H1N1 pandemic since each pandemic is unique. He commented on the mutations (see 11/30/09 entry below) found in H1N1 but suggests the vaccine should work in preventing the majority of these viruses from causing disease.
The CDC reported that a scam involving fraudulent emails about state-sponsored vaccinations was circulating on the web. The CDC said it has no program that requires individuals to register personal information at a web site to get a vaccine dose and cautions people not to respond to such offers by email.
11/30/09: The CDC today reported that widespread flu decreased for 43-32 states and that visits to doctors for flu-like symptoms also decreased. However, the numbers of deaths due to pneumonia and influenza remained high (above the epidemic threshold) for the last eight weeks.
In the past weeks, two mutations in H1N1 have been reported to occur in H1N1 in Norway and Ukraine. These two mutations are termed D225G and D225E. These two changes are in the virus sites that allow the virus to bind to host (human) tissues. The D225G binding site has been noted previously in the 1918 flu pandemic strains. D225E is still being studied, but investigators speculate it does not have the same affinity for lung tissue as D225G. Although only a few viral strains isolated have these mutations, it is not yet clear how they affect virulence of the H1N1 virus. Some investigators have strongly suggested that D225G helps to increase the chance of deep lung infections, but this is still under investigation. Unfortunately, four people infected with D225G have died, according to reports from Ukraine officials. In addition, the CDC has received sporadic reports of these changes found in viral H1N1 isolates from Australia, Brazil, China, Japan, Mexico, Saudi Arabia, Uruguay, and the United States. The H275Y mutation in H1N1 (associated with Tamiflu resistance) has not yet been reported to occur in these D225 mutant strains, but investigators are aware that such viral strains that contain multiple mutations may eventually be found.
11/27/09: BMC Infectious Diseases, a research publication, is publishing a study that claims school closings can reduce the pandemic spread of the flu by 21%. The study concludes this reduction by using mathematical models with data gathered from a survey of eight European countries. They caution that the "expected large macroeconomic costs of school closures would have to be balanced against these benefits."
11/26/09: This week, Chinese experts on the flu warned that China needs to be on the lookout for a mutation that could mix H1N1 with H5N1, the avian flu virus. Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases, said the presence of both viruses in China meant they could mix and become a monstrous hybrid -- a bug packed with strong killing power that can transmit efficiently among people. "China, as you know, is different from other countries. Inside China, H5N1 has been existing for some time, so if there is really a reassortment between H1N1 and H5N1, it will be a disaster," Zhong said. "This is something we need to monitor, the change, the mutation of the virus. This is why reporting of the death rate must be really transparent."
The WHO, in a separate announcement, warned on Tuesday that H5N1 had erupted in poultry in Egypt, Indonesia, Thailand, and Vietnam, posing once again a threat to humans.
The CDC has reported an increase in serious cases of pneumococcal disease coincident with increases in influenza-associated hospitalizations. The example of limited data the CDC quoted is from the Denver area (five-year average number of coincident cases in October, ~20; total number in October 2009, 58). The CDC noted the data is preliminary and is planning to examine this situation further. Although many coincident flu/pneumococcal disease usually occurs in people 65 and older with seasonal flu, the Denver cases occurred primarily (62%) in ages 20-59 and are H1N1.
11/25/09: The pigs that get the swine flu have not been forgotten. A H1N1 vaccine for pigs has been developed at Iowa State University with about 20,000 doses sent to pig farmers. Professor Harris at Iowa State confirmed the known fact that there is no threat of humans getting H1N1 from eating pork from pigs that had H1N1 virus.
OSHA (Occupational Safety and Health Administration) issued a compliance directive to identify and minimize or eliminate high-risk occupational exposures to the 2009 H1N1 influenza A virus. It follows the CDC recommendation for the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for health-care personnel who are in close contact (within 6 feet) with patients who have suspected or confirmed 2009 H1N1 infection. Where respirators are not commercially available, employers will be considered to be in compliance if they can show a good-faith effort has been made to acquire respirators.
11/24/09: The CDC indicated 51,798,420 doses of H1N1 have been shipped throughout the U.S.
11/23/09: The Public Health Service of Wales has reported nine cases of H1N1 in a ward, five of which are resistant to Tamiflu. One is not resistant, and the other three are being studied. Patient-to-patient transfer is being investigated. Worldwide, the WHO has reported about 57 patients with Tamiflu-resistant H1N1, so only an extremely small number of drug-resistant cases have been identified, and Tamiflu is still considered an excellent antiviral drug to treat the vast majority of H1N1 infections.
11/22/09: According to the WHO, after 65 million doses of H1N1 vaccine have been given, the main side effects are pain, swelling, and redness at the injection site and occasional fever and headache that are gone after 48 hours. The WHO said that deaths (a total of 41 from six different countries) in those who obtained the vaccine were not directly related to the vaccine; the WHO deemed H1N1 vaccines as safe as the conventional flu vaccine.
11/21/09: Four people with H1N1 now form the largest cluster of Tamiflu-resistant H1N1 reported in the U.S. Health officials at Duke University reported all four people were located and diagnosed at their facility over the last six-week period. The ill patients were reportedly located in a cancer treatment unit, and three of the four people have died.
11/20/09: In a CDC briefing, Dr. Schuchat indicated a decrease in flu activity, although for this time in the season, activity was still relatively high. Because of the unusual behavior so far of H1N1, she indicated that no one can predict if the decrease will continue or a new wave of infections will begin. She urged people to check the Flu.gov web site and view the CDC's recommendations for this holiday season's travel tips to lessen the chances of spreading the flu. She indicated how sorry she was that people are still frustrated in seeking H1N1 vaccine and not getting it. She noted that vaccine is being shipped to state health departments and is being shipped as soon as possible after production. In response to a question about mutant viruses found in Norway, she stated that the CDC will follow this information but said that currently there is no evidence the mutation has changed the H1N1 virus to make it more virulent or diminish vaccine response. She also noted that the CDC will follow developments reported in Wales where a small cluster of patients with of Tamiflu-resistant H1N1 have been reported. When asked about the approximate one-third of pediatric deaths that occur in previously healthy children, Dr. Schuchat indicated that a major common problem that developed in these H1N1-infected patients was a severe secondary bacterial lung infection with either Streptococci or Pneumococci. She indicated that a pneumococcal vaccine is available for children under 5 years old and encouraged its use.
As per two reports (from Mexico and the U.S. Armed Forces Health Surveillance Center (AFHSC) in Silver Spring, Maryland) that indicate that people vaccinated with the seasonal flu either show some protective response to H1N1 or less severe H1N1 disease, Dr. Schuchat indicated that current results from two other studies in Australia and the U.S. show no increase or decrease in protection from H1N1 with the conventional (seasonal) flu vaccine. There may be conflicting data from these four reports and perhaps with other reports. Regardless, Dr. Schuchat said, "What I can say is that we believe the seasonal flu vaccine is a good idea to protect against seasonal flu strains in general and the H1N1 vaccine is needed to protect against H1N1 disease." She also indicated it is likely that a strain of H1N1 virus will be included as one of the viruses included in the trivalent conventional vaccine for the next flu season.
11/19/09: A major contraindication for people not to get H1N1 flu vaccine (and other flu vaccines) is allergy to eggs; currently approved vaccines are produced using eggs. Dr. Catherine Monteleone, an allergist at the University of Medicine and Dentistry of New Jersey, has noted that there are ways for such people to get the H1N1 vaccine. She suggests that egg allergic or suspected egg allergic patients contact an allergist and get skin tested for egg allergy. If the test is negative, the person can get vaccinated; if the test is positive, some people can still get the vaccine using a special method. "It may still be possible to administer the vaccine in graded doses," she explained. "During the office visit, increasing doses are given every 15 minutes, for a total of five doses." Then the person is observed for 30 minutes, and if there are no reactions, the person is considered vaccinated. However, this vaccination needs to be done in a special setting where emergency interventions can be done if the person has an allergic reaction.
11/18/09: Two reports about H1N1 testing were available today. The first report from Loyola University warns that the current rapid flu tests may be dangerous because they are wrong so often (about 50%) and may cause caregivers to delay important treatment. The second report is that the FDA just gave Roche an emergency-use authorization for a new PCR test for H1N1 after multiple studies suggest it is reliable.
11/17/09: Novavax, Inc., announced it will begin studies in Mexico on a new vaccine against H1N1. Initially, about 1,000 people will participate. The new vaccine is made from virus-like particles (VLPs) that mimic a viral strain's outer coat but contain no viral genetic material. VLPs are produced by cell-culture technology and do not require culture in eggs like most currently approved flu vaccines.
The FDA has approved a fifth vaccine for use against H1N1; this vaccine is made by ID Biochemical Corporation of Quebec, Canada. Like the other four approved for use in the U.S., this vaccine is produced by growing the virus in eggs. This new approval will help get more vaccine to the U.S.
Researchers at La Jolla Institute for Allergy & Immunology have found that previous flu infections may provide at least some level of immunity to H1N1 by looking at molecular markers for seasonal influenza viruses dating back 20 years and comparing them with the molecular markers of the H1N1 virus. The study was published today in the proceedings of the National Academy of Sciences and suggests that T cells more readily recognize H1N1 than B cells and maybe these cells are responsible for less severe infections in individuals who have been exposed to flu viruses that have some similar molecular structures to the H1N1 virus. The investigators suggest that T cells, while not able by themselves to prevent H1N1 infection, do recognize these similar molecular structures and attack H1N1 in many individuals before the infection becomes severe. Since only about 17% of B cells that produce antibody recognized H1N1, the researchers said vaccination is still the best way to combat H1N1, especially for prevention.
11/16/09: People in other countries are experiencing the same concerns about H1N1 safety. The response from most medical departments is similar to that expressed in the U.S. For example, the Irish Department of Health says that the new vaccine is not related to the 1976 vaccine, that no evidence shows that thimerosal causes any problems, the vaccine is safe to use in pregnancy, and that its benefits far outweigh any risk. They reemphasized these points so that populations in other countries where H1N1 is prevalent (about 206 countries in the world) can gain confidence in the vaccine.
11/13/09: Yesterday afternoon, the CDC published revised estimates of numbers of U.S. people infected with H1N1. In the CDC report (http://www.cdc.gov/h1n1flu/
estimates_2009_h1n1.htm), the administrators describe the rationale for these new figures; they are based on best estimates of underreported cases and deaths from H1N1 flu due to the inability of each case being laboratory confirmed and the lag time of reporting from many hospitals and clinics. The CDC goes on to suggest the actual numbers may never be known and suggest the "true" numbers are most likely to be in the mid-level ranges (see above table). Their methodology and rationale is further detailed in several publications cited in this CDC web article.
The CDC also published estimated deaths from H1N1. The following is from the CDC:

CDC Estimates of 2009 H1N1 Cases and Related Hospitalizations and Deaths from April-October 17, 2009, by Age Group

2009 H1N1	Mid-Level Range*	Estimated Range *
Cases
0-17 years	~8 million	~5 million to ~13 million
18-64 years	~12 million	~7 million to ~18 million
65 years and older	~2 million	~1 million to ~3 million
Cases Total	~22 million	~14 million to ~34 million
Hospitalizations
0-17 years	~36,000	~23,000 to ~57,000
18-64 years	~53,000	~34,000 to ~83,000
65 years and older	~9,000	~6,000 to ~14,000
Hospitalizations Total	~98,000	~63,000 to ~153,000
Deaths
0-17 years	~540	~300 to ~800
18-64 years	~2,920	~1,900 to ~4,600
65 years and older	~440	~300 to ~700
Deaths Total	~3,900	~2,500 to ~6,100
* Deaths have been rounded to the nearest ten. Hospitalizations have been rounded to the nearest thousand, and cases have been rounded to the nearest million.

In an afternoon CDC news conference, Dr. Schuchat discussed the above estimates and indicated the data would be revised about every three weeks. She also addressed the lack of vaccine and indicated people should still seek out local sources that may have it. She addressed a question about some doctors and others who do not think the vaccine is "safe" and do not recommend it; she indicated that the CDC is as transparent on this issue as possible -- the CDC has repeatedly indicated it is safe. Dr. Schuchat also indicated that to date, that although this H1N1 flu is different from conventional (seasonal) flu, it is nowhere near the severity of the 1918 flu pandemic.
This week, the FDA approved GlaxoSmithKline's supplemental biologics license application for its unadjuvanted influenza A (H1N1) pandemic vaccine and also approved CSL Biotherapies' application for accelerated approval of its seasonal flu vaccine, Afluria (influenza virus vaccine) for use in the pediatric population aged 6 months and older. The FDA approval included labeling for CSL Biotherapies' influenza A (H1N1) 2009 monovalent vaccine, which is an inactivated influenza virus vaccine now indicated for active immunization of people 6 months of age and older against influenza disease caused by pandemic (H1N1) 2009 virus. These approvals may allow additional vaccine supplies to become available.
11/12/09: Headlines (for example, CNN, New York Times) state CDC officials calculate over 4,000 deaths (as opposed to about 1,200 currently reported) are due to H1N1 flu. However, the new estimate of deaths will not be released until sometime next week because the CDC's consultants are still looking over the figures, said Glen Nowak, a CDC spokesman. The new data from the CDC will be based on both confirmed and likely H1N1 infections associated with deaths.
Amarillo Bioscience announced that studies with interferon (oral and nasal) have had good responses in controlling viral infections in animals, while another study group suggests that interferon can be used to control human flu infections. This is still in the developmental stages of research and has not been approved for use in the U.S. Another company, GalaxoSmithKline, announced that Pandemrix, an adjuvant used to enhance the flu vaccine, was very successful in a human trial to boost the immune response to vaccine. This is not approved for use in the U.S., but other countries may consider its use to reduce the vaccine amount needed to get an immune response and thereby have more vaccine doses available.
The Lancet just put online (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61638-X/fulltext) an article about the results on H1N1 flu in Mexico, from April to July 31, 2009, on a large number of individuals (6,945 confirmed H1N1). The results are quite different from initial observations. The authors report that although the infection rate was highest in young people, the highest death rates were in the elderly (>70 years old was 10.3%). The authors indicated that people who had obtained regular yearly flu vaccinations were 35% less likely to get infected with H1N1. The data for the death rate under age 70 is as follows:

60-69 years 5.7%;
50-59 years 4.5%;
40-49 years 2.7%;
30-39 years 2%;
under 1 year 1.6%;
20-29 years 0.9%;
1-9 years 0.3%;
10-19 years 0.2%.

11/11/09: NanoViricides, Inc., representatives have been invited to participate in a panel discussion at the Influenza Congress USA 2009, in Washington, D.C., on Nov. 19 due to the research success of "FluCide," an experimental antiviral drug reportedly highly effective against all forms of influenza A, including the recent "swine flu" 2009/CA/H1N1 strain, seasonal flu strains, as well as H5N1 bird flu strains. The antiviral has not been approved for use in humans, but it represents a new class of drugs that may useful in treating human viral infections in the near future.
11/9/09: A Harvard study conducted a poll of U.S. citizens (1, 073 people over age 18) from Oct. 30-Nov. 1 on the availability of the H1N1 vaccine. The results showed that 17% of American adults, 41% of parents, and 21% of high-priority adults have tried to get the H1N1 vaccine and 70% of adults who tried to get it for themselves were unable to get it. Only 34% of parents who tried to get the H1N1 vaccine for their children were successful in getting their children vaccinated. Among high-priority adults who tried to get the H1N1 vaccine, 66% were unable to get it. About 33% said they were frustrated in their efforts, but about 91% who failed to get the vaccine said they would try again.
Yesterday, the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Association for Professionals in Infection Control and Epidemiology (APIC) urged the Obama administration to issue an immediate moratorium on the Occupational Safety and Health Administration's (OSHA) enforcement of the current requirements to use N95 masks by health-care workers. This was done since two articles have indicated the N95 masks (which are in short supply and are expensive) do not offer better protection against H1N1 flu than the standard surgical masks.
11/6/09: The CDC's Dr. Schuchat commented on the availability of vaccine doses against novel H1N1 flu. She indicated that about 8-10 million doses per week would becoming available in the next few weeks. Although she noted some glitches in the distribution system, in general, it is still being distributed by population percentages. She indicated that about 38 million doses are currently available with about one-third being the nasal type; however, she empathizes with those seeking vaccine but cannot find it available. In terms of the H1N1 disease progression, she said, "More than half the hospitalizations are in people under 25. Ninety percent of the deaths are in people under 65 -- a flip-flop from what we see with seasonal flu. The pediatric deaths are high. Children have died from flu where the typing wasn't done, but that's an increase from last week's number. Two-thirds of the children who died from the H1N1 virus have underlying conditions that are increasing their risk of this problem. The leading underlying conditions in children who have died are severe neurologic problems like cerebral palsy and muscular dystrophy and asthma in terms of contributing to the severe outcomes." She further indicated that antiviral drugs are effective treatments and commented that the use of an intravenous antiviral medication has recently begun.
When asked about the risk of H1N1 mutating, Dr. Schuchat said, "Well, influenza viruses change. That's inevitable. Mutations occur. The key part is will we see something in the near future that makes it change markedly to something more severe than what we are seeing or is there a change that would occur to leave the virus to escape the vaccine? Both of those changes are possible. Fortunately, we haven't seen any of those yet. We have been testing many of the viruses. It hasn't changed genetically or in the immune characteristics." So far, that is good news because the H1N1 vaccine remains potentially effective in preventing most infections.
11/5/09: The American Veterinary Medical Association (AVMA) reported that health officials in Iowa confirmed that a domestic cat had tested positive for H1N1 swine flu. This is the first documented H1N1 domestic cat infection; the cat has recovered. Several family members had flu-like symptoms before the cat became ill. This is another likely case of human-to-animal flu transfer; such transfers have been reported in several countries (from humans to pigs), and there have been reports of transfer from humans to turkeys in Chile and Canada. The H1N1 virus has also been detected in other bird types and in ferrets, but the link to humans is not as clear as in the pig and cat transfers.
One of the few contraindications to getting the H1N1 flu vaccine is allergy to eggs or egg products. Phadia produces an ImmunoCAP allergy test that measures IgE antibodies, which indicates a clinical allergic reaction, to both egg white (f1) and ovomucoid (f233). The f1 test can help the physician to confirm or rule out an allergy to egg white. If an allergy to egg white is confirmed, the f233 follow-up test can be conducted to identify the severity of egg allergy and whether the child is at low or high risk for an allergic reaction. The FDA has approved this test for clinical IgE measurements.
11/4/09: At an afternoon CDC press conference yesterday, Dr. Frieden reiterated the need for both conventional (seasonal) and H1N1 vaccinations. He said that the supplies of both are being increased and was pleased that people were actively seeking vaccinations. He encouraged the use of antivirals according to the published CDC guidelines. He mentioned that people who are obese (body mass index = 40 or more) seem to have an increased risk for H1N1 complications but studies are ongoing. He indicated that donations of vaccine to other countries were still under study as to when that would occur. He was asked about a new journal article (JAMA 302.17 (2009): 1896-1902.) twice because the data found a higher death rate in older patients (>50) than younger once they were hospitalized, even though a higher number of younger people (<25 years old) were hospitalized. The paper states, "Overall fatality was 11% (118/1088) and was highest (18%-20%) in persons aged 50 years or older." This data was accumulated in California between Apr. 23 and Aug. 11, 2009. Dr Frieden indicated CDC data agreed with the findings of more hospitalizations in young people (<25 years old) and said caregivers "should think of H1N1 influenza in all age groups. It doesn't change what our recommendations would be for vaccination."
On the technical front, two new products are offered to improve diagnosis of H1N1. Repro-Med Systems, Inc., announced a new Specimen Collection Kit (SCK) for its RES-Q-VAC portable handheld suction pump. They claim the new kit makes it especially convenient for medical personnel to collect samples in accordance with guidance recommendations and local procedures, while other researchers suggest that data shows "flocked" (velvet-like surface) swabs collect better specimens for H1N1 detection.
11/3/09: WHO officials reported a rise in deaths (700) in the last week, with most occurring in the Americas; they further report an estimated 440,000 confirmed H1N1 flu cases. Flu experts state that the number of infected people is likely much higher since only confirmed infections and deaths are now being collected. The WHO also recommended only one-dose injection in children because of the world shortage of vaccine; however, the U.S. still recommends two doses in children ages 6 months through 9 years. The U.S. data suggests that a maximum of 55% of children showed protective antibodies 21 days after a single injection with younger children (6 months to 35 months) far less (25%). In other world-related news about H1N1, the Ukrainian prime minister closed schools, universities, public gatherings, and imposed travel restrictions for three weeks because of 53 deaths attributed to H1N1. The Afghan government has also closed schools for three weeks due to the rise in H1N1 flu cases.
The CDC announced that studies in pregnant women showed that a single dose of the injectable H1N1 vaccine showed protective antibodies in 92% of women after 21 days.
11/2/09: The CDC published (http://www.cdc.gov/eid/content/15/12/pdfs/
09-1413.pdf) the most recent estimates of novel H1N1 infections in the U.S. using methods that even local health districts can use to estimate their local number of H1N1 infections. The CDC estimates that between April and July 2009 about 1.8-5.7 million people in the U.S. became infected with H1N1. They also estimated about 9-21,000 hospitalizations during that time.
Research is ongoing for the development of antiviral vaccines, especially against novel H1N1 flu. A company, FluGen, announced that it has produced a CHO-cell line (Chinese Hamster Ovary cell line) in which the H1N1 virus can replicate (grow), thus producing H1N1 for vaccine production that is not based on viral growth in eggs. The company reports its viral growth is much faster than that for eggs yet produces good viral yields. This process is not yet in a production phase, and the vaccine is not yet approved by the FDA but eventually may result in a fast, less expensive egg-free way to produce flu (and other) vaccines.
A controversial research paper was presented that proposes that vaccination of children ages 6 months to 5 years of age theoretically could be detrimental if another pandemic of flu strikes. The authors said, "Preventing infection with seasonal influenza viruses by vaccination might prevent the induction of heterosubtypic immunity to pandemic strains, which might be a disadvantage to immunologically naïve people, such as infants." Because this is so controversial and may be construed by some people that as meaning that they should not vaccinate young children, the journal has published a commentary by other researchers that stated, "Public-health decisions should be based on the best clinical evidence available. There is ample evidence for the great burden of influenza in young children, and this burden appears during every influenza season. By contrast, there is no clinical evidence that vaccinating children against influenza would prevent the induction of heterosubtypic immunity and thereby be disadvantageous to children in the long run. While waiting for improved influenza vaccines, the simple question is Should we let young children suffer from a severe and potentially lethal but easily preventable illness just because there is a theoretical possibility that withholding vaccination might result in a slightly less severe illness sometime in the future? We believe that the answer to this question is a simple one (No)." Access to the two articles (research and commentary) can be done by going to http://www.lancet.com/journals/laninf/onlinefirst.
11/1/09: The CDC and others concerned about vaccines in children again indicated that the millions of children who are already battling other diseases -- including asthma, rheumatoid arthritis, HIV, irritable bowel disease (IBD), and other digestive disorders such as Crohn's disease -- can receive the H1N1 vaccine when already taking an immunosuppressant medication that weakens the immune system but controls their disease. The family members of such children should also obtain the vaccine to reduce any chance of exposure to the virus. However, the nasal spray vaccine, which contains live attenuated virus, is not to be used in patients taking any immunosuppressants.
The Strategic Advisory Group of Experts (SAGE) that provides advice to WHO on H1N1 indicated that, worldwide, teenagers and young adults continue to account for the majority of cases, with hospitalization highest in very young children. About 1%-10% of patients with clinical illness require hospitalization, while 10%-25% of those hospitalized require admission to an intensive care unit. About 2%-9% die. Approximately 7%-10% of all hospitalized patients are pregnant women in their second or third trimester. According to their report, pregnant women are 10 times more likely to need care in an intensive-care unit when compared with the general population. Although the SAGE group has begun to evaluate the several types of vaccines available to countries outside the U.S., including vaccines made with adjuvants, most of the recommendations parallel those made by the CDC for age, dosage, and susceptible groups. One recommendation that does not follow the CDC recommendations is the use of nasal (live, attenuated virus) in pregnant individuals. Based on animal studies and data suggesting the high risk of a poor outcome in pregnant individuals, SAGE advised the WHO to recommend that any (including the live, attenuated virus in the nasal mist) approved vaccine available to pregnant females should be used, providing no specific contraindication is present.
10/30/09: Dr. Frieden of the CDC gave an update on H1N1 and said that 48 states now had widespread flu, and in the last two months, more people have been hospitalized under the age of 65 than the number seen in a conventional flu season. Although a few areas were reporting a reduction in flu cases, overall the numbers of cases in the U.S. continue to increase. He also reported a high number of deaths (total 114, last week, 19) in children. Because of the high death rate in children, he said, "On Oct. 1, we released 300,000 (Tamiflu) courses from the strategic national stockpile (SNS). We are now releasing an additional 234,000 courses of liquid Tamiflu from the strategic national stockpile. That is the entire supply from the SNS." In addition, he mentioned that qualified pharmacists can now use adult capsules of Tamiflu to compound the lower pediatric fluid doses. He expressed concern that high-risk people are not seeking medical care in a timely manner and this could increase hospitalizations and deaths. He said vaccine availability was less than demand for both the conventional and H1N1 flu vaccine and said supplies were constantly being increased, although it would likely take time (weeks to months) to begin to meet demand.
News on research findings done to diagnose and treat H1N1 flu was announced today. In an article that will be published in the November 2009 print issue of the FASEB Journal (http://www.fasebj.org), Dr. Matalon and colleagues from the University of Alabama showed that the flu virus damages lungs through its "M2 protein," which attacks the cells that line the inner surface of lungs (epithelial cells). Specifically, the viral M2 protein disrupts lung epithelial cells' ability to remove liquid from the lungs, which often allows pneumonia and other lung problems to develop. The research shows, in the laboratory, that viral M2 protein can be markedly inhibited by antioxidants, thus potentially providing another method to treat severely ill flu patients. In another study done by investigators at Translational Genomics Research Institute (TGen), a new test was developed that can detect not only the strain of flu (for example, conventional or novel H1N1 flu) but also whether or not the strain may be resistant to oseltamivir (Tamiflu). The company is applying to the FDA for approval for use in human testing.
In world-related novel H1N1 news, the WHO is planning new recommendations for vaccinations to be announced next week. Because of reduced vaccine production, there are likely to be shortages of doses available to other countries that have little or no vaccine production. This availability reduction is exemplified by the following statement from HHS Secretary Kathleen Sebelius, "As vaccine becomes more available, I think evaluation will be made as to when it's appropriate for donation (to other countries) to begin, but I can tell you at this point the priority is getting the vaccine to citizens in this country, and that's what we're working on 24/7."

HHS Secretary Kathleen Sebelius visits H1N1 vaccination clinics at McKinley High School in Washington, D.C. Photo courtesy of Pierre Paret/Flu.gov

10/29/09: The CDC has contracted with GE Healthcare to obtain surveillance data for both H1N1 and seasonal influenza. GE healthcare can gather information from about 14 million patient records. The CDC will use the data to track H1N1 spread and get information on areas where outbreaks occur. The data will also help the CDC to better determine population susceptibilities to the virus. The data is updated daily, which allows the CDC to quickly adapt and provide guidelines and responses to counter the H1N1's rapid advance.
10/28/09: The government said it is dependent on the approved suppliers of H1N1 vaccines to provide the estimate of vaccine availability, and it is clear the suppliers overestimated the availability of H1N1 vaccine doses. Eventually, enough vaccine will be available for those who want it. Dr. Anne Schuchat, head of the CDC's National Center for Immunization and Respiratory Diseases, said, "It's hard to predict how long the H1N1 wave will continue, so even getting vaccinated a few months from now -- when vaccine supplies are more plentiful -- won't be too late." Meanwhile, some hospitals have reported an increased number of people who require extended care for H1N1. Doctors at Johns Hopkins and other physicians (for example, in Denver, Seattle, and San Diego) are concerned that increasing numbers of H1N1 patients who require intensive care may force some hospitals to cancel elective surgery cases.
Researchers (University of Alabama, Birmingham) claim that a combination of Tamiflu, Symmetrel, and ribavirin (Rebetol, Copegus) showed excellent ability to stop viral growth, even with drug-resistant H1N1 virus. However, this research was done in lab tests only and has not been tried in vivo or approved for human use. Such research offers a new approach for potential treatment methods.
10/26/09: The first IV drug to treat certain individuals with H1N1 infection has been approved by the FDA. Peramivir is approved for limited uses. The parameters for adults and pediatric patients are as follows:

The patient is not responding to either oral or inhaled antiviral therapy
When drug delivery by a route other than an intravenous route (for example, enteral [absorbed by the intestines] or inhaled) is not expected to be dependable or feasible
For adults only, when the clinician judges IV therapy is appropriate due to other circumstances

10/25/09: Friday night, President Obama declared the H1N1 flu a national emergency; the declaration was announced Saturday. The declaration will allow medical facilities to waive some federal requirements to allow a more rapid handling of flu patients. President Obama said the pandemic keeps evolving, the rates of illness are rising rapidly in many areas, and there's a potential "to overburden health-care resources." With the declaration, Health and Human Services Secretary Kathleen Sebelius now has authority to bypass federal rules when opening alternative care sites, such as off-site hospital centers at schools or community centers if hospitals seek permission to do this. Now hospitals could modify patient rules; for example, people would be required to give less information during registration to speed patient care. The declaration also addresses a financial question for hospitals. For example, federal rules do not allow hospitals to put up treatment tents more than 250 yards away from the doors and get payment for patient care. The declaration would now allow sites further away, and the hospitals would still be able to apply for patient-care payment. Part of the problem is the lack of available H1N1 flu vaccine, due to the low yield of the virus grown in chicken eggs. With low yields, fewer viruses are available to be made into vaccine. Now the government projection is for about 50 million doses available by mid-November, far fewer than the 45 million originally projected by Oct. 15. CDC Director Dr. Thomas Frieden said, "We are nowhere near where we thought we'd be by now. We share the frustration of people who have waited in line or called a number or checked a web site and haven't been able to find a place to get vaccinated. Since the beginning of the pandemic, we've seen more than 1,000 deaths and 20,000 hospitalizations. We expect it to occur in waves, but we can't predict when those waves will happen."
10/23/09: In an article published online in the Journal of Heart and Lung Transplantation, physicians representing the International Society for Heart & Lung Transplantation's (ISHLT) Infectious Disease Council issued an advisory for all programs in cardiothoracic transplantation related to novel H1N1 concerning donor tissue and recipients. The article reemphasizes that all donor recipients are likely high-risk individuals because of immunosuppressive drug treatments and that donors' tissue records should be searched for H1N1 vaccination information. They also suggested that the donor or tissue be rapidly tested for H1N1 infection before the transplant is utilized. This is a safety procedure that may be useful in other transplant patients and their donors or donor's tissues.
At the CDC press conference, Dr. Frieden reported that novel H1N1 flu was widespread in 46 states, estimated that "many millions" have been infected, and stated that he expects many more to become infected. He indicated production of the injectable vaccine is far less than was previously projected (45 million doses by Oct. 15) because to date, only 16 million are available and about 11 million were sent out to the 50 states. This large shortfall is due to the less-than-predicted output by vaccine companies which, in turn, was related to less H1N1 growth in eggs than predicted. He also noted that the conventional (seasonal) flu vaccine was beginning to experience some shortfalls but is encouraged by the demand. The following is what he said about pregnant individuals and H1N1: "Pregnancy is a risk factor for influenza each year. It's also a risk factor for serious illness and death from H1N1 influenza; you are about six times more likely to die from H1N1 influenza if you're pregnant. So, women who are pregnant are a high priority for the vaccine. There is no evidence that thimerosal increases the risk of problems, but we would like a thimerosal-free vaccine for those who want it. The challenge is that it is used for multi-dose vials and you may have more of that product. So, finding that vaccine for those who want it may be a challenge."
10/22/09: Many physicians would have difficulty in searching their medical records to identify high-risk patients in their practices. However, Practice Fusion Inc., a free, web-based electronic health record system for physicians, today implemented a first-of-its-kind tool that allows its physician users to quickly and accurately identify all high-risk candidates for H1N1 vaccination from their patient populations using criteria published by the Centers for Disease Control and Prevention (CDC). Dr. Tamara Cheney, a family practice physician, requested Practice Fusion to provide information to Dr. Cheney that could be used to identify her high-risk patients. Practice Fusion used CDC criteria as a screen to identify high-risk patients and took an extra step and released the high-risk information to every physician in the Practice Fusion system, benefiting the entire patient community. About 300,000 individuals were identified and their respective physicians then notified.
10/21/09: Aethlon Medical, Inc., announced that a new instrument, Hemopurifier, is the first-in-class medical device able to selectively remove infectious viruses and immunosuppressive proteins from the bloodstream. During in vitro research studies, the Hemopurifier removed 68% of H1N1 virus from blood plasma in 30 minutes, 80% of the virus in two hours, and a 96% reduction of H1N1 was observed at six hours. The studies were performed by third-party researchers approved by the United States Department of Health and Human Services (HHS) to house and conduct research on the current pandemic strains of H1N1 virus. The report does not document use with human patients but is a new research tool that may be useful in treatment methods in the future.
Today, the American Journal of Roentgenology placed three articles online at http://www.ajronline.org because they show the differences that can be seen with CT as compared to chest X-rays in high-risk patients with novel H1N1 infections. They suggest that CT scans are the best way to evaluate high-risk patients. The articles will be published in the December issue, but because of the current pandemic, the journal wanted to make the findings widely available to health-care providers now.
10/20/09: At the WHO conference in Washington, D.C., WHO experts now recommend that anyone with symptoms of the flu or pneumonia be immediately treated with antiviral drugs. One reason for this recommendation is that apparently in those few susceptible people who develop viral (H1N1) pneumonia have the novel H1N1 viruses penetrating deeply into lung tissue where it seems to cause more problems than the conventional or seasonal flu viruses.
10/19/09: Florida state health officials are reported to be establishing guidelines on which patients will get ventilators if a huge number of patients with H1N1 overwhelm the hospital system. Reportedly, terminal cancer and end-stage multiple sclerosis patients would not be put on ventilators, and terminally ill patients on ventilators may be removed from them to allow others who have a better chance of survival to use the machines. Fortunately, this dire situation has not developed in the U.S., but it seems likely that other health officials are considering similar situations as they must plan for disaster situations even if they do not develop.
The USDA (U.S. Department of Agriculture) announced confirmation that a pig at the Minnesota State fair has caught swine flu. This is the first reported case in the U.S. Canadian officials had reported a similar infection in pigs over a month ago that apparently occurred when a person who got the H1N1 flu during a trip to Mexico came in contact with the Canadian pigs. This transfer of the H1N1 flu to pigs shows the relative ease of cross-species infection with this virus. Australia, Argentina, Ireland, the United Kingdom, and Norway have also reported cases of pigs catching the H1N1 flu after exposure to infected people. However, people cannot get the H1N1 flu from eating properly processed pork products.
10/16/09: At the CDC's press conference today, Dr. Schuchat indicated the novel H1N1 was widespread in 41 states with a total of 86 deaths in children under age 18. She said, "About half of the deaths that we've seen in children since Sept. 1 have been occurring in teens between the ages of 12 and 17. These are very sobering statistics, unfortunately, they are likely to increase." She indicated that H1N1 vaccine production was not as high as predicted so the availability of the vaccine will not be as widespread in October as previously predicted (shortage is about 10-12 million doses) but hopes by the end of October or early November the supply will be widespread. She also commented on the shortage of conventional or seasonal flu vaccine and believes that it will be more available over time. She commented on a question about ICU availability and said that about 15%-20% of hospitalized H1N1 flu patients need ICU support but says she is not aware of any ICU bed shortages to date. The CDC will investigate this potential problem. Again she tried to reassure those who are concerned about the safety of the injectable H1N1 vaccine. "It's important for people to know that the H1N1 influenza vaccine is being made exactly the same way that the seasonal flu vaccines are made...100 million people get those every year and we believe there's a very strong safety record for them including many, many pregnant women who get those vaccines every year and many, many children who get those vaccines every year. We have increased our safety monitoring efforts here to be aware and ready and able to investigate any problems or rumors that emerge so that we, although we're all expecting a very safe vaccine, we're not taking that for granted. No shortcuts are being taken at all in the way this vaccine is being produced. And that's very important for people to know."
The Society for Healthcare Epidemiology of America (SHEA) had urged the CDC, based on clinical experience and scientific evidence, to remove the use of N95 respirators from its recommendations for routine care in favor of the first-line use of surgical masks. SHEA suggests that N95 respirators should be reserved for procedures associated with a higher risk of aerosolization of the H1N1 virus.
The Japanese government (Ministry of Health, Labor and Welfare) today announced that about 6480 schools in Japan have been closed because of the H1N1 swine flu.
Current CDC statistical data shows that about 45% of adults hospitalized with H1N1 had an underlying illness before catching the new strain of flu. Asthma was the most common illness (26%), followed by diabetes (10%). Also, 8% had other chronic lung diseases and 7.6% had immunosuppressive disorders. About 6.1% of those hospitalized were pregnant women.
Today the FDA (Food and Drug Administration) warned that a number of Web-based businesses are selling products (including products that claim to be Tamiflu) that do not work or that are not what they represent to be in the ads. The FDA urged consumers to only purchase FDA-approved products from licensed pharmacies located in the United States for treatment of the flu.
10/14/09: The CDC held a brief press conference yesterday. Dr. Schuchat said the following about the individuals who needed hospitalization with H1N1 flu: "In adults, the most common underlying conditions were asthma and chronic lung disease, chronic heart disease, and immunosuppression. And in children, the most common underlying conditions were asthma and chronic lung disease, neurologic or neuromuscular diseases, and sickle cell or other blood disorders." In about 45% of adults hospitalized, no clear underlying condition was present, but the data are still preliminary, and the CDC is looking into obesity as being a possible high-risk factor for H1N1. Although about 9.8 million doses of H1N1 vaccine are available to be ordered this week, only about 5.8 million doses have been requested. Dr. Schuchat said that distribution and ordering problems are being addressed and she would likely have data on doses released to individual states during a press conference planned for Friday, Oct. 16.
Researchers suggest that CT scanning may be useful in detecting H1N1 infections, possibly leading to earlier diagnoses of severe cases and complications (pulmonary emboli) in the future, according to a study published online in the American Journal of Roentgenology. The study will be published in the December issue. Since the northern hemisphere is entering the flu season, and the H1N1 flu is causing some younger people to have severe disease, there have been editorials in journals (Journal of the American Medical Association or JAMA) and several research papers (for example, New England Journal of Medicine [NEJM] on 10/08/09) that have mentioned the potential problems with intensive-care bed availability due to an influx of patients. For example, "In Winnipeg -- site of the largest cohort of pandemic patients in Canada -- all intensive-care beds were occupied with H1N1 flu patients when the outbreak peaked in June…And, in Mexico City, six major hospitals were so busy that admission to intensive care was delayed, and four patients died in the emergency department before they could get to the ICU," according to the Associated Press. ICU bed availability is a concern among many emergency medicine and intensive care doctors because even without H1N1 flu infections, many hospitals in the U.S. often have few or no ICU beds immediately available for patients.
10/12/09: The Journal of the American Medical Association announced, in a Web format, findings that will be published soon in JAMA describing 68 patients with severe influenza-associated (mainly novel H1N1 flu) ARDS that were treated with ECMO (extracorporeal membrane oxygenation). These infected patients were often young adults, pregnant or postpartum, obese, and required mechanical ventilation support. These patients had a median age of 34.4 years and had developed severe respiratory failure before ECMO treatment. The median duration of ECMO support was 10 days. At the time of reporting, 54 of the 68 patients had survived and 14 (21%) had died. Since many of these patients often die, the authors concluded: "This information should facilitate health-care planning and clinical management for these complex patients during the ongoing pandemic."
Two related articles, also to be published in the same JAMA issue as above, conclude: Critical illness from 2009 influenza A (H1N1) in Mexico and Canada occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies and had a high case-fatality rate (17.3% in the Canadian study and 41.4% in the Mexico study).
10/10/09: Yesterday afternoon, CDC official Dr. Schuchat stated, "The H1N1 virus is in virtually the entire country. Unfortunately, we're seeing more illnesses, more hospitalizations, and more deaths from it. Flu is widespread in 37 states. That's up from 27 states last week. Unfortunately, 19 more pediatric deaths from influenza got reported to us this past week. We're now up to 76 children having died from the 2009 H1N1 virus. To put that in context, the past three years, the total pediatric influenza deaths ranged from 46 to 88. We have had 76 children dying from the 2009 H1N1 virus. And it's only the beginning of October. Of course, the flu season often will last all of the way until May." They go on to say that next week the injectable vaccine should be shipped and start to be available, but there will not be enough available for everyone immediately. However, weekly shipments should eventually supply enough doses for all that request vaccine. "Vaccine against flu is the best way to protect yourself from the influenza and those around you," said Dr. Schuchat. She further tried to reassure those people who hear rumors about the vaccine that it is safe and that it was produced by the same companies and methods used for the safe flu vaccines produced over many years. Dr. Fauci, from the NIH, reported that clinical trials have now shown that it is safe and effective to get both the conventional and H1N1 flu vaccine shots at the same time. He reiterated that data shows a single shot of both vaccines produces an effective immune response in the majority of people. He indicated that current clinical trials were still ongoing with patients in several high-risk groups such as HIV-positive individuals and those with severe asthma.
10/8/09: WHO officials expressed confidence in novel H1N1 swine flu vaccines as being safe. They considered data from about 39,000 people who have obtained the vaccine and very few had any side effects such as muscle cramps or headaches. WHO official G. Hartl said, "The vaccine is the single most important tool that we have against influenza."
10/6/09: As of yesterday and today, a number of states have obtained the first vaccine shipments for H1N1 swine flu. Most states have obtained a fraction of what was requested, but the CDC has indicated as supplies become available, the vaccine will be shipped. The bulk of these first shipments are of the nasal spray form of the vaccine that can only be administered to healthy individuals 2-49 years of age. For many states and cities, the distribution of such small amounts is a problem as the initial demand volume outstrips the supply. For example, San Antonio, Texas, with a population of about 1.9 million, obtained only 500 nasal spray doses.
10/5/09: The Washington Post reported that recent analysis of data showed that by the end of August 2009, more than 100 pregnant women have been hospitalized in intensive-care units and 28 have died from novel H1N1 flu. They quoted the CDC official, Dr. Schuchat, saying that anecdotal reports find "…doctors around the country...have never seen this kind of thing before." Further, Dr. Schuchat called the novel H1N1 vaccine "an important way to protect yourself" and encouraged pregnant women to get vaccinated as soon as possible, adding that "no corners have been cut" in testing it.
There is a new test for novel H1N1 swine flu. Kirk Ririe, chief executive officer of Idaho Technology, announced that Idaho Technology's Joint Biological Agent Identification and Diagnostic System (JBAIDS) has been approved by the military to run tests for the H1N1 virus. The JBAIDS instrument will be used to test military personnel and their families all over the world at military installations for influenza A, swine flu A, and H1 swine flu in less than an hour. These test kits were manufactured by the Centers for Disease Control (CDC), and initial data from the United States Army Medical Research Institute for Infectious Diseases (USAMRIID) at Fort Detrick, Maryland, showed accurate identification of the H1N1 virus on the JBAIDS instrument. Currently, there is no indication when and if this quick and apparently accurate test will be available to the public.
New flu guidelines are available from the government. Officials from the U.S. Department of Health and Human Services (HHS) and the White House Office for Faith-based and Neighborhood Partnerships began distributing a new flu response guide. The document, titled "H1N1 Flu: A Guide for Community and Faith-Based Organizations," provides information about 2009 H1N1 swine flu. The new guide is available for download at http://flu.gov and http://www.hhs.gov/partnership or in hard copy from the Department of Health and Human Services.
10/4/09: The Journal of the American Medical Association (JAMA) announced that it is publishing a study that shows that surgical masks protect health-care providers from novel H1N1 flu viruses about as well as the more expensive N95 masks. "Surgical masks appear to be no worse than, and nearly as effective as, N95 respirators in preventing influenza in health-care workers, according to a study released early online today by JAMA." Out of over 200 nurses in each group wearing masks, 50 got the flu wearing a surgical mask while 48 got the flu wearing the N95 masks. The authors conducted the study because of the short supply of N95 masks worldwide. However, the authors caution use as follows: "Our findings apply to routine care in the health-care setting. They should not be generalized to settings where there is a high risk for aerosolization, such as intubation or bronchoscopy, where use of an N95 respirator would be prudent. In routine health-care settings, particularly where the availability of N95 respirators is limited, surgical masks appear to be non-inferior to N95 respirators for protecting health-care workers against influenza."
10/2/09: Sanofi Pasteur's influenza A (H1N1) 2009 monovalent vaccine trial in adults 18-64 years of age and over the age of 65 years, administered to adults, including the oldest study participants, was announced today. The company said data shows the vaccine induces a robust antibody response 21 days post-vaccination that is considered protective. These data from a placebo-controlled study of 849 adults help confirm preliminary NIH data from a few vaccine recipients. In the 18-64-year-old group, 98% of the vaccinated people developed a protective level of antibodies in 21 days, while in the older group (over 65), 93% developed protective levels. Both groups obtained a single 15 mcg dose of the vaccine. They further announced, "No serious adverse events have been observed to date in this clinical trial. Local injection site redness, swelling, and pain and systemic complaints of mild fever, headache, and fatigue were reported. Overall, the safety profile observed to date is very similar to that of the seasonal influenza vaccine."
9/30/09: Once again, the CDC and other health officials are urging people, especially parents, to avoid establishing or attending "swine flu parties" for themselves and their children. The idea of the parties is to get exposure to a person with the novel H1N1 swine flu so that uninfected people can get the disease and then recover and avoid vaccinations. This is considered risky behavior since the individual's response to the flu, especially in some individuals such as young children and individuals with known or unknown underlying disease, may be poor and could require hospitalization.
National news (NBC) has reported a death in a previously healthy teen whose doctor followed the current CDC guidelines for observation and nontreatment. The press speculates that this case may cause the CDC to modify again its recommendations for treatment by encouraging more people get antiviral drugs.
9/29/09: As stated yesterday, the CDC plans to closely monitor the novel H1N1 swine flu vaccine for any adverse effects. One of the major ways they will monitor for side effects will consist of evaluating any increases in the normal rates for major health problems such as miscarriages, heart attacks, strokes, and other problems. Although the vaccines have been tested on a relatively healthy population and no major adverse problems have been identified (otherwise they would not be approved for distribution), the goal is to immunize over half the U.S. population, many of whom are not classified as "relatively healthy." Consequently, monitoring of the vaccine for potential problems is warranted.
In a separate vaccine issue, the WHO announced that in addition to the nine countries that have agreed to share about 10% of their purchased novel H1N1 vaccine with underdeveloped countries, other countries now are planning to donate 10% of their vaccine stock. This should help the approximately 85 underdeveloped countries that otherwise would have no vaccine to distribute to their people, according to U.N. official David Nabarro.
9/28/09: CDC officials expressed concern about the role of rumors and press coverage of them as the new vaccination efforts start in October. Because of the Internet and immediate access to TV news by the public, CDC official have realized they must be prepared to reassure the public quickly when rumors of "problems with the vaccines" become widespread. For example, in the U.S., there are about 2,400 miscarriages, 3,000 heart attacks, 2,200 strokes, and 550 new seizure patients a day, so the CDC suspects that a few individuals are likely, simply by coincidence, to develop a serious health problem after getting a novel H1N1 swine flu shot. Such incidences may be sensationalized by some people and cause others to avoid getting the vaccine. The CDC has established a "war room" to address these potential problems immediately and plan to have live updates and updates available at the Web site http://flu.gov, as well as on Facebook and Twitter sites. Further, the CDC has given assurances that the vaccine efforts will be closely monitored to determine if any problems develop.
9/26/09: Yesterday, Dr. Thomas Frieden from the CDC gave a press conference update on the novel H1N1 swine flu. He reviewed the current situation and said the vaccines being produced against the novel H1N1 virus should be very effective. He again encouraged people in the high-risk groups to get vaccinated early and reiterated that people age 10 and older will need only one shot of vaccine. He further stated that although a Canadian study (not yet published) suggested that vaccination against the conventional flu makes some people more likely to be susceptible to the novel H1N1flu, the CDC had no information that this was happening. Although Dr. Frieden said he would study the Canadian data when it was available, he indicated that all of the Australian and U.S. data do not indicate that the conventional flu vaccine make people more susceptible to getting novel H1N1 flu.
9/25/09: Recently, the Food and Drug Administration (FDA) established an approved method for compounding Tamiflu in capsules (pills), creating a liquid mixture that ensures the most effective and proper dosing in a liquid form. The liquid Tamiflu is most often used to treat children. Because the Roche commercially prepared supplies of Tamiflu of liquid are low, Walgreens pharmacies across the nation are now beginning to produce Tamiflu Oral Suspension from the capsules according to the FDA recommendations for compounding. This will make liquid Tamiflu more available to the pediatric population. This was announced on Sept. 24 by the Walgreens senior vice-president of pharmacy.
9/23/09: An early review of an article scheduled to be published in the October 2009 Lancet medical journal suggests that vaccination against the novel H1N1 swine flu will help reduce cardiac deaths. The authors reviewed data collected from the 1930s to present about cardiac deaths and their relation to flu epidemics/pandemics and found that when effective vaccines were used against the flu, there were fewer cardiac deaths. They recommend that patients with cardiac problems obtain the flu vaccine.
9/21/09: Dr. A. Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases (NIAID), announced that children 10 years old and older will need only one shot to be vaccinated against novel H1N1 swine flu. Children 6 months to 9 years of age will need two shots, about 21 days apart, of both the conventional and novel H1N1 flu vaccines to establish a good immune response to the viruses. Data suggests that the novel H1N1 vaccine is about 76% effective in producing protection against swine flu. This percentage is considered "not bad at all" in protecting people from the flu.
WHO officials have stated the amount of novel H1N1 swine flu vaccine available worldwide is not expected to reach the amounts first projected. Most of the first vaccine batches have been purchased by the more wealthy developed countries. However, at least nine countries (Australia, Brazil, France, Italy, New Zealand, Norway, Switzerland, Britain, and the U.S.) have pledged to donate vaccine to developing nations that have little or no access to the vaccine. These vaccine doses will be added to the 120 million vaccine doses that two pharmaceutical companies, GlaxoSmithKline and Sanofi-Pasteur, pledged to the WHO. U.S. officials suggest that about 10% of the U.S. vaccine supply will be donated to these underdeveloped countries.
9/18/09: The CDC announced the first vaccine released will be the nasal spray form of the novel H1N1 swine flu vaccine. The CDC estimates about 3.4 million doses will be released during the first week in October, with more releases scheduled in the following weeks. However, this vaccine is composed of live attenuated virus and should be given only to healthy people ages 2-49. People who have asthma or respiratory problems, and those that are immunocompromised or pregnant, should not get the nasal spray vaccine.
9/17/09: The FDA approved clinical studies of LEAPS technology (Ligand Epitope Antigen Presentation System) that allows the CEL-CSI company to direct an immune response against specific disease epitopes, which, for this clinical study, are the non-changing regions of H1N1 (and other flu viruses). This study is designed to help hospitalized patients overcome severe novel H1N1 infections.
9/15/09: Two studies suggest that blacks and Hispanics may be about four times more likely to be hospitalized than other races for the novel H1N1 swine flu. This statistic is likely due to the higher predominance of diabetes and asthma in these populations.
Today the FDA approved H1N1 novel swine flu vaccine from four vaccine suppliers, CSL, AstraZeneca, Novartis, and Sanofi-Aventis. This early FDA approval may allow distribution to occur earlier in October than thought previously. In addition, the vaccination process may require only one shot instead of two for the H1N1 swine flu. Health and Human Services Secretary Kathleen Sebelius said most adults produce a "robust" immune response to this vaccine in eight to 10 days. Pathology reports from autopsies on people who have died from H1N1 swine flu show that the virus penetrates deep into the lungs and disrupts the alveoli, where oxygen and CO₂ are exchanged. Over two-thirds of H1N1 deaths are attributable to the virus and about one-third due to secondary bacterial infections. Autopsy results show large amounts of virus in the blood, feces, and urine of infected individuals, which suggests these may be sources of infection for other people. Dr. Sherif Zaki from the CDC reported these findings at the U.S. Institute for Medicine this week.
9/14/09: Data from three different studies (from Canada, Mexico, and Singapore) reported at the American Society for Microbiology Meetings showed that H1N1 flu is still transmitted among humans even after fever is gone for 24 hours. The authors suggest that a better indicator may be the lack of coughing and that the infectious period may extend over a week longer than previously thought. The researchers do not know if the data will cause the CDC to modify its current recommendations about it being OK to resume work or school 24 hours after untreated fever stops.
9/10/09: Australian and U.S. researchers announced that 76%-96% of people who obtained a single dose of a novel H1N1 swine flu virus vaccine should be protected. U.S. data confirms the Australian data. The data is only for adults; the studies are not yet finished for children. This data may alter the current view that two doses (two shots) of the novel H1N1 vaccine will be needed to get a good immune response. This finding may effectively double the amount of available vaccine. In addition, researchers and other experts still encourage people to get the vaccine (one shot) for the conventional seasonal flu as soon as possible. The conventional flu vaccine is now available in many locations (clinics, stores) in the U.S.
A professor of biostatistics from the University of Washington reported that analysis of statistics predict that October vaccinations will be too late to curb the first wave of novel H1N1 swine flu but should help limit a second wave of the flu. He further suggested that vaccination of children is important, as every infected child statistically infects about 2.4 other people and that 30%-40% of all viral transmissions are from an infected person to others in the home.
9/8/09: The CDC had a press briefing today on interim guidelines for the use of antiviral medications. Dr. Schuchat indicated that three modifications were being suggested to the interim guidelines for use of Tamiflu and Relenza.

1. Patients with high risk factors should discuss flu symptoms and when to use antiviral medications; doctors should provide a prescription for the antiviral drug for the patient to use if the patient is exposed or develops flu-like symptoms without having to go in to see the doctor. 2. "Watchful waiting" was added as a response to taking antiviral medications, with the emphasis that those people who develop a fever and have a preexisting health condition should then begin the antiviral medication. 3. The antiviral drugs are the first-line medicines for treatment of novel H1N1 swine flu, and most current cases of flu are novel H1N1 and are, to date, susceptible to Tamiflu and Relenza. 9/7/09: During the weekend, colleges across the nation began to report their experiences with the novel H1N1 swine flu. Most cases seem mild to moderate, but many colleges report a large number of students affected. For example, Washington state officials estimate that about 2,100 students have the flu. Another school, Emory University, has opened a dorm on campus for students with the flu. The student's have nicknamed the dorm "Flu U."
9/4/09: The CDC published the guidelines for child-care providers and childhood care centers. The emphasis is on the following: "Importantly, infants less than 6 months of age represent a particularly vulnerable group because they are too young to receive the seasonal or 2009 H1N1 influenza vaccine; as a result, individuals responsible for caring for these children constitute a high-priority group for early vaccination." Details of the guidelines are provided in this lengthy document that can be found at http://www.flu.gov/professional/school/childguidance.html. The guidelines are very similar to those recently published for workplace prevention of flu and emphasize the need for caregivers to quickly separate sick children from others and delineate methods to follow for facility closures.
9/3/09: Today, a CDC official, Dr. Thomas Frieden, gave a briefing on the novel H1N1 swine flu. The good news is that swine flu cases here and in the southern hemisphere have not shown an enhanced severity or death rate; the vast majority of cases have been mild or moderate. However, the pattern of age groups has continued to be different from conventional flu in that a younger population, rather than the elderly, is most affected. Of specific concern is the numbers of children affected and who have died. Children with health or developmental problems seem to have more incidences of severe disease or death, said Frieden, "in most of the cases -- cerebral palsy, muscular dystrophy, long-standing respiratory or cardiac problems. So, most of the children who had fatal H1N1 infection this past spring had an underlying condition." Secondary bacterial infections caused severe disease or death in the few children that did not have known underlying problems. The CDC plans to monitor this trend closely and consult with pediatric physicians about reducing the numbers of these cases.
Vaccinations were discussed and reviewed; the CDC again emphasized the importance of vaccinations and stressed the need for children, pregnant women, and people with underlying health problems to get vaccinated as soon as the vaccine is available. The CDC has set aside about $1.5 billion for vaccines that are predicted to become available in mid-October. The CDC expects some adverse vaccine-related events and will modify recommendations if the situation warrants.
Concern was expressed about overwhelming the health-care system in the U.S.; consequently, Frieden stated that "There's no reason to see a doctor or go to the emergency department unless you're severely ill." He reiterated the CDC's published precautions that people with underlying diseases should take. People should stay informed because situations can change rapidly; "Flu is unpredictable. Flu season is just beginning."
8/28/09: From the CDC: Flu activity appears to be increasing in the Southeast based on influenza-like illness data reported by health-care providers. Below is a summary of the most recent key indicators:

Visits to doctors for influenza-like illness (ILI) were highest in February during the 2008-09 flu season but rose again in April 2009 after the new H1N1 virus emerged. Current visits to doctors for influenza-like illness are down from April, but are higher than what is expected in the summer and have increased over the last two weeks.
Total influenza hospitalization rates for adults and children are similar to or lower than seasonal influenza hospitalization rates, depending on age group.
The proportion of deaths attributed to pneumonia and influenza (P&I) was low and within the bounds of what is expected in the summer.
Most state health officials are reporting regional or sporadic influenza activity. Two states (Alaska and Georgia) and Puerto Rico are reporting widespread influenza activity at this time. Any reports of widespread influenza activity in August are very unusual.
Almost all of the influenza viruses identified were the new 2009 H1N1 influenza A viruses. These 2009 H1N1 viruses remain similar to the viruses chosen for the 2009 H1N1 vaccine and remain susceptible to antiviral drugs (oseltamivir and zanamivir) with rare exceptions.

Today the WHO published a report that gives advice about preparations for the second wave of novel H1N1 swine flu, based on the current worldwide outbreaks. They suggest that now the predominant flu strain in the world is H1N1, that it has not markedly increased in its current ability to cause serious disease, and that although a few strains have been found to be resistant to antiviral drugs, the vast majority of tested strains remain susceptible. However, WHO officials say that vigilance is necessary to determine that resistant strains do not increase in number. Further, the pattern of susceptible people continues to be remarkably different from conventional flu in that the most vulnerable people are younger, have more deaths, have more respiratory problems, and are more likely to overburden intensive care facilities. They suggest that now is the time to plan for the second wave likely to occur in the northern hemisphere in the upcoming months.
8/27/09: Brazil has reported 552 deaths to date and now surpasses the U.S. as the country with the most deaths due to novel H1N1 swine flu.
8/25/09: The President's Council of Advisors on Science and Technology released a report on Monday that says swine flu could infect up to about 120 million people and cause about 1.8 million hospitalizations with up to 90,000 thousand deaths. The advisors base their numerical estimates on analysis of data from the spring-summer outbreak in the northern hemisphere and the current winter pandemic in the southern hemisphere. They suggest these numbers of patients would severely stress the current hospital system because there are only a finite number of intensive-care beds available in the U.S. The advisors warn that schools could be acutely affected and urges the release of vaccines and drugs in mid-September, in contrast to current thoughts that flu vaccines would only be available in the U.S. in October. One of the reasons to move up the timing is that most experts believe people will need two doses of the vaccine, delivered at least two weeks apart, to develop full immunity to the new H1N1 flu. In addition, people likely will need a vaccine for the conventional seasonal flu. The advisors also urged the U.S. Food and Drug Administration to quickly decide on the safety and efficacy of new intravenous (IV) formulations of flu drugs, such as Roche AG's Tamiflu, GlaxoSmithKline's Relenza, and BioCryst Pharmaceuticals' experimental drug, peramivir. IV formulations of these drugs may be the only way to administer antiviral agents to people severely ill with novel H1N1 swine flu. The advisors state that the current novel H1N1 swine flu is "a serious threat to our nation."
8/21/09: CDC recommendations for college students and the flu were published yesterday afternoon. Like the CDC recommendations for businesses and employers, the recommendations are voluminous and detailed. They can be found at http://www.cdc.gov/h1n1flu/institutions/guidance/. One of the main aims of the CDC is to facilitate self-isolation of students (and others) at higher education institutions to lessen the chance of individuals spreading the flu. Also, the CDC published a "toolkit" for educational institutions that provides fact sheets, templates, informational posters, and other items for use.
8/19/09: Today the CDC released guidelines for businesses and employers for the 2009-2010 flu season. It is an extensive document that covers many pages of recommendations. The document is published at the following Web site: http://www.cdc.gov/h1n1flu/business/guidance. Key aspects of the guidelines involve details about the following:

Sick people should stay home.
Sick employees at work should be asked to go home.
Cover coughs and sneezes.
Improve hand hygiene.
Clean surfaces and items that are more likely to have frequent hand contact.
Encourage employees to get vaccinated.
Take measures to protect employees who are at higher risk for complications of influenza.
Prepare for increased numbers of employee absences due to illness in employees and their family members, and plan ways for essential business functions to continue.
Advise employees before traveling to take certain steps.
Prepare for the possibility of school dismissal or temporary closure of child-care programs.

If the flu season becomes severe, the CDC recommends the following additional precautions:

Consider active screening of employees who report to work.
Consider alternative work environments for employees at higher risk for complications of influenza during periods of increased influenza activity in the community.
Consider increasing social distancing in the workplace.
Consider canceling nonessential business travel and advising employees about possible disruptions while traveling overseas.
Prepare for school dismissal or closure of child-care programs.
Other considerations

Each one of the above points is described in detail at the Web site. One important subset of recommendations that should be highlighted is as follows: "CDC recommends that workers who appear to have an influenza-like illness upon arrival or become ill during the day be promptly separated from other workers and be advised to go home until at least 24 hours after they are free of fever (100 F [37.8 C] or greater), or signs of a fever, without the use of fever-reducing medications."
8/16/09: Egypt and other countries have banned people under age 12 and over age 65 from going on pilgrimage to Mecca during Ramadan in an effort to prevent novel H1N1 swine flu spread. Apparently, not all of those planning a pilgrimage are aware of the restrictions that went into effect Sunday morning, as angry people reacted to the travel restrictions at the Cairo airport today. A number of people were removed after they had already boarded planes bound for Mecca.
8/14/09: The CDC reported today the total number of patients hospitalized (7,511) and total deaths (477) due to novel H1N1 swine flu. The mortality, or death rate, for hospitalized patients is about 6.7%. The CDC reported that as of 8/8/09, only two novel H1N1 strains out of 318 tested showed resistances to oseltamivir, and none were resistant to zanamivir.
8/11/09: Novel H1N1 swine flu vaccine trials began in the U.S. yesterday in St. Louis with several hundred volunteers obtaining the vaccine inoculation. Not all doctors think that starting school classes during this flu pandemic is a good idea. For example, a U.K. professor, Dr. Price, says, "There is no greater way of facilitating the spread of swine flu than allowing children to mix in schools. If we had a vaccine, it would be a different matter, but given we don't yet, it would in my view be foolhardy to allow children back to school. It's a discussion that needs to be had." Currently, the CDC and many other international health agencies recommend schools reopen, and any closures should be determined by local officials.
8/09/09: Several reports now have noted the presence of Tamiflu-resistant novel H1N1 virus. Some investigators have suggested the resistance is due to the production of H274Y, a new surface antigen that has reportedly been detected in several resistant flu isolates. Researchers suggest that resistant isolates may be more common than thought, since recent tests have detected a number of isolates with H274Y antigen.
8/7/09: The CDC has published extensive and technical recommendations for schools to consider during the upcoming 2009-2010 flu season. All of the details can be found at http://www.pandemicflu.gov/plan/school/schoolguidance.html. The following points are taken directly from the report and are presented in two parts that consider actions depending on the potential severity of the flu season:
CDC-recommended school responses for the 2009-2010 school year
Under conditions with similar severity as in spring 2009

Stay home when sick: Those with flu-like illness should stay home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay home even if they are using antiviral drugs. (For more information, visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm.)
Separate ill students and staff: Students and staff who appear to have flu-like illness should be sent to a room separate from others until they can be sent home. The CDC recommends that they wear a surgical mask, if possible, and that those who care for ill students and staff wear protective gear such as a mask.
Hand hygiene and respiratory etiquette: The new recommendations emphasize the importance of the basic foundations of influenza prevention: Stay home when sick, wash hands frequently with soap and water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available).
Routine cleaning: School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. Special cleaning with bleach and other non-detergent-based cleaners is not necessary.
Early treatment of high-risk students and staff: People at high risk for influenza complications who become ill with influenza-like illness should speak with their health-care provider as soon as possible. Early treatment with antiviral medications is very important for people at high risk because it can prevent hospitalizations and deaths. People at high risk include those who are pregnant, have asthma or diabetes, have compromised immune systems, or have neuromuscular diseases.
Consideration of selective school dismissal: Although there are not many schools where all or most students are at high risk (for example, schools for medically fragile children or for pregnant students), a community might decide to dismiss such a school to better protect these high-risk students.

Under conditions of increased severity compared with spring 2009
The CDC may recommend additional measures to help protect students and staff if global and national assessments indicate that influenza is causing more severe disease. In addition, local health and education officials may elect to implement some of these additional measures. Except for school dismissals, these strategies have not been scientifically tested. But the CDC wants communities to have tools to use that may be the right measures for their community and circumstances.

Active screening: Schools should check students and staff for fever and other symptoms of flu when they get to school in the morning, separate those who are ill, and send them home as soon as possible. Throughout the day, staff should be vigilant in identifying students and other staff who appear ill.
High-risk students and staff members stay home: People at high risk of flu complications should talk to their doctor about staying home from school when an outbreak of flu is circulating in the community. Schools should plan now for ways to continue educating students who stay home through instructional phone calls, homework packets, Internet lessons, and other approaches.
Students with ill household members stay home: Students who have an ill household member should stay home for five days from the day the first household member got sick. This is the time period they are most likely to get sick themselves.
Increase distance between people at schools: The CDC encourages schools to try innovative ways of separating students. These can be as simple as moving desks farther apart or canceling classes that bring together children from different classrooms.
Extend the period for ill people to stay home: If influenza severity increases, people with flu-like illness should stay home for at least seven days, even if they have no more symptoms. If people are still sick, they should stay home until 24 hours after they have no symptoms.
School dismissals: School and health officials should work closely to balance the risks of flu in their community with the disruption dismissals will cause in both education and the wider community. The length of time schools should be dismissed will vary depending on the type of dismissal as well as the severity and extent of illness. Schools that dismiss students should do so for five to seven calendar days and should reassess whether or not to resume classes after that period. Schools that dismiss students should remain open to teachers and staff so they can continue to provide instruction through other means.

Reactive dismissals might be appropriate when schools are not able to maintain normal functioning; for example, when a significant number and proportion of students have documented fever while at school despite recommendations to keep ill children home.
Preemptive dismissals can be used proactively to decrease the spread of flu. The CDC may recommend preemptive school dismissals if the flu starts to cause severe disease in a significantly larger proportion of those affected.
8/6/09: Controversy is brewing over the accuracy of tests that are used to rapidly detect influenza virus infection. Most of these tests are used in doctor's offices or urgent care and emergency centers and do not indicate if the person tested has novel H1N1 swine flu. These tests only indicate if flu virus is present or, in some tests, if the virus is type A or B (novel H1N1 swine flu is type A like most seasonal flu). Different studies suggest rapid tests many have only 20%-80% accuracy in detecting flu, depending on which test is used and the skill of the personnel running the test. The CDC is reportedly going to publish a study of these tests "soon." Meanwhile, Dr. Timothy M. Uyeki, a CDC official, says, "We're saying you need to understand the limitations of these tests. The clinician should not base a decision to treat or not treat on the basis of a negative result." Detection and identification of novel H1N1 swine flu virus is usually not done in doctors' offices or hospital labs, but in state labs usually with a sensitive and specific PCR test that most other labs do not use because of expense, training requirements, and time needed to run the test.
8/5/09: China closed summer camps in areas affected by swine flu (Beijing and Guangzhou) yesterday. Other areas in China that have swine flu may also be closed. China has reported 2,162 cases of swine flu but no deaths. In the U.S., physicians suggest that one of the major problems encountered with novel H1N1 swine flu is pneumonia. They suggest that another common vaccine, Pneumovax, may help prevent pneumonia in many patients that get the flu. Data presented to the CDC vaccine committee suggests that about one-third of all pneumonias associated with the flu may be prevented by Pneumovax. Unfortunately, there is no study that shows this effect, but some physicians plan to recommend the vaccine to patients with chronic lung problems.
8/3/09: The Pan American Health organization announced today that Tamiflu-resistant strains of novel H1N1 swine flu virus have been detected in the U.S. in El Paso and near McAllen, Texas, along the Texas-Mexico border. Other countries (Japan, Denmark, and Canada) have also detected similar resistant viral strains. Viral experts suggest the drug Tamiflu may be overused by people who take it "at the first sneeze," especially in countries where Tamiflu does not require a prescription (Mexico, Canada).
7/31/09: The WHO reported that several countries have noted an increased flu risk in pregnant women, particularly during the second and third trimesters of pregnancy in women infected with novel H1N1 swine flu. Also, an increased risk of fetal death or spontaneous abortions in infected pregnant women has been reported, which was noted in previous pandemics. WHO officials suggest pregnant females be given Tamiflu within 48 hours of developing flu symptoms for greatest benefits; they also suggest this treatment even after 48 hours as it may reduce the chance for pneumonia and hospitalization. The WHO suggests that other groups at increased risk of severe or fatal illness from novel H1N1 infection include people with underlying medical conditions such as chronic lung disease (including asthma), cardiovascular disease, diabetes, and immunosuppressed individuals. WHO officials say preliminary studies suggest that obesity, especially extreme obesity, may be a risk factor for more severe disease.
Novel H1N1 swine flu can progress rapidly. The following is a list of danger signs provided by WHO officials that may appear in infected individuals:

shortness of breath, either during physical activity or while resting;
difficulty in breathing;
turning blue;
bloody or colored (not clear) sputum;
chest pain;
altered mental status;
high fever that persists beyond three days;
low blood pressure; and
in children, danger signs include fast or difficult breathing, lack of alertness, difficulty in waking up, and little or no desire to play.

Novel H1N1-infected people with any of these danger signs need to seek medical help immediately.
7/29/09: The CDC committee on vaccine use today published recommendations about who should get the novel H1N1 flu vaccines when vaccine is first available:

pregnant women,
people who live with or care for children younger than 6 months of age,
health-care and emergency-services personnel,
people between the ages of 6 months through 24 years of age, and
people from ages 25 through 64 years of age who are at higher risk for novel H1N1 because of chronic health disorders or compromised immune systems.

The groups listed above total approximately 159 million people in the United States, so at least that number of doses of vaccine will be needed. It is possible that initially the vaccine will be available only in limited quantities. If this occurs, the committee recommended that the following groups receive the vaccine before others:

pregnant women,
people who live with or care for children younger than 6 months of age,
health-care and emergency-services personnel with direct patient contact,
children 6 months through 4 years of age, and
children 5 through 18 years of age who have chronic medical conditions.

Current data suggests that the risk for infection among people age 65 or older for novel H1N1 flu is less than the risk for younger age groups, which is not the usual situation for seasonal flu. However, the CDC suggests people 65 and older get the seasonal flu vaccine as soon as it becomes available.
The CDC says that the novel H1N1 vaccine does not replace the conventional flu vaccine, so individuals still need to be vaccinated against the seasonal flu. The CDC indicated that when appropriate, an individual can get both vaccines administered on the same day.
7/28/09: Controversy continues about the safety of European fast-track novel H1N1 swine flu vaccines. WHO officials continue to caution against the fast-track approach because of safety concerns; they want more extensive testing done to avoid problems like those that occurred with the 1976 flu vaccine that resulted in hundreds of people getting Guillain-Barré syndrome (autoimmune-induced weakness or paralysis), other side effects, or dosage-related low or no immune response. The U.S. is not following a fast-track approach. 7/27/09: Several European countries (Britain, France, and Greece) indicated they will fast-track novel H1N1 swine flu vaccine trials. WHO officials warned officials about potential dangers (missed side effects and adequate vaccine dosage determinations) if a fast-track method is used. The European officials say the benefits outweigh the risks and will allow earlier vaccinations (within weeks) to be done. The U.S. is taking a more conservative approach and plans to have a vaccine campaign ready in October.
7/24/09: The WHO reported today that novel H1N1cases are increasing worldwide, with the median age of infected people being 12 -17 years of age. Because pandemics often run for about two years, the patient population and the most susceptible people may change as the disease progresses over time. The WHO suggests that although vaccine yields are not as high as hoped, they expect vaccines to be available during the month of September. The CDC press conference today released data indicating that 43,771 laboratory-identified cases with 302 deaths were due to the new novel H1N1 virus. The officials indicate several flu outbreaks have occurred at summer camps and cautioned that more outbreaks may occur in a similar fashion when schools open in September. Use of Tamiflu (and other antiviral medications) was not recommended for any flu prevention except in high-risk individuals (for example, pregnancy, asthma) and people were urged to go to CDC Web sites for guidelines. Currently, flu vaccines were not going to be mandated for school-aged children, but the CDC did recommend that all children between 6 months and 17 years of age be vaccinated against flu viruses. The CDC now reports that labs have detected about five novel H1N1 cases that are Tamiflu-resistant, but the vast majority of isolates is still susceptible to antiviral drugs. During the conference, several reporters tried to get Dr. Schuchat to estimate the death rate for novel H1N1, but Dr. Schuchat only indicated that overall rates from both the conventional flu and novel H1N1 flu are likely to be higher than the approximately 36,000 deaths per year seen with only the conventional flu. The CDC would not speculate about how much higher the expected death rates would be. New influenza vaccine recommendations were released today by the CDC and can be found at http://www.cdc.gov.
7/22/09: The National Institute of Allergy and Infectious Diseases (NIAID) is set to begin clinical trials of vaccines for novel H1N1 swine flu. Initial studies will try to determine if one or two doses of vaccine will be safe and generate a good immune response in normal adult volunteers and the elderly (age 65 and older). Another trial will determine if a mix (a single shot) of the seasonal flu vaccine and the novel H1N1 vaccine will provide a safe and good immune response to both viral strains in normal adult volunteers and the elderly (age 65 and older). First examinations of the results will occur about 21 days after immunization. If these trials initially show the vaccines are safe, other trials will be started on children (6 months to 17 years of age).
7/20/09: Transcripts from the CDC press conference on 7/17/09 indicate that planning is ongoing for the upcoming flu season. Both the novel H1N1 pandemic flu strain and the conventional flu strain are expected to be present during the upcoming flu season. Because the novel H1N1 strain continues to infect individuals, they expect the flu season to start early this year, especially when schools begin to open in September. On 7/29/09, planning for immunization will commence, to recommend which people should get vaccinated first. The CDC suggests that additions to the vaccines to make them more effective (adjuvants) are contingent upon showing that such additives are needed to boost vaccine immunogenicity. The studies are ongoing.
7/17/09: Today, the CDC reports a total of 40,617 suspected or proven cases of H1N1 swine flu with a total of 263 deaths in the U.S., with Wisconsin reporting the largest number of cases (6,031) and New York the largest number of deaths (57). As stated previously (6/29/09), the CDC suspects the bulk of cases (over 1,000,000) are not reported, and people have mild or moderate flu symptoms that resolve.
7/16/09: WHO officials have changed reporting practices for the pandemic H1N1 swine flu cases. The officials say that further spread is inevitable and suggest that only those that occur in newly affected countries need reporting. In addition, WHO officials request that unusual situations, such as clusters of severe or fatal cases, be reported.
7/13/09: WHO officials identified several objectives that countries could adopt as part of their pandemic vaccination strategy and published these current recommendations by their Strategic Advisory Group of Experts (SAGE) on the current H1N1 flu pandemic:

All countries should immunize their health-care workers as a first priority to protect the essential health infrastructure. As vaccines available initially will not be sufficient, a stepwise approach to vaccinate particular groups may be considered. SAGE suggested the following groups for consideration, noting that countries need to determine their order of priority based on country-specific conditions: pregnant women; those over 6 months of age with one of several chronic medical conditions; healthy young adults 15-49 years of age; healthy children; healthy adults 50-64 years of age; and healthy adults 65 years of age and older.
Since new technologies are involved in the production of some pandemic vaccines, which have not yet been extensively evaluated for their safety in certain population groups, it is very important to implement post-marketing surveillance of the highest possible quality. In addition, rapid sharing of the results of immunogenicity and post-marketing safety and effectiveness studies among the international community will be essential for allowing countries to make necessary adjustments to their vaccination policies.
In view of the anticipated limited vaccine availability at a global level and the potential need to protect against "drifted" strains of virus, SAGE recommended that promoting production and use of vaccines, such as those that are formulated with oil-in-water adjuvants and live attenuated influenza vaccines, was important.
As most of the production of the seasonal vaccine for the 2009-2010 influenza season in the northern hemisphere is almost complete and is therefore unlikely to affect production of pandemic vaccine, SAGE did not consider that there was a need to recommend a "switch" from seasonal to pandemic vaccine production.

7/11/09: U.S. government agencies (CDC, Homeland Security, Health and Human Services and others) begin a joint meeting to determine plans to respond to the upcoming flu season.
7/8/09: Denmark, Japan, and the Special Administrative Region of Hong Kong, China, have informed WHO officials that they have detected a few novel H1N1 viruses which are resistant to the antiviral drug oseltamivir (Tamiflu). Currently, these strains have shown resistance when tested under laboratory conditions, and the vast majority of tested novel H1N1 swine flu strains still show sensitivity to oseltamivir. There is no change in recommendations about antiviral drug use from WHO officials. Argentina and Australia report the highest number of new cases in this reporting period (898 and 730, respectively) as the southern hemisphere continues its flu season.
7/3/09: The WHO has reported 77,201 cases worldwide with 332 deaths; Chile and the United Kingdom reported the highest increases in new cases since the last reporting period.
6/30/09: Today, CDC flu experts recommended that children, pregnant women, the elderly, and people with chronic diseases should avoid the hajj pilgrimage when asked for advice from the Saudi government about how to avoid H1N1 swine flu problems. The CDC suggested the people would be at highest risk for getting flu complications. The pilgrimage attracts about 3 million people to Mecca and Medina. The Saudi government said they recommend pilgrims get flu shots, once they are available, at least two weeks before leaving their country before they go on pilgrimage.
6/26/09: Dr. Anne Schuchat, a CDC administrator, indicated today that the U.S. is still reporting increasing numbers of H1N1 flu cases even though the routine flu season is essentially over. She indicates the unique situation in which the U.S. is seeing increases while decreases in cases should be happening. About 99% of all isolates are the new (or novel) H1N1 influenza A virus. The CDC investigators estimate that over 1 million people have been infected in the U.S., based on the reported number of cases. Currently, the most cases occur in people under age 25 with deaths averaging at age 37. Outbreaks have been noted in several summer camps across the nation; guidelines for campers have been issued at http://www.cdc.gov. She commented about the increases in cases in the southern hemisphere, since it is their winter season, and thinks many more cases will occur. She states that about 75% of deaths associated with novel H1N1 flu occur in individuals with underlying health problems or conditions. She indicated that five vaccine manufacturers should have clinical trials beginning later this summer and that the CDC has not yet established who should get the vaccine(s) first when they become available. The logistics of vaccinations could be complex if about 600 million doses need to be administered (about two doses for most of the U.S. population).
6/22/09: The WHO reports 52,160 cases of H1N1 swine flu with 231 deaths. The country with the most reported cases (21,449) is the U.S.
6/19/09: Recommendations for health-care personnel were published today by the CDC to help prevent flu spread to health-care workers. The following is quoted from the CDC press release: "Probably the single most important thing is that infectious patients be identified at the front door. Whether these patients are coming in through the emergency department or the ambulatory care clinic, identifying them up front is essential so health-care personnel know that they should be doing the things that we recommend; that consistent application of precautions is important to make sure that there isn't occupational exposure."
The current recommendations include using a single patient room for infectious individuals and have them cover their cough. And use respirators, gloves, eye protection when they're with a patient with probable H1N1. As always, careful attention to hand hygiene is part of standard precautions that continue to be recommended. For novel H1N1 we currently also recommend that special procedures that might generate a fine aerosol be performed in a special room with negative pressure air handling so other parts of the hospital aren't exposed to potentially infectious material."
6/18/09: Venezuela authorities have quarantined 1,219 cruise ship passengers and 460 crew members when three ship crew members tested positive for swine flu during the cruise. The quarantine will last 10 days, and the passengers and crew will remain on the ship.
6/17/09: The CDC just published two major articles on research results about H1N1 swine flu in the New England Journal of Medicine (360:2605 and 2616, 2009). The articles are written for researchers and clinicians and summarize the basic genetic and clinical data accumulated as of June 3, 2009. Two new terms are introduced that may be seen in future articles on the flu. The first is S-OIV (Swine-Origin Influenza Virus) and refers to the novel Swine-Origin Influenza A (H1N1) that is causing the first pandemic flu in 41 years. The second term is "triple-reassortant." Triple-reassortant means the virus has a mix of eight RNA strands (genes) from three sources: avian, human, and swine viruses. They further identify S-OIV, the novel H1N1 virus, as being a triple-reassortant strain that differs from other triple-reassortant strains such as other H1N1 by having only three classic North American swine RNA strands, two Eurasian swine RNA strands, two avian RNA strands, and one human flu RNA strand instead of five classic North American swine RNA strands, two avian, and one human flu RNA strand found in the current H1N1 flu. They provide data that indicate the majority of cases of S-OIV (novel H1N1) occur in people aged 10-18 years old (40%). Diarrhea and vomiting, symptoms not usually seen in flu patients, are reported in 25% of S-OIV patients. Patients that required hospitalization were 9% of the total number of detected cases and showed a death rate of about 5% (2/36) of hospitalized patients. Anyone who wants a detailed explanation, with data, about the current pandemic viral strain of flu should read these two papers.
6/15/09: The WHO reports 76 countries with a total of 35,928 cases and 163 deaths of H1N1 influenza A swine flu.
6/11/09: WHO director Dr. Margaret Chan announced a level 6 pandemic for H1N1 2009 influenza A swine flu. The decision to declare a pandemic was reached after widespread human-to-human transmission was reached in another WHO-designated region of the globe (Australia), thus fulfilling the WHO level 6 pandemic criteria. However, officials reminded everyone that declaration of a pandemic for H1N1 flu does not indicate any major change in either the way countries respond to the disease or that the H1N1 flu has any major change in its characteristic presentation, it just indicates there is worldwide spread. The WHO suggests there is no increase in severity of symptoms of the 2009 H1N1 flu. The WHO has also not suggested any travel restrictions due to the level 6 pandemic. The WHO said that H5N1 flu is still at WHO level 3 and remarks how unusual it is to concurrently have two types of flu at these two levels. They also express caution because the H1N1 can change, and although it seems relatively stable, they express concern that it might change when the northern hemisphere enters flu season this fall. Today, the WHO reports about 28,744 H1N1 infections in 74 countries with 144 deaths around the world. The first cases on the African continent have been detected in Egypt. In a related news release, four major vaccine producers are in the early stages of H1N1 vaccine development.
6/9/09: WHO administrator Dr. Keiji Fukuda said the WHO is close to announcing a level 6 pandemic alert because of the rapid spread (over 1,000 cases reported with about 125 new cases daily) of H1N1 in Australia. The WHO has been criticized by some flu experts who think countries have pressured the WHO not to declare a pandemic. WHO officials say they are waiting to verify case reports in several countries before they declare level 6 (pandemic). The WHO has not declared a level 6 pandemic in the last 41 years.
6/7/09: The WHO reports 21,940 cases and 125 deaths worldwide.
6/5/09: Wisconsin continues to report the highest number of confirmed and suspected cases in the U.S. (2,217, an increase of 603 cases in four days). Total U.S. cases are 13,217 with 27 deaths.
6/3/09: The WHO reports that the U.S. and Australia reported the highest number of new cases in the last reporting period (1,078 and 204, respectively).
6/1/09: The CDC reports that to date there are 10,053 confirmed and probable cases of H1N1 swine flu in the U.S. with Wisconsin having the most cases (1,641). The CDC estimates that only about one in 20 cases are reported, so the CDC suggests the actual number of U.S. cases is about 200,000 cases. There have been 17 deaths reported in the U.S. Most of the cases of H1N1 currently produce mild flu symptoms. The WHO reports H1N1 swine flu in 62 countries with a total of 15,410 cases and 115 deaths. There are no cases reported on the African continent to date. Public-health officials have dropped the term "swine flu" and now use "2009 H1N1 flu" since pigs are not transmitting the disease.
5/29/09: The WHO reports that a total of 53 countries now have confirmed a total of 15,510 cases of H1N1 swine flu with a total of 99 deaths. As of today, 8,975 cases have been confirmed in the U.S. with 15 deaths. The U.S. has the highest number of confirmed cases and Mexico the highest number of deaths (85). The high number of confirmed U.S. cases may be due to testing methods available in almost every U.S. state. Today, Chinese officials released 21 U.S. students after five days of quarantine when an individual on their flight developed swine flu.
5/28/09: Australia advises about 2,000 passengers on a cruise ship docked in Sydney to quarantine themselves after at least nine confirmed cases of swine flu were found.
5/26/09: Sanofi Pasteur announces it has obtained a $190 million contract from the U.S. government to produce a swine flu vaccine. In Kuwait, 18 U.S. soldiers are reported to have swine flu.
5/23/09: CDC researchers suggest that analysis of over 50 strains of H1N1 are closely related and suggest that a single flu vaccine will likely target most, if not all, of the currently detected strains. They further suggest these findings would facilitate making an effective vaccine. The Department of Health and Human Services set aside about $1 billion for vaccine development on Friday. The WHO reports 43 countries with a total of 12,022 confirmed H1N1 cases and 86 deaths.
5/22/09: The CDC reports that only 1% of the reportedly confirmed H1N1 swine flu cases have occurred in people older than 65 years of age, while the majority of cases occurred in people 5-24 years of age. The officials speculate that older people may have been exposed to viruses in the 1930s-1950s that share some antigenic similarity to H1N1 strains and thus may provide some resistance to the virus.
5/20/09: The WHO reports 11,034 confirmed cases worldwide with a total of 85 deaths from H1N1 swine flu. To date, the WHO has not upgraded to a level 6 (pandemic); it is still at a level 5. Although CDC officials consider H1N1 to be widely spread in the U.S., WHO officials are waiting to see if H1N1 flu becomes widespread in other countries before raising the level to 6.
5/19/09: New York increases its school closings to 17 due to the numbers of suspected cases of H1N1 swine flu. WHO Director-General Dr. M. Chan addressed World Public Health Representatives today and said that the current pattern of mild illness with few deaths continues for H1N1. She cautioned the officials that because influenza viruses change rapidly, the viruses may have given everyone a "grace period" of time to better understand and treat the disease. She is concerned that the virus may interact with the H5N1 avian influenza virus populations that are "firmly established in poultry in several countries." CDC officials have estimated that about 100,000 people in the U.S. are infected with the flu virus and about half that number is infected with H1N1 swine flu; the confirmed case numbers are much smaller (5,123 cases as of May 19).
5/18/09: New York closes 11 schools after a school administrator died after getting H1N1 swine flu. The WHO is starting a conference today (World Health Assembly) about key public-health issues; the flu is likely to be a major topic of this conference. The WHO reports 40 countries are now positive for H1N1 swine flu (as compared to 29 countries reported by the WHO on May 10), with a total of 8,829 confirmed cases and 74 deaths.
5/17/09: The CDC publishes figures on the types of flu viruses reported from May 2 to May 9; the majority of isolates were novel influenza A H1N1 (34.3%) and influenza A viruses that were either unsubtyped or unsubtypable (total 40.2%). The unsubtypable viruses are thought to be variations of the novel influenza A H1N1 virus. They further report that novel influenza H1N1 virus is "antigenically and genetically unrelated to seasonal influenza A (H1N1)" and suggest that little or no protection would be afforded by current seasonal influenza vaccines. They do report some good news; to date, all tested isolates (96) of novel influenza A H1N1 are susceptible to both oseltamivir and zanamivir. However, the CDC reports that seasonal influenza A H1N1 is only sensitive to zanamivir. For more details about these reports, see http://www.cdc.gov/flu/weekly/pdf/External_F0918.pdf; data and graphs are available.
5/15/09: The WHO reports, to date, that 34 countries have officially reported a total of 7,250 cases of H1N1 swine flu worldwide. The CDC reports H1N1 has been detected in 47 states, with a total of four deaths. Confirmed and "probable" cases are totaled at 4,714 in the U.S. Several schools were closed for one week in New York when many students and some adult staff developed flu symptoms.
5/13/09: The CDC reports that a new PCR test kit (a test that detects the genetic material of the virus) for H1N1 swine flu has been produced and is being shipped to all U.S. states and also internationally. The CDC reports that a number of novel H1N1 and "unsubtypable" viruses are being detected. Novel H1N1 viruses cause a wide range of clinical symptoms such as fever, cough, sore throat, body aches, headache, chills, and fatigue and often have accompanying nausea, vomiting, or diarrhea. The CDC considers "unsubtypable" virus to be antigenic variations of the novel H1N1 virus. Some investigators suggest that H1N1 mutates rapidly because there are numerous "unsubtypable" viruses.
5/12/09: Dr. A. Schuchat, interim deputy director with the CDC, says the CDC is focusing on the coming fall flu season and that the current numbers of flu cases are increasing so fast they may consider stopping counting cases. The counted cases may only represent the tip of the iceberg for the actual number of cases. Other investigators have revised the H1N1 swine flu mortality rate to be 0.4%-1.4% of cases but reiterate that the data is still incomplete.

Interim Deputy Director for Science and Public Health Program Rear Admiral Anne Schuchat, MD, speaks during a CDC press briefing. Photo by James Gathany/CDC

5/10/09: The WHO reports, to date, that 29 countries have officially reported a total of 4,379 cases of H1N1 swine flu worldwide, and the infection has reached another continent -- Australia.
5/8/09: Mexico reopens all high schools and universities today after a two-week closure. Although two more deaths were reported in Mexico (revised total number of deaths in Mexico now at 44), Health Minister Jose Angel Cordova said the flu cases were declining. Argentina, Brazil, and Colombia are the first South American countries to report H1N1 swine flu cases. World Health Organization (WHO) authorities say that up to 2 billion people could be infected if the H1N1 swine flu becomes a two-year pandemic. Confirmed H1N1 cases have been detected in two more U.S. states for a total of 43 states.
5/7/09: Currently, at least 41 U. S. states have reported confirmed cases of H1N1 swine flu. The southern hemisphere is beginning the fall/winter season, and epidemiologists and other researchers plan to closely monitor this area of the world to see if H1N1 swine flu increases in numbers of cases and severity. Some investigators suggest that how H1N1 infects populations in southern hemisphere countries (for example, New Zealand) over the next few months will help predict what N1H1 will do in the upcoming flu season of the northern hemisphere. The WHO has reported H1N1 swine flu cases confirmed in 23 countries with a total of 2,099 cases. The WHO published revised case and death numbers in Mexico to 1,112 cases and 42 deaths; this shows a marked reduction in both cases and deaths from the numbers reported by Mexico about one week ago.
5/6/09: An announcement from vaccine producers and U.S. government sources suggests that a vaccine is being developed for the more common seasonal flu virus strain and that a second vaccine is being made specific for the H1N1 2009 swine flu virus. Authorities suggest that this second vaccine is likely to require an initial injection followed by another injection at a later date. They project this requirement because people have not been exposed to H1N1 and to get a good immune response, people will need a "booster shot" (a second immunization) to enhance a person's immune response to the new H1N1 virus. Consequently, a total of three vaccine shots for the 2009-2010 flu season will likely necessary to provide an immune response that may protect individuals from the various flu viruses. Many doctors think that obtaining three, instead of one, vaccine inoculations will hamper attempts to vaccinate the general population. The WHO said about 1,600 cases of H1N1 are confirmed in about 23 countries worldwide.
5/5/09: The first U.S. death reportedly due to H1N1 virus was reported in Texas in a 33-year-old woman with multiple health issues. Over 400 schools are closed nationwide, but investigators suggest this has not been effective and suggest schools be opened since the virus is already being passed person-to-person in over 35 U.S. states. Mexico today began reducing restrictions on businesses and allowing shops to open because flu cases have begun to decline and the severity of the disease seems much less than first thought.
5/4/09: The U.S. reports a total of over 200 cases of H1N1 swine flu confirmed in about 31 states; currently, there have been no fatalities other than one child (with additional health issues) in Texas that got the disease while in Mexico. CDC officials have cautious optimism that this epidemic may not cause as many severe cases as first thought.
5/3/09: Reports from Egypt indicate many pig farms are killing off their pigs in an effort to prevent spread of "swine flu." Most investigators think this drastic step is not warranted. Canadian officials suggest a pig farm in Alberta was exposed to H1N1 virus when a farmer who visited Mexico returned. The officials say that pigs that test positive for H1N1 are being isolated. This is the first report of H1N1 infection transferred from an infected human to pigs.
5/2/09: The WHO and others jointly put out a notice that said to date there is no evidence N1N1 swine flu virus is transmitted by food, and properly handled and cooked pork or pork products will not be a source of infection.
5/1/09: Pork producers agree with U.S. researchers that "swine flu" should be renamed H1N1 2009 flu because the flu cannot be caught from eating properly cooked pork products. Virus researchers agree that no flu viruses are passed to humans through processed pork products.
Editorial note by Dr. Charles P. Davis:
After about one week, several significant things have occurred with H1N1 influenza A 2009 swine flu virus infections. First, the virus has been documented to spread rapidly from Mexico to the majority of U.S. states and now across borders to Europe, Asia, and South America; it has taken only about one to two weeks to accomplish this. This is good evidence that the virus spreads rapidly from person to person and that a large number of people may develop the disease. Second, with revised data from Mexico about mortality (deaths), the disease may not be nearly as deadly as first speculated. Third, most countries' health authorities are closely monitoring the disease on a daily basis, and the WHO and other national organizations worldwide are sharing data and opening up supplies (antiviral medications). This international cooperation helps everyone to understand and treat this disease. Finally, joint efforts between government agencies and pharmacological companies have already begun to work on producing a vaccine to prevent or reduce the effects of this disease. These efforts and findings that have occurred over such a short period of time should reassure people that although they should be vigilant about ways to avoid getting this disease (especially hand washing), there is no reason to be obsessively protective or to panic about H1N1 influenza A swine flu

CDC on Swine Flu (H1N1) - What is the swine flu?

2010-08-13T12:13:00.000-07:00

The swine influenza A (H1N1) virus that has infected humans in the U.S. and Mexico is a novel influenza A virus that has not previously been identified in North America. This virus is resistant to the antiviral medications amantadine (Symmetrel) and rimantadine (Flumadine), but is sensitive to oseltamivir (Tamiflu) and zanamivir (Relenza). Investigations of these cases suggest that on-going human-to-human swine influenza A (H1N1) virus is occurring.

CDC - What are the symptoms of swine flu (H1N1)?

Although uncomplicated influenza-like illness (fever, cough or sore throat) has been reported in many cases, mild respiratory illness (nasal congestion, rhinorrhea) without fever and occasional severe disease also has been reported. Other symptoms reported with swine influenza A virus infection include vomiting, diarrhea, myalgia, headache, chills, fatigue, and dyspnea. Conjunctivitis is rare, but has been reported. Severe disease (pneumonia, respiratory failure) and fatal outcomes have been reported with swine influenza A virus infection. The potential for exacerbation of underlying chronic medical conditions or invasive bacterial infection with swine influenza A virus infection should be considered.

CDC - Interim Recommendations

2010-08-13T12:12:00.000-07:00

For clinical care or collection of respiratory specimens from a symptomatic individual (acute respiratory symptoms with or without fever) who is a confirmed case, or a suspected case (ill close contact of a confirmed case) of swine influenza A (H1N1) virus infection:
Infectious Period
Persons with swine influenza A (H1N1) virus infection should be considered potentially contagious for up to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might potentially be contagious for longer periods. The duration of infectiousness might vary by swine influenza A (H1N1) virus strain. Non-hospitalized ill persons who are a confirmed or suspected case of swine influenza A (H1N1) virus infection are recommended to stay at home (voluntary isolation) for at least the first 7 days after illness onset except to seek medical care.
Case definitions
A confirmed case of swine influenza A (H1N1) virus infection is defined as a person with an acute respiratory illness with laboratory confirmed swine influenza A (H1N1) virus infection at CDC by one or more of the following tests:

real-time RT-PCR
viral culture
four-fold rise in swine influenza A (H1N1) virus-specific neutralizing antibodies

A suspected case of swine influenza A (H1N1) virus infection is defined as a person with acute febrile respiratory illness with onset within 7 days of close contact with a person who is a confirmed case of swine influenza A (H1N1) virus infection.
Close contact is defined as: within about 6 feet of an ill person who is a confirmed or suspected case of swine influenza A (H1N1) virus infection.

Close contact is defined as: within about 6 feet of an ill person who is a confirmed case of swine influenza A virus infection

Acute respiratory illness is defined as recent onset of at least two of the following: rhinorrhea or nasal congestion, sore throat, cough (with or without fever or feverishness)
Recommendations for public health personnel
For interviews of healthy individuals (i.e. without a current respiratory illness), including close contacts of cases of confirmed swine influenza virus infection, no personal protective equipment or antiviral chemoprophylaxis is needed. See section on antiviral chemoprophylaxis for further guidance.
For interviews of an ill, suspected or confirmed swine influenza A virus case, the following is recommended:

Keep a distance of at least 6 feet from the ill person; or
Personal protective equipment: fit-tested N95 respirator [if unavailable, wear a medical (surgical mask)].

For collecting respiratory specimens from an ill confirmed or suspected swine influenza A virus case, the following is recommended:

Personal protective equipment: fit-tested disposable N95 respirator [if unavailable, wear a medical (surgical mask)], disposable gloves, gown, and goggles.
When completed, place all PPE in a biohazard bag for appropriate disposal.
Wash hands thoroughly with soap and water or alcohol-based hand gel.

CDC - Infection Control

2010-08-13T12:11:00.001-07:00

CDC - Infection Control

Recommended Infection Control for a non-hospitalized patient (ER, clinic or home visit):

Separation from others in single room if available until asymptomatic. If the ill person needs to move to another part of the house, they should wear a mask. The ill person should be encouraged to wash hand frequently and follow respiratory hygiene practices. Cups and other utensils used by the ill person should be thoroughly washed with soap and water before use by other persons.

CDC - Antiviral Treatment

Suspected Cases
Empiric antiviral treatment is recommended for any ill person suspected to have swine influenza A (H1N1) virus infection. Antiviral treatment with either zanamivir alone or with a combination of oseltamivir and either amantadine or rimantadine should be initiated as soon as possible after the onset of symptoms. Recommended duration of treatment is five days. Recommendations for use of antivirals may change as data on antiviral susceptibilities become available. Antiviral doses and schedules (http://www.cdc.gov/flu/professionals
/antivirals/dosagetable.htm#table) recommended for treatment of swine influenza A (H1N1) virus infection are the same as those recommended for seasonal influenza:
Confirmed Cases
For antiviral treatment of a confirmed case of swine influenza A (H1N1) virus infection, either oseltamivir or zanamivir may be administered. Recommended duration of treatment is five days. These same antivirals should be considered for treatment of cases that test positive for influenza A but test negative for seasonal influenza viruses H3 and H1 by PCR.
Pregnant Women
Oseltamivir, zanamivir, amantadine, and rimantadine are all "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Only two cases of amantadine use for severe influenza illness during the third trimester have been reported. However, both amantadine and rimantadine have been demonstrated in animal studies to be teratogenic and embryotoxic when administered at substantially high doses. Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, these four drugs should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus; the manufacturers' package inserts should be consulted. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to such women.
Antiviral Chemoprophylaxis
For antiviral chemoprophylaxis of swine influenza A (H1N1) virus infection, either oseltamivir or zanamivir are recommended. Duration of antiviral chemoprophylaxis is 7 days after the last known exposure to an ill confirmed case of swine influenza A (H1N1) virus infection. Antiviral dosing and schedules (http://www.cdc.gov/flu/professionals/antivirals/dosagetable.htm#table) recommended for chemoprophylaxis of swine influenza A (H1N1) virus infection are the same as those recommended for seasonal influenza:
Antiviral chemoprophylaxis (pre-exposure or post-exposure) with either oseltamivir or zanamivir is recommended for the following individuals:

Household close contacts who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) of a confirmed or suspected case.
School children who are at high-risk for complications of influenza (persons with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed or suspected case.
Travelers to Mexico who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly).
Border workers (Mexico) who are at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly).
Health care workers or public health workers who had unprotected close contact with an ill confirmed case of swine influenza A (H1N1) virus infection during the case's infectious period.

Antiviral chemoprophylaxis (pre-exposure or post-exposure) with either oseltamivir or zanamivir can be considered for the following:

Any health care worker who is at high-risk for complications of influenza (persons with certain chronic medical conditions, elderly) who is working in an area with confirmed swine influenza A (H1N1) cases, and who is caring for patients with any acute febrile respiratory illness.
Non-high risk persons who are travelers to Mexico, first responders, or border workers who are working in areas with confirmed cases of swine influenza A (H1N1) virus infection.

CDC - Will a face mask protect me from getting the swine flu (H1N1), and are there differences in face masks?

2010-08-13T12:10:00.001-07:00

Information on the effectiveness of facemasks and respirators for the control of influenza in community settings is extremely limited. Thus, it is difficult to assess their potential effectiveness in controlling swine influenza A (H1N1) virus transmission in these settings. In the absence of clear scientific data, the interim recommendations below have been developed on the basis of public health judgment and the historical use of facemasks and respirators in other settings.

When used properly, facemasks may help reduce one's influenza risk. Photo courtesy of the CDC

In areas with confirmed human cases of swine influenza A (H1N1) virus infection, the risk for infection can be reduced through a combination of actions. No single action will provide complete protection, but an approach combining the following steps can help decrease the likelihood of transmission. These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings.
When it is absolutely necessary to enter a crowded setting or to have close contact with persons who might be ill, the time spent in that setting should be as short as possible. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on your face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time.
When crowded settings or close contact with others cannot be avoided, the use of facemasks or respirators in areas where transmission of swine influenza A (H1N1) virus has been confirmed should be considered as follows:

Whenever possible, rather than relying on the use of facemasks or respirators, close contact with people who might be ill and being in crowded settings should be avoided.
Facemasks should be considered for use by individuals who enter crowded settings, both to protect their nose and mouth from other people's coughs and to reduce the wearers' likelihood of coughing on others; the time spent in crowded settings should be as short as possible.
Respirators should be considered for use by individuals for whom close contact with an infectious person is unavoidable. This can include selected individuals who must care for a sick person (e.g., family member with a respiratory infection) at home.

These interim recommendations will be revised as new information about the use of facemasks and respirators in the current setting becomes available.
What are the types of face masks and respirators?

Unless otherwise specified, the term "facemasks" refers to disposable masks cleared by the U.S. Food and Drug Administration (FDA) for use as medical devices. This includes facemasks labeled as surgical, dental, medical procedure, isolation, or laser masks. Such facemasks have several designs. One type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape. Another type of facemask is pre-molded, adheres to the head with a single elastic band, and has a flexible adjustment for the nose bridge. A third type is flat/pleated and affixes to the head with ear loops. Facemasks cleared by the FDA for use as medical devices have been determined to have specific levels of protection from penetration of blood and body fluids.
Unless otherwise specified, "respirator" refers to an N95 or higher filtering facepiece respirator certified by the U.S. National Institute for Occupational Safety and Health (NIOSH).
Three feet has often been used by infection control professionals to define close contact and is based on studies of respiratory infections; however, for practical purposes, this distance may range up to 6 feet. The World Health Organization uses "approximately 1 meter"; the U.S. Occupational Safety and Health Administration uses "within 6 feet." For consistency with these estimates, this document defines close contact as a distance of up to 6 feet.

Swine Flu (H1N1 Influenza Virus) At A Glance

2010-08-13T12:09:00.001-07:00

Swine flu (swine influenza) is a respiratory disease caused by viruses (influenza viruses) that infect the respiratory tract of pigs and result in nasal secretions, a barking-like cough, decreased appetite, and listless behavior.
Swine flu viruses may mutate (change) so that they are easily transmissible among humans.
The 2009 swine flu outbreak is due to infection with the so-called H1N1 virus and was first observed in Mexico.
Symptoms of swine flu in humans are similar to most influenza infections: fever (100 F or greater), cough, nasal secretions, fatigue, and headache.
Two antiviral agents, zanamivir (Relenza) and oseltamivir (Tamiflu), have been reported to help prevent or reduce the effects of swine flu if taken within 48 hours of the onset of symptoms.

Swine Flu Index

2010-08-13T12:08:00.000-07:00

Featured: Swine Flu Main Article
Novel H1N1 influenza A virus infection (swine flu) is an infection that generally is transferred from an infected pig to a human, however there have been reported cases where infection has occured with no contact with infected pigs. Symptoms of swine flu are "flu-like" and include fever, cough, and sore throat. Treatment is generally with the antibiotics oseltamivir (Tamiflu) or zanamivir (Relenza).

Patient Discussions: Swine Flu - Concerns

Pictures, Images & Illustrations

Medications

FDA Drug Labels on RxList.com

How to take Medicine

2010-07-20T13:26:00.000-07:00

Medicine

Also called: Drugs, Medications

Everyone knows what medicines are for - to make you feel better when you are sick. But many people don't realize that all medicines have risks as well as benefits. The risks of medicines include unwanted side effects or interactions with food or other medicines you may be taking. Some risks are not very serious, like an upset stomach. Others, like liver damage, are more serious.
When a medicine's benefits outweigh its known risks, the U.S. Food and Drug Administration considers it safe enough to approve. Both prescription and over-the-counter medicines must be approved before they can be sold in the U.S.
To reduce the risk of a problem, follow the directions carefully when taking medicines. Make sure that your health care provider knows all of the medicines and supplements you are using. Also, make sure to mention if you are pregnant or nursing. Some medicines can hurt your baby.

Instructions

STEP :- 1

Devise a list of everything you take and how often you take it. Include over-the-counter medications such as vitamins, painkillers and antihistamines. Keep this list current and keep a copy in your purse or wallet.

STEP :- 2

Make sure your doctor knows everything you are taking. Your doctor may not know that a specialist or a medical professional at a clinic prescribed something for you

STEP :-3

Know your medication allergies and always remind doctors and pharmacists you have them.

STEP :-4

Read labels regularly. It's easy to assume you know the directions for taking medicines, but sometimes the directions change with a new prescription

STEP :-5

Take only what the doctor prescribes. Cutting pills in half to make them last longer changes the medicine and its effectiveness. Taking more medicine doesn't make it work better

STEP :-6

Keep track of side effects, especially with a new medicine. Let your doctor know when a new side effect occurs. Pharmacists have detailed listings of potential side effects associated with prescription medicine
.

STEP :-7

Talk to the pharmacist every time you get a new medicine. Pharmacists can share advice on how to take medicine safely.

Tips & Amp; Warnings

Use the same pharmacy whenever possible. Computerized records of prescription history help the pharmacist advise you on safely taking medications in combination.

Always know your child's current weight. This affects the dose so you can safely administer medications.

Know what medications are for. This is especially important for seniors who take more than one kind of medicine on a regular basis.

Utilize a pill organizer when taking multiple medications.

History

2010-06-27T07:50:00.000-07:00

Main article: History of medicine

The ancient Sumerian god Ningishzida, the patron of medicine, accompanied by two gryphons

Prehistoric medicine incorporated plants (herbalism), animal parts and minerals. In many cases these materials were used ritually as magical substances by priests, shamans, or medicine men. Well-known spiritual systems include animism (the notion of inanimate objects having spirits), spiritualism (an appeal to gods or communion with ancestor spirits); shamanism (the vesting of an individual with mystic powers); and divination (magically obtaining the truth). The field of medical anthropology examines the ways in which culture and society are organized around or impacted by issues of health, health care and related issues.

Statuette of ancient Egyptian physician Imhotep, the first physician from antiquity known by name.

Early records on medicine have been discovered from ancient Egyptian medicine, Babylonian medicine, Ayurvedic medicine (in the Indian subcontinent), classical Chinese medicine (predecessor to the modern traditional Chinese Medicine), and ancient Greek medicine and Roman medicine. The Egyptian Imhotep (3rd millennium BC) is the first physician in history known by name. Earliest records of dedicated hospitals come from Mihintale in Sri Lanka where evidence of dedicated medicinal treatment facilities for patients are found. The Indian surgeon Sushruta described numerous surgical operations, including the earliest forms of plastic surgery.

The Greek physician Hippocrates (ca. 460 BCE – ca. 370 BCE), considered the father of Western medicine^.

The Greek physician Hippocrates, considered the "father of medicine",laid the foundation for a rational approach to medicine. Hippocrates introduced the Hippocratic Oath for physicians, which is still relevant and in use today, and was the first to categorize illnesses as acute, chronic, endemic and epidemic, and use terms such as, "exacerbation, relapse, resolution, crisis, paroxysm, peak, and convalescence". The Greek physician Galen was also one of the greatest surgeons of the ancient world and performed many audacious operations, including brain and eye surgeries. After the fall of the Western Roman Empire and the onset of the Dark Ages, the Greek tradition of medicine went into decline in Western Europe, although it continued uninterrupted in the Eastern Roman (Byzantine) Empire.

A Latin copy of The Canon of Medicine, written by Avicenna, who is also considered the father of medicine.

After 750 CE, the Muslim Arab world had the works of Hippocrates, Galen and Sushruta translated into Arabic, and Islamic physicians engaged in some significant medical research. Notable Islamic medical pioneers include the polymath, Avicenna, who, along with Imhotep and Hippocrates, has also been called the "father of medicine".He wrote The Canon of Medicine, considered one of the most famous books in the history of medicine.Others include Abulcasis, Avenzoar,and Averroes.Rhazes was one of first to question the Greek theory of humorism, which nevertheless remained influential in both medieval Western and medieval Islamic medicine.The Islamic Bimaristan hospitals were an early example of public hospitals.However, the fourteenth and fifteenth century Black Death was just as devastating to the Middle East as to Europe, and it has even been argued that Western Europe was generally more effective in recovering from the pandemic than the Middle East.In the early modern period, important early figures in medicine and anatomy emerged in Europe, including Gabriele Falloppio and William Harvey.

An ancient Greek patient gets medical treatment: this aryballos (circa 480-470 BCE, now in Paris's Louvre Museum) probably contained healing oil

The major shift in medical thinking was the gradual rejection, especially during the Black Death in the 14th and 15th centuries, of what may be called the 'traditional authority' approach to science and medicine. This was the notion that because some prominent person in the past said something must be so, then that was the way it was, and anything one observed to the contrary was an anomaly (which was paralleled by a similar shift in European society in general - see Copernicus's rejection of Ptolemy's theories on astronomy). Physicians like Ibn al-Nafis and Vesalius improved upon or disproved some of the theories from the past.

Modern scientific biomedical research (where results are testable and reproducible) began to replace early Western traditions based on herbalism, the Greek "four humours" and other such pre-modern notions. The modern era really began with Edward Jenner's discovery of the smallpox vaccine at the end of the 18th century (inspired by the method of inoculation earlier practiced in Asia), Robert Koch's discoveries around 1880 of the transmission of disease by bacteria, and then the discovery of antibiotics around 1900. The post-18th century modernity period brought more groundbreaking researchers from Europe. From Germany and Austrian doctors (such as Rudolf Virchow, Wilhelm Conrad Röntgen, Karl Landsteiner, and Otto Loewi) made contributions. In the United Kingdom Alexander Fleming, Joseph Lister, Francis Crick, and Florence Nightingale are considered important. From New Zealand and Australia came Maurice Wilkins, Howard Florey, and Frank Macfarlane Burnet). In the United States William Williams Keen, Harvey Cushing, William Coley, James D. Watson, Italy (Salvador Luria), Switzerland (Alexandre Yersin), Japan (Kitasato Shibasaburo), and France (Jean-Martin Charcot, Claude Bernard, Paul Broca and others did significant work). Russian Nikolai Korotkov also did significant work, as did Sir William Osler and Harvey Cushing.

As science and technology developed, medicine became more reliant upon medications. Throughout history and in Europe right until the late 18th century not only animal and plant products were used as medicine, but also human body parts and fluids.Pharmacology developed from herbalism and many drugs are still derived from plants (atropine, ephedrine, warfarin, aspirin, digoxin, vinca alkaloids, taxol, hyoscine, etc.). The first of these was arsphenamine / Salvarsan discovered by Paul Ehrlich in 1908 after he observed that bacteria took up toxic dyes that human cells did not. Vaccines were discovered by Edward Jenner and Louis Pasteur. The first major class of antibiotics was the sulfa drugs, derived by French chemists originally from azo dyes. This has become increasingly sophisticated; modern biotechnology allows drugs targeted towards specific physiological processes to be developed, sometimes designed for compatibility with the body to reduce side-effects. Genomics and knowledge of human genetics is having some influence on medicine, as the causative genes of most monogenic genetic disorders have now been identified, and the development of techniques in molecular biology and genetics are influencing medical technology, practice and decision-making.

Evidence-based medicine is a contemporary movement to establish the most effective algorithms of practice (ways of doing things) through the use of systematic reviews and meta-analysis. The movement is facilitated by modern global information science, which allows as much of the available evidence as possible to be collected and analyzed according to standard protocols which are then disseminated to healthcare providers. One problem with this 'best practice' approach is that it could be seen to stifle novel approaches to treatment. The Cochrane Collaboration leads this movement. A 2001 review of 160 Cochrane systematic reviews revealed that, according to two readers, 21.3% of the reviews concluded insufficient evidence, 20% concluded evidence of no effect, and 22.5% concluded positive effect.

Clinical practice

The Doctor, by Sir Luke Fildes (1891)

In clinical practice doctors personally assess patients in order to diagnose, treat, and prevent disease using clinical judgment. The doctor-patient relationship typically begins an interaction with an examination of the patient's medical history and medical record, followed a medical interviewand a physical examination. Basic diagnostic medical devices (e.g. stethoscope, tongue depressor) are typically used. After examination for signs and interviewing for symptoms, the doctor may order medical tests (e.g. blood tests), take a biopsy, or prescribe pharmaceutical drugs or other therapies. Differential diagnosis methods help to rule out conditions based on the information provided. During the encounter, properly informing the patient of all relevant facts is an important part of the relationship and the development of trust. The medical encounter is then documented in the medical record, which is a legal document in many jurisdictions.Followups may be shorter but follow the same general procedure.

The components of the medical interview and encounter are:

Chief complaint (cc): the reason for the current medical visit. These are the 'symptoms.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'presenting complaint.'
History of present illness / complaint (HPI): the chronological order of events of symptoms and further clarification of each symptom.
Current activity: occupation, hobbies, what the patient actually does.
Medications (Rx): what drugs the patient takes including prescribed, over-the-counter, and home remedies, as well as alternative and herbal medicines/herbal remedies. Allergies are also recorded.
Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past infectious diseases and/or vaccinations, history of known allergies.
Social history (SH): birthplace, residences, marital history, social and economic status, habits (including diet, medications, tobacco, alcohol).
Family history (FH): listing of diseases in the family that may impact the patient. A family tree is sometimes used.

Review of systems (ROS) or systems inquiry: a set of additional questions to ask which may be missed on HPI: a general enquiry (have you noticed any weight loss, change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems (heart, lungs, digestive tract, urinary tract, etc.).

The physical examination is the examination of the patient looking for signs of disease ('Symptoms' are what the patient volunteers, 'Signs' are what the healthcare provider detects by examination). The healthcare provider uses the senses of sight, hearing, touch, and sometimes smell (e.g. in infection, uremia, diabetic ketoacidosis). Taste has been made redundant by the availability of modern lab tests. Four actions are taught as the basis of physical examination: inspection, palpation (feel), percussion (tap to determine resonance characteristics), and auscultation (listen). This order may be modified depending on the main focus of the examination (e.g. a joint may be examined by simply "look, feel, move". Having this set order is an educational tool that encourages the practitioner to be systematic in their approach and refrain from using tools such as the stethoscope before they have fully evaluated the other modalities.

The clinical examination involves study of:

Vital signs including height, weight, body temperature, blood pressure, pulse, respiration rate, hemoglobin oxygen saturation
General appearance of the patient and specific indicators of disease (nutritional status, presence of jaundice, pallor or clubbing)
Skin
Head, eye, ear, nose, and throat (HEENT)
Cardiovascular (heart and blood vessels)
Respiratory (large airways and lungs)
Abdomen and rectum
Genitalia (and pregnancy if the patient is or could be pregnant)
Musculoskeletal (including spine and extremities)
Neurological (consciousness, awareness, brain, vision, cranial nerves, spinal cord and peripheral nerves)
Psychiatric (orientation, mental state, evidence of abnormal perception or thought).

It is likely to be focussed on areas of interest highlighted in the medical history and may not include everything listed above.
Laboratory and imaging studies results may be obtained, if necessary.

The medical decision-making (MDM) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses (the differential diagnoses), along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient's problem.

The treatment plan may include ordering additional laboratory tests and studies, starting therapy, referral to a specialist, or watchful observation. Follow-up may be advised.

This process is used by primary care providers as well as specialists. It may take only a few minutes if the problem is simple and straightforward. On the other hand, it may take weeks in a patient who has been hospitalized with bizarre symptoms or multi-system problems, with involvement by several specialists.

On subsequent visits, the process may be repeated in an abbreviated manner to obtain any new history, symptoms, physical findings, and lab or imaging results or specialist consultations.

Institutions

Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations. The characteristics of any given health care system have significant impact on the way medical care is provided.

Advanced industrial countries (with the exception of the United States) and many developing countries provide medical services through a system of universal health care which aims to guarantee care for all through a single-payer health care system, or compulsory private or co-operative health insurance. This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay. Delivery may be via private medical practices or by state-owned hospitals and clinics, or by charities; most commonly by a combination of all three.

Most tribal societies, but also some communist countries (e.g. China) and the United States, provide no guarantee of health care for the population as a whole. In such societies, health care is available to those that can afford to pay for it or have self insured it (either directly or as part of an employment contract) or who may be covered by care financed by the government or tribe directly.

Modern drug ampoules

Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality and pricing greatly affects the choice by patients / consumers and therefore the incentives of medical professionals. While the US health care system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.

Delivery

Branches

Working together as an interdisciplinary team, many highly trained health professionals besides medical practitioners are involved in the delivery of modern health care. Examples include: nurses, emergency medical technicians and paramedics, laboratory scientists, (pharmacy, pharmacists), (physiotherapy,physiotherapists), respiratory therapists, speech therapists, occupational therapists, radiographers, dietitians and bioengineers.

The scope and sciences underpinning human medicine overlap many other fields. Dentistry, while a separate discipline from medicine, is considered a medical field.

A patient admitted to hospital is usually under the care of a specific team based on their main presenting problem, e.g. the Cardiology team, who then may interact with other specialties, e.g. surgical, radiology, to help diagnose or treat the main problem or any subsequent complications / developments.

Physicians have many specializations and subspecializations into certain branches of medicine, which are listed below. There are variations from country to country regarding which specialties certain subspecialties are in.

The main branches of medicine used in Wikipedia are:

Basic sciences of medicine; this is what every physician is educated in, and some return to in biomedical research.
Medical specialties
interdisciplinary fields, where different medical specialties are mixed to function in certain occasions.

Basic sciences

Anatomy is the study of the physical structure of organisms. In contrast to macroscopic or gross anatomy, cytology and histology are concerned with microscopic structures.
Biochemistry is the study of the chemistry taking place in living organisms, especially the structure and function of their chemical components.
Biostatistics is the application of statistics to biological fields in the broadest sense. A knowledge of biostatistics is essential in the planning, evaluation, and interpretation of medical research. It is also fundamental to epidemiology and evidence-based medicine.
Cytology is the microscopic study of individual cells.
Embryology is the study of the early development of organisms.
Epidemiology is the study of the demographics of disease processes, and includes, but is not limited to, the study of epidemics.
Genetics is the study of genes, and their role in biological inheritance.
Histology is the study of the structures of biological tissues by light microscopy, electron microscopy and immunohistochemistry.
Immunology is the study of the immune system, which includes the innate and adaptive immune system in humans, for example.
Medical physics is the study of the applications of physics principles in medicine.
Microbiology is the study of microorganisms, including protozoa, bacteria, fungi, and viruses.
Neuroscience includes those disciplines of science that are related to the study of the nervous system. A main focus of neuroscience is the biology and physiology of the human brain and spinal cord.
Nutrition science (theoretical focus) and dietetics (practical focus) is the study of the relationship of food and drink to health and disease, especially in determining an optimal diet. Medical nutrition therapy is done by dietitians and is prescribed for diabetes, cardiovascular diseases, weight and eating disorders, allergies, malnutrition, and neoplastic diseases.
Pathology as a science is the study of disease—the causes, course, progression and resolution thereof.
Pharmacology is the study of drugs and their actions.
Physiology is the study of the normal functioning of the body and the underlying regulatory mechanisms.
Toxicology is the study of hazardous effects of drugs and poisons.

Specialties

Main article: Medical specialty

In the broadest meaning of "medicine", there are many different specialties. In the UK most specialities will have their own body or college (collectively known as the Royal Colleges, although currently not all use the term "Royal") which have their own entrance exam. The development of a speciality is often driven by new technology (such as the development of effective anaesthetics) or ways of working (e.g. emergency departments) which leads to the desire to form a unifying body of doctors and thence the prestige of administering their own exam.

Within medical circles, specialities usually fit into one of two broad categories: "Medicine" and "Surgery." "Medicine" refers to the practice of non-operative medicine, and most subspecialties in this area require preliminary training in "Internal Medicine". In the UK this would traditionally have been evidenced by obtaining the MRCP (An exam allowing Membership of the Royal College of Physicians or the equivalent college in Scotland or Ireland). "Surgery" refers to the practice of operative medicine, and most subspecialties in this area require preliminary training in "General Surgery." (In the UK: Membership of the Royal College of Surgeons of England (MRCS).)There are some specialties of medicine that at the present time do not fit easily into either of these categories, such as radiology, pathology, or anesthesia. Most of these have branched from one or other of the two camps above - for example anaesthesia developed first as a faculty of the Royal College of Surgeons (for which MRCS/FRCS would have been required) before becoming the Royal College of Anaesthetists and membership of the college is by sitting the FRCA (Fellowship of the Royal College of Anesthetists).

Surgery

Main article: Surgery

Surgical specialties employ operative treatment. In addition, surgeons must decide when an operation is necessary, and also treat many non-surgical issues, particularly in the surgical intensive care unit (SICU), where a variety of critical issues arise. Surgery has many subspecialties, e.g. general surgery, cardiovascular surgery, colorectal surgery, neurosurgery, maxillofacial surgery, orthopedic surgery, otolaryngology, plastic surgery, oncologic surgery, transplant surgery, trauma surgery, urology, vascular surgery, and pediatric surgery. In some centers, anesthesiology is part of the division of surgery (for historical and logistical reasons), although it is not a surgical discipline.

Surgical training in the U.S. requires a minimum of five years of residency after medical school. Sub-specialties of surgery often require seven or more years. In addition, fellowships can last an additional one to three years. Because post-residency fellowships can be competitive, many trainees devote two additional years to research. Thus in some cases surgical training will not finish until more than a decade after medical school. Furthermore, surgical training can be very difficult and time consuming.

'Medicine' as a specialty

Main article: Internal Medicine

Internal medicine is the medical specialty concerned with the diagnosis, management and nonsurgical treatment of unusual or serious diseases, either of one particular organ system or of the body as a whole. According to some sources, an emphasis on internal structures is implied.In North America, specialists in internal medicine are commonly called "internists". Elsewhere, especially in Commonwealth nations, such specialists are often called physicians.These terms, internist or physician (in the narrow sense, common outside North America), generally exclude practitioners of gynecology and obstetrics, pathology, psychiatry, and especially surgery and its subspecialities.

Because their patients are often seriously ill or require complex investigations, internists do much of their work in hospitals. Formerly, many internists were not subspecialized; such general physicians would see any complex nonsurgical problem; this style of practice has become much less common. In modern urban practice, most internists are subspecialists: that is, they generally limit their medical practice to problems of one organ system or to one particular area of medical knowledge. For example, gastroenterologists and nephrologists specialize respectively in diseases of the gut and the kidneys.

In Commonwealth and some other countries, specialist pediatricians and geriatricians are also described as specialist physicians (or internists) who have subspecialized by age of patient rather than by organ system. Elsewhere, especially in North America, general pediatrics is often a form of Primary care.

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