Avian Flu Diary

Sharp Increase In Reported Flu Deaths In France & UK

2009-11-26T15:06:00.001-05:00

# 4085

While the numbers are most certainly undercounts, and some of the increase in this week’s fatalities may be due to better surveillance and reporting, both France and the UK are reporting major jumps in their flu-related fatalities over the past week.

France saw an increase in the official death toll from 46 to 68, nearly a 50% jump. The UK meanwhile saw their deadliest week with 31 fatalities, a one week surge of roughly 15%.

As in the US, official (lab-confirmed) deaths from this virus around the world likely represent just `the tip of the iceberg’.

Two reports.

Sharp Increase in Swine Flu Deaths in France

November 26, 2009

PARIS (Reuters) - The number of deaths in mainland France from the H1N1 swine flu virus jumped in the last week, according to official data on Thursday.

The toll rose to 68 deaths as of November 22, with 22 new deaths last week. Six of the 68 victims had no underlying health problems, the country's health monitoring institute said. Health minister Roselyne Bachelot said 750,000 people had already been vaccinated but admitted that many vaccination centers were facing long waiting lines.

(Continue . . . )

Swine flu: last seven days sees record number of UK deaths

Thirty-one deaths is highest weekly number since outbreak began, although number of infections falls for third week in a row

More people have died from swine flu in the past seven days than in any week since the outbreak began, the Department of Health revealed today.

Thirty-one deaths associated with the H1N1 virus were recorded bringing the total number of fatalities since May to 245. The estimate for new cases in England fell slightly again to 46,000 – the third successive week it has declined.

The unusual pattern of fewer infections but more deaths suggests a second major peak in cases is unlikely to be imminent. Around a million patients – and more health workers – have already been vaccinated against the virus.

(Continue. . . )

VAERS Vaccine Safety Report

2009-11-26T11:45:00.001-05:00

# 4084

From the VAERS (Vaccine Adverse Event Reporting System) we get the latest US pandemic vaccine safety report – dated November 25th, and current through November 20th.

Summary of 2009 Monovalent H1N1 Influenza Vaccine Data – Vaccine Adverse Event Reporting System

This report paints a picture of a safe and well tolerated vaccine, one whose safety profile is comparable to the seasonal flu vaccine.

Follow the link to read the whole thing, but here is the summary:

An adverse event is a health problem that is reported after someone gets a vaccine or medicine. Note that persons may experience adverse events shortly after vaccination which may or may not be caused by the vaccine. While VAERS is an important system for helping to find potential signs, VAERS cannot determine if an adverse event was caused by vaccination.

VAERS Summary:

•      As of November 20, 2009, 46 million doses of 2009 H1N1 vaccine had been shipped to vaccination providers in the United States.

•      As of November 20, 2009, VAERS had received 3182 adverse event reports following 2009 monovalent H1N1 vaccination.

•      The vast majority (94%) of adverse events reported to VAERS after receiving the 2009 monovalent H1N1 vaccine have not been serious (e.g., they encompass things like soreness at the vaccine injection site).

•      Of the 3182 reports, 177 (6%) were reports that involved what would be considered serious health events (defined as life threatening or resulting in death, major disability, abnormal conditions at birth, hospitalization, or extension of an existing hospitalization)*.

•      The percentage of reports involving what would be considered serious health events is not different between 2009 H1N1 and seasonal influenza vaccines. Additionally, no new or unusual events or pattern of adverse events have emerged. VAERS reports continue to be monitored as more vaccine is administered.

•      Among the 177 reports of serious health events, there were 11 reports of death.

•      The 11 VAERS reports that involve deaths are under review by CDC, FDA and the states where the reported deaths occurred. Preliminary findings do not indicate a common cause or pattern (such as similarities in age, gender, geographic location, illness surrounding death, or underlying medical conditions) to suggest that these deaths were associated with the vaccine. These cases are under further review pending additional medical records (e.g. autopsy reports, medical files).

•      VAERS has received 10 reports of Guillian-Barré syndrome (GBS), for which follow-up assessments are underway. In the United States, about 80-160 cases of GBS are expected to occur each week, regardless of vaccination.

Sixth Antiviral Resistant Case In Wales

2009-11-26T08:53:00.001-05:00

# 4083

Last Friday we learned of two hospitals – one in North Carolina,and one in Cardiff, Wales – that reported small clusters of Tamiflu resistant H1N1 infections among their patients.

Further investigation has turned up a 6th case in the Wales hospital, and there may yet be another.

While these reports are concerning, and of scientific interest, it is import to remember that for now Tamiflu remains effective in the overwhelming number of cases. And Relenza, another antiviral, is still effective when Tamiflu is not.

The number of resistant cases that have been reported is still very small. Given the heavy usage of Tamiflu, it would not be unexpected to see more resistant cases develop over time.

In just over a year seasonal H1N1 went from being more than 90% sensitive to oseltamivir (Tamiflu) to nearly 100% resistant. So we know the potential is there for seeing something like that happen with novel H1N1.

Which is why we watch developments such as these with interest, particularly when it involves the transmission of a resistant strain.

Antivirals were always viewed as a stop-gap measure during a pandemic. The best defense against a novel influenza strain is vaccination.

This report from the BBC.

New drug-resistant swine flu case

Page last updated at 11:55 GMT, Thursday, 26 November 2009

A sixth person has tested positive for a Tamiflu-resistant strain of swine flu, public health officials say.

The patient is linked to five people who last week became the world's first confirmed cases of person-to-person transmission of such as a strain.

Another person in direct contact with the group at University Hospital of Wales, Cardiff, has been tested.

Three patients remain in hospital, with one in critical care and the other two treated in isolation.

Public health officials said vaccinations remain the most effective way of combating swine flu.

Dr Roland Salmon, director of the National Public Health Service for Wales' Communicable Disease Surveillance Centre, said it was "not unexpected" that more patients on a unit treating people with severe underlying health conditions would test positive for the Tamiflu-resistant strain.

He said: "In this case, the resistant strain of swine flu does not appear to be any more severe than the swine flu virus that has been circulating since April.

(Continue . . . )

Effect Measure: Happy Blogiversary

2009-11-26T07:53:00.001-05:00

# 4082

As I spent yesterday afternoon in the dentist’s chair, and last night in a vicodin induced haze, I missed the fact that yesterday was Effect Measure’s 5th blogiversary.

Since most of what I know about the science of influenza I gleaned from their terrific blog, it would be churlish on my part not to offer my heartfelt congratulations, and thanks, for their combined hard work.

If Effect Measure isn’t already a daily stop on your Internet rounds, you are missing the best public health blog on the web.

If you read the comments to their blogiversary blog, you’ll find I’m not alone in this appraisal. So go join in the celebration and read:

Fifth blogiversary

CIDRAP News on The Rise In Pneumococcal Disease

2009-11-25T19:54:00.001-05:00

# 4081

Since I was (unfortunately) back in the dentist’s chair this afternoon, I missed today’s CDC press briefing.

Luckily, Lisa Schnirring of CIDRAP News was not similarly sidelined, and so we have excellent coverage of the big story out of that conference . . . a serious rise reported in pneumococcal disease.

This is just an excerpt of a much longer (and very important) story. Follow the link to read it in its entirety.

CDC warns about rise in serious pneumococcal disease

Lisa Schnirring Staff Writer

Nov 25, 2009 (CIDRAP News) – In a worrisome but not unexpected pandemic-related development, the US Centers for Disease Control and Prevention (CDC) said today that it is seeing a spike in serious pneumococcal disease, particularly in younger patients.

Anne Schuchat, MD, director of the CDC's National Center for Immunization and Respiratory Diseases, told reporters at a press briefing that the CDC is seeing an increasing number of invasive pneumococcal disease cases around the country, but the numbers were particularly high in Denver at a time when pandemic H1N1 activity was peaking in the area.

Over the past 5 years the Denver area averaged 20 pneumococcal disease cases in October, but this year the area recorded 58, and most were in adults between the ages of 20 and 59, many of whom had underlying medical conditions.

Health officials expect to see more pneumococcal disease when seasonal flu circulates, but the infections typically strike people who are older than 65. In past pandemics secondary bacterial pneumonia infections, particularly those involving Streptococcus pneumoniae, frequently contributed to illnesses and deaths.

(Continue . . . )

MMWR: 35 Pediatric Flu Deaths Reported Last Week

2009-11-25T12:21:00.001-05:00

# 4080

Another bad week for influenza pediatric mortality to report.

After a drop in last week’s report to 21 deaths (ordinarily a very high number), the MMWR (US Morbidity and Mortality Weekly Report) is once again reporting 35 pediatric deaths for week 46, ending November 21st.

This week’s FluView report won’t be out until next Monday, I believe, due to the long Holiday weekend. Today’s release of the MMWR is a day earlier than normal.

While 35 pediatric deaths are reported, some of those may be from previous weeks (or even months), as sometimes there is a bit of lag time in testing and reporting.

But the 5-year weekly average for this time of year is Zero.

Week 46: 35 new deaths reported
Cumulative 2009: 301 total deaths reported

NH (1), MA (1), RI (2), PA (2), MN (1), MO (1), NC (2), FL (3), TN (1), TX (2), CO (1), NM (8), WA (1), CA (1), IL (3), IN (1), KY (1), NY (1), SC (2)

To put this into perspective, 2009 is on track to record 10 times as many pediatric influenza-related deaths as were reported to the CDC in either 2005 or 2006.

And, according to the CDC, the actual number of pediatric deaths is likely to be higher than is being reported.

Thanksgiving Is National Family History Day

2009-11-25T09:06:00.001-05:00

# 4079

As a former paramedic, I am keenly aware of how important it is for everyone to know their personal, and family, medical history.

Every Thanksgiving since 2004 the Surgeon General has declared Thanksgiving as National Family History Day. Over the holiday weekend - while you are visiting with family - it is an ideal time to ask about and share family medical history.

The CDC and the HHS have a couple of web pages devoted to collecting your family history, including a web-based tool to help you collect, display, and print out your family’s health history.

Family History: Collect Information for Your Child's Health

Surgeon General's Family Health History Initiative

And finally, a repost of one of my earlier blogs on a similar topic . . .

Those Who Forget Their History . . .

. . . . are condemned to wait longer in triage.

Not where you thought I was going, is it?

But this is an important aspect of personal preparedness.

Knowing, and having immediately available, a medical history on every member of your family.

As a former paramedic - one who has struggled to take thousands of medical histories in the back of a moving vehicle, or at the scene of a medical emergency - I know how difficult getting an accurate and complete medical history can be.

As you might imagine, when someone is unconscious, or unable to respond to questions, getting a medical history becomes more problematic.

You have to rely on relatives, friends, neighbors . . .and sometimes even snooping in their medicine cabinet.

Often, people don’t even know what medicines they are taking, or why.

If I had a nickel for every time a patient denied taking meds, but under the pressure of additional questioning, admitted to taking `a red one, a blue one and two white ones in the morning . . and 3 white ones at night’ - well, I’d have a lot of nickels.

Since I act as a medical advocate for several relatives, I maintain a pretty elaborate medical history on each of them. When one of them falls ill, a copy goes with them to the doctor or the emergency room.

I never see my doctor without bringing him an update history. Sure, he knows me. But he sees hundreds of patients, and me only every few months. There is no way he can remember the details of my medical history.

So I provide him with a short, 1 page synopsis that he can scan in about 30 seconds, to make his life, and mine, easier.

Since you can’t always know, in advance, when you might need medical care it is important to carry with you some kind of medical history at all times. It can tell doctors important information about your history, medications, and allergies when you can’t.

Many hospitals and pharmacies provide – either free, or for a very nominal sum – folding wallet medical history forms with a plastic sleeve to protect them.

I’ve scanned the one offered by one of our local hospitals below. It is rudimentary, but covers the basics.

In a medical emergency, minutes can make the difference between life and death. And even in less urgent cases, having all of this information can go a long ways towards speeding your treatment.

You should make it a point, this week, to get medical history forms for every member of your family – regardless of their age – and fill them out.

Except for small children, everyone should find a way to carry it with them at all times.

This is not a one-time, make it and forget, prep. You need to update it every time you add or change your medications, or your medical history changes. It only takes a few minutes now.

But it could save a lot of time later.

Referral: EM On Thanksgiving & Swine Flu

2009-11-25T08:43:00.001-05:00

# 4078

Although it is still early in the day, the `must read’ thus far is Effect Measure’s take on the multi-generational population mixing that is an annual event here in the United States; Thanksgiving.

For an epidemiologist’s questions and concerns regarding this year’s holiday, read:

Thanksgiving and swine flu

And with the winter holidays (including the largest annual human migration on earth, Chinese New Years) ahead, what happens here with Thanksgiving may well be an early harbinger of what happens in other countries this winter as well.

Stay tuned.

Referral: Black Swan Flu

2009-11-25T07:29:00.001-05:00

# 4077

Crof at Crofsblog picked up overnight a piece on Forbes.com called Black Swan Flu, where Trevor Butterworth interviews Maryn McKenna on the media’s coverage of the H1N1 pandemic.

Readers of this blog, or of CIDRAP News are no stranger to Maryn’s work, and hopefully you are visiting her Superbug Blog website regularly for the best coverage of MRSA around. Her next book, Superbug: The Fatal Menace of MRSA, will be published by the Free Press next March.

You can access this interview either through Crofsblog or by going to: Black Swan Flu.

China: Zhong Nanshan On Viral Reassortment

2009-11-25T07:07:00.001-05:00

# 4076

In early 2003, at a time when SARS was burning its way through parts of China and the Chinese government actively hid that information from its people, its doctors, and the rest of the world, one man boldly went before the TV cameras and told the truth.

That man was Zhong Nanshan, director of Guangzhou's Institute of Respiratory Diseases and a member of China’s Academy of Sciences.

Zhong did something that isn’t normally conducive to good health and long life in China . . . he publicly challenged official government statements.

In doing so, Zhong Nanshan became a much respected and revered household name in China. And since that time, he has repeatedly voiced his opinions, even when they contradict the `official line’ of the Chinese government.

Last week Zhong publicly questioned the official death toll from the H1N1 virus (see Zhong Nanshan On China’s Death Toll), which brought a response 24 hours later from the Health Ministry, promising to punish anyone caught hiding fatalities.

Today, Reuters has a long and very informative article regarding his concerns over the possible reassortment of the pandemic H1N1 virus with H5N1 bird flu.

Reassortment occurs when two compatible viruses infect the same host (human, pig, bird, etc.) at the same time, and swap genetic material. This can produce a hybrid virus, with parts of both viral donors.

While we know reassortments happen, and they have caused pandemics in the past, we really don’t know how likely it is that the H5N1 virus will mix with H1N1 and produce a biologically `fit’ hybrid; one that replicates well and is easily transmissible.

Obviously biologically fit reassortments don’t happen very often, else we’d be hip deep in new viruses all the time.

But while speculative, when Zhong Nanshan is worried, one would be wise not to dismiss the idea.

He isn’t alone, by the way. Other scientists have publicly worried over the possibility. You may recall a recent blog regarding Alan Sipress’s column in the Washington Post Alan Sipress: Playing chicken with a nightmare flu.

Follow the link to read the entire article.

China expert warns of pandemic flu mutation

Wed Nov 25, 2009 3:29pm IST

By Stefanie McIntyre

HONG KONG (Reuters) - China must be alert to any mutation or changes in the behavior of the H1N1 swine flu virus because the far deadlier H5N1 bird flu virus is endemic in the country, a leading Chinese disease expert said.

Zhong Nanshan, director of the Guangzhou Institute of Respiratory Diseases in China's southern Guangdong province, 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 in an interview with Reuters Television.

"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 World Health Organization warned on Tuesday that H5N1 had erupted in poultry in Egypt, Indonesia, Thailand and Vietnam, posing once again a threat to humans.

"First, it places those in direct contact with birds -- usually rural folk and farm workers -- at risk of catching the often-fatal disease. Second, the virus could undergo a process of "reassortment" with another influenza virus and produce a completely new strain," it said.

"The most obvious risk is of H5N1 combining with the pandemic ... (H1N1) virus, producing a flu virus that is as deadly as the former and as contagious as the latter."

(Continue . . . )

Branswell Reports On GSK Vaccine Allergic Reactions

2009-11-24T22:09:00.001-05:00

# 4075

Helen Branswell, medical and science correspondent for the Canadian Press, tracks down what is known about the suspect batch of GSK vaccine which has been pulled from use in Canada due to excess allergic reactions, and answers some questions about anaphylaxis.

For my American readers, THIS RECALL DOES NOT APPLY TO U.S. VACCINES.

While answers about this batch of vaccine are still in short supply, Ms. Branswell asks and answers a number of general questions about anaphylaxis and vaccines.

As with any Branswell article, this is well worth reading.

GSK says still no answer on whether H1N1 vaccine batch triggers more reaction

By Helen Branswell Medical Reporter (CP)

TORONTO — The investigation into whether a batch of H1N1 vaccine may have triggered a higher-than-normal rate of allergic reactions hasn't yet come up with answers, vaccine manufacturer GlaxoSmithKline said Tuesday.

And health officials in Quebec said they are still trying to determine if the death of an elderly man who died of anaphylaxis after receiving a pandemic flu shot was triggered or hastened by the vaccination.

"Investigations being undertaken by GSK, Health Canada and the Public Health Agency of Canada (PHAC) have not yet been completed," GSK spokesperson Megan Spoore said in an email about the pulled batch of vaccine.

(Continue . . . )

UK: H1N1 Serology Tests Reveal Significant Asymptomatic Rate

2009-11-24T15:54:00.001-05:00

# 4074

It comes as no surprise that a certain percentage of people who are exposed to the pandemic flu virus go on to develop antibodies without experiencing clinical symptoms.

With seasonal flu, it is expected that anywhere from 1/3rd to 1/2 of people exposed, never fall ill.

But when a new virus appears, until serology tests can be conducted, we don’t have a good handle on what percentage might remain asymptomatic.

Earlier this months I reported on New Zealand’s plans to test the blood of 2,500 people (see New Zealand To Conduct Seroprevalence Studies) to try to determine the actual rate of infection over the summer. Other countries are doing so, as well.

Today we learn of a relatively small study, conducted in the UK, of school aged children to determine how many have elevated antibody titers to the novel H1N1 virus.

The results are encouraging, in that a substantial percentage (about 1/3rd) of the children tested show antibodies to the virus, while only about 1 in 10 reported flu symptoms.

This report from the BBC.

More children 'than expected have had swine flu'

By Nick Triggle
Health reporter, BBC News

Up to a third of children in some areas may have had swine flu, but many will not have been ill, analysis shows.

The Health Protection Agency has reviewed blood tests which showed higher levels of infection among children than originally thought.

In hotspot areas, such as London and the West Midlands, a third of school-aged children may have had the virus, but only one in 10 or less got ill.

Across the UK, the figure is probably about a fifth, the HPA said.

The findings reinforce the fact the pandemic is a mild strain of flu.

Flu, whether it is seasonal or swine, always affects more people than actually get ill.

The ratio is normally about 50-50 and pandemic flu is probably not much different, the HPA said.

(Continue . . . )

Fergus Walsh, medical correspondent for the BBC, who writes the Fergus on Flu blog, has more at:

Up to a third of children in some areas have been infected

Fergus Walsh | 16:54 UK time, Tuesday, 24 November 2009

Referral: Virology Blog On D225G Mutation

2009-11-24T14:41:00.001-05:00

# 4073

Vincent Racaniello – who is a Professor of Microbiology at Columbia University Medical Center - gives us a virology lesson today on the much discussed H1N1 mutations announced in Norway last week.

He argues that the change – an amino acid substitution (D225G) –impairs the `fitness’ of the virus to transmit to other hosts, and therefore isn’t as big of threat as some have suggested.

Since I am woefully out of my league here (despite listening to his excellent podcasts each week on TWiV), I’ll simply step aside and direct you to his informative blog entry.

The D225G change in 2009 H1N1 influenza virus is not a concern

by Vincent Racaniello on 24 November 2009

A Reader’s Question & A Partial Answer

2009-11-24T09:15:00.001-05:00

# 4072

Yesterday one of my readers left this question in the comments section of ECDC On Norway Mutation & Tamiflu Resistance.

h1n1_watcher said...

regarding the concern about mutations there is one thing I don't understand: If influenza viruses are constantly changing by genetic drift anyway, then why has this never led to a more dangerous form of the seasonal influenza during all those years and decades of constant genetic drift. i.e. ongoing mutation ?

The pathogenicity/CFR or virulence of seasonal influenza seems to be almost exactly the same every year for decades despite the fact that the virus is constantly mutating.

Why is this so ? and why is a pandemic virus supposed to be more prone to "dangerous" mutations than the seasonal ones ?

As far as I know the mutation (drift) rates are similar for both seasonal and pandemic viruses. Yet is has never been observed that a seasonal influenza virus has mutated to a more deadlier form. (Usually, the only consequence of the mutations is that we have to update our vaccines accordingly ...)

h1n1_Watcher has posed some intriguing questions, and while I don’t have all of the answers, I’d like to take a stab at part of it.

While several points are raised, the recurring central issue is:

If influenza viruses are constantly changing by genetic drift anyway, then why has this never led to a more dangerous form of the seasonal influenza during all those years and decades of constant genetic drift. i.e. ongoing mutation ?

The problem here is, I don’t think we can make this assumption.

There have been great variations documented in the virulence (and transmissibility) of seasonal influenza viruses from one year to the next.

The CDC statement that influenza kills 36,000 Americans every year is a bit misleading, because the death toll between 1990 and 1999 from which that estimate arose was calculated to range from a low of 17,000 to a high of 52,000.

And none of those were `pandemic years’.

Some of this variation can be attributed to years when the more virulent H3N2 virus was the dominant strain, as opposed to the milder H1 strain, but we’ve seen year-to-year variations in the virulence of the same seasonal virus.

I’m going to be drawing a good deal of material from an absolutely fascinating EID Journal article: Viboud C, Tam T, Fleming D, Miller MA, Simonsen L. 1951 influenza epidemic, England and Wales, Canada, and the United States.

Abstract (Excerpt)

Influenza is responsible for large increases in deaths in pandemic seasons when emerging viral subtypes with novel surface antigens become predominant, and also in some interpandemic seasons, when established subtypes exhibit antigenic drift (1).

The circulating viral subtype is associated with varying severity of influenza epidemics (2): in the last 2 decades in the United States, estimated excess death rates were on average 2.8-fold higher in A/H3N2-dominated seasons than in A/H1N1 and B seasons (3).

Within a given subtype, however, the strain-specific determinants of epidemic severity are still poorly understood. For instance in the United States in the same period, excess death rates varied nearly 4-fold among A/H3N2 seasons, even after adjustments for population aging (3).

So, even over the past quarter century, we’ve seen major differences in the virulence of the same seasonal flu strain.

The most telling example, however, came in 1950-51.

The no-name epidemic of 1951 was one that, for a few weeks - mostly in England and Canada- proved to be deadlier than the 1918 Spanish Flu.

For most of the world, 1951 remained an average flu year. The dominate strain of influenza that year was the so-called `Scandinavian strain', which produced mild illness in most of its victims.

In fact, if you look at the graph for the United States, running from 1945 to 1956, you'll see nary a blip.

But in December of 1950 a new strain of virulent influenza appeared in Liverpool, England, and by the end of the flu season, had spread across much of England, Wales, and Canada.

Again, from the EID Study.

The 1951 influenza epidemic (A/H1N1) caused an unusually high death toll in England; in particular, weekly deaths in Liverpool even surpassed those of the 1918 pandemic. . . . . Why this epidemic was so severe in some areas but not others remains unknown and highlights major gaps in our understanding of interpandemic influenza.

According to this study, the effects on the city of origin, Liverpool, were horrendous.

In Liverpool, where the epidemic was said to originate, it was "the cause of the highest weekly death toll, apart from aerial bombardment, in the city's vital statistics records, since the great cholera epidemic of 1849" (5). This weekly death toll even surpassed that of the 1918 influenza pandemic (Figure 1)

This extraordinary graph shows the excess deaths in Liverpool during this outbreak (red line), while the black line shows the peak deaths during the 1918 pandemic. This chart shows excess deaths by A) respiratory causes (pneumonia, influenza and bronchitis) and B) all causes.

For roughly 5 weeks Liverpool saw an incredible spike in deaths due to this new influenza. And it did not remain just in Liverpool. While it appears not to have spread as easily as the dominant Scandinavian strain, it managed to infect large areas of England, Wales, and Canada over the ensuing months.

For reasons we don't understand, this new strain never managed to spread much beyond England, Wales, and Canada. It did not reappear the next flu season either. It vanished as mysteriously as it appeared.

Another example, but one that affected the transmissibility and not the virulence of the seasonal virus, occurred in 1947. The so-called `vaccine failure’ year, when a new H1N1 virus swept quickly around the world.

In what would later be described as the Pseudopandemic of 1947, a new variant of the H1N1 appeared on military bases – first noticed in Japan – and quickly spread from there. While it produced a generally mild illness (sound familiar?) there were apparently low levels of immunity in the population.

1947 is little remembered today, except by epidemiologists, because while widespread, this new flu strain produced few excess deaths.

While we tend to worry about mutations and antigenic changes to pandemic strains, the truth is, plain old seasonal influenza is quite capable of throwing us a curveball.

It has in the past, and no doubt will do so again in the future.

My thanks for the question, and an opportunity to revisit one of my favorite influenza research papers. Hopefully this answers at least part of the reader’s question.

It Isn’t Just Swine Flu

2009-11-24T07:48:00.001-05:00

# 4071

More than 2 1/2 years ago I wrote a blog entitled It Isn't Just Bird Flu, where I wrote about a number of possible pandemic and epidemic threats. I opened with:

In this increasingly crowded world of ours, where there are large areas of poverty and poor medical care, there are literally scores of deadly pathogens that could spark the next epidemic, or pandemic. Bird flu, or the H5N1 virus, is high on the list of diseases we watch, but it is by no means the only one out there.

When we prepare for a bird flu pandemic, we are also preparing for any other disease outbreak.

As it turned out, it was something other than H5N1 that leapt onto the global health stage, and many of our preparations for bird flu were quickly revised to deal with the swine flu threat.

The three years of pandemic planning have paid off, even if things haven’t always gone as smoothly as we’d like.

The swine flu pandemic of 2009 – while not the killer strain we feared would come – has given us an opportunity to see where we need to make improvements in our response.

But it is important that we take these lessons to heart. There is no guarantee that we have years or decades before the next pandemic strain emerges.

No guarantees at all.

Among the avian influenza's, H5N1 is currently our primary concern. It is a novel virus, it has become endemic in birds in many countries, and it has shown that it can jump species and infect humans. It has all of the criteria needed to spark a pandemic, save one:

It hasn't developed the ability to be easily transmitted from human-to-human.

And perhaps there is some biological barrier to prevent that from ever happening. We simply don’t know.

But we do know that viruses are constantly mutating, adapting, and evolving. What may not be possible today may become commonplace tomorrow.

Which brings us to this report in Monsters & Critics today, where the WHO warns not to become complacent about avian flu.

WHO warns of resurgence of avian flu virus

Health News

Nov 24, 2009, 6:48 GMT

Manila - The World Health Organization (WHO) warned Tuesday of a possible resurgence of bird flu amid new cases of the disease in poultry in Egypt, Indonesia, Thailand and Vietnam.

The Manila-based WHO Western Pacific Office said the presence of the H5N1 virus in poultry placed those in direct contact with the birds at risk of getting infected with the disease.

It added that it was also closely monitoring the risk of the H5N1 virus combining with the H1N1 swine-flu virus to produce a new and deadlier strain.

'We don't know if this is possible, but we are certainly aware of the risk,' said Shin Young-Soo, WHO regional director for the Western Pacific. 'We are on alert for this development.'

(Continue . . .)

Of course, there are other avian influenza viruses out there – and some of those may have pandemic potential as well.

Earlier this month we saw another rare human infection by the H9 virus in Hong Kong, something that has been detected several times in that region over the past decade.

H7N7 infected 89 people and caused 1 death in the Netherlands in 2003, while two other H7 viruses were detected in humans in the UK in 2006 and 2007. And lastly H10N7 infected two infants in Egypt in 2004.

The best overview of avian influenzas that I’m aware of is CIDRAP’s

Avian Influenza (Bird Flu): Implications for Human Disease

While it may be due, in part, to better surveillance – we are seeing more species jumping zoonotic diseases than ever before.

As man encroaches deeper into jungles and remote areas, and as he factory farms animals in crowded and often unsanitary conditions, he exposes himself to previously unknown animal borne diseases.

Consuming `bush meat’ is another potential source of zoonotic infection, something that Nathan Wolfe: Virus Hunter and a worldwide network of more than 100 scientists working with the Global Viral Forecasting Initiative (GVFI) hope to detect.

It was just this sort of human-animal interaction in Guangdong Province in 2002 that is believed to have precipitated the SARS outbreak which infected more than 8,000 people and killed roughly 800.

SARS apparently came about due to the penchant of some prosperous Chinese to dine on exotic animals. These animals were slaughtered, and served, in `Wild Flavor' restaurants, particularly in Guangdong Province.

A previously unknown coronavirus, which subsequently was discovered in civet cats served in these establishments, was determined to be the likely cause of the SARS outbreak.

SARS has since receded back into the wild, but the threat is certainly not gone. It could seep back into the human population again.

Nipah and Hendra are two particularly nasty pathogens that have caused outbreaks in South East Asia and Australia. In 2008 a new strain of ebola was discovered in Africa, and this year Ebola Reston (a strain which does not currently sicken humans) was found in pigs in the Philippines.

Earlier this year, a new arenavirus was isolated from 5 patients in South Africa and Zambia (see Lujo Virus: Newly Identified Arenavirus).

Ironically, in 1969, the Surgeon General of the United States, William H. Stewart, declared, "The war against diseases has been won."

He clearly was an optimist.

In the four decades since that proclamation, more than 3 dozen new zoonotic diseases have emerged or have been identified, including HIV, Hanta, Nipah, Hendra, West Nile Virus, Lyme Disease, H5N1, and now novel H1N1.

Old scourges are making a comeback as well.

Some, like Tuberculosis seemed as if they would be beaten by modern antibiotics, but now have become resistant. Polio continues to surface in Asia and Africa. And Dengue, Malaria, and now Chikungunya are all marching around the globe.

While some of these may seem like rare and exotic tropical diseases, I would remind my readers that Key West, Florida has recently seen dozens of Dengue Fever cases. Chikungunya showed up in Italy, of all places, a couple of years ago.

In October of 2008 Lloyd's issued a pandemic impact report for the Insurance industry, which can be downloaded here.

The Lloyds report takes pains to point out that while we worry about an influenza pandemic the most, there are other candidates out there that could spark a pandemic (or at least an epidemic).

They list:

Hendra Virus
Nipah Virus
Cholera
Small Pox
HIV/AIDS
Bubonic Plague
Tuberculosis
Lassa fever
Rift Valley fever
Marburg virus
Ebola virus
Bolivian hemorrhagic fever
MRSA
SARS

I could add Dengue, Chikungunya, and of course Pathogen X, the one we don't know about yet, to this list.

Not all of these are capable of sparking a worldwide pandemic, of course. Some, particularly the vector borne diseases and bacterial infections, are unable to spread globally the way that influenza viruses do.

But all of these are capable of producing, at the very least, serious regional epidemics or localized outbreaks.

Emerging infectious diseases are national, and global, security threats. They can also have immense economic ramifications.

Whether it is a new emerging disease, or an old foe making a comeback, the world must remain alert and prepared to deal with the next pathogenic threat.

And that means funding public health initiatives and scientific research both domestically and around the world.

And if we had any sense, we’d do it with the same commitment and vigor as we fund our military.

Because, while I can’t tell you which threat is coming next, I can assure you that nature’s biological laboratory is open 24/7 and is fully capable of serving up plenty of nasty surprises down the road.

H1N1 Mutation Found In Hong Kong

2009-11-23T19:19:00.001-05:00

# 4070

In an announcement today Hong Kong authorities tell of a year-old boy hospitalized for 3 days last July who tested positive for the same mutation in the H1N1 virus as made headlines last week.

The amino acid change in the HA1 gene at position 222 (225 in influenza H3 numbering) from aspartic acid (D) to glycine (G) had been found in three cases of severe pandemic Influenza in Norway.

The assumption by some has been that this mutation must increase the virulence of the virus because it was found in several severe cases in Norway, some with fatal outcomes.

While it may indeed prove to be a factor in the virulence of H1N1, what we don’t have a good handle on is how many mild cases have occurred with this mutation?

Without knowing that, it is very difficult to assess the relative dangers of this single amino acid substitution.

The case announced today would appear only to have been of moderate severity, as the child was only hospitalized for 3 days and has fully recovered.

The other key point here is that of 123 samples tested in Hong Kong, only one showed the mutation.

Which would suggest it isn’t widespread in that community, and may simply be a spontaneous mutation.

Also, the boy’s family did not fall ill, and the virus remained sensitive to antivirals.

The significance of this mutation is not yet clear. But each day brings us more data which will hopefully give us a better idea in the weeks and months to come.

Two reports:

H1N1 flu virus mutation detected in HK

www.chinaview.cn 2009-11-24 07:33:52

HONG KONG, Nov. 23 (Xinhua) -- Hong Kong's Department of Health announced Monday that it had found the same mutation in a H1N1 flu virus sample as the one detected in Norway recently.

The department said that it had examined the genetic sequence of H1N1 flu viruses in its monitoring system. Out of the 123 sequences studied, one sample showed the same mutation as the Norway strain.

The virus was taken from a year-old boy who developed flu-like symptoms July 22. He was admitted to Prince of Wales Hospital July25 and discharged three days later. He has recovered.

Mutations are frequently encountered in influenza viruses. According to the World Health Organization, the same mutation of the virus has been found on the Chinese mainland and in other countries, including Brazil, Japan, Mexico, Ukraine and the United States.

The virus with this mutation remained sensitive to antiviral drugs, Tamiflu and Relenza. No evidence suggests these mutations are leading to an unusual increase in the number of H1N1 flu infections or a greater number of severe or fatal cases.

And an excerpt from the Hong Kong Standard

Mutated swine flu found in tot
Mary Ann Benitez
Tuesday, November 24, 2009

EXCERPT

The Department of Health announced last night that it found the same mutation in the boy, who developed symptoms on July 22 and tested positive for the virus on July 25 when he was admitted to Prince of Wales Hospital.

He was discharged on July 28 and recovered completely. His family members did not fall ill.

A department spokesman said: "The virus with this mutation remained sensitive to antiviral drugs oseltamivir [Tamiflu] and zanamivir [Relenza]."

The spokesman said there is no evidence that these mutations are leading to an unusual increase in the number of swine flu infections or a greater number of severe or fatal cases.

<SNIP>

Stene-Larsen added: "Based on what we know so far, it seems that the mutated virus does not circulate in the population, but might be a result of spontaneous changes."

Japan: Influenza Related Encephalopathy

2009-11-23T15:52:00.001-05:00

# 4069

Encephalopathy isn’t a distinct disease, but rather refers to a syndrome of diffuse brain dysfunctions, which may be associated with a variety of causes.

Viral and bacterial infections are among the common culprits, but encephalopathy may also be caused by trauma, prions, toxic chemical exposures, and even a thiamine deficiency (Wernicke’s Encephalopathy).

The overriding hallmark of encephalopathy is an altered mental state, although depending and severity of encephalopathy, common neurological symptoms such as progressive memory loss and changes in cognitive ability, personality changes, inability to concentrate, lethargy, and loss of consciousness may be seen.

In recent years Influenza has been seen as a rare cause of encephalopathy.

In an eMedicine article on Influenza by Robert W Derlet, MD, Professor of Emergency Medicine, University of California at Davis School of Medicine encephalopathy is listed under clinical presentation:

Acute encephalopathy has recently been associated with influenza A virus. In a case series of 21 patients, Steininger et al described clinical, CSF, MRI, and EEG findings.4 Clinical features included altered mental status, coma, seizures, and ataxia. Of those who underwent further testing, most had abnormal CSF, MRI, and EEG findings.

The CDC’s MMWR (July 23rd issue) reported on 4 pediatric patients with the novel H1N1 virus who presented with neurological symptoms including unexplained seizures and altered mental status.

Neurologic Complications Associated with Novel Influenza A (H1N1) Virus Infection in Children --- Dallas, Texas, May 2009

Neurologic complications, including seizures, encephalitis, encephalopathy, Reye syndrome, and other neurologic disorders, have been described previously in association with respiratory tract infection with seasonal influenza A or B viruses (1--2), but not with novel influenza A (H1N1) virus.

On May 28, 2009, the Dallas County Department of Health and Human Services (DCHHS) notified CDC of four children with neurologic complications associated with novel influenza A (H1N1) virus infection admitted to hospitals in Dallas County, Texas, during May 18--28.

And as previously mentioned, even seasonal influenza has been linked to very rare neurological symptoms. The editorial note from the MMWR stated that:

Considering that clusters of influenza-associated encephalopathy in children have been reported during previous community outbreaks of seasonal influenza (1--2) and that children appear to be infected with novel influenza A (H1N1) virus more frequently than adults (3), additional neurologic complications in children are likely to be reported as the pandemic continues.

Clinicians should consider influenza associated encephalopathy in the differential diagnosis of children with ILI and seizures or mental status changes, and remain aware of the potential for severe neurologic sequelae associated with seasonal or novel influenza A (H1N1) virus infection.

The incidence of neurological involvement with most influenza viruses appears to be quite low, although obviously not unheard of.

Earlier this month, Children's Hospital of Pittsburgh reported 5 kids with encephalitis over the past 6 weeks.

Today we learn via the Daily Yomiuri Online that a surprising number of H1N1 patients in Japan have presented with encephalopathy since July.

In a normal year, Japanese health officials say they might see 40 to 50 such cases – but in the past four months they’ve seen more than twice that many.

A hat tip to Treyfish on FluTrackers for posting this link.

132 flu patients hit with brain disorders since July

The Yomiuri Shimbun

A total of 132 influenza patients in Tokyo and 27 prefectures have developed encephalopathy, or swelling of the brain, since July, according to the National Institute of Infectious Diseases.

Normally, only about 40 to 50 seasonal flu sufferers develop encephalopathy each year, meaning the latest figure has already more than doubled in four months since the new strain of flu began spreading.

Encephalopathy occurs when viruses cause the immune system to overreact, resulting in a swelling of the brain.

Though the ages of the 132 people in question range from 1 to 67, most were under 15.

By age, 7-year-olds constituted the largest group, with 22 sufferers. This is older than the average age for encephalopathy sufferers, who are most often aged between 1 and 3.

Further examination of 60 of the 132 patents revealed consciousness-related malfunctions.

The period over which these malfunctions occurred following the initial fever ranged from one day for 12 people, two days for 36 people, and four days for eight people.

The examination reconfirmed that in many cases, the serious symptoms occurred in the early stages of the disease.

Of 59 patients whose symptom development had ended, three, or 5 percent, died. Seven, or 12 percent, suffered aftereffects such as physical paralysis or mental or nerve disorders.

Forty-nine, or 83 percent, fully recovered.

Nobuhiko Okabe, chief of the institute's Infectious Disease Surveillance Center, said: "If a patient exhibits such symptoms as slow responses or saying strange things, encephalopathy could be the cause. In such cases, patients should see a doctor immediately."

(Nov. 24, 2009)

Novartis To Open Next Generation Vaccine Plant In NC

2009-11-23T14:52:00.001-05:00

# 4068

The bottleneck in producing ample pandemic vaccine for the US, and the world, was caused in large part because we rely on the 50-year-old technology of growing antigen in chicken eggs.

There are newer cell-based technologies on the horizon, but production facilities must be built, manufacturing problems solved, and these novel vaccines approved for use by the FDA.

Maggie Fox, Health & Science Editor for Reuters brings us word of a new factory in Holly Springs, North Carolina, that in a few years will hopefully be capable of producing as much as 150 million doses of adjuvanted cell-based vaccine within 6 months of a pandemic virus being isolated.

The problems aren’t all technical or logistical, however.

This cell technology is new, unfamiliar to most Americans, and the use of adjuvants in this country is currently viewed with suspicion.

The hope is, that we’ll come out of this pandemic season with a lot more safety data on the use of adjuvants.

Tens of millions of adjuvanted vaccines have already been delivered to the arms of people in Canada and Europe without apparent problems, and by the time this factory is ready to produce, it is hoped Americans may be more inclined to accept the product.

Next-generation flu vaccine plant to open in U.S.

Mon Nov 23, 2009 11:53am EST

* New factory first in U.S. to use cells to make flu shots

* Novartis hopes U.S. market will accept boosted vaccines

* First dose won't come before 2011

By Maggie Fox, Health and Science Editor

WASHINGTON, Nov 23 (Reuters) - Novartis (NOVN.VX) will officially open the first next-generation flu vaccine plant in the United States on Tuesday, but it will be years before it makes its first vaccine.

The factory in Holly Springs, North Carolina, will use batches of dog cells to grow influenza vaccine, instead of the chicken eggs widely used now. While the cell method is only slightly faster, it can be scaled up more quickly.

Federal advisers to the U.S. Food and Drug Administration last week asked for more safety data on another cell-based vaccine, one made by privately held Protein Sciences Corp. But U.S. officials said the new Novartis shot is not as experimental.

"I see them as totally different. The whole point of pushing on cell culture was increasing capacity and surge capacity," Dr. Bruce Gellin, head of the U.S. Health and Human Services Department's National Vaccine Program Office, said in an interview.

HHS spent $487 million helping Novartis build the plant, which was planned before the current pandemic of H1N1 swine flu.

(Continue . . .)

Thanksgiving Roll Call 2009

2009-11-23T13:04:00.001-05:00

# 4067

This is my fourth Thanksgiving blogging at AFD.

In November of 2006 I began what has turned out to be a joyous tradition for me - taking the time to publicly acknowledge and thank those working to prevent, or mitigate, this and future pandemics.

Each year I update this essay to include some new people, and to mention some of the friends I've met along the way on this remarkable journey through Flublogia.

While I pen AFD alone, this is by no means a solitary effort. I rely (heavily) on the the advice, expertise, and hard work of dozens of others in Flublogia, without whom, this blog would not be possible.

This is my once-a-year chance to thank them.

You’ll find earlier editions of this roll call at:

Thanksgiving Roll Call - 2008

Thanksgiving Roll Call, Redux

AVIAN FLU THANKSGIVING ROLL CALL

Our regular schedule of doom and gloom will continue shortly. In the meantime, I invite you to take a moment to reflect on those who are out there doing good work to try to avert a disaster.

You may know some of these people by name, and some by the organizations they represent, while others you may not be aware of at all.

This is, in no way, a complete list.

There are far too many good people, agencies, and organizations doing good work out there to mention. But it’s a start.

So, in no particular order, a tip of the hat and a world of thanks go to:

The HHS which found itself in the midst of a pandemic outbreak in the opening months of a new administration, even before a new Secretary had been appointed.

Kudos must go to first to the career members of the HHS, CDC, and FDA who have dealt with a difficult situation during a time of political transition. Luckily they already had a pandemic playbook in place, and while it required revision and adjustment for a milder virus, it gave those agencies a big advantage going into this crisis.

Much of the credit for that preparedness must go to former HHS Secretary Michael Leavitt, who spearheaded the US pandemic movement starting in 2005.

This year, once again the HHS invited several bloggers to Washington D.C. to take part in a day-long pandemic tabletop exercise along side representatives from the HHS, CDC, FEMA, Homeland Security, the FDA , State and local Health Departments, and print and broadcast journalism.

At this conference I was delighted to meet and talk at some length to Dr. Bruce Gellin, Director of the National Vaccine Program Office at the HHS, and to spend the day interacting with HHS Secretary Kathleen Sibelius, Admiral Anne Schuchat, Dr. Anthony Fauci and Dr. Jay Butler . . . among others.

That trip also allowed me to renew my acquaintance with Forrest Sawyer, and once again see Sharon Sanders of Flutrackers and Dr. Greg Dworkin of the Flu Wiki, and to spend time with two of the best reporters in the business, Lisa Schnirring of CIDRAP News and Maggie Fox of Reuters.

I was also able to meet up again with Stephanie Marshall of the HHS, and to finally meet Mary Carlson and Andrew Wilson (@AndrewPWilson on Twitter).

Barely three weeks after that event, I was extremely fortunate to be invited to participate in the CIDRAP Pandemic Summit in Minneapolis (see Next Week’s H1N1 CIDRAP Summit). My gratitude goes to Dr. Michael Osterholm, and everyone at CIDRAP, for the opportunity to be a part of that event.

It was a thrill that will not be soon forgotten.

On the 2nd day of the summit I took part in two 90-minute media panel discussions - moderated by Joel Kramer of Minnpost.com -along with Amy Burkholder of CBS Evening News with Katie Couric, Betsy McKay of the Wall Street Journal, and chief science correspondent of NBC news Robert Bazell.

Readers of this blog no doubt have noticed that I’ve referenced the work of CIDRAP often over the years.

The reason is simple: They are very good at what they do.

The reporting from CIDRAP News is always first rate, with most of the heavy lifting done by Editor Robert Roos, and the previously mentioned Lisa Schnirring. Contributing writer and blogger Maryn McKenna lends even more expertise.

Maryn's 7-part award winning series on the Pandemic Vaccine Puzzle is an absolute must-read. Maryn is also the author of Beating Back The Devil, the inside story of the CDC’s Epidemic Intelligence Service, and an upcoming book on MRSA.

CIDRAP also issues comprehensive reports on public health related subjects, such as the recent Pandemic Influenza, Electricity, and the Coal Supply Chain by Nick Kelley, MSPH and Michael Osterholm, PhD, MPH and the HR Toolkit for businesses based on the recent summit.

Dr. Michael Osterholm, Director of CIDRAP, has achieved near rock star status in the flu world, and rightfully so. Before devoting his attentions to CIDRAP, Dr. Osterholm served for 24 years (1975-1999) in various roles at the Minnesota Department of Health (MDH), the last 15 as state epidemiologist and chief of the Acute Disease Epidemiology Section.

He is, as they say, a heavy hitter. And his lectures on the threat of an Avian Flu pandemic, his writings, and his appearance on Oprah have brought pandemic flu awareness to millions of people.

CIDRAP, of course, is made up of more than just the handful of people I've mentioned. A more complete list is available here along with their mission statement.

Moving on, some other names that deserve mention include:

Dr. David Nabarro, Senior United Nations system Coordinator for Avian and Human Influenza. Formerly one of the worlds top public health officials with WHO (World Health Organization), Dr. Nabarro has led the fight at the UN on the Avian flu front, and has pulled no punches in his assessments of the threat it poses.

Dr. Robert G. Webster, perhaps the world’s most famous virologist, and the head of the virology department of St. Jude’s Research Hospital. In addition to his life long study of viral pathogens, and the numerous papers he has produced, Dr. Webster was perhaps the first scientist to recognize the threat of the H5N1 virus in Hong Kong 10 years ago, and is largely responsible for the eradication of the threat at that time. He quite likely saved the world from a pandemic a decade ago.

Today, Dr. Webster continues his research, and reminds us of the stark realities of what a pandemic could bring the world. His message hasn’t always been popular, and he has undoubtedly stepped on some toes along the way, but this mild mannered man is a superhero in disguise.

The list of doctors and researchers is extensive, and there are many unsung heroes among them. People like Greg Poland of the Mayo Clinic, and John Oxford, Professor of Virology at St Bartholomew’s and the Royal London Hospital, and Richard Webby of St. Judes, among others. Names you may never have heard of, unless you follow virology closely.

There are countless people at the CDC, the NIH, the WHO, FAO, and OIE who are working, mostly anonymously and often in less than optimal conditions, to mitigate this pandemic and hopefully prevent the next one.

And there are universities and medical centers around the world; places like the University of Minnesota, St. Judes Research Hospital, UPMC Center For Biosecurity, and Baylor College of Medicine in Houston which are major sponsors of influenza and emerging infectious disease research - along with many others.

John M. Barry, author of the quintessential book on the 1918 pandemic, The Great Influenza: The Epic Story of the Deadliest Plague in History, almost single handedly has reminded us of the horrors of our last great pandemic. If you haven’t read this book, you should. Period.

Dr. Michael Greger, author of Bird Flu: A Virus of Our Own Hatching has provided us with a compelling, and all too often disturbing look at the factory farming business, and how it contributes to the threat of a pandemic.

The entire text is available online, without charge (thank you Dr. Greger!).

I promise you. Read it, and you'll never look at chicken the same way again. An informative and entertaining lecturer, click here to view his latest video on factory farming.

Helen Branswell, health reporter for the Canadian Press. If anyone in the field of journalism deserves the Paul Revere Award, it is Ms. Branswell. She has produced some of the finest reportage on the emergence of the H5N1 virus (and now H1N1) as exists anywhere in the world, and she started back when few had heard of the threat.

Her writing is clear, concise, and absent of the breathless prose that many lesser journalists rely upon. Whenever I find a Branswell article, I know in advance it is going to be well worth reading.

Maggie Fox, the Health and Science Editor for Reuters, is another standout in the world of journalism. Her reporting on the pandemic threat (along with a myriad of other topics) has been consistently excellent.

Maggie has an advantage over many other news reporters in that she understands the science, having completed fellowships at the National Institutes of Health on Genomics, at Harvard Medical School on infectious disease, and at the University of Maryland on child and family health policy. And it shows.

Declan Butler, senior reporter for Nature, and blogger, who very early on called the attention of the world to the pandemic threat, and who has used Google Earth to great effect mapping avian flu outbreaks around the world.

Other notable names include would Jason Gale of Bloomberg, Patrick Thibodeau of ComputerWorld, Betsy McKay at the Wall Street Journal, Robin McDowell of the AP, and Emmy Fitri of the Jakarta Post. There are others of course.

Thank you all. We need a hundred more, just like you.

On the Internet we have a number of dedicated and astute bloggers, and they too deserve special mention. Among them:

Crawford Kilian, author of Crofsblog, was one of the first, and arguably remains the best flu blogger out there. His site is resource rich, his comments are invariably on target, and his tone is always professional. He does a far better job covering the flu news than anyone I know of.

In short, Crof showed the world how an avian flu blog should be done, and those with any sense have followed his example.

The Reveres, anonymous authors of Effect Measure, which has my nomination as the best public health blog on the Internet. Don’t be put off by their anonymity, these guys (or gals) are the real deal. They have the ability to explain the science of avian and swine influenza (and other health threats) better than anyone else in the blogosphere.

If you want to know what this humble author reads, you should know that Effect Measure is at the top of my list each day.

SophiaZoe, my cyber-twin and dear friend, who writes the remarkable Pandemic Chronicle.

One of the outright joys of being a blogger is that I've gotten to meet a number of people in Flublogia. SZ and I have, over the past four years, become fast friends. She never ceases to amaze me with her encyclopedic knowledge of pandemic issues, and her ability to get to the crux of the matter.

Another blogger I've had the great fortune to meet, and work with on several occasions, is DemFromCt, editor of the Flu Wiki and a blogger on the Daily Kos.

We've worked together on four projects so far; The 2007 HHS Pandemic Leadership Blog, the 2008 Pandemic Tabletop Exercise, the 2009 Pandemic Tabletop Exercise, and are both contributors to GetPandemicReady.Org.

This year I finally got to meet the irrepressible Scott Mcpherson, after several years of email correspondence. We were both part of the CIDRAP summit in September, and I got to spend two glorious days hanging out with him and fellow blogger Indigo Girl.

A fellow Floridian, Scott is the CIO of the Florida House of Representatives, and rubs elbows with State and Federal officials every day. His insights, often sprinkled with a dash of healthy whimsy, are always a pleasure to read.

Indigo Girl on Allnurses.com has been the driving force behind their pandemic forum for several years. Her long-running analysis of avian and H1N1 flu news has brought a keener awareness and understanding of pandemic issues to her fellow nurses.

Working on the frontlines, Indigo has a healthy appreciation of the day-to-day challenges of dealing with pandemic flu.

While distance makes face-to-face meetings between bloggers rare-but-happy events, we often share information and ideas via Skype, email, and other backchannels.

I’m happy to say there isn’t even a hint of rivalry among us, and we are all genuinely pleased to see others do well. Hence the frequent hat tips and referrals between us.

While not necessarily flu-centric, some other bloggers of note include:

Vincent Racaniello’s always excellent Virology Blog, which devotes a good deal of time to influenza. His TWiV podcasts are also highly recommended.

Assistant Professor of Epidemiology, Tara Smith’s blog Aetiology.

Joel at Preparedness and Response writes based on his private and professional experience in the areas of preparedness and response. He covers public health and emergency management issues.

And in the general preparedness arena there’s also Jimmy Jazz at Breakglass and John Solomon at In Case Of Emergency.

And some of the best essays on avian influenza issues comes from people who don't have a regular blog, but post instead to flu forums.

Many of those are what are known as Newshounds.

Every day, dozens of hardworking volunteer flubies scour foreign language news reports, using search engines, text-finding software, and translating programs to bring us the latest tidbits of news from around the world.

They do an awesome job. If the CIA and the NSA aren't envious, they should be.

It would be impossible to mention them all, and I fear insulting those I miss. But a partial list (in no particular order) of some of the most recently active newshounds includes :

Dutchy, Ironorehopper, Treyfish, Commonground, Florida1, DemFromCt, SusanC, Kobie, Carol@SC, Pixie, mojo, bgw in MT, Readymom, pugmom, Frenchiegirl, AlohaOr, UK-Bird, Rick, Canada Sue, Theresa42, Mosaic, Cottontop, Influentia2, Mojo, Michelle in OK, Mary In Hawaii, dbg, flubergasted, Laidback Al, Alaska Denise, Siam, InKy, History Lover . . .

To those I missed (and there are many), mea culpa.

Some of these newshounds can be found on multiple flu forums, while others stick with one particular home base. Regardless, the information is freely shared between all of the flu forums, and dissected by knowledgeable and interested parties.

The work they do is remarkable. And I couldn't do much of what I do without them. Thank you all.

The owners and moderators of the flu forums deserve mention, too.

Labors of love, and devourer's of both time and money, flu forums provide a place for laymen and professionals to gather to discuss the various aspects of pandemic planning, and quite often, the science behind influenza and epidemiology.

The founders and moderators do a terrific job keeping things on track, and do so without compensation. Most of the time, the costs (which can run into the hundreds of dollars each month) are borne by the owners.

There are a number of flu forums out there, but the most popular are Flu Wiki, Flutrackers, PFP, and PFI. Each has their own style and personality, and in many cases, members of one forum belong to several other forums as well.

The Flu Wiki, the first of the dedicated flu forums, was founded by DemFromCt, Pogge, and Melanie Matson. Last year, we lost Melanie after a long illness. She was a pioneer, and an activist, and is greatly missed.

You can read more about her, and her legacy, here.

FluTrackers, founded by Sharon Sanders (but run with the aid of dozens of tireless volunteer moderators), boasts nearly 2,000 member and prides themselves on maintaining an impressive library of scientific literature on pandemic influenza and other emerging infectious diseases.

Over the past year Sharon has also interviewed some of the biggest names in Flublogia on Radio Sandy Springs’s Infectious Disease Show, which is hosted by David Moxley.

Recent shows have included 08/17/09 Guest William Schaffner, MD 08/10/09 Guest Author John Barry, 06/29/09 Guest Gregory Härtl of the WHO , and 05/26/09 Guest Dr. Michael Osterholm.

Sharon is also a dear friend, confidant, and unindicted co-conspirator.

There is also Francophones des FluTrackers, which is a French language section of Flutrackers, moderated by Muscade, Éditeur et Directeur.

There are other non-English language flu forums as well, such as Zone Grippe Aviaire H5N1 en français which is run by Lyro out of Quebec. This forum provides translations of many news articles, and blogs, into the French language along with commentary.

And then there are the flubies, which number in the thousands.

Some are active posters on the flu forums, while others take a more passive role. Many have become activists in their communities.

Readymom, whom I've highlighted before in these pages, started the Readymom's Organization. RM now runs her own website Emergency Home Preparation.

The Readymom's organization, now led by Dr. Susan Chu (Flu Wiki Emeritus), not only appears at public venues promoting pandemic preparedness, they have free downloadable toolkits available so than anyone can help spread the message in their community.

Starting in mid-2007, more than a dozen volunteers worked to put together the GetPandemicReady.Org website. There you will find more than 3 dozen easy-to-follow preparedness guides, written by some pretty familiar names from the Flu Forums.

This site is hosted by the Lewiston-Nez Perce County Board of Commissioners, and came about in large part due the hard work of Mel Johnson, Director of Emergency Management.

And StudentsPrepAmerica.Org was created by Justin Kamen and others at Columbia University, and is designed to get the preparedness word out to College and University Students.

Behold the power for the flu forums.

Now is a good time to remind my readers that agencies like the Red Cross, Red Crescent, CARE, Save The Children, The H2P Project, UNICEF, and others are working around the world every day to combat poverty and disease, including pandemic flu.

They could use your support.

These NGO’s do a great deal with very little, and even small donations can help make a difference.

Often forgotten, I also send out thanks to all who wear the uniform of our country, and who will are often called upon to be on the front lines during any crisis, including a pandemic.

This includes our military and national guard troops, both at home and abroad. You guys and gals do a tough, often thankless job, 365 days a year; and are deserving of both our respect and our nation's gratitude.

Please know, you have mine.

There are hundreds of thousands of doctors, nurses, technicians, EMT's, paramedics, firefighters, and law enforcement officers out there who put it on the line each and every day. I'm proud to have been able to be a part of that universe. And my thanks, and fervent best wishes go out to each of you.

And of course, thanks go to the readers of these forums and blogs. There are far more of you out there than you imagine. Those that post on flu forums, or comment on blog sites are just the tip of the iceberg. Ninety percent of our visitors read and absorb the information here, and say nothing. We know you are out there because our web counter software logs every visit.

No, I’m not going to `out' anyone. Your secret is safe with me.

But even this humble blog gets visits every day from hundreds of corporations, government agencies, financial institutions, and even medical research facilities. Names that you would readily recognize. And that is both extremely gratifying and humbling at the same time.

Thank you for being a part of all of this.

Visitors to AFD by country for November 2009

It has been an amazing journey, these past four years blogging on avian and now pandemic flu. I've been fortunate enough to meet scores of people, either in person, or via email or chat, from around the world due to this blog.

I've collected more than a few good friends along the way.

To all of those who have written me, thank you. And keep them coming. I appreciate each and every email.

Even the ones with suggestions as to what I can do with my blog.

And lastly, a special thank you (in no particular order) to just some of the people in the Flu Community who have gone out of their way to extend kindness, friendship, and counsel to this old medic.

To SZ, and Crof, and Scott, Camille, chacal, the Revere's, Anne, Phytosleuth, Sharon, Maryn, MTO at CIDRAP Lisa & Nick & Robert at CIDRAP , Dr. Michael Greger, DemFromCt, Stephanie, Sally, Emmy, Maggie, Helen, Jackie, Karen, Cliff, Susan, Anne, Blitzen, Snick, Corky, Bluesky, Redwolf, GR, hoggie, Seazar, Paul, Joel, AnnieRn, Caroldn,and Bonnie (and many more I've no doubt left out) a special holiday thanks to you and your families.

You guys, whether you know it or not, help light the path for me every day.

And to everyone else, a safe and happy Holiday.

Canada: GSK Puts Some Flu Shots On Hold

2009-11-23T11:00:00.001-05:00

# 4066

GlaxoSmithKline, makers of the Arepanrix vaccine, have ordered doctors to hold off giving any more doses from one particular batch while the company investigates a higher than normal number of allergic reactions.

The number of doses on hold are about 170,000 – a fraction of the 7.5 million doses already delivered to Canada. Six cases of anaphylaxis from this batch were reported in Manitoba, and while all victims have recovered, it has spurred further investigation.

Two reports, first this one from Bloomberg News (hat tip Florida1 at FluTrackers), and then one from Manufacturing Net, which talks of Japan’s concerns regarding this development.

Glaxo Puts Hold on Some Swine Flu Shots in Canada (Update1)

By Michelle Fay Cortez

Nov. 23 (Bloomberg) -- Canadian doctors should hold off on using a batch of GlaxoSmithKline Plc’s swine flu vaccine temporarily while the company probes reports of higher-than- expected occurrences of a side effect known as anaphylaxis, a spokeswoman for the U.K. drugmaker said today.

The batch of 172,000 doses of Arepanrix was linked to more cases of acute allergic reactions, including swollen tongues and throats, than is normally expected, spokeswoman Gwenan White said in a telephone interview. Typically, about 1 person in 100,000 will suffer such a reaction, she said.

(Continue. . .)

GlaxoSmithKline Halts H1N1 Vaccinations In Canada
Manufacturing.Net - November 23, 2009

WASHINGTON (Kyodo) -- British drug maker GlaxoSmithKline Plc. is suspending the use of 170,000 doses of its new H1N1 influenza vaccine in Canada given a higher-than-usual rate of reported side effects, Canadian media reported Monday.

Japan's Health, Labor and Welfare Ministry, which has a contract with the pharmaceutical firm to buy two-shot doses for 37 million people, will send a fact-finding mission to Canada by early December, health minister Akira Nagatsuma said in Tokyo.

<SNIP>

The Japanese health ministry was informed of the development by the company's Japanese unit, GlaxoSmithKline K.K., and is gathering information to determine if the problem is related to specific batches or the vaccine as a whole, ministry officials said.

(Continue . . .)

ECDC On Norway Mutation & Tamiflu Resistance

2009-11-23T07:09:00.001-05:00

# 4065

The ECDC (European Centre for Disease Prevention and Control) releases a daily (5 times a week) update on the influenza pandemic, with the latest numbers along with update on recent news and their analysis or comments.

On Friday of last week 3 big stories carried the day; the announcement by the Norwegian Health Officials that they’d discovered a mutation in the H1N1 virus and two separate reports (North Carolina & Wales) of multiple cases of Tamiflu resistance.

Not surprisingly, wild Internet rumors, rampant speculation, and conspiracy theories have already begun to appear regarding these events. What most of these stories lack in logic and evidence they make up for with imagination and chutzpah.

Before I get letters, I will gladly stipulate that `official statements’ from many government agencies (and NGOs) from around the world are often carefully crafted to impart a reassuring tone, sometimes gloss over important information, and must be read with a certain amount of skepticism as well.

Some official sources are more reliable than others, but Caveat Lector is a good policy, regardless of the source.

Today the ECDC releases their Monday morning update with some analysis of the events of late last week. This is a far more detailed release of information than we saw from the WHO on Friday.

Mutation in the Haemagglutinin gene of pandemic Influenza A(H1N1)v reported from Norway

The Norwegian Institute of Public Health reported on 20 November 2009 the detection of a mutation in the viruses affecting three cases of severe pandemic Influenza A(H1N1)v infection.

Overall approximately 70 influenza viruses from ill patients have been sequenced in Norway, including six from patients who died. The three viruses with this mutation were isolated from the first two fatal cases of pandemic influenza in Norway and one patient with severe respiratory disease.

The two fatal cases , who were not epidemiologically linked, died in July and August, 2009. Based on the currently available information it appears that the mutated virus is not circulating in the Norwegian population, but may the result of a spontaneous change occurring in severely ill patients [1].

In a note responding to the report from Norway WHO reported that worldwide, a similar mutation has been was detected in viruses from several other countries, with the earliest detection reported in April. In addition to Norway, the mutation has been observed in Brazil, China, Japan, Mexico, Ukraine and the USA.[2]

Link1

Link2

ECDC comment:

The amino acid change in the haemagglutinin HA1 gene at position 222 (225 in influenza H3 numbering) from aspartic acid (D) to glycine (G) observed, may influence receptor binding specificity and therefore has the potential to affect the pathogenicity of the virus.

This might allow the mutated virus to infect tissues deeper in the respiratory tract, although the receptor binding preferences have not been determined yet. Currently, there is no evidence about the consequences of this mutation on the biological properties of the virus.

In addition, if the receptor preference of the mutated virus corresponds to the deeper airways, this most likely will tend to reduce the likelihood for easy human-to-human spread. A likely explanation of this finding is that it is an adaptive mutation of the virus.

At this moment there is no indication of change in the virulence of the circulating pandemic Influenza A(H1N1)v virus. The virus with this mutation remains sensitive to oseltamivir and zanamivir. Studies show that the currently available vaccines confer protection.

Continued close virological monitoring in particular of severe cases, is needed to elucidate any potential relationship between the mutation and the clinical outcome of infection.

Two clusters of possible transmission of oseltamivir resistant Pandemic Influenza A(H1N1)v among hospitalized patients, United Kingdom and United States

UK: Nine Pandemic Influenza A(H1N1)v confirmed cases have been reported amongst patients on a hospital ward in Wales.[3] Five of these cases are determined to be resistant to oseltamivir, one is sensitive and for three resistance status is currently unknown. The cluster is in a group of patients with haematological problems which result in immuno-suppression either because of the disorder or the chemotherapy given to treat the disorder.

Although further epidemiological investigation is underway, it would seem likely that transmission of oseltamivir-resistant H1N1 virus has taken place. Further follow-up of cases and their close contacts both on the ward and in the community is underway to ascertain if there is evidence of transmission. The virus remains sensitive to the other licensed neuraminidase inhibitor zanamivir which is being used as an alternative antiviral and to which patients are responding.[3]

USA: Four patients at a hospital in North Carolina who developed influenza in October were found to have oseltamivir resistant pandemic influenza A(H1N1) [4].   The cluster was detected when the patients did not respond to oseltamivir treatment. Three of the four patients have died. All of the patients were located in a ward for people with cancer or severe blood disorders. All were severely ill and were highly susceptible to infections.

Preliminary genetic evidence suggests that the virus spread among patients at the hospital. The U.S. Centers for Disease Control and Prevention (CDC) is testing virus samples from the patients at Duke to see whether they're indistinguishable from one another. In addition to investigating the hospital cluster, state and federal epidemiologists are trying to determine whether oseltamivir resistant influenza is circulating elsewhere in North Carolina.

Link3

Link4

ECDC comment:

Oseltamivir resistance to influenza viruses is well documented in immunosuppressed individuals and can develop quickly if oseltamivir is being given. It is likely to be associated with the high viral load which may occur during infection in these patients. In addition, immunosuppressed people may be more susceptible to infection (i.e., a smaller exposure may result in infection in these patients). It is thus not surprising that spread of resistant virus may occur from patients in whom resistance is more likely to develop during treatment to patients who are very susceptible, especially in a confined setting such as a hospital ward.

The range of manifestations (e.g., asymptomatic, mild, severe) of influenza infection, such as observed with the 2009 A(H1N1) pandemic, makes it difficult, if not impossible, to determine if any given patient or healthcare worker is carrying virus. Thus, people in contact with an index patient can innocently spread influenza to other patients.

Unvaccinated healthcare workers and visitors in contact with these patients may be at risk for being infected with this resistant strain. At this time it is difficult to predict the likelihood of spread of this resistant strain into the community through these people or another means.

The conditions under which these clusters occurred are likely to be present at other medical centres throughout the EU. That is, transmission of influenza in the community with immunocompromised patients in healthcare settings receiving either prophylactic or therapeutic oseltamivir. Thus, member states should remain vigilant for similar clusters now and in the future.

Unless oseltamivir resistance becomes more common, it remains appropriate to use oseltamivir for the treatment and prophylaxis of influenza in the UK, the US and elsewhere. Treatment failure is a reason to consider alternative treatment and to test a viral isolate for resistance. The continuous surveillance for resistance from a sample of isolates taken from community infections should be maintained in countries where resources for testing are available.

Countries without resistance testing capacity should send samples elsewhere for testing on a periodic basis.    The best ways to prevent the spread of antiviral susceptible and antiviral resistant influenza in the healthcare setting and between healthcare settings and the community is to ensure healthcare workers are immunized and that there is strict adherence to infection control procedures.

Referral: EM on Swine Flu In China

2009-11-22T16:07:00.001-05:00

# 4064

For anyone who has doubts about China’s ability, willingness, and sheer ruthlessness in hiding public health threats I would invite you to read Karl Taro Greenfeld’s terrific account of the SARS outbreak; The China Syndrome: The True Story of the 21st Century's First Great Epidemic.

Since that 2002-03 outbreak China has made repeated promises regarding transparency and international cooperation, but few observers have a warm and fuzzy feeling about their surveillance and reporting.

Last week, Zhong Nanshan – a highly respected respiratory disease specialist on the mainland – accused Beijing of covering up the full extent of the Swine Flu outbreak (see Zhong Nanshan On China’s Death Toll).

Twenty-four hours later the Health Ministry responded, vowing to punish anyone covering up H1N1 fatalities ( see China Warns Local Officials Not To Conceal Cases).

While we may get revised totals from the Health Ministry at some point, along with some sacrificial heads on a platter, the prospects of getting good data out of China are still pretty slim.

Which bring us to Revere’s piece on Chinese transparency in Effect Measure today.

Swine flu in China: no problem

HHS Webcast Monday

2009-11-22T13:53:00.001-05:00

# 4063

November 23^rd 3:30 PM EST

H1N1 Briefing for Bloggers and Their Readers

Join the live Webcast to learn detailed information about influenza prevention and treatment, warning signs for parents, anti-viral medications, and vaccinations. A question and answer session will provide the opportunity to engage directly with leading communication and public health experts, including:

Kathleen Sebelius, Secretary, HHS

Anne Schuchat, Director, National Center for Immunization and Respiratory Diseases, CDC

Flu.gov Archive Videos

Browse our on on-demand videos

Know What to Do About the Flu Webcasts

H1N1 News Briefings

Public Service Announcements (PSAs)

ECDC Surveillance Report Week 46

2009-11-22T11:11:00.001-05:00

# 4062

The ECDC (European Centre for Disease Prevention and Control) has released its weekly influenza surveillance report, similar to the the US FluView and Canada’s FluWatch.

Not every European country reports every week to the ECDC, and the depth of surveillance and reporting may vary from one nation to the next, so week to week and cumulative numbers may be a bit hard to interpret.

Still, we get some excellent snapshots of subsets of information, including demographic information (age, gender, vaccination status, underlying conditions) of many of those hospitalized with SARI (Severe Acute Respiratory Infection).

I’ve just posted some excerpts. This week’s complete report (Pdf file) can be downloaded at this link.

Main surveillance developments in week 46/2009

Sentinel surveillance of influenza like illness (ILI)/ acute respiratory illness (ARI): Three countries reported very high intensity, nine countries reported high intensity and 16 countries reported medium intensity.

Still, most of the countries (seventeen) reported an increasing trend.

Virological surveillance: Sentinel physicians collected 3903 respiratory specimens, of which 1745 (44%) were positive for influenza virus. All but three of the influenza A sub-typed viruses were type A(H1N1)v.

Aggregate numbers of pandemic H1N1 2009: As most of the countries stopped counting total number of cases, the aggregated reporting presents the reported number of deaths.

Hospital surveillance of severe acute respiratory infection (SARI): Three hundred and thirty-five SARI cases were reported, 23% of whom had no known underlying medical condition.

Hospital surveillance – severe acute respiratory infection (SARI)

Weekly analysis – SARI

In week 46/2009, 335 SARI cases were reported. Since the beginning of this surveillance, seven EU countries have reported 1616 cases including 47 fatalities (2.9%, see Table 5). The trend in numbers of SARI cases has been steadily increasing since week 36, which could be due to improved reporting or reflect the increasing influenza
activity in the reporting countries.

The female/male ratio in week 46 was approximately 1.2 and 66% of cases were younger than 45 years (Table 6).

Since the beginning of the season, a significant majority of SARI cases related to influenza infection were caused by the pandemic virus (Table 7).

Of the 92 SARI patients for which treatment status was reported during week 46/2009, 30% received antiviral treatment (Table 8). Nevertheless, it is too early for any conclusion to be made regarding the potential benefits of such treatment.

Sixty two SARI patients needed intensive care treatment in week 46, of whom at least nine required ventilator assistance (Table 9).

Fifty five (64%) of 86 SARI cases reported in week 46 developed a complication (Table 12). Of the 111 SARI cases for whom an underlying condition was reported, 22 (20%) had no known medical condition; however, 21 (19%) had more than one underlying condition (Figure 5).

Updating The Ukraine Flu Story

2009-11-22T09:15:00.001-05:00

# 4061

After 3 weeks of wild, reckless and unfounded rumors regarding the flu outbreak in Ukraine that have conjured up the disturbing specters of bioterrorism and pneumonic plague (see Ukraine and the Internet Rumor Mill), it appears that some level of normalcy is beginning to return to that flu battered nation.

Schools are starting to reopen this week, most of the wild speculation appears to be on the wane, and public concerns are subsiding.

The flu is still there, of course.

But the numbers we’ve seen don’t support the wild assertions above, or that anything more ominous than a nasty outbreak of H1N1 (perhaps in concert with some other respiratory viruses) has been taking place in Ukraine.

Nearly 400 deaths in just under a month is tragic, but out of 1.5 million reported infections, about what you’d expect from an outbreak of influenza.

Two stories today from the Kyiv Post, outlining the number of cases, and the return to school.

Health Ministry confirms 374 deaths caused by influenza and acute respiratory viral infections
Today at 13:55 | Ukrainian News
The ministry of healthcare of Ukraine has confirmed 374 lethal cases caused by influenza and acute respiratory viral infections from October 29 to November 21, in 24 regions, the cities of Kyiv and Sevastopol, and in the Autonomous Republic of Crimea, reads a report made by the ministry.

<SNIP>

For the last 24 hours eleven people have died.

In total, 1,599,103 people have contracted influenza and other acute respiratory viral infections since October 29; including 22,900 cases for the last 24 hours.

Since the beginning of the epidemic, 93,866 people taken to hospitals, of whom 66,091 already discharged.

As Ukrainian News earlier reported, the health ministry confirmed 362 people died of influenza and acute respiratory viral infections in 23 regions, the cities of Kyiv and Sevastopol, and in Crimea as of November 20.

Quarantine ends in educational institutions of Kyiv on Nov. 25
Yesterday at 08:01 | (Wire reports)
All educational institutions and kindergartens will resume work on Wednesday, November 25.

The state anti-epidemic committee took the relevant decision at its sitting on Friday, the press service of the Kyiv City State Administration reported.

"The quarantine at all schools and higher educational institutions of Kyiv will end on November 25. The work of all kindergartens will be resumed," First Deputy Head of Kyiv City State Administration Irena Kylchytska said.

According to her, the committee has taken this decision because the infection rate of flu and acute respiratory disease has decreased among the population of the city.

The chief state sanitary doctor of Kyiv on November 19 sent Kyiv Mayor Leonid Chernovetsky a proposal to end the quarantine at educational institutions of the city on November 25.