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Thursday, April 30, 2009

WHO Raises Pandemic Level to 5

A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases

In this update:
[1] WHO announces Pandemic level 5
[2] WHO update confirmed cases
[3] PAHO update confirmed cases in the Americas
[4] USA confirmed cases
[5] Mexico - MOH press releases
[6] Canada PHA confirmed cases

[1] WHO announces Pandemic level 5
Date: 29 Apr 2009
Source: WHO website [edited]

Statement by WHO Director-General, Dr Margaret Chan 29 Apr 2009;
Swine influenza:

Ladies and gentlemen,

Based on assessment of all available information, and following
several expert consultations, I have decided to raise the current
level of influenza pandemic alert from phase 4 to phase 5.

Influenza pandemics must be taken seriously precisely because of
their capacity to spread rapidly to every country in the world.

On the positive side, the world is better prepared for an influenza
pandemic than at any time in history.

Preparedness measures undertaken because of the threat from H5N1
avian influenza were an investment, and we are now benefiting from
this investment.

For the 1st time in history, we can track the evolution of a pandemic
in real-time.

I thank countries who are making the results of their investigations
publicly available. This helps us understand the disease.

I am impressed by the work being done by affected countries as they
deal with the current outbreaks.

I also want to thank the governments of the USA and Canada for their
support to WHO, and to Mexico.

Let me remind you, new diseases are, by definition, poorly
understood. Influenza viruses are notorious for their rapid mutation
and unpredictable behaviour.

WHO and health authorities in affected countries will not have all
the answers immediately, but we will get them.

WHO will be tracking the pandemic at the epidemiological, clinical,
and virological levels.

The results of these ongoing assessments will be issued as public
health advice, and made publicly available.

All countries should immediately activate their pandemic preparedness
plans. Countries should remain on high alert for unusual outbreaks of
influenza-like illness and severe pneumonia.

At this stage, effective and essential measures include heightened
surveillance, early detection and treatment of cases, and infection
control in all health facilities.

This change to a higher phase of alert is a signal to governments, to
ministries of health and other ministries, to the pharmaceutical
industry and the business community that certain actions should now
be undertaken with increased urgency, and at an accelerated pace.

I have reached out to donor countries, to UNITAID, to the GAVI
Alliance, the World Bank and others to mobilize resources.

I have reached out to companies manufacturing antiviral drugs to
assess capacity and all options for ramping up production.

I have also reached out to influenza vaccine manufacturers that can
contribute to the production of a pandemic vaccine.

The biggest question, right now, is this: how severe will the
pandemic be, especially now at the start?

It is possible that the full clinical spectrum of this disease goes
from mild illness to severe disease. We need to continue to monitor
the evolution of the situation to get the specific information and
data we need to answer this question.

From past experience, we also know that influenza may cause mild
disease in affluent countries, but more severe disease, with higher
mortality, in developing countries.

No matter what the situation is, the international community should
treat this as a window of opportunity to ramp up preparedness and

Above all, this is an opportunity for global solidarity as we look
for responses and solutions that benefit all countries, all of
humanity. After all, it really is all of humanity that is under
threat during a pandemic.

As I have said, we do not have all the answers right now, but we will get them.

Thank you.

Communicated by:
ProMED-mail Rapporteur Kunihiko Iizuka
ProMED-mail Rapporteur Brent Barrett

[For a discussion on the stages of pandemic alert, see

"Phase 5 is characterized by human-to-human spread of the virus into
at least 2 countries in one WHO region. While most countries will not
be affected at this stage, the declaration of Phase 5 is a strong
signal that a pandemic is imminent and that the time to finalize the
organization, communication, and implementation of the planned
mitigation measures is short."

At present, there are cases in Canada and the United States who do
not have a history of travel to Mexico, so there are now 3 countries
(USA, Canada and Mexico) that are reporting human to human spread of
the virus (see below for more details). At present, the definition of
a suspected case in many countries includes a history of travel to
Mexico or another country (such as the USA or Canada) that has
confirmed cases. This may bias towards a later recognition of
indigenous transmission of the novel H1N1 virus in countries not
presently known to have local cases. - Mod.MPP]

[2] WHO update confirmed cases
Date: 29 Apr 2009
Source: WHO Epidemic and Pandemic Alert and Response (EPR) [edited]

Swine influenza - update 5-29 Apr 2009
The situation continues to evolve rapidly. As of 19:00 GMT, [29 Apr
2009], 9 countries have officially reported cases of swine influenza
A/H1N1 infection. The United States Government has reported 91
laboratory confirmed human cases, with one death. Mexico has reported
26 confirmed human cases of infection including 7 deaths.

The following countries have reported laboratory confirmed cases with
no deaths - Austria (1), Canada (13), Germany (3), Israel (2), New
Zealand (3), Spain (4) and the United Kingdom (5).

Further information on the situation will be available on the WHO
website on a regular basis.

WHO advises no restriction of regular travel or closure of borders.
It is considered prudent for people who are ill to delay
international travel and for people developing symptoms following
international travel to seek medical attention, in line with guidance
from national authorities.

There is also no risk of infection from this virus from consumption
of well-cooked pork and pork products. Individuals are advised to
wash hands thoroughly with soap and water on a regular basis and
should seek medical attention if they develop any symptoms of
influenza-like illness.

Communicated by:

[3] PAHO update confirmed cases in the Americas
Date: 29 Apr 2009
Source: PAHO website [edited]

Influenza cases by a new sub-type: Regional Update (29 Apr 2009 13:00
hrs. WDC time) Epidemiological Alerts Vol. 6, No. 15
On [18 Apr 2009], the National IHR Focal Point of the United States
notified the laboratory confirmation of 2 human cases of swine
influenza A/H1N1 in 2 children of 9 and 10 years old living in the
state of California (one in the County of San Diego and the other one
in Imperial County).

To date, a total of 91 human cases of swine influenza have been
confirmed in the United States (1 in Arizona, 14 in California, 1 in
Indiana, 2 in Kansas, 2 in Massachusetts, 2 in Michigan, 1 in Nevada,
51 in New York City, 1 in Ohio and 16 in Texas). The 1st death
attributable to swine influenza in the United States has been
confirmed. A child of 22 months old that came from Mexico died in a
hospital of the Houston area.

Other suspected cases are being investigated. Indigenous transmission
has been demonstrated only in one case, in Kansas. The most recent
cases detected as well as the registered death suggest that more
serious cases could appear in the United States.

This virus has been described in the United States as a new subtype
of swine influenza A/H1N1 not previously detected in pigs or humans.

In addition, since the end of March 2009, Mexico observed an unusual
pattern of acute respiratory infection (SARI) cases, which increased
even more in the 1st weeks of April 2009. From 17 to 28 Apr [2009],
1551 suspected cases of influenza with severe pneumonia were
reported, including 84 deaths. These figures are smaller than those
reported yesterday [28 Apr 2009] due to the investigation work and
clean-up of data that are being carried out in field. The suspected
cases were recorded in 31 of the 32 states of Mexico.

There are 286 probable cases of swine influenza A/H1N1. Most of the
suspected cases of influenza with severe pneumonia have occurred in
the Federal District, Guanajuato, State of Mexico, and San Luis
Potosi, the majority of them in previously healthy young adult
people. There have been few cases in individuals under 3 or over 59
years old.

To date, the number of cases confirmed remains valid (26 cases).
However, this figure can significantly vary on the next 2 days when
the laboratory tests of the probable cases under investigation are

Furthermore, the number of confirmed dead cases remains 7. This
figure is also subject to variation depending on the new laboratory

In Canada to date, 13 human cases of swine influenza A/H1N1 have been
confirmed (2 in Alberta, 4 in the province of New Scotland, 3 in
British Columbia and 4 in Ontario), some of them with recent trip
history to Cancun, Mexico. All the cases developed a mild form of
influenza like illness. Two of the cases presented, in addition,
gastrointestinal symptoms. All of them are currently recovered, and
none required hospitalization. Laboratory tests were conducted in
Winnipeg, Canada. Indigenous transmission is not discarded since not
all the confirmed cases have trip history to Mexico.

The press has reported information on suspected cases in several
countries of the region; however this information has not been

In relation to the laboratory results; in the 2 1st confirmed cases
in the United States, virus A/California/04/2009 and
A/California/05/2009 were isolated. They show a pattern of genetic
reassortment of a virus of swine influenza from the Americas with a
swine influenza virus from Eurasia. This particular genetic
combination had not been detected in the past. Both proved to be
resistant to amantadine and rimantadine, but sensitive to
neuraminidase inhibitors, oseltamivir and zanamivir. Both have been
cultured in MDCK cells and inoculated in ferrets for the production
of antisera. The complete genome of the virus A/California/04/2009
has been published and is available in the database of the GISAID
The viruses of other confirmed cases in the United States correspond
to the same new strain.

In summary:
* There is evidence of circulation of a strain previously undetected
in pigs and humans.
* Studies are being conducted in order to determine the extent of
the human to human transmission.

Epidemiological surveillance and outbreak investigation in the
affected countries:

In the United States, investigations are being conducted to determine
the source of infection and whether there are additional cases. So
far, none of the cases have previous contact with pigs.

On the other hand in Mexico, prevention and control measures are
being coordinated, including intensified surveillance activities. As
a precautionary measure, the closing of day-care centers, schools,
and universities was enacted in the city of Mexico. Similarly, social
and cultural activities were suspended for a period of 10 days.

This new subtype of the virus could be circulating in the population
of pigs; which is being reviewed and investigated.

International Health Regulations (IHR)
At the request of the Director-General (DG) of WHO, the IHR Emergence
Committee has been summoned and is advising the DG on the event. On
its 1st day of deliberation, [25 Apr 2009], it concluded that the
present event constitutes a Public Health Emergency of International
Concern. To date, no temporal recommendations have been taken.

The 2nd meeting of Emergency Committee was held on [27 Apr 2009]. The
Committee advised about the need of raising the alert level, and
accordingly the DG has raised the pandemic alert level from 3 to 4.
[See notice in section [1] of this update; the pandemic alert level
has been raised to [5] by the DG at approximately 3:45 PM GMT-4. -

Efforts should be aimed at mitigating rather than trying to contain
the virus, because it has spread quite far, and containment is no
longer feasible.

The Director-General recommends not closing borders or restricting
travel. However, it is prudent for people who are sick to delay
travel. Moreover, returning travelers who have become sick should
seek medical attention in line with guidance from national

Production of seasonal vaccine should continue, but at same time, WHO
should facilitate the process to develop vaccine for swine influenza

The Committee will continue to advise the DG on the basis of the
available information.

Recommendations: Enhanced surveillance
At this time, enhanced surveillance is recommended. On its web page,
PAHO has published orientations for the enhancement of surveillance
activities, which are directed to the investigation of:

* Clusters of cases of ILI/SARI of unknown cause
* Severe respiratory disease occurring in one or more health workers
* Changes in the epidemiology of mortality associated with ILI/SARI;
increase of observed deaths by respiratory diseases; or increase of
the emergence of severe respiratory disease in previously healthy
* Persistent changes observed in the response to the treatment or
evolution of a SARI.

The following risk factors should also cause suspicion of swine
influenza A/H1N1 virus:

* Close contact with a confirmed case of swine influenza A/H1N1
while the case was sick
* Recent travel to an area where there are confirmed cases of swine
influenza A/H1N1

Virological surveillance of swine influenza A/H1NI:

It is recommended that National Influenza Centers (NIC) immediately
submit to the WHO Collaborating Center for influenza (CDC of the
United States) all positive but un-subtypable specimens of influenza
A. Shipment procedures are the same as those used by NICs for
seasonal influenza specimens.

The test protocols for the detection of seasonal influenza by
Polymerase Chain Reaction (PCR) cannot confirm swine influenza A/H1N1
cases. The Centers for Disease Control and Prevention of the United
Sates are preparing testing kits that will include the primers and
probes as well as the required positive control samples. The kits
will be sent in the 1st week of May to those NICs that currently use
the CDC protocol.

Infection prevention and control in health care facilities:

Since the main form of transmission of this disease is by droplets,
it is recommended strengthening the basic precautions to prevent
their dissemination, for example the hygiene of hands, adequate
triage in the health facilities, environmental controls, and the
rational use of the personal protective equipment in accordance with
the local regulations.

The complete guides "Epidemic-prone & pandemic-prone acute
respiratory diseases, Infection prevention & control in health-care
facilities" are available at:

Communicated by:

[4] USA confirmed cases
Date: 29 Apr 2009
Source: CDC Swine flu webpage [edited]

Swine Influenza (Flu); Swine Flu website last updated 29 Apr 2009, 11:00 AM ET

U.S. Human Cases of Swine Flu Infection (As of 29 Apr 2009, 11:00 AM ET)
States: number of laboratory confirmed cases / Deaths
Arizona: 1 / 0
California: 14 / 0
Indiana: 1 / 0
Kansas: 2 / 0
Massachusetts: 2 / 0
Michigan: 2 / 0
Nevada: 1 / 0
New York City: 51 / 0
Ohio: 1 / 0
Texas: 16 / 1

Total counts: 91 cases / 1 death

The outbreak of disease in people caused by a new influenza virus of
swine origin continues to grow in the United States and
internationally. Today, CDC reports additional confirmed human
infections, hospitalizations and the nation's 1st fatality from this
outbreak. The more recent illnesses and the reported death suggest
that a pattern of more severe illness associated with this virus may
be emerging in the U.S. Most people will not have immunity to this
new virus and, as it continues to spread, more cases, more
hospitalizations and more deaths are expected in the coming days and

CDC has implemented its emergency response. The agency's goals are to
reduce transmission and illness severity and provide information to
help health care providers, public health officials and the public
address the challenges posed by the new virus. Yesterday [28 Apr
2009], CDC issued new interim guidance for clinicians on how to care
for children and pregnant women who may be infected with this virus.
Young children and pregnant women are 2 groups of people who are at
high risk of serious complications from seasonal influenza. In
addition, CDC's Division of the Strategic National Stockpile (SNS)
continues to send antiviral drugs, personal protective equipment, and
respiratory protection devices to all 50 states and U.S. territories
to help them respond to the outbreak. The swine influenza A (H1N1)
virus is susceptible to the prescription antiviral drugs oseltamivir
and zanamivir. This is a rapidly evolving situation, and CDC will
provide updated guidance and new information as it becomes available.

Communicated by:

[5] Mexico - MOH press releases
Date: 29 Apr 2009
Source: Press Communication, Ministry of Health Mexico [trans. by
Mod.MPP, edited]

[29 Apr 2009] Press Communication No. 135
The Ministry of Health reports that the results of recent specimens
received by the laboratory this morning [29 Apr 2009] indicate 23
cases positive for porcine influenza or swine flu. With this finding,
and in accordance with the data obtained up through the present, the
total number of persons infected [by the novel H1N1 "swine flu"
virus] is 49, and of these, the number of deaths remains at 7.

This conforms with laboratory analyses of specimens from presumptive
cases of porcine influenza or swine flu by the Ministry of Health.

Communicated by:

[According to a press release from 28 Apr 2009
there were officially 2498 cases of severe atypical pneumonia
reported nationally as of 28 Apr 2009, of which 159 had died.

According to this report, information combined from the IMSS (Mexican
Social Security Institute), ISSSTE (Mexican Institute of Security and
Social Services for Government Employees), National Institutes of
Health, as well as federal entities, as of 28 Apr 2008, there were
1311 persons presently hospitalized (for pneumonia).

These numbers are significantly higher than the stated number of
confirmed cases, 26 according to reports from WHO and PAHO (see

for the PAHO updated figures).

[6] Canada PHA confirmed cases
Date: 29 Apr 2009
Source: Public Health Agency, Canada [edited]

[29 Apr 2009] Cases of Human Swine Influenza in Canada
The Public Health Agency is committed to sharing information about
the human swine influenza cases with Canadians. This page will be
updated as PHAC receives confirmation of human swine influenza cases
from provinces and territories.

Province: Confirmed cases of human swine influenza

Alberta: 2
British Columbia: 6
Nova Scotia: 4
Ontario: 7

Total: 19

Communicated by:

[7] News briefs - suspected cases
Date: 29 Apr 2009

The below links are to newswire reports on suspected cases of H1N1
("swine flu") reported by the media, not as yet confirmed:

Americas region:
Guatemala - one suspected case with history of travel to Mexico

Costa Rica - one "confirmed case" with history of travel to Mexico
reported by media on 28 Apr 2009 but not confirmed according to WHO
and PAHO data

Colombia - 42 suspected cases, all with a history of travel to Mexico

Chile - 24 suspected cases
Brazil - 11 suspected cases
Bolivia - 2 suspected cases with history of travel to Mexico
Uruguay - 2nd suspected case under investigation

Slovakia - one suspected case with history of travel to Mexico

Belgium - 7 suspected cases, all with history of travel to Mexico or the USA

France - 32 suspected cases, of which 2 are considered probable (the
2 probable had a history of travel to Mexico)

Poland - 3 suspected cases with history of travel to Mexico

Australia - 91 suspected cases

Communicated by:

[To summarize the status of confirmed cases and suspected cases as
best as one can (given the exponential growth of press releases and
press interviews leading to thousands of newswires): There are
presently 91 confirmed cases in the United States involving 10
States: Arizona (1), California (14), Indiana (1), Kansas (2),
Massachusetts (2), Michigan (2), Nevada (1), New York City (51), Ohio
(1), Texas (16, with 1 death in a Mexican child). The majority of
these cases have been relatively mild and self-limited infections. In
Mexico, there have been over 2498 reported cases of severe pneumonia
(hospitalized) in 31 of 32 States, with 159 reported fatalities.
According to the PAHO update, there are presently 286 probable cases,
with presently 26 confirmed by laboratory testing, of which 7 were
fatal. There have been 19 cases confirmed in Canada: Alberta (2),
British Columbia (6), Nova Scotia (4), Ontario (7). Not all of the
cases in Canada have a history of travel to Mexico, so indigenous
transmission is likely. All 19 cases have been mild with self-limited

In addition to the confirmed cases in North America, there are
confirmed cases in Europe: Austria (1), Germany (3), Spain (4) and
the United Kingdom (5); the Middle East: Israel (2); and Oceana: New
Zealand (3).

Suspected cases are being reported from many countries including
others in Latin America (Argentina, Bolivia, Brazil, Chile, Colombia,
Costa Rica, Ecuador, Guatemala, Uruguay) and Europe (Belgium, France,
Poland, Slovakia, Poland) and Oceana (Australia).

At this point, any individual with a history of travel to a location
with known confirmed cases of the novel H1N1 virus who develops an
influenza-like illness (ILI) is considered a suspected cases until
results from laboratory testing are available. One would expect the
volume of reports of suspected cases to grow, as more and more
travelers return to their countries of origin, with a proportion of
them having ILI's, an often observed illness following airline
flights. The challenge will be the early detection of human-to-human
transmission in these countries among those individuals without a
history of travel to countries with known human to human transmission
ongoing (Canada, USA, Mexico). - Mod.MPP]

[see also:
Influenza A (H1N1) "swine flu": worldwide (06) 20090429.1614
Influenza A (H1N1) "swine flu": worldwide (05) 20090428.1609
Influenza A (H1N1) "swine flu": worldwide (04) 20090428.1601
Influenza A (H1N1) "swine flu": worldwide (03) 20090428.1600
Influenza A (H1N1) "swine flu": Worldwide (02) 20090427.1586
Influenza A (H1N1) "swine flu": Worldwide 20090427.1583
Influenza A (H1N1) virus, human: worldwide 20090426.1577
Influenza A (H1N1) virus, human - New Zealand, susp 20090426.1574
Influenza A (H1N1) virus, human - N America (04) 20090426.1569
Influenza A (H1N1) virus, human - N America (03) 20090426.1566
Influenza A (H1N1) virus, human - N America (02) 20090425.1557
Influenza A (H1N1) virus, human - N America 20090425.1552
Acute respiratory disease - Mexico, swine virus susp 20090424.1546
Influenza A (H1N1) virus, swine, human - USA (02): (CA, TX) 20090424.1541
Influenza A (H1N1) virus, swine, human - USA: (CA) 20090422.1516
Influenza A (H1N1) virus, swine, human - Spain 20090220.0715
Influenza A (H1N1) virus, swine, human - USA (TX) 20081125.3715
Influenza A (H2N3) virus, swine - USA 20071219.4079
Influenza, swine, human - USA (IA): November 2006 20070108.0077]

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